Modeling quality of life in patients with rheumatic diseases: the role of pain catastrophizing, fear-avoidance beliefs, physical disability, and depression
Abstract
PURPOSE: To examine factors in the fear-avoidance model, such as pain, pain catastrophizing, fear-avoidance beliefs, physical disability, and depression and their relationships with physical and psychological quality of life in patients with rheumatic diseases. MATERIALS AND METHODS: The data were obtained from 360 patients with rheumatic diseases who completed self-report measures assessing study variables. Structural equation modeling was used to examine the hypothesized relationships among factors specified in the fear-avoidance model predicting physical and psychological quality of life. RESULTS: Final models fit the data well, explaining 96% and 82% of the variance in physical and psychological quality of life, respectively. Higher pain catastrophizing was related to stronger fear-avoidance beliefs that had a direct negative association with physical disability and depression, which, in turn, negatively affected physical quality of life. Pain severity was also directly related to physical disability. Physical disability also affected physical quality of life indirectly through depression. The hypothesized relationships specified in the model were also confirmed for psychological quality of life. However, physical disability had an indirect association with psychological quality of life via depression. CONCLUSION: The current results underscore the significant role of cognitive, affective, and behavioral factors in perceived physical disability and their mediated detrimental effect on physical and psychological quality of life in patients with rheumatic diseases. Implications for rehabilitation The fear-avoidance model is applicable to the prediction of quality of life in patients with rheumatic diseases. As pain-catastrophizing and fear-avoidance beliefs are important factors linked to physical disability and depression, intervening these cognitive factors is necessary to improve physical function and depression in patients with rheumatic diseases. Considering the strong association between depression and physical and psychological quality of life, the assessment and treatment of the former should be included in the rehabilitation of patients with rheumatic diseases. Interventions targeting physical function and depression are likely to be effective in terms of improving physical and psychological quality of life in patients with rheumatic diseases.
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In the Fear-Avoidance Model, catastrophizing, pain-related fear, and low self-efficacy promote pain avoidance, resulting in increased physical symptoms and depression and reduced overall quality of life.
“In this model, the role of catastrophizing, pain-related fear, and low self-efficacy is emphasized in promoting pain avoidance, resulting in an increase in physical symptoms and depression and reducing overall quality of life (Vlaeyen and Linton, 2012; Shim et al., 2018).”
From Guided internet-based cognitive-behavioral therapy for patients with rheumatic conditions: A systematic review (2021) · cites this paper as Shim et al., 2018
Internet-based exposure therapy may be an effective treatment for patients with rheumatic conditions who exhibit pain avoidance behaviors, in line with the Fear-Avoidance Model.
“This type of therapy may thus be an effective treatment for patients with rheumatic conditions who exhibit these pain avoidance behaviors which can ultimately exacerbate chronic pain and disability, in line with the previously described Fear-Avoidance Model (Lethem et al., 1983; Shim et al., 2018; Vlaeyen and Linton, 2012).”
From Guided internet-based cognitive-behavioral therapy for patients with rheumatic conditions: A systematic review (2021) · cites this paper as Shim et al., 2018
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Lin, X., Lan, Y., Lin, X., Lai, Y., Shen, J., & Liu, H. (2026) · Frontiers in Immunology · doi:10.3389/fimmu.2026.1816005
- Authors
- Shim, E.-J., Hahm, B.-J., Go, D. J., Lee, K.-M., Noh, H. L., Park, S.-H., & Song, Y. W.
- Affiliations
- Pusan National University (KR)
- Seoul National University (KR)
- Department of Psychology, Pusan National University, Busan, Republic of Korea;
- Corresponding author
- Song, Yeong Wook
- Venue
- Disability and Rehabilitation
- Publisher
- Informa UK Limited
- Published
- 2017-03-14
- Volume
- 40
- Issue
- 13
- Pages
- 1509-1516
- ISSN
- 0963-8288 (ISSN-L)
- 1464-5165
- OpenAlex
- W2748960126
- Cited by
- 54
- References
- 48
- Citations by year
- 2026: 2 · 2025: 5 · 2024: 3 · 2023: 9 · 2022: 9 · 2021: 9 · 2020: 6 · 2019: 5 · 2018: 6
- FWCI
- 3.25
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Disability and Rehabilitation (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Korea Health Industry Development Institute
- Ministry of Health and Welfare (HI14C1277)
- Ministry of Science, ICT and Future Planning (NRF-2015M3A9B6052011, F16HR31D1802)
- National Research Foundation of Korea
- the Ministry of Health & Welfare, Korea (HI14C1277)
- the Ministry of Science, ICT and Future Planning, Korea (NRF-2015M3A9B6052011)
- Topics
- Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
- Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Medical Practices and Rehabilitation
- Health Sciences › Medicine › Psychiatry and Mental health › Psychosomatic Disorders and Their Treatments
- Keywords
- rheumatic diseases, quality of life, pain catastrophizing, fear-avoidance beliefs, fear-avoidance model, physical disability, depression, pain intensity, psychological quality of life, physical quality of life, rehabilitation
- MeSH terms
- Depression, Fear, Female, Persons with Disabilities, Humans, Male, Middle Aged, Negativism, Phobic Disorders, Quality of Life, Rheumatic Diseases, Catastrophization
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