Psychology 817
2011. Vol.2, No.8, 817-823
Copyright © 2011 SciRes. doi:10.4236/psych.2011.28125
The Role of Anxiety Sensitivity, Fear of Pain and Experiential
Avoidance in Experimental Pain
Ana Isabel Masedo Gutiérrez1, María Rosa Esteve Zarazaga1,
Stefaan Van Damme2
1Department of Personality, Assessment and Psychological Treatment, Universit y of Mal aga, Málaga, Spain;
2Department of Psychology, Ghent University, Ghent, Belgium.
Received June 1st, 2011; revised August 9th, 2011; accepted September 11th, 2011.
The aim of this study was to investigate whether distraction is less effective when pain is perceived as threaten-
ing. Forty-one female undergraduate participants were assigned to distraction and not distraction conditions that
consisted in performing a distraction task and the threat value of the pain stimuli was manipulated using instruc-
tions. AS, EA and FP were considered as covariates. Results indicated that distraction manipulation had a main
effect on less pain intensity, more tolerance and less catastrophic thoughts. Interestingly, the covariate AS had a
significant effect over tolerance and EA had an effect on distress and anxiety related to pain. These results sug-
gest that AS and EA are distinct processes and that each could play a different role in the response to pain.
Anxiety sensitivity involves behavioural avoidance, whereas EA is a rejection of the internal experience that
contributes to an increase in emotional distress.
Keywords: Distraction, Threat Value, Experiential Avoidance, Anxiety Sensitivity, Fear to Pain, Experimental
Distraction is a commonsense strategy used to control pain,
and attention diversion training is an important element in most
types of cognitive behavioural therapy. Nevertheless, the effec-
tiveness of distraction in controlling pain is still a controversial
matter and the results from clinical and experimental research
are inconclusive (Ahles, Blanchard, & Leventhal, 1983; Cioffi,
1991; Goubert, Crombez, Eccleston, & Devulder, 2004; Hodes,
Howland, Lightfoot, & Cleeland, 1990; Leventhal, 1992;
McCaul & Malott, 1984; Morley, Shapiro, & Biggs, 2003;
Roelofs, Peters, Van der Zijden, & Vlaeyen, 2004; Seminowicz
& Davis, 2007; Turk, Meichenbaum & Genest, 1983; Ville-
mure & Bushnell, 2002). Several studies have suggested that
the effect of distraction or attention seems to be influenced by
dispositional variables and the history of chronic pain (Fanurik,
Zeltzer, Roberts, & Blount, 1993; Goubert et al., 2004; Heyne-
man, Fremouw, Gano, Kirkland, & Heiden, 1990).
Current cognitive-behavioural models of chronic pain (Le-
them, Slade, Troup, & Bentley, 1983; Vlaeyen & Linton, 2000)
suggest that fear of pain plays a crucial role in the transition
from acute to chronic pain. Anxiety sensitivity (AS) has been
proposed as an explanation for individual differences regarding
pain-related fear (Norton & Asmundson, 2003) and pain-related
avoidance behaviour, even after controlling for the effects of
pain severity (Asmundson & Taylor, 1996; Plehn, Peterson, &
Williams, 1998). AS is defined as a tendency to be specifically
fearful of anxiety-related sensations such as arousal and to be
alert to more possible threats (Keogh & Cochrane, 2002; Reiss
& McNally, 1985) and, consequently, to avoid threatening
stimuli (Lethem et al., 1983; Vlaeyen & Linton, 2000). The
fear-avoidance model conceives of fear of pain as a specific
phobia (Lethem et al., 1983; Vlaeyen & Linton, 2000), since
fear responses will be specifically linked to potentially painful
stimuli. In contrast, the so-called AS approach considers that
fear of pain is a manifestation of a more fundamental fear: the
fear of anxiety symptoms (Asmundson & Hadjistavpoulos,
2007; Norton & Asm undson, 2003).
Several studies have postulated that the relationship between
AS and fear of pain could be explained by attentional processes.
