# Motivation and emotion/Book/2020/Fear of pain

* Multimedia presentation (3 min)

## Overview

* Algophobia/Fear of pain is the scientific classification for phobia of pain, classified[repeated word in opening sentence] as an abnormal and persistent fear of pain that is more powerful in comparison to a standard individual (Casselman, 1998).
* Those who suffer from Algophobia often experience a high level of anxiety from thinking of pain let alone experiencing the pain. This anxiety may be intense enough to trigger panic attacks
* Algophobia is commonly associated with chronic pain, with vast research focusing on its relationship and impacts.
* The fear of pain is similar to FOWO (Fear of Working Out)
* The purpose of this chapter is to assist individuals in understanding and improving their motivational and emotional lives, with reference to psychological science.
* Focus questions:
* How does Fear of Pain/Aglophobia[spelling?] affect our daily lives?
* How can we prevent Algophobia?
* To what effect do treatment methods have on Algophobia[awkward expression?]?

## What is algophobia?

* Algophobia is commonly referred to as phobia of pain, classified as an abnormal and persistent fear of pain that is more powerful in comparison to a standard individual (Casselman, 1998).
* Algophobia is closely associated with fear & anxiety.
* Those who suffer from Algophobia often experience a high level of anxiety from thinking of pain let alone experiencing the pain. This anxiety may be intense enough to trigger panic attacks.

## Theoretical underpinnings

Algophobia is simply a heightened and perpetual experience of intense fear, [grammar?] Algophobia occurs when the subconscious mind of an individual is constantly anticipating pain and provoking painful reactions (Doina & Roxana, 2014). Algophobia is characterised by a series of external events such as trauma, shock or chronic pain and external factors such as psychosomatic disorders and personality traits (Doina & Roxana, 2014). Increases in fear and anxiety often result in emotional and behavioural avoidance responses that cause disability, distress and depression (Mittinty, et al., 2018). Such fear and anxiety have the potential to heighten the experience of pain, and cause its onset to last for longer durations of time as well as increase its intensity experienced by the individual.

### Chronic pain

Algophobia is highly associated with chronic pain, with a plethora of research focusing on the relationship and impacts of the fear of pain on chronic pain. Chronic pain is highly prevalent, complex and a comorbid disorder (Mittinty, et al., 2018). There are significant economic burdens that such as health care expenses, loss of work productivity and medical leave, furthermore it is estimated that 30-50% of the global population suffered from moderate to severe chronic pain (De Souze, et al., 2017). There are numerous factors that impact understanding of the current literature regarding chronic pain, such as emotional impacts and pain expression.
Chronic Pain is a physical-emotional experience that impairs physical functioning, engagement in social events which can cause varying degrees of anxiety, fear, worry and anger (Mittinty, et al., 2018). Furthermore, those who suffer from chronic pain are more susceptible to conditions such as depression and even suicide (Hassett, Jordan, & Ilgen, 2014). Behavioural responses to pain are strongly guided by two psychosocial factors: Fear and anxiety (Crombez, et al., 2012). Such individuals with higher fear and anxiety are more subject to infer their pain as damaging and aversive, which triggers the onset of avoidance behaviours. However, those who are more prone to fear and anxiety do not exaggerate or heighten their pain, which aids their recovery and healing process[say what?]. Fear and anxiety can also affect the future onset of painful experiences, and can influence pain inhibition or sensitivity (Mittinty, et al., 2018). Therefore, to understand chronic pain it is vital to analyse and understand the impacts of the fear of pain, to create optimal care practises.
Traditional biomedical treatment models for chronic pain focus on structural and biomechanical abnormalities which fail to sufficiently explain chronic pain and its associated disabilities (Leeuw, et al., 2007). Therefore, a biopsychosocial model is recommended as it incorporates psychological and social factors such as fear.

### Fear

Fear is defined as an emotional reaction to a specific, identifiable and immediate threat such as a dangerous animal (Rachman, 1998 as cited in Leeuw, et al., 2007). Fear is not all negative and aversive, [grammar?] it functions as a protective factor to the brain and the physical body as it aims to protect the body from dangers and harmful stimuli. Research has found that individuals with a phobia (Extreme, often irrational expression of fear) do not always have to have a history of being exposed to traumatic incidents (Hermans, et al., 2006). Furthermore, during periods of extinction (unlearning of a previously conditioned/paired stimuli, no unlearning takes places, instead new learning overtakes the original association but leaves the original association intact, making relapse likely (Bouton, 2002). Finally, it should also be noted that individual differences can affect how fear is experienced, acquired or maintained over time (Mineka & Zinbarg, 2006).

