Fear of Injury Predicts Self-Reported and Behavioral Impairment in Patients With Chronic Low Back Pain

Fear of injury has been posited as crucial in pain-related anxiety and in the development of chronic pain; however, research has only measured fear of injury indirectly through other constructs (eg, fear of illness and fear of movement). The current study tested fear of injury as an independent contributor to pain-related anxiety and impairment. Patients (n = 78; 37% women) in a work-hardening treatment program for chronic low back pain completed self-report measures of pain-related anxiety, anxiety sensitivity, fear of injury, current pain, and impairment. Behavioral measures of impairment included lifting capacity, treatment outcomes, and days absent from treatment. Structural equation modeling tested the role of fear of injury within contemporary theory. Fit for the theoretical model was excellent and superior to an alternative model. Variance accounted for in pain-related anxiety by fear of injury, anxiety sensitivity, and current pain was 64%, while pain-related anxiety and current pain predicted 49% of variance in latent impairment. Fear of injury directly predicted pain-related anxiety (β = .42) and indirectly predicted impairment through pain-related anxiety (β = .19). Fear of injury may warrant theoretical and clinical consideration as an important contributor to pain-related anxiety and impairment; however, research is needed to explore how it may be causally related with other constructs.PerspectiveFear of injury directly predicts pain-related anxiety and indirectly predicts self-reported and behavioral impairment. Fear of injury may warrant inclusion in contemporary theories of chronic pain. Clinicians may benefit from considering the construct in interventions for chronic pain.     

Fear of Pain in Recurrent Headache Sufferers

We investigated the role of fear of pain in headache sufferers using the Fear of Pain Questionnaire (FPQ). Seventy-six headache sufferers and 58 controls completed the FPQ and measures of depression, anxiety, and anger. Headache sufferers also completed measures of stress-related physical symptoms and coping with pain. We found that the FPQ has excellent internal consistency as well as good concurrent and construct validity indicated by the high correlations between the FPQ subscales and both anxiety and depression but low correlations with anger. There were marked differences between headache sufferers and controls on the FPQ; headache sufferers showed much greater fear of severe and medical pain and lower fear of minor pain. Fear of pain was generally not related to headache characteristics such as frequency, severity, or duration. On the other hand, it was related to headache impact such as disruption of pleasurable activities. These results are consistent with models of chronic pain disorders which emphasize the role of fear of pain over the nociceptive intensity of the pain stimulus.     

Fear of Pain, Pain Catastrophizing, and Acute Pain Perception: Relative Prediction and Timing of Assessment

Pain-related fear and catastrophizing are important variables of consideration in an individual's pain experience. Methodological limitations of previous studies limit strong conclusions regarding these relationships. In this follow-up study, we examined the relationships between fear of pain, pain catastrophizing, and experimental pain perception. One hundred healthy volunteers completed the Fear of Pain Questionnaire (FPQ-III), Pain Catastrophizing Scale (PCS), and Coping Strategies Questionnaire-Catastrophizing scale (CSQ-CAT) before undergoing the cold pressor test (CPT). The CSQ-CAT and PCS were completed again after the CPT, with participants instructed to complete these measures based on their experience during the procedure. Measures of pain threshold, tolerance, and intensity were collected and served as dependent variables in separate regression models. Sex, pain catastrophizing, and pain-related fear were included as predictor variables. Results of regression analyses indicated that after controlling for sex, pain-related fear was a consistently stronger predictor of pain in comparison to catastrophizing. These results were consistent when separate measures (CSQ-CAT vs PCS) and time points (pretask vs “in vivo”) of catastrophizing were used. These findings largely corroborate those from our previous study and are suggestive of the absolute and relative importance of pain-related fear in the experimental pain experience.

Perspective

Although pain-related fear has received less attention in the experimental literature than pain catastrophizing, results of the current study are consistent with clinical reports highlighting this variable as an important aspect of the experience of pain.     

Fear of pain, not pain catastrophizing, predicts acute pain intensity, but neither factor predicts tolerance or blood pressure reactivity: an experimental investigation in pain-free individuals.

