(English) Fibromyalgia and overloading: an integrative hypothetical model

John L. Zant, Leo D. Roorda, Sharon Voet, Jos H.M. Dekker, Joost Dekker
All authors work at the Department of Rehabilitation Medicine and Psychology in the Jan van Breemen Institute, Amsterdam, The Netherlands; Professor Joost Dekker also works at the Department of Rehabilitation Medicine and the EMGO Institute, VU University Medical Centre, Amsterdam,

Jan van Breemen Institute, Amsterdam, The Netherlands

Summary

This study focuses on the concepts of over-activity, persistence, ergomania and endurance in relation to the etiology of fibromyalgia (FM). With respect to the etiology an integrative overloading model for FM is formulated on the basis of data from the few studies investigating this subject, and on the basis of clinical experience gained from a great number of well-documented psychological life-histories of patients with FM. Clinical implications are outlined. This model may serve as an agenda for further research on the etiologial relation between overloading and fibromyalgia.

Introduction

Fibromyalgia (FM) is one of the chronic non-specific or medically unexplained pain syndromes. The etiology of FM is still unknown (van Houdenhove, 2004). There is, however, growing evidence that psychological factors play an important role in the etiology of FM (Boissevain,1991; Clauw, 1995; Brosschot, 2001; Linton, 2002; 2005). FM has been described as a depressive disorder (Alfici, 1989; Raphael, 2004), as an affective disorder (Hudson, 2003), and as a stress-related disorder (van Houdenhove, 2004). In a study of dysfunctional psychological dimensions in FM-patients, factor analyses identified several psychological dimensions, including cognitive (catastrophizing, external control beliefs), emotional (alexithymia), behavioral (restless behavior) and social (need for support) dimensions (Colangelo, 2004). Van Houdenhove (1986; 1994; 1995; 2001ab; 2004) showed that action-proneness, or a pre-morbid overactive life-style, can be an etiological factor related to FM, an that it plays a role in 70% of chronic pain patients. Alfici (1989) reported that, among other factors, dependence, obsessive-compulsive personality and pre-pain ergomania were characteristic of FM-patients. Hasenbring (1994; 1996; 2001; 2006) demonstrated that avoidance behavior and endurance strategies were psychological predictors of pain persistence in lumbar disc patients. Vlaeyen (2004) hypothesizes that either disuse (fear-avoidance model) or overuse (persistence model) will lead to disability and chronic pain. There is growing evidence to support the fear-avoidance model (Vlaeyen, 2004; Leeuw, 2007)). However, studies on overuse and persistence have, until now, been relatively scarce (McCracken, 2007). According to these studies it seems that the concept of overloading plays an important role in the etiology of FM (and other non-specific pain- and fatigue-syndromes (van Houdenhove, 2004); this concept contains terms such as action-proneness, overactive life-style, ergomania, endurance strategies, overuse and persistence. A comprehensive theoretical model of overloading (overuse) has not yet been developed (Vlaeyen, 2004).

Integrative hypothetical model

We have tried to formulate an integrative hypothetical model of overloading, based on the afore-mentioned studies and on our own clinical experience gained from some thousands of life-histories of FM-patients documented by our psychologists during the past fifteen years. According to van Houdenhove (2002) and Wentz (2004) the patient’s biography should be part of each diagnostic evaluation and considered an important focus of psychological/ psychiatric research in fibromyalgia and chronic fatigue syndrome; it illustrates the possible etiological role of adverse childhood experiences, premorbid overactivity and intense activity or hypomanic helpfulness. The model describes cognitive, emotional, behavioral and environmental conditions in the development of an overloading life-style, eventually leading to FM: Parental behavior and personality development In family situations in which the parents are not able to show warm and appreciative behavior towards their children, or when parents are overambitious or perfectionists, children may learn to disregard their own strivings and needs and to fulfill the needs of the parents in all respects. High demand, in combination with more negative than positive feedback, may lead to fear of failure, low self-esteem and a compulsory tendency to please the parents and avoid their criticism. It is also possible that a child has to take adult responsibilities when, for example, the mother is absent because of death, illness, divorce or a full-time job. When this pattern of disregarding one’s own strivings and needs and of hypomanic helpfulness has been learnt in childhood, adult relationships may develop into asymmetrical patterns in which one invests more energy in others than vice versa. This could lead to physical and mental overloading, and finally to chronic pain, exhaustion and inactivity. When a child learns that expressing his emotions elicits punishment he will suppress his emotions and will become alienated from his own feelings, which may lead to depression, especially when there is no positive feedback from relevant others. To avoid falling into a depression some people throw themselves into their work and other activities (in a compulsory way) which increases overloading until they are no longer able to work, due to increasing pain and fatigue, and yet depression will develop. There is growing evidence that adverse childhood experiences play an important role in the development of chronic pain- and fatigue-syndromes (McBeth, 1999; Wentz, 2004)). According to Zant (1997) and Fisher (2003), lack of affection and over-protection play an important role in the etiology of FM. Imbierowicz (2003) found a relationship between sexual and physical maltreatment in childhood and the development of FM. Waerden (2005) found that fearful and preoccupied attachment-styles are associated with symptom reporting via a negative model of the self and negative affectivity. Life-style and asymmetrical relationships In an asymmetrical relationship between a helpful person and a privileged person, the latter learns that he has to invest minimally in the relationship because the former is helpful under all circumstances (a-selective reinforcement). Because helpfulness is so easily gained, the privileged person does not learn to value the helpful behavior, and will experience it as a matter of course. If, later on, the helpful person wants to achieve a more symmetrical interaction, he will meet resistance because the other does not want to relinquish his privileges. And what is more, the helpful person has not learnt how to be assertive. This process will lead to continuously overloading behavior in the helpful person. It may be clear that for someone who has learnt to be more helpful to others than to satisfy his own needs, and who has developed a network of asymmetrical relationships, it requires a great deal of effort to reform most of his relationships with relevant others to achieve symmetrical and equivalent interactions. Even if the patient has learnt through psychotherapy to be more assertive, to express his feelings and to negotiate more effectively, it will take a lot of time and energy to implement the newly acquired abilities. The overloading person will receive little recognition of, and appreciation for, his helpful behavior because the privileged person has learnt to take it for granted. Moreover, the overloading person will receive little recognition of his pains and exhaustion from physicians, who are usually unaware of the pre-morbid overactive life of this momentarily very inactive patient with pain, but little or no physical defects. Therefore, physicians often see no valid reason for sick-leave or social security benefits. In our society, working hard and being helpful are valued positively, and can therefore not be unhealthy. Failing to protect one’s personal life is often regarded as a weakness, and as a sign of personal ineptitude. As mentioned above there is some evidence that FM is associated with concepts such as action-proneness and overactive life-style (van Houdenhove 1986, 1994, 1995, 2001ab, 2004), ergomania (Alfici, 1989), endurance strategies, overuse and persistence (Hasenbring, 1994, 1996, 2001; Vlaeyen, 2004). Complaints and somatization In contacts with the health services the patient often learns that diagnostic and therapeutic actions are primarily focused on his physical symptoms and the physical locus of pain, and much less and much later on underlying psychological aspects. Thus the patient learns to present his complex problem by communicating his (initially relatively innocent) physical pain problem. Perhaps as a child the patient learnt from his parents to communicate with physical complaints when he had emotional problems. At first, such a patient may receive attention and recognition, and there may even be temporary legitimacy to no longer be helpful and overloading. The result, however, for the patient is that the only way to continue to receive this beneficial environmental behavior is to suffer pain and other complaints. If the partner and other relevant people recognize the pain, fatigue and disability, and if they pay extra attention to the patient and recognize that the patient is discharged from his overloading duties, the complaints will be reinforced. The patient will be reinforced because of his complaints and not or much less because he is a valuable person (selective reinforcement). If these other people take care of the patient this even seems to result in “symmetrical” relationships. However, to continue this “equivalence” it is necessary that the pain or other complaints continue. There is substantial evidence that the environmental reinforcement of complaints (operant factors) leads to (further) somatization and inactivity ( e.g. Fordyce, 1978). Our hypothetical model of overloading in relation to the etiology of FM is summarized in Figure 1.

