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Anxiety sensitivity and its impact on pain experiences and conditions: A state of the art

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Abstract

This paper serves as an introduction to the special issue of Cognitive Behaviour Therapy devoted to the topic of anxiety sensitivity (AS) and its impact on pain experiences and conditions. We provide a historical overview of relevant cognitive behavioural models of chronic pain, summarize recent models incorporating the AS construct, and introduce the papers in the special issue. These papers are organized into two sets--basic laboratory-based investigations and relatively more applied studies. We attempt to highlight some of the most important findings from each of these investigations and studies, in turn. Then, we consider several important conclusions derived from the set of special issue papers and the implications of these for the practice of cognitive-behavioural interventions with pain populations. Finally, we make several suggestions for directions for future investigations in this burgeoning area of cognitive behavioural research and practice.
Anxiety sensitivity and its impact on pain experiences
and conditions: A state of the art
Sherry H. Stewart
1
and Gordon J. G. Asmundson
2
1
Dalhousie University, Departments of Psychiatry and Psychology, and
2
University of
Regina, Faculty of Kinesiology and Health Studies and Department of Psychology
Abstract. This paper serves as an introduction to the special issue of Cognitive Behaviour Therapy
devoted to the topic of anxiety sensitivity (AS) and its impact on pain experiences and conditions. We
provide a historical overview of relevant cognitive behavioural models of chronic pain, summarize
recent models incorporating the AS construct, and introduce the papers in the special issue. These
papers are organized into two sets basic laboratory-based investigations and relatively more
applied studies. We attempt to highlight some of the most important findings from each of these
investigations and studies, in turn. Then, we consider several important conclusions derived from the
set of special issue papers and the implications of these for the practice of cognitive-behavioural
interventions with pain populations. Finally, we make several suggestions for directions for future
investigations in this burgeoning area of cognitive behavioural research and practice. Key
words: anxiety sensitivity; experimental pain; cold pressor; fear of pain; pain catastrophizing;
anticipatory anxiety; fear-avoidance models; persistent headache; chronic pain
Correspondence address: Sherry H. Stewart, Ph.D., Department of Psychology, Dalhousie University,
Life Sciences Centre, 1355 Oxford Street, Halifax, Nova Scotia, Canada, B3H 4J1. Tel: (902) 494-
3793; Fax: (902)-494-6585. E-mail: sstewart@dal.ca
Anxiety sensitivity (AS) is a cognitive indivi-
dual difference variable characterized by a
fear of anxiety-related symptoms (Reiss,
1991). For example, people with high levels
of AS may believe that when they are
experiencing difficulty concentrating that
this may portend a loss of control, or they
may expect that when they experience a
racing heart, this could result in a heart
attack. Consistent with the predictions of
Reiss’ (1991) expectancy model of anxiety,
longitudinal research has now established AS
as a risk factor for panic attacks and anxiety
disorders (e.g., Schmidt, Lerew, & Jackson,
1999). More recently, AS has also been
conceptualized as a risk factor for chronic
pain (e.g., Asmundson, 1999). Indeed, studies
have shown that AS is associated with acute
pain experienced in the laboratory and with
persistent or chronic pain conditions (e.g.,
Keogh & Asmundson, 2004).
It is important to place current chronic pain
theories that incorporate AS into historical
context. Philips (1987) expanded on the
foundational work of Fordyce (1976);
Lethem, Slade, Troup, and Bentley (1983);
and Linton, Melin, and Go¨testam (1984) in a
model of chronic pain that emphasized the
roles of avoidance behaviour and cognitive
factors in maintaining the pain condition. She
noted that chronic pain patients are charac-
terized by extensive avoidance, including
avoidance of stimulation, movement, activity,
and social/leisure pursuits. Philips explained
that this avoidance behaviour is not only
ineffective as a longer-term pain management
strategy, but it actually may be harmful in
terms of maintaining or exacerbating pain.
