Fear-Avoidance of Pain

There’s a divide between chronic pain experts and their patients that rarely gets crossed. The divide centers on the issue of fear-avoidance. On one side of the divide, among chronic pain experts, fear-avoidance is one of the most well established facts about chronic pain and chronic pain-related disability. Over more than a decade, researchers and clinicians have extensively studied fear-avoidance and almost every month another study on it gets published in the professional journals. As such, it’s a well established fact among chronic pain experts. On the other side of the divide, it’s rare to find a chronic pain patient who has ever heard of it.

It’s a strange state of affairs that goes on between chronic pain providers and their patients. We know something important about chronic pain and chronic pain-related disability and our patients don’t know it. And yet, it goes unsaid. You’d think that everyone involved would want it shared. But, still, it doesn’t.

While I’ve never seen a study that could shed light on why the divide occurs, I have some thoughts about it. There are actually two reasons, but they go hand in hand.

First, we don’t share what we know about fear-avoidance because we aren’t very good at teaching patients (and maybe even the public) about what chronic pain is. Patients (and the public) commonly consider the sensation of pain as solely and only a physical sensation. As such, it’s thought that psychological aspects have very little to do with the sensation of pain itself. At most, the psychological aspects of pain are thought of as consequences of pain – that the distressed thoughts and moods, like fear, and the behaviors that go along with them are really just reactions to the physical sensation of pain. As chronic pain experts, though, we know that it isn’t true. While it requires and involves a physical sensation, to be sure, the experience of pain also inherently involves unpleasant and distressing thoughts, feelings, and behaviors. Any explanation of fear-avoidance requires this understanding of chronic pain – that it is more than simply and only a physical sensation. However, it is hard to communicate this notion. It’s difficult to teach patients to expand their understanding of chronic pain and incorporate its inherent cognitive, emotional, and behavioral components. Moreover, besides being hard to communicate, it has to be communicated well – with compassion and sensitivity — in order for most patients to succeed in understanding the true nature of chronic pain. This point leads us to the second reason for the great divide between chronic pain experts and their patients.

Second, to be frank, there can be a little pushback from patients when it comes to explaining that chronic pain is more than simply a physical sensation and that it in fact involves psychological as well as medical aspects. Frank discussion of the inherent psychological aspects of chronic pain can tend to get inhibited because it opens up the possibility of critical judgment and stigma by others. It’s safer to insist that chronic pain and its related difficulties are solely and only physical because in our society it is acceptable if you struggle with a medical condition. It’s not acceptable to acknowledge that you’re psychologically struggling. Consequently, and understandably, patients can resist coming to understand how chronic pain is inherently both a medical and a psychological condition – what healthcare providers call a biopsychosocial condition.

This resistance reinforces any unwillingness of healthcare providers to bring up the notion of fear-avoidance because it assumes a foundational understanding that chronic pain is both a medical and a psychological condition. To convey the latter, though, as indicated, it’s hard work. To succeed in doing so, it requires a high level of skill on the part of healthcare providers – a degree of interpersonal compassion and sensitivity. It also involves a level of interpersonal skill on the part of the patient – the ability to develop a safe, trusting relationship in which the patient can be assured that no critical judgment will occur.

Fear-avoidance is therefore a sensitive issue, which challenges the skills of both chronic pain experts and patients, if we are to ever bring it up. We have to admit that providers have a hard time talking about it and patients tend to have a hard time hearing about it. So, we avoid the topic. It’s a bit ironic: we avoid discussions of fear-avoidance. The great divide in knowledge and understanding subsequently continues.

If you’re game to talk about it, though, I’m game. Let’s give it a try.

There’s significant benefit if we can pull this off. As chronic pain experts, we know that fear-avoidance is one of the most important factors that lead to chronic pain-related disability (Crombez, Vlaeyen, Heuts, & Lysens, 1999; Leeuw, et al., 2007; Vlaeyen & Linton, 2012). If you can learn about it, and acknowledge it when it occurs, then you can begin to challenge it and change it. It’s not an exaggeration to say that overcoming fear-avoidance is essential if you want to self-manage pain successfully. It’s really that important. So, let’s talk about it. Ready?

