pain-related anxiety in the prediction of chronic low-back pain distress

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Journal of Behavioral Medicine [jobm] pp1102-jobm-479524 January 19, 2004 7:40 Style file version Feb 25, 2000

Journal of Behavioral Medicine, Vol. 27, No. 1, February 2004 ( C© 2004)

Pain-Related Anxiety in the Predictionof Chronic Low-Back Pain Distress

Kevin E. Vowles,1,4 Michael J. Zvolensky,2 Richard T. Gross,3

and Jeannie A. Sperry3

Accepted for publication: May 17, 2003

This study evaluated the relation of particular aspects of pain-related anxietyto characteristics of chronic pain distress in a sample of 76 individuals withlow-back pain. Consistent with contemporary cognitive–behavioral modelsof chronic pain, the cognitive dimension of the Pain Anxiety Symptoms Scale(PASS; McCracken, Zayfert, and Gross, 1992, Pain 50: 67–73) was uniquelypredictive of cognitive-affective aspects of chronic pain, including affectivedistress, perceived lack of control, and pain severity. In contrast, the escapeand avoidance dimension of the PASS was more predictive of behavioralinterference in life activities. Overall, the findings are discussed within thecontext of identifying particular pain-related anxiety mechanisms contributingto differential aspects of pain-related distress and clinical impairment.

KEY WORDS: chronic pain; pain-related anxiety; low-back pain.

INTRODUCTION

Chronic low-back pain is perhaps the most common and disabling ofthe pain conditions, resulting in significant personal, social, health, and oc-cupational impairment (Nachemson, 1992). In an illustrative example, theincidence of low-back pain in North America alone is approximately 10%,

1Department of Psychology, West Virginia University, P.O. Box 6040, Morgantown, WestVirginia 26506-6040.

2Department of Psychology, University of Vermont, Burlington, Vermont 05405-0134.3Oasis Occupational Rehabilitation and Pain Management, P.O. Box 4013, Morgantown, WestVirginia 26504-4013.

4To whom correspondence should be addressed; e-mail: [email protected].

77

0160-7715/04/0200-0077/0 C© 2004 Plenum Publishing Corporation

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78 Vowles, Zvolensky, Gross, and Sperry

with a substantial percentage of these persons being unresponsive to tradi-tional medical interventions (Frymoyer, 1993). Perhaps not surprisingly, thecost to the health care system is immense, resulting in over $50 billion indirect and indirect costs each year (Frymoyer, 1993; Hoffman et al., 1993;Nachemson, 1992; Tollison et al., 1985).

Historically, low-back pain conceptualizations have been dominated bythe medical model in which pain is proportional to identified pathology (e.g.,tissue damage). Unfortunately, such a perspective has not contributed to abetter understanding of the complex nature of chronic pain nor the underly-ing processes involved with pain-related disability (Turk, 1990). Accordingly,to better account for the highly varied individual expression of chronic low-back pain, contemporary cognitive–behavioral models portray the conditionas a sensory-affective response, involving physiological, cognitive, and be-havioral components (Waddell, 1987).

Within this context, researchers have begun to focus their scientificefforts to understanding the nature of chronic low-back pain at the psycho-logical level of analysis, and pain-related anxiety has been highlighted asone of the most disabling aspects of the chronic pain experience (Lethemet al., 1983; Turk and Okifuji, 2002; Vlaeyen and Linton, 2000). Specifi-cally, heightened levels of anxiety about pain are believed to contributeto avoidance of activities that are perceived to promote pain, which inturn, often lead to physical deconditioning, secondary behavioral problems(e.g., weight gain), and reduced social contact (Hadjistavropoulos andLaChapelle, 2000). Moreover, this pattern of responding is likely to becomecyclical in nature, such that emotional responsivity and physical decondi-tioning lead to greater levels of severe pain, behavioral interference, per-ceived lack of control over life activities, and affective distress (Asmundson,1999; Asmundson et al., 1997; McCracken, 1997). In this model, then, anx-iety about pain is a critical psychological factor involved with the pro-duction of maladaptive responding, behavioral interference, and emotionaldistress.

