Personality traits and preoperative anxiety: Interpreting individual differences in pain perception

Abstract

Preoperative anxiety is often described as a temporary response to surgical stress, but this does not account for the variation in anxiety and pain among patients undergoing similar surgical procedures. Preoperative anxiety is proposed to be a trait-based cognitive appraisal process in the review. Personality traits affect patients’ perception of the threat of surgery, emotion regulation and attention to bodily signals. Emotional stability is related to threat sensitivity and emotional reactivity, whereas conscientiousness is related to vigilance and monitoring. These processes influence anxiety and pain through partly independent pathways. The overlap between state and trait anxiety, self-report measures and cross-sectional designs limit current research. This review proposes a trait-based framework integrating personality, cognition, and physiological stress responses and supporting more individualised perioperative assessment and intervention.

Key Words: Preoperative anxiety; Pain perception; Personality traits; Conscientiousness; Emotional stability; Patient-centered care

Core Tip: Preoperative anxiety is not simply a situational response to the surgery. It reflects stable differences in how patients process threat, regulate emotion and monitor bodily signals. This review proposes a trait-based framework to explain the differences in anxiety and pain across patients. It suggests psychological calibration as a means to customise communication and intervention to the individual patient profile. This view promotes more individualised screening and perioperative care.

INTRODUCTION

Preoperative anxiety is common in surgical care, but often not sufficiently addressed. It may affect perioperative outcome, patient experience and recovery after surgery[1-4]. Patients with higher preoperative anxiety may experience more postoperative pain, require more anaesthetic support, have slower recovery time and less satisfied with care[5,6]. In a clinical setting, anxiety is often assessed with tools such as the Amsterdam Preoperative Anxiety and Information Scale and Visual Analogue Scales to identify patients who may require additional support[7,8]. These tools are useful but do not fully explain why preoperative anxiety occurs.

In many perioperative studies, preoperative anxiety has been defined as a short-term emotional response to surgery, anaesthesia, uncertainty and possible adverse outcomes[5]. This has been useful to clinicians in the development of general strategies for the reduction of anxiety such as the provision of information, reassurance or medication. However, this approach does not explain the large inter-individual variability in anxiety, pain expectation and coping behaviour of patients undergoing similar procedures and exposed to similar risks[9]. This difference indicates that preoperative anxiety is independent of the surgical scenario. It may also be a marker of stable psychological traits that influence how patients interpret and respond to surgical stress.

The theory of personality can usefully explain these differences. Temperament and character were suggested by early biosocial models to influence anxiety vulnerability[10]. Later research has also demonstrated that personality traits influence stress perception, emotion regulation and coping in medical and non-medical settings[11,12]. Stability of emotions is particularly important. Less emotionally stable patients tend to perceive stressors as more threatening and more difficult to control. More emotionally stable patients are generally better at controlling their emotions. Conscientiousness can also affect perioperative responses; for example, conscientious patients may focus more on bodily sensations, potential risks and medical details.

Personality traits can also affect how we perceive pain. Current models of pain do not see pain as a simple sensory signal. Pain is rather seen as an experience that is modulated by attention, expectation, appraisal and emotion[13-15]. Threat-sensitive patients may interpret bodily sensations in a more negative way. Both anxiety and pain perception may be enhanced[16-18]. Patients with more stable emotional states may not exaggerate their discomfort as much. This means there is a link between anxiety and pain, but it is not always a direct or simple one.

There will be some measurement issues to solve too. Brief measures such as the Ten-Item Personality Inventory are convenient to administer in a busy clinical setting but may not capture personality traits in sufficient detail[19]. Observed relationships between personality, anxiety and pain may also be affected by self-report data, common method bias and cultural adaptation problems[20,21]. At the same time, psychophysiology and behavioural medicine research shows that stress responses are linked with cortisol reactivity, autonomic regulation, lifestyle factors, ecological momentary assessment and biosignal-based monitoring[22-25]. Research on mindfulness-based stress reduction also shows that some psychological techniques can change anxiety[26].

Therefore, this opinion review conceptualises preoperative anxiety as a cognitive appraisal process influenced by traits, rather than a short-term response to surgery. It draws on personality psychology, pain research and perioperative medicine. It summarises recent advances, addresses unanswered questions, proposes a trait-based precision psychology framework, and explores clinical and research opportunities for personality-informed surgical care.

CURRENT ADVANCES IN UNDERSTANDING PERSONALITY, PREOPERATIVE ANXIETY, AND PAIN PERCEPTION

Recent studies demonstrated that the sensory and emotional experiences in the perioperative period are affected by the type of surgery and stable individual differences[16,17]. Personality traits are important because they influence threat perception, emotion regulation, attentional control, and management of uncertainty in patients.

The emotional stability is associated with preoperative anxiety in five-factor model[27,28]. Those patients with lower emotional stability are more vulnerable to pre-surgical anxiety, greater emotional reactivity and sensitivity to threat[20,21]. They may think surgery is risky, unpredictable or unmanageable. Those higher on emotional stability may appraise the same situation more balanced and cope with distress more effectively. This may also explain the different anxiety profiles even among patients undergoing similar surgery[9].

Conscientiousness may also operate through another mechanism[29,30]. This characteristic is often linked to health behaviour, treatment adherence, and self-control. However, in surgical care it may also increase vigilance and self-monitoring. The conscientious patient might follow closely the procedural details, bodily changes and possible complications. This does not necessarily lead to increased emotional distress. It could lead instead to a more cognitive anxiety with more checking, monitoring and anticipation.

This personality-based view is supported by pain research. Pain has sensory, cognitive, emotional and evaluative components[31-37]. Neurocognitive models show that attention, expectation and appraisal can increase or decrease pain perception[15]. Any of these processes could be influenced by personality traits. Neuroticism may lead to pain catastrophising and negative interpretation of bodily signals[36]. Conscientiousness may result in increased awareness of pain, because of increased attention to physical changes. Hence anxiety and pain may arise by somewhat different routes. One way is more emotional and related to the reactivity. The other way is more cognitive, something to do with vigilance and monitoring.

Research in measurement and physiology has also progressed the field. Amsterdam Preoperative Anxiety and Information Scale and Visual Analogue Scales provide an efficient means for clinicians to assess anxiety[7,8]. Short personality measures[19] enable dispositional screening in clinical work. Physiological markers (e.g., cortisol and autonomic nervous system activity) might also reflect stress reactivity[22]. Researchers can monitor anxiety and stress changes in real time through ecological momentary assessment and biosignal monitoring[24,25]. These approaches allow a shift from a static view of the state to a more personalised model of perioperative anxiety.

CONTROVERSIES AND UNRESOLVED ISSUES

A key debate is whether preoperative anxiety should be conceptualised as a mostly transient