The impact of experiential avoidance on the relations between illness representations, pain catastrophising and pain interference in chronic pain
Abstract
Objective The aim of this study was to examine the effects of experiential avoidance (EA) on the indirect relationship of chronic pain patients' illness representations to pain interference, through pain catastrophising Design and main outcome measure: The sample consisted of 162 patients diagnosed with an arthritis-related or a musculoskeletal disorder. The effects of EA on the pathway between illness representations, pain catastrophising and pain interference were examined with PROCESS, a computational tool for SPSS Results: After controlling for patient and illness-related variables and pain severity, the 'illness representations-pain catastrophising-pain interference' pathway was interrupted at the higher levels of EA. The reason was that, at the high levels of EA, either the relation of illness representations to pain catastrophising or the relation of pain catastrophising to pain interference was not statistically significant. Conclusion The findings indicate that EA is not a generalised negative response to highly aversive conditions, at least as far as the factors examined in this study are concerned. EA may rather reflect a coping reaction, the impact of which depends on its specific interactions with the other aspects of the self-regulation mechanism. At least in chronic pain, EA should become the focus of potential intervention only when its interaction with the illness-related self-regulation mechanism results in negative outcomes.
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The AAQ-II was first published as a measure of psychological inflexibility and experiential avoidance, and this is ingrained in the literature.
“the AAQ-II was first published as a measure of psychological inflexibility and experiential avoidance is ingrained in the literature (e.g., Karademas et al., 2017; Karekla & Panayioutou, 2011; Sung, et al., 2018).”
From The Acceptance and Action Questionnaire-II (AAQ-II) as a measure of experiential avoidance: Concerns over discriminant validity (2019) · cites this paper as Karademas et al., 2017
Cites
(2013) · Cited by 44,563 · see citing works
The Pain Catastrophizing Scale: Development and validation.
Sullivan, M. J. L., Bishop, S. R., & Pivik, J. (1995) · Psychological Assessment · doi:10.1037//1040-3590.7.4.524 · Cited by 8,227 · see citing works
Ecological momentary assessment
Shiffman, S., Stone, A. A., & Hufford, M. R. (2008) · Annual Review of Clinical Psychology · doi:10.1146/annurev.clinpsy.3.022806.091415 · Cited by 6,454 · see citing works
(1999) · Cited by 5,934 · see citing works
Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., Waltz, T., & Zettle, R. D. (2011) · Behavior Therapy · doi:10.1016/j.beth.2011.03.007 · Cited by 3,950 · see citing works
Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996) · Journal of Consulting and Clinical Psychology · doi:10.1037//0022-006x.64.6.1152 · Cited by 3,595 · see citing works
Psychological flexibility as a fundamental aspect of health
Kashdan, T. B., & Rottenberg, J. (2010) · Clinical Psychology Review · doi:10.1016/j.cpr.2010.03.001 · Cited by 3,054 · cited 6× · see citing works
“The Acceptance and Action Questionnaire-Greek version (AAQ-II; Karekla & Michaelides, in press; based on the English version, see Bond et al., 2011), is a 7-item measure of EA.”
BackgroundInfluentialThe revised illness perception questionnaire (IPQ-R)
Moss-Morris, R., Weinman, J., Petrie, K., Horne, R., Cameron, L., & Buick, D. (2002) · Psychology & Health · doi:10.1080/08870440290001494 · Cited by 2,949 · see citing works
Rudd (2006) · doi:10.1002/(issn)1097-4679 · Cited by 2,635 · see citing works
Measuring experiential avoidance: A preliminary test of a working model
Hayes, S. C., Strosahl, K., Wilson, K. G., Bissett, R. T., Pistorello, J., Toarmino, D., Polusny, M. A., Dykstra, T. A., Batten, S. V., Bergan, J., et al. (2004) · The Psychological Record · doi:10.1007/bf03395492 · Cited by 2,140 · see citing works
