Operant learning theory in pain and chronic pain rehabilitation

[Dolphin]

Curr Pain Headache Rep. 2012 Apr;16(2):117-26. doi: 10.1007/s11916-012-0247-1.
Operant learning theory in pain and chronic pain rehabilitation.
Gatzounis R1, Schrooten MG, Crombez G, Vlaeyen JW.

Research Group Health Psychology, University of Leuven, Leuven, Belgium. Rena.Gatzounis@ppw.kuleuven.be


Abstract

The application of operant learning theory on chronic pain by Fordyce has had a huge impact on chronic pain research and management.

The operant model focuses on pain behaviors as a major component of the pain problem, and postulates that they are subject to environmental contingencies.

The role of operant learning in pain behaviors generally has been supported by experimental studies, which are reviewed in the present article.

Subsequently, the rationale, goals, and methods of operant behavioral treatment of chronic pain are outlined.

Special attention is paid to three therapeutic techniques (graded activity, activity pacing, and time-contingent medication management), which are discussed in detail with regard to their operationalization, effectiveness, and (possible) mechanisms of action.

Criticisms of the operant model are presented, as are suggestions for the optimization of (operant) behavioral treatment efficacy.

PMID:
22261987
DOI:
10.1007/s11916-012-0247-1
[Indexed for MEDLINE]

 

[Dolphin]

These replied to the PACE trial in a letter to the Lancet. I now have a better idea where they are coming from following reading the paper.

Peter White and colleagues’ sophisticated randomised PACE trial1 clearly shows that “adaptive pacing” is not more effective than specialist medical care in improving chronic fatigue outcomes. Although the results are in line with recent findings that activity pacing is not associated with disability in fibromyalgia,2 we raise several concerns about adaptive pacing therapy.

First, the basic assumptions that excessive task persistence in chronic fatigue increases symptoms and that regular pauses or activity alternation are needed are not supported empirically.3 The cognitive and motivational consequences of task interruption are largely unknown for fatigue and pain disorders.

Second, there is no clear definition of pacing as a treatment technique, probably because of the lack of an empirically tested mechanism of behavioural interruptions.

Third, activity pacing can involve at least three different approaches to task interruption. For example, symptom contingent pacing uses fatigue or pain as signals for exertion, to avoid exacerbations. Time-contingent pacing encourages patients to interrupt when a preset time window has elapsed, irrespective of symptom change.4 Goal-contingent pacing guides patients in dividing higher-order goals into smaller, manage able pieces, with task interruption occurring after completion of lower-order goals, promoting a sense of control and mastery.5 Mixing of these different contingencies, as seems to occur in the PACE study, could create confusion in patients, reducing their unique effects.

Since the term “pacing” is widely used, but poorly defined, we would like to call for a better understanding and affective-motivational examination of the effects of task interruptions in the context of fatigue and pain.

We declare that we have no conflicts of interest.

*Johan W S Vlaeyen, Petra Karsdorp, Rena Gatzounis, Saskia Ranson, Martien Schrooten

johan.vlaeyen@psy.kuleuven.be

*Research Group Health Psychology, University of Leuven, 3000 Leuven, Belgium (JWSV, RG, MS); and Department of Clinical Psychological Science, Maastricht University, Maastricht, Netherlands (JWSV, PK, SR, MS)

1 White P, Goldsmith K, Johnson A, et al, on behalf of the PACE trial management group. Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial. Lancet 377: 611–90.

2 Karsdorp PA, Vlaeyen JW. Active avoidance but not activity pacing is associated with disability in fi bromyalgia. Pain 2009; 147: 29–35.

3 Gill JR, Brown CA. A structured review of the evidence for pacing as a chronic pain intervention. Eur J Pain 2009; 13: 214–16.

4 Fordyce WE. Behavioral methods for chronic pain and illness. St Louis: Mosby, 1976.

5 Nielson WR, Jensen MP, Hill ML. An activity pacing scale for the chronic pain coping inventory: development in a sample of patients with fi bromyalgia syndrome. Pain 2001; 89: 111–15.

