Pain 99 (2002) 485–491

www.elsevier.com/locate/pain

Fear-avoidance beliefs and catastrophizing: occurrence and risk factor in

back pain and ADL in the general population
Nina Buer a,b,*, Steven J. Linton c
a
Neurotec Department, Division of Physiotherapy, Karolinska Institute, Stockholm, Sweden
b
Department of Health Promotion for Personnel, Örebro University Hospital, SE-701 85 Örebro, Sweden
c
Department of Occupational and Environmental Medicine, Örebro University Hospital, SE-701 85 Örebro, Sweden
Received 11 April 2002; accepted 21 June 2002

Abstract
Fear-avoidance beliefs and catastrophizing have been shown to be powerful cognitions in the process of developing chronic pain problems
and there is a need for increased knowledge in early stages of pain.
The objectives of this study were therefore, firstly, to examine the occurrence of fear-avoidance beliefs and catastrophizing in groups with
different degrees of non-chronic spinal pain in a general population, and secondly to assess if fear-avoidance beliefs and catastrophizing were
related to current ratings of pain and activities of daily living (ADL).
The study was a part of a population based back pain project and the study sample consisted of 917 men and women, 35–45 years old,
either pain-free or with non-chronic spinal pain. The results showed that fear-avoidance beliefs as well as catastrophizing occur in this
general population of non-patients. The levels were moderate and in catastrophizing a ‘dose–response’ pattern was seen, such that more the
catastrophizing was, the more was pain. The study showed two relationships, which were between fear-avoidance and ADL as well as
between catastrophizing and pain intensity. Logistic regression analyses were performed with 95% confidence intervals and the odds ratio for
fear-avoidance beliefs and ADL was 2.5 and for catastrophizing and pain 1.8, both with confidence interval above unity. The results suggest
that fear-avoidance beliefs and catastrophizing may play an active part in the transition from acute to chronic pain and clinical implications
include screening and early intervention. q 2002 International Association for the Study of Pain. Published by Elsevier Science B.V. All
rights reserved.
Keywords: Back pain; Catastrophizing; Fear-avoidance beliefs; General population

1. Introduction avoidance behaviour and suggested that avoidance beha-

The term fear-avoidance was first coined by Lethem et al.
(1983) while describing the fear-avoidance model of exag-
gerated pain perception. According to this model there are
two extreme responses to pain: the adaptive response or
confrontation and the non-adaptive response or avoidance.
The confronter is likely to view pain as something tempor-
ary and therefore prepared to confront the pain. Furthermore
he/she is probably motivated to return to work and normal
activities. The importance of psychological mechanisms
and consequences will in this case be minor. Avoidance,
on the other hand, might create physical as well as psycho-
logical consequences that increase the individual’s beliefs
of feared but also actual disability. The avoidance behaviour
may in this case be promoted and prolonged. Later, Philips
(1987) emphasised the importance of cognitions influencing
* Corresponding author. Tel.: 146-19-602-5772; fax: 146-19-602-5778.
E-mail address: nina.buer@orebroll.se (N. Buer).
viour is a prominent component of chronic pain. The direct
relationship between pain and disability has been shown to
be low (e.g. Riley et al., 1988; Williams et al., 1989;
Waddell et al., 1993; Linton and Buer, 1995) and the impact
of cognitive processes, like beliefs and expectations have
been found to be important.
These first theoretical propositions have been followed by
a number of publications aiming at delineating the role that
fear-avoidance beliefs play in the development and main-
tenance of pain in chronic pain patients (Crombez et al.,
1999; Waddell et al., 1993; Vlaeyen et al., 1995a, Asmund-
son et al., 1999).
Vlaeyen et al. (1995b) suggested a more specific form of
fear-avoidance, namely fear of movement/(re) injury, see
Fig. 1. A chain of reactions including catastrophizing and
avoidance can lead to disuse, disability and depression,
creating a vicious circle. The non-catastrophizing and
confronting alternative would promote recovery.