Fear-avoidance defined

Pain is a naturally unpleasant and distressing experience. We don’t laugh or jump up and down for joy when in pain. Rather, we cry and become alarmed. Pain captures our attention and our thoughts become concerned about it. We think about what’s causing it and how to get rid of it. Emotionally, we are alarmed and distressed. These cognitive and emotional aspects to the experience motivate us to get help, stop the pain, and avoid it again in the future.

These ways of experiencing pain and reacting to it are not chosen or the result of intentional decisions. When in pain, we don’t intentionally decide to perceive it as unpleasant or distressing, and subsequently begin to cry and emotionally become alarmed. Moreover, we don’t typically choose how we are going to think about pain and how we might make sense of it. Rather, pain just is inherently emotionally distressing and alarming. As such, even though we can tend to think of it as solely a physical sensation, we cannot wholly divorce the sensation of pain from how we perceive it, cognitively and emotionally. The cognitive and emotional distress is just part and parcel of the experience of the sensation. The whole experience also involves behaviors that are indicative of being in pain – the grimacing, verbal expressions, guarding, and the like. None of these behaviors are typically thought of as chosen behaviors. Subsequently, we might say that all these cognitive, emotional, and behavioral aspects to the experience of pain are automatic or reflexive.

Let’s take an example. Consider what happens when you burn your hand on the stove. Behaviorally, you reflexively pull your hand away and guard it. Tears might come to your eyes and you might exclaim all sorts of utterances. Cognitively, your thoughts are focused on the pain and what to do about it. Emotionally, you are upset and alarmed. Your emotional distress motivates you to act. It also motivates you to be careful next time. Later, you’ll apt to be apprehensive and take steps to avoid getting burned again.

Experts in chronic pain management call this constellation of cognitive, emotional, and behavioral components to the experience of pain, “fear-avoidance.”

Fear-avoidance is all well and good in an acute injury. It’s an adaptive and helpful response. It helps us to get better and avoid future injury.

What’s good for an acute injury, however, is not always good for chronic pain. Persistent fear-avoidance in chronic pain leads to persistent emotional distress and impairments in activities. In other words, chronic fear-avoidance is one of the most important factors that lead people with chronic pain to become disabled.

If, like the alarming nature of acute pain, chronic pain remains alarming indefinitely, then the natural reaction to pain is to always try to stop it or get rid of it. Since, though, the pain is chronic, there’s not much the typical chronic pain patient can do to stop it. Of course, there are medications and various kinds of therapies, but at best these approaches only reduce pain. It can then seem like the only thing that’s left to do is to stop doing activities that make pain worse.

If work makes your pain worse, and you struggle to tolerate it, coming home distraught by the pain night after night, then it can seem reasonable to conclude that maybe you shouldn’t go to work anymore. If the pain of sitting in the bleachers at your child’s sporting event or musical performance was too excruciating the last time you went, then you might find yourself making the tough decision to stay home tonight instead. Over time, you can come to anticipate when pain is going to become too overwhelming and consequently avoid those activities too. You end up declining invitations to the extended family reunion, the weekend trip that includes the long car ride, the outing to the amusement park, or other similar activities. All these examples are examples of fear-avoidance of pain and its associated activities.

Notice that inherent in all these examples is that pain is something that’s concerning and distressing, which then leads to not doing the activities that bring on pain. For after all, if, when doing some activity, the pain wasn’t alarming, then we’d say the pain was tolerable and we’d keep doing the activity. The pain would still be there, of course, but we’d do the activity without any concern or sense of alarm about it. In the examples above, though, the pain involved in the activities is distressing and alarming and so the activities are stopped. In the short hand of pain experts, these examples involve fear-avoidance of pain and the activities associated with pain.