She also recognized the role of a variety of
fear-based cognitive factors (e.g., pain expec-
tancies, pain-related self efficacy, memories of
past aversive/painful experiences) and, thus,
set the stage for later consideration of the role
of AS a cognitive variable.
Like Philips’ (1987) model, the now popular
fear-avoidance model (e.g., Vlaeyen & Linton,
2000) also emphasizes the role of avoidance
behaviour in maintaining chronic pain. In this
# 2006 Taylor & Francis ISSN 1650-6073
DOI 10.1080/16506070601090457
Cognitive Behaviour Therapy Vol 35, No 4, pp. 185–188, 2006
model, it is the fear of pain (an emotional
variable) that is thought to motivate pain-
related avoidance and escape behaviour
which, in turn, maintains exaggerated percep-
tions of pain through processes such as
deconditioning. Others have since built upon
the fear-avoidance model to incorporate the
role of AS in explaining pain chronicity.
Because AS reflects a general propensity to
develop fears (Reiss, 1991), Asmundson,
Norton, and Norton (1999) proposed that
AS plays a key role in the onset and
maintenance of chronic pain by amplifying
the tendency to develop fear of pain. The fear
of pain then elevates pain-related avoidance,
leading to deconditioning and increased pain
experiences. These increased pain experiences
result in further avoidance and negative
expectancies regarding pain, as described in
earlier models. Later, as the role of ‘‘pain
catastrophizing’’ (another cognitive variable)
became increasingly recognized (see Sullivan
et al., 2001), the fear-avoidance model was
amended. The amended model conceptualizes
cognitive variables of appraisal and expectan-
cies of pain as feeding into pain castrophizing
which, in turn, leads to pain-related fear and
associated avoidance (Norton & Asmundson,
2004). Asmundson et al. (2000) further su-
ggested that AS (particularly the physical
concerns component) promotes catastrophic
cognitions regarding pain. Thus, in the
amended model, AS was seen to exert its
actions on pain via effects on pain catastro-
phizing. Additional refinements to the fear-
avoidance model are outlined by Asmundson,
Norton, and Vlayen (2004).
Other theorists have focused on attempting
to explain the role of AS in contributing to the
severity of acute pain experiences. Schmidt
and Cook (1999) suggested that AS should
enhance pain intensity by increasing a person’s
vulnerability to experiencing anxiety which, in
turn, should promote increased pain experi-
ences. In this model, AS is seen as a distal,
trait measure, and anxiety as a proximal, state
measure. Similarly, Watt and Stewart (2000)
suggested that AS may represent a general
tendency to perceive any source of arousal as
threatening. Thus, AS should amplify the
experience of bodily sensations related to a
wide range of somatic events, including pain.
The current special issue involves papers
representing the state-of-the-art in this area of
research. They are divided into two main sets –
basic laboratory-based and relatively more
applied studies. The first four papers consist
of basic, laboratory-based investigations with
non-clinical populations where the focus is on
understanding the nature of the relation
between AS and the pain experience. All of
these laboratory-based investigations make use
of experimental pain-induction methods and
involve consideration of the mechanisms
underlying the known association between
AS and aspects of acute pain. The first paper,
by Uman, Stewart, Watt, and Johnston, links
AS to specific aspects of the pain experience
(i.e., pain intensity and fear of pain) in a
laboratory-based cold pressor investigation
with university women. This investigation
shows that the relationship of AS to pain
intensity is mediated through the association of
AS with a fearful response to the pain stimulus.
