Fear and avoidance drive chronic pain. But what exactly are we afraid of?
I want to try and tease this apart, conceptually. Its important to identify the fear precisely, so it can be neutralized, and so we can design the right learning experiences to reduce the fear and avoidance.
Here is a 3-part framework for some main things we might fear regarding the pain:
- fear of what the pain means – cannot dance, run, etc.
- fear of the pain itself – the sensation itself being so awful and debilitating
- fear of bodily injury – if i bend, i will rupture a disc, tear a tendon, etc
(There is also fear of non-pain stimuli – emotions, relationships. This is a whole can of worms to be saved for another post.)
Exposures would be designed to promote learning about one (or more) of these, to reduce fear. We can learn that doing a certain activity is very likely not damaging the body, by seeing that the next day things are pretty much the same. And we can try to challenge thoughts about the meaning of pain – you CAN run and dance, along with pain. Somatic tracking is one way to reduce fear of the sensations themselves. But this can be tough especially when pain is high, because pain sensations really are very unpleasant (that is their point).
Curious what people think about this framework. And – if you have had pain – which of those 3 was your main fear? Or all the above?
I experienced all three at one time or another. I feared that the pain meant: I can’t work at the job I love, I can’t do the activities I used to enjoy, I might be in pain for the rest of my life. I feared the pain itself: I feel like pain became my identity for awhile. I feared bodily injury: I was told that my neck was so malformed that I was at risk for paralysis if I did anything to damage it further. So, no more advanced yoga, which I loved, motor boating, snowmobiling, or roller coasters. I also had a knee injury that I worried about exacerbating, so I was very careful not to do anything that might require too much knee involvement like skiing or playing basketball.
@Yoni_Ashar thank you for offering this opportunity. Yes, all three cycle in and out. Thoughts become ordinary and we are not aware of them. The fear thoughts can get caught into the ordinary (we have lots of stimuli, but when asked if we noticed something, we often can’t identify or recall it), especially when chronic. Once thoughts are brought into awareness, we can identify/categorize them (safe/not safe, pleasure/displeasure). Thoughts can be categorized in ways that are not useful for us (Tomato is considered a vegetable often, but it is really a fruit). When thoughts are identified, whether it be lifting something a different way or giving ourself a pep talk to push through, etc., we can than say, “I gotcha!” and categorize them as fear or repressive. Once we are aware and categorized, the fear may become neutralized. You can see an example in this series of videos…
Watch the first video: selective attention test - YouTube. Then watch the second video. The Monkey Business Illusion - YouTube
After the first video we become aware and categorize the lesson and then the second video shows how even though we became aware and categorized, (spoiler alert)….Added the note below so you can watch the video first without seeing the note. Ask yourself, where is it true that fear exists and then create an evidence list for each fear. Work towards proving that it is something that exists for you rather than asking if it is…
It happens again.
@Amanda_Hall this is a pretty cool convo you might appreciate.
I saw all of these types of fear when I was working more regularly in the clinic as a PT, especially fear of what the pain means. I think when I used to get back pain of my own in the clinic, I also had a fear of what the pain meant. I wanted to be good at my job, and felt that when the pain flared, it occupied so much of my mind that I wasn’t able to concentrate on working with patients and being my most competent self at work. And this activated a fearful cascade of its own adjacent to the pain.