What it all comes down to is that, when it comes to chronic pain-related disability, the cognitive, emotional, and behavioral aspects of the experience of pain are the most important components, not the actual physical sensation. It’s the sense of alarm that is the tipping point and stops people from doing things. Of course, the sensation plays a role, but without the sense of alarm – the cognitive and emotional ways of perceiving the sensation – the sensation itself would be tolerable and there’d be no need to avoid or otherwise stop the activity.

Now, here is where patients can start to get a little uncomfortable.

Common patient reactions to the notion of fear-avoidance

When first hearing about fear-avoidance, a common reaction among patients is something like the following: “It’s not my emotional or behavioral reactions to pain that disable me, it’s the physical pain!” The sentiment involves a concern for being judged and also being a little put off. Both sentiments are understandable.

At the end of the day, though, is it accurate and is it necessary? Would the patient be better off by coming to understand the truth about fear-avoidance and then learning how to overcome it? Let’s take a close look at these issue.

As suggested above, the point of the resistance to fear-avoidance is really two-fold, but they go hand in hand. First, it is an assertion about what pain is – that pain is a physical sensation that is wholly different from any cognitive, emotional, and behavioral factors related to pain. Second, it is an assertion that if psychological aspects of the experience of pain are acknowledged, then they open up chronic pain patients to the potential shame of stigma and the critical judgments of others. The two assertions work hand in hand because insistence on the notion that pain is solely and only a physical sensation puts it into the medical category of conditions and it is typically socially acceptable to be disabled from medical problems. But, if we acknowledge that there are psychological aspects to the pain experience, then we run the risk of putting it into the psychological category of conditions, and it just isn’t acceptable to be disabled by psychological problems.

As we said, it’s a sensitive issue.

Any response to this common patient reaction requires, not only an expert understanding of what chronic pain is, but also a deep level of compassion and sensitivity in order to convey this understanding to patients, making it okay enough for them to acknowledge and learn from.

Let’s try to show how it might just be true that the psychological aspects of the experience of pain are more important than the physical sensation, especially when it comes to chronic pain-related disability.

Consider, for the moment, two patients with chronic low back pain, Mr. Smith and Ms. Jones. Let’s further suppose that they each have the same exact degenerative changes in their lumbar spine, as evidenced by recent scans. Over the last month, each of their pain has been worsening.

Mr. Smith has been told and therefore believes that the degenerative changes in his spine are inevitably progressive. He conceptualizes his condition as that his ‘discs are degenerating.’ He believes (and may have been told) that given the degenerative nature of his condition he will likely end up in a wheelchair someday. During the last month, his pain has been worsening and he takes it as evidence of his inevitably degenerating condition. This perception of his pain is alarming. Out of this resultant fear, he responds with rest and inactivity. From his perspective, it makes all the sense in the world to rest and remain inactive. Given his understanding of his pain as the result of a fragile orthopedic condition that is inevitably getting worse, he reasons that he needs to not engage in activities as a means to prevent, or at least slow down, the degenerative process in his spine. Just as you wouldn’t walk on a broken leg, rest and not doing too much seems like the best approach for his condition. He rates his pain as intolerable.

Ms. Jones has been told that she has degenerative changes in her spine, but she has also been told it is normal for a person of her age. It was explained to her that the term ‘degenerative disc disease’ is actually a misnomer and that we now know it really isn’t degenerative or a disease. We know, for instance, that most of the time degenerative changes of the spine get better, not worse, and even in those situations where they don’t get better, they almost always stay the same. It was explained to her that chronic pain is actually a complex condition and that her pain is only partly attributable to her stable degenerative changes in spine. The overall state of her nervous system, in terms of central sensitization, and external stressors, can also play a role in maintaining her chronic pain.

