Treatment of fear, anxiety, and avoidance

[David Baxter PhD]

Fear/Anxiety/Avoidance – treatments review
by adiemusfree, HealthSkills Weblog
Sept. 27, 2010

For years, clinicians working in pain management have mixed together a rich assortment of strategies to help people function better. But to identify the ‘active ingredients’ of multidisciplinary pain management using a cognitive behavioural approach, it’s been important to tease each element apart. One size does not fit all – and just as a physician chooses the most effective medication for a disorder, in time I hope we will be able to choose the most effective strategy for the problems each individual experiences rather than applying our current ‘scatter-gun’ approach.

Yesterday I gave a brief overview of the three main treatments to helping people who are fearful/anxious of their pain (or harm) and avoid activities as a result. They are:

1. Graded exposure in vivo
2. Graded activation or reactivation
3. Acceptance and Commitment Therapy

…and the combined or mixed sort of multi-modality approach used in most settings.

Bailey and colleagues have conducted one of the first reviews to summarise the effectiveness of these treatments. It’s too soon to carry out a full meta-analysis because so few of the published papers are RCT’s. After searching the various databases, and personally approaching researchers known to the authors, 17 studies were identified, made up of eight randomized clinical trials (RCTs), eight replicated single-case studies, and one case study. Over 1200 patients have been involved in these studies, but there was a fairly high drop-out rate in both case studies and RCT’s, and while reasons for drop-out were not given in many cases, in those that were it was found participants thought the treatment was ‘too psychological’ (didn’t give enough of a biomedical explanation for their pain) or weren’t sufficiently motivated to complete. Of course, I’d suggest that motivation is a case of readiness to engage – and that motivation can be enhanced, but nonetheless, this is what was stated in two of the papers.

The type of patients in terms of age, gender and pain duration were fairly similar in all of these studies (and very similar to the type of patient I see each day). The participants were attending research-oriented pain management centres, so possibly look a little different from the people seen in community settings, or in primary care. Their pain was mainly lower back, with a subset having pain from whiplash or similar.

The main treatment outcome measures used were the Tampa Kinesiophobia Scale for most of the studies with the PHODA, or photographs of daily activities being used alongside this for most of the graded exposure studies. The Roland Disability Questionnaire was the most commonly used disability measure, Beck Depression Inventory the most common depression measure, and Pain Catastrophising Scale and Pain Anxiety Symptoms Scale used for pain-related anxiety. Only one study used physical performance measures as part of the outcome measurement, and none used individualised or patient-specific goal achievement as a measure.

So, what did they find?
From this set of studies, graded exposure and ACT appear to have the greatest positive effect on disability and reducing fear of pain compared with waitlist groups or graded activation. Graded exposure was also superior to graded activation for reducing fear of movement, catastrophising and perceived harm, while ACT was demonstrated as effective for reducing pain and disability in all of the studies in which it was used. Both graded exposure and ACT appear to be effective in addition to ‘treatment as usual’ (participants weren’t asked to refrain from using other treatments), but this finding doesn’t always occur.

Unfortunately, the mixed CBT approaches don’t demonstrate such clear-cut results on catastrophising, fear of movement/reinjury, and disability. The authors suggest that the mixed protocols probably don’t provide greater effectiveness than waiting list or a combination of cognitive therapy and ‘physical therapy’ (what ever that looks like!).

Graded exposure does seem to offer some advantages over ACT in terms of reducing pain-related catastrophising, and overall require fewer sessions than ACT (at least in these studies) – but there does appear to be a greater chance for people to drop out.

Our problems with this summary are that these are not direct RCT comparisons of different treatments, and because of differences in context, and size of the study groups and different methodology. And an interesting feature is that most of the graded exposure studies were carried out in Netherlands, Sweden, and the United Kingdom, and only one study was conducted in North America. This is quite at odds with the majority of studies looking at chronic pain management. There are considerable differences between these countries and the US in terms of litigation and access to various treatment modalities (particularly psychological treatments). As the authors say “Potentially more important is that these same countries do not rely on insurance models for psychology-augmented multidisciplinary health care.”

What can we learn from this review?
Rather than suggesting that graded activation shouldn’t be used as widely as it is, I think this review shows that there are at least two other treatment protocols that can be successfully applied to this sub-group of people who are fearful/anxious and avoid activities because of their pain.

There were no generally-applied cut-off scores on, say, TSK or PCS to help clinicians in other settings decide who would best benefit from graded exposure vs a broader approach, which makes it a little difficult to select patients – but my initial thinking is that if you have a person reporting that they avoid activities, particularly if they have specific movements they avoid (like bending or reaching), these people may be candidates for graded exposure. For people who are basically deactivated and are not avoiding any specific movements, maybe ACT or graded activation could be a better bet.

The question to ask too is, can physiotherapists, occupational therapists and other ‘non-psychologists’ apply these treatments successfully? My thoughts are that yes, of course – provided that clinicians take the time to learn about the approaches and theoretical basis for conducting them.

My worry is that some of the subtleties of graded exposure especially may not always be picked up by people unfamiliar with the idea of eliciting specific thoughts, beliefs or concerns about a movement – this can lead to inadvertently failing to expose the person to their fear, and potentially incorporating ‘safety behaviours’ into the treatment. This prevents the patient from learning to manage what they are actually afraid of, and can replace complete avoidance with a set of almost ‘magical’ beliefs – such as using a specific lifting technique to ‘prevent’ damage.

