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. Author manuscript; available in PMC: 2022 Mar 1.
Published in final edited form as: Psychol Health Med. 2020 May 12;26(3):289–297. doi: 10.1080/13548506.2020.1764598

Pain Intensity, Pain-Related Anxiety, and Somatic and Mental Health Symptoms: A Test among Latinx Young Adults

Michael J Zvolensky a,b,c, Brooke Y Kauffman a, Justin M Shepherd a, Daniel Bogiaizian d, Jafar Bakhshaie a, Andres G Viana a,e, Natalia Peraza a, Pamella Nizio a
PMCID: PMC7657961  NIHMSID: NIHMS1595906  PMID: 32393057

Abstract

Latinx individuals demonstrate significant pain-related health disparities compared to other racial/ethnic groups. Moreover, young adulthood (18–25 years of age) is a primary developmental window wherein pain-related health problems are first encountered and may be related to more severe somatic and mental health symptoms. Pain-related anxiety may be one mechanistic construct linking individual differences in the experience of pain intensity to poorer somatic experiences and mental health among Latinx young adults. Thus, the current study examined pain-related anxiety as an explanatory factor underlying the relationship between pain intensity and body vigilance, perceptions of health, worry, anxious arousal, and depressive symptoms among Latinx young adults. Participants included 401 Latinx young adults (Mage = 21 years; SD =2.02; age range: 18–25 years; 83% female) at a large, southwestern university. Results revealed that individual differences in pain intensity had a significant indirect effect on the studied somatic and negative affect variables through pain-related anxiety. These novel findings suggest future work should continue to explore pain-related anxiety in the association between the experience of pain and somatic and mental health among Latinx young adults.

Keywords: Pain Intensity, Pain-Related Anxiety, Somatic Health, Mental Health, Anxiety, Latinx

There has been increased recognition that Latinx persons demonstrate pain-related health disparities compared to other racial/ethnic groups (Anderson, Green, & Payne, 2009). For example, Latinx persons demonstrate greater pain sensitivity and less tolerance to an array of pain eliciting stimuli (e.g., cold) compared to non-Latinx Whites (Rahim-Williams et al., 2007). Interestingly, the vast majority of research on pain experience and its clinical correlates has thus far focused on adults and older adult populations (Hollingshead, Ashburn-Nardo, Stewart, & Hirsh, 2016). This limitation is unfortunate, as Latinx young adults represent a growing segment of the population (Stepler & Brown, 2016) and young adulthood (18–25 years of age) is a primary developmental window wherein pain-related health problems are first encountered (Katz et al., 2000; West, 1997) and subsequently persist in a chronic course (Blum, 2009).

Although pain intensity or severity may be related to more severe somatic and mental health symptoms among Latinx adults (Anderson et al., 2009; Rahim-Williams et al., 2007), there is a need to explicate the mechanisms in such relations. A promising construct to better understand the pain-somatic/mental health association is pain-related anxiety (McCracken, Zayfert, & Gross, 1992). Pain-related anxiety pertains to worry about the negative consequences of pain (McCracken et al., 1992) and is theorized to be an affect-generating individual difference factor (Zvolensky, Goodie, McNeil, Sperry, & Sorrell, 2001). Moreover, extant work has found Latinx persons tend to cope with pain by catastrophizing pain-related experiences to a greater extent than non-Latinx Whites (Edwards, Moric, Husfeldt, Buvanendran, & Ivankovich, 2005).

Theoretically, greater pain intensity among Latinx young adults may be related to greater pain-related anxiety. Worry about the potential adverse consequences of pain symptoms may then elicit greater reactivity to such perturbation (e.g., more severe symptoms) and a corresponding tendency to regulate such distress via escape or avoidance behavior (Asmundson, Norton, & Norton, 1999). This occurrence of inflexible efforts to escape/avoid pain may, in turn, contribute to health problems, including greater intensity of negative emotional symptoms (e.g., worry, anxious arousal, and depression), hypervigilance to somatic sensations, and lower perceptions of health (Peters, Vlaeyen, & Weber, 2005). This perspective suggests a potential model wherein pain-related anxiety explains, in part, the relation between pain intensity and somatic and negative affect symptoms.

Thus, the present study sought to test whether pain-related anxiety maintains an explanatory role in the relation between pain intensity and body vigilance, perceived health, worry, anxious arousal, and depression among Latinx young adults. It was hypothesized that greater levels of pain intensity would be associated with lower perceived health and greater body vigilance as well as negative emotional symptoms (worry, anxious arousal, and depression) via pain-related anxiety.

