Emotional Style & Chronic Pain
Neuroscientist and psychologist Richard Davidson describes in his book, The Emotional Life of Your Brain, a range of emotional styles which we can all be measured. Davidson was one of the first neuroscientists to study the brain basis of emotions, and has been an active and prominent researcher in this field (‘affective neuroscience’) for the last 30 years.
One of the first important discoveries he made was that rather than the limbic system being the only brain area relating to emotions, as had previously been thought, the frontal lobes of the brain are also highly relevant. In particular, he discovered that distressed emotion is related to elevated neural activity in the right prefrontal cortex. The neo-cortex is the most recent part of the human brain in our evolutionary history, and the assumption has been that the prefrontal lobe (the area directly behind your forehead) is involved in purely ‘executive functions’, such as problem solving, planning, philosophising, making sense of your experience, etc.
In the early 1980’s, Davidson’s research revealed that the distinction between the emotional limbic system (entailing brain structures such as the thalamus, the hypothalamus, the hippocampus, the amygdala) and the frontal lobes of the cortex was less solid that what was previously believed. His studies showed that when people are in an emotionally distressed state, there is a great deal of neural activity going on in their right prefrontal cortex. This is a characteristic brain signature of people who are depressed. Conversely, when people display a positive mood, or more generally, are typically happy people, their brain’s show a dominance in the left prefrontal cortex. As people move from being depressed to a state of more positive emotionality, their brains show the shift from right prefrontal cortex dominance to left prefrontal dominance. As this is a stable finding in neuroscience, aided by imaging technologies such as fMRSs, it has challenged the notion that distressed emotion is purely a function of the limbic system alone. And more broadly, it has even challenged the very notion of the limbic system as being a separate functional collection of structures within the brain. The current findings suggest that the limbic system (if it is a notion to be retained in neuroscience at all) needs to extend to include the prefrontal lobes. Overall, the evidence points to the brain functioning in a unified manner. Yes, there are obviously separate functional modules within the brain (such as the amygdala, the prefrontal lobes, the nucleus accumbens, the anterior cingulate cortex, etc), but these units obviously function in a coordinated and highly interrelated manner, in much the same way as the various muscles of your legs, back and torso need to work together to allow you to run.
The other important aspect of Davidson’s work is the notion of there being a set of emotional styles, the dimensions of which we all differ on. Further, his research reveals that these emotional styles are related to specific patterns of brain functioning, both in terms of the actions of particular brain modules, and also in terms of patterns of interactions between these modules. Again, these specific patterns are identifiable on fMRI scans which highlight areas of oxygen use in the brain that is associated with heightened activity. The implication of his approach is that we actually have more choice in these emotional styles than previously believed. We are able to move where we are on each of the following dimensions, and also alter the brain functioning (and even structures) which underlie these styles.
You can test your where you are located on the following dimensions by doing a simple questionnaire on the following website:- https://www.facebook.com/investigatinghealthyminds?sk=app_320433878002397
The six emotional styles are:-
- the Resilience dimension
- the Outlook dimension
- the Social Intuition dimension
- the Self Awareness dimension
- the Sensitivity to Context dimension
- the Attention dimension.
Of relevance to chronic pain sufferers in relation to the TMS model are the Outlook, Resilience, and Self Awareness dimensions. In discussing these, suggestions will be made as how to create brain changes which are likely to support a movement away from chronic pain.
The Outlook dimension:
This dimension refers to the level of positive or negative mood which characterises individuals, and is highly related to levels of optimism. Some people always see the silver lining in the cloud, whereas others only see the darkness of the cloud. People are rarely entirely positive/optimistic or negative/pessimistic. Rather, we all lay somewhere along the continuum. Different situations are likely to bring out different tendencies within us along this continuum, however we all have a typical characteristic style along this dimension.
