Pictured
The fear-avoidance model of pain
Johan W.S. Vlaeyen*, Geert Crombez, Steven J. Linton
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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
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 05/18/2024
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 (Figure 1)
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.8,12
2. 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.1,4 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) (see
panels 1 and 2).11 Learning typically occurs with interoceptive
or proprioceptive CSs. 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 (see panel 3). 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.14
3. 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
The authors have no conflicts of interest to declare.
This work was supported by the long-term structural funding Methusalem Grant
“Asthenes” by the Flemish Government (Belgium) to J.W.S. Vlaeyen (METH/15/011),
and Grant G091812N to J.W.S. Vlaeyen and G. Crombez by the Research
Foundation—Flanders, Belgium (Fonds Wetenschappelijk Onderzoek [FWO]
Vlaanderen). Research Group on Health Psychology, KU Leuven, University of
Leuven, Belgium
*Corresponding author. Address: Research Group on Health Psychology,
KU Leuvcen, 3000 Leuven, Belgium. Tel.: +3216325915; fax: +3216325923.
E-mail address: johannes.vlaeyen@kuleuven.be (J.W.S. Vlaeyen).
http://dx.doi.org/10.1097/j.pain.0000000000000574
1588 J.W.S. Vlaeyen et al. • 157 (2016) 1588–1589
Copyright Ó 2016 by the International Association for the Study of Pain. Unauthorized reproduction of this article is prohibited.
only one to be pursued in an environment with concomitant,
often competing goals.3 Fear-related protective behaviors are
inhibited when the value of another life goal outweighs the
value of pain and is given priority.2 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.7
4. Extinction of pain-related fear
Inhibitory responses can be learned when avoidance behavior
is omitted, and the individual is exposed to the stimuli and sit-
uations that were previously avoided (see panel 4). In such ex-
posure treatments, new nonthreat associations with the CSs
are formed, and subsequently may generalize across time
and contexts.7 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 youngsters.10,13
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