Cousins

1. The role of neuroticism, pain catastrophizing and pain-related fear
in vigilance to pain: a structural equations approach
Liesbet Gouberta,b,*,1
, Geert Crombeza,b
, Stefaan Van Dammea,b
a
Department of Experimental–Clinical and Health Psychology, Ghent University, Henri Dunantlaan 2, B-9000 Ghent, Belgium
b
Research Institute for Psychology and Health, Utrecht, The Netherlands
Received 19 June 2003; received in revised form 27 October 2003; accepted 7 November 2003
Abstract
The present study aimed at clarifying the precise role of pain catastrophizing, pain-related fear and personality dimensions in vigilance to
pain and pain severity by means of structural equation modelling. A questionnaire survey was conducted in 122 patients with chronic or
recurrent low back pain. Results revealed that pain catastrophizing and pain-related fear mediated the relationship between neuroticism and
vigilance to pain. Furthermore, vigilance to pain was found to be associated with heightened pain severity. Finally, we found that neuroticism
moderated the relationship between pain severity and catastrophic thinking about pain. The results strongly support the idea that vigilance to
pain is dependent upon catastrophic thinking and pain-related fear. Neuroticism is best conceived of as a vulnerability factor; it lowers the
threshold at which pain is perceived as threatening, and at which catastrophic thoughts about pain emerge.
q 2003 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
Keywords: Vigilance; Pain catastrophizing; Pain-related fear; Personality; Neuroticism
1. Introduction
The notion of heightened vigilance is often invoked to
explain the heightened experience of pain (Aldrich et al.,
2000; Chapman, 1978; McDermid et al., 1996). Although it
is still a matter of debate which attentional processes are
involved (Eysenck, 1992; Van Damme et al., 2003a,b),
there is a growing consensus that hypervigilance is an
emergent property of the threat value of pain (Chapman,
1978; Eccleston and Crombez, 1999): especially, persons
who appraise bodily sensations as dangerous are believed to
develop a habit of selecting pain over other competing
demands. In line with this idea, self-reported vigilance to
pain has been found to be strongly related to pain
catastrophizing—an exaggerated negative interpretation of
actual and anticipated pain experience—and pain-related
fear—the fear of pain and activities associated with pain—
(Roelofs et al., 2003).
An unresolved issue pertains to the role of personality in
vigilance topain.Ofthefivepersonalitydimensionsidentified
by Costa and McCrae (1987), both neuroticism and extraver-
sion seem to be the most plausible to have an effect upon
vigilance to pain. In particular, neuroticism, which is the trait-
like tendency to experience a broad range of negative feelings
such as distress, worry, and anxiety, has been associated with
a heightened experience of bodily sensations (Watson and
Pennebaker, 1989; Geisser et al., 2000). According to Watson
and Pennebaker (1989), persons scoring high on neuroticism
are more likely to notice and attend to internal physical
sensations and minor aches because their attentional scanning
of both the external and internal environment is fraught with
anxiety and uncertainty. Also the personality dimension
introversion–extraversion may affect selective attention to
pain (Eysenck, 1967). Psychophysiological studies indicated
that introverts exhibit a greater sensitivity to physical stimuli
than extraverts (Stelmack, 1990).
Few studies have directly investigated the interdepen-
dency of the above psychosocial variables in explaining
vigilance to pain. According to the cognitive-affective
model (Eccleston and Crombez, 1999), pain-related fear and
pain catastrophizing are instantiations of the threat value of
pain, and should therefore be considered as crucial
Pain 107 (2004) 234–241
www.elsevier.com/locate/pain
0304-3959/$20.00 q 2003 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.pain.2003.11.005
1
Research Assistant of the Fund for Scientific Research, Flanders,
Belgium, F.W.O.
* Corresponding author. Address: Department of Experimental-Clinical
and Health Psychology, Ghent University, Henri Dunantlaan 2, B-9000
Ghent, Belgium. Tel.: þ32-09-2646262; fax: þ32-09-2646489.
E-mail address: liesbet.goubert@ugent.be (L. Goubert).

