Preoperative anxiety among patients and its correlation with their personality type and pain: A cross-sectional study

Abstract

BACKGROUND

Preoperative anxiety is a significant concern for patients, as it affects surgical outcomes, satisfaction, and pain perception. Although both anxiety and pain are common in surgical settings, their relationship with personality traits has not been previously investigated in the Lebanese population.

AIM

To examine the prevalence of preoperative anxiety, pain perception, and personality traits among Lebanese surgical patients, and to assess the associations between these factors.

METHODS

A descriptive cross-sectional study was conducted between April 2024 and January 2025 across Lebanese hospitals. A total of 392 adult patients were recruited through convenience sampling. Data were collected using a questionnaire that included sociodemographic, clinical, and surgical variables, the Amsterdam Preoperative Anxiety and Information Scale for anxiety, the Visual Analog Scale and Numerical Pain Rating Scale for preoperative pain, and the Ten-Item Personality Inventory for personality traits. Ethical approval was obtained from the Institutional Review Boards of Makassed General Hospital and Hammoud University Medical Center.

RESULTS

Overall, 25% of participants experienced preoperative anxiety, and 34.5% reported moderate pain. Personality assessment showed that the majority of participants had moderate extraversion (84.1%), moderate emotional stability (65.1%), high conscientiousness (61%), high agreeableness (54.1%), and moderate openness (49.2%). High conscientiousness was significantly associated with higher pain perception (P < 0.05), while high emotional stability was associated with lower levels of anxiety (P < 0.05). No significant association was found between preoperative anxiety and pain (P > 0.05).

CONCLUSION

This study challenges the assumption that preoperative anxiety and pain are directly correlated and highlights the role of personality traits in shaping patient experience. These findings support the potential value of integrating psychological profiling into preoperative care and lay the groundwork for developing personalized interventions to improve patient-centered surgical outcomes.

Key Words: Preoperative anxiety; Pain perception; Personality traits; Conscientiousness; Emotional stability; Lebanese hospitals; Surgical patients; Personalized care strategies

Core Tip: This study is the first in Lebanon to explore the relationship between preoperative anxiety, pain perception, and personality traits in surgical patients. Among 392 participants, emotional stability was inversely associated with anxiety, while conscientiousness correlated with higher pain perception. Surprisingly, no significant link was found between anxiety and pain. These findings underscore the value of psychological profiling in preoperative care and suggest that tailoring interventions based on personality traits may enhance patient outcomes and satisfaction.

INTRODUCTION

Anxiety is defined as the anticipation of future threat, distinguished from fear, which is the emotional response to real or perceived danger[1]. Psychologically, anxiety can be classified as state anxiety, which is a brief psychological and physiological response to an unfortunate circumstance at a distinct time, and trait anxiety, a personality characteristic associated with proneness to exhibit anxiety frequently[2]. Preoperative anxiety affects nearly half of surgical patients, demonstrated as a pooled prevalence of 48%[3]. Personality is a unique illustration of an individual’s character, behavior, and interactions with surroundings that grants him the ability to adjust to various aspects of life[4]. The Five Factor model describes personality through five traits: Neuroticism, extraversion, agreeableness, openness, and conscientiousness[4]. Pain is an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage[5].

Preoperative anxiety negatively impacts anesthesia and postoperative outcomes as it correlates with increased pain and recovery period[6]. Therefore, understanding the factors that potentiate anxiety in surgical settings is important for enhancing preoperative care strategies. A study conveyed that there is a relationship between anxiety and the Five-Factor personality traits, especially higher levels of neuroticism that were often linked with heightened anxiety levels[2]. Research has shown that the patient’s perception of pain impacts their susceptibility to anxiety in stressful settings[7].

Approximately 16.7% of the Lebanese population reported a lifetime prevalence of anxiety disorders, surpassing rates of mood (12.6%), impulse control (4.4%) and substance use (2.2%) disorders[8]. This elevated prevalence is attributed to multiple factors of regional war and conflicts, economic instability, and social challenges, where these stressors have been linked to increased risks of anxiety, mood, and impulse control disorders[9]. Moreover, the fear of anesthesia is a significant concern among patients in Lebanon, where the majority expressed preoperative worries[10].

