67

Pain, 50 (1992) 67-73

0 1992 Elsevier Science Publishers B.V. All rights reserved 0304-3959/92/$05.00

PAIN 02068

The Pain Anxiety Symptoms Scale: development and validation

of a scale to measure fear of pain
Lance M. McCracken qb,Claudia Zayfert a and Richard T. Gross b*c
a De~art#lent

of Psychofogy, West Virginia U~~l~ersi~, ~o~a~town,

and c Department

ofAnesthesiology,

WV 265~6-#4U

IUSAI,

De~~t~ent

of BehaL,j~raf ~edicjne

West Virginia Unioersity Health Sciences Center, Margantown,

WV26506

and ~~chjat~,

(USA)

(Received 29 July 1991, revision received 30 December 1991, accepted 9 January 1992)

Fear of pain has been implicated in the development and maintenance of chronic pain behavior.
Summary
Consistent with conceptualizations of anxiety as occurring within three response modes, this paper introduces an
instrument to measure fear of pain across cognitive, overt behavioral, and physiological domains. The Pain Anxiety
Symptoms Scale (PASS) was administered to 104 consecutive referrals to a multidisciplinary pain clinic. The alpha
coefficients were 0.94 for the total scale and ranged from 0.81 to 0.89 for the subscales. Validity was supported by
significant correlations with measures of anxiety and disability. Regression analyses controlling for measures of
emotional distress and pain showed that the PASS made a significant and unique contribution to the prediction of
disability and interference due to pain. Evidence presented here supports the potential utility of the PASS in the
continued study of fear of pain and its contribution to the development and maintenance of pain behaviors. Factor
analysis and behavioral validation studies are in progress.
Key words: Chronic pain; Pain behavior; Fear of pain; Anxiety; Disability; Pain assessment

introduction

Medical professionals are often frustrated by the

intractable nature of chronic pain. This frustration
results from the frequent failure of medical treatment
and the persistence of pain, suffering, and disability in
the absence of organic pathology (Wall 1979). Recently, Lethem et al. (1983) proposed an explanation of
exaggerated or persistent pain behavior based on fear
of pain. They pointed out that behaviora indicators of
pain can become desynchronous with the organic/
sensory component of pain. In other words, verbal
complaints of pain, reduced activity, and other observable expressions of pain can increase, decrease, or
remain stable independent of changes in tissue damage. Specifically, Lethem et al. (1983) addressed the
problem of behavioral indicators of pain that persist as

Correspondence to: Richard T. Gross, Ph.D., Department

of
Behavioral Medicine and Psychiatry, West Virginia University Health
Sciences Center, Morgantown, WV 26506 (USA)

tissue damage decreases or remits. They attribute this

persistence of pain indicators to the emotional response to pain. According to their model, as with other
fears, avoidance associated with fear of pain leads to
greater fear and to increasingly limited activity. As
tissue injury remits and fear remains, pain behaviors
are no longer elicited by an internal sensory stimulus
but rather become largely avoidance responses maintained by subsequent reduction of emotionai distress.
Recent data support the analogy between pain behaviors and fear behaviors. For example, Phillips and
Jahanshahi (1985) demonstrated that when chronic pain
patients were exposed to an aversive stimulus, avoidance led to increased sensitivity to the pain stimulus
and increased avoidance on subsequent trials. Phillips
(1987) suggested that avoidance in chronic pain sufferers may be related to beliefs and memories of the
sufferer which lead to expectations that pain wiI1 increase following exposure to .pain-related stimuli. If
this model is correct, processes which explain the modification of fear and anxiety, such as habituation, sensitization, and disconfirmation may also be applicable to

68

understanding changes in pain behavior as well (Phillips 1987).

