I am interested in investigating the role of stress and emotion regulatory system in chronic pain and substance use. Ultimately, I want to develop mechanisms-based psychological interventions for patients suffering from chronic pain to optimize pain management strategies with less medications and substances and to help patients live meaningful life.
Instructor, Anesthesiology, Perioperative and Pain Medicine
Internship: Wright State University School of Psychology (2017) OH
PhD Training: Texas A and M University Office of the Registrar (2017) TX
Fellowship: Stanford University Division of Pain Medicine CA
BSN, Hanyang University, Nursing (1997)
BA, Case Western Reserve University, Psychology (2007)
MS, Texas A&M University, Clinical Psychology (2012)
PhD, Texas A&M University, Clinical Psychology (2017)
Pain Catastrophizing and Prescription Opioid Craving
Adherence to prescription opioid and opioid tapering as indicated are critical for safe chronic opioid therapy for chronic pain, but this can be difficult for patients experiencing prescription opioid craving. Because pain catastrophizing is proposed as a possible treatment target by our and others' preliminary results, the proposed study aims to determine whether pain catastrophizing is a treatment target to reduce prescription opioid craving and to investigate whether negative affect and stress hormones are potential mediators. The findings from the current study will inform whether a psychology intervention to lower pain catastrophizing will reduce opioid craving, and whether psychological and physical distress will be potential mediators of the treatment effect.
Stanford is currently not accepting patients for this trial. For more information, please contact SNAPL lab, 650-723-8346.
Perceived Injustice Mediates the Relationship Between Perceived Childhood Neglect and Current Function in Patients with Chronic Pain: A Preliminary Pilot Study.
Journal of clinical psychology in medical settings
Cumulative evidence supports the association between perceived childhood neglect and adulthood psychological and physical health. To date, pathways mediating this association remain largely unknown, though other evidence suggests that negative patterns of appraisal, including injustice perception related to pain, may be shaped by prior adverse social experiences. Consequently, the current study examined perceived injustice about chronic pain as a possible factor connecting childhood neglect and pain-related outcomes, given its relevance for both adaptation to chronic pain and to prior adverse life experiences. Patients (n = 742) visiting a tertiary pain clinic completed a survey administered via the Collaborative Health Outcomes Information Registry. Path modeling analyses were used to examine perceived injustice as a mediator of the relationships between childhood neglect and affective distress and physical function, after controlling for pain intensity and pain catastrophizing. Patients endorsing childhood neglect reported higher levels of perceived injustice and worse affective distress and physical function. Further, inclusion of perceived injustice as a mediator fully accounted for the relationship between neglect and current levels of physical function, and accounted for a significant proportion of the relationship between neglect and current levels of affective distress. These preliminary findings suggest that perceived injustice appears to be a more proximal factor by which prior experiences of neglect may adversely affect adaptation to chronic pain. Given the single-item assessment of childhood neglect and cross-sectional nature of the current findings, further research may focus on replicating these findings in longitudinal studies with validated measures and examining other adverse social experiences (e.g., abuse, social disparities) that may contribute to injustice perception and poor pain-related outcomes.
View details for DOI 10.1007/s10880-020-09722-8
View details for PubMedID 32382872
Hyperalgesia after a Drinking Episode in Young Adult Binge Drinkers: A Cross-Sectional Study.
Alcohol and alcoholism (Oxford, Oxfordshire)
Rodent studies propose potential mechanisms linking excessive drinking and pain hypersensitivity (hyperalgesia), such that stress hormones (i.e. epinephrine and cortisol) mediate induction and maintenance of alcohol withdrawal-induced hyperalgesia. The first aim of this study was to examine whether hyperalgesia would occur within 48 h after a drinking episode in healthy young adult binge drinkers. The second was to examine whether stress hormones and negative effect would be associated with binge drinking or alcohol withdrawal-associated hyperalgesia.A cross-sectional experiment was conducted in five groups with naturally occurring drinking (mean age = 19.6, range 18-29 years): abstainers (n = 43, 54% female), moderate drinkers with (n = 50, 50% female) or without recent drinking (i.e. within 48 h, n = 23, 26% female) and binge drinkers with (n = 36, 58% female) or without recent drinking (n = 25, 44% female). All types of drinkers endorsed drinking about 2-3 times a month and 2-3 years of drinking history.Muscle pressure pain thresholds were significantly lower in the binge group with recent drinking compared to other groups, but cutaneous mechanical and heat pain thresholds were not significantly different across the five groups. Basal epinephrine levels were significantly higher in binge groups regardless of recent drinking, but cortisol and negative effect were not significantly different across the five groups.This is the first study to show that alcohol withdrawal-associated muscle hyperalgesia may occur in healthy episodic binge drinkers with only 2-3 years of drinking history, and epinephrine may play a role in binge drinking-associated hyperalgesia.
