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European Journal of Pain 8 (2004) 31–38
www.EuropeanJournalPain.com
The tridimensional personality theory and pain: harm avoidanceand reward dependence traits correlate with pain perception
in healthy volunteers
Dorit Pud a,b,c,*, Elon Eisenberg a,b,d, Elliot Sprecher b,d, Zeev Rogowski b,d,David Yarnitsky b,e,d
a Pain Relief Unit, Rambam Medical Center, Haifa, Israelb Haifa Pain Research Group, Israel
c Faculty of Social Welfare and Health Studies, University of Haifa, Haifa 31905, Israeld The Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Israel
e Department of Neurology, Rambam Medical Center, Israel
Received 2 September 2002; accepted 26 May 2003
Abstract
The aim of the present study was to examine the possible role of personality traits in determining the variability of pain per-
ception among individuals. More specifically, it was intended to test whether or not the three personality dimensions suggested by
Cloninger in 1987 – mainly harm avoidance (HA), but also reward dependence (RD), and novelty seeking (NS), can predict in-
terpersonal differences in responsiveness to experimental pain. Seventy healthy volunteers participated in the study. Their per-
sonality traits were evaluated through Cloninger�s tridimensional personality questionnaire (TPQ). Pain threshold (latency to pain
onset), pain magnitude (VAS), and pain tolerance (time to withdrawal) were measured by using the cold pressor test. Bonferroni-
adjusted correlations were found between HA and the pain parameters as follows: a negative correlation between HA and threshold
(q ¼ �0:297, Padj ¼ 0:039); no significant correlation between HA and tolerance (q ¼ �0:219, Padj ¼ 0:207); and a trend for a
positive correlation between HA and VAS (q ¼ 0:266, Padj ¼ 0:081). Possible correlations between pain perception and the various
possible combinations of high and low scoring for each of the three traits were also investigated. Correlations were found only for
the combinations of high/low HA and high/low RD. The low HA/low RD combination demonstrated the lowest responsiveness to
pain (VAS 65.2� 21.4; tolerance 107.6� 71.8 s), whereas the high HA/low RD combination was correlated with the highest re-
sponsiveness (VAS 83.3� 10.8; tolerance 30.8� 28.4 s). The results indicate that HA personality trait correlates best with pain
responsiveness. As such, a high HA are likely to predict a heightened pain response. RD may modify this pattern. The possible
relevant behavioral and neuro-chemical mechanisms are discussed.
� 2003 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Ltd. All
rights reserved.
Keywords: Cold pressor test; Pain magnitude; Pain threshold; Pain tolerance; Personality traits; Tridimensional personality theory
1. Introduction
There are large individual differences in the percep-tion of clinical and experimental pain, in the propensity
to develop painful syndromes, and in the response to
pain-relieving treatments. Experimental pain studies
show a wide range of stimulus–response relations
* Corresponding author. Tel.: +972-4-8288013; fax: +972-4-8288017.
E-mail address: doritpud@research.haifa.ac.il (D. Pud).
1090-3801/$30 � 2003 European Federation of Chapters of the International
reserved.
doi:10.1016/S1090-3801(03)00065-X
between the intensity of the noxious stimulus and the
reported magnitude of pain perception (Mogil, 1999a).
Furthermore, considerable interpersonal variability inpain thresholds has been demonstrated for pressure pain
(Brennum et al., 1989; Isselee et al., 1997), cold pressor
tolerance (Chen et al., 1989), and heat pain (Kleinbohl
et al., 1999; Yarnitsky et al., 1995, 1996).
Much effort has been invested over the years in an
attempt to identify factors predicting pain perception.
Although the results have not always been consistent,
Association for the Study of Pain. Published by Elsevier Ltd. All rights
32 D. Pud et al. / European Journal of Pain 8 (2004) 31–38
several factors have been found to correlate with dif-ferent pain parameters. First, most clinical trials have
found gender-dependent differences in pain perception,
with women reporting more intense, prolonged and
frequent pain than men (Fillingim and Maixner, 1995;
Keefe et al., 2000; Riley et al., 1998; Unruh, 1996).
