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Comparing Counterconditioning and Extinction as Methods to Reduce Fear of Movement-Related Pain

  • Ann Meulders
    Correspondence
    Address reprint requests to Ann Meulders, PhD, Department of Psychology, University of Leuven, Tiensestraat 102, box 3726, 3000 Leuven, Belgium.
    Affiliations
    Research Group on Health Psychology, University of Leuven, Leuven, Belgium

    Center for Excellence on Generalization in Health and Psychopathology, University of Leuven, Leuven, Belgium
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  • Petra A. Karsdorp
    Affiliations
    Clinical and Health Psychology, Utrecht University, Utrecht, The Netherlands

    Department of Clinical Psychological Science, Maastricht University, The Netherlands
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  • Nathalie Claes
    Affiliations
    Research Group on Health Psychology, University of Leuven, Leuven, Belgium

    Department of Experimental, Clinical and Health Psychology, Ghent University, Belgium
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  • Johan W.S. Vlaeyen
    Affiliations
    Research Group on Health Psychology, University of Leuven, Leuven, Belgium

    Center for Excellence on Generalization in Health and Psychopathology, University of Leuven, Leuven, Belgium

    Department of Clinical Psychological Science, Maastricht University, The Netherlands
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Published:October 02, 2015DOI:https://doi.org/10.1016/j.jpain.2015.09.007

      Highlights

      • Counterconditioning is as effective as extinction to reduce pain-related fear.
      • Adding a reward to a painful movement did not attenuate pain-related fear.
      • Adding a reward to a painful movement did not reduce the painfulness.
      • Adding a reward to a painful movement did not reduce the pain unpleasantness.
      • Both extinction and counterconditioning changed the acquired stimulus valence.

      Abstract

      Cognitive-behavioral treatments for chronic pain typically target pain-related fear; exposure in vivo is a common treatment focusing on disconfirming harm expectancy of feared movements. Exposure therapy is tailored on Pavlovian extinction; an alternative fear reduction technique that also alters stimulus valence is counterconditioning. We compared both procedures to reduce pain-related fear using a voluntary joystick movement paradigm. Participants were randomly allocated to the counterconditioning or extinction group. During fear acquisition, moving the joystick in 2 directions (conditioned stimulus [CS+]) was followed by a painful electrocutaneous stimulus (pain-unconditioned stimulus [US]), whereas moving the joystick in 2 other directions was not (CS−). During fear reduction, 1 CS+ was extinguished, but another CS+ was still followed by pain in the extinction group; in the counterconditioning group, 1 CS+ was extinguished and followed by a monetary reward-US, and another CS+ was followed by both USs (pain-US and reward-US). The results indicate that counterconditioning effectively reduces pain-related fear but that it does not produce deeper fear reduction than extinction. Adding a reward-US to a painful movement attenuated neither fear nor the intensity/unpleasantness of the pain. Both procedures changed stimulus valence. We contend that changing the affective valence of feared movements might improve fear reduction and may prevent relapse.

      Perspective

      This article reports no immediate differences between counterconditioning and extinction in reducing pain-related fear in the laboratory. Unexpectedly, both methods also altered stimulus valence. However, we cautiously suggest that methods explicitly focusing on altering the affective valence of feared movements may improve the long-term effectiveness of fear reduction and prevent relapse.