View details for DOI 10.1093/alcalc/agaa035
View details for PubMedID 32476005
Emotions Matter: The Role of Emotional Approach Coping in Chronic Pain.
European journal of pain (London, England)
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.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 vs. young/middle-age adults) moderated the mediated relationships of EAC with pain-related variables through negative affect.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.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.
View details for DOI 10.1002/ejp.1625
View details for PubMedID 32603553
- Evaluation of the Preliminary Validity of Misuse of Prescription Pain Medication Items from the Patient-Reported Outcomes Measurement Information System (PROMIS)(R) PAIN MEDICINE 2019; 20 (10): 1925–33
- International Stakeholder Community of Pain Experts and Leaders Call for an Urgent Action on Forced Opioid Tapering PAIN MEDICINE 2019; 20 (3): 429–33
Cumulative Childhood Adversity as a Risk Factor for Common Chronic Pain Conditions in Young Adults
2019; 20 (3): 486–94
Multiple and specific types of childhood adverse events are risk factors for chronic pain conditions. Although both can covary, no study has evaluated one aspect while controlling for the other. Therefore, the current study examined whether more adverse events would be a risk factor for common chronic pain conditions and pain medication use in young adults after controlling for different adversity types such as physical, emotional, and sexual traumatic events or vice versa.This cross-sectional study recruited 3,073 undergraduates (72% female, mean age = 18.8 years, SD = 1.4 years) who completed the survey for current health status and early life traumatic events.More adverse events were associated with a 1.2-1.3-fold increase in the odds of any chronic pain, chronic back pain, headache, and dysmenorrhea with adjusting for adversity types, but they were not associated with the risk of comorbid pain conditions and use of pain medications. In contrast, specific adversity types were unrelated to chronic pain conditions when controlling for the number of adverse events.Cumulative childhood adverse events may be a more relevant risk factor for chronic pain conditions than the experience of a specific type of adverse event. Clinicians and researchers need to evaluate cumulative childhood adversity when assessing its link to chronic pain.
View details for DOI 10.1093/pm/pny106
View details for Web of Science ID 000467966600009
View details for PubMedID 30011037
View details for PubMedCentralID PMC6387984
Negative Affect-Related Factors Have the Strongest Association with Prescription Opioid Misuse in a Cross-Sectional Cohort of Patients with Chronic Pain.
Pain medicine (Malden, Mass.)
Increased opioid prescription to relieve pain among patients with chronic pain is associated with increased risk for misuse, potentially leading to substance use disorders and overdose death. We aimed to characterize the relative importance and identify the most significant of several potential risk factors for the severity of self-reported prescribed opioid misuse behaviors.A sample of 1,193 patients (mean age ± SD = 50.72 ± 14.97 years, 64.04% female) with various chronic pain conditions completed a multidimensional registry assessing four pain severity measures and 14 physical, mental, and social health status factors using the National Institutes of Health's Patient-Reported Outcomes Measurement Information System (PROMIS). A validated PROMIS measure of medication misuse was completed by 692 patients who endorsed currently taking opioid medication. Patients taking opioid medications were compared across all measures with those who do not take opioid medications. Subsequently, a data-driven regression analysis was used to determine which measures best explained variability in severity of misuse. We hypothesized that negative affect-related factors, namely anxiety, anger, and/or depression, would be key predictors of misuse severity due to their crucial role in chronic pain and substance use disorders.Patients taking opioid medications had significantly greater impairment across most measures. Above and beyond demographic variables, the only and most significant predictors of prescribed opioid misuse severity were as follows: anxiety (β = 0.15, P = 0.01), anger (β = 0.13, P = 0.02), Pain Intensity-worst (β = 0.09, P = 0.02), and depression (β = 0.13, P = 0.04).Findings suggest that anxiety, anger, and depression are key factors associated with prescribed opioid misuse tendencies in patients with chronic pain and that they are potential targets for therapeutic intervention.
