Pain-Related FeaR Exposure-Based

Treatment of Chronic Pain

by Johan W.S. Vlaeyen, Stephen J. Morley, Steven J. Linton, Katja Boersma, and Jeroen de Jong

Pa

in-R

ela

te

d F

ea

R

VlaeyenMorleyLinton

Boersmade Jong

Many people with chronic pain avoid activities that they fear may result in harm. This book provides a guide to the treatment of pain-related fear based on the principles of exposure. International experts provide practical advice on assessment, treatment goals, and graded-exposure behavioral experiments that may be easily applied in routine clinical practice.

“This is the definitive handbook on fear avoidance. It is essential reading for all clinicians and researchers in the field and will serve as an excellent text for students learning how to apply exposure-based treatments for chronic pain. A tremendously valuable contribution!” Warren Nielson, PhD, St. Joseph’s Health Care, London, ON, Canada

“This book is an indispensable tool for clinicians and researchers interested in how pain-related fear affects pain and disability. It is loaded with practical tips on how to assess and treat pain-related fear. The authors have played a key role in the development and testing of both assessment and treatment approaches.” Francis Keefe, PhD, Duke University, Durham, NC, USA

Johan W.S. Vlaeyen, PhD, is a professor in Research Group Health Psychology, Faculty of Psychology and Educational Sciences, University of Leuven, Belgium and in the Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, The Netherlands

Stephen J. Morley, MPhil, PhD, is a professor in Clinical Psychology, Institute of Health Sciences, University of Leeds, and Department of Clinical Health Psychology, St James’ University Hospital, Leeds, United Kingdom.

Steven J. Linton, PhD, is a professor in the Center for Health and Medical Psychology, Örebrö University, Örebrö, Sweden

Katja Boersma, PhD, is a lecturer in the Center for Health and Medical Psychology, Örebrö University, Örebrö, Sweden

Jeroen de Jong, PhD, is a researcher, movement scientist, and behavior therapist at the Department of Rehabilitation, Maastricht University Hospital, Maastricht, The Netherlands

9 780931 092879

9 0 0 0 0ISBN 978-0-931092-87-9

International Association for the Study of Pain

Pain-Related Fear

Mission Statement of IASP Press®Th e International Association for the Study of Pain (IASP) brings together scientists, clinicians, health care providers, and policy makers to stimulate and support the study of pain and to translate that knowledge into im-proved pain relief worldwide. IASP Press publishes timely, high-quality, and reasonably priced books relating to pain research and treatment.

Pain-Related FearExposure-Based Treatment

for Chronic Pain

IASP PRESS® ♦ SEATTLE

Johan W.S. Vlaeyen, PhDResearch Group Health Psychology, Faculty of Psychology and Educational

Sciences, University of Leuven, Belgium; Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University,

Th e Netherlands

Stephen J. Morley, MPhil, PhDInstitute of Health Sciences, University of Leeds, and Department of Clinical

Health Psychology, St James’ University Hospital, Leeds, United Kingdom

Steven J. Linton, PhDCenter for Health and Medical Psychology, Örebrö University, Örebrö, Sweden

Katja Boersma, PhDCenter for Health and Medical Psychology, Örebrö University, Örebrö, Sweden

Jeroen de Jong, PhDDepartment of Rehabilitation, Maastricht University Hospital,

Maastricht, Th e Netherlands

© 2012 IASP Press®International Association for the Study of Pain®All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher.

Timely topics in pain research and treatment have been selected for publication, but the information provided and opinions expressed have not involved any verifi cation of the fi ndings, conclusions, and opinions by IASP®. Th us, opinions expressed in Pain-Related Fear: Exposure-Based Treatment for Chronic Pain do not necessarily refl ect those of IASP or of the Offi cers and Councilors.

No responsibility is assumed by IASP for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or ideas contained in the material herein. Because of the rapid advances in the medical sciences, the publisher recommends that there should be independent veri-fi cation of diagnoses and drug dosages.

