Hypervigilance can play a massive role in the development of chronic pain. It occurs when we choose to focus on something in the body, for example an ache or pain, asymmetry, discomfort or other symptom, and continue to revisit the sensations in the area, on what we might consider to be a pathological or unhelpful number of times during the day. Usually, there tends to be some meaning attached to the sensations. In the event that these meanings attach a sense of worry, danger or fear to the sensations, then we have the potential for a problem.
At a neurological level, when we constantly use a particular set of neural pathways, they become stronger and more efficient at working in that order. In effect, the connections become so strong and practiced that it becomes a lot more automatic and takes less effort for the brain to use those particular connections. This is helpful for us when we are learning skills, as once we master them they can seem effortless. When this occurs in hypervigilance, it can create a scenario where the pathways to “check in” on that area, wire together with the worries and fears around those sensations. Over time, they can become extremely proficient – essentially, the brain can rewire itself so that there is very frequent attention on a body component and an accompanying worrysome thought that goes with it. You can imagine how this can become all encompassing for a person in pain.
An example of this might be the tennis player who hurts their shoulder. Whilst their pain might be mild, there is likely to be a fair bit of fear attached to the sensation, particularly if the person is concerned that it might stop them from playing the sport that they love. This is a very normal scenario and as clinicians, we will see this every day. For some people though, particularly when they haven’t received adequate reassurance about their condition or have sought inappropriate information (Google doctor anyone?) this normal scenario can snowball into a problem.
The research tells us that hypervigilance is a major factor in conditions such as fibromyalgia, chronic low back pain and irritable bowel syndrome. It tends also to go hand in hand with catastrophic thinking.( 1,2.) From here, the pathway to a deconditioning cycle is an obvious one- for our tennis player with a four month history of a grumpy shoulder it might look something like this:
- My shoulder is worse today than normal
- I did some weight bearing and overhead work at the gym yesterday
- It must have aggravated my shoulder
- I can’t do anything overhead because it makes my shoulder worse (and I won’t be able to play tennis again) NEW RULE
What the person might have missed though in making these assumptions or rules, is that they had done exactly the same workout the last few weeks with no problems. This increase in pain may have nothing to do with the workout – at four months the pain is beginning to behave a little bit more like chronic pain – it can tend to have a less defined pattern, the pain can be more widespread and tell less of a picture of what is going on at the level of the tissue. The increase in pain may have had nothing to do with the overhead components of the workout, and these are likely to be important for recovery.
This is not to deny that biomechanics will be playing a role in this instance. Addressing the biomechanical components in a case like this is crucial and will be important for recovery – like most things though, it would be much better if this part was managed by a health profession who could better assess these factors, rather than the patient making the assumptions themselves or with the help of Google doctor!
So how do we help?
- To see if this hypervigilance scenario is at play, look for the accompanying catastrophising thoughts – they will be there! Ask open ended questions that can walk the patient down the path to access those thoughts. Together you can then debunk the rules and thoughts that don’t fit well with the actual scenario.
- Set out your diagnosis and management plan so that there is a level of reassurance. Then keep reassuring throughout. If there is less fear associated with the sensation, there is less of a need to keep checking in on it.
- Help the patient to feel a bit more in control of their situation by encouraging active approaches. Having that reassuring sense of self proficiency provides an alternative neural pathway that they might be able to access, rather than defaulting to the dark side of worry and hypervigilance.
Posserud, L., Svedlund, J., Wallin, j., & Simren,m. (2009). Hypervigilance in irritable bowel syndrome compared with organic gastrointestinal disease. Journal of Psychosomatic Research, 66 (5), 399-405.
Crombex, G., Eccleston, C., Vanden Broeck, A., Goubert, L., & Van Houdenhove, B. (2004). Hypervigilance to pain in fibromyalgia: the mediating role of pain intensity and catastrophic thinking about pain. Clinical Journal of Pain, 20(2), 98-102.