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. Author manuscript; available in PMC: 2021 Mar 2.
Published in final edited form as: Eur J Pain. 2020 Jul 20;24(9):1775–1784. doi: 10.1002/ejp.1625

Emotions matter: The role of emotional approach coping in chronic pain

Maisa S Ziadni 1, Dokyoung S You 1, Lucia Johnson 1, Mark A Lumley 2, Beth D Darnall 1
PMCID: PMC7923247  NIHMSID: NIHMS1675341  PMID: 32603553

Abstract

Background:

Emotional approach coping (EAC) is a potentially adaptive emotion-focused coping style that involves understanding or processing one’s emotions and expressing them appropriately. Although EAC has been studied in various populations, little is known about this construct among people with chronic pain, including potential mediators such as negative affect, which might link EAC to pain-related variables, and moderators of these relationships.

Methods:

Participants (N = 670; 76% women; 30% older adults—age 60 or over) with chronic pain completed online the Emotional Approach Coping Scale and measures of pain severity, pain interference and negative affect. Analyses correlated EAC to pain severity and interference and tested whether gender and age group (older adults versus young/middle-age adults) moderated the mediated relationships of EAC with pain-related variables through negative affect.

Results:

Findings reveal that higher EAC was associated with lower pain intensity through lower negative affect in the young/middle-age portion of the sample, but not older adults. Also, higher EAC was associated with lower pain interference through lower negative affect among women in the sample, but not men. The associations of EAC to pain intensity and interference are small in magnitude, however, and should be considered preliminary.

Conclusion:

EAC is associated with lower pain intensity in young/middle-age adults and lower pain interference in women, and lower negative affect mediates these relationships. These results suggest the potential value of assessing and bolstering emotional approach coping processes in some people with chronic pain.

1 |. INTRODUCTION

The role of emotional processes in chronic pain is increasingly recognized (Lumley et al., 2011). Negative emotions and stress are linked to increased pain and disability (Caes, Orchard, & Christie, 2017; Edwards, Dworkin, Sullivan, Turk, & Wasan, 2016; Vachon-Presseau et al., 2016). Emotional stressors precipitate, exacerbate or prolong pain conditions (Clauw & Chrousos, 1997), and theory suggests that cognitive-emotional processes mediate the effects of stressful experiences on pain (Borkovec, Roemer, & Kinyon, 1995). Because emotional avoidance is generally maladaptive (Lind, Delmar, & Nielsen, 2014; Lumley et al., 2011), emotional experiencing, expression and processing may reduce stress and somatic symptoms, including pain (Finan, Zautra, & Davis, 2009; Frattaroli, 2006; Hsu et al., 2010; Slavin-Spenny, Lumley, Thakur, Nevedal, & Hijazi, 2013).

Stanton, Danoff-Burg, Cameron, and Ellis (1994) developed the construct and a measure of emotional approach coping (EAC), which refers to emotional processing/understanding and emotional expression. Research shows that EAC predicts better health and adjustment (Batenburg & Das, 2014; Ghetti, 2011; Hassija, Luterek, Naragon-Gainey, Moore, & Simpson, 2012; Hoyt et al., 2013; Stanton, Danoff-Burg, et al., 2000) across various patient and non-patient populations (Batenburg & Das, 2014; Cho, Park, & Blank, 2013; Hoyt et al., 2013). Yet EAC has been rarely studied in pain populations. In patients with myofascial pain, greater EAC was associated with less depression and pain severity (Smith, Lumley, & Longo, 2002), and in women with fibromyalgia, greater EAC emotional expression was associated with less fibromyalgia impact (Geenen, van Ooijen-van der Linden, Lumley, Bijlsma, & van Middendorp, 2012). More research on EAC is needed among patients with chronic pain.