First printing, 2012Cover design by Lori Wardian

Library of Congress Cataloging-in-Publication DataPain-related fear : exposure-based treatment for chronic pain / Johan W. Vlaeyen ... [et al.]. p. cm. “International Association for the Study of Pain.” Includes bibliographical references and index. ISBN 978-0-931092-87-91. Chronic pain--Psychological aspects. 2. Chronic pain--Treatment. 3. Pain--Treatment. 4. Anxiety--Treatment. I. Vlaeyen, Johan W. S. (Johan Wolfgang Silvain), 1957- II. Interna-tional Association for the Study of Pain. RB127.P3385 2012 616’.0472--dc23 2012028388

Published by:IASP Press®International Association for the Study of Pain111 Queen Anne Ave N, Suite 501Seattle, WA 98109-4955, USAFax: 206-283-9403www.iasp-pain.org

Printed in the United States of America

v

ContentsContents of Book

Preface vii1. Th e Context of the Fear-Avoidance Model 12. Pain-Related Fear in Chronic Pain 253. Selection and Assessment 474. Essential Guide to Treatment 675. Obstacles and Challenges 956. Evaluating Graded Exposure as a Treatment 1157. Experimental Single-Case Series 1298. Randomized Controlled Trials 1599. Future Directions 171Index 187

Contents of DVDTh erapist Materials1. Understanding Behavioral Experiments2. Behavioral Experiment Form3. Guidelines for Behavioral Experiments4. Complicating Factors of In Vivo Exposure Treatment

Patient Materials5. General Information6. Th e Vicious Cycle7. Patient Information About Treatment8. Understanding Behavioral Experiments 9. Strategies for Preventing a Relapse

Videos1. Intake2. Education Session3. Establishing a Fear Hierarchy4. Exposure in Behavioral Experiments: Climbing Stairs5. Exposure in Behavioral Experiments: Lifting6. Exposure in Behavioral Experiments: Bicycling7. Evaluation of the Exposure Treatment

vii

PrefaceTh e idea for this book began with a conversation between two of us (Johan Vlaeyen and Stephen Morley) about how to disseminate the treatment based on the fear-avoidance model that had been developed in Maastricht (the Netherlands) by Johan Vlaeyen, Jeroen de Jong, and their colleagues, and further tested by the Örebro group (Steven Linton, Katja Boersma, and their colleagues) in Sweden. Th e Maastricht group had developed a manual for use in a randomized controlled trial [1], but it was only avail-able in Dutch [2], and Morley asked whether an English version was avail-able. Our initial thought was simply to prepare a translation of this manu-al, but we were aware that many clinicians who might be interested in the treatment might also value a more extended introduction to the theoreti-cal basis of the treatment. When we discussed the idea further, we added a wish list that included providing users with guidance on how to evaluate their own implementation and some resources to use. Hence, the idea for this book was born.

We are grateful to IASP for taking on the project, and we thank the the IASP publications staff for their great patience and understanding, especially Elizabeth Endres and Kathy Havers and latterly Ivar Nelson in the IASP offi ce, and Cathy Bushnell and Maria Adele Giamberardino as the IASP offi cers.

Th e project has had a longer gestation than we initially planned because we “slightly” overestimated the demands placed on each of us. Morley drafted chapters 1, 6, 7, and 8, and Vlaeyen drafted chapters 2, 3, and 4. Boersma drafted chapter 5 and SL chapter 9. Each chapter was commented on and contributed to by all authors. de Jong’s invaluable hands-on clinical expertise not only enabled him to make major contri-butions to the text but can also be seen on the accompanying DVD. His immense clinical skill makes treatment look unbelievably simple. We ask readers not to be deceived by appearances. If you do decide to introduce the methods reported in this text, we strongly advise that you work as a team and receive supervision from a qualifi ed cognitive-behavioral thera-pist who has experience of behavioral exposure in clinical settings.

It is not surprising that learning theory models of fear and avoid-ance have dominated the fi eld of psychopathology in relation to phobias,

[1] Leeuw M, Goossens ME, van Breukelen GJ, de Jong JR, Heuts PH, Smeets RJ, Koke AJ, Vlaeyen JW. Exposure in vivo versus operant graded activity in chronic low back pain patients: results of a randomized controlled trial. Pain 2008;138:192–207.

