correlation between high anxiety levels and increased pain perception in children with
migraines and sufferers of back pain and pelvic pain (Feuerstein et al. 1987; McGowan
et al. 1998). In a recent experimental study participants took part in the cold pressor test
which involves placing the hand and arm in icy water as a means to induce pain. Their
trait anxiety was assessed and some were actively distracted from thinking about their
pain (James and Hardardottir 2002). The results showed that both distraction and low
anxiety reduced the pain experience.Fear
Many patients with an experience of pain can have extensive fear of increased pain or
of the pain reoccurring which can result in them avoiding a whole range of activities
that they perceive to be high risk. For example, patients can avoid moving in particular
ways and exerting themselves to any extent. However, these patients often don’t describe
their experiences in terms of fear but rather in terms of what they can and cannot
do. Therefore, they don’t report being frightened of making the pain worse by lifting a
heavy object, but they state that they can no longer lift heavy objects. Fear of pain and
fear avoidance beliefs have been shown to be linked with the pain experience in
terms triggering pain in the first place. For example, Linton et al. (2000) measured fear
avoidance beliefs in a large community sample of people who reported no spinal pain
in the preceding year. The participants were then followed up after one year and the
occurrence of a pain episode and their physical functioning was assessed. The results
showed that 19 per cent of the sample reported an episode of back pain at follow-up and
that those with higher baseline scores of fear avoidance were twice as likely to report
back pain and had a 1.7 times higher risk of lowered physical functioning. The authors
argue that fear avoidance may relate to the early onset of pain. Some research also
suggests that fear may also be involved in exacerbating existing pain and turning acute
pain into chronic pain. For example, Crombez et al. (1999) explored the interrelationship
between attention to pain and fear. They argued that pain functions by demanding
attention which results in a lowered ability to focus on other activities. Their results
indicated that pain related fear increased this attentional interference suggesting that
fear about pain increased the amount of attention demanded by the pain. They con-
cluded that pain related fear can create a hyper-vigilance towards pain which could
contribute to the progression from acute to chronic pain. These conclusions were further
supported by a comprehensive review of the recent research. This indicates that treat-
ment which exposes patients to the very situations that they are afraid of, such as
going out and being in crowds, can reduce fear avoidance beliefs and modify their pain
experience (Vlaeyen and Linton 2000).The role of cognition
Catastrophizing
Patients with pain, particularly chronic pain, in line with many other patients often
show catastrophizing. Keefe et al. (2000) described catastrophizing as involving three292 HEALTH PSYCHOLOGY