Fear-Avoidance Model of Chronic Pain: The Next Generation

Crombez, Geert; Eccleston, Christopher; Van Damme, Stefaan; Vlaeyen, Johan W.S.; Karoly, Paul

doi:10.1097/ajp.0b013e3182385392

Cited by 960Musculoskeletal pain and rehabilitationPain Management and TreatmentPediatric Pain Management Techniques

Fear-Avoidance Model of Chronic Pain: The Next Generation

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Crombez, Geert, Eccleston, Christopher, Van Damme, Stefaan, Vlaeyen, Johan W.S., Karoly, Paul·2012·The Clinical Journal of Pain

DOI 10.1097/ajp.0b013e3182385392

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Abstract

OBJECTIVE: The fear-avoidance (FA) model of chronic pain describes how individuals experiencing acute pain may become trapped into a vicious circle of chronic disability and suffering. We propose to extend the FA model by adopting a motivational perspective on chronic pain and disability. METHODS: A narrative review. RESULTS: There is ample evidence to support the validity of the FA model as originally formulated. There are, however, some key challenges that call for a next generation of the FA model. First, the FA model has its roots in psychopathology, and investigators will have to find a way to account for findings that do not easily fit within such framework. Second, the FA model needs to address the dynamics and complexities of disability and functional recovery. Third, the FA model should incorporate the idea that pain-related fear and avoidance occurs in a context of multiple and often competing personal goals. DISCUSSION: To address these 3 key challenges, we argue that the next generation of the FA model needs to more explicitly adopt a motivational perspective, one that is built around the organizing powers of goals and self-regulatory processes. Using this framework, the FA model is recast as capturing the persistent but futile attempts to solve pain-related problems to protect and restore life goals.

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The assumptions underlying experimental paradigms and models of AB remain often untested for chronic pain.
“However, the assumptions that underlie these paradigms and models remain often untested for chronic pain [3,5].”
From Attentional bias and chronic pain: Where to go from here? (2014) · cites this paper as [3]
In ‘Key Challenge 1: Exploring Fear and Avoidance Beyond Psychopathology’ (page unavailable), the paper says attentional-bias paradigms are frequently used to test hypervigilance in chronic pain and questions a psychopathology-based assumption of the fear-avoidance model. It does not say that the assumptions underlying attentional-bias paradigms and models often remain untested for chronic pain. (LLM, conf=0.78)
Experimental — accuracy not yet measured
Multiple authors have pointed out the lack of other relevant psychological phenomena such as motivation, associative learning, attention regulation, personality, trauma, and social relationships from the traditional yellow flag framework.
“Multiple authors have pointed out the lack of other relevant psychological phenomena such as motivation (Crombez et al., 2012), associative learning (Krypotos et al., 2022;Vlaeyen, 2015), attentionregulation (Boselie & Vlaeyen, 2017;Crombez et al., 2012), personality (Crofford, 2015;Goubert et al., 2004;Wong et al., 2015), trauma (Afari et al., 2014), and social relationships (Edwards et al., 2016”
From Beyond yellow flags: The Big‐Five personality traits and psychologically informed musculoskeletal rehabilitation. (2023) · cites this paper as Crombez et al., 2012
In “Key Challenge 3” and “Call for the Next Generation” (pages unavailable), the paper says the fear-avoidance model has largely ignored broader motivation and needs a more explicit motivational perspective. Its “FA Model of Chronic Pain” section says attentional processes were not explicit in the original model, though hypervigilance was subsequently introduced. The cited paper discusses gaps in the fear-avoidance model, not explicitly in a ‘traditional yellow flag framework’; the other phenomena in the sentence are attributed to different citations. (LLM, conf=0.82)
Experimental — accuracy not yet measured
Fear can cause avoidance behaviors even in the absence of pain, creating a cycle of inactivity and disability, as described in the Fear-Avoidance Model.
“This fear can cause avoidance behaviors even in the absence of pain, creating a cycle of inactivity and disability, as described in the Fear-Avoidance Model.16, 17, 18”
From Role of Anxiety in Individuals with Generalized Joint Hypermobility: A Systematic Review (2025) · cites this paper as [17]
The FA MODEL OF CHRONIC PAIN section says fear of pain and injury can lead people to avoid activities they expect to worsen their condition, and that persistent avoidance may reduce activity and contribute to disability. It does not explicitly establish that this avoidance occurs when pain is absent; its discussion of anticipated future pain does not settle that qualifier. No page number was provided for these passages. (LLM, conf=0.84)
Experimental — accuracy not yet measured
The Fear-Avoidance Model describes core cognitive-behavioural processes, including pain catastrophising, pain-related fear, pain hypervigilance and pain avoidance, which contribute to the transition from acute to persistent pain, including maintaining and exacerbating processes.
“The Fear-Avoidance Model (FAM)65–71 describes core cognitive–behavioural processes, including pain catastrophising, pain-related fear, pain hypervigilance and pain avoidance, which contribute to the transition from acute to persistent pain, including maintaining and exacerbating processes.”
From Optimising psychological treatment for pain after breast cancer: a factorial design study protocol in Denmark (2023) · cites this paper as [67]
Fear avoidance limits the opportunity to attune expectations to actual experiences, leading to long-term disability.
“It is worth noting that fear avoidance limits the opportunity to attune expectations to actual experiences, leading to long-term disability [79].”
From Virtual Reality–Based Training in Chronic Low Back Pain: Systematic Review and Meta-Analysis of Randomized Controlled Trials (2024) · cites this paper as [79]