The second paper, by Keogh, Barlow, Mounce,
and Bond, also used the cold pressor to
confirm that AS is related to experimentally-
induced pain. Their findings suggest that there
may be gender differences in how AS relates to
pain. AS appears related to self-report mea-
sures of pain in women and to behavioural
measures of pain in men. The third paper, by
Tsao, Lu, Kim, and Zeltzer, describes the
results of an investigation using the cold
pressor and two other types of laboratory pain
stimuli (thermal pain and pressure pain) to
investigate underlying mechanisms relating AS
to pain experience in children. Their work
shows that the relation of AS to pain intensity
operates indirectly through the association of
AS to anticipatory anxiety while children await
painful stimuli. Further, their work contributes
to a fledgling body of research that extends the
relation of AS and pain from adults to
children. The last paper in this section, by
Conrod, describes an investigation linking AS
to increased anticipatory anxiety when await-
ing a painful stimulus in the laboratory.
Through the inclusion of a social stressor
control condition, this investigation also
shows that the elevated anticipatory anxiety
of high AS participants is not specific to pain
situations.
The second set of papers are relatively more
applied than the first set in terms of the type of
pain investigated (e.g., persistent headache
pain), the population investigated (e.g.,
chronic musculoskeletal pain patients), or the
186 Stewart and Asmundson COGNITIVE BEHAVIOUR THERAPY
treatment focus of the investigation (e.g., an
intervention study). In the first paper of this
second set, Drahovzal, Stewart, and Sullivan
describe the results of a survey study with
undergraduates that investigated the relations
between AS and pain catastrophizing and their
relative contributions to various aspects of
persistent headache pain. Their results suggest
that although AS and pain catastrophizing are
highly correlated, they are separable psycho-
metrically, and they independently contribute
to the prediction of persistent headache pain.
The next paper, by Carleton, Asmundson,
Collimore, and Ellwanger, examined differ-
ences between chronic musculoskeletal pain
patients and controls on responses to a startle
probe paradigm tapping automatic and stra-
tegic attention allocation to several types of
pain-schema relevant words. One result from
this investigation was that chronic pain
patients with high AS appear to have more
difficulty disengaging attention from words
indicative of physical harm. In the final paper,
Watt, Stewart, Lefaivre, and Uman present on
the results of a randomized controlled trial.
Their findings show that high AS participants
randomized to a cognitive behavioural inter-
vention focused on reducing AS levels, dis-
played concomitant reductions in fear of pain.
There are several common conclusions that
emerge from the results of this set of papers.
The first involves the intervening or mediating
role of more proximal state anxiety-type
constructs in explaining the previously-estab-
lished relationship between the more distal trait
variable of AS and the pain experience. The
findings of Uman et al., Tsao et al., and
Conrod all consistent with the theoretical
predictions of Schmidt and Cook (1999)
suggest that fear of pain and anxiety when
anticipating painful stimulation should be
targets of intervention in cognitive behavioural
interventions for high AS chronic pain
patients. This suggestion is consistent with
emerging clinical interventions for chronic pain
(Asmundson, Vlaeyen, & Crombez, 2004).
A second conclusion is that the indirect
relationship of AS to increased pain experi-
ence, via increased state anxiety, generalizes
across a variety of different pain induction
methods. Although most studies in the first
section of this special issue made use of the
traditional cold pressor task, Tsao et al.
extended these findings to thermal and
pressure pain and Conrod extended them to
pain induced by mild electric shock. We can
have more confidence in this set of findings
knowing that they generalize across a wide
range of types of pain experience.
The findings also converge in suggesting
that the role of AS in pain experiences and
conditions may be more complex than origin-
ally conceptualized. On the one hand, the
results of Watt et al. are consistent with the
position of Asmundson et al. (1999) that AS
drives the fear of pain, because an interven-
tion focused on AS-reduction resulted in
concomitant reductions in fear of pain. On
the other hand, the findings of Drahovzal et
al. are not entirely consistent with predictions
of the amended Vlaeyen-Linton fear-avoid-
ance model that AS exerts its effects on pain
via its effects on pain catastrophizing. If this
were the case, pain catastrophizing would
have been the only significant predictor of
persistent headache when both AS and pain
catastrophizing were simultaneously entered
as predictors in the regression. Instead, AS
must have some additional influences on
persistent pain that are not mediated through
effects on pain catastrophizing. These effects
might be mediated through other cognitive
processes, such as the difficulties disengaging
attention from general physical threat cues
identified by Carleton et al.