### Anxiety

Anxiety, is future orientated[grammar?] yet it affects the present situation as the source of the threat is elusive and without clear focus (Leeuw, et al., 2007). To compare fear and anxiety, it is observed that anxiety is less intense and is more associated with preventative behaviours such as avoidance, whereas fear engages more defensive behaviours. A key component of anxiety is hypervigilance, which occurs when an individual observes an environment for sources of threat and selectively attends to threat-related stimuli (Eysenck, 1992 as cited in Leeuw, et al., 2007). Such hypervigilance and avoidance behaviours assist to reduce anxiety in the short term, but are often counterproductive in the long term (Leeuw, et al., 2007). It is important to note that the terms fear and anxiety are often used interchangeably in clinical settings (Leeuw, et al., 2007). "The distinction between anxiety and fear is theoretically correct, but difficult to make in a clinical context, especially in chronic pain where the threatening stimulus (pain) is constantly present" (Leeuw, et al., 2007, p.78).

### Measurements of fear of pain

Multiple scales exist that have been developed to measure concepts such as fear and anxiety in their relation to fear of pain. Such scales are the:
* Fear-Avoidance of Pain Scale (FAPS)[factual?]
* Fear Avoidance Beliefs Questionnaire (FABQ)[factual?]
* Pain Anxiety Symptoms Scale (PASS)[factual?]
* Anxiety Sensitivity Index (ASI)[factual?]
* Fear of Pain Questionnaire-III (FPQ-III)[factual?]
Such scales contain overlapping concepts that relate to the fear of pain, avoidance behaviours, catastrophising, and pain-related anxiety, such scales focus on the feelings of the individual. The FPQ-III however, is one of the more unique and more valid scales as it assesses both pain-related fear and anxiety, which provides norms for both patient and general population groups (Mittinty, et al., 2018). The scale measures 3 aspects of fear and anxiety: fear of severe pain, fear of minor pain and fear of medical pain. Mittinty, et al., (2018) found the validity and reliability of the FPQ-III had been assessed in healthy participants, college students, medical patients and chronic pain patients and was found to be accurate and valid. The test requires further analysis and testing to identify how it can be improved to identify individuals who may experience longer duration and greater frequency of pain.

### Brain regions

White (2006) conducted a study and found a high correlation between the Fear of Pain Questionnaire and the right lateral orbital frontal cortex, an area of the brain that when activates[grammar?] in response to pain regulation and evaluation. It was further found that higher scores on the Anxiety Sensitivity Index (ASI) were correlated with higher activation of the medial prefrontal gyrus, the brain region involved with self-awareness, attention and body image (White, 2006). The ASI is a 16-item self-report questionnaire designed to assess the severity of anxiety, through the use of a five-point Likert scale (Rodriguez, et al., 2004). It is a widely used measure of anxiety, due to its validity and psychometric properties (Rodriguez, et al., 2004). Direct psychological research on Algophobia is limited and further research is required to investigate its causes and impacts. Once a deep understanding has been established, research should focus on treatment methods and possible prevention strategies.

## Fear avoidance model

The fear-avoidance model was designed to model, identify and explain complications such as disability associated with pain and fear that develop within multiple populations (Leeuw, et al., 2007). Figure 1 highlights the two pathways an individual may take towards the interpretation and experience of their pain, with the healthy coping method causing no fear and a successful recovery. However, a more complicated approach that is associated with Algophobia causes an intense fear of pain which leads to an aversive stimuli reaction such as depression or disability which is then cycled through over periods of time. When the fear and anxiety response combine, as they often do in chronic pain conditions,, a psychophysiological response is excited (heightened muscle reactivity), along with escape and avoidance behaviours and catastrophising thoughts (cognitive elements) (Leeuw, et al., 2007).
The fear avoidance model was developed by Lethem, et al., 1983; Phillips, 1987, Waddell, et al., 1993, Vlaeyen, et al., 1995 & Linton, 2000 as cited in Leeuw, et al, (2007) and provides a simple explanation of how pain is interpreted. When acute pain is perceived as non-threatening, individuals are more likely to maintain their usual engagement in daily activities and thus functional recovery is promoted (Leeuw, et al., 2007). Utilising figure 1 to explain such a concept is helpful, an individual would experience pain (A thumb prick for example), then they would experience that pain as a sharp stinging pain possibly and minor blood loss. If the individual had followed a healthy coping strategy that resulted from non-threatening pain, they would experience no fear and confront their pain by possibly reassuring themselves that it is a minor cut and nothing to stress about. This is then followed by the recovery stage, which would see the individual return to their usual affairs in a short period of time after experiencing the aversive painful stimuli.
However, imagine if the individual experienced the same thumb prick but reacted aversively as they perceived it as life-threatening. The individual would be pricked and begin to experience minor blood loss and slight pain (The experience of pain), however during this stage their fear/ anxiety would trigger and they may begin to fear the thumb prick as far more severe than its reality. E.g. the individual may believe that they will lose large amounts of blood and faint from the prick, or that they will attract an infection, this fear/ anxiety can be debilitating to the individual. During the next stage (Avoidance of activity) the individual might completely avoid the activity that had caused them to sustain that thumb prick, even if that activity were vital and part of their daily activities. Moving forward, the disuse/disability/depression would set in and cause the individual to remain fearful of the simply thumb prick and the lack of activity may impact their mental state due to the fear of having a similar injury repeat itself. At this point, the cycle repeats itself and the individual may find it difficult to escape their new-found cognitive play that causes them to avoid certain activities.