Reference
Bailey, K., Carleton, R., Vlaeyen, J., & Asmundson, G. (2010). Treatments Addressing Pain-Related Fear and Anxiety in Patients with Chronic Musculoskeletal Pain: A Preliminary Review Cognitive Behaviour Therapy, 39 (1), 46-63 DOI: 10.1080/16506070902980711

 

[David Baxter PhD]

Fear/Anxiety/Avoidance – and some treatments
by adiemusfree, HealthSkills Weblog
Sept. 27, 2010

I’ve been pondering the post by Neil O’Connell on Body in Mind in which he comments on a paper by Foster, Thomas, Bishop, Dunne and Main (2010) in which he makes the point that “There is a huge emphasis on psychological variables in research and current care for low back pain. My experience (the usual biased, unreliable, non-replicable shambles) tells me that this is justifiably so. But in this rigorous study the four psychological variables found to have a unique influence individually explained just 2.5% of the variance or less. The big players were the level of disability when the patient arrived at the GP and demographic factors which together explained 50%.”

Now this flies in the face of the general trend towards emphasising psychosocial variables associated with pain and disability over the past 10 – 15 years. Or does it?
​

The ‘yellow flags’ or psychosocial risk factors associated with chronic disability associated with pain were introduced in the mid 1990′s and represented a change in emphasis for early management of back pain. By attending to these factors as soon as they became evident, it was hoped that some of the long-term problems would be better managed, and some of the disability could be prevented or mitigated.

In the enthusiasm for more attention to psychosocial factors (which I share, I openly admit!) maybe one thing that I recall Dr Nick Kendall repeating over and again has been forgotten: if someone responds to a psychological approach this does NOT mean their pain is ‘psychological’ – and in the same breath, psychological treatments can have profound effects on wellbeing even when the ’cause’ is quite clearly physical.

To this end I’m not going to spend time justifying my attention to psychosocial factors in acute pain (at least, not today!), instead I’m going to return to that enormous unknown: what treatments help people with high levels of disability associated with their pain?
​

There are three main groups of psychological approach to helping people with high avoidance related to their anxiety or fear of pain: most clinicians are well aware of the graded reactivation approach (although perhaps not of the psychological basis for this), recently we have the well-regarded exposure paradigm, and the final ‘group’ are cognitive behavioural approaches with a more psychological or cognitive orientation. This final group is a fairly heterogenous set of methods that is reasonably difficult to unpack to determine the components actually do the work of helping people return to being people rather than patients.

The basic premise of fear/anxiety avoidance models goes like this:

“1. When pain is perceived, a judgment of the meaning or purpose of the pain is placed on the experience (pain experience).
2. For most people, pain is judged to be undesirable and unpleasant but not catastrophic or suggestive of a major calamity (no fear). Typically, the person engages in appropriate behavioral restriction followed by graduated increases in activity (confrontation) until healing has occurred (recovery).
3. For a significant minority of people, a catastrophic meaning is placed on the experience of pain (pain catastrophizing). Catastrophizing, influenced by predispositional and current psychological factors, leads to fear of pain (and/or reinjury) and thereafter spirals into a vicious and self-perpetuating cycle that promotes and maintains avoidance, activity limitations, disability, pain, further catastrophizing, and so forth.”

There has been a wealth of research providing support for this model, or variations of this. Since 2001, an increasing number of papers have examined different strategies for treating the disability associated with anxiety/fear and avoidance. Three basic variations are found:

• Graded exposure in vivo - a process of deliberately exposing patients to movements and tasks that have been avoided because of fear of pain or reinjury.

It involves psychoeducation about the model and the purpose of the exposure activities; followed by a series of interactive therapy sessions involving graded exposure techniques and “behavioral experiments.” These involve an an individualized hierarchy of avoided activities, with patients gradually exposed to each activity in the hierarchy, rating their fear and pain expectation before and after each exposure. Patients are encouraged to practice these activities in natural contexts outside of clinic-based sessions.

• Graded Activation (or reactivation) – an active process where healthy behaviours are shaped through positive reinforcement of predefined activity quotas.

Patients identify specific functional activities that have been reduced as a result of their pain, and treatment goals are established based on these activities. Patients are asked to estimate their tolerance for carrying out these activities, and baselines are set at this level. The avoided activities and associated tolerances form a time-contingent treatment schedule, not unlike a fear hierarchy, with patients starting their activities at 70 – 80% of their estimated tolerance. Gradually, patients increase activity levels on a pre-determined quota.

These two approaches, while superficially similar, are based on two different conditioning approaches. Graded exposure in vivo uses classical conditioning to elicit the conditioned response (usually physiological arousal) then supporting the person to develop inhibitory responses instead of maintaining their previous avoidance pattern. Graded activation is based on operant conditioning, using positive reinforcement to modify behaviours – such as therapist praise and positive regard for maintaining adherence to the quota, and withdrawal of positive regard when the quota is not maintained.

• Acceptance and Commitment Therapy - is based on concepts of mindfulness, acceptance, and values-based action.

This approach asks patients to experience pain, but not attempt to control it. This is achieved through observing it as a sensation, and then accepting it as part of present reality without judging it. Patients are encouraged to consciously choose to engage in satisfying, rewarding activities despite their pain. This process supports patients in a shift of life focus away from the pain and onto things of greater value.

The key difference between the ACT approach to the cognitive components of pain management and the ‘traditional’ cognitive behavioural approach is the emphasis being less on the content of the cognitions, and more on the ‘workability’ or function of those cognitions.

References
Bailey, K., Carleton, R., Vlaeyen, J., & Asmundson, G. (2010). Treatments Addressing Pain-Related Fear and Anxiety in Patients with Chronic Musculoskeletal Pain: A Preliminary Review Cognitive Behaviour Therapy, 39 (1), 46-63 DOI: 10.1080/16506070902980711

Foster NE, Thomas E, Bishop A, Dunn KM, & Main CJ (2010). Distinctiveness of psychological obstacles to recovery in low back pain patients in primary care. Pain, 148 (3), 398-406 PMID: 20022697