More research has to be performed as to the interrelations between adverse childhood experiences, personality, an overloading life-style and FM (and other chronic pain- and fatigue-syndromes), cross-sectionnaly as well as longitudinally. This integrative hypothetical model could serve as an agenda for future research.

Clinical implications

From our overloading-model we formulated a multidimensional treatment program: If the behavior of the overloading patient has been directed more by external factors than by internal factors, then treatment has to result into a shift at cognitive, emotional, behavioral and relational (environmental) level from “what am I supposed to do” to “what can I do and what do I want to do myself”. In order to reach these results the patient needs to obtain insight into his present and his desired behavior (recognition) and to learn new skills to implement these insights into his life-pattern. Within this model treatment-results may be formulated as follows: Cognitive level: The patient now recognizes his cognitive patterns in which he strives at fulfilling demands of others and at pleasing others without taking into account what he can and what he wants. The patient now masters skills to decide when and how to draw a line and formulate his opinions, wishes and arguments in an assertive way, instead of trying to diminish his pain and fatigue symptomatically. Emotional level: The patient now recognizes he is suppressing his feelings and the fact that others restrict or even punish his expression of emotions. The patient now masters skills to admit and to express his feelings, especially anger when others place too great demands on him or ignore his opinions or feelings, in stead of going on and on in order not to experience his negative emotions. The patient feels no longer depressed or anxious. Behavioral level: The patient now recognizes overloading signals in his body and realizes that if he does not draw a line himself, his body will do it for him by pain and fatigue. The patient now masters skills to diminish his level of activity or to alternate activities or to take a rest in time. In case of resistance from other people the patient is able to stick to his guns and to negotiate or even think of or apply sanctions if necessary. Environmental (operant) level: The patient now recognizes that he mainly receives support and attention from others because of his complaints and that support and attention are/were hard to obtain in other ways. The patient now masters skills to secure support and attention from others not by complaining but by making others clear that it is their turn to be nice and supporting, not because the patient is ill but because he is a valuable person.

Acknowledgments

We thank the Jan van Breemen Institute for its financial and logistical support in setting up and conducting this study.

