The Journal of Pain, Vol 8, No 5 (May), 2007: pp 405-411

Available online at www.sciencedirect.com

Conflict About Expressing Emotions and Chronic Low Back Pain:

Associations With Pain and Anger
James W. Carson, Francis J. Keefe, Kathryn P. Lowry, Laura S. Porter, Veeraindar Goli,
and Anne Marie Fras
Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina.

Abstract: There has been growing interest among researchers and clinicians in the role of ambivalence over emotional expression (AEE) in adjustment to chronic illness. Because of the salience of
anger in chronic low back pain, this condition provides a particularly good model in which to examine
the role of AEE. This study examined the relation of AEE to pain and anger in a sample of 61 patients
with chronic low back pain. Patients completed standardized measures of AEE, pain, and anger.
Correlational analyses showed that patients who had higher AEE scores reported higher levels of
evaluative and affective pain as well as higher levels of state and trait anger and the tendency to hold
in angry thoughts and feelings. Mediational analyses revealed that most of the associations between
AEE and pain, and AEE and anger, were independent of one another. These findings suggest that a
potentially important relationship exists between AEE and key aspects of living with persistent pain.
Perspective: This preliminary study suggests that there is a relation between ambivalence over
emotional expression and pain and anger in patients with chronic low back pain. Patients who report
greater conflict with regard to expressing emotions may be experiencing higher pain and anger.
2007 by the American Pain Society
Key words: Ambivalence over emotional expression, pain, anger, chronic low back pain.

ecently, there has been growing interest in the role

of ambivalence over emotional expression in adjustment to chronic illness.12,22,27 Ambivalence
over emotional expression (AEE) has been defined as the
tendency to be conflicted about expressing ones emotions, potentially including both negative emotions (eg,
anger) and positive emotions (eg, affection).14 Persons
who are highly ambivalent about emotional expression
may have difficulty with expressing emotions when they
want to be expressive, refraining from emotional expression when they do not want to be expressive, and expressing emotions but later regretting the expression.
Because of the salience of anger in chronic low back
pain (CLBP),5,6,10,21 this condition provides a particularly
good model in which to examine the role of AEE. CLBP
patients often face challenges that may elicit anger that
they feel ambivalent about expressing. Patients, for exReceived July 17, 2006; Revised October 2, 2006; Accepted November 14,
2006.
Supported in part by funds from the Fetzer Institute.
Address reprint requests to Dr. James W. Carson, Pain Prevention and
Treatment Research Program, Department of Psychiatry, Duke University
Medical Center, Box 90399, Durham, NC 27708. E-mail: jim.carson@
duke.edu
1526-5900/$32.00
2007 by the American Pain Society
doi:10.1016/j.jpain.2006.11.004

ample, who are unable to get an adequate explanation

of the cause of their pain may feel angry and frustrated
but reluctant to express these feelings for fear of negative consequences. Patients may feel angry that they are
not being offered definitive surgical or medical treatments for pain but fear that expressing this anger may
lead to abandonment by treatment providers. At times,
patients may feel pressured by others into sharing their
feelings when they preferred to hold in their feelings of
anger. Or patients may lose control over their anger
when expressing themselves toward a significant other
or family members and then regret having done so.
Moreover, patients who frequently feel ambivalent
about expressing emotions such as anger may experience higher levels of anger and greater difficulty in managing their anger. When unexpressed or when expression is regretted, anger may trigger a vicious cycle. Anger
may feed on itself and begin to dominate a persons
emotional life, creating further difficulty in managing
anger.
Furthermore, both theory and research suggest that
ambivalence over expressing emotions may be linked to
increased pain. Earlier theoretical models of pain processing8,9 suggested that emotional conflicts affect the
experience of pain, and recent evidence has tended to
405