In a related area, several researchers have chosen to
examine the relationship between anxiety and pain.
Studies of the effects of induced anxiety on responses
to acute laboratory pain stimuli suggest that anxiety
related to pain increases ratings of perceived pain
intensity (Weisenberg et al. 1984; Cornwall and Donderi 1988; Al Absi and Rokke 19911 while anxiety
unrelated to pain increases pain tolerance (Bobey and
Davidson 1970) and decreases galvanic skin responses
to pain (Weisenberg et al. 1984). Results of Arntz et al.
(19911 suggest that attention to pain increases the
impact of pain and that anxiety about pain directs
attention to pain. Researchers have afso suggested that
pain-related anxiety may influence the emotional response to pain (Cornwall and Donderi 1988) and thus
may increase what Fordyce (1976) refers to as the
suffering component of the pain experience.
Recognizing the importance of emotional and cognitive responses to pain in determining the extent of
suffering experienced by pain patients, researchers have
developed a variety of measures to assess these responses indirectly. Thus, self-report measures of patient behavior in response to pain evaluate subjective
aspects of the pain experience such as negative cognitions (Cognitive Error Questionnaire, Lefebvre 1981;
Inventory of Negative Thoughts in Response to Pain,
Gil et al. 19901, adaptive and maladaptive thoughts
(Pain Cognitions Questionnaire, Boston et al 19901
positive and negative cognitive and overt behavioral
pain coping strategies (Coping Strategies Questionnaire (CSQ), Rosenstiel and Keefe 19831, and beliefs
and attitudes associated with functional impairment
(Pain and Impairment Relationship Scale, Riley et al.
1988; Slater et al. 1991). While these are clearly important dimensions to assess, they do not yield information
which directly pertains to pain-related anxiety and
which would further our understanding of its role in
the chronic pain experience.
There has been one attempt to assess fear responses
to pain in chronic pain patients. This was a 6-item Fear
Self-Statements subscale included in an expanded version of the CSQ (Gil et al. 19891. In their study of
patients with pain from sickle cell disease, Gil et al.
(1989) found that high scores on a negative thinking
and passive adherence coping factor (which included
the Fear Self-Statements subscale) predicted greater
severity of painful episodes, lower Ievels of activity,
more psychological distress, and more frequent health
care utiiization.
The numerous self-report measures discussed above.
including the CSQ Fear Self-Statements subscale of
Gil et al. (19891, focus on ~ognitions only. With the
exception of the CSQ, which includes behavioral pain
coping responses, these commonly used measures de-

vote little or no attention to overt behavioral and

physiological responses to pain which are of particular
interest in the study of anxiety states.
This paper describes the development of a self-report instrument, the Pain Anxiety Symptoms Scale
(PASS), to measure fear of pain. This measure is
intended to provide a means of evaluating the importance of fear of pain in exaggerated or persistent pain
behaviors. As a research tool, it may prove useful for
classifying pain patients with respect to their level of
pain-related anxiety. This information will, in turn,
allow examination of how anxiety responses interact
with other factors to enhance the experience of pain.
Furthermore, it may facilitate development of individuahzed treatment inte~entions based on the degree to
which fear is a component in an individuals pain
experience. Thus, as we gain a better understanding of
the role of anxiety in clinical pain, this instrument may
have important clinical utility as well.
This instrument may also contribute to available
measures of pain behavior by broadening the scope of
assessment to include physiological and motoric response domains. Consistent with the Three-Systems
Model of fear (Lang 1968; Hugdahl 19811, this instrument assesses fear of pain behaviors in 3 response
modalities: cognitive, physiologic and motoric. Thus,
patients are asked to respond to items which describe
(a> fearful thoughts and ruminations about the consequences of their pain, (b) physiological symptoms of
fear associated with the experience of pain, and (c>
avoidance and escape of activities which they believe
may increase pain. Such a tri-modal assessment of fear
of pain will facilitate its study within the current framework employed in the study of anxiety disorders. For
exampie. it has been shown that individuals who report
specific fears (i.e., phobias) often show discordance or
desynchrony of response modalities in the expression
of their fears (Hodgson and Rachman 1974; Rachman
and Hodgson 1974). Similarly, fear of pain may be
expressed disproportionately
among the 3 response
channels, and behaviors of these separate channels
may respond differently to inte~entions. If, like other
phobias, fear of pain exhibits individual differences in
the dominant response channel, the information
gleaned from a multimodal assessment may have important implications for treatment of chronic pain
problems.

