Fear Increases Pain, But There’s Something We Can Do About It

chronic pain

Pain

Studies dating back more than a decade have revealed that fear of pain is a prognostic factor in chronic pain. That is, fear of pain and severity of pain are very much linked. This can create avoidance behaviour that, though helpful in the short term, can “become a maladaptive response leading to increased fear, limitation of activity, and other physical and psychological consequences that contribute to disability and persistence of pain [1].” A recent study has revealed that there is something we can do about this though, and the key lies in understanding the very thing we fear.

Contemporary fear-avoidance models, backed by research, have shown us that a cognitive shift takes place during fear invoked by pain, and this can enhance threat perception “further feeding the catastrophic appraisal of pain, avoidance activity, and disability.” Additionally, if a person is prone to catastrophic interpretations of pain (i.e. extremely negative experiences and attitudes involving pain), this can induce physiological, cognitive and behavioural fear responses [1].

Fear of pain therefore becomes a physical phenomenon, not just a mental and emotional one.  Sean McKey (MD, PhD, and author of a 2006 Stanford study on the pain-fear relationship) stated [2]:

“I can tell you as a pain doctor that fear is the No.1 issue that I deal with in helping people to better manage their chronic pain…I have a strong believe that fear and anxiety play a significant role in how we perceive pain and how we all perceive pain differently.”

A study co-authored by McKey found a high correlation between the Fear of Pain Questionnaire (a measurement tool used in the study) and the activity of the area of the brain that regulates and evaluates responses to pain. McKey and colleagues also found a high correlation between the Anxiety Sensitivity Index (another measurement tool in the study) and “the medial prefrontal gyrus—the region of the brain involved with self-focused attention about, or reflection on, one’s own body. In other words, it’s the area that searches for things that are wrong [2].”

Since then, the greater study of pain has gone on to confirm the role of fear in chronic pain. This brings us to the 2015 study that shows us a little of what we can do about it. The study took 36 chronic pain patients and explored the causes of pain-related fear. It found that “the most common cause of pain-related fear is its inexplicability and unpredictability [3].”

The study examined three groups of patients. The first group comprised those who were fearful due to “diagnostic uncertainty.” The second group was made up of those who “feared their pain symptoms were a sign of damage or impending damage” and experienced confusion as to how to fix the problem. The third and final group were those who had consulted healthcare providers due to the loss of function their pain caused, but whose treatments had failed to restore full function. All participants in the study experienced chronic, non-specific low back pain. They all experienced pain that was intense, unpredictable and difficult to control [4].

The authors of the study remarked that, “the overarching theme was a LBP [low back pain] experience that did not make sense. For all participants, the experience of LBP as unpredictable, uncontrollable and/or intense made it threatening to them.” This, as we have seen from previous studies, had the potential to increase their perception of pain.

In discussing the clinical implications of the study, the authors highlighted the importance of considering the beliefs and underlying fears of the individuals and “provide targeted interventions to help them make sense of their pain.”

“Individuals presenting with damage beliefs are likely to benefit from an acceptable, individualised, biopsychosocial understanding of [chronic non-specific low back pain] using unambiguous language [4].”

They also highlighted the importance of asking about past health experiences, including what they had been told about their condition, and remarked that linking pain-control strategies with functional goals was also a positive strategy in managing pain-related fear. They also cited research establishing the role of cognitive therapies in pain management.

It appears that the more we can reduce the fear, the more we can empower patients to make better sense of their pain the limitations it actually presents them with (as opposed to the limitations that are assumed because of fear and lack of information).

It is a small study, and not without its limitations in terms of pain-measurements. But it does show us the powerful role that brain and belief play in managing and perceiving what is going on in the body.

References

[1] Turk D, Wilson H (2011), “Fear of Pain as a Prognostic Factor in Chronic Pain: Conceptual Models, Assessment, and Treatment Implications,” Curr Pain Headache Rep. 2010 Apr; 14(2): 88-95 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2872063/ retrieved 8 June 2017

[2] White T (2006), “People who fear pain are more likely to suffer it,” Standford News, http://news.stanford.edu/news/2006/february1/med-anxiety-020106.html retrieved 8 June 2017

[3] Fryer J (2017), “Study finds understanding their pain may help lessen fear in patients,” Dynamic Disc Designs, https://dynamicdiscdesigns.com/pain-may-help-lesson-fear-patients/ retrieved 8 June 2017

[4] Bunzli S, Smith A, Schutze R, O’Sullivan P, (2015) “Beliefs underlying pain-related fear and how they evolve: a qualitative investigation in people with chronic back pain and high pain-related fear,” BMJ Open,  http://bmjopen.bmj.com/content/bmjopen/5/10/e008847.full.pdf retrieved 8 June 2017

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