Despite the clinical relevance of preoperative anxiety, pain perception, and personality traits, the interplay among them in the Lebanese hospital settings remains unclear. This study seeks to provide knowledge that can guide the development of an effective individualized intervention to address patients’ anxiety and improve outcomes.

Thus, the aim of this study is to measure the preoperative anxiety, personality type and pain intensity among Lebanese patients aged above 18 while focusing on two objectives. The primary objective being to determine the prevalence and association of these factors among patients present in hospitals distributed around Lebanon. The secondary objective being to investigate whether the patient’s gender, age, financial status, type of surgery (minor or major), and type of anesthesia may hold an effect on the patient’s preoperative anxiety, personality, and pain. We hypothesize that there is an association between preoperative anxiety, personality type and pain perception in the Lebanese hospital settings at the end of the study.

MATERIALS AND METHODS

Study design and participants

A descriptive cross-sectional study was conducted between April 2024 and January 2025. According to the Ministry of Public Health[11], the resident population aged 18 years and above in Lebanon is approximately 3160000. Based on a 95% confidence level and a 5% margin of error, the study required a minimum sample size of 385 (± 5%). A total of 392 patients were recruited through convenience sampling.

Eligible participants were adults (> 18 years) undergoing surgery in Lebanese hospitals. Patients scheduled for emergency surgery or those who had received preoperative anxiolytic medication were excluded.

Survey implementation

Data were collected using a five-part structured questionnaire as follows.

Sociodemographic data: Nationality, gender, age, residence, marital status, smoking status, education, employment, healthcare background, payment method, and income level.

Clinical and surgery-related information: History of chronic illnesses, diagnosis and treatment of depression, current medication use (including but not limited to analgesics, antihypertensives, antidiabetics, antidepressants), companionship, previous surgeries and complications, current type of surgery, and knowledge about anesthesia.

Knowledge about anesthesia was assessed in three ways: (1) General knowledge about anesthesia types; (2) Knowledge about the type of anesthesia intended for the current surgery; and (3) The anesthesiologist’s record of the actual anesthetic method performed.

Pain assessment: Pain levels were measured preoperatively (within 24 hours before surgery) using two tools: The Visual Analogue Scale (VAS) and the Numerical Pain Rating Scale (NPRS). For the VAS, participants marked a point on a 10-cm horizontal line to reflect pain severity. For the NPRS, participants rated their pain on a scale of 0-10 at three time points (current, worst, best within the past 24 hours), and an average score was calculated[12,13]. Both VAS and NPRS scores were collected preoperatively, within 24 hours before surgery.

Preoperative anxiety and information needs: The Amsterdam Preoperative Anxiety and Information Scale (APAIS) was used, comprising six items grouped into two subscales. Four items assessed anxiety related to anesthesia and surgery, while two items assessed the need for information. Each item was scored on a 5-point Likert scale, with higher scores reflecting greater anxiety or information needs[14].

Personality traits: The Ten-Item Personality Inventory (TIPI) assessed the Big Five traits. Each trait was measured by two items on a 7-point Likert scale: Extraversion (items 1, 6), agreeableness (2, 7), conscientiousness (3, 8), emotional stability (reverse of neuroticism; items 4, 9), and openness (5, 10)[15]. Trait scores were categorized into low (≤ 33^rd percentile), moderate (34^th-66^th percentile), and high (≥ 67^th percentile) in line with prior cross-cultural applications of TIPI.

Translation and reliability

The questionnaire was initially developed in English, translated into Arabic using forward-backward translation, and provided in both languages. A pilot study was conducted in April 2024 with 39 participants to assess feasibility, clarity, and cultural appropriateness. Internal consistency in the present sample was acceptable, with Cronbach’s alpha ranging from 0.638 to 0.911 across the scales. Internal consistency of the Arabic versions of APAIS, TIPI, VAS, and NPRS in our sample was acceptable, with Cronbach’s alpha ranging from 0.638 to 0.911 and presented in Table 1.

