Background & Aims
The fear and avoidance psychological model of maladaptation to pain is well-established for chronic musculoskeletal pain. It is based in robust psychological theory, and the basis of effective psychological interventions. There was no place in psychological theory for the site of pain to influence the psychological problems associated with it, so the model was extrapolated to visceral pains without testing.
We are conducting a large-scale qualitative study of five painful visceral disorders: endometriosis, inflammatory bowel disease (Crohn’s disease and ulcerative colitis), polycystic kidney disease, pelvic mesh complications, and bladder pain. We aim to characterise the psychology of living with these pains: it may fit the fear and avoidance model, or it may not.
Methods
For each visceral painful disease area, we are conducting (1) a systematic review and metasynthesis of qualitative studies, and (2) direct qualitative work to understand the experience of pain and its impact on quality of life.
Results
Two qualitative meta-syntheses completed to date (endometriosis, and pelvic mesh) shared themes of lost confidence in the body and its functions; disappointing encounters with medical care; emotional self-regulation in relation to symptoms; and sensitivity about disclosure and symptom visibility in social situations.
Compared to musculoskeletal pain, there were far fewer accounts of fear of pain or damage, or avoidance of activity. Concern about progression of disease (endometriosis) or damage (pelvic mesh) were not associated with avoidance of particular activities. Individual interviews (endometriosis, inflammatory bowel disease) described sense-making about pain and disease to try to control it; the broader, largely negative impact of pain and disease on many areas of life; and complex relationships with medical care.
Conclusions
Conclusions are provisional because we have more reviews and interviews to complete. But so far we have little evidence either from the qualitative reviews or the individual interviews to fit a model of fear and avoidance. It may be that our findings are partly attributable to having a definitive rather than a contested diagnosis, as in much musculoskeletal pain, but those diagnoses can take years to establish.
We believe that the fear and avoidance model needs serious reconsideration in the context of chronic visceral pain, in particular in relation to disclosure, stigma, and social pressures.
References
Vlaeyen JWS, Crombez G, Linton SJ. The fear-avoidance model of pain. PAIN 2016;157:1588–9.
Vlaeyen JWS, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: A state of the art. PAIN 2000;85:317–32.
Williams ACdeC, McGrigor H. A thematic synthesis of qualitative studies and surveys of the psychological experience of painful endometriosis. BMC Women’s Health 2024;24:50.
Presenting Author
Amanda C de C Williams
Poster Authors
Topics
- Mechanisms: Psychosocial and Biopsychosocial