Understanding and Treating Fear of Pain

390 Pages·2004·1.34 MB·English

by  Gordon Asmundson

Understanding and
treating fear of pain
Gordon J.G. Asmundson
Johan W.S. Vlaeyen
Geert Crombez
Editors
OXFORD UNIVERSITY PRESS
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Understanding and treating
fear of pain
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Oxford University Press makes no representation,express or implied,that the
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Understanding and
treating fear of
pain
Edited by
Gordon J.G. Asmundson
Professor and Research Director
Faculty of Kinesiology and Health Studies
University of Regina
Canada
Johan W.S. Vlaeyen
Associate Professor
Department of Medical, Clinical, and
Experimental Psychology
Maastricht University
Netherlands
Geert Crombez
Professor of Health Psychology
Faculty of Psychology and Educational Sciences
Ghent University
Belgium
1
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1
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Dedications
To Karen and Graham,for being such vibrant and colourful siblings—
G.J.G.A.
To Nicole,Yana,and Jolinde,most precious people in my life—J.W.S.V.
To Lien,Jana,and Ewout,as evidence that thinking can lead to something
you can see and touch—G.C.
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Foreword
Kenneth D. Craig
Professor of Psychology
Senior Investigator
Canadian Institutes of Health Research
University of British Columbia
Bottom line:Embracing the innovative understanding ofpain and the related
healthcare interventions carefully described in this volume would lead to dra-
matic improvement in care provided to people suffering or disabled by pain.
Put in less scholarly terms:“Warning! Failure to heed the messages in this vol-
ume leads to unnecessary suffering.”
This outburst ofintemperate,non-academic language is provoked by the
gravity ofthe problem.Acute pain is virtually inevitable and universal;while it
almost always can be controlled through pharmacological and psychological
interventions,under-management ofpain is commonplace and anxiety,fears
of pain,avoidance behavior and related psychological states can render an
individual’s stress unmanageable.Another serious problem is pain that per-
sists beyond when healing would be expected ifthe pain had a basis solely in
tissue damage or disease.Chronic pain ofthis type is the focus ofthis book.At
least one in five persons suffers some form ofchronic pain requiring health
care or leading to personal or social distress and impairment.While many suf-
fer from injuries or diseases adequate to explain the suffering,explanations
grounded in physical pathology are inadequate for the majority ofpeople suf-
fering from chronic pain. The best medical interventions will have failed for
these people and there is likely to be mounting biological,psychological,and
social damage.These commonplace challenges ofacute and chronic pain con-
front all ofus,including our loved ones,and many members ofour commun-
ities.Thus,a sense of urgency to improve pain control reasonably reflects
self-interest,altruistic concern for others,and an appreciation of the enor-
mous health care system costs ofthis major public health problem.Innovative
approaches to pain and pain management must be taken seriously.
One could ask,does the volume represent a novel perspective on pain
capable ofsatisfying the needs ofmany ofthese unhappy people? The answer
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viii FOREWORD
is decidedly yes ifthe question refers to a remarkably well developed,original
synthesis ofresearch and theory incorporating both clinical and basic science
issues as well as evidence-based assessment and treatment strategies and tools.
The answer perhaps would be no if one were asking whether recognition
ofthe role fear plays in pain were novel.Emotions were recognized as power-
ful features of pain in ancient writings.However,only in recent decades,
culminating in the current surge ofinterest,have resources been devoted to
understanding their important role or have methodologies been developed for
clinicians concerned about controlling destructive fear and anxiety that com-
monly is the root ofpain related disability.Fortunately,the concepts have cap-
tured the attention ofclinical investigators long enough for controlled trials
demonstrating the effectiveness ofinterventions focusing specifically upon
fear-avoidance and related psychological processes.These are well described in
this volume.
A deliberate focus on understanding and controlling emotional processes
rather than sensory features ofpain stands in contrast to widespread conven-
tional approaches to pain.Definitions typically characterize pain as a subjec-
tive experience with sensory and affective features,but there is a widespread
tendency to focus upon sensory qualities.This resonates with most peoples’
personal experiences ofpain,as they are commonly perceived as sensations
arising from injury or disease,although even cursory discussions with people
about pain rapidly lead to an examination offeelings,thoughts,and personal
and social consequences.Reinforcing the focus on pain as a specific sensation
was the major surge ofenthusiasm for biomedical research discoveries in the
19th and 20th Centuries.Studies ofanatomy,physiology,and chemistry were
remarkably successful in helping us understand peripheral mechanisms of
pain,with these leading to an appreciation ofspinal cord processes.The neuro-
science approach became progressively more reductionistic,with molecular
biology and biopharmacological sciences enjoying great strength at present.
Unquestionably,there have been tremendous breakthroughs in the under-
standing ofbasic mechanisms responsible for nociception in the past several
decades.One also can have confidence that the genome project,protein map-
ping,molecular structure calculations and the like will continue to yield
extremely important information about how pain works.
Surprisingly however,neuroscience advances in understanding pain have
not justified the considerable optimism that the discoveries would lead to
novel classes of analgesic drugs.They have not translated into dramatic
improvements in pharmacological control ofpain—opioids and drugs related
to salicylic acid (aspirin,etc.) have remained the mainstay analgesic drugs
and their properties have provided the basis for practically every pain reliever
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FOREWORD ix
available.Unfortunately,these are insufficient,as the legion ofchronic pain
sufferers attests.The current armamentarium ofpain drugs does not provide
wholly adequate analgesia.There are substantial individual differences in how
people respond to specific analgesics,certain forms ofpain are not responsive
to the usual analgesics,for example,neuropathic pain,and side effects are often
unpleasant,ifnot dangerous,e.g.,gastric lesions arising from salicylates.As
well,many people suffer from unrecognized,poorly assessed,under-estimated,
and inadequately controlled pain because the complex social structures
designed to provide care are often unduly preoccupied with biomedical man-
agement.Advances in care will arise from attending to psychological and
social features ofpain,including those related to the concerns delineated at
the beginning ofthe previous sentence.
Models of pain that include consideration of the social contexts of pain,
cognition,and emotional processes,particularly fear and anxiety,improve
control by introducing novel interventions that focus upon these features of
pain.They reflect an appreciation ofcentral and higher order,divergent and
interactive brain mechanisms that for long remained elusive,in part because
research methodologies did not lend themselves to investigation ofbrain sys-
tems.Brain imaging technologies are now beginning to provide insights into
the brain mechanisms responsible for the complexities ofthe biological sys-
tems that regulate the multiple cognitive,affective and sensory features ofpain
experience.Ofcourse,it is no surprise to the health care practitioner already
familiar with the complexities of pain that both distributed and sequential
brain activities are engaged or that the substantial individual differences in the
experience of pain are associated with variations in brain activity.It would
have been surprising if this were not the case.There clearly is a lot to be
learned about the biological systems that subserve fear ofpain,pain-related
anxiety,catastrophic thinking,attentional mechanisms related to pain,etc.,
but studies focusing upon behavioral outcomes have provided a good under-
standing ofthe functions biological systems must serve.
In part,the advances in understanding and controlling pain described in
this volume reflect a willingness to address uniquely human capabilities.
There is great merit in a detailed understanding ofevolved nociceptive sys-
tems in progenitor nonhuman animal species that are well-conserved in
humans.But,evolution produced a different animal in Homo sapiensand the
unique features ofhuman biology and its expression in experience and behav-
ior must be considered.Innate mechanisms acquired in hominidancestral
environments included the remarkable human capabilities for social learning
and the martialing ofresources available through the use ofcomplex social
systems.“Medically unexplained pain”,a concept that applies to most chronic