Ms. Jones has taken these lessons to heart and is confident that she knows what her pain is and that it is chronic and stable. She has so fully accepted it that it no longer alarms her. She knows that reasonable activities are not going to make her stable degenerative changes worse. She’s identified for herself that if she stays home when having a bad pain day she has nothing to do but focus in on how much pain she has. As a result, her response to pain is to get up and go do something. Of course, she’s reasonable about it and she paces herself when needed. Nonetheless, she sees staying active and productive as ways to cope with pain. Because she knows her degenerative condition is stable, she reasons that the increase in pain over the last month isn’t due to a worsening of her spinal condition and subsequently looks to other reasons for the pain increase. She recognizes that the increase in pain corresponds, for instance, to the last few months of poor sleep and, sometimes, outright insomnia. She knows that her poor sleep is itself due to the stress of some recent family issues — one of her children is going through a difficult divorce and her grandson, from another one of her children, was recently diagnosed with autism. She recognizes that her increased pain is due to the stress of these family issues and the resulting insomnia. So, she sets out to take better care of herself and manage her stress better. She notes that her pain has increased but it still remains tolerable.

Mr. Smith and Ms. Jones have the same degenerative condition and, we assume, the same physical sensation. However, how they make sense of it is very different. How they feel about it is very different. How they behaviorally cope with it is very different. Mr. Smith experiences pain through the lens of it being indicative of a threatening condition that’s inevitably going to bring about severe impairments. Ms. Jones sees her pain as indicative of a benign and stable condition. She also recognizes that she has some control over how much pain she has by managing the state of her nervous system and how much stress she has. Mr. Smith sees his pain as largely out of his control. Mr. Smith’s moods are mostly fear-based. Ms. Jones is mostly confident. Mr. Smith engages in passive coping strategies of rest and inactivity. Ms. Jones engages in active coping strategies of remaining active, productive, and often getting out of the house. Mr. Smith experiences his pain as intolerable. Ms. Jones still rates her pain as tolerable, even though it has increased over the last month.

Mr. Smith, we might say, is fear-avoidant. Ms. Jones is not.

While hypothetical, the case examples show how it is possible that the psychological components to the experience of pain can make all the difference. The physical sensation, we assume, remains constant across both individuals. However, the beliefs about the sensation, the quality of the attention given to it, the mood states that occur during the sensation, and the behavioral responses to it, all have a reciprocal affect on the quality and intensity of the overall experience of pain.

In one instance, these psychological components make the pain intolerable and impairing. In the other instance, the psychological components make the pain tolerable and she refrains from becoming disabled.

A vast array of experimental and clinical research supports our hypothetical cases. Of course, a review of the biopsychosocial nature of chronic pain is beyond the scope of this blog post. I’d refer the reader, though, to any of the numerous reviews of the matter (e.g., Bushnell, Ceko, & Low, 2013; Linton, 2000). You’ll find that beliefs, particularly beliefs of the threatening nature of pain, can influence the self-rated unpleasantness and intensity of pain (Gracely, et al., 2004). It’s well established that people rate their pain as worse when they believe it’s somehow threatening to them, than if they believe it’s benign, even when the painful stimuli is held constant across both groups. You’ll find that it is well established that pain is worse when your attention is focused on it than when your attention is distracted (Bantick, et al., 2002; Eccleston & Crombez, 1999). It’s well established that people with negative mood states will have higher pain ratings than people with more positive mood states, again, even when the painful stimuli is held constant (Tang, et al., 2008; Villemure & Bushnell, 2009; Wiech & Tracey, 2009; Wiech, Ploner, & Tracey, 2008). It’s also well established that people who engage in passive coping strategies, such as rest and inactivity, tend to have higher rates of pain and disability than those who don’t (Jensen, Turner, Romano, & Karoly, 1991; Samwel, Evers, Crul, & Kraaimaat, 2006).

In all, there’s just no getting around the fact that the nature of chronic pain is such that it has both physical and psychological aspects inherent to it. The notion that pain is solely a physical sensation that can be wholly divorced from cognitions, emotions, and behaviors is just not true. In fact, like in the case of fear-avoidance, the psychological components can make all the difference in what makes pain tolerable or not.

As chronic pain experts, we need to find a way to routinely educate patients and the public about the true biopsychosocial nature of chronic pain. We also need to be able to do it well – with compassion and sensitivity. We need to understand why patients might tend to resist what we take as established truth. It’s because of stigma. It’s because in this day and age it is still not socially acceptable to see chronic pain as a psychological condition, even if it is only in part psychological. We need to be able to develop trusting relationships where the truth can be told and discussed, and patients remain accepted and respected.