There are several interesting avenues for
future research that emanate from the results
of the present set of papers. For example,
more research is needed on the underlying
mechanisms to explain how elevated state
anxiety contributes to increased pain in high
AS individuals. One possibility is that elevated
anticipatory anxiety contributes to increased
physiological arousal (e.g., increased muscle
tension) which contributes to an increased
pain experience. Conrod’s study tested this
possibility and did not provide support for an
intervening role of increased physiological
arousal. Future research might consider the
role of cognitive variables, including attention
(see Carleton et al.).
The question of whether the relation of AS
to pain experiences and conditions varies by
gender also deserves further study. One study
in the special issue that directly tested for
gender effects found important differences in
the relation of AS to manifestations of pain in
women versus men (i.e., Keogh et al.).
VOL 35, NO 4, 2006 187
However, two other studies that directly
tested for gender effects failed to provide
support for any differences in the relation of
AS to pain constructs in males versus females
(i.e., Conrod; Tsao et al.). Future research
should systematically examine the conditions
under which gender moderation effects are
and are not observed. For example, do such
gender differences emerge with development?
Finally, the Watt et al. study suggests novel
avenues for intervention research. Watt et al.
showed that by intervening at the level of AS
via cognitive-behavioural methods, one could
also impact fear of pain in a non-clinical
sample. Important next steps would be to
determine whether these results: extend to the
treatment of chronic pain patients; apply to a
wider range of outcomes (e.g., perceived
disability, pain self-efficacy, pain catastrophiz-
ing); and persist at longer-term follow-up.
Moreover, future investigations should com-
pare Watt et al.’s new ‘AS-reduction approach’
to ‘graded in vivo exposure treatment’ which
involves exposure to movements and tasks that
chronic pain patients have avoided due to
fear of (re)injury (see de Jong et al., 2005).
Watt et al.’s recommended focus on AS in
treatment fits well with recent findings
(Greenberg & Burns, 2003) that pain anxiety
is better viewed as a manifestation of AS
than as a specific phobia of pain (since the
latter position would favour a focus on
reducing avoidance behaviour, as in graded
in vivo exposure treatment). Only future
randomized controlled trials will tell which
of these approaches produces the greatest
benefit in the cognitive behavioural treat-
ment of chronic pain, or whether these two
approaches can be usefully combined.
References
Asmundson, G. J. G. (1999). Anxiety sensitivity
and chronic pain: Empirical findings, clinical
applications, and future directions. In S. Taylor
(Ed.), Anxiety sensitivity: Theory, research, and
treatment of the fear of anxiety (pp. 269–285).
Mahwah, NJ: Erlbaum.
Asmundson, G. J. G., Norton, P., & Norton, G. R.
(1999). Beyond pain: The role of fear and
avoidance in chronicity. Clinical Psychology
Review, 19, 97–119.
Asmundson, G. J. G., Norton, P. J., & Vlaeyen, J. W.
S. (2004). Fear-avoidance models of chronic
pain: An overview. In G. J. G. Asmundson, J. W.
S. Vlaeyen & G. Crombez (Eds), Understanding
and treating fear of pain (pp. 3–24). Oxford, UK:
Oxford University Press.
Asmundson, G. J. G., Vlaeyen, J. W. S., &
Crombez, G. (Eds) (2004). Understanding and
treating fear of pain. Oxford, UK: Oxford
University Press.
de Jong, J. R., Vlaeyen, J. W., Onghena, P.,
Cuypers, C., den Hollander, M., & Ruijgrok,
J. (2005). Reduction of pain-related fear in
complex regional pain syndrome type I: The
application of graded exposure in vivo. Pain,
116, 264–275.