0304-3959/02/$20.00 q 2002 International Association for the Study of Pain. Published by Elsevier Science B.V. All rights reserved.
PII: S 0304-395 9(02)00265-8
486 N. Buer, S.J. Linton / Pain 99 (2002) 485–491
Fig. 1. Cognitive-behavioural model of fear-of-movement/(re) injury based on Vlaeyen et al. (1995b).
A relationship between fear-avoidance beliefs, as power-
ful and specific cognitive behavioural components, and
chronic pain has been reported in the literature (Waddell
et al., 1993; Burton et al., 1995; Vlaeyen et al., 1995a,b,
1999; Asmundson and Taylor, 1996). Catastrophizing,
which is said to be the exaggerated and negative orientation
toward pain, may have a role as a mediator to pain (Geisser
et al., 1994; Sullivan et al., 1995; Crombez et al., 1998a).
Individuals that catastrophise, expect that they cause a new
episode of pain or activate an earlier injury. That could
create fear of movement and reinforcement of avoidance
behaviour. The issue of fear-avoidance beliefs raises further
questions, since most of the research is conducted with
chronic low back pain patients. Are fear-avoidance beliefs
developed in a chronicity process and thus a result of the
pain process, in line with theories of learning? Are fear-
avoidance beliefs presented already before injury, as a
tendency to react in an avoiding way generally?
The body of knowledge has to date some limitations
concerning the level of fear-avoidance beliefs in the acute
phase of pain. Fritz et al. (2001) showed that fear-avoidance
beliefs about work were present in acute low back pain
patients. Furthermore, the beliefs functioned as a predictor
of 4-week disability. In a prospective study, fear-avoidance
beliefs had a relationship with the inception of back pain 1
year later (Linton et al., 2000).
In order to search for some of the answers, further studies
are needed, among others, to investigate if these beliefs
occur in the normal population. There are numerous pain
experiences from different locations of the body that indi-
viduals can relate to and also different modes of pain. In a
cross-sectional design, we wanted to focus on pain experi-
ences from the spinal area, i.e. back, neck and shoulders,
since these locations are very common sites for pain. We
wanted to utilise the possibility to grade different levels of
non-chronic pain that might be a factor that influenced the
reporting of fear-avoidance beliefs. Individuals without pain
from the back, neck and shoulders would also constitute one
category. Another aspect of fear-avoidance beliefs concerns
the impact on pain experience and activities of daily living
(ADL) and the role of fear-avoidance beliefs as a risk factor.
Since catastrophizing forms a part of the fear of movement/
(re) injury model, the role of catastrophizing was also a
matter of interest.
The objective of this study was two-fold, firstly to exam-
ine the occurrence of fear-avoidance beliefs and catastro-
phizing in groups with different degrees of non-chronic
spinal pain in a general population, and secondly to assess
if fear-avoidance beliefs and catastrophizing are related to
current ratings of pain and ADL.
2. Methods
2.1. Design
This is a cross-sectional study from the population based
middle-Sweden Back Pain project (Linton et al., 1998), at
the Department of Occupational and Environmental Medi-
cine at the Örebro University Hospital. A screening postal
questionnaire was distributed to a random sample of 3000
35–45 year olds from the census (Sema Group Infodata,
Stockholm, Sweden), who were residents in three different
communities in central Sweden representing rural and city
environments. Based on self-reports from this pool of 3000,
individuals were selected and an additional questionnaire
was subsequently distributed.
2.2. Selection
The response rate from the random sample of 3000 indi-
viduals was 2329 (78%). Sixty-five individuals were
excluded because either of early retirement or misreporting
about age or gender, leaving 2264. Since the matter of inter-
est was non-chronic pain, another 793 individuals were
excluded due to the over all exclusion criterion which was
sick leave .30 days. Leaving 1471, subjects were selected
into one of three categories of pain intensity, labelled no
pain, mild pain and moderate pain. Individuals who had
indicated that they had not experienced pain from the low
back, neck or shoulders during the past 12 months were
labelled no pain. Individuals who reported that they had
experienced some pain (#4) from the low back, neck or
shoulders on a numeric rating scale (NRS) for pain intensity
(0–10), and had been sick-listed ,15 days, formed the mild
 N. Buer, S.J. Linton / Pain 99 (2002) 485–491
pain category. Individuals that reported pain (NRS $5) and
that they had ,31 days off work, constituted moderate pain.
An additional questionnaire was distributed to the 1471
individuals and the response rate was 949 or 65%. Due to
missing data on one of the instruments for prediction, the
modified form of the fear-avoidance beliefs questionnaire
(mFABQ, see below), 32 individuals were excluded, leav-
ing 917 to constitute the study group.
2.3. Subjects
The no pain category finally consisted of 431 individuals;
