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. Author manuscript; available in PMC: 2026 Jan 24.
Published in final edited form as: J Am Coll Health. 2018 Oct 25;67(3):275–282. doi: 10.1080/07448481.2018.1481071

Worry and rumination: Explanatory roles in the relation between pain and anxiety and depressive symptoms among college students with pain

Andrew H Rogers a, Jafar Bakhshaie a, Joseph W Ditre b, Kara Manning a, Nubia A Mayorga a, Andres G Viana a, Michael J Zvolensky a,c
PMCID: PMC12828677  NIHMSID: NIHMS2132964  PMID: 29979938

Abstract

Objective

Pain affects a significant proportion of college students in the United States and has been linked to anxiety and depressive symptoms. Rumination and worry, two transdiagnostic factors linked to comorbidity, may explain the relationship between pain and mental health symptoms.

Current Study:

The current study examined worry and rumination as explanatory factors in the relationship between pain and anxiety and depressive symptoms in a sample of college students with pain (n = 1,577; 79.9% female).

Results:

Results indicated that both rumination and worry explained the relationship between pain and depressive and social anxiety symptoms, while rumination alone explained the relationship between pain and anxious arousal symptoms.

Conclusion:

The current study provides novel empirical evidence that worry and rumination each help explain the relationship between pain and anxiety and depressive symptoms among college students with current pain, and college students in pain may benefit from targeted psychosocial strategies aimed at decreasing worry and ruminative responses.

Keywords: Anxiety, depression, pain, rumination, worry, young adults

The experience of pain affects over 126 million adults in the United States,1 resulting in substantial healthcare costs and decreased productivity.2,3 College aged-young adults (ages 18–25) are particularly vulnerable, as past work suggests as many as 66% of this group report some form of pain.4,5 Such pain complaints among college students specifically are associated with opioid misuse,6 and past research suggests that college students misuse opioids at significantly elevated rates compared to the general population.7,8 Additionally, experiences of pain have been associated with poorer mental health,9 and this is particularly important for college students, as past work suggests that college students are particularly vulnerable and report elevated rates of mental health problems.10-12 Yet the relationship between pain and mental health among college students is understudied. In studies with adults, anxiety and depressive symptoms, in particular are highly associated with more severe and disabling pain.13 In fact, there are complex bidirectional relations between pain and anxiety/depression, with some work indicating pain can increase anxiety/depression,14 and other work suggesting anxiety/ depression can exacerbate pain severity.15 Yet little research has focused on the relationship of pain and mental health problems, as well as their underlying explanatory mechanisms, among college students, despite elevated rates of reported pain and mental health problems, as well as the clinically significant relations that exist between pain and anxiety/depression in the general population.

Recent advances in affective science have begun to identify transdiagnostic factors that underlie complex clinical conditions.16 This work suggests that the underlying cause of many forms of anxiety and depressive symptoms and disorders, as well as their comorbidity with other conditions (eg, pain), may be underpinned by a smaller set of transdiagnostic vulnerability processes.17 In the context of pain research, initial work suggests that how one responds to aversive internal sensations may partially explain the relationship between pain intensity and anxiety/depression severity.18,19

Notably, little research to date has examined the potential explanatory value of individual differences in worry in the context of pain and anxiety/depression among college students, despite the fact that this construct is a common component of a broad range of mood-related psychopathology.20 Worry is operationalized as a verbal-linguistic process focused on the possibility of future negative events.21,22 Such cognitive-affective activity functions as a contrast avoidance strategy that prolongs and maintains a perpetual state of negative affectivity and prevents the worrier from experiencing sharp changes in negative emotions.23 Worry is frequently considered to be a ‘formative element’ to many types of anxiety psychopathology.24 Individuals with greater tendencies to worry often believe that worry will help them cope with feared events or prevent those events from occurring altogether.25,26 In fact, a substantial empirical literature indicates that elevated worry is related to greater distress and impairment, restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance.27

Research focused on worry and pain experience among college students is surprisingly limited. Of the available work among adults, one study examined pain catastrophizing in a sample of adults with Irritable Bowel Syndrome and found that worry was associated with greater pain symptoms.28 In another study focused on adults with chronic pain, worry about pain was found to be associated with greater depressive symptoms.29 However, past work has not yet examined college students and explored whether worry may help explain the relation between pain intensity and anxiety/depression. In extrapolating from non-pain research, theoretically, a heightened tendency to worry could be related to perceptions of pain as a personal threat, greater frustration when dealing with pain, and less confidence about coping with pain symptoms.30 Additionally, studies examining worry in generalized anxiety disorder show that worriers experience emotions more intensely, which could extend to pain31 Such worry-related experience may thereby exacerbate anxiety/depression.

