The relationship between fear of social and physical threat and its effect on social distress and physical pain perception

Abstract

Past research has found that measuring individuals’ fear of pain predicts their physical pain perceptions: those reporting higher levels of fear of pain report higher levels of pain. We investigated links between fear of social threat and fear of physical pain, testing whether these fears predict responses to social distress and physical pain. In 3 studies, we found that fear of social and physical threat were related yet distinct psychological constructs (study 1), that fear of social (but not physical) threat predicted the perception of social distress (study 2), and that fear of physical (but not social) pain predicted the perception of physical pain (study 3). Thus, we found that, similar to the influence of fear of physical pain on physical pain perception, fear of social threat moderated the perception of social distress. However, we also found that these effects were specific, such that each type of fear uniquely predicted the experience of the same type of distress. We argue that timely identification of high levels of social threat-related fear is critical for identifying individuals who will benefit most from preventative interventions aimed to limit negative cycles of high avoidance and increased social threat perception. Furthermore, our work sets a boundary condition to pain overlap theory by showing that high levels of fear of one type of pain (e.g., social) are specifically linked to increased perception of that particular type of pain (e.g., social) but not the other (e.g., physical).

Full text

The relationship between fear of social and physical threat and its
effect on social distress and physical pain perception
Paolo Riva
a,
⇑
, Kipling D. Williams
b
, Marcello Gallucci
a
a
Department of Psychology, University of Milano-Bicocca, Milan, Italy
b
Department of Psychology, Purdue University, West Lafayette, IN, USA
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
article info
Article history:
Received 11 January 2013
Received in revised form 4 October 2013
Accepted 15 November 2013
Keywords:
Fear of pain
Ostracism
Pain overlap theory
Social threat
abstract
Past research has found that measuring individuals’ fear of pain predicts their physical pain perceptions:
those reporting higher levels of fear of pain report higher levels of pain. We investigated links between
fear of social threat and fear of physical pain, testing whether these fears predict responses to social
distress and physical pain. In 3 studies, we found that fear of social and physical threat were related
yet distinct psychological constructs (study 1), that fear of social (but not physical) threat predicted
the perception of social distress (study 2), and that fear of physical (but not social) pain predicted the per-
ception of physical pain (study 3). Thus, we found that, similar to the influence of fear of physical pain on
physical pain perception, fear of social threat moderated the perception of social distress. However, we
also found that these effects were specific, such that each type of fear uniquely predicted the experience
of the same type of distress. We argue that timely identification of high levels of social threat-related fear
is critical for identifying individuals who will benefit most from preventative interventions aimed to limit
negative cycles of high avoidance and increased social threat perception. Furthermore, our work sets a
boundary condition to pain overlap theory by showing that high levels of fear of one type of pain (e.g.,
social) are specifically linked to increased perception of that particular type of pain (e.g., social) but
not the other (e.g., physical).
Ó2013 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
1. Introduction
The observation that social distress activates some of the brain
regions known to be associated with the experience of physical
pain gave rise to pain overlap theory [11–13,26], according to
which a system that uses similar signals for social separation and
physical damage may have been evolutionarily advantageous
[26]. Although the need for a more cautious interpretation was re-
cently advised [21], data that show activation in the so-called pain
matrix in response to social distress nevertheless suggests new
testable hypotheses about potential relationships between physi-
cal pain and social distress. For instance, research showed that
physical pain and social distress can cause similar psychological
consequences [36].
Here, we turn our attention to the possible overlapping factors
that might explain interindividual variability of both social distress
and physical pain. We argue that the key role of cognitive and
emotional processes related to the subjective experience of
physical pain may be important for the perception of social distress
as well. In particular, fear of threat may be a common factor
explaining interindividual differences in the experience of physical
pain and social distress. In the context of physical pain, despite the
key role of fear of pain in promoting the individual’s safety and
survival, theorists suggested that high levels of fear of pain can
be detrimental [2]. Accordingly, several experiments found that
physical pain-related fear (assessed by the Fear of Pain Question-
naire [29]) was a consistently stronger predictor of pain perception
compared to other predictors [16,19].
However, a generic fear of pain may not necessarily account for
the specific reactions to the 2 experiences. In keeping with this
reasoning, hierarchical structural models of fears [42,43] posit there
is a hierarchy of general and specific mechanisms that affect one’s
tendency to develop fears. General factors, such as neuroticism, re-
late to the acquisition of most fears, whereas specific factors are
particular to a given type of stimulus (e.g., spiders). Therefore, fear
of specific kind of threat (e.g., social) should be distinct (albeit asso-
ciated) from other threat-related fears (e.g., fear of physical pain).
Our aim was to investigate the relationship between fear of so-
cial and physical threat and to test whether fear of social threat
influences the reactions to social distress in a similar way in which
fear of physical pain influences the reactions to physical pain.
0304-3959/$36.00 Ó2013 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.pain.2013.11.006
⇑
Corresponding author. Address: Department of Psychology, University of
Milano-Bicocca, Piazza Ateneo Nuovo, 1, 20126 Milan, Italy. Tel.: +39 02 6448
3775; fax: +39 02 6448 3706.
E-mail address: paolo.riva1@unimib.it (P. Riva).
PAIN
Ò
155 (2014) 485–493
www.elsevier.com/locate/pain

Specifically, the current set of studies was designed to test the fol-
lowing predictions. As hypothesis 1, we hypothesized that fear of
social threat is related to, yet distinct from, fear of physical pain.