## Impacts on daily functioning

Someone suffering from Algophobia may find themselves avoiding what they fear, which can be taken to extremes. Such an individual may completely avoid any environment that could expose them to pain, this type of worry can be detrimental and lead to serious malfunction. In studies that observe the impacts of chronic pain, which is highly correlated to the fear of pain, the amount of exercise undertaken is below recommended levels. Such a decline in an individuals[grammar?] physical performance and regular activity can be detrimental and even cause disability, further affecting their daily functioning (Dueñas, et al., 2016). Individuals may fear exercising as they are afraid of tearing a muscle, falling over and hurting themselves or simply sweating and then catching a cold, and for those irrational reasons some individuals avert themselves from completing any physical activity. The flow-on health detriments carry over to quality of life implications.
An individuals[grammar?] quality of life, either mental or physical is a sound measure of the negative repercussions of feared pain. Sleep disturbances are commonly experienced, which can increase stress levels and make it difficult to complete common or simple tasks, while also impairing cognitive abilities (Dueñas, et al., 2016). Dueñas, et al., (2016) found a bidirectional association between sleep and pain, where one night of poor sleep was followed by an increase in pain intensity the following day, similarly a day of intense pain was followed by a night of intense sleep disturbance. Impacts on workplace functions are also vital and detrimental to algophobia sufferers.
Studies have shown that individuals who are affected by deep pains and fears of pain present problems of absenteeism (Dueñas, et al., 2016). Individuals in this situation may often lose their jobs, and sending them into a much worse situation simply due to the fear of an injury, cognitive overload or any irrational fear that debilitates the individual. Even if the individual were to attend their work, while combating their fear of pain they are likely to be far less efficient and productive. Those who suffer from chronic pain, and do not take time off work to deal with their pain were found to be 21.5% less productive (Dueñas, et al., 2016).

## Therapeutic interventions and treatments

[Provide more detail]

### Mindfulness-based stress reduction (MSBR)

A study by Hjeltnes, Binder, Moltu & Dundas (2015) found that mindfullness[spelling?]-based stress reduction (MBSR) programs were effective in reducing the amount of anticipated fear and anxiety commonly associated with Algophobia. Direct research on the fear of pain and its impacts on academic achievement and daily functioning is limited, however research does exist on the effectiveness of MSBR strategies which aim to reduce fear and anxiety, research that can be extrapolated to algophobia.
University students were found to report a high prevalence of mental health problems that relate to performance anxiety and fear of failure (Hjeltnes, et al., 2015). The high prevalance[spelling?] of mental health issues stated highlight the need for suitable interventions to be implemented that address the specific and unique needs of university students. MSBR strategies aim to highlight awareness, non-striving, and acceptance of their present moment experience, which reduces the anxiety of future-focused activities or outcomes. (Hjeltnes, et al., 2015). Mindfulness is defined as "a process of paying attention, on purpuse[spelling?], in the present moment and nonjudgmentally to the unfolding of experience moment by moment" (Kabat-Zinn, 2003, p. 145). MSBR strategies focus on keeping the individual in the present moment, in simple terms and not allowing the person to stress or fear future events that do not currently concern them. The management of stress reactions is emphasised through situational awareness and acceptance of physical and psychological experience (Hjeltnes, et al., 2015). It has been found to be an effective intervention strategy for multiple fear and anxiety psychological symptoms (Baer, 2003; De Vibe, Bjørndal, Tipton, Hammerstrøm, & Kowalski, 2012; Hofmann, Sawyer, Witt, & Oh, 2010, as cited in Hjeltnes, et al., 2015). While no direct studies have studied the impacts of MSBR on algophobia or its impact on pre-emptive experience of pain, the current body of literature shows promise that MSBR strategies could be utilised to keep an individual in the present moment and allow them to be situationally aware of their surroundings and avoid avoidance behaviours and aversive behaviours. Over the past decade, research has increased that aims to identify the specific role of fear in the onset, development and maintenance of pain (Asmundson, Norton & Vlaeyen, 2004)[past decade vs. 2004?].