[2] Leeuw M, Vlaeyen JWS, de Jong JR, Goossens MEJB. Behandelprotocol exposure in vivo bij chronische lage rugpijn. Amsterdam: Boom; 2006.

viii

anxiety, obsessive-compulsive behavior, and related problems. But until recently, fear-avoidance has been far from mainstream thinking about how to provide treatment for chronic pain patients. When Vlaeyen and Morley were discussing the book project, we noted that each of us had been infl uenced by a signifi cant fi gure in this fi eld. Vlaeyen had spent a year with the late Bill Fordyce in Washington in the 1980s and had been profoundly infl uenced by his powerful concepts and ideas. Fordyce was not only a superb mentor, but taught us—among many insights—the cru-cial diff erence between “hurt” and “harm” with respect to chronic pain. Often patients who experience pain avoid physical activity as they are con-vinced that the pain associated with movement signals the presence of bodily damage. Although not recognized by many, one of the strengths of Bill Fordyce’s clinical approach was his ability to use metaphors in his educational session with patients to elucidate the mechanisms of learn-ing. For example, Bill talked about the painful movement of the arm after successful healing of a bone fracture to illustrate that pain can be a result of muscle weakness (immobility due to the cast) rather than injury. We decided to extend Fordyce’s work in identifying such fear of movement and injury as a primary issue in chronic pain management, and design a treatment systematically targeting these fears. Morley completed his PhD studies under the guidance and tutelage of Clare Philips, who had begun to apply ideas of fear-avoidance initially in the fi eld of headache and then more generally. Her kindly infl uence has for many years remained a model of how to stimulate and supervise students.

Our respect for both Bill and Clare is immense, and as an expres-sion of deep appreciation we would like to dedicate this book to the mem-ory of the late Bill Fordyce and to Clare Philips. Th ank you, both of you.

We would also like to thank all of our colleagues and members of the interdisciplinary treatment teams we have successfully worked with over the past few years. We are grateful for the fruitful collabora-tions and numerous and inspiring discussions. We also thank our patients with chronic pain for their confi dence and for their help in developing the exposure in vivo treatment, even they may not have been aware of their contribution. Vlaeyen was supported by the Odysseus Grant “Th e Psy-chology of Pain and Disability Research Program” funded by the Research Foundation, Flanders, Belgium (FWO Vlaanderen), and by the University of Leuven Center of Excellence on Generalization Research in Ill Health and Psychopathology (GRIPP).

Johan W.S. Vlaeyen, Stephen Morley, Steven J. Linton,Katja Boersma, and Jeroen de Jong March 2012, Leuven, Leeds, Örebro, and Maastricht

Preface

16 J.W.S. Vlaeyen et al.

Nevertheless, it is often clinically advantageous to plan treatment using a hierarchy of fearful situations.

An Outline of the Fear-Avoidance Model of Chronic PainTh e fi nal strand of current CBT in chronic pain is the application of the fear-avoidance model. Fordyce noted the importance of avoidance, and papers began to explore the relationship between fear, avoidance, and pain in the 1980s. Based on previous work [29,38,49], the development of the fear-avoidance model largely mirrored developments occurring else-where, as outlined in Vlaeyen and Linton’s initial statement of the model [48]. Th e basic fear-avoidance conditioning model specifi c for movement and pain is shown in Fig. 2. Generally, two components are distinguished, a classical component and an operant component. Th e classical compo-nent refers to the process in which a neutral stimulus receives a negative meaning or valence. Th e person learns to predict events in his/her en-vironment. An injury elicits an automatic response such as muscle ten-sion and sympathetic activation including fear and anxiety. An external

Classical conditioning component

Operant conditioning component

CRSympathetic activation:

fear,anxiety,

muscle tension

RAvoidant pain behavior:

“I can’t have pain,” grimacing,resting, taking leave from work

Sd/CS

SRReinforcementvia reduction offear/anxietyrelated tension

Fig. 2. Classical (Pavlovian) and operant conditioning components in the fear-avoidance model. Redrawn from Vlaeyen and Linton [48].