Table 1 Cronbach alpha of scales.

Scale	NRPS	Anxiety	Need for information	Consciousness	Agreeableness	Emotional stability	Openness	Extraversion
Cronbach alpha	0.911	0.834	0.902	0.74	0.769	0.687	0.762	0.638

NRPS: Numerical Pain Rating Scale.

Data collection

Data was collected physically by the researchers in Institutional Review Board-approved hospitals: Makassed General Hospital, approval No. 160724; and Hammoud University Medical Center, approval No. 010824. Participants completed the questionnaires independently or with the researcher’s assistance. Attrition rate was approximately 0.5%.

Ethical consideration

Prior to conducting this research, approval was taken from the Institutional Review Board of Makassed General Hospital and Hammoud University Medical Center. Prior to filling the questionnaire, the participants provided informed consent if they agreed to partake. Participation was voluntary, and anonymity was ensured so that their identities would not be linked to their responses. No names or other identifiers were requested from the participants and the collected data was only accessible to the researchers and their supervising principal investigators. The study is considered of minimal risk, where the risks do not exceed those of everyday life.

Statistical analysis

All data were entered, cleaned, and analyzed using the Statistical Package for Social Science (SPSS, version 25). Descriptive statistics were reported as means with standard deviations for continuous variables and as frequencies with proportions for categorical variables.

Normality of continuous variables was assessed using the Shapiro-Wilk test. Since most variables demonstrated non-normal distribution (P < 0.05), non-parametric tests were employed. Specifically, the Mann-Whitney U test was used to compare two groups, and the Kruskal-Wallis test was applied when comparing more than two groups. The χ² test of Independence was used to examine associations between categorical variables.

To address the issue of multiple testing, Bonferroni correction was applied to correlation analyses and group comparisons, and adjusted P values were reported where appropriate. Spearman’s rank correlation was used to assess associations between ordinal variables (e.g., age and pain scores). Bonferroni correction was applied within each set of related comparisons. For example, when five personality traits were tested for association with pain, the adjusted significance level was α = 0.05/5 = 0.01. Throughout the results and tables, we indicate whether each association remained significant after correction.

Cronbach’s alpha values for each scale were calculated to evaluate internal consistency and are reported in the Methods section above. A binary logistic regression model was performed to determine whether pain levels (VAS) and personality traits predicted the presence of preoperative anxiety, with low trait levels serving as the reference category. Odds ratios and 95% confidence intervals were reported. A P value < 0.05 was considered statistically significant, and values < 0.001 were interpreted as strongly significant after correction for multiple comparisons.

RESULTS

Out of a total 392 participants, 63% were females with a mean age of 46.87 ± 18.069. Sociodemographic characteristics are displayed in Table 2. Clinical and Surgery-related information such as chronic illness, depression, prior surgeries, and anesthesia type of participants are presented in Table 3.

Table 2 Sociodemographic characteristics of participants.

Characteristic		Frequency	Distribution (%)
Gender	Female	247	63.0
	Male	145	37.0
Nationality	Lebanese	289	73.7
	Palestinian	37	9.4
	Syrian	62	15.8
	Other	4	1.0
Place of residency	Akkar	2	0.5
	Baalbek	4	1.0
	Beirut	96	24.5
	Beqaa	68	17.3
	Keserwan	3	0.8
	Mount Lebanon	57	14.5
	Nabatiyeh	12	3.1
	North Lebanon	3	0.8
	South Lebanon	147	37.5
Marital status	Single	77	19.6
	Married	277	70.7
	Widowed	31	7.9
	Divorced	6	1.5
	Separated	1	0.3
Smoking	No	205	52.3
	Yes	187	47.7
Education	None	154	39.3
	High school	110	28.1
	University	128	32.7
Working	No	249	63.5
	Yes	143	36.5
Health care work	No	375	95.7
	Yes	17	4.3

Table 3 Participants’ clinical and surgery-related information.