View details for DOI 10.1093/pm/pnz249
View details for PubMedID 31617916
Evaluation of Candidate Items for Severe PTSD Screening for Patients with Chronic Pain: Pilot Data Analysis with IRT Approach.
Pain practice : the official journal of World Institute of Pain
Post-traumatic Stress Disorder (PTSD) commonly co-occurs with chronic pain. Although PTSD symptoms are associated with negative health outcomes in patients with chronic pain, PTSD is typically under-detected and under-treated in outpatient pain settings. There is a need for rapid, brief screening tools to identify those at greatest risk for severe PTSD symptoms. To achieve that goal, our aim was to use item response theory (IRT) to identify the most informative PTSD symptoms characterizing severe PTSD in patients with chronic pain.Fifty-six patients (71% female, 61% White) with mixed etiology chronic pain completed the PTSD Checklist Civilian Version (PCL-C) as part of their appointment with a pain psychologist at a tertiary outpatient pain clinic. We used an IRT approach to evaluate each item's discriminant (a) and severity (b) parameters.Findings revealed that 'feeling upset at reminders' (a = 3.67, b = 2.44) and 'avoid thinking or talking about it' (a = 3.61, b = 2.17) as being highly discriminant for severe PTSD.We identified two candidate items for a brief PTSD screener as they were associated with severe PTSD symptoms. These two items may provide clinical utility in outpatient pain treatment settings to identify those suffering from severe PTSD enabling physicians to refer them to trauma-specific evaluation or therapy. Future research is needed to further validate and confirm these candidate PTSD items in a larger clinic sample.
View details for DOI 10.1111/papr.12848
View details for PubMedID 31646748
- Is it Too Soon to Meet? Examining Differences in Geosocial Networking App Use and Sexual Risk Behavior of Emerging Adults SEXUALITY AND CULTURE 2018; 22 (1): 1–21
CARE Scale - 7: Development and preliminary validation of a measure assessing factors that impact self-care in chronic pain
Clin J Pain
View details for DOI 10.1097/AJP.0000000000000606
Generalized Pain Sensitization and Endogenous Oxytocin in Individuals With Symptoms of Migraine: A Cross-Sectional Study
2018; 58 (1): 62–77
The current study examined pain and neurogenic inflammation responses to topical capsaicin during the interictal period (between headache) and their relationship with plasma oxytocin in individuals with migraine.Individuals with migraine can experience generalized (extracephalic) hyperalgesia, which can persist even between headache attacks. Elevated levels of plasma and cerebrospinal fluid oxytocin have been observed during migraine attacks, oxytocin levels being positively associated with the intensity of migraine symptoms. However, whether oxytocin plays a role in the mechanisms of generalized pain sensitization and neurogenic inflammation during the interictal period has not been studied yet. Understanding migraineurs' interictal pain phenotype and endogenous oxytocin might help identify individuals who would benefit from intranasal oxytocin treatment.Thirty-two subjects with migraine and 26 healthy controls underwent pain testing. The current study compared capsaicin-induced pain, central sensitization (areas of secondary mechanical allodynia and hyperalgesia), and neurogenic inflammation (capsaicin-induced flare) responses on the nondominant volar forearm between migraineurs and healthy controls. Additionally, we studied plasma oxytocin levels and their relationship to migraine symptoms, experimental pain and affect.The results indicated a significant group effect (P = .019): Migraineurs reported greater capsaicin-induced pain unpleasantness (M = 1.2, SD = 1.4) on a 0-10 scale and showed larger areas of flare (LnM = 2.8, SD = 0.4) than healthy controls (M = 0.5, SD = 0.8; LnM = 2.6, SD = 0.4; ps < .032). In a subgroup analysis, enhanced capsaicin-induced pain unpleasantness was found in the chronic (P = .007), but not the episodic (Ps > .200), migraineurs. The oxytocin levels were elevated in migraineurs and accounted for 18% of the group difference in capsaicin-induced pain unpleasantness. Within migraineurs, interictal oxytocin levels were negatively associated with psychological distress (Ps < .030). However, during the interictal period, pain sensitivity in extracephalic regions and plasma oxytocin levels were unrelated to migraine symptom parameters (Ps > .074). Lastly, the results found no group difference in areas of secondary mechanical allodynia and hyperalgesia (Ps >.298).The current