Treatments Addressing Pain-Related Fear and Anxiety in Patients with Chronic Musculoskeletal Pain: A Preliminary Review

Abstract

This review covers the current cognitive behavioural treatments available to address fear-avoidance beliefs in patients with chronic musculoskeletal pain (CMP). Four types of treatment protocols were identified for inclusion in the review: (a) graded in vivo exposure (GivE); (b) graded activity (GA); (c) acceptance and commitment therapy (ACT); and (d) mixed cognitive behavioural protocols. Most of the research suggests that GivE and ACT result in the best outcomes for treating fear-avoidance beliefs in patients with CMP. There is also a readily apparent paucity of research from North America; indeed, most of the available studies were conducted in the Netherlands and Scandinavia. This relative absence of North American research raises potentially important questions about the role of compensation status and access to care, which differ between countries, on treatment outcome. Implications and directions for future research are discussed.     

Fear of Pain is Elevated in Adults with Co‐Occurring Trauma‐Related Stress and Social Anxiety Symptoms

The aim of this study was to determine whether fear of pain and related fear constructs are elevated in people with co‐occurring trauma‐related stress and social anxiety symptoms relative to people with 1 or neither of these conditions. Eighty students were selected from a larger sample and divided into 4 equal groups comprising those with both high trauma‐related stress and social anxiety symptom scores (TRS/SAS), only high trauma‐related stress symptom scores (TRS), only high social anxiety symptom scores (SAS), or neither (N). Results indicated that the TRS/SAS group had significantly higher scores on all fear of pain measures, anxiety sensitivity, and illness/injury sensitivity than any other group, even when level of current pain was included as a covariate. These findings suggest that people with co‐occurring trauma‐related and social anxiety symptoms are most likely to be fearful of pain and to thereby be at increased risk of developing chronic and disabling pain. Implications for future research and treatment are discussed.     

The Effect of d-Cycloserine on Subliminal Cue Exposure in Spider Fearful Individuals

Research on d-cycloserine (DCS) has demonstrated a significant effect on symptom reduction in human studies that utilized conventional exposure-based approaches. Recent studies have offered promising results for targeting fears through subliminal paradigms. In this double-blind, randomized placebo-controlled study, 45 spider fearful individuals received DCS or placebo pills prior to completing a subliminal cue exposure task to images of spiders. Participants completed self-report questionnaires and a behavioral approach task to a live caged tarantula. After repeated exposure to subliminal spider cues, participants in the DCS group reported a greater reduction in disgust than individuals in the placebo group. No difference was observed in fear ratings. These findings suggest that DCS augments the reduction in disgust in spider fearful subjects after subliminal exposure to spider cues.     

A dirty animal is a scary animal! Effects of disgust-related information on fear beliefs in children

The present study investigated whether disgust-valenced information has an impact on children's fear beliefs about animals. Non-clinical children aged between 9 and 13 years (n=159) were presented with disgust-related and cleanliness-related information about unknown animals (Australian marsupials). Before and after information, beliefs of disgust and fear regarding the animals were assessed. Results showed that disgust-related information not only induced higher levels of disgust but also increased children's fear beliefs in relation to these animals. The other way around, cleanliness-related information decreased levels of disgust and resulted in lower levels of fear. The implications for the role of disgust in the development of animal fear are briefly discussed.     

大学生亲密恐惧的图式干预研究

为研究图式治疗对大学生亲密恐惧的临床疗效,以54名有亲密恐惧问题的大学生为被试,采用支持咨询和图式治疗对比的实验研究,对疗效评估的各项指标进行了重复测量(前测、后测和追踪测量)的方差分析。结果表明干预后图式组亲密恐惧以及情感剥夺、缺陷/羞耻、伤害/疾病的易感性、情感抑制等四个适应不良图式都显著低于支持组,而且干预后图式组人际功能和适应功能等两项心理治疗效果评估指标都显著高于支持组。结论:图式治疗比支持支持咨询能更有效地减轻大学生亲密恐惧。     

情景变换诱发已消退恐惧记忆重现的神经环路

暴露疗法是治疗创伤后应激障碍的主要行为疗法。当被试反复暴露于可引起恐惧反应的条件刺激(如白噪音), 但却不伴有非条件刺激(如足底电击)时, 恐惧记忆将被消退, 形成消退记忆。但恐惧记忆并未从根本上被擦除, 当被试在消退训练以外的情景暴露于条件刺激时, 已消退的恐惧记忆将会重现。海马、内侧前额叶皮层、杏仁核等脑区及其相互连接的神经环路是情景诱发恐惧记忆重现的生理基础。情景变化诱发恐惧记忆重现过程中, 海马可能是通过直接投射至杏仁核基底核、杏仁核外侧核或通过边缘前皮质间接调控杏仁核基底核、杏仁核外侧核的功能, 产生恐惧反应。     

状态焦虑对条件恐惧习得和消退的影响

采用44名正常女性大学生作为被试, 通过心理社会压力暴露的方法诱发焦虑组被试的状态焦虑, 采用主观预期值作为指标, 考察焦虑对条件恐惧习得和消退的直接影响, 并探讨这种影响是否也表现在评价性条件作用上。结果表明：心理社会压力暴露显著提高了焦虑组被试的状态焦虑。在习得阶段, 状态焦虑降低了被试对条件刺激的辨别条件恐惧反应, 具体而言, 状态焦虑降低了被试对CS+的主观预期值, 但是却提高了对CS?的主观预期值; 在消退阶段, 状态焦虑抑制了被试对条件刺激的消退。状态焦虑的影响也表现在评价性条件作用上, 和控制组相比, 焦虑组在习惯化和消退阶段对条件刺激表现出了更为负性的效价评定。     

Trends in Anxiety Assessment

Trends in anxiety assessment were established by examining the methods reported in anxiety-related papers published in three prominent behavior therapy journals from 1970 to 2002. Assessment methods were categorized using Lang's three-system concept of anxiety (P. J. Lang, 1968) as an organizational framework. Analysis of the research methods suggests two primary patterns. First, multisystem assessment declined in the last several years by comparison with previous years whereas the assessment of a single response system (typically self-report) has increased. Second, among anxiety-related papers reporting multimodal assessment, physiological assessment returned to 1970s-era frequency in recent years after an upsurge in the mid-1980s and early 1990s. Some possible interpretations and implications of these trends are discussed.     

The Malicious Serpent: Snakes as a prototypical stimulus for an evolved module of fear

As reptiles, snakes may have signified deadly threats in the environment of early mammals. We review findings suggesting that snakes remain special stimuli for humans. Intense snake fear is prevalent in both humans and other primates. Humans and monkeys learn snake fear more easily than fear of most other stimuli through direct or vicarious conditioning. Neither the elicitation nor the conditioning of snake fear in humans requires that snakes be consciously perceived; rather, both processes can occur with masked stimuli. Humans tend to perceive illusory correlations between snakes and aversive stimuli, and their attention is automatically captured by snakes in complex visual displays. Together, these and other findings delineate an evolved fear module in the brain. This module is selectively and automatically activated by once-threatening stimuli, is relatively encapsulated from cognition, and derives from specialized neural circuitry.