Method
Subjects
The subjects were 104 outpatients
(48 males, 56 females) evaiuated consecutively
at a multidiscipljna~
pain management
center.
Mean age of the sample was 45.0 years (SD. = 13.4). Seventy-five
percent of the patients were married, 12% single, 9% divorced. and

69
4% widowed. Mean years of education was 12.0 (SD. = 2.3). The
majority of patients presented with back pain (69%), but the sample
also included patients with extremity, facial/head, and torso pain
complaints. Pain complaints were chronic in nature. All patients
reported pain that persisted despite multiple medical interventions.
The mean duration of pain was 63.1 months (SD. = 105.8). Forty
percent of patients had undergone at least 1 pain-related surgery,
and 52% were taking narcotic analgesics on a regular basis.
The PASS was administered as part of a comprehensive pain
assessment procedure. Patients completed the PASS and other standardized inventories at home several weeks prior to their scheduled
appointment in the pain management center. The standardized
inventories included commonly employed measures of depression,
anxiety, pain, and disability and are described below.

Measures
PASS. The initial scale consisted of 62 rationally derived items
generated to assess fear of pain in each of the 3 response modes.
Items were modeled after items of commonly used anxiety measures
and the criterion for item inclusion was a logical rather than empirical relationship with the fear of pain construct. Item content represented anxiety symptoms frequently described in the anxiety disorders literature and patients descriptions of their fears related to
pain.
Items were developed for inclusion in 4 subscales. The 1st subscale, Fear of Pain (19 items), was intended to measure fearful
thoughts related to the experience of pain or anticipated negative
consequences of pain. The 2nd subscale, Cognitive Anxiety (10
items), was designed to assess cognitive symptoms related to the
experience of pain, such as racing thoughts or impaired concentration. The 3rd subscale, Somatic Anxiety (16 items), assessed symptoms reflecting physiological arousal related to the experience of
pain. The 4th subscale, Escape and Avoidance (17 items), assessed
overt behavioral responses to pain. Table I shows sample items for
each of these subscales.

Patients were instructed to rate the frequency of occurrence of

each of the 62 behaviors on a 6-point scale from 0 never to 5
always. The total score was computed by reversing 11 negatively
keyed items and summing the ratings across the entire measure.
Subscale scores were computed by totaling responses to items designated for each subscale.
Beck Depression Incwntory (BDI). The BDI (Beck et al. 1961) is a
21-item, self-report measure of depression. It assesses common cognitive and vegetative symptoms of depression. More than 25 years of
research evaluating the psychometric properties of the BDI has
indicated that it has excellent reliability and validity (Beck et al.
1988).
Cognirive Somatic Anxiety Questionnaire (C&IQ). Symptoms of
anxiety were assessed with the CSAQ (Schwartz et al. 1978). The
CSAQ consists of a list of 14 symptoms of anxiety, including both
cognitive and somatic aspects. Respondents are asked to rate the
degree to which they experience each of these symptoms when they
are anxious. Factor analyses of the CSAQ have identified distinct
somatic and cognitive factors (Steptoe and Kearsley 1990). The scale
yields separate scores for each of these aspects.
Coping Strategies Questionnaire (CSQ). The CSQ (Rosenstiel and
Keefe 1983) is a 42-item questionnaire which assesses self-reported
use of 7 different cognitive and behavioral pain coping strategies.
Only the Catastrophizing subscale was calculated for this study. This
6-item scale assesses negative thinking in response to pain.
McCiN Pain Questionnaire (MPQ). The MPQ (Melzack 1975)
consists of 20 subclasses of 78 adjectives divided among 4 dimensions: sensory, affective, evaluative, and miscellaneous. The purpose
of the MPQ is to provide quantitative indices of the subjective pain
experience. It has become the most widely used measure of pain and
has demonstrated acceptable reliability and face, construct, discriminant, and concurrent validity (Reading 1983). The MPQ yields several variables including scores for each of the separate dimensions
and a total score.
Mu~tidimensionnl Pain Inventory (MPI). The MPI (formerly the
WHYMPI, Kerns et al. 1985) is a brief, comprehensive measure of
important aspects of the subjective experience of chronic pain based

TABLE I
SAMPLE ITEMS FROM THE PAIN ANXIETY SYMPTOMS SCALE (PASS)
Subscale

Item content

Somatic anxiety

I become sweaty when in pain.

