Emotions and emotional approach and avoidance strategies in fibromyalgia

Abstract

Objective

Disturbances in emotional functioning may contribute to psychological and physical symptoms in patients with fibromyalgia. This study examined emotions and emotion-regulation strategies in women with fibromyalgia and in controls, and how these variables relate to symptoms of fibromyalgia.

Methods

We compared 403 women with fibromyalgia to 196 control women using self-report questionnaires.

Results

Negative emotions and the use of emotional-avoidance strategies were elevated, and positive emotions were reduced, in fibromyalgia patients; the alexithymia scale “difficulty identifying feelings” showed a large deviation from normal. Emotional-approach measures were not deviant. In the fibromyalgia sample, emotional-avoidance strategies were highly correlated with more mental distress and were modestly correlated with more pain and fatigue, while emotional-approach strategies were only minimally related to better functioning. We tested two interaction models. The intense experiencing of emotions was related to more pain only in patients who lack the ability to process or describe emotions. Although fibromyalgia patients showed deficits in the experiencing of positive affect, positive affect did not buffer the association between pain and negative affect.

Conclusion

This study demonstrates increased negative emotions and decreased positive emotions, as well as increased emotional-avoidance strategies, in women with fibromyalgia. Research should test whether interventions that reduce emotional avoidance lead to health improvements in women with fibromyalgia.

Introduction

Fibromyalgia is characterized by widespread musculoskeletal pain, tender points, and complaints of fatigue, sleeping problems, and disturbed mood [1]. Emotions such as sadness and anger, as well as strategies to regulate those emotions either by approaching (e.g., emotional processing and expression) or by avoiding (e.g., alexithymia and suppression) them, may play a role in the maintenance or exacerbation of fibromyalgia symptoms. The disabling consequences of fibromyalgia and the lack of a clear etiology and pathophysiology may also impact emotions and the use of emotion-regulation strategy. Compared with controls, people with fibromyalgia or related syndromes report increased negative emotional disturbances, including depression and anxiety [2], [3], and increased use of emotional-avoidance strategies [4], [5], [6]. Furthermore, these emotional characteristics have been associated with higher symptom levels [5], [7], [8], whereas fewer symptoms occur in patients with more positive affect [9] and who engage in an emotional-approach strategy of expressing their emotions in a writing intervention [10].

In addition to general relationships between emotional factors and symptoms, it is likely that relationships are limited to some subsets of patients. For example, according to the dynamic model of affect, negative emotions will be related to pain (and perhaps fatigue) only among patients who experience low levels of positive affect [9], [11]. Among patients with fibromyalgia, a deficit in positive affect regulation, which may account for the high co-occurrence of pain and negative affect in this population, has been demonstrated [12].

A second model that specifies for whom certain emotional factors are important suggests that emotional-approach and emotional-avoidance strategies may interact with the intensity of emotional experiencing in predicting symptoms [13], [14]. Intensely experienced emotions that are avoided and not expressed can lead to physiological hyperreactivity and physical symptoms [15], [16], whereas strongly experienced emotions that are approached and processed may not be problematic.

The few available studies of emotional functioning in fibromyalgia have various limitations, including small samples, heterogeneous samples that include other medically unexplained or chronic pain conditions, and the use of only a limited set of emotion-related measures. This study sought to advance extant knowledge regarding emotional functioning and symptoms in fibromyalgia by redressing these limitations and by explicitly testing hypotheses regarding the interactive effects of emotion measures on symptoms.

The first aim of this study was to examine differences between large samples of women with fibromyalgia and control women in a broad array of emotions and emotion-regulation strategies that differ in valence, intentionality, and degree of awareness. A second aim was to examine how these emotion measures, separately and in interaction, relate to symptoms of fibromyalgia. We hypothesized that women with fibromyalgia would show higher levels of negative affect and lower levels of positive affect, and would make more use of emotional-avoidance strategies and less use of emotional-approach strategies. We hypothesized that negative emotions and emotional-avoidance strategies would be related to higher mental distress, pain, and fatigue among women with fibromyalgia, whereas positive emotions and emotional-approach strategies would be related to lower symptoms. The association of negative emotions with pain was expected to be mitigated by the level of positive emotions experienced. Affect intensity was expected to be related to higher symptom levels in individuals who are high on emotional avoidance and low on emotional processing.