Self-citationLeventhal, H., Diefenbach, M., & Leventhal, E. A. (1992) · Cognitive Therapy and Research · doi:10.1007/bf01173486 · Cited by 1,573 · see citing works
Experiential avoidance as a functional dimensional approach to psychopathology: An empirical review
Chawla, N., & Ostafin, B. (2007) · Journal of Clinical Psychology · doi:10.1002/jclp.20400 · Cited by 805 · cited 4× · see citing works
“Given that EA is considered a severe risk factor for well-being in general (Chawla & Ostafin, 2007; Hayes et al., 2004), and for adaptation to pain in particular (e.g. Feldner et al., 2006; Ramírez-Maestre et al., 2014; Zettle et al., 2012), we expected higher levels of EA to result in stronger…”
BackgroundInfluentialClinical Effectiveness and Cost-Effectiveness of Treatments for Patients With Chronic Pain
Turk, D. C. (2002) · Clinical Journal of Pain · doi:10.1097/00002508-200211000-00003 · Cited by 642 · see citing works
Pain, catastrophizing, and depression in the rheumatic diseases
Edwards, R. R., Cahalan, C., Mensing, G., Smith, M., & Haythornthwaite, J. A. (2011) · Nature Reviews Rheumatology · doi:10.1038/nrrheum.2011.2 · Cited by 596 · see citing works
The Common-Sense Model of Illness Representation: Theoretical and Practical Considerations
Diefenbach, M. A., & Leventhal, H. (1996) · Journal of Social Distress and the Homeless · doi:10.1007/bf02090456 · Cited by 559 · see citing works
Gouze, J.-N., Bordji, K., Gulberti, S., Terlain, B. L., Netter, P., Magdalou, J., Fournel‐Gigleux, S., & Ouzzine, M. (2006) · Arthritis & Rheumatism · doi:10.1002/(issn)1529-0131 · Cited by 530 · see citing works
Catastrophizing and pain in arthritis, fibromyalgia, and other rheumatic diseases
Edwards, R. R., Bingham, C. O., Bathon, J. M., & Haythornthwaite, J. A. (2006) · Arthritis Care & Research · doi:10.1002/art.21865 · Cited by 511 · see citing works
The Brief Pain Inventory User Guide
Cleeland, C. S. (2009) · Cited by 464 · see citing works
Asmundson, G. J. G., Norton, P. J., & Norton, G. R. (1999) · Clinical Psychology Review · doi:10.1016/s0272-7358(98)00034-8 · Cited by 461 · see citing works
What Does the Acceptance and Action Questionnaire (AAQ-II) Really Measure?
Wolgast, M. (2014) · Behavior Therapy · doi:10.1016/j.beth.2014.07.002 · Cited by 421 · cited 1× · see citing works
“For example, there is evidence that there is some circularity in the measurement of EA using AAQ-II and measures of general distress and negative emotion (Wolgast, 2014).”
MethodCambridge Handbook of Psychology, Health and Medicine
(2001) · doi:10.1017/cbo9780511543579 · Cited by 393 · see citing works
Foster, N. E., Bishop, A., Thomas, E., Main, C. J., Horne, R., Weinman, J. A., & Hay, E. M. (2008) · Pain · doi:10.1016/j.pain.2007.12.007 · Cited by 276 · see citing works
The Sage handbook of health psychology
(2005) · Choice Reviews Online · doi:10.5860/choice.42-6538 · Cited by 256 · see citing works
Verbal relations and the evolution of behavior analysis.
Hayes, S. C., & Hayes, L. J. (1992) · American Psychologist · doi:10.1037/0003-066x.47.11.1383 · Cited by 239 · see citing works
The assessment of anxiety and fear in persons with chronic pain: A comparison of instruments
Mccracken, L. M., Gross, R. T., Aikens, J., & Carnrike, C. L. M. (1996) · Behaviour Research and Therapy · doi:10.1016/s0005-7967(96)00057-5 · Cited by 232 · see citing works
Influence of Catastrophizing on Treatment Outcome in Patients With Nonspecific Low Back Pain
Wertli, M. M., Burgstaller, J. M., Weiser, S. R., Steurer, J., Kofmehl, R., & Held, U. (2013) · Spine · doi:10.1097/brs.0000000000000110 · Cited by 218 · see citing works
The Role of Catastrophizing in the Prediction of Postoperative Pain
Papaioannou, M., Skapinakis, P., Damigos, D., Mavreas, V., Broumas, G., & Palgimesi, A. (2009) · Pain Medicine · doi:10.1111/j.1526-4637.2009.00730.x · Cited by 205 · see citing works
Verbal Relations and the Evolution of Behavior Analysis
Hayes, S. C., & Hayes, L. J. (2015) · Routledge eBooks · doi:10.4324/9781315745138-18 · Cited by 200 · see citing works
Coping and experiential avoidance: Unique or overlapping constructs?
