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TheRelationshipBetweentheFear-AvoidanceModelofPainandPersonalityTraitsinFibromyalgiaPatients

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The Relationship Between the Fear-Avoidance Model of Painand Personality Traits in Fibromyalgia Patients

Marıa Pilar Martınez • Ana Isabel Sanchez •

Elena Miro • Ana Medina • Marıa Jose Lami

� Springer Science+Business Media, LLC 2011

Abstract This study examined the relationship between

several cognitive-affective factors of the fear-avoidance

model of pain, the big five model of personality, and

functional impairment in fibromyalgia (FM). Seventy-four

FM patients completed the NEO Five-Factor Inventory, the

Pain Catastrophizing Scale, the Pain Anxiety Symptoms

Scale-20, the Pain Vigilance and Awareness Question-

naire, and the Impairment and Functioning Inventory.

Results indicated that the cognitive-affective factors of

pain are differentially associated with personality traits.

Neuroticism and conscientiousness were significant pre-

dictors of pain catastrophizing, and neuroticism, openness,

and agreeableness were significant predictors of pain anx-

iety. Personality traits did not contribute significantly to

vigilance to pain. The effect of neuroticism upon pain

anxiety was mediated by pain catastrophizing, and neu-

roticism showed a trend to moderate the relationship

between impairment and pain anxiety. Results support the

fear-avoidance model of pain. Implications of the findings

for the understanding and management of FM are

discussed.

Keywords Fibromyalgia � Pain catastrophizing �Pain anxiety � Vigilance to pain � Neuroticism

Introduction

Fibromyalgia (FM) is a chronic pain syndrome of uncertain

origin that leads to a significant deterioration of patient’s

quality of life. According to the American College of

Rheumatology (ACR; Wolfe et al., 1990), this disease is

characterized by the presence of widespread musculoskel-

etal pain for at least three months in all four quadrants of

the body, as well as pain in digital palpation in at least 11

of the 18 sensitive points of the body. Although FM may

have a very heterogeneous nature, the most important

diagnostic variables are widespread pain, cognitive symp-

toms, unrefreshed sleep, fatigue, and a number of somatic

symptoms (Wolfe et al., 2010). Considerable links between

these variables have been reported (e.g. Miro et al., 2011).

According to epidemiological studies, the prevalence of

FM ranges from 10.2 to 15.7% in visits to rheumatologists

(Neumann & Buskila, 2003), and FM is the third most

common rheumatic disorder after low back pain and

osteoarthritis (Lawrence et al., 2008). Aside from personal

discomfort, FM causes a notable economic burden for the

healthcare system. The annual medical costs for FM

patients ($4065) are significantly higher than those for

control patients not diagnosed with FM ($2766) (Lachaine,

Beauchemin, & Landry, 2010).

Although the etiology of FM is not clearly established,

accumulating evidence suggests that patients with FM have

a dysregulation of the hypothalamic–pituitary–adrenal

(HPA) axis that occurs in response to a chronic stressor and

is associated to impaired immunity (Ross et al., 2010).

Bazzichi et al. (2007) found higher levels of cytokines in

FM patients than in controls, which suggests the presence

of an inflammatory response system (for reviews, see

Bazzichi et al., 2007; Nishikai et al., 2001; Pamuk & Cakir,

2007). In fact, some FM symptoms are reminiscent of

M. P. Martınez (&) � A. I. Sanchez � E. Miro � A. Medina �M. J. Lami

Departamento de Personalidad, Evaluacion y Tratamiento

Psicologico, Universidad de Granada, Facultad de Psicologıa,

Campus Universitario de Cartuja, 18071 Granada, Spain

e-mail: mnarvaez@ugr.es

123

J Clin Psychol Med Settings

DOI 10.1007/s10880-011-9263-2

‘‘sickness behavior,’’ a syndrome of pain, fatigue, depres-

sion, and impaired cognition caused by the production of

pro-inflammatory cytokines (Ross et al., 2010).

In addition, there is growing acceptance of the role that

psychological factors play in exacerbation of the symptoms

as well as dysfunctional adjustment. These psychological

factors mainly include coping and appraisal styles and

personality traits. Cognitive appraisal is a dual process. In

primary appraisal, individuals assess the significance of a

particular encounter with the environment for their well-

being; in secondary appraisal, individuals assess whether

they can take action to improve their relationship with the

environment, and which coping strategies (cognitive and

behavioral efforts aimed to manage the demand of the

environment) may be useful for this (Lazarus & Folkman,

1984). Personality traits are distinguishing qualities or

characteristics of individuals, that is, a readiness to think or

act in a similar fashion in response to a variety of different

stimuli or situations (Carver & Scheier, 2000).

