The perceived opportunity to avoid pain paradoxically increases pain-related fear through increased threat appraisals

Christine M van Vliet*, Ann Meulders, Linda M G Vancleef, Johan W S Vlaeyen

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

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BACKGROUND: Although pain-related avoidance is mainly intended to reduce the accompanying anticipatory fear, avoidance behavior may paradoxically increase fear when a previous avoidance response is no longer available, suggesting that there is a bidirectional relationship between pain-related fear and avoidance.

PURPOSE: We hypothesized that avoidance can serve as a source of information that fuels irrational pain-related threat appraisals, which, in turn, increases pain-related fear.

METHODS: Participants (N = 66) were exposed to a painful heat stimulus and randomly assigned to the avoidance or control group. They were instructed to avoid the full heat intensity by pressing a stop button in the presence of a stop cue. Only avoidance group participants received a stop cue and were allowed to press the stop button, while control group participants received the same instructions but never had the opportunity to avoid the full heat intensity. In reality and unknown to participants, the intensity and duration of the heat stimulus was independent of the avoidance response. In the subsequent test phase, the avoidance response was unavailable for both groups. We measured pain-related fear, threat appraisals/harmfulness, and pain intensity.

RESULTS: In line with our expectations, pain-related fear levels were higher when the avoidance response was no longer available compared to those when the avoidance response was available. Increased threat appraisals mediated the relationship between avoidance behavior and increased pain-related fear.

CONCLUSIONS: The perceived opportunity to avoid increased pain-related fear through threat appraisals, suggesting a more complicated relationship between pain-related fear, threat appraisals, and avoidance behavior than the unidirectional relationships proposed in the fear-avoidance model. Clinical implications are discussed.

Original languageEnglish
Pages (from-to)216-227
Number of pages12
JournalAnnals of Behavioral Medicine
Issue number3
Early online date25 Jul 2020
Publication statusPublished - Mar 2021


  • Avoidance
  • Pain intensity
  • Pain-related fear
  • Threat appraisals

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