Previous studies of the Fear-Avoidance Model of Exaggerated Pain Perception have commonly included patients with chronic low back pain, making it difficult to determine which psychological factors led to the development of an "exaggerated pain perception". This study investigated the validity of the Fear-Avoidance Model of Exaggerated Pain Perception by considering the influence of fear of pain and pain catastrophizing on acute pain perception, after considering sex and anxiety. Thirty-two males and 34 females completed the State-Trait Anxiety Inventory, the Fear of Pain Questionnaire, and the Coping Strategies Questionnaire. Subjects underwent a cold pressor procedure and tolerance, pain intensity, and blood pressure reactivity were measured. Sex, anxiety, fear of pain, and pain catastrophizing were simultaneously entered into separate multiple regression models to predict different components of pain perception. Tolerance was not predicted by fear of pain, pain catastrophizing, or anxiety. Pain intensity at threshold and tolerance were significantly predicted by fear of pain, only. Blood pressure reactivity to pain was significantly predicted by anxiety, only. These results suggest that fear of pain may have a stronger influence on acute pain intensity when compared to pain catastrophizing, while neither of the factors predicted tolerance or blood pressure reactivity.     

Observational Learning and Pain-Related Fear: An Experimental Study With Colored Cold Pressor Tasks

The primary aim of the current study was to experimentally test whether pain-related fear can be acquired through observational learning, whether extinction occurs after actual exposure to the aversive stimulus, and whether pain-related fear was associated with increased pain ratings. During an observation phase, female volunteers watched a video showing models performing cold pressor tasks (CPT), of which the color served as a conditioned stimulus (CS). In a differential fear conditioning paradigm, each of 2 colors were either paired with models’ painful (CS+) or neutral (CS−) facial expressions. Exposure consisted of participants performing CPTs of both colors (10°C). Self-reported fear of pain and expected pain ratings were obtained after the observation period, while actual pain and avoidance measures were obtained during and after exposure. Results show that after observing another person performing the CPT associated with the painful faces, subjects report more fear of pain and expect more intense and unpleasant pain as compared with the CPT associated with the neutral faces. This effect of observational learning on pain-related fear persisted until after exposure. During and after exposure no stimulus-type effect for pain ratings was found. This study provides preliminary evidence for observational learning of pain-related fear in humans.

Perspective

Fear of pain can be more disabling than pain itself, and is a risk factor for chronic pain. Knowledge about the acquisition of pain-related fear may help to develop novel pain management programs. This study is one of the first to demonstrate the effects of observational learning on pain-related fear.     

Pain-Related Fear,Pain Intensity and Function in Individuals With Chronic Musculoskeletal Pain: A Systematic Review and Meta-Analysis

Pain-related fear is considered a strong psychological predictor for both chronic pain and disability. The aims of this study were to systematically review and critically appraise the concurrent association and the predictive value of pain-related fear affecting both pain intensity and disability in individuals with chronic musculoskeletal pain (MSK). PubMed, AMED, CINAHL, PsycINFO, PubPsych, and the grey literature were searched from inception to January 2019. Observational studies reporting cross-sectional and longitudinal associations between pain-related fear and pain intensity and/or disability were included. The GRADE criteria judged whether the overall quality and strength of the evidence was high or low in terms of risk of bias, inconsistency, indirectness, imprecision and publication bias. Seventy observational studies (97% cross-sectional) were included with a total sample of 15,623 individuals (63.56% females) with chronic MSK. Pain-related fear is composed of fear of pain, pain-related anxiety, and fear-avoidance beliefs. Greater levels of fear of pain, pain-related anxiety, and fear-avoidance beliefs were significantly associated with greater pain intensity and disability. However, the quality and strength of the evidence was very low owing to the imprecision of results, risk of bias, indirectness, and publication bias were common across the included studies. Despite these limitations, these findings highlight the potential role that pain-related fear may play in chronic MSK and disability. The field would benefit from research using higher quality studies and longitudinal designs.PerspectiveThis article presents promising results about the concurrent association between pain-related fear and both pain intensity and disability in individuals with chronic MSK. Nevertheless, the overall quality and strength of the evidence was very low in terms of risk of bias, indirectness, imprecision, and publication bias. Thus, the findings should be taken with caution, and further research is needed.PROSPERO: CRD42018082018     

Dutch version of the Fear of Pain Questionnaire for adolescents with chronic pain

Background: Fear of pain is important in the development and maintenance of chronic pain. The Fear of Pain Questionnaire-Child version has been developed to assess pain related fear in children and adolescents.