References

Alfici S, Sigal M, Landau M. Primary fibromyalgia syndrome-a variant of depressive disorder? Psychother Psychosom 1989; 51(3): 156-61. Boissevain MD, McCain GA. Toward an integrated understanding of fibromyalgia syndrome. II. Psychological and phenomenological aspects. Pain 1991; 45(3): 239-48. Brosschot JF, Aarsse HR. Restricted emotional processing and somatic attribution in fibromyalgia. Int J Psychiatry Med 2001; 31(2): 127-46. Clauw DJ. The pathogenesis of chronic pain and fatigue syndromes, with special reference to fibromyalgia. Med Hypotheses 1995; 44(5): 369-78. Colangelo N, Bertinotti L, Nacci F, Conforti ML, Beneforti E, Pignone A, Matucci-Cerinic M, Zoppi M. Dimensions of psychological dysfunction in patients with fibromyalgia: development of an Italian questionnaire. Clin Rheumatol 2004; 23(2): 102-8. Fisher L, Chalder T. Childhood experiences of illness and parenting in adults with chronic fatigue syndrome. J Psychosom Res 2003; 54(5): 439-43 Fordyce W. Learning processes in pain. In R.A.Sternbach: Psychology of Pain, New York, Raven Press, 1978. Hasenbring M, Plaas H, Fischbein B, Willburger R. The relationship between activity and pain in patients six months after lumbar disc surgery: do pain-related coping modes act as moderator variables. Eur J Pain 2006; 10: 701-9. Hasenbring M, Hallner D, Klasen B. Psychologische Mechanismen im Prozess der Schmerzchronifizierung, unter- oder überbewertet? Schmerz 2001; 15: 442-7. Hasenbring M. Kognitive Verhaltenstherapie chronische rund prächronischer Schmerzen. Psychotherapeut 1996; 41: 313-325. Hasenbring M, Marienfeld G, Kuhlendahl D, Soyka D. Risk factors of chronicity in lumbar disc patients. A prospective investigation of biologic, psychologic, and social predictors of therapy outcome. Spine 1994; 19(24): 2759-65. van Houdenhove B, Egle UT. Fibromyalgia: a stress disorder? Piecing the biopsychosocial puzzle together. Psychother Psychosom 2004; 73(5): 267-75. Van Houdenhove B. Why we should pay more attention to the story of the patient. J Psychosom Res 2002; 52(6): 495-9. van Houdenhove B, Neerinckx E, Lysens R, Vertommen H, van Houdenhove L, Onghena P, Westhovens R, D’Hooghe MB. Victimization in chronic fatigue syndrome and fibromyalgia in tertiary care: a controlled study on prevalence and characteristics. Psychosomatics 2001a; 42(1): 21-8. van Houdenhove B, Neerinckx E, Onghena P, Lysens R, Vertommen H. Premorbid “overactive” lifestyle in chronic fatigue syndrome and fibromyalgia. An etiological factor or proof of good citizenship? J Psychosom Res 2001b; 51(4): 571-6. van Houdenhove B, Onghena P, Neerinckx E, Hellin J. Does high ‘action-proneness’ make people more vulnerable to chronic fatigue syndrome? A controlled psychometric study. J. Psychosom Res 1995; 39(5): 633-40. van Houdenhove B. Prevalence and psychodynamic interpretation of premorbid hyperactivity in patients with chronic pain. Psychother Psychosom 1986; 45(4): 195-200. van Houdenhove B, Vasquez G, Neerinckx E. Tender points or tender patients? The value of the psychiatric in-depth interview for assessing and understanding psychopathological aspects of fibromyalgia. Clin Rheumatol 1994; 13(3): 470-4. Hudson JI, Mangweth B, Pope HG, De CC, Hausmann A, Gutweniger S, Laird NM, Tsuang MT. Family study of affective spectrum disorder. Arch Gen Psychiatry 2003; 60(2): 170-7. Imbierowicz K, Egle UT. Childhood adversities in patients with fibromyalgia and somatoform pain disorder. Eur J Pain. 2003; 7(2): 113-9. Leeuw M, Goossens ME, Linton SJ, Crombez G, Boersma K, Vlaeyen JW. The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med 2007; 30: 77-94. Linton SJ. Why does chronic pain develop? A behavioral a approach. New Avenues for the prevention of chronic musculoskeletal pain and disability. Pain Res Clin Manag. 2002; 12 (6): 67-80. Linton SJ. Do psychological factors increase the risk for back pain in the general population in both a cross-sectional and prospective analysis? Eur J Pain 2005; 9: 355-361. McBeth J. The association between tenderpoints, psychological distress and adverse childhood experiences. Arthritis & Rheumatism 1999; 42: 1397-1404. McCracken LM, Samuel VM. The role of avoidance, pacing and other activity patterns in chronic pain. Pain 2007; 130: 119-125. Raphael KG, Janal MN, Nayak S, Schwartz JE, Gallagher RM. Familial aggregation of depression in fibromyalgia: a community-based test of alternate hypotheses. Pain 2004; 110(1-2): 449-60. Vlaeyen JWS, Morley S. Active despite pain: the putative role of stop-rules and current mood. Pain 2004; 110: 512-516. Waerden AJ, Lamberton N, Crook N, Walsh V. Adult attachment, alexithymia and symptom reporting, an extension of the four category model of attachment. J Psychosom Res 2005; 58: 279-88. Wentz KA, Lindberg C, Hallberg R. Psychological functioning in women with fibromyalgia: a grounded theory study. Health Care for Women Int 2004; 25(8): 702-9. Zant JL, Mooij A, Griep EN, Boersma JW, de Kloet ER. Fibromyalgia in relation to the process of early attachment. Ned T Pijn Pijnbestrijding 1997; 2: 25-27. Note We searched systematically in PubMed and PsycINFO 1990-2008: Aetiol/childhood/determine/development/etiol/future/predict/premorbid/prognos/prospective/risk And Action-prone/endur/ergomania/hyperactive/persistence/overactive/overloading/overuse/surmenage And Chronic pain/fatigue/fibromyalgia/musculoskeletal pain/somatoform pain/ unexplained pain/ widespread pain And Attachment/catastrophiz/coping/emotional/life style/personal/psychologic/psychopath/reinforcement/self-efficacy/social/stress.