2. mediators that account for the relationship between
personality and vigilance to pain. However, to our knowl-
edge, no study has provided a direct test of the putative
mediating role of pain catastrophizing and pain-related fear
in a sample of chronic pain patients. This was, therefore, the
first objective of this cross-sectional study. We designed and
tested a structural equations’ model with the following
assumptions: (1) vigilance to pain leads to the experience of
more severe pain, (2) both pain catastrophizing and pain-
related fear mediate the relationship between personality
dimensions and vigilance to pain, and (3) pain catastrophiz-
ing is a precursor to pain-related fear (Vlaeyen and Linton,
2000). A further objective was to explore the moderating
role of neuroticism within a diathesis-stress framework
(Eysenck, 1992). More specifically, we tested whether high-
neurotic persons who experience pain are more prone to
develop catastrophic thinking about pain and pain-related
fear (see also Wade and Price, 2000).
2. Method
2.1. Participants
One hundred and twenty-two patients with non-specific
chronic or recurrent back pain (mean age ¼ 43.72,
SD ¼ 9.56) were recruited from a physical revalidation
unit and from an orthopaedic unit at two university
hospitals. All participants were white Caucasians. The
majority of participants were female (60.7%), 84.2% were
married or cohabiting, and 22% had a higher education
(longer than the age of 18 years). The average duration of
pain since time of onset was 97.98 months (SD ¼ 104.17;
range ¼ 3 months–45 years). More than half of the patients
(54.1%) reported that their pain started gradually, 74.5%
reported radiation of the pain, and 40.4% of the patients had
undergone at least one spinal surgery. Almost one third of
the patients (30.8%) were in paid employment and 37.5% of
the patients were receiving worker’s compensation.
2.2. Questionnaires
Patients completed a battery of questionnaires designed to
assess the following constructs: pain severity, vigilance to
pain, catastrophic thinking about pain, fear of movement/
(re)injury, and personality characteristics. Pain severity was
assessed by the Dutch version of the Multidimensional Pain
Inventory—Part 1 (MPI; Lousberg et al., 1999). Part 1 of the
MPI-DV consists of five scales: pain severity (3 items),
interference with daily life due to pain (11 items), perceived
life control (4 items), affective distress (3 items) and social
support (3 items). The Dutch version of the MPI has shown to
have good reliability and validity (Lousberg et al., 1999).
Vigilance to pain was assessed by the Dutch version of the
Pain Vigilance and Awareness Questionnaire (PVAQ;
McCracken, 1997; Roelofs et al., 2002, 2003). This is
a 6-point 16-item measure of attention to pain that assesses
awareness, consciousness and vigilance to pain. The PVAQ
consists of two subscales: attention to pain (e.g. ‘I pay close
attention to pain’) and attention to changes in pain (e.g. ‘I am
quick to notice changes in pain intensity’) (Roelofs et al.,
2003). The questionnaire can be used in both clinical
(McCracken, 1997; Roelofs et al., 2003) and non-clinical
(McWilliams and Asmundson, 2001; Roelofs et al., 2002)
samples. The Dutch version of the PVAQ is reliable and valid
(Roelofs et al., 2002, 2003).
Catastrophic thinking about pain was assessed by the
Dutch version of the Pain Catastrophizing Scale (PCS;
Sullivan et al., 1995; Crombez et al., 1998). This is a 13-item
scale developed for both nonclinical and clinical populations.
Participants reflect on past painful experiences and indicate
the degree to which they experienced thoughts or feelings
during pain on a 5-point scale. The Dutch version has been
shown to have good reliability and validity in a student
population and in a clinical population (Van Damme et al.,
2002a). The PCS consists of three subscales (Van Damme
et al., 2002a): rumination (e.g. ‘I can’t seem to keep it out of
my mind’), magnification (e.g. ‘I become afraid that the pain
will get worse’) and helplessness (e.g. ‘I feel I can’t stand it
anymore’).
Fear of (re)injury due to movement was measured by the
Dutch version of the adjusted Tampa Scale for Kinesiopho-
bia (TSK-AV; Kori et al., 1990; Goubert et al., 2003). It
consists of 13 items measured on a 4-point scale with scoring
alternatives ranging from ‘strongly agree’ to ‘strongly
disagree’. Confirmatory factor analysis revealed that the
adjusted version (in which the inversed items are omitted)
more adequately fitted the data than the original version. The
TSK-AV is sufficiently reliable and valid (Goubert et al.,
2003). Confirmatory factor analyses revealed two valid
subscales, namely harm (e.g. ‘My body is telling me I have
something dangerously wrong’) and fear-avoidance (e.g.,
‘Simply being careful that I do not make any unnecessary
movements is the safest thing I can do to prevent my pain
from worsening’) (Goubert et al., 2003).