Reiss, Peterson, Gursky, & McNally (1986) were the first to
propose that high AS may be characterized by hypervigilant
self-monitoring of internal physical sensations. Moreover, AS
is related to cognitive biases toward physically threatening and
pain-related stimuli (Keogh, Dillon, Georgiou, & Hunt, 2001;
Stewart, Conrod, Gignac, & Pihl, 1998). Asmundson, Kuperos
and Norton (1997) found that individuals with chronic pain and
low AS were able to shift their attention away from stimuli
related to pain, in contrast to the subjects with high AS. Keogh
and Cochrane (2002) found that the tendency to negatively
interpret ambiguous bodily sensations related to panic mediated
the association between AS and emotional responses to cold
pressor pain. Of note, AS was still related to affective pain
scores when controlling for fear of pain .
Experiential avoidance (EA) is another related construct
which is defined as the general tendency to avoid internal
events, to make excessively negative evaluations of unwanted
private thoughts, feelings and sensations, to be unwilling to
experience these private events and to make deliberate efforts
to control or escape from them (Kashdan, Barrios, Forsyth and
Steger, 2006). Several studies have indicated that individuals
reporting higher levels of EA had lower pain endurance and
tolerance and recovered more slowly from these particular
types of aversive events (Marx & Sloan, 2002; Orsillo & Batten,
2005; Feldner, Hekmat, Zvolensky, Vowles, Secrist, &
Leen-Feldner, 2006). Although AS and EA are related con-
structs, they only share 9% of their variance (Hayes et al.,
However, it seems that the effect of distraction on pain de-
pends on fear of pain and AS. Keogh and Mansoor (2001)
found that high AS individuals reported more pain in the
avoidance condition than when they used focused strategies to
cope with pain. Roelofs, Peters, Van der Zijden and Vlaeyen
(2004) found that high fear of pain individuals obtained more
benefit from focalization strategies than from distraction strate-
Apart from any individual differences that make individuals
more prone to avoid internal events and sensations related to
pain, the evaluative context of the noxious stimuli affects the
pain it evokes, specifically any perceived tissue damage and its
meaning (Moseley & Arntz, 2007). It has been argued that the
selection of pain by the attentional system is strongly guided by
the evolutionary adaptive urge to escape bodily threat (Crom-
bez, Van Damme, & Eccleston, 2005). Standford, Kersh, Thorn,
Rich and Ward (2002) found that the self-reported appraisal of
threat was related to decreased tolerance to experimental pain.
Van Damme et al. (2008) hypothesized that a high threat value
of pain may interfere with the effects of distraction, and thus,
that giving threatening instructions to the participants would
reduce the effect of distraction on pain. They found that a high
threat value of pain did not interfere with distraction, whereas
performance worsened in the distraction task when threatening
instructions were given. However, this study did not explore
any vulnerability factors that might possibly influence the ef-
fects of threat on the effectiveness of distraction. The present
study investigates the interaction between some dispositional
variables related to avoidance and the evaluative context to
determine the influence of distraction on the experience of pain.
To recapitulate, in the light of previous research, it was pos-
tulated that the effectiveness of distraction to control pain
would be less in a negative and threatening evaluative context
and when the levels of FP, AS and EA were higher.
Thirty-six female undergraduate psychology students (mean
age = 20.21 years) voluntarily participated for course credits.
All participants gave their informed consent and were free to
terminate the experiment at any time. Exclusion criteria were
the presence of a circulatory disorder, hypertension, diabetes,
Raynaud’s disease, or a heart condition. No participants were
excluded for any of these reasons. As indicated by Cohen
(1988), the size of the experimental groups meant that the
analysis had medium-high power (0.65) to detect medium-size
effects (0.25) at a 0.05 significance level with one degree of
Apparatus and Measures
Cold Pressor Task. The cold pressor apparatus consisted of
two 50 cm × 30 cm × 30 cm metal containers. One of the con-
tainers was filled with water at room temperature (approxi-
mately 21˚C). The other container was divided into two sec-
tions by a wire screen. It was filled with water and the ice was
placed on one side of the wire place, with the subjects hand and
forearm immersed in the ice-free side. The water was main-
tained at 6˚C - 7˚C via a circulating pump. Water temperature
was measured using a digital thermometer immersed in the
water and fixed to the container. A colder temperature was not
considered appropriate for the purpose of this study, since a
sufficiently large range of tolerance effects was required; how-
ever, a limit of three hundred seconds was established to avoid
any physical risk (Turk, 1984).
