Sometimes, even with the best practice, treatment doesn’t go the way you expect it to. Graded exposure, using a phobia treatment model, can be one of those amazingly quick methods – or it can be a long-haul challenge. This paper by Flink, Boersma and Linton, just published in European Journal of Pain identifies one of the intervening variables that might make a difference.
Kinesiophobia, or the fear of movement, is thought to be generated by an underlying fear of harm, negative affectivity and avoidance. The avoidance component works to prevent the person from disconfirming their belief that the movements that hurt (or might hurt), thus helping the person to remain fearful of movements and therefore continuing their disability. Negative affectivity is a tendency to see events as more negative than positive (the glass is half-empty not half full). And catastrophising has been thought of as one of the elements that can influence and maintain the avoidance – it’s the ‘what if’ thought, or thinking the worst belief.
Several psychological variables are thought to influence treatment outcome. Most of the research into chronic pain in the 1980’s looked at depression, but more recently attention has turned to anxiety, and in particular, health anxiety or pain anxiety. Anxiety is a broader construct than fear, where fear is thought to be about a specific event or object, while anxiety is about generalised concern. Treatment for anxiety usually involves both cognitive elements – using mindfulness, disputing unrealistic beliefs and so on – as well as behavioural aspects such as remaining in situ despite increased physiological arousal.
In this study, the authors firstly looked at outcomes of graded exposure and whether anxiety, depression and catastrophising moderated these. While anxiety was found to influence outcome generally (leading to poorer outcomes for those who were more anxious), catastrophising was found to have a more complex relationship. Graded exposure was effective for low and moderate catastrophising, but for those with high catastrophising the results were far less spectacular. And depression? Made little difference to outcome at all.
After finding that high levels of catastrophising influenced outcome, the next step in this study was to examine those people who made a good deal of changein disability and compare them with those who made much less change in disability. For this part of the study, descriptive data was used, and it was found that people who made a great deal of change also had high levels of change across depression, anxiety and catastrophising – while those who made less change in disability changed little, if at all, across these measures.
Flink, Boersma and Linton indicate that they believe catastrophising is an important moderator of outcome, while all three variables are influential in terms of the process of therapy, even if not the actual outcome.
What does this mean for us?
I’m not sure how many clinicians who are involved in exposure in vivo treatment routinely assess anxiety, catastrophising and depression. It looks like it’s an important aspect of treatment outcome that we might need to attend to – it might mean excluding those with high levels of anxiety and catastrophising, and those who are depressed so that these can be treated effectively prior to embarking on graded exposure. Alternatively it might mean providing concurrent treatment for these areas while participants undergo graded exposure therapy.
A point raised by the authors suggests that in people with high levels of catastrophising, very subtle ‘safety behaviours’ occur that may not be noticed by therapists.
Safety behaviours are actions an individual employs as a way to reduce the anxiety they experience while carrying out exposure treatment. This can be inadvertently reinforced by us as therapists – instruction to use specific lifting techniques, relying on the therapist being present while carrying out the movements, even using slightly modified movements like bracing the abdominal muscles while moving can become safety behaviours that then limit the effectiveness of exposure. After all, exposure therapy is based on the idea that to extinguish the fear, it needs to be activated while encountering the triggering stimulus – any method of reducing that fear before encountering the triggering stimulus will mean the power of the treatment is reduced.
We might also need to consider the assessment measures we use. Something I’ve noticed recently is that the Tampa Scale for Kinesiophobia has two subscales – fear of harm and somatic focus. The fear of harm subscale may be moderated by information – and many of the people I see have repeatedly been told they don’t need to fear their pain, that it is not a sign of damage. At the same time they carry on avoiding movements because of pain – and remain just as disabled as they were before being told hurt doesn’t equal harm. I wonder if we need to substitute fear of harm with fear of experiencing pain – because it seems to be the fear that pain may overwhelm that the people I work with are hoping to avoid. This is one reason I’m considering using the Pain Anxiety Symptoms Scale, because I think it may capture that part of the fear/anxiety dimension that is not being caught by the TSK.
Flink, I., Boersma, K., & Linton, S. (2010). Catastrophizing moderates the effect of exposure in vivo for back pain patients with pain-related fear European Journal of Pain, 14 (8), 887-892 DOI: 10.1016/j.ejpain.2010.02.003