Experimental pain studies, on the other hand, have been
less consistent regarding gender differences in pain per-
ception, depending partially on the pain modality used(Fillingim et al., 1997; Lautenbacher and Strain, 1991;
Lautenbacher and Rollman, 1993). Second, high anxiety
levels have been found to correlate with post-operative
pain magnitude (Thomas et al., 1998), labor pain
(Green, 1993), and experimental pain induced by elec-
trical stimulation (Janssen and Arntz, 1999). Third,
cultural background has been shown to influence the
response to experimental and acute pain (see the reviewby Williams, 1999). Fourth, pain perception has been
shown to be associated with autonomic activity, as re-
flected in the association between increased arterial
blood pressure and decreased perception of pain (al�Absi
et al., 1999; Ditto et al., 1993; Ghione et al., 1988; Zamir
and Shuber, 1980). Finally, recent animal studies have
demonstrated the influence of genetic factors on pain
perception (Mogil et al., 1999b; Mogil, 1999c).An area of great interest in this context is the role of
personality traits in pain perception. Personality traits
are defined as ‘‘deeply ingrained patterns of behaviors,
which include the way one relates to, perceives, and
thinks about the environment and oneself that are ex-
hibited in a wide range of social and personal contexts’’
(American Psychiatric Association, 1994). Since pain is
widely accepted to be a bio-psychosocial process (Turk,1996), it is very likely to be influenced by personality.
Over the years, researchers have investigated the con-
tribution of personality to pain perception, both
through experimentally induced pain models as well as
in various clinical settings. The different parameters
measured include pain threshold, pain magnitude, tol-
erance, and pain behavior. Still, findings are inconsistent
and the relationship between personality and the variouspain parameters remains unclear (Phillips and Gatchel,
2000).
A unique personality theory that appears to make a
great contribution to the understanding of psychiatric
disorders is Cloninger�s tridimensional personality the-
ory (Cloninger, 1986, 1987; Hansenne et al., 1998; Nel-
son and Cloninger, 1997; Russo et al., 1994). This theory
is derived from the unified bio-social model of person-ality and is based on the hypothesis that neuro-chemical
transmitters determine stimulus–response characteris-
tics. Accordingly, three sets of behavioral manifestations
and their corresponding neuro-transmitters are hy-
pothesized: (1) Novelty seeking (NS), described as a
tendency to respond with intense excitement to novel
stimuli, leading to pursuit of rewards and escape from
punishment. This trait is associated with dopamine. (2)Harm avoidance (HA), defined as a tendency to respond
intensely to previously established signals of aversive
stimuli and to learn to passively avoid punishment,
novelty and frustrating non-reward. This trait is asso-
ciated with serotonin. (3) Reward dependence (RD),
characterized as a tendency to respond intensely to sig-
nals of reward and to maintain behavior previously as-
sociated with reward or with relief of punishment. Thistrait is associated with noradrenaline.
This theory is assumed to have relevance for pain
perception given that serotonin and noradrenaline are
the major neurotransmitters in the inhibitory modula-
tion of pain through descending pathways (Fields and
Basbaum, 1999). Dopamine may also be involved in
pain processing, as suggested by the painful syndromes
described in Parkinsonian patients (Chudler and Dong,1995). Furthermore, behaviors along the lines delineated
by the Cloninger theory may correspond to pain-related
behavior. For example, avoidance of harm is probably
equivalent to avoidance of pain, so that high scores on
harm avoidance would likely produce relatively high
scoring of painful stimuli.
The aim of our study was to examine the possible role
of personality traits in explaining the variability of painperception among individuals. Specifically, we at-
tempted to identify the relationships between personal-
ity traits and the parameters of pain threshold, tolerance
and magnitude estimation. To the best of our knowl-
edge, this is the first attempt to implement Cloninger�stheory in the context of pain perception. Our working
hypothesis was that individuals with high HA scoring,
who are nearly always fearful and anticipating harm,pessimistic and inhibited by unfamiliar situations, would
probably express high pain response. We assumed that
the other two dimensions will not, by themselves, predict
pain perception; NS because of the unpredictability of
the individual response, and RD because of their heavy
inconsistency and dependence on circumstances.
