The role of social anxiety in chronic pain and the return-to-work process
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Henrik Børsting Jacobsen
and
Silje Endresen Reme
In this issue of the Scandinavian Journal of Pain, Johanna Thomten and her coworkers [1] report on the relationship between social anxiety, pain catastrophizing, and the ability to communicate patients pain-related needs at work. The idea of catastrophizing being a common element in both social anxiety and pain is enticing, especially considering the evidence demonstrating how social factors determine the relationship between catastrophizing and pain outcomes [2]. The inclusion of work-related expectancy and communication adds to the novelty of the study and its aims. Work relationships are considered a crucial element in the rehabilitation of low-back pain [3,4], but perhaps not when multidisciplinary treatment is given by specialized pain clinics. This could be due to the existing studies largely being concerned with non-specific and specific low-back pain, but it could also be because hospitals are organized within the health-care sector and communication between stakeholders is time consuming and challenging [5].
1 Social anxiety outperformed pain catastrophizing
Results from the current study showed a moderate correlation between pain catastrophizing, social anxiety (0.39) and pain severity (0.29). Social anxiety on the other hand was only weakly correlated with pain severity, indicating that elements of the social anxiety measure affect pain catastrophizing, but not pain severity. The authors performed a multiple linear regression model that explained a total of 16% of the variance in patient-reported ability to communicate pain-related needs. The outcome was a seven-item subscale on the return-to-work self-efficacy questionnaire. It is noteworthy that social anxiety outperformed pain catastrophizing and pain severity as predictors of the chosen outcome. Still, the degree of pain severity could perhaps not be expected to act as an indicator of your communication skills, given that voicing of pain concerns increase as a safety behaviour according to the communal coping model of pain catastrophizing [2].
2 Clinical implications of the findings
The study has several limitations, as the authors themselves comment and discuss. The cross-sectional design makes it impossible to draw causal inferences about the direction of association with return-to-work self-efficacy, the participants were self-selected, and there is no information about non-responders. This all increases the risk of bias and limit our possibilities of strong conclusions. Still the results do have several interesting implications. First, the inclusion of social anxiety as a predictor provides us with information about a specific form of psychological distress that has received little attention in the return-to-work process for persistent pain. Second, there are several efficient evidence-based treatments for social anxiety that can easily be implemented into existing clinical practice. The results might therefore have clinical implications. Data indicating that self-efficacy gradually declines with pain duration, substantiates anxiety and lack of confidence as a target for intervention [6]. The longer you suffer from pain, the less confident you are in your ability to influence outcomes, a feeling intuitively related to avoidance.
3 The challenging aspects of “worry”
The primary aim of this study was to see whether social anxiety moderated the relation between pain catastrophizing and the perceived ability to communicate pain-related needs, which it did not. The rationale for the hypothesis was that a common factor in both constructs is perseverative cognitions (worry) exacerbating avoidance behaviour in the participant. The observed lack of significance could be due to the choice of measurement methods. Although enticing, the idea that worry represents a common factor in pain catastrophizing and social anxiety depends on the concept of “worry” being accurately and sufficiently measured by the chosen instruments. As an example, one could argue that the repetitive negative cognition measured here is more a measure of worry being present rather than how often one worries, or how the person chooses to act (or not act) on the worrying thoughts. How we choose to relate to worrying thoughts is the focus of several current psychotherapeutic models, where patients are taught and trained to recognize the worrying thoughts, while choosing not to act on them (e.g. with avoidance). In other words, not letting them have too much attention in their lives. Ironically, this means that we could see an increase in patient-reported catastrophizing from “third-wave psychotherapy”, but in the long run, this is thought to be a better form of coping. So the concept of worry is a challenging one, and studies including it should ideally define frequency, metacognitive beliefs about control, relevance to situations (pain versus social interaction), and cognitive model alignment. This could be a task for future studies to take on, as a follow-up of the important first steps made by Thomten et al. Hence, it is tempting to speculate, and would have been interesting to see, whether regression analyses of the subscales of the pain catastrophizing scale (e.g. magnification) could have influenced the results of this study. Further, it would also have been interesting to investigate potential differences in men and women. Had the sample been larger (i.e. more male participants), this question could indeed have been addressed by running separate analyses stratified on gender with all predictors included.
In conclusion, this study and its results both recognize the success of the past perspectives and at the same time targets areas where progress is insufficient. These areas include, but are not limited to, the identification of important therapeutic processes and the linking of theoretical assumptions with clinical technique. More specifically, the study results highlight the potential importance of social anxiety in the return-to-work process for patients struggling with persistent pain. Social anxiety has not received much attention in this context before, and therefore represents an important contribution to the field that should be followed up with more studies with stronger designs. Since social anxiety is a well-known problem to the psychology community in general, with efficient methods to help patients overcome this problem, the potential for bringing this knowledge into the field of pain-related work disability appears very promising.
DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2015.10.005.
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Conflict of interest: None declared.
References
[1] Thomtèn J, Boersma K, Flink IK, Tillfors M. Social anxiety, pain catastrophizing and return-to-work self-efficacy in chronic pain: a cross-sectional study. Scand J Pain 2016;11:98–103.Search in Google Scholar
[2] Sullivan MJL. The communal coping model of pain catastrophising: clinical and research implications. Can Psychol 2012;53 (1):32–41.Search in Google Scholar
[3] Loisel P, Abenhaim L, Durand P, Esdaile JM, Suissa S, Gosselin L, Simard R, Tur-cotte J, Lemaire J. A population-based, randomized clinical trial on back pain management. Spine 1997;22 (24):2911–8.Search in Google Scholar
[4] Loisel P, Côté P. The work disability paradigm and its public health implications. Handbook of work disability. Springer; 2013. p. 59–67.Search in Google Scholar
[5] Loisel P, Buchbinder R, Hazard R, Keller R, Scheel I, van Tulder M, Webster B. Prevention of work disability due to musculoskeletal disorders: the challenge of implementing evidence.J Occup Rehabil 2005;15 (4):507–24.Search in Google Scholar
[6] Pincus T, Burton AK, Vogel S, Field AP. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine (Phila Pa 1976) 2002;27 (5):E109–20.Search in Google Scholar
© 2016 Scandinavian Association for the Study of Pain
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