Authors: John L. Zant, Leo D. Roorda, Sharon Voet, Jos H.M. Dekker All authors work at the Department of Rehabilitation Medicine and Psychology in the Jan van Breemen Institute, Amsterdam, The Netherlands Correspondence to: Dr. J.L. Zant, psychologist, Department of Rehabilitation Medicine and Psychology, Jan van Breemen Institute, Dr. Jan van Breemenstraat 2, 1056 AB Amsterdam, The Netherlands Tel. 0031205896337 Fax 0031204896704 E-mail j.zant@janvanbreemen.nl

Abstract

This study focuses on the concepts of over-activity, persistence, ergomania and endurance in relation to the etiology of fibromyalgia (FM). With respect to the etiology an integrative overloading model for FM is formulated on the basis of data from the few studies investigating this subject, and on the basis of clinical experience gained from a great number of well-documented psychological life-histories of patients with FM. Clinical implications are outlined. This model may serve as an agenda for further research on the etiologial relation between overloading and fibromyalgia.

Introduction

Fibromyalgia (FM) is one of the chronic non-specific or medically unexplained pain syndromes. The etiology of FM is still unknown [1]. There is, however, growing evidence that psychological factors play an important role in the etiology of FM [2, 3, 4, 5, 6]. FM has been described as a depressive disorder [7, 8], as an affective disorder [9], and as a stress-related disorder [1]. In a study of dysfunctional psychological dimensions in FM-patients, factor analyses identified several psychological dimensions, including cognitive (catastrophizing, external control beliefs), emotional (alexithymia), behavioral (restless behavior) and social (need for support) dimensions [10]. Van Houdenhove [1, 11, 12, 13, 14, 15] showed that action-proneness, or a pre-morbid overactive life-style, can be an etiological factor related to FM, an that it plays a role in 70% of chronic pain patients. Alfici [7] reported that, among other factors, dependence, obsessive-compulsive personality and pre-pain ergomania were characteristic of FM-patients. Hasenbring [16, 17, 18, 19] demonstrated that avoidance behavior and endurance strategies were psychological predictors of pain persistence in lumbar disc patients. Vlaeyen [20] hypothesizes that either disuse (fear-avoidance model) or overuse (persistence model) will lead to disability and chronic pain. There is growing evidence to support the fear-avoidance model [20, 21]. However, studies on overuse and persistence have, until now, been relatively scarce [22]. According to these studies it seems that the concept of overloading plays an important role in the etiology of FM (and other non-specific pain- and fatigue-syndromes [1]; this concept contains terms such as action-proneness, overactive life-style, ergomania, endurance strategies, overuse and persistence. A comprehensive theoretical model of overloading (overuse) has not yet been developed [20].

Integrative hypothetical model

We have tried to formulate an integrative hypothetical model of overloading, based on the afore-mentioned studies and on our own clinical experience gained from some thousands of life-histories of FM-patients documented by our psychologists during the past fifteen years. According to van Houdenhove [23] and Wentz [24] the patient’s biography should be part of each diagnostic evaluation and considered an important focus of psychological/ psychiatric research in fibromyalgia and chronic fatigue syndrome; it illustrates the possible etiological role of adverse childhood experiences, premorbid overactivity and intense activity or hypomanic helpfulness. The model describes cognitive, emotional, behavioral and environmental conditions in the development of an overloading life-style, eventually leading to FM: Parental behavior and personality development In family situations in which the parents are not able to show warm and appreciative behavior towards their children, or when parents are overambitious or perfectionists, children may learn to disregard their own strivings and needs and to fulfill the needs of the parents in all respects. High demand, in combination with more negative than positive feedback, may lead to fear of failure, low self-esteem and a compulsory tendency to please the parents and avoid their criticism. It is also possible that a child has to take adult responsibilities when, for example, the mother is absent because of death, illness, divorce or a full-time job. When this pattern of disregarding one’s own strivings and needs and of hypomanic helpfulness has been learnt in childhood, adult relationships may develop into asymmetrical patterns in which one invests more energy in others than vice versa. This could lead to physical and mental overloading, and finally to chronic pain, exhaustion and inactivity. When a child learns that expressing his emotions elicits punishment he will suppress his emotions and will become alienated from his own feelings, which may lead to depression, especially when there is no positive feedback from relevant others. To avoid falling into a depression some people throw themselves into their work and other activities (in a compulsory way) which increases overloading until they are no longer able to work, due to increasing pain and fatigue, and yet depression will develop. There is growing evidence that adverse childhood experiences play an important role in the development of chronic pain- and fatigue-syndromes [25, 24]. According to Zant [26] and Fisher [27], lack of affection and over-protection play an important role in the etiology of FM. Imbierowicz [28] found a relationship between sexual and physical maltreatment in childhood and the development of FM. Waerden [29] found that fearful and preoccupied attachment-styles are associated with symptom reporting via a negative model of the self and negative affectivity. Life-style and asymmetrical relationships In an asymmetrical relationship between a helpful person and a privileged person, the latter learns that he has to invest minimally in the relationship because the former is helpful under all circumstances (a-selective reinforcement). Because helpfulness is so easily gained, the privileged person does not learn to value the helpful behavior, and will experience it as a matter of course. If, later on, the helpful person wants to achieve a more symmetrical interaction, he will meet resistance because the other does not want to relinquish his privileges. And what is more, the helpful person has not learnt how to be assertive. This process will lead to continuously overloading behavior in the helpful person. It may be clear that for someone who has learnt to be more helpful to others than to satisfy his own needs, and who has developed a network of asymmetrical relationships, it requires a great deal of effort to reform most of his relationships with relevant others to achieve symmetrical and equivalent interactions. Even if the patient has learnt through psychotherapy to be more assertive, to express his feelings and to negotiate more effectively, it will take a lot of time and energy to implement the newly acquired abilities. The overloading person will receive little recognition of, and appreciation for, his helpful behavior because the privileged person has learnt to take it for granted. Moreover, the overloading person will receive little recognition of his pains and exhaustion from physicians, who are usually unaware of the pre-morbid overactive life of this momentarily very inactive patient with pain, but little or no physical defects. Therefore, physicians often see no valid reason for sick-leave or social security benefits. In our society, working hard and being helpful are valued positively, and can therefore not be unhealthy. Failing to protect one’s personal life is often regarded as a weakness, and as a sign of personal ineptitude. As mentioned above there is some evidence that FM is associated with concepts such as action-proneness and overactive life-style [11, 12, 13, 14, 15, 1], ergomania [7], endurance strategies, overuse and persistence [16, 17, 18, 19, 20]. Complaints and somatization In contacts with the health services the patient often learns that diagnostic and therapeutic actions are primarily focused on his physical symptoms and the physical locus of pain, and much less and much later on underlying psychological aspects. Thus the patient learns to present his complex problem by communicating his (initially relatively innocent) physical pain problem. Perhaps as a child the patient learnt from his parents to communicate with physical complaints when he had emotional problems. At first, such a patient may receive attention and recognition, and there may even be temporary legitimacy to no longer be helpful and overloading. The result, however, for the patient is that the only way to continue to receive this beneficial environmental behavior is to suffer pain and other complaints. If the partner and other relevant people recognize the pain, fatigue and disability, and if they pay extra attention to the patient and recognize that the patient is discharged from his overloading duties, the complaints will be reinforced. The patient will be reinforced because of his complaints and not or much less because he is a valuable person (selective reinforcement). If these other people take care of the patient this even seems to result in “symmetrical” relationships. However, to continue this “equivalence” it is necessary that the pain or other complaints continue. There is substantial evidence that the environmental reinforcement of complaints (operant factors) leads to (further) somatization and inactivity [30]. Our hypothetical model of overloading in relation to the etiology of FM is summarized in Figure 1.

