Safety behavior can hamper the extinction of fear of movement-related pain: An experimental investigation in healthy participants

doi:10.1016/j.brat.2012.06.004

Behaviour Research and Therapy

Volume 50, Issue 11, November 2012, Pages 735-746

https://doi.org/10.1016/j.brat.2012.06.004 Get rights and content

Abstract

Excessive fear of movement-related pain (FMRP), and its associated avoidance behavior, is considered a major risk factor for disability in chronic musculoskeletal pain. The current study aimed to investigate whether engaging in safety behavior, conceptualized as an avoidance response, hampers the extinction of FMRP. In a differential conditioning paradigm, we used joystick movements as conditioned stimuli (CSs) and a painful electrocutaneous stimulus as the unconditioned stimulus (US). In the Safety group, participants received the opportunity to avoid the pain-US by pressing a safety button during the extinction phase, whereas in the Control group, this option was not included. In a subsequent test phase, this safety button was no longer available. In two experiments, results demonstrate successful acquisition and extinction. Retrospective FMRP ratings in both experiments revealed a return of fear of pain in the test phase in the Safety group, but not in the Control group. In Experiment 1, mean eyeblink startle reflex amplitudes partly corroborated the self-report findings on fear of pain. The present results suggest that performing safety behavior during cognitive-behavioral interventions, i.e., exposure, might increase the risk of a return of FMRP.

Highlights

► We examined the effect of safety behavior on the extinction of fear of pain. ► We performed two differential conditioning experiments with proprioceptive stimuli. ► Safety behavior can interfere with extinction and promote a return of fear. ► The effects of safety behavior during and after extinction are different.

Section snippets

Participants

Fifty-two healthy students from the University of Leuven (31 men, age M = 22, range 18–50 years) participated in this study and provided written informed consent. The experimental protocol was approved by the Ethical Committee of the Department of Psychology of the University of Leuven.

Apparatus and stimulus material

Software. The experiment was programmed using Affect (version 4.0; Spruyt, Clarysse, Vansteenwegen, Baeyens, & Hermans, 2010). The entire experiment was run on a Windows XP computer (Dell Optiplex 755) with 2 GB

Participants

74 healthy students from the University of Leuven (44 men, age M = 20, range 15–26 years, 37 in each group) participated in this study and provided written informed consent. The experimental protocol was approved by the Ethical Committee of the Department of Psychology at the University of Leuven.

Apparatus and stimulus material

The apparatus and stimulus material used in this experiment were identical to those used in Experiment 1, including the selection of a shock intensity at a level described as “mildly painful and

General discussion

Two experimental studies using the VJMP were conducted to investigate whether safety behavior fosters protection from extinction in FMRP. The results of both Experiment 1 and Experiment 2 are generally in line with the expectations. Participants rapidly learned to distinguish which movements were painful (B+ and C+) and which one was not (A−). Consequently, more fear was elicited by the painful movements than by the non-painful or “safe” movement. Most importantly, a return of fear was observed

Acknowledgments

Steven De Peuter is a postdoctoral fellow of the Research Foundation – Flanders, Belgium (FWO). The authors would like to thank Ellen Beets and Quirin Dalemans for their assistance in the data collection and Jeroen Clarysse for his assistance in programming matters. The data of Experiment 2 have been presented as a poster at the 7th Congress of the European Federation of IASP^® Chapters (EFIC) Pain in Europe VII, Hamburg, Germany, September 2011.

