Understanding and Treating Fear of Pain

Abstract

In Understanding and Treating Fear of Pain, the authors identify and discuss how pain-related fear and anxiety can lead to chronic pain even after healing of tissue damage has occurred. This fear can produce avoidance behaviour that, over time, leads to deconditioning, decreased mobility, further pain experiences, negative expectancies, and reinforced avoidance. This information is crucial to our measurement and management of ongoing pain-related disability, especially when objective findings do not support the disability observed. This book is well organized, with 15 chapters divided into 4 major sections. Section 1 (Chapters 1–7) examines theoretical foundations and empirical findings on fear avoidance and its relation to chronic pain. An overview of models was used to explain chronic pain and fear and anxiety are identified as the major factors leading to avoidance behaviour. The authors suggest that anxiety precipitates cognitive scanning of symptoms, which leads to increased physiologic autonomic arousal, motivating individuals to prevent painful or perceived painful situations. These factors may explain the maintenance of disability in chronic pain after tissue healing has occurred. Arguments are presented to suggest that pain-related fear and subsequent avoidance are conditioned phenomena or learned behaviours. A behavioural analysis of pain-related fear identifies primary (fear of pain) and secondary (social and emotional) factors that influence behaviour. These behaviours, in turn, have consequences for the client, including reduced responsibilities, a diminished sense of achievement, disturbed social relations, and discouragement of social contacts. The concept of hypervigilance is used to explain high symptom reporting when symptoms are medically unexplained. The hypervigilant person constantly scans their body looking for pain and may misinterpret normal somatic sensations as pathological. Hypervigilance appears to be related to high anxiety and other emotional factors, including negative affectivity and catastrophizing. High levels of anxiety sensitivity may lead individuals to interpret normal somatic sensations as harmful. The second section (Chapters 8–11) examines assessment. Assessment of fear-avoidance beliefs should encompass the object of fear and how it interrupts the individual's identity. This information can then be used to educate the person with chronic pain. Fear and anxiety related to pain must be examined using motor, physiological, and cognitive activity measures. Cognitive activity is measured with self-report questionnaires, such as the Fear-Avoidance Beliefs Questionnaire (FABQ), the Fear of Pain Questionnaire-III (FPQ-III), the Pain Anxiety Symptoms Scale (PASS), and the Tampa Scale of Kinesiophobia (TSK). Physiologic measures may include electromyographs (EMG) and cardiovascular tests, as well as electroencephalographs (EEG). Motor measures include assessing facial features and measuring physical impairment/disability, as in functional capacity evaluations (FCE). Much of the research suggests that fear avoidance is the strongest predictor of disability and function, stronger than intensity of pain. Early identification of fear and anxiety is important for treatment, because at-risk patients will likely not improve with medical care and/or physical therapy. Patient–therapist relationships are crucial in working with fearful-avoidant clients, as these patients are trying to find biomedical answers and may not be open to treatment based on a bio-psychosocial approach. A goal of treatment is to educate and to encourage a change of belief “that all pain means harm.” Collaborative goal setting, highlighting client self-efficacy, and practising empathy in difficult situations are identified as key to building a strong therapeutic relationship. The third section (Chapters 12–14) discusses treatment. In the primary-care setting, assessing and treating psychosocial factors may be difficult. Many primary practitioners, including physical therapists, hold and encourage fear-avoidance behaviour. Furthermore, the research suggested that the more we approach pain from a biomechanical perspective, the more likely we are to encourage rest. Methods suggested as helpful in the primary-care setting are explaining examination findings and encouraging resumption of regular activity as soon as possible. Education on hurt versus harm is also advocated. Cognitive-behavioural therapy (CBT) for treatment of fear and avoidance is identified as helpful. The authors suggest that CBT may not treat pain directly but can reduce the fear, anxiety, and depression associated with chronic pain. The most promising aspect of treatment presented is in vivo exposure, a technique to produce systematic disconfirmations between expectations of pain and harm. The premise of exposure therapy is that persons with chronic pain tend to overestimate how intense their pain will be with action but, after being exposed, will correctly match predictions with actual experience. Research on in vivo exposure has been very supportive of this form of treatment. Chapter 15, which constitutes the final section of the book, addresses future challenges and research directions. Some interesting ideas are discussed, including the question of whether or not there is a genetic predisposition to chronic pain. For example, anxiety may be a heritable trait causing dysregulations of serotinergic or gabanergic systems. Understanding and Treating Fear of Pain presents a new understanding of chronic pain and promising new treatment approaches and would benefit those working in primary-care or chronic pain settings.