Karekla, M., & Panayiotou, G. (2011) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2010.10.002 · Cited by 196 · see citing works
Self-citationMcCracken, L. M., & Velleman, S. C. (2010) · Pain · doi:10.1016/j.pain.2009.10.034 · Cited by 191 · see citing works
Emotional avoidance and panicogenic responding to a biological challenge procedure
Karekla, M., Forsyth, J. P., & Kelly, M. M. (2004) · Behavior Therapy · doi:10.1016/s0005-7894(04)80017-0 · Cited by 163 · see citing works
Self-citationKoleck, M., Mazaux, J., Rascle, N., & Bruchon‐Schweitzer, M. (2005) · European Journal of Pain · doi:10.1016/j.ejpain.2005.01.003 · Cited by 150 · see citing works
Pain catastrophizing as repetitive negative thinking: A development of the conceptualization
Flink, I. L., Boersma, K., & Linton, S. J. (2013) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2013.769621 · Cited by 137 · see citing works
Greek Brief Pain Inventory: Validation and Utility in Cancer Pain
Mystakidou, K., Mendoza, T., Tsilika, E., Befon, S., Parpa, E., Bellos, G., Vlahos, L., & Cleeland, C. (2001) · Oncology · doi:10.1159/000055294 · Cited by 123 · cited 1× · see citing works
“The Brief Pain Inventory (Cleeland, 1989, 2009; Greek adaptation: Mystakidou et al., 2001) was used to assess (a) pain severity, which served as a control variable in this study in order to avoid the possibility that participants’ responses to pain catastrophising and representations were affected…”
MethodAssessment in Health Psychology
(2015) · Hogrefe Publishing eBooks · doi:10.1027/00452-000 · Cited by 104 · see citing works
The Role of Positive Traits and Pain Catastrophizing in Pain Perception
Pulvers, K. M., & Hood, A. (2013) · Current Pain and Headache Reports · doi:10.1007/s11916-013-0330-2 · Cited by 103 · see citing works
Experiential avoidance and self‐compassion in chronic pain
Costa, J., & Pinto‐Gouveia, J. (2013) · Journal of Applied Social Psychology · doi:10.1111/jasp.12107 · Cited by 100 · cited 1× · see citing works
“For example, EA has been related to more symptoms of depression and anxiety in adults with chronic pain visiting primary health care units (Costa & Pinto-Gouveia, 2013), greater anxiety, depression, pain-related impairment, catastrophising and hypervigilance in patients with chronic spinal pain…”
BackgroundGalli, U., Ettlin, D. A., Palla, S., Ehlert, U., & Gaab, J. (2009) · European Journal of Pain · doi:10.1016/j.ejpain.2009.08.011 · Cited by 96 · see citing works
The role of experiential avoidance in acute pain tolerance: A laboratory test
Feldner, M. T., Hekmat, H., Zvolensky, M. J., Vowles, K. E., Secrist, Z., & Leen-Feldner, E. W. (2006) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2005.03.002 · Cited by 94 · see citing works
Acceptance and related processes in adjustment to chronic pain
Thompson, M., & McCracken, L. M. (2011) · Current Pain and Headache Reports · doi:10.1007/s11916-010-0170-2 · Cited by 89 · see citing works
Psychological flexibility, acceptance and commitment therapy, and chronic pain
Scott, W., & McCracken, L. M. (2015) · Current Opinion in Psychology · doi:10.1016/j.copsyc.2014.12.013 · Cited by 82 · see citing works
van der Have, M., Brakenhoff, L. K. P. M., van Erp, S. J. H., Kaptein, A. A., Leenders, M. B., Scharloo, M., Veenendaal, R. A., van der Heijde, D. M. F. M., Jong, A. E. V. D. M., Hommes, D. W., et al. (2014) · Journal of Crohn s and Colitis · doi:10.1093/ecco-jcc/jju025 · Cited by 74 · see citing works
Experiential avoidance as a common psychological process in European cultures
Monestès, J.-L., Karekla, M., Jacobs, N., Michaelides, M. P., Hooper, N., Kleen, M., Ruiz, F. J., Miselli, G., Presti, G., Luciano, C., et al. (2018) · European Journal of Psychological Assessment · doi:10.1027/1015-5759/a000327 · Cited by 71 · see citing works
Self-citationRamírez‐Maestre, C., Esteve, R., & López-Martínez, A. E. (2014) · Annals of Behavioral Medicine · doi:10.1007/s12160-014-9619-6 · Cited by 64 · see citing works
Clinical assessment of behavioral coping responses: Preliminary results from a brief inventory
McCracken, L. M., Eccleston, C., & Bell, L. (2005) · European Journal of Pain · doi:10.1016/j.ejpain.2004.04.005 · Cited by 62 · see citing works
Differential Strategies in Coping with Pain as a Function of Level of Experiential Avoidance
Zettle, R. D., Hocker, T. R., Mick, K. A., Scofield, B. E., Petersen, C. L., Song, H., & Sudarijanto, R. P. (2005) · The Psychological Record · doi:10.1007/bf03395524 · Cited by 60 · see citing works
Feinstein, A. B., Forman, E. M., Masuda, A., Cohen, L. L., Herbert, J. D., Nandini Moorthy, L., & Goldsmith, D. P. (2011) · Journal of Clinical Psychology in Medical Settings · doi:10.1007/s10880-011-9243-6 · Cited by 57 · cited 2× · see citing works
“…in patients with chronic spinal pain (Ramírez-Maestre, Esteve, & López-Martínez, 2014), lower quality of life in adolescents with juvenile idiopathic arthritis (Feinstein et al., 2011) and in adults with various pain conditions even after controlling for pain intensity (McCracken & Velleman, 2010).”
