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Contemporary pain models highlight cognitive-processing biases (ie, attention bias [AB], interpretation bias [IB], and memory bias [MB]) as key processes that contribute to poor pain outcomes. However, existing research has yielded inconsistent findings regarding the presence and impact of these biases on pain outcomes. Recognizing the need to explore these biases simultaneously, contemporary pain models suggest that cognitive biases (CBs) are interrelated, and may have a combined impact upon pain problems. The current study aims to investigate the interrelationships between CBs using the PainAIM paradigm, a novel approach enabling simultaneous evaluation of pain-related AB, IB, and MB using cues signaling actual pain rather than symbolic information. We hypothesized the presence and positive associations of biases for pain-related cues and the predictive value of combined AB and IB for poor pain outcomes. Eighty-four healthy participants completed the PainAIM paradigm, followed by a cold pressor task probing pain experience and pain-related task interference. The results indicated an inverse relationship between AB and IB for ambiguous pain cues. In addition, there was a positive association between participants' AB for ambiguous pain and their MB for the same cues. Contrary to our hypotheses, CB indices did not predict experimental pain outcomes. These findings provide support for the interrelationships between pain-related CBs. However, future research on the temporal order of CBs and their combined impact on pain outcomes is needed. By overcoming the limitations associated with traditional paradigms, the PainAIM paradigm offers a promising research tool for the further study of combined CBs in the context of pain. PERSPECTIVE: The current study provides insight into the associations between pain-related CBs (AB, IB, and MB) using ecologically valid (ambiguous) pain cues. The results indicated an inverse association between pain-related AB and IB, while a positive association was found between AB and MB. CBs did however not predict experimental pain outcomes.

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BACKGROUND AND OBJECTIVES: The Best Possible Self (BPS) has been found to be an effective manipulation to temporarily improve optimism and affect. The BPS has been used in different formats. In some versions, participants just write about their best possible future, while in others this is combined with imagery. An imagery only version has not been tested yet. The aim of the current study was to examine the effectiveness of three different versions of the BPS and their equivalence in improving optimism and affect. METHODS: In an online study format, participants (N = 141) were randomly assigned to one of four conditions: (1) writing and imagery BPS; (2) writing BPS; (3) imagery BPS; and (4) a typical day (TD) control condition. RESULTS: Results showed that each BPS condition significantly improved optimism (i.e. increased positive future expectancies and decreased negative future expectancies) and affect (i.e. increased positive affect and decreased negative affect). Equivalence testing showed that all online BPS conditions were equivalent in increasing optimism and affect, thereby confirming that both the writing and imagery elements of the BPS can independently from each other increase optimism and positive affect in a healthy population. LIMITATIONS: Only the immediate effects of the BPS formats on increasing optimism and affect were measured. CONCLUSIONS: The BPS manipulation can be employed in different ways for potential future exploration, depending on the research question, design and context and/or E-mental health applications for the treatment of individuals suffering from psychological complaints.

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Background: Cognitive factors play an essential role in the development and maintenance of anxiety problems. Among individuals with illness anxiety problems, their interpretation of bodily symptoms is a crucial factor in the determination of their ability to regulate their emotions. The catastrophic interpretation of ambiguous bodily symptoms and changes, known as interpretation bias, in line with the failure to reappraise the symptoms in safer ways, is supposed to increase the levels of anxiety in illness-anxious individuals. Methods: This study aimed to address the statistical limitations of the direct (self-report) measure of interpretation bias, using an indirect (online interpretation bias task) measure for assessing biased interpretations of bodily symptoms. In addition, we examined the contribution of self-report anxiety sensitivity (AS), intolerance of uncertainty (IU), interpretation bias, and reappraisal to illness anxiety problems in a subclinical population and compared it with controls with low levels of illness anxiety. Findings: Illness-anxious individuals made more negative interpretations of ambiguous, potentially health-threatening information. They used less reappraisal to regulate their emotion. Among the measures, the physical subscale of AS and the reaction time to the safe resolution of ambiguous information were the best factors that could contribute to the differentiation between the illness-anxious individuals and non-anxious individuals. Conclusion: Our findings provided further support for the biased processing of information related to physical symptoms among individuals with illness anxiety. AS-physical and safe resolutions for ambiguous situations could differentiate the illness-anxious and the control groups better than other factors. These findings suggest that a change of interpretation of ambiguous bodily symptoms among individuals suffering from chronic conditions can be a possible intervention to target anxiety and improve patients' lives.