      Key words

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      References

        • Bakeman R.
        Recommended effect size statistics for repeated measures designs.
        Behav Res Methods. 2005; 37: 379-384
        • Boersma K.
        • Linton S.
        • Overmeer T.
        • Jansson M.
        • Vlaeyen J.
        • de Jong J.
        Lowering fear-avoidance and enhancing function through exposure in vivo. A multiple baseline study across six patients with back pain.
        Pain. 2004; 108: 8-16
        • Bouton M.E.
        Context and ambiguity in the extinction of emotional learning: implications for exposure therapy.
        Behav Res Ther. 1988; 26: 137-149
        • Bouton M.E.
        A learning theory perspective on lapse, relapse, and the maintenance of behavior change.
        Health Psychol. 2000; 19: 57-63
        • Bouton M.E.
        Context, ambiguity, and unlearning: sources of relapse after behavioral extinction.
        Biol Psychiatry. 2002; 52: 976-986
        • Bradley M.M.
        • Lang P.J.
        Measuring emotion: the self-assessment manikin and the semantic differential.
        J Behav Ther Exp Psychiatry. 1994; 25: 49-59
        • Christiansen S.
        • Oettingen G.
        • Dahme B.
        • Klinger R.
        A short goal-pursuit intervention to improve physical capacity: a randomized clinical trial in chronic back pain patients.
        Pain. 2010; 149: 444-452
        • Claes N.
        • Crombez G.
        • Vlaeyen J.W.S.
        Pain-avoidance versus reward-seeking: an experimental investigation.
        Pain. 2015; 156: 1449-1457
        • Claes N.
        • Karos K.
        • Meulders A.
        • Crombez G.
        • Vlaeyen J.W.S.
        Competing goals attenuate avoidance behavior in the context of pain.
        J Pain. 2014; 15: 1120-1129
        • Collins D.
        • Shanks D.
        Momentary and integrative response strategies in causal judgment.
        Mem Cognit. 2002; 30: 1138-1147
        • Craske M.G.
        • Hermans D.
        • Vansteenwegen D.
        Fear and Learning: From Basic Processes to Clinical Implications.
        American Psychological Association, Washington, DC2006
        • Craske M.G.
        • Kircanski K.
        • Zelikowsky M.
        • Mystkowski J.
        • Chowdhury N.
        • Baker A.
        Optimizing inhibitory learning during exposure therapy.
        Behav Res Ther. 2008; 46: 5-27
        • Craske M.G.
        • Wolitzky-Taylor K.B.
        • Labus J.
        • Wu S.
        • Frese M.
        • Mayer E.A.
        • Naliboff B.D.
        A cognitive-behavioral treatment for irritable bowel syndrome using interoceptive exposure to visceral sensations.
        Behav Res Ther. 2011; 49: 413-421
        • Crombez G.
        • Eccleston C.
        • Van Damme S.
        • Vlaeyen J.W.
        • Karoly P.
        Fear-avoidance model of chronic pain: the next generation.
        Clin J Pain. 2012; 28: 475-483
        • Crombez G.
        • Eccleston C.
        • Vlaeyen J.W.
        • Vansteenwegen D.
        • Lysens R.
        • Eelen P.
        Exposure to physical movements in low back pain patients: restricted effects of generalization.
        Health Psychol. 2002; 21: 573-578
        • De Houwer J.
        • Thomas S.
        • Baeyens F.
        Association learning of likes and dislikes: a review of 25 years of research on human evaluative conditioning.
        Psychol Bull. 2001; 127: 853
        • de Jong J.R.
        • Vangronsveld K.
        • Peters M.L.
        • Goossens M.E.J.B.
        • Onghena P.
        • Bulté I.
        • Vlaeyen J.W.S.
        Reduction of pain-related fear and disability in post-traumatic neck pain: a replicated single-case experimental study of exposure in vivo.
        J Pain. 2008; 9: 1123-1134
        • de Jong J.R.
        • Vlaeyen J.W.
        • Onghena P.
        • Cuypers C.
        • den Hollander M.
        • Ruijgrok J.
        Reduction of pain-related fear in complex regional pain syndrome type I: the application of graded exposure in vivo.
        Pain. 2005; 116: 264-275
        • de Jong J.R.
        • Vlaeyen J.W.
        • Onghena P.
        • Goossens M.E.
        • Geilen M.
        • Mulder H.
        Fear of movement/(re)injury in chronic low back pain: education or exposure in vivo as mediator to fear reduction?.
        Clin J Pain. 2005; 21: 9-17
        • de Jong J.R.
        • Vlaeyen J.W.
        • van Eijsden M.
        • Loo C.
        • Onghena P.
        Reduction of pain-related fear and increased function and participation in work-related upper extremity pain (WRUEP): effects of exposure in vivo.
        Pain. 2012; 153: 2109-2118
        • den Hollander M.
        • de Jong J.R.
        • Volders S.
        • Goossens M.E.
        • Smeets R.J.
        • Vlaeyen J.W.
        Fear reduction in patients with chronic pain: a learning theory perspective.