BackgroundKarekla, M., & Michaelides, M. P. (2016) · Journal of Contextual Behavioral Science · doi:10.1016/j.jcbs.2016.11.006 · Cited by 51 · see citing works
Self-citationCosta, E. C. V., Vale, S., Sobral, M., & Pereira, M. G. (2015) · Psychology Health & Medicine · doi:10.1080/13548506.2015.1109673 · Cited by 50 · see citing works
Esteve, R., & Ramírez‐Maestre, C. (2013) · Annals of Behavioral Medicine · doi:10.1007/s12160-013-9499-1 · Cited by 37 · see citing works
Behavioral and Psychopharmacologic Pain Management
(2010) · Cambridge University Press eBooks · doi:10.1017/cbo9780511781445 · Cited by 31 · see citing works
Response to the Letter to the Editor
Wertli, M. M., Burgstaller, J. M., Held, U., Steurer, J., & Weiser, S. R. (2014) · Spine · doi:10.1097/brs.0000000000000537 · Cited by 11 · see citing works
Zettle, R. D., Barner, S. L., Gird, S. R., Boone, L. T., Renollet, D. L., & Burdsal, C. A. (2012) · The Psychological Record · doi:10.1007/bf03395812 · Cited by 9 · see citing works
Pain: a multidimensional perspective
Turk, D. C., & Burwinkle, T. M. (2001) · Cambridge University Press eBooks · doi:10.1017/cbo9780511543579.031 · Cited by 4 · see citing works
Pharmacologic approaches to pain management
Gallagher, R. M. (2011) · Cambridge University Press eBooks · doi:10.1017/cbo9780511781445.009 · Cited by 2 · see citing works
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1 of the 56 references couldn’t be matched to a known paper.
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Tyndall, I., Waldeck, D., Pancani, L., Whelan, R., Roche, B., & Pereira, A. (2020) · Behavior Modification · doi:10.1177/0145445518820036 · Cited by 104 · see citing works
Wang, Y., Tian, J., & Yang, Q. (2024) · Psychiatry and Clinical Psychopharmacology · doi:10.5152/pcp.2024.23777 · Cited by 78 · see citing works
Vasiliou, V. S., Karademas, E. C., Christou, Y., Papacostas, S., & Karekla, M. (2021) · The Journal of Pain · doi:10.1016/j.jpain.2020.06.006 · Cited by 45 · see citing works
Self-citationTyndall, I., Waldeck, D., Riva, P., Wesselmann, E. D., & Pancani, L. (2018) · Journal of Contextual Behavioral Science · doi:10.1016/j.jcbs.2018.02.001 · Cited by 43 · see citing works
“Indeed, Karademas et al. (2017) reported that the relationship between experiential avoidance and pain catatstophising in chronic pain patients was not uniform but quite context dependent.”