Pain seems to cause my heart to pound or race.
When I sense pain, I feel dizzy or faint.
I have pressure or tightness in my chest when in pain.
I can stay relaxed when I hurt.

Cognitive Anxiety

I feel disoriented and confused when I hurt.

When I hurt, I think about the pain constantly.
I am bothered by unwanted thoughts when Im in pain.
My thoughts are agitated and keyed up as pain approaches.
During painful episodes it is difficult for me to think of anything besides the pain.
I worry when I am in pain.

Fear

I think that pain is a signal that means I am damaging myself.

I dread feeling pain.
When pain comes on strong, I think that I might become paralyzed or totally disabled.
I am afraid that I will have more pain if I am not careful.
I think that if my pain gets too severe, it will never decrease.

Escape/Avoidance

When I feel pain I try to stay as still as possible.

I try to avoid activities which cause pain.
As soon as pain comes on I take medication to reduce it.
I seek reassurance that I am OK during times of more severe pain.
I go immediately to bed when I feel severe pain.

Note: subjects respond to each item by selecting a frequency rating from 0 never to 5 always.

70
TABLE

II

SUMMARY

STATISTICS

FOR PASS SUBSCALES

AND TOTAL

SCALE

SCORES

Subscale

No. of items

Item means

S.D.

Alpha

Somatic
Cognitive
Fear
Est./Avoid

14
10
14
15

1.73
2.56
2.21
2.54

1.12
1.10
1.04
0.92

0.89
0.87
0.85
0.8 I

0.68
0.64
0.48

0.70
0.5 I

0.45

Total

53

2.24

0.88

0.94

0.85

0.86

0.85

All correlations

significant

0.74

at P < 0.001. N = 104

on the cognitive-behavioral
perspective
of chronic pain. The 52
items of the MPI divide into 3 major parts, each containing
several
subscales. The inventory examines the impact of pain on the patients
life, responses of significant others to the patients pain behaviors,
and level of participation
in typical daily activities. Research with the
MPI suggests that it has achieved adequate
reliability, validity, and
clinical utility (Kerns et al. 1985).
Pain Disability Index (PDI). The PDI (Pollard 19841 is a 7-item,
self-report
measure which assesses patients perceived level of disability in 7 life areas. The PDI yields a total score, as well as factor
scores for pain-related
disability in discretionary
and obligatory activities. Recent research
has supported
the factor structure,
validity,
and retest reliability of the PDI (Tait et al. 19901 and its construct
validity (Jerome and Gross 1991).
Spielberger Truit Anxiety Scale (STAI-T). The STAI-T (Spielberger et al. 1970) is a 20-item inventory which assesses individuals
predisposition
to judge situations as dangerous or threatening
and to
respond with increased
levels of state anxiety. The scale is widely
used and has been found to have high internal consistency as well as
high retest reliability
and expected
correlations
with personality
based measures of anxiety such as the Taylor Manifest Anxiety Scale.

TABLE

Intercorrelations

Results
Scale development and psychometrics

Preliminary analyses included examination of frequency distributions for item responses and corrected
item-scale correlations (correlations of items with their
respective scale scores computed with the item omitted). Based on these analyses, 1 item was eliminated
because of a highly skewed distribution and 7 items
were eliminated because they correlated more highly
with a subscale other than the one for which they were
written. In these cases, examination of item content
indicated that these items were not conceptually similar to the other subscales. A final item was eliminated
from further analyses because it was not significantly
correlated (at P < 0.05) with any of the PASS subscales. The final inventory submitted to further analyses consisted of 53 items, 14 assessing somatic anxiety,