Despite the general theoretical promise of fear-avoidance conceptual-izations of chronic pain (Arntz and Peters, 1995; Craig, 1994; Jensen et al.,1994), researchers have only relatively recently began to systematically ex-plore the association between anxiety about pain and clinically relevantdimensions of chronic low-back pain. This research has been facilitated bythe development of valid and reliable methodologies that can assess variousaspects of anxiety about and fear of pain (e.g., Kori et al., 1990; McNeil andRainwater, 1998; Vlaeyen et al., 1999; Waddell and Main, 1984). The PainAnxiety Symptoms Scale (PASS; McCracken et al., 1992), which assessesfour dimensions of pain-related anxiety, including fearful pain appraisals,

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Pain-Related Anxiety 79

cognitive symptoms, physiological symptoms, and escape and avoidance be-havior, represents one of these methods.

Consistent with fear-avoidance models of chronic pain (e.g., Asmund-son et al., 1999; Lethem et al., 1983; Vlaeyen and Linton, 2000), research usingthe PASS has found that patients with chronic pain disorders demonstrategreater pain-related anxiety relative to matched comparison groups, overpredict the intensity of pain, cope poorly with pain sensations (e.g., avoidanceof physical activity), and evidence greater somatic reactivity in anticipationof pain-eliciting physical activity (McCracken et al., 1993a, 1998; Zvolenskyet al., 2001). The PASS total score is also positively correlated with mea-sures of general anxiety, pain, and self-reported disability (Crombez et al.,1999; McCracken et al., 1992), as well as nonspecific physical complaints(McCracken et al., 1998). Furthermore, Burns and colleagues reported thatphysical ability, as indexed by one’s ability to lift or carry certain amountsof weight, was negatively related to scores on the PASS (Burns et al., 2000).Taken together, the PASS has proven to have strong relations with manyaspects of the chronic pain experience, especially cognitive aspects of fearand pain (cf. physiological, Crombez et al., 1999). The importance of PASSscores is further supported by their strong relation to treatment outcomes inchronic pain, independent of other theoretically relevant factors such as de-pressive symptoms and physical ability (McCracken et al., 2002; McCrackenand Gross, 1998).

Given the existing literature supporting the utility of the PASS, it re-mains important to evaluate whether specific components of the PASS pre-dict the clinically- and theoretically-relevant dimensions of pain severity,behavioral interference, perceived lack of control over life activities, andaffective distress explicitly highlighted in chronic pain models (e.g., Arntzand Peters, 1995; Asmundson, 1999; Vlaeyen et al., 1999). Although the to-tal score has been widely used as an index of fear of pain, the utility ofthe subscale scores and their relation to aspects of chronic pain is relativelyunexplored. To address this issue, this study evaluated the relation of thedifferent subscales of the PASS with established indices of chronic paindistress (i.e., behavioral interference, perceived lack of control, affectivedistress, and pain severity; Coft et al., 1995), as well as other theoretically-relevant variables of pain duration, surgical history, lumbar range of motion,sensory experience of pain, and demographic variables. Consistent with con-temporary cognitive-behavioral models of chronic pain (Asmundson, 1999)and anxiety-related disorders (Clark et al., 1989; Eifert et al., 1999), it washypothesized that cognitive symptoms dimension of the PASS would beuniquely predictive of cognitive-affective aspects of chronic pain. In con-trast, the escape and avoidance dimension of the PASS would be more

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predictive of behavioral interference in life activities because of the paincondition.

METHOD

Participants

Participants were 76 consecutive chronic low-back pain patients. In to-tal, 33 (43.4%) females and 43 (56.6%) males, ranging in age from 21 to58 (Mean age = 40.4 years, SD = 8.7 years). All participants were Cau-casian and had a prolonged history of chronic pain (Mean duration of painchronicity = 21.3 months, SD = 12.1 months). Additionally, 100% of thepatients were occupationally disabled due to their low-back pain problem.Approximately 75% of the sample had completed at least the equivalentof a high school education. The marital status of the participants consistedof 55.3% (n = 42) being married, 30.2% (n = 23) being separated or di-vorced, 14.5% (n = 11) being single. Finally, 52.6% (n = 37) of the patientshad previously received surgery for their presenting low-back problem. Aspart of an intake appointment, each participant completed a number ofself-report questionnaires, a general medical history, and a physical therapyevaluation.

