Background and objective: Biopsychosocial conceptualizations of clinical pain conditions recognize the multi-faceted nature of pain experience and its intersection with mental health. A primary cognitive-behavioural framework is the Fear-Avoidance Model, which posits that pain catastrophizing and fear of pain (including avoidance, cognitions and physiological reactivity) are key antecedents to, and drivers of, pain intensity and disability, in addition to pain-related psychological distress. This study aimed to provide a comprehensive analysis of the magnitude of the cross-sectional association between the primary components of the Fear-Avoidance Model (pain catastrophizing, fear of pain, pain vigilance) with negative affect, anxiety, depression, pain intensity and disabilities in studies of clinical pain.

Databases and data treatment: A search of MEDLINE and PubMed databases resulted in 335 studies that were evaluated in this meta-analytic review, which represented 65,340 participants.

Results: Results from the random effect models indicated a positive, medium- to large-sized association between fear of pain, pain catastrophizing, and pain vigilance measures and outcomes (pain-related negative affect, anxiety, depression and pain-related disability) and medium-sized associations with pain intensity. Fear of pain measurement type was a significant moderator of effects across all outcomes.

Conclusions: These findings provide empirical support, aligned with the components of the fear-avoidance (FA) model, for the relevance of both pain catastrophizing and fear of pain to the pain experience and its intersection with mental health. Implications for the conceptualization of the pain catastrophizing and fear of pain construct and its measurement are discussed.

Significance: This meta-analysis reveals that, among individuals with various pain conditions, pain catastrophizing, fear of pain, and pain vigilance have medium to large associations with pain- related negative affect, anxiety, and depression, pain intensity and disability. Differences in the strength of the associations depend on the type of self-report tool used to assess fear of pain.