Anxiety sensitivity (AS) is basically the fear of feeling anxious, or feeling anxiety-related symptoms. Typically, when people are fearful of their own symptoms of anxiety, they’ll work to avoid getting into situations where they may experience these symptoms.  AS has been shown to be a predisposing factor in some anxiety-related disorders such as panic attacks.   Lance McCracken and others at the University of Bath have been studying AS in pain, as well as producing a substantial amount of research relating to acceptance of pain, and contextual cognitive behavioural therapy.

This paper examines various measures of acceptance, mindfulness and values-based action, along with distress, disability and a measure of anxiety sensitivity in a group of patients with chronic pain. I’m not going to look at the wider issue of acceptance and mindfulness and so on, what I want to look at is the relationship between anxiety sensitivity and disability and distress.

The methodology for this study was quite simple - a group of patients were asked to complete a number of questionnaires at admission to the pain service, before their first appointment. The data collected from the questionnaires was then analysed using correlations and multiple regression (if you’re not certain about multiple regression, go here for more information). The specific questionnaires used are given in the paper itself, but included the Anxiety Sensitivity Index, a depression measure, several acceptance-based questionnaires, the Pain Anxiety Symptoms Scale, and the Sickness Impact Profile. Quite a swag of questionnaires!

What did the analysis show? I’m only going to briefly discuss the ones related to AS and distress and disability - the others are for another time!

The main finding is that Anxiety Sensitivity and its components are associated with more pain, more distress and more disability - which makes sense when you consider that AS is all about fear of feeling negative experiences. This isn’t the first study to show this (Asmundson and Norton have shown this too), but as McCracken and Keogh indicate, this study extends the findings to that AS is associated with greater depression, pain-related anxiety, disability and GP visits related to pain.

So what seems to happen is that people who are worried about feelings of anxiety experience chronic pain, they cope much less successfully than people who don’t have this underlying degree of concern. McCracken and Keogh suggest that AS can be thought of as a sort of ‘distress amplifier’ that ‘contributes additional adverse psychological meaning and influences to emotional experiences’.

They go on to suggest that ‘AS may be considered as part of a more general tendency to respond in a distressed and avoidant way toward one’s own experiences of emotions. If so, then what the ASI might be tapping is a behaviour pattern that generalises to experiences of other emotional experiences such as anger, depression, fear, frustration and perhaps others such as guilt, shame or embarrassment.’

Using the model of Acceptance and Commitment Therapy, these authors suggest that the findings in this study might support treatments based on helping people develop a more flexible approach towards experiencing unpleasant emotions - instead of working hard to control or avoid them, people might develop a different way of viewing them. As they put it ‘…on altering the meaning derived and the influences exerted in emotion and behaviour from what is thought or felt.’ What this means is helping people distinguish between the experience and the meaning (judgement or interpretation) of that experience so they can tolerate rather than avoid or eliminate something that can’t be eliminated.

Well, where does that leave me?
Apart from the known drawbacks of conducting a descriptive study in a group of people with measures taken only at one time, and manipulation of any variables (ie there can’t be any conclusions drawn about causal relationships), and that it was a fairly small clinical group of participants, this study adds to the information about anxiety sensitivity and its relationship to behaviours that are problematic in chronic pain.

After all, it’s not chronic pain per se that is the problem - it’s the inactivity, interference with daily functioning and the distress and depression that are really the problem. And these problems occur because of people’s judgements about having pain and what they believe the pain is about.

If we can establish that some people just don’t like feeling the fear - and instead of doing it, they don’t even want to think about doing it - then we can begin to work out ways to reduce their beliefs or interpretation of these experiences. We can help them recognise that they can experience them without the world falling apart, and that they can do this and carry out valued activities at the same time. We might be able to reduce their feelings of helplessness as they try to control what is uncontrollable. We might reduce their reliance on medications that not only dull pain, but also dull other experiences too.

Thinking about chronic pain management as essentially about being willing to feel the feelings and do it anyway might allow people to be more flexible about life in general. And I have a suspicion that psychological flexibility is an important part of resilience, or being able to cope with the ups and downs that life bring us. What do you think?

If you’ve enjoyed this post and want to read more, you can subscribe using the RSS feed link above, or you can bookmark and visit again.  I write most week days, with time off for good behaviour over the weekend!  I love comments, and usually respond quickly.  Don’t forget that if you do make a comment, it will be visible to others - if you want to respond more privately, head over to my About page where you can drop me a line.

