4.2 Pain Avoidance: The Role of One Inherited Temperament Trait in Avoiding TN Pain
By Dr Leesa Scott-Murrow, PhD, JD, LP (USA)
Every animal has a set of behaviors they use to defend themselves against danger. Perceived threats to survival require an urgent, immediate response, and it is for this reason that the brain mechanisms underlying the response to perceived threat have evolved to operate instinctually, in a wordless part of the brain. For all animals, humans included, defensive behaviors occur instantly in response to perceived threat; freezing in place, fleeing, or fighting, all occur automatically in response to danger. Securing survival is time-urgent; there is no time to think about taking defensive action.
For humans, the brain initiates a cascade of physiological changes that equip us to successfully respond to threats. Muscle tone increases to facilitate fleeing or fighting. Heart rate and blood pressure increase to ensure abundant blood supply to vital organs. Pupils dilate as the brain activates. These primal changes and many other associated changes initiate below awareness, outside the realm of choice. Most importantly, these physiological changes are involved in every kind of fearful response to some degree, even in those fearful experiences that do not involve threat to life or limb. Sudden painful experiences inevitably trigger the physiological threat response, even in instances when the pain is not life-threatening and even when the individual knows that the pain is not life-threatening. The cascade of physiological changes occurring in response to threats occurs even in response to threats that are purely emotional or imagined. The body cannot tell the difference between being exposed to a near-miss car accident and being suddenly surprised in a haunted house tour. For individuals with anxiety, the body can respond to a public speaking experience as if it were life-threatening.
For biologically complex animals, those with thinking brains, a lot of learning occurs in response to threatening experiences. We have the mental capacity to identify potential threats on the basis of tiny little signals in the environment and to adjust our behaviors accordingly. This blend of perception, cognitive interpretation, and behavioral response constitutes a kind of learning that is only partially conscious, however.
It is important to understand that, even though this kind of learning arises in response to the environment, it is ultimately biological. Newly learned information has to be stored in the brain in the form of a memory; this is a biological process. These memories have to wire themselves to other brain-based nuggets of knowledge in order to be useful; again, this a biological process. And the act of attaching meaning to these memory complexes is also ultimately biological. Learning at this last level is dynamic. What we know, and believe, can change, and when it does, our associated perceptions of threat also change. When our perceptions of threats change, our physical responses change. Change is possible, but because these stress-related processes occur instantly, largely below the threshold of awareness, change is difficult to achieve. Changing these responses requires becoming more self-aware in order to defeat, or override, the automaticity of the response.
Remember, the capacity to form fear–perception–action complexes evolved to protect animals (including humans) from the dangers of life-threatening injury. Because physical survival typically depends upon taking immediate action, the part of the neuroendocrine system that creates the stress response evolved to work very rapidly, too rapidly to include word-based cognition and analysis. The process of thinking about something that is happening and forming a problem-solving dialogue in our heads takes far too long to be effective under threatening circumstances; thus, the brain skips the problem-solving part to prioritize speed over everything else. Because nature has prioritized speed over all else, fear-based learning is error-prone. For example, if you have facial pain, the neuroendocrine system may fire a defensive reaction when you step outside on a windy day, without having actually felt any wind, or pain, simply because you have felt pain under windy conditions in the past. Indeed, the system may fire at the mere thought of going outside on a windy day, without your actually having stepped outside. As you can see, from a psychophysiological perspective, in the context of chronic pain, things can get complicated as unconscious learning compounds over time. Indeed, the more time an individual has struggled with pain, the more automatic defensive behaviors they will have learned, and the greater the likelihood this learning will involve error. This error will express itself in a set of beliefs, which, of course, the individual will resist changing unless they understand the necessity of doing so. Psychotherapists should approach this relearning process with compassion. Because fear-based behaviors and anxieties form automatically, they are difficult to identify. From the perspective of the person fearing pain, their beliefs feel correct and reasonable. Challenging the erroneous thinking that underlies pain-defensive behavior requires empathy, and it is crucial for the therapist to allow time for the patient to observe patterns in this behavior so that these patterns can be discussed in session. When it comes to automatic behaviors like fear responses, the methodology of change is technical and not particularly intuitive. If feeling anxious is a common part of your experience, it is a good idea to get professional help. Indeed, reading this section is a form of professional help, so let’s keep going.
Let’s dig a little deeper. As you can see, perception of threats and responses to perceived threats become extremely complicated because of our big brains. Because we have the ability to imagine things, we can worry about potential threats that will never happen. We call these apprehensive cognitions anxiety. It will not surprise you to learn that the tendency to feel anxious is biologically driven and that it powerfully affects personality structure. Some people see threats just about everywhere, whereas others easily shake off their worries. These two types of people will respond to facial pain in quite different ways. To illustrate these differences, consider fear of flying, a less provocative but more common situation. Imagine two people sitting next to one another on a plane that is flying through a turbulent storm. Because they are sitting side by side, their physical experience of turbulence is essentially identical. Yet, one person walks off the plane with little if any apprehension about their next flight, whereas the other person swears they will never get on another plane. These two people had the same objective experience during the turbulent flight, but their subjective experiences were quite different. They attached vastly different meanings to their experience based on the way they evaluate threats. Indeed, for human beings, the subjective experience of threat is an enormously powerful individualized force that shapes our beliefs and behavior.
Personality Structure. People are different from one another, but these differences are not random. The individual who will never fly again will likely respond fearfully to other scenarios they perceive to be dangerous, whereas their easy-going seatmate will not be as inclined to interpret situations fearfully. The difference between these two people is grounded in identity, or as we say in psychology, in personality structure. Their tendency to perceive a threat and evaluate it as potentially catastrophic, or not, is inherent in who they are. When I say inherent, I mean that this tendency is literally inherited.
For many decades, psychologists studying personality structure restricted their efforts to learning why certain people behave in ways that cause them interpersonal difficulty in most all settings. These psychologists were trying to better understand personality disorders. Yet, as a matter of logic, the existence of abnormal personalities in humans suggests there must be some human quality that constitutes a normal personality. Consequently, modern researchers have begun looking for the foundational aspects of personality, ones that define both normal and abnormal personality configurations. Their research tells us that personality has a structure, one that consists of identifiable traits, or factors, that are, for the most part, biologically determined. This research hinges on the assumption that these core traits are common to all humans and that, like other human qualities, these traits are coded in our genes. Eye color, a trait we all recognize as genetic, involves just a few genes. Certain dispositional behavioral traits are also genetic, but they are extraordinarily complex, involving the interaction of many genes. That makes the study of these traits difficult, but still possible.
Psychologists use true/false or multiple-choice tests that have been statistically designed to identify the traits that underlie personality. These tests query the individual about their self-perceptions, their beliefs about others, and their perceptions of the world at large. The most widely used of these tests have been translated into many languages, with data collected from people from many different cultures. After all, if something is truly biological at its foundation, it should be recognizable in all people, regardless of the individual’s cultural or racial origins. Indeed, this research has identified a core set of personality traits that appear to be genetically based and universally human. Some research has identified four traits; other research has identified five.
C. Robert Cloninger, a Professor Emeritus in the Department of Psychiatry at Washington University in St. Louis, USA, is a leading researcher exploring heritable personality traits. I find his work fascinating, but more importantly, I find his research helpful in understanding my patients’ experience of pain. I think a basic understanding of his research will be helpful to you, too, so let’s take a look.
The Temperament and Character Inventory. Cloninger has identified four core personality traits, which he refers to as temperament traits, that appear to be genetic in nature. These traits are harm avoidance, reward dependence, novelty seeking, and persistence. The four temperament traits are best understood as the engine that drives our motivations. Harm avoidance is the degree to which we are motivated to avoid harm, just as it sounds. Reward dependence is the degree to which we are motivated by social rewards. These rewards can be as simple as a thank you or a hug, or as complex as the desire and effort to win an election or promotion. What all these things have in common is the need for positive interpersonal and social feedback to stay interested in something or someone. Novelty seeking is the degree to which we are motivated for new experiences. People who are high in novelty seeking tend to bore easily, and they are likely to be more impulsive than others who are lower in this trait. Persistence is the degree to which we are motivated to persevere toward a goal or task completion, despite frustration and fatigue.
Each of us has some amount of these four traits. People can be low, medium, or high on each trait, and their levels on each trait do not tend to change over the lifespan. Also, their level on one trait has nothing to do with their level on any of the other traits. For example, an individual might be high on harm avoidance and also high on reward dependence. Recalling the frightened person on the turbulent flight, maybe this person fears flying (high harm avoidance) but really wants to connect with family and friends over the holidays (high reward dependence). This person might board the plane in a near state of panic just to get home and see the family. The point is, even though these traits are independent of one another, they do interact to create the complex behaviors we identify as human.