Measures

Pain Anxiety Symptoms Scale (PASS)

The PASS (McCracken et al., 1992) is a 40-item self-report measure inwhich respondents indicate anxiety related to pain on a 6-point Likert-typescale ranging from 0 (never) to 5 (always). The summation of individualitems allows the derivation of a total score and four subscale scores. Thecontent of the four subscales includes (a) cognitive anxiety symptoms re-lated to the experience of pain, (b) escape and avoidance responses relatedto reducing pain, (c) fearful appraisals of pain, and (d) physiological anxi-ety symptoms related to pain. The measure has demonstrated good internalconsistency across items, with reported alpha’s ranging from 0.74 to 0.94,and excellent 2-week test–retest reliability, all r ’s ≥ 0.93, with the excep-tion of the escape/avoidance subscale, which had an r = 0.77 across dif-ferent administrations (McCracken et al., 1992, 1993b). Finally, the validityof the four subscale scores is supported by significant positive correlationswith measures of general anxiety, pain, and disability (McCracken et al.,1992).

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Multidimensional Pain Inventory (MPI)

The MPI (Kerns et al., 1985) is a well-established three-part measurethat assesses pain appraisals, pain severity, impact of pain on specified lifedomains (e.g., work), and particular behaviors that are performed as a resultof the pain. The MPI has demonstrated adequate reliability and validity inchronic pain populations (Kerns et al., 1985). As is typical of research inthis area, in the present study we utilized Section I of the MPI. This seg-ment of the instrument assesses the conceptually- and clinically-relevantdomains of pain severity, life control, affective distress, and behavioral in-terference due to pain. Within each subscale, reported interitem reliabili-ties have ranged from 0.68 to 0.90 (Ferrari et al., 2000; Kerns et al., 1985),and 2-week test–retest reliabilities range from 0.62 to 0.91 (Kerns et al.,1985).

McGill Pain Questionnaire-Short Form (MPQ-SF)

The MPQ-SF (Melzack, 1987) is a self-report measure that assessessensory and affective aspects of a pain problem. Ratings are made on a 4-point Likert-type scale, ranging from 0 (none) to 3 (severe); items are addedtogether to derive a total score, as well as sensory and affective subscales,which assess specific components of the pain experience. The psychometricproperties of the MPQ-SF are well established (see Melzack and Katz, 2001for a review); reported 15- and 30-day test–retest reliabilities range from 0.58to 0.92 (Burckhardt and Bjelle, 1993; Georgoudis et al., 2001) and internalconsistency is adequate (Cronbach’sα = 0.71; Georgoudis et al., 2000). In thepresent study, we used the MPQ-SF sensory scale (total score) rather than acombined sensory and affective total score because the latter may confoundthe measurement of the sensory experience of pain with pain-related anxiety(Asmundson and Taylor, 1996).

Lumbar Range of Motion

To provide an index of actual physical movement capacity in the lowback, a physical therapist assessed lumbar flexion during a routine physicalexamination using an inclinometer (possible range: 0–360◦). Although theinterrater reliability of physical therapy examinations has been generallylow, lumbar flexion has been identified as one of the most reliable measure-ments with reported interrater reliabilities from 0.87 to 0.93 (Waddell et al.,1992).

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RESULTS

Descriptive Data and Zero-Order Relations Between Predictorand Criterion Variables

Means and standard deviations for the psychological variables are pre-sented in Table I. Zero-order correlations were computed between each ofthe predictor variables and each of the dependent measures to determinethe relation between these theoretically relevant constructs. As can be seenin Table II, the results generally indicated that the PASS subscales signifi-cantly correlated in a content-specific fashion with the various MPI subscales.In a representative example, the PASS cognitive subscale correlated in themost robust manner with the MPI subscales tapping cognitive-affective as-pects of pain-related distress (i.e., affective distress, perceived life control,and pain severity) and to a lesser extent with the MPI subscale tappingbehavioral interference. Additionally, divergent validity was demonstratedwith the PASS subscales tapping visceral arousal (physiological) and be-havioral activation (i.e., escape and fear dimensions) showing a nonsignif-icant positive relation with cognitive-affective aspects of pain distress. Theindices of surgical history, lumbar flexion, and duration of pain problemshowed nonsignificant relations with all of the MPI dimensions, reflect-ing independence of medical/physical parameters associated with functionaldisability.

Table I. Means and Standard Deviations of Predictor andCriterion Psychological Variables

Measure Mean (SD)

PASSCognitive anxiety 25.6 (9.9)Escape and avoidance 23.8 (9.2)Fearful appraisals 18.3 (8.9)Physiological anxiety 18.2 (9.8)

MPIAffective distress 48.1 (9.1)Behavioral interference 57.8 (8.4)Life control 50.3 (7.9)Pain severity 50.3 (8.2)

MPQ-SF 11.8 (7.7)

Note. N = 76. PASS: Pain Anxiety Symptoms Scale(McCracken et al., 1992); MPI: Multidimensional PainInventory (Kerns et al., 1985); MPQ-SF: McGill PainQuestionnaire-Short Form, sensory scale (Melzack, 1987).