Rumination is another transdiagnostic construct that may be mechanistically involved in the relation between pain intensity and anxiety/depression among college students. In contrast to worry, rumination reflects repetitive thinking about past negative thoughts and feelings. Rumination has been postulated to negatively bias thinking, interfere with problem solving ability, and has been associated with more severe anxiety and depressive symptoms.32-34 Although limited in scope, some research has explored the relationship between pain and rumination among adults. In one experimental study, participants who were instructed to ruminate (vs. employing distraction) during a cold-pressor task reported more distress, higher levels of pain, and evinced greater avoidance for affective pain words.35 Additionally, in a sample of adults with chronic pain, rumination was related to lower levels of life functioning.36 However, no previous work has examined whether rumination may help to explain the relationship between pain intensity and anxiety/depression. Theoretically, a greater tendency to ruminate should be associated with repetitive thinking about past painful experiences, poor problem solving for pain management, and greater avoidance of pain-related sensations.37 Such rumination may thereby increase the probability of more severe anxiety and depressive symptoms.

Together, the present investigation sought to address whether worry and rumination explained (in a simultaneous analytic model) the relation between pain intensity and anxiety/depression among college students with current pain. College students with pain are a high-risk group for experiencing mental health problems, which can exacerbate pain-related problems.9 Dependent measures included depressive, social anxiety, and anxious arousal symptoms, as these are the most common negative emotional symptoms among college-aged young adults.38,39 It was hypothesized that both worry and rumination would uniquely explain the relation between pain experience and the dependent measures over and above the effects of one another. Additionally, it was expected that observed effects would be evident above and beyond the variance accounted for by gender, ethnicity, and current substance use.

Method

Participants

Participants were 1,577 college students (79.9% female, Mage = 22.17, SD = 5.24) recruited to participate in an online survey-based study for course credit. Participants had to be currently enrolled in a psychology course and interested participants responded to flyer/email ads and were invited to participate. All participants in the current study reported the experience of pain (M = 2.66, SD = 0.81) over the last 4 weeks on a scale of 0 (no pain) to 5 (severe pain) on the Short Form General Health Survey.40 The sample was highly diverse: 30.0% Hispanic (n = 473), 25.1% Asian/Pacific Islander (n = 396), 24.5% White (non-Hispanic; n = 387), 14.8% Black (non-Hispanic; n = 233), and 5.6% other (n = 88).

Measures

Graded chronic pain scale

The Graded Chronic Pain Scale is an 8-item self-report measure assessing the impact of chronic pain on daily life.3 Participants are asked to rate the number of days they were disabled by pain in the last 3 months, as well as the intensity of their pain and the disability due to pain over the last 3 months using a 0 (No pain) to 10 (Pain as bad as it can be) scale. The scale yields 2 subscales, pain disability and pain intensity, and the pain intensity subscale was used as the predictor variable in the analyses. The pain intensity subscale showed good internal consistency (Cronbach’s αs = .78).

Penn State Worry Questionnaire

The Penn State Worry Questionnaire (PSWQ) is a 16-item self-report measure used to assess trait levels of worry (eg, “I know I should not worry about things, but I just cannot help it.”).41 Each item is rated on a 5-point Likert scale from 0 (not at all typical of me) to 4 (very typical of me). Higher scores on the PSWQ indicate more worry. The PSWQ yields a total score and it showed good internal consistency in the current study (Cronbach’s α = 0.82).

Ruminative Responses Scale

The Ruminative Responses Scale (RRS) is a 22-item self-report measure assessing how often individuals use specific thinking styles in response to depression (eg, “think about how alone you feel”), rated on a 4-point Likert scale from 1 (Almost never) to 4 (Almost always).42 The scale yields a total score, where higher scores indicate more rumination in response to depression; the RRS showed excellent internal consistency in the present investigation (Cronbach’s α = 0.96).

The core alcohol and drug survey

The Core Alcohol and Drug Survey is a self-report measure designed to assess the substance use attitudes, patterns, and demographic information in a college setting.43 As a part of this questionnaire participants were asked if they had used any drugs in the past 30 days, including tobacco, alcohol, designer drugs (MDMA, ecstasy), steroids, marijuana, cocaine, amphetamines, sedative (non-opioid), opiate, hallucinogen, inhalants, and other. A dichotomous variable was created for the past 30 days (use=1 or no use=0).