Lance M. McCracken, & Edmund Keogh (2009). Acceptance, mindfulness, and values-based action may counteract fear and avoidance of emotions in chronic pain: an analysis of anxiety sensitivity The Journal of Pain, 10 (4), 408-415
Asmundson, G. J., Wright, K. D., Norton, P. J., & Veloso, F. (2001). Anxiety sensitivity and other emotionality traits in predicting headache medication use in patients with recurring headaches: implications for abuse and dependency. Addictive Behaviors, 26(6), 827-840.

It’s funny, earlier someone said I must be an employee of Bay Recovery due to my praise of Dr. Rand and Bay recovery because I sound like a traveling advertisment for them. I wish I were, the longer I deal with Dr. Rand and his staff, the more like family they have become. If I have a problem or need to speak to someone, I can call, or even just drop by and I know I will be taken care of even if I have to wait awhile on a drop in.
I have also been accused I guess of being a pussy as I tell everyone my wife saved my life by getting me to Dr. Rand, I owe her everything and love her unconditionally.
I have been in chronic pain since October of 2003 when I was rear ended while stopped. I have needed surgery, but it is complicated by having damage at 4 levels in my cervical vertebrate. Until June of 2008, when I just about went nuts and my wife got me into Bay Recovery, I spent almost 5 years undergoing “Pain Management”, which has become in America a euphemism for legal drug pushers. I have no problem with the drug companies or even with opiates or other pain medicines. We as a society need ongoing health care, medicine and research. We are supposed to however, look to and trust our doctors and medical system to do the right thing for all of us. Yes, I know, I realize how niave this now sounds, but I did believe in the system and hoped I would be treated properly. After getting into Bay Recovery and getting to know Dr. Rand, I really started looking at the system differently. Dr Rand seems to have this uncanny ability to see through the symptons and treats all of the root problems and uses whatever tools are available to solve all your problems. An example, I had always been a good sleeper until after the accident, and due to the pain, I didn’t sleep well, was groggy and irritable all day, couldn’t focus, etc.. Dr. Rand looked at the underlying problem from the accident and after, had studies done and because of the neck pain and the opiates compounding it, I had developed severe sleep apnea to the point where I was getting less than 15% of normal oxygen intake during the night. How did Dr. Rand get from neck pain to opiates to sleep apnea? By looking at correcting the total problem you have and applying good medicine, diagnostics and a way to correct a problem without more harmful medicine.
Enough about Dr. Rand and Bay Recovery.
I spent almost 5 years in “pain management” destroying my body. All I wanted was to feel no pain and the “pain management specialists” just kept putting more and more drugs down my system. Little did I know the medicine was doing more damage than the pain in my neck. I spoke before, that I now have overall less pain than when on opiates. I have been told that is impossible, but its not. As explained to me, the opiates and the mental and physical need for them actually stimulate the receptors and increase the pain levels. At least in my case this is true. I am sitting here writing this in nasty pain, but Bay Recovery has taught me how to control and block some of it.
I give my wife and Dr. Rand a lot of the credit for saving my life and I also wanted to share with you a book I read while recovering.
During my years on drugs, I didn’t realize how bad shape I had gotten into physically and mentally. Late last year my brother gave me a book, “YOUNGER NEXT YEAR” written by Chris Crowley and Dr. Harry Lodge. I read it, thought about it, and ended up reading it again. There is really nothing new or astounding or amazing about it, but it hits you right between the eyes as it explains simply about the aging process and how to slow it down in a simple, very funny format. I was 58 last year when I thought I was going nuts, I was overweight, out of shape, had all kinds of physical ailments due to the neck problem and had become sedentary due to fear of pain. I was 58 and thought I was ready to croak, I looked and felt like an old man.
I started taking the book by heart and though I utilize swimming as my primary activity now, the basic concepts of “YOUNGER NEXT YEAR” are incredible. I think that Chris Crowley goes a little overboard on some things like the heart rate monitor and calculations, I think all the ideas make sense. I now have his little list plasted around the house to remind me whats important.
If you are over about 50 years old and want to lead a good life, please read this book.