the mild pain 222 individuals and the moderate pain 264
individuals. Mean age in each of the groups was 40 years
and the distribution between men and women was quite
similar at about 50% women in each of the groups. The
age stratum 35–45 years old was chosen due to the fact
that there seems to be a peak in back pain incidence around
40 years of age (Biering-Sörensen, 1984).
2.4. Assessment instruments
The additional questionnaire was distributed after the
selection procedure and it contained instruments to measure
fear-avoidance beliefs, catastrophizing and ADL. Fear-
avoidance beliefs were measured by a modified form of
FABQ (Waddell et al., 1993), which is a 16-item, self-report
scale that focus specifically on patient’s beliefs about how
physical activity and work affects their pain. Four items
were selected from the physical activity factor to form the
modified version (mFABQ). The statements were modified
in order to also be answered by the group of individuals that
did not have pain. The items were: 1. pain is caused by
physical activity; 2. physical activity makes one’s pain
worse; 3. physical activity might be harmful; and 4. one
should not do physical activities which (might) make
one’s pain worse. Consistent with the FABQ, the items
are answered on a verbal (Likert-type) scale on a 0–6
basis (score sum 0–24), from strongly disagree to strongly
agree, high scores indicate stronger beliefs. In a pilot testing
with 36 acute back pain sufferers, the four-question mFABQ
was found to be highly correlative with the five-question
physical activity scale of the FABQ (r ¼ 0:97).
The pain and catastrophizing scale (PCS) (Sullivan et al.,
1995) was included in order to detect exaggerated and nega-
tive interpretations of pain. The PCS is a self-report scale
that consists of 13 items. The respondents were asked to
reflect on past painful experiences and the respondent is to
indicate to which degree he/she experienced e.g. helpless-
ness or rumination, when feeling pain. This is made on a 0–4
basis (score sum 0–52) from not at all to all the time, high
score sum indicating stronger catastrophizing.
Five questions dealt with ADL (Linton, 1990). Respon-
dents rated how well they could participate in these activ-
ities on a 0–10 scale, and ‘cannot do it because of pain’ to
‘can do it without a pain problem’, were written at the
endpoints. A total score (0–50) is obtained by summing
487
the scores, high scores indicate higher levels of activity.
Since the questions assume that the participants have back
pain, the individuals with no pain could not complete these
questions. The Research Ethics Committee, Örebro Univer-
sity Hospital, approved the study.
2.5. Statistical analyses
To describe the occurrence of fear-avoidance beliefs and
catastrophizing, score sums were calculated for the mFABQ
(fear-avoidance beliefs) and the PCS (catastrophizing) and
presented for each of the three categories: no pain, mild pain
and moderate pain. Due to the skewed distribution, the
median was used as a measure of central tendency and
quartiles as a measure of dispersion. Box and Whisker-
plots graphically display the distribution. Differences
between categories were tested with the Kruskal–Wallis
non-parametric analysis of variance.
To introduce a multivariate perspective, we performed
logistic regression analysis where fear-avoidance beliefs
and catastrophizing were used simultaneously as predictor
variables for pain and ADL. In these analyses we also tested
for statistical interaction between mFABQ and PCS, but
since interaction was rejected at the 5% significance level
the model was reformulated as a purely additive model
without interactions. Adjustments were also made for smok-
ing and gender since they are known risk factors and possi-
ble confounders (Nachemson and Jonsson, 2000). Pain as an
outcome variable, was dichotomised into no pain and pain,
where the mild and moderate pain categories constituted
‘pain’. The other outcome variable was ADL, where a
median split was used.
3. Results
3.1. Fear-avoidance beliefs
One of the objectives was to examine the occurrence of
fear-avoidance beliefs in a general population. In order to
perform this, a three-category selection based on pain
reporting and sick leave was used. The illustration in Fig.
2 shows the relative frequency of 917 sum scores from the
mFABQ, where higher sum scores mean more fear-avoid-
ance beliefs. It demonstrates that fear-avoidance beliefs are
present in this general population with non-chronic pain.
The scores range through the whole scale in all the three
categories and differences between categories seem to be
quite small. The distribution is non-normal (Shapiro–Wilk
W test for normality).
Another image of fear-avoidance beliefs in the general
population is illustrated in Fig. 3. Although the three cate-
gories showed distinguished characteristics in pain, the level
of fear-avoidance beliefs i.e. the central tendency did not
differ much between the groups and a ‘dose–response’
pattern was not seen. A comparison of the categories
showed a quite small but statistically significant difference
488 N. Buer, S.J. Linton / Pain 99 (2002) 485–491