Fordyce, W. E. (1976). Behavioral methods for
chronic pain and illness. St. Louis, MO: Mosby.
Greenberg, J., & Burns, J. W. (2003). Pain anxiety
among chronic pain patients: Specific phobia or
manifestation of anxiety sensitivity? Behaviour
Research and Therapy, 41, 223–240.
Keogh, E., & Asmundson, G. J. G. (2004).
Negative affectivity, catastrophizing, and anxi-
ety sensitivity. In G. J. G. Asmundson, J. W. S.
Vlaeyen & G. Crombez (Eds), Understanding
and treating fear of pain (pp. 91-115). Oxford:
Oxford University Press.
Lethem, J., Slade, P. D., Troup, J. D. G., &
Bentley, G. (1983). Outline of a fear-avoidance
model of exaggerated pain perception - I.
Behaviour Research and Therapy, 21, 401–408.
Linton, S. J., Melin, L., & Go¨testam, K. G. (1984).
Behavioral analysis of chronic pain and its
management. Progress in Behavior
Modification, 18, 1–42.
Norton, P. J., & Asmundson, G. J. G. (2004).
Anxiety sensitivity, fear and avoidance beha-
viour in headache pain. Pain, 111, 218–223.
Philips, H. C. (1987). Avoidance behaviour and its
role in sustaining chronic pain. Behaviour
Research and Therapy, 25, 273–279.
Reiss, S. (1991). Expectancy model of fear, anxiety,
and panic. Clinical Psychology Review, 11,
141–153.
Schmidt, N. B., & Cook, J. H. (1999). Effects of
anxiety sensitivity on anxiety and pain during a
cold pressor challenge in patients with panic
disorder. Behaviour Research and Therapy, 35,
313–323.
Schmidt, N. B., Lerew, D. R., & Jackson, R. J.
(1999). Prospective evaluation of anxiety sensi-
tivity in the pathogenesis of panic: Replication
and extension. Journal of Abnormal Psychology
,
108, 532–537.
Sullivan, M. J. L., Thorn, B., Haythornthwaite, J.
A., Keefe, F. J., Martin, M., Bradley, L. A.,
et al. (2001). Theoretical perspectives on the
relation between catastrophizing and pain.
Clinical Journal of Pain, 17, 52–64.
Vlaeyen, J. W., & Linton, S. J. (2000). Fear-
avoidance and its consequences in chronic
musculoskeletal pain: A state of the art. Pain,
85, 317–332.
Watt, M. C., & Stewart, S. H. (2000). Anxiety
sensitivity mediates the relationships between
childhood learning experiences and elevated
hypochondriacal concerns in young adulthood.
Journal of Psychosomatic Research, 49,
107–118.
188 Stewart and Asmundson COGNITIVE BEHAVIOUR THERAPY
... There is substantial evidence that the relationship between AS and chronic pain conditions is affected by fear of pain and closely related cognitive-affective factors, such as pain catastrophizing (i.e., a set of exaggerated, negative cognitive schema activated during or in anticipation of a painful experience), pain sensitivity (i.e., the threshold for detecting and experiencing pain), and pain-related anxiety (Asmundson et al., 2000;Ocañez et al., 2010;Stewart & Asmundson, 2006). Individuals with chronic pain and high AS exhibit more catastrophic cognition about pain, heightened attention to physical threat-related words, and greater fearful appraisal of pain (Asmundson, Norton, & Veloso, 1999;Stewart & Asmundson, 2006), as well as difficulty disengaging attention from health, pain, and injury-related cues (Asmundson, Kuperos, & Norton, 1997;Carleton, Asmundson, Collimore, & Ellwanger, 2006). ...