Objective: Translating the original questionnaire into Dutch, and investigating internal consistency and construct validity to enable use in the Dutch pain rehabilitation setting for treatment and research.

Methods: Cross-sectional validation study: After forward and back translation of the FOPQ-C, adolescents (11–22 years old) with chronic musculoskeletal pain completed an assessment containing the Dutch Fear of Pain Questionnaire, and questionnaires about demographics, pain catastrophizing, functional disability, and pain intensity. Internal consistency and construct validity were evaluated through exploratory factor analysis (principal axis factoring with oblique rotation) and hypotheses testing using pain catastrophizing, functional disability, and pain intensity as comparative constructs.

Results: Eighty-six adolescents completed the assessment. Exploratory factor analysis resulted in a two-factor structure, explaining 43% of the variance. Internal consistency was strong (Cronbach’s α?=?0.92 total scale, α?=?0.88 factor 1, and α?=?.86 factor 2). Five out of 6 hypotheses were confirmed.

Conclusions: The Dutch version demonstrated good internal consistency and good construct validity in a population of adolescents with chronic musculoskeletal pain.

• Implications for rehabilitation

• The Fear of Pain Questionnaire-Child version was developed to measure fear of pain and avoidance in children and adolescents with chronic pain.

• Identification of fear of pain and activities that are being avoided are important during screening and assessment of the adolescent for chronic pain rehabilitation treatment.

• The presence of fear of pain and/or avoidance behavior is important information to shape and target multidisciplinary rehabilitation treatment.

     

Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability

There is growing evidence for the idea that in back pain patients, pain-related fear (fear of pain/physical activity/(re)injury) may be more disabling than pain itself. A number of questionnaires have been developed to quantify pain-related fears, including the Fear-Avoidance Beliefs Questionnaire (FABQ), the Tampa Scale for Kinesiophobia (TSK), and the Pain Anxiety Symptoms Scale (PASS). A total of 104 patients, presenting to a rehabilitation center or a comprehensive pain clinic with chronic low back pain were studied in three independent studies aimed at (1) replicating that pain-related fear is more disabling than pain itself (2) investigating the association between pain-related fear and poor behavioral performance and (3) investigating whether pain-related fear measures are better predictors of disability and behavioral performance than measures of general negative affect or general negative pain beliefs (e.g. pain catastrophizing). All three studies showed similar results. Highest correlations were found among the pain-related fear measures and measures of self-reported disability and behavioral performance. Even when controlling for sociodemographics, multiple regression analyses revealed that the subscales of the FABQ and the TSK were superior in predicting self-reported disability and poor behavioral performance. The PASS appeared more strongly associated with pain catastrophizing and negative affect, and was less predictive of pain disability and behavioral performance. Implications for chronic back pain assessment, prevention and treatment are discussed.     

Alike,But Not Quite: Comparing the Generalization of Pain-Related Fear and Pain-Related Avoidance

Pain-related fear and –avoidance crucially contribute to pain chronification. People with chronic pain may adopt costly avoidance strategies above and beyond what is necessary, aligning with experimental findings of excessive fear generalization to safe movements in these populations. Furthermore, recent evidence suggests that, when avoidance is costly, it can dissociate from fear. Here, we investigated whether concurrently measured pain-related fear and costly avoidance generalization correspond in one task. We also explored whether healthy participants avoid excessively despite associated costs, and if avoidance would decrease as a function of dissimilarity from a pain-associated movement. In a robotic arm-reaching task, participants could avoid a low-cost, pain-associated movement trajectory (T+), by choosing a high-cost non-painful movement trajectory (T-), at opposite ends of a movement plane. Subsequently, in the absence of pain, we introduced three movement trajectories (G1-3) between T+ and T-, and one movement trajectory on the side of T- opposite to T+ (G4), linearly increasing in costs from T+ to G4. Avoidance was operationalized as maximal deviation from T+, and as trajectory choice. Fear learning was measured using self-reported pain-expectancy, pain-related fear, and startle eye-blink electromyography. Self-reports generalized, both decreasing with increasing distance from T+. In contrast, all generalization trajectories were chosen equally, suggesting that avoidance-costs and previous pain balanced each other out. No effects emerged in the electromyography. These results add to a growing body of literature showing that (pain-related) avoidance, especially when costly, can dissociate from fear, calling for a better understanding of the factors motivating, and mitigating, disabling avoidance.PerspectiveThis article presents a comparison of pain-related fear- and avoidance generalization, and an exploration of excessive avoidance in healthy participants. Our findings show that pain-related avoidance can dissociate from fear, especially when avoidance is costly, calling for a better understanding of the factors motivating and mitigating disabling avoidance.     