The Short-form general health survey

The General Health Survey is a 20-item questionnaire in which respondents indicate on Likert-type scales perceptions of their own health status and functional limitations attributed to that health status.40 It assesses perceived health, functional impairment, and recent bodily pain. In the current study, only the perceived physical health item of “In general, would you say your health is…” rated on a 5-point Likert scale (1 = excellent to 5 = poor) and the bodily pain item of “How much bodily pain have you had over the past 4 weeks” rates on a 5-point Likert scale (1 = none to 5 = severe) was employed.

Inventory of depression and anxiety symptoms

The Inventory of Depression and Anxiety Symptoms is a 64-item self-report measure used to assess anxious and depressive symptoms, rated on a 5-point Likert scale from 1 (Not at all) to 5 (Extremely).44 The scale yields 10 specific symptom scales (Suicidality, Lassitude, Insomnia, Appetite Loss, Appetite Gain, Ill Temper, Well-Being, Anxious Arousal, Social Anxiety, and Traumatic Intrusions), as well as 2 global factors (General depression and Dysphoria). For the current study, the General Depression (Cronbach’s α = 0.92), Anxious Arousal (Cronbach’s α = 0.91), and Social Anxiety (Cronbach’s α = 0.87) specific symptom scales were used in the present study.

Data analysis

Analyses were conducted using the SPSS version 24. Multiple mediation analyses were conducted using the PROCESS macro.45 All models adjusted for gender, ethnicity, and substance use. Both direct and total effects for each model were reported. To detect the significance of the indirect effects, bootstrapping with 10,000 bootstrap re-samplings was conducted. Bootstrapping estimates the sampling distribution of an estimator based on re-sampling with replacement from the data set, which creates an empirically generated sampling distribution.45 A bootstrapped confidence interval that does not include zero indicates a statistically significant indirect effect.46 Effect sizes were calculated using percent mediation (PM), which indicates the percent of the total effect that can be accounted for by the indirect effect.47,48 Little’s Missing Completely at Random test revealed a nonsignificant result, suggesting that the data were missing at random (p = .813). Analyses were conducted using listwise deletion for missing data.

Results

Demographics

Descriptive statistics and correlations between variables are shown in Table 1. Of note, worry and rumination scores were both significantly correlated with pain intensity, as well as depression, social anxiety, and anxious arousal symptoms. Additionally, drug use was significantly correlated with depression scores, whereas alcohol use was significantly associated with anxious arousal and social anxiety symptoms. Worry and rumination were significantly correlated with each other.

Table 1.

Bivariate correlations and descriptive statistics.

1 2 3 4 5 6 7 8 M (SD) or %
1. Gender (female) 1 79.9%
2. Race/ethnicity 0.003 1
3. Substance use 0.047 0.019 1 60.5 %
4. Rumination 0.026 0.035 0.034 1 45.88 (15.62)
5. Worry .195** −.072** .066** .494** 1 35.33 (10.69)
6. Pain intensity .057* 0.034 0.042 .171** .139** 1 7.93 (5.63)
7. Depression −0.001 0.047 0.029 .646** .441** .241** 1 46.77 (14.22)
8. Social anxiety −0.029 0.001 −.076** .490** .337** .160** .667** 1 10.01 (4.74)
9. Anxious arousal −0.011 0.027 −0.046 .393** .166** .231** .623** .668** 12.35 (5.77)
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Note. Ruminative Responses Scale: Rumination; Penn State Worry Questionnaire: Worry; Graded Chronic Pain Scale; Pain Intensity; Inventory of Depression and Anxiety Symptoms: Depression, Social Anxiety, Anxious Arousal.

*

Indicates p < .05

**

indicated p < .01.

Multiple mediation

See Table 2 for full mediation results.

Table 2.

Multiple mediation models.