Tolerance. Tolerance time is the length of time that the hand
and forearm is under the cold water. The immersion time,
measured in seconds, was recorded using a digital stopwatch.
Distraction task. For the purposes of the study, the distraction
task had to fulfil the following requirements: 1) there had to be
no effort to suppress their thinking, sensations or emotions
because paradoxical effects (Masedo & Esteve, 2007); 2) all the
participants had to find the task easy to do. These requirements
were fulfilled by designing a detection task that used LEDs.
A panel was placed between the containers and the partici-
pants. The panel contained two LEDs 5 cm above the holes
where each hand was to be placed. The left-to-right distance
between the LEDs was 31 cm. The participant’s head was
maintained in a median position by a chin-rest device. When
performing the distraction task the participants responded to the
LEDs by means of two pedals, left and right, pressed by the
dominant foot.
The distraction task consisted of presenting one of the LEDs
(left or right) for 200 ms and the participants had to press the
corresponding left or right pedal as soon as possible. The
duration of the task depended on the duration of immersion in
the water. A maximum number of 135 trials were presented
(corresponding to the limit of 300 seconds of immersion in the
cold water) and time responses were recorded. The mean reac-
tion time was 589 ms (SD = 216 ms). The inter-trial interval
ranged between one and three seconds to avoid temporal pre-
dictability and increase atten t ional engagement.
Self-Report Instruments
Anxiety Sensitivity was assessed using the Spanish version of
the Anxiety Sensitivity Index (ASI; Peterson, & Reiss, 1992;
Sandin, Chorot, & McNally, 1996) which is fully equivalent to
the original and whose construct and concurrent validity have
been supported by cross-cultural evidence (Sandin, Chorot, &
McNally, 1996). The Spanish version of the ASI has shown
good psychometric properties for both reliability and validity
(Sandín, Valiente, Chorot, & Santed, 2005). This is a 16-item
questionnaire in which participants are asked to indicate the
degree to which they fear the negative consequences of anxiety
symptoms on a 5-point Likert-type scale (ranging from 0 = very
little to 4 = very much). The original ASI has very high internal
consistency and good test-retest reliability (Peterson & Plehn,
1999; Peterson & Reiss, 1992). The total score was used as the
global AS factor.
Fear of pain was measured using the Spanish version of the
Fear of Pain Questionnaire (FPQ-III; Camacho & Esteve, 2005;
McNeil & Rainwater, 1998). It consists of 30 items that are
scored on a 5-point scale ranging from 1 (not at all) to 5 (ex-
treme). It has three subscales related to three painful stimulus
situations: fear related to severe pain (eg, breaking your arm);
fear related to minor pain (e.g., having sand in your eye) and
fear related to medical pain (e.g., receiving an injection in your
mouth). The English version has suitable psychometric proper-
ties (Osman, Breitenstein, Barrios, Gutierrez, & Koper, 2002)
and the Spanish version has proven high internal consistency
and a factorial structure similar to the former. It yielded a cor-
related three-factor structure which corresponds to the three
subscales of the instrument (Camacho & Esteve, 2005). The
total fear of pain score was used.
