International Journal of Behavioral Medicine

, Volume 22, Issue 2, pp 197–205 | Cite as

The German PASS-20 in Patients with Low Back Pain: New Aspects of Convergent, Divergent, and Criterion-Related Validity

  • Nina Kreddig
  • Adina C. Rusu
  • Katja Burkhardt
  • Monika I. HasenbringEmail author



The PASS-20 (McCracken and Dhingra, Pain Res Manag 7:45−50, 2002) is a shortened version of the Pain Anxiety Symptoms Scale (PASS), a self-report measure of pain anxiety. The PASS-20 demonstrates good psychometric characteristics but has not yet been validated in a German population.


The aims of the present study were to (1) examine the factor structure and psychometric characteristics of the German PASS-20; (2) investigate its construct validity with respect to depression, fear-avoidance, and endurance; and (3) determine its criterion-related validity with a special emphasis on pain, disability, and quality of life.


A principal component analysis was performed on a sample (N = 195) of patients with acute, subacute, and chronic low back pain. Reliability was examined with Cronbach’s α. Validity was assessed by correlating the PASS-20 to measures of depression, anxiety, disability, quality of life, and avoidance-endurance-related behavioral pain responses.


The original four-factor structure proposed for the PASS-20 was replicated using the original subscale labels. The reliability of the total score and the subscales was satisfactory to excellent, and both convergent and divergent validity were moderate to high in the expected directions, showing positive correlations with anxiety, fear, depression, and fear-avoidance and negative correlations with endurance and quality of life. The PASS-20 showed unique predictive ability and advantages over the Tampa Scale of Kinesiophobia.


The results for the German PASS-20 support the original factor structure and provide evidence of satisfactory psychometric characteristics and usefulness in patients with low back pain.


Pain anxiety Avoidance Endurance Back pain Assessment Disability Quality of life 



This study was supported by a research grant from the German Research Foundation (DFG: HA 1684) awarded to MIH.

Ethical Standards

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all patients included in the study.

Conflict of Interest

Authors Kreddig, Burkhardt, Rusu, and Hasenbring declare that they have no conflict of interest.


