Fear of pain, a significant emotional response to anticipated or experienced pain, can significantly impact an individual's life. It's a complex phenomenon influenced by factors like negative interpretations of pain, catastrophic thinking, and avoidance behaviors. The Fear of Pain Questionnaire-III (FPQ-III) is a widely used instrument to measure fear of pain, but the existing Italian version has limitations. This research aimed to develop and validate a shorter, more psychometrically sound Italian version of the FPQ-III. The study's significance lies in providing a reliable and valid tool for assessing fear of pain in the Italian context, enabling researchers and clinicians to better understand and address this crucial aspect of pain experience. The study hypothesized a three-factor structure mirroring the original FPQ-III (severe, medical, minor pain), measurement invariance across genders, and convergent and discriminant validity with other relevant measures.

Existing literature extensively explores the concept of fear of pain and its impact on various aspects of life. The FPQ-III, while being a widely used measure, has seen adaptations and refinements across multiple languages. Studies have investigated its psychometric properties, and noted potential limitations, emphasizing the need for continued validation and adaptation. Furthermore, the literature highlights the association of fear of pain with variables like pain catastrophizing, locus of control, coping mechanisms, and gender differences in pain perception and response. The current study builds upon this existing research by focusing specifically on the Italian context, aiming to enhance the accuracy and applicability of the FPQ-III within this population.

The study employed a multi-stage approach involving translation, sample recruitment, psychometric testing, and validation. The FPQ-III was translated into Italian following EORTC guidelines, with forward and backward translations and a focus group to ensure clarity and cultural relevance. The main sample consisted of 1064 participants (708 for the initial psychometric analysis and a subsequent sample of 292 for convergent validity). Participants were recruited through email contact with university students, primarily using online data collection. Exploratory Factor Analysis (EFA) was used to identify the underlying factor structure, followed by Confirmatory Factor Analysis (CFA) to confirm the model's fit. Measurement invariance across gender was tested using a nested model approach. Convergent validity was assessed by correlating the FPQ-III with the Pain Catastrophizing Scale (PCS), Locus of Control of Behavior Scale (LCBS), and Coping Orientations to Problems Experienced (COPE) questionnaires. For discriminant validity, a separate laboratory study (n=64) was conducted using videos depicting varying levels of pain (severe, medical, minor) to induce changes in fear of pain, with pre- and post-FPQ-III scores compared using repeated measures ANOVA.

EFA and CFA confirmed the three-factor structure (severe, medical, and minor pain) of a 13-item version of the Italian FPQ-III (χ² = 148.092, CFI = 0.971, TLI = 0.962, RMSEA = 0.046). The model showed excellent fit indices. Measurement invariance was established across genders, indicating the instrument's suitability for both male and female populations. Convergent validity was supported by significant positive correlations between the FPQ-III subscales and the PCS (particularly brooding), external locus of control (LCBS), and avoidance coping (COPE). The discriminant validity study showed significant increases in FPQ-III scores after exposure to pain-inducing videos, confirming the instrument's ability to capture state changes in fear of pain. Specifically, the videos depicting severe and medical pain elicited significantly greater fear compared to the control and minor pain video group. Interestingly, the minor pain video group showed a (unexpected) decrease in fear scores. Females demonstrated significantly higher latent means for fear of pain in all three subscales compared to males.

The findings strongly support the validity and reliability of the 13-item Italian short form of the FPQ-III. The three-factor structure, measurement invariance, and good convergent and discriminant validity suggest its suitability for research and clinical applications within the Italian population. The significant correlations with measures of pain catastrophizing, locus of control, and coping strategies highlight the interplay between emotional, cognitive, and behavioral factors in fear of pain. The results of the discriminant validity study add valuable evidence for the instrument’s sensitivity in detecting state-related changes in pain fear. This contributes to a broader understanding of how situational factors influence fear of pain. Gender differences confirmed by the study reiterate the importance of considering gender-specific factors in pain assessment and management. The unexpected decrease in fear scores after viewing the minor pain videos might reflect a sense of self-efficacy and coping ability in less severe pain situations, requiring further investigation.

This study successfully validated a concise and psychometrically robust 13-item Italian short form of the FPQ-III. Its strong psychometric properties and cross-gender applicability make it a valuable tool for assessing fear of pain in the Italian context. Future research could explore the instrument's utility in diverse populations and clinical settings, examine the longitudinal relationship between fear of pain and pain outcomes, and investigate the mechanisms underlying the unexpected findings related to the minor pain video condition.

The primary sample consisted mainly of university students, which might limit the generalizability of findings to older or more diverse populations. Although the convergent and discriminant validity studies provided further support for the instrument’s validity, additional validation with larger and more diverse samples is recommended. The videos used in the discriminant validity study were selected based on student ratings, which represents a potential source of bias. Further research with standardized, controlled stimuli is needed. The cross-sectional design limits the ability to draw causal inferences about relationships between variables.