III

CORRELATIONS

OF

PASS

SUBSCALES

AND

TOTAL

SCORES

WITH

MEASURES

OF

PAIN,

ANXIETY,

DEPRESSION

DISABILITY
PASS scores
Somatic

Cognitive

Fear

Est./Avoid

Total

CSAQ
Cognitive
Somatic

0.49 **
0.74 **

0.61 **
0.55 * *

0.53 **
0.56 * *

0.25
0.17

0.54 **
0.61 **

McGill
Sensory
Affective
STAI-T

0.45 **
0.51 **
0.52 **

0.26 *
0.33 **
0.67 **

0.20
0.36 **
0.53 **

0. I6
0.31 **
0.29 *

0.31 **
0.44 **
0.60 * *

MPI
Pain severity
Interference

0.35 **
0.28 *

0.25 *
0.33 **

0.28 *
0.31 **

0.18
0.36 **

0.32 * *
0.39 **

0.67
0.51
0.39
0.25

0.67
0.67
0.39
0.27

0.66 * *
0.50 **
0.40 **
0.19

0.42 **
0.30 **
0.30 * *
0.16

0.73
0.57
0.45
0.29

CSQ
Catastrophizing
BDI
PDI
Tranquilizer/anxiolytic

use

**
**
**
*

Note: * P < 0.01, * * P < 0.001. All probability

**
**
**
*

values are l-tailed.

**
**
**
*

AND

71

10 assessing cognitive anxiety, 14 assessing fear, and 15

assessing escape and avoidance responses.
Table II includes summary statistics for the 4 subscales and the total scale score. Cronbachs coefficient
alpha was computed for each scale demonstrating adequate internal consistency (see Table II). Scale intercorrelations indicate that the subscales significantly
intercorrelate. Squaring the interscale correlations reveals that overlapping variance ranges from 0.20 to
0.45, indicating that each scale provides unique information.
Construct validity

Construct validity represents the extent to which a

test is demonstrated to measure a theoretical construct
or non-operationalized
variable. One way to provide
evidence for construct validity is to examine the correlations of a measure with theoretically related measures. To assess the construct validity of the PASS, the
relationships between the various PASS scores and
measures of anxiety, pain, and maladaptive coping
responses
to pain were assessed with Pearson
product-moment
correlations (see Table III). The validity of the somatic and cognitive anxiety scales of the
PASS is supported by higher correlations between reTABLE

spective somatic and cognitive factors of the CSAQ.

Significance tests for differences between correlated TS
confirmed the statistical significance of these results in
comparisons of the correlations of the PASS Cognitive
Anxiety and Somatic Anxiety subscales with the CSAQ
cognitive factor (t (101) = 1.92; P < 0.05) and the correlations of these PASS subscales with the CSAQ
somatic factor (t (101) = 7.61; P < 0.001).
All PASS variables demonstrated higher correlations with the affective dimension of the MPQ than
with the sensory dimension. Finally, the trait form of
the STAI, the pain severity scale of the MPI, and the
catastrophizing scale of the CSQ showed consistent
significant correlations with PASS subscales, demonstrating predictable overlap between these concepts
and the behaviors assessed on the PASS (see Table
III).
Concurrent validity

While construct validity involves theoretical considerations, it also is important to demonstrate the practical or criterion-related
validity of a measure. In the
case of the PASS, criterion-related
validity can be
assessed by examining correlations of the PASS subscales with patient outcome variables that it should

IV

RESULTS OF HIERARCHICAL
REGRESSION
ANALYSES
EMPLOYING
DISTRESS
IN ADDITION
TO THE PASS TOTAL SCORE AS PREDICTORS
ENCE DUE TO PAIN (MPI)
Dependent
Step
Interference
Equation

