The Mediating Role of Cognitive Avoidance in the Relationship Between Intolerance of Uncertainty and Chronic Pain in Multiple Sclerosis Patients: A Structural Equation Modeling Approach

Hossein Mirinasab; Hoda Zaraj; Azam Motahedi

Authors

Hossein Mirinasab Ph.D. in Health Psychology, Department of Psychology, University of Tehran, Tehran, Iran Author https://orcid.org/0009-0001-4872-2841
Hoda Zaraj Ph.D. in Health Psychology, Department of Psychology, University of Tehran, Tehran, Iran Corresponding Author https://orcid.org/0000-0002-0902-3589
Azam Motahedi Department of Psychology, Sha.C., Islamic Azad University, Shahrood, Iran Author https://orcid.org/0000-0002-5098-5528

Keywords:

Multiple Sclerosis, Cognitive Avoidance, Chronic Pain, Intolerance of Uncertainty

Abstract

Chronic pain is a prevalent and debilitating symptom in multiple sclerosis (MS). While psychological factors, such as intolerance of uncertainty (IU), are known contributors, the specific mechanisms underlying them are underexplored. This study aimed to investigate whether cognitive avoidance (CA) mediates the relationship between IU and chronic pain severity in this population. In this cross-sectional study, 339 patients with MS (151 men, 178 women) were recruited via convenience sampling from medical centers in Tehran, Iran. Participants completed the Intolerance of Uncertainty Scale (IUS), the Cognitive Avoidance Questionnaire (CAQ), and the Brief Pain Inventory-Short Form (BPI-SF). Data were analyzed using structural equation modeling (SEM). A partial mediation model demonstrated an excellent fit to the data (CFI = 0.99, RMSEA = 0.055, χ2/df = 2.02). The analysis revealed both a significant direct effect of IU on chronic pain and a significant indirect effect mediated by CA, which was confirmed via bootstrapping. The final model accounted for 13% of the variance in chronic pain. Our findings highlight the crucial role of cognitive-behavioral mechanisms in MS-related chronic pain. Individuals with higher IU tend to engage in cognitive avoidance, which exacerbates their pain, identifying CA as a key therapeutic target. Psychological interventions aimed at reducing avoidance and enhancing tolerance to uncertainty may therefore provide a promising approach to improving pain management and well-being in individuals with MS.

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