study revealed that individuals with migraine exhibit enhanced extracephalic capsaicin-induced pain unpleasantness and flare responses during interictal periods. In addition, migraineurs, especially those with chronic migraine, had slightly elevated interictal oxytocin levels compared to controls, which was associated with their affective component of experimental pain. Therefore, treatment targeting affective pain during the interictal period may help to reduce generalized pain in migraine. Furthermore, endogenous increases in oxytocin may be a compensatory mechanism that may help decrease affective distress in migraineurs. The therapeutic effects of intranasal oxytocin may benefit migraineurs by reducing their affective distress.
View details for DOI 10.1111/head.13213
View details for Web of Science ID 000419067600006
View details for PubMedID 29094347
Diagnostic Efficiency of Caregiver Report on the SCARED for Identifying Youth Anxiety Disorders in Outpatient Settings.
Journal of clinical child and adolescent psychology : the official journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53
2018; 47 (sup1): S161–S175
This study investigated the diagnostic and clinical utility of the parent-rated Screen for Child Anxiety Related Emotional Disorders (SCARED-P) for detecting youth anxiety disorders. Youth ages 6 to 12 years, 11 months were recruited from 9 outpatient mental health clinics (N = 707). Consensus diagnoses were based on semistructured interviews (Schedule for Affective Disorders and Schizophrenia for School-Age Children) with youth and caregivers; 31% were diagnosed with at least one anxiety disorder. Caregivers completed the SCARED-P to describe youth anxiety levels. SCARED-P scores were not considered during the consensus diagnoses. Areas under the curve (AUCs) from receiver operating characteristic analyses and diagnostic likelihood ratios (DLRs) quantified performance of the SCARED-P total score and subscale scores (generalized anxiety disorder and separation anxiety disorder). SCARED-P total scores had variable efficiency (AUCs = .69-.88), and Generalized Anxiety Disorder and Separation Anxiety subscale scores were excellent (AUCs = .86-.89) for identifying specific anxiety disorders. Optimal subscale cutoff scores were computed to help rule in (DLRs = 2.7-5.4) or rule out (DLRs < 1.0) anxiety disorders among youth. Results suggest that the Generalized Anxiety Disorder and Separation Anxiety SCARED-P subscales accurately identify their respective matched diagnoses. DLRs may aid clinicians in screening for youth anxiety disorders and improve accuracy of diagnosis.
View details for DOI 10.1080/15374416.2016.1188698
View details for PubMedID 27485325
View details for PubMedCentralID PMC5729056
Enhanced Area of Secondary Hyperalgesia in Women with Multiple Stressful Life Events: A Pilot Study.
Pain medicine (Malden, Mass.)
2016; 17 (10): 1859–64
Stressful life events are associated with increased pain severity and chronicity. However, the mechanism underlying this association remains disputed. Recent animal studies suggest that chronic stress increases pain sensitivity and persistence by enhancing peripheral and central sensitization mechanisms. To test this hypothesis in humans, the authors examined whether sensitization is enhanced in healthy women reporting more stressful life events using the topical capsaicin test.Thirty-two healthy young women reporting varying levels of stressful life events were invited for laboratory pain testing. Capsaicin was applied topically to the volar forearm. Measurements included capsaicin-induced spontaneous pain and area of secondary hyperalgesia in the region surrounding capsaicin application. Physiological (heart rate and skin conductance) and self-reported affective (emotional valence and arousal) states were also measured.The results indicate that more stressful life events predicted a linear increase in the area of secondary hyperalgesia (β = 0.40, p = 0.023, R2 = 0.16), but not the intensity of secondary hyperalgesia nor capsaicin-induced spontaneous pain. These findings suggest that life stressors may be associated with heightened central sensitization manifested by an increased area of secondary hyperalgesia. Additionally, life stressors were related to greater sympathetic cardiac, but not to affective responses to capsaicin-induced pain.This study shows that women reporting more stressful life events show a larger area of secondary mechanical hyperalgesia. These preliminary findings suggest that life stressors may facilitate pain processing by enhancing central sensitization.