Fig. 2. Relative frequency and distribution of sum scores (0–24) for fear-avoidance beliefs measured by the four-question modified fear-avoidance beliefs
questionnaire (mFABQ), divided by the three pain categories. Total n ¼ 917.

(Kruskal–Wallis P , 0:05), however, probably caused by P , 0:01) probably, however, influenced by the large
the large number of subjects. number of subjects.

3.3. Effects on pain

3.2. Catastrophizing
We wanted to investigate the relationship between fear-
Catastrophizing, as measured by the PCS, seems to have a
avoidance beliefs and pain. Table 1 summarises the fear-
tendency towards a more stepwise pattern of ‘dose–
avoidance beliefs used as a predictor variable for the risk of
response’. Fig. 4 indicates that higher level of pain has a
experiencing pain. Pain was dichotomised into pain/no pain.
relationship with more catastrophizing, with small differ-
The results showed that the risk of experiencing pain was
ences that are statistically significant (Kruskal–Wallis
somewhat increased by fear-avoidance beliefs. The adjusted

Fig. 3. Box and Whisker-plot with median, range, first and third quartile for
score sums of fear-avoidance beliefs measured by the four-question modi-
fied fear-avoidance beliefs questionnaire (mFABQ), each pain category
illustrated. No pain md ¼ 9, mild pain md ¼ 8, moderate pain md ¼ 10.
Total n ¼ 917.
Fig. 4. Box and Whisker-plot with median, range, first and third quartile for
score sums of catastrophizing measured by the PCS, each pain category
illustrated. No pain md ¼ 9, mild pain md ¼ 10, moderate pain md ¼ 12.
Total n ¼ 912. p ¼ extreme out-lier
 N. Buer, S.J. Linton / Pain 99 (2002) 485–491 489

Table 1
Adjusted odds ratio (OR) for pain (n ¼ 886, missing cases n ¼ 26) a

n Adjusted OR b 95% CI

mFABQ Q1 0–5 225 (reference category) 1.00 –

Q2 6–8 188 0.99 0.67–1.47
Q3 9–12 215 0.95 0.65–1.39
Q4 13–24 258 1.25 0.87–1.81
PCS 0–9 403 (reference category) 1.00 –
10–52 483 1.75 1.33–2.30
a
The fear-avoidance beliefs questionnaire (mFABQ) is divided by quartiles and the pain catastrophizing scale (PCS) is divided by the median.
b
Adjusted for smoking and gender.