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ABSTRACT: The fear-avoidance model of chronic pain predicts that catastrophic (mis)interpretation of pain elicits pain-related fear that in turn may spur avoidance behaviour leading to chronic pain disability. Here, we investigated whether performing a movement to avoid a painful stimulus in the context of a novel movement increases threat and pain-related fear towards this novel movement and whether avoidance behaviour persisted when given the choice between performing the acquired movement to avoid a painful stimulus or an alternative, novel movement. Applying a robotic arm-reaching task, participants could choose between 2 movements to reach a target location: a short, but painful movement trajectory, or a longer nonpainful movement trajectory. After avoidance acquisition, the option to choose the painful trajectory was removed. The experimental group (N = 50) could choose between the longest trajectory or a novel intermediate trajectory, whereas the control group (N = 50) was allowed to only perform the novel trajectory. In a final test, participants of both groups were allowed to choose any of the 3 trajectories. After acquisition, experimental group participants showed elevated pain expectancy and pain-related fear towards the novel trajectory, compared with the control group. During test, the experimental group participants persisted in performing the longest pain-free (avoidance) trajectory and were less likely to choose the novel trajectory. In addition, these participants maintained higher levels of pain-related fear for the novel trajectory compared with the control group. These findings suggest that avoidance in the context of other neutral activities/movements may lead to the development and maintenance of threat appraisals and irrational fears.

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BACKGROUND: Although pain-related avoidance is mainly intended to reduce the accompanying anticipatory fear, avoidance behavior may paradoxically increase fear when a previous avoidance response is no longer available, suggesting that there is a bidirectional relationship between pain-related fear and avoidance. PURPOSE: We hypothesized that avoidance can serve as a source of information that fuels irrational pain-related threat appraisals, which, in turn, increases pain-related fear. METHODS: Participants (N = 66) were exposed to a painful heat stimulus and randomly assigned to the avoidance or control group. They were instructed to avoid the full heat intensity by pressing a stop button in the presence of a stop cue. Only avoidance group participants received a stop cue and were allowed to press the stop button, while control group participants received the same instructions but never had the opportunity to avoid the full heat intensity. In reality and unknown to participants, the intensity and duration of the heat stimulus was independent of the avoidance response. In the subsequent test phase, the avoidance response was unavailable for both groups. We measured pain-related fear, threat appraisals/harmfulness, and pain intensity. RESULTS: In line with our expectations, pain-related fear levels were higher when the avoidance response was no longer available compared to those when the avoidance response was available. Increased threat appraisals mediated the relationship between avoidance behavior and increased pain-related fear. CONCLUSIONS: The perceived opportunity to avoid increased pain-related fear through threat appraisals, suggesting a more complicated relationship between pain-related fear, threat appraisals, and avoidance behavior than the unidirectional relationships proposed in the fear-avoidance model. Clinical implications are discussed.

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BACKGROUND AND OBJECTIVES: Amongst social contextual influences on pain, the manner in which pain and painful procedures are communicated to patients is considered an important contributor to the subjective experience of pain. Threatening information, e.g., by the use of technical language, is suggested to increase pain reports. Validation, or communicating understanding towards another person reporting personal experiences, is suggested to reduce pain. The current study examines effects of both information language (technical vs. plain language) and validation (validation vs. invalidation) on the subjective experience of experimentally induced pain. METHODS: Pain-free participants (N = 132) were randomly assigned to one of four groups as formed by manipulations of validation and information language. After reading a description concerning the upcoming thermal stimulus formulated in technical or plain language, participants engaged in a computer controlled simulation (CCS; based on virtual reality technology). Participants received three thermal stimuli while interacting with an avatar who either validated or invalidated their experience during the CCS. Pain intensity and pain unpleasantness were assessed after each stimulus. RESULTS: The validation manipulation showed to be effective, but the information language manipulation did not induce differential threat expectancies. Results show no effect of validation or information language on subjective pain reports. LIMITATIONS: Suboptimality of the information language manipulation and shortcomings of the CCS procedure might account for current findings. CONCLUSIONS: The study offers an interesting model for the further experimental study of isolated and combined effects of (social) contextual factors on pain. Diverse future research avenues are discussed.