Patients too need to practice having the ego strength to acknowledge this truth and do so without shame. You don’t have to buy relief from stigma by insisting on something that’s not true – the belief that chronic pain is solely and only a physical sensation that is separable from any psychological factors. The challenge is to practice remaining confident that you are doing nothing that’s worthy of criticism. We might rightfully judge and criticize someone who lies, cheats, or steals. But, we don’t judge or criticize those who struggle to cope with any of life’s psychological problems, chronic pain included.

Indeed, if we all could overcome stigma, then healthcare providers could openly talk about the well established psychological aspects of chronic pain, such as fear-avoidance, and our patients could openly hear it. Together, we could make significant progress in helping people to learn to live well despite having chronic pain. In so doing, we could bridge the divide that has prevented us from acknowledging what we all know is true.

References

Bantick, S. J., Wise, R. G., Ploghaus, A., Clare, S., Smith, S. M., & Tracey, I. (2002). Imaging how attention modulates pain in humans using functional MRI. Brain, 125(2), 310-319.

Bushnell, M. C., Ceko, & Low, L. A. (2013). Cognitive and emotional control of pain and its disruption in chronic pain. Nature Reviews Neuroscience, 14(7), 502-511.

Crombez, G., Vlaeyen, J. W., Heuts, P. H., & Lysens, R. (1999). Pain-related fear is more disabling than pain itself: Evidence on the role pain-related fear in chronic back pain disability. Pain, 80(1), 329-339.

Eccleston, C. & Crombez, G. (1999). Pain demands attention: A cognitive-affective model of the interruptive function of pain. Psychological Bulletin, 125(3), 356-366.

Gracely, R. H., Geisser, M. E., Giesecke, T., Grant, M. A., Petzke, F., Williams, D. A., & Clauw, D. J. (2004). Pain catastrophizing and neural responses to pain among persons with fibromyalgia. Brain, 127(4), 835-843.

Jensen, M. P., Turner, J. A., Romano, J. M., & Karoly, P. (1991). Coping with chronic pain: A critical review of he literature. Pain, 47(3), 249-283.

Leeuw, M. Goossens, M. E., Linton, S. J., Crombez, G., Boersma, K., & Vlaeyen, J. W. (2007). Fear-avoidance model of chronic musculoskeletal pain: Current state of scientific evidence. Journal of Behavioral Medicine, 30(1), 77-94.

Linton, S. J. (2000). A review of psychological risk factors in back and neck pain. Spine, 25(9), 1125-1156.

Samwel, H. J., Evers, A. W., Crul, B. J., & Kraaimaat, F. W. (2006). The role of helplessness, fear of pain, and passive pain-coping in chronic pain patients. Clinical Journal of Pain, 22(3), 245-251.

Tang, N. K., Salkovskis, P. M., Hodges, A., Wright, K. J., Hanna, M., & Hester, J. (2008). Effects of mood on pain responses and pain tolerance: An experimental study in chronic back pain patients. Pain, 138(2), 392-401.

Vlaeyen, J. W. & Linton, S. J. (2012). Fear-avoidance model of chronic musculoskeletal pain: 12 years on. Pain, 153(6), 1144-1147.

Villemure, C. & Bushnell, M. C. (2009). Mood influences supraspinal pain processing separately from attention. Journal of Neuroscience, 29(3), 705-715.

Wiech, K., & Tracey, I. (2009). The influence of negative emotions on pain: Behavioral effects and neural mechanisms. NeuroImage, 47(3), 987-994.

Wiech, K., Ploner, M. & Tracey, I. (2008). Neurocognitive aspects of pain perception. Trends in Cognitive Sciences, 12(8), 306-313.