18 J.W.S. Vlaeyen et al.

confrontation and avoidance, and presents possible pathways by which injured patients get caught in a spiral of increasing avoidance, disability, and pain. Th e model predicts several ways in which pain-related fear can lead to disability as follows: (1) negative appraisals regarding pain and its consequences, such as catastrophic thinking, are considered a potential precursor for pain-related fear; (2) fear is characterized by escape and avoidance behaviors, the immediate consequences of which are that daily activities (expected to produce pain) are not accomplished, and avoidance of daily activities results in functional disability; (3) because avoidance be-haviors occur in anticipation of pain rather than in response to pain, these behaviors may persist because there are fewer opportunities to correct the (wrongful) expectancies and beliefs of pain as a signal of threat to physical integrity; (4) longstanding avoidance and physical inactivity has a detri-mental eff ect on the musculoskeletal and cardiovascular systems, lead-ing to the so-called disuse syndrome, which can further worsen the pain problem. In addition, avoidance also means the withdrawal from essential reinforcers, increasing mood disturbances such as irritability, frustration, and depression. Both depression and disuse are known to be associated

Injury

Recovery

Pain Catastrophizing

Nega ve AThreatening Illness Informa on

No Fear

Confronta on

Pain ExperiencePain-Related

Fear

AvoidanceHypervigilance

DisuseDepressionDisability

Fig. 3. Simple schematic representation of the fear-avoidance model. Redrawn from Vlaeyen and Linton [48].

48 J.W.S. Vlaeyen et al.

Specifi c Questionnaires to Assess Fear or Anxiety in Relation to PainQuestionnaires can off er a quick and robust method for the initial screening of potentially suitable patients. In addition, questionnaires are often used to measure the outcome of treatment. We have used them for both of these purposes. Several questionnaires that measure fear of pain-related activity have been developed. Th e major ones are shown in Table I, which also includes sample items. Generally, these measures can be grouped into three classes as follows: those that measure attitudes about pain, those that measure catastrophizing about pain, and those that measure pain-related fear.

Attitudes About PainAn early attempt to assess fear of pain is the Pain and Impairment Re-lationship Scale (PAIRS), developed to study attitudes of patients with chronic pain concerning activity and pain [27]. Th e scale has 15 items that are rated on a 7-point Likert scale, and it has been found to have good psychometric characteristics. Th e original study demonstrated that beliefs that activity would increase pain were related to physical im-pairment. Th e Survey of Pain Attitudes [15] was developed to assess pa-tients’ attitudes toward the following fi ve dimensions of the chronic pain experience: pain control, pain-related disability, medical cures for pain, solicitude of others, and medication for pain. Th e authors added a fur-ther subscale (harm) based on their clinical observations of an associa-tion between chronic patients’ hesitancy to exercise and the expressed fear of possible injury. In addition to the Disability and Control scales, the Harm scale appeared to independently predict levels of dysfunc-tion. Th ese questionnaires have good psychometric qualities in that they show high internal consistency, good test stability, and indications of va-lidity. Th ey are specifi cally focused on the central component of the fear-avoidance model, that is, the catastrophic appraisal of the relationship between activity and anticipated harm. Although we have tended not to use these questionnaires, there are occasions (see Chapter 6) where we have taken specifi c items from the questionnaires to construct a measure for use in a particular study.

60 J.W.S. Vlaeyen et al.

interviews, it is not always possible to cover the questions in the order given in Box 1 because patients often need to tell their clinical story in their preferred manner. With practice, it is possible to retain the essential contents of the questions in Box 1 and to map the patient’s answers onto the fear-avoidance model.

