Chronic Pain and Anxiety: Breaking the Cycle
For many individuals, chronic pain is perpetuated by an ongoing cycle of fear and avoidance (see part one of the blog series). Here, we provide evidence-based strategies for breaking out of the fear avoidance cycle and re-engaging in life.
STEP ONE: Reframe Catastrophic Thinking
Ask yourself, "Is what I am telling myself realistic or helpful?" If the answer is no, then it can be helpful to reframe your thoughts into healthier and more balanced alternatives. Examples include the following:
Recognize and acknowledge the thought: For many, if not most people, thoughts are automatic and often go unnoticed. Try to slow this process down and observe the unhelpful words and stories your mind is telling you. Especially pay attention to words like “always”, “never”, “can’t”, “should”, “hate”, “stupid”, “failure” or “worst”. Remember: Just because we have a thought, it does not mean it is true.
Ask yourself, “Is the thought realistic?” To accomplish this, look for the evidence in support of or against the automatic negative thought. For example, is it true that the pain will never go away? Have there been moments where you have felt some relief? If there have been any moments where there has been some relief from pain, then the thought that you will never feel better is likely not realistic.
Create an alternative, more balanced thought: Through cognitive restructuring, or the process of identifying and disputing unhealthy patterns of thinking, you can learn to create alternative, healthier thought patterns. For example, if you are engaging in magnification (e.g. “My pain means something bad is going to happen.”), you want to create a more reasonable alternative that takes into consideration evidence for/against the automatic negative thought, alternative viewpoints, and most likely scenarios. Therefore, it may be more realistic to think, “My pain makes me scared and I have been able to cope with it while still engaging in my day to day activities.”
STEP TWO: Challenge and Change Avoidant Behaviors
Set Goals: Research shows that for individuals with chronic pain, gradual engagement in activity leads to less avoidance¹. Therefore, set small, realistic, time-sensitive, and achievable goals. For example, if your goal is to walk 10,000 steps a day, break the goal down. Begin by setting a smaller goal of walking 200 steps a day and gradually build-up to the larger goal of 10,000 steps. This approach to goal setting will allow for a greater number of "successes" and enhance your motivation to keep going.
Practice Mindfulness: Mindfulness is the practice of focusing on what one is sensing in a particular moment with non-judgmental awareness. The benefit of mindfulness for chronic pain is that it allows individuals to be present with their thoughts, feelings, and sensations without catastrophizing or trying to alter them². For example, if an individual is experiencing pain, they can practice mindfulness by thinking, "I am having pain now and I am feeling frustrated. And my frustration will pass. This is where I am at this moment." Some mindfulness practices also include guided visualization, mediation (guided or unguided), yoga, journaling, and deep breathing.
Getting Help: For many, the fear-avoidance cycle becomes so distressing that it greatly impacts how they live, think, and feel³. For these individuals, it often makes sense to seek out professional help for breaking out of this cycle. Cognitive Behavior Therapy (CBT) and Acceptance and Commitment Therapy (ACT) are two evidence based treatments:
Cognitive Behavior Therapy: CBT is a present-focused approach in which individuals learn to recognize the unhelpful patterns of thoughts, feelings, and behaviors which may be serving to maintain the cycle of chronic pain. Cognitive behavior therapists can help individuals make connections between their physical sensations, emotions, and behaviors. By doing so, they are able to modify their maladaptive thinking and change their avoidant behaviors⁴.
Acceptance and Commitment Therapy: ACT focuses on helping individuals respond more flexibly to their pain experience. Specifically, through metaphors, experiential exercises, and values work, individuals stop trying to control or eliminate their pain and instead learn to live as well as possible with it.⁵
If you think that you may be stuck in a cycle of chronic pain and anxiety, talk to your healthcare provider. You don’t have to struggle in silence or fight through it alone. For resources and information on pain management you can visit The American Chronic Pain Association (theacpa.org) or talk to your pain management specialist.
References
Sharpe, L., Jones, E., Ashton-James, C.E., Nicholas, M.K., Refshauge, K. (2020) Necessary components of psychological treatment in pain management programs: A Delphi study. European Journal of Pain. 24(6), 291-302.
Hilton, L., Hempel, S., Ewig, B.A. et al. (2017) Mindfulness meditation for chronic pain: Systematic review and meta-analysis.
Crombez, G., Eccleston, C., Van Damme, S., Vlaeyen, J.W. (2012). Fear-avoidance model of chronic pain: The next generation. Clinical Journal of Pain. 28(6). 475-483
Bradley, L. A. (1996). Cognitive-behavioral therapy for chronic pain. In R. J. Gatchel & D. C. Turk (Eds.), Psychological approaches to pain management: A practitioner's handbook (p. 131–147). The Guilford Press.
McCracken, L.M., Thompson, M. (2011) Acceptance and commitment therapy for chronic pain. In Mindfulness and Acceptance in Behavioral Medicine: Current Theory and Practice.