Overcoming Fear of Chronic Pain

Fear of chronic pain is a natural reaction, but this emotion actually contributes to the pain cycle! Let’s figure out how to break the pain-fear cycle!

Acute pain is a warning system for your body and mind, letting you know something is wrong. So when you experience pain it’s natural to worry about it and protect the area that hurts. During acute pain when your body is injured, pain serves its protective purpose, helping the body to heal.

However, when pain becomes chronic, it means that this warning system is broken; you continue to experience pain without an injury or danger being present. So, while it’s natural that your reaction to chronic pain would be to focus on it, to worry about it and to want to rest to promote healing, this fear and avoidance behaviour can keep you locked in a fear and pain cycle, sustaining the pain experience indefinitely.

Many patients start to fear things that might make their pain worse, perhaps avoiding a situation which caused their original injury; maybe because a certain situation or action has made their chronic pain symptoms flare in the past; or sometimes even worrying about situations which aren’t based on any previous experience, anticipating pain before it happens.

What is the fear avoidance model?

The concept of patients avoiding situations that they feel may cause or worsen chronic pain was developed in the 1980s; this is now known as the fear avoidance model.

Patients develop and compound negative beliefs about their chronic pain and start to fear movement (also known as kinesiophobia). They fear that exercising and even normal day to day functioning that requires them to move their body, is going to worsen their pain or damage their body. This fear leads them to avoid those situations, acting in a way that they mistakenly feel is protecting themselves.

This fear and avoidance causes patients to become hypervigilant about their pain, meaning that they are constantly aware of it and considering it in every part of their life. They catastrophize about their pain, meaning that they are worrying about it in an extreme way. This study explains that, Pain-related fear of movement (kinesiophobia) leads to hypervigilance, muscular reactivity, and avoidance.

Fear activates our ‘fight or flight’ response and keeps us stuck in that chronic pain and stress cycle, one feeding into the other. There have been many studies that prove that patient’s who anticipate pain during an activity, will actually experience more pain and be able to function less, as shown in this study.

Fear of movement worsening their symptoms leads to patient’s avoiding exercise, avoiding socializing, going out, daily functioning and so much more; this increases isolation, depression and disability. Not moving their bodies then leads to muscles weakening, causing more stress on the body and more pain in turn; this is sometimes described as disuse syndrome. This article explains that disuse syndrome can cause,

cardiovascular vulnerability, obesity, musculoskeletal fragility, depression and premature aging.

How is fear avoidance measured?

One of the first steps to looking at moving forward from this fear avoidance, is to work out how much it is affecting an individual’s life. This is typically done with a questionnaire by medical professionals. There are a few types of questionnaire which might be used: Pain Anxiety Symptom Scale (PASS), Fear-Avoidance Components Scale (FACS), Fear-Avoidance Beliefs Questionnaire (FABQ), Tampa Scale of Kinesiophobia (TSK), Photograph Series of Daily Activities (PHODA). 

These scales sound complicated but essentially are all based around the same concept; they include questions that pose difference scenarios and situations, asking you to rate in severity how you experience your pain and how you react during certain situations in your day to day life. These sort of tools, alongside your clinical history and other tests, can help a medical professional to understand how your chronic pain is affecting your day to day life, how active you are and to what extent the fear avoidance model is influencing your life. From there they can help you to get the help that you need.

Therapies which address fear and chronic pain

Fear is a natural and understandable reaction to pain, it’s not usually a conscious or chosen reaction; it doesn’t mean that it’s your fault that you are in pain. I can completely understand as a chronic pain patient that this can sound daunting and perhaps can be interpreted as someone invalidating your pain. However, as you start to learn the science behind what is compounding your pain, you can become more consciously aware of how you are processing that pain, in order to improve your life.

The fear avoidance model can make things sound a bit dire but don’t worry, there are plenty of ways that you can break the cycle and overcome this fear. Let’s look at how fear can be treated and beaten.

  • Therapeutic Neuroscience Education

Educating patients about the cause of their pain and helping them to understand how it works can relieve anxiety and fear around pain; this can in turn calm an overactive pain system and reduce pain levels. 

  • Cognitive Behavioural Therapy (CBT)

Cognitive Behavioural Therapy (CBT) is a talking therapy that helps patients to understand how their thoughts can impact their behaviours; it helps you to replace negative thoughts like fear and behaviours like avoidance, with positive, helpful thoughts and behaviours which increase daily functioning, exercise and fundamentally, help you get your quality of life back.

CBT teaches patients to understand the cause of their pain; once you understand the science behind it, it helps to reduce that fear. It aids you in taking your focus away from catastrophizing about your pain and teaches you how to redirect that energy in a helpful way, so that you are taking control over your chronic pain.

  • Acceptance and Commitment Therapy (ACT)

Rather than changing the thoughts you are having about your pain, Acceptance and Commitment Therapy (ACT) focuses on accepting those thoughts and feelings, understand that what you are going through physically and emotionally is valid and that it isn’t going to ‘hurt’ you. 

ACT teaches you that a negative thought or a feeling of pain is just a feeling you are having in the present; you don’t have to run from it, you don’t have to try and ignore it or avoid it. This reduces fear and avoidance and instead empowers patients to face their condition head on and not limit their life. Depending on the individual, ACT or CBT may be more effective; both have proven results.  