Several cognitive-affective factors have contributed to

further understanding of FM. A few examples are helpless-

ness (Nicassio, Schuman, Radojevic, & Weisman, 1999),

hypervigilance to pain (Crombez, Eccleston, Van den

Broeck, Goubert, & Van Houdenhove, 2004), fear of pain

(Turk, Robinson, & Burwinkle, 2004), pain catastrophizing

(Hassett, Cone, Patella, & Sigal, 2000), self-efficacy expec-

tancies (Buckelew, Murray, Hewett, Johnson, & Huyser,

1995), and coping strategies (Garcıa-Campayo, Pascual,

Alda, & Gonzalez-Ramırez, 2007). Strong links between

some of these cognitive-affective factors have been reported

in FM patients (Sanchez, Martınez, Miro, & Medina, 2011).

Moreover, a number of reports have indicated that FM is

related to personality traits such as neuroticism (Malt,

Olafsson, Lund, & Ursin, 2002), alexithymia (Brosschot &

Aarsse, 2001), hypochondriasis and hysteria (Trygg,

Lundberg, Rosenlund, Timpka, & Bjorn, 2002), perfection-

ism (Mcallister, 2000), and harm avoidance (Anderberg,

Forsgren, Ekselius, Marteinsdottir, & Hallman, 1999).

Additionally, recent studies suggest that the clinical person-

ality profile of FM patients is mainly oriented to expressing a

great variety of somatic complaints, health problems, and

physical malfunctioning (Perez-Pareja, Sese, Gonzalez-Ordi,

& Palmer 2010). Despite previous reports, the role of per-

sonality in the abovementioned cognitive and emotional

dimensions of pain has not been sufficiently explored. It

should be noted that the status of some of the psychological

characteristics mentioned has not definitively established.

For example, there is controversy about whether pain catas-

trophizing should be considered as a personality trait or as a

situation-specific response (for a review, see Quartana,

Campbell, & Edwards, 2009; Turner & Aaron, 2001).

The ‘‘fear-avoidance’’ model (Leeuw et al., 2007;

Vlaeyen & Linton, 2000) is an influential theoretical

approach that addresses chronic pain. It considers the

contribution of personality in the cognitive-affective fac-

tors of pain. The model suggests that negative appraisal of

pain and its consequences (pain catastrophizing) is a

potential precursor to pain-related fear and this fear leads

patients to focus their attention on possible somatic signals

of threat (hypervigilance) and to show avoidance/escape

behaviors. All these factors aggravate the pain problem,

leading to disability, gradual deterioration of the muscular

system, and depression. The latter maintain the pain

experience, thereby contributing to a spiral of increasing

fear and avoidance. According to the model, pain catas-

trophizing is influenced by negative affectivity (neuroti-

cism) and threatening illness information. While this model

has scientific support in chronic musculoskeletal pain prob-

lems (e.g. Cook, Brawer, & Vowles, 2006), its explanatory

value in FM patients is unknown.

Various studies have examined the relationship between

personality traits and pain cognitive-affective factors in

non-clinical samples as well as samples with no FM pain.

In an experimental study of pain among college students,

Thorn et al (2004) found that the tendency to describe

oneself as emotionally vulnerable mediated sex differences

in pain catastrophizing. Muris et al. (2007) observed that

pain catastrophizing in young adolescents was explained

by the behavioral inhibition system, reactive temperament

traits (fear), and perceptual sensitivity. In a study of two

experimental pain models with healthy individuals, Lee

(2009) found that neuroticism was positively correlated

with somatosensory amplification, fear of pain, and pain

catastrophizing; the study found that these cognitive-

affective factors were generally more strongly related to

qualitative and quantitative pain measures than personality

indices. In a clinical sample composed of patients with low

back pain, Goubert, Crombez, and Van Damme (2004)

found that neuroticism moderated the relationship between

pain severity and catastrophic thinking about pain; they

also observed that pain catastrophizing and pain-related

fear mediated the relationship between neuroticism and

vigilance to pain. However, other studies have not identi-

fied a link between personality and appraisal of pain. For

example, in patients with chronic pain, Herrero, Ramırez-

Maestre, and Gonzalez (2008) found that personality

profiles (schizoid-compulsive-dependent, antisocial-com-

pulsive, and compulsive) did not differ in the type of

cognitive appraisal of pain (harm, threat, and challenge

appraisal). The discrepancy observed in these studies

points to the need to collect new evidence on the rela-

tionship between chronic pain and personality.

To the best of our knowledge, current study is the first to

explore the links between personality traits and cognitive-

affective factors of pain in FM patients, according to the

fear-avoidance model. Although neuroticism appears to be

J Clin Psychol Med Settings

123

an important factor in the heightened experience of pain,

other personality traits may also play a prominent role. It is

important to take the big five personality model into

account, as it greatly contributes to the understanding of

individual’s physical and emotional well-being. It has been

found that neuroticism and conscientiousness are relevant

to understanding depressive moods (Vearing & Mak,

2007), neuroticism and extraversion have predicted the

severity of bodily anxiety symptoms (Kristensen, Mortensen,

& Mors, 2009), and neuroticism and introversion are linked

to greater pain-related cardiac vagal tone changes (Paine,

Kishor, Worthen, Gregory, & Aziz, 2009). Therefore,

taking into account the fear-avoidance model and previous

findings with other chronic pain conditions, the objectives

of this cross-sectional study in FM patients were the fol-

lowing: (1) analyze the relationships between personality

dimensions and pain catastrophizing, pain anxiety, and

vigilance to pain; (2) determine the contribution of per-

sonality dimensions in these cognitive-affective factors; (3)

explore the mediating role of pain catastrophizing in the

relationship between neuroticism and pain anxiety; and (4)

explore the moderating role of neuroticism in the rela-

tionship between impairment and both pain catastrophizing

and pain anxiety.