Personality was measured by the Dutch version of the
Big Five Personality Questionnaire (NEO-FFI; Costa and
McCrae, 1992; de Fruyt and Mervielde, 1998). This 60-item
questionnaire measures five personality dimensions, i.e.
neuroticism, extraversion, openness, agreeableness and
conscientiousness. Research has shown that the NEO-FFI
is sufficiently reliable (a coefficients vary between 0.68 and
0.86) (de Fruyt and Mervielde, 1998). Also the construct-
and concurrent validity has been well documented (de Fruyt
and Mervielde, 1998).
2.3. Statistical analysis
Structural equation modelling (SEM) was performed
using LISREL 8.52 (Jo¨reskog and So¨rbom, 1993) with
maximum likelihood estimation. In line with the recommen-
dations of Bollen and Long (1993), several fit indices were
L. Goubert et al. / Pain 107 (2004) 234–241 235

3. used to assess model fit. In the present study, model fit was
assessed using the following goodness-of-fit indices: x2
;
goodness-of-fit index (GFI), adjusted goodness-of-fit index
(AGFI), root mean square error of approximation (RMSEA)
and comparative fit index (CFI).
The most frequently used fit index is x2
. This likelihood-
ratio test statistic is used to determine whether a significant
amount of observed covariance between items remains
unexplained by the model. A disadvantage of this index is its
sensitivity to sample size. In a small sample, a poor fit may
result in a non-significant x2
. It is also possible that in a large
sample a good fit results in a statistically significant x2
(Marsh et al., 1988). In the present study, the x2
is the normal
theory weighted least squares x2
as the other fit indices are
based upon this index in the LISREL 8.52 program. The GFI
and the AGFI (Jo¨reskog and So¨rbom, 1984) assess the extent
to which the model provides a better fit compared to no model
at all. These indices generally range between 0 and 1, with
high values (GFI . 0.90 and AGFI . 0.80) reflecting a good
fit of the model. The RMSEA (Browne and Cudeck, 1993) is
a fit measure based on population error of approximation.
The idea behind this is that it is unreasonable to assume that
the model holds exactly in the population. The RMSEA takes
into account the error of approximation in the population.
According to Browne and Cudeck (1993), a RMSEA value of
0.05 indicates a close fit and values up to 0.08 represent
reasonable errors of approximation in the population.
Finally, the CFI (Bentler, 1990a) is an incremental fit index
that produces a statistic in the range between 0 and 1. It
represents the proportionate improvement in model fit by
comparing the target model with a baseline model (usually a
null model in which all the observed variables are
uncorrelated). CFI values larger than 0.90 indicate an
adequate fit (Bentler, 1990b).
Furthermore, we investigated whether neuroticism mod-
erated the relationship between pain severity and both pain
catastrophizing and pain-related fear. To test for neuroticism
as a moderator, it is necessary to enter the cross-product
terms of neuroticism and pain severity in a separate block in a
hierarchical regression analysis, following the entry of pain
severity and neuroticism as first-order terms (Baron and
Kenny, 1986). To reduce the effects of multicollinearity,
variables were centered (Aiken and West, 1991). Statistically
significant interactions are interpreted by plotting regression
lines for high and low values of the moderator variable
(Aiken and West, 1991; Holmbeck, 2002).