More research has to be performed as to the interrelations between adverse childhood experiences, personality, an overloading life-style and FM (and other chronic pain- and fatigue-syndromes), cross-sectionnaly as well as longitudinally. This integrative hypothetical model could serve as an agenda for future research.

Clinical implications

From our overloading-model we formulated a multidimensional treatment program: If the behavior of the overloading patient has been directed more by external factors than by internal factors, then treatment has to result into a shift at cognitive, emotional, behavioral and relational (environmental) level from “what am I supposed to do” to “what can I do and what do I want to do myself”. The aim of this treatment program is not to diminish the pain or how to cope with the pain, but to change the overloading life-pattern in a structural way. In order to reach these results the patient needs to obtain insight into his present and his desired behavior (recognition) and to learn new skills to implement these insights into his life-pattern. Within this model treatment-results may be formulated as follows: Cognitive level: The patient now recognizes his cognitive patterns in which he strives at fulfilling demands of others and at pleasing others without taking into account what he can and what he wants. The patient now masters skills to decide when and how to draw a line and formulate his opinions, wishes and arguments in an assertive way, instead of trying to diminish his pain and fatigue symptomatically. Emotional level: The patient now recognizes he is suppressing his feelings and the fact that others restrict or even punish his expression of emotions. The patient now masters skills to admit and to express his feelings, especially anger when others place too great demands on him or ignore his opinions or feelings, in stead of going on and on in order not to experience his negative emotions. The patient feels no longer depressed or anxious. Behavioral level: The patient now recognizes overloading signals in his body and realizes that if he does not draw a line himself, his body will do it for him by pain and fatigue. The patient now masters skills to diminish his level of activity or to alternate activities or to take a rest in time. In case of resistance from other people the patient is able to stick to his guns and to negotiate or even think of or apply sanctions if necessary. Environmental (operant) level: The patient now recognizes that he mainly receives support and attention from others because of his complaints and that support and attention are/were hard to obtain in other ways. The patient now masters skills to secure support and attention from others not by complaining but by making others clear that it is their turn to be nice and supporting, not because the patient is ill but because he is a valuable person.

Acknowledgments

We thank the Jan van Breemen Institute for its financial and logistical support in setting up and conducting this study. We thank Prof. Joost Dekker for his valuable advice.