Experiential avoidance. The Acceptance and Action Ques-
tionnaire (AAQ; Hayes et al., 2004; Barraca, 2004) consists in
9 items that are scored on a 7-point Likert scale. It assesses
tendencies to make negative evaluations of private events (e.g.,
anxiety is bad), unwillingness to be in contact with private
events, the need/desire to control or alter the form and fre-
quency of private events and the inability to take action in the
face of negatively evaluated private events. The Spanish ver-
sion (Barraca, 2004) shows high internal consistency and valid-
Appraisal of the Experience of Pain
Participants also completed items related to the pain experi-
ence on 11-point rating scales adapted from Van Damme et al
(2008). The items assessed the following: a) pain intensity (0 =
no pain; 10 = the worst imaginable pain) using 4 items measur-
ing pain during and after the cold pressor procedure; b) distress
(0 = no distress; 10 = worst imaginable distress) using 3 items
related to distress associated with pain; and c) general anxiety,
using four items measuring how anxious and fearful they felt
during the cold w a t er procedure.
Catastrophic thinking about pain during the cold water pro-
cedure was assessed using the Pain Catastrophizing Scale (PCS;
Sullivan et al., 1995) adapted to the experimental pain context.
The original instrument is a 13-item scale that measures the
level of catastrophic thinking about past pain episodes. Items
more appropriate for the experimental pain situation were se-
lected and translated into a 8-item scale where participants were
asked to reflect on the experimental painful experience and to
indicate the degree to which they experienced these thoughts or
feelings during the pain task (e.g., Helplessness “I felt I
couldn’t stand it anymore”, rumination “I was thinking all the
time about when the pain was going to be over” and magnifica-
tion “I was thinking the pain was horrible and was overwhelm-
ing me”). The internal consistency of the total scale was high
and the total score was used.
First, the participants completed the ASI, AAQ and FPQ in
class several days before the experimental session and were
then scheduled for the experimental studies. When the partici-
pants arrived the experimenter were told that the aim of the
study was to examine pain perception by use of a cold pressor
test. Exclusion criteria were checked and the participants signed
an informed consent document. Participants were randomly
assigned to one of four conditions based on the manipulation of
attention (distraction versus no distraction task) and threat
(threatening information versus neutral information).
Threat was manipulated by means of verbal instructions. Par-
ticipants assigned to the threat condition received instructions
about the cold pressor task adapted from previous studies
(Jackson et al., 2005; Van Damme et al., 2008). They were told
that “exposure to cold water can lead to freezing in the long
term and that this may be associated with pain, tingling and
numbness in the immersed hand”. In the neutral condition par-
ticipants were told that “exposure to cold water is harmless, but
it can be associated with some discomfort or pain, which is
absolutely normal and has no further consequences”.
Attention was manipulated by means of the distraction task.
Only the participants in the distraction condition performed the
task, but no information about the purpose of this task was
given. They were asked to respond to visual targets as quickly
as possible by pressing a foot pedal. They were instructed to
immerse their non-dominant hand in the basin filled with
room-temperature water to standardize its temperature for later
immersion in cold water, and to keep their hand there for as
long as possible. However, it was emphasized that they could
withdraw their hand at any time during the cold water proce-
dure. The participants in the distraction condition were in-
structed to do the task at the same time as they had their hand in
the cold water, whereas the participants in the non-distraction
condition had to undergo the cold pressor condition but without
performing any task.
Tolerance time was measured using a stopwatch. When par-
ticipants withdrew their hand from the container they were
given a towel to dry themselves and then completed the rating
scales and the adapted PCS.
To assess the effect of distraction and threat manipulations,
ANCOVAs were performed to determine whether the groups
differed in relation to the pain experience (tolerance, reported
pain and distress, general anxiety and catastrophizing ratings)
after controlling for the influence of AS, EA and FP. Table 1
shows the means of the dependent variables as a function of
The analyses showed a significant main effect for the distrac-
tion manipulation. The distraction group showed more toler-
ance (F(1) = 10,08, p = .004), reported less pain (F(1) = 5,54, p
= .026) and had fewer catastrophic thoughts (F(1) = 11,34, p
= .002) compared to the group that did not perform any task.