Retired physician with a disability fights for the right to get around on a Segway

By RYAN E. SMITH BLADE STAFF WRITER

 Dr. Patrick McNamara gets out of his silver minivan and hobbles a few steps, leaning heavily on a homemade wooden cane. There is pain in every awkward movement the 51-year-old makes - until he pops open the trunk and grins. “In a moment, I will no longer be handicapped,” he declares. The next thing you know, he’s zipping around the parking lot like Willy Wonka - he’s still holding the cane - using a Segway to run circles around an observer. He continues to show off inside a nearby supermarket, gliding around with ease, pushing a shopping cart, and exhibiting no trace of the nerve ailment that leaves him in severe pain most of the time. “I’m not disabled when I’m on this,” says Dr. McNamara, who has complex regional pain syndrome and retired from internal medicine three years ago. “It’s such a completely rehumanizing experience.” That’s what interests the Sylvania Township man most. Sometimes the solution is flashy and high-tech, like the Segway he uses to get around. At other times, it’s as old-school as the canes that he makes from scratch in his basement workshop. It all began when Dr. McNamara injured his back while exercising and found that he had trouble walking even a short distance due to the extreme pain. He investigated all sorts of help: scooters, wheelchairs, hiking sticks, metal canes, but each had its own problem. “The devices that you use to get around kind of mark you,” he says. Consider aluminum canes, for example. “They’re ugly, they’re cold, they’re uncomfortable,” he says. “They mark you as someone sick or disabled.” Then he tried a Segway and everything changed. When the two-wheeled device was unveiled in 2001, it was envisioned as a way to transform car-clogged cities, not as a tool for people with impaired mobility. But that hasn’t stopped Jerry Kerr, president of Disability Rights Advocates For Technology in St. Louis, from calling it “one of the greatest things ever designed for people with disabilities.” Mr. Kerr said there are thousands of people who have difficulty walking who use Segways, which move forward simply based on the user leaning in that direction. Karen A. Whalen, owner of Segway of Ohio: Toledo, says people with disabilities make up about 30 percent of her sales. (Most of the rest come from police and security companies.) “It really gives them back their lives,” she says. “They just get this huge smile.” It’s a smile that’s seen often on Dr. McNamara’s face when he talks about how the invention revolutionized his life, allowing him to go to the store or join his family for his son’s baseball games. It also keeps him at eye-level, unlike a wheelchair, which he finds painful. These days, Dr. McNamara doesn’t leave home without his Segway. He keeps it ready to go in the back of his van where, once it’s turned on, he can easily roll it down a pair of portable tracks. “The Segway is, I think, an idea whose time has come for disabled people,” Dr. McNamara says. While federal buildings under the jurisdiction of the U.S. General Services Administration allow Segway use by people with disabilities, not everyone else does, sometimes citing safety concerns. Nationally, the spotlight is on Walt Disney, which prohibits people from bringing personal Segways into its parks. Locally, it became a kind of quest for Dr. McNamara to make the city more Segway-friendly for the disabled and to raise awareness. He said he hasn’t had any trouble at private businesses and worked with the Ability Center of Greater Toledo to gain access to the Metroparks of the Toledo Area. Getting his Segway into One Government Center proved more difficult. In 2007, Dr. McNamara tried to use his Segway there and was not allowed to in an incident he called humiliating. The Ohio Civil Rights Commission found probable cause that he was denied access to a place of public accommodation due to his disability in violation of state discrimination law. “We essentially didn’t see that this was all that different from a motorized wheelchair,” says spokesman Brandi Martin. In November, more than a year after the original incident, the Ohio Building Authority, which owns the building, put in effect a new policy regarding Segway use on the same day Dr. McNamara filed a federal lawsuit against it. He has since received a settlement from the OBA. Dr. McNamara’s claim against the other defendant in the lawsuit, Reuben Management, which manages One Government Center, has not been resolved. Lisa L. Nagel, an attorney for Reuben Management, says it enforced existing policy and provided a wheelchair as a reasonable accommodation. Nationally, access issues don’t seem to be widespread. A bigger roadblock is price. Segways start at more than $5,000 and are not covered by health insurance, putting them out of reach for many. “The Segway was not designed as a mobility device and has not been approved by the FDA as a medical device so we are not allowed to market it as a medical device,” says Carol Valianti, a spokesman for Segway Inc. Fortunately, Dr. McNamara has found lower-tech and less expensive ways to help humanize those with disabilities. After all, the Segway can help him in the grocery store but he still needs something to get him around the house. So he bought some tools a year ago and learned to make wooden canes from scratch. “It kind of gives me a purpose in life,” he says. “I get to make something that’s not only comfortable and useful, but also beautiful.” Working downstairs, a stack of wood nearby, he shaves the wood with purpose and molds a cane handle until it conforms perfectly to his hand. The result is something elegant and distinguished. “I wanted something that was comfortable and attractive and doesn’t say, ’sick person,’” he says. Already Dr. McNamara has donated about a dozen of his creations to the Ability Center and more are in the works. The Ability Center plans to loan them out for a nominal fee. “I can’t practice medicine any longer,” he says, “but I have found another way to be helpful to others.” http://toledoblade.com/apps/pbcs.dll/article?AID=/20090329/ART16/903280262/-1/ART06

Deliberately using imagery, attention diversion and mindfulness to cope with pain is not something new.  It’s great though, to find that it has some very positive results when studied in a formal clinical research setting.