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Safety behaviors are usually adaptive when they prevent realistic harm; however, they become pathological when they persist in the absence of threat in addition to inflicting impairments and results in cost to the individual (i.e., costly safety behaviors). Empirical studies (Lovibond, Mitchell, Minard, Brady, & Menzies, 2009; Pittig, 2019; Rattel, Miedl, Blechert, & Wilhelm, 2017; Volders, Meulders, de Peuter, Vervliet, & Vlaeyen, 2012) showed that if US-avoidance was constantly engaged to the CS+ during extinction trials, participants would attribute the absence of a US to their US-avoidance, thus protecting them from extinction learning (i.e., protection from extinction). Therefore it is of clinical interest to reduce safety behaviors as it likely reduces protection from extinction and the inflicted impairments, thus enhancing the effectiveness of exposure-based treatments (see also Helbig-Lang & Petermann, 2010; Wells et al., 1995).
Exposure-based treatment involves repeated presentation of feared stimuli or situations in the absence of perceived threat (i.e., extinction learning). However, the stimulus or situation of fear acquisition (CS+) is highly unlikely to be replicated and presented during treatment. Thereby, stimuli that resemble the CS+ (generalization stimuli; GSs) are typically presented. Preliminary evidence suggests that depending on how one generalizes fear (i.e., different generalization rules), presenting the same GS in extinction leads to differential effectiveness of extinction learning. The current study aimed to extend this finding to safety behaviors. After differential fear and avoidance conditioning, participants exhibited discrete generalization gradients that were consistent with their reported generalization rules (Similarity vs Linear). The Linear group showed stronger safety behaviors to a selected GS compared to the Similarity group, presumably due to higher threat expectancy. After extinction learning to this GS, the Linear group exhibited stronger reduction in safety behaviors generalization compared to the Similarity group. The results show that identifying distinct generalization rules allows one to predict expectancy violation to the extinction stimulus, in addition to corroborating the idea that strongly violating threat expectancy leads to better extinction learning and its generalization. With regard to clinical implications, identifying one's generalization rule (e.g., threat beliefs) help designing exposure sessions that evoke strong expectancy violation, enhancing the reduction in the generalization of maladaptive safety behaviors.
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Positive affect is hypothesized to improve safety learning taking place during extinction (i.e., the core mechanism of exposure treatment), therefore improving the maintenance of treatment outcomes. We investigated whether positive affect during extinction attenuates the subsequent return of pain-related avoidance and fear. In an operant pain-related avoidance conditioning paradigm, sixty healthy volunteers performed arm-reaching movements using a robotic arm. During acquisition, they learned to avoid an easy but painful movement (T1) by choosing more effortful movements that were sometimes (T2) or never (T3) painful. Then, the Positive affect group wrote about and imagined their best possible self, which is known to induce positive affect, whereas the Control group wrote about and imagined a typical day. During extinction with response prevention (RPE), participants were only allowed to perform T1, which was no longer paired with pain. Next, two painful stimuli were presented when participants were not moving (i.e., reinstatement manipulation). During test, all movements were available, and we examined whether fear and avoidance of the previously painful movements would re-emerge. Pain-related avoidance returned in both groups, but the two groups did not differ herein. The Positive affect group reported increased positive affect, though not more than the Control group. Nevertheless, they generalized the learned safety of T1 to the other movements during RPE, whereas they also retrospectively rated the pain as less intense and less unpleasant. These results add to the literature of positive affect as a resilience factor.
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Avoidance is a hallmark symptom and a primary maintaining factor in anxiety disorders. Theories of anxiety disorders have focused not only on overt avoidance, but also on more subtle avoidance known as ‘safety behaviours’. Safety behaviours involve behaviours which aim to reduce anxiety or prevent a feared outcome from occurring. In the long-term, however, these behaviours prevent the disconfirmation of threat because safety is incorrectly attributed to the safety behaviour, thus perpetuating anxiety. As a result, reducing or eliminating safety behaviours is an important target for many cognitive behaviourally oriented treatments. Notably, despite the relevance of anxiety to people with chronic health problems, the role of safety behaviours is rarely discussed in these contexts. Further, safety behaviours among those with chronic health problems pose a particularly complex problem. Distinguishing adaptive safety precautions from maladaptive safety behaviours can be a difficult task. In this paper, we discuss the role of safety behaviours in maintaining and treating anxiety problems in healthy adults, and whether these same principles apply to those with chronic illness. We propose a functional and contextual model of differentiating between safety behaviours and safety precautions amongst those with chronic physical illness. Lastly, we propose methods for adapting the treatment of anxiety disorders in the context of chronic physical illness.
