ARTICLE IN PRESS JID: YJPMN [mNS;February 26, 2024;14:25] Pain Management Nursing xxx (xxxx) xxx Contents lists available at ScienceDirect Pain Management Nursing journal homepage: www.painmanagementnursing.org Original Research Experiential Avoidance as a Factor in Generalized Psychological Vulnerability: In the Relationship Between Chronic Pain and Pain Anxiety With Pain Disability Razieh Pak, Ph.D. *,1 , Majid Mahmoud Alilou, Ph.D. † , Abass Bakhshipour Roudsari, Ph.D. † , Fatemeh Yousefpour, M.A. (Psychology) ‡ * Faculty of Education and Psychology, University of Tabriz, Tabriz, Iran † Department of Psychology, Faculty of Psychology and Educational Sciences, University of Tabriz, Tabriz, Iran ‡ Faculty of Education and Psychology, Persian Gulf University, Bandar Bushehr, Iran a r t i c l e i n f o Article history: Received 23 September 2023 Received in revised form 4 January 2024 Accepted 28 January 2024 Available online xxx a b s t r a c t Background: Pain is a major socio-psychological problem worldwide. Chronic pain has a negative effect on areas of psychological functioning such as depression, anxiety, and perceived stress. Aim: The present study investigated the mediating role of experiential avoidance in the relationship between chronic pain and pain anxiety with pain disability. Methods: Participants were treatment-seeking patients (N = 361) at an outpatient pain clinic in Shiraz (Fars, Iran). The Multidimensional Pain Inventory (MPI), Pain Anxiety Symptom Scale (PASS-20), Pain Dis- ability Questionnaire (PDQ), and Acceptance and Action Questionnaire-II (AAQ-II) were used to measure multidimensional pain, anxiety, pain disability, experiential avoidance, and pain severity. Results: The results of the correlation revealed that a significant relationship exists between multidimen- sional pain and pain anxiety, pain disability, and experiential avoidance. Experiential avoidance mediated the associations from multidimensional pain and pain disability significantly. Also, experiential avoid- ance moderated associations between pain anxiety and pain disability significantly. In general, Structural Equation Modeling (SEM) showed that experiential avoidance mediated the relationship between multi- dimensional pain and pain anxiety with pain disability. Conclusion: In general, the results revealed that experiential avoidance can mediate the relationship among pain, pain anxiety, and pain disability as a maladaptive regulation strategy. The results obtained from this study seem to introduce experiential avoidance as a vulnerability factor effectively. © 2024 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved. Introduction Chronic pain refers to a pain that persists for three months or more sporadically or continuously (Cohen et al., 2013). It is esti- mated that 20% of people experience some form of chronic pain. Chronic pain causes a great deal of mental stress and strain on in- dividuals and the health care system (Goldberg & McGee, 2011). Beyond the sensory and emotional experience of pain, patients with chronic pain are three times more likely to develop anxiety than the general population (Goldenberg, 2010; Tsang et al., 2008). Anxiety is defined as an emotional stress-induced reaction. Therefore, anxiety is introduced as a perceived emotional ex- perience with a particular content (Folkman & Lazarus, 1985). According to the theoretical literature, the interaction of key 1 Address correspondence to: Razieh Pak, Ph.D., University of Tabriz, Tabriz, Iran. E-mail address: pak_r@tabrizu.ac.ir (R. Pak). psychological factors such as fear, catastrophizing, and pain-related anxiety leads to depression and disability which, in turn, result in pain persistence (Fisher et al., 2018). Pain anxiety is described as a pervasive and future-oriented emotional state (Carleton & As- mundson, 2009). Behaving anxiously in the context of chronic pain calls for a number of unhelpful responses such as greater disabil- ity (McCracken et al., 1992), less coping with pain (McCracken & Gross, 1993), frequent pain behavior and help seeking (McCracken et al., 1996), and more reports of a wide range of physical com- plaints (McCracken et al., 1998). Pain anxiety is also a stronger predictor of disability compared to pain severity (McCracken et al., 1992). Experiential literature (e.g., Benore et al., 2015; Kaczynski et al., 2011; Keogh et al., 2010; McCracken et al., 1992; Meredith et al., 2006) state that there is a relationship between pain anx- iety and pain disability so that reducing anxiety can significantly predict functional ability, and pain anxiety is considered as a stronger predictor of disability in comparison to pain intensity. https://doi.org/10.1016/j.pmn.2024.01.007 1524-9042/© 2024 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved. Please cite this article as: R. Pak, M. Mahmoud Alilou, A. Bakhshipour Roudsari et al., Experiential Avoidance as a Factor in Generalized Psychological Vulnerability: In the Relationship Between Chronic Pain and Pain Anxiety With Pain Disability, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2024.01.007