« Re-considérer » la thérapie d'exposition concernant la peur-évitement de la douleur chronique

Pain is not limited to the somatic expression of a disorder or a dysfunction. Pain is caused by the combination of physiological, pathological, emotional, psychological, cognitive, environmental, behavioral and social factors (Holdcroft, 2003). People with chronic pain experience a high level of emotional suffering that is the result of the temporal nature of their pain. This emotional pain has a consequence: the limited effect of medical interventions on the physical well-being of people with chronic pain (Winterowd et al., 2003). The management of chronic pain is, in large measure, a project to adapt to chronic pain. This adaptation is to be considered in terms of moderators and mediators (Morley and Keefe, 2007). Studies on the factors that contribute to the chronicity of pain highlight the contribution of processes and psychological factors. These processes are prime targets for cognitive behavioral therapy for chronic pain (Roussel and Dossetto, 2012). Anxiety is a common comorbidity of chronic pain syndromes (Demyttenaere et al., 2007). Anxiety contributes to the chronicity and perpetuation of pain. It leads to a pessimistic and catastrophic view of pain. Anxiety reduces the self-efficacy of the subject faced with pain, reduces the ability to control pain, and can promote chronicity of pain. Otherwise, pain is an emotional experience associated with the representation of a threat, generating fear of pain, which in turn exacerbates the pain. Fear of pain generates avoidance and hypervigilance. Our contribution aims to develop arguments in favor of a reconsideration of exposure therapy to change fear-avoidance phenomena in the context of chronic pain. Respondent conditioning and avoidance are two processes involved in the perpetuation of pain. Exposure is a procedure to promote patients' confrontation with their external and internal reality and thus help them to control avoidance. Exposure therapy is a classical approach to treat fear and anxiety disorders (Eraldi-Gackiere and Graziani, 2007). Although exposure is widespread in psychotherapies other than CBT (e.g., as a verification of efficacy, as advice for changing somatic medicine, as an 'obligation' in functional rehabilitation), exposure therapy is less used in the field of pain and chronic pain. Anxiety and algophobia promote avoidant coping strategies for patients. They also reinforce the syndrome of exclusion by negligence, inactivity and perceived disability. As part of inhibition by learning, exposure to the conditioned stimulus, which determines avoidance and the mobilization of the affected body part, must be centered not on a longer exposure time, but on the mismatch between fear related to the movement and experience during the exposition. Indeed, limitations of exposure therapy could be linked, in particular, to the deficit in learning by inhibition. This fact is important because inhibition deficit is considered as a central element in the extinction of dysfunctional behavior (Bouton, 1993). Exposure applied to chronic pain may benefit from an “optimization” of both immediate and remote results: the development of the learning process by inhibition may lead to the detriment of the habituation process. Amongst anxious patients with chronic pain it is important to optimize learning by inhibiting during exposure therapy to increase the effectiveness of this therapy and reduce inhibition deficits for anxious patients. These strategies of optimization (Craske, 2014) highlight the mismatch between expectation and experience as well as the suppression of safety signals present in chronic pain patients who are anxious. Using cognitive behavioral therapy, substantial improvements for anxious chronic pain patients can be envisaged through exposure designed in view of extinction (by learning) of inhibition.