Understanding and Treating Fear of Pain. Edited by Gordon J. G. Asmundson, Johan W. S. Vlaeyen & Geert Crombez. Oxford: Oxford University Press. 2004. 390pp. £49.50 (hb). ISBN 0198525141

Many of those who develop chronic pain have disproportionately few organic findings to explain their degree of distress. Many of these individuals are classified as suffering from a somatoform disorder. There is debate about the genesis of prolonged pain in these patients.

This book, edited by three psychologists from Canada, Holland and Belgium, posits that fear of pain explains the mechanism of psychological distress in vulnerable patients who become disabled with pain. In those that are predisposed, the perception of pain is interpreted in a malign way through a process of what is described as catastrophisation. The cause of the pain is viewed in a horrific light and there is further rumination and worry about effects on the body. The authors explain that this occurs because of previous life experiences, particularly those of situations involving pain, anxiety and perceived threats to physical integrity. When faced with comparable situations, the sufferer amplifies painful feelings and avoids activities that give rise to further pain. This reduction in mobility limits the process of re-establishment of physical routines that are essential in enabling recovery from injury, and the painful state is reinforced. In others, fear of pain occurs because of fear of anxiety-related sensations associated with painful episodes, as part of a classical conditioning process.

The authors devote 11 of the 15 chapters in this book to explaining this fear–anxiety–avoidance model of the genesis of chronic pain. This part may appear somewhat convoluted to the scientist grounded in didactic enquiry, but the model described has value in treatment. Specific attention to overcoming fearful cognitions has been found to achieve treatment success in patients with back pain (Von Korff et al, 2005), and these authors contribute one of the four chapters in the treatment section. Graded exposure to anxiety-provoking situations can enable patients to learn to manage both anxiety and pain together. Cognitive–behavioural therapy is also effective.

This book prompts all that are managing patients with painful conditions to examine the nature and quality of the attributions and beliefs of the pain sufferer. Since the book has been published it has been demonstrated that up to 10% of the disability associated with and intensity of chronic painful complaints can be attributed to fearful cognitions of the sufferers (Peters et al, 2005). It is timely for those involved in treating individuals with chronic pain to consider fear of pain as a possible origin of their distress.