Current fear-avoidance models consider pain-related fear as a crucial factor in the development of chronic pain. Yet, pain-related fear often occurs in a context of multiple, competing goals. This study investigated whether pain-related fear and avoidance behavior are attenuated when individuals are faced with a pain avoidance goal and another valued but competing goal, operationalized as obtaining a monetary reward. Fifty-five healthy participants moved a joystick towards different targets. In the experimental condition, a movement to one target (Conditioned Stimulus; CS+) was followed by a painful unconditioned stimulus (pain-US) and a rewarding unconditioned stimulus on 50% (reward-US) of the trials, whereas the CSmovement was not. In the control condition, the CS+ movement was followed by the pain-US only. Results showed that pain-related fear was elevated in response to the CS+ compared to the CS-movement, but that it was not influenced by the reward-US. Interestingly, participants initiated a CS+ movement slower than a CS-movement in the control condition, but not in the experimental condition. Also, in choice trials, participants performed the CS+ movement more frequently in the experimental than in the control condition. These results suggest that the presence of a valued competing goal can attenuate avoidance behavior. Perspective:The current study provides experimental evidence that both pain and competing goals impact on behavioral decision making and avoidance behavior. These results provide experimental support for treatments of chronic pain that include valuable daily life goals pursued by an individual, rather than limiting focus to pain reduction only.

Exposure therapy, i.e., repeated exposure to fear-provoking stimuli, is an effective cognitive behavioral therapy strategy for the treatment of anxiety and trauma-related disorders (Hofmann & Smits, 2008). Extinction learning is considered a major mechanism for the reduction of fear during exposure, as it involves learning that the stimulus previously appraised as threatening no longer leads to the feared outcome (Lonsdorf et al., 2017). The predominant view is that extinction hereby results in a new memory (i.e., extinction memory) that competes with the fear memory and can inhibit anticipatory fear reactions (Bouton, 1988). Although exposure therapy has been shown to be effective in the treatment of anxiety disorders when compared to placebo treatments (Hofmann and Smits,

Cognitive-behavioral treatments for chronic pain typically target pain-related fear -exposure in vivo is a common treatment focusing on disconfirming harm expectancy of feared movements. Exposure therapy is tailored on Pavlovian extinction; an alternative fear reduction technique that also alters stimulus valence is counterconditioning. We compared both procedures to reduce pain-related fear using a Voluntary Joystick Movement Paradigm.Participants were randomly allocated to the Counterconditioning or Extinction Group. During fear acquisition, moving the joystick in two directions (CS+) was followed by a painful electrocutaneous stimulus (pain-US), while moving the joystick in two other directions was not (CS-). During fear reduction, one CS+ was extinguished, but another CS+ was still followed by pain in the Extinction Group; in the Counterconditioning Group one CS+ was extinguished and followed by a monetary reward-US, and another CS+ was followed by both USs (pain-US and reward-US). Results indicate that counterconditioning effectively reducespain-related fear but that it does not produce deeper fear reduction than extinction. Adding a reward-US to a painful movement did neither attenuate fear nor the intensity/unpleasantness of the pain itself. Both procedures changed stimulus valence. We contend that changing the affective valence of feared movements might improve fear reduction and may prevent relapse.

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