Method

Participants

The sample was comprised of 401 Latinx young adults in college (Mage = 21 years; SD =2.02; age range: 18–25 years; 83% female). Participants received extra credit towards their psychology course for participation in the study. Participants were excluded for non-proficiency in English and if they were younger than 18 years of age.

Measures

Demographic Questionnaire.

A demographic questionnaire was used to collect sociodemographic data, including gender and age.

Short-form General Health Survey (Stewart, Hays, & Ware, 1988).

The short-form general health survey is a 20-item questionnaire of health status (Stewart et al., 1988). The short-form general health survey has demonstrated adequate psychometric properties (Stewart et al., 1988). In the current study, the physical functioning subscale and health perceptions subscale were used.

Subjective Social Status (SSS; Adler, 2009).

Subjective social status was assessed with the community version of the MacArthur Scale (Adler, 2009). Respondents were presented with a picture of a 10-rung ladder and asked to rate where they believe they stand in the community, relative to others. This measure has demonstrated adequate psychometric properties (Franzini & Fernandez-Esquer, 2006; Ostrove, Adler, Kuppermann, & Washington, 2000; Reitzel, Kendzor, Cao, & Businelle, 2014).

Graded Chronic Pain Scale (GCPS; Von Korff, Ormel, Keefe, & Dworkin, 1992).

The GCPS is a 7-item self-report measure that assesses pain intensity and disability. Past work has reported acceptable psychometric properties (Von Korff, 2001). In the current study, the GCPS current pain intensity subscale was employed (α = .70).

Pain Anxiety Symptoms Scale (PASS; McCracken et al., 1992).

The PASS is a 40-item self-report measure of pain-related anxiety. The PASS total score is a reliable and valid measure (McCracken et al., 1992) and demonstrated excellent internal consistency in the present study (α=.93).

Body Vigilance Scale (BVS; Schmidt, Lerew, & Trakowski, 1997).

The BVS is a 4-item self-report measure of attentional focus to bodily sensations, perceived sensitivity to bodily sensations, and average duration of time spent attending to bodily sensations. The BVS has demonstrated adequate psychometric properties in previous work (Bernstein, Zvolensky, Sandin, Chorot, & Stickle, 2008; Schmidt et al., 1997). The BVS total score was utilized in the current study (α = .74).

Penn State Worry Questionnaire (PSWQ; Meyer, Miller, Metzger, & Borkovec, 1990).

The PSWQ is a 16-item self- report measure used to assess worry. The PSWQ has demonstrated good psychometric properties in past work (Behar, Alcaine, Zuellig, & Borkovec, 2003; Brown, Antony, & Barlow, 1992; Fresco, Mennin, Heimberg, & Turk, 2003; Meyer et al., 1990). The total PSWQ score demonstrated good internal consistency in the current study (α=.87).

Inventory of Depression and Anxiety Symptoms (IDAS; Watson et al., 2007).

The IDAS is a 64-item self-report measure that assesses affect dimensions. The IDAS subscales show strong psychometric properties in past work (Paulus et al., 2016; Watson et al., 2008; Watson et al., 2007). In the present study the anxious arousal (α = 0.91) and the general depression (α = 0.92) subscale were used as criterion variables.

Procedure

Latinx young adults recruited through an online self-report survey at a large, southwestern university. All participants completed informed consent over the internet before proceeding to the survey. This study protocol was approved by the Institutional Review Board at the University where the study took place.

Analytic Strategy

Participants were selected for the current study based on ethnicity (i.e., Latinx) and age (age ≤ 25) from a larger sample of college students (N = 1589). In all models, pain intensity served as the predictor variable, and pain-related anxiety served as the intermediary variable for the following criterion variables (Y1–5): (1) health perceptions (2) body vigilance, (3) worry, (4) anxious arousal, and (5) general depression. Covariates included age, gender, physical functioning, and subjective social status.

Analyses were conducted in the current study using bootstrapping techniques through PROCESS (Hayes, 2013). As recommended, the confidence intervals around the point-estimate were subjected to 10,000 bootstrap re-samplings and 95-percent confidence intervals (CIs) were estimated (Hayes, 2009; Preacher & Hayes, 2004, 2008). Effect sizes were calculated using percent mediation (PM; Ditlevsen, Keiding, Christensen, Damsgaard, & Lynch, 2005; Preacher & Kelley, 2011).