... There is substantial evidence that the relationship between AS and chronic pain conditions is affected by fear of pain and closely related cognitive-affective factors, such as pain catastrophizing (i.e., a set of exaggerated, negative cognitive schema activated during or in anticipation of a painful experience), pain sensitivity (i.e., the threshold for detecting and experiencing pain), and pain-related anxiety (Asmundson et al., 2000;Ocañez et al., 2010;Stewart & Asmundson, 2006). Individuals with chronic pain and high AS exhibit more catastrophic cognition about pain, heightened attention to physical threat-related words, and greater fearful appraisal of pain (Asmundson, Norton, & Veloso, 1999;Stewart & Asmundson, 2006), as well as difficulty disengaging attention from health, pain, and injury-related cues (Asmundson, Kuperos, & Norton, 1997;Carleton, Asmundson, Collimore, & Ellwanger, 2006). Importantly, findings from pain induction experiments support the notion that AS increases vigilance to and fear of pain, as opposed to the other way around, suggesting that AS may be a distal vulnerability factor for developing both a specific sensitivity to and fear of pain-related sensations (e.g., Keogh & Birkby, 1999;Vlaeyen & Linton, 2000). ...
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Anxiety sensitivity (AS; fear of anxiety-related symptoms) is an established transdiagnostic risk factor for psychiatric disorders and is related to a variety of chronic medical conditions. However, AS has not been established as a risk factor for chronic medical conditions. In this study, we review studies on AS and chronic medical conditions (and symptoms/behaviors related to chronic medical conditions) and propose four pathways through which AS may increase risk of chronic medical conditions: (a) increasing fear of medical condition-specific symptoms, (b) perpetuating avoidance of healthy activities, (c) promoting engagement in unhealthy behaviors, and (d) increasing risk of detrimental pathophysiological and pathomechanical alterations. We also discuss the potential utility of using AS reduction interventions as a means of reducing risk of chronic medical conditions.
... Anxiety sensitivity (defined as fear of the potential negative consequences related to anxiety-related symptoms and sensations; Reiss et al. 1986) has been linked to more severe nicotine dependence (Avallone et al. 2015;Bakhshaie et al. 2016;Zvolensky et al. 2019) and poorer pain outcomes (e.g., impairment, persistence; Asmundson et al. 1999;Ocañez et al. 2010;Stewart et al. 2006), respectively. Anxiety sensitivity may also increase the actual and anticipated analgesic and anxiolytic effects of nicotine (Baker et al. 2004;Evatt et al. 2010) and individuals who experience more severe pain/anxiety may come to derive greater negative reinforcement from nicotine, thereby contributing to heavier use and the maintenance of dependence . ...
... Anxiety sensitivity may also amplify propensity to escape/avoid actual or anticipated pain and anxiety, thereby directly contributing to disuse or prolonged physical inactivity and the progression of pain (Stewart et al. 2006). A meta-analytic study demonstrated small to medium effects in associations between anxiety sensitivity and pain severity (Ocañez et al. 2010). ...
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Anxiety sensitivity (fear of potential negative consequences of anxiety-related symptoms/sensations) has been identified as a transdiagnostic factor in comorbid pain and nicotine dependence and evidence suggests that anxiety sensitivity may be indirectly associated with nicotine use via greater pain severity. Therefore, this study tested the hypothesis that anxiety sensitivity is associated with cigarette and e-cigarette use/co-use directly and indirectly via greater pain severity. Participants included 273 online survey respondents with chronic musculoskeletal pain (34% female; Mage = 32.9). Anxiety sensitivity was positively associated with cigarette smoking, e-cigarette use and cigarette/e-cigarette co-use (ps < .05). Furthermore, anxiety sensitivity was indirectly and positively associated with cigarette smoking, e-cigarette use and co-use via greater chronic pain severity. Pain severity may play an important role in associations between anxiety sensitivity and nicotine dependence and prospective research should examine temporal/causal effects of anxiety sensitivity in relation to pain severity and nicotine/tobacco use.