odds ratio (OR) for fear-avoidance beliefs’ effect on pain
was 1.25 for the fourth quartile, but the 95% confidence
interval (CI) fell below unity (0.87–1.81). Catastrophizing
as a risk factor showed a somewhat higher OR ¼ 1.75, with
95% CI above unity (1.33–2.30). Thus, the relationship
between fear-avoidance beliefs and pain was slightly
weaker than for catastrophizing and pain.
3.4. Effects on ADL
ADL was also used as an outcome variable for fear-
avoidance beliefs and catastrophizing and was divided by
the median for the logistic regression analysis. Fear-avoid-
ance beliefs as a risk factor for influencing ADL, i.e. for
individuals to have a lower level of activity, were more than
doubled, OR ¼ 2.5 for the highest quartile. Here, we found a
stepwise dose–response pattern that was statistically signif-
icant for all levels. For catastrophizing as a risk factor for
influencing the level of activity, the OR was 1.8 (see Table
2). The 95% CI’s all fell above unity. In summary, the
relation between fear-avoidance beliefs and ADL was
more pronounced than the one for catastrophizing.
4. Discussion
The overall aim of this study was to examine the role that
fear-avoidance beliefs and catastrophizing play in pain and
disability with a sample from the general population. We
found that in this population, fear-avoidance beliefs and
catastrophizing were present in the early stages of the pain
process and also that the findings are in line with the fear of
movement/(re) injury model (Vlaeyen et al., 1995b) as well
as previous studies with chronic pain patients (Vlaeyen and
Linton, 2000). The results indicate that fear-avoidance
beliefs and catastrophizing might be good screening vari-
ables and also important targets for early interventions.
One of the aims was to examine the occurrence of fear-
avoidance beliefs and catastrophizing in this non-chronic
population. Catastrophizing was present at quite low levels,
but however, showed a ‘dose–response’ pattern, such that
higher the level of catastrophizing, the more pain was
reported. This is in line with the excessive focus on pain
sensations and hypervigilance for threatening somatic infor-
mation that is suggested to be a characteristic of catastro-
phizing (Crombez et al., 1998a, Sullivan et al., 1995). In
terms of fear-avoidance beliefs, they were present at a
moderate level with a small tendency towards a difference
between pain categories, i.e. no pain, mild pain and moder-
ate pain. The level of beliefs may be due to the fact that the
items of the mFABQ relate more to physical activity than to
pain. We had expected that the different pain categories
would relate to the reporting of fear-avoidance beliefs in a
‘dose–response’ pattern, but our results suggest that this
relationship is not especially strong at this early stage.
With regard to the second aim, which was to assess the
relationship of fear-avoidance beliefs and catastrophizing to
ratings of pain and ADL, we found that fear-avoidance and
ADL were related. The results showed a stepwise ‘dose–
response’ pattern, with confidence intervals above unity for
all levels. The OR was 2.5 for the fourth quartile, i.e. the OR

