Integration of the avoidance cycle with the schema enmeshment model of pain: Relationships with quality of life and disability in chronic, nonmalignant pain

Persons living with chronic pain encounter a host of physical and psychosocial problems resulting in a loss of quality of life and increased disability. The construct of avoidance has been proposed as a mechanism by which these changes in functioning occur. This study explored the Acceptance and Commitment Therapy (ACT) construct of experiential avoidance and its conceptualization within the ACT model of avoidance, the Cycle of Avoidance. The model is introduced as a framework for integrating an existing model of chronic pain and avoidance, the Schema Enmeshment Model of Pain (SEMP), thus providing a more comprehensive perspective. The study used empirically validated measures to explore constructs integral to the Avoidance Cycle, namely anxiety sensitivity, catastrophizing, experiential avoidance, and their associations with anxiety, depression, quality of life, and disability. The construct of enmeshment, which is a major component of the SEMP, was examined as a conceptualization of the Avoidance Cycle's stage of Entanglement. The study also examined participant's perceptions of the temporal relationships in the Avoidance Cycle. The ACT and SEMP constructs were examined using multi-method assessment including written questionnaires, brief interview, and chart review. Participants were 139 adults with chronic, nonmalignant pain, recruited from a university pain clinic. Results showed that the components of the Avoidance Cycle of catastrophizing and pain-specific experiential avoidance predicted participants' degree of enmeshment and enmeshment in turn predicted the mental component of quality of life and disability. Pain-specific experiential avoidance was shown to partially mediate the relationship between pain intensity and mental quality of life and disability, but enmeshment was not shown to be mediator between pain intensity and functional status. Regarding the temporal nature of chronic pain and psychological symptoms, rates of participants with self-reported psychological problems increased by 70% after onset of chronic pain. Further those participants who had higher scores on measures of catastrophising, enmeshment, and experiential avoidance were more likely to report their health as worse than one year ago. These results support the utility of using the Avoidance Cycle and SEMP as models of avoidance in chronic pain and explore relationships within the model