The relationship of adult attachment dimensions to pain-related fear, hypervigilance, and catastrophizing

Despite the prominence of fear-avoidance models of chronic pain, there is a paucity of research regarding the origins of pain-related fear. Based on the premise that insecure attachment could be a developmentally based origin of elevated fear of pain, associations between adult attachment dimensions and constructs included in fear-avoidance models of chronic pain were investigated. Consistent with Bartholomew and Horowitz's [Bartholomew K, Horowitz LM. Attachment styles among young adults: a test of a four-category model. J Pers Soc Psychol 1991;61:226-44.] model, attachment was conceptualized as being comprised of a model of self dimension (i.e., degree of anxiety regarding rejection based on beliefs of personal unworthiness) and a model of others dimension (i.e., degree of interpersonal mistrust and discomfort with interpersonal closeness). A large university student sample free of chronic pain (N=278) completed a measure of adult romantic attachment (i.e., Experiences in Close Relationships Questionnaire; [Brennan KA, Clark CL, Shaver PR. Self-report measurement of adult attachment: an integrative overview. In: Simpson JA, Rholes WS, editors. Attachment theory and close relationships. New York: The Guilford Press, 1998. p. 46-76.]), the Fear of Pain Questionnaire-III [McNeil DW, Rainwater AJ. Development of the fear of pain questionnaire - III. J Behav Med 1998;21:389-410.], the Pain Vigilance and Awareness Questionnaire [McCracken LM. Attention to pain in persons with chronic pain: a behavioural approach. Behav Ther 1997;28:271-84.], and the Pain Catastrophizing Scale [Sullivan MJ, Bishop SR, Pivik J. The pain catastrophizing scale: development and validation. Psychol Assess 1995;7:24-532.]. It was hypothesized that insecure attachment would be positively associated with reports of pain-related fear, hypervigilance, and catastrophizing and that the model of self dimension would be the attachment variable most strongly associated with these variables. Correlation and multiple regression analyses supported these hypotheses. The model of self dimension had significant positive associations with each of the fear-avoidance constructs. The model of others dimension had a significant positive association with pain catastrophizing, but was not significantly associated with fear of pain and pain hypervigilance. Future research directions and potential clinical implications are discussed.     

Is the Latent Structure of Fear of Pain Continuous or Discontinuous Among Pain Patients? Taxometric Analysis of the Pain Anxiety Symptoms Scale

Elevated fear of pain is believed to denote a potential mechanism through which pain is maintained over time; however, our knowledge about fear of pain, its measurement, and its conceptualization is far from complete. It has been assumed that the latent structure of fear of pain is multidimensional and continuous. Although there is factor analytic evidence that it is multidimensional, there have been no empiric efforts to establish whether fear of pain is continuous or discontinuous (ie, taxonic or dichotomous latent class variable) in nature. Using taxometric methods in a sample of 650 patients seeking treatment for musculoskeletal or headache pain, we evaluated the latent structure of fear of pain as indexed by the Pain Anxiety Symptoms Scale. Results from analyses of simulated Monte Carlo data, MAXEIG-HITMAX, and MAMBAC and L-mode external consistency tests indicated that the latent structure of fear of pain was nontaxonic, characterized by latent continuity. Results are discussed in relation to the conceptual understanding of fear of pain, implications for treatment, and future directions for research on issues pertinent to pain-related fear. PERSPECTIVE: This article presents an analysis designed to establish whether fear of pain is continuous or discontinuous in clinical samples. The findings, indicating that fear of pain is continuous, are important for understanding the nature of fear of pain and to designing appropriately targeted interventions.     