406
support a role for emotional conflicts in adjustment to
chronic pain.1,7,12,30 Evidence from nonmedical samples
indicates that individuals who are high in AEE experience
much higher levels of psychological distress,11,13 and, recently, Tucker et al27 found the same pattern among
rheumatoid arthritis patients. Both the gate control theory and neuromatrix theory provide an explanation for
how psychological distress related to AEE could increase
pain.18 These theories and the data supporting them
hold that pain perception always integrates a complex
set of variables, including substantive input from affective factors. Research has shown, for instance, that induction of negative affect decreases tolerance for laboratory pain stimuli.29 It is conceivable therefore that
distress related to AEE could affect pain in a similar
way. In a recent study, we found that among patients
with gastrointestinal cancer pain, AEE was associated
with higher self-reported pain ratings.22
However, no study thus far has examined the role of
AEE in non disease-related pain. Many patients with
chronic pain grapple with a high degree of uncertainty
about the causes of their pain.28 Such uncertainty may
make AEE and increased psychological distress and pain
more likely.
The purpose of the present study was to examine the
following hypotheses: (1) that CLBP patients high in AEE
would report higher levels of pain and (2) that CLBP
patients high in AEE would report higher levels of anger.
An additional purpose of the study was to determine
whether any significant associations between AEE and
pain on the one hand, and AEE and anger on the other
hand, are independent of one another.

Materials and Methods

Participants
Participants for this study were 61 adults with lower
back pain that was chronic (ie, present for at least 6
months). Patients were recruited from the Pain and Palliative Care Clinic at Duke University Medical Center (n
31) and from surrounding communities by advertisements placed in local newspapers (n 30). Patients were
excluded if they had significant cognitive impairments,
acute suicidality or homicidality, pending disability/legal
claims, or concurrent treatment for major medical disorders that may have affected their pain or disability (eg,
chronic obstructive pulmonary disease). A series of regression and 2 analyses determined that the clinic and
community subsamples were similar in terms of demographic characteristics and means of dependent variables, with the exception of disability status. The clinic
group contained significantly more recipients of disability benefits, 2(2, N 61) 9.99, P .007, with 45% (14
patients) being recipients vs 10% (3 patients) in the community group. Analyses of the remaining characteristics
of the sample, calculated across both groups, indicated
the mean age was 50.90 (range 25 to 80); 60% of the
participants were female; 62% were Caucasian, 36%
were African American, and 2% were of other racial origin; 46% were married, 23% were divorced or sepa-

Conflict About Expressing Emotions

rated, 8% were widowed, and 23% were single; 5% had
not completed high school, 33% had graduated from
high school, 43% had attended college, and 19% had
attended graduate school. The average pain duration
for the sample was 131.93 months (SD 112.13).

Procedure
The protocol for this study was approved by the Duke
Institutional Review Board. Before the study, informed
consent was obtained from all participants. A series of
measures was then given to all patients.

Measures
Ambivalence Over Emotional Expression
Patients completed the Ambivalence Over Emotional
Expression Questionnaire.14 This questionnaire consists
of 28 items rated on a 5-point scale from 1 (I have never
felt like this) to 5 (I frequently feel like this). Items
pertain to wanting to express emotion and being unable
to do so as well as expressing emotion and later regretting it. Sample items include I would like to express my
affection more physically, but I am afraid others will get
the wrong impression, Often Id like to show others
how I feel, but something seems to be holding me back,
I feel guilty after I have expressed anger to someone,
and I try to show people I love them, although at times
I am afraid that it may make me appear weak or vulnerable. The Ambivalence Over Emotional Expression
Questionnaire has good internal reliability and stability
over a period of 6 weeks.14 The reliability coefficient in
the current sample was very good (0.94). This measure
also has demonstrated divergent and convergent validity, showing negative correlations in the range of 0.20
to 0.30 with measures of emotional expressiveness,
and positive correlations in the range of 0.30 to 0.50 with
negative affect, depression, and neuroticism.11,13,14 Evidence of external validity has been demonstrated by observer ratings of social interactions in which women high
in AEE were rated as less positive in their verbal statements, more constricted in their nonverbal expressions,
and less congruent in their verbal and nonverbal communication.20