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Tabl

eII

.Zer

o-O

rder

Rel

atio

nsB

etw

een

Pre

dict

oran

dC

rite

rion

Var

iabl

es

Inst

rum

ent

12

34

56

78

910

1112

1314

15

1.PA

SS(C

ogni

tive

)—

0.41∗∗

0.69∗∗

0.58∗∗

0.38∗∗

0.27∗−0

.51∗∗

0.23∗−0

.05

0.18

0.13−0

.20−0

.01−0

.07

0.09

2.PA

SS(E

scap

e)—

0.70∗∗

0.48∗∗

0.01

0.31∗∗

0.00

0.25∗−0

.07

0.13−0

.11−0

.29∗∗

0.08

0.07

0.06

3.PA

SS(F

ear)

—0.

61∗∗

0.21

0.26∗−0

.17

0.23∗−0

.13

0.15−0

.08−0

.13

0.07−0

.08

0.12

4.PA

SS(P

hysi

olog

ical

)—

0.20

0.21

−0.1

10.

21−0

.05

0.12

0.07−0

.30∗∗

0.19−0

.05

0.01

5.M

PI

(Aff

ecti

vedi

stre

ss)

—0.

39∗∗−0

.40∗∗

0.27∗

0.16

0.16−0

.05

0.06

0.06−0

.10

0.03

6.M

PI

(Int

erfe

renc

e)—

−0.0

8−0

.26∗

0.09

0.14

0.00−0

.02

0.01

0.08−0

.05

7.M

PI

(Lif

eco

ntro

l)—

−0.2

9∗0.

030.

140.

080.

040.

080.

050.

048.

MP

I(P

ain

seve

rity

)—

0.04

0.22−0

.26∗

0.02

−0.0

1−0

.06

0.10

9.M

PQ

-SF

—0.

040.

070.

080.

100.

040.

0310

.Age

(yea

rs)

—−0

.09−0

.02

0.09−0

.02

0.11

11.E

duca

tion

(yea

rs)

—0.

090.

07−0

.19

0.06

12.G

ende

r(1=

mal

e;2=

fem

ale)

—0.

070.

20∗

0.06

13.P

ain

dura

tion

(mon

ths)

—0.

24∗

0.14

14.S

urgi

calh

isto

ry(f

requ

ency

)—

0.04

15.L

ow-b

ack

flexi

on(d

eg.)

—

Not

e.N=

76.P

ASS

:Pai

nA

nxie

tySy

mpt

oms

Scal

e(M

cCra

cken

etal

.,19

92);

MP

I:M

ulti

dim

ensi

onal

Pai

nIn

vent

ory

(Ker

nset

al.,

1985

).∗ p<

0.05

;∗∗ p<

0.01

.

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Prediction of Pain-Related Distress

Hierarchical multiple regression analyses were performed with each ofthe primary dependent measures. Independent variables were divided intothree levels in the hierarchy: (a) demographic variables of gender, age, andeducation were at level one, (b) medical and physical variables of duration ofchronic pain problem, lumbar flexion, MPQ-SF sensory score, and surgeryhistory were included at level two, and (c) PASS subscales at level three.Although demographic, medical, and physical variables were generally un-related to the subscales of MPI in the present sample, previous investigationshave indicated their importance in both chronic pain (Miaskowski, 1999) andpain responding (Carter et al., 2002); therefore, they were included in thepresent analyses in order to assess the independent value of each of the PASSsubscales. First- and second-level variables were entered into the analysis,and the stepwise method was used for third-level variables. For all analyses,partial correlations (Sr) were included to represent effect sizes only for thosevariables retained in the equation.

In terms of the MPI affective distress, the results indicated a significantoverall effect, F(1, 76) = 9.9, p ≤ .01 (r2 = 0.12; adjusted r2 = 0.11). Asexpected, the PASS cognitive subscale significantly predicted variance inMPI affective distress (β = 0.35, p ≤ 0.01, Sr = 0.28), whereas none of theother independent variables added a significant amount of variance in thisequation.

