Recent research finds that fear-avoidance beliefs may not be a high risk factor in contirbuting to chronic pain. (Photo by Yan Krukau)
For decades, fear-avoidance beliefs have played a central role in how clinicians and researchers understand chronic pain. When pain is interpreted as a sign of harm, people may avoid movement or activity, leading to physical deconditioning, emotional distress, and disability. This framework has shaped assessment tools, treatment approaches, and patient education across pain care.
However, a 2025 study published in The Clinical Journal of Pain suggests the psychological landscape of chronic pain may be more interconnected and more nuanced than fear-based models alone imply.
A team of researchers, led by Dr. Gwen van der Wijk from the University of Maastricht in the Netherlands, used a complex systems approach to examine how fear, avoidance, mood symptoms, pain intensity, and disability relate to one another when analyzed together rather than each factor in isolation. Their findings point to a dense web of psychological factors with depression and pain intensity emerging as stronger drivers of disability than fear-avoidance beliefs once other variables are accounted for.
Beyond single-factor explanations
Chronic pain is widely recognized as a biopsychosocial condition, shaped by biological processes, psychological states, and social context. Yet much of the existing research has focused on individual pathways, such as fear leading to avoidance, or anxiety worsening pain, without examining how these elements interact simultaneously.
To address this gap, the research team analyzed data from two large clinical samples in Belgium, totaling more than 2,300 patients with chronic musculoskeletal pain. Participants completed standardized questionnaires measuring pain-related fear, avoidance beliefs, anxiety, depression, pain intensity, and pain-related disability.
Rather than testing a single causal model, the researchers used network analysis, a statistical method that maps how variables are conditionally related to one another within a system. In this framework, each psychological factor is represented as a “node,” and connections between nodes reflect unique associations after controlling for all other variables.
The result is a visual and quantitative representation of chronic pain as an interacting psychological network rather than a linear chain of cause and effect.
What the networks revealed
Across both patient samples, the researchers observed dense networks of positive relationships among all six variables. Pain-related disability sat at the center of these networks, connected to fear, avoidance, anxiety, depression, and pain intensity.
However, when the relative importance of each factor was examined, fear-avoidant beliefs were less central than many earlier studies have suggested. Depression and pain intensity showed the strongest and most consistent unique associations with disability, meaning they explained more variance in functional impairment when all factors were considered together.
A highly central factor like depression in Sample A or pain-related disability in Sample B is not just present alongside other symptoms but are strongly intertwined with them. Changes in these highly central factors are more likely to ripple through the system.
Pain intensity has low centrality in both samples, meaning it is relatively weakly connected to other symptoms. This helps explain why reducing pain severity alone often does not lead to meaningful improvements in function or mental health.
This does not mean fear-avoidance beliefs are irrelevant. Rather, the findings suggest that their influence may be smaller and more context-dependent than previously assumed, particularly when mood symptoms and pain severity are also present.
The findings echo a growing body of research suggesting that fear alone may not be the primary force shaping life with chronic pain. A 2023 study analyzed data from more than 1,600 people living with chronic pain and found that fear-related beliefs, while present, were not the most influential factors in predicting disability. Instead, pain intensity and emotional distress — particularly depression — played a stronger role in determining how much pain interfered with daily life.
A similar pattern emerged in A network analysis of clinical variables in chronic pain, which examined how psychological symptoms, pain severity, and functional limitations interact across patient populations. That study found that pain intensity and mood symptoms consistently sat at the center of the network, while fear-avoidance beliefs played a more peripheral role.
Pain intensity still matters
While some models have emphasized fear as more disabling than pain itself, this study found that pain intensity had the strongest unique relationship with disability across both samples.
Because the data are cross-sectional, the study cannot determine whether higher pain causes greater disability or whether disability exacerbates pain or both. Still, the findings reinforce the idea that pain severity should not be downplayed when considering functional outcomes.
For clinicians, this highlights the importance of addressing both subjective pain experience and psychological distress rather than prioritizing one domain at the expense of the other.
Subtle shifts at higher pain levels
The study also explored whether pain intensity or fear affected relationships within the psychological network. Two small effects emerged in one of the samples: As pain intensity increased, the relationship between avoidance and disability weakened, and the relationship between avoidance and anxiety shifted from slightly negative to slightly positive.
These effects were modest and not consistently stable across analyses, meaning they should be interpreted cautiously. Still, the researchers raised the possibility that psychological patterns may change depending on how severe a person’s pain is. This idea could have implications for tailoring interventions to different patient subgroups.
Equity and context
Although the study focused on psychological variables, its findings also intersect with broader conversations about equity in pain care. Depression, anxiety, and pain intensity do not exist in a vacuum. They are shaped by social stressors, access to care, prior treatment experiences, and structural inequities, which are often unevenly distributed across populations.
As previously covered in health equity in pain care, chronic pain research frequently lacks detailed social and demographic data, limiting insight into how psychological models apply across diverse groups.
When depression and pain severity emerge as central drivers of disability, it raises questions about how socioeconomic stress, discrimination, and healthcare access may indirectly influence functional outcomes by shaping these very factors.
Understanding chronic pain as a complex system may therefore complement efforts to make pain research more representative and clinically relevant, rather than relying on simplified psychological explanations that may not hold across contexts.
The authors emphasized that their findings do not invalidate fear-avoidance theory; instead, it contributes to identifying robust cross-sectional patterns that any comprehensive theory of chronic pain must account for.
For clinicians, this perspective reinforces the value of multidisciplinary care, addressing mood, pain severity, beliefs, and function together while remaining cautious about overemphasizing any one psychological factor.
Dezare Lozano
Dezare graduated from of San Diego State University in 2025 where she earned a degree in journalism with a minor in English. During her studies, she emphasized news writing and gained experience reporting and producing news stories.
Dezare is focused on expanding her skills across additional areas of journalism, including working in a newsroom at a large newspaper organization and traveling to capture compelling photojournalism. She also aspires to become a journalism professor in the future.
In her free time, Dezare enjoys sharpening her camera and writing skills. She also likes cooking, animating, and working on creative writing side projects.
