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