Characteristic		Frequency	Distribution (%)
Chronic diseases	No	217	55.4
	Yes	175	44.6
Cardiovascular	No	46	26.3
	Yes	129	73.7
Pulmonary	No	168	96.0
	Yes	7	4.0
Nervous	No	169	96.6
	Yes	6	3.4
Diabetes	No	110	62.9
	Yes	65	37.1
Cancer	No	163	93.1
	Yes	12	6.9
Others	No	152	86.9
	Yes	23	13.1
Diagnosed with depression	No	368	93.9
	Yes	24	6.1
If diagnosed with depression, does the patient take medication for it?	No	12	50.0
	Yes	12	50.0
Does the patient take any medication (analgesics or other treatments)?	No	195	49.7
	Yes	197	50.3
Company	No	24	6.1
	Yes	368	93.9
Previous surgeries	No	104	26.5
	Yes	288	73.5
Post-operative complications	No	255	88.5
	Yes	33	11.5
Type of surgery	Minor	208	53.1
	Major	184	46.9
Knowledge about types of anesthesia	No	246	62.8
	Yes	146	37.2
Knowledge about type of anesthesia for this surgery	No	200	51.0
	Yes	192	49.0
Type of anesthesia used	General	194	49.5
	Regional	92	23.5
	Local	106	27.0
Fees	Personal	151	38.5
	Insurance	111	28.3
	Other	130	33.2
Income	Low	142	36.2
	Middle	229	58.4
	High	21	5.4

The mean preoperative VAS score was 24 (SD = 30) indicating low to moderate pain levels. According to NPRS results, 34.2% experienced moderate pain and 33.2% had mild pain as seen in Table 4.

Table 4 Pain levels assessed by Numerical Pain Rating Scale.

Characteristic		Frequency	Distribution (%)
NPRS	Nothing	89	22.7
	Mild	130	33.2
	Moderate	134	34.2
	Severe	39	9.9

NPRS: Numerical Pain Rating Scale.

One fourth of participants were classified as anxious and 51% expressed need for information as shown in Table 5. Personality traits assessed using TIPI showed that majority exhibited moderate extraversion (84.1%), moderate emotional stability (65.1%), high conscientiousness (61%), high agreeableness (54.1%), and moderate openness (49.2%) as presented in Table 6.

Table 5 Anxiety and Need for information frequencies assessed by Amsterdam Preoperative Anxiety and Information Scale.

Characteristic		Frequency	Distribution (%)
Anxiety	Anxious	98	25
	Not anxious	294	75
Need for information	No	192	49
	Yes	200	51

Table 6 Personality traits assessed by Ten-Item Personality Inventory.

Characteristic		Frequency	Distribution (%)
Conscientiousness	Low	10	2.6
	Moderate	142	36.2
	High	240	61.2
Agreeableness	Low	43	11.0
	Moderate	137	34.9
	High	212	54.1
Emotional stability	Low	41	10.5
	Moderate	255	65.1
	High	96	24.5
Openness	Low	164	41.8
	Moderate	193	49.2
	High	35	8.9
Extraversion	Low	30	7.7
	Moderate	332	84.7
	High	30	7.7

Associations between pain, preoperative anxiety and personality traits

A statistically significant association was found between pain and conscientiousness (P = 0.013) where individuals with high conscientiousness reported higher levels of pain (mean rank = 204.71) than those with low conscientiousness (mean rank = 106). Although an initial association was found between pain and conscientiousness (P = 0.013), this did not remain significant after Bonferroni correction (adjusted threshold α = 0.01). Anxiety was only significantly associated with emotional stability (P = 0.010). The association between anxiety and emotional stability remained significant after Bonferroni correction (P = 0.010; α_adj = 0.01). Moreover, participants who expressed the need for further information about their procedure were more likely to display preoperative anxiety with 74.5% of those who requested additional information showing anxiety in comparison with 43.2% who did not with a highly significant association (P < 0.001). The strong association between need for information and anxiety remained highly significant after correction (P < 0.001).

However, no significant association was observed between pain and preoperative anxiety (P = 0.227). Pain was also not significantly related with agreeableness (P = 0.214), emotional stability (P = 0.276), openness (P = 0.088), and extraversion (P = 0.886).