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Exposure in vivo is a theory-driven and widely used treatment to tackle functional disability in people with chronic primary pain. Exposure is quite effective; yet, in line with exposure outcomes for anxiety disorders, a number of patients may not profit from it, or relapse. In this focus article, we critically reflect on the current exposure protocols in chronic primary pain, and provide recommendations on how to optimize them. We propose several adaptations that are expected to strengthen inhibitory learning and/or retrieval of the extinction memory, thus likely decreasing relapse. We summarize the limited, but emerging experimental data in the pain domain, and draw parallels with experimental evidence in the anxiety literature. Our reflections and suggestions pertain to the use of the fear hierarchy, reassurance, positive psychology interventions, exposure with a range of stimuli and within different contexts, and the use of safety behaviors during treatment, as well as associating the fear-inducing stimuli with novel outcomes. In addition, we reflect on the importance of specifically tackling (the return of) pain-related avoidance behavior with techniques such as disentangling fear from avoidance and reinforcing approach behaviors. Finally, we discuss challenges in the clinical application of exposure to improve functioning in chronic primary pain and possible avenues for future research.
Inspired by recent advances in learning theory and its applications on the treatment of anxiety disorders, we reflect on the delivery of exposure treatment for chronic primary pain and propose strategies to improve its long-term outcomes.
Once an Avoider Always an Avoider? Return of Pain-Related Avoidance After Extinction With Response Prevention
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In exposure for chronic pain, avoidance is often forbidden (extinction with response prevention; RPE) to prevent misattributions of safety. Although exposure is an effective treatment, relapse is common. Little is known about the underlying mechanisms of return of pain-related avoidance. We hypothesized that pain-related avoidance would recover when becoming available again after RPE and after unexpected pain episodes (“reinstatement”), especially when restricting avoidance during RPE (compared to instructing not to use it). In an operant pain-related avoidance conditioning paradigm, healthy volunteers used a robotic arm to perform various arm reaching movements differing in pain-effort trade-off. During acquisition, participants learned to avoid pain by performing more effortful movements. During RPE they only performed the formerly pain-associated movement under extinction, and were either forbidden (Restricted group) or merely instructed (Instructed group) not to perform other movements. One day later, we tested spontaneous recovery and reinstatement of pain-related fear and avoidance with availability of all movements. Results showed that pain-related fear and avoidance re-emerge after RPE, though not to pretreatment levels. The reinstatement manipulation had no additional effect. No group differences were observed. We discuss findings in the context of learning processes in (chronic) pain disability and relapse prevention in chronic pain treatment.
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Excessive maladaptive avoidance has been claimed to be one of the mechanisms through which intolerance of uncertainty (IU) may play its causal role in the development and maintenance of several anxiety and compulsive disorders. Consistently, Flores et al. (2018) found that individuals with higher Prospective IU (P-IU), a specific IU subfactor, display excessive avoidance response repetitions in a free-operant discriminative task to avoid an aversive noise. In the present study we tested the hypothesis that P-IU not only predicts the amount of avoidance responses but also how well the temporal distribution of such responses fits the temporal distribution of threats.
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Our results are exclusively based on the use of a low-cost avoidance response, and the present study does not clarify the precise mechanisms that lead high P-IU people to engage in non-optimal avoidance response distribution through time.
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¹: These authors are supported by the Odysseus grant “The Psychology of Pain and Disability Research Program”, Fund for Scientific Research – Flanders (FWO – Vlaanderen).

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Safety behavior can hamper the extinction of fear of movement-related pain: An experimental investigation in healthy participants

Abstract

Highlights

Section snippets

Participants

Apparatus and stimulus material

Participants

Apparatus and stimulus material

General discussion

Acknowledgments

Behaviour Research and Therapy

Behaviour Research and Therapy

Behaviour Research and Therapy

Journal of Behavior Therapy and Experimental Psychiatry

Pain

Behaviour Research and Therapy

Journal of Behavior Therapy and Experimental Psychiatry

Biological Psychiatry

Journal of Anxiety Disorders

Pain

Clinical Psychology Review

Behaviour Research and Therapy

Behaviour Research and Therapy

Journal of Behavior Therapy and Experimental Psychiatry

Pain

Pain

Behaviour Research and Therapy

Behaviour Research and Therapy

Journal of Behavior Therapy and Experimental Psychiatry

Behaviour Research and Therapy

Behaviour Research and Therapy

Behaviour Research and Therapy

Behaviour Research and Therapy