The Fear-Avoidance cycle is an experience associated with the experience of chronic pain, amongst other traumatic experiences. The anticipated threat of intense pain will often result in the constant vigilance and monitoring of pain sensations, which, in turn, can cause even low-intensity sensations of pain to become unbearable for the person. Can you think of experiences like this in your life? I can. Just the anticipation of increased pain or reinjury can exacerbate avoidance behaviors. A vicious cycle may develop, in which fears of increased pain or reinjury contribute to the avoidance of many activities, leading to inactivity and, ultimately, to greater disability.
What is fear-avoidance in chronic pain?
This is a model used to explain the relationship between fear and avoidance behaviors in chronic pain. This model aims to help people understand how their behaviors can actually contribute to the persistence and intensification of chronic pain so that we can improve our pain.
Individuals who experience chronic pain may develop a fear of certain movements or activities that they believe will exacerbate their pain. As a result, they begin to avoid these activities, leading to decreased physical activity. Also leading to smaller and smaller lives and more suffering.
This avoidance behavior then reinforces the belief that these activities are dangerous, leading to more fear and more avoidance. This creates a vicious cycle that can contribute to increased disability and reduced quality of life. We all agree that’s bad, right?
Understanding this fear avoidance cycle is crucial to begin addressing better pain management. Breaking this cycle requires an active effort to change beliefs and behaviors that perpetuate fear and avoidance. Fear reduction exercises can be an effective way to accomplish this goal.
Two Different Paths?
It’s a theory, right? Let me be very clear. I do not think that this model is perfect. I think the idea that fear can drive unhelpful choices is right. It’s really unclear if it’s “the thing” that causes chronic pain – and I’m gonna guess it’s not one thing that leads to chronic pain. I do know by addressing these behaviors and beliefs we CAN create change. Most people in pain don’t really wanna hear about the psychological impact or concepts. However, they matter. They help us heal. Let’s try to understand it and take away what’s useful and leave the rest.
The common road… otherwise known as the healing road.
When pain/injury occurs, people who are not threatened by the pain generally just go back to living. This path of continuing their independence without negative thoughts of the pain they are suffering from, therefore leading them to accept that they have this pain that ultimately accumulates to a faster recovery. This path can be fostered by being believed and helped when medical intervention is sought. In fact, it’s a key factor in getting on this path. It has been shown that people who follow this path demonstrate dispositional traits such as pain resilience and optimism. ( All things we can build if we don’t have them!)
The road less traveled… otherwise known as fear-avoidance
Fear avoidance is a common and reasonable response to chronic pain. Sadly it can perpetuate the pain experience and lead to greater disability too. In fact, research has shown that individuals who continue their independence without negatively thinking about pain tend to recover faster and experience less disability overall.
I see this in my own story. When I believed all my pain was from a poorly aligned pelvis, I felt very fragile and was super afraid to move wrong and hurt myself more. Once I no longer believed that, the pain didn’t scare me as much and I recovered from a few nasty bumps in the road much faster and differently.
The fear-avoidance model can be likened to a mouse trap with fear avoidance acting as bait. When individuals become afraid of certain movements or activities due to the pain they experience, they tend to avoid them altogether. This fear and avoidance can actually lead to more pain and a decrease in overall physical function.
There is evidence to suggest that fear avoidance is closely related to increased pain, physical disability, and long-term sick leave. However, there is still some debate among researchers over the validity of the fear-avoidance model. As one researcher put it, “If fear drives disability, then could severe disabling pain make one fearful?” This classic “chicken and egg” conundrum highlights the complexities of chronic pain and the many factors that can influence it.
It’s important to note that fear avoidance doesn’t just affect movement. It can also impact an individual’s psychological and emotional well-being, creating a cycle of fear, avoidance, and disability. This is why it’s crucial for those with chronic pain to work with healthcare professionals to develop strategies for fear reduction and improved movement. By taking steps to overcome fear avoidance, individuals can improve their overall quality of life and move toward recovery.
Catastrophic Thinking
I hate this term. I really do. It makes me think of all the times I was told that I “just needed to calm down” or that “I was being ridiculous”. Or the subtle – and sometimes overt dismissal of my pain and thoughts at the ER. I hear you! This is a crap term. However, it is a term in the academia for people studying pain. Let me be super clear. I understand that when we experience chronic pain, our thoughts can become quite dark. We can end game things in a way that is very unhelpful. I think being neurodivergent can also exacerbate this part of living with pain. Your thoughts are wrong. They make sense. I also know they are not helping the desire to get better.
Let’s define catastrophic thinking, shall we?
Defined as “an exaggerated negative mental set brought to bear during actual or anticipated pain experiences. Negative appraisals about pain may lead to catastrophic thinking, which then contributes to feelings of pain-related fear. See how it’s this double-edged sword? Losing myself to pain sucks – that wasn’t catastrophic… well ok it was, but it was also REAL. It also did not help me recover!
Catastrophic thinking in 3 parts. All part of fear-avoidance.
- 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.”).
There are a number of tests that can measure your level of these types of thinking to help you know if this is something you can focus on changing to improve your recovery. Talk to your pain coach, PT, Psychologist or MD for more information.
In becoming a certified “Empowered Relief” provider, I learned from Dr. Beth Darnell of Stanford University, that changing this aspect of our pain journey opens up amazing opportunities to live larger and heal. This is important because we do it for ourselves! I know it’s hard to talk about, harder to face, and takes work to overcome. It’s worth it. I promise.
So how do I treat my fear- avoidance?
The elements I believe are critical to reframing, seeing things differently, and approaching life a new way is:
- Accurate Facts
- Curiosity
- acceptance that this is what ya got today
- Willingness to think a new way
These ideas are exactly what the core values of my coaching, courses, and group programs are based on.
You’ll find a more “tidy” explanation of these ideas by looking at traditional talk therapies.
Cognitive Behavioral Therapy
CBT) and mindfulness-based interventions have been associated with significantly greater improvements for those with Dear- avoidance than other forms of therapy. CBT may be a clear choice when focusing on cognitive factors that may foster strong effects, as well as aid 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. CBT is a structured, time-limited, present-focused approach to psychotherapy that aims to help patients engage in an active coping process that may serve to maintain their chronic pain experience. * Please note not all CBT practitioners are created equal. Chances are you have some trauma in your background. MAKE SURE YOUR PROVIDER IS TRAUMA INFORMED.
Acceptance and Commitment Therapy
(ACT) is under the umbrella of CBT but is more specific and works to help patients find a way to live fuller life despite their pain. ACT is one of the more actively researched approaches among the third wave of developing psychotherapies. It is a flexible, experiential therapeutic process that uses acceptance and mindfulness approaches mixed with commitment and behavior-change strategies to increase psychological flexibility. This is a method I tend to prefer, as it allows for more experiences, values, and thoughts.
Other Approaches
Graded Exposure: allowing yourself to slowly add in movement and expose yourself to things that have been scary in the past. This can be movement or thoughts!
Guided visualization guides you through a process of imagining pictures that serve as messages from the unconscious to consciousness.
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. I talk a lot about that here
Yoga has been shown to help with chronic pain. It has also been shown beneficial in 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. (If yoga isn’t your thing, try other movement-related meditation.)
In Summary
It’s ok to be afraid. It’s something that is pretty common amongst those of us in pain. It can be changed. Changing fear-avoidance can wildly improve your quality and enjoyment of life, often leading to reduced pain. The terms suck, but the research is solid. Let me help you get started reducing your fear and increasing your life. Just click the button at the top of the page that says work with me!
