Address patients’ fear to manage chronic pain
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LAS VEGAS — Recognition of the fear avoidance model, which is how one develops chronic pain through avoidant behavior, can help clinicians treat pain in patients, according to a presenter at PAINWeek 2022.
“We’re not addressing the pain itself; we’re addressing the fear,” said David Cosio, PhD, ABPP. “Without the fear, the pain would not be chronic.”
Cosio, a psychologist at the Pain Clinic and interdisciplinary pain program at the Jesse Brown VA Medical Center in Chicago, said that variables involved in the perpetuation of chronic pain include pain anxiety, pain helplessness and fear of pain, which can be accompanied by depression and anxiety.
The process is protective, indicating the need for a flight or fight response. “However, it can be harmful, because if we continue to use this process, we’ll engage in thinking and behaviors that can get us stuck,” Cosio said. “We’re trying to get unstuck.”
The first step in breaking the cycle is acknowledging it.
“People are scared to talk about catastrophic thinking,” which involves rumination, magnification and helplessness, he said. “It’s maladaptive, negative thinking.”
Patients can overgeneralize by thinking if one treatment does not work, none of them will; applying a mental filter that gets them focused on negative thoughts, jumping to conclusions and reasoning based on their emotions, Cosio said.
He suggested having patients fill out questionnaires while in the waiting room, such as the Pain Anxiety Symptom Scale or the Fear Avoidance Components Scale.
Other measures are available to evaluate physical activity and perceived harmfulness in daily activities.
“The No. 1 treatment for pain is movement,” Cosio said. “Everything else is for the person to move. We prescribe medications for them to move. We do injections and procedures for them to be comfortable to move. We do psychotherapy so they’re not afraid to move.”
Fear avoidance can be treated a number of different ways, he said.
Reality-based education involves telling the patient what their diagnosis is, what their prognosis is and what the treatment plan is.
“An interdisciplinary approach is preferred,” Cosio said. “If you work as a front-line provider, it takes a village with some of these patients.”
The biopsychosocial model is beneficial, he said.
“When it comes to psychotherapy, the most beneficial is exposure therapy,” Cosio said.
He emphasized the importance of a gradual, repetitive approach when moving from level to level.
Relaxation techniques are helpful in this situation as well as positive self-talk.
Cognitive behavioral therapy helps the patient restructure maladaptive thinking and unhealthy behaviors, Cosio said.
“When we have pain, we know it will negatively affect our thinking and probably our behaviors,” he said. “If it affects it in one direction, it affects it in the other direction as well. If thoughts affect the way I behave, then if I change the way I behave, it will also affect how I think.
“Look at what thoughts are present, identify those that are maladaptive, and take those to court,” he continued. “Find evidence that does and does not support that thought. The new thought has to be believable.”
Cosio said he has found that the most common experiences in patients with chronic pain were anger and sleep problems, even over depression and anxiety.
“We need to talk about anger management and sleep,” he said. “Some people can identify their stress well, but a lot of patients don’t.”
Acceptance and commitment therapy and mindfulness-based therapy can help patients live a fuller life despite their pain, Cosio said.
Other mind-body approaches may involve medication, yoga, positive self-statements, prayer, behavioral activities and exercise.