The Psychological Inflexibility in Pain Scale (PIPS) – Statistical properties and model fit of an instrument to assess change processes in pain related disability
Abstract
Recent developments within CBT have emphasized acceptance rather than control of pain and distress in treatments aimed at improving functioning and life quality, but there is still a lack of reliable and valid instruments to assess relevant processes in such interventions. The Psychological Inflexibility in Pain Scale (PIPS) was developed to assess target variables in exposure and acceptance oriented treatments. A preliminary validation study resulted in a two‐factor solution with subscales for avoidance and cognitive fusion related to pain, showing satisfactory psychometric properties. This study sought to evaluate the instrument with 611 participants with whiplash associated disorders. Exploratory and confirmatory factor analyses supported a two‐factor solution with 12 items which showed an acceptable model fit, adequate internal consistencies, and strong relations with criteria variables (e.g. disability and life satisfaction). The construct validity of the instrument was supported by high correlations with subscales from the Chronic Pain Acceptance Questionnaire (CPAQ) and the Tampa Scale of Kinesiophobia (TSK). Notably, hierarchical regression analyses illustrated that PIPS explained more variance than TSK in pain, disability, life satisfaction and depression. Furthermore, PIPS was found to mediate the relationship between e.g. pain and disability, suggesting the usefulness of PIPS as a process measure in treatments of people with chronic pain. Thus, it is argued that this 12‐item version of PIPS may be used to explore the importance of psychological in/flexibility in chronic pain and to analyse processes of change in exposure based interventions, as well as for clinicians in tailoring interventions for patients with chronic debilitating pain.
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The Psychological Inflexibility in Pain Scale revealed an avoidance of pain factor and a cognitive fusion with pain factor.
“the Psychological Inflexibility in Pain Scale (Wicksell et al., 2010) revealed an avoidance of pain factor and a cognitive fusion with pain factor.”
From Psychological inflexibility in university students: the european portuguese version of the acceptance and action questionnaire—university students (2023) · cites this paper as Wicksell et al., 2010
Previous studies have shown Cronbach's alphas of 0.89 and 0.87 for the PIPS, illustrating adequate internal consistency.
“In terms of reliability, previous studies have shown Cronbach’s alphas of 0.89 [32] and 0.87 [14], illustrating that the questionnaire has adequate internal consistency.”
From Baseline Pro-Inflammatory Cytokine Levels Moderate Psychological Inflexibility in Behavioral Treatment for Chronic Pain (2022) · cites this paper as [14]
Psychological inflexibility is a central treatment target in ACT.
“Psychological inflexibility, as assessed with, e.g., Psychological Inflexibility in Pain Scale (PIPS) [14], is thus a central treatment target in ACT.”
From Baseline Pro-Inflammatory Cytokine Levels Moderate Psychological Inflexibility in Behavioral Treatment for Chronic Pain (2022) · cites this paper as [14]
Psychological inflexibility is characterized by rigid behavioral repertoires aimed at avoiding pain and related distress, which may work well in the short term but over time result in a gradual decrease in functioning without any corresponding alleviation of pain or distress.
“Psychological inflexibility is characterized by rigid behavioral repertoires aimed at avoiding pain and related distress [14,15], which may work well in the short term, but over time result in a gradual decrease in functioning without any corresponding alleviation of pain or distress [16].”
From Baseline Pro-Inflammatory Cytokine Levels Moderate Psychological Inflexibility in Behavioral Treatment for Chronic Pain (2022) · cites this paper as [14]
The PIPS subscales were significantly correlated with both subscales of the Chronic Pain Acceptance Questionnaire and the activity avoidance subscale of the Tampa Scale of Kinesiophobia.
“Regarding construct validity, the psychometric evaluations also showed that the PIPS subscales were significantly correlated (p < 0.001) with both subscales of the Chronic Pain Acceptance Questionnaire (CPAQ) as well as the activity avoidance subscale of the Tampa Scale of Kinesiophobia (TSK).”
From Baseline Pro-Inflammatory Cytokine Levels Moderate Psychological Inflexibility in Behavioral Treatment for Chronic Pain (2022) · cites this paper as [14]
PIPS accounted for a significant amount of variance in pain, medication use, work absence, life satisfaction, pain disability, anxiety, depression, kinesiophobia and acceptance, indicating adequate concurrent criteria validity.
“Finally, PIPS accounted for a significant amount of variance in pain, medication use, work absence, life satisfaction, pain disability, anxiety, depression, kinesiophobia and acceptance [14], indicating adequate concurrent criteria validity.”
From Baseline Pro-Inflammatory Cytokine Levels Moderate Psychological Inflexibility in Behavioral Treatment for Chronic Pain (2022) · cites this paper as [14]
The Psychological Inflexibility in Pain Scale has adequate psychometric properties and responsivity to change in a Swedish chronic pain sample.
“In the original validation in a Swedish chronic pain sample, adequate psychometric properties and responsivity to change were shown (Wicksell et al., 2010).”
From Internet-delivered acceptance and commitment therapy as microlearning for chronic pain: A randomized controlled trial with 1-year follow-up (2021) · cites this paper as Wicksell et al., 2010
Psychological inflexibility in pain, as measured by PIPS, comprises avoidance to pain, which is linked to fear of movement and the anticipated threat value of intense pain.
