Motivation and emotion/Book/2018/Chronic pain and maladaptive behaviour

Overview
Pain is generally considered to have an adaptive purpose, in that it warns of injury and disease (Katz, Rosenbloom & Fashler, 2015). However, when pain continues beyond the standard healing time it can become a motivator for many maladaptive behaviours. Pain that lasts for a period of six months or more is referred to as chronic pain and is discussed in this chapter, along with the maladaptive behaviours that follow.

A key maladaptive behaviour that follows as a result of chronic pain, is the experience of many emotional disorders, with these disorders also increasing sensitivity to the pain experienced (Dezutter et al. 2017). Many coping techniques that individuals apply also provide for maladaptive purposes. This chapter discusses studies showing that individuals who experience chronic pain often report feeling frustrated and angry more often than those who do not experience chronic pain (Dow et al. 2012). Many theories suggest that chronic pain can be operantly learned through behaviours of those around the individual and through the personal occurrence of pain. This chapter discusses the effects of the fear-avoidance model and the theory of learned helplessness on individuals with chronic pain and their maladaptive behaviours. The self-determination theory seeks to provide understanding for what motivates individuals with chronic pain to undertake maladaptive behaviours. To treat particular maladaptive behaviours that are motivated by chronic pain, a range of psychological approaches are used, such as operant conditioning, fear-avoidance, acceptance and cognitive therapy, and cognitive-behavioural therapy.

Take your time reading through the sections of this chapter and imagine what it would be like to be an individual experiencing chronic pain. Quizzes have been provided for you to test your knowledge as you go.

"you can't plan anything. That's another thing, you know, I was always quite organised and I can't be organised now because I don't know how I'm going to be the next day or even later on that day. My relationship with my husband has suffered because he likes to go out, well we both used to like to go out ... But you can't plan an evening in the morning because you don't know how you're going to be by the time you get to the evening and, if I feel I can't do it, then the guilt comes in ... Sort of all the time you're feeling guilty and frustrated and that's horrible." (Dow et al. 2012).

Chronic pain and maladaptive behaviours
Acute pain is used by the brain to warn of disease or injury, however chronic pain has no adaptive purpose (Katz, Rosenbloom, & Fashler, 2015). Chronic pain is defined as pain that continues beyond regular tissue healing time and incorporates a complex interaction of emotional and sensory constituents (Dow, Roche & Ziebland, 2012). This is generally reported as pain that has lasted for a period greater than six months with significant suffering (Stiles & Wright, 2008). Molton et al. (2008) stipulated that pain considerably effects quality of life due to sleep disruption, limited social functioning, disability or functional dependency, amplified health care and associated costs, and enlarged negative affect. Chronic pain can also be the cause of a number of losses including, quality of life, function, and identity (Katz et al. 2015; MacDonald, 2000; Scott, McCracken, & Trost, 2013; Wischkaemper & Gordon, 2015). A study by Stiles and Wright (2008) found that individuals with chronic pain regularly felt lost in treatment techniques that did not cater to their needs, this is generally the cause of differing perspectives of pain being either physical or psychological.

In addition to experiencing pain, individuals with chronic pain are likely to experience sensory pain-induced emotional disorders, for example, stress, anxiety, and depression (Dezutter et al. 2017; Radat et al. 2008; Wang et al. 2017). These disorders are also likely to increase the sensitivity to pain and individuals diagnosed with these conditions more often exhibit maladaptive behaviours than those who are not. This is likely due to the stress caused by pain and the constant fear of pain returning. The anticipation of pain can also result in the overuse of pain medication (Radat et al. 2008).



Coping techniques that involve problem focus or emotion focus are not an adaptive option. Instead coping strategies should focus on adjusting and re-evaluating goals (Dezutter et al. 2017). When an individual uses their internal abilities to control or function despite their pain in an attempt to deal with a chronic pain condition, it is referred to as active coping. However, passive coping involves helplessness and relinquishes the control of the pain to external resources instead (Baastrup et al. 2016). Passive coping strategies generally involve catastrophizing, chronicity of pain, maladaptive behaviour, and increases in depression and anxiety. The study by Baastrup et al. (2016) found that individuals with chronic pain were more likely to implement passive coping strategies and undertake maladaptive behaviour than individuals without chronic pain. Baastrup et al. (2016) found that the inability to cope in an adaptive way increases the chances of the individual experiencing a decreased quality of life.

