Join Ann Meulders discussing what she wants people challenged by pain to know about. Explore the current state of pain science research and clinical practice in this straight-to-the-point interview with Ann Meulders.
About Ann Meulders
Ann Meulders is an Assistant Professor at the Faculty of Psychology and Neuroscience at Maastricht University (The Netherlands), and a Visiting Professor at the Faculty of Psychology and Educational Sciences at the KU Leuven (Belgium). Dr. Meulders published more than 70 peer-reviewed journal articles and 5 book chapters. Her work concerns psychological mechanisms in the transition from acute to chronic pain. Her research focused on learning processes in pain-related fear and avoidance. More info can be found on her research profile.
Ann encouraged viewers of this video to look into the following resources: Meulders, A. (2019). From fear of movement-related pain and avoidance to chronic pain disability: A state of the art review [invited review]. Current Opinion in Behavioral Sciences, 26,130-136. https://doi.org/10.1016/j.cobeha.2018.12.007
Meulders, A. (in press). Fear in the context of pain: Lessons learned from 100 years of fear conditioning research. Behaviour Research and Therapy. https://doi.org/10.1016/j.brat.2020.103635
Transcript
So Ann, what’s the one thing you want people challenged by pain to know about?
I think the one thing that I want to tell people who are suffering from chronic pain would be face your fears. We know that the fear of pain, the fear of re-injury, the fear of movement, and associated avoidance behaviours are important contributors to development and the maintenance of chronic pain. But we also know that although these behaviours are important in the beginning to promote healing and recovery, that they may paradoxically worsen the situation.
So, if you are afraid of moving, you avoid it to reduce the fear you feel. But we have shown in a series of experimental research that this may make the situation worse. Being afraid of moving maintains your fear. It may even make your fear worse, and it maintains the threat or the harm beliefs you have.
There are several mechanisms that may be involved in this. One mechanism is exconsequential reasoning, which means that you can use your own behaviour to infer threats. In this case, the reasoning you have is ‘I’m avoiding this movement, so it must be painful or harmful for me.’ This may maintain the beliefs you have.
The second thing is that the avoidance behaviour may also generalize to novel situations which are not threatening for you, or may not cause harm. And of course, to a certain degree, this generalization is adaptive. If you have hurt your back when you lift up a very heavy object, it’s reasonable that you also are careful when you lift up other heavy objects.
But if you start generalizing this behaviour to very safe movements, this may become problematic. For example, if you’re also afraid to pick up your paper in front of your doorstep, this may and maintain this fear to the point where it becomes maladaptive. It reduces your activity level, and this may lead to disability.
What I’m trying to say is that I think that learning about harm is important but learning about safety is just as important. What we have shown in our research is that people who suffer from chronic pain show impaired safety learning – they are worse in picking up which activities or movements are actually safe. This can then lead to overgeneralization like I just described and may be a maintaining factor in disability.
But the last tricky part about avoidance is that it’s also self-sustaining. If we avoid something, we will never be able to confirm whether this was necessary or not. If you avoid the movements and nothing bad happens, you think that it was necessary. But you will never be able to find that out, so safety is attributed to that avoidance behaviour. Again, this may paradoxically continue this vicious cycle of fear and avoidance.
So, to people with chronic pain, I would say face your fears and know that while fear can lead to discomfort it does not lead to disability. To become disabled, you also need to avoid the things that you’re afraid of. That needs to generalize to a very broad range of situations. Challenge your thoughts. Challenge what you think might worsen your pain, or what might lead to harm. Because violation of harm expectancy and breaking this cycle of avoidance behaviour may be the key to recovery.
Yeah that’s really great. It sounds like so much of this is learned. It seems to be easy to get caught into this fear-avoidanec learned behaviour. Can we use learning to undo it?
Learning can occur very quickly. The sad part is that there’s a dissociation. You can acquire this fear after one painful or traumatic episode. But the dissociation occurs when you want to unlearn fear. It seems that the initial associations occur very quickly but it’s very difficult to unlearn it.
I personally don’t like the term ‘unlearning’, because I think the current learning theory says that you can never unlearn something. You can only learn there is an exception to the rule, and you need a lot of experiences with the exception to the rule to actually start behaving in that way.
And that makes sense, because if something is potentially dangerous you want to be careful. It takes longer to learn that something is safe. Unlearning something in the current learning theory should really be learning that something is safe again. It means that you would learn a new memory or an association between a certain movement and safety, and the context, or how many times you have experienced that this is actually holding, then eventually hopefully you can start to behave in that way.
This technique has already been used in clinical practice. Extinction learning – this is what we call ‘unlearning of fear’. This is the basis of exposure therapy. What we have been trying to do with patients in the clinic is facing their fears in the same manner I just described. We let them perform the movements they’re afraid of, in little behavioural experiments, while we try to show them that the harmful thoughts or fears they have about the movement won’t happen. If they think something in their back will snap when they lift something heavy up, we say, “We think it will not, so go ahead and try it”. If they get a lot of this confirmation then hopefully they will be able to overcome their threat beliefs.