BackgroundSchwartz, J., OH, P. I., Takito, M. Y., Saunders, B., Dolan, E., Franchini, É., Rhodes, R. E., Bredin, S. S. D., Coelho, J. P., dos Santos, P., et al. (2021) · Frontiers in Cardiovascular Medicine · doi:10.3389/fcvm.2021.712696 · Cited by 32 · see citing works
Blakey, S. M., Halverson, T. F., Evans, M. K., Patel, T. A., Hair, L. P., Meyer, E. C., DeBeer, B. B., Beckham, J. C., Pugh, M. J., Calhoun, P. S., et al. (2021) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2021.07.033 · Cited by 31 · see citing works
Mechanisms of change in acceptance and commitment therapy for primary headaches
Vasiliou, V. S., Karademas, E. C., Christou, Y., Papacostas, S., & Karekla, M. (2022) · European Journal of Pain · doi:10.1002/ejp.1851 · Cited by 21 · see citing works
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Rehfeldt, R. A., & Tyndall, I. T. (2021) · Behavior Analysis in Practice · doi:10.1007/s40617-021-00592-6 · Cited by 15 · see citing works
Assessing Psychological Flexibility in Chronic Illness
Tyndall, I., Vagos, P., Cano, S., Pinto, H., & Trindade, I. A. (2023) · The Psychological Record · doi:10.1007/s40732-023-00572-y · Cited by 12 · see citing works
Kasinopoulos, O., Vasiliou, V. S., & Karekla, M. (2023) · Internet Interventions · doi:10.1016/j.invent.2023.100611 · Cited by 11 · see citing works
Self-citationHealth correlates of experiential and behavioral avoidance among trauma-exposed veterans
Schwartz, E. K. C., Palmisano, A. N., Petrakis, I. L., Pietrzak, R. H., & Sofuoglu, M. (2024) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2024.06.014 · Cited by 8 · see citing works
Vasiliou, V., Konstantinou, N., Christou, Y., Papacostas, S., Constantinidou, F., Heracleous, E., Seimenis, I., & Karekla, M. (2024) · European Journal of Pain · doi:10.1002/ejp.4734 · Cited by 8 · see citing works
Self-citationIllness and treatment beliefs and health outcomes in chronic pain: a meta-analysis
Hagger, M. S., McKinley-Rodriguez, L. E., & Hamilton, K. (2025) · Psychology and Health · doi:10.1080/08870446.2025.2497417 · Cited by 5 · see citing works
Hurrell, Z., Vasiliou, V., Sirois, F., & Thompson, A. (2026) · British Journal of Health Psychology · doi:10.1111/bjhp.70048 · Cited by 2 · see citing works
Self-citationConnolly, S., Ferreira, N. B., McGarrigle, L., & Amicis, L. D. (2018) · Journal of Contextual Behavioral Science · doi:10.1016/j.jcbs.2018.12.005 · Cited by 3 · see citing works
Wang, Y., Tian, J., & Yang, Q. (2024) · Frontiers in Psychology · doi:10.3389/fpsyg.2024.1465424 · Cited by 2 · see citing works
Ryan, A., Ferreira, N. B., Moffat, H., Eugenicos, M. P., Howson, W., Casburn-Jones, A., Moroni, F., Stevens, P., Wolters, M. K., & Gillanders, D. T. (2025) · Journal of Contextual Behavioral Science · doi:10.1016/j.jcbs.2025.100887 · Cited by 1 · see citing works
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Yang, Q., & Wang, Y. (2026) · European Journal of Sport Science · doi:10.1002/ejsc.70124
- Authors
- Karademas, E. C., Karekla, M., Flouri, M., Vasiliou, V. S., Kasinopoulos, O., & Papacostas, S. S.
- Affiliations
- University of Crete (GR)
- University of Cyprus (CY)
- Cyprus Institute of Neurology and Genetics (CY)
- Corresponding author
- Karademas, Evangelos C.
- ORCID
- Venue
- Psychology & Health
- Publisher
- Informa UK Limited
- Published
- 2017-07-03
- Volume
- 32
- Issue
- 12
- Pages
- 1-16
- ISSN
- 0887-0446 (ISSN-L)
- 1476-8321
- OpenAlex
- W2730022229
- Cited by
- 22
- References
- 56
- Citations by year
- 2026: 2 · 2025: 2 · 2024: 5 · 2023: 3 · 2021: 4 · 2020: 1 · 2019: 1 · 2018: 4
- FWCI
- 1.15
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Psychology and Health (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
- Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Pediatric Pain Management Techniques
- Keywords
- experiential avoidance, illness representations, pain catastrophizing, pain interference, chronic pain, self-regulation, coping, arthritis, musculoskeletal disorders, mediation
- MeSH terms
- Adaptation, Psychological, Adult, Aged, Attitude to Health, Avoidance Learning, Female, Humans, Male, Middle Aged, Young Adult, Catastrophization, Chronic Pain
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