For the perceived life control dimension of the MPI, there was an over-all significant effect, F(1, 76) = 22.2, p ≤ 0.001. The r2 for this equa-tion was 0.24 (adjusted r2 = 0.23). As hypothesized, the PASS cognitivesubscale significantly predicted variance in MPI perceived control (β =−0.48, p ≤ 0.001, Sr = −0.54). The PASS fear appraisal subscale was theonly other variable to significantly contribute to this equation (β = 0.29,p ≤ 0.01, Sr = 0.18), adding an additional 5% of variance (adjusted r2

change 0.04).For the behaviorally-oriented domain of life interference on the MPI,

the results indicated a significant effect, F(1, 76) = 9.2, p ≤ 0.01 (r2 =0.11; adjusted r2 = 0.10). As hypothesized, the PASS escape subscale wasthe only variable to significantly predict variance in behavioral interference(β = 0.34, p ≤ 0.01, Sr = 0.22).

Finally, for pain severity dimension of the MPI, the results of the re-gression indicated an overall significant effect, F(1, 76) = 6.4, p ≤ 0.01(r2 = 0.09; adjusted r2 = 0.08). As hypothesized, the cognitive subscale ofthe PASS predicted a significant amount of variance (β = 0.28, p ≤ 0.01,Sr = 0.17). No other independent variables added a significant amount ofvariance in predicting pain severity.

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Regression equations were also conducted separately for the two gen-ders and resulted in similar findings. In general, the cognitive subscale of thePASS explained a significant amount of variance in the more cognitive as-pects of the MPI and the escape/avoidance subscale was more useful in theprediction of the MPI-Interference scale across both genders. In women,however, the cognitive subscale of the PASS did not explain a significantamount of variance in either affective distress or pain severity.

DISCUSSION

Persons with chronic low-back pain often demonstrate clinically signif-icant levels of anxiety about pain. Such heightened pain-related anxiety isassociated with maladaptive coping responses, medication use, and occupa-tional disability (McCracken et al., 1992). Yet, it remains unknown to whatextent specific aspects of the global pain-related anxiety construct predictclinically relevant dimensions of chronic low-back pain distress. To addressthis issue, the present study was designed to evaluate specific pain-relatedcomponents as differential predictors of established indices of chronic paindistress (Coft et al., 1995) relative to other theoretically relevant variables ofpain duration, surgical history, lumbar flexion, sensory experience of pain,and demographic variables.

As expected, consistent with contemporary cognitive–behavioral mod-els of chronic pain (Asmundson, 1999; Craig, 1994; Vlaeyen et al., 1999), thecognitive dimension of the PASS was uniquely and significantly predictiveof affective distress, perceived lack of control, and pain severity. The fear ap-praisal subscale added a significant, albeit small amount of variance, only forperceived life control. In contrast, the escape and avoidance PASS dimensionwas significantly predictive of behavioral interference due to pain. This samepattern of findings also was visible when inspecting the zero-order relationsbetween variables. Specifically, there was a greater level of response concor-dance between cognitive variables and psychological-affective respondingto pain, and greater levels of response discordance between psychological-affective distress and historical and physical aspects of the pain problem (i.e.,surgical history, duration of pain problem, low-back flexion). Such relativeresponse concordance-discordance is a well-established finding in the studyof emotion generally (Rachman, 1991) and in studies of pain respondingspecifically (Craig, 1994). The present study’s results extend this result tothe fear-avoidance model of chronic pain. Indeed, the results lend further(correlational) support to the perspective that emotional experiences suchas pain are best understood as partially independent response systems ratherthan a more unified construct (Barlow, 1991; Zinbarg, 1998).

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Overall, these findings are theoretically important to chronic pain mod-els in that they empirically demonstrate a high degree of specificity with thepain-related anxiety construct in a low-back pain population. In particular,the higher the level of correspondence between the particular pain-relatedanxiety domain and aspects of the pain problem that closely match that fear,the better particular pain indices of distress can be predicted. It is impor-tant to note that these findings converge with a larger body of literature inthe area of anxiety-related disorders, whereby elevated anxiety is primarilyproduced when triggered by cues that closely match the object/event of con-cern (e.g., Clark et al., 1989; Cox, 1996; Eifert et al., 1999; McNally and Eke,1996). Accordingly, it is becoming increasingly apparent that the specific ten-dency to respond in an anxious and fearful manner to pain-related eventsshould be more predictive of certain cognitive and behavioral dimensionsof chronic pain problems than others. In this way, particular pain-relatedanxiety components may function as distinct pathways to different aspectsof pain-related distress.