Importantly, the mechanism by which EAC may confer benefits such as reduced pain severity and interference remains unknown. In theory, the capacity to understand, process and express one’s emotions results in adaptive emotion regulation and reduces negative emotional states such as anxiety and depression. There is some evidence that EAC predicts lower negative affect (Stanton, Danoff-Burg, et al., 2000; Stanton et al., 1994), but negative affect has not been tested as a mediator linking EAC to pain outcomes. Additionally, there has been growing interest in the role that gender plays in influencing relationships between coping, pain and treatment responses, albeit with some inconsistent findings (Fillingim & Gear, 2004; Sharifzadeh et al., 2017; Ziadni, Carty, et al., 2018). Similarly, age differences in both emotional processes and pain-related measures have been identified in lifespan developmental research and several theories of aging and emotion, including Socioemotional Selectivity and Affect Regulation theories, which suggest that different strategies or goals are salient in different age groups.

We sought to determine the associations between EAC and pain-related outcomes, whether these associations are mediated by negative affect, and whether age and gender moderate the mediated associations. We hypothesized that EAC would be inversely related to negative affect as well as pain intensity and interference, and that negative affect would mediate the association between EAC and these pain outcomes. Given the possibility of gender and age differences in how emotional processes are related to pain, we explored whether the benefits of EAC occur in both women and men and apply across the age spectrum—especially to older adults (age 60+)—given the unique emotion regulation strategies identified in this population.

2 |. METHODS

2.1 |. Participants and procedures

Participants (N = 670; 76% women; 30% older adults—age 60 or over) were treatment-seeking patients at the Stanford Pain Management Center, a large tertiary care pain clinic, who agreed to be contacted for research purposes by the Stanford Neuroscience and Pain Laboratory. Potentially interested respondents were asked to complete a set of questionnaires, which were administered using the REDCap online survey system (Harris et al., 2009). All responses were anonymous, and the study was approved by the Stanford University Institutional Review Board. Participant consent was obtained electronically after being provided a study information sheet.

2.2 |. Measures

2.2.1 |. Demographic information

Patient demographics and pain characteristics included age, sex, marital status, education level, disability status, employment status, annual income, race/ethnicity, ongoing litigation related to pain condition, pain duration and pain diagnoses.

2.2.2 |. Emotional approach coping

The 8-item Emotional Approach Coping Scale (EAC) (Stanton, Kirk, Cameron, & Danoff-Burg, 2000) assesses both emotional processing and emotional expression (Stanton et al., 1994). The emotional processing subscale assesses peoples’ attempts to understand, explore and acknowledge their emotions, such as “I take time to figure out what I’m really feeling,” and “I acknowledge my emotions.” The emotional expression subscale assesses the volitional expression of one’s emotions, such as “I take time to express my emotions,” and “I feel free to express my emotions.” Patients rated items on a 4-point scale from 1 (I don’t do this at all) to 4 (I do this a lot), and ratings were summed to yield a total EAC score (ranging from 8 to 32) as well as the two subscale scores (ranging from 4 to 16). Higher scores indicate greater levels of EAC. In our sample, we found high internal consistency for the total scale (α = 0.89), as well as for the emotional processing (α = 0.88) and emotional expression (α = 0.89) subscales.

2.2.3 |. Negative affect: Anxiety and depression

These constructs were assessed with the Patient-Reported Outcomes Measurement Information System (PROMIS) (Hung et al., 2014; Lai et al., 2011; Revicki et al., 2009; Revicki et al., 2014). PROMIS Depression and Anxiety scales were administered using 4-item short forms and referred participants to the last 7 days (Cella et al., 2010). Cronbach’s alphas for the PROMIS measures in this sample were very good (0.91 and 0.90 for Depression and Anxiety scales, respectively). As expected, the two measures correlated highly with each other (r = 0.71), so to create a single measure of negative affect, depression and anxiety T scores were combined and averaged for each individual (Hays, Spritzer, Schalet, & Cella, 2018). PROMIS measures use T scores, which have a M = 50 and SD = 10.

2.2.4 |. Pain intensity

Average pain intensity over the previous 7 days was rated on an 11-point numerical rating scale (NRS), from 0 (no pain) to 10 (the worst pain imaginable). The NRS has been identified as a suitable assessment of pain intensity in acute and chronic pain populations in previous studies (Cook et al., 2013).

