Gatzounis Rena, den Hollander Marlies, Meulders Ann
Experimental Health Psychology, Department of Clinical Psychological Science, Maastricht University, The Netherlands.
Department of Rehabilitation Medicine, Care and Public Health Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands; Adelante Centre of Expertise in Rehabilitation, Hoensbroek, The Netherlands.
J Pain. 2021 Nov;22(11):1315-1327. doi: 10.1016/j.jpain.2021.04.012. Epub 2021 May 21.
Exposure in vivo is a theory-driven and widely used treatment to tackle functional disability in people with chronic primary pain. Exposure is quite effective; yet, in line with exposure outcomes for anxiety disorders, a number of patients may not profit from it, or relapse. In this focus article, we critically reflect on the current exposure protocols in chronic primary pain, and provide recommendations on how to optimize them. We propose several adaptations that are expected to strengthen inhibitory learning and/or retrieval of the extinction memory, thus likely decreasing relapse. We summarize the limited, but emerging experimental data in the pain domain, and draw parallels with experimental evidence in the anxiety literature. Our reflections and suggestions pertain to the use of the fear hierarchy, reassurance, positive psychology interventions, exposure with a range of stimuli and within different contexts, and the use of safety behaviors during treatment, as well as associating the fear-inducing stimuli with novel outcomes. In addition, we reflect on the importance of specifically tackling (the return of) pain-related avoidance behavior with techniques such as disentangling fear from avoidance and reinforcing approach behaviors. Finally, we discuss challenges in the clinical application of exposure to improve functioning in chronic primary pain and possible avenues for future research. PERSPECTIVE: Inspired by recent advances in learning theory and its applications on the treatment of anxiety disorders, we reflect on the delivery of exposure treatment for chronic primary pain and propose strategies to improve its long-term outcomes.
体内暴露是一种基于理论且广泛应用于治疗慢性原发性疼痛患者功能障碍的方法。暴露疗法相当有效；然而，与焦虑症的暴露治疗结果一致，一些患者可能无法从中获益，或出现复发。在这篇重点文章中，我们批判性地反思了慢性原发性疼痛目前的暴露治疗方案，并就如何优化这些方案提出建议。我们提出了几种调整方法，预计这些方法能够加强抑制性学习和/或消退记忆的提取，从而可能减少复发。我们总结了疼痛领域有限但不断涌现的实验数据，并将其与焦虑症文献中的实验证据进行对比。我们的思考和建议涉及恐惧等级的使用、安慰、积极心理干预、在一系列刺激下及不同情境中的暴露、治疗期间安全行为的使用，以及将引发恐惧的刺激与新的结果联系起来。此外，我们思考了通过诸如将恐惧与回避行为分离以及强化趋近行为等技术专门应对（疼痛相关回避行为的）复发的重要性。最后，我们讨论了暴露疗法在改善慢性原发性疼痛功能方面临床应用中的挑战以及未来研究的可能途径。观点：受学习理论及其在焦虑症治疗应用方面的最新进展启发，我们反思了慢性原发性疼痛的暴露治疗方法，并提出改善其长期效果的策略。