At a more general level, the results provide additional evidence thatpsychological variables are important in the prediction of the problematicaspects of chronic low-back pain (Craig, 1994). Indeed, whereas specificpain-related anxiety components predicted pain-related distress, there wasno evidence that the duration of chronic pain, surgical history, lumbar flexion,sensory experience of pain, or relevant demographic variables functioned inthe same way. Thus, focusing scientific and clinical attention on anxiety andfear of pain is critical to understanding the complex nature of chronic low-back pain. Furthermore, although changes in pain-related anxiety appearto be important in the prediction of multidisciplinary treatments for chronicpain (McCracken et al., 2002; McCracken and Gross, 1998; Vowles and Gross,2003), it is not yet clear whether reductions in particular pain-related anx-iety components are differentially related to other indices of change (e.g.,physical capacity functioning).

It also is important to note that from a psychometric perspective, theresults of this study provide support for the discriminative validity of pain-related anxiety construct as being composed of specific dimensions, as severaldistinct PASS dimensions varied in their association with chronic pain dis-tress and disability. These findings converge with other research in the areaof anxiety pathology, identifying the differential predictive power of spe-cific pain-related anxiety dimensions (Schmidt, 1999). We also found thatthe PASS and MPI generally share a low, significant (positive) relation withone another, providing convergent validity data for the PASS in a clinicalpopulation of low-back pain patients.

There are a number of interpretative-related caveats that warrant con-sideration in this study. First, because the psychological variables were

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assessed with the same type of methodology, it is possible that the observedfindings were, at least in part, due to shared method variance. Future re-search therefore could employ experimental cognitive methodologies (e.g.,Stroop task) to explore more automatic types of processes in which anxi-ety about pain contributes to emotional distress in low-back pain patients(Mogg and Bradley, 1998). Second, the correlational design while usefulat this stage of research development does not permit causal explanations,leaving the results open to a number of alternative explanations in termsof type and direction of the observed relations. Finally, we did not providea prospective assessment of how pain-related anxiety relates to various as-pects of pain distress. Given the present results, in conjunction with otherstudies in this general area (Asmundson and Taylor, 1996), researchers arein a good position to evaluate the relative stability of the observed findingsover time.

Taken together, this study evaluated pain-related anxiety, along withother theoretically relevant variables, as predictors of pain severity, affectivedistress, perceived lack of control, and behavioral interference. Overall, thefindings reiterate the importance of anxiety about pain in understandingdistress produced by chronic pain problems, and suggest that the higherlevel of correspondence between the particular pain-related domain andevents that closely match that fear, the better problematic aspects of thepain problem can be predicted, and subsequently addressed.

REFERENCES

Arntz, A., and Peters, M. (1995). Chronic low back pain and inaccurate predictions of pain: Isbeing too tough a risk factor for the development and maintenance of chronic pain? Behav.Res. Ther. 33: 49–53.

Asmundson, G. J. G. (1999). Anxiety sensitivity and chronic pain: Empirical findings, clinicalimplications, and future directions. In Taylor, S. (Ed.), Anxiety Sensitivity: Theory, Research,and Treatment of the Fear of Anxiety, Erlbaum, Mahwah, NJ, pp. 269–285.

Asmundson, G. J. G., Kuperos, J. L., and Norton, G. R. (1997). Do patients with chronic painselectively attend to pain-related information? Preliminary evidence for the mediating roleof fear. Pain 72: 27–32.

Asmundson, G. J. G., Norton, P. J., and Norton, G. R. (1999). Beyond pain: The role of fear andavoidance in chronicity. Clin. Psychol. Rev. 19: 97–119.

Asmundson, G. J. G., and Taylor, S. (1996). Role of anxiety sensitivity in pain-related fear andavoidance. J. Behav. Med. 19: 573–582.

Barlow, D. H. (1991). Disorders of emotion. Psychol. Inq. 2: 58–71.Burckhardt, C. S., and Belle, A. (1993). A Swedish version of the Short Form McGill Pain

Questionnaire. Scand. J. Rheumatol. 23: 77–81.Burns, J. W., Mullen, J. T., Higdon, L. J., Wei, J. M., and Lansky, D. (2000). Validity of the

Pain Anxiety Symptoms Scale (PASS): Prediction of physical capacity variables. Pain 84:247–252.