Associations with sociodemographic data and clinical profiles of participants

Smoking status was not significantly associated with any of the personality traits, pain and preoperative anxiety (P > 0.05). However, there are significant associations between employment status and conscientiousness (P = 0.047), emotional stability (P = 0.014), and openness (P = 0.005) while there is no association with extraversion and agreeableness (P > 0.05).

Pain was not associated with presence of chronic diseases (P = 0.659). Conversely, there was a significant association between pain and cardiovascular diseases (P = 0.022), individuals with no cardiovascular disease (mean rank = 102.08) experienced more pain than those diagnosed with cardiovascular disease (mean rank = 82.98).

A significant association between emotional stability and patients diagnosed with depression (P = 0.026) but not with other traits. Furthermore, individuals diagnosed with depression reported preoperative anxiety (P = 0.001), where patients diagnosed with depression were more anxious (54.16%) than those not diagnosed (23.09%).

Previous surgical experience was not significantly associated with pain (P = 0.170). However, there was a significant association between type of surgery and pain (P = 0.013), where major surgeries (mean rank = 211.17) are associated with more pain than minor surgeries (mean rank = 183.52).

Patient’s knowledge about anesthesia was significantly associated with pain (P = 0.030), where patients with knowledge (mean rank = 212.15) felt more pain compared to those who without (mean rank = 187.21). Additionally, the type of anesthesia performed was highly significantly associated with pain experienced (P = 0.001), where patients with general anesthesia experienced the highest pain (mean rank = 217.5) compared to local (mean rank = 182.35) and regional anesthesia (P = 168.52). There is a significant association between type of anesthesia performed and anxiety experienced by the patient (P = 0.045), where patients undergoing general anesthesia (28.35%) experienced the highest anxiety compared to regional (28.26) and local (16.037). A full summary of statistical associations and their P values are posted in Table 7.

Table 7 Association between sociodemographic and patient clinical and surgical variables with scales.

Characteristic		VAS		APAIS (P value)		TIPI (P value)
		Mean rank	P value	Need of information	Anxiety	Conscientiousness	Agreeableness	Emotional stability	Openness	Extraversion
Gender	Male	202.31	0.423	0.037a	0.003a	0.73	0.009a	0.261	0.608	0.172
	Female	193.09
Age	Numerical value	-	0.147	0.269	0.474	0.885	0.145	0.058	0.029a	0.230
Place of residence	Akkar	252.75	0.004a	0.270	0.698	0.214	0.133	0.900	0.048a	0.015a
	Baalbek-Hermel	305.38
	Beirut	196.45
	Beqaa	235.86
	Keserwan-Jbeil	205.00
	Mount Lebanon	202.47
	Nabatiyeh	179.71
	North	280.17
	South	171.77
Marital status	Single	197.20	0.028a	0.417	0.130	0.620	0.102	0.206	0.556	0.811
	Married	201.49
	Widowed	138.39
	Divorced	252.75
	Separated	225.50
Smoking	Yes	206.00	0.102	0.134	0.861	0.116	0.179	0.236	0.918	0.374
	No	187.84
Employment status	Yes	210.39	0.058	0.298	0.102	0.047a	0.298	0.014a	0.005a	0.717
	No	188.52
Chronic illness	Yes	193.77	0.659	0.172	0.319	0.594	0.029a	0.461	0.117	0.734
	No	198.70
Diagnosed with depression	Yes	210.54	0.518	0.246	0.001a	0.849	0.752	0.026a	0.283	0.800
	No	195.58
Previous surgeries	Yes	191.93	0.170	0.830	0.187	0.049a	0.253	0.992	0.178	0.421
	No	209.16
Type of surgery	Minor	183.52	0.013a	0.704	0.161	0.299	0.466	0.462	0.417	0.258
	Major	211.17
Knowledge about anesthesia for this surgery	Yes	215.66	0.001a	0.680	0.816	0.403	0.010a	0.319	0.001a	0.194
	No	178.11
Type of anesthesia	General	217.50	0.001a	0.415	0.045a	0.271	0.525	0.732	0.144	0.168
	Regional	168.52
	Local	182.35

^aP < 0.05, association is significant.