That is, individuals with high fear of social threat should also exhi-
bit high fear of physical pain, but these 2 constructs should be
empirically distinguishable (study 1). As hypothesis 2, we hypoth-
esized that, similar to the influence of fear of physical pain on the
perception of physical pain, fears of social threat should exacerbate
perception of social distress (study 2). Finally, as hypothesis 3, we
hypothesized that individuals high in fear of one type of threat
would report increased distress perception from being subjected
to that type of distress than the other type (studies 2 and 3).
2. Study 1
In study 1, we examined the degree of overlap between fear of
social and physical threat. We predicted that fear of social threat
and fear of physical pain would factor separately, and these factors
would be positively correlated (hypothesis 1). We also examined
the degree to which fear of social threat might overlap with other
constructs that would be expected to be conceptually associated
with it. More specifically, we examined the relationship of fear of
social threat and fear of physical pain as they overlapped with
rejection sensitivity (e.g., the tendency to anxiously expect, readily
perceive, and overreact to social rejection [10]), pain catastrophiz-
ing (e.g., cognitions of ruminating on negative outcomes resulting
from the experienced pain, thinking pain is unbearable, and the
inability to tolerate painful situations [16,19,40]), anxiety [32],
depression [38], loneliness [29], and items related with past expe-
riences of social distress and physical pain. The latter were in-
cluded to investigate links between past experiences of social
distress and physical pain and current levels of fears [3,9,22,24].
2.1. Methods
2.1.1. Participants
Four independent samples were recruited for study 1. This
methodological choice was adopted because our focus was on
the relationships between the fear of social and physical threat
and each of the considered concurrent constructs, rather than on
the full matrix of relationships among all the measures. In this
way, we avoided overloading the participants with a large number
of items and avoided possible distortions in the correlation coeffi-
cients resulting from specific characteristics of a single sample.
Our samples comprised 272 participants (135 female subjects;
mean age 19.48 years, standard deviation [SD] 2.92) for sample 1,
111 participants (38 female subjects; mean age 19.56 years, SD
1.53) for sample 2; 113 participants (42 female subjects; mean
age 19.48 years, SD 1.55) for sample 3, and 146 participants (90 fe-
male subjects; mean age 19.36 years, SD 3.76) for sample 4. All
participants were students at Purdue University who participated
in this study as part of a course requirement.
2.1.2. Procedures and materials
Each participant in every sample completed a written informed
consent form, a brief demographic questionnaire, and the Fear of
Social Threat Scale and the Fear of Pain Questionnaire, along with
a number of additional measures.
Fear of Social Threat Scale. Given that no fear of social threat
assessment currently exists, we drew on the item structure of
the Fear of (physical) Pain Questionnaire [30] and constructed a
15-item self-report scale that incorporated a variety of instances
of social threatening events. These instances included feeling so-
cially excluded [1], ostracized [45,46], humiliated [17,33], betrayed
[15], interpersonally devalued [23], and verbally abused (i.e., being
harmed by others with words [7]). For item reduction, a pilot study
was conducted to identify a set of items from the 25 items initially
generated. Forty-five students (21 women; 19.76 years, SD 2.34) at
Purdue University took part in a preliminary study to exchange
course credits. Ten items were dropped from the original set of
25 items. Specifically, 3 items were removed because they demon-
strated a ceiling effect, and the remaining 7 items were dropped
because of conceptual overlap and varying degrees of redundancy
with the content in other items. The final Fear of Social Threat Scale
consisted of 15 items, with 4 items related to relational devalua-
tion (e.g., ‘‘your partner forgetting your birthday’’), 3 items related
to ostracism (e.g., ‘‘feeling ignored by someone who is important to
you’’), 2 items related to rejection (e.g., ‘‘being left out of a group’’),
2 items related to betrayal (e.g., ‘‘being betrayed by someone who
is important to you’’), 2 items related to humiliation (e.g., ‘‘being
embarrassed in front of your classmates by your professor’’), and
2 items related to verbal abuse (e.g., ‘‘being verbally abused by
your boss’’). Our primary aim was to build a short scale that could
provide a valid and reliable index of fear of social threat and be
comparable to the overall score of the Fear of Pain Questionnaire.
Fear of Pain Questionnaire. The FPQ-III is a 30-item self-report
instrument measuring fear of a variety of physical pain-related
stimuli [30]. For the purposes of the present study, we used a shorter
version of the Fear of Pain Questionnaire. We selected 9 items,
retaining the 3 items that in the original validation study [30]
showed the highest factor loadings on each of the 3 domains of
the Fear of Pain Questionnaire (the same procedure for item selec-
tion has been previously adopted; e.g., [6]). Considering the aims
of the present investigation, we focused more on obtaining a brief
measure of the construct of fear of physical pain in order to compare
it with fear of social threat rather than on distinguishing its specific
subdimensions (e.g., severe pain, minor pain, medical pain).