2.2.5 |. Pain interference

The interference subscale from the Brief Pain Inventory-Short-Form (BPI) (Keller et al., 2004) assessed pain interference during the past 7 days in seven domains: mood, general activity, normal work (inside and outside the home), enjoyment of life, relations with other people, walking ability and sleep, on an 11-point scale (0 = does not interfere, 10 = completely interferes). Item ratings were summed to yield a total score. Cronbach’s alpha for this subscale in this sample was excellent (α = 0.91).

2.3 |. Statistical analyses

SPSS version 24 was used to conduct initial analyses, which consisted of descriptive statistics, bivariate correlations and multiple regressions. First, independent t tests were conducted to examine gender and age group differences on EAC scores and study variables. Degrees of freedom were adjusted when Levene’s test indicated unequal variances. Second, bivariate Pearson correlations were computed to examine the relationships between EAC scores, negative affect and pain-related variables (pain intensity and interference). Next, the PROCESS macro (version 3.1) for SPSS statistical software was used to examine whether negative affect mediated the relationship between EAC and pain measures and whether gender (men or women) and age (young/middle-age adults = less than or equal to 59 years; older adults = 60 or older; Uchmanowicz, Jankowska, Uchmanowicz, & Morisky, 2019; Evenson, Buchner, & Morland, 2012) would moderate the mediated relationships (Hayes, 2018). For moderated mediation analyses, EAC, negative affect, pain intensity and pain interference scores were transformed to z-scores. Age (0 = young/middle-age adults, 1 = older adults) and gender (0 = women, 1 = men) were binary coded. Standardized regression coefficients (βs) were considered significant at p values of <.05 when F statistics of corresponding full models were also significant at p values of <.05. There were no missing values, and examination of distributions identified no outliers.

3 |. RESULTS

3.1 |. Sample characteristics

As detailed in Table 1, the sample was 76% women and predominantly Caucasian (82.7% of the overall sample). To enhance anonymity, age was reported by participants in specific decades rather than exact years, and the median age of the sample was in the 50–59 decade. More than half the sample reported being married (53.9%) at the time of data collection. Median education level was a completed bachelor’s degree, and the median household income level was $65,000-$84,999 USD annually. Around a quarter of the sample reported being on disability (n = 163, 24.3%), and a small number reported ongoing litigation (n = 38, 5.7%) related to their pain condition. A third of the sample reported full-time employment (32.7%), and a fifth reported being retired (20.4%). Regarding psychological health, 37.5% of the sample reported a previous mental health diagnosis, 57% reported no prior mental health diagnosis and 5.5% declined to answer. Pain diagnosis information, presented in Table 1, was obtained via self-report and was broadly categorized according to common causes of pain (e.g. nerve pain) or common pain diagnoses (e.g. fibromyalgia). The most commonly endorsed pain categories were chronic low back pain, fibromyalgia and headaches or migraines.

TABLE 1.