Author: Murray J. McAllister, PsyD

Date of last modification: 9-9-2013

How People Cope with Pain Really Well: 2

In the last post, we started a discussion about how people cope with chronic pain really well. Specifically, we looked at five attributes and skills that people do when coping well with chronic pain. The point of the discussion was that it is a way to learn how to cope better. Coping with chronic pain is a set of skills like any other set of skills and you learn how to cope with pain just like you learn other skills – like learning how to knit or play the piano or play tennis. If you wanted to learn how to play the piano really well, you would do a number of things (such as take piano lessons), but one of the most important things is that you would study those who are better than you. You would play their recordings and listen and watch how they do it. You would then try to do what they do. The same can be true with learning how to better cope with pain. With this idea in mind, we looked at five attributes and skills that people do when they cope with pain really well.

These five things were the following:

  • Being open to change and learning from others
  • Accepting that chronic pain is chronic
  • Focusing on self-management
  • Engaging in a mild, low-impact aerobic exercise on a regular basis
  • Understanding the relationship between pain and stress, and managing stress well

These are things that people do when coping really well with chronic pain.

Lets look at five more attributes and skills that make for good coping. As we do, remember one more thing from the last post. It was the discussion about how there is no shame in acknowledging that you can learn to cope with pain better. All skills, including the skills of coping, can be seen as on a spectrum for which there is no point at which you are as good as you ever will get. Rather, if you take any skill imaginable, you can always get better at doing it no matter how good you are at it. Any guitar player can get better with learning and practice – even rock and roll superstars. Any tennis player can get better too – even the pros. Similarly, anyone with chronic pain can learn to cope better — no matter how good you are at it. So, there is no shame in acknowledging that you can learn a thing or two. You are in the same boat as everyone else. So, let’s look at five more ways to cope better with chronic pain.

1. People who cope really well don’t react to their chronic pain as if it is acute pain.

If you accidentally stepped into a hole and broke your ankle, the pain of the broken ankle would be considered acute pain. The normal reaction to such an injury would be to become alarmed, seek help, stop using the ankle, stay at home, and rest. With the pain of acute injuries, such as a broken ankle, this set of reactions would not only be normal but largely helpful. Generally, a broken ankle gets put into a brace or cast and we are told to stay off it. By doing these things, we allow the bone fracture to heal. Subsequently, the pain goes away. As such, this set of reactions to acute pain is a good thing.

However, what’s good for acute pain is not good for chronic pain. The normal sense of alarm that goes along with being in pain becomes problematic when occurring on a chronic basis. It can become any number of negative emotions, such as fear, anxiety, irritability, and even depression. The normal reaction of resting becomes problematic too when done on a chronic basis. While resting can help an acute injury, it can make chronic pain worse. Your body is made to move and if you don’t use it for too long you get stiff, achy, and sore. It’s not just you. It’s true for everyone of us. We also get out of shape and gain weight when we are inactive for too long. Becoming de-conditioned in these ways can make pain worse too. Staying home and resting for too long also leads to what healthcare providers call “fear-avoidance.” Fear-avoidance is the cycle of avoiding activities out of concern that the activities will increase pain. Any number of normal activities of daily life can increase pain and so it can become easy to stop doing them out of anticipation that they will cause pain. When done in response to acute pain, it might be helpful. When done on a chronic basis, it’s one of the ways pain can become disabling. Moreover, staying home and not doing your normal daily activities for too long can lead to becoming chronically bored or aimless or depressed. In all these ways, responding to chronic pain as if it is acute pain becomes problematic.

People who cope with pain really well make the transition in their understanding that their pain is no longer acute pain but chronic pain. They know what their chronic pain is and are no longer alarmed by it. They understand that chronic pain is a nervous system condition and not a long-lasting orthopedic injury. They understand that engaging in normal activities won’t make the nervous system condition worse, as it might if it was an acute orthopedic injury, like a bone fracture. Consequently, they no longer become alarmed that they will make the underlying condition worse when they do normal activities of life.

Now, of course, their pain might be worse when they do things, even if it doesn’t make the underlying nervous system condition worse. However, they recognize that not doing things makes their pain worse too. Staying home and resting doesn’t serve a useful purpose when done on a long-term basis. So, people who cope with pain well respond to their pain by saying, “I got to get up and do something!” or “I’ve got to get out of the house or else I’ll go stir-crazy!” That is to say, they react to their chronic pain in ways that are almost opposite to how you normally react to acute pain.