2. Method
2.1. Subjects
Seventy healthy volunteers participated in the study
at Rambam Medical Center in Haifa, Israel. The study
included 38 male and 32 female subjects, with ages
ranging from 18 to 40 years (mean 24.3� 3.9, SD). Thevolunteers were recruited mostly from the student body
of the medical and nursing schools, and enrolled in the
study after meeting the following criteria: (1) freedom
from chronic pain of any type; (2) no use of any medi-
cation (except oral contraceptives); and (3) ability to
understand and follow the instructions of the study. All
subjects were paid for participating the study. A written
D. Pud et al. / European Journal of Pain 8 (2004) 31–38 33
informed consent was obtained from all subjects prior tobeginning the study. The study protocol was approved
by the hospital�s Ethics Committee and the National
Board of Health in Israel.
2.2. Instruments
2.2.1. Personality trait evaluation
The tridimensional personality questionnaire (TPQ)is a 100-item true/false self-report inventory (Cloninger,
1987). It has been translated into several languages and
used in a variety of studies. The questionnaire has been
translated into Hebrew, and this version�s reliability was
demonstrated by high Cronbach�s alpha (0.90 for NS,
0.89 for HA, and 0.85 for RD) (Gil, 2003). Nixon and
Parsons (1989) provided evidence for the construct va-
lidity of the questionnaire in a sample of 225 male andfemale college students. They analyzed scores for each
personality dimension with respect to gender, academic
major, college GPAs, and abstraction test scores. Their
results support Cloninger�s theoretical concept of three
essentially independent personality dimensions. This
instrument measures the three primary personality fac-
tors thought to be involved in the mediation of partic-
ular types of stimuli, with 34 questions relating to NS,another 34 questions to HA, and 30 questions to RD
(Cloninger et al., 1991). Two questions (No. 61 and 71)
were excluded from scoring because of non-specificity
(correlations with multiple factors) (Cloninger, 1987).
Test–retest correlations were found to be moderately
high (Cloninger et al., 1991). The total score for each
dimension was calculated.
2.2.2. Experimental cold tonic pain
The cold pressor test (CPT) apparatus (Heto CBN
8-30 Lab equipment, Allerod, Denmark) is a tempera-
ture-controlled water bath of 1.0 �C, with a maximum
temperature variance of �0.5 �C, that is continuously
stirred by a pump.
2.3. Study protocol
All subjects completed the Hebrew version of the
TPQ. As for the cold pressor test, following the standard
protocol (see e.g., Wolff, 1984), subjects were asked to
place their non-dominant hand in the CPT bath in a still
position with the fingers wide apart for as long as they
could. A cut-off time of 3 min was set for safety reasons.
This initial immersion was considered training or fa-miliarization, and the results were not used in the sta-
tistical analysis. Thirty minutes later, a second CPT
immersion was conducted in the same manner and re-
garded as the baseline measure.
Subjects were instructed to indicate the exact point in
time when the cold sensation began to hurt, and they
first felt pain. This was defined as the pain threshold.
The latency to intolerability (spontaneous hand re-moval) was defined as pain tolerance. Tolerance for
subjects that did not withdraw their hand for the entire
180 s was recorded as 180 s. Immediately after with-
drawing their hand, subjects were asked to mark on a
100 mm VAS ruler the maximal pain intensity they ex-
perienced during the cold stimulus. The VAS was de-
fined a priori to the subjects as a continuum with one
anchor at 0, representing �no pain at all�, and the otheranchor at 100, representing the �worst pain one can
imagine�. This mark was defined as the pain magnitude.
2.4. Statistical analysis
Statistical analysis employed ANOVA, linear regres-
sion and Spearman correlations (q indicates Spearman
correlation). Shapiro–Wilk tests were used to examinethe deviation of result distributions from normality.
Arcsine, log, or square root transformations (Zar, 1984)
were employed as needed to improve the normality of
result distributions and to enable the use of ANOVA.
Excel (Microsoft Corp., WA, USA), JMP, and SAS
(SAS Institute, NC, USA) were employed in the statis-
tical analyses. Results were considered significant at the
0.05 levels; if multiple tests were required, raw P valueswere Bonferroni-adjusted appropriately. All results are
given as means� SD.