Results

Zero-order correlations among all study variables are presented in Table 1. Regarding health perceptions, higher reported levels of pain intensity were associated with lower reported levels of health perceptions indirectly through greater reported levels of pain-related anxiety (a*b = −0.05, SE = 0.02, CI95% = −0.086, −0.020, PM = .19; see Table 2). For body vigilance, higher reported levels of pain intensity were associated with higher reported levels of body vigilance, which occurred indirectly through the greater reported levels of pain-related anxiety (a*b = 0.04, SE = 0.01, CI95% = 0.017, 0.060, PM = .57; see Table 2). In terms of worry, higher levels of pain intensity were associated with greater reported levels of worry through greater reported levels of pain-related anxiety (a*b = 0.04, SE = 0.01, CI95% = 0.018, 0.056, PM = .40; see Table 2). For anxious arousal, higher reported levels of pain intensity were associated with higher reported levels of anxious arousal indirectly through greater reported levels of pain-related anxiety (a*b = 0.03, SE = 0.01, CI95% = 0.011, 0.048, PM = .30; see Table 2). Regarding general depression, higher reported levels of pain intensity were associated with higher reported levels of general depression, which occurred indirectly through the greater reported levels of pain-related anxiety (a*b = 0.06, SE = 0.02, CI95% = 0.027, 0.102, PM = .21; see Table 2).

Table 1.

Descriptive Statistics and Bivariate Correlations between Study Variables (N = 401)

Variable 1 2 3 4 5 6 7 8 9 10 11
1. Agea -
2. Gendera .10 -
3. Physical Functioninga −.04 −.01 -
4. SSSa −.01 −.03 .02 -
5. Pain Intensityb .06 .06 −.16** −.05 -
6. Pain-related Anxietyc .03 .08 −.10* −.01 .25*** -
7. Health Perceptionsd −.09 −.03 .27*** .17** −.32*** −.28*** -
8. Body Vigilanced .10* .01 −.10* −.10 .16** .33*** −.25*** -
9. Worryd .08 .19*** −.06 −.11* .21*** .32*** −.27*** .19*** -
10. Anxious Arousald .09 .04 −.11* −.13* .26*** .33*** −.35*** .28*** .15** -
11. General Depressiond .10* .03 −.08 −.20** .28*** .29*** −.45*** .27*** .40*** .61*** -
Mean/n (SD/%) 21.01 (2.01) 333 (83%) 93.35 (16.93) 5.83 (1.79) 9.63 (12.96) 61.68 (30.72) 64.91 (12.84) 12.08 (6.24) 60.25 (7.08) 11.31 (5.25) 43.20 (13.84)
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Note.

***

p < .001,

**

p < .01,

*

p < .05.

a

Covariate;

b

Predictor;

c

Intermediary variable;

d

Criterion;

Gender: % listed as females (Coded: 0 = male and 1 = female); Physical Functioning = Short-form General Health Survey-Physical Functioning subscale (Stewart et al., 1988); SSS = Subjective Social Status-Community Subscale (Adler, 2009); Pain Intensity = Graded Chronic Pain Scale-Pain Intensity subscale (Von Korff et al., 1992); Pain-related Anxiety = Pain Anxiety Symptoms Scale (McCracken et al., 1992); Health Perceptions = Short-form General Health Survey-Health Perceptions subscale (Stewart et al., 1988); Body Vigilance = Body Vigilance Scale (Schmidt et al., 1997); Worry = Penn State Worry Questionnaire (Meyer et al., 1990); Anxious arousal = Inventory of Depression and Anxiety Symptoms-Anxious Arousal subscale (Watson et al., 2007); General Depression = Inventory of Depression and Anxiety Symptoms-General Depression subscale (Watson et al., 2007).

Table 2.

Indirect Effect of Pain Intensity on Health Perceptions, Body Vigilance, Worry, Anxious Arousal, and General Depression via Pain-related Anxiety.