For sample 1, participants completed a questionnaire that in-
cluded a set of items developed to assess fear of social threat
(
a
= .943) and a subset of items taken from the Fear of Pain Ques-
tionnaire (
a
= .833) [30]. The items used for both scales can be seen
in the Supplementary Appendix. For sample 2, the questionnaire
package included the 15-item Fear of Social Threat Scale
(
a
= .940), the 9-item subset of the Fear of Physical Pain Scale
[30] (
a
= .850), and the Rejection Sensitivity Questionnaire [10]
(
a
= .827). Sample 3 completed the 15-item Fear of Social Threat
Scale (
a
= .921), the 9-item subset of the Fear of Physical Pain Scale
(
a
= .848), and the Pain Catastrophizing Scale [39] (
a
= .916). Final-
ly, participants in sample 4 were asked to complete the 15-item
Fear of Social Threat Scale (
a
= .946), the 9-item subset of the Fear
of Physical Pain Scale (
a
= .846), the Beck Anxiety Inventory [4]
(
a
= .916), the Beck Depression Inventory [5] (
a
= .874), the 3-item
Scale for Measuring Loneliness [20] (
a
= .832), and 2 sets of ad-hoc
composed indexes regarding past experience of social (
a
= .747)
and physical (
a
= .878) pain. The 3 items for the Past Experience
of Social Distress Index were: ‘‘In the past, people have not been
there to give me warmth, comfort, and affection’’; ‘‘In the past, I of-
ten felt excluded and ignored’’; and ‘‘In the past, I haven’t felt that I
am special to someone.’’ The 3 items for the Past Experience of
Physical Pain Index were: ‘‘In the past, I have suffered a lot from ill-
ness and injury’’; ‘‘In the past, I have suffered much physical pain’’;
and ‘‘In the past, I often had pain in my body.’’ Responses to all
these items were recorded on a 1 (‘‘Completely untrue of me’’) to
7 (‘‘It describes me perfectly’’) scale and were averaged together
to create the 2 overall indexes. For each sample, the order of the
presentation of scales and items in each scale was randomized.
2.2. Results
2.2.1. Data management
The means, standard deviations, and corrected item total corre-
lations of the items are presented in Table 1. The 2 subscales also
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155 (2014) 485–493

were tested for normality. The Fear of Social Threat Scale had a
skewness of .437 (SE = .148) and a kurtosis of .288 (SE = .294).
The Kolmogorov-Smirnov test was nearly significant,
D(272) = .51, P= .082, suggesting a tendency of a deviation from
normality. However, the Fear of Physical Pain Scale had a skewness
of .365 (SE = .148) and a kurtosis of .218 (SE = .294), and the Kol-
mogorov-Smirnov test was significant, D(272) = .58, P< .026, indi-
cating an even more extreme deviation from normality. Therefore,
our subsequent analyses were conducted with both the original
data and with log-transformed data that normalized the distribu-
tion of scores [41]. The results were equivalent in both cases; we
thus report only the results on the original, nontransformed data.
2.2.2. Factor analysis
To investigate the dimensionality of the 2 subscales, a principal
axis factor analysis was performed on the scores of the 24 items
(15 items related to fear of social threat and 9 items related to fear
of physical pain). Two indices suggested that the overall set of
items from this sample were appropriate for principal axis factor
analysis [41]: Kaiser’s measure of sampling adequacy was
0.897, and Bartlett’s test of sphericity was significant,
v
2
(276) = 4846.73, P< .001. Principal axis factor analysis was cho-
sen on the basis of early guidelines on exploratory factor analytic
techniques [8,14], which recommend this extraction technique
when data are not normally distributed. Two factors were ex-
tracted and subjected to an oblimin rotation [41]. These methodo-
logical choices (ie, principal axis factoring with oblimin rotation)
were highly consistent with those adopted in the validation pro-
cess of the Fear of (physical) Pain Questionnaire [34].
The requested 2-factor solution accounted for 51.8% of the var-
iance. As shown in Table 2, the 2-factor solution can be interpreted
as comprising factors related to fear of social threat (factor 1) and
fear of physical pain (factor 2). The structure was simple, with no
cross-loading items. Indeed, all items had a factor loading greater
than .50 on one factor and less than .20 on the other factor.
2.2.3. Correlation between fear of social threat and fear of physical
pain
As predicted, the 2 scales correlated with each other, r= .436,
P< .001 (2-tailed—sample 1). Furthermore, in all our next 3 addi-
tional samples, we found that fear of social threat was moderately
correlated with fear of physical pain (r= .498; P< .001 in sample 2;
r= .467; P< .001 in sample 3; r= .427; P< .001 in sample 4). Thus,
fear of social threat seems to be positively related to fear of phys-
ical pain, but the correlation is not so high as to render the newly
generated fear of social threat set of items redundant with those
related to fear of physical pain.
2.2.4. Correlation among fear of social threat and fear of physical pain
and their potentially related constructs
In terms of relationships among fear of social threat, fear of
physical pain, and their related constructs, we found that fear of
social threat was significantly correlated with rejection sensitivity
(r= .363, P< .001). Also, fear of physical pain was significantly cor-
related with rejection sensitivity (r= .322, P< .001) (Table 3). Fear
of social threat was significantly correlated with physical pain
measures, such as pain catastrophizing (r= .306, P< .001). In line
with past research [19], fear of physical pain and pain catastrophiz-
ing were positively associated (r= .472, P< .001).