Demographics

Study variable N (% of sample)
Gender
  Men 161 (24.0)
  Women 509 (76.0)
Age
  18–29 50 (7.5)
  30–39 112 (16.7)
  40–49 115 (17.2)
  50–59 189 (28.2)
  60–69 139 (20.7)
  70–79 59 (8.8)
  80+ 6 (0.9)
Race/Ethnicity
  Caucasian/Non-Hispanic 554 (82.7)
  Asian 45 (6.7)
  Hispanic 12 (1.8)
  African American 11 (1.6)
  Other, including bi- and multi-racial 48 (7.2)
Marital status
  Married 361 (53.9)
  Never married 101 (15.1)
  Divorced 98 (14.6)
  Partnered 53 (7.9)
  Widowed 12 (1.8)
  Other 45 (6.7)
Educations
  Less than high school 7 (1.0)
  High school diploma/GED 169 (25.2)
  Associate’s degree 102 (15.2)
  Bachelor’s degree 189 (28.2)
  Master’s, doctoral and professional school degrees 203 (30.3)
Employment
  Full-time 219 (32.7)
  Retired 137 (20.4)
  Part-time 81 (12.1)
  Homemaker 25 (3.7)
  Unemployed 47 (7.0)
  Temporarily laid off/medical leave 12 (1.8)
  Other 87 (13.0)
Annual income
  <$25,000 93 (13.9)
  $25,000–$64,999 172 (15.6)
  $65,000–$84,999 85 (12.7)
  $85,000–$104,999 88 (13.1)
  $105,000 + 232 (34.6)
Pain condition
  Chronic low back pain 417 (62.2)
  Fibromyalgia 181 (27.0)
  Headaches/migraine 136 (20.3)
  Post-surgical/surgical recovery 132 (19.7)
  Complex regional pain syndrome 116 (17.3)
  Gastrointestinal/irritable bowel syndrome 104 (15.5)
  Pelvic pain 72 (10.7)
  Temporomandibular disorder 42 (6.3)
  Other (including overlapping conditions) 259 (38.7)
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3.2 |. Descriptive statistics and preliminary analyses

Descriptive statistics of study variables can be found in Table 2. Independent t tests were conducted to examine gender and age-group differences on all variables listed in Table 2. There was a gender difference in EAC total, t(668) = 2.54, p = .011, and emotion expression subscale scores, t(668) = 3.55, p < .011, with women endorsing more use of emotion expression than men. In contrast, EAC total and the two subscale scores were nearly identical between the young/middle-age adult and older adult groups (ps > .94). Gender differences were also found in pain interference, t(668) = 2.05, p = .041, overall negative affect, t(668) = 1.99, p = .047 and anxiety, t(668) = 2.04, p = .042, with women endorsing these symptoms to a greater degree than men. Age differences were observed only in overall negative affect, t(668) = 3.12, p = .002, depression, t(668) = 2.96, p = .003 and anxiety, t(668) = 2.83, p = .005, with young/middle-age adults endorsing these symptoms at a greater degree than older adults.

TABLE 2.

Study variables by gender and age

Study variables Total sample (N = 670), M (SD) Gender
 Age
Women (n = 509), M (SD) Men (n = 161), M (SD) d Young/middle-age adults (n = 466), M (SD) Older adults (n = 204),
M (SD)		 d
EAC
Total score 19.8 (5.6) 20.1 (5.8) 18.8 (5.0) 0.24* 19.8 (5.8) 19.8 (5.2) 0.00
Emotion processing 10.3 (3.3) 10.4 (3.4) 10.1 (2.9) 0.09 10.3 (3.3) 10.3 (3.1) 0.00
Emotion expression   9.4 (3.1)   9.7 (3.2)   8.7 (2.7) 0.34***   9.5 (3.2)   9.4 (2.8) 0.03
Pain intensity   5.9 (1.8)   6.0 (1.7)   5.8 (1.9) 0.11   6.0 (1.8)   5.9 (1.7) 0.06
Pain interference 40.8 (15.6) 41.5 (14.8) 38.6 (17.8) 0.18* 41.3 (15.8) 39.7 (15.0) 0.10
Negative affect 58.8 (8.3) 59.2 (8.1) 57.7 (8.9) 0.18* 59.5 (8.4) 57.3 (7.9) 0.27**
Depression 57.8 (9.0) 58.2 (8.9) 56.8 (9.3) 0.15 58.5 (9.1) 56.3 (8.5) 0.25**
Anxiety 59.8 (8.9) 60.2 (8.7) 58.6 (9.5) 0.18* 60.5 (9.0) 58.4 (8.6) 0.24**
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Note: EAC: Emotion approach coping.

*

p < .05,

**

p < .1,

***

p < .001.

3.3 |. Zero-order correlations

Pearson correlations between EAC and pain-related variables are shown in Table 3. The two EAC subscales were moderately correlated with each other (r = 0.57, p < .001), so our primary analyses focused on the EAC total score. As hypothesized, higher EAC total scores were significantly related to lower pain intensity, pain interference and negative affect. These correlations, however, were small in magnitude (rs = −0.16 to −0.08).