Pain
Pain was assessed using the McGill Pain Questionnaire
(MPQ).17 This questionnaire consists of 20 groups of
single-word pain descriptors, with each successive word
in the word set denoting an increased score, termed the
Pain Rating Index. Participants were asked to check the 1
adjective in each word set that best describes their pain.
A total Pain Rating Index is computed by summing the
ranks of all the items. There are also 3 major subscales of
the questionnaire that assess the affective, evaluative,
and sensory dimensions of pain experience. Previous research has provided strong support for the reliability and
validity of this instrument (see Melzack and Katz,19 1992,
for a review of this literature).

ORIGINAL REPORT/Carson et al

Anger
The State-Trait Anger Expression Inventory-II (STAXI-II)
was used to measure individuals anger.26 This 57-item,
self-report inventory measures the experience and expression of anger, using 4-point Likert-type items ranging from 1 to 4. The 15-item state anger scale measures
the intensity of angry feelings that are momentary and
potentially transitory at the time of test administration;
the 10-item trait anger scale assesses individual differences in angry feelings that have a more constant and
dispositional nature. The anger-in, anger-out, angercontrol-in, and anger-control-out scales of the questionnaire each contain 8 items. Anger-in items measure how
frequently angry feelings are suppressed or inhibited,
and anger-out items measure how frequently the individual expresses anger toward other people or objects in
the environment. Anger-control-in items assess the frequency with which an individual attempts to control angry feelings by calming down; anger-control-out items
assess attempts to control the outward expression of anger. Good internal consistency has been reported for the
various scales.26

Statistical Analysis Procedures

Because we were concerned about the need to balance
committing Type 1 error against the possibility of dismissing potentially important relations, a minimum
level of 0.05 was used for all analyses. To examine how
AEE related to pain and anger measures, correlational
analyses (Pearsons r) were conducted. To further illustrate AEE-related differences in pain and anger scores,
the 61 patients were stratified into tertiles of roughly 20
patients each and analyzed according to their AEE score:
lowest AEE, 2.40 (n 20); medium AEE, 2.40 to 3.00
(n 20); and highest AEE, 3.00 (n 21), respectively.
Lastly, a series of analyses were conducted to determine (a) whether significant effects of AEE on pain variables could be accounted for by significant associations
between anger variables and AEE; and (b) vice versa,
whether significant effects of AEE on anger variables
could be accounted for by significant associations between
pain variables and AEE. In other words, these procedures
examined whether the observed AEE associations are attributable to, or mediated by, a pattern in which patients
who score higher on pain scales also are likely to score
higher on anger scales,5,6,21 or, alternatively, whether
AEE is independently associated with pain outcomes and
anger outcomes.
An advanced mediational statistical procedure was
used for these analyses.23 This regression procedure simultaneously estimates both the direct and indirect (mediated) associations between predictor, criterion, and
potential mediator variables, thus obviating the need for
performing additional regression tests as a prerequisite
to mediational analyses (ie, tests to establish that the
potential mediator variable has a significant effect on
the criterion variable while controlling for the predictor
variable, or that the predictor variable is significantly
associated with the criterion variable while controlling