  • Graded Exposure Therapy

Graded Exposure Therapy can be used to address all kinds of fears and phobias; it has proven results on fear avoidance with chronic pain. It works by gradually exposing patients to situations that they are afraid of, working up from situations that evoke only minimal concern and building confidence along the way.

As patient’s face situations that they thought they could not cope with or were afraid of, they actively see that they can face these situations and that their body wasn’t damaged by taking that action. Confidence in their own abilities grows while fear and helplessness is reduced.

You may hear reference to Graded Exercise Therapy, which is part of the same concept and focuses on actively increasing the amount and intensity of exercise a patient is doing.

This study found that Graded Exposure Therapy, “appears to be the most effective treatment for chronic pain in individuals with increased fear and avoidance”

  • Graded Motor Imagery

Graded Motor Imagery deals with the concept of central sensitization, which is basically an over sensitive nervous system causing chronic pain; it uses imagery techniques to help patients retrain their brains away from chronic pain.

Graded Motor Imagery has proven to be very effective in breaking the chronic pain cycle. This therapy essentially ‘rewires’ the brain, using imagery to guide the brain through the processes of a specific movement without activating the pain sensors; therefore, the brain learns that this movement doesn’t cause pain. It works on a step by step scale, working up to the patient being able to function and perform those movements without experiencing pain.

  • Physical Therapy

A physical therapist can help you with exercises to strengthen your body. They can help you re-learn how to move your body and build your confidence in daily functioning.

  • Mindfulness techniques

Mindfulness techniques can be varied and include activities like meditation, guided visualizations, yoga and more. Mindfulness is about being grounded in the moment, accepting the emotions you are feeling, the pain you may be experiencing and what is happening around you, rather than worrying about what is ahead. These sorts of techniques can help you to relax, which in turn reduces stress and helps you to get out of the pain and stress cycle.

What can you do to help yourself?

You might be wondering what you can to actively help yourself overcome this fear and avoidance.

  • Seek out therapy: the therapies we have mentioned can be accessed through your doctor, sought out privately, or accessed online through an app like Pathways Pain Relief (update Aug 2023: Pathways is now a web app! Start our program here). Advocate for yourself with medical professionals and seek out the help in the way that you feel is most appropriate for your situation.
  • Educate yourself: learning about what is causing your pain can allow you to see that your chronic pain condition is not going to damage your body; this can give you confidence in being more active and take that fear away.
  • Exercise regularly: trying to do regular gentle exercise is beneficial. Exercise can help you to build confidence and tackle avoidance behaviours, to build muscle strength and to be healthier overall.
  • Set goals: setting a list of goals for each day or for your future, can help to keep yourself motivated and give you purpose in being active and continuing to function even when your pain is at its worst.
  • Practice self-care: self-care is any action that is actively improving your life and helping yourself, whether this is doing something fun, eating healthy foods, doing your housework, taking medication or anything else. You deserve the best and that includes from yourself!
  • Don’t be too hard on yourself: this fear reaction is inherent within us, it’s completely natural and it doesn’t mean that you have done anything wrong. Don’t be too harsh with yourself, instead try to focus on what you can change.

Eliminating the fear of chronic pain and breaking the cycle is a long road, but it can be done. You can take control back and live a high functioning, joy-filled life without fear of your chronic pain! 

Please note: This article is made available for educational purposes only, not to provide personal medical advice.


  • Pain Medicine, Volume 2, Issue 4, Pages 259-266, Michael Pfingsten, PD, PhD, Eric Leibing, DSc, Wulf Harter, PhD, Birgit Kröner-Herwig, Doreen Hempel, Uta Kronshage, Jan Hildebrandt, (2001), “Fear-Avoidance Behavior and Anticipation of Pain in Patients With Chronic Low Back Pain: A Randomized Controlled Study”
  • The Western Journal of Medicine, Bortz WM, (1984), “The disuse syndrome.”
  • The Anterior Cruciate Ligament, Second Edition, Pages 498-500. Mark F.Sommerfeldt MD. FRCSC., LouiseThoma DPT., Laura C.Schmitt PT, PhD., Joshua S.Everhart MD., David C.Flanigan MD, (2018), “Psychological Predictors of Anterior Cruciate Ligament Recovery Outcomes”
  • Practical Pain Management, Volume 19, Issue 5, David Cosio, PhD, ABPP, (2019), “Fear-Avoidance and Chronic Pain: Helping Patients Stuck in the Mouse Trap”
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  • Steven Z. George, PT, PhD.,Virgil T. Wittmer, PhD., Roger B. Fillingim, PhD., Michael E. Robinson, PhD, (2010), “Comparison of Graded Exercise and Graded Exposure Clinical Outcomes for Patients With Chronic Low Back Pain”
  • Journal of Clinical Psychology in Medical Settings, Volume 14, Issue 2, pp 113–122, Jessica A. Lohnberg, (2007), “A Review of Outcome Studies on Cognitive-Behavioral Therapy for Reducing Fear-Avoidance Beliefs Among Individuals With Chronic Pain”
  • Translational Behavioural Medicine, Thomas P Guck, PhD, Raymond V Burke, PhD, Christopher Rainville, MD, Dreylana Hill-Taylor, MD, Dustin P Wallace, PhD, (2014), “A brief primary care intervention to reduce fear of movement in chronic low back pain patients”

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