Most people have an ability to experience positive emotions, even those people who are depressed- their moment of joy may be barely noticeable, however, due to its short duration. What characterizes the Outlook dimension is not the ability to feel happy or sad in any one moment, but the ability to maintain a positive mood over time. This is what we tend to differ on- how well we can keep the positive feeling alive. The Outlook dimension reflects how thoroughly, and for how long you are able to sustain positive emotions after something good happens in your life, or as a result of thinking positive thoughts.
People on the Positive end of the Outlook dimension are able to maintain an ‘up’ mood over longer periods of time, and typically do this via a range of psychological strategies. These strategies may be natural or inherent to the person, perhaps as a result of their genetic predisposition or early life experiences and lessons learnt from family. Or people are able to deliberately engineer these strategies by cultivating practices such as:- selective attention (choosing to not look at the negative aspects of life or situations); denial and repression (either deliberately or unconsciously ‘keeping a lid’ on negativity, not allowing it much air-time in one’s awareness); exercising the relevant brain areas (the prefrontal cortex) by delaying gratification, planning for future rewards, and using distraction from immediate gratification; doing ‘well-being therapy’ exercises, such as:- each day writing down your positive characteristics three times; expressing gratitude to others; and complimenting others.
People who are not inherently Positive (or have had any inherent positivity knocked out of them by bad life experiences) are often engaging in an active process of trying to suppress their negativity and cultivate their positivity. This is an understandable preferred option in that it can make the emotional load lighter, and life more rewarding. They may spontaneously use the type of strategies detailed above, or their own variations; or have learnt through books and therapy to engage in these types of positive activities. We live in a culture (especially in countries like Australia and America) which advocates positivity and optimism as the preferred option, and provides many ongoing psychological cues as to its desirability and how to attain or maintain positivity.
As with all the emotional styles, there is a brain basis to the Outlook dimension. When both non-depressed and depressed people are shown pictures of happy situations (eg. puppies playing) in MRI studies, the brain areas relevant to the ‘reward circuit’ (prefrontal cortex and the ventral striatum- in particular the Nucleus Accumbens, or NAcc) show a great increase in activity. The ventral striatum is located below the cortical surface in the middle of the brain and becomes active in anticipation of rewards or pleasure. The NAcc is a cluster of neurons within the ventral striatum. It sits at the head of the Anterior Cingulate Cortex (Acc), and is critical in regards to motivation, and to generating a sense of reward. It is also loaded with neurons which release or receive dopamine (a brain chemical relevant to positive emotions, motivation and desire), as well as endorphines (the body’s own endogenous opiates, associated with pleasure). The NAcc is important in teaching the rest of the brain how to evaluate and react to the outside world.
What differentiates depressed from the non-depressed people is not the ability to feel pleasure, but the ability to maintain pleasure over time. In depressed people, the pleasure that has been generated from a positive situation is seen to last only minutes, whereas in non-depressed people the pleasure can last an entire day. The reason is that the NAcc is on the receiving end of nerve messages from the prefrontal cortex, which is able to send instructions to intensify and maintain happy feelings. The prefrontal cortex in Positive Outlook people is able to will their NAcc to feel rewarded, with persistent messages of ‘Keep it up! No flagging! Don’t give up yet!’ In depressed people (those who are at the Negative end of the Outlook dimension), the amount of ‘keep it up!’ messages from their prefrontal cortex declines after only minutes, resulting in less activation of their reward circuit (NAcc). Either the messages are not being sent by their prefrontal cortex, or are being diluted in transit to the NAcc. The greater the amount of neural activity in the NAcc, sustained by signals from the prefrontal cortex, the more at the Positive end of the Outlook dimension people are. Conversely, the less neural activity in the NAcc, and the less neural traffic between this and the prefrontal cortex, the more at the Negative end people are on the Outlook dimension.
As detailed in The Hidden Psychology of Pain, this is relevant for chronic pain sufferers as long term research published last year by Baliki and colleagues at Northwestern University reveals that it is the exact same neural activity (the Positive Outlook pathway) which is seen with chronic pain. When people undergo an injury, only a portion of them will advance from the associated acute pain to chronic pain. The amount of activation of these brain areas, and the associated neural traffic between them was found to exist in 85% of people whose pain advanced to become chronic. The strength of this relationship is beyond chance. Having high levels of brain activity between the prefrontal cortex and the NAcc is therefore related to both chronic pain and to the maintenance of positive emotionality.
