A 2015 study of 36 chronic pain patients sought to explore the causes of pain-related fear in the hopes of contributing to research that might help practitioners develop avoidance models in the future. The study found that the most common cause of pain-related fear is its inexplicability and unpredictability—because patients could not make any reasonable sense of when their pain would occur or how to control it, they experienced the potential of future pain as a threat and limited their physicality in response to their anxiety.
The authors of the study examined three sets of patients: those who were fearful due to diagnostic uncertainty; those who feared their pain symptoms were a sign of damage or impending damage to their bodies and who faced confusion as to how to ‘fix’ their problem and; those who reached out to healthcare providers due to the loss of function (ability to complete tasks) they had experienced because of their pain, but whose treatments had failed to restore their full functionality. These patients were therefore unable to make sensible decisions about how to function to avoid or lesson their pain.
Subjects involved in the study were adult general practitioner, chiropractor, physiotherapy, or pain clinic patients between the ages of 18-65 years. Each of the subjects had experienced intense lower back pain for a minimum of six months. Patients with spondylolisthesis, radicular pain caused by nerve compression, and pregnant women were excluded from the study. Those with particularly high pain-related fear, as determined by their scores on the administered TSK questionnaire, were included in the study. The average age of the study participants was 42 years, and the subjects were 69 percent female. The typical subject had been experiencing pain for around seven years and had high (47/68) TSK scores.
The patients conducted taped interviews in their homes or by telephone, which were immediately transcribed. The researchers sought to identify and understand the overarching theme common to most patients with pain-related fear. Using an agreed-upon system of inductive coding, the study researchers were able to determine a common theme in all three subtypes of pain-related fear subjects: the inability of understand or make sense of their own pain.
Across all three groups of the study’s participants, it was the unpredictability of lower back pain that created the most anxiety and affected the day-to-day physical and psychological existence of patients. Negative past experiences, the fear of suffering and a loss of functionality, and repeated failure of practitioners to control their pain all contributed to the patients’ inability to make sense of their pain, which increased their anxiety and fear. Not knowing when or how the pain might be triggered, how long it would last, what, exactly, was the cause of, or whether they would be able to find sufficient relief from their pain to function caused fear in pain patients and altered how they went about their daily lives. A poor understanding of diagnostic ‘jargon’ also contributed to the patients’ fear of injury and pain, in particular when they were diagnosed with a condition such as disc degeneration from which there was no ‘cure.’
Discussion & Implications
Because people with chronic pain they cannot understand may be more likely to catastrophize their symptoms, which can lead to increased pain-related fear and a possible increase in the pain itself, the study’s authors suggest it could be helpful for practitioners to improve methods of pain control and patient-education about the causes and possible consequences of their pain. Doing so could empower chronic pain-suffering patients by allowing them to better make sense of their pain.
Targeted interventions designed to help patients understand their pain could be effective in reducing pain-related fear. Improvement of pain control measures, a reduction in the pain’s intensity, and better methods of predicting pain could help reduce the vicious cycle of pain-related fear and fear-induced pain. Cognitive functional therapy could help control pain and lesson the anxiety associated with the unpredictability of pain.
The study’s authors suggest practitioners query their pain patients regarding the previous experience with pain to determine appropriate intervention strategies that will replace negative associations with more optimistic expectations regarding therapeutic outcomes.