“Psychological inflexibility in pain, as measured by PIPS, comprises avoidance to pain [24], which is known to be inherently linked to fear of movement [23] and the anticipated threat value of intense pain.”
From The bed nucleus of the stria terminalis as a brain correlate of psychological inflexibility in fibromyalgia (2020) · cites this paper as [23]
Previous research with adults with chronic pain supports the psychometric properties and the use of PIPS as a process measure to assess changes in pain-related disability after ACT-based treatment.
“Previous research with adults with chronic pain supports the psychometric properties and the use of PIPS as a process measure to assess changes in pain-related disability after ACT-based treatment [28,29,30].”
The original PIPS studies confirmed a two-factor solution and acceptable reliability and validity.
“The studies confirmed a two-factor solution and acceptable reliability and validity.”
The core feature of psychological flexibility is 'confrontation instead of avoidance', consistent with the theory of Exposure.
“this is in line with the idea that the core feature of psychological flexibility is 'confrontation instead of avoidance' (Wicksell et al., 2010), consistent with the theory of Exposure.”
From Exposure and CBT for chronic back pain: An RCT on differential efficacy and optimal length of treatment (2018) · cites this paper as Wicksell et al., 2010
The pain avoidance item is based on the Psychological Inflexibility in Pain Scale.
“the pain avoidance item is based on the Psychological Inflexibility in Pain Scale,65”
From Development, evaluation and implementation of a digital behavioural health treatment for chronic pain: study protocol of the multiphase DAHLIA project (2022) · cites this paper as [65]
The Psychological Inflexibility in Pain Scale (PIPS) has adequate statistical properties.
“Results from two previous studies illustrate that the questionnaire has adequate statistical properties (Wicksell et al. 2010).”
From Low-grade inflammation may moderate the effect of behavioral treatment for chronic pain in adults (2016) · cites this paper as Wicksell et al. 2010
The Psychological Inflexibility in Pain Scale (PIPS) Swedish language original has satisfactory reliability (α = .87) and validity.
“The Swedish language original (used in this study) has been shown to have satisfactory reliability (α = .87) and validity (Wicksell, Lekander, et al., 2010).”
From Predictors and mediators of outcome in cognitive behavioral therapy for chronic pain: The contributions of psychological flexibility (2021) · cites this paper as Wicksell, Lekander, et al., 2010
The PIPS has demonstrated acceptable validity and reliability.
“This measure has demonstrated acceptable validity and reliability (Wicksell, Lekander, et al., 2010).”
From Predictors and mediators of outcome in cognitive behavioral therapy for chronic pain: The contributions of psychological flexibility (2021) · cites this paper as Wicksell, Lekander, et al., 2010
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“[8, 9]; the samples included participants with mixed pain conditions and a large sample with participants who had disorders associated with whiplash.”
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Self-citationThe psychometric properties of the cognitive fusion questionnaire in adolescents
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Does Intolerance of Uncertainty Affect the Magnitude of Limitations or Pain Intensity?
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Acceptance & Commitment Therapy for ME/CFS (Chronic Fatigue Syndrome) – A feasibility study
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“66 for the Cognitive Fusion subscale [47, 48].”
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Self-citationPredicting and Preventing Chronic Postsurgical Pain and Disability
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Self-citationNeuropsychiatric Symptoms in Pediatric Chronic Pain and Outcome of Acceptance and Commitment Therapy
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Application of a diagnosis-based clinical decision guide in patients with low back pain
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- Authors
- Wicksell, R. K., Lekander, M., Sorjonen, K., & Olsson, G. L.
- Affiliations
- Karolinska University Hospital (SE)
- Karolinska Institutet (SE)
- Corresponding author
- Wicksell, Rikard K.
- Venue
- European Journal of Pain
- Publisher
- Wiley
- Published
- 2010-08
- Volume
- 14
- Issue
- 7
- Pages
- 771.e1-14
- ISSN
- 1090-3801 (ISSN-L)
- 1532-2149
- OpenAlex
- W2090496708
- Cited by
- 176
- References
- 46
- Citations by year
- 2026: 11 · 2025: 17 · 2024: 10 · 2023: 13 · 2022: 16 · 2021: 17 · 2020: 13 · 2019: 14 · 2018: 9 · 2017: 9 · 2016: 9 · 2015: 13 · 2014: 8 · 2013: 5 · 2012: 3
- FWCI
- 6.34
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- European Journal of Pain (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
- Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- psychological inflexibility, chronic pain, pain-related disability, acceptance and commitment therapy, avoidance, cognitive fusion, whiplash-associated disorders, kinesiophobia, life satisfaction, depression, process indicators, psychometric validation
- MeSH terms
- Adaptation, Psychological, Adolescent, Adult, Aged, Aged, 80 and over, Chronic Disease, Factor Analysis, Statistical, Female, Humans, Male, Middle Aged, Pain, Pain Measurement, Personal Satisfaction, Psychometrics, Quality of Life, Surveys and Questionnaires, Severity of Illness Index, Cognitive Behavioral Therapy, Chi-Square Distribution, Pain Management
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