A major meta-analysis of 335 studies and over 65,000 participants found that how we think and feel about pain may be closely linked to disability, anxiety, and depression. Here’s what the research suggests.
Pain is something most of us experience at some point. For many people, however, it becomes a long-term problem. Chronic pain, defined as pain lasting three months or longer, is thought to affect roughly one in ten people worldwide.
Living with chronic pain can affect far more than the body. Research consistently links it with anxiety, depression, reduced mobility, and lower quality of life. Treating chronic pain often involves a range of approaches, from painkillers and physical therapy to psychological support.
But why do some people with pain recover while others go on to develop lasting disability? A growing body of evidence points to psychological factors, particularly the way a person thinks about and responds to their pain, as playing a key role.
What Is the Fear-Avoidance Model of Pain?
The fear-avoidance model is the most widely studied psychological framework for understanding chronic pain. It was first described in the late 1990s and has been refined over more than two decades of research.
In simple terms, the model suggests that when people experience pain, certain psychological responses can make things worse. These responses include:
- Pain catastrophising – a pattern of exaggerated negative thinking about pain, such as believing the worst will happen or feeling helpless.
- Fear of pain – a state of dread or anxiety about experiencing pain, which may include avoiding movement (sometimes called kinesiophobia) and heightened physical tension.
- Pain vigilance (hypervigilance) – a tendency to pay very close attention to pain sensations, which may amplify the experience.
According to the model, these responses can lead to avoidance behaviours. People may stop exercising, withdraw from social activities, or limit their daily routines. Over time, this avoidance can contribute to increased disability, emotional distress, and a cycle of worsening pain.
What Did the Meta-Analysis Examine?
A meta-analysis published in the European Journal of Pain in 2022 brought together data from 335 studies involving over 65,000 participants. The researchers aimed to assess the strength of the link between the core components of the fear-avoidance model and five key outcomes:
- Pain-related negative affect (emotional responses to pain such as anger or helplessness)
- Anxiety
- Depression
- Pain intensity
- Pain-related disability
The review included adults experiencing a wide range of pain conditions, from chronic low back pain and fibromyalgia to cancer-related pain and neuropathic pain. The studies were drawn from the MEDLINE and PsycInfo databases.
What Did the Research Find About Pain Catastrophising?
Pain catastrophising showed a moderate association with all five outcomes measured. The strongest and most consistent links were with anxiety and depression, with pooled correlations of 0.50 and 0.51 respectively, based on data from thousands of participants.
The association with pain-related disability was also moderate (pooled correlation 0.45), while the link with pain intensity, though still statistically meaningful, was somewhat smaller (pooled correlation 0.38).
These findings suggest that the tendency to think about pain in catastrophic terms may be an important factor in the overall pain experience, and may be more closely linked with mental health outcomes and disability than with pain severity itself.
Important: These findings are based on cross-sectional data, meaning the studies measured associations at a single point in time. They cannot confirm that pain catastrophising causes worse outcomes, only that the two tend to occur together.
What Did the Research Find About Fear of Pain?
Fear of pain also showed moderate associations with emotional distress and disability. The pooled correlations ranged from 0.27 for pain intensity to 0.41 for depression, based on data from between 8,670 and 20,028 participants depending on the outcome.
An interesting finding was that the strength of the association varied depending on which questionnaire was used to measure fear of pain. Tools such as the Pain Anxiety Symptoms Scale (PASS) tended to show stronger associations than the Fear of Pain Questionnaire (FPQ). This suggests that different questionnaires may be measuring slightly different aspects of pain-related fear.
Overall, the pattern of results reinforces the idea that fear and avoidance of pain are associated with worse emotional and functional outcomes, supporting the core predictions of the fear-avoidance model.
What About Pain Vigilance and Hypervigilance?
Fewer studies examined pain vigilance, but the available evidence pointed in a similar direction. Pain vigilance showed moderate associations with anxiety, depression, pain intensity, and disability, though these findings were based on smaller numbers of studies (between 9 and 21).
No studies were found that assessed the link between pain vigilance and pain-related negative affect. The authors noted this as an important gap in the evidence, given that the fear-avoidance model predicts vigilance should be related to emotional outcomes.
Some researchers have suggested that pain vigilance may not be an entirely independent factor, but may instead depend on pain catastrophising and fear of pain. More research is needed to clarify these relationships.
What Do These Findings Mean for People Living with Chronic Pain?
Taken together, the results of this meta-analysis suggest that psychological responses to pain, particularly catastrophising and fear of pain, are moderately associated with disability, anxiety, and depression in people with pain conditions.
This supports the view that chronic pain is not simply a physical problem. The way a person thinks about and responds to pain appears to be closely linked with their overall wellbeing and ability to function.
Pain catastrophising showed the strongest associations across all outcomes. This suggests it may be a particularly important psychological factor in the pain experience.
The findings are consistent with a biopsychosocial understanding of pain, which recognises that biological, psychological, and social factors all contribute to the experience of chronic pain. This perspective has informed the development of a range of psychological therapies for pain management.
What Treatments May Help Address Fear-Avoidance in Chronic Pain?
Several psychological therapies are designed to target the processes described in the fear-avoidance model. Previous research has suggested that approaches such as cognitive behavioural therapy (CBT), graded exposure therapy, and acceptance and commitment therapy (ACT) may help reduce pain catastrophising, fear of pain, and associated disability. However, outcomes can vary between individuals.
Beyond psychological approaches, chronic pain management typically involves a combination of strategies. These may include physical therapy, exercise programmes, and medications such as non-steroidal anti-inflammatory drugs (NSAIDs) or, in some cases, opioids. Each approach has its own potential benefits and risks, and what works best can vary from person to person.
What Are the Limitations of This Research?
It is important to consider the limitations of this meta-analysis when interpreting the findings:
- All included studies were cross-sectional, meaning they measured variables at a single point in time. This means the research cannot establish whether psychological factors cause worse pain outcomes, or vice versa.
- There was high variability (heterogeneity) between studies across most outcomes, which suggests that results may differ depending on the population studied, the questionnaires used, and other factors.
- For pain intensity, there was evidence of small-study bias, meaning smaller studies may have produced somewhat inflated results.
- The number of studies examining pain vigilance was relatively small, so the evidence for this component of the model is less robust.
- The research relied on self-report questionnaires, which may not fully capture the complexity of pain-related fear and behaviour.
How Is Chronic Pain Managed in the UK?
In the UK, chronic pain is typically managed through a combination of approaches tailored to the individual. These may include physical therapies, psychological support, lifestyle changes, and medications. For some patients, commonly used medicines may not provide adequate relief, or may be associated with unwanted side effects.
Since November 2018, medical cannabis has been available on prescription from specialist doctors in the UK. It is typically considered only where conventional treatments have not been effective. Patients with chronic pain and other conditions may be eligible for a specialist consultation to discuss whether medical cannabis could be a suitable option for them.
Medical cannabis is not suitable for everyone and is not a first-line treatment. It is prescribed only by specialist doctors after a thorough assessment of a patient’s medical history and previous treatments. This article is for informational purposes only and does not constitute medical advice. If you are experiencing chronic pain, please speak to a healthcare professional about the options available to you.
Could You Be Eligible for a Consultation?
If you are living with chronic pain and have found that other treatments have not provided adequate relief, you may be eligible for a specialist consultation. Complete our free online eligibility assessment to find out more.