A Principal Components Analysis of Negative Affect-Related Constructs Relevant to Pain: Evidence for a Three Component Structure

A number of negative affect-related constructs are important in pain. Some are general, such as anxiety, depression and negative affectivity, whereas others are more specifically pain-related (eg, fear of pain, pain anxiety, and pain catastrophizing). In addition, some more specific fear-related constructs, such as anxiety sensitivity, illness/injury sensitivity, and fear of negative evaluation have emerged as important to pain. Although these various constructs are considered conceptually separate, there is likely to be overlap between them. Since the extent of this overlap is unknown, the aim of the current study was to investigate these constructs in 1 sample in order to identify their common and unique features. Frequently used psychological measures were completed by 508 pain-free participants. Principal components analysis resulted in the extraction of three components: 1) General distress; 2) Fear of pain from injury/insult; and 3) Cognitive intrusion of pain. The results presented here suggest that there is indeed commonality between constructs, which may be due to either an overlap between items within measures or to close conceptual relatedness. The implications of these core dimensions are discussed with reference to future research and theory.PerspectiveThis article explores the relationships between various negative-affect pain-related measures and discusses the results from a principal components analysis. The findings show that some questionnaires may measure the same latent construct. A measure could be developed to measure these 3 core components more concisely for both clinical and research purposes.     

The Interplay of Pain-Related Self-Efficacy and Fear on Functional Outcomes Among Youth With Headache

Pain-related self-efficacy and pain-related fear have been proposed as opposing predictors of pain-related functional outcomes in youth with chronic pain. Self-efficacy is a potential resiliency factor that can mitigate the influence that pain-related fear has on outcomes in youth with chronic pain. Drawing from theoretical assertions tested among adults with chronic pain, this study aimed to determine whether pain-related self-efficacy mediates the adverse influence of pain-related fear on functional outcomes in a sample of youth with chronic headache. In a cross-sectional design of 199 youth with headache, self-efficacy was strongly associated with fear, disability, school impairment, and depressive symptoms. Pain intensity and self-efficacy were only modestly related, indicating that level of pain has less influence on one's confidence functioning with pain. Self-efficacy partially mediated relationships between pain-related fear and both functional disability and school functioning but did not mediate the relationship between pain-related fear and depressive symptoms. These results suggest that confidence in the ability to function despite pain and fear avoidance each uniquely contributes to pain-related outcomes in youth with chronic headache. These results further suggest that treatment for chronic headache in youth must focus not only on decreasing pain-related fear but also on enhancing a patient's pain-related self-efficacy.PerspectivePain-related self-efficacy is an important resiliency factor impacting the influence of pain-related fear on functional disability and school functioning in youth with headache. Enhancing self-efficacy may be a key mechanism for improving behavioral outcomes. Clinicians can reduce pain-related fear and enhance pain-related self-efficacy through interventions that encourage accomplishment and self-confidence.     

Pain-Related Anxiety in Spanish-Speaking Mexican Americans Who Report Chronic Pain: Psychometric Evaluation of a New Spanish Adaptation of the 20-Item Pain Anxiety Symptom Scale (PASS-20)

The 20-item Pain Anxiety Symptom Scale (PASS-20) was adapted for Spanish-speaking Mexican Americans who report chronic pain (SSMACP). The instrument measures pain-related anxiety with fear, physiological, avoidance/escape, and cognitive anxiety as subtypes. In SSMACP, the Spanish PASS-20′s psychometric properties were evaluated while exploring relationships between pain-related anxiety with other variables. Using convenience sampling, 188 SSMACP (women = 108, men = 77; mean age = 37.20 years, standard deviation = 9.87) were recruited across the United States. Confirmatory factor analyses examined the structural validity of the hierarchical factor structure. Hierarchical multiple regression examined incremental validity. Correlational analyses examined convergent validity. Cronbach’s coefficient alphas and McDonald’s omegas examined internal consistency. Pearson’s r, t-tests, and analysis of variance tests examined relationships between demographic variables and PASS-20 scores. Confirmatory factor analyses supported the hierarchical factor structure (root mean square error of approximation = .061, standardized root mean residual = .038, comparative fit index = .940). Total and subscale PASS-20 scores had acceptable convergent validity and internal consistency (range = .75–.93). Hierarchical multiple regression found that total and subscale PASS-20 scores have adequate incremental validity, considering that they contributed uniquely to the prediction of generalized anxiety scores above and beyond other pain-related scores. Demographic variables were significantly related to total and subscale PASS-20 scores. Evidence supports the use of Spanish total and subscale PASS-20 scores in SSMACP. Exploratory evidence also informed on the possible consequences and predictors of their pain-related anxiety. The results also encourage pain research in specific populations from Latin America (eg, Mexican Americans).PerspectiveThe Spanish PASS-20 has adequate psychometric properties in SSMACP. This instrument can help catalyze pain research in SSMACP by informing on their pain-related anxiety and by helping evaluate other pain-related instruments. Evidence also informed on pain-related anxiety in SSMACP.     