Method

Subjects and Procedure

Seventy-four subjects with FM (70 women and four men)

with a mean age of 46.54 years (SD = 8.13, ran-

ge = 24–62 years) recruited from a FM association in

Granada (Spain), participated in this study. All the patients

were diagnosed with FM in a rheumatology clinic

according to the criteria of the American College of

Rheumatology (ACR; Wolfe et al., 1990). The fulfillment

of the following criteria was required: (1) age range from

18 to 65 years; (2) no history of alcoholism or drug

addiction; (3) absence of concomitant major medical con-

ditions (e.g., inflammatory rheumatic diseases, endocrine

disorders), and (4) no presence of major depressive disor-

der with severe symptoms or suicide ideation, or other

major axis I diagnoses of the DSM-IV-TR (APA, 2000).

The patients of the FM association were contacted by

telephone and invited to participate in the study. From a

potential sample of 100 people, 74 participants were

selected as the final clinical group for the study. Of the

sample contacted, 15 patients refused to participate in the

study, four subjects met the criteria of major depressive

disorder with severe symptoms, and seven had comorbidity

with other rheumatic diseases (mainly arthritis). The

remarkable percentage of female patients selected

(70 women vs. 4 men) matches that found in several epi-

demiological studies. For example, the female/male ratio of

patients with FM ranged from 9:1 (Burckhardt, Jones, &

Clark, 1998) to 20:1 (Schneider, 1995). Moreover, a recent

study reported that, in the context of rheumatology, 94% of

patients with FM were women (Branco et al., 2010).

Participants were asked to complete an interview (semi-

structured format) with a duration of approximately one

hour. The interview focused on onset and course of symp-

toms, life history, lifestyle, work, personal relations, the

family and the participant’s attitudes about his/her illness,

and psychological status. After the interview, participants

were given a set of questionnaires to be completed at home.

It was verified that patients had an adequate level of reading

comprehension of the self-report measures. Questionnaires

were delivered in one week at the most. All participants were

informed about the characteristics of the study and informed

consent was obtained. Patients did not receive any incentives

to participate in the study. The study received ethical

approval from the University of Granada ethics committee.

Most of the participants were married (74.3%), had

elementary or secondary education (57.8%), and had an

inactive work situation (59.5%). The mean duration of

the diagnosed disease was 4.11 years (SD = 3.07).

Among participants, 94.6% were receiving current phar-

macological treatment (mainly analgesics, anxiolytics,

anti-inflammatory drugs, skeletal muscle relaxants, and

anti-depressants), and 93.2% of them also received other

treatments (e.g. physical exercise, acupuncture, oxygen

therapy, psychotherapy). At the time of the study, patients

had a stabilized pharmacological pattern and none of them

were receiving structured cognitive-behavioral therapy for

their problem.

Measurements

The Short-Form McGill Pain Questionnaire (SF-MPQ;

Melzack, 1987)

The SF-MPQ assesses pain experience using 15 verbal pain

descriptors, a current pain intensity index, and a visual

analogue scale (VAS) to assess pain intensity during the

previous week, anchored with ‘‘no pain’’ (1) and ‘‘extreme

pain’’ (10). Several studies have reported the reliability and

validity of the Spanish version of the MPQ (e.g. Lazaro

et al., 2001). The internal consistency of the MPQ was .74

(Masedo & Esteve, 2000). The VAS was used in this study.

The Impairment and Functioning Inventory

(IFI; Ramırez-Maestre & Valdivia, 2003)

The 19-item IFI evaluates daily functioning and deterio-

ration of patients with chronic pain in several areas of life.

J Clin Psychol Med Settings

123

The IFI includes two general indices (Functioning and

Impairment) and four specific dimensions (Household

activity, Independent functioning, Social activities, and

Leisure activities). This inventory has adequate reliability

(.76 in functioning and .72 in impairment) and a factor

analysis confirmed its four-factor structure (Ramırez-

Maestre & Valdivia, 2003). The Impairment index was

used in this study.

The Pain Catastrophizing Scale (PCS; Sullivan, Bishop, &

Pivik, 1995)

The PCS assesses the rumination, magnification, and

helplessness associated with pain. It includes 13 items

measured on a 5-point Likert scale ranging from 0 (not at

all) to 4 (all the time). The PCS shows adequate internal

consistency and concurrent and discriminant validity

(Osman et al., 2000). In the present study, the Cronbach

alpha of the Spanish version of the PCS was .93.

The Pain Anxiety Symptoms Scale-20 (PASS-20;

McCracken & Dhingra, 2002)

The PASS-20 assesses the fear, cognitive anxiety, escape/

avoidance behavior, and physiological anxiety associated

with pain. This is a 20-item scale where subjects respond to

a 6-point Likert scale ranging from 0 (never) to 5 (always).

