Consider one of my patients, a woman with FM who reported that when her symptoms flared up, she lay down to rest. She noted, and her husband confirmed, that his typical responses were to bring her some medication, to take the children out to the park to give her some quiet time, and to assume some household chores. Such responses positively rewarded my patient’s behavior so that she increased the amount of time she spent reclining, despite no change in her symptoms. In other words, her symptom behaviors were being maintained by the learned positive consequences—attention and avoidance of household chores.
People with FM may not be consciously communicating their symptoms to obtain attention or to avoid undesirable activities. In my patient’s case, her behaviors were likely to have been shaped gradually in a way that neither she nor her husband recognized.
Health care professionals may also positively and inadvertently reinforce symptoms by their responses. The physician who prescribes medication when the patient complains of symptoms may be reinforcing the symptom reporting. That is, the patient learns that his or her behavior elicits a response from the physician, and if the response provides some relief, the patient may learn to report pain to obtain the desired outcome.
This is the case when pain medication is prescribed on a take-as-needed (PRN) basis. With PRN dosing, the patient must recognize that the pain has increased before she can take the medication. If the medication provides some reduction of symptoms then the attention to and self-rating of symptoms may be maintained by the anticipated outcome of relief.30,31 The combination of reinforced pain behaviors and neglected well behaviors is common in patients who have FM (Table 1).
Much research has been directed toward identifying cognitive factors that contribute to pain and disability.31,32 These studies have consistently demonstrated that patients’ attitudes, beliefs, and expectancies about their plight, themselves, their coping resources, the future, and their health care system affect their reports of pain, activity, disability, and response to treatment.33-35
Clearly, it is essential for people who have chronic pain to develop adaptive beliefs about impairment, pain, suffering, and disability, and to de-emphasize the role of the symptoms in their everyday functioning. In fact, results from numerous treatment outcome studies have shown that changes in pain level do not parallel changes in other variables of interest, including a patient’s activity level, medication use, return to work, rated ability to cope with pain, and pursuit of further treatment.36
Self-efficacy expectations—a personal conviction that one can successfully execute a course of action to produce a desired outcome in a given situation—appear to be particularly important. Lower self-efficacy beliefs are related to greater pain, disability, and depressive mood in FM.32,37 Patients with relatively low self-efficacy beliefs who underwent physical training and exercise had lower posttreatment physical activity than those with higher self-efficacy beliefs. Furthermore, improvements in self-efficacy beliefs during treatment were associated with lower tender point scores and pain intensity.37