TABLE 3.

Pearson correlations between study variables

Variable Pain intensity Pain interference Negative affect
Emotional approach coping −0.10* −0.09* −0.15***
Emotional processing (a) −0.10* −0.08* −0.10**
Emotional expression (b) −0.07 −0.09* −0.16***
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*

p < .05,

**

p < .01,

***

p < .001.

3.4 |. Primary analyses

3.4.1 |. Aim1: Investigate the relationship between EAC and pain intensity, with negative affect as a potential mediator and gender and age as potential moderators

The PROCESS Model 76 macro was used to examine whether the effect of EAC on pain intensity through negative affect would be moderated by age and gender. The overall model was significant, F (5, 664) = 6.90, p < .001. Figure 1 shows the model. In this dual moderated mediation model, higher EAC total was associated with lower negative affect (a: β = −0.20, SE = 0.05, t = 4.25, p < .0001) and lower pain intensity (c’: β = −0.10, SE = 0.05, t = 2.16, p = .031). Negative affect was positively associated with pain intensity (b: β = 0.26, SE = 0.05, t = 5.29, p < .0001). This model found significant interactions of age by negative affect (β = −0.20, SE = 0.09, t = 2.35, p = .019) and gender by negative affect (β = 0.20, SE = 0.08, t = 2.41, p = .016) in predicting pain intensity. The interactions of age by EAC and gender by EAC were not significant (ps > .09). Significant indirect effects of EAC on pain intensity through negative affect were observed in young/middle-age adult women (a × b effect = −0.05, boot SE = 0.02, 95% CI: −0.09 to −0.02) and young/middle-age adult men (a × b effect = −0.10, boot SE = 0.05, 95% CI: −0.20 to −0.02), but not in the older adult women or older adult men (95% CIs included zeros). The indirect effects were not significantly different between women and men in either the two age groups (95% CIs included zero). These results indicate the indirect effect of EAC on pain intensity was significant only for the young/middle-age adult groups of both genders. In sum, the effect of EAC on pain intensity is partially mediated by negative affect, and this partial mediation effect depends on age; more use of EAC is associated with less reported pain through less negative affect in the young/middle-age adult portion of the sample, but not in older adults.

FIGURE 1.

FIGURE 1

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The relationship between emotion approach coping and pain intensity, with negative affect as mediator and gender and age as moderators. Solid lines represent significant paths and dashed line represent non-significant paths

3.4.2 |. Aim 2: Investigate the relationship between EAC and pain interference, with negative affect as a potential mediator and gender and age as potential moderators

The PROCESS Model 76 macro was used to examine whether the effect of EAC on pain interference through negative affect would be moderated by age and gender. The overall model was significant, F (5, 664) = 6.90, p < .001. Figure 2 shows this model. In this dual moderated mediation model, higher EAC scores were not directly related to pain interference (c’: p > .05), but negative affect was positively associated with pain interference (b: β = 0.57, SE = 0.04, t = 13.63, p < .0001). This model found a significant interaction of gender by negative affect (β = 0.16, SE = 0.07, t = 2.28, p = .02) in predicting pain interference, but no significant age by negative affect interaction (p = .18). The interactions of age by EAC and gender by EAC were not significant (ps > .23) in predicting pain interference. Significant indirect effects of EAC on pain interference through negative affect were observed in young/middle-age adult women (a × b effect = −0.08, boot SE = 0.04, 95% CI: −0.16 to −0.01) and older adult women (a × b effect = −0.09, boot SE = 0.03, 95% CI: −0.16 to −0.03, but not in men of either age group (95% CIs included zeros). The indirect effects were not significantly different between the two age groups in either the women or men (95% CIs included zero). These results suggested that the indirect effect of EAC on pain interference was significant only for women regardless of age. In sum, the effect of EAC on pain interference is fully mediated by negative affect, and this full mediation effect depends on gender; more use of EAC is associated with less pain interference through less negative affect in women, but not in men.