... Elsewhere, we encounter studies that address anxiety sensitivity (AS), which has been defined as a trait that predisposes someone to experience a fear of pain and develop anxiety disorders (38). Several scholars have posited that through its predisposition to the fear of pain, AS is directly related to the adoption of escape or avoidance behaviors (39)(40)(41). Experiential avoidance is a key pattern of behavior that is located at the other extreme from acceptance (42), whereby it may be argued that AS is indirectly related to the acceptance of this feeling. When we consider the findings of these studies as a whole, they all suggest that anxiety plays a crucial role as a predictor of low acceptance in contexts of chronic pain. ...
... The results are consistent with the findings reported by other scholars on a negative and robust correlation between pain-related anxiety and the components of its acceptance (11-13, 21, 35-37). This therefore highlights the importance that pain-related anxiety might have as a variable linked to the acquisition of fear and escape or avoidance behaviors in the face of pain, as reported by other scholars in the literature reviewed (39)(40)(41). According to pain-avoidance models (77,78), escape behavior impedes an elaborative processing of the stimuli being avoided (e.g., sensorial aspects of pain, thoughts, emotions or sensations) (79), which leads to the acquisition of fear related to the pain itself, and a biased interpretation of the symptoms as threatening (25,80). ...
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... [28][29][30] Studies have revealed that high AS which is a risk factor for the development of anxiety disorders also enhances acute pain and increases the likelihood for chronic pain. [31][32][33] AS and pain perception may be mediated by other factors like state anxiety, fear of pain or pain catastrophizing. 7,[34][35][36] We hypothesized that subjects perceive the painfulness of the electric stimuli differently in the anxiety condition as compared to the fear condition. ...
... Previous studies indicated that high AS is generally associated with enhanced pain perception. 31,32,35 Our results suggest that this association is not perfectly general but rather depends on the emotional predictability of the situation. ...
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... We also showed that the intervention had impacts on anxiety-related psychopathology. A three-way interaction was revealed between AS group, intervention condition, and time on pain-related anxiety (an outcome strongly linked to AS; Stewart & Asmundson, 2006): Only the high AS participants in the active CBT intervention showed reductions in this anxiety-related outcome from pre-to 10-weeks postintervention . ...
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... 9 Research has demonstrated independent, positive associations between anxiety sensitivity and heavy/problematic substance use 77,78 and greater pain impairment/ persistence. [79][80][81] There is also evidence that greater anxiety sensitivity may contribute indirectly to the association between pain and poorer outcomes related to substance use and health. 82 ...
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... Studies have suggested that especially the physical concerns subscale is important to consider in the context of pain (e.g. Keogh, 2004;Stewart & Asmundson, 2006). All items are scored on a 5-point Likert-scale, ranging from 0 ("not at all agree") to 4 ("totally agree"). ...
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People who suffer from chronic pain are typically found to be more anxious and fearful of pain than those who do not. Recent evidence has shown that the fear itself serves as a mechanism through which chronic pain is maintained over time. Even once the muscle or tissue damage is healed, a fear of further pain can lead to avoidance behaviour, which over time, leads to deconditioning (e.g. decreased mobility, weight gain). This in turn leads to further pain experiences, negative expectancies, and strengthened avoidance. It is the reciprocal relationship between fear and avoidance that is thought to be responsible for maintaining pain behaviour and disability. With fear of pain known to cause significant suffering and functional disability, there is a need for a greater understanding of this condition. This is the first book to explore this topic. It starts by introducing the current theoretical positions regarding pain-related fear and anxiety along with relevant empirical findings. It then provides comprehensive coverage of assessment issues and treatment strategies. Finally, the book suggests further areas for investigation. Pain-related fear and anxiety are now receiving considerable attention, and efficient and effective treatments are fast becoming available. This book will help guide and extend our understanding of a condition that has been shown to be associated with substantial suffering and disability.