References

1. van Houdenhove B, Egle UT: Fibromyalgia: a stress disorder? Piecing the biopsychosocial puzzle together. Psychother Psychosom 2004; 73(5): 267-75. 2. Boissevain MD, McCain GA: Toward an integrated understanding of fibromyalgia syndrome. II. Psychological and phenomenological aspects. Pain 1991; 45(3): 239-48. 3. Clauw D: The pathogenesis of chronic pain and fatigue syndromes, with special reference to fibromyalgia. Med Hypotheses 1995; 44(5): 369-78. 4. Brosschot JF, Aarsse HR: Restricted emotional processing and somatic attribution in fibromyalgia. Int J Psychiatry Med 2001; 31(2): 127-46. 5. Linton SJ: Why does chronic pain develop? A behavioral a approach. New Avenues for the prevention of chronic musculoskeletal pain and disability. Pain Res Clin Manag. 2002; 12 (6): 67-80. 6. Linton SJ: Do psychological factors increase the risk for back pain in the general population in both a cross-sectional and prospective analysis? Eur J Pain 2005; 9: 355-361. 7. Alfici S, Sigal M, Landau M: Primary fibromyalgia syndrome-a variant of depressive disorder? Psychother Psychosom 1989; 51(3): 156-61. 8. Raphael KG, Janal MN, Nayak S, Schwartz JE, Gallagher RM: Familial aggregation of depression in fibromyalgia: a community-based test of alternate hypotheses. Pain 2004; 110(1-2): 449-60. 9. Hudson JI, Mangweth B, Pope HG, De CC, Hausmann A, Gutweniger S, Laird NM, Tsuang MT: Family study of affective spectrum disorder. Arch Gen Psychiatry 2003; 60(2): 170-7. 10. Colangelo N, Bertinotti L, Nacci F, Conforti ML, Beneforti E, Pignone A, Matucci-Cerinic M, Zoppi M: Dimensions of psychological dysfunction in patients with fibromyalgia: development of an Italian questionnaire. Clin Rheumatol 2004; 23(2): 102-8. 11. van Houdenhove B: Prevalence and psychodynamic interpretation of premorbid hyperactivity in patients with chronic pain. Psychother Psychosom 1986; 45(4): 195-200. 12. van Houdenhove B, Vasquez G, Neerinckx E: Tender points or tender patients? The value of the psychiatric in-depth interview for assessing and understanding psychopathological aspects of fibromyalgia. Clin Rheumatol 1994; 13(3): 470-4. 13. van Houdenhove B, Onghena P, Neerinckx E, Hellin J: Does high ‘action-proneness’ make people more vulnerable to chronic fatigue syndrome? A controlled psychometric study. J. Psychosom Res 1995; 39(5): 633-40. 14. van Houdenhove B, Neerinckx E, Lysens R, Vertommen H, van Houdenhove L, Onghena P, Westhovens R, D’Hooghe MB: Victimization in chronic fatigue syndrome and fibromyalgia in tertiary care: a controlled study on prevalence and characteristics. Psychosomatics 2001a; 42(1): 21-8. 15. van Houdenhove B, Neerinckx E, Onghena P, Lysens R, Vertommen H: Premorbid “overactive” lifestyle in chronic fatigue syndrome and fibromyalgia. An etiological factor or proof of good citizenship? J Psychosom Res 2001b; 51(4): 571-6. 16. Hasenbring M, Marienfeld G, Kuhlendahl D, Soyka D: Risk factors of chronicity in lumbar disc patients. A prospective investigation of biologic, psychologic, and social predictors of therapy outcome. Spine 1994; 19(24): 2759-65. 17. Hasenbring M: Kognitive Verhaltenstherapie chronische rund prächronischer Schmerzen. Psychotherapeut 1996; 41: 313-325. 18. Hasenbring M, Hallner D, Klasen B: Psychologische Mechanismen im Prozess der Schmerzchronifizierung, unter- oder überbewertet? Schmerz 2001; 15: 442-7. 19. Hasenbring M, Plaas H, Fischbein B, Willburger R: The relationship between activity and pain in patients six months after lumbar disc surgery: do pain-related coping modes act as moderator variables. Eur J Pain 2006; 10: 701-9. 20. Vlaeyen JWS, Morley S: Active despite pain: the putative role of stop-rules and current mood. Pain 2004; 110: 512-516. 21. Leeuw M, Goossens ME, Linton SJ, Crombez G, Boersma K, Vlaeyen JW: The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med 2007; 30: 77-94. 22. 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Eur J Pain. 2003; 7(2): 113-9. 29. Waerden AJ, Lamberton N, Crook N, Walsh V: Adult attachment, alexithymia and symptom reporting, an extension of the four category model of attachment. J Psychosom Res 2005; 58: 279-88. 30. Fordyce W: Learning processes in pain. In R.A.Sternbach: Psychology of Pain, New York, Raven Press, 1978.

Gesprek met Prof. Rob de Wijk

Gesprek met Prof. Rob de Wijk Inleiding

Het Humanistisch Vredes Beraad (HVB) wil gesprekken voeren met wetenschappers in Nederland over onderzoek naar de legitimiteit en de effectiviteit van de inzet van Nederlandse soldaten in internationale conflicten. Prof. Rob de Wijk (1954) studeerde geschiedenis aan de Rijksuniversiteit Groningen. Hij promoveerde op een proefschrift over de militaire strategie van de NAVO. Hij is directeur van het Den Haag Centrum voor Strategische Studies (HCSS). Hij is hoogleraar Internationale Betrekkingen aan de Universiteit Leiden. Van 1999-2008 was hij hoogleraar aan de Nederlandse Defensie Academie. Van 2000-2003 was hij directeur van het onderzoekscentrum van de Koninklijke Militaire Academie (KMA) te Breda. Hij adviseerde als Hoofd Defensie Concepten van het Ministerie van Defensie de Chef van de Defensiestaf. Daarnaast heeft hij vele adviesfuncties in binnen- en buitenland. Hij is een veelgevraagd commentator op gebied van veiligheidsvraagstukken en schrijft een wekelijkse column in Trouw. Tijdens ons gesprek verwijst hij naar zijn boek ‘The art of military coercion’ (Amsterdam: Mets & Schilt, 2005).

“Gesprek met Prof. Rob de Wijk” verder lezen

Gesprek met Dr. Philip Everts

Inleiding

Het Humanistisch Vredes Beraad (HVB) wil gesprekken voeren met wetenschappers in Nederland over onderzoek naar de legitimiteit en de effectiviteit van de inzet van Nederlandse soldaten in internationale conflicten. Dr. Philip Everts (1938) studeerde rechten en sociologie, en promoveerde op het onderwerp “Public opinion, the churches and foreign policy”. Van 1970-2003 was hij directeur van het interfacultair Instituut voor Internationale Studiën (IIS) van de Universiteit Leiden. Hij is nu nog verbonden aan de afdeling Politieke Wetenschap. Hij is ook lid van de Raad van Toezicht van IKV Pax Christi en van de (regerings-) Adviesraad Internationale Vraagstukken. Zijn recent verschenen boek “De Nederlanders en de Wereld, publieke opinies na de Koude Oorlog” (van Gorcum, 2008) vormt de leidraad in ons gesprek.