Maladaptive behaviours that are often a result of chronic pain are guarding (Figure 1), pain-contingent rest and social support (Molton et al. 2008). Individual’s who experience chronic pain can sometimes feel a sense of injustice, which can negatively affect recovery. This has been associated with an increase in pain intensity, pain behaviour, narcotic use, depressive symptoms, persistent post-traumatic stress symptoms, and a decrease in the likelihood of returning to work (Scott et al. 2013).

The study by Wischkaemper and Gordon (2015) found that individuals experiencing chronic pain exhibited body-focused repetitive behaviours which comprised of a range of behaviours varying in severity and resulting in negative social or physical outcomes. These behaviours were found to be maintained by maladaptive thinking patterns caused by states of anxiety. Individuals experiencing chronic pain generally face difficulties in undertaking physical activity and health promotion tactics even though these are considered an efficient method in the management of pain and improvement of health (Brooks  et al. 2018).

 {What are the adaptive functions of acute pain?}

- To gain intelligence - To enhance cognitive ability - To understand emotions + To warn of injury

{What does passive coping comprise of?}

- catastrophizing - increase of depression and anxiety - maladaptive behaviour + all of the above

Frustration and anger
Frustration in individuals with chronic pain is often associated with the reasonable reaction to the inability to reach goals or act in a spontaneous manner, due to the unpredictable occurrence of pain and physical limitations. Frustration in individuals with chronic pain has also been found to be a result of pain interrupting tasks persistently, leading to the deprivation of performance, and the repeated attempts to solve the cause of pain, leading to negatively focusing on themself (Dow et al. 2012). A common complaint in individuals with chronic pain is frustration in the invisibility of the pain and the restrictions of health care in pain management and diagnosis (Dow et al. 2012). It can often be challenging to get pain recognised by others due to the lack of physical manifestation.

"You're in pain but you're being told by your doctors. "No, no you haven't got pain, it's just a pain you're feeling in your head". It just destroys you completely and it gives you a double burden to carry and that's what had happened to me and I was destroyed by it." (Dow et al. 2012)



Levels of frustration make a substantial impact on the negative feelings of pain. With frustration being an antecedent of anger, the way it is expressed, whether it be internal or external, can have multidimensional influences on the pain and well-being of the individual. Anger that has been internalised may be expressed as pain and increase the likelihood of pain-related depression. While externalised anger results in the reduction of personal relationships, a lack of obedience to pain management, and maladaptive health habits. This suggests that treatment targeting levels of frustration and anger could be effective in reducing levels of chronic pain (Dow et al. 2012). In an attempt to do this, doctors should focus on efficient communication techniques that represent a partnership in order to decrease levels of frustration (Figure 2).

"I have been known to, to, you know, storm out, be, you know, what's the word, a difficult patient because I'm frustrated. You know, if you feel you're not being listened to, it's frustrating, really frustrating." (Dow et al. 2012)

Overt pain behaviours


Wright and Stiles (2008) found that the usual pain behaviours that were presented by individuals with chronic pain were:
 * Verbal expressions of pain such as moaning, sighing, and subjective intensity ratings;
 * Physical motor pain behaviours such as limping, using a walking stick, grimacing, guarding and rubbing;
 * Lowering activity levels via sitting or lying down more often (see Figure 3); and
 * Consuming medications and utilising therapeutic devices to control pain.

Overt well behaviours should also be considered which are generally the opposite of the above list and include verbal expressions of reduced pain, increased activity level, and reduced medication use (Wright & Stiles, 2008).

"But, as time goes on, I found it becoming less and less predictable. So yes, I do tend to have bad days after I've done too much, but sometimes I don't and sometimes I have bad days for virtually no reason possible. And that's actually been the most frustrating part, is the fact that I can have a bad day and think, "I've done nothing, why am I worse than I was before?" (Dow et al. 2012)

Exaggerated pain behaviours
Dow et al. (2012) found that individual’s with chronic pain often exaggerated overt pain behaviours in order to receive acknowledgement and an explanation of their pain. This study also found that individual’s who felt unable to share emotions and feelings about their pain due to social constraints had negatively impacted psychological adjustments. In addition to this, the need to accentuate the negative effect of the pain in order to receive recognition can result in a impediment to psychological adjustment.

Conflicts
Often individuals experiencing chronic pain report a conflict described as the "sociological ambivalence" which includes the individual wanting to seem able to cope as a capable member of society whilst also being exempted from certain aspects of life (Dow et al. 2012).