        Expert Rev Neurother. 2010; 10: 1733-1745
        • Dirikx T.
        • Hermans D.
        • Vansteenwegen D.
        • Baeyens F.
        • Eelen P.
        Reinstatement of extinguished conditioned responses and negative stimulus valence as a pathway to return of fear in humans.
        Learn Mem. 2004; 11: 549-554
        • Engelen U.
        • De Peuter S.
        • Victoir A.
        • Van Diest I.
        • Van Den Bergh O.
        Verdere validering van de Positive and Negative Affect Schedule (PANAS) en vergelijking van twee Nederlandstalige versies.
        Gedrag & Gezondheid: Tijdschrift voor Psychologie en Gezondheid. 2006; 34 ([in Dutch]): 89-102
        • Flink I.K.
        • Nicholas M.K.
        • Boersma K.
        • Linton S.J.
        Reducing the threat value of chronic pain: a preliminary replicated single-case study of interoceptive exposure versus distraction in six individuals with chronic back pain.
        Behav Res Ther. 2009; 47: 721-728
        • Gatzounis R.
        • Schrooten M.G.
        • Crombez G.
        • Vlaeyen J.W.
        Operant learning theory in pain and chronic pain rehabilitation.
        Curr Pain Headache Rep. 2012; 16: 117-126
        • Goubert L.
        • Francken G.
        • Crombez G.
        • Vansteenwegen D.
        • Lysens R.
        Exposure to physical movement in chronic back pain patients: no evidence for generalization across different movements.
        Behav Res Ther. 2002; 40: 415-429
        • Hofmann W.
        • De Houwer J.
        • Perugini M.
        • Baeyens F.
        • Crombez G.
        Evaluative conditioning in humans: a meta-analysis.
        Psychol Bull. 2010; 136: 390
        • Jensen M.P.
        • Nielson W.R.
        • Kerns R.D.
        Toward the development of a motivational model of pain self-management.
        J Pain. 2003; 4: 477-492
        • Jones K.D.
        • Burckhardt C.S.
        • Bennett J.A.
        Motivational interviewing may encourage exercise in persons with fibromyalgia by enhancing self efficacy.
        Arthritis Rheum. 2004; 51: 864-867
        • Kerkhof I.
        • Vansteenwegen D.
        • Baeyens F.
        • Hermans D.
        Counterconditioning: an effective technique for changing conditioned preferences.
        Exp Psychol. 2011; 58: 31
        • Lakens D.
        Calculating and reporting effect sizes to facilitate cumulative science: a practical primer for t-tests and ANOVAs.
        Front Psychol. 2013; 4: 863
        • Leeuw M.
        • Goossens M.E.
        • van Breukelen G.J.
        • de Jong J.R.
        • Heuts P.H.
        • Smeets R.J.
        • Koke A.J.
        • Vlaeyen J.W.S.
        Exposure in vivo versus operant graded activity in chronic low back pain patients: results of a randomized controlled trial.
        Pain. 2008; 138: 192-207
        • Linton S.J.
        • Boersma K.
        • Jansson M.
        • Overmeer T.
        • Lindblom K.
        • Vlaeyen J.W.
        A randomized controlled trial of exposure in vivo for patients with spinal pain reporting fear of work-related activities.
        Eur J Pain. 2008; 12: 722-730
        • Logan G.D.
        • Schacar R.J.
        • Tannock R.
        Impulsivity and inhibitory control.
        Psychol Sci. 1997; 8: 60-64
        • Macedo L.G.
        • Latimer J.
        • Maher C.G.
        • Hodges P.W.
        • McAuley J.H.
        • Nicholas M.K.
        • Tonkin L.
        • Stanton C.J.
        • Stanton T.R.
        • Stafford R.
        Effect of motor control exercises versus graded activity in patients with chronic nonspecific low back pain: a randomized controlled trial.
        Phys Ther. 2012; 92: 363-377
        • McCracken L.
        Contextual Cognitive-Behavioral Therapy for Chronic Pain.
        IASP Press, Seattle2005
        • McNeil D.W.
        • Rainwater A.J.
        Development of the Fear of Pain Questionnaire–III.
        J Behav Med. 1998; 21: 389-410
        • Meulders A.
        • Vandebroek N.
        • Vervliet B.
        • Vlaeyen J.W.S.
        Generalization gradients in cued and contextual pain-related fear: an experimental study in healthy participants.
        Front Hum Neurosci. 2013; 345
        • Meulders A.
        • Vansteenwegen D.
        • Vlaeyen J.W.S.
        The acquisition of fear of movement-related pain and associative learning: a novel pain-relevant human fear conditioning paradigm.
        Pain. 2011; 152: 2460-2469
        • Meulders A.
        • Vlaeyen J.W.S.
        Reduction of fear of movement-related pain and pain-related anxiety: an associative learning approach using a voluntary movement paradigm.
        Pain. 2012; 153: 1504-1513
        • Meulders A.
        • Vlaeyen J.W.S.
        The acquisition and generalization of cued and contextual pain-related fear: an experimental study using a voluntary movement paradigm.
        Pain. 2013; 154: 272-282
        • Olatunji B.O.
        • Forsyth J.P.