Y Path R2 b SE t p CI (l) CI (u)
1 Pain Intensity → Pain-related Anxiety (a) .07*** 0.55 0.12 4.70 < .001 0.319 0.779
Pain-related Anxiety → Health Perceptions (b) .22*** −0.08 0.02 −4.35 < .001 −0.122 −0.046
Pain Intensity → Health Perceptions (c’) −0.23 0.05 −4.88 < .001 −0.317 −0.135
Pain Intensity → Health Perceptions (c) .07*** −0.27 0.05 −5.91 < .001 −0.363 −0.182
Pain Intensity → Pain-related Anxiety → Health Perceptions (a*b) −0.05 0.02 −0.086 −0.020
2 Pain-related Anxiety → Body Vigilance (b) .14*** 0.06 0.01 6.43 < .001 0.044 0.083
Pain Intensity → Body Vigilance (c’) 0.03 0.02 1.29 .198 −0.016 0.077
Pain Intensity → Body Vigilance (c) .05*** 0.07 0.02 2.71 .007 0.018 0.112
Pain Intensity → Pain-related Anxiety → Body Vigilance (a*b) 0.04 0.01 0.017 0.060
3 Pain-related Anxiety → Worry (b) .16*** 0.06 0.01 5.73 < .001 0.042 0.085
Pain Intensity → Worry (c’) 0.07 0.03 2.56 .011 0.016 0.120
Pain Intensity → Worry (c) .09*** 0.10 0.03 3.83 < .001 0.050 0.155
Pain Intensity → Pain-related Anxiety → Worry (a*b) 0.04 0.01 0.018 0.056
4 Pain-related Anxiety → Anxious Arousal (b) .16*** 0.05 0.01 5.85 < .001 0.032 0.064
Pain Intensity → Anxious Arousal (c’) 0.07 0.02 3.62 < .001 0.032 0.109
Pain Intensity → Anxious Arousal (c) .09*** 0.10 0.02 4.89 < .001 0.058 0.136
Pain Intensity → Pain-related Anxiety → Anxious Arousal (a*b) 0.03 0.01 0.011 0.048
5 Pain-related Anxiety → General Depression (b) .17*** 0.10 0.02 4.87 < .001 0.062 0.147
Pain Intensity → General Depression (c’) 0.22 0.05 4.32 < .001 0.121 0.322
Pain Intensity → General Depression (c) .12*** 0.28 0.05 5.44 < .001 0.178 0.380
Pain Intensity → Pain-related Anxiety → General Depression (a*b) 0.06 0.02 0.027 0.102
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Note.

***

p < .001,

**

p < .01,

*

p < .05.

Path a is equal in all cases Y1–5; therefore, it is presented only once to avoid redundancies. N for analyses is 401 cases. The standard error and 95% CI for the indirect effects (a*b) are obtained through bootstrapping with 10,000 re-samples. a path = Effect of X on M; b paths = Effect of M on Yi; c’ paths = Direct effect of X on Yi controlling for M; c paths = Total effect of X on Yi. Pain Intensity = Graded Chronic Pain Scale-Pain Intensity subscale (Von Korff et al., 1992); Pain-related Anxiety = Pain Anxiety Symptoms Scale (McCracken et al., 1992); Health Perceptions = Short-form General Health Survey-Health Perceptions subscale (Stewart et al., 1988); Body Vigilance = Body Vigilance Scale (Schmidt et al., 1997); Worry = Penn State Worry Questionnaire (Meyer et al., 1990); Anxious arousal = Inventory of Depression and Anxiety Symptoms-Anxious Arousal subscale (Watson et al., 2007); General Depression = Inventory of Depression and Anxiety Symptoms-General Depression subscale (Watson et al., 2007). Covariates included age, gender, physical functioning, and subjective social status.

Discussion

In the current study, greater pain intensity was related to increased pain-related anxiety, which in turn, was related to lower perceptions of health and increased levels of body vigilance, worry, anxious arousal, and depression among Latinx young adults. Such results are broadly in line with past work that found pain-related anxiety explained, in part, the relationship between pain severity and mental health and disability among non-Latinx Whites (Rogers, Bakhshaie, Zvolensky, & Vowles, 2019; Vowles, Zvolensky, Gross, & Sperry, 2004) and extends this work to a sample of Latinx young adults.

Clinically, it may be beneficial to understand and clinically address pain-related anxiety in the context of pain experience to enhance resiliency in relation to perceptions of health, body vigilance, and anxiety/depressive symptoms. There are evidenced-based psychosocial programs among non-Latinx Whites that have shown reducing pain-related anxiety is related to improved mental and physical health (e.g., Acceptance and Commitment Therapy; Vowles & McCracken, 2008; Vowles, Wetherell, & Sorrell, 2009). Thus, there may be utility in exploring the relevance of reducing pain-related anxiety via these therapeutic approaches or further culturally adapting them to the Latinx population.

There are some study limitations that are important to note. First, the data were cross-sectional in nature, and therefore, did not permit testing of temporal sequencing. Second, there is the possibility that the noted relations may be observed, in part, because of shared method variance. Future studies may benefit from implementing a multi-method assessment approach. Finally, 83% of the sample were female. Future studies may benefit from sampling a larger pool of males to ensure generalizability of the results across gender.

To our knowledge, the current study provides the first empirical test of pain-related anxiety as a mechanistic construct linking individual differences in the experience of pain intensity, among Latinx young adults, to poorer somatic experiences and mental health. Future work is needed to explore the extent to which pain-related anxiety accounts for relations between pain intensity and other health-related problems commonly associated with pain problems (e.g., fatigue, obesity) among Latinx young adults to advance pain-related health disparity models among this underserved population.

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