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Avoidance is considered key in the development of chronic pain. However, little is known about how avoidance behavior subsequently affects pain-related fear and pain. We investigated this using a robotic arm reaching avoidance task. In a between-subjects design both Experimental Group (n = 30) and Yoked Control Group (n = 30) participants perform either of 3 movement trajectories (T1-T3) to reach a target location. During acquisition, only participants of the Experimental Group could partially or fully avoid a painful electrocutaneous stimulus by choosing the intermediate trajectory (T2; 50% reinforcement) or the longest trajectory (T3; 0% reinforcement) versus the shortest trajectory (T1: 100% reinforcement). After acquisition, contingencies changed (all trajectories 50% reinforced), and the acquired avoidance behavior no longer effectively prevented pain from occurring. The Yoked Control Group received the same reinforcement schedule as the Experimental Group irrespective of their behavior. When avoidance behavior became ineffective for the Experimental Group, pain-related fear increased for the previously safe(r) trajectories (T2 and T3) and remained the same for T1, whereas pain threshold and tolerance declined. For the Yoked Group, pain-related fear increased for all trajectories. The Experimental Group persisted in emitting avoidance behavior following the contingency change, albeit at a lower frequency than during acquisition. PERSPECTIVE: Results indicate participants become more afraid of and sensitive to pain, when previously acquired avoidance is no longer effective. Also, participants continue to show avoidance behavior despite it being not adaptive anymore. These findings suggest that ineffective avoidance may play role in the maintenance and development of chronic pain.

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BACKGROUND: Children of chronic pain patients run greater risk for developing chronic pain themselves. Exposure to chronic pain of the parent might install cognitive (e.g., pain catastrophizing, interpretation and attentional bias) and affective (e.g., pain anxiety) vulnerability which increase the risk for the development of chronic pain complaints in offspring. This study examines whether pain-free offspring of parents with chronic pain complaints make more health-threatening interpretations and display a stronger pain-related attentional bias compared to the offspring of pain-free parents. We furthermore examined differences between both groups on pain catastrophizing, pain anxiety and somatic symptoms and explored the relations between parental pain catastrophizing and aforementioned pain vulnerability measures in offspring. METHODS: Offspring of parents with chronic pain complaints (n = 24) and pain-free parents (n = 27) completed measures of attentional bias (i.e., pictorial dot probe), interpretation bias (i.e., ambiguous word association task), pain catastrophizing, pain anxiety and somatic symptoms. Parents completed measures of pain catastrophizing and psychological distress. RESULTS: No differences between offspring of parents with and without pain complaints were observed on pain catastrophizing, pain anxiety and somatic symptoms. Both groups of healthy adolescents predominantly showed benign, non-health-threatening interpretations. Children of pain-free parents showed an attention bias for pain stimuli, while offspring of parents with pain complaints showed no such bias. CONCLUSIONS: Future research is needed to further elucidate the precise role of parental pain in the development of pain-related biases and the significance of these biases in the onset and/or maintenance of a chronic pain condition in children and adolescents. SIGNIFICANCE: Parental chronic pain may install psychological vulnerability for developing chronic pain and associated complaints in offspring. This study did not show differences in pain-directed attentional and interpretation bias between offspring of parents with chronic pain complaints and offspring of pain-free parents. Further (longitudinal) research is needed to elucidate the precise role of parental pain factors in the development of pain-related vulnerability in offspring of chronic pain parents, thereby identifying important targets for the prevention and early intervention of chronic pain.

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Background and aims Interpreting pain- and illness-related stimuli as health-threatening is common among chronic pain patients but also occurs in the general population. As interpretation bias (IB) may affect pain perception and might even play part in the development and maintenance of chronic pain, it is important to improve our understanding of this concept. Several studies suggest an association between IB and pain-related anxiety. However, those studies often rely on verbal and pictorial IB tasks that do not entail a threat of actual pain, therefore lacking personal relevance for healthy participants. The current study investigated whether healthy individuals show an IB towards ambiguous health-related stimuli in a context of actual pain threat, and explored whether this bias is associated to pain anxiety constructs. Methods Thirty-six healthy participants were conditioned to expect painful electrocutaneous shocks (unconditioned stimulus - US) after health-threat words (CS+) but not after neutral (non-health-threat) words (CS-) in order to establish fear of pain. Subsequently, they completed a verbal interpretation task that contained new CS+ and CS- stimuli as well as ambiguous non-reinforced health-threat and non-health-threat words. IB was assessed through shock expectancy ratings and startle responses to ambiguous and evident health threatening or neutral word stimuli. Pain-related anxiety was measured with validated questionnaires. Results The results show a general IB towards ambiguous health-related words on pain expectancies but not on startle response. An exploratory analysis suggests that this effect exists irrespective of pain-related anxiety levels which however may be due to a lack of power. Conclusion We present a novel experimental paradigm employing actual health threat that captures IB towards health-related stimuli in healthy individuals. Taken together, results provide evidence for the further consideration of IB as a latent vulnerability factor in the onset and maintenance of pain chronicity. In contrast to previous studies employing a safe, pain-free context, we found that healthy participants show an IB towards ambiguous health-related stimuli, when confronted with pain threat. Implications Like chronic pain patients, healthy individuals display an IB towards health-threat stimuli when these stimuli become personally relevant by carrying information about pending health threat. Therefore, the presented paradigm could be valuable for pain-related cognitive bias research in healthy participants as it may have a higher ecological validity than previous study designs. Future studies will have to elucidate the influence of anxiety constructs on IB in larger samples.