“Gesprek met Dr. Philip Everts” verder lezen

De ene doelgroep is de andere niet

De ene doelgroep is de andere niet Reclameboodschap

Het doel van commerciële reclame is het geïnteresseerd maken van zoveel mogelijk tot nu toe ongeïnteresseerde, want onwetende, klanten voor een nieuw product. Op het moment dat een reclameboodschap op deze klanten wordt afgevuurd is het attentieniveau van de klant relatief laag en de weerstand om zich te concentreren op het zoveelste product relatief groot. De aandacht van deze relatief ongeïnteresseerde en ongeconcentreerde klant moet kort en puntig gepenetreerd en tot leven gewekt worden. Het is effectiever de reclameboodschap te beginnen met de prestaties en resultaten van het product dan met voorlichting over het productieproces of de handleiding voor gebruik.

Psychologisch rapport

De doelgroep van een psychologisch rapport is een kleine groep geïnteresseerde en gemotiveerde klanten. De patiënt en diens hulpverleners worstelen al enige tijd vergeefs met het oplossen van de problemen van de patiënt. Ze zijn vaak reeds op de hoogte van belangrijke elementen die een mogelijke rol spelen in het ontstaan en onderhouden van het klachtenpatroon; ze zijn redelijk ingevoerd in de materie. Het doel van een psychologisch rapport is het zodanig ordenen en combineren van brokstukken van bij de klanten bekende informatie, dat, al dan niet met toevoeging van enkele nieuwe brokstukken, een doorbreking van de impasse ontstaat, waarin een mogelijke verklaring voor de klachten wordt geformuleerd en een traject in de richting van een mogelijke oplossing. De bedoeling is dat in dit gepresenteerde nieuwe model alle brokstukken op hun plaats vallen en een heldere lijn richting oplossing zichtbaar wordt. Het is effectiever de brokstukken stap voor stap te ordenen en te combineren zodanig dat een voor ieder inzichtelijk resultaat ontstaat dan te beginnen met het resultaat, c.q. een behandelvoorstel, dat voor de ingewijden pardoes uit de lucht komt vallen en niet (meteen) als zinvol wordt herkend.

Resultaat of proces

Voor een commercieel bedrijf tellen resultaten in termen van verkoopcijfers, winst, etc. Voor een detective- of een liefdesroman is het belangrijk niet eerst de afloop te kennen alvorens je het boek gaat lezen. Je wilt je als lezer laten meeslepen in het gedachteproces en in de verwikkelingen om aan het eind al dan niet vast te stellen dat je het steeds al had gedacht (wie de dader is of wie wie krijgt). In het ene geval is het resultaat belangrijker dan het proces, in het andere geval omgekeerd.

Smaken verschillen

Is het voor de een belangrijker dat je eigen club wint ongeacht het vertoonde spel, een ander beleeft vooral plezier aan de mooie combinaties, de individuele techniek en de creatieve spelmomenten. Is het voor de een belangrijk bij te houden hoe vaak er klaargekomen wordt per tijdseenheid en per aantal sekspartners, een ander probeert vooral van het seksuele spel te genieten.

Conclusie

Een psychologisch rapport is bestemd voor ingewijden die geïnteresseerd zijn in het proces.

Bloedzuigertje spelen

BLOEDZUIGERTJE SPELEN

De regels van het moordende machtsspel tussen een ondergeschikte en een bovengeschikte

Inleiding

Over het algemeen wordt het nuttig geacht een leider aan te stellen als er een groepsproduct moet worden geleverd. Het erkennen van het nut van leiderschap is snel geaccepteerd, het opvolgen van de aanwijzingen van de leider is minder makkelijk te accepteren, zeker als diens aanwijzingen afwijken van de wensen en verwachtingen van het groepslid; de legitimering van de leider door het groepslid is in het geding en de machtsstrijd kan beginnen. Een van de krachtigste pogingen om het gezag van de leider te ondermijnen is het bloedzuigertje spelen.

