Should I stay or should I go? When goals conflict in the context of pain

Why is it that some individuals with chronic pain stay fairly active, and others are not? Why do individuals act the way they do? One possible answer to both questions might be motivation. Imagine being an individual suffering from chronic pain. When you experience pain, it may push you to pursue or avoid activities in order to control pain or prevent further harm. However, this goal to prevent further harm does not occur in isolation, but in a context with many other goals, as you are not ‘just’ an individual with chronic pain, but maybe also a mother, lover, swimmer, ceramics enthusiast… Pursuing activities related to our roles, hobbies or our social life might not be compatible with pain reduction, resulting in having to choose between these activities and pain reduction/control/avoidance. Unfortunately, however, patients with chronic pain indeed seem to withdraw from activities they previously enjoyed in order to avoid pain or try to promote recovery.[1]

Although a lot of research has identified pain-related fear and accompanying avoidance behavior as potentially detrimental factors in the development, maintenance and aggravation of chronic pain (e.g., Fear-Avoidance Model of chronic pain)[2-3], they are rarely considered within a broad motivational context. The main focus of my PhD and subsequent research has been to experimentally investigate the impact of goal competition on pain-related fear and avoidance behavior.  The presence of goal conflict and its effects in patients with chronic pain was – and is, in our opinion – still poorly understood.

In a recently published study,[4] we mapped to what extent goal conflict is present in and experienced by patients with chronic pain compared to individuals not suffering from chronic pain. To this purpose, we invited 40 patients with fibromyalgia and 37 healthy control participants to our lab. During an individual session, participants completed a semi-structured interview based on the Daily Reconstruction Method (DRM) of Kahneman and colleagues.[5] To start, they reconstructed their previous day, starting with waking up and ending when going to sleep. Next, participants identified goal conflicts that had occurred the previous day. We explained to participants that goal conflict is a situation in which indecisiveness or doubt about which of two (or more) activities to pursue occurs, as engaging in one activity to attain a goal might (temporarily) create a stalemate in the attainment of another goal (see also the theoretical accounts of goal conflict of Lewin[6] and Miller[7]). Subsequently, participants classified each of their goals in one of the following pre-defined categories: pain avoidance/control, social, work, intrapersonal, leisure, household, general health, or other. Lastly, participants assessed the experience of their conflicts and rated their pain, fatigue, emotions and overall experience of the previous day.

Contrary to our hypothesis, we found that patients did not spontaneously report more goal conflict than controls. They do however differ in the type of goal conflicts they reported. Not only did patients with fibromyalgia report more goal conflict involving pain reduction, control or avoidance, they also reported fewer social-, work- and leisure-related goal conflicts. More than half (57.4%) of all conflicts reported by patients included a pain goal. These pain goals most often conflicted with household goals, social goals, and intrapersonal goals. Furthermore, patients with fibromyalgia appraised their conflicts more negatively and as more difficult to choose one of both activities than did control participants. This finding was not affected by the number of conflicts experienced. Additionally, we uncovered that a higher average pain intensity was associated with a strong increase in the number of pain-related conflicts in patients, and that the number of pain-related goal conflicts was associated with more cognitive intrusions as well as more anxiety in patients.

What do these results mean? First, the differences in type of conflict and the type of goals conflicting with pain goals might be dependent on contextual characteristics. It may be that patients’ lives are predominantly focused on pain, and therefore experience less conflict in other life domains. Furthermore, these findings suggest that pursuing goals in the face of pain may deplete resources in an already vulnerable population, which in turn may lead to increased pain or feeling more hampered by pain. It also seems that experiencing goal conflict is closely tied with our interpretation of a situation in a catastrophic way, which may relate to how negatively we perceive the conflict to be. We feel that the inclusion of a broad motivational perspective in existing explanatory models of chronic pain, such as the fear-avoidance model is warranted,[8] but further scientific scrutiny is needed.

Want to know more about our research? Check out the paper here.

About Nathalie Claes

Nathalie Claes pain researcherNathalie is a postdoctoral researcher in the Research Group Health Psychology (OGP; KU Leuven) and focuses mainly on investigating decision-making processes and their impact on fear and avoidance as well as potential ways to enhance treatment strategies (extinction) for chronic bodily symptoms. The latter research line fits well with her job as quality manager at Tumi Therapeutics, a multidisciplinary expertise center specialized in the prevention, diagnosis, treatment, and research of chronic bodily symptoms and stress-related complaints that collaborates closely with OGP.

References

[1] Crombez, G., Eccleston, C., Van Damme, S., Vlaeyen, J. W. S., & Karoly, P. (2012). Fear-avoidance model of chronic pain: the next generation. The Clinical Journal of Pain, 28(6), 475–83.

[2] Vlaeyen, J. W., & Linton, S. J. (2000). Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain, 85(3), 317–32.

[3] Vlaeyen, J., & Linton, S. J. (2012). Fear-avoidance model of chronic musculoskeletal pain: 12 years on. Pain, 153(6), 1144–7.

[4] Claes, N., Vlaeyen, J. W. S., Lauwerier, E., Meulders, M., & Crombez, G. (2018). Goal conflict in chronic pain: day reconstruction method. PeerJ, 6, e5272.

[5] Kahneman, D., Krueger, A. B., Schkade, D. A., Schwarz, N., & Stone, A. A. (2004). A survey method for characterizing daily life experience: the day reconstruction method. Science, 306(5702), 1776–80.

[6] Lewin, K. (1935). A dynamic theory of personality. New York: McGraw-Hill.

[7] Miller, N. E. (1944). Experimental studies of conflict. In J. M. Hunt (Ed.), Personality and behavior disorders (pp. 431–464). New York: The Ronald Press Company.

[8] Vlaeyen JW, Crombez G, Linton SJ. (2016). The fear-avoidance model of pain. Pain, 157(8), 1588-9.