Chapter
People who suffer from chronic pain are typically found to be more anxious and fearful of pain than those who do not. Recent evidence has shown that the fear itself serves as a mechanism through which chronic pain is maintained over time. Even once the muscle or tissue damage is healed, a fear of further pain can lead to avoidance behaviour, which over time, leads to deconditioning (e.g. decreased mobility, weight gain). This in turn leads to further pain experiences, negative expectancies, and strengthened avoidance. It is the reciprocal relationship between fear and avoidance that is thought to be responsible for maintaining pain behaviour and disability. With fear of pain known to cause significant suffering and functional disability, there is a need for a greater understanding of this condition. This is the first book to explore this topic. It starts by introducing the current theoretical positions regarding pain-related fear and anxiety along with relevant empirical findings. It then provides comprehensive coverage of assessment issues and treatment strategies. Finally, the book suggests further areas for investigation. Pain-related fear and anxiety are now receiving considerable attention, and efficient and effective treatments are fast becoming available. This book will help guide and extend our understanding of a condition that has been shown to be associated with substantial suffering and disability.
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People who suffer from chronic pain are typically found to be more anxious and fearful of pain than those who do not. Recent evidence has shown that the fear itself serves as a mechanism through which chronic pain is maintained over time. Even once the muscle or tissue damage is healed, a fear of further pain can lead to avoidance behaviour, which over time, leads to deconditioning (e.g. decreased mobility, weight gain). This in turn leads to further pain experiences, negative expectancies, and strengthened avoidance. It is the reciprocal relationship between fear and avoidance that is thought to be responsible for maintaining pain behaviour and disability. With fear of pain known to cause significant suffering and functional disability, there is a need for a greater understanding of this condition. This is the first book to explore this topic. It starts by introducing the current theoretical positions regarding pain-related fear and anxiety along with relevant empirical findings. It then provides comprehensive coverage of assessment issues and treatment strategies. Finally, the book suggests further areas for investigation. Pain-related fear and anxiety are now receiving considerable attention, and efficient and effective treatments are fast becoming available. This book will help guide and extend our understanding of a condition that has been shown to be associated with substantial suffering and disability.
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Avoidance behaviour is a prominent and extensive component of chronic pain behaviour. Its unadaptive consequences are delineated and the puzzling issue of its persistence is raised. An explanation is put forward emphasizing the functional relationship between cognitions and avoidance behaviour. A psychological model which emphasizes the important role of cognitions in influencing avoidance behaviour is advanced. The research and clinical implications of this model are discussed.
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The personal history of pain and personal coping strategies for pain are two of the contributory factors in the Fear-Avoidance Model of exaggerated pain perception proposed by Lethem, Slade, Troup and Bentley (1983, this issue, pp. 401–408). In order to test this aspect of the hypothesis, a questionnaire was designed and has been completed by 165 students (93 female, 72 male) at the University of Liverpool.They were asked about the severity of externally-produced pain (e.g. fracture), of internally-produced pain (e.g. headache) and of back pain; about the strategies they adopted for coping with internallyproduced pain (e.g. did they ignore the pain and carry on—an active strategy—or did they go and rest—a passive strategy); and about the effects of back pain on each of 10 activities or postures (from ‘no effect’ to ‘had to stop completely’) in order to obtain an index of back-pain avoidance.Out of 165, 91 reported previous back pain (Back Pain group) and their average rating for the severity of externally-produced pain was significantly higher than for the No Back Pain group; but there were no differences between these two groups for their coping strategies for internally-produced pain. However, of the Back Pain group with two or more previous attacks, 35 gave a history indicating decreasingly severe attacks and 28, increasingly severe: the coping strategies of the latter group for internally-produced pain were significantly more passive. The ratings for severity of back pain correlated significantly with the indices for back-pain avoidance and with the ratings for severity of internally-produced pain.These findings are in line with the prediction that personal pain history and personal coping strategies are relevant to the Fear-Avoidance Model of exaggerated pain perception and may therefore influence the adoption of an avoidance or a confrontation response by the patient with chronic back pain.