Pain Anxiety Symptoms Scale
Pain Anxiety Symptoms Scale (PASS) · Also known as: PASS, Anxiety Symptoms Scale
The Pain Anxiety Symptoms Scale (PASS) is a 20-item self-report instrument developed by Asmundson and colleagues in 1996 to measure anxiety symptoms specifically related to pain. The PASS captures fear of pain, avoidance behaviors, cognitive anxiety, and physiological anxiety responses that commonly accompany chronic pain and contribute to disability through fear-avoidance mechanisms.
Read the full method
Sign in with a free account to read this section.
Method map
The neighbourhood of related methods — select a node to explore.
When to use it
The PASS is indicated for assessment of chronic pain patients to measure pain-specific anxiety and identify fear-avoidance patterns. It is particularly useful for identifying patients at high risk for disability through anxiety-driven avoidance (PASS ≥50), selecting candidates for exposure-based cognitive-behavioral therapy or fear-avoidance rehabilitation, monitoring progress during fear extinction or exposure therapy, and research investigating anxiety's role in pain chronicity. The PASS complements general anxiety measures by focusing specifically on pain-related rather than generalized anxiety.
Strengths & limitations
- Measures pain-specific anxiety distinct from generalized anxiety; captures fear of pain, avoidance behaviors, and anxiety symptoms uniquely related to pain experience
- Strong psychometric properties: Cronbach's alpha ≥0.80-0.95 (total scale), test-retest reliability r ≥0.75-0.85, convergent validity with disability, fear-avoidance beliefs, and pain outcomes
- Responsive to change: PASS decreases with exposure-based cognitive-behavioral therapy and fear-avoidance rehabilitation; sensitive to treatment effects
- Predictive validity: baseline PASS scores predict pain disability, treatment response, and chronicity; elevated PASS identifies high-risk patients
- Brief (20 items, 5-10 minutes) and available in multiple languages; free and publicly available
- Measures anxiety symptoms but does not diagnose anxiety disorder; elevated PASS requires clinical assessment for formal diagnosis
- PASS captures state anxiety about pain but not trait anxiety; patients with generalized anxiety disorder may score high on PASS, making it difficult to isolate pain-specific anxiety
- Some PASS items address avoidance behaviors; high scores may reflect realistic activity limitation (genuine physical constraint) rather than fear-driven avoidance
- Response bias potential: patients may minimize anxiety responses to appear emotionally stable or maximize responses to justify activity restriction
Frequently asked
Is pain anxiety the same as depression?
No. Pain anxiety is specific fear and avoidance related to pain sensation; depression is broader mood disturbance, hopelessness, and anhedonia. Patients can have high pain anxiety with low depression, or vice versa. PASS measures anxiety specifically; complement with depression measures (PHQ-9, BDI-II) for comprehensive psychological assessment.
If a patient has high PASS but also severe pain, is exposure therapy safe?
Yes, with appropriate pacing. Graded exposure (gradually increasing activity despite pain anxiety) is safe and effective for fear-avoidance pain. Start with low-threat activities the patient avoids due to anxiety (not actual danger), gradually progress. Exposure differs from pushing through severe pain; it targets anxiety-driven avoidance while respecting pain's biofeedback. Medical clearance and therapist guidance essential.
Can PASS scores be too high to treat?
No. Even very high PASS scores (90-100) can improve with systematic fear-extinction and cognitive-behavioral therapy. Severe pain anxiety may require slower pacing and sometimes concurrent anxiety medication support, but exposure-based treatment is indicated. High baseline PASS predicts longer treatment duration but not treatment futility.
What if PASS doesn't improve despite pain reduction?
Pain reduction and pain anxiety reduction follow different mechanisms; anxiety sometimes persists despite pain improvement due to learned avoidance habits or cognitive fears independent of current pain. If PASS remains elevated despite pain improvement, explicitly target fear-avoidance through exposure therapy and cognitive restructuring—anxiety treatment separate from pain treatment.
Sources
- McWilliams, L.A., Asmundson, G.J., & Gauthier, N. (2006). Pain anxiety symptoms scale: Brief 20-item version (PASS-20). Journal of Pain, 7(7), 479-485. link ↗
- Asmundson, G.J., Norton, P.J., & Norton, G.R. (1999). Beyond pain: The role of fear and avoidance in chronicity. Clinical Psychology Review, 19(1), 97-119. DOI: 10.1016/S0272-7358(98)00034-8 ↗
- McCracken, L.M., & Dhingra, L. (2002). A short version of the Pain Anxiety Symptoms Scale (PASS-20): Preliminary development and validity. Pain Research & Management, 7(1), 45-50. DOI: 10.1155/2002/517163 ↗
How to cite this page
ScholarGate. (2026, June 3). Pain Anxiety Symptoms Scale (PASS). ScholarGate. https://scholargate.app/en/pain-medicine/pain-anxiety-symptoms-scale
Which method?
Set this method beside its closest kin and read them side by side — the library lays the books on the table; the choice is yours.
- Central Sensitization InventoryPain Medicine↔ compare
- Chronic Pain Acceptance QuestionnairePain Medicine↔ compare
- Pain Catastrophizing ScalePain Medicine↔ compare
- Pain Self-Efficacy QuestionnairePain Medicine↔ compare