Carter, L. E., McNeil, D. W., Vowles, K. E., Sorrell, J. T., Turk, C., Ries, B., and Hopko, D. R.(2002). Effects of emotion on pain reports, tolerance and physiology. Pain Res. Manage. 7:21–30.

P1: JWF



Clark, D. A., Beck, A. T., and Brown, G. (1989). Cognitive mediation in general psychiatricoutpatients: A test of the content-specificity hypothesis. J. Pers. Soc. Psychol. 56: 958–964.

Coft, P. R., Papageorgio, A. C., Thomas, E., Jayson, M. I., and Silman, A. J. (1995). Psychologicdistress and low back pain. Evidence from a prospective study in the general population.Spine 15: 2731–2737.

Cox, B. J. (1996). The nature and assessment of catastrophic thoughts in panic disorder. Behav.Res. Ther. 34: 363–374.

Craig, K. D. (1994). Emotional aspects of pain. In Wall, P. D. and Melzack, R. (Eds.), TheTextbook of Pain, Churchill Livingstone, Edinburgh, pp. 261–274.

Crombez, G., Vlaeyen, J., W. S., Heuts, P. H. T. G., and Lysens, R. (1999). Pain-related fear ismore disabling than pain itself: Evidence on the role of pain-related fear in chronic backpain disability. Pain 80: 329–339.

Eifert, G. H., Zvolensky, M. J., Sorrell, J. T., Hopko, D. R., and Lejuez, C. W. (1999). Predictors ofself-reported anxiety and panic symptoms: An evaluation of anxiety sensitivity, suffocationfear, heart-focused anxiety, and breath-holding duration. J. Psychopathol. Behav. Assess.21: 293–305.

Ferrari, R., Novara, C., Sanavio, E., and Zerbini, F. (2000). Internal structure and validity ofthe Multidimensional Pain Inventory, Italian language version. Pain Med. 1: 123–130.

Frymoyer, J. W. (1993). Quality: An international challenge to the diagnosis and treatment ofthe disorders of the lumbar spine. Spine 18: 2147–2152.

Georgoudis, G., Oldham, J. A., and Watson, P. J. (2001). Reliability and sensitivity measuresof the Greek version of the short form of the McGill Pain Questionnaire. Eur. J. Pain 5:109–118.

Georgoudis, G., Watson, P. J., and Oldham, J. A. (2000). The development and validation of aGreek version of the short-form McGill Pain Questionnaire. Eur. J. Pain 4: 275–281.

Hadjistavropoulos, H. D., and LaChapelle, D. L. (2000). Extent and nature of anxiety experi-enced during physical examination of chronic low back pain. Behav. Res. Ther. 38: 13–29.

Hoffman, R. M., Wheeler, K. J., and Deyo, R. A. (1993). Surgery for herniated discs: A literaturesynthesis. J. Gen. Intern. Med. 8: 487–496.

Jensen, M. P., Turner, J. A., and Romano, J. M. (1994). Correlates of improvement in multidis-ciplinary treatment for chronic pain. J. Consult. Clin. Psychol. 62: 172–179.

Kerns, R. D., Turk, D. C., and Rudy, T. E. (1985). The West Haven–Yale Multidimensional PainInventory. Pain 23: 345–356.

Kori, S. H., Miller, R. P., and Todd, D. D. (1990). Kinesiophobia: A new view of chronic painbehavior. Pain Manage. 3: 35–64.

Lethem, J., Slade, P. D., Troup, J. D. G., and Bentley, G. (1983). Outline of a fear-avoidancemodel of exaggerated pain perception–I. Behav. Res. Ther. 21: 401–408.

McCracken, L. M. (1997). “Attention” to pain in persons with chronic pain: A behavioralapproach. Behav. Ther. 28: 271–284.

McCracken, L. M., Faber, S. D., and Janeck, A. S. (1998). Pain-related anxiety predicts nonspe-cific physical complaints in persons with chronic pain. Behav. Res. Ther. 36: 621–630.

McCracken, L. M., and Gross, R. T. (1998). The role of pain-related anxiety reduction in theoutcome of multidisciplinary treatment for chronic low back pain: Preliminary results. J.Occup. Rehabil. 8: 179–189.

McCracken, L. M., Gross, R. T. and Eccleston, C. (2002). Multimethod assessment of treatmentprocess in chronic low back pain: Comparison of reported pain-related anxiety with directlymeasured physical capacity. Behav. Res. Ther. 40: 585–594.

McCracken, L. M., Gross, R. T., Sorg, P. J., and Edmunds, T. A. (1993a). Prediction of painin patients with chronic low back pain: Effects of inaccurate prediction and pain-relatedanxiety. Behav. Res. Ther. 31: 647–652.

McCracken, L. M., Zayfert, C., and Gross, R. T. (1992). The Pain Anxiety Symptoms Scale:Development and validation of a scale to measure fear of pain. Pain 50: 67–73.

McCracken, L. M., Zayfert, C., and Gross, R. T. (1993b). The Pain Anxiety Symptoms Scale:A multimodal measure of pain specific anxiety symptoms. Behav. Therap. 16: 183–184.

P1: JWF



McNally, R. J., and Eke, M. (1996). Anxiety sensitivity, suffocation fear, and breath-holdingduration as predictors of response to carbon dioxide challenge. J. Abnorm. Psychol. 105:146–149.

McNeil, D. W., and Rainwater, A. J. (1998). Development of the Fear of Pain Questionnaire–III.J. Behav. Med. 21: 389–410.

Melzack, R. (1987). The short-form McGill Pain Questionnaire. Pain 30: 191–197.Melzack, R., and Katz, J. (2001). The McGill Pain Questionnaire: Appraisal and current status.

In Turk, D. C., and Melzack, R. (Eds.), Handbook of Pain Assessment, 2nd ed., Guilford,New York, pp. 35–52.

Miaskowski, C. (1999). The role of sex and gender in pain perception and responses to treatment.In Gatchel, R. J., and Turk, D. C. (Eds.), Psychosocial Factors in Pain: Critical Perspectives,Guilford, New York, pp. 401–411.

Mogg, K., and Bradley, B. P. (1998). A cognitive-motivational analysis of anxiety. Behav. Res.Ther. 36: 809–848.

Nachemson, A. L. (1992). Newest knowledge of low back pain. Clin. Orthop. 279: 8–20.Rachman, S. J. (1991). Disorders of emotion: Causes and consequences. Psychol. Inq. 2: 86–87.Schmidt, N. B. (1999). Examination of differential anxiety sensitivities in panic disorder: A test

of anxiety sensitivity subdomains in predicting fearful responding to a 35% CO2 challenge.Cogn. Ther. Res. 23: 3–19.

Tollison, C. D., Kriegel, M. L., and Downie, G. R. (1985). Chronic low back pain: Results oftreatment at the pain therapy center. South. Med. J. 78: 1291–1300.

Turk, D. C. (1990). Customizing treatment for chronic pain patients: Who, what, and why? Clin.J. Pain 6: 255–270.

Turk, D. C., and Okifuji, A. (2002). Psychological factors in chronic pain: Evolution and revo-lution. J. Consult. Clin. Psychol. 70: 678–690.

Vlaeyen, J. W. S., and Linton, S. J. (2000). Fear-avoidance and its consequences in chronicmusculoskeletal pain: A state of the art. Pain 85: 317–332.

Vlaeyen, J. W. S., Seelen, H. A. M., Peters, M., de Jong, P., Aretz, E., Beisiegel, E., and Weber,W. E. J. (1999). Fear of movement/(re)injury and muscular reactivity in chronic low backpain patients: An experimental investigation. Pain 82: 297–304.

Vowles, K. E., and Gross, R. T. (2003). Work-related beliefs about injury and physical capabilityfor work in individuals with chronic pain. Pain 101: 291–298.

Waddell, G. (1987). A new clinical model for the treatment of low back pain. Spine 12: 632–644.Waddell, G., and Main, C. J. (1984). Assessment of severity in low back pain disorders. Spine 9:

204–208.Waddell, G., Somerville, D., Henderson, I., and Newton, M. (1992). Objective clinical evaluation

of physical impairment in chronic low back pain. Spine 17: 617–628.Zinbarg, R. E. (1998). Concordance and synchrony in measures of anxiety and panic reconsid-

ered: A hierarchical model of anxiety and panic. Behav. Ther. 29: 301–323.Zvolensky, M. J., Goodie, J. L., McNeil, D. W., Sperry, J. A., and Sorrell, J. T. (2001). Anxiety

sensitivity in the prediction of pain-related fear and anxiety in a heterogeneous chronicpain population. Behav. Res. Ther. 39: 683–696.

pain-related anxiety in the prediction of chronic low-back pain distress

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