Where it is not spontaneous and inherent to a person’s character, positive emotionality (as an enduring trait as opposed to a momentary experience), is a somewhat cultivated tendency. People tend to use a lot of the psychological strategies presented above in order to engineer and maintain positive mood. Part of this engineering of positivity involves the suppression of negative thoughts, emotions, or the ignoring of negative aspects of experience. While this is highly adaptive from a mood perspective, it can come at a cost in regards to susceptibility to chronic pain.
The TMS model suggests that people experience chronic pain as a result of an unconscious need to keep negative thoughts, feelings, memories and their associations at an unconscious level. In susceptible people, there is a tendency towards the cultivation of emotional resilience (coping), and an intolerance of negativity. Repression and suppression of negativity are essential tools in this personality profile; and these tools are also necessary to the ability to maintain positive mood. Viewing Baliki’s findings in light of what Davidson’s research tells us about emotional style reveals a neurological basis to the TMS model.
The diagram on p.108 of The Hidden Psychology of Pain, shows a see-saw effect between chronic physical pain and emotional pain. This appears to be supported by cutting edge neuroscience. We tend to either suffer from emotional pain, or from chronic physical pain. The more that the level of physical pain increases for the TMS sufferer, the more their underlying emotional pain tends to decrease to an unconscious level. For the emotional pain sufferer, the more conscious they are of their emotional pain, the more their physical pain tends to diminish. Of course, as with a real see-saw, people can (and usually are) anywhere between these two extreme ends- most people will be somewhere on the see-saw other than the full extent of either option. Those who give in to their distress may feel overwhelmed with emotional problems, but they tend not to suffer from as much chronic pain as do people who attempt to remain positive. Distressed feelings tend to make their impact felt either directly as debilitating emotions, or indirectly as the avoidant strategy which is chronic pain.
Is the suggestion here that we should be deliberately cultivating negativity in order to lessen the risk of chronic pain? No. The suggestion is that we would be well served by consciously acknowledging the negative aspects of our reality (not generating them), rather than attempting to force a cultivated positivity. Activities which deliberately cultivate positivity, such as writing down your positive traits, regularly expressing gratitude and complimenting others, are likely to improve your mood via strengthening the neural connections between your pre-frontal cortex and NAcc. And these neural changes are also more likely to make you vulnerable to chronic pain (as seen in the TMS-emotional pain see-saw diagram). Rather than leaping into defense mechanisms as default positions, we are able to explore the negative aspects of our experience further. Creating space for the negative raises certain constructive possibilities. We may be able to address unsatisfactory relationships; we may be able to confront our fears and anxieties; we may be able to look at and heal trauma from our past; we may be able to work out how to manage bad situations; we may be able to seek and gain emotional support in facing our challenges. All of these actions are the opposite to suppressing emotional distress, and relying on defense mechanisms such as denial to help us avoid having to do the needed psychological work. The very act of acknowledging the negative can be healing in itself, even if we choose to do nothing about them. Canadian mind/body health physician Gabor Maté suggests that this focus on the negative is powerful, and the many clients who I have seen recover from pain when they overcome their denial would support this contention. The very act of allowing the negative, of no longer attempting to force positivity in the face of bad circumstances or a traumatic past, is likely to create the brain changes which Baliki and colleagues have demonstrated are related to a decreased risk of chronic pain.
Davidson’s research also supports the notion that we are able to change the functioning and even the structure of our brains through both experiences and even our thoughts. This notion is referred to as neuroplasticity, and such brain changes have been seen to result from experience in a matter of only days. The goal of decreasing your degree of Positive Outlook only makes sense in relation to Baliki’s research, showing that too much neural activity in and between the prefrontal cortex and the NAcc is associated with chronic pain. As such, you may like to try and decrease this brain activity in order that you move more into a neurological pattern which is associated with less chronic pain, ie. less neural activity within and between the prefrontal cortex and the NAcc.