Elomaa, Williams and Kalso use a fairly straightforward research design to examine the effects, in a clinical population, of systematic training in the ‘limitation of the impact of pain either by switching attention to another stimulus or retuning attention to pain so that aspects are attended to which are less distressing and interruptive’. They followed the treatment manual developed by Morley, Shapiro And Briggs in which six 90 minute cognitive behavioural group sessions are conducted, training up to 7 participants in each group how to use strategies such as:

• basic attention management - brief relaxation, internal and external attention focus
• attention diversion and mindfuless - Focus on the details of experience, mindfulness breathing exercises, integrating mindfulness in everyday activities, external, mental and somatic focus of attention
• use of imagery and mindfulness - Creating vivid and pleasant images to concentrate on
• pain transformation images - Creating images to transform pain
• intense pain and flare-ups - Identifying responses to pain and vicious cycles in thoughts, images and behaviour, defusing catastrophizing and breaking vicious cycles
• pain coping strategies - Coping self-statements, signal-breathing, discussion on dealing with pain and relationship to pain and its chronic nature, discussion of all sessions and the use of skills

The results of this study were assessed by changes in several questionnaire scores from pre-treatment to three and six months following the intervention.  I’m not going to detail the questionnaires, but instead move straight to the results.

In the first time period until 3 month follow-up, pain intensity reduced significantly - this is interesting given that these patients were advised that pain intensity was not the focus per se, but instead participants were told ‘while pain intensity was not likely to diminish in the long term, techniques might produce a short-term reduction in pain intensity’, and the strategies were designed to address anxieties about experiencing pain.    This pain reduction was maintained at 6 month follow-up, but to a lesser degree - which isn’t surprising given that this is a skill that people need to practice (rather than a pill to swallow or a procedure to undergo).

Fear avoidance scores, and vigilance to pain reduced over time, while anxiety and functional abilities didn’t really change much.  There was a difference in effect size between those who attended both the 3 and 6 months follow-up, with those attending both demonstrating a better effect.

Participants reported they used brief relaxation, use of imagery, and distraction towards external objects most regularly, and reported these benefits:

• skills to deal with pain (n = 9),
• altered attitudes to pain (n = 10),
• improved sleep (n = 8),
• peer support (n = 7),
• stress reduction (n = 4)

Some points to think about

It’s rare to offer a single form of coping strategy like attention management in isolation from other aspects of a cognitive behavioural approach to pain management.  In this study, it was great to see that a single element was the focus - but this could have reduced the overall effect size that could be achieved in a more common pain management setting where multiple modalities are used.

I wonder what the results would have looked like had the participants also been undergoing exercise or activities of daily living reactivation at the same time - this would have combined both the cognitive and the behavioural components of most pain management programmes, and could have demonstrated a greater (and more realistic) effect.  However that would have reduced the purity of the study design, and now that we have a reasonable level of evidence for a cognitive behavioural approach to pain management, it is time to establish the specific elements that are helpful.

This programme was delivered by a clinical psychologist.  I’m not sure that the professional background of the person delivering the programme is as essential as having good experience with facilitating group programmes, and having sound knowledge and practice at delivering attention management skills using a cognitive behavioural model.

Patients selected for this study may well represent a sub-group of especially compliant or motivated people - and this is acknowledged in the discussion section of the paper.  This type of coping strategy takes both practice on a regular basis, and readiness and ability to actively use this coping instead of reaching for more passive options such as medications or injections.  In many practice settings the level of persistence in patients who may be very anxious, somewhat depressed - and often being seen by medical practitioners who don’t necessarily appreciate the way that medication use can interfere with active coping - can be quite low.  It really is easier to take a pill.

I’m hopeful that studies like this might encourage therapists of many persuasions to develop their skills in providing these strategies to complement their usual treatment.  This might flow through to increase the acceptance and effectiveness of ‘mind stuff’ by medical practitioners who might then be able to review their own actions with respect to prescribing or injecting.

ELOMAA, M., DECWILLIAMS, A., & KALSO, E. (2009). Attention management as a treatment for chronic pain European Journal of Pain DOI: 10.1016/j.ejpain.2008.12.002

Morley S, Shapiro D, Biggs J. Developing a treatment manual for attention
management in chronic pain. Cognitive Behav Ther 2004;33:1–11.

Hope can at times elude me. It seems just as I get a good grasp on it, as I seem to really have my mind wrapped well around it, it slips out a back door.