3. Results
3.1. Personality traits
Analysis of the 70 TPQ questionnaires from the
present study showed a NS mean score of 16.4� 4.4; an
HA mean score of 9.6� 5.6; and a RD mean score of
19.2� 4.7.
3.2. Pain perception
The results demonstrate that exposure to the CPTproduced significant pain, as measured by the three
different variables of threshold, tolerance, and magni-
tude (see Table 1), without causing any harm to the
subjects. These results are in line with those reported in
previous studies (Cleeland et al., 1996; Eckhardt et al.,
1998; Fromm et al., 1997; Garcia de-Jalon et al., 1985;
Jones et al., 1988; Lovallo, 1975; Peckerman et al., 1994;
Poulsen et al., 1995). Results of the CPT are as follows.
3.2.1. Threshold
Mean threshold was 7.1� 4.5 s, ranging from 1 to 24 s
(see Fig. 1A). Since the distribution of threshold among
subjects was not normal, a log transformation was used
for normalization, as confirmed by the Shapiro–Wilk test
(P ¼ 0:279).
Table 1
Pain parameters in response to CPT (n ¼ 70)
Threshold (s) (THRE) Tolerance (s) (TOL) VAS (0–100)
Mean� SD 7.1� 4.5 54.8� 46.9 72.8� 15.8
Median 6 38 73
Range 1–24 6–180 20–100
34 D. Pud et al. / European Journal of Pain 8 (2004) 31–38
3.2.2. Tolerance
Mean tolerance was 54.8� 46.9 s, ranging from 6 to
180 s (see Fig. 1B). About two-thirds of the subjects
demonstrated high sensitivity to cold stimuli and could
tolerate the pain for no more than 60 s. The others were
found to be more tolerant to cold pain and could keep
their hands in the water for a longer time. This distri-
bution is similar to previously published data (Chenet al., 1989; Cleeland et al., 1996). The distribution of
this data was not normal, and no conventional trans-
formation technique was able to normalize it.
3.2.3. Pain magnitude
Mean VAS was 72.8� 15.8, ranging from 20 to 100
(see Fig. 1C). Since the distribution of pain magnitude
among subjects was not normal, the arcsine transfor-mation was successfully used for normalization, as
confirmed by the Shapiro–Wilk test (P ¼ 0:755).Spearman correlations, on untransformed data, for
non-parametric variables found a significant positive
correlation between threshold and tolerance (q ¼ 0:622,P < 0:0001) and negative correlations between VAS and
tolerance (q ¼ �0:218, P ¼ 0:038), as well as between
VAS and threshold (q ¼ �0:208, P ¼ 0:048).
Fig. 1. Threshold (A), tolerance (B), and magnitude (C) of pain in
response to CPT.
3.3. Relationship between personality traits and pain
perception
In order to avoid statistical problems with non-normal
distributions and outlying data, we performed three
Spearman correlations, relating the HA scores separately
to each of the three pain measures. Raw P values were
Bonferroni-adjusted by multiplication by 3. Correlations
were found between HA and the pain parameters as
follows: a negative correlation between HA and thresh-
old (q ¼ �0:297, P ¼ 0:013, Padj ¼ 0:039) (see Fig. 2A);no significant correlation between HA and tolerance
(q ¼ �0:219, P ¼ 0:069, Padj ¼ 0:207) (see Fig. 2B); and atrend for a positive correlation between HA and VAS
(q ¼ 0:266, P ¼ 0:027, Padj ¼ 0:081) (Fig. 2C).Thus, individuals with high HA scores demonstrated
enhanced sensitivity to painful stimuli, as expressed by a
low pain threshold and increased pain perception. In a
separate analysis, NS and RD failed to demonstratesignificant correlations with any of the pain parameters.
A further analysis using linear regression on trans-
formed data indicated that, when taken together, HA
and RD demonstrated a trend toward a correlation with
pain magnitude (P ¼ 0:084). The other combinations of
the personality traits (HA and NS; NS and RD) failed to
show correlations with any pain parameter.