Y Model B SE t p LLCI ULCI
1 Pain Intensity → Rumination (a1) 0.48 0.07 6.71 <.001 0.34 0.62
Pain Intensity → Worry (a2) 0.24 0.05 4.94 <.001 0.14 0.33
Rumination → Depression (b1) 0.50 0.02 24.36 <.001 0.46 0.54
Worry → Depression (b2) 0.22 0.03 7.42 <.001 0.16 0.28
Pain Intensity → Depression (c) 0.63 0.06 9.77 <.001 0.50 0.75
Pain Intensity → Depression (c′) 0.34 0.05 6.79 <.001 0.24 0.44
Pain Intensity → Rumination → Depression (a1*b) 0.24 0.04 — — 0.16 0.32
Pain Intensity → Worry → Depression (a2*b) 0.05 0.01 — — 0.03 0.08
2 Rumination → Social Anxiety (b1) 0.12 0.01 15.87 <.001 0.11 0.14
Worry → Social Anxiety (b2) 0.06 0.01 5.35 <.001 0.04 0.08
Pain Intensity → Social Anxiety (c) 0.14 0.02 6.55 <.001 0.10 0.18
Pain Intensity → Social Anxiety (c′) 0.07 0.02 3.53 .004 0.03 0.10
Pain Intensity → Rumination → Social Anxiety (a1*b) 0.06 0.01 — — 0.04 0.08
Pain Intensity → Worry → Social Anxiety (a2*b) 0.01 0.004 — — 0.01 0.02
3 Rumination → Panic (b1) 0.14 0.01 14.13 <.001 0.12 0.16
Worry → Panic (b2) −0.02 0.01 −1.57 >.05 −0.05 0.01
Pain Intensity → Panic (c) 0.24 0.03 9.40 <.001 0.19 0.29
Pain Intensity → Panic (c′) 0.18 0.02 7.42 <.001 0.13 0.23
Pain Intensity → Rumination → Panic (a1*b) 0.07 0.01 — — 0.05 0.09
Pain Intensity → Worry → Panic (a2*b) −0.01 0.003 — — −0.01 0.001
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Note. a: Effects of X on M; b: effects of M on Y; c: total effect of X on Y; c′: direct effect of X on Yi controlling for M; Path a is consistent in all models; therefore, it presented only in model 1. Pain intensity the predictor; Rumination and Worry the mediator variables; Depression, Social Anxiety, and Panic, the outcome variables in models 1–3, respectively. LLCI lower bound of a 95% confidence interval; ULCI upper bound; → affects. The indirect effect (a*b) is the product of path a and path b. Bolded values are statistically significant. Gender, race/ethnicity, and substance use were covariates.

Depression

In predicting depression, there was a significant total effect of pain intensity (B = 0.63, SE = 0.06, p < .001). Additionally, there was a significant indirect effect of pain intensity through rumination (B = 0.24, SE = 0.04, 95% Bootstrapped CI [0.16, 0.32], PM = 0.38) and worry (B = 0.05, SE = 0.01, 95% Bootstrapped CI [0.03, 0.08], PM = 0.08) for depression. After controlling for the effects of worry and rumination, there was a significant direct effect of pain intensity in relation to depression (B = 0.34, SE = 0.05, p <.001).

Social anxiety

For social anxiety, there was a significant total effect of pain intensity (B = 0.14, SE = 0.02, p < .001). Additionally, there was a significant indirect effect of pain intensity through both rumination (B = 0.06, SE = 0.01, 95% Bootstrapped CI [0.04, 0.08], PM = 0.42) and worry (B = 0.01, SE = 0.004, 95% Bootstrapped CI [0.01, 0.02], PM = 0.10) in regard to social anxiety. There was a significant direct effect of pain intensity in terms of social anxiety (B = 0.07, SE = 0.02 p = .004).

Anxious arousal

In predicting anxious arousal, there was a significant total effect of pain intensity (B = 0.24, SE = 0.03, p < .001). There was a significant indirect effect of pain intensity through rumination (B = 0.07, SE = 0.01, 95% Bootstrapped CI [0.05, 0.09], PM = 0.28) in terms of anxious arousal; no effect was evident for worry (B = −0.01, SE = 0.004, 95% Bootstrapped CI [−0.01, 0.001]). A significant direct effect of pain intensity was evident in regard to anxious arousal (B = 0.18, SE = 0.02 p < .001).

Discussion

Despite empirical evidence that college students report elevated pain4 and mental health problems,9 there is little understanding as to mechanisms underlying associations between pain intensity and anxiety/depressive symptoms among this population. The present investigation sought to begin to address this clinically important gap in the extant literature by exploring the simultaneous role of worry and rumination in the relation between pain experience and some of the most common and disabling emotional symptoms among a sample of college students.