Next, we found that scores on the Beck Anxiety Inventory were
significantly correlated with those on the Fear of Social Threat
Scale (r= .208, P< .05) and those on the Fear of Physical Pain Scale
(r= .282, P< .001). Similarly, it emerged that scores on the Beck
Depression Inventory were positively related with those on the
Fear of Social Threat Scale (r= .306, P< .001) and Fear of Physical
Pain Scale (r= .223, P< .001). The same pattern of results was true
for experiences of loneliness: the Short Scale for Measuring
Loneliness correlated with fear of both social (r= .281, P< .001)
and physical (r= .181, P< .05) pain. Finally, fear of social (but not
physical) pain was positively associated with past experiences of
social threat (r= .246, P< .001). In a parallel way, fear of physical
(but not social) pain positively correlated with past experiences
of physical pain (r= .174, P< .05). We also ran a partial correlation
analysis considering fear of social threat and fear of physical pain
and controlling for scores on anxiety and depression in order to
get a better estimate of the unique overlap between the 2 types
of fear. This analysis showed that the relationship between fear
of social threat and fear of physical pain remained significant
(r= .386, P< .001) after controlling for anxiety (i.e., scores on Beck
Anxiety Inventory) and depression (scores of Beck Depression
Inventory), indicating that the correlation between the 2
dimensions of fear was not—at least in its largest part—due to
the intervening variance of anxiety or depression.
2.3. Discussion
We tested whether fear of social threat and fear of physical pain
were related to each other. To do so, we emulated the Fear of
(physical) Pain Questionnaire, maintaining its instructions, syntax,
grammar, and presentation and changing only the types of pain to
include social threat (e.g., feeling interpersonally devalued, ostra-
cized, socially excluded, humiliated, betrayed, and verbally
abused). Scores obtained for those items support cross-situational
consistency of fear-related reactions to a variety of situations
involving a social threat. The same analysis on the short version
of the Fear of Physical Pain Scale indicated good internal validity.
Furthermore, principal axis factor analysis (PAF) of the responses
indicated that the items related to fear of social threat and those
related to fear of physical pain yielded 2 distinct yet correlated
dimensions. Crucially, the association between scores on the Fear
of Social Threat Scale and scores on the Fear of Physical Pain Ques-
tionnaire provided support for hypothesis 1: individuals’ fears of
Table 1
Means, SDs, and corrected item total correlations of the 15 items of the Fear of Social
Threat Scale (items 1 to 15) and of the 9 items of the Fear of Physical Pain (items 16 to
24; study 1).
a
Item Mean SD Corrected item,
total correlation
1 3.94 1.762 .680
2 3.62 1.771 .716
3 3.54 1.723 .712
4 3.54 1.699 .717
5 5.61 1.673 .658
6 5.01 1.691 .786
7 4.96 1.905 .749
8 4.02 1.898 .686
9 4.15 2.050 .619
10 4.23 2.092 .711
11 4.15 2.076 .694
12 5.45 1.900 .721
13 4.02 1.864 .703
14 4.36 2.052 .693
15 3.98 1.941 .747
16 3.75 1.967 .805
17 3.93 1.980 .807
18 5.14 2.012 .824
19 2.14 1.483 .819
20 2.04 1.495 .819
21 2.38 1.584 .818
22 3.03 2.086 .820
23 2.72 1.968 .812
24 2.99 1.917 .820
SD, standard deviation.
a
Fear of Social Threat Scale overall scores: mean = 4.30, SD = 1.39. Fear of
Physical Pain Scale overall scores: mean = 3.12, SD = 1.21); N= 272.
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155 (2014) 485–493 487

one type of pain were related to fears of the other type of pain.
Nonetheless, the results indicated that the 2 measures were
factorially distinct from each other, consistent with hierarchical
conceptualizations of different types of fears [42,43].
We then found initial evidence for discriminant validity of the
Fear of Social Threat Scale to other theoretically relevant
constructs. Although scores on the Fear of Social Threat Scale were
positively correlated with scores on the Rejection Sensitivity Ques-
tionnaire, the Short Scale for Measuring Loneliness, the Beck Anx-
iety Inventory, and the Beck Depression Inventory, the strength of
coefficients between variables ranged from low to moderate
(Table 3), suggesting that the Fear of Social Threat Scale, rather
than measuring a redundant construct with already existing ones,
taps into a distinct psychological dimension.
Moreover, the correlation matrix reveals a significant degree of
overlap between fear of social threat, fear of physical pain, and
other specific types of social (e.g., rejection sensitivity, loneliness,
depression) and physical (ie, pain catastrophizing) pain-related
constructs. For example, the tendency toward pain catastrophizing,
a construct traditionally associated with fear of physical pain [19],
was also related to fear of social threat. Namely, individuals with
high levels of fear toward socially painful situations reported high
levels of pain catastrophizing. Likewise, rejection sensitivity, a con-
struct arguably related to fear of social threat, was also related to
fear of physical pain. A similar pattern was found for depression
and loneliness: high levels of fear of physical pain were associated
with higher scores on depression and loneliness.
In addition to overlaps among measures potentially related to
both fear of social and fear of physical pain, we found unique asso-
ciations between past experiences of each type of distress and fears
for each type of threat. Indeed, high scores of past experiences of
social threat were related to high fear of social, but not physical,
threat. By contrast, high levels of past experiences of physical pain
were associated with high levels of fear of physical, but not social,
threat. This pattern of findings is in line with previous research
[3,24] and suggested the possibility that the relationship between
fear of threat and distress perception might be type specific, such
that each type of fear of threat might be uniquely associated with
the perception of the same type of threat (hypothesis 3).
3. Study 2
Study 2 tested the hypothesis that, similar to what happens with
the perception of physical pain [16], high levels of fear of social
threat would predict greater perception of social threat (hypothesis
2). Moreover, in study 2, we investigated whether factors (e.g., fear
of physical pain) known to regulate the perception of one type of
distress (e.g., physical pain) also regulate the perception of the other
type (e.g., social distress) [11]. Thus, study 2 tested the specificity of
the effect of fear of social threat on social distress by comparing its
Table 2
Factor loads obtained from principal axis factor of the 24 fear of social and physical threat items (study 1).