407
for the potential mediator). This approach also overcomes notable deficiencies of other common methods of
mediation analysis. These include problems with Baron
and Kennys2 widely used mediational model (eg, failure
to provide a specific statistical test for the mediational
effect that a predictor has on a criterion via a proposed
mediator, and problems with omitted variables that may
bias parameter estimates) and Sobels test25 (eg, unwarranted multivariate normality assumption especially
relevant in small samplesand greater probability of
Type I errors).15,16,23,24 Other advantages of this statistical procedurewhich are shared with structural equation modeling methods for mediation testinginclude
greater flexibility in model specification and estimation
options. Moreover, this procedure is easily implemented
and compatible with common software packages (we
used SPSS, Chicago, IL).
The procedure used herein relies on a resampling
method known as bootstrapping for estimating the statistical significance of mediation effects. Bootstrapping
is a nonparametric approach to effect-size estimation
and hypothesis testing that is increasingly recommended
for many types of analyses, including mediation.16,24
Rather than impose questionable distributional assumptions, bootstrapping generates an empirical approximation of the sampling distribution of a statistic by repeated random resampling from the available data, and
uses this distribution to calculate P values and construct
confidence intervals (5,000 resamples were taken for
these analyses). This procedure supplies superior confidence intervals that are bias-corrected and accelerated.23 However, to maintain congruence with results
produced by more familiar mediational analyses, our description of significant findings below includes data that
conform with Baron and Kennys2 mediational model.

Results
Before analyzing associations between AEE and the
pain and anger measures, tests were conducted to determine if the demographic variables (age, sex, race, education, duration of CLBP, disability status) were related to
AEE. None of these tests revealed significant effects (all
P .282). Table 1 presents data on the means and standard deviations for the AEE, pain, and anger measures.
The mean for AEE in this CLBP sample, 2.68 (SD 0.69), is
very similar to that reported by Tucker et al27 for rheumatoid arthritis patients, 2.64 (SD 0.692), but somewhat higher than that reported by Porter et al22 for patients with gastrointestinal cancer, 1.89 (SD 0.62). The
means of pain and anger scores in this sample are similar to
other patients with chronic pain.3,4

Relation of AEE to Pain

As can be seen in Table 1, there were significant positive correlations between AEE and the affective pain and
evaluative pain scales of the McGill Pain Questionnaire.
Patients scoring high on AEE were much more likely to
report higher pain on the affective pain and evaluative
pain scales. In addition, a trend approaching statistical

408

Conflict About Expressing Emotions

Correlation of Ambivalence Over

Emotional Expression to Pain Measures and
Anger Measures

Table 1.

Ambivalence Over Emotional

Expression (AEE)
Pain measures (MPQ)
Pain Rating Index
Affective pain
Evaluative pain
Sensory pain
Anger Measures (STAXI-II) (M, SD)
State anger
Trait anger
Anger-in
Anger-out
Anger control-in
Anger control-out

MEANS (SD)

CORRELATION
WITH AEE

2.68 (0.69)

--

26.08 (13.60)
3.00 (2.96)
2.78 (2.08)
15.25 (8.60)

0.201
0.256*
0.314
0.201

17.79 (5.53)
15.93 (4.01)
16.11 (4.15)
13.98 (4.06)
23.89 (5.67)
24.25 (5.62)

0.340
0.216*
0.453
0.054
0.022
0.077

NOTE. *P .05, P .01, P .001; trend (P .10); n 60 for pain

measures, n 61 for anger measures.

significance was evident between AEE and the overall

composite scale (Pain Rating Index) of the MPQ and between AEE and the sensory scale of the MPQ. No significant differences were found in pain scores according to
AEE tertiles.

Relation of AEE to Anger

As can be seen in Table 1, significant positive correlations
were obtained between AEE and measures of state anger,
trait anger, and anger-in. These findings indicate that patients who reported higher levels of AEE were much more
likely to report higher levels of momentary and dispositional anger. They were also much more likely to report
suppression of angry feelings. In addition, significant differences between AEE tertiles were revealed in state anger (F[2, 60] 5.13, P .009) and anger-in (F[2, 60]
11.98, P .001). For state anger, the highest tertile (M
20.62) was significantly different from both the lowest
tertile (M 15.60, P .003) and the medium tertile
(M 17.00, P .029). For anger-in, the highest tertile
(M 17.95) was significantly different from the lowest
tertile (M 12.95, P .001); also the medium tertile
(M 17.35) was significantly different from the lowest
tertile (P .001).

