Peter J. Norton

Beyond pain: The role of fear and avoidance in chronicity

The purpose of the present article is to provide unification to a number of somewhat disparate themes in the chronic pain and phobia literature. First, we present a summary review of the early writings and current theoretical perspectives regarding the role of avoidance in the maintenance of chronic pain. Second, we present an integrative review of recent empirical investigations of fear and avoidance in patients with chronic musculoskeletal pain, relating the findings to existing cognitive-behavioral theoretical positions. We also discuss several new and emerging lines of investigation, specifically related to information processing and anxiety sensitivity, which appear to be closely linked to pain-related avoidance behavior. Finally, we discuss the implications of the recent empirical findings for the assessment and treatment of individuals who experience disabling chronic musculoskeletal pain and suggest possible avenues for future investigation.

Posttraumatic Stress Disorder and Work-Related Injury

The literature indicates a substantial overlap between chronic pain and posttraumatic stress disorder (PTSD) symptoms in individuals who sustain accidental injury. To date, however, there have been no studies of PTSD symptoms in individuals who experience work-related injury. Consequently, we assessed 139 consecutive injured workers using the Modified PTSD Symptom Scale (Falsetti, Resnick, & Kirkpatrick, 1993), as well as a number of general measures of psychopathology. Most participants reported chronic pain and all were receiving workers compensation. Results indicated that 34.7% and 18.2% of the sample reported symptoms consistent with PTSD and partial PTSD, respectively. When PTSD symptom frequency and severity were considered criterion variables in multiple regression analyses, depression was found to be significantly associated with the former and anxiety sensitivity, social fears, and somatic focus with the later. Finally, these measures of general psychopathology correctly classified 78.6% of individuals with PTSD and 81.3% of those with no PTSD. These results suggest that a considerable proportion of injured workers display symptoms consistent with PTSD and that these symptoms are related to general negative affect. Implications, including the suggestion of clinical intake screening of PTSD in this population, are discussed.

Depression Anxiety and Stress Scales (DASS-21): psychometric analysis across four racial groups.

Abstract Growing cross-cultural awareness has led researchers to examine frequently used research instruments and assessment tools in racially diverse populations. The present study was conducted to assess the psychometric characteristics of the 21-item version of the Depression, Anxiety, and Stress Scales (DASS-21) among different racial groups. The DASS-21 was chosen because it appears to be a reliable and easy to administer measure, ideal for both clinical and research purposes. Results suggest that the internal consistency, and convergent and divergent validity of the DASS-21 are similar across racial groups. Multigroup CFA, however, indicated that item loadings were invariant, while scale covariances were not invariant. This suggests that, although the items may load similarly on the depression, anxiety and stress constructs, these constructs may be differentially inter-related across groups. Implications for application in clinical practice are discussed.

Efficacy of Transdiagnostic Treatments: A Review of Published Outcome Studies and Future Research Directions

Theory and evidence relating to biological and psychological vulnerabilities, comorbidity, latent structure, cognitive and behavioral maintaining factors, and treatment outcome suggest that commonalities across emotional disorders may outweigh the differences. Thus, researchers have recently begun evaluating transdiagnostic (or unified) treatment protocols, which target common maintaining factors, by applying them to individuals with multiple disorders or to mixed-diagnosis groups. The aim of this article is to review the efficacy of unified protocols for anxiety and mood disorders. Evidence suggests that unified treatments are associated with symptom improvement, generally perform better than wait-list controls, are associated with improvements in comorbid disorders, and may compare well to diagnosis-specific treatments. Unified protocols are also associated with high client satisfaction, therapeutic alliance, group cohesion, and positive treatment expectations. However, these conclusions are tempered by the small number of studies and methodological limitations. We propose directions for future research.

Anxiety sensitivity, fear, and avoidance behavior in headache pain

Abstract Recent research has implicated anxiety sensitivity (AS), the fear of anxiety‐related sensations, as a mitigating factor involved in fear and avoidance in patients with chronic back pain [Understanding and treating fear of pain (2004) 3]. Given reported similarities between individuals experiencing chronic pain and those experiencing recurrent headaches, it is theoretically plausible that AS plays a role in influencing fear of pain and avoidance behavior in people with recurrent headache. This has not been studied to date. In the current study we used structural equation modeling to examine the role of AS in fear and avoidance behavior of patients experiencing recurrent headaches. Treatment seeking patients with recurrent headaches completed measures of AS, headache pain severity, pain‐related fear, and pain‐related escape and avoidance behavior. Structural equation modeling supported the prediction of a direct significant loading of AS on fear of pain. Headache severity also had a direct loading on fear of pain. Results also revealed that AS and headache severity had indirect relationships to pain‐related escape and avoidance via their direct loadings on fear of pain. Headache severity also had a small direct loading on escape and avoidance behavior. These results provide compelling evidence that AS may play an important role in pain‐related fear and escape and avoidance behavior in patients with recurrent headaches.