Hope is a joyful experience. It is comforting like an old quilt or fluffy down comforter to be wrapped or immersed in hope. When my body is aching, again, or I am without energy to do my daily tasks, it is having hope that keeps me going.

I find my hope in the Lord. I find my hope in the belief that He works all things out for good for me, even if I don’t understand it now. That is where I am grounded, that is where the foundation of my hope lies.

I believe I am also given the gift of hope through people and their stories, their faith, their courage. When I am hurting so badly that I feel taking a shower would be too much work, I am given hope when I reflect on what others I know have contended with. When someone shares an inspirational quote, a message of freedom, or a even a small success in their lives, it inspires me to hold on tighter to hope.

It can be tricky though, a person struggling with illness or depression can find their mind squeezing the hope out of a good situation. It is easy for a person struggling with depression or pain, to see another person’s victories and say to themselves, “I will never be able to do that.” or “Lucky them.” But what I encourage you to do, along with me, is when a thought like that comes into your mind immediately replace it! Be bold. Don’t hold back. Tell yourself that although you may not feel it, you are capable of good and wonderful things! You are valuable. You are worthwhile. You are important. Never mind if you don’t actually feel that way at the moment, tell yourself again! Don’t let your hope escape.

There is an element of choice here, you must choose to do it. It is not a simple task for many, including myself. But when you feel hope inside your heart, you will also feel real joy and peace.

It is worth all the effort.

I have battled with depression, among other things, since my teen years. I have not won the war entirely, but I continue to fight. We must not give up when we feel weak, we must be courageous and strong.

“The LORD is my strength and my shield; my heart trusts in him, and I am helped.” Psalm 28:7 (NIV)

“I sought the Lord, and He answered me; He delivered me from all of my fears.” Psalm 34:4 (NIV)

Are you afraid dear friends? In our area of Kentucky we recently had ice storms that took away our heat and power for days. Other areas we hear of in the news have wildfires, floods, or droughts.

Suddenly our world seems crazy and we realize that we are not really as much in control of our lives as we thought. I could not cook hot food. Normally our home is nice and has heat, air conditioning, an electric stove! But I was powerless and left to the elements of nature. It was humbling and scary to bee so cold and there was nothing I could do about it!

Maybe your fear is financial. Many of us with chronic illnesses cannot work. We cannot contribute financially to our families, or supply our own needs like we feel we should. Many healthy, normal people we know personally are afraid for their jobs. Our health insurance may change or be taken away. The recession has hit close to us in a hurry! And we realize that once again we are powerless.

Dear friends, I am right with you in this fear. So I am writing down some verses to tape up around my kitchen. Psalm 34:7 “The angel of the Lord encamps around those that fear Him, and He delivers them.” Psalm 46:1 “God is our refuge and strength, an ever present help in times of trouble.” Deuteronomy 33:27 “The eternal God is your refuge, and underneath are the everlasting arms.” Zephaniah 3:17 “The Lord your God is with you, He is mighty to save. He takes great delight in you, He will quiet you with His love, He will rejoice over You with singing.”

Dear ones, I hope and pray that the wonderful Word of God will calm you, and bless you, and bring greater faith and trust in His mighty love. Amen

ABOUT THE AUTHOR
Sandra Platt is a Minister’s wife and mother of two college aged kids. She has multiple chronic pain conditions, but praises God that they have drawn her closer to Him. She is blessed by the many friends that she has made through Rest Ministries. You may visit her in the Sunroom.

A collegue of mine, Blair Cross, is conducting a survey on beliefs and attitudes about back pain in occupational therapists.  Here is his introduction to the survey:

Invitation to Complete an OT Internet Survey

BE IN TO WIN!! ‘The Back Pain Revolution’ - a textbook by G. Waddell ($220)

Dear fellow OT’s

I have developed an on-line survey about beliefs regarding chronic low back pain. You are invited to complete this survey if you have assessed someone, in the last year, who reported having low back pain for 3 months or longer. NB. Pain does not have to be their primary problem.

The survey takes 10 -15 minutes to fill out. More information is given in the survey introduction. You do not have to put your name on the survey.

If you are unable to fill the survey out at this moment, you could make a note in your diary to fill it in within the next 8 days J. Your response would be greatly appreciated - it will help contribute to the body of OT research, and you have the chance of winning a very helpful book on back pain.

Please click on this webpage link to view the survey. You may have to hold down the control key.

Here is the link

If you’re not an occupational therapist practicing in New Zealand, please don’t complete the survey.  When results from the survey are completed, I’ll be sure to include them on this blog.

Thanks heaps!