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Fear-avoidance models propose that pain-related fear may spur avoidance behavior leading to chronic pain disability. Pain-related fear elicits avoidance behavior, which is typically aimed at reducing fear. We hypothesized that engaging in avoidance may (paradoxically) increase rather than decrease pain-related fear (ie, bidirectionality hypothesis). In a between-subject design, participants (n = 64) were randomly assigned to the avoidance group or the control group. Avoidance group participants were led to believe they could avoid full exposure to a painful heat stimulus by pressing the stop button, whereas control group participants believed they were exposed to the full painful heat stimulus at all times. In reality and unknown to the participants, the intensity and duration of the heat stimulus was independent of the avoidance response, and was identical in both groups. During the test, the avoidance response (ie, pressing the stop button) was no longer available. As expected, pain-related fear levels were higher after avoiding the painful heat stimulus. Interestingly, in the avoidance group, pain-related fear increased after receiving instructions that avoidance would be possible, even before actually engaging in avoidance behavior. In the control group, no significant change was observed in pain-related fear throughout the experiment. The eyeblink startle measures did not corroborate this data pattern. PERSPECTIVE: These observations provide partial support for the bidirectionality hypothesis between avoidance behavior and fear. These findings may have clinical implications and suggest that allowing avoidance behaviors during treatment may thwart fear reduction.

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BACKGROUND AND AIMS: Interrupting ongoing activities with the intention to resume them again later is a natural response to pain. However, such interruptions might have negative consequences for the subsequent resumption and performance of the interrupted activity. Activity interruptions by pain may be more impairing than interruptions by non-painful stimuli, and also be subjectively experienced as such. These effects might be more pronounced in people high in pain catastrophizing. These hypotheses were investigated in two experiments. METHODS: In Experiment 1, healthy volunteers (n=24) performed an ongoing task requiring a sequence of joystick movements. Occasionally, they received either a painful electrocutaneous or a non-painful vibrotactile stimulus, followed by suspension of the ongoing task and temporary engagement in a different task (interruption task). After performing the interruption task for 30s, participants resumed the ongoing task. As the ongoing task of Experiment 1 was rather simple, Experiment 2 (n=30) included a modified, somewhat more complex version of the task, in order to examine the effects of activity interruptions by pain. RESULTS: Participants made more errors and were slower to initiate movements (Experiment 1 & 2) and to complete movements (Experiment 2) when they resumed the ongoing task after an interruption, indicating that interruptions impaired subsequent performance. However, these impairments were not larger when the interruption was prompted by painful than by non-painful stimulation. Pain catastrophizing did not influence the results. CONCLUSIONS: Results indicate that activity interruptions by pain have negative consequences for the performance of an activity upon its resumption, but not more so than interruptions by non-painful stimuli. Potential explanations and avenues for future research are discussed. IMPLICATIONS: Interrupting ongoing activities is a common response to pain. In two experiments using a novel paradigm we showed that activity interruptions by pain impair subsequent activity resumption and performance. However, this effect seems to not be specific to pain.