Item no. Item description Factor 1 Factor 2
1 Being left out of a group .774 .105
2 Being ignored during a party .843 .173
3 Being ignored during a conversation .842 .167
4 Being excluded from a conversation .837 .147
5 Being betrayed by someone who is important to you .655 .031
6 Feeling ignored by someone who is important to you .801 .004
7 Someone who is important to you stops talking to you .736 .061
8 Not being invited to a party organized by your friends .665 .095
9 Being verbally abused by a family member .552 .160
10 Your partner forgetting your birthday. .671 .111
11 Your spouse/partner forgetting your anniversary .667 .068
12 Being betrayed by your partner .690 .101
13 Being embarrassed in front of your classmates by your professor .657 .122
14 Your professor telling at you that you are an incompetent student .629 .156
15 Being verbally abused by your boss .707 .111
16 Breaking your arm .013 .724
17 Breaking your leg .065 .683
18 Breaking your neck .133 .503
19 Hitting a sensitive bone in your elbow—your funny bone .005 .603
20 Getting a paper cut on your finger .066 .614
21 Getting strong soap in both eyes while bathing or showering .063 .575
22 Having a blood sample drawn with a hypodermic needle .006 .508
23 Receiving an injection in your arm .015 .556
24 Receiving an injection in your hip/buttocks .006 .476
Table 3
Means, SDs, and zero-order correlations for Fear of Social Threat, Fear of Physical Pain, and related constructs (study 1).
Item no. Scale Mean SD Fear of Social Threat Scale Fear of Physical Pain Scale
1 Fear of Social Threat Scale 4.26 1.30 ...
2 Fear of Physical Pain Scale 3.41 1.29 .498
⁄⁄
...
3 Rejection Sensitivity Questionnaire 8.94 3.17 .363
⁄⁄
.322
⁄⁄
4 Pain Catastrophizing Scale 1.59 .79 .306
⁄⁄
.472
⁄⁄
3 Beck Anxiety Inventory 10.80 10.02 .208
⁄
.282
⁄⁄
4 Beck Depression Inventory 10.78 8.35 .306
⁄⁄
.223
⁄⁄
5 Short Scale for Measuring Loneliness 2.94 1.36 .281
⁄⁄
.181
⁄
6 Past Experience of Social Distress Index 2.16 1.10 .246
⁄⁄
.151
7 Past Experience of Physical Pain Index 1.89 1.15 .147 .174
⁄
SD, standard deviation.
Significance levels of correlations of
⁄⁄
P< .01 (2-tailed) and
⁄
P< .05 (2-tailed).
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predictive ability to that of 2 other related constructs: fear of phys-
ical pain and rejection sensitivity (hypothesis 3).
3.1. Methods
3.1.1. Participants
One hundred thirty-six students in an introductory psychology
course at Purdue University (58 female subjects, mean age
19.16 years, SD 1.39) volunteered to take part in the study in ex-
change for course credit.
3.1.2. Procedures and materials
Participants were tested in individual cubicles in sessions last-
ing approximately 45 min. They were told that the study was
investigating the effects of mental visualization [47]. Then they
were informed that they would be asked to fill out some personal-
ity measures, take part in a mental visualization exercise, and then
evaluate their mental visualization experience.
Participants were asked to complete their demographic
information and a package of questionnaires, which included the
15-item set of the Fear of Social Threat Scale (
a
= .923), the 9-item
subset related to the Fear of Physical Pain Scale [30] (
a
= .859),
and the Rejection Sensitivity Questionnaire [10] (
a
= .841). The
order of the presentation of scales and items in each scale was
randomized.
During an ostensibly separate study, participants completed a
standard manipulation of social distress (ie, Cyberball [47]). More
specifically, the Cyberball paradigm has been created to induce
ostracism (ie, being excluded and ignored; [45,46]). This paradigm
is designed to resemble an online game that users access through a
network connection. Participants are told that they will engage in a
ball-throwing game with 2 players, ostensibly real participants, for
the purposes of exercising their mental visualization abilities. They
are told that what matters is that they visualize all aspects of the
game, the players, and the location—that who gets or throws the
ball is of no importance to the purpose of the game. In actuality,
the 2 computer characters that appear on the screen are computer
players programmed to either include or exclude the real partici-
pant from the game. In the ostracism condition, after a few throws,
the 2 computer players stop throwing the ball to the actual partic-
ipant for the remainder of the game. In the inclusion condition, the
computer players throw the ball to the actual participant for
approximately one-third of the total tosses [47].
After performing Cyberball, participants were asked to fill in an
NRS-11 [18], an 11-point numerical rating scale on which partici-
pants were asked to rate the unpleasantness (0 = not unpleasant,
10 = most unpleasant experience imaginable) and the intensity
(0 = not at all intense, 10 = most intense imaginable) of the social dis-
tress they felt during Cyberball. The 2 items were combined in an
overall index of social distress. Cronbach’s alpha was .911.
After completing the experiment, participants were thoroughly
debriefed and thanked.
3.2. Results
The influence of fear of social threat and the social distress
manipulation (social inclusion vs ostracism) on reported pain
was explored with a series of moderated multiple regressions. As
revealed by the analyses, both social distress manipulation and
fear of social threat proved to be (on average) predictors of the par-
ticipants’ reported pain (Table 4): induction of social distress re-
sulted in higher levels of self-reported distress compared to the
control condition. However, these results were qualified by a sig-
nificant interaction between social distress manipulation and fear
of social threat. Simple slopes show that in the social distress con-
dition, fear of social threat was significantly related to the reported
pain (B=.433, t(132) = 4.12, P< .001), whereas in the social inclu-
sion condition, it was not (B=.035, t(132) = .336, P= .737) (Fig. 1).