Mean rank values in non-parametric tests represent the relative ranking of groups when all observations are pooled; they are not equivalent to raw scale scores. Higher mean ranks indicate relatively greater values of the measured variable compared. Bonferroni correction applied within sets of related comparisons. For associations between the five personality traits and pain or anxiety, the adjusted significance threshold was α = 0.01. For categorical variables with multiple levels (e.g., type of anesthesia), adjusted thresholds were based on the number of groups. After correction, only the associations between emotional stability and anxiety (P = 0.010), need for information and anxiety (P < 0.001), knowledge about anesthesia and pain (P = 0.001), and type of anesthesia and pain (P = 0.001) remained statistically significant. VAS: Visual Analog Scale; APAIS: Amsterdam Preoperative Anxiety and Information Scale; TIPI: Ten-Item Personality Inventory.

Multivariate analysis of anxiety with pain and personality traits

A binary logistics regression was conducted to examine whether pain intensity (VAS) and personality traits predicted the presence of preoperative anxiety. Each personality trait is categorized into three levels (low, moderate and high) with low level serving as reference group. The overall model was statistically significant for emotional stability (P = 0.027). Compared with individuals of low emotional stability, those with high emotional stability were about three times more likely to report no preoperative anxiety (odds ratio = 2.95, P = 0.030). Pain levels and the other personality traits were not found associated with anxiety (P > 0.05). Full regression results are present in Table 8. As logistic regression is a multivariable model, Bonferroni correction was not applied to these results.

Table 8 Logistics regression predicting preoperative anxiety based on pain and personality traits.

Predictor variable	B	SE	Wald	P value	OR [Exp(B)]
VAS (continuous)	-0.004	0.004	1.262	0.261	0.996
Conscientiousness	-	-	1.442	0.486	-
Moderate vs low	-1.176	1.089	1.165	0.280	0.309
High vs low	-1.279	1.089	1.377	0.241	0.278
Agreeableness	-	-	1.301	0.522	-
Moderate vs low	0.118	0.403	0.085	0.770	1.125
High vs low	0.374	0.409	0.835	0.361	1.454
Emotional stability	-	-	7.212	0.027a
Moderate vs low	0.220	0.402	0.298	0.585	1.246
High vs low	1.083	0.500	4.698	0.030a	2.953
Openness	-	-	0.809	0.667	-
Moderate vs low	-0.196	0.259	0.575	0.448	0.822
High vs low	0.106	0.478	0.049	0.825	1.111
Extraversion	-	-	1.674	0.433	-
Moderate vs low	0.535	0.441	1.474	0.225	1.708
High vs low	0.320	0.606	0.279	0.597	1.377
Constant	1.444	1.188	1.476	0.224	4.236

^aP < 0.05, association is significant.

VAS: Visual Analog Scale; OR: Odds ratio; SE: Standard error; Exp: Exponentiated coefficient; B: Unstandardized regression coefficient.

DISCUSSION

In this study, preoperative pain (VAS) was not associated with preoperative anxiety. While much of existing literature had focused on how anxiety is used as a predictor of postoperative pain, fewer studies have investigated the influence of baseline pain levels on anxiety before surgery. A study conducted in Ethiopia suggests that preoperative pain may increase psychological distress and fear of surgical and anesthesia-related complications, which in turn heighten anxiety levels[16]. However, another study shows that there is no association after adjusting for confounders such as marital status and sociodemographic factors[17]. Our findings align with this perspective, reflecting the psychological traits of Lebanese patients who have been exposed to chronic stressors over the years and may have developed adaptive coping mechanisms, which seems to have normalized anxiety levels[18]. As a result, anxiety might not have a significant correlation with pain anymore.

In the context of preoperative care, the study showed a highly significant positive relation between anxiety and the patient’s need for information before surgery. Previous research shows that anxious patients often seek more information to feel more prepared and reduce uncertainty[19,20]. This allows them to review their procedure with their physicians and clear any uncertainties. This finding highlights the crucial role of establishing good provider-patient communication, as it would help alleviate patients’ anxiety from one hand and reinforce the patient’s sense of control and involved decision-making[21].