Quality of life impairment in generalized anxiety disorder, social phobia, and panic disorder

Interest in the assessment of quality of life in the anxiety disorders is growing. The present study examined quality of life impairments in individuals with generalized anxiety disorder (GAD), social phobia, and panic disorder. Results showed that individuals with these disorders reported less satisfaction with their quality of life than non-anxious adults in the community. However, the degree of quality of life impairment is similar across these three disorders. Additionally, comorbid depression, but not anxiety, was found to negatively impact quality of life in these individuals. Finally, diagnostic symptom severity was not found to influence quality of life, indicating that subjective measures of quality of life offer unique information on the effects of anxiety disorders.

Hierarchical Model of Vulnerabilities for Anxiety: Replication and Extension with a Clinical Sample

This study served to replicate and extend our previously obtained hierarchical model of the relationships among general anxiety vulnerabilities, specific anxiety vulnerabilities and specific anxiety manifestations including panic symptoms, health anxiety, obsessive‐compulsive symptoms and worry. Questionnaires assessing these variables, as well as positive affectivity and depressiveness, were administered to 125 outpatients seeking treatment for panic disorder, social anxiety disorder, obsessive‐compulsive disorder, generalized anxiety disorder or major depressive disorder. The results, using a clinical sample, were highly consistent with the hierarchical model obtained in the previous study using a student sample. A more elaborate model, based on published theoretical and empirical evidence, was identified and tested, and similar results were obtained. Negative affectivity had expected direct positive effects on all of the specific anxiety and depression manifestations, with the exception of health anxiety, which showed a negative relationship, and OCD symptoms, which showed no relationship. Positive affectivity was found to be a specific risk factor for depression, while intolerance of uncertainty was found to be a specific risk factor for worry and depression. Finally, anxiety sensitivity appears to be a significant risk factor for panic and health anxiety.

Anxiety sensitivity and fear of pain in patients with recurring headaches

Anxiety sensitivity (AS) plays an important role in the cognitive, affective and behavioral profiles of patients with chronic pain related to musculoskeletal injury. However, investigators have not considered whether these findings extend to patients with other classes of chronic pain. The primary purpose of this investigation was to address this issue in 72 patients with recurring headaches who completed a self-report questionnaire inventory during a treatment visit to an outpatient neurology clinic. The mean ASI score for the group (mean = 24; SD = 11) was relatively high. When patients were classified on the basis of ASI scores, 20 (28%) met criteria for high, 41 (57%) for medium and 11 (15%) for low AS. Multivariate analysis of variance confirmed that these groups differed on specific aspects of their cognitive, affective, and behavioral profiles. High AS patients reported greater depression, trait anxiety, pain-related escape/avoidance behavior and fearful appraisals of pain than did patients with medium or low AS. High AS patients also indicated greater cognitive disruption in response to pain than did patients with low AS. Groups did not differ in headache severity, physiological reactivity, change in lifestyle, anger, nor did they differ in use of over-the-counter or prescribed analgesics. Multiple regression analysis identified AS, pain-related cognitive disruption, and sensory pain experience as significant predictors of fear of pain. Lifestyle changes attributed to headache were, on the other hand, predicted by headache severity, physiological and cognitive anxiety and escape/avoidance behavior. These results provide further evidence of the important association between AS and fear responses of patients with chronic pain syndromes. Implications and future directions are discussed.

Transdiagnostic versus diagnosis-specific cbt for anxiety disorders: a preliminary randomized controlled noninferiority trial.

Transdiagnostic cognitive–behavioral treatments for anxiety disorders have been gaining increased attention and empirical study in recent years. Despite this, research on transdiagnostic anxiety treatments has, to date, relied on open trials, or comparisons to waitlist conditions, published benchmarks, or relaxation‐based interventions.

Transdiagnostic approaches to the treatment of anxiety disorders: A quantitative review.

Transdiagnostic cognitive-behavioral group treatments for anxiety, treatments that are designed to be applicable to diagnostically mixed groups of anxiety disorder clients, have been garnering interest in recent years. At least 7 independent research teams have developed transdiagnostic anxiety treatment protocols and reported preliminary outcomes data. In this review, we outline the basic theoretical rationale underlying transdiagnostic models of anxiety and review each of the treatment protocols that have been reported to date. Finally, the efficacy of these treatments is examined using meta-analytic methods. Results indicated that overall, transdiagnostic treatments are associated with a very large pre- to posttreatment effect size, and stable maintenance of gains through follow-up. Recommendations for transdiagnostic treatment implementation are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved).