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14 Articles in Volume 19, Issue #5
Agonism and Antagonism of the Muscles of the Shoulder Joint: An SEMG Approach
Analgesics of the Future: The Potential of IV Formulations for Post-Op Treatment of Pain
Blood Biomarkers Show Promise for Precision Pain Management
Can I Call Myself a “Pain Specialist?”
Cases in Urine Drug Monitoring Interpretation: How to Stay in Control (Part 2)
Fear-Avoidance and Chronic Pain: Helping Patients Stuck in the Mouse Trap
How to Avoid Patient Alienation When Discussing Stress
Managing Phantom Limb Pain with Medication
Nerve Blocks Lead to Improved Quality of Life
Sacroiliac Joint Dysfunction: New Methods in Evaluation and Management
SCS Therapy in a Patient with Advanced Bilateral Kienbocks
Thoracic Epidural Abscess with Cord Compression Following a High-Frequency SCS Trial
What is the evidence to support clonidine as an adjuvant analgesic?
What’s In A Name? In This Case, That Which We Call Addiction Is Not Dependence

Fear-Avoidance and Chronic Pain: Helping Patients Stuck in the Mouse Trap

How clinicians can approach catastrophic thinking and other diversion tactics used by struggling patients.
Pages 18-21

Psychosocial factors have become increasingly recognized as important moderators and determinants of the pain experience.1 There are a number of variables that tap into a negative pain schema, including pain anxiety, helplessness, and fear. These factors share significant variance with broader negative affect constructs, such as depression.2

Fear is the emotional reaction to a specific, identifiable, and immediate threat, such as an injury.3 Fear may protect an individual from imminent danger as it prompts the defensive behavior that is associated with the fight or flight response.4 Fear may lead to the avoidance of activities that people with chronic pain associate with the occurrence or exacerbation of pain. Confrontation and avoidance are two extreme responses to this fear, of which the former leads to the reduction of fear over time. Whereas avoidance can be adaptive in the acute phase, the use of continued avoidance during the chronic phase may lead to distress, disability, absenteeism, and increased healthcare costs down the line.

What is the Fear-Avoidance Model?

The fear-avoidance model describes how individuals develop chronic, musculoskeletal pain as a result of avoidant behavior based on fear.5 The model states that negative appraisals about pain and its consequences, including catastrophic thoughts, may result in feelings of pain-related fear, avoidance of daily activities, and body hypervigilance (see Figure 1).6 As a result of this misinterpretation, the individual repeatedly avoids the pain-inducing activity and is likely to overestimate any future pain from such activity. In turn, the avoidance response ultimately results in physical deconditioning, depression, disability from work, and an inability to participate in recreation or family activities.7

Figure 1. The Fear-Avoidance Model. Modified from Reference 6.

This cycle perpetuates the pain experience as opposed to moving toward recovery. Once the avoidant behavior stops being reinforced, the individual exits the positive feedback loop.8 In contrast, if an individual continues his or her independence without negatively thinking about pain, this response style in most cases leads them to accept that they have pain, which is meant to ultimately move them toward a faster recovery.

Think of a mouse trap, representing negative appraisal. With its heavy spring-loaded bar and a trip to release it, food (fear-avoidance) may be placed as bait. The spring-loaded bar forcefully and rapidly swings down when a mouse touches the trip. The mouse is trapped (physical deconditioning, depression, work disability, etc.) and then released by pulling the bar and/or by avoiding future trappings (confronting fear).

There is clear evidence that fear-avoidance is closely related to increased pain, physical disability, and long-term sick leave in patients living with chronic pain.9 However, there is still considerable debate over the fear-avoidance model among researchers.10 While it is argued that the model may be too simplistic for every situation involving fear, discomfort, and chronic pain,11 it is generally acknowledged among the medical community as a means to diagnosing and understanding how humans positively and negatively react to fear.12

Therefore, the question remains: if fear drives disability, then could severe disabling pain make one fearful? It is a classic “chicken and egg” conundrum to determining the direction of causation between fear and disability due to pain.

Patients in the fear avoidance model, with negative appraisal, often seem to be "stuck in the mouse trap." (Source: 123RF)

Catastrophic Thinking

While previous research has focused on an array of coping responses, such as ignoring sensations and diverting attention, the greatest attention has been directed at catastrophic thinking, defined as “an exaggerated negative mental set brought to bear during actual or anticipated pain experiences.”13,14 Negative appraisals about pain may lead to catastrophic thinking, which then contribute to feelings of pain-related fear.

Catastrophic thinking has been further defined using a three-factor construct that has been replicated in several studies:15,16

  • rumination: a relative inability to inhibit pain-related thoughts in anticipation of, during, or following a painful encounter (eg, “I can’t stop thinking about how much it hurts.”).
  • magnification: the tendency to magnify the threat of pain (eg, “I’m afraid something serious might happen.”).
  • helplessness: feeling helpless in the context of pain (eg, “There is nothing I can do to reduce the pain.”).

Current conceptualizations of catastrophic thinking describe the process in terms of appraisal or a set of maladaptive beliefs.17 Maladaptive thinking falls into four categories with many individual variations within each:18

  • overgeneralization: taking isolated cases and using them to make generalizations (eg, “If one treatment does not help, then no treatment will help.”).
  • mental filter: focusing almost exclusively on specific negative or upsetting aspects of an event while ignoring positive aspects (eg, catastrophic thinking; “I’m feeling better after my treatment and the staff was so kind, but the doctor was so rude.”).
  • jumping to conclusions: drawing negative conclusions from little to no evidence (eg, mind-reading/fortune-telling; “The doctor must think I’m lying because he is asking me more questions than usual.”).
  • emotional reasoning: making decisions and arguments based on intuition rather than an objective rationale (eg, “My doctor simply doesn’t care.”).

Measuring Fear-Avoidance

There is no exact prevalence of clinical fear of pain because establishing a cut-off point is difficult. However, fear-avoidance beliefs may be assessed using several different questionnaires, including the Pain Anxiety Symptom Scale (PASS), the Fear-Avoidance Components Scale (FACS), the Fear-Avoidance Beliefs Questionnaire (FABQ), the Tampa Scale of Kinesiophobia (TSK), or the Photograph Series of Daily Activities (PHODA), as described below:

  • PASS measures fear and anxiety responses to pain related to exaggerated pain behaviors. Associations have been made between PASS and catastrophic thinking.19
  • FACS measures pain-related fear-avoidance with a specific pain catastrophic thinking component.
  • FABQ has been used to show that fear-avoidance beliefs about physical activities are strongly related to work loss.7
  • TSK assesses dysfunctional beliefs about physical abilities.20
  • PHODA was developed to determine the perceived harmfulness of daily activities in patients with chronic low back pain and to construct a hierarchy of feared movements.6

    Assessment of pain-related fear is recommended because treatment may only be appropriate for patients who are more likely to be avoiders.

Treating Fear-Avoidance

Reality-based education about a patient’s diagnosis and prognosis may help prevent distorted and catastrophic views of health outcomes. It has been shown that employing an interdisciplinary approach based on the biopsychosocial model is beneficial. In terms of psychotherapy, graded exposure to activities can help overcome pain-related fears and negative fear-avoidance beliefs.21 The basic idea is to gradually expose oneself to the feared situation in a way that allows one to control their fear at each step.

Cognitive behavioral therapy (CBT) and mindfulness-based interventions have been associated with significantly greater improvements in maladaptive coping responses to pain than controls.22 CBT may be a clear choice when focusing on cognitive factors that may foster strong effects, as well as aiding with restructuring maladaptive thinking and unhealthy behaviors. This type of therapy in pain management is typically based on the cognitive-behavioral model, grounded on the notion that pain is a complex experience influenced by its underlying pathophysiology and the individual’s cognition, affect, and behavior.23 CBT is a structured, time-limited, present-focused approach to psychotherapy that aims to help patients engage in an active coping process which may serve to maintain their chronic pain experience.

Acceptance and commitment therapy (ACT) works to help patients find a way to live a fuller life despite their pain. ACT is one of the more actively researched approaches among the third wave of developing psychotherapies.24 It is a flexible, experiential therapeutic process that uses acceptance and mindfulness approaches mixed with commitment and behavior-change strategies to increase psychological flexibility.

Overall, research has shown that using mindfulness-based therapies for chronic headaches showed significantly greater improvements in maladaptive thinking.25 In another study, mindfulness-based interventions were effective for improving maladaptive thinking about pain in those with a history of recurrent depression associated with rheumatoid arthritis.22

Other mind-body approaches, such as guided visualization, meditation, and yoga may be effective adjuncts to treating fear-avoidance:

  • Guided visualization guides the patient through a process of imagining pictures that serve as messages from the unconscious to consciousness, practiced at least once daily.
  • Meditation is a devotional exercise of or leading to contemplation. Practicing short meditation exercises has been shown to improve pain and reduce anxiety, depression, and poor sleep.26
  • Yoga has been shown to help with conditions such as arthritis; back and neck pain; and headaches. It has also shown beneficial with improving sleep, strength, balance, circulation, flexibility, and overall well-being. There has been promising evidence to support the use of yoga and other movement-based exercises for non-cancer-related pain conditions, such as low back pain.27

Clinicians may also consider recommending to their patients similar holistic techniques, such as using positive self-affirmations, reinterpreting pain, hopefulness and praying, and increasing behavioral activities and exercise.

Avoiding Discussions about Fear-Avoidance

Fear-avoidance is a sensitive issue which challenges both pain management practitioners and patients who suffer from chronic pain. There can be pushback from patients with chronic pain when providing education about the psychological aspects of chronic pain. This resistance typically occurs due to the continued stigma in the general public that believes pain is only a physical sensation, despite years of research that provides evidence to the contrary.

Furthermore, individuals who suffer from chronic pain are often concerned about being judged and the potential risk that comes with opening themselves up to these psychological concepts. This resistance reinforces any unwillingness of healthcare providers to provide necessary education. However, providers must take on this challenge by showing compassion and sensitivity when talking with patients.28

Last updated on: August 2, 2019
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Pain Catastrophizing: What Practitioners Need to Know
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