The threat group was compared to the neutral group. No sig-
nificant group differences were found regarding catastrophic
thoughts (F(1) = .074, p= .787), pain reports (F(1) = .018, p =
895) and tolerance (F(1) = .019, p = .890). The threat group
showed more general anxiety (F(1) = 4,88, p = .035) and more
distress (F(1) = 2,89, p = .09), but distress rating differences
showed a tendency to be significant. The interaction between
the distraction and threat manipulation factors did not reach
significance for any of the dependent variables (all F(s) < 1.65,
Sig.(s) > 0.30).
The covariates had significant effects on the experience of
pain. AS had a significant influence on tolerance (F(1) = 6,81, p
= .014), EA had a effect on distress (F(1) = 5,17, p = .031) and
general anxiety (F(1) = 7,07, p = .013 ) and FP did not have any
Table 1.
Mean and standard deviations of dependent variables in function of distr action and threat.
Total (N = 36) Threat (N = 16) Neutral (N = 20)
Mean (SD) Distract (8) Non distract (8) Distract (11) Non distract (9)
135,97 (109,47)
6.95 (1.31)
9.75 (5.72)
22.83 (11,68)
19,58 (8,34)
193,87 (118,51)
6.71 (1,30)
8,12 (5,43)
30,25 (11,12)
20,00 (7,01)
85.12 (89,16)
7.21 (1.12)
11.75 (5.20)
22,37 (7,20)
23.62 (9,60)
164,36 (111,75)
6.30 (1.55)
5.91 (3.83)
20,27 (12.08)
14,72 (9,37)
95,00 (92,93)
7,74 (.68)
14.11 (5.23)
19.77 (13,64)
21,55 (4,24)
effect on the dependent variables.
Figure 1 summarizes the significant relationships found be-
tween the dispositional variables (fear of pain, AS and EA),
contextual variables (distraction and threat), and the dependent
The aim of this study was to investigate whether distraction
is less effective when pain is perceived as threatening. Several
notable results emerged from this study. The participants in the
distraction condition reported less pain intensity, showed longer
tolerance times to the cold water and reported fewer catastro-
phic thoughts than participants who were not distracted. The
effect of distraction did not interact with the threatening in-
structions. These results are in line with a previous study (Van
Damme et al., 2008) that failed to find any interaction between
distraction and threat manipulations in a cold pressor procedure.
They also obtained similar results: specifically, distraction ma-
nipulation resulted in less pain once the cold pressor procedure
was stopped and there tended to be less catastrophic thinking.
The authors did not measure tolerance time, but they found that
fewer participants withdrew from the cold pressor procedure
when they were distracted. Both studies seem to show the bene-
ficial effects of distraction (also see Hodes et al., 1990; James
& Hardardottir, 2002; Johnson & Petrie, 1997; Miron et al.,
1989; Petrovic et al., 2000). A number of reports show that pain
is perceived as less intense when individuals are distracted from
the pain (Bushnell & Duncan, 1999; Miron et al., 1989) despite
the threat value of pain. Clinical applications would incorporate
distraction only as a contextual key. In the present study, it had
beneficial effects on a simple task in which the subjects had to
respond to another sensory modality stimulus which competed
with pain and that would not involve controlled and demanding
processes (Koster, Rassin, Crombez, & Naring, 2003; Van
Damme et al., 2007). Participants in Keogh and Mansoor’s
(2001) study were instructed to ignore the sensations in the
distraction condition and it was found that focused strategies
were clearly superior. Moreover, these results are in line with
previous studies which suggested that when distraction is ap-
plied in the form of direct instructions or auto-instructions
(“Think about this and try not to think about pain), paradoxical
effects could be enhanced (Cioffi & Holloway, 1993; Masedo
& Esteve, 2007). According to these results, the best form of
distraction is to engage in daily activities. This result is consis-
tent with therapeutic principles of acceptance, which suggest
that avoidant behaviours often lead to disability and social iso-
lation, and which aim at training patients to actively contact
their experience while behaving effectively (Hayes et al.,
The threat conditi o n resulted in a more distressing experience
of pain. The effect of threat on anxiety during the cold pressor
did not reach significance; however, the scores were in the
predicted direction. Jackson et al. (2005) found that threatening
instructions led to the decreased use of distraction strategies,
and Van Damme et al. (2007) found that threat led to less en-
gagement in the distraction task. An important technical limita-
tion of the present study is that engagement with the distraction
task and reaction times were not measured. Nevertheless,
threatening instructions elicited negative emotional reactions
that could be expected to affect the general performance of a
task and even the overall experience of pain.