Developing Graded HierarchiesOnce we have established the applicability of the fear-avoidance model for a patient, we need to determine more precisely the essential stimuli that elicit the perception of threat and avoidance behaviors. Thus far, there are no standardized questionnaires for identifying these stimuli that are early in the chain of events leading to avoidance and protective safety behavior. Often, the stimuli are those that were immediately fol-lowed by the aversive event during the onset of pain, if such an onset can be recollected. In our experience, it is often difficult for patients with pain to estimate and report the threat value of different situations. One of the problems is that the avoidance behaviors are not really ac-knowledged as consequences of fear but as a direct consequence of

Injury“Cause”

Pain Catastrophizing

Negative AffectivityThreatening Illness Information

Pain ExperiencePain Related

Fear

AvoidanceHypervigilance

DisuseDepressionDisability

1

2

3

4

5

6

7 8

10

9

11

12

14

13

14

15 16

Expectationsof Treatmentand Recovery

Fig. 1. Th is fi gure shows the relationship between the questions in Box 1 and a simple schematic representation of the fear-avoidance model.

Essential Guide to Treatment 69

Graded Activity, In Vivo Exposure, and Behavioral ExperimentsIn Vivo Exposure Versus Graded ActivityAt fi rst glance, in vivo exposure might appear quite similar to the more widely applied graded activity programs [20,28], in that it gradu-ally increases activity levels despite pain. However, both conceptually and practically, these treatments are quite diff erent (see Table I). First, graded activity is based on instrumental (operant) learning principles, and selected behaviors are shaped by positively reinforcing a predefi ned quota of activities (for more information on graded activity, see [19,38]). In vivo exposure, which stems from the behavior therapy tradition, is

Table I Differences between graded activity, in vivo exposure, and behavioral experiments

Graded Activity In Vivo ExposureBehavioral Experiments

Theoretical basis

Operant conditioning. Changing pain-rest contingencies to reduce disabling pain behaviors and increase healthy behaviors

Respondent conditioning. Extinction of conditioned fear responses via exposure to the conditioned stimulus (e.g., physical activity) in the absence of the unconditioned stimulus (e.g., increased pain, physical harm)

Challenging cognitive “errors”

Treatment goal

To increase function despite pain by increasing/shaping healthy behaviors

To increase function by reducing pain-related fear and avoidance behaviors

To increase function by changing beliefs and correcting cognitive errors

Treatment preparation

Establishment of activity tolerance levels and identification of discriminative stimuli eliciting pain behaviors

Establishment of a pain-relevant fear hierarchy

Cognitive analysis of the pain-related beliefs

Typical treatment techniques

Positive reinforcement of successive approximations to preset functional goals

Graded exposure to fear-eliciting painful activities

Hypothesis testing via manipulation of patients’ own behavior

Essential Guide to Treatment 75

with a medical specialist. Th e purpose of this consultation is to explain to the patient that they have probably overestimated the value of these tests and that in symptom-free individuals, similar abnormalities can also be found. In this context, informing patients about study fi ndings that reveal

Dialog Box 1(TH = Therapist, PA = Patient)

TH: You just talked to the physician about the medical tests that were carried out a week ago. Can you tell me more about that?

PA: Well, we both looked at the scans, and they appeared less alarming than I thought. Apparently there are no fractures, and no trapped nerves. The doctor said that the scans show some wear and tear, but that this is not unusual for a person of my age.

TH: How was it for you to hear this information?

PA: Well, some relief because there is nothing dangerous going on. At the same time, diffi cult to understand … because why is it that I have so much pain and cannot walk or lift properly? There must be some reason.

TH: In people suff ering from chronic pain such as yourself, it is not unusual to see that the medical diagnostics are quite normal and that there are no signs of physical damage.

PA: Are you suggesting that my pain is all imagined?

PAIN

UNKNOWNCAUSE

THOUGHTS

FEELINGS

BEHAVIOR

CONSEQUENCES

Physical weakness.No fun in Life.Financial problems.

My vertebrae are damaged. If I’m not careful, I could become paralyzed and end up in a wheelchair.

Tense. Worried. Worthless.

Stop working.Take rests.See doctors.Avoid lifting heavy loads.

Fig. 1. Diagrammatic formulation for George.

