Peter Slade

Outline of a fear-avoidance model of exaggerated pain perception—I

Abstract The present paper describes a theoretical model for exaggerated pain perception which has been generated from a multidisciplinary team approach to the problem of chronic low-back pain. The model is an attempt to explain how and why some individuals develop a more substantial psychological overlay to their pain problem than do others. Central to the model is the concept of ‘fear of pain’ which, it is suggested, leads to differing responses in different individuals. The two extreme responses are those of ‘confrontation’ and ‘avoidance’, although most individuals probably exhibit a mixture of the two. The former, it is argued, leads the individual to resume an increasing range of physical and social activities as the organic basis for the pain resolves and, as a consequence, ensures minimal psychological overlay. By contrast, an avoidance strategy is thought to produce a number of physical and psychological consequences which promote the development of the invalid status and the phenomenon of exaggerated pain perception. The model suggests that the type of strategy adopted (i.e. confrontation or avoidance) is influenced by a number of psychosocial factors.

The prediction of chronicity in patients with an acute attack of low back pain in a general practice setting.

Study Design. Three hundred patients, attending their general practitioners with attacks of acute low back pain, formed the subject population for a study of fear avoidance and other variables in the prediction of chronicity. Follow-up was at 2 and 12 months. Objective. The hypothesis to be tested was that evidence of psychological morbidity, particularly fear-avoidance behavior, would be manifest from the outset of the presenting attack in susceptible subjects. Summary of Background Data. While back pain is an almost universal human experience, only about 5% of sufferers seek medical advice. Most of these respond to conservative treatment. However, approximately 10% of those who experience an acute attack of low back pain go on to become chronic sufferers. Methods. Psychosocial and physiological data (including fear-avoidance measures) were collected from a sample of 300 acute low back pain patients within 1 week of presentation and at 2 months, to try to predict 12 month outcome. Results. Data analysis showed that subjects who had not recovered by 2 months were those who went on to become chronic low back pain patients (7.3%). Using multiple regression analyses, fear-avoidance variables were the most successful in predicting outcome. Using multiple discriminant function analyses, the results suggest that the outcome in terms of the future course of low back pain can be correctly classified in 66% from fear-avoidance variables alone and in 88% of patients from all variables. Conclusions. The results suggest that, at the earliest stage of low back pain, fear of pain should be identified by clinicians and, where this is severe, pain confrontation should arguably form part of the approach to treatment.

The measurement of hallucinatory predisposition in male and female prisoners

Abstract This paper describes the development of a 12-item questionnaire scale to measure hallucinatory predisposition. The scale, which conforms to at least one mathematical model of unidimensionality, includes both pathological items and other items which appear to represent sub-clinical forms of hallucinatory experience. The scale was used to test certain hypotheses concerning the link between aggressive-paranoid tendencies and hallucinatory predisposition (using the Eysencks P scale) in a prison sample. The significant results presented do confirm such a link, although the precise behavioural correlates of hallucinatory predisposition require further definition.

Positive and negative perfectionism

Abstract Previous research into perfectionism has focused on clinical populations resulting in a bias towards a negativistic, pathologically inclined conceptualization. The present study investigated the possibility of distinguishing aspects of perfectionism on the basis of perceived consequences, mirroring a behavioural distinction between positive and negative reinforcement. A 40-item questionnaire, designed to measure perfectionism defined in terms of both positive and negative outcome, was administered to 281 women; a comparison group (N = 225), an eating disordered group (N = 21), a depressed group (N = 15) and successful athletes (N = 20). A factor analysis of the results extracted three factors; negative perfectionism including both personal and social items; positive personal perfectionism; and positive social perfectionism. Limiting the number of factors to two yielded a clear distinction between positive and negative perfectionism. Group comparisons yielded significance differences; for athletes high positive perfectionism was associated with a low negative perfectionism score; for the eating disorders group a high positive perfectionism score was associated with a high negative score. When analysed in terms of personal and social items the distinguishing factors were the negative and positive components, athletes and eating disordered groups obtaining comparably high positive personal perfectionism scores and the clinical groups obtaining comparably high negative perfectionism scores.

A dual process model of perfectionism based on reinforcement theory

This article begins with a brief review of the current literature on the structure and measurement of perfectionism. It is concluded from this review that two major types can be distinguished, a normal/healthy form and a pathological form. These two forms are then defined as positive and negative perfectionism and related directly to Skinnerian concepts of positive and negative reinforcement. The positive/negative distinction is then further elaborated on in terms of approach/avoidance behavior, goal differences, self-concept involvement, emotional conrelates, and the promoting environment. Finally, some of the more obvious theoretical and practical implications are briefly explored.

Reliability of a scale measuring disposition towards hallucination: a brief report

Two forms of the Launey-Slade Hallucination Scale (LSHS) measuring disposition toward hallucination were given to 150 male undergraduate students. Scores on both forms were approximately normally distributed and a high test-retest reliability was observed. All the items except one on each scale were judged by at least some Ss as applying to themselves. The percentage of Ss scoring pathological items as certainly applying to themselves was consistent with previous research that suggests that a surprisingly large percentage of people experience hallucinations at some time in their lives.

