Pain psychology · functional reading

Fear-avoidance model

The fear-avoidance model describes the possible relationships between how a person interprets pain, fear, avoidance and activity restriction. It is an explanatory model, not a diagnosis.

Scientific basis

Proposed in the early 1980s (Lethem et al. 1983) and later developed by Vlaeyen and Linton (2000; 2012), the model distinguishes two possible trajectories in response to pain. When pain is interpreted as not very threatening, the person gradually resumes their activities. When it is interpreted as highly threatening, fear, hypervigilance and avoidance can set in; prolonged and generalized avoidance can reduce activity and participation.

Pain-related avoidance. Avoiding is not always harmful. A distinction is made between occasional or protective avoidance, modifying a movement, reducing an activity, anticipatory avoidance and lasting restriction. In the acute phase or after an injury, avoidance can be appropriate; it is its rigidity, its generalization and its duration that can become a problem.

Prolonged avoidance, reduced activity and deconditioning. A lasting reduction in activity can contribute to physical deconditioning, but deconditioning has other determinants: the pain itself, prior activity, illness, sleep, the environment. The chain of fear, avoidance, deconditioning and chronicity is neither universal nor inevitable.

Prognostic data are heterogeneous: depending on the population, the type of pain and its duration, fear-avoidance predicts the course of pain more or less well (Pincus et al. 2006; Leeuw et al. 2007).

Pain catastrophizing. This refers to a tendency to adopt a negative, repetitive and amplified interpretation of actual or anticipated pain, which includes rumination, magnification of the perceived threat and a sense of helplessness (Quartana et al. 2009). Within the model, it is a possible antecedent of avoidance, not a mandatory step; its prognostic value is also variable (Wertli et al. 2014). It is neither the sole cause of pain nor a challenge to the reality of pain.

Blue Portance / SBNFA™ reading

In the SBNFA™ reading, the model sheds light on how a fear or an avoidance strategy can reduce the options for action that are actually available, without making it the cause of the pain. The problem is not the existence of a protective strategy, but its rigidity, its generalization, its duration and its consequences for the options for action.

Contribution to the analysis of sitting

Seating analysis measures neither fear nor avoidance. It describes the opportunities for variation and adjustment that the sitting position offers; how a person explores them also depends on their history, their symptoms and their context.

Not to be confused with

Kinesiophobia, a specific fear of movement and a possible component of the model; Algophobia, an intense fear of pain; Occasional or protective avoidance, often appropriate; Deconditioning, a possible consequence with multiple determinants; Pain catastrophizing, a possible component of a threatening interpretation; Central sensitization, a neurophysiological mechanism; Chronic pain, pain that persists beyond three months.

Sources and scope

An established and debated scientific model, not a diagnosis. The chain of fear, avoidance, deconditioning and chronicity is not automatic; avoidance is not always harmful; deconditioning does not result from avoidance alone; chronic pain is not "caused by fear." Pain catastrophizing never calls into question the reality of pain.