Table 2
Adjusted odds ratio (OR) for ADL (n ¼ 462, missing cases n ¼ 24) a

n Adjusted OR b 95% CI

mFABQ Q1 0–5 117 (reference category) 1.00 –

Q2 6–8 96 1.82 1.03–3.22
Q3 9–12 106 2.32 1.33–4.06
Q4 13–24 143 2.47 1.46–4.19
PCS 0–9 177 (reference category) 1.00 –
10–52 285 1.80 1.20–2.68
a
The modified fear-avoidance beliefs questionnaire (mFABQ), is divided by quartiles and the pain catastrophizing scale (PCS), is divided by the median.
b
Adjusted for smoking and gender.
490 N. Buer, S.J. Linton / Pain 99 (2002) 485–491
of having a decreased ADL was more than doubled for the
highest fear-avoidance beliefs. This is in agreement with the
results from a study with chronic pain patients (Waddell et
al., 1993), with the strongest relationship between disability
in ADL and fear-avoidance beliefs about work and activ-
ities. One clinical problem of back pain sufferers, among
others, is the decrease in mobility and activity, both physi-
cally and socially. In a study where patients were classified
into either confronters or avoiders, the authors suggested a
close link between fear cognitions related to pain/(re) injury
and avoidance and physical deconditioning (Crombez et al.,
1998b). As for fear-avoidance in relation to pain, the
adjusted OR was 1.25 for the fourth quartile, but this result
was not statistically significant. These results indicate a
stronger relationship between fear-avoidance beliefs and
level of activity than fear-avoidance beliefs and pain.
Catastrophizing was related to ADL with an OR of 1.8
and the OR for catastrophizing in relation to pain was about
the same at 1.75. A possible confounder of effects could be
the interrelationship between fear-avoidance beliefs and
catastrophizing, which was however, statistically controlled
as both variables and their interaction were tested and then
the interaction was rejected. In summary, we found clear
relationships between pain intensity and catastrophizing as
well as between ADL and fear-avoidance beliefs.
It is necessary to consider limitations in this study and
two issues on the matter of methodology are important to
raise. This study employs a cross-sectional design and there-
fore causal inferences of the results cannot be made.
Secondly, both the dependent and the independent variables
are based on self-reports. This is a subjective measure,
however, our aim was to assess the relationship of fear-
avoidance beliefs and catastrophizing based on the subject’s
current ratings of pain and ADL. In the literature, the influ-
ence of fear-avoidance beliefs and catastrophizing to date
has been more focused on chronic pain than towards the
non-chronic perspective. Since the subjects were selected
from a population of 35–45 years old and not among
patients, which we consider to be a strength of this study,
the findings extend to a non-patient group. Another question
of selection concerns the selection of pain groups according
to the pain intensity criterion as well as sick leave, which
means that the mild pain and the moderate pain categories
might not demonstrate pain intensity only.
In the introduction, the question was raised for what role
fear-avoidance plays in learning and experience and to what
extent it is based on expectations. Are there certain indivi-
duals who tend to always react on painful stimuli with fear-
avoidance beliefs? Our results are in line with the fear of
movement/(re) injury model (Vlaeyen et al., 1995b) that
was referred to in the introduction; however, the objective
of our study was not to test the model. The fear of move-
ment/(re) injury model suggests links between pain experi-
ence, catastrophizing, fear-avoidance beliefs and disability.
Our study showed two relationships between the variables,
firstly the association between fear-avoidance beliefs and
ADL, i.e. a connection between avoidance behaviour and
a lower activity level or disability. Decreased activity may
lead to physical deconditioning, to the detriment of working
capacity and health (Nachemson and Jonsson, 2000).
Secondly, an association between a higher rating of pain
and catastrophizing was found, the latter being hypothesised
to be a mediator of pain (e.g. Crombez et al., 1998a). This
relationship might be the pathway into the vicious circle of
the model mentioned above.
Fear-avoidance beliefs about work, in particular, have
shown to be predictive with regard to disability due to low
back pain in a chronic pain sample (Waddell et al., 1993) as
well as in acute low back pain (Fritz et al., 2001, Klenerman
et al., 1995). This study has explored the early stages of a
possible chronic pain process in a non-chronic population,
and we suggest that fear-avoidance beliefs and catastrophiz-
ing are important in the transition from acute to chronic
pain. We conclude that fear-avoidance beliefs and catastro-
phizing seem to be an active part of the development of
chronic pain and clinical implications of this knowledge
include screening procedures and identification of risk
patients as well as early intervention and treatment. A
door also opens to further research concerning beliefs and
cognitions in early stages of pain, from the spinal area as
well as from other sites for musculoskeletal pain or even of
other aetiologies, e.g. pain from fractures.
Acknowledgements
This study was partly supported by the Örebro University
Hospital, Sweden and FAS (Swedish Council for Working
Life and Social Research). We are grateful to Lennart Bodin
for statistical advice and comments on the manuscript and
Ing-Liss Bryngelsson for data management.
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