In line with previous studies, AS, as a dispositional variable
which promotes avoidance, was associated with tolerance times
(Asmundson & Norton, 1995; Asmundson & Taylor, 1996;
Plehn, Peterson & Williams, 1998; Esteve & Camacho, 2008).
In the context of experimental pain, tolerance could be consid-
ered the behavioural measure of pain avoidance (Camacho &
Esteve, 2007). Although AS was associated with shorter toler-
ance time, no significant association was found between fear of
pain and the experience of pain. These results support the AS
approach (Asmundson & Hadjistavpoulos, 2007; Esteve &
Camacho, 2008). Nevertheless, AS was not significantly asso-
ciated with the subjective distress ratings, which contrasts with
previous studies that only found differences between AS groups
regarding subjective ratings of pain (Keogh & Birkby, 1999;
Figure 1.
Relationships between psicosocial antecedent variables, factors and dependent variables.
Schmidt & Cook, 1999; Keogh & Mansoor, 2001), but none in
relation to tolerance.
In contrast to the association between AS and behavioural
avoidance, a significant association was found between EA and
the subjective experience of pain which is consistent with pre-
vious findings (Kashdan et al., 2006). Similarly, EA has been
related to the ability to tolerate physical and psychological dis-
tress which is a key determinant of emotional adaptation to
aversive events (Feldner, Eifert, & Brown, 2001; Feldner et al.,
2006). Thus, the potential importance of EA as a broad-based
vulnerability to emotional distress has been supported by the
present study (Feldner et al., 2006). Of further interest is the
fact that the clinical implications of this result lend support to
an approach based on acceptance of pain as the antithesis of EA
(Orsillo, Roemer, & Barlow, 2003). Acceptance studies suggest
that emotional avoidance processes may increase the intensity
of pain experiences and acceptance strategies lead to better
pain-related emotional adjustment (Hayes et al., 1999).
These results suggest that AS and EA are distinct processes
and that each could play a different role in the response to
chronic pain. Anxiety sensitivity involves behavioural avoid-
ance, whereas EA is a rejection of the internal experience that
contributes to an increase in emotional distress. A disconnec-
tion between subjective experience and behaviour could lead to
this behaviour persisting despite increased distress. Future
studies could test whether AS is more related to avoidance and
EA to endurance coping as a maladaptative pain-related coping
style to bear chronic pain (Hassenbring, Hallner, & Rusu,
The findings of this study showed that vulnerability variables
play a relevant role in the avoidance of pain and in the subjec-
tive experience of pain. Studies with chronic pain population
show also that certain clinical personality patterns were associ-
ated with poor adjustment to chronic pain, concretely cognitive
appraisal of harm predicted higher anxiety levels and greater
perceived pain in chronic pain patients (Herrero, Ramírez-
Maestre, & González, 2008). This has important implications
since prevention programs could be optimized regarding effi-
cacy if specific therapeutic approaches were designed to treat
individuals with high scores in EA and AS.
The present study has important limitations. The ability to
generalize the results is limited because of the small sample
size. Furthermore, this study was conducted with undergradu-
ates. Caution should be exercised in generalizing these results
to clinical populations until these effects have been examined
more extensively. Like previous studies (Keogh & Mansoor,
2001; Roelof, Peters, Van der Zijden, & Vlaeyen, 2004), this
study was limited to women since previous research has found
that women often score higher on the ASI than men. Future
research may be designed to further explore the relationship
between AS and gender.
This research was supported by grants from the University of
Málaga, Dirección General de Enseñanza Superior (BSO2002-
02939) and the Junta de Andalucía (HUM-566).
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