FAV

It seems obvious that something unpleasant is something to be avoided – and if we’re meant to avoid it, we’re likely to be just a little bit afraid of it. Yesterday I talked about health anxiety in general, and today I want to touch on a specific sub-group of health anxiety – pain-related anxiety.

Many people will be familiar with pain-related anxiety and avoidance, the model of so-called ‘fear avoidance’ that is a compelling explanation for how so many people become deactivated and disabled when they have persistent pain. It might be a surprise to some that the term ‘fear avoidance’ is actually not technically correct! There are two parts to the phenomenon: fear (or really, pain anxiety) and avoidance. It’s possible to be fearful or anxious about something but not avoid it – and it’s the avoidance part that creates the disability, which is why we are so keen to get people to DO things, even if they’re afraid.

If we look at yesterday’s post about anxiety, and review Beck’s cognitive model of anxiety, we can see that it’s really about how a person perceives a situation rather than the facts of a situation that is the problem in health anxiety. With an increased perception of the probability that something horrible will happen, multipled by the ‘awfulness’ factor we can begin to understand how some people will be really afraid of having pain. This is modifed by their personal resources and ‘rescue’ factors which might be things that other people do to reduce the person’s distress or decrease the ‘awfulness’ factor.

Pain anxiety is somewhat more problematic, IMHO, than general health anxiety. The reason being that so many conflicting messages are available in the community about having pain. It’s all around us that to have pain means ‘something is wrong’ – we’ve all grown up with this belief, developed through our own experiences with acute pain, and the media and almost all health care pushes the idea that we should not have to experience pain. Which is all very well except that it creates an unrealistic expectation for people who have persistent pain that doesn’t respond to pharmacology, surgery, injections or anything else that is ‘done to’ the person. Because like it or not, we don’t yet have all the answers to all the health care problems – just think of the common cold!

In the case of classic health anxiety, there is usually a nice clear-cut statement from a medical person that ‘there is nothing wrong’, health investigations are clear, there is nothing sinister going on, the person is not going to die from something nasty. In pain? Well all around us there are messages saying that ongoing pain is not OK, and it only takes one practitioner to suggest that there is some removable cause for their pain that will take the pain away for a person to start to worry again about their pain (and start looking for ‘the cure’).

It’s understandable. Pain isn’t pleasant – that’s part of the definition of pain! But people don’t die simply from having chronic pain. It can be depressing, distressing, and invade much of life, ruining the quality of life in many spheres – but many many people do cope well despite having pain, and have rewarding, fulfilling lives even though they have persistent pain.

The difference between being anxious about pain and living well with pain? Not so certain actually. We do know a lot about people who have pain and look for treatment. In fact, we know heaps about these people. We don’t know very much about people who don’t look for treatment simply because they don’t turn up at treatment centres. As a result, we don’t really know how people who live good lives despite their pain actually do so.

Maybe this group of people have developed ways of viewing their pain that reduces the ‘awfulness’ factor, maybe they have more resources, maybe they can be flexible about how they go about achieving what is important in their lives, maybe their goals are different, maybe they don’t have some of the vulnerability factors discussed in the paper I’ve identified today.

The fact is, we simply don’t know. Almost all our research on pain and coping is on people who are worried about their pain, anxious about it, and want it gone. Our treatments are based on models like Beck’s and Vlaeyen’s, that are developed from our understanding of people who don’t live well with their pain. So we focus on reducing the level of catastrophising, reducing the use of ‘safety behaviours’ and ‘checking’ and ‘reassurance’, increasing the use of active coping, help people confront what they fear and find out that it doesn’t make life unbearable and intolerable.

This paper by Carleton, Abrams and colleagues identifies that pain-related anxiety might be a separate type of fear that exists alongside other anxiety types – blood/needle phobia, panic, OCD and so on.

It might have taken a while to recognise it, but maybe it’s important to recognise that for a reasonably large group of people, having pain, or anticipating that pain will be experienced, is such an anxiety-provoking problem that this fear needs to be treated rather than the pain itself. This is why simply removing the pain doesn’t solve the problem – in the case of a simple phobia, just not being able to see a spider doesn’t remove the fear of there possibly being spiders under the bed, in the garden, in the shed! In fact, reassurance that there are no spiders doesn’t actually help if the person still looks for one. In the same way, removing pain through anaesthetic blocks or medication or even surgery doesn’t help if the person still fears having the pain – because they’ll be checking their body, any investigations and probably any other body sensations to try to make sure there is nothing going wrong. You can be sure that any slight change in body sensation will be monitored, and in someone who is anxious about having pain, be evidence that there is something wrong, eliciting all those worries and leading to avoidance.

What to do? Not sure yet – while we can help individuals, it only takes one person to re-establish that fear by inadvertently suggesting that ‘something is there’, or that pain ‘must be’ abolished – and the whole anxiety process starts again. More on this tomorrow!