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Persistent pain can lead to difficulties in executive task performance. Three core executive functions that are often postulated are inhibition, updating, and shifting. Optimism, the tendency to expect that good things happen in the future, has been shown to protect against pain-induced performance deterioration in executive function updating. This study tested whether this protective effect of a temporary optimistic state by means of a writing and visualization exercise extended to executive function shifting. A 2 (optimism: optimism vs no optimism) × 2 (pain: pain vs no pain) mixed factorial design was conducted. Participants (N = 61) completed a shifting task once with and once without concurrent painful heat stimulation after an optimism or neutral manipulation. Results showed that shifting performance was impaired when experimental heat pain was applied during task execution, and that optimism counteracted pain-induced deterioration in task-shifting performance. PERSPECTIVE: Experimentally-induced heat pain impairs shifting task performance and manipulated optimism or induced optimism counteracted this pain-induced performance deterioration. Identifying psychological factors that may diminish the negative effect of persistent pain on the ability to function in daily life is imperative.

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BACKGROUND/AIMS: Pain can interrupt and deteriorate executive task performance. We have previously shown that experimentally induced optimism can diminish the deteriorating effect of cold pressor pain on a subsequent working memory task (i.e., operation span task). In two successive experiments we sought further evidence for the protective role of optimism on pain-induced working memory impairments. We used another working memory task (i.e., 2-back task) that was performed either after or during pain induction. METHODS: Study 1 employed a 2 (optimism vs. no-optimism)×2 (pain vs. no-pain)×2 (pre-score vs. post-score) mixed factorial design. In half of the participants optimism was induced by the Best Possible Self (BPS) manipulation, which required them to write and visualize about a life in the future where everything turned out for the best. In the control condition, participants wrote and visualized a typical day in their life (TD). Next, participants completed either the cold pressor task (CPT) or a warm water control task (WWCT). Before (baseline) and after the CPT or WWCT participants working memory performance was measured with the 2-back task. The 2-back task measures the ability to monitor and update working memory representation by asking participants to indicate whether the current stimulus corresponds to the stimulus that was presented 2 stimuli ago. Study 2 had a 2 (optimism vs. no-optimism)×2 (pain vs. no-pain) mixed factorial design. After receiving the BPS or control manipulation, participants completed the 2-back task twice: once with painful heat stimulation, and once without any stimulation (counter-balanced order). Continuous heat stimulation was used with temperatures oscillating around 1°C above and 1°C below the individual pain threshold. RESULTS: In study 1, the results did not show an effect of cold pressor pain on subsequent 2-back task performance. Results of study 2 indicated that heat pain impaired concurrent 2-back task performance. However, no evidence was found that optimism protected against this pain-induced performance deterioration. CONCLUSIONS: Experimentally induced pain impairs concurrent but not subsequent working memory task performance. Manipulated optimism did not counteract pain-induced deterioration of 2-back performance. IMPLICATIONS: It is important to explore factors that may diminish the negative impact of pain on the ability to function in daily life, as pain itself often cannot be remediated. We are planning to conduct future studies that should shed further light on the conditions, contexts and executive operations for which optimism can act as a protective factor.

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Individuals with pain-related concerns are likely to interpret ambiguous pain-related information in a threatening manner. It is unknown whether this interpretation bias also occurs for ambiguous pain-related facial expressions. This study examined whether individuals who habitually attach a catastrophic meaning to pain are characterized by negative interpretation bias for ambiguous pain-related facial expressions. Sixty-four female undergraduates completed an incidental learning task during which pictures of faces were presented, each followed by a visual target at one of two locations. Participants indicated target location by pressing one of two response keys. During the learning phase, happy and painful facial expressions predicted target location. During two test phases, morphed facial expressions of pain and happiness were added, equally often followed by a target at either location. Faster responses following morphs to targets at the location predicted by painful expressions compared to targets at the location predicted by happy expressions were taken to reflect pain-related interpretation bias. During one test phase, faces were preceded by either a safe or threatening context cue. High, but not low, pain-catastrophizers responded faster following morphs to targets at the location predicted by painful expressions than to targets at the other location (when participants were aware of the contingency between expression type and target location). When context cues were presented, there was no indication of interpretation bias. Participants were also asked to directly classify the facial expressions that were presented during the incidental learning task. Participants classified morphs more often as happy than as painful, independent of their level of pain catastrophizing. This observation is discussed in terms of differences between indirect and direct measures of interpretation bias.

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Accumulating evidence suggests that dispositional optimism might be a protective factor against experiencing pain. The current paper presents two studies investigating the association between dispositional optimism and experimental pain. Moreover, the influence of pain-specific expectations on this association is investigated. In Study 1, mediation of pain-specific expectations in the relation between dispositional optimism and pain was hypothesized. Expected and experienced pain ratings were obtained from 66 healthy participants undergoing a cold pressor tolerance task. In Study 2, the moderating effect of dispositional optimism on the association between induced pain expectations and pain reports was studied in 60 healthy participants undergoing a 1-min cold pressor task. Both studies controlled for individual differences in fear of pain. Significant associations between dispositional optimism and pain ratings were found in both studies, although the exact time point of these associations differed. Subscale analyses revealed that only the pessimism subscale contributed significantly to these findings. We found no evidence for hypothesized mediation and moderation effects. Alternative explanations for the optimism-pain association are discussed.

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Coping with the demands of pain diminishes self-regulatory capacity and causes self-regulatory fatigue, which then leads to deteriorated executive task performance. It has been suggested that optimism can counteract the depletion of self-regulatory capacity. This study employed a 2 (optimism/no optimism)×2 (pain/no pain) between-subjects design to explore whether (1) experimentally induced pain (cold pressor task) deteriorates subsequent executive task performance, and (2) whether an optimism induction can counteract this sustained deteriorating effect of pain on executive task performance. Results indicated that although pain led to significantly worse performance on the executive functioning task in the no optimism condition, this sustained deteriorating effect of pain on task performance was abolished in the optimism condition. This finding is imperative because it suggests that optimism may be an important factor to implement in current psychological treatment approaches to diminish the negative impact of chronic pain on the ability to function in daily life.

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Previous studies have demonstrated a relation between dispositional optimism and lower pain sensitivity, but the causal status of this link remains unclear. This study sought to test the causal status by experimentally inducing a temporary optimistic state by means of writing about and visualizing a future best possible self. In addition, we explored pain expectations and (situational) pain catastrophizing as possible underlying mechanisms of the link between optimism and pain. Seventy-nine university students participated in a cold pressor task (CPT). Before the CPT, half of them received the optimism manipulation and the other half a control manipulation. Induced optimism was related to lower pain intensity ratings during the CPT compared to the control group, thereby experimentally confirming causality. This effect was not explained by pain-related expectations about the task. Situational pain catastrophizing, however, did seem to mediate the relation between optimism and pain. This study is novel in that it confirms the causal status of optimism towards pain. Additionally, the results reveal that positive interventions might provide a useful alternative in reducing pain catastrophizing as an extremely relevant target in pain treatment.

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BACKGROUND AND AIMS: Prior research has demonstrated the role of perceived control and self-efficacy beliefs over pain in reducing pain and pain-related disability. The present study aimed to examine the independent influence of perceived control and self-efficacy beliefs on the subjective evaluation of pain. METHODS: Healthy participants (N = 79) were randomly assigned to one of four conditions that were formed by manipulations of perceived control and self-efficacy. At two occasions in the experimental procedure pain was induced by means of electrical stimulation (16 s) to the lower forearm. Prior to and following upon each pain stimulus, participants completed ratings of pain intensity and pain unpleasantness. RESULTS: High self-efficacy regarding the ability to exert control over pain resulted in a significant reduction in anticipated pain intensity, anticipated pain unpleasantness, and experienced pain intensity ratings. Furthermore, anticipated pain intensity was found to mediate the relation between self-efficacy and experienced pain intensity. CONCLUSIONS: It is concluded that in order to observe beneficial effects of offering control over pain, it is important that individuals are convinced (i.e. have high self-efficacy) that they are able to exert this control successfully.

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Research has identified several anxiety and fear constructs that contribute directly or indirectly to the chronic course of pain. One way to gain insight into the frequently observed interrelations between these constructs may be by conceptualizing them within a hierarchical structure. In this structure, general and specific constructs are proposed at different levels of a hierarchical tree. The present study sought to find evidence for this idea by exploring the dimensional and componential structure of a hierarchical representation of pain-related anxiety constructs. Small cards describing the individual items of 9 pain-related anxiety measures were presented to undergraduate students (N = 294), who were asked to sort them into piles of what they perceived as items of similar meaning. Cluster analysis (additive tree analyses) revealed cluster groups that could be interpreted along the lines of the proposed hierarchical structure. Multidimensional scaling analysis showed that the similarity data are characterized by a dimension that runs from general affective to pain-specific concerns. This study thus offers empirical support for the postulation of a general and specific hierarchical ordering of these constructs. Furthermore, its results endorse the independent use of various pain-related anxiety measures in research and practice aiming to assess negative emotional constructs that contribute to pain.

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