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: