Don’t be afraid of pain – part 2 – the ‘why-files’
“Don’t be afraid of pain”, that was the quote that inspired part one, where I discussed the possible benefits of being exposed to minor or moderate painful situations. But why are people afraid of pain, and especially, why are they more afraid of pain than seems useful? Let’s have a look…
It’ll be a rather long blog, so instead of a song, I’ll share a whole live concert: Cory Henry and the Funk Apostles, live in Paradiso, Amsterdam
There are many reasons, but we can put them in three categories: ‘organism’, ‘task’, and ‘environment’ (inspired by the ‘constraints-led-approach of movement’). The ‘organism’ category consists of two reasons: intrapersonal differences, and the smoke detector principle. The second and third categories are more-or-less self explanatory: the ‘environment’ category is the world we live in (non-human), and the people we interact with (human). The ‘task’ category, is of course, what we do in that environment.
The ‘organism’ category needs a bit of elaboration. Let’s talk about the smoke detector principle. The basic idea is the following: we like smoke detectors to be very sensitive, so we are alarmed by every possibility of fire, even if this means having occasional false alarms. We don’t like false alarms at all, but we tolerate them, because the costs are relatively low compared to missing a real fire (with extremely high costs). Randolph Nesse, pioneer of evolutionary medicine, wrote about this in here (free pdf!).
You’d rather be alarmed by that sound in the bushes, even though that sound probably most of the time is only a little bird or rodent, because it could be the last time you hear anything at all if it really was something dangerous, like a sabertooth tiger. On the other hand, failing to see a bush full of ripe berries is also unwanted, but has less disastrous consequences. This principle also explains why children need more positive feedback than negative, why one harsh criticism about your work is troubling you at night, even though the majority of the feedback was excellent…
So people are very alert to negative signals, like pain, and tend to react strongly to them. Because of the normal variation of personality traits, this may even be more so for some people (and less so for others, of course). These are the intrapersonal differences I was referring to.
Now, let us consider a schematic (and thus simplified) view of our behaviour. You could consider it being pulled by different factors (vectors) in different directions. In our case, and for the sake of simplicity, we’ll take two directions, opposing each other. One direction is security, the other direction is uncertainty. Ideally, there should be a kind of dynamic balance or a tension between these opposing situations, where the forces acting upon the behaviour put you in a healthy and goal-achieving position.
In our daily lives, our behaviour is constantly pulled, by various vectors, in both directions. We have our sensitive protection mechanisms pulling us towards one side, but we have things to do in the world pulling us towards the other side.
Mind you, there is no one ideal position. Depending to the circumstances, the ‘ideal zone’ is more towards the left or the right. Two simple examples:
1. When you sprain your ankle while running, there’s danger reception in the tissues (or at least danger perception in the central nervous system), and your protective systems pull you more towards the safety side of the continuum (rest). You will probably stop running, maybe feel pain, limp, move less, … Although this may not be pleasant, it promotes healing and long term functioning. This is an example of internal protective forces pulling at your behaviour.
2. When you sprain your ankle, while running away from a big brown bear, the same protective pulling may be there, but there will be an even bigger pull in the opposite direction (movement). While maybe suboptimal for ankle health, it ensures long term functioning because, well, you stay alive. This is an example of an external force pulling at your behaviour.
Now take a person who has an episode of acute low back pain, the first time in his life, where mechanical overload due to heavy manual lifting is an important contributing factor. Like our first example above, we’d expect a shift in behaviour towards safety, rest, avoidance of pain, etc. This, on average, is health promoting. But when the danger has cleared and while the tissues are healing, the behaviour should shift back towards the other side. We need some factors pulling towards the ‘normal’ zone, towards more movement, more freedom, more real life. This is especially necessary, because we know that due to the smoke detector principle, our systems have a tendency to react quickly and strongly, maybe even too much so. Again, this is protective, but needs to be balanced.
What could be the necessary pulling factors? Probably many, but let me explain two important ones: environmental factors and task-related factors.
Imagine our man with back pain is a hunter-gatherer who strained his back while lifting and carrying a carcass of the eland he hunted. His behaviour shifts towards safety, rest, avoidance of pain. Because of the great cooperation in a hunter-gatherer band, people will help him, feed him, support him. But as soon as possible, the tasks of life (survival) pull him towards the other side of the continuum. Add to this the natural environment in which these tasks are performed and the behaviour changes even more.
My hypothesis is that in our modern lives, the balance is skewed towards one side: the side of safety, fear and avoidance. And this because of a decrease in pulling from the environment and the tasks. Most people have tasks requiring minimal movement. Minimal in amount, intensity and variety. And we do these tasks in an essentially flat and un-textured environment. This pulls us too much towards the safety side of the continuum, and keeps us there (or at least too long).
We could reframe this as an information problem. Protective measures are quick, strong, instinctive. Once started, the protective systems need information to adjust the initial, strong reaction, to make it more nuanced. What’s the most important form of information? Yes: movement! And what does a person do when in pain? Yes: avoid movement, restrict freedom of movement, move stereotypically (e.g. limping). This seems like an impasse, a deadlock. The system needs information through movement, but the system causes movement restriction (amount, variety)…
By now you, the intelligent reader, should already know that is only an apparent deadlock, at least, in natural circumstances. Walking, running, crawling, climbing, jumping, lifting, carrying, throwing, digging, swimming, … in a natural environment with lots of different textures, structures, shapes, slopes, … causes huge amounts of informational input. So our hunter with back pain, as soon as he’s able (but not sooner), starts moving (survival tasks in natural environment) and starts giving information to his protective systems. With this information, these systems nuance the protection and thus lessen their pull towards the safety side (in case of normal healing).
And yes, in a modern, western situation, this apparent deadlock often really is a deadlock. Or at least, the behaviour is skewed too much towards safety and prevents optimal healing.
But this is not all: there’s another form of information that’s relevant to this story, a more top-down influence on our behaviour. Our thoughts, believes, expectations have the power to pull us towards both sides of the spectrum. And yes, in our modern, western lives, on average, these thoughts, believes ad expectations pull us towards the safety side too strongly! And yes, the medical professions are contributing to this fear mongering! And yes, we should stop this form of misinformation!
Maybe this is a time to put in another, hypothetical factor. The metaphor I’m using makes me think of attachment parenting and the concept of a secure base.
“A secure base is provided through a relationship with one or more sensitive and responsive attachment figures who meet the child’s needs and to whom the child can turn as a safe haven, when upset or anxious. When children develop trust in the availability and reliability of this relationship, their anxiety is reduced and they can therefore explore and enjoy their world, safe in the knowledge that they can return to their secure base for help if needed?” (source)
The secure base may not be exactly the same as the safety end of the continuum in our model, but it is necessary to explore and live in the world. John Bowlby summarises it nicely: “All of us, from the cradle to the grave, are happiest when life is organised as a series of excursions, long or short, from the secure base provided by our attachment figures.” In this quote you notice the same tension between safety and danger, the same movement between order and chaos. This leads to an interesting hypothesis: could there be a relationship between the level of secure base one has, and the way one copes with pain?
So, in our modern lives, our behaviour is pulled too much towards the side of safety. The main reasons for this are the effects of strong protective measures (smoke detector principle) not being counteracted (enough) by real, varied movement in a complex world. For some people, this could even be fortified by less than optimal secure bases (attachment theory), and/or some personality traits.
Safety, unchecked by exposure to real movement in the natural world, leads to problems.
Now, let me add some science to the mix and cite another nice study by Belgian researchers: ‘The opportunity to avoid pain may paradoxically increase fear’ (van Vliet et al, J Pain, 2018).
They show that: “Engaging in avoidance may (paradoxically) increase rather than decrease pain-related fear.” Avoidance (safety seeking behaviour) of pain prevents feared outcomes and “may start a vicious circle: safety-seeking behaviour increased threat perception in turn increasing safety-seeking behaviour, and so on.” This, “in turn may spur avoidance behaviour leading to chronic pain and disability.” “The decrease of threat value in the control group [non-avoidance group] is consistent with results of exposure studies.”
Avoidance, unchecked by exposure to pain, leads to problems.
Randolph Nesse gives us another example of the vicious circle, applied to the smoke-detector-principle and anxiety problems: “The difficulty is that people respond to these false alarms as if they had really encountered a predator, with subsequent lowering of the panic threshold, and frequent development of agoraphobia with its strong tendency to stay at home, if at all possible. Modern life makes staying at home possible, thus, such patients may not go out for weeks. When they finally do venture out, the least cue of danger, or no discernable cue at all, can set off another attack, illustrating how positive feedback can create a medical disorder.”
“Modern life makes staying at home possible,” is exactly what I’m talking about. Modern life allows for safety seeking behaviour to be unchecked… Fear leads to avoidance, which is logic, biologically speaking: fear of snakes makes you avoid them, because they are dangerous, at least some of them. But if you live in the East African savannah, like Hadza hunter-gatherers, there is no possibility to avoid them totally. You will encounter them. You will be exposed to them and learn how to deal with them. The tasks and the environment keep the safety seeking behaviour balanced…
Security, unchecked by exposure to uncertainty, leads to problems.
When you fall of your horse, you’ve got to get back on it.
As always, I’d love to hear your thoughts… There’ll be a next blog elaborating on the implications, both therapeutic and for life!