What is being suggested here is not a deliberate engineering of negativity, but the removal of a deliberate engineering of positivity. Feeling spontaneously or naturally positive or happy is of itself not a problem in regards to chronic pain. The trap is in the deliberate cultivation of positivity, in so far as this entails a denial or suppression of the negative. Such a cultivation of positivity is more likely to result in ‘happy-ism’, rather than genuine happiness. While the latter refers to an emotional experience which we all move in and out of, the former refers to a deliberately engineered facsimile of happiness- it is this (which is maintained through an act of will via the prefrontal cortex commands to the NAcc) which makes people vulnerable to chronic pain.
Davidson suggests that if you are too Pollyannish, being unrealistically positive, one strategy to decrease the activity of your prefrontal cortex and NAcc is to envision potential negative outcomes. If you are considering leaving your job for another, spend time thinking about what could go wrong with such a move. If you are wanting to dial down your Positive Outlook, Davidson suggests placing around your home and workplace reminders of threats to your well-being. Images of natural disasters, or news stories about environmental threats or economic dangers could achieve this end. Writing angst-filled poetry could also help with this, as will listening to misery-inducing music, or exposing yourself to ‘down’ books or movies. Keep in mind that you will need to be balanced in this. There is no suggestion that becoming depressive will help your chronic pain (in fact, it will probably make the pain worse). However, putting less energy into cultivating positivity could shift the balance in the chronic pain see-saw as described above.
The most important suggestion here is to allow and create space for negativity. We live in a culture in which negativity is an anathema- almost a modern heresy. If you are having a hard time in your relationship or at work, acknowledge this reality. If you were traumatised through abuse as a child, recognise this reality. Allowing space for negativity is usually a first and necessary step in dealing with it in an adaptive manner. It can lead on to social support (if you choose to share it with others); it can lead on to problem solving so as to address the negative situation; and it can lead on to you choosing to address your trauma via adequate psychotherapy.
After a few weeks of refraining from engineering positivity, reflect on what changes you have noticed in your Outlook style. You might like to re-do the Emotional Style questionnaire to gauge any changes. If you have noticed shifts, then these changes are likely to be neurologically supporting a movement away from chronic pain.
The Resilience dimension:
This is the degree to which you are able to shrug off bad experiences, and like the other dimensions, exists on a continuum. At the low resilience end of the continuum is the Slow to Recover pole, while Fast to Recover is at the high end of the Resilience dimension. People at the low end tend to find it difficult to ‘get over’ an argument with their spouse in the morning, allowing it to ruin their entire day. They may find themselves fuming for hours if the roads were congested and slow on their way to work. It may be very difficult for them to recover from the loss of a loved one, spending months or years feeling debilitated and despairing. The ability to recover from small setbacks, such as traffic jams, is predictive of the ability to recover from larger setbacks, such as with grief. People at the Fast to Recover pole will not enjoy any of these experiences either, but find that they are more able to regain their emotional equilibrium much quicker. High resilience is related to greater left prefrontal cortex activity in the brain (can be as much as 30 times more activation in Fast to Recover people compared to Slow to Recover people), while low resilience is related to greater right prefrontal cortex activity.
The other brain module of importance in Resilience is the amygdala, a limbic system structure which is highly involved with distressed emotions, especially fear and anxiety. (As with all brain modules, apart from the pineal gland, there are in fact two amygdala, one in each hemisphere of the brain). Like all brain areas, the relationship between the prefrontal cortex and the amygdala is extremely important to our experience. It appears that the left prefrontal cortex is able to inhibit the amygdala, and thereby allow resilient people to recover from adversity much quicker than less resilient people. MRI studies have revealed that the more connections (in the form of neuronal axons) between brain cells in the left prefrontal cortex and the amygdala there are, the more emotionally resilient people are. Conversely, the less neural connections there are between these two brain areas, the less resilient people are. The fewer connections means there are fewer signals travelling from the left prefrontal cortex to the amygdala. Activity in the left prefrontal cortex shortens the period of amygdala activation, which allows us to recover quickly from upsetting experiences.