Finally, we controlled for the specificity of this effect (ie, fear of
social threat predicts the experience of social distress) by estimat-
ing the same regression model with possible confounding variables
(and their interaction with the manipulation) as covariates. When
fear of physical pain was added to the analysis, the effect of social
distress manipulation, fear of social threat, and their interaction
remained significant; the effects of fear of physical pain did not
(Table 5). The same pattern occurred when scores on the Rejection
Sensitivity Questionnaire were included in the analysis (Table 5).
3.3. Discussion
In the current experiment, we randomly assigned participants
to be ostracized or included. Consistent with the main hypothesis
of this set of studies (hypothesis 2), people with higher levels of
fear of social threat were more likely to report greater social
distress when ostracized. Supporting hypothesis 3, we found that
this effect was specific to fear of social threat: when concurrent
predictors, such as fear of physical pain or rejection sensitivity,
were entered into the regression analyses, they were not signifi-
cant predictors of the perception of social distress (e.g., ostracism).
4. Study 3
Study 3 was designed to test the hypothesis that assessing fear
of physical pain would predict perception of physical pain better
than would assessing fear of social threat or rejection sensitivity.
In doing so, we further investigated the hypothesis that high levels
of fear of one type of pain (in this case, physical) is linked to in-
creased perception of the same type of unpleasant experience
(hypothesis 3).
4.1. Methods
4.1.1. Participants
Sixty-three students in an introductory psychology course at
Purdue University (30 female subjects; mean age 18.87 years, SD
Table 4
Fear of social threat predicting the experience of social distress (dependent variable: NRS-11; study 2).
Predictor Bt P
Social Distress Manipulation (Cyberball) .950 6.72 <.001
Fear of Social Threat .258 3.61 <.001
Social Distress Manipulation Fear of Social Threat .350 2.46 .015
R
2
= .349, F(3, 132) = 23.60, P< .001
Simple slope coefficients of Fear of Social Threat at:
Cyberball = inclusion .035 .336 .737
Cyberball = ostracism .433 4.120 <.001
NRS-11, numerical rating scale.
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1.14) took part in physical pain manipulation. Participants volun-
teered to take part in the experimental procedures in exchange
for course credit.
4.1.2. Procedures and materials
Participants were tested individually. Similar to study 2, partic-
ipants were told that the study was investigating the effects of
mental visualization.
The same premanipulation measures used in study 2 were
adopted in the present study. Participants completed the 15-item
subset of the Fear of Social Threat Scale (
a
= .923), the 9-item
subset of the Fear of Physical Pain Scale [30] (
a
= .871), and the
Rejection Sensitivity Questionnaire [10] (
a
= .786).
Then participants completed a standard physical pain induction
manipulation (ie, Cold Pressor Task; [31]). Participants were told
that the task was aimed at practice their mental visualization
abilities. Participants were randomly assigned to place the non-
dominant hand up to their wrist into a bucket of water maintained
either at a cold temperature (41°Fto42°F[5°Cto6°C]; the phys-
ical pain induction) or to room temperature (75°Fto80°F [24 °Cto
27 °C]; the physical pain control). They were told they could re-
move the hand at any time if the distress of the experience became
too intense. The duration of exposure to the water was recorded
(video surveillance allowed the experimenter, without being in
the same room, to register the amount of time participants kept
their hand in the water). However, in order to standardize the
amount of physical stimulation, participants were asked to try to
keep their hand inside the cold water for 1 min, an amount of time
usually well tolerated by subjects [44].
Similar to study 2, after performing the pain manipulation, par-
ticipants completed the NRS-11 [18] (
a
= .986), which assessed the
unpleasantness and the intensity of the pain they felt during the
physical pain induction manipulation.
4.2. Results
The influence of the physical pain manipulation (warm water vs
cold water) and of fear of physical pain on reported pain was ex-
plored with a series of moderated multiple regressions. The effects
of the physical pain manipulation, fear of physical pain, and their
interaction were estimated after all continuous variables were
standardized and the manipulation variable was centered to zero.
Table 6 summarizes the results of the regression analysis for the
dependent variable NRS-11. Both physical pain manipulation and
fear of physical pain proved to be predictors of the participants’
pain report, thus confirming that our manipulation of physical pain
by its induction resulted in high levels of self-reported pain com-
pared to the control condition. However, the analyses revealed a
significant interaction of physical pain manipulation fear of
physical pain. Simple slopes showed that in the cold-water condi-
tion, the fear of physical pain was significantly related to the re-
ported pain (B=.338, t(57) = 4.25, P< .001), whereas in the
control condition (ie, warm water) it was not (B=.027,
t(57) = .288 P= .774) (Fig. 2).
We then controlled for the specificity of the effect (ie, fear of
physical pain in predicting the experience of physical pain) by esti-
mating the same model with additional predictor and their interac-
tion with the manipulation as covariates. When fear of social threat
or rejection sensitivity were included in the analyses, physical pain
manipulation, fear of physical pain, and their interaction remained
significant in predicting participants’ pain report, while neither
fear of social threat or rejection sensitivity showed a significant
main effect or an interaction (Table 7).