Consequently, the subjects were then categorized into
two different groups for each trait, with the mean point
score delineated as the cut-off point. A mean rather than
median was used, in order to follow as closely as pos-
sible the original report by Cloninger (1987). Thus, sixdifferent subgroups (high score and low score for each
trait) were created. This was followed by a pairing of the
traits (e.g., HA and RD) so as to produce three 2� 2
cross-tabulations (e.g., high and low HA vs. high and
low RD). For the HA/RD interaction, we found that the
low HA/low RD group demonstrated the lowest pain
magnitude (VAS 65.2� 21.4), whereas high HA/low RD
showed the highest pain magnitude (VAS 83.3� 10.8).The other two groups (low HA/high RD and high HA/
Fig. 2. Scatter plots of correlations between threshold (A), tolerance
(B), and pain magnitude (C), and HA scores. The P value for each
Spearman correlation has been Bonferroni-adjusted for the three
comparisons.
D. Pud et al. / European Journal of Pain 8 (2004) 31–38 35
high RD) were in-between (VAS 73.6� 15.1 and
73.2� 14.3) (see Fig. 3). ANOVA on the transformed
data indicated that this difference was statistically sig-
nificant (P ¼ 0:026).The same pattern was found in regard to pain toler-
ance. The low HA/low RD group demonstrated the
longest tolerance (107.6� 71.8 s), whereas the high HA/
low RD group showed the shortest tolerance(30.8� 28.4 s). Here too, the other two groups were in-
between (54.4� 42.9) and (51.6� 46.4), with statistical
significance at the P ¼ 0:002 level. Likewise, regarding
pain threshold, the low HA/low RD group demon-
strated the longest threshold (7.3� 4.6 s), whereas the
high HA/low RD group showed the shortest threshold
(5.2� 3.2 s). The other two groups were in-between
(6.9� 4.1 and 7.0� 3.2 s). ANOVA indicated only atrend toward significance for this variable (P ¼ 0:083).
Analysis of HA vs. NS and of RD vs. NS, using thesame methodology, failed to show any significant results.
4. Discussion
The findings of the present study suggest that per-
sonality traits can play an important role in the under-
standing of the variability of pain perception amongindividuals in pain perception. More specifically, they
indicate that the personality traits described by Clon-
inger may predict responsiveness to cold-induced ex-
perimental pain. High HA level alone and – even more
so – a combination of high HA and low RD seems to be
the most important traits in the determination of
heightened cold pain perception.
Clinically, Cloninger�s model has been the basis for alarge number of studies on various psychiatric disorders,
such as depression, anxiety disorders, and suicidal be-
havior (Gil, 2003; Hansenne et al., 1998; Herran and
Vazquez, 1998; Nelson and Cloninger, 1997; Starcevic
et al., 1996). Hansenne et al. (1998) demonstrated higher
harm avoidance scores and lower novelty seeking scores
among depressed patients as compared to healthy con-
trols. Gil (2003) found that psychiatric patients charac-terized by high levels of both HA and NS are at greater
risk for suicide attempt. Menza et al. (1993) found low
scores for the novelty-seeking trait, which represents
dopaminergic activity, among Parkinson�s patients as
compared to a group of other orthopedic patients with
motor disturbances.
Possible relations between personality traits and pain
perception have been discussed by several earlier writers.A common theoretical perspective used to examine
personality was proposed by Eysenck (1960), who di-
vided personality into two main independent, uncorre-
lated factors: extroversion–introversion and neuroti
cism-stability. He defined extroverted people as more
outgoing, uninhibited and socially active, whereas in-
troverts were considered to be quieter, more introspec-
tive and reserved. In examining the relationship betweenpersonality and experimental heat pain, Lynn and Ey-
senck (1961) found higher tolerance among extroverted
subjects, whereas other researchers (Brown et al., 1973;
Martin and Inglis, 1965) using the cold pain model
failed to report a significant relationship.
As for clinical pain, Bond et al. (1976) found higher
pain magnitude among extroverted patients suffering
from back surgery pain, whereas Taenzer et al. (1986)found no correlation between personality dimensions
and post-operative gallbladder pain. It should be men-
tioned that pain assessment was performed by different
methodologies in different studies and that the person-
ality questionnaire was not always completed at the
same point in time, which may account for conflicting
results.
