Feeling the fear – and not even thinking about doing it

Anxiety sensitivity (AS) is basically the fear of feeling anxious, or feeling anxiety-related symptoms. Typically, when people are fearful of their own symptoms of anxiety, they’ll work to avoid getting into situations where they may experience these symptoms.  AS has been shown to be a predisposing factor in some anxiety-related disorders such as panic attacks.   Lance McCracken and others at the University of Bath have been studying AS in pain, as well as producing a substantial amount of research relating to acceptance of pain, and contextual cognitive behavioural therapy.

This paper examines various measures of acceptance, mindfulness and values-based action, along with distress, disability and a measure of anxiety sensitivity in a group of patients with chronic pain. I’m not going to look at the wider issue of acceptance and mindfulness and so on, what I want to look at is the relationship between anxiety sensitivity and disability and distress.

The methodology for this study was quite simple – a group of patients were asked to complete a number of questionnaires at admission to the pain service, before their first appointment. The data collected from the questionnaires was then analysed using correlations and multiple regression (if you’re not certain about multiple regression, go here for more information). The specific questionnaires used are given in the paper itself, but included the Anxiety Sensitivity Index, a depression measure, several acceptance-based questionnaires, the Pain Anxiety Symptoms Scale, and the Sickness Impact Profile. Quite a swag of questionnaires!

What did the analysis show? I’m only going to briefly discuss the ones related to AS and distress and disability – the others are for another time!

The main finding is that Anxiety Sensitivity and its components are associated with more pain, more distress and more disability – which makes sense when you consider that AS is all about fear of feeling negative experiences. This isn’t the first study to show this (Asmundson and Norton have shown this too), but as McCracken and Keogh indicate, this study extends the findings to that AS is associated with greater depression, pain-related anxiety, disability and GP visits related to pain.

So what seems to happen is that people who are worried about feelings of anxiety experience chronic pain, they cope much less successfully than people who don’t have this underlying degree of concern. McCracken and Keogh suggest that AS can be thought of as a sort of ‘distress amplifier’ that ‘contributes additional adverse psychological meaning and influences to emotional experiences’.

They go on to suggest thatAS may be considered as part of a more general tendency to respond in a distressed and avoidant way toward one’s own experiences of emotions. If so, then what the ASI might be tapping is a behaviour pattern that generalises to experiences of other emotional experiences such as anger, depression, fear, frustration and perhaps others such as guilt, shame or embarrassment.’

Using the model of Acceptance and Commitment Therapy, these authors suggest that the findings in this study might support treatments based on helping people develop a more flexible approach towards experiencing unpleasant emotions – instead of working hard to control or avoid them, people might develop a different way of viewing them. As they put it ‘…on altering the meaning derived and the influences exerted in emotion and behaviour from what is thought or felt.’ What this means is helping people distinguish between the experience and the meaning (judgement or interpretation) of that experience so they can tolerate rather than avoid or eliminate something that can’t be eliminated.

Well, where does that leave me?
Apart from the known drawbacks of conducting a descriptive study in a group of people with measures taken only at one time, and manipulation of any variables (ie there can’t be any conclusions drawn about causal relationships), and that it was a fairly small clinical group of participants, this study adds to the information about anxiety sensitivity and its relationship to behaviours that are problematic in chronic pain.

After all, it’s not chronic pain per se that is the problem – it’s the inactivity, interference with daily functioning and the distress and depression that are really the problem. And these problems occur because of people’s judgements about having pain and what they believe the pain is about.

If we can establish that some people just don’t like feeling the fear – and instead of doing it, they don’t even want to think about doing it – then we can begin to work out ways to reduce their beliefs or interpretation of these experiences. We can help them recognise that they can experience them without the world falling apart, and that they can do this and carry out valued activities at the same time. We might be able to reduce their feelings of helplessness as they try to control what is uncontrollable. We might reduce their reliance on medications that not only dull pain, but also dull other experiences too.

Thinking about chronic pain management as essentially about being willing to feel the feelings and do it anyway might allow people to be more flexible about life in general. And I have a suspicion that psychological flexibility is an important part of resilience, or being able to cope with the ups and downs that life bring us. What do you think?

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Lance M. McCracken, & Edmund Keogh (2009). Acceptance, mindfulness, and values-based action may counteract fear and avoidance of emotions in chronic pain: an analysis of anxiety sensitivity The Journal of Pain, 10 (4), 408-415
Asmundson, G. J., Wright, K. D., Norton, P. J., & Veloso, F. (2001). Anxiety sensitivity and other emotionality traits in predicting headache medication use in patients with recurring headaches: implications for abuse and dependency. Addictive Behaviors, 26(6), 827-840.

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