As hypothesized, results indicated that worry and rumination both significantly partially explained the relationship between pain intensity, depression, and social anxiety. However, in contrast to prediction, only rumination was a significant mediator of the association between pain intensity and anxious arousal. Although results indicated that the effect sizes for rumination were larger than worry for both depressive and social anxiety symptoms, both were independently important in explaining unique variance in the dependent variables. Moreover, in all models, significant indirect effects were evident above and beyond the variance accounted for by gender, race/ethnicity, and current substance use. These results are broadly in line with previous work documenting relations between worry28 and rumination36 in terms of pain experience.

The present findings uniquely add to a larger literature on worry and rumination and their linkages to negative emotional symptoms and disorders20,34 by documenting the constructs as potential explanatory factors in the relation between the experience of pain and anxiety and depressive symptoms among college students. Specifically, college students with greater pain intensity may be at an increased risk of experiencing more severe and disabling anxiety and depressive symptoms, in part because they have greater tendencies to ruminate and worry about aversive mood states, sustaining and prolonging their negative emotions.23 These results additionally add to the literature among college students by providing novel assessment and intervention targets for problems commonly reported in this population. Although the precise processes by which these explanatory paths work was not tested, past work would suggest numerous possible routes, including rumination-related activation of memories, impaired problem solving, information processing biases,49,50 worry-related threat potentiation, and impaired self-efficacy.51 For example, a college-aged young adult who ruminates more about their pain experience may be especially prone to depressive, social anxiety, and anxious arousal symptoms. Likewise, young adults in pain who have a greater propensity to worry, and therefore sustain negative affect states,52 may be more likely to experience severe depressive and social anxiety symptoms. Based upon the present work, additional research is needed to explore the inferred mediational pathway using longitudinal designs so as to clarify the processes by which rumination and worry contribute to the pain intensity-anxiety/depressive symptoms relation.

Clinically, the present findings suggest that it may be helpful to address rumination and worry among college students reporting co-occurring pain, anxiety, and depression to improve mental health. Importantly, past research suggests that college students seek out health and mental health care on campus,53-55 suggesting that healthcare providers on college campuses should be made aware of the interplay of physical and mental health conditions. Specifically, it may be advisable to develop tailored psychosocial interventions that can modulate ruminative response styles or tendencies to worry among young adults who endorse more intense pain. For example, Mindfulness-Based Stress Reduction56 and Acceptance and Commitment Therapy57 have each shown promise in reducing worry/rumination. These treatments may be particularly applicable to college campuses, as research suggests that implanting evidenced-based practice into college healthcare may improve overall health outcomes.55 The development of specialized treatments to specifically target worry and rumination in the context of pain may be of public health importance in terms of reducing the negative impact of pain intensity on mental health outcomes.

The current investigation has several limitations that warrant comment. First, the data collected were crosssectional, preventing claims regarding causality or temporal precedence. Longitudinal investigations should be conducted to further corroborate and extend these findings. Second, although the sample reported experiencing current pain, they were not a clinical pain sample. Future work should replicate these findings in a population with clinical pain disorders. Additionally, by design, the current study focused on young adults with pain, but it may be useful to evaluate the generalizability to other age ranges. Third, the present sample was largely female, and future work should evaluate test these models in samples with more balanced gender distributions. Fourth, although we focused on mental health symptoms that are clinically-relevant to college students and individuals who experience pain,38,39 future work may benefit from examining worry and rumination in the relation to other outcomes such as opioid misuse, pain-related disability, and life impairment. For example, future work may benefit from exploring the explanatory role of worry and rumination in the relation between pain intensity and opioid misuse, pain-related disability, and life impairment. Additionally, it may be useful to assess the presence/severity of clinical psychiatric disorders, rather than symptoms, to better gauge the utility of the present model to comorbid psychopathology.

Overall, the current study provides novel empirical evidence that worry and rumination may each help to explain the relationship between pain intensity and anxiety/depressive symptoms among a large and diverse sample of college students. Future work is needed to explore the extent to which college students in pain may benefit from targeted psychosocial strategies aimed at decreasing worry and ruminative response styles, with the ultimate goal of improving pain-related mental health disparities among this high-risk group.

Footnotes

Conflict of interest disclosure

The authors have no conflicts of interest to report. The authors confirm that the research presented in this article met the ethical guidelines, including adherence to the legal requirements, of the United States and received approval from the Institutional Review Board of the University of Houston.

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