Let’s look at the interaction between harm avoidance and pain. From an emotional perspective, persons who are high in harm avoidance especially struggle when confronted with chronic pain. Research indicates that these individuals are more susceptible to depression and anxiety within the context of chronic pain than individuals who are low in harm avoidance. Most importantly, high harm-avoidant individuals are predisposed to fear-avoidant behavior and pain hypervigilance, which can cause a life-shrinking effect. Among my patients, there is a subgroup who pulled away from social activity with their families after the diagnosis of facial pain. These patients tend to be highly harm-avoidant individuals. Often, these patients tell me about experiences when they declined opportunities to go out for dinner with loved ones and friends, or they might have declined the opportunity to attend their child’s dance recital, or they might have declined to attend an office party. The point is that they are pulling back from opportunities to interact with others all for fear they will suffer a facial pain attack during the interaction. They typically explain their social withdrawal in what seems to them to be rational terms. They might say that loud noises and busy environments cause them to experience pain. They might say that a young niece or nephew will want to be held, but they fear that, if they hold the child, the child might touch their face and cause a pain attack. It is not hard to imagine how harm-avoidant fears could cause devastating emotional losses in a marriage. Because of their high harm-avoidant nature, these individuals tend to imagine only negative outcomes. This is a behavior psychologists call catastrophizing.
Psychologists have developed successful ways of treating catastrophizing. Breaking the behavioral pattern that underlies catastrophic thinking can be done but doing so will probably require help. It is difficult to change this behavior without help, because, if you are highly avoidant, you understandably believe that you are doing the right thing by avoiding threats in as many ways, and in as many settings, as you can. But fear-avoidant behavior comes at a price. Constant fearful hypervigilance to pain is miserably distressing. It makes happiness impossible. Fearful social withdrawal inevitably negatively impacts relationships with family, friends, and colleagues, weakening these relationships and causing them to deteriorate.
It is crucial for the highly harm-avoidant person to recognize two things:
(1) Their fears are a natural result of their temperament. It is certainly not the case that they are choosing to be fearful. Fear is an automatic response to pain for all people, but for the high-harm-avoidant individual, pain hypervigilance persists beyond the episodic experience of pain. These individuals become generally hypervigilant.
(2) From the perspective of the highly harm-avoidant individual, hypervigilance is the only rational response to pain. This assumption involves cognitive error, but it does not feel like that to the highly harm-avoidant individual.
A portion of the highly harm-avoidant individual’s fear is directed toward low-probability events that are unlikely to occur, but it is difficult for the highly harm-avoidant individual to distinguish low-probability threats from high-probability events. All potential threats are regarded as highly, and equally, likely to occur. To harken back to an earlier example, most planes do not crash. But to the highly harm-avoidant individual, it feels like the plane they are in will be one of the few that does; this involves probabilistic error, but it certainly does not feel that way to the highly harm-avoidant individual. Consequently, they are overcome with fearful apprehension at the thought of flying, and they go to great pains to avoid doing so.
In the context of chronic pain, fear of low-probability pain-related outcomes inevitably develops in highly harm-avoidant individuals. Among my patients, I find that common fears include fear that all treatment will ultimately fail; fear that loved ones will abandon them because they are, at times, unable to participate in social activities; fear that, if they do participate in social activities, others will not take their pain seriously; fear that, if they do participate in social activities and choose to leave because of pain, it will anger those who are important to them; and fear that their relationships will fall apart, leaving them alone to confront overwhelming pain. In short, the list of catastrophic fears is extraordinarily long and highly personalized. Without learning to discern high-probability threats from low-probability threats, fear of pain will come to dominate one’s experience. Indeed, over time, for highly harm-avoidant individuals, fears compound, and resulting anxiety becomes the dominant feature of their emotional experience. As this happens, these individuals avoid more and more activities, which causes their lives to progressively shrink to the confines of their homes, with little social interaction. Indeed, the interpersonal and experiential losses that come with persistent fear of pain and associated anxiety can be extreme.
In my experience, patients who struggle with high harm avoidance are relieved to have the support and guidance of a therapist once they make the decision to engage therapy. The therapist may be one of the few people who really understands what it is like for them to live with chronic pain. Certainly, the therapist knows how to technically address catastrophic thinking and help the patient unload unproductive worries. It should be said that the process of psychotherapy is not a one-sided effort. Successful treatment requires initiative on the part of both the therapist and the patient. Ideally, there should be a sense of compassion and understanding that is strong enough to support difficult work. This requires building a relationship, which will take time up front. Until that relationship solidifies, you should expect to be evaluating your therapist while feeling some degree of doubt about whether the relationship is what you want. That is normal. With time, however, if a good working relationship develops, doubt about your therapist will ease and largely disappear. I personally find my work with patients to be the most gratifying part of my life. These relationships matter to me, and I admire the effort my patients exert to feel better. I think of my patients as courageous people. I know how hard it is to leave behind hypervigilance to injury and pain. In the beginning, it is normal to feel extremely vulnerable, and it is during those moments that feeling trust for your therapist matters most. You should expect to have a warm and committed relationship with your therapist; anything less will not produce maximally successful results. But understand: you are part of building that relationship.