3. Results
3.1. Patient characteristics
In comparison with the MPI-DV results of a patient
group entering a cognitive-behavioural rehabilitation pro-
gram (Lousberg et al., 1999), the severity of the pain
complaints in the present patient sample was moderate to
average. The mean score of the pain severity scale was 3.89
(SD ¼ 1.17; mean of comparison group ¼ 4.50;
tð121Þ ¼ 25:51; P , 0:001) and the mean score of the
interference scale was 4.25 (SD ¼ 1.13; mean of compari-
son group ¼ 4.52; tð121Þ ¼ 22:53; P , 0:05Þ:
3.2. Preliminary analyses
Table 1 presents the means, SD, Cronbach’s a and
Pearson intercorrelations for each of the self-report
variables. Vigilance to pain was significantly correlated
with pain severity, pain catastrophizing, fear of movement/
(re)injury and the personality dimensions of neuroticism
and agreeableness. Furthermore, pain catastrophizing was
significantly correlated with pain severity, fear of move-
ment/(re)injury, and the personality dimensions of neuroti-
cism, extraversion, openness to experience and
agreeableness. In addition, fear of movement/(re)injury
was significantly correlated with pain severity, neuroticism,
openness to experience and agreeableness.
3.3. Value of the personality dimensions in predicting
vigilance to pain
A hierarchical multiple regression analysis was per-
formed to investigate the unique contribution of each
personality dimension to the prediction of vigilance to pain.
In a first step, age and gender (males were coded as 0 and
Table 1
Means ðMÞ; standard deviations (SD), internal consistency ðaÞ and intercorrelations of all measures
M (SD) a 2 3 4 5 6 7 8 9
1 Vigilance to pain 46.81 (11.02) 0.81 0.21* 0.60*** 0.56*** 0.31** 20.14 20.02 20.19* 0.10
2 Pain severity 3.89 (1.17) 0.84 – 0.30** 0.29** 0.06 20.18 20.21* 20.04 20.02
3 Pain catastrophizing 21.38 (8.18) 0.89 – 0.58*** 0.33*** 20.19* 20.21* 20.24** 20.04
4 Fear of movement/(re)injury 32.71 (7.31) 0.78 – 0.28** 20.15 20.19* 20.28** 20.08
5 Neuroticism 34.25 (7.50) 0.80 – 20.50*** 20.25** 20.28** 20.36***
6 Extraversion 41.56 (6.44) 0.75 – 0.36*** 0.19* 0.39***
7 Openness to experience 36.67 (6.18) 0.69 – 0.19* 0.27**
8 Agreeableness 45.43 (5.84) 0.73 – 0.22*
9 Conscientiousness 47.82 (5.58) 0.79 –
*P , 0.05; **P , 0.01; ***p , 0.0005
L. Goubert et al. / Pain 107 (2004) 234–241236

4. females as 1) were entered into the equation to control for
sociodemographic variables. In a second step, pain severity
and pain duration were entered. Next, the five personality
dimensions were entered. Variance-inflation factors (range
1.00–1.66) were acceptable, suggesting that there was no
problem of collinearity. Our results revealed that of the five
personality dimensions only neuroticism and conscientious-
ness had a unique contribution in predicting vigilance to
pain (see Table 2). As only neuroticism proved (1) to have a
significant zero-order association with vigilance to pain, and
(2) to be a unique predictor of vigilance to pain in the
multiple regression analysis, further analyses were only
performed with this personality dimension.
3.4. Model testing
In order to use SEM, latent constructs of the observed
data were constructed. Fear of movement/(re)injury as a
latent construct was specified by the two subscales of the
TSK-AV: TSK-harm and TSK-fear. The latent construct
pain catastrophizing was indicated by the three subscales of
the PCS: PCS-rumination, PCS-magnification and PCS-
helplessness. Vigilance to pain was specified as a latent
construct measured by the two subscales of the PVAQ:
PVAQ-vigilance to pain and PVAQ-vigilance to changes in
pain. Because neuroticism was measured by one variable we
fixed the error variance to 0 and the loading value to 1.
Finally, pain severity as a latent construct was indicated by
the three items of the pain severity scale of the MPI. Missing
values were omitted, leaving valid data of 121 patients.
Before the structural model was tested we used confirmatory
factor analysis to examine the measurement model. It
showed a good fit of the data, x2
ð35Þ ¼ 53:26 ðP ¼ 0:02Þ;
RMSEA ¼ 0.07 (90% Confidence interval: 0.02–0.10),
CFI ¼ 0.97, GFI ¼ 0.93 and AGFI ¼ 0.86. This indicates
that the subscales of the TSK-AV, PCS, PVAQ and MPI
may be considered as valid operationalisations of the latent
constructs fear of movement/(re)injury, pain catastrophiz-
ing, vigilance to pain and pain severity. All subscales of the
questionnaires loaded significantly on the appropriate latent
construct.
