Emotional intelligence impairments in women with fibromyalgia: Associations with widespread pain

Introduction

Fibromyalgia is a common disease (prevalence is around 3% of the adult general population) that is most prevalent among women, with female-to-male ratio of 9:1 (Branco et al., 2010). Fibromyalgia is a heterogeneous disease (Estévez-López et al., 2017) in which people experience chronic pain and an array of additional symptoms (e.g. fatigue, sleep disturbances, depression and physical disability) (Álvarez-Gallardo et al., 2017; Diaz-Piedra et al., 2015; Løge-Hagen et al., 2019; Overman et al., 2016). In the earliest criteria, the diagnosis of fibromyalgia was based solely on the presence of chronic widespread musculoskeletal pain (Wolfe et al., 1990). In addition to pain, people with fibromyalgia experience an array of symptoms, including, but not limited to, increased fatigue and poor mental health (Segura-Jiménez et al., 2015; Wolfe et al., 1990). The polysymptomatic nature of fibromyalgia was recognised in later updates of the original diagnostic criteria (Wolfe et al., 2016). Interestingly, only pain is included in all of the set of available criteria (Wolfe, 2017); emphasising the importance of pain in this disease. In the most updated fibromyalgia criteria, pain is identified as chronic widespread pain (Wolfe et al., 2016).

Previous research has suggested that emotions are related to pain. Early studies followed a ‘which and how much’ or emotional states approach, while more recent literature has moved to a ‘how and why’ or emotional processes approach (Lumley, 2010). From the latter approach, research has studied the role of specific emotional processes in the experience of pain. For instance, in comparison to peers not with chronic pain, people with chronic pain have poorer emotional awareness/appraisal (Di Tella and Castelli, 2016; Zunhammer et al., 2015). Previous studies on the impact of these emotional deficits in people with chronic pain are inconclusive (Di Tella and Castelli, 2016). A number of studies have demonstrated that maladaptive strategies of emotion regulation are related to increased pain (Baker et al., 2016), while others did not find such an association (Hamilton et al., 2007). Although some research has been conducted in people with chronic pain, there is limited work exploring the relationship between emotion and fibromyalgia. In the fibromyalgia population, we identified only one previous study in which higher anger inhibition and lower anger expression were related to more pain, which suggested a relationship between a specific emotional process (i.e. emotion regulation) and pain but this was limited to a particular emotion (i.e. anger) (Van Middendorp et al., 2010).

As opposed to the study of specific emotional processes in isolation, emotional intelligence is a more comprehensive construct that jointly takes account of diverse emotional processes, which is of interest in the perception of chronic pain. Emerging evidence suggests differences between people with and not with chronic pain (i.e. cases and controls, respectively) in specific dimensions, but not in general levels, of emotional intelligence (Costa et al., 2014). The impaired dimensions of emotional intelligence may differ across chronic pain populations. Although still under debate, the main hypothesis for the pathogenesis of fibromyalgia is the existence of central aberrations (Baek et al., 2016; De la Coba et al., 2018). Chronic pain may lead to impaired emotional processing due to changes at different levels, such as morphological, neurochemical and gene expression (Cao et al., 2009; Lumley et al., 2011). For instance, alterations in white matter microstructure are related to deficits in understanding and managing emotions (Pisner et al., 2017).

Deficits in emotional intelligence may have an impact on people with chronic pain. For instance, higher emotional intelligence is associated with lower pain (Burri et al., 2015a; Costa et al., 2017) and prevents the onset of chronic pain (Burri et al., 2015b). Indeed, past studies concluded that emotional intelligence is more strongly related to chronic pain than genetic (Burri et al., 2015b) or other emotional factors (Doherty et al., 2017).

There are very few studies analysing the association of either isolated emotional processes or emotional intelligence in those with chronic pain, which precludes definitive conclusions. Furthermore, the co-existence of several theoretical models for studying emotional intelligence and diverse approaches for assessing emotional intelligence makes it difficult to compare previous studies. Overall, there are two different approaches, namely, the ability models and the mixed/trait models (Cherniss, 2010; Mayer et al., 2000). Emotional intelligence, from the ability models, is the skill to perceive and express emotion, assimilate emotion in thought, understand and reason with emotion and regulate emotion in the self and others (Mayer et al., 2016a). Emotional intelligence is considered as a hot-type of intelligence (Mayer et al., 2016a) involving the management of the most significant information of a person: his or her sense of social acceptance, identity coherence and emotional well-being. Failures in these aspects result in psychic pain, which is processed within the same brain regions that process physical pain (Eisenberger, 2015).

