An Emotional Exposure-Based Treatment of Traumatic Stress for People with Chronic Pain: Preliminary Results for Fibromyalgia Syndrome.

Chronic pain is a common source of disability and distress, and fibromyalgia syndrome (FMS) is particularly problematic. This condition, which afflicts about 4% of U.S. adults, primarily women, is marked by widespread muscular pain, multiple tender points, and often by fatigue, sleep problems, disability, and mood disturbance. Controversy surrounds FMS because of the lack of tissue pathology in the face of often incapacitating symptoms, the elevated levels of psychological distress found in many patients, and the limited effectiveness of medical and psychological interventions. Both patients and providers are often quite frustrated. Many patients with FMS have had serious psychological trauma or conflict. Childhood or adult victimization is common, even before FMS onset and even when compared to other pain conditions. Over half of FMS patients have post-traumatic stress disorder (PTSD) or subclinical PTSD (Cohen et al., 2002), and patients with FMS respond to interpersonal conflict with increased pain (Davis, Zautra, & Reich, 2001). Trauma likely creates difficulties in emotion regulation, such as emotional suppression and avoidance, as well as in relationships, such as balancing trust and autonomy. These emotional and interpersonal problems likely contribute to FMS onset or severity in many patients, and may be key reasons that treatments often fail. How should one deal with the trauma and its affective and relational consequences found in many patients with FMS? Standard cognitive-behavioral approaches to pain management (e.g., relaxation, distraction, cognitive reappraisal, problem solving), usually bypass the trauma and avoid or minimize negative emotions to reduce the affective arousal that contributes to pain. Yet, theoretical advances and empirical research on emotion regulation, emotional processing, experiential avoidance, and emotional approach coping suggest an alternative view—avoiding negative emotions is often problematic. Exposure and emotional processing treatments for PTSD and other anxiety disorders demonstrate the adaptive nature of accessing, experiencing, and expressing such emotions (Foa & Kozak, 1986), which informs action tendencies, allows the assimilation of cognitions and emotions, and facilitates stress resolution. Interestingly, the pain management literature, which typically advocates emotional avoidance techniques, has developed independently of the exposure-based literature. One exception that demonstrates the value of emotional expression and processing for pain is written emotional disclosure about traumatic experiences, which we view as a low-intensity, self-directed version of exposure therapy. This technique has shown small positive effects for a number of problems, including FMS (Gillis, Lumley, Mosley-Williams, Leisen, & Roehrs, 2006). We believe that a key limitation of available psychological treatments for FMS and many other chronic pain conditions is the failure to directly address trauma and subsequent emotional and relational difficulties found in a substantial subset of patients. To redress this, we have developed an intervention that integrates a range of theories and techniques. Our approach is strongly influenced by emotional processing theory for anxiety disorders, and it incorporates written emotional disclosure as well as the distinction between primary and secondary emotions. Also important to our model is the unifying framework of “affect phobia” (McCullough et al., 2003), which translates psychodynamic formulations into the parsimonious perspective that emotional experience is fundamentally what is avoided, and encourages creative, “dosed” (hierarchically presented) experiential exercises to engage avoided affects. We further incorporate the view that the therapeutic relationship can be a powerful corrective emotional experience when patients try new relational behaviors that they typically avoid, particularly meta-communication. We pilot tested this intervention in a sample of patients with FMS who also had unresolved stress to determine the intervention’s feasibility and its efficacy with respect to psychological outcomes, pain, and disability.