assessment of fear avoidance in chronic pain - dr johan w s vlaeyen
DESCRIPTION
Lecture given to the North British Pain Association on 16th May 2008 by Dr Johan Vlaeyen. In this talk, Dr Vlaeyen discusses the mechanisms, assessment and treatment of fear avoidance in patients with chronic pain. Edinburgh, UK. www.nbpa.org.ukTRANSCRIPT
Assessment of Pain-related Fear in Chronic
PainJohan W.S. Vlaeyen, PhD
Pain and Disability Research ProgramUniversity of Leuven, Belgium
Maastricht University, Netherlands
Edinburgh, Scotland 16 May 2008
Northern British Pain Association
• Pain: a mental representation• The threat value of pain• Management of pain-related fear• Effectiveness• Conclusion
Overview
Traditional Disease Model
Stimuli Behaviour
- 25o
Arntz & Claasens, PAIN 2005
++++ ++ Pain ratings:Mediation: perceived harmfulness
A
Very cold
B
Very hot
Info:
First Conclusion …
Stimuli Behaviour
Mental representation of stimulus
• Pain: a mental representation• The threat value of pain• Management of pain-related fear• Effectiveness• Conclusion
Overview
Pain urges to avoid/escape
Catastrophic interpretations of pain
• I continuously wonder whether the pain will stop
• I think this is terrible and it will never get any better
• I become afriad that the pain will increase• I wonder whether something serious might
happen
When I am in pain…
Pain Catastrophizing Scale
Sullivan et al, 1995
Pain, 2006
Catastrophic interpretations of pain
Catastrophizing
Fear
How does fear of pain develop?
Ivan Petrovich Pavlov (1849-1936)
Associative Learning
US: Food salivation
CS: light
CR:UR:
Meaning
Pain
Mental representatio
n of Pain
Disuse
Nociception
US
Interoception Proprioception Exteroception
CS Defense
Arousal Attention Avoidance
CR
Meaning
Mental representatio
n of Pain
Disuse
Defense
Arousal Attention Avoidance
CR
CS
Kinesiophobia
Acquisition
Threat: shock
Safe: no shock
Bradley et al, PAIN, in Press
Test
1. Arousal
Test
2. Fear directs attentional focus
a. Body Scanning
b. Selective Attention
c. Problems Disengaging from source of threat
Crombez, Van Damme and Eccleston
0
20
40
60
80
100
120
140
160
180
Lifting time
low fearful
high fearful
Avoidance behavior
Secs.
*
0
10
20
30
40
50
60
baseline exposure
Low fearful
High fearful
Subjective tension
VAS
*
3. Escape and Avoidance behavior
Vlaeyen et al., Pain, 1995
Vlaeyen & Linton, Pain, 2000
Catastrophic misinterpretations
DISUSE
INJURY/STRAIN
PAINDEFENSE
AVOIDANCEATTENTION
DISABILITY
Fear-Avoidance Model
• Pain: a mental representation• The threat value of pain• Management of pain-related fear• Effectiveness• Conclusion
Overview
Meaning
Mental representatio
n of PainCS
Kinesiophobia
Exposure in vivo with response
prevention
Fear-Avoidance Model: Clinical applications
a.Educate about paradox of safety seeking behaviors
b.Activate fear network
c.Challenge expectancies with behavioral experiments
Vlaeyen et al., CJP 2002
M o v e m e n t A : t o e t o u c h
M o v e m e n t B : s t r a i g h t l e g r a i s i n g
1 2 3 4
1 2 3 4
O r d e r c o u n t e r b a l a n c e d : A A B B o r B B A A
Crombez et al, Health Psychology, 2002
Bas
elin
eP
AIN
Exp
ecte
dP
AIN
Exp
erie
nced
PA
IN
First trial
Second trial
2. Fear hierarchy
Exposure in vivo in chronic pain
3. Education
4. Exposure in vivo
1. Treatment Goals
http://www.psychology.unimaas.nl/phoda-sev/
• Pain: a mental representation• Pain urges to escape• Management of pain-related fear• Effectiveness• Conclusion
Overview
0
2
4
6
8
10
Baseline Exposure Exercise
0
2
4
6
8
10
Baseline Exposure Exercise
Clin J Pain, 2002
0123456789
10
A B C X F
0123456789
10
A B D X F
EDU EXPOS EDU EXERC
Clin J Pain, 2005
012345678910
A B C D
fear pain push the baby buggy lift a child
0
10
20
30
40
50
60
Baseline POST Follow-up
EXPGA
Threat value of movements
P < .001
0
10
20
30
40
50
60
Baseline POST Follow-up
EXPGA
Functional disability
P = .088
Pain, in press
Pain, in press
Acquisition – Extinction Assymetry
Acquisition: learning new rules Extinction:
learning exceptions to
the rule
Understanding and treating fear of pain. Asmundson GJG, Vlaeyen JWS, Crombez G. Oxford: Oxford University Press, 2004.ISBN 0 19 8525141.
Conclusions
• Pain-related fear is a normal response to longlasting pain
• Fear-related defensive responses may have paradoxical effects
• Other goals may overule this primary goal
• Multiple goals may lead to conflicting responses
Maastricht (NL):Madelon PetersLinda van CleefKaroline van GronsveldJeroen de JongHanne KindermansMaaike LeeuwIlse SwinkelsJeanine VerbuntMarielle GoossensSaskia NijstSaskia RansonPetra KarsdorpMartien SchrootenLeuven (B):Steven de PeuterIlse van DiestOmer van den Bergh
International:Geert Crombez, BelgiumStephen Morley, UKMick Sullivan, CanadaGordon Asmundson, CanSteven Linton, SwedenKatja Boersma, Sweden
Teamwork: