Jump to ContentJump to Main Navigation
Show Summary Details
More options …

Scandinavian Journal of Pain

Official Journal of the Scandinavian Association for the Study of Pain

Editor-in-Chief: Werner, Mads

CiteScore 2018: 0.85

SCImago Journal Rank (SJR) 2018: 0.494
Source Normalized Impact per Paper (SNIP) 2018: 0.427

See all formats and pricing
More options …
Volume 16, Issue 1


Pain anxiety and fear of (re) injury in patients with chronic back pain: Sex as a moderator

Nina Kreddig
  • Corresponding author
  • Department of Medical Psychology and Medical Sociology, Faculty of Medicine, Ruhr-University of Bochum, Universitätsstrasse, 44780 Bochum, Germany
  • Email
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Monika I. Hasenbring
  • Department of Medical Psychology and Medical Sociology, Faculty of Medicine, Ruhr-University of Bochum, Universitätsstrasse, 44780 Bochum, Germany
  • Email
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
Published Online: 2017-07-01 | DOI: https://doi.org/10.1016/j.sjpain.2017.03.009

Graphical Abstract


Background and aims

Anxiety and fear are increasingly seen as related, but distinct concepts, with anxiety describing a reaction to unclear or future threats, and fear to immediate threats. Anxiety and fear both play influential roles in pain. Yet, the two concepts have not been clearly distinguished in pain research. Their reported intensity differs between the sexes, and sex differences in the way pain anxiety and fear of (re)injury relate to pain intensity have been found separately in previous studies. However, they seem to be of a curious nature: In one study, pain anxiety was associated with elevated pain intensity in men, while in another, fear of (re)injury was associated with elevated pain intensity in women. This indicates a moderator effect of sex. The present study is the first to unite previous findings, and to show a more integrative picture, by examining and discussing this moderator effect of sex in a joint study of both pain-related anxiety and fear in both sexes.


In 133 patients (mean age 43.6 years, 62% female) with chronic low back pain (mean duration 7.7 years), sex differences were examined with correlations and a multiple linear regression analysis with interaction terms. Differences between subgroups of low and high anxiety/fear were explored via t-tests, following previous studies.


Sex was supported as a moderator in the association of pain intensity with pain anxiety (PASS-20), and fear of (re)injury (TSK). Higher pain intensity was linked to higher pain anxiety only in men, and to higher fear of (re)injury only in women. A basic regression model with fear, anxiety, sex and disability as predictors (R2 = .14, F(4,123) = 3.24,p = .042) was significantly improved by the addition of the interaction terms Fear×Sex and Anxiety × Sex (R2 = .18, F(2,121) = 4.90, p = .001), which were both shown as significant predictors for pain intensity. Further t-tests revealed a significant difference in pain intensity between high and low anxiety in men (t(47) = −2.34, p = .023,d = −.43), but not in women. Likewise, a significant difference in pain intensity between high and low fear showed in women (t(80) = −2.28, p = .025, d = −.42), but not in men.


The results support a moderator effect of sex and suggest differential mechanisms between the sexes in pain anxiety and fear in development and maintenance of back pain. The current study is the first to report and analyse this moderator effect. As potential underlying mechanisms, evolution and socialization are discussed, which may elucidate why fear might be more relevant for pain in women, and anxiety more relevant for pain in men.


The results indicate the need for a more cautious conceptual separation of fear and anxiety in research. Future studies on fear and anxiety in pain should be aware of the distinction, in order to avoid reporting only half of the picture. The next step would be to solidify the results in different samples, and to examine whether a distinction between anxiety and fear in the sexes could have any benefit in pain treatment.

Keywords: Sex; Pain; Anxiety; Pain anxiety; Fear; Fear of pain


  • [1]

    Balagué F, Mannion AF, Pellisé F, Cedraschi C. Non-specific low back pain. Lancet 2012;4:482–91.Google Scholar

  • [2]

    Krein SL, Kadri R, Hughes M, Kerr EA, Piette JD, Holleman R, Kim HM, Richardson CR. Pedometer-based internet-mediated intervention for adults with chronic low back pain: randomized controlled trial. J Med Internet Res 2013, http://dx.doi.org/10.2196/jmir.2605.PubMed

  • [3]

    Pincus T, Kent P, Bronfort G, Loisel P, Pransky G, Hartvigsen J. Twenty-five years with the biopsychosocial model of low back pain – is it time to celebrate? A report from the Twelfth International Forum for Primary Care Research on Low Back Pain. Spine 2013;38:2118–23.PubMedCrossrefGoogle Scholar

  • [4]

    Liebers F, Brendler C, Latza U. Age- and occupation-related differences in sick leave due to frequent musculoskeletal disorders. Low back pain and knee osteoarthritis. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2013;56:367–80.PubMedGoogle Scholar

  • [5]

    Crombez G, Vlaeyen JW, Heuts PH, Lysens R. Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability. Pain 1999;80:329–39.PubMedCrossrefGoogle Scholar

  • [6]

    Sylvers P, Lilienfeld SO, LaPrairie JL. Differences between trait fear and trait anxiety: implications for psychopathology. Clin Psychol Rev 2011;31:122–37.PubMedCrossrefGoogle Scholar

  • [7]

    Gray JA, McNaughton N. The neuropsychology of anxiety: an enquiry into the functions of the septo-hippocampal system. New York: Oxford University Press; 2000.Google Scholar

  • [8]

    Barlow DH, Chorpita BF, Turovsky J. Fear, panic, anxiety, and disorders of emotion. In: Hope DA, editor. Nebraska Symposium on Motivation, 1995: perspectives on anxiety, panic, and fear. Current theory and research in motivation (43). Lincoln: University of Nebraska Press; 1996. p. 251–328.Google Scholar

  • [9]

    Wong WS, McCracken LM, Fielding R. Factor structure and psychometric properties of the Chinese version of the 20-item Pain Anxiety Symptoms Scale (ChPASS-20). J Pain Symptom Manage 2012;43:1131–40.CrossrefPubMedGoogle Scholar

  • [10]

    Vancleef LM, Vlaeyen JW, Peter ML. Dimensional and componential structure of a hierarchical organization of pain-related anxiety constructs. Psychol Assess 2009;21:340–51.CrossrefPubMedGoogle Scholar

  • [11]

    Roelofs J, McCracken L, Peters ML, Crombez G, van Breukelen G, Vlaeyen JW. Psychometric evaluation of the Pain Anxiety Symptoms Scale (PASS) in chronic pain patients. J Behav Med 2004;27:167–83.PubMedCrossrefGoogle Scholar

  • [12]

    Lundberg M, Grimby-Ekman A, Verbunt J, Simmonds MJ. Pain-related fear: a critical review of the related measures. Pain Res Treat 2011, http://dx.doi.org/10.1155/2011/494196.

  • [13]

    Smitherman TA, Ward TN. Psychosocial factors of relevance to sex and gender studies in headache. Headache 2001;51:923–31.Google Scholar

  • [14]

    Edwards RR, Doleys DM, Lowery D, Fillingim RB. Pain tolerance as a predictor of outcome following multidisciplinary treatment for chronic pain: differential effects as a function of sex. Pain 2003;106:419–26.CrossrefPubMedGoogle Scholar

  • [15]

    Sato H, Droney J, Ross J, Olesen AE, Staahl C, Andresen T, Branford R, Riley J, Arendt-Nielsen L, Drewes AM. Gender, variation in opioid receptor genes and sensitivity to experimental pain. Mol Pain 2013, http://dx.doi.org/10.1186/1744-8069-9-20.PubMed

  • [16]

    Fillingim RB, Browning AD, Powell T, Wright RA. Sex differences in perceptual and cardiovascular responses to pain: the influence of a perceived ability manipulation. J Pain Symptom Manage 2002;3:439–45.Google Scholar

  • [17]

    Racine M, Tousignant-Laflamme Y, Kloda LA, Dion D, Dupuis G, Choinière M. A systematic literature review of 10 years of research on sex/gender and experimental pain perception – part 1: are there really differences between women and men? Pain 2012;153:602–18.CrossrefPubMedGoogle Scholar

  • [18]

    Racine M, Tousignant-Laflamme Y, Kloda LA, Dion D, Dupuis G, Choinière M. A systematic literature review of 10 years of research on sex/gender and pain perception – part 2: do biopsychosocial factors alter pain sensitivity differently in women and men? Pain 2012;153:619–35.CrossrefPubMedGoogle Scholar

  • [19]

    Thibodeau MA, Welch PG, Katz J, Asmundson GJ. Pain-related anxiety influences pain perception differently in men and women: a quantitative sensory test across thermal pain modalities. Pain 2013;154:419–26.CrossrefPubMedGoogle Scholar

  • [20]

    Goodwin L, Fairclough SH, Poole HM. A cognitive-perceptual model of symptom perception in males and females: the roles of negative affect, selective attention, health anxiety and psychological job demands. J Health Psychol 2012;18:848–57.PubMedGoogle Scholar

  • [21]

    Paterniti S, Dufouil C, Bisserbe JC, Alpérovitch A. Anxiety, depression, psychotropic drug use and cognitive impairment. Psychol Med 1999;29:421–8.CrossrefPubMedGoogle Scholar

  • [22]

    McLean CP, Anderson ER. Brave men and timid women? A review of the gender differences in fear and anxiety. Clin Psychol Rev 2009;26:496–505.Google Scholar

  • [23]

    Edwards RR, Augustson EM, Fillingim R. Sex-specific effects of pain-related anxiety on adjustment to chronic pain. Clin J Pain 2000;16:46–53.CrossrefPubMedGoogle Scholar

  • [24]

    Bränström H, Fahlström M. Kinesiophobia in patients with chronic musculoskeletal pain: differences between men and women. J Rehabil Med 2008;40:375–80.CrossrefPubMedGoogle Scholar

  • [25]

    Roelofs J, Sluiter JK, Frings-Dresen MH, Goossens M, Thibault P, Boersma K, Vlaeyen JW. Fear of movement and (re)injury in chronic musculoskeletal pain: evidence for an invariant two-factor model of the Tampa Scale for Kinesiophobia across pain diagnoses and Dutch, Swedish, and Canadian samples. Pain 2007;131:181–90.PubMedCrossrefGoogle Scholar

  • [26]

    Kori SH, Miller RP, Todd DD. Kinesiophobia: a new view of chronic pain behavior. Pain Manag 1990;3:35–43.Google Scholar

  • [27]

    Kreddig N. Angst und Furcht bei Patienten mit chronischem Rückenschmerz: Eine geschlechtsspezifische Perspektive [Anxiety and fear in patients with chronic back pain: a sex-specific perspective]. Bochum: Ruhr University Bochum; 2015.Google Scholar

  • [28]

    Rusu AC, Kreddig N, Hallner D, Hülsebusch J, Hasenbring MI. Fear of movement/(re)injury in chronic low back pain: validation of a German version of the Tampa Scale for Kinesiophobia with special focus on fear-avoidance and endurance. BMC Musculoskelet Disord 2014, http://dx.doi.org/10.1186/1471-2474-15-280.

  • [29]

    McCracken LM, Dhingra L. A short version of the Pain Anxiety Symptoms Scale (PASS-20): preliminary development and validity. Pain Res Manag 2002;7:45–50.CrossrefGoogle Scholar

  • [30]

    McCracken LM, Zayfert C, Gross RT. The Pain Anxiety Symptoms Scale: development and validation of a scale to measure fear of pain. Pain 1992;50:67–73.PubMedCrossrefGoogle Scholar

  • [31]

    Kreddig N, Rusu A, Burkhardt K, Hasenbring MI. The German PASS-20 in patients with low back pain: new aspects of convergent, divergent and criterion-related validity. Int J Behav Med 2014;22:197–205.Google Scholar

  • [32]

    Fairbank JCT, Pynsent PB. The Oswestry Disability Index. Spine 2000;25:2940–53.CrossrefGoogle Scholar

  • [33]

    Mannion AF, Junge A, Fairbank JC, Dvorak J, Grob D. Development of a German version of the Oswestry Disability Index. Part 1: cross-cultural adaptation, reliability, and validity. Eur Spine J 2006;15:55–65.Google Scholar

  • [34]

    Field AP. Discovering statistics using IBM SPSS Statistics. fourth edition London: Sage publications; 2013.Google Scholar

  • [35]

    Peters ML, Vlaeyen JW, Weber WE. The joint contribution of physical pathology, pain-related fear and catastrophizing to chronic back pain disability. Pain 2005;113:45–50.CrossrefPubMedGoogle Scholar

  • [36]

    Aguilar R, Gil L, Gray JA, Driscoll P, Flint J, Dawson GR, Giménez-Llort L, Escorihuela RM, Fernández-Teruel A, Tobeña A. Fearfulness and sex in F2 Roman rats: male display more fear though both sexes share the same fearfulness traits. Physiol Behav 2003;78:723–32.CrossrefPubMedGoogle Scholar

  • [37]

    Lundberg M. Kinesiophobia – various aspects of moving with musculoskeletal pain. Gothenburg: The Sahlgrenska Academy; 2006.Google Scholar

  • [38]

    Vlaeyen JW, Kole-Snijders AM, Rotteveel AM, Ruesink R, Heuts PH. The role of fear of movement/(re)injury in pain disability. J Occup Rehabil 1995;5:235–52.CrossrefGoogle Scholar

  • [39]

    Dalla C, Shors TJ. Sex differences in learning processes of classical and operant conditioning. Physiol Behav 2009;97:229–38.CrossrefPubMedGoogle Scholar

  • [40]

    Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJ. Comparative Risk Assessment Collaborating Group. Selected major risk factors and global and regional burden of disease. Lancet 2002;360:1347–60.CrossrefGoogle Scholar

  • [41]

    Keogh E, Hamid R, Hamid S, Ellery D. Investigating the effect of anxiety sensitivity, gender and negative interpretative bias on the perception of chest pain. Pain 2004;111:209–17.PubMedCrossrefGoogle Scholar

  • [42]

    Perkins AM, Corr PJ. Reactions to threat and personality: psychometric differentiation of intensity and direction dimensions of human defensive behaviour. Behav Brain Res 2006;169:21–8.CrossrefPubMedGoogle Scholar

  • [43]

    Wrangham RW, Peterson D. Demonic males: apes and the origins of human violence. Boston, MA: Houghton Mifflin; 1996.Google Scholar

  • [44]

    Campbell A. The evolutionary psychology of women’s aggression. Phil Trans R Soc B 2013;368:20130078.CrossrefGoogle Scholar

  • [45]

    Campbell A. Staying alive: evolution, culture, and women’s intrasexual aggression. Behav Brain Sci 1999;22:203–14.PubMedGoogle Scholar

  • [46]

    Gijsbers van Wijk CM, Huisman H, Kolk AM. Gender differences in physical symptoms and illness behavior. A health diary study. Soc Sci Med 1999;49:1061–74.Google Scholar

  • [47]

    Sieverding M. Achtung! Die männliche Rolle gefährdet Ihre Gesundheit! Psychomed 2004;16:25–30.Google Scholar

  • [48]

    Greenspan JD, Craft RM, LeResche L, Arendt-Nielsen L, Berkley KJ, Fillingim RB, Gold MS, Holdcroft A, Lautenbacher S, Mayer EA, Mogil JS, Murphy AZ, Traub RJ, the Consensus Working Group of the Sex. Gender, and Pain SIG of the IASP. Studying sex and gender differences in pain and analgesia: a consensus report. Pain 2007;132:26–45.CrossrefGoogle Scholar

  • [49]

    Mineka S. Animal models of anxiety-based disorders: their usefulness and limitations. In: Tuma AH, Maser JD, editors. Anxiety and the anxiety disorders. Hillsdale, NJ: Erlbaum; 1985. p. 199–244.Google Scholar

  • [50]

    LeUnes AD, Nation JR, Turley NM. Male–female performance in helplessness. J Psych 1980;104:255–8.Google Scholar

  • [51]

    Nolen-Hoeksema S. Sex differences in unipolar depression: evidence and theory. Psychol Bull 1987;101:259–82.CrossrefPubMedGoogle Scholar

  • [52]

    Nolen-Hoeksema S. Emotion regulation and psychopathology: the role of gender. Annu Rev Clin Psychol 2012;8:161–87.PubMedCrossrefGoogle Scholar

  • [53]

    Lang PJ. The motivational organization of emotion: affect–reflex connections. Hillsdale, NJ: Erlbaum; 1994.Google Scholar

  • [54]

    Insel TR, Scanlan J, Champoux M, Suomi SJ. Rearing paradigm in a nonhuman primate affects response to beta-CCE challenge. Psychopharmacology (Berl) 1988;96:81–6.CrossrefGoogle Scholar

  • [55]

    Bongers D. Das Körperselbstbild von Männern. In: Brähler E, editor. Körpererleben. Berlin: Springer; 1986. p. 137–46.Google Scholar

About the article

Ruhr University Bochum, Department of Medical Psychology and Medical Sociology, Universitätsstrasse 150, 44780 Bochum, Germany.

Received: 2017-01-06

Revised: 2017-03-17

Accepted: 2017-03-29

Published Online: 2017-07-01

Published in Print: 2017-07-01

Ethical issues: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.Informed consent was obtained from all individual participants included in the study.

Conflict of interest: The authors declare that they have no conflict of interest. No funding sources were provided.

Citation Information: Scandinavian Journal of Pain, Volume 16, Issue 1, Pages 105–111, ISSN (Online) 1877-8879, ISSN (Print) 1877-8860, DOI: https://doi.org/10.1016/j.sjpain.2017.03.009.

Export Citation

© 2017 Scandinavian Association for the Study of Pain.Get Permission

Citing Articles

Here you can find all Crossref-listed publications in which this article is cited. If you would like to receive automatic email messages as soon as this article is cited in other publications, simply activate the “Citation Alert” on the top of this page.

Javier Martinez-Calderon, Mar Flores-Cortes, Jose Miguel Morales-Asencio, and Alejandro Luque-Suarez
The Journal of Pain, 2019

Comments (0)

Please log in or register to comment.
Log in