Although conscientiousness was initially associated with higher reported pain levels (P = 0.013), this association did not remain significant after Bonferroni correction. Conscientious individuals tend to be hypervigilant and closely monitor their bodily sensations, making them more aware of discomfort and more likely to report higher pain levels[22-24]. This aligns with evidence suggesting that conscientiousness influences health behaviors and symptom reporting. However, it is worth noting that other studies have linked high conscientiousness with favorable health outcomes, such as lower pain frequency, better adherence to medical protocols, and more effective coping strategies, ultimately contributing to improved long-term health and longevity[23,24].

It is important to note that after applying Bonferroni correction for multiple testing, only the associations between emotional stability and preoperative anxiety, need for information and anxiety, knowledge of anesthesia and pain, and type of anesthesia and pain remained significant. In contrast, the observed association between conscientiousness and pain did not withstand correction, suggesting this may have been a chance finding. This strengthens the robustness of the remaining associations and minimizes the risk of type I error.

Patients with higher emotional stability were less anxious, and this association remained significant even after Bonferroni correction (P = 0.010). Emotional stability, often referred to as the ability to remain calm and composed under stressful situations, plays a key role in modulating anxiety, especially in preoperative settings. High emotionally stable people can overcome stressful situations by being able to maintain a relaxed state[25]. This is more understood by their ability to suppress negative thoughts and exaggerated perceived threats, clearing their mind, and allowing them to focus on possible ways to solve a situation, and by that reflecting problem-solving abilities and adaptive coping mechanisms.

Our study found that preoperative anxiety is more prevalent in females than males. This aligns with global epidemiologic trends showing anxiety is much more common in females[26]. Several biological and psychosocial factors contribute to these results. A neurological and structural study shows that there are sex-related differences in brain regions that affect anxiety, such as the prefrontal cortex, hippocampus, and amygdala[27,28]. Estrogen and progesterone fluctuations also play a role in the neurobiology of anxiety disorders[28]. Beyond biological factors, gender socialization and cultural norms influence reported anxiety levels, where it is discouraged for males to express emotions, which leads them to underreport anxiety levels whilst also helping them develop coping mechanisms[27]. These findings highlight the importance of considering gender when assessing anxiety levels.

A significant positive association was found between the patient’s knowledge about the type of anesthesia they would receive - whether local, general, or spinal - and both their reported pain levels and personality trait of openness. In our study, patients who knew more about their anesthetic procedures tended to experience higher pain levels on the VAS. This is explained by heightened bodily awareness, as patients who seek detailed information may also pay closer attention to every sensation, particularly pain. One study shows that the more knowledge the patient has, the more alert and anxious they become, and hence the more pain they perceive[29]. Conversely, Celik and Edipoglu[30] found that anxiety could be mitigated effectively with proper education, thereby enhancing all perioperative factors including pain. Those with a high degree of openness usually seek to explore and learn about new experiences or events in their lives. In the hospital setting, such patients tend to be more curious and aware of every change in their perception, especially pain[31].

In our study, higher agreeableness was associated with no patient knowledge about the type of anesthesia. Previous research suggests that agreeable individuals tend to engage more with health information and cooperate with health providers, leading to improved patient–provider communication and satisfaction[32]. However, agreeableness can also be seen as empathy and preference for harmony[33]. In the preoperative care context, highly agreeable patients would opt for emotional reassurance and interpersonal trust over technical comprehension of surgery and anesthesia. They may feel more comfortable with emotional support and guidance over technical information. This would explain why highly agreeable patients in our study had lower knowledge about types of anesthesia.