Like the Positive pole of the Outlook dimension, the highly related Resilience dimension has important implications for chronic pain sufferers. As with positivity, the extent to which resilience occurs naturally, or has to be engineered is relevant to the TMS model. Bouncing back from adversity is highly desirable, but if people do this in a forced manner, attempting to cultivate positive emotionality as part of their recovery, it may just feed in to a tendency to deny the negative. This reminds me of the knight in Monty Python’s Holy Grail, who insisted that each loss of limb was no more than ‘a mere flesh wound’- a great example of resilience, and denial. As detailed in The Hidden Psychology of Pain, after a period of physical and emotional trauma, I managed to bounce back from the car accident which nearly killed me as an 18 year old. I remain grateful that I did find this resilience, but it came at a cost to me- nearly twenty years of chronic groin pain. In hindsight, it may have been possible for me to find a balance between the pits of despair which I experienced in the six months after my accident, and the sensational recovery curve which I then experienced. I suspect that my chronic pain was related to a suppression of emotional trauma. Once I was in my recovery curve, I certainly cultivated resilience and positivity- and I was in chronic pain for the next 18 years.
If you decide that being highly resilient is part of your psychological profile which could be adding to chronic pain, you might like to consider reducing it- not by fostering a lack of resilience, but by refraining from engineering extreme resilience (ie. choosing to not be like Monty Python’s knight). Again, simply being realistic about the setback is an important step. Creating room for and acknowledging it is the opposite to denial and repression. It would perhaps have been better for the mentioned knight to acknowledge the negative reality of having lost an arm, before he proceeded to lose all other limbs as well because of his denial.
Davidson recommends the following strategies if you decide that you would like to reduce your set point on the Resilience dimension by quietening the activity of your prefrontal cortex and weakening it’s signals to your amygdala. You may achieve this by intently focusing on the negative emotional pain which you are feeling as a result of the setback. Instead of keeping away from a negative situation, such as a going for a walk rather than remaining in an argument with your spouse (an act of denial), choose to remain in the situation. Allow reminders of a negative situation to remain around you. Look at how differently cultures which are not crippled by psychophysiological pain disorders typically handle death and grief- they indulge in it, spending days/weeks/months wailing and engaging in elaborate grief rituals with plenty of reminders of the deceased person. We, in the Anglo world, on the other hand try to minimize the grief as well as any reminders (and we tend to suffer from TMS). Non-Anglo cultures engage in the opposite to denial and repression; we cultivate a forced positivity and happy-ism, and it is we who are more likely to suffer from chronic pain.
This dimension relates to the ability for introspection, and is relevant to both an awareness of feelings and physical sensations which give rise to our emotions. Some people are extremely unaware of their own sensations and feelings, while other people are painfully over-aware.
One of the characteristics of people suffering from chronic pain is a heightened level of sensitivity to pain and discomfort. The Pain Vigilance and Awareness Questionnaire (Appendix 1 in The Hidden Psychology of Pain) assesses people’s level of ‘hypervigilance’ in regards to their pain—how focused you are on every aspect and variation in it. High scores on this scale have been linked in research to pain intensity, psychological distress from the pain, as well as high levels of psycho-social disability from the pain. People who score high on this scale would also score high on the Self-awareness dimension, as it is assessing the same characteristic.
The brain area highly related to self-awareness is the insula, which is located between the temporal lobe and the frontal lobes. The insula, especially the insula in the right hemisphere, is also highly involved in the experience of emotional as well as physical pain. It contains a ‘viscerotpic’ map, which registers what is happening with each of the internal organs- the heart, liver, colon, sexual organs, lungs, stomach, and kidneys. The insula also sends messages to these organs, instructing, eg. the lungs to breath quicker or the heart to pump faster. Higher insula activation is associated with greater awareness of both physical sensations and emotions. This is fine, and usually viewed as desirable, however it can spill over into hypochondria and panic attacks when excessive. And it also poses a problem when you are in chronic pain, as it is associated with a hyperawareness of every little change in bodily sensations- part of the chronic pain profile.