  1. 1.
    Liebers F, Brendler C, Latza U. Age- and occupation-related differences in sick leave due to frequent musculoskeletal disorders, low back pain and knee osteoarthritis. Bundesgesundheitsbl Gesundheitsforsch Gesundheitsschutz. 2013;56(3):367–80.CrossRefGoogle Scholar
  2. 2.
    Hallner D, Hasenbring M. Classification of psychosocial risk factors (yellow flags) for the development of chronic low back and leg pain using artificial neural network. Neurosci Lett. 2004;361(1–3):151–4.CrossRefPubMedGoogle Scholar
  3. 3.
    Hasenbring MI, Verbunt JA. Fear-avoidance and endurance-related responses to pain: new models of behavior and their consequences for clinical practice. Clin J Pain. 2010;26(9):747–53.CrossRefPubMedGoogle Scholar
  4. 4.
    Scholich SL, Hallner D, Wittenberg RH, Hasenbring MI, Rusu AC. The relationship between pain, disability, quality of life and cognitive-behavioural factors in chronic back pain. Disabil Rehabil. 2012;34(23):1993–2000.CrossRefPubMedGoogle Scholar
  5. 5.
    Crombez G, Vlaeyen JW, Heuts PH, Lysens R. Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability. Pain. 1999;80(1–2):329–39.CrossRefPubMedGoogle Scholar
  6. 6.
    McCracken LM, Gross RT, Aikens J, Carnrike Jr CL. The assessment of anxiety and fear in persons with chronic pain: a comparison of instruments. Behav Res Ther. 1996;34(11–12):927–33.CrossRefPubMedGoogle Scholar
  7. 7.
    McCracken LM, Zayfert C, Gross RT. The Pain Anxiety Symptoms Scale: development and validation of a scale to measure fear of pain. Pain. 1992;50(1):67–73.CrossRefPubMedGoogle Scholar
  8. 8.
    Lundberg M, Grimby-Ekman A, Verbunt J, Simmonds MJ. Pain-related fear: a critical review of the related measures. Pain Res Treat. 2011. doi: 10.1155/2011/494196.PubMedCentralPubMedGoogle Scholar
  9. 9.
    McCracken LM, Dhingra L. A short version of the Pain Anxiety Symptoms Scale (PASS-20): preliminary development and validity. Pain Res Manag. 2002;7(1):45–50.PubMedGoogle Scholar
  10. 10.
    Abrams MP, Carleton RN, Asmundson GJ. An exploration of the psychometric properties of the PASS-20 with a nonclinical sample. J Pain. 2007;8(11):879–86.CrossRefPubMedGoogle Scholar
  11. 11.
    Coons MJ, Hadjistavropoulos HD, Asmundson GJ. Factor structure and psychometric properties of the Pain Anxiety Symptoms Scale-20 in a community physiotherapy clinic sample. Eur J Pain. 2004;8(6):511–6.CrossRefPubMedGoogle Scholar
  12. 12.
    Roelofs J, McCracken L, Peters ML, et al. Psychometric evaluation of the Pain Anxiety Symptoms Scale (PASS) in chronic pain patients. J Behav Med. 2004;27(2):167–83.CrossRefPubMedGoogle Scholar
  13. 13.
    Burns JW, Mullen JT, Higdon LJ, Wei JM, Lansky D. Validity of the pain anxiety symptoms scale (PASS): prediction of physical capacity variables. Pain. 2000;84(2–3):247–52.CrossRefPubMedGoogle Scholar
  14. 14.
    Cho S, Lee SM, McCracken LM, Moon DE, Heiby EM. Psychometric properties of a Korean version of the Pain Anxiety Symptoms Scale-20 in chronic pain patients. Int J Behav Med. 2010;17(2):108–17.CrossRefPubMedGoogle Scholar
  15. 15.
    Leeuw M, Goossens MLEJB, Linton SJ, et al. The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med. 2006;30(1):77–94.CrossRefPubMedGoogle Scholar
  16. 16.
    Asmundson GJG, Parkerson HA, Petter M, Noel M. What is the role of fear and escape/avoidance in chronic pain? Model, structural analysis and future directions. Pain Manag. 2012;2(3):295–303.CrossRefPubMedGoogle Scholar
  17. 17.
    Crombez G, Eccleston C, Van Damme S, Vlaeyen JWS, Karoly P. Fear-avoidance model of chronic pain the next generation. Clin J Pain. 2012;28(6):475–83.CrossRefPubMedGoogle Scholar
  18. 18.
    Vlaeyen JW, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;85(3):317–32.CrossRefPubMedGoogle Scholar
  19. 19.
    Hasenbring MI, Hallner D, Klasen B, et al. Pain-related avoidance versus endurance in primary care patients with subacute back pain: psychological characteristics and outcome at a 6-month follow-up. Pain. 2012;153(1):211–7.CrossRefPubMedGoogle Scholar
  20. 20.
    Hasenbring MI, Plaas H, Fischbein B, Willburger R. The relationship between activity and pain in patients 6 months after lumbar disc surgery: do pain-related coping modes act as moderator variables? Eur J Pain. 2006;10(8):701–9.CrossRefPubMedGoogle Scholar
  21. 21.
    Brislin R. Back translation for cross-cultural research. J Cross-Cult Psychol. 1970;14(3):185–216.CrossRefGoogle Scholar
  22. 22.
    Bullinger M, Alonso J, Apolone G, Leplege A, Sullivan M, Wood-Dauphinee S, et al. Translating health status questionnaires and evaluating their quality: the IQOLA Project approach. J Clin Epidemiol. 1998;51(11):913–23.CrossRefPubMedGoogle Scholar
  23. 23.
    Kori SH, Miller RP, Todd DD. Kinesiophobia: a new view of chronic pain behavior. Pain Manag. 1990;3:35–43.Google Scholar
  24. 24.
    Rusu AC, Kreddig N, Hallner D, Hülsebusch J, Hasenbring MI. Fear of movement/(re)injury in chronic low back pain: validation of a German version of the Tampa Scale for Kinesiophobia with special focus on fear-avoidance and endurance. Manuscript submitted for publicationGoogle Scholar
  25. 25.