People who cope with pain well have gotten back into the normal activities of their lives despite the pain because the pay off is that it leads to improved coping. They are no longer bored or aimless or depressed. They are getting things done, checking things off their lists, and even having fun on occasion. Because they are doing these things, they feel productive. They feel like they are going somewhere and have a direction again to their life. Their self-esteem is on the rise. In all these ways, they are now coping better and their improved abilities to cope buffer the increased pain they may have from doing these activities.

2. People who cope with pain well pace their activities.

Having gotten back into the normal activities of life, people who cope with pain well are reasonable about how much they do. They do some things, but not everything. They break up a large activity or their entire ‘to do’ list into manageable size chunks. Referring to the story about the tortoise and hare, they might joke that their motto is “slow and steady wins the race.” That is to say, they have overcome any tendencies to engage in what psychologists call “all-or-nothing” approaches to life.

Additionally, they are reasonable about what they do, and not just how much they do. They might not expect to be able to water ski or dirt bike race. Nonetheless, they make it a point to still do a lot of fun things.

3. People who cope well with pain overcome any perfectionist or workaholic tendencies they may have had.

Perfectionists and workaholics get a lot of kudos in our society. They get a lot done and what they do they do very well. Employers love them and reward them for it. So, if you are a perfectionist or workaholic, it may have gotten you far before the onset of chronic pain. However, now that you have chronic pain, perfectionism and workaholism are problematic.

Perfectionism and workaholism are problematic in many ways. First, perfectionists and workaholics engage in “all-or-nothing” thinking and as such tend to struggle with pacing themselves. If they have a good day in terms of their pain level, they clean, not just the kitchen, but the entire house. As they do, they might say to themselves, ‘If you are going to do it, do it right or not at all.’ However, their strict adherence to perfectionistic standards leads to exacerbating their pain through over-activity. Second, their ‘do it right or not at all’ attitude lends itself to the ‘not at all’ side of the equation because they have chronic pain and the pain makes it difficult to ‘do it right.’ Not doing things leads to all the problems described above – getting out of shape, weight gain, aimlessness, and more pain. Third, once they have stopped doing things, they are prone to self-criticism. Their perfectionistic standards are hard taskmasters. When they don’t live up to their standards, they get down on themselves. No one is harder on him- or herself than the perfectionist or workaholic. Such persistent self-criticism can lead to poor self-worth and depression. Fourth, perfectionism and workaholism tend to make people inflexible and poor adapters. We reviewed in our last post that one attribute of a good coper is someone who is flexible and can adapt. The ‘all-or-nothing’ thinking of the perfectionist or workaholic makes it hard to adapt and be flexible. They have difficulty finding the middle ground between their ‘either-or’ thinking. In all these ways, perfectionism and workaholism do not lend themselves to coping well with pain.

People who cope with pain well tend to have worked through their perfectionist and workaholic tendencies. With persistent effort and time, they have broken themselves of the habit of holding themselves accountable to perfectionistic standards. They have come to see that even before the onset of their chronic pain they never really did achieve those standards. Whatever they did, they could always find some fault or room for improvement. There was always something more on the list to do. It never really was a very good recipe for happiness. By overcoming perfectionism, they came to see that what they thought was happiness was really just temporary satisfaction. The feeling associated with a job well done lasted only as long as it took to move on to the next thing on the ‘to do’ list. And there was always more to do on the ‘to do’ list. So, people who cope with pain well have worked through these issues and no longer hold themselves to perfectionistic and workaholic standards.

4. People who cope with pain well maintain a regularly structured day.

Everyone has a routine. We typically go to bed and get up at more or less the same time each day. We typically eat our first meal in the morning, our second meal in the early afternoon, and our third meal in the late afternoon or early evening. We typically shower or bathe shortly after awakening or shortly before bed. Our typical daily chores and activities also follow a routine. We all do better when, more or less, we follow a routine.