Self-determination theory


A universal structure for understanding human motivation is the self-determination theory (see Figure 4) which comprises of three essential and distal needs that stimulate behavioural self-regulation, progression, and peak functioning when fulfilled (Brooks et al. 2018). The three needs are:
 * Autonomy – initiation and regulation of health behaviours;
 * Competence – seeking out ideal challenges that will enhance skills and opportunities in an effective manner; and
 * Relatedness – being emotionally linked and interpersonally involved in caring and warm relationships.

Brooks et al. (2018) found that elements of the self-determination theory, particularly the need for competency, were significantly associated with the involvement of individuals with chronic pain in physical activity and other adaptive behaviours. This reiterates the importance of ensuring basic needs are met.  {What are the innate psychological needs described in the Self-Determination Theory?}

- Autonomy, Respect, & Competence - Assertiveness, Relatedness, & Competence + Autonomy, Relatedness, & Competence - Autonomy, Relatedness, & Compassion

{Which of the needs identified in the Borrks et al. 2018 study was found to be the most significant in the involvement of physical activity for individuals experiencing chronic pain?}

- Autonomy + Competence - Compassion -Relatedness

Operant conditioning
Stimuli following a response is a positive reinforcement if it increases the likelihood of that response recurring (Stiles & Wright, 2008, p. 30).

The above comment indicates that behaviours that produce positive outcomes are more likely to continue, whilst negative or aversive outcomes are more likely to reduce or remove the occurrence of a behaviour (Stiles & Wright, 2008). This produces the theory that when pain behaviours are reinforced they are more likely to occur again, thus creating a chronic problem.

Certain body movements may cause pain that is considered a negative reinforcer and will therefore reduce the likelihood of the individual completing that movement again in the future (Stiles & Wright, 2008). Similarly, in the study by Turk, Swanson, and Tunks (2008) it was proposed that pain behaviours were strengthened by negative reinforcement due to the pain being terminated as a result of ceasing or avoiding a certain behaviour.

Avoidance
The fear-avoidance model (see Figure 5) is used to explain functional disability due to chronic pain. The model is based on thoughts of anxiety that result in concerns about painful consequences in relation to particular behaviours and therefore enhancing the avoidance of that behaviour (Samwel et al. 2007). Similarly, avoiding particular behaviours results in reinforcement of the anxiety cognitions and thus heightening the motivation to continue the maladaptive behaviours (Quartana, Burns, & Lofland, 2007). When an individual makes an assumption based on experience that terminating an activity or behaviour will reduce pain it is a learned response that the avoidance of that activity or behaviour has a positive effect. This is a positive outcome that negatively reinforces these behaviours in the future (Turk et al. 2008).

Scott et al. (2013) found that strategies of avoidance increased distress when the avoided internal experiences are re-encountered, with attempts to avoid challenging personal experiences associated with initiating and maintaining psychological distress and maladaptive patterns of behaviour. Whilst avoidance may result in initial short-term relief, its continuance is likely to prevent engagement in activities that were once valued by the individual which will result in greater long-term suffering. Likewise, the suppression of difficult thoughts and emotions relating to the occurrence of chronic pain is likely to result in avoidance and leads to an increase in the intensity of pain and maladaptive pain behaviours.

Another example of avoidant behaviour is the avoidance of health care professionals due to the sense of injustice and disbelief the individual feels when attending medical appointments (Scott et al. 2013). This is displayed when an individual actively evades medical intervention and remedies.

The anticipation of pain provokes a fear response, which can aggravate pain by eliciting physiological reactivity (Turk et al. 2008).



{What is an example of pain avoidant behaviour? Avoiding:}

- chocolate because you want to lose weight + lifting weights because it hurts your wrist - visiting your family because they disapprove of your life choices - all of the above

Learned helplessness


Learned helplessness (see Figure 7) occurs in instances of experience to occasions that are uncontrollable and paired with helplessness. This is evident in individuals experiencing chronic pain in daily life due to the inability to escape the outcomes of pain (Samwel et al. 2007). Individuals who experience chronic pain are often unsure whether they will find relief, which causes a state of uncertainty, which can be associated with a sense of helplessness. The construct of helplessness can be useful in understanding the occurrence of maladaptive behaviours (Nicassio et al. 1999). Research has indicated that helplessness is associated with increased dissatisfaction with daily living activities, enhanced disability and higher levels of pain. As observed in Figure 8, individuals with higher levels of pain experience an increased rate of helplessness and decreased internality, which is likely to lead to depression.



Treatment methods
There are many treatment methods that can be applied to individuals that are excperiencing chronic pain. From a psychological perspective, the following treatment approaches are some of the many that can be used to reduce maladaptive behaviour in individuals experiencing chronic pain.