 

[Dolphin]

Unlike the traditional biomedical model, which focuses on pain intensity as cause of disability and target of treatment, the operant model has pain behaviors at its core. Pain behaviors, namely actions, verbalizations, or facial expressions that occur in response to pain, might be adaptive when pain is acute, in the sense that they facilitate minimization of damage through protecting one’s self from the source of pain or through eliciting support from others by communicating distress and danger (protective and communicative pain behaviors, respectively; [8, 9]). However, such behaviors can become dysfunctional when they persist despite the absence of danger.

Who gets to decide this? The whole paper is based on this view/approach.

 

[Dolphin]

The aim of behavioral treatment, in contrast to interventions stemming from the biomedical model, is not to diminish the pain experience, but rather to increase functioning despite the pain [1, 24]. To achieve this goal, behavioral therapists attempt to decrease the frequency of pain behaviors and increase the frequency of healthy behaviors by removing reinforcers from the former and adding them to the latter [19, 41].

Again, acting despite pain is seen as healthy.

 

[Dolphin]

A more recently developed treatment, which also has its roots in the operant and behavioral tradition and has rule-governed behavior at its core, is Acceptance and Commitment Therapy (ACT) [84, 85]. The central feature of the ACT analysis is that a person’s language history can lead them to a state of “psychological inflexibility” such that they are dominated by their pain experience. The aims of ACT are essentially the same as those of the operant treatment approach: to facilitate a person’s engagement with a range of valued activities in the presence of pain, and to change the control over behavior by altering the context. For a discussion on ACT, see [86].

 

[Dolphin]

Special attention is paid to three therapeutic techniques (graded activity, activity pacing, and time-contingent medication management), which are discussed in detail with regard to their operationalization, effectiveness, and (possible) mechanisms of action.

It is interesting to read the rationale for these therapies. It is all about conditioning the patient to keep going and not stop based on symptoms.

These don't seem very appropriate approaches for ME/CFS.

I find what they suggest to be a bit creepy to be honest. But perhaps they are of use for some people with other conditions who are paralysed with fear.

 

[Effi]

I now have a better idea where they are coming from following reading the paper.

I looked them up because I thought they might be the crew behind the so called CFS centre at the University Clinic in Leuven (which patients are allover very unhappy with, as it is utterly unhelpful and possibly damaging), but they're not. This article seems to come from a PhD project by Gatzounis. The others are her promotors. In case anyone is interested, some background info:

Rena Gatzounis

For her PhD project, Rena investigates activity interruptions in the context of pain – in other words, what happens when one’s ongoing task is interrupted by pain and what can we do to minimize the negative consequences that interruptions probably have.

Johan Vlaeyen

The main interest of Johan W.S. Vlaeyen is the understanding of cognitive and behavioral mechanisms of chronic disability due to somatic complaints and pain in particular, and the development and evaluation of customized cognitive-behavioral management strategies for individuals suffering chronic pain.

His experimental work has highlighted the role of the threat value of pain in the engagement of defensive responses such as increased physiological arousal, hypervigilance and escape/avoidance behaviors. He and his team currently are examining the role of fear learning, and the pathways to the development of pain-related fear including. These include fear learning through direct experience, contextual fear learning when pain is unpredictable, observational fear learning, and learning through verbal instructions.

Johan Vlaeyen and his team also have developed exposure-based treatments for fear-reduction and they have utilized randomized controlled trials as well as replicated single-case experimental designs to evaluate the effects of behavioral interventions for patients with chronic pain.

Martien Schrooten

Most of Martien's research has focused on understanding the cognitive and motivational mechanisms underlying anxiety and (anticipated) pain by using behavioural experiments.

Geert Crombez

Currently, he is coordinating the research on the psychology of (chronic) illness, in particular the role of psychological and social variables on symptom perception, disability and suffering, and its implications for clinical practice. His approach is grounded in contextual functionalism. He focuses upon the development of integrative models of symptom perception, disability and suffering that are built primarily around the dynamic nature of goals and self-regulation.

They seem to make lots of assumptions, based on little more than theories. The idea of 'exposure-based treatments for fear-reduction' in the context of pain is downright scary... It all fits in perfectly with the rationale behind PACE!

 

[valentinelynx]

The evil specter of Behaviorism will not die! Operant conditioning, indeed!