Mediation Effects
Separate tests were conducted that paired each significantly related pain outcome (evaluative pain, affective
pain) with each potential mediator (state anger, trait
anger, anger-in) as well as tests pairing each significantly
related anger outcome (state anger, trait anger, angerin) with its potential mediators (evaluative pain, affective pain). Most of these tests ruled out mediation by
demonstrating no significant effect of the potential mediator on the outcome when controlling for the effect of
AEE (thus not fulfilling a commonly accepted require-

ment for mediation ). In 2 teststhe examination of the

effect of AEE on affective pain as mediated by state anger and the corresponding test of the effect of AEE on
state anger as mediated by affective painthe potential
mediators were significantly related to the outcome
when controlling for AEE. Of these 2, only the test of the
effect of AEE on affective pain as mediated by state anger produced significant results. As shown in Table 2 and
further illustrated in Fig 1, bootstrap results showed
state anger to be significant beyond the P .05 level
(note that whenever zero is not contained within the
bootstrap confidence intervals, we can conclude that the
effect is indeed significantly different from zero23). As
the remaining effect of AEE was no longer significant
when competing for variance with state anger in the
mediation model, these results indicate a case of complete mediation according to Baron and Kennys2 approach. Lastly, because the 2 subsamples (clinic and community) comprising this sample of patients differed in
disability status, to rule out this as a potential confound,
we tested and found no relation between compensation
status and state anger (P .322).

Discussion
In this study, we found evidence that ambivalence over
emotional expression is meaningfully related to pain and
anger scores in patients with persistent lower back pain.
Furthermore, we found that most of the associations between AEE and pain on the one hand and AEE and anger
on the other were independent of one another. To our
knowledge, the current study is 1 of the first to examine
how AEE relates to pain and anger in patients having
persistent, non disease-related pain.

Mediation Estimates for the Effect of

Ambivalence Over Emotional Expression
(AEE) on Affective Pain as Mediated By
State Anger

Table 2.

Effect

Total effect of AEE on affective pain

Effect of state anger on affective pain
Effect of AEE on state anger
Remaining direct effect of AEE on
affective pain

1.11
0.16
2.72
0.67

2.02
2.32
2.70
1.20

.048
.024
.009
.235

Bootstrap Test for Mediation of Effect of AEE on Affective

Pain via State Anger
b
Mediation via state anger

CIlower CIupper

0.44

0.11

0.99

P
.05

Sobels Test for Mediation of Effect of AEE on Affective

Pain via State Anger

Mediation via state anger

0.44

1.78

.075

NOTE. Confidence intervals (CIs) are bias-controlled and accelerated;

bootstrap resamples 5000; n 60 for all tests.

ORIGINAL REPORT/Carson et al

409

Figure 1. Illustration of the effect of ambivalence over emotional expression (AEE) on affective pain as mediated by state anger.

One of the most important questions addressed by this

study was whether AEE is related to pain. The findings
indicate that, congruent with our hypotheses, patients
who scored higher on AEE reported higher ratings on the
evaluative and affective subscales of the McGill Pain
Questionnaire. These results, obtained in a chronic pain
sample, are in keeping with Porter et als22 finding that
AEE is associated with higher self-reported pain ratings in
patients with gastrointestinal cancer pain. Findings from
mediation tests performed on these associations showed
that whereas the relation of AEE to evaluative pain is relatively independent of corresponding associations with
anger measures, the relation of AEE to affective pain is
largely indirect and can be attributed to its association
with state anger, and state angers direct relation to affective pain. It appears therefore that AEE may affect
pain directly in the evaluative domain and indirectly
through state anger in the affective domain. Interestingly, these differing effect paths appear to match the
pain domains themselves: A potentially powerful emotion, momentary anger, subsumes the relation between
AEE and the emotional aspect of pain, whereas the more
cognitive or judgmental aspect of pain is related to AEE
in a way that is independent of anger variables.
Our findings are consistent with current models of pain
that propose that emotional/cognitive processes such as
AEE and anger can interact with the pain experience.18
These findings have potentially important clinical implications. First, they suggest that clinicians need to be
aware that patients who report conflict about expressing
their emotions may experience and report more pain.
Second, although further research is needed to clarify
the directionality of the relations found in our data, it is
possible that interventions that help reduce patients
ambivalence about emotional expression (eg, psychological interventions that address emotion expression) could
have both direct and indirect effects that reduce pain.
The present findings also revealed a link between AEE
and anger. Patients who reported higher levels of AEE
had higher levels of current (state) anger and disposi-