The PASS-20 has good convergent validity and reliability

(Roelofs et al., 2004). In the present study, the Cronbach

alpha of the Spanish version of the PASS-20 was .88.

The Pain Vigilance and Awareness Questionnaire (PVAQ;

McCracken, 1997)

The PVAQ consists of 16 items that evaluate attention to

pain using a 6-point Likert scale ranging from 0 (never) to

5 (always). The PVAQ shows adequate convergent validity

and internal consistency (Roelofs, Peters, McCracken, &

Vlaeyen, 2003). In the present study, the Cronbach alpha of

the Spanish version of the PVAQ was .79.

The NEO Five-Factor Inventory, NEO-FFI

(Costa & McCrae, 1992)

The NEO-FFI is a well validated self-report inventory

that assesses the big five personality factors: neuroticism,

extraversion, openness, agreeableness, and conscientious-

ness. The inventory includes 60 items measured on a

5-point Likert scale ranging from ‘‘strongly disagree’’ to

‘‘strongly agree.’’ The present study used the Spanish

version by TEA Ediciones. In this version the factors

showed an internal consistency between .82 and .90.

Data Analyses

Statistical analyses were performed with SPSS 15.0 soft-

ware for Windows. The moderational and mediational

effects were performed using MedGraph (Jose, 2003) and

ModGraph (Jose, 2008). All the analyses were two-tailed

and probabilities of less than .05 were taken as significance

levels. The statistical power of the analyses was greater

than .80. The minimum required sample size for the study

was 56 subjects, given an alpha level of .05, seven pre-

dictors, an anticipated effect size of .30 (medium), and a

desired statistical power level of .80.

In order to determine the association between the cog-

nitive-affective factors of pain and personality traits,

Pearson’s correlation coefficient was obtained. A multi-

variate regression analysis was performed to explore the

contribution of personality traits to the prediction of cog-

nitive-affective factors.

The mediator effect of pain catastrophizing in the

relationship between neuroticism and pain anxiety was

analyzed using the criteria developed by Baron and Kenny

(1986). The following conditions had to be met to estab-

lish the mediation: (1) variations in neuroticism (inde-

pendent variable, IV) significantly account for variations

in pain anxiety (dependent variable, DV) (path c); (2)

variations in neuroticism (IV) significantly account for

variations in pain catastrophizing (mediator) (path a); (3)

variations in pain catastrophizing (mediator) significantly

account for variations in pain anxiety (DV) (path b); and

(4) the previous relationship between neuroticism and pain

anxiety is no longer significant once pain catastrophizing

(mediator) is controlled (path c’). Several linear regression

analyses were performed to test these conditions. The

Sobel test was used as a post-hoc analysis of the media-

tion effect.

The moderator effect of neuroticism was also analyzed

using the criteria put forward by Baron and Kenny

(1986): in predicting pain catastrophizing or pain anxiety

(DVs), the model considers the impact of the impairment

(VI), the impact of neuroticism (moderator), and the

interaction of both (VI 9 moderator); the moderator

effect is supported if the interaction is significant. Sev-

eral hierarchical regression analyses were conducted to

test this condition. Following the recommendations of

Aiken and West (1991) to eliminate multicollinearity

effects, the variables were centered (scores are put into

deviation score form by subtracting the sample mean

from all individual scores). Later, the interaction term

was formed by multiplying the centered scales. As a

post-hoc analysis of the moderation effects, several

regression lines were plotted for low, medium and high

levels of neuroticism.

J Clin Psychol Med Settings

123

Results

Descriptive Analyses

Descriptive statistics and correlation coefficients for all

measures are shown in Table 1. The mean score in pain

intensity (SF-MPQ) was 7.38. This score is within the

expectations for FM patients and indicates relatively high

levels of pain. The mean score of impairment level (3.76)

in the FM group was very similar to that reported by

patients with musculoskeletal chronic pain (Ramırez-

Maestre, Esteve, & Lopez, 2008). The mean scores of

patients with FM on the PCS, PASS-20, and PVAQ were

slightly to moderately higher than those reported in pre-

vious studies with FM patients (Roelofs et al., 2003, 2004).

Taking into account the Spanish normative data in the

NEO-FFI (Manga, Ramos, & Moran, 2004), the FM group

obtained mean scores corresponding to percentiles 85 in

neuroticism, 15 in extraversion, 30 in openness, 65 in

agreeableness, and 50 in conscientiousness.

Men (n = 4) and women with FM (n = 70) in the

present study did not differ significantly in the following

demographic variables: age (U = 110.00, p = .473), mari-

tal status (v32 = .68, p = .877), educational level (v3

2 =

3.05, p = .383) and work status (v42 = 6.65, p = .155).

No significant differences were found between men and

women (U values between 74.00, p = .107 and 132.50,

p = .894) or age groups (\40.75 years vs. [53.00 years,

groups established considering percentiles 25 and 75) in

the clinical variables analyzed (t35 values between -1.83,

p = .075 and 1.57, p = .125).

Relationship Between Self-Report Variables

Table 1 shows the mean, standard deviation and Pearson

intercorrelations of all the measures. The main results were

the following: (1) significant positive correlations between

neuroticism and pain catastrophizing and pain anxiety, and

between agreeableness and vigilance to pain; (2) significant

negative correlations between extraversion and pain

catastrophizing and between openness and pain intensity as

well as pain anxiety; (3) significant positive correlations

between cognitive-affective factors of pain; (4) significant

positive correlations between pain intensity and both pain

catastrophizing and pain anxiety, and (5) significant posi-

tive correlations between impairment and both pain

catastrophizing and pain anxiety.

Value of Personality Traits in Predicting Cognitive-

Affective Factors of Pain

The multivariate regression analysis that predicted cogni-

tive-affective factors of pain is shown in Table 2. When

pain catastrophizing was considered as the DV, the model

including pain variables (pain intensity and pain duration)

and personality traits (neuroticism, extraversion, openness,

agreeableness, and conscientiousness) as predictors was

significant (F7,63 = 3.43, p \ .05) and accounted for 20%

of the variance. Neuroticism and conscientiousness made a

significant contribution in predicting pain catastrophizing.

When pain anxiety was the DV, the model composed of

pain variables and personality traits was also significant

(F7,63 = 7.03, p \ .01) and explained 38% of the variance

in pain anxiety. Pain intensity, neuroticism, openness, and

agreeableness significantly contributed to predicting pain

anxiety. Finally, when vigilance to pain was considered as

the DV, the model including pain variables and personality

traits was not significant. However, agreeableness was

found to make a significant contribution in predicting

vigilance to pain.

Further analyses were only performed with neuroti-

cism because it significantly correlated with both pain

Table 1 Means (M), standard deviations (SD), and correlations among all measures

M (SD) 2 3 4 5 6 7 8 9 10

1. Pain intensity 7.38 (1.65) .19 .28* .43** .18 .09 -.15 -.26* -.06 .06

2. Impairment 3.76 (3.12) – .25* .22* .09 .06 -.01 -.01 .10 .07

3. Pain catastrophizing 25.35 (11.80) – .70** .50** .36** -.23* -.19 .06 .16

4. Pain anxiety 52.42 (17.39) – .34** .39** -.17 -.26* .14 .03

5. Vigilance to pain 48.77 (11.54) – .06 -.15 -.16 .31** -.02

6. Neuroticism 29.01 (9.47) – -.39** -.07 -.17 -.16

7. Extraversion 24.08 (8.75) – .33** -.05 .11

8. Openness 26.93 (8.73) – .15 .11

9. Agreeableness 31.88 (7.36) – -.09

10. Conscientiousness 30.01 (6.98) –

* p \ .05, ** p \ .01

J Clin Psychol Med Settings

123

catastrophizing and pain anxiety and obtained the highest B

values in predicting these variables. Taking into account

the significant correlation between pain intensity and pain

catastrophizing (potential mediator), pain intensity was

included as a controlled variable in the mediational

analysis.

Pain Catastrophizing as a Mediator Between

Neuroticism and Pain Anxiety

Several regression analyses were performed to explore the

mediation of pain catastrophizing in the relationship

between neuroticism and pain anxiety, controlling for the

effect of pain intensity. In Analysis 1 (path c), both pain

intensity (b = .39, p \ .001) and neuroticism (b = .36,

p \ .001) were significant predictors and explained 28% of

the variance in pain anxiety (F2,69 = 15.27, p \ .001). In

Analysis 2 (path a) in which pain catastrophizing was

entered as the DV, both IVs were significant (pain inten-

sity, b = .23, p \ .05; and neuroticism, b = .34, p \ .01)

and explained 16% of the variance (F2,70 = 7.98, p \ .05).

In Analysis 3 (path b), pain intensity (b = .27, p \ .001)

and pain catastrophizing (b = .63, p \ .001) were signifi-

cant predictors and explained 56% of the variance in pain

anxiety (F2,70 = 46.92, p \ .001). In Analysis 4 (path c’),

pain anxiety was included as the DV (as in Analysis 1), and

pain intensity and pain catastrophizing were entered as

additional IVs with neuroticism. All of them were signifi-

cant predictors (pain intensity, b = .26, p \ .001; pain

catastrophizing, b = .58, p \ .001; and neuroticism,

b = .18, p \ .05) and explained 57% of the variance

(F3,68 = 32.74, p \ .001). The contribution of neuroticism

to pain anxiety greatly decreased (b from .36 to .18) when

the effect of pain catastrophizing was considered. The

difference between path c and path c’ was significant, as

revealed by the Sobel test (z = 2.86, p \ .01). The ratio

index (computed by dividing the indirect effect by the total

effect; Jose, 2003) indicated that 53% of the influence of

neuroticism on pain anxiety was mediated by pain

catastrophizing.

Neuroticism as a Moderator Between Impairment

and Pain Catastrophizing

To test for neuroticism as a moderator between impairment

and pain catastrophizing, the cross-product terms neuroti-

cism and impairment were entered in a separate block in a

hierarchical regression analysis, following the entry of

Table 2 Multivariate regression analysis predicting pain catastrophizing, pain anxiety, and vigilance to pain

Dependent variable Independent variable B SEB t Adjusted R2 F

Pain catastrophizing Pain intensity 1.14 .80 1.41 .20 3.43*

Pain duration .18 .41 .44

Neuroticism .49 .15 3.29*

Extraversion -.01 .17 -.11

Openness -.24 .16 -1.53

Agreeableness .33 .17 1.84

Conscientiousness .43 .18 2.38*

Pain anxiety Pain intensity 3.72 1.05 3.53** .38 7.03**

Pain duration .86 .53 1.61

Neuroticism .89 .19 4.55**

Extraversion .22 .22 1.01

Openness -.43 .21 -2.04*

Agreeableness .67 .23 2.85*

Conscientiousness .33 .24 1.40

Vigilance to pain Pain intensity .64 .84 .76 .09 2.01

Pain duration .02 .43 .06

Neuroticism .10 .15 .69

Extraversion -.02 .17 -.11

Openness -.25 .16 -1.47

Agreeableness .60 .18 3.23*

Conscientiousness .06 .19 .35

* p \ .05, ** p \ .01

J Clin Psychol Med Settings

123

impairment and neuroticism as first-order terms. Signifi-

cant main effects were found for impairment (b = .24,

p \ .05) and neuroticism (b = .34, p \ .01). Yet, the

interaction impairment 9 neuroticism was not a significant

predictor of pain catastrophizing (b = .08, p = .449).

Neuroticism did not have a significant moderating effect on

the relationship between impairment and pain

catastrophizing.

Neuroticism as a Moderator Between Impairment

and Pain Anxiety

To explore neuroticism as a moderator, we tested whether

the interaction impairment 9 neuroticism was a signifi-

cant predictor of pain anxiety, after controlling the influ-

ence of impairment and neuroticism. Significant main

effects were observed for impairment (b = .23, p \ .05)

and neuroticism (b = .39, p \ .001). An effect close to

statistical significance was observed in the impair-

ment 9 neuroticism interaction (b = .20, p = .06),

revealing that the link between impairment and pain anx-

iety is probably moderated by neuroticism. The overall

model explained 21% of the variance in pain anxiety

(F3,68 = 7.36, p \ .01).

Figure 1 shows the interaction between impairment and

neuroticism. The low, medium and high levels (for both

impairment and neuroticism) were computed using the

mean as the medium value, considering 1 SD below the

mean as the low value and 1 SD above the mean as the high

value (following Aiken & West, 1991). Simple slopes for

the medium-neuroticism line (t70 = 2.20, p \ .05) and

high-neuroticism line (t70 = 2.86, p \ .01) were signifi-

cant. Results suggest that the pain anxiety level remained

stable in the low neuroticism group under low, medium and

high impairment conditions. However, in the medium and

high-neuroticism groups, pain anxiety level increased sig-

nificantly in the medium and high impairment conditions.

Discussion

The present study aimed to clarify the relationship between

pain appraisal (pain catastrophizing, pain anxiety, and

vigilance to pain), personality, and impairment in FM

taking into account the fear-avoidance model of pain and

the big five personality model. A number of interesting

findings were observed. First, there was a strong relation-

ship between cognitive-affective factors of pain and per-

sonality styles. The tendency to make catastrophic

appraisals of pain was positively related to neuroticism and

negatively related to extraversion; the tendency to experi-

ence pain stimuli-related anxiety was positively related to

neuroticism and negatively related to openness; and the

tendency to focus attention on painful sensations was

positively related to agreeableness. Second, personality

traits accounted for a substantial proportion of the variance

in pain catastrophizing and pain anxiety. Neuroticism was

the most important predictor in both cognitive-affective

factors. Third, personality traits did not contribute signifi-

cantly to vigilance to pain. Fourth, the effect of neuroticism

upon pain anxiety was mediated by pain catastrophizing,

and neuroticism showed a trend to moderate the relation-

ship between impairment and pain anxiety.

The cognitive-affective factors of pain seem to be dif-

ferentially related to personality. Pain catastrophizing and

pain anxiety are associated with a neurotic personality style

characterized by a tendency to experience more negative

emotions and adhere to dysfunctional beliefs, and less

ability to control impulses and cope with stress. This result

agrees with previous empirical evidence, which suggests

that neuroticism in chronic pain patients is a significant

predictor of maladaptive behavioral manifestations of pain

(Lauver & Johnson, 1997) and is associated to greater use

of passive coping strategies and higher pain intensity

(Ramırez-Maestre, Lopez-Martınez, & Esteve-Zaragoza,

2004). It has also been found that interpersonally distressed

pain patients show higher levels of neuroticism than

adaptive coping pain patients (Nitch & Boone, 2004).

The present findings agree with those reported by

Goubert et al. (2004) and Muris et al. (2007), who revealed

that neuroticism (and similar temperamental traits) are

closely related to the tendency to interpret the meaning of

painful sensations in an extreme and dysfunctional way.

This personality trait may be a significant factor that pre-

disposes individuals to have a worse general health per-

ception and react in an extreme and dysfunctional way to

physical discomfort, including pain. In fact, some authors

Fig. 1 Moderating role of neuroticism in the relationship between

impairment and pain anxiety

J Clin Psychol Med Settings

123

have argued that neuroticism may not simply reflect over-

reporting of physical complaints but can also be seen as a

potential vulnerability factor to poor health (Johnson,

2003). This trait has also been found to predispose indi-

viduals to psychological distress and not to show positive

emotions, which in turn may lead to medically unexplained

symptoms (De Gucht, Fischler, & Heiser, 2004).

Interestingly, our findings suggest that neuroticism

(negative affectivity) was the greatest contributor to both

pain catastrophizing and pain anxiety. The present study

also found that 53% of the influence of neuroticism on

pain anxiety was mediated by pain catastrophizing. This

finding is consistent with the ‘‘fear-avoidance’’ model of

pain developed by Leeuw et al. (2007). The present results

agree with previous studies that showed that pain catas-

trophizing and pain-related fear mediated the relationship

between neuroticism and vigilance to pain (Goubert et al.,

2004). However, they differ from those reported by

Asghari and Nicholas (2006), who found, in a prospective

study with chronic pain patients, that neuroticism was not

a significant predictor of residualized change in catastro-

phizing over time. The present data also differ from those

reported by Goubert et al. (2004), who observed that

neuroticism predicted vigilance to pain. It should be noted

that the present study did not analyze exactly the same

paths as those reported by Goubert et al., that it did not

use the prospective design by Asghari and Nicholas, and

that none of these studies included FM patients. Addi-

tionally, we observed that neuroticism is probably a sig-

nificant moderator in the relationship between impairment

in daily functioning and anxiety responses associated to

painful stimuli: pain anxiety tends to be more marked at

higher levels of impairment when neuroticism is high.

This result is in line with the study performed by Goubert

et al. (2004), who found that neuroticism moderated

the relationship between pain severity and pain

catastrophizing.

The fact that neuroticism shows a trend to moderate the

relationship between impairment and pain anxiety but not

between impairment and pain catastrophizing may be

explained considering that pain anxiety involves a more

severe stage than pain catastrophizing in the spiral of fear-

avoidance. The PASS-20 assesses a broad construct that

includes alarmist appraisal of pain (like the PCS), but also

avoidance and escape strategies of coping with pain, and

physiological anxiety responses. Therefore, when faced

with the functional limitations associated with his/her dis-

ease, a FM patient with a neurotic personality style may

tend to respond in a maladaptive way at multiple levels

(cognitive, behavioral, or physiological), reflecting a

greater degree of pain anxiety. Further studies are needed

to explain the hierarchical relationship between the cog-

nitive-affective factors associated with pain.

The present findings indicate maladaptive aspects of

neuroticism, which is consistent with the abovementioned

studies and evidence that show that this personality trait is

associated with many psychological and physical problems

(see review by Lahey, 2009). However, neuroticism as a

strategy may have an adaptive value. According to Watson

and Casillas, (2003), extremely low levels of neuroticism

increase individual’s vulnerability to several types of

threat, so neuroticism may play an active and beneficial

role in health-related awareness.

The present research considers pain catastrophizing as

an appraisal process, however, different theoretical con-

ceptualizations of pain catastrophizing have been proposed.

For example, the communal coping model suggests that

catastrophizing represents an interpersonal strategy to cope

with pain (Sullivan et al., 2001). Catastrophizers may

exaggerate pain expression to obtain proximity, assistance

and support from others, thereby heightening pain experi-

ence and making difficult adaptation to pain. According to

this model, solicitous or reinforcing responses from others

may contribute to maintain the exaggerated pain expression

of catastrophizers.

The present study also highlighted the role of other

personality dimensions such as conscientiousness, open-

ness, and agreeableness in pain appraisal. The findings

show that a high level of conscientiousness (characterized

by a tendency to plan, persistence, control, and motivation

in goal-directed behavior) is a significant predictor of pain

catastrophizing. This finding differs from those reported by

Goubert et al. (2004), who found that conscientiousness

was not a significant predictor of pain catastrophizing but

of vigilance to pain. Some studies have shown that the

relationship between this personality trait and health is

influenced by gender differences. For example, conscien-

tious women report more lumps or growths while consci-

entious men report less depression and constipation as

well as better general health perception and more vitality

(Jerram & Coleman, 1999).

Our study revealed that a low level of openness to

experience is closely related to pain-related anxiety and

predicts a significant proportion of variance in this cogni-

tive-affective factor. Individuals with lower levels of

intellectual curiosity, creativity, and open-mindedness to

fantasy, internal feelings, news activities, values, etc., show

a greater tendency to react anxiously to painful stimuli.

This is in line with some reports that suggest high openness

is associated with positive appraisals to health (Jerram &

Coleman, 1999; Nitch & Boone, 2004).

We observed that a high level of agreeableness (char-

acterized by a tendency to be altruistic, cooperative and

helpful towards others) was a significant predictor of pain

anxiety. Similarly, this personality trait was related to

vigilance to pain, explaining a significant proportion of the

J Clin Psychol Med Settings

123

variance. It is necessary to consider that these finding may

be showing the alexithymic trends of FM patients. People

with high levels of agreeableness tend to inhibit commu-

nicating negative emotions to others. Previous studies have

reported that FM subjects scored higher on alexithymia

than healthy controls, even when negative affectivity was

considered as a covariate (Brosschot & Aarsse, 2001) and

difficulty identifying feelings is the dimension of alexi-

thymia most closely associated with FM (Sayar, Gulec, &

Topbas, 2004). This is consistent with the well-known

difficulty of patients with somatoform pain to communicate

their emotions and pain experiences (Cox, Kuch, Parker,

Shulman, & Evans, 1994). It is noteworthy, however, that

findings on agreeableness differ from those obtained in

previous studies (Jerram & Coleman, 1999).

Although several studies have supported the role of

catastrophizing as a cognitive vulnerability-stress factor

related to emotional distress in chronic pain patients (Lee,

Wu, Lee, Cheing, & Chan, 2008), this study suggests that

other more basic personality traits influence the develop-

ment of these dysfunctional cognitive styles that disrupt

mood and adjustment in FM. Personality is probably an

important factor in the pathophysiology of FM. Studies

about the alterations of the autonomic nervous system and

the HPA axis suggest a contribution of these stress-

response systems in vulnerability to FM or in symptom

expression in FM (Dadabhoy, Crofford, Spaeth, Russell, &

Clauw, 2008). Recent research has analyzed the association

between personality traits and the HPA axis, reporting that

high levels of neuroticism were associated with elevated

levels of evening cortisol in subjects under 75 years old

(Gerritsen et al., 2009). In this context, a marked neurotic

style may influence the way individuals cognitively process

pain-related stimuli, reduce their perceived ability to

manage distress, and predispose individuals with limita-

tions in daily functioning to experience pain anxiety. All

this ultimately leads to exacerbation of disease. Much more

research is needed to understand the vulnerability role of

neuroticism and other personality dimensions in FM.

Limitations and Conclusions

The present study has some limitations. All the measures

used were self-reported. Although the VAS of the SF-MPQ

has good sensitivity and specificity, and these values are

considerably similar to those obtained with dolorimetry

(Marques, Assumpcao, Matsutani, Pereira, & Lage, 2008),

in future research, it would be advisable to use a pressure

algometer. The algometer may offer complementary

information to that provided by self-report measures.

Another limitation of our study is the small sample, which

we hope to expand in future studies. This is a preliminary

study within broader research we are currently conducting.

The cross-sectional design did not provide knowledge

about the direction of causality of the relationships

explored. In addition, since only one pain sample was used,

it was not possible to determine whether the findings were

specific to FM or would have also been identified in other

chronic pain problems. Patients in this study came from a

FM association and may have different clinical character-

istics (including perception of pain and ability to manage

it) from those observed in patients of rheumatology ser-

vices. In future research, it would be advisable to replicate

the study using a longitudinal design as well as a sample of

patients with different pain conditions from other medical

contexts.

Lastly, the combination of personality traits may explain

some of the differences observed between studies. It would

be useful for future studies to explore in FM patients with

high-neuroticism whether agreeableness, openness, and

conscientiousness are associated with worse perception of

physical health. It would also be important to study whe-

ther the role of these personality traits is due to some

specific facets of the traits and can be modulated by vari-

ables such as sex, health status, pain intensity, and so on.

Additional studies are needed to clarify the conditions

under which the big five factors influence the experience of

pain.

Our findings have relevant practical implications.

Keeping in mind the heterogeneity of FM patients, it

would be very useful to assess personality traits that

predispose individuals to have a greater risk of experi-

encing pain as threatening and fearful. Early identification

of FM patients with high levels of these traits seems

crucial, given that such patients could greatly benefit from

therapies focused on changing dysfunctional attitudes

toward pain. This is relevant to successfully preventing

disability. Several reviews have reported that cognitive-

behavioral interventions are effective in reducing fear-

avoidance beliefs in chronic pain (Lohnberg, 2007) and

catastrophizing in FM (Glombiewski et al., 2010), how-

ever, it is unknown how personality traits influence the

efficacy of this type of intervention. Considering our

findings, neuroticism might modulate the degree of change

in pain anxiety of FM patients and might therefore be a

useful predictor of treatment outcomes. Future research

analyzing the relationship between personality traits and

the fear-avoidance model in greater depth is needed to

improve our understanding of FM and its clinical

management.

Acknowledgments This study is part of a broader research project

financially supported by the Spanish ministry of science and inno-

vation (research project PSI2009-13765PSIC). The authors wish to

thank AGRAFIM (Association of People Affected with FM in Gra-

nada, Spain) for its cooperation in the study.

J Clin Psychol Med Settings

123

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