4.3. Discussion
In the present experiment, we randomly assigned participants
to submerge their hand in either cold water or room-temperature
water. Otherwise, participants followed the same procedure of
study 2. We found that higher levels of fear of physical pain pre-
dicted higher levels of self-reported pain during the procedure.
However, supporting hypothesis 3, this effect was specific to fear
of physical pain. When concurrent predictors, such as fear of social
threat or rejection sensitivity, were entered into the regression
Fig. 1. Effect of fear of social threat on the perception of social distress (e.g.,
ostracism): Participants high in fear of social threat perceived higher levels of pain
intensity and unpleasantness when ostracism was induced. When social inclusion
was induced, fear of social threat did not affect perception of social distress.
Table 5
Series of multiple regressions testing fear of social threat predicting the experience of
social distress with the effects of fear of physical pain and rejection sensitivity
covarying (dependent variable: NRS-11; study 2).
Predictor Bt P
Social Distress Manipulation (Cyberball) .946 6.64 <.001
Fear of Social Threat .243 3.11 .002
Social Distress Manipulation Fear of Social Threat .318 2.04 .043
Social Distress Manipulation Fear of Physical Pain .090 .583 .561
Social Distress Manipulation (Cyberball) .962 6.83 <.001
Fear of Social Threat .216 2.91 .004
Social Distress Manipulation Fear of Social Threat .229 2.02 .045
Social Distress Manipulation Rejection Sensitivity .097 .662 .509
NRS-11, numerical rating scale.
Table 6
Fear of Physical Pain predicting the experience of physical pain (dependent variable:
NRS-11; study 3).
Predictor Bt P
Physical Pain Manipulation 1.66 13.74 <.001
Fear of Physical Pain .182 2.96 .004
Physical Pain Manipulation Fear of Physical Pain .311 2.52 .014
R
2
= .784,
F(3,59) = 71.18, P< .001
Simple slope coefficients of Fear of Physical Pain at:
Manipulation = warm water .027 .288 .774
Manipulation = cold water .338 4.25 <.001
NRS-11, numerical rating scale.
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analyses, they did not show a significant effect on physical pain
perception. Our data thus suggest that high levels of fear of one
type of threat (e.g., physical) is linked to increased perception of
its associated type of distress (e.g., physical) but not to the other
(e.g., social).
5. Discussion
As a German proverb states, ‘‘Fear makes the wolf bigger than
he is.’’ The current investigation supported this observation. Our
study was inspired by medical research documenting that fear of
pain is one of the most important predictors of the experience of
physical pain [16,19,25]. In light of the recently proposed theoret-
ical framework provided by the pain overlap theory [11], we ex-
tended these findings by testing a common effect underlying
reactions to both social distress and physical pain.
First, we found that fear of social threat and fear of physical pain
yielded 2 distinct yet correlated constructs (hypothesis 1). This
finding is compatible with hierarchic structural models of fears
[42,43] and empirical studies on fear of physical pain, which found
that fears of physical pain were associated with social anxiety and
social phobia [2]. Moreover, when we extended our analysis, we
found that constructs such as depression, anxiety, loneliness, and
pain catastrophizing showed a low to moderate correlation with
fear of social and physical threat. Thus, both fear of social and
physical threat related to other conceptually similar constructs,
yet they were not empirically redundant with them.
Second, similar to the effect of fear of physical pain on the per-
ception of physical pain [16,19], we found that fear of social threat
increased the perception of social distress (hypothesis 2). This ef-
fect provides evidence for the common role of fear of threat in
explaining between-person differences in the perception of social
distress and physical pain.
Third, the present results suggest the specificity of the effect in
that each fear was able to predict the increased perception of its
associated type of distress (ie, fear of social threat predicted so-
cially painful experiences; fear of physical pain predicted physi-
cally painful experiences), but not the other (hypothesis 3). By
showing the specificity of the link between the fear of one type
of threat and the selectively increased perception of its associated
type of distress, we provided further support for hierarchical con-
ceptualizations of fears suggesting that different fears are structur-
ally related yet distinct from each other [42,43]. More specifically,
we argue that, within a hierarchical conceptualizations of fears
[42,43], fear of social threat and fear of physical pain are parallel
in structure; they operate at the same level of specificity within
the hierarchical structure, both under higher-order factors (e.g.,
neuroticism) and both above factors that are stimulus specific
(e.g., fear of needles, fear of betrayal). However, the specificity ef-
fect indicates that the increased perception of a particular type of
threat may not be due only to a general fear or to a general sensi-
tivity trait, but additionally to a specific component. In this regard,
we also note that this finding might provide a boundary condition
to pain overlap theory. Indeed, pain overlap theory posits that
traits related to a heightened sensitivity to one type of pain (e.g.,
physical) should also relate to a heightened sensitivity to the other
type of pain (e.g., social) [11]. This statement should lead to the
expectation that a trait known to be related to heightened sensitiv-
ity to physical pain, such as fear of physical pain [16,19], should be
related to sensitivity to social threat as well. This is not what our
data showed. Indeed, we found that high levels of fear of one type
of pain (e.g., social) are specifically linked to increased perception
of that particular type of distress (e.g., social), but not the other
(e.g., physical). The pattern of these results is compatible with
the notion that intense and repeated past experiences of one type
of distress might selectively sensitize the individual toward that
specific type of distress [37] and that the personal pain history of
the individual could affect his or her perception of pain [3,24].
