This content is designed for the participants of the GGC Pain Management Programme. 

Slide 1

The aim of this presentation is to explore the relationship between pain and fear.

Is fear a part of your pain experience?

Many of the patients we meet in the pain service tell us that they worry a great deal about the presence of pain and what it might mean.

Perhaps they have been told things by health professionals that make them feel as through there is no hope? Perhaps they have seen others with similar conditions get worse over time.

Perhaps there is a growing sense that something must have been missed on examination.

Often this develops into a fear of causing further damage by doing certain things and so it feels safer to shy away from those things.

Have you noticed if you have developed any pain avoidance tactics?

Are there things you have stopped doing altogether to play it safe?

Slide 2

What is fear?

It is our emotional response to something that feels threatening to us.

Sometimes are fears are well founded and sometimes not so much.

What are your fears or phobias?

What has been your experience when you have been face to face with something that makes you feel afraid?

Often the choice comes down to either confronting the fear and moving ahead

Or

Worrying even more about it and feeling overwhelmed and a bit helpless

It is a normal response to feel fear with pain. Pain has historically let us know when something is wrong. Pain is a very intense and unpleasant feeling and if there was something we could do to reduce that pain, then it would be natural to do so.

Again, this is where we need to stop and consider the differences between acute pain and chronic pain.

In the case of acute pain we would definitely want to listen to that pain and sort out the problem. That often calls for a form of avoidant behaviour e.g. not walking on a broken leg, not continuing to hold our hand over a steaming kettle

In chronic pain, if we continue to try to avoid the pain we can find that we have developed some more complicated behaviours and it is harder to reverse the changes that have taken place in our bodies and in our mind.

Slide 3

We are going to spend a few moments thinking about how we can learn to fear certain movements

You may have heard of Pavlov. He was a famous researcher who trained dogs to associate their food with a bell.

He would notice how much the dogs mouth’s watered when they anticipated their meal

When it was time to feed the dogs he would ring a bell simultaneously with the food

Over time all it would take was the ringing of the bell without any food to produce this effect

The dogs learned to associate the bell with food and an automatic, unconscious physiological response took place in their bodies even when the food wasn’t in sight.

Something similar happens for us when we experience pain with a movement. For example, I bent forward to pick up my bag and my bag was in agony. What can happen over time is that even the thought of the movement, or a reminder of the activity such as seeing the bag, leads to an increase in pain.

We can become understandably fearful of repeating the movement in case the same thing happens again, so we learn to avoid it. The bag is now at the back of the wardrobe and we don’t like to think about it.

If a particular movement has increased your pain in the past it is understandable that you have perhaps learned to avoid that movement now

If you worry that pain will cause more damage it is natural that fear is part of this process

Over time, even the thought of doing that movement might be enough to trigger a response of fear

Our brain decides that it is safer not to perform that movement or activity and this lowers the sense of threat we feel.

If the pain causes a very real fear of movement it makes sense that over time that movement will be lost and more difficult to regain.

We can learn to avoid all sorts of things if they feel threatening to us. This can go beyond physical movements and become things like socialising, working, even maintaining a daily routine

Slide 4

Have a think about this cycle and see if you can relate to it.

Not everyone we see in the pain clinic describes fear as being something they are aware of. We simply ask that you consider if anything here describes your experience.

As pain persists, there is often an association between a movement or an activity leading to more pain. This leads to the development of a worry that this might be causing us more damage or harm.

The instruction from the brain to the body is automatically to protect so it seems wise to stop or reduce what we are doing.

It then develops into a fear of the pain itself as we learn the different triggers. E.g. bending causes pain so we fear the movement of bending because we know it will lead to pain. We know that fear is part of the process if there are fight or flight symptoms. This is when we feel quite on edge, maybe feel our heart rate increasing or notice a change in our breathing. We can feel clammy or even a little nauseous. Our mouth may feel dry and our body feels tense.

