Fear/Anxiety/Avoidance – and some treatments!


I’ve been pondering the post by Neil O’Connell on Body in Mind in which he comments on a paper by Foster, Thomas, Bishop, Dunne and Main (2010) in which he makes the point that “There is a huge emphasis on psychological variables in research and current care for low back pain. My experience (the usual biased, unreliable, non-replicable shambles) tells me that this is justifiably so. But in this rigorous study the four psychological variables found to have a unique influence individually explained just 2.5% of the variance or less. The big players were the level of disability when the patient arrived at the GP and demographic factors which together explained 50%.”

Now this flies in the face of the general trend towards emphasising psychosocial variables associated with pain and disability over the past 10 – 15 years.  Or does it?

The ‘Yellow flags’ or psychosocial risk factors associated with chronic disability associated with pain were introduced in the mid 1990’s and represented a change in emphasis for early management of back pain.  By attending to these factors as soon as they became evident, it was hoped that some of the long-term problems would be better managed, and some of the disability could be prevented or mitigated.

In the enthusiasm for more attention to psychosocial factors  (which I share, I openly admit!) maybe one thing that I recall Dr Nick Kendall repeating over and again has been forgotten: if someone responds to a psychological approach this does NOT mean their pain is ‘psychological’ – and in the same breath, psychological treatments can have profound effects on wellbeing even when the ’cause’ is quite clearly physical.

To this end I’m not going to spend time justifying my attention to psychosocial factors in acute pain (at least, not today!), instead I’m going to return to that enormous unknown: what treatments help people with high levels of disability associated with their pain?

There are three main groups of psychological approach to helping people with high avoidance related to their anxiety or fear of pain: most clinicians are well aware of the graded reactivation approach (although perhaps not of the psychological basis for this), recently we have the well-regarded exposure paradigm, and the final ‘group’ are cognitive behavioural approaches with a more psychological or cognitive orientation.  This final group is a fairly heterogenous set of methods that is reasonably difficult to unpack to determine the components actually do the work of helping people return to being people rather than patients.

The basic premise of fear/anxiety avoidance models goes like this:

“1. When pain is perceived, a judgment of the meaning or purpose of the pain is placed on the experience (pain experience).
2. For most people, pain is judged to be undesirable and unpleasant but not catastrophic or suggestive of a major calamity (no fear). Typically, the person engages in appropriate behavioral restriction followed by graduated increases in activity (confrontation) until healing has occurred (recovery).
3. For a significant minority of people, a catastrophic meaning is placed on the experience of pain (pain catastrophizing). Catastrophizing, influenced by predispositional and current psychological factors, leads to fear of pain (and/or reinjury) and thereafter spirals into a vicious and self-perpetuating cycle that promotes and maintains avoidance, activity limitations, disability, pain, further catastrophizing, and so forth.”

There has been a wealth of research providing support for this model, or variations of this. Since 2001, an increasing number of papers have examined different strategies for treating the disability associated with anxiety/fear and avoidance. Three basic variations are found:

  • Graded exposure in vivo – a process of deliberately exposing patients to movements and tasks that have been avoided because of fear of pain or reinjury.

It involves psychoeducation about the model and the purpose of the exposure activities; followed by a series of interactive therapy sessions involving graded exposure techniques and “behavioral experiments.”  These involve an an individualized hierarchy of avoided activities, with patients gradually exposed to each activity in the hierarchy, rating their fear and pain expectation before and after each exposure.  Patients are encouraged to practice these activities in natural contexts outside of clinic-based sessions.

  • Graded Activation (or reactivation)an active process where healthy behaviours are shaped through positive reinforcement of predefined activity quotas.

Patients identify specific functional activities that have been reduced as a result of their pain, and treatment goals are established based on these activities.  Patients are asked to estimate their tolerance for carrying out these activities, and baselines are set at this level.  The avoided activities and associated tolerances form a time-contingent treatment schedule, not unlike a fear hierarchy, with patients starting their activities at 70 – 80% of their estimated tolerance.  Gradually, patients increase activity levels on a pre-determined quota.

These two approaches, while superficially similar, are based on two different conditioning approaches.  Graded exposure in vivo uses classical conditioning to elicit the conditioned response (usually physiological arousal) then supporting the person to develop inhibitory responses instead of maintaining their previous avoidance pattern.  Graded activation is based on operant conditioning, using positive reinforcement to modify behaviours – such as therapist praise and positive regard for maintaining adherence to the quota, and withdrawal of positive regard when the quota is not maintained.

  • Acceptance and Commitment Therapy – is based on concepts of mindfulness, acceptance, and values-based action.

This approach asks patients to experience pain, but not attempt to control it. This is achieved through observing it as a sensation, and then accepting it as part of present reality without judging it. Patients are encouraged to consciously choose to engage in satisfying, rewarding activities despite their pain. This process supports patients in a shift of life focus away from the pain and onto things of greater value.

The key difference between the ACT approach to the cognitive components of pain management and the ‘traditional’ cognitive behavioural approach is the emphasis being less on the content of the cognitions, and more on the ‘workability’ or function of those cognitions.

Tomorrow I’ll go through the findings of this study – and muse upon some of the implications of this for everyday clinical practice.

Bailey, K., Carleton, R., Vlaeyen, J., & Asmundson, G. (2010). Treatments Addressing Pain-Related Fear and Anxiety in Patients with Chronic Musculoskeletal Pain: A Preliminary Review Cognitive Behaviour Therapy, 39 (1), 46-63 DOI: 10.1080/16506070902980711

Foster NE, Thomas E, Bishop A, Dunn KM, & Main CJ (2010). Distinctiveness of psychological obstacles to recovery in low back pain patients in primary care. Pain, 148 (3), 398-406 PMID: 20022697



  1. Thank you for being such a clear writer Bronnie! I don’t think I ever realized before that there was a difference between graded exposure and graded activation – I’m sure I thought they were synonymous. Thumbs up on this post!

    1. Diane, you’re not alone in not knowing there is a difference – this paper is an excellent summary of the two, but Johan Vlaeyen has also published a paper detailing the difference between graded exposure and graded activation. It makes for quite a difference in terms of the therapist ‘tasks’ within each session because in graded exposure the aim is to ensure the person is being exposed to what they are fearful of – so it can increase their distress temporarily, and not all therapists are keen on doing this!

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