In terms of social threat understanding and management, the
present findings provide insights as to at least one reason why
individuals differ in their experiences of social distress (including
reactions to ostracism, exclusion, and rejection): their fears of so-
cial threat differ. People who fear humiliation are more likely to
experience higher levels of social threat when they are humiliated.
These results might also inform our understanding of how individ-
ual differences in fear of social threat moderates the relationship
between experiences of social distress (e.g., social separation)
and individuals’ reactions to them. The current study is consistent
with previous research that showed that social anxiety moderated
responses to social exclusion, such that participants high in social
anxiety exhibited more evidence of maladaptive social responses
[27]. Indeed, fear and anxiety can increase the perception of social
threat, thus promoting avoidance and withdrawal rather than
motivation to connect with others.
Moreover, by showing the overlap of the effect of the same
underlying factor (ie, fear of threat on increased distress percep-
tion) on both social distress and physical pain, our findings suggest
that the same effect might account for the onset of the perception
of persistent social distress and physical pain. In the context of
physical pain, fear avoidance models [2] predict that the onset of
Fig. 2. Effect of fear of physical pain on the perception of physical pain. Participants
high in fear of physical pain perceived high levels of pain intensity and unpleas-
antness when physical pain was inducted. When physical pain was absent, fear of
physical pain did not affect the perception of pain.
Table 7
Series of multiple regressions testing fear of Physical Pain predicting the experience of
physical pain with the effects of fear of social threat and rejection sensitivity
covarying (dependent variable: NRS-11; study 3).
Predictor Bt P
Physical Pain Manipulation 1.66 13.50 <.001
Fear of Physical Pain .178 2.68 .010
Physical Pain Manipulation Fear of Physical Pain .309 2.33 .023
Physical Pain Manipulation Fear of Social Threat .012 .091 .928
Physical Pain Manipulation 1.64 13.19 <.001
Fear of Physical Pain .167 2.65 .010
Physical Pain Manipulation Fear of Physical Pain .286 2.26 .027
Physical Pain Manipulation Rejection Sensitivity .141 .943 .350
NRS-11, numerical rating scale.
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a vicious cycle of high physical pain-related fears, increased phys-
ical pain perception, and avoidance tendencies are likely to lead to
chronic physical pain. In the context of social threat, the same cycle
of high fear?increased distress perception?avoidance tendencies
might be involved in the long-term experiences of ostracism and
social exclusion. Indeed, individuals with high levels of fear of so-
cial threat might be more prone to avoid, rather than seek, social
connections [28]. Accordingly, we argue that timely identification
of high levels of (social or physical) threat-related fear is critical
for identifying individuals who will benefit most from preventative
interventions aimed to limit negative cycles of high avoidance and
increased distress perception. Considering the common brain re-
sponses for social distress and physical pain [13], an interesting
question concerns the potential common antecedent of chronic so-
cial distress and physical pain. Future research is needed to address
this issue.
5.1. Limitations
This study has several limitations. First, in the present research,
we incorporated only self-report measures of fear of physical pain,
fear of social threat, and the experience of social distress and phys-
ical pain. Therefore, future studies should adopt implicit and/or
physiological measures of fear of threat (e.g., skin conductance)
and use different strategy to assess social distress and pain percep-
tion (e.g., fMRI). However, previous research has shown that neural
activation correlates strongly with self-report scores of fear of pain
and with pain ratings [13]. Second, although we have shown initial
evidence for convergent (study 1), predictive (study 2), and diver-
gent (study 3) validity of our newly developed scale, more research
is needed to further evaluate other psychometric properties of the
Fear of Social Threat Scale. Third, our sample population consisted
of university students (pain-free individuals) who received extra
credit for their participations. Thus, replicating the pattern of our
results with a community sample would be necessary before
attempting generalizations and norms. Furthermore, as we have al-
ready pointed out, future studies should investigate the role of fear
of social threat in the experience of long-term episodes of social
threat and its overlap with the experience of chronic physical pain.
In this sense, the questions raised here are the beginning of a pro-
gram of research investigating fear of social threat and its impact
on perception of social distress. So as many questions as we hoped
to answer, there are many more that we could ask. For instance,
which factors determine one’s tendency to become fearful of pain
(fear-proneness)? How does threat-related fear increase the per-
ception of social distress (ie, via which neural processes [35])?
How does this mechanism serve to maintain social distress? Is this
the path to the development of chronic feelings of ostracism and
social exclusion? How can we best treat individuals with high fear
of social threat? Future research should start to address some of
these important questions.
5.2. Conclusion
Decades of research on physical pain perception have shown
that the simple proportionality that was initially presumed to oc-
cur between the strength of a stimulus and the degree of perceived
pain lacks empirical support. Several factors intervene in modulat-
ing pain perception, among which fear seems to be one of the most
key predictor of the perception of physical pain. On the basis of
pain overlap theory [11], we tested whether fear of social threat
could modulate the perception of social distress. We found that,
similar to the influence of fear of physical pain on physical pain
perception, fear of social threat moderated the perception of social
distress (e.g., ostracism). Yet we also found a specific type-related
effect, such that the specific type of threat one fears (e.g., social)
predicts the perception of its associated type of distress (e.g., so-
cial), but not the other (e.g., physical). Thus, we provided evidence
for a general effect (e.g., the role of fear in increasing the percep-
tion of distress) but also evidence that high levels of fear of one
type of threat is selectively linked to increased perception of that
particular type of distress.
Conflict of interest
The authors report no conflict of interest.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at http://dx.doi.org/10.1016/j.pain.2013.11.006.
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