De spelregels

  • Het groepslid neme een inhoudelijk onderwerp bij de kop; het maakt niet uit of het een belangrijk of een onbelangrijk onderwerp is. Het gaat om het machtsspel en niet om de inhoud.
  • Het groepslid begint te zuigen: Het groepslid geeft aan het niet eens te zijn met de aanwijzingen van de leider en gaat de strijd met de leider aan op een beschuldigende toon. Het groepslid betoogt dat hem geen enkele blaam treft en kiest voor systematisch externaliseren van de verantwoordelijkheid.
  • Essentieel is dat de verantwoordelijkheid voor het conflict bij de leider wordt gelegd. De argumentatie is van ondergeschikt belang; het doel is niet gelijk te hebben, maar gelijk te krijgen, een subtiel doch belangrijk verschil.
  • Het groepslid doet er goed aan verbaal en vooral nonverbaal te zoeken naar steun van de andere groepsleden en speculeert erop dat er altijd andere groepsleden zullen zijn die ook nog een appeltje met de leider hebben te schillen, ook al betreft het inhoudelijk een heel ander onderwerp.
  • Door de beschuldigende toon is de leider meteen in het defensief gedrukt en des te sterker naarmate andere groepsleden hun kans ook schoon zien de leider eens stevig aan te pakken. Vanuit die defensieve positie is het zeer lastig opereren voor de leider: Hij kan op vele wijzen verkeerd reageren en maar op één, nogal ingewikkelde manier, correct.
  • Door de beschuldigende opmerking te negeren en niet te reageren, laadt de leider het verwijt op zich van desinteresse, veronachtzaming, lafheid, etc. De leider wordt gedwongen te reageren.
  • Door met het groepslid in discussie te gaan over de inhoud van de beschuldiging, is de leider gedoemd te verliezen, omdat zowel het onderwerp als de inhoudelijke argumentatie er volstrekt niet toe doen; door te pogen het groepslid op inhoudsniveau te bestrijden delft de leider het onderspit, zelfs als hij in staat is aan te tonen dat hij inhoudelijk gelijk heeft, want de bereidheid om hem zijn gelijk te geven ontbreekt. Met speels gemak brengt het groepslid desnoods een nieuw onderwerp in en laat het spel gewoon weer opnieuw beginnen.
  • De enig correcte manier om te reageren is met metacommunicatie die neerkomt op de opmerking: “jij bent bloedzuigertje aan het spelen”. Dit is weliswaar de enig juiste voortzetting, maar geen voldoende voorwaarde voor succes.
  • Het groepslid kan verontwaardigd ontkennen dat er sprake is van bloedzuigertje spelen en met droge ogen beweren dat het hem uitsluitend om een inhoudelijk verschil van mening gaat. Dit is een effectieve leugen op het moment dat de leider zich alsnog laat verleiden tot een inhoudelijke discussie.
  • Ook als de leider niet in deze val trapt en persisteert in de stelling dat het groepslid bloedzuigertje aan het spelen is, is de strijd nog steeds niet in zijn voordeel beslecht.
  • Als het groepslid merkt dat hij ontmaskerd dreigt te worden en de strijd niet op het inhoudsniveau kan houden, staat hem nog een uiterst krachtige manoeuvre ter beschikking: de slachtofferrol, de troefkaart bij uitstek in ieder machtsspel.
  • Met opgezwollen aderen en rode vlekken in de hals kan het groepslid met door opwellende tranen verstikte stem naar voren brengen dat hij het gevoel heeft dat het vertrouwen bij de leider in het groepslid ontbreekt of dat het gedrag van de leider het groepslid een verdrietig gevoel bezorgt. Aangezien het een gevoel van het groepslid betreft, heeft de leider daar geen enkele grip op, zeker niet – het zij nogmaals benadrukt – met inhoudelijke argumenten.
  • Juist door het slachtoffergedrag op agressieve wijze in de machtsstrijd te brengen verschaft het groepslid de leider een valide reden tot wantrouwen; door dit te doen bewijst het groepslid dat hij niet te vertrouwen is.
  • Ieder mens die verbaal maar vooral non-verbaal zijn emotionele nood kenbaar maakt, kan rekenen op bijna reflexmatige, dus niet op de ratio gebaseerde, emotionele steun van andere groepsleden. Dus het groepslid hoeft slechts hulpeloos met betraande ogen de groepsgenoten aan te kijken en de kans dat vervolgens meer groepsleden beschuldigend naar de leider kijken is bijna honderd procent.
  • Dit is het spannendste moment; de leider loopt het risico zich emotioneel te laten meeslepen in dit machtsspel en kan door de verwarring in de verleiding komen alsnog de strijd terug te brengen naar het inhoudsniveau. Dat heeft het ogenschijnlijk voordeel dat daarmee de emotionele spanning terzijde wordt geschoven, maar het groepslid ruikt bloed en zal het spel vanuit de oersterke emotionele slachtofferrol blijven spelen.
  • Opnieuw dient gesteld te worden, dat het groepslid door te externaliseren en de slachtofferrol uit de hoed te toveren poogt de leider onderuit te halen in plaats van een zogenaamd inhoudelijk probleem op te lossen.
  • De leider kan nu op twee manieren reageren: 1. De leider deelt de rode kaart uit onder het uitspreken van de formule: “Jij bent bloedzuigertje aan het spelen en dat is verboden”. Bij pogingen dit spel voort te zetten worden harde sancties in het vooruitzicht gesteld en bij herhaling worden deze sancties geëffectueerd. 2. De leider onderkent dat iemand die vaak bloedzuigertje speelt een gekwetst ego heeft als gevolg van verregaande krenking door belangrijke autoriteitsfiguren in het verleden. De persoon met het gekwetste ego is voortdurend op zoek naar erkenning en bevestiging met name van autoriteitsfiguren en neemt daardoor altijd veel tijd en aandacht in beslag. Kenmerkend is dat hierbij ieder gevoel van (zelf)relativering ontbreekt. Door een kleinigheid kan het groepslid zich wederom gekwetst voelen door de leider. Anderzijds nodigt het gedrag van het groepslid de leider niet bepaald uit tot erkenning en bevestiging. Zo ontstaat gemakkelijk een vicieuze cirkel. De oplossing kan uitsluitend worden gevonden door wederzijds inzicht en erkenning van deze vicieuze cirkel, waarbij het groepslid afziet van verder bloedzuigertje spelen, externaliseren en de slachtofferrol zoeken, en waarbij de leider extra aandacht besteedt aan het geven van erkenning en bevestiging. Misschien dat dan alsnog wederzijds vertrouwen kan groeien in het besef dat krachten die buiten de relatie van de leider en het groepslid liggen hun relatie belasten. Misschien dat het groepslid uiteindelijk zelfs tot een uitspraak kan komen zoals die van een wereldberoemd gekwetst ego dat uiteindelijk veel internationale erkenning heeft gekregen: “I burn a lot of calories to be me”.