Fig. 3. Pain perception in the four subgroups based on combined HA and RD scores. Highest pain perception (dark gray) in high HA/low RD
subgroup; lowest pain perception (white) in low HA/low RD subgroup, and intermediate perception in the other two subgroups (light gray).
36 D. Pud et al. / European Journal of Pain 8 (2004) 31–38
According to the results of the present study, indi-
viduals with a high score of HA in combination with a
low score of RD appear to be the most responsive topain, whereas those with a low score of HA and a low
score of RD appear to be the least responsive to pain.
The principal factor that seems to determine pain per-
ception is the scoring of HA. HA individuals tend to be
fearful and anticipate harm even under supportive cir-
cumstances, are typically pessimistic and inhibited by
unfamiliar situations, and generally avoid taking risks.
High scores on this trait seem to predict high pain per-ception, as reflected in our results showing higher pain
perception in high HA volunteers.
According to Cloninger�s theory, individuals with low
RD scores are typically independent and non-conform-
ist, socially detached, unwilling to share their intimate
feelings with others, content to be alone, cynical and
insensitive to social cues and pressures, and only mini-
mally motivated to please others. It may be that low RDserves to unmask pain behavior from possible social and
cultural biases, thereby allowing the HA trait to emerge
as a �net� expression. Thus, Cloninger�s suggested traits
do indeed seem to be relevant to pain perception.
However, further studies are needed to support these
preliminary findings.
In parallel to this psychological rationale, a neuro-
chemical explanation can also be formulated, although
facing the complexity of personality and behavior, re-lating the latter to measures such as levels of specific
neurotransmitters might be an oversimplification of
these mechanisms. Several studies have examined the
relations between the Cloninger personality dimensions
in healthy volunteers and brain neurotransmitters.
Hansenne and Ansseau (1999) found a relationship be-
tween harm avoidance scores and serotonin by showing
a correlation between HA scores and prolactin responseto intra-venous Flesinoxan (5-HT1A agonist) in healthy
volunteers. Garvey et al. (1996) demonstrated a positive
correlation between urinary noradrenaline metabolite
level (HMPG) and reward dependence scores. Gerra
et al. (2000) demonstrated positive correlations between
each specific personality trait (NS, HA, and RD) and
dopaminergic, serotonergic and noradrenergic functions
in healthy subjects by challenging the monoamine sys-tems with specific agonists (bromocriptine, DD-fenflur-
amine, and clonidine, respectively). These findings
support the suggested relations between neurotransmit-
ters and personality traits, as proposed by Cloninger.
The neuro-chemical explanation for our findings
points to serotonin as the main neurotransmitter. We
D. Pud et al. / European Journal of Pain 8 (2004) 31–38 37
suggest that the level of serotonin determines the basicperception of pain. Accordingly, higher levels of sero-
tonin predict high pain responsiveness and vice versa.
Serotonin serves as the main neurotransmitter in the
descending pain inhibitory pathways (Fields and Bas-
baum, 1999). As such, one would expect high levels of
serotonin to express a higher degree of inhibition, re-
sulting in less pain.
Our results, however, indicate higher pain respon-siveness in high HA subjects. A possible explanation
relates to the model suggested by Liu et al. (2000). Ac-
cording to this model, brainstem interneurons in the
periaqueductal grey–dorsal raphe nucleus (PAG–DRN)
complex exert serotoninergic inhibition upon the raphe
serotoninergic neurons. The latter send their axons
down the spinal cord and inhibit pain messages at their
entrance to the cord. Thus, a disinhibition effect willcause an overall heightened pain perception in these
subjects.
In conclusion, the present study demonstrates a re-
lationship between personality traits and pain percep-
tion in response to cold stimuli. These findings may
contribute to our understanding of the possible mecha-
nisms underlying individual differences in pain percep-
tion. The results may also indicate that Cloninger�stridimensional personality theory can be used as a tool
for improving pain management. The identification of
specific personality traits that can predict pain percep-
tion will facilitate the design of individually tailored pain
management plans.
Acknowledgements
The study was supported by the Israel Cancer Asso-
ciation, through the Raya (Rela) Golambo MemorialFund Grant No. 20000009-c.
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