The Concept of Contexts in Pain: Generalization of Contextual Pain-Related Fear Within a de Novo Category of Unique Contexts

The experience of unpredictable pain fluctuations can trigger anticipatory pain-related fear. When discrete predictors for pain are lacking, fear typically accrues to the broader environmental context: a phenomenon referred to as contextual pain-related fear. We examined whether conceptual similarity between discrete contexts facilitates pain-related fear generalization; this mechanism is known as category-level fear generalization. Using a voluntary joystick movement paradigm, pain-free participants performed movements in 2 contexts (within-subjects design); context was manipulated by varying background color screens. In the predictable context, one movement predicted pain and another did not. In the unpredictable context, 2 other movements never predicted pain but pain was unpredictably delivered during the context. Participants subsequently learned to categorize novel background colors (ie, generalization contexts) as being similar to either the unpredictable or predictable pain context. Then we tested fear generalization to these novel contexts. We measured self-reported pain-related fear, expectancy, and eyeblink startle. Results indicated higher pain-related fear reports, but no elevated startle responses, for generalization contexts that were trained to be similar to the original unpredictable context rather than the predictable pain context. This highlights a potential pathway through which neutral contexts can elicit pain-related fear and motivate avoidance behavior associated with chronic pain disability.

Pain-related anxiety influences pain perception differently in men and women: A quantitative sensory test across thermal pain modalities

The sexes differ with respect to perception of experimental pain. Anxiety influences pain perception more in men than in women; however, there lacks research exploring which anxiety constructs influence pain perception differentially between men and women. Furthermore, research examining whether depression is associated with pain perception differently between the sexes remains scant. The present investigation was designed to examine how trait anxiety, pain-related anxiety constructs (ie, fear of pain, pain-related anxiety, anxiety sensitivity), and depression are associated with pain perception between the sexes. A total of 95 nonclinical participants (55% women) completed measures assessing the constructs of interest and participated in quantitative sensory testing using heat and cold stimuli administered by a Medoc Pathway Pain and Sensory Evaluation System. The findings suggest that pain-related anxiety constructs, but not trait anxiety, are associated with pain perception. Furthermore, these constructs are associated with pain intensity ratings in men and pain tolerance levels in women. This contrasts with previous research suggesting that anxiety influences pain perception mostly or uniquely in men. Depression was not systematically associated with pain perception in either sex. Systematic relationships were not identified that allow conclusions regarding how fear of pain, pain-related anxiety, and anxiety sensitivity may contribute to pain perception differentially in men and women; however, anxiety sensitivity was associated with increased pain tolerance, a novel finding needing further examination. The results provide directions for future research and clinical endeavors and support that fear and anxiety are important features associated with hyperalgesia in both men and women.     