    Hasenbring MI, Hallner D, Rusu AC. Fear-avoidance- and endurance-related responses to pain: development and validation of the Avoidance-Endurance Questionnaire (AEQ). Eur J Pain. 2009;13(6):620–8.CrossRefPubMedGoogle Scholar
  26. 26.
    Pollard CA. Preliminary validity study of the Pain Disability Index. Percept Mot Skills. 1984;59:974.CrossRefPubMedGoogle Scholar
  27. 27.
    Dillmann U, Nilges P, Saile H, Gerbershagen HU. Behinderungseinschätzung bei chronischen Schmerzpatienten. Schmerz. 1994;8:100–10.CrossRefPubMedGoogle Scholar
  28. 28.
    Fairbank JC, Couper J, Davies JB. The Oswestry Low Back Pain Questionnaire. Physiotherapy. 1980;66:271–3.PubMedGoogle Scholar
  29. 29.
    Mannion AF, Junge A, Fairbank JC, Dvorak J, Grob D. Development of a German version of the Oswestry Disability Index. Part 1: cross-cultural adaptation, reliability, and validity. Eur Spine J. 2006;15(1):55–65.CrossRefPubMedCentralPubMedGoogle Scholar
  30. 30.
    Zale EL, Lange KL, Fields SA, Ditre JW. The relation between pain-related fear and disability: a meta-analysis. J Pain. 2013;14(10):1019–30.CrossRefPubMedCentralPubMedGoogle Scholar
  31. 31.
    EuroQol Group. EuroQol—a new facility for the measurement of health-related quality of life. Health Policy. 1990;16:199–208.CrossRefGoogle Scholar
  32. 32.
    Stark RG, Reitmeir P, Leidl R, König HH. Validity, reliability, and responsiveness of the EQ-5D in inflammatory bowel disease in Germany. Inflamm Bowel Dis. 2010;16:42–51.CrossRefPubMedGoogle Scholar
  33. 33.
    Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4(6):561–71.CrossRefPubMedGoogle Scholar
  34. 34.
    Kammer D. Eine Untersuchung der psychometrischen Eigenschaften des deutschen Beck-Depressionsinventars (BDI). Diagnostica. 1983;29:48–60.Google Scholar
  35. 35.
    Radloff LS. The CES-D scale: a self report depression scale for research in the general population. Appl Psychol Meas. 1977;1:385–401.CrossRefGoogle Scholar
  36. 36.
    Hautzinger M, Bailer M. Allgemeine Depressions Skala. Manual. Göttingen: Beltz Test GmbH; 1993.Google Scholar
  37. 37.
    Tabachnik BG, Fidell LS. Using multivariate statistics. Needham Heights: Allyn & Bacon; 2001.Google Scholar
  38. 38.
    Costello AB, Osborne JW. Best practices in exploratory factor analysis: four recommendations for getting the most from your analysis. PARE. 2005;10(7):1–9.Google Scholar
  39. 39.
    Cohen J. Statistical power analysis for the behavioral sciences. Hillsdale: Lawrence Erlbaum Associates; 1988.Google Scholar
  40. 40.
    Mounce C, Keogh E, Eccleston C. A principal components analysis of negative affect-related constructs relevant to pain: evidence for a three component structure. J Pain. 2010;11(8):710–7.CrossRefPubMedGoogle Scholar
  41. 41.
    Carleton RN, Asmundson GJ. The multidimensionality of fear of pain: construct independence for the Fear of Pain Questionnaire-Short Form and the Pain Anxiety Symptoms Scale-20. J Pain. 2009;10(1):29–37.CrossRefPubMedGoogle Scholar
  42. 42.
    Barlow DH, Chorpita BF, Turovsky J. Fear, panic, anxiety and disorders of emotion. Neb Symp Motiv. 1996;43:251–328.Google Scholar
  43. 43.
    Coste J, Bouée S, Ecosse E, Leplège A, Pouchot J. Methodological issues in determining the dimensionality of composite health measures using principal component analysis: case illustration and suggestions for practice. Qual Life Res. 2005;14(3):641–54.CrossRefPubMedGoogle Scholar
  44. 44.
    Wong WS, McCracken LM, Fielding R. Factor structure and psychometric properties of the Chinese version of the 20-item Pain Anxiety Symptoms Scale (ChPASS-20). J Pain Symptom Manag. 2012;43(6):1131–40.CrossRefGoogle Scholar
  45. 45.
    Osman A, Barrios FX, Osman JR, Schneekloth R, Troutman JA. The Pain Anxiety Symptoms Scale: psychometric properties in a community sample. J Behav Med. 1994;17(5):511–22.CrossRefPubMedGoogle Scholar
  46. 46.
    Kline P. The handbook of psychological testing. 2nd ed. London: Routledge; 1999.Google Scholar
  47. 47.
    Loewenthal KM. An introduction to psychological tests and scales. 2nd ed. London: Psychology Press; 2001.Google Scholar
  48. 48.
    Asmundson GJ, Norton GR, Allerdings MD. Fear and avoidance in dysfunctional chronic back pain patients. Pain. 1997;69(3):231–6.CrossRefPubMedGoogle Scholar
  49. 49.
    Wegner DM, Schneider DJ, Carter SRIII, White TL. Paradoxical effects of thought suppression. J Pers Soc Psychol. 1987;53:636–47.CrossRefGoogle Scholar
  50. 50.
    Kovacs FM, Abraira V, Zamora J, Teresa Gil del Real M, Llobera J, Fernández C, et al. Correlation between pain, disability, and quality of life in patients with common low back pain. Spine. 2004;29:206–10.CrossRefPubMedGoogle Scholar

Copyright information

© International Society of Behavioral Medicine 2014

Authors and Affiliations

  • Nina Kreddig
    • 1
  • Adina C. Rusu
    • 1
    • 2
  • Katja Burkhardt
    • 1
  • Monika I. Hasenbring
    • 1
    Email author
  1. 1.Department of Medical Psychology and Medical Sociology, Faculty of MedicineRuhr-University of BochumBochumGermany
  2. 2.Department of PsychologyRoyal Holloway University of LondonEghamUK

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