This is the body’s built-in response to stress. It can be useful when we really need it to get out of a threatening or dangerous situation.

But what happens when we start feeling like this when it is everyday things that seem to bring it on? Like getting in and out of the bath, or having to go to the shops?

By avoiding something, we reinforce the notion that ‘it is just safer not to do it’, then the brain agrees with that idea because it seems less threatening.

The nervous system can become so sensitive to this potential threat that even thinking about a certain activity or watching someone else do it, can bring on the fight or flight feelings and sensations.

Over time we lose the ability to do the things we were doing before and this makes us even more aware how much pain controls us and in turn makes us more fearful about trying things again.

Because the behaviour doesn’t change, the cycle doesn’t change

You might not even be aware that it is fear. You have maybe just always said it’s the pain

We talk more about developing an awareness of our thoughts, feelings, behaviours and body sensations in our talk on cognitions. We also use mindfulness techniques as a way to develop a greater awareness as part of pain management and there are presentation on this topic too.

Slide 5

Pain gets our attention.

Our thoughts and beliefs play a significant role when we start to unpick some of our responses to pain.

It goes without saying that pain can be a very distressing experience and we will naturally look for escape routes if they present themselves to us.

If we have learned over time that something makes our pain better or worse we will naturally make a decision based upon that information.

Remember that our brain is trying to protect us and make us feel safe.

But…

It forces us to make decisions about what seems best for the pain rather than what is best for us.

What if you are someone who really liked being active and now you feel forced to avoid moving?

What if you used to enjoy the physical feeling of being strong and able to manage a big food shopping as well as managing projects around the house?

Have you had to change your job or give up work all together?

Does your head feel a bit like this picture?

Let’s pause for a moment to make a few notes. (next slide)

Slide 6

You may have already come across this diagrams in the talk on our thinking presented by Anna who is one of the psychologists on the team.

This model comes from Cognitive Behavioral Therapy and illustrates the interactions between our thoughts, our physical sensations, our emotions and our behavior. We call it the Hot Cross Bun.

We can use it to help us explore why we do what we do.

If we think about the photo of Emma bending over to pick up the rucksack from the floor, it is possible that may have triggered a thought in your mind.

It may be something like – the last time I bent down like that I thought I was going to get stuck

This may even bring on a sensation in your back reminding you of how bad the pain was

This makes you feel anxious and the behavior is likely that you avoid this movement now.

We use this diagram often in pain management because it helps us link behaviors with thoughts and feelings.

If the thought is less threatening the behaviors is more likely to change as a result.

If someone is no longer afraid that bending will damaged their back, it makes sense that they would be more willing to try it more regularly. Over time the feelings and emotions become less threatening and new memories can be made.

Have you started to make connections between how you think about things and what you do or don’t do when it comes to your pain?

Slide 7

Can you make a link between a fear of pain and avoidance of certain movements or activities?

Take a few moments to pause the presentation here. Use the worksheet provided or a notebook of your own to write down anything that comes to mind.

We would really encourage you to explore this for a few moments as we will discuss this as a group.

Why do you think this is apart from the pain? It can become too automatic to just say I don’t do that anymore because of the pain. Spend a few moments asking yourself why else it may have become too difficult for you. Use the hot cross bun to think about how pain affects your thoughts, feelings and behaviours.

Slide 8

If you stay as you are things are unlikely to change all that much. At this point, you may feel as though you have managed to work things out to suit you and your lifestyle quite well.

But has that come with a cost? Are you avoiding any things that were once very important to? Has it affected your relationships? Or your mood? Or your physical strength and function?

What would the other road look like?

You could learn that pain does not mean tissues are being damaged by what you do.

Once you can agree with this it reduces that sense of worry and fear.

This allows you to step back into doing things that matter and having the courage to set goals

It will feel as though you are no longer stuck and instead, making some headway again

End of video script

Return to preparation for session 6