Our study also suggests that patients undergoing general anesthesia reported higher levels of anxiety compared to those receiving local or regional anesthesia. Similarly, Celik and Edipoglu[30] found that such patients had higher preoperative anxiety scores than those undergoing regional anesthesia (P = 0.029), attributing this to a fear of general anesthesia reflected by a feeling of “out of control”. This increased anxiety may stem from the fear of not waking up from anesthesia, postoperative pain, anesthetic side effects, inability to perform daily routines, and fear of death. This all comes back to the importance of educating patients about anesthesia to relieve their anxiety[34].

This study shows no significant association between having a history of previous surgeries and perception of pain among patients. Although many would assume that patients who had undergone surgery might experience more pain due to complications or scar tissue, studies have shown the opposite. One study suggested that several factors such as surgery type, patient’s general health status, and psychological factors influence the level of pain experienced rather than surgical history[35].

The Beqaa region reported the highest pain level on the VAS scale compared to other areas in Lebanon. While our data does not categorize injury types based on region, a study highlights a high burden of traumatic and disabling injuries in West Beqaa, suggesting a higher incidence of orthopedic and traumatic cases, which explains elevated pain levels and the tendency to require major surgeries[36]. Moreover, our finding that major surgeries are associated with higher levels of pain aligns with a broad body of surgical literature. A study explains that major surgeries, particularly those related to orthopedics, oncology, and complex general surgeries, often involve intensive nociceptive input contributing to central sensitization, making patients more susceptible to pain preoperatively and postoperatively[37]. These findings highlight the importance of a tailored pain management strategy following major surgeries to ensure optimal patient recovery and comfort.

Our study had some limitations. As a cross-sectional study, which captures exposure and outcome at a single point in time, it does not define causation in a relation. Additionally, there is selection bias due to convenience sampling, potentially limiting generalizability. Although scales were translated using back-translation, formal psychometric validation (factor analysis, cultural adaptation) was not performed. While Arabic versions of APAIS have been validated[14], no fully validated Arabic TIPI exists to our knowledge. This should be considered when interpreting results. Another limitation is that data collection sometimes required researcher assistance, which may have introduced social desirability bias, especially for sensitive questions about anxiety and personality traits. Moreover, Cronbach alpha of TIPI ranged between 0.63-0.75, which was used due to our brief approach to patients regarding the limited time. Also, the type of surgical condition (e.g., orthopedic, gastrointestinal, urologic, traumatic vs. elective) was not stratified in our analysis. Since surgical pathology may influence baseline pain, this remains a potential confounder. Finally, medication use was recorded in aggregate and did not differentiate analgesics from other treatments, which may have confounded the interpretation of pain perception findings.

On the other hand, one of the strengths of this research lies in it being the first in Lebanon to study the comprehensive exploration of preoperative anxiety and its correlation with both personality types and pain among patients in Lebanese hospitals. Additionally, it was conducted upon minimal patient risk and in accordance with ethical guidelines. Furthermore, it encourages the development of a preoperative intervention personalized to each patient’s preoperative anxiety and may serve as a foundation for future studies aimed at interventions targeting preoperative anxiety. The findings in this study can further be used and applied on a regional population.

From a clinical perspective, personality profiling may help anesthesiologists and surgeons identify patients at higher psychological risk before surgery. For example, patients with high conscientiousness may benefit from targeted counseling on pain management, while those with low emotional stability may require enhanced preoperative reassurance or anxiolytic support. Integrating personality assessment into preoperative evaluation could therefore guide personalized communication and perioperative psychological interventions.

More research should be done around interventional studies that implement strategies to control preoperative anxiety based on the patient’s personality as well as their effect on recovery time and postoperative pain.

CONCLUSION

This study, to our knowledge, the first to study the correlation between anxiety, personality type and pain in preoperative surgical settings in Lebanon. Given the known impact of preoperative anxiety on surgical outcomes, understanding its relationship with these factors help optimize the preoperative care and patient satisfaction. Our study found contrary to our initial hypothesis, that there was no correlation between preoperative anxiety and pain. On the other hand, we found that some personality traits, particularly emotional stability, and conscientiousness, were linked to anxiety and pain, respectively. These findings suggest that enhanced personalized care strategies, including adjusting doses of analgesics or providing psychological support, could improve perioperative care and patient outcomes in Lebanese surgical settings.