### Cognitive behaviour therapy

Graded exposure therapy, a form of cognitive behaviour therapy (CBT), has shown promise to be an effective intervention to reducing the fear of pain in individuals. Within graded exposure therapy, a hierarchy of fearful activities is established and patient are then encouraged to participate in moderately feared activities in a safe and controlled environment (typically in a clinical setting) until the discomfort or fear of pain alleviates (Turk & Wilson, 2010). As it is a hierarchy, patients will then go on to a more feared task until they perform the activities that are most feared. How graded exposure therapy actually works is quite interesting- such activities challenge the catastrophic interpretations of the consequences of the feared activity. Graded exposure has been found to be effective in altering fear-avoidance and catastrophising beliefs, while also reducing pain in chronic pain patients (Hjeltnes, et al., 2015). "Several studies have demonstrated the potential for cognitive-behaviour therapy to cause a reduction in fear-avoidance beliefs, and that treatment success may be mediated by changes in fear-avoidance beliefs" (Turk & Wilson, 2010, p.92).
It should be noted however that, such research assumes the premise of knowing what the feared or target behaviour is. The issue with algophobia is that the fear of pain is multi-faceted and is not clear or objective, with considerations needing to be taken for individual differences. Graded exposure therapy guides the clinician to create a hierarchy of anticipated fears and then allow the individual to gradually expose themselves and acclimatise and desensitise themselves to the fears. A major issue here is that those fears may not be able to be identified, furthermore an individual can succeed in graded exposure therapy since it is controlled, but if an unknown aversive stimuli appears that individual may not have the cognitive skill set to deal with the fear. Hence, it is suggested that MSBR is a more effective treatment strategy currently for the fear of pain, as it allows for a broad understanding of fear and anxiety and the strategy can be easily implemented across different situations and applications. Overall, the following steps are effective treatment protocols that may assist in reducing fear-avoidance beliefs (Turk & Wilson, 2010).
| | Treatment Protocol |
| Step 1: | Assess the fear belief |
| Step 2: | Address the fear and reassure the patient that pain does not equal harm |
| Step 3: | Allow the patient to set goals and expectations on how to deal with their anticipated pain & provide coping strategies |
| Step 4: | Gradually expose the individual to their feared stimuli, working towards the ultimate fear. Track their progress during each progressive stage |
| Step 5: | Encourage self-monitoring, provide positive reinforcement to encourage continuation and to decrease catastrophising beliefs |
* Recap! What have we learned so far?
* MSBR is an effective treatment strategy for fear of pain.
* Further research is needed for direct treatments that look at the fear of pain treatment
* The Fear-Avoidance Model is a model that describes how individuals interpret pain, and the pathways that follow the interpretation.

### Quiz

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## Conclusion

Algophobia or the fear of pain is a heightened and perpetual experience of intense fear. This fear of pain often debilitates individuals and causes them great difficulty just to complete their daily activities, and causes intense levels of stress, fear and anxiety. Such a fear often results in avoidance behaviours taking place, which are detrimental to an individuals[grammar?] daily life as those behaviours often have flow-on effects and can even result in the loss of jobs, relationships and sense of identity. A plethora of research exists that discusses the impacts of the fear of pain in relation to chronic pain, with research suggesting that intense algophobia causes the onset of detrimental avoidance behaviours. Currently a biomedical treatment model exists, however it is suggested and recommend that the model shifts to a biopsychosocial model that incorporates significant emotions such as fear and anxiety which were found to be vital components of algophobia and the fear of pain.
The measurements of fear of pain are plenty, with 5 scales being mentioned. The most vital and important scale would be the FPQ-III due to its increased validity, reliability and widespread research and use. Studies that utilised similar tests to the FPQ-III found that certain brain regions activated in response to painful stimuli. Such regions were the medial prefrontal gyrus which is responsible for self awareness and the right lateral orbital frontal cortex which was responsible for pain regulation and evaluation. The fear-avoidance model is a helpful model that explains how pain is interpreted, and how it can be dealt with efficiently and positively or the perception of pain can end up detrimental and cause an on-going cycle of pain & anxiety.
It is recommend and vital that further research seeks to investigate the biological impacts of pain and perceived pain (Fear), and once a biological basis has been established, research can shift to creating an effective treatment intervention strategy. Further research should also focus on creating strategies that prevent individuals from experiencing the heightened fear in the first place, following positive psychology intervention methodologies of creating a healthy-coping strategy for individuals before the perceived problem becomes a major engrained issue.