tional (trait) anger. Higher levels of AEE were also related to an anger management style characterized by
holding in angry thoughts and feelings. Findings from
mediation tests performed on these associations indicated each is independent of corresponding associations
with pain. Lastly, significant differences were found in
state anger and anger-in by AEE tertiles tests. To our
knowledge, this is the first study to demonstrate that
there is an association between AEE and anger-related
variables. The finding regarding AEE and anger-in is consistent with findings that individuals high in AEE tend to
be emotionally inexpressive.11,14 There is growing recognition that anger and anger management styles are important in understanding the adjustment of persons having persistent pain.10 Future studies are needed to
replicate and extend the findings of this study. In particular, future studies need to examine mechanisms that
link AEE to anger in persons having chronic pain. Such
studies, for example, could examine potential biological
mechanisms (eg, endogenous opioid dysfunction, alterations in immune function), behavioral mechanisms (eg,
maladaptive pain behaviors, marital dysfunction, difficulty in relationships with health care providers), and
affective mechanisms (eg increased depression) that may
link AEE and anger in persons having pain.10 Also, because several items in the AEE measure refer specifically
to anger-related reactions (eg, I feel guilty after I have
expressed anger to someone), it may be useful to create
a subscale and investigate its associations with anger
variables. Moreover, there is a growing consensus that
psychological interventions for patients having chronic
pain need to be expanded to better address issues of
anger and anger management.10 Thus, another important future direction is to determine whether anger
management protocols that include a component addressing AEE may be more effective for persons having
persistent pain than conventional anger management
protocols that do not include such a component. Our
finding that state anger mediates the effects of AEE on
affective pain suggests this approach may be useful.

410

Conflict About Expressing Emotions

This study has several limitations, each of which raises a

question that can only be addressed by future studies.
First and foremost, the design was cross-sectional, and
thus results do not enable us to make causal inferences.
Therefore, we cannot be certain whether AEE leads to
increased anger and pain, or vice versa. Experimental
studies could be conducted to better examine causal effects of AEE on pain and anger. For example, one could
systematically alter AEE in a laboratory study and examine the effects of increasing versus decreasing AEE on
anger and pain variables. Second, levels of AEE may
change over time. Thus, prospective investigations, perhaps using daily measures, are needed to examine within
person changes in AEE and how such changes relate to
the individuals levels of pain and anger. Third, the results of this study are based on self-report measures only.
Future studies should incorporate behavioral measures
(eg, cold pressor pain task) and other methodologies, and

also assess a more comprehensive set of pain-related outcomes (eg, depression, health care use). Fourth, the present
study relied on a sample of 61 individuals having chronic
low back pain. Although this sample was diverse with regard to age, race, and sex, the findings obtained need to be
replicated in other populations of patients suffering from
chronic pain syndromes (eg, headache, fibromyalgia).
Considered overall, the findings of this small, preliminary study suggest that there may be a relation between
AEE and important aspects of living with persistent pain.
These findings raise the possibility that AEE may be significantly associated with an individuals pain and anger.
Taken together, our results suggest that additional research examining the concept of AEE in patients with
persistent pain is warranted. In the meantime, clinicians
may find it worthwhile to consider the potential importance of ambivalence about expressing emotions in the
chronic pain patients they treat.

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