FIGURE 2.

FIGURE 2

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The relationship between emotion approach coping and pain interference, with negative affect as mediator and gender and age as moderators. Solid lines represent significant paths and dashed line represent non-significant paths

4 |. DISCUSSION

Emotional approach coping, defined as coping processes that entail identifying one’s emotions and expressing them appropriately, is a potentially adaptive coping style that has been little studied in the pain literature. To our knowledge, this is one of only a handful of studies to report on the relation between EAC and pain-related variables among patients with chronic pain. In addition, this is the first study to examine the mediating role of negative affect, and the moderating role of age and gender in the mediated associations between EAC and pain-related variables. We next discuss three key findings.

First, this study found that greater EAC is related to less pain intensity and pain interference. This finding is aligned with our expectations, and contrasts sharply with much research on emotion-focused coping (Evers, Kraaimaat, Geenen, & Bijlsma, 1998; Jensen, Turner, Romano, & Karoly, 1991; Sullivan & D’Eon, 1990). Numerous studies over several decades show that emotion-focused coping is rarely adaptive; such coping is correlated with greater pain severity and interference (Evers et al., 1998; Jensen et al., 1991; Sullivan & D’Eon, 1990). Traditional measures of emotion-focused coping, including pain-related coping measures, however, are confounded by negative response bias. Stanton et al. (1994) demonstrated that emotion-focused coping scales are inherently biased by negative wording; items in such scales typically include negative emotions, such as being angry, upset or blaming oneself; or they reflect negative self-evaluations. This item content/valence bias leads such scales to correlate positively with measures of dysfunction or poor adjustment, including greater pain intensity and interference. Notably, the EAC scale was created to be free from negative response bias; as a result, it tends to correlate inversely with both negative affect and measures of health problems. The obtained correlations, however, are rather small in magnitude, which we also found, perhaps because EAC does not reflect psychopathology, deficits and problems, like many other self-report measures do. EAC items also do not contain language that artificially inflates their correlations with pain-related measures; for example the measure does not contain the word “pain” nor refer to behavioural impairment. Thus, although the obtained correlations between EAC and pain intensity and interference are small, they likely reflect a more accurate, less biased measure of the role of emotional processes in pain. Importantly, the results suggest that emotional processing and expression are adaptive rather than maladaptive for people with chronic pain.

Second, this study indicates that EAC is related to less pain and better functioning through the mediation of lower levels of negative affect (i.e. a composite of anxiety and depression). EAC was related to lower negative affect, which is likely due to the adaptive nature of emotional processing and expression in reducing negative affect. That is people who engage in understanding, using and expressing emotions have, on average, less psychological distress because these emotional processes help people to mitigate and resolve stressors and cope better. These findings are consistent with prior research showing that EAC may result in positive health outcomes by reducing negative affect (e.g. Berghuis & Stanton, 2002). This is also conceptually aligned with appraisal-based models of emotion (Lazarus, 1999) and empirical research (Pressman & Cohen, 2005) that identify affective responses to stressors or general affective states as critical determinants of adjustment. Thus, awareness and expression of one’s emotions may be an adaptive form of coping with chronic pain through reducing negative affect, a finding with important clinical implications.

Third, moderating models of mediated associations yielded interesting findings. For the mediated relationship between EAC and pain intensity, moderating effects of age revealed that these associations were observed in the young/middle-age adults (age 59 or less) but not the older adults in the sample (age 60 or older). This finding is consistent with theories of socioemotional selectivity (Löckenhoff & Carstensen, 2004) and affect regulation (Lachman, 2002), which suggest that older adults engage in more effective regulation of emotion; they prioritize meaningful experiences and do so by shifting their social relationships to those that are more positive, and they alter their attention, beliefs and environments so as to maximize positive and dampen negative affect (Carstensen, 1998; Carstensen, Isaacowitz, & Charles, 1999; Labouvie-Vief, 1993; Labouvie-Vief & Medler, 2002; Lachman, 2002; Löckenhoff & Carstensen, 2004). As a result, older adults report lower depression and anxiety than those who are younger, which we also found in this sample. Thus, the ability to process and express emotions may not be particularly relevant or helpful to older adults. In contrast, these abilities may be particularly helpful for young/middle-age adults with chronic pain, who tend to have greater negative affectivity and need for improved emotion regulation. This suggests that perhaps the pain experience of most young/middle-age adults—but not older adults—may be more influenced by EAC, because older adults appear to regulate their emotions and pain through different strategies—largely social and cognitive.

