A Self-Regulation Perspective on Avoidance and Persistence Behavior in Chronic Pain

Abstract

Objective: Behavioural factors such as avoidance and persistence have received massive theoretical and empirical attention in the attempts to explain chronic pain and disability. The determinants of these pain behaviours remain, however, poorly understood. We propose a self-regulation perspective to increase our understanding of pain-related avoidance and persistence.Methods: A narrative review.Results: We identified several theoretical views that may help explaining avoidance and persistence behaviour, and organized these views around 4 concepts central in self-regulation theories: (1) identity, (2) affective-motivational orientation, (3) goal cognitions, and (4) coping. The review shows that each of these self-regulation perspectives allows for a broadened view in which pain behaviors are not simply considered passive consequences of fear, but proactive strategies to regulate the self when challenged by pain.Discussion: Several implications and challenges arising from this review are discussed. In particular, a self-regulation perspective does not consider avoidance and persistence behaviour to be intrinsically adaptive or maladaptive, but argues that their effects on disability and wellbeing rather depend on the goals underlying these behaviours. Such view would require a shift in how avoidance and persistence behaviour are assessed and approached in clinical interventions.

Avoidance, pacing, or persistence in multidisciplinary functional rehabilitation for chronic musculoskeletal pain: An observational study with cross-sectional and longitudinal analyses

“…Most of our patients were in a professional reintegration program with a 1-year average pain duration, and the functional and vocational setting of our project may shed a new light on the possible relationships between patients’ goals and activity patterns. Self-regulation and motivational theories, indeed, postulate that behaviors should be studied for their relationship with identity and valued goals[9]. In the context of functional and vocational rehabilitation, a person in pain who valued returning as a “good worker” after an injury (in others words to become as close as possible to the same person he or she was before), may display more efforts despite pain which seems in accordance with our results.…”

“…It includes different strategies such as slowing down, alternating activity and pause, or dividing activity into smaller tasks. Persistence, also labeled as endurance, confronting, or overdoing, has received more attention over the past few years[7–9]. It has been defined as continuing activity despite pain, with high or more fluctuating levels of activity, and detrimental effects due to overuse[8].…”

“…Behavioral activity strategies are seen as ways to solve these discrepancies[23] (persistence for staying the same person, avoidance for self-protection). Within these recent and more integrative perspectives, behavioral strategies are not functional or dysfunctional per se, their effects on disability and mood being more related to underlying personal goals and contextual factors[9]. Rehabilitation often offers different therapeutic contexts and objectives to improve the patient’s functioning (focusing on pain management, on functional restoration, or on vocational activity).…”

Avoidance and Persistence

“…In their letter to the editor, Andrews and colleagues 1 provide a thoughtful reflection on some of the issues that have been raised in our review 2 on avoidance and persistence in chronic pain. They discuss the validity of objective measures of physical activity, i.e., accelerometry, as indicators of avoidance, persistence, and over-activity.…”

The “self” in pain: the role of psychological inflexibility in chronic pain adjustment

“…In chronic pain contexts, self-discrepancy occurs when patients perceive themselves as failing to fulfill their own hopes (i.e., ideal self) or responsibilities (i.e., ought self) as a result of unsuccessful goal attainment or goal conflict. Based on the value-expectancy models of motivation, whether a person is motivated to pursue their goals depends on the value of the goals and the expectation that the goals can actually be achieved (Edwards, 1954;Van Damme & Kindermans, 2015). Similarly, a review of chronic pain patients' goal pursuits indicates that, whether a person initiates a goaldirected behavior is determined by their goal intention as well as their intention realization (Gollwitzer & Sheeran, 2006;Schrooten et al, 2012).…”