Results revealed that our hypothesized structural model
had a good fit (see Fig. 1): x2
ð40Þ ¼ 66:45 ðP ¼ 0:005Þ;
RMSEA ¼ 0.07 (90% confidence interval: 0.04–0.10),
CFI ¼ 0.96, GFI ¼ 0.91 and AGFI ¼ 0.85. As expected,
our findings show that pain catastrophizing and fear of
movement/(re)injury mediated the relationship between
neuroticism and vigilance to pain. Testing a structural
Fig. 1. Structural equation model showing the role of neuroticism, pain catastrophizing and fear of movement/(re)injury in vigilance to pain. NEO-N,
neuroticism subscale of the NEO-FFI; RUM, rumination subscale of the PCS; MAGN, magnification subscale of the PCS; HELP, helplessness subscale of the
PCS; HARM, harm subscale of the TSK-AV; FEAR-AV, fear-avoidance subscale of the TSK-AV; PVAQ-AP, vigilance to pain subscale of the PVAQ; PVAQ-
ACP, vigilance to changes in pain subscale of the PVAQ. *P , 0:05:
Table 2
Hierarchical regression analysis predicting vigilance to pain from age, sex, pain severity, pain duration, neuroticism, extraversion, openness to experience,
agreeableness, and conscientiousness
Criterion variable Step Predictor b DR2
Adjusted R2
Vigilance to pain 1 Age 20.10 0.03 0.02
Sex 20.16
2 Pain severity 0.20* 0.06* 0.06
Pain duration 20.09
3 Neuroticism 0.36** 0.16*** 0.19
Extraversion 20.07
Openness to experience 0.08
Agreeableness 20.08
Conscientiousness 0.26**
*P , 0:05; **P , 0:01; ***P , 0:005. Standardized bs are displayed.
L. Goubert et al. / Pain 107 (2004) 234–241 237

5. model in which pain catastrophizing and fear of movement/
(re)injury changed places, also revealed a good model fit:
x2
ð40Þ ¼ 61:40 ðP ¼ 0:02Þ; RMSEA ¼ 0.07 (90% confi-
dence interval: 0.03–0.10), CFI ¼ 0.96, GFI ¼ 0.91 and
AGFI ¼ 0.86. The direct link between neuroticism and
vigilance to pain was not significant. Finally, vigilance to
pain was positively associated with the experience of more
severe pain. Standardized b-coefficients and R2
values are
shown in Fig. 1, with R2
values shown above each
endogenous variable.
3.5. Value of the personality dimensions in predicting pain
catastrophizing and fear of movement/(re)injury
To investigate the unique value of the personality
dimensions in predicting pain catastrophizing and fear of
movement/(re)injury, two multiple regression analyses were
performed. Variance-inflation factors (range 1.00–1.66)
were acceptable, suggesting that there was no problem of
collinearity. The first analysis revealed that only neuroti-
cism had a unique contribution in predicting pain catastro-
phizing, beyond age, gender (males were coded as 0 and
females as 1), pain duration and pain severity (see Table 3).
None of the other personality dimensions had a significant
contribution. A similar analysis with fear of movement/
(re)injury as dependent variable revealed identical results.
Only neuroticism had a unique contribution in predicting
fear of movement/(re)injury (see Table 3). Based upon these
results, it was decided to perform only moderation analyses
with the personality dimension ‘neuroticism’.
3.6. Moderation analyses
3.6.1. Moderational role of neuroticism in the relationship
between pain severity and pain catastrophizing
We examined whether the interaction variable (pain
severity £ neuroticism) was a significant predictor of
pain catastrophizing, after controlling for the effects of pain
severity and neuroticism (Aiken and West, 1991; Holmbeck,
2002). Significant main effects were found for pain severity
ðb ¼ 0:31; P , 0:0005Þ and neuroticism ðb ¼ 0:30; P ,
0:0005Þ: Also the interaction pain severity £ neuroticism
was a significant predictor ðb ¼ 0:16; P , 0:05Þ; revealing
that the association between pain severity and pain
catastrophizing is conditional on the values of neuroticism.