Johan W.S. Vlaeyen, PhD, is a professor in the Research Group Health Psychology, Faculty of Psychology and Educational Sciences, University of Leuven, Belgium, and at the Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, Th e Nether-lands. He received an honorary doctorate from Örebro University, Sweden. His research interests include the aff ective and motivational mechanisms of task interference due to persistent pain. Vlaeyen and his team developed exposure-based therapy for patients with chronic pain. Th ey have conducted randomized controlled trials as well as replicated single-case experiments to evaluate the eff ects of behavioral interventions in chronic pain.

Stephen J. Morley, MPhil, PhD, is a professor of clinical psychology and di-rector of the clinical psychology training program at the Institute of Health Sciences, University of Leeds, United Kingdom. He is also a practicing clini-cal psychologist at St James’ University Hospital, Leeds. His research inter-ests include the eff ects of pain on self-identity and the development of clinical methods for evaluating the eff ectiveness of psychological treatments for chronic pain. He is section editor of the European Journal of Pain

Steven J. Linton, PhD, is professor of clinical psychology at the School of Law, Psychology, and Social Work and research director of the Center for Health and Medical Psychology (CHAMP) at Örebrö University, Örebrö, Sweden. His research interests include the role of psychological factors in sleep disorders, ways to match psychological interventions to the specifi c needs of patients with chronic pain, and behavioral therapies for restoring function and quality of life in patients with disability from persistent musculoskeletal pain.

Katja Boersma, PhD, is associate professor at the School of Law, Psychol-ogy, and Social Work and a researcher at the Center for Health and Medical Psychology, Örebrö University, Örebrö, Sweden. Her research interests include biopsychosocial aspects of pain, including fear-avoidance and catastrophizing.

Jeroen de Jong, PhD, is a movement scientist, behavior therapist, and re-searcher at the Department of Rehabilitation, Maastricht University Hospital, Maastricht, Th e Netherlands. Along with Vlaeyen, de Jong is recognized as one of the founders of graded exposure in vivo therapy in chronic pain.

Pain-Related FeaR Exposure-Based

Treatment of Chronic Pain

by Johan W.S. Vlaeyen, Stephen J. Morley, Steven J. Linton, Katja Boersma, and Jeroen de Jong

Pa

in-R

ela

te

d F

ea

R

VlaeyenMorleyLinton

Boersmade Jong

Many people with chronic pain avoid activities that they fear may result in harm. This book provides a guide to the treatment of pain-related fear based on the principles of exposure. International experts provide practical advice on assessment, treatment goals, and graded-exposure behavioral experiments that may be easily applied in routine clinical practice.

“This is the definitive handbook on fear avoidance. It is essential reading for all clinicians and researchers in the field and will serve as an excellent text for students learning how to apply exposure-based treatments for chronic pain. A tremendously valuable contribution!” Warren Nielson, PhD, St. Joseph’s Health Care, London, ON, Canada

“This book is an indispensable tool for clinicians and researchers interested in how pain-related fear affects pain and disability. It is loaded with practical tips on how to assess and treat pain-related fear. The authors have played a key role in the development and testing of both assessment and treatment approaches.” Francis Keefe, PhD, Duke University, Durham, NC, USA

Johan W.S. Vlaeyen, PhD, is a professor in Research Group Health Psychology, Faculty of Psychology and Educational Sciences, University of Leuven, Belgium and in the Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, The Netherlands

Stephen J. Morley, MPhil, PhD, is a professor in Clinical Psychology, Institute of Health Sciences, University of Leeds, and Department of Clinical Health Psychology, St James’ University Hospital, Leeds, United Kingdom.

Steven J. Linton, PhD, is a professor in the Center for Health and Medical Psychology, Örebrö University, Örebrö, Sweden

Katja Boersma, PhD, is a lecturer in the Center for Health and Medical Psychology, Örebrö University, Örebrö, Sweden

Jeroen de Jong, PhD, is a researcher, movement scientist, and behavior therapist at the Department of Rehabilitation, Maastricht University Hospital, Maastricht, The Netherlands

9 780931 092879

9 0 0 0 0ISBN 978-0-931092-87-9

International Association for the Study of Pain