Sometimes, of course, it’s fun to break up the routine. When we are on vacation, we enjoy the break in the routine. Right after retirement or obtaining disability, it is nice to have a break in our usual routines and many people have some fun with it.

However, if the break in the usual routine never returns to the normal routine or is never supplanted by a new routine, a couple of problematic things happen that reduce our abilities to function well in life. First, we become aimless. After awhile, we don’t know what to do with ourselves if we don’t have a focus for the day. Without a focus for our concentration and efforts, our attention tends to focus in on the problems of life. For those with chronic pain, our attention gets focused on pain and all the stressful problems associated with living a life in chronic pain. Second, we tend to start napping. Now, an occasional nap is fine, but when it starts happening everyday, it become problematic. It disrupts our nightly bedtime routines. It’s hard to fall asleep because of the nap earlier in the day. Once we start falling asleep later in the evening, we tend to start sleeping in longer and longer in the morning. In turn, this shift pushes the naptime later into the afternoon, which subsequently pushes bedtime later and later. As a result, a shift occurs in your sleep-wake cycle, sleeping more and more into the day and awake more and more at night. Chronic disruption in your sleep-wake cycle is a common cause of social isolation, aimlessness, persistent fatigue, and depression.

I often tell patients that we all need a reason to get up in the morning. We need to have some idea of what we are going to do with ourselves throughout the day. When, on a chronic basis, we don’t have any plans or routine to guide us through the day, then every moment requires a decision – “What am I going to do?” The question can become surprisingly hard to answer! It’s like when you were a kid during the last few weeks of summer vacation and you and the neighborhood kids have done everything you wanted to do; you sit around the house or backyard, staring at each other, asking, “What do you want to do? Oh, I don’t care, what do you want to do?” Back and forth it goes and boredom and aimlessness are the result. Routines serve the function of allowing us not to think so hard. We just know what we are supposed to do from one thing to the next. They keep our minds focused on getting things done, rather than becoming aimless or, worse yet, becoming focused in on all the problems of life while awake in the middle of the night when every one else is sleeping. That’s not what good coping looks like.

5. People who cope with pain well engage in a daily relaxation exercise.

Like mild aerobic exercise, a regular relaxation exercise is an essential component of successful self-management. People who cope with pain really well engage in both on a regular basis.

People commonly misunderstand the role of relaxation in pain management. They tend to think of it as something you do when experiencing a lot of pain in order to get through it. When they try it, it doesn’t work real well and so give up.

While a relaxation exercise can be done in the midst of a pain flare (think, for example, the deep breathing women learn for childbirth), relaxation for this purpose is a very difficult skill to achieve and it takes a lot of practice – more than most people are initially willing to do.

The most important reason a relaxation exercise is an effective treatment for chronic pain is that it is an intervention that targets the nervous system and reduces its reactivity over time. It’s more of a prevention type treatment than something you do in the midst of a pain flare.

Chronic pain is the result of the nervous system being stuck in a persistent state of reactivity that makes nerves highly sensitive to pain. As you know, any normal movement can be painful. Mild pressure like massage or even touch in the painful area of the body can feel painful. Of course, normal movements and massage and touch shouldn’t be painful, but they are because the nerves and the rest of the nervous system are stuck in a persistent state of reactivity, making the nerves in the painful area sensitive. It’s called central sensitization.

A daily relaxation exercise is one of many treatments for this condition. A relaxation exercise targets the nervous and relaxes it for a short period of time. After awhile, the nervous system returns to its high level of reactivity. If you do it again everyday, however, the nervous system begins to return to lower and lower levels of reactivity. As a result, you have less and less pain over time.

You are also more grounded and less stressed. As a result, you also tend to cope better.

A daily relaxation exercise is a two-fer: less pain over time and improved coping over time.

There are literally countless ways to get better at coping with pain. In this post, we reviewed five of them. We reviewed a different five ways in the last post. I intend to periodically review more ways to cope with pain on this blog.

 

Author: Murray J. McAllister, PsyD

Date of last modification: 9-27-2013