DEVELOPMENT AND PRELIMINARY VALIDATION OF THE BODY SATISFACTION SCALE (BSS)

Abstract This paper describes the development of a simple paper-and-pencil test designed to measure satisfaction/dissatisfaction with 16 body parts. It is based on the body-cathexis scale of Secord and Jourard (1953) but takes only 2–3 minutes to complete. The factorial structure of the scale is described together with the three summative scales (“general,” “head parts” and “body parts” dissatisfaction) which are derived. The internal consistency of the scales was found to be acceptable. Significant positive correlations are also reported with the Body Shape Questionnaire (Cooper et al., 1987). The paper reports data for female comparison groups (college students, nursing students and female volunteers) and for samples of eating disorder patients and overweight subjects. The latter two groups report significantly higher body dissatisfaction than the comparison groups. Finally, it is argued that the scale is useful for work in health related fields and some current applications are briefly described.

A review of body-image studies in anorexia nervosa and bulimia nervosa

THE notion of a fundamental body-image disorder in patients with anorexia nervosa was first suggested by Hilde Bruch (BRUCH, 1962) and elaborated upon in her subsequent writings (e.g. BRUCH, 1974). Bruch described three key symptoms which she views as having causal significance in the development of anorexia nervosa: these are (a) a disturbance of delusional proportions in the body image and body concept, (b) a disturbance in the accuracy of perception (or cognitive interpretation) of stimuli arising in the body and (c) a paralysing sense of ineffectiveness. The present review will concentrate on experimental attempts to investigate the first of these three key features and in particular “disturbed size awareness” in anorexia nervosa and bulimia. In the late sixties/early seventies Gerald Russell and myself, impressed by the clinical observations of Bruch and the ideas of Arthur Crisp on weight phobia (CRISP, 1970), and indeed by similar clinical observations of our own, set out to investigate experimentally this apparent disorder. Of the various experimental procedures then available we opted to use a modified form of the visual-size-estimation task used by REITMAN and CLEVELAND (1964) with schizophrenic patients. Using a procedure in which anorexic and control subjects were required to estimate their physical widths, at various levels, with reference to the separation between two lights, a measure of body perception accuracy (BPI) was derived for each body level as follows:

The Fear-Avoidance Model of exaggerated pain perception--II.

Abstract The personal history of pain and personal coping strategies for pain are two of the contributory factors in the Fear-Avoidance Model of exaggerated pain perception proposed by Lethem, Slade, Troup and Bentley (1983, this issue, pp. 401–408). In order to test this aspect of the hypothesis, a questionnaire was designed and has been completed by 165 students (93 female, 72 male) at the University of Liverpool. They were asked about the severity of externally-produced pain (e.g. fracture), of internally-produced pain (e.g. headache) and of back pain; about the strategies they adopted for coping with internallyproduced pain (e.g. did they ignore the pain and carry on—an active strategy—or did they go and rest—a passive strategy); and about the effects of back pain on each of 10 activities or postures (from ‘no effect’ to ‘had to stop completely’) in order to obtain an index of back-pain avoidance. Out of 165, 91 reported previous back pain (Back Pain group) and their average rating for the severity of externally-produced pain was significantly higher than for the No Back Pain group; but there were no differences between these two groups for their coping strategies for internally-produced pain. However, of the Back Pain group with two or more previous attacks, 35 gave a history indicating decreasingly severe attacks and 28, increasingly severe: the coping strategies of the latter group for internally-produced pain were significantly more passive. The ratings for severity of back pain correlated significantly with the indices for back-pain avoidance and with the ratings for severity of internally-produced pain. These findings are in line with the prediction that personal pain history and personal coping strategies are relevant to the Fear-Avoidance Model of exaggerated pain perception and may therefore influence the adoption of an avoidance or a confrontation response by the patient with chronic back pain.

Eating disorders and perceived relationships with parents.

Many clinicians have theorized about the role of family dynamics in the development of eating disorders (e.g., Minuchin, Rosman & Baker, 1978; Palazzoli, 1974). On the same theme, in recent years, a major research study has produced unequivocal evidence for the therapeutic value of family therapy, at least with the younger client (Russell, Szmukler, Dare & Eisler, 1987). However, there are still relatively few data on the nature of family interaction patterns in patients with an eating disorder. To date, there have been two reports on the use of the Parental Bonding Instrument (PBI) (Parker, Tupling & Brown, 1979) with this clinical population. The present report is the third and largest such study, contrasting 98 patients with anorexic and bulimic eating disorders and 242 comparison subjects. In line with the two previous studies, eating-disordered patients recalled that both parents were lower in perceived care/warmth and, in line with the second study, they recalled that their fathers (but not their mothers) were more overprotective. The latter finding appears an intriguing one and requires further exploration.