variable

R2

Beta

COMMON
MEASURE
OF PAIN AND PSYCHOLOGICAL
OF SELF-RATED
DISABILITY
(PDI), AND INTERFER-

St.2

Fchange

Probability

1
0.23
0.24

0.38
0.17

0.096
0.019

27.43
2.36

0.0000
0.12

STAI-T
PASS
Equation 3

0.11
0.17

0.17
0.28

0.018
0.052

11.54
5.46

0.001
0.02

MPQ sensory
PASS
Equation 4

0.008
0.15

- 0.030
0.39

0.0008
0.14

0.82
15.39

0.37
0.0002

0.18
0.25

0.33
0.28

0.10
0.070

20.47
8.76

0.0000
0.004

0.18
0.24

0.23
0.32

0.035
0.068

19.32
8.41

0.0000
0.005

STAI-T
PASS
Equation 3

0.12
0.21

0.11
0.38

0.008
0.094

11.70
10.44

0.0009
0.002

MPQ sensory
PASS
Equation 4

0.03
0.20

0.04
0.44

0.0015
0.17

3.03
20.39

0.085
0.0000

0.25
0.34

0.40
0.32

0.14
0.095

31.51
13.60

0.0000
0.0004

BDI
PASS
Equation

Pain severity
PASS
Disability
Equation
BDI
PASS
Equation

Pain severity
PASS

72

predict. When criterion-related validity is evaluated by

correlating measures administered at one point in time,
this type of validity is referred to as concurrent. Concurrent validity for the PASS was assessed by examining the relationships between the PASS scores and
common measures of disability and depression. Correlational analyses indicated that PASS scores related
significantly to scores from the interference scale of the
MPI, scores from the BDI, and self-rated disability as
measured by the PDI. In addition, point biserial correlations between PASS scores and a dichotomous variable representing use of tranquilizing or anxiolytic
medications indicated that the Somatic and Cognitive
Anxiety subscales as well as the total score were positively related to use of these medications (see Table
III).
Next, a series of hierarchical multiple regression
analyses were performed. These assessed the significance of the unique increment in variance accounted
for by the PASS in the prediction of disability after
controlling for various measures of pain and psychological distress. Dependent variables were the PDI total
score and the interference scale of the MPI. Independent variables entered into the equations before testing
for the contribution of the PASS included the MPQ
sensory score, the MPI pain severity scale score, the
BDI score, and the STAI-T score. Results are included
in Table IV. With one exception the PASS scores
significantly contributed to the prediction of disability
and interference due to pain after controling for variance related to the other predictors. The squared
semi-partial correlation coefficients indicate that, in
those equations in which the PASS contributed significantly, it accounted for a unique portion of variance
which ranged from 5.2% to 17%. It consistently accounted for more unique outcome variance than the
STAI or the sensory dimension of the MPQ.

Discussion

Preliminary analyses support the reliability and validity of the PASS as a measure of pain-related fear
and anxiety. High alpha coefficients suggest that the
PASS and its subscales demonstrate good internal consistency. Interscale correlations demonstrate that subscales are meaningfully related but also provide independent information about fear and anxiety responses.
Construct validity of the PASS was supported by
moderate correlations with other measures of anxiety.
Moreover, although 4 of 5 variables from the PASS
correlate with the CSAQ factors at a moderate to high
moderate level, results support a differential relationship between the Cognitive and Somatic subscales of
the PASS and the respective cognitive and somatic
factors of the CSAQ. This finding supports the con-

struct validity of these PASS subscales. All subscales

and the total PASS score showed higher correlations
with the MPQ affective dimension than with the MPQ
sensory dimension, indicating that fear related to pain
is not simply a function of the sensory experience of
pain.
The results also confirm the concurrent validity of
the PASS in relation to measures of disability, depression, and medication use, all pervasive consequences of
chronic pain. Correlation analyses revealed that painrelated fear and anxiety, as measured by the PASS, are
significant predictors of disability and interference with
daily activities due to pain. Regression analyses controlling for measures of pain and psychological distress
revealed that, with one exception, the PASS made a
significant unique contribution to the prediction of
disability. The PASS was a much better predictor of
disability and interference than the Sensory subscale of
the MPQ. The PASS also proved to be a better predictor of disability and interference than a measure of
general anxiety (STAI-T). Relative to a measure of
emotional distress, i.e., the BDI, the PASS made a
greater contribution to the prediction of disability but
added little to the prediction of interference. Overall,
these results suggest that the PASS predicts important
patient outcomes and provides information which is
not currently available from other commonly used
measures.
The validity results discussed above include a large
number of significance tests, implying a possibly unacceptable level of chance findings. Three points are
relevant to understand better this limitation of the
data. First, variables from the PASS demonstrate consistent patterns of relations with other variables, suggesting that chance does not play an important role in
the results. For example, both the CSAQ and the
STAI-T are measures of trait anxiety. Although item
content of these measures is different, both measures
demonstrated similar relations with the PASS increasing confidence in these findings. Likewise, similarities
between the variables assessed by the MPI Interference subscale and the PDI, and by the MPI Pain
Severity subscale and the MPQ sensory factor, tend to
increase our confidence in the correlational results.
Second, examination of the probability values associated with most of our results reveals the majority of the
results attain low probability values. Third, to help
reduce reliance on possibly spurious results, a more
conservative significance criterion was chosen for Table
III.
Overall, the findings discussed above suggest that
fear of pain can be conceptualized as a multidimensional response which may contribute significantly to
the chronic pain experience. Further investigations of
the psychometric properties of the PASS should seek
to establish the temporal stability of the measure, as

73

well as the behavioral validity of the Somatic and

Escape/Avoidance
subscales. For example, it will be
important to demonstrate that high scores on these
subscales are highly correlated with the physiological
measures of arousal in response to pain, with clinical
observations, and spouse reports of escape and avoidance behaviors. This latter point is crucial since the
validity data presented here only include intercorrelations of self-report instruments. Shared variance related to the method of data collection may contribute
to these correlations. Finally, factor analyses should be
conducted in order to establish the factor structure of
the PASS and its concordance with the intended subscales. Creating subscales with greater discriminant
validity also would be valuable. Scale overlap, particularly between the Fear and Cognitive Anxiety subscales, may be reduced by examining factor results and
further examining item-scale correlations to eliminate
items that reduce subscale independence.
The purpose of this instrument is to facilitate the
study of pain-related fear and anxiety in chronic pain
populations with the goal of improving treatment outcome. The PASS may be particularly useful in this
respect if it enables clinicians to identify empirical
subtypes of pain patients who may respond differentially to treatment interventions. For example, it is
conceivable that individuals whose fear of pain is manifested primarily in the physiological response system
may be more responsive to relaxation training than to
attempts at cognitive restructuring. In order to determine whether the PASS is useful in distinguishing
subgroups of patients, cluster analyses of the PASS on
a broader sample of chronic pain patients are currently
being conducted.
References
Al Absi, M. and Rokke, P.D., Can anxiety help us tolerate pain?,
Pain, 46 (1991) 43-51.
Arntz, A., Dreessen, L. and Merckelbach,
H., Attention,
not anxiety,
influences pain, Behav. Res. Ther., 29 (1991) 41-50.
Beck, A.T., Steer, R.A. and Garbin, M.G., Psychometric
properties
of the Beck Depression
Inventory:
twenty-five
years of evaluation, Clin. Psychol. Rev., 8 (1988) 77-100.
Beck, A.T., Ward, C.H., Mendelson,
M., Mock, J. and Erbaugh, J.,
An inventory
for measuring
depression,
Arch. Gen. Psych., 4
(1961) 561-571.
Bobey, M.J. and Davidson, P.O., Psychological
factors affecting pain
tolerance,
J. Psychosom. Res., 14 (1970) 371-376.
Boston, K., Pearce, S.A. and Richardson,
P.H., The Pain Cognitions
Questionnaire,
J. Psychosom. Res., 34 (1990) 103-109.
Cornwall,
A. and Donderi,
D.C., The effect of experimentally
induced anxiety on the experience of pressure pain, Pain, 35 (1988)
105-113.
Fordyce, W.E., Behavioral
Methods
in Chronic
Pain and Illness,
C.V. Mosby, St. Louis, MO, 1976, 236 pp.

Gil, K.M., Abrams, M.R., Phillips, G. and Keefe, F.J., Sickle cell
disease pain: relation of coping strategies to adjustment,
J. Consult. Clin. Psychol., 57 (1989) 725-731.
Gil, K.M., Williams,
D.A., Keefe, F.J. and Beckham,
J.C., The
relationship
of negative thoughts to pain and psychological
distress, Behav. Ther., 21 (1990) 349-362.
Hodgson,
R. and Rachman,
S., Desynchrony
in measures
of fear,
Behav. Res. Ther., 12 (1974) 319-326.
Hugdahl, K., The three-system
model of fear and emotion: a critical
examination,
Behav. Res. Ther., 19 (1981) 75-85.
Jerome, A. and Gross, R.T., Pain Disability Index: construct
and
discriminant
validity, Arch. Phys. Med. Rehab., 72 (1991) 920-922.
Kerns, R.D., Turk, D.C. and Rudy, T.E., The West Haven-Yale
Multidimensional
Pain Inventory
(WHYMPI),
Pain, 23 (1985)
345-356.
Lang, P.J., Fear reduction
and fear behavior: problems in treating a
construct.
In: J.M. Shilen (Ed.), Research in Psychotherapy,
Vol.
3, American
Psychological
Association,
Washington,
DC, 1968,
pp. 90-103.
Lefebvre,
M.F., Cognitive
distortion
and cognitive
errors in depressed psychiatric
and low back pain patients, J. Consult. Clin.
Psychol., 49 (1981) 517-525.
Lethem, J., Slade, P.D., Troup, J.D.G. and Bentley, G., Outline of a
fear-avoidance
model of exaggerated
pain perception-I,
Behav.
Res. Ther., 21 (1983) 401-408.
Melzack, R., The McGill Pain Questionnaire:
major properties
and
scoring methods, Pain, 1 (1975) 277-299.
Phillips, H.C., Avoidance behavior and its role in sustaining chronic
pain, Behav. Res. Ther., 25 (1987) 273-279.
Phillips, H.C. and Jahanshahi,
M., Chronic pain: an experimental
analysis of the effects of exposure, Behav. Res. Ther., 23 (1985)
281-290.
Pollard, C.A., Preliminary
validity study Pain Disability Index, Percept. Motor Skills, 59 (1984) 974.
Rachman,
S. and Hodgson,
R., Synchrony and desynchrony
in fear
and avoidance, Behav. Res. Ther., 12 (1974) 311-318.
Reading, A.E., The McGill Pain Questionnaire:
an appraisal.
In: R.
Melzack (Ed.), Pain Measurement
and Assessment,
Raven Press,
New York, 1983, pp. 55-61.
Riley, J.F., Ahern, D.K. and Follick, M.J., Chronic pain and functional impairment:
assessing beliefs about their relationship,
Arch.
Phys. Med. Rehab., 69 (1988) 579-582.
Rosenstiel, A.K. and Keefe, F.J., The use of coping strategies in low
back pain patients:
relationship
to patient characteristics
and
current adjustment,
Pain, 17 (1983) 33-40.
Schwartz,
G.E., Davidson,
R.J. and Goleman,
D.J., Patterning
of
cognitive and somatic processes in the self-regulation
of anxiety:
effects of meditation
versus exercise, Psychosom. Med., 40 (1978)
321-328.
Slater, M.A., Hall, H.F., Atkinson,
H. and Garfin, S.R., Pain and
impairment
beliefs in chronic low back pain: validation
of the
Pain and Impairment
Relationship
Scale (PAIRS), Pain, 44 (1991)
51-56.
Spielberger,
C.D., Gorsuch, R.L. and Lushene, R.E., Manual for the
State-Trait
Anxiety Inventory, Consulting Psychologist Press, Palo
Alto, CA, 1970.
Steptoe, A. and Kearsley, N., Cognitive and somatic anxiety, Behav.
Res. Ther., 28 (1990) 75-81.
Tait, R.C., Chibnall, J.T. and Krause, S., The Pain Disability Index:
psychometric
properties,
Pain, 40 (1990) 171-182.
Wall, P.D., On the relation of injury to pain, Pain, 6 (1979) 253-264.
Weisenberg,
M., Aviram, O., Wolf, Y. and Raphaeli,
N., Relevant
and irrelevant
anxiety in the reaction
to pain, Pain, 20 (1984)
371-383.