Although the personality and dispositional attributes, as targeted by the mixed/trait models, also contribute to reason and solve problems, they should not be confused with emotional intelligence understood as a (discrete and measurable) mental ability (Mayer et al., 2008b). Another common limitation in the literature is that emotional intelligence was assessed only by self-reported questionnaires instead of by ability tests, which can give inaccurate results (Brackett et al., 2006) by including non-intellectual features: for example, self-confidence, self-esteem, misunderstandings of what is involved in successful reasoning or wishful thinking (Mayer et al., 2016a). Thus, the inclusion of objective assessments is of interest in fibromyalgia (Estévez-López et al., 2018; Munguía-Izquierdo et al., 2019; Pulido-Martos et al., 2019). Previous research, which measured emotional intelligence as an ability, demonstrated robust associations with (mental and physical) health (Martins et al., 2010) in several environments, such as social, academic and work (Mayer et al., 2008a). In chronic pain, research has been focused on specific or diverse emotional processes, the latter under the umbrella term of emotional intelligence, and has always used self-reported measures and mostly from mixed/trait models. There is, therefore, a paucity of knowledge of the role of emotional intelligence ability in people with chronic pain.

Several mechanisms may explain the potential role of emotional intelligence ability on chronic pain. For instance, lower levels of emotional intelligence ability might lead to inappropriate pain coping strategies and, consequently, to higher pain (Costa et al., 2017; Di Tella and Castelli, 2016), while higher levels of this ability may help to suppress or reverse negative emotions (Mayer and Salovey, 1997; Ruiz-Aranda et al., 2010), which may be related to lower pain experience. The pathways through which emotional intelligence ability may impact the experience of pain might be shared with pain catastrophizing, defined as the tendency to focus on and magnify pain experiences and to feel helpless during pain episodes (García Campayo et al., 2008): that is, directly through alterations of neural processes involved in pain perception and attention and indirectly through promoting negative emotions and maladaptive responses to pain (Lumley et al., 2011). An alternative explanation of the potential role of emotional intelligence ability on chronic pain might be the social component of the later. It is well-known that social factors contribute to reduce the experience of pain: for example, social support (Montoya et al., 2004). Higher levels of emotional intelligence ability are related to better social interaction and can promote positive social functioning (Brackett et al., 2011; Kafetsios, 2004; Lopes et al., 2005), which may result in less perceived pain. Despite these potential mechanisms, only two previous studies assessed emotional processes with an ability measure in people with chronic pain; these studies excluded those with fibromyalgia (Doherty et al., 2017; Zunhammer et al., 2015).

Therefore, the aims of this study were, for the first time, (1) to test differences in emotional intelligence ability between women with fibromyalgia and their age-matched counterparts not with fibromyalgia from the general population and (2) to analyse the association between emotional intelligence ability, as a hot intelligence, and widespread pain in women with fibromyalgia.

Methods

Results

Figure 1 shows the flowchart of participants through the study, and the characteristics of the 210 women who were included in the study are presented in Table 1. Women with fibromyalgia (i.e. cases, n = 133) and women not with fibromyalgia from the general population (i.e. controls, n = 77) were matched on age (t = 1.03, p = .306).

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Figure 1.

Participants’ flowchart of this study.

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Table 1.

Characteristics of the participants (n = 210).

Characteristics	Women with fibromyalgia (i.e. cases, n = 133)	Women not with fibromyalgia from the general population (i.e. controls, n = 77)	p-value	Effect size
Age (37–61 years)	50.9 (6.2)	50.1 (5.3)	.306	.14
Emotional intelligence (MSCEIT; 65–135)
Overall emotional intelligence	104.8 (20.8)	108.2 (20.3)	.254	.17
Emotion perception	104.4 (14.5)	100.9 (15.2)	.106	.23
Emotion facilitation	100.7 (21.0)	100.0 (17.6)	.805	.04
Emotion understanding	88.1 (11.7)	95.2 (14.6)	<.001	.57
Emotion management	94.4 (16.0)	98.1 (14.6)	.093	.24
WPI (0–19)	13.7 (3.5)
PCS (0–52)	24.4 (11.9)

MSCEIT: Mayer–Salovey–Caruso Emotional Intelligence Test; WPI: Widespread Pain Index; PCS: Pain Catastrophizing Scale.

Data are represented as M (SD); p-values based on either t-test (age) or multivariate analysis of variance (emotional intelligence); effect size based on Cohen’s d.

Association of emotional intelligence and widespread pain

The bivariate correlation between emotion understanding and widespread pain was not significant (r = −.08, p = .372). However, the remaining dimensions, as well as overall emotional intelligence, significantly correlated with widespread pain (r = −.23 to −.24, all ps ⩽ .007). The significance of these associations was similar in regression models when controlling for pain catastrophizing (Table 2). The amount of the variance of widespread pain explained by pain catastrophizing and emotional intelligence was similar (4% and 3%, respectively). It is noteworthy that the contribution of emotional intelligence was over and above pain catastrophizing.