The insula, along with the orbital frontal cortex and the amygdala, form a circuit which gives an emotional value to thoughts and sensations. The right frontal insula is where conscious physical sensation and conscious emotional awareness co-emerge. It is active when you experience either physical or emotional pain. You detect both the state of your body and the state of your mind via your right frontal insula, and as such, it is where your mind and body unite. This happens as a result of the strong connections between the insula and i) the amygdala (linking strong emotions to experiences, people and things) ii) the orbitofrontal cortex (critical for self discipline, planning and priorities vis-a-vis rewards and punishments, and iii) the Acc (allowing you to monitor your behaviour for mistakes, correct and avoid errors, evaluate context, plan and carry out actions that have emotional and motivational significance). The Acc is also highly involved in the experience of pain, and appears to be the brain module which teaches the rest of the brain to ‘do’ chronic pain.
If you recognise that you have a too high level of Self-Awareness, you may choose the following approaches which are designed to settle down your insula. Cognitive-behaviour therapy can be useful in helping you to reappraise the significance of internal bodily cues. Messages from The Back Book are an excellent example of this cognitive strategy (see p.158 of The Hidden Psychology of Pain). In particular, the message that ‘pain does not mean damage’ is a prime example. You have a choice to interpret a sensation in your back as a danger signal, foretelling doom for your spine; or view it as yet another innocuous sensation which is related to a painful but essentially harmless condition, TMS. In fact, all of Sarno’s books, as well as my book, are examples of cognitive change strategies in relation to chronic pain. Read them. Absorb the messages, and be confident that in doing so you are actually creating some of the neurological changes necessary for settling down your insula which is necessary for pain reduction.
An additional strategy for decreasing your level of Self-Awareness is to decrease the rest of the brain’s reactivity to the messages which come from the insula- in particular, the goal is to reduce the activation of the amygdala and the orbitofrontal cortex in response to the insula. By reducing the level of activity in this circuit, your brain can start to perceive bodily sensations in a less alarmed manner, beginning to see the reality that ‘hurt does not mean harm.’ Self-Awareness will still be present, but you won’t be hijacked by it with increasing emotional and physical pain. Meditation and mindfulness awareness of the present moment (see Chapter 17 of The Hidden Psychology of Pain) are effective means of reducing the activity of your amygdala and orbital frontal cortex. The goal is to quieten your mind to the extent that you can simply observe various thoughts or physical sensations as they rise and fall without attaching a great deal of importance to them. This non-judgemental perceiving can result in breaking the chain of associations which have developed around, eg. back pain and the notion of serious damage. Rather than responding to a flare-up with, ‘Oh no! This means that my spine is getting even worse’, with the aid of meditation and mindfulness, you can develop the ability to respond with, ‘Oh. A signal from my back has reached my brain’.
One of the keys to success with meditation and mindfulness is perseverance. Benefits often accrue quickly, and the longer you persevere, the more the benefits accrue.
As with creating change in the other emotional dimensions, you can also have an impact on over Self-Awareness with changes in your environment, as our brains are highly reactive to our surroundings. Make changes so that you have more external stimuli to focus on, such as leaving a radio or TV on. Be willing to multitask so that you have less neurological resources available for focusing on inner sensations. Avoid sitting around doing nothing. Be active and ensure that your attention is captured by what you are doing.
In summary, cutting-edge findings in neuroscience are able to add pieces to the jigsaw puzzle of chronic pain. Having an awareness of some of the brain activity which is relevant to chronic pain can inform us what to do about it. We can deliberately aim for brain changes which support a movement away from chronic pain, via mental, behavioural and environmental changes as detailed here.