Chronic Pain and Anxiety: The Fear Avoidance Model
According to the CDC¹, in 2019, 20.4% of adults suffered from chronic pain and 7.4% of adults had chronic pain that frequently limited life or work activities. In this two-part series, we introduce a chronic pain model that explores the connection between chronic pain and anxiety. We also share research-based tips for how to start breaking out of the chronic pain cycle.
The Fear Avoidance Model of Chronic Pain
The Fear Avoidance Model² (below) describes how individuals experiencing acute pain can become trapped in a vicious cycle of suffering, avoidance, and anxiety.
Adapted from Reference 3
Components of the Fear Avoidance Model
Chronic Pain
Chronic pain is recurrent, persistent, and lasts longer than three months. Studies show that chronic pain is connected to limitations in mobility and daily activities, opioid dependence, increased anxiety and depression, poorer perception of health, and reduced quality of life⁴. The onset of pain can be gradual (through degenerative or progressive diseases) or brought on suddenly (post-surgery or after an accident). For some individuals, the pain is not always constant — they may have good days or weeks and then have periods where the pain takes over.
Catastrophizing
Catastrophizing is a process in which a person over-focuses on the unfavorable outcomes of a situation — the "worst-case scenarios". In a chronic pain cycle, a person feels pain and then starts to engage in one (or several) types of catastrophic thinking patterns:
Magnification: Intensifying the threat of the pain (“My pain means something bad is going to happen.”)
Helplessness: Thinking that there is nothing one can to do to help the pain (“I will never be free from my pain. I am just stuck like this.”)
Overgeneralization: Seeing a single negative event as a never-ending pattern of defeat. (“I have been to 4 doctors. No one will be able to help me.”)
Jumping to conclusions: Making assumptions without evidence (“The people at the gym will think I am lazy because I can’t do the exercises correctly.”)
Emotional Reasoning: Assuming that your negative emotions necessarily reflect the way things really are: (“I’m mad at my partner. Therefore, he/she must not care about my pain.")
Fear of Pain
When a person engages in catastrophic thinking, it can lead to a fear of pain. Fear of pain is a fear of experiencing pain sensations or a fear of activities that may elicit pain. The anticipated fear then results in hypervigilance and monitoring of pain sensations.
Fear Avoidance
Fear or anxiety about pain can also result in avoidance behaviors. For example, individuals with pain may procrastinate, avoid certain people, places, or things, repress uncomfortable thoughts, be overly vigilant or self-protective, or avoid uncomfortable physical sensations (exercise, sex, deep breathing, etc.). The problem with avoidance is that it doesn't help alleviate negative thought patterns or pain. Instead, by engaging in avoidant behaviors, we teach ourselves that the only way to tolerate fear and pain is through avoidance.
Increased Distress or Disability
Due to avoidance, an individual with chronic pain may have stopped exercising, reaching out to loved ones, or even going to work or school. This detachment and disengagement from physical activity, social connection, or other activities of daily living increases overall levels of pain, disability, and/or distress.
Pain can make people feel powerless; and it can keep them from moving toward recovery. However, this cycle does not have to perpetuate itself, and individuals can how learn to have more power over their pain, emotions, and life.
To learn more about how to start breaking out of this cycle, read part two of this blog series here.
References
Dahlhamer J, Lucas J, Zelaya, C, et al. (2018) Prevalence of chronic pain and high-impact chronic pain among adults — United States, 2016. Morbidity and Mortality Weekly Report, Center for Disease Control. 67(36), 1001-1006.
Vlaeyen, J.W.S., Crombez, G., Linton, S.J. (2016). The fear-avoidance model of pain. International Association for the Study of Pain. 157 (8) 1588-1589.
Boselie, J.L.M., & Vlaeyen, J.W.S. (2017). Broadening the fear-avoidance model of chronic pain. Scandinavian Journal of Pain. 17, 176-177.
Cosio, D. (2019). Fear-avoidance and chronic pain: Helping patients stuck in the mousetrap. Practical Pain Management. 19 (5), 18-21.
Vlaeyen W.S., Vlaeyen, J.W.S., Crombez G. (2004) Understanding and treating fear of pain. Oxford University Press.