View details for DOI 10.1093/pm/pnw049
View details for PubMedID 27056957
Comparing the Diagnostic Accuracy of Five Instruments for Detecting Posttraumatic Stress Disorder in Youth.
Journal of clinical child and adolescent psychology : the official journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53
2015; 46 (4): 511–22
The purpose of the study was to compare diagnostic accuracy of five posttraumatic stress disorder (PTSD) measures in a large outpatient sample of youths 11-18 years of age. Index tests included a parent report (a rationally derived scale from the Child Behavioral Checklist), a teacher report (the Teacher Report Form), and three youth reports-a PTSD scale from the Youth Self Report (YSR), Child PTSD Symptom Scale, and Child and Adolescent Trauma Survey. Interviews with the youth and caregiver using Schedule for Affective Disorders and Schizophrenia for School-Age Children generated criterion diagnoses of PTSD. Diagnoses were blind to scores on the index tests. Based on consensus diagnoses (N = 458), 10% of youth had PTSD. Area under the curve (AUC) from receiver operating characteristic analyses and multilevel likelihood ratios evaluated test performance. All youth reports (AUCs .67-.73) outperformed the teacher report (AUCs .42-.48) at identifying PTSD. The YSR outperformed the caregiver reports (AUCs .57-.58). Combining tests did not improve prediction of PTSD. The YSR predicted PTSD even after controlling for a self-reported traumatic event, but checklist ratings of traumatic events had no incremental value after controlling for YSR scores. When a youth endorsed few symptoms, the likelihood of the youth having PTSD was low. Very high scores on the YSR were associated with a moderate increase in the likelihood of PTSD diagnosis. The YSR appeared to be a useful diagnostic aid for youth PTSD and could facilitate differential diagnosis of youth PTSD in outpatient settings.
View details for DOI 10.1080/15374416.2015.1030754
View details for PubMedID 25946667
View details for PubMedCentralID PMC4703561
Effect of written emotional disclosure on secondary hyperalgesia in women with trauma history.
2014; 76 (5): 337–46
This study investigated the effects of written emotional disclosure on a model of chronic pain in healthy women with and without trauma history.Participants were prescreened for their trauma history (N = 78) and randomized to a disclosure or a control writing condition. Pain testing occurred either 1 day or 1 month after disclosure. Capsaicin was applied to the forearm to evoke spontaneous burning pain at the application site and mechanical secondary hyperalgesia in the surrounding untreated skin.As hypothesized, the effect of disclosure on the area and intensity of secondary hyperalgesia depended on trauma history and time of testing (F(1,69) ≥ 7.37, p = .008). Disclosure increased secondary hyperalgesia in participants with trauma history compared with those without trauma when testing occurred 1 day after writing (F(1,69) ≥ 5.27, p ≤ .025), whereas the opposite pattern was observed 1 month later (F(1,69) ≥ 4.88, p ≤ .031). Of the participants with trauma history in the disclosure condition, secondary hyperalgesia was reduced at 1 month compared with 1 day after writing (p = .001). Moreover, greater use of positive emotional words predicted reduced secondary hyperalgesia at 1 month (β = -0.71, p = .022). In contrast, disclosure had no effect on spontaneous pain.Disclosure modulates secondary hyperalgesia observed in women with trauma history, producing a short-term enhancement and a long-term reduction. This suggests that disclosure has a long-term protective effect that reduces sensitization of pain, which may explain the therapeutic effects of disclosure in patients with chronic pain.
View details for DOI 10.1097/PSY.0000000000000064
View details for PubMedID 24911979