To illustrate the pattern reflected in this statistically
significant interaction term, we plotted regression lines for
high (þ1 SD above the mean) and low (21 SD below the
mean) values of the moderator variable (see Aiken and West,
1991; Holmbeck, 2002, Fig. 2). Significance tests for both
slopes indicated that the slope for the high-neuroticism
regression line was significant (b ¼ 0:46; P , 0:0005),
indicating that pain catastrophizing tends to be more
pronounced at higher levels of pain severity when neuroti-
cism is high. The slope for the low-neuroticism regression
line was not significant ðb ¼ 0:15; nsÞ:
3.6.2. Moderational role of neuroticism in the relationship
between pain severity and fear of movement/(re)injury
We entered the cross-product terms of neuroticism and
pain severity in a separate block in a hierarchical regression
Table 3
Hierarchical regression analyses predicting pain catastrophizing and fear of movement/(re)injury from age, sex, pain severity, pain duration, neuroticism,
extraversion, openness to experience, agreeableness, and conscientiousness
Criterion variable Step Predictor b DR2
Adjusted R2
Pain catastrophizing 1 Age 20.07 0.01 0.00
Sex 20.06
2 Pain severity 0.26*** 0.12*** 0.11
Pain duration 20.14
3 Neuroticism 0.30*** 0.13*** 0.20
Extraversion 20.02
Openness to experience 20.09
Agreeableness 20.13
Conscientiousness 0.13
Fear of movement/(re)injury 1 Age 0.06 0.06* 0.05
Sex 20.21*
2 Pain severity 0.25*** 0.11*** 0.15
Pain duration 20.17
3 Neuroticism 0.27** 0.09* 0.21
Extraversion 0.05
Openness to experience 20.05
Agreeableness 20.12
Conscientiousness 0.05
*P , 0:05; **P , 0:01; ***P , 0:005: Standardized betas are displayed.
L. Goubert et al. / Pain 107 (2004) 234–241238

6. analysis, following the entry of pain severity and neuroticism
as first-order terms. We found significant main effects of pain
severity ðb ¼ 0:28; P , 0:001Þ and neuroticism ðb ¼
0:25; P , 0:01Þ: The interaction term pain severity £
neuroticism, however, was not a significant predictor of
fear of movement/(re)injury ðb ¼ 0:14; P , 0:10Þ: Although
the interaction term was not significant, we performed a post-
hoc probing analysis. The results revealed similar results as
for pain catastrophizing: the slope for the high-neuroticism
regression line was again significant (b ¼ 0.42,
P , 0.0005), indicating that fear of movement/(re)injury
tends to be more pronounced at higher levels of pain severity
when neuroticism is high. The slope for the low-neuroticism
regression line was not significant (b ¼ 0.15, ns).
4. Discussion
The present study aimed at clarifying the role of
catastrophic thinking about pain, pain-related fear and
neuroticism in its relationship with vigilance to pain and
pain severity. The results can be readily summarized. First,
vigilance to pain was related to the experience of more
severe pain. Second, of the five personality dimensions that
were investigated, only neuroticism was found to be
consistently related to vigilance to pain, pain catastrophiz-
ing and fear of movement/(re)injury. Third, pain catastro-
phizing and fear of movement/(re)injury mediated the
relationship between neuroticism and vigilance to pain.
Fourth, neuroticism was found to moderate the relationship
between pain severity and pain catastrophizing. Analyses
predicting pain-related fear were in the same line, but only
showed a trend to significance.
Of particular interest to this study was the finding that the
effect of neuroticism upon pain vigilance is largely
mediated by pain catastrophizing and pain-related fear.
This is not in line with the symptom perception model of
Watson and Pennebaker (1989), which postulates a direct
effect of neuroticism on vigilance to pain. Our results
support the idea that vigilance to pain is critically dependent
upon its immediate threat value (Chapman, 1978; Eccleston
and Crombez, 1999; Price, 1999).
Our findings point out that neuroticism may be conceived
of as a vulnerability factor within a diathesis-stress frame-
work. When a person is confronted with the stressor of
(acute) pain, neuroticism may influence whether the person
appraises the pain as threatening or not (see also Sullivan
et al., 2003; Thorn et al., 2003). Neuroticism may lower the
threshold at which pain is perceived as threatening, and at
which pain elicits catastrophic thoughts. For high-neurotic
individuals, a low pain severity is sufficient to be perceived
as threatening, and consequently, to provoke catastrophic
thoughts about pain. Our results argue for a modern and
dynamic view on personality instead of a traditional
personality approach that stresses cross-situational stability
of personality traits. In a dynamic view, behaviours are not
assumed to be stable across situations, but vary depending
on the specific situation (Mischel and Shoda, 1998).
