Fear-Avoidance Maintaining Chronic Pain?

Fear-Avoidance Conditioning: Maintaining the Chronic Pain Cycle? – Pain – International Association for the Study of Pain | August 11, 2016

In an article recently published in Pain, researchers at the University of Leuven, Belgium propose a model for the transition from acute to chronic pain, based on fear-avoidance

With this model, which describes the distinct behaviors underlying perpetuation of or breaking from pain, researchers seek to guide pain-related research as well as pain management

In this model, conditioning plays a central role in the maintenance of pain, and authors argue that its disruption may lead to recovery.  

Pain has biological value, as it indicates threat to the individual’s integrity and triggers fear and associated protective behaviors (eg, heightened arousal, withdrawal and avoidance), all of which contribute to self-preservation.

In the proposed model,

  1. an initial nociceptive stimulus triggers pain,
  2. which is perceived by the individual as a threat of either low or high grade.

A low grade threat in conjunction with a positive affect (eg, optimism) will result in prioritization of “valued life goals”, enabling identification of the adequate approach to reach recovery.

When pain is perceived as a high threat and associated with a negative affect (eg, representation of harm) priority is given to pain control, leading sequentially to

  1. fear,
  2. avoidance,
  3. interference and
  4. further negative affect,

a series of events which promote the persistence of pain.  


Below is the actual JAMA article upon which the above was based.

The fear-avoidance model of pain : PAIN : August 2016

1. Fear and avoidance of pain

The large individual variations in response to a similar nociceptive stimulus and the development of persistent pain after an acute pain episode have puzzled researchers and clinicians alike.

Pain is a biologically relevant and vital signal of bodily threat, urging protective behaviors, which include increased arousal, prioritization of attention to the sources of pain, instant withdrawal, facial expression, and avoidance.

The Fear-Avoidance model has been introduced as a theoretical model to guide pain research and management, describing the cascade of events after pain that is perceived as threatening.*

* Lethem J, Slade PD, Troup JD, Bentley G. Outline of a Fear-Avoidance Model of exaggerated pain perception–I. Behav Res Ther 1983

The citation for the above is from 1983, so this is an ancient concept being dragged back up from the past and repackaged as catastrophizing.

  1. Acquisition and generalization

Fear is the anticipatory emotional response to imminent threat, and adaptive learning takes place rapidly, either through direct experience,9 observation,5 or verbal instructions.

Initial neutral cues (conditioned stimuli, CS) causally or functionally associated with pain may capture the attention and elicit protective fear responses (conditioned responses such as avoidance), that may be different from unconditioned responses (UR) such as the immediate escape from the unconditioned pain stimulus (US)

Chronic pain may develop when pain-related fear and avoidance persists despite healing, or when protective responses generalize to novel situations (GS) that share features with the CS (

Avoidance behavior is overt or covert behavior that prevents or postpones the encounter with an aversive stimulus, and is a key element in the FA model.

Avoidance behavior once acquired is notoriously persistent, and usually maintains pain-related fear.

Avoidance usually implies activity restrictions, interference with valued life activities, and negative affect.

Avoidance can be used as a source of information to derive danger, for example: “I am avoiding, therefore there must be danger.”

The relief that the expected threat did not occur may reinforce avoidance behaviors, and hence maintaining it

  1. Pain in context

Pain-related fear is not always associated with avoidance behavior. The expression of pain-related fear and avoidance behavior is dependent on context.

The goal to avoid pain is only one to be pursued in an environment with concomitant, often competing goals.

Fear-related protective behaviors are inhibited when the value of another life goal outweighs the value of pain and is given priority.

Negative affect and harm representations may increase the engagement in pain control, whereas positive affect6 and optimism may foster the priority to valued life goals

  1. Extinction of pain-related fear

Inhibitory responses can be learned when avoidance behavior is omitted, and the individual is exposed to the stimuli and situations that were previously avoided.

In such exposure treatments, new nonthreat associations with the CSs are formed, and subsequently may generalize across time and contexts.

In contrast to its acquisition, the extinction of pain-related fear is fragile, context-dependent, and it does not easily generalize to novel situations.

Exposure-based treatments have been shown to be effective in various pain syndromes, both in adults and youngster  

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One thought on “Fear-Avoidance Maintaining Chronic Pain?

  1. Pingback: Chronic Pain IS a Catastrophe | EDS and Chronic Pain News & Info

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