Finally, models examining pain interference as an outcome showed that the relationship of EAC to lower interference through negative affect occurred for women, but not men, irrespective of age. These effects are aligned with general literature showing less pain and depression among women with higher EAC (Smith et al., 2002). Our results are aligned with research showing associations between depression and disability among women with back pain, and associations of somatic awareness and depression among women, but not men (Bolton, 1994), which highlights possible fundamental differences in the psychological profile between the genders or, perhaps, gender differences in reporting psychological status. Findings are also aligned with experimental research showing that men and women may benefit from EAC in different ways; men with high EAC reported more positive affect, whereas women with high EAC reported less negative affect (Juth, Dickerson, Zoccola, & Lam, 2015). This finding suggests that an assessment of positive affect in future research may be indicated. We note, however, that our findings are not consistent with showing stronger relationships between negative affect and pain-outcomes among men (Edwards, Augustson, & Fillingim, 2000; McCracken & Houle, 2000). Collectively, these findings suggest a complex set of relationships with gender and the importance of continuing to study these relationships.

This study has several limitations. First, the study sample was comprised solely of treatment-seeking patients who were relatively well-educated and predominantly Caucasian, which limits generalizability of the results. Second, the data are cross-sectional and correlational, and true mediation is untestable in such data; however, we developed this model based on theory of how emotional approach coping strategies impact psychological and pain-related outcomes in patients with chronic pain. Nonetheless, longitudinal studies of these variables are indicated, with age as a continuous variable to explore other parts of the age spectrum for potential moderation. Although the relatively large sample reduces concerns about the reliability of the findings, replication would be of value, especially with respect to the moderators. Also, reasons for seeking care may be a confounding factor across age groups, and future research should examine its potential role. Finally, although the large sample size provides greater confidence in the reliability of the findings, the magnitude of the observed associations is rather small, suggesting limited clinical relevance.

Despite these limitations, this study was the first to examine potential mechanisms of EAC in chronic pain, and the first to investigate the moderation role of gender and age differences as related to EAC among patients with chronic pain. Although additional research is needed, these findings provide preliminary evidence that understanding, processing and expressing one’s emotions is adaptive for people with chronic pain, especially young/middle-age adults and women of all ages. Broadly speaking, because emotion unawareness and suppression are prevalent in chronic pain, this study highlights the potential value of assessing patients’ emotional processes and providing psychological interventions to enhance their emotional awareness and expression. For example interventions such as Emotional Awareness and Expression Therapy or Training (Lumley & Schubiner, 2019a; Lumley et al., 2017; Thakur et al., 2017; Ziadni, Carty, et al., 2018) and mindfulness-based interventions for pain (Hilton et al., 2016), appear to accomplish this goal, with subsequent improvement in pain-related outcomes. Such emotion-focused interventions may optimally be part of a broader, integrative treatment that also addresses dysfunctional cognitions and behaviours (Lumley & Schubiner, 2019b).

Significance.

Findings provide preliminary evidence that understanding processing and expressing one’s emotions may be adaptive for people with chronic pain, especially among adults under age 60 and women of all ages. For clinical practice, building skills of emotional processing and expression may be particularly helpful for these groups of patients with chronic pain, who may experience difficulty with emotion regulation

Acknowledgments

Funding information

K23 DA047473 (MSZ).

Footnotes

CONFLICTS OF INTEREST

We have no conflicts of interest to disclose.

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