Personality is then characterized by stable situation-
behaviour (if…then) relations. This dynamic view is similar
to a diathesis-stress framework in which personality traits
influence the way in which people cognitively process the
meanings that chronic pain holds for their life (Wade et al.,
1992).
The personality dimensions ‘extraversion’, ‘openness’,
‘agreeableness’ and ‘conscientiousness’ do not seem to be
of crucial importance in the emergence of vigilance to pain.
We found no evidence for the idea that introverts tended to
be more vigilant to pain (see Stelmack, 1990). The effects of
conscientiousness upon vigilance to pain are preliminary,
and await replication. They are however intriguing. As
conscientious individuals carefully plan before acting and
avoid situations involving risk or danger (Watson et al.,
1994), it is possible that they become frustrated when
confronted with the insolubility of the problem of chronic
pain and its uncontrollable effects upon daily life. Chronic
pain may then be experienced as (partly) taking over
control, and dominating awareness.
Neuroticism was also the only personality dimension
that uniquely accounted for pain catastrophizing and pain-
related fear. Correlational analyses however showed that
pain catastrophizing was negatively related to extraversion,
openness to experience, and agreeableness. The latter two
personality characteristics were also negatively related to
pain-related fear. This is in line with the findings of Jerram
and Coleman (1999), who found that openness to
experience and agreeableness were associated with positive
health perceptions. Regarding extraversion, our results
suggest that extraverted people have fewer catastrophic
thoughts about pain. This is in line with the suggestion of
Phillips and Gatchel (2000), that extraversion–introversion
is a factor that affects how a person experiences and
responds to pain.
Fig. 2. Regression lines for the relationship between pain severity and pain
catastrophizing as moderated by neuroticism. b, unstandardized regression
coefficient (i.e. simple slope); SD, standard deviation. *P , 0:0005:
L. Goubert et al. / Pain 107 (2004) 234–241 239

7. The results of this study have a number of important
clinical implications. When pain is perceived as highly
threatening, patients become vigilant to pain, and may
experience difficulties to disengage attention from pain-
related information (Van Damme et al., 2002b, 2003a). As a
consequence, attentional distraction strategies may not be
effective in these patients. It may be more effective to
diminish the threat value of pain by means of cognitive
restructuring techniques (Thorn and Williams, 1993;
Warwick et al., 1996) or exposure techniques that
disconfirm the belief of catastrophic outcomes (Crombez
et al., 2002; Goubert et al., 2002; Vlaeyen et al., 2002).
This study has a number of limitations, each of which
point to directions for future research. First, all findings are
based on cross-sectional and correlational data. Significant
correlations do not indicate causal effects. In future research,
this structural equations model needs to be applied to
longitudinal data, in order to provide firm evidence on the
causal relations between the variables. Second, the variables
in this study were assessed only using self-report instru-
ments. Further research should include multiple methods to
assess vigilance to pain, including experimental and
psychophysiological procedures. A third limitation is that
neuroticism is probably not the only variable that accounts
for pain catastrophizing (see Rainville et al., 2000). Other
pathways may also lead to pain catastrophizing and pain-
related fear. Sullivan et al. (2001) proposed that a learning
history characterized by heightened pain experience, may
itself lead to the development of a pain schema, containing
threatening information and catastrophic expectancies about
painfulstimuli. Fourth, although conscientiousness provedto
be a unique predictor of vigilance to pain in the multiple
regression analysis, the zero-order correlation was not
significant. Further research into the potential role of
personality characteristics, in particular of conscientiousness
and neuroticism, in vigilance to pain and in the development
of pain catastrophizing and pain-related fear is needed.
Acknowledgements
The authors want to thank Petra De Vlieger, Els Persijn,
Leen Van Vlierberghe, Stephen Morley and two anonymous
reviewers for their helpful comments on earlier drafts of the
manuscript.
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