Operant conditioning
Stiles and Wright (2008) found that treatment from a psychological perspective for individuals with chronic pain, specifically those based on operant conditioning and fear-avoidance principles. The essential elements of operant conditioning treatments are graded activation, social reinforcement, and time-contingent medication. It is important that an assessment of physical pathology is undertaken to ensure realistic goals for change are set. Verbal praise during this exercise can also provide assistance in the learning process. Removing the association of medication intake and reduced pain, by placing time contingencies on medication scheduling rather than the individual taking it on an as-needed basis, can reduce the dependencies on medication.

Solicitous behaviours displayed by spouses and family members can increase the likelihood of pain due to the positive reinforcement they provide. It is important that families of individual’s with chronic pain reward well behaviours and reduce the reinforcement of pain behaviours. The main aspect here is for member’s of the individual’s social life to avoid responding to pain behaviour and increasing support and encouragement of well behaviours.

Graded activation is used to combat the cycle of individual’s undertaking activities until they experience considerable pain and have to stop. The individual is required to work on a particular activity for a pre-arranged period of time or repetitions and then rest. It's important that the time or repetitions allow for the activity to be completed within the individual's threshold of comfort.

Fear-avoidance
Graded activation is also used in treatment based on the fear-avoidance model, which considers that individual’s tend to over anticipate the amount of pain certain activities may cause. Education of the individual is used here to assist them to understand their condition and its ability to be self-managed rather than being a condition requiring vigilant protection (Stiles & Wright, 2008). Turk et al. (2008) found that the progressive increase of activity in individuals who were found to previously avoid specific activities due to fear of pain assisted in the reconditioning of muscles. Molton et al. (2008) proposed that persisting with tasks through pain occurrence, relaxation, spreading out activities, and coping self-statements including positive affirming thoughts, could provide assistance in the treatment of maladaptive behaviours caused by chronic pain. Some of these exercises involve the individual participating in an activity that would normally induce pain but ceasing prior to the occurrence of pain.

Acceptance and cognitive therapy
Scott et al. (2013) suggested the use of Acceptance and Commitment Therapy, which constitutes a framework of psychological flexibility and inflexibility that aims to change behaviour of individuals by altering the way in which they relate to private experiences, can be effective in the treatment of maladaptive behaviours caused by chronic pain. This includes mediation between unwanted cognitive, sensory and emotional experiences and opposing outcomes, which describes the motivation of personal experiences on behaviour, and how these experiences result in patterns of behaviour that are not aligned with values and goals. This study found that Acceptance and Commitment Therapy is useful for individuals who are unlikely to find a cure to their pain.

Cognitive-behavioural therapy
Cognitive-behavioural therapies are useful in individuals who believe that they have an inability to function due to their pain and are helpless in their situation (Turk et al. 2008). This treatment type is based on assisting individuals to recognise that their condition can be managed with skills and education on more adaptive responses to pain. The aim is to provide individuals with a sense of hopefulness and resourcefulness. Individuals learn to identify maladaptive thoughts when undertaking problematic situations and replace them with coping thoughts and behaviours.

Throughout the research, there have been no treatment techniques that have been successful in fully eliminating pain as most are used to assist individuals adapt to the pain and remain persistent despite symptoms.

 {Which treatment technique involves the mediation between unwanted cognitive, sensory and emotional experiences and opposing outcomes}

- Operant Conditioning - Graded Activation - Cognitive-behavioural Therapy + Acceptance and Commitment Therapy

Conclusion
In conclusion, this book chapter has provided an insight into the experiences of individuals with chronic pain and their motivations towards undertaking maladaptive behaviours. The experience of chronic pain itself is a maladaptive behaviour that can be learnt through operant conditioning and fear-avoidance models. Often chronic pain can result in several emotional disorders and can significantly impact an individuals quality of life. These experiences all have an effect on individuals and can motivate particular behaviours that they may not realise are not beneficial to their adaptivity. An example is the reduction in physical activity that individuals with chronic pain undertake, even though this is maladaptive due to negative health outcomes. Individuals who experience chronic pain report higher levels of frustration and anger than those who live pain free, which has been found to significantly effect relationships and quality of life. Overt pain behaviours, whether exaggerated or not, were found to provide a means of maintaining chronic pain through operant conditioning. Further research on the use of reinforcement and punishment in individuals experiencing chronic pain is suggested in order to provide a means of reduction in the motivation of maladaptive behaviours in individual's experiencing chronic pain.