By a strange coincidence, after writing about regulating activity levels yesterday, I came across a pre-print editorial in the European Journal of Pain discussing exactly this: avoidance or persistence.
We’ve become quite familiar with the avoidance idea – avoidance leading to deactivation, leading to disability, loss of roles, depression and so on. There have been several models to explain this, most recently Vlaeyen’s pain-related anxiety and avoidance model which implicates an underlying negative affectivity, health anxiety and catastrophising, and ultimately leading to kinesiophobia, or fear of movement. Treatments arising from this model include graded exposure, along with reduced physiological arousal and cognitive restructuring around catastrophising.
What has been discussed much less often is the ‘boom and bust’ pattern I described yesterday, and the even less frequently discussed ‘overdoing’ group of people. In the ‘boom and bust’ group, people seem to pursue activity to a high level, then stop to ‘recover’, returning to a high level of activity only to need to stop to recover again. This pattern can lead to a gradual decline in activity as the high level of activity gradually reduces over time – notably when pain is used as a guide for how much and how long activities are carried out.
In the overdoing group, the pattern seems to be one of consistently pushing to complete activities throughout the day, only to become exhausted at night, sleep poorly and begin the busy-ness the next day. Sometimes this continues for a long time, only to subside in deactivation when the person reaches exhaustion, becomes depressed, or sustains another illness.
The problem with both of these activity patterns is that there is to date little research describing this pattern. We simply don’t know a lot about this type of behaviour. There have been several theoretical models trying to describe this subgroup, but as Karsdorp & Vlaeyen point out in this editorial, there is very little evidence to support any of them. The model discussed in this editorial is the avoidance-endurance model developed by Hasenbring et al (2009), which includes affective, cognitive and behavioural responses – the fear-avoidance group is ‘characterised by fear of pain, catastrophising thoughts about pain and avoidance behaviour patterns. The endurance group … displays suppression of pain-related thoughts and reports positive affect and persistence behaviour despite the pain’. As noted in the editorial, the endurance group doesn’t appear to demonstrate the same disability levels as the avoidance group – the rationale being that they ‘may withstand the interruptions of pain during daily activities and therefore may show less disability’.
In my experience, this may hold true at the beginning of a pain episode. Over time, however, I think the area that becomes strained is the emotional resilience. People I’ve observed may use internal cognitive rules about the need to complete activity (such as ‘I must be a good mother and clean the house’, or ‘I should be a good worker and finish this job’), and use this to persist in behaviour. Without adequate recovery time, however, fatigue (particularly emotional fatigue) becomes evident, and eventually with the advent of perhaps another stressor such as personal illness, job change, family demands, the person begins to use either a ‘boom and bust’ pattern, or turns to an avoidance pattern.
I suspect several things are missing in our current models of activity pattern in chronic pain – one is the trajectory over time. This is mentioned in Karsdorp & Vlaeyen’s editorial, where they suggest that ‘a more process-oriented approach’ is required in research on endurance and avoidance because we don’t know whether these behaviours are stable over time.
The second is the role of external events such as a secondary stressor or behavioural reinforcement. The pain-related anxiety and avoidance model doesn’t include contextual factors such as compensation, social cognitive factors such as other people’s behaviour, it simply describes the individual’s own cycle. There are huge social reinforcements in being a ‘workaholic’. Not simply rewards as in remaining in employment, but also rewards by avoiding guilt, especially if the ‘work’ is that of being a parent caring for children.
Secondary stressors may erode resilience over time and create an environment where coping falls away, leading to longer periods of recovery – this is the ‘boom and bust’ pattern, which as I suggested earlier can lead to gradually lower and lower levels of activity over time.
I’m not sure that there needs to be One Grand Model describing all pain-related disability. Perhaps the pain-related anxiety and avoidance model explains one aspect of pain-related disability. Perhaps another set of factors interacts with these to create the persistence behaviour – and contributes to the ‘boom and bust’ pattern.
At this stage, I think once again we’ll be left with questions – ahhh! the bliss of working in a field where there is so much to be discovered!
Karsdorp, P., & Vlaeyen, J. (2009). Chronic pain: Avoidance or endurance? European Journal of Pain DOI: 10.1016/j.ejpain.2009.02.001