Pain-Related Anxiety as a Mediator of the Effects of Mindfulness on Physical and Psychosocial Functioning in Chronic Pain Patients in Korea

Mindfulness involves reducing potential influences from aversive cognitions, sensations, and emotions on behavior. Mindfulness may influence the experience of pain-related anxiety, and thereby enhance other aspects of physical and psychosocial functioning. Thus, the purpose of this study was to investigate a potential mediating role of pain-related anxiety between mindfulness and physical and psychosocial functioning in chronic pain patients. This cross-sectional/correlational study used archival data (N = 226) obtained from the larger Korean Pain Study at a university-based pain-management center in Korea. Based on the inclusion criterion for the present study, archival data were analyzed for a final sample of 179 patients with chronic pain. Structural equation analyses showed that both the partial- and full-mediation models had adequate goodness-of-fit indices for physical and psychosocial functioning. Subsequent chi-square tests, however, indicated that the more parsimonious full-mediation model was preferred to the partial-mediation model for physical and psychosocial functioning. Bootstrapping procedures yielded significant mediation effects of pain-related anxiety in the full-mediation models on physical and psychosocial functioning. These findings suggest that being mindful may lead indirectly to a decrease in the disabling influences of pain-related anxiety, thereby contributing to better physical and psychosocial functioning, rather than playing a direct contributing role for better functioning among chronic pain patients in Korea.PerspectiveThis article examines the mediating role of pain-related anxiety between mindfulness and physical/psychosocial functioning. Results suggest that mindfulness methods may benefit patients having pain-related anxiety and consequent disability. These benefits may derive from the way processes of mindfulness interact with processes of avoidance and with cognitive influences on emotional suffering.     

Exploratory factor analysis of the Pain Anxiety Symptoms Scale in patients with chronic pain complaints

The Pain Anxiety Symptoms Scale (PASS) is a 40-item self-report measure that consists of four subscales measuring aspects of pain-related anxiety and avoidance. Despite its growing popularity, there have been few studies of its psychometric properties. The primary purpose of this study was to determine the factor structure of the PASS in a sample of 259 chronic pain patients. Principal component analysis with oblique (Oblimin) rotation provided partial support for the factorial validity of the PASS. Five factors were extracted: (1) catastrophic thoughts, (2) physiological anxiety symptoms, (3) escape/avoidance behaviours, (4) cognitive interference, and (5) coping strategies. The use of analgesic medication did not influence the factor solution. The factors were characterised by correlating them with pain-related measures, and with measures of mood state. Implications are considered for revising the PASS subscales to provide a more comprehensive and factorially valid assessment of pain-related fear and avoidance.     

Sex Differences in Negative Emotional Responses to Chronic Pain

We proposed a sequential model of pain processing with pain intensity as stage 1, pain unpleasantness as stage 2, pain-related emotions (depression, anxiety, frustration, anger, fear) as stage 3, and overt behavioral expression of pain as stage 4. We tested hypotheses about relationships between sex and the first 3 stages of pain processing by conducting simultaneous regression analysis using LISREL-8 with data collected from 967 women and 680 men with chronic pain. We found the following results: (1) women reported higher pain-related frustration and fear; (2) frustration related most highly to pain intensity among women, as compared with anxiety and depression among men; (3) depression and frustration related most highly to usual and highest pain unpleasantness among women, as compared with frustration among men; and (4) contrary to expectations, pain-related emotions were more strongly related to pain for men. Consistent with the sequential model of pain processing, emotional response to pain was more closely related to pain unpleasantness than to pain intensity across sex. Anxiety and frustration were the emotions most highly related to pain. The current results highlight sex differences in the experience of chronic pain and the importance of assessing a range of emotions in patients with pain.     

Fear of Pain in the Context of Intensive Pain Rehabilitation Among Children and Adolescents With Neuropathic Pain: Associations With Treatment Response

Recent research has implicated pain-related fear in relation to functional outcomes in children with chronic pain. The current study examined fear of pain, disability, and depression within the context of an intensive pain rehabilitation program. One hundred forty-five children and adolescents who participated in an intensive interdisciplinary pediatric pain rehabilitation day program were assessed in this study. Patients completed measures of pain intensity, pain-related fears, functional disability, and depressive symptoms at admission, discharge, and on average, 2 months postdischarge. After controlling for pain intensity, pain-related fear was significantly related to disability and depressive symptoms at all time points. As predicted, a decline in pain-related fear was significantly associated with a decrease in disability and depressive symptoms. Interestingly, high levels of pain-related fears at admission predicted less reduction in functional disability and depression at discharge, suggesting that high levels of pain-related fear may be a risk factor in relation to treatment outcomes. Overall, results indicate that the relationship between fear of pain and changes in disability and depressive symptoms are closely linked, with fear of pain playing an important role in treatment.