Carleton, R., Abrams, M., Asmundson, G., Antony, M., & McCabe, R. (2009). Pain-related anxiety and anxiety sensitivity across anxiety and depressive disorders☆ Journal of Anxiety Disorders, 23 (6), 791-798 DOI: 10.1016/j.janxdis.2009.03.003

One of the biggest challenges when working with someone who is fearful of pain and avoids movement is that although it’s very much like any sort of phobia, it differs on one essential point: people who are spider phobic, socially phobic, fearful of flying or heights or whatever are usually aware at some level that their fear is out of proportion to the ‘real’ risk. People who are kinesiophobic (kinesio – movement, phobic – fearful) are much more likely to believe that their fear is realistic and to have their concerns about moving despite pain reinforced both inadvertently and deliberately by others (including health professionals!).

So, to introduce the idea of beginning to move despite fear of pain or harm requires a bit of a delicate touch!

Some people advocate ‘just tell them’, and spend a good deal of time going through a psychoeducational approach about the difference between hurt and harm until they believe they have convinced the person that it’s OK to move. And sometimes this does reduce the ‘threat value’ of pain.
But just as the spider phobic person (and I was one!) is not reassured by the knowledge that in New Zealand we have very few poisonous spiders, and the one or two we do have are quite rare, the person who is afraid of moving when they are sore can remain unconvinced and continue to avoid moving despite the best ‘information’ or education available.

So, what can you do?
Well, let me tell you how I’ve started working with my current client. The man I’m working with is in his late 20’s, he has a slight disc bulge in his lumbar spine, with little evidence of nerve compression, and he has a 12 month history of low back pain.

His back pain started after he lifted some timber at work, and tripped, falling onto his side with the wood on top of him. He has had a very thorough orthopaedic examination, been seen by a neurosurgeon who doesn’t want to pursue surgery because of the somewhat equivocal findings both neurologically and on imaging studies. He’s now being seen by me and a physiotherapist, and having his low mood treated with pharmacology. He uses paracetamol for pain relief but no other medications.

Functionally, he still has good power in his lower limbs, has no neurological findings, but his activity level and movement patterns are extremely limited. He sits for about 3 – 5 minutes before getting up and slowly stretching. He walks (albeit slowly) to keep comfortable, and can stand for only a few minutes before leaning or stretching.

He has completed a set of questionnaires, including the short version of the Tampa Kinesiophobia Scale, and his score on this questionnaire was well above the cut-off we use to identify those a risk of kinesiophobia.

When I completed the 99 picture PHODA with him, he indicated he would not attempt nearly 70 of the pictures, including any pictures of bending forward, twisting his trunk, jarring (eg going up and down stairs, or riding a bike over a kerb or using a mini-trampoline), carrying anything, or reaching above his head. In his daily activities, he is not working, he makes his bed (he has a duvet only), carries out his personal activities of daily living, but is otherwise either inactive (lying down to rest), or he walks.

He is living with family who are doing all of the household activities, so his responsibilities are very low. In addition, he is quite depressed although starting to look more future-oriented, he has an unsupportive family who are quite critical of his limitations despite carrying out his household responsibilities, and he has broken up from a long-term relationship about six months ago.

I started with using a motivational interviewing approach, and suggested we review some of the areas that other people often find helpful when they are thinking about managing pain. Using a menu of options, he identified sleep, medication use, relationships and work as his main concerns.

I asked him what he had found useful about previous therapies, and also what he had found not so helpful about those approaches. My aim was to help him identify that his previous attempts to control his pain by avoiding activities had not reduced his pain, and had increased the difficulties he faced living his life according to the values he holds.

I asked him whether he thought his movement patterns were helping him or whether there were some not so good features about the way he moved. He agreed that although sometimes it meant that he could avoid doing a movement that he thought increased his pain, for much of the time his pain remained and he had to keep on being ‘careful’ of any movements he did, and this was exhausting!

I then asked him how important it was to him to be able to return to normal activities even if it meant he needed to bring his pain along as well – and he indicated that it was very important. Using the ‘scaling questions’ (Why do you think it’s so important to you? Why give it a 9/10 and not a 6/10?), he told me that he thought his life was becoming very restricted, he wasn’t able to work, and he didn’t think there was going to be a medical way to reduce his pain.

I then went through his confidence that he would be able to carry out normal activities despite his pain, and he told me it was 3/10. Once again, using ‘scaling questions’, I asked him what it would take to help him move his confidence up a little, had he ever successfully made a change in his life despite it being quite hard, and he was able to talk about how he had worked his way up in the workplace despite not being a proficient reader, and that he knew he could make changes because if he took things one step at a time, he could see progress.

I then went through the PHODA pictures, and asked him which of the images he thought were most important for him to be able to do. He indicated that bending forward (eg to do dishes and clean teeth) was important, and also to put on shoes and pick things up from the floor.

I suggested to him that we weren’t sure why he thought he shouldn’t do these things, and asked him what went through his mind when he thought of himself doing these activities. He told me immediately that as he looked at photographs of people bending he could see himself falling forward and hitting the ground, or he could see his vertebrae grinding ‘bone on bone’ and see himself clutching his back because of the pain saying ‘I couldn’t cope with that sort of pain’.

Three things to note here:

the catastrophic image which generates an emotional response,
the misbelief that his vertebrae had no ‘padding’ so they were ‘grinding’ when he moved, and
the belief that he ‘couldn’t cope’ with high levels of pain

Each of these automatic thoughts/images are open to reappraisal, but unless they’re paired with actual movement, they are not likely to help him actually do things.

So – tomorrow I’ll discuss the next step in his programme: working towards ‘exposure’