The Fear-Avoidance Model

[Ftaghn!]

Hey everyone,
Being that this is not very accessible to most people, I wanted to introduce you to something the scientific literature calls the Fear-Avoidance Model. The model itself has some age (2000), but has gained huge attention over the last 15 years, along with compounding evidence. It's a highly cited paper (more than 2600 citations, which is fairly immense) with some very interesting conclusions. The big idea is this:

• Acute pain becomes chronic pain through two things: fear of pain, and avoidance of activity.

• Fear of pain has a symbiotic role with pain catastrophizing (described as misinterpretation of the consequences of pain), both of which act together to direct attention towards, and amplify the pain. They have a sort of chicken & egg relationship.

• Fear of pain acts on behavior, creating a pattern of avoidance, which in turns increases sensitivity to pain.

• There are debates on whether anxious or depressive behaviors are stronger predictors of developing chronic pain.

A follow-up study was also done, which I'll link here. The ideas behind TMS are far more mainstream than they seem at first, but I think they may not be as accessible to medical professionals as they should be.

The original paper (Vlaeyen 2000): https://lirias.kuleuven.be/bitstream/123456789/206277/2/Vlaeyen,+Linton_2000.pdf

Follow-up paper (Vlaeyen 2012): https://www.researchgate.net/profil...2_years_on/links/0fcfd50143ae6e7c4c000000.pdf

Edit: Something worth mentionning; in their model, other things like hypervigilance and catastrophization also matter, but they are seen as originating from the first big two.

 

[eskimoeskimo]

Thanks for the article. Reassuring to see some hard science regarding the psychological contributors to pain. Do you know of any scientific research that's got something optimistic to say about treatment and/or prognosis? I think it holds me back to think that mainstream science's current position is basically that people don't really get better from chronic pain. For me, the Sarno and Schubiner studies don't cut it. Best, E.

 

[Ftaghn!]

There are plenty of studies right now on the effect of attention and emotional state on pain. Both seem to be thought to be two different effects, but also mutually dependent. There was this study on the pain-relief effect of an improvement in emotional states and bringing attention away from the pain, both individually and simultaneously. It was something on the order of morphine, if I recall, but I'll try to find it.

In any case, the literature seems to mention two different effects touching respectively attention and emotional state: pain sensation and emotional sensation (as in, you feel negatively from pain). Both of which seem to be essential parts of the chronic pain experience.

It's worth noting that Sarno's advice is consistent with theory that didn't exist during his time, touching those two dimensions of emotion and attention. Reassuring yourself that there's nothing wrong with you, bringing your attention away, and returning to normal, etc.

 

[Forest]

Thanks for posting this, @Ftaghn!. I haven't had a chance to read it yet, but it looks interesting and potentially very important.

From what I've seen so far, it seems to boil down to something fairly simple, summarized in the following picture. It looks like, when we experience pain for whatever reason ("PAIN EXPERIENCE"), things can go two ways. Negative affect (i.e. bad feelings) or threatening illness information (i.e. a nocebo) can lead us to think the worst (catastrophize). This leads to fear, avoiding activities, and hypervigilance on our symptoms. If we go this way, these can evolve into the three evolve into the "three horsemen" of Disuse, Depression and Disability. According to the science, this leads to more pain and the cycle continues. Of course, we all know that it doesn't have to be that way, and that is the second arrow. If we understand that we are actually fine, we can confront the activities that we fear (resume all physical activities, as Dr. Sarno teaches), and we will recover.

That sounds a lot like how my TMS went. And it echoes what @balto and many others have learned on the forums: that fear is absolutely central to TMS. If we can overcome our fear and resume our activities, finding happiness in life, then we can get our freedom back.

 

[Forest]

To put it in a more positive light, if certain things cause pain, then not having them would be part of recovery. In my mind, this model says that what matters most in recovery is avoiding fear by recognizing that our bodies aren't fragile (knowledge is the penicillin of TMS) and resuming activities rather than avoiding them.

... Which reminds me of a picture we made a little while back:

​

Overcoming fear is where our strength comes from.

 

[Gigi]

Nice graphic, Forest. At the end of my weekly yoga session, the instructor has us do "I am" statements. She suggests "I am slow to anger" etc. I always say either "I am healthy" or "I am strong." I like those messages.

 

[tgirl]

I am wondering how people feel about this. I most certainly fixate on my pain and fear it tremendously, but I do force myself to do activities, regardless. So in relation to the model stated above I fulfil only one of the two aspects in the fear - avoidance model. I fear pain, but don't limit my activities. Do you think the fact I fear my pain so much and that I fixate on it could be enough to create TMS?

 

[Forest]

Interesting question, tgirl. I haven't finished the paper, so I'm just going to throw this out there. I wouldn't be surprised if these two particular papers focus on a cycle that involves inactivity. However, I bet that there are hundreds of other scientific articles related to the model and perhaps even thousands of scientists reading those papers. If it's anything like economics, then it is a community of thinkers, and each different thinker may have a slightly different approach. For example, Dr. Schubiner's model is very brain-based and it probably relies on many of the same articles that these papers are based on (the hundreds of articles I mentioned before). His model is quite similar, and the main fear center of the brain, the amygdala, plays an important role in it.

 

[Andy Bayliss]

fear of pain, and avoidance of activity

It's worth noting that Sarno's advice is consistent with theory that didn't exist during his time, touching those two dimensions of emotion and attention. Reassuring yourself that there's nothing wrong with you, bringing your attention away, and returning to normal, etc.

So it seems Dr. Sarno's work successfully, in a pioneering way nailed down four important things:

-don't fear the pain
-resume activity
-there is nothing wrong with you (related to don't fear the pain, and resume activity)
-bring your attention to something else

That is a pretty great list, now being supported by these studies...

Andy B

 

[tgirl]

Forest, I have another point to make in addition to my last post. I said I don't limit my physical activities and that is true, but I have altered my life path due to the fear of my pain. I have let it paralyze me in a sense. For example I want to head in a different direction in my career but for some reason having pain is stopping me dead in my tracks. Would this type of 'inactivity' be similar to actual physical inactivity? If so, then maybe I do fit the model, fulfilling both requirements- fearing pain and activity avoidance.

I will snowshoe, travel and on and on, but I find it difficult to make life changes.

 

[Forest]

Hi @tgirl, I'll be traveling for a bit, so I might not be able to respond until next week, but I'm curious, what sort of life changes are you thinking of?

 

[tgirl]

I am not sure exactly, but a career change for sure. I have sold real estate for a long time, but don't any longer. I am in limbo and feel stuck. Also, my 18 year old daughter went to the west coast of Canada for university so life has changed for me here, in Toronto- that is for sure. There are probably other things I am not thinking of right now.