        • Cherian A.
        Evaluative differential conditioning of disgust: a sticky form of relational learning that is resistant to extinction.
        J Anxiety Disord. 2007; 21: 820-834
        • Olejnik S.
        • Algina J.
        Generalized eta and omega squared statistics: measures of effect size for some common research designs.
        Psychol Methods. 2003; 8: 434-447
        • Pappens M.
        • Schroijen M.
        • Sütterlin S.
        • Smets E.
        • Van den Bergh O.
        • Thayer J.
        • Van Diest I.
        Resting heart rate variability predicts safety learning and fear extinction in an interoceptive fear conditioning paradigm.
        PLoSOne. 2014; 9: e105054
        • Raes A.K.
        • De Raedt R.
        The effect of counterconditioning on evaluative responses and harm expectancy in a fear conditioning paradigm.
        Behav Ther. 2012; 43: 757-767
        • Roelofs J.
        • Peters M.L.
        • Deutz J.
        • Spijker C.
        • Vlaeyen J.W.
        The Fear of Pain Questionnaire (FPQ): further psychometric examination in a non-clinical sample.
        Pain. 2005; 116: 339-346
        • Schrooten M.
        • Vlaeyen J.W.
        • Morley S.
        Psychological interventions for chronic pain: reviewed within the context of goal pursuit.
        Pain Manag. 2012; 2: 1-10
        • Spielberger C.D.
        Manual for the State-Trait Anxiety Inventory (STAI-Form Y).
        Consulting Psychology Press, Palo Alto, CA1983
        • Spruyt A.
        • Clarysse J.
        • Vansteenwegen D.
        • Baeyens F.
        • Hermans D.
        Affect 4.0: a free software package for implementing psychological and psychophysiological experiments.
        Exp Psychol. 2010; 57: 36
        • Sullivan M.J.
        • Bishop S.R.
        • Pivik J.
        The pain catastrophizing scale: development and validation.
        Psychol Assess. 1995; 7: 524-532
        • Van Damme S.
        • Crombez G.
        • Bijttebier P.
        • Goubert L.
        • Van Houdenhove B.
        A confirmatory factor analysis of the pain catastrophizing scale: invariant factor structure across clinical and non-clinical populations.
        Pain. 2002; 96: 319-324
        • Van Damme S.
        • Crombez G.
        • Eccleston C.
        Coping with pain: a motivational perspective.
        Pain. 2008; 139: 1-4
        • Van Damme S.
        • Van Ryckeghem D.M.
        • Wyffels F.
        • Van Hulle L.
        • Crombez G.
        No pain no gain? Pursuing a competing goal inhibits avoidance behavior.
        Pain. 2012; 153: 800-804
        • Vansteenwegen D.
        • Francken G.
        • Vervliet B.
        • De Clercq A.
        • Eelen P.
        Resistance to extinction in evaluative conditioning.
        J Exp Psychol Anim Behav Process. 2006; 32: 71
        • Vlaeyen J.W.
        • de Jong J.
        • Geilen M.
        • Heuts P.H.
        • van Breukelen G.
        Graded exposure in vivo in the treatment of pain-related fear: a replicated single-case experimental design in four patients with chronic low back pain.
        Behav Res Ther. 2001; 39: 151-166
        • Vlaeyen J.W.
        • de Jong J.
        • Geilen M.
        • Heuts P.H.
        • van Breukelen G.
        The treatment of fear of movement/(re)injury in chronic low back pain: further evidence on the effectiveness of exposure in vivo.
        Clin J Pain. 2002; 18: 251-261
        • Vlaeyen J.W.
        • Linton S.J.
        Fear-avoidance model of chronic musculoskeletal pain: 12 years on.
        Pain. 2012; 153: 1144-1147
        • Vlaeyen J.W.S.
        • Crombez G.
        • Linton S.J.
        The fear-avoidance model of pain: we are not there yet. Comment on Wideman et al. “A prospective sequential analysis of the fear-avoidance model of pain” [Pain, 2009] and Nicholas “First things first: reduction in catastrophizing before fear of movement” [Pain, 2009].
        Pain. 2009; 146: 222
        • Vlaeyen J.W.S.
        • de Jong J.R.
        • Leeuw M.
        • Crombez G.
        Fear reduction in chronic pain: graded exposure in vivo with behavioural experiments.
        in: Asmundson G.J.G. Vlaeyen J.W.S. Crombez G. Understanding and Treating Fear of Pain. Oxford University Press, Oxford2004
        • Vowles K.E.
        • McCracken L.M.
        Acceptance and values-based action in chronic pain: a study of treatment effectiveness and process.
        J Consult Clin Psychol. 2008; 76: 397-407
        • Watson D.
        • Clark L.A.
        • Tellegen A.
        Development and validation of brief measures of positive and negative affect: The PANAS Scales.
        J Pers Soc Psychol. 1988; 47
        • Woods M.P.
        • Asmundson G.J.
        Evaluating the efficacy of graded in vivo exposure for the treatment of fear in patients with chronic back pain: a randomized controlled clinical trial.
        Pain. 2008; 136: 271-280