PTSD is associated with greater pain severity and disability among abuse victims.
“It is also associated with elevated pain severity and disability among abuse victims 73, 74.”
From Evaluating psychosocial contributions to chronic pain outcomes (2018) · cites this paper as [73]
At the core of the fear avoidance model is how patients interpret pain, and changing these interpretations is the key process of change.
“As a recent review of the model clarifies, 'at the core of the FA model is how patients interpret pain' (p 476) 12 and changing these interpretations is the key process of change within this approach.”
From The Psychological Flexibility Model: A Basis for Integration and Progress in Psychological Approaches to Chronic Pain Management (2014) · cites this paper as [12]
Recently some of those involved in the development of the FA model proposed that it needs to meet several important challenges and that this would create a next generation of the model.
“Recently some of those involved in the development of the FA model proposed that it needs to meet several important challenges and that this would create a next generation of the model. 12”
From The Psychological Flexibility Model: A Basis for Integration and Progress in Psychological Approaches to Chronic Pain Management (2014) · cites this paper as [12]
Three primary elements of the FA model were identified as lacking: a model of normal psychological processes rather than pathological ones, a proposal for how recovery from fear and avoidance is to occur, and appreciation of the context of multiple goals.
“Three primary elements of the model were identified as lacking: (a) a model of normal psychological processes rather than pathological ones, (b) a proposal for how recovery from fear and avoidance is to occur, and (c) appreciation of the context of multiple goals, meaning, in their words, that 'pain-related fear and avoidance cooccur [sic] in a context of multiple and often competing goals.' 12”
From The Psychological Flexibility Model: A Basis for Integration and Progress in Psychological Approaches to Chronic Pain Management (2014) · cites this paper as [12]

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Authors: Crombez, G., Eccleston, C., Van Damme, S., Vlaeyen, J. W. S., & Karoly, P.
Affiliations: Ghent University (BE)
KU Leuven (BE)
Maastricht University (NL)
Arizona State University (US)
Corresponding author: Crombez, Geert
ORCID: Crombez, Geert
Eccleston, Christopher
Vlaeyen, Johan W.S.
Karoly, Paul
Venue: The Clinical Journal of Pain
Publisher: Ovid Technologies (Wolters Kluwer Health)
Published: 2012-07
Volume: 28
Issue: 6
Pages: 475-483
ISSN: 0749-8047 (ISSN-L)
DOI: 10.1097/ajp.0b013e3182385392
OpenAlex: W2091637698
Cited by: 960
References: 116
Citations by year: 2026: 65 · 2025: 67 · 2024: 80 · 2023: 75 · 2022: 73 · 2021: 79 · 2020: 83 · 2019: 65 · 2018: 78 · 2017: 59 · 2016: 63 · 2015: 59 · 2014: 59 · 2013: 36 · 2012: 14
FWCI: 6.22
Type: journal article
Language: en
Open access: green
biblio.ugent.be
Licence: other-oa
Locations: Clinical Journal of Pain (publishedVersion)
PubMed (publishedVersion)
Ghent University Academic Bibliography (Ghent University) (submittedVersion, other-oa)
Lirias (KU Leuven) (submittedVersion, other-oa)
Funders: Fonds Wetenschappelijk Onderzoek
Universiteit Gent (BOF-GOA2006/001)
Topics: Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Treatment
Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Pediatric Pain Management Techniques
Keywords: fear-avoidance model, chronic pain, fear of pain, avoidance behavior, disability, functional recovery, goals, self-regulation, psychopathology
MeSH terms: Anxiety, Avoidance Learning, Fear, Forecasting, Humans, Models, Psychological, Chronic Pain

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