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Table 2.

Individual associations of emotional intelligence and widespread pain in women with fibromyalgia (n = 133).

Criterion variable	b	SE	β	Δ Adj. R2
Overall emotional intelligence	−0.03	0.02	−.19*	.03*
Emotion perception	−0.05	0.02	−.19*	.03*
Emotion facilitation	−0.03	0.02	−.19*	.03*
Emotion understanding	−0.01	0.03	−.04	−.01
Emotion management	−0.05	0.02	−.21*	.04*

MSCEIT: Mayer–Salovey–Caruso Emotional Intelligence Test; WPI: Widespread Pain Index; b: unstandardised regression coefficient; β: standardised regression coefficient with significance levels of t; SE: standard error; Δ Adj. R²: change in adjusted R² with significance levels on F-change.

All the analyses were adjusted for Pain Catastrophizing (by means of the PCS, the Pain Catastrophizing Scale), which was entered in a first step (b = 0.07, SE = 0.03, β = .22, p = .01, Δ Adj. R² = .04, p = .01).

*

p < .05.

Table 3 shows the independent association of pain catastrophizing and the dimensions of emotional intelligence with widespread pain using forward stepwise methods. Emotion perception entered in the first step (t = 2.82, p = .006) and emotion management in the second step (t = 2.10, p = .038). Pain catastrophizing, emotion facilitation and emotion understanding were not entered in the regression model (data not presented). Overall, the potential contribution of emotion perception and management on widespread pain was 7 per cent.

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Table 3.

Independent associations of emotional intelligence and widespread pain in women with fibromyalgia (n = 133).

Criterion variable	b	SE	β	Δ Adj. R2
Step 1
Emotion perception	−0.06	0.02	−.24**	.05**
Step 2
Emotion management	−0.04	0.02	−.18*	.02*

MSCEIT: Mayer–Salovey–Caruso Emotional Intelligence Test; WPI: Widespread Pain Index; b: unstandardised regression coefficient; β: standardised regression coefficient with significance levels of t; SE: standard error; Δ Adj. R²: change in adjusted R² with significance levels on F-change.

Pain catastrophizing and emotional intelligence (i.e. perception, facilitation, understanding and management) were entered as independent variables using forward stepwise methods.

*

p < .05; **p < .01.

Discussion

This case–control cross-sectional study found three key findings. First, emotion understanding ability was worse among women with fibromyalgia (i.e. cases) than in age-matched women from the general population (i.e. controls). Second, in fibromyalgia, higher overall emotional intelligence ability and all its dimensions, except emotion understanding, were individually associated with lower widespread pain; even when taking into account pain catastrophizing. Third, emotion perception and emotion management abilities were independently related to widespread pain; even when pain catastrophizing, emotion facilitation, and emotion understanding were accounted for.

Previous case–control studies suggested that people with chronic pain have deficits in specific emotional processes (e.g. awareness/appraisal; Di Tella and Castelli, 2016; Zunhammer et al., 2015) but not in general levels of emotional intelligence (Costa et al., 2014). Most of the previous research omitted the study of fibromyalgia (as a particular chronic pain disease) or included a mixed sample of chronic pain including different diseases (Baker et al., 2016). Only one previous study in fibromyalgia (based on a mixed/trait model) showed an association of higher anger inhibition and lower anger expression with more pain in women with fibromyalgia (Van Middendorp et al., 2010). In this study and in line with previous literature on chronic pain, we observed that women with fibromyalgia performed worse in emotion understanding than their age-matched counterparts from the general population, but not in general emotional intelligence. Emotion understanding, along with emotion management, is part of strategic emotional intelligence (Mayer et al., 2016a). Thus, our findings seem to point out that people with fibromyalgia experience deficits on their ability to deliberately and deeply process emotional information, which in turn may hamper their ability to make strategic judgements (MacCann et al., 2014).

In this study, the differences between women with fibromyalgia and their age-matched counterparts not with fibromyalgia from the general population in emotion understanding ability might be consequence of central nervous system impairments. For instance, alterations in the white matter microstructure might be related to worse emotion understanding ability (Pisner et al., 2017). Additional changes in the neurons from the amygdala to the hypothalamus might drive emotionally maladaptive responses to coping with pain (as a threatening stimulus), which may perpetuate pain (Bartley et al., 2009).

The literature suggests that, in people with chronic pain, specific emotional processes are not related to their pain (Di Tella and Castelli, 2016; Hamilton et al., 2007). However, when emotional processes are jointly considered in the construct of emotional intelligence, higher levels of general emotional intelligence are associated with lower pain (Burri et al., 2015a; Costa et al., 2017). The findings of this study suggest that, in line with chronic pain literature, women with fibromyalgia with higher emotional intelligence experience lower widespread pain. According to our findings, interventions for improving emotional intelligence may be not only related to benefits for women with fibromyalgia but also to decrease the costs of healthcare systems (Mikolajczak and Van Bellegem, 2017).

It is well-known that catastrophizing is a contributing factor to pain, particularly in fibromyalgia (Ellingson et al., 2018). Interestingly, over and above pain catastrophizing, the single association of each specific dimension of emotional intelligence explained an additional 3 per cent of the widespread pain in our sample of women with fibromyalgia; one exception was emotion understanding, which was not significantly related to widespread pain. Furthermore, independently of pain catastrophizing and the other dimensions of emotional intelligence, we found that higher emotion perception and emotion management were associated with lower widespread pain. Thus, the findings of this study corroborate the importance of emotional processes in the understanding of the experience of pain in fibromyalgia. It may be the case that the ability of perceiving and managing emotions might impact on pain through the same pathways that catastrophizing does (Lumley et al., 2011).

In relation to the association of emotion perception and emotion management with pain, it should be born in mind that the sensory-discriminative aspect of pain (Melzack and Casey, 1968) is assessed in the WPI. Thus, deficits in emotional awareness/appraisal may be related to poor emotion perception and consequently to somatosensory amplification (Lumley et al., 2011). It may be the case that a state of pain exacerbation exists in which painful and non-painful stimuli are confused, leading to increases widespread pain in women with fibromyalgia with poor emotion perception (Lane et al., 2009).

Deficits in the sensory-discriminative aspect of pain and the close relationship between emotion management ability and several psychological outcomes (Côté et al., 2011; Wranik et al., 2007) may result in poorer emotion management driving negative emotions and maladaptive responses to pain in fibromyalgia (Lumley et al., 2011). It has been demonstrated that the association of higher emotional intelligence and lower pain is mediated by negative affect; as higher emotional intelligence is related to lower negative affect and the latter to lower pain (Ruiz-Aranda et al., 2011). Defined as the ability to perceive and reverse negative emotions (which is a type of emotion management), higher emotional repair is associated with both lower negative affect and pain (Ruiz-Aranda et al., 2010). Emotion management may suppress or reverse negative emotions (Mayer and Salovey, 1997) and consequently improve the experience of pain.

Another potential mechanism behind the association identified in this study between emotion management and widespread pain is the social aspects of pain. Higher levels of emotional intelligence are related to better social interaction and can promote positive social functioning, which in turn may positively influence the experience of pain by, for instance, increasing the levels of perceived social support (Montoya et al., 2004).

Before drawing conclusions, it should be highlighted that in this study women with fibromyalgia might have comorbidities (e.g. irritable bowel syndrome) and women from the general population might have other diseases. Thus, further research is warranted (1) testing the impact of having comorbidities in emotional intelligence levels of women with fibromyalgia and (2) including a sample of people with a chronic disease similar to fibromyalgia (e.g. other chronic pain diseases or chronic fatigue syndrome/myalgic encephalomyelitis), which will allow testing whether our findings are specific to fibromyalgia or generalisable to other similar diseases. A limitation of this study is that, while the features of fibromyalgia might differ between genders, only women participated in this study. In addition, this study did not account for the treatment that participants with fibromyalgia received, which may differ among them. Thus, replication of our study in a larger sample, including men with fibromyalgia and testing the impact that current treatment received by people with fibromyalgia has in the variables under study is warranted. The main strength of this study was that emotional intelligence was assessed by means of an ability measure instead of a self-reported assessment. In our analysis, we also adjusted for pain catastrophizing, a traditional and well-known pain-related cognition, when testing the associations of emotional intelligence with widespread pain.

To conclude, this study showed that, in comparison to age-matched women from the general population (i.e. controls), women with fibromyalgia have worse emotion understanding ability. In women with fibromyalgia, higher overall emotional intelligence ability and all its dimensions, except emotion understanding, were individually associated with lower widespread pain; even when account of pain catastrophizing was taken. Emotion perception and emotion management abilities were related to widespread pain; even when pain catastrophizing, emotion facilitation and emotion understanding were accounted for. Further experimental research to address the causality of our findings is warranted. It would be of particular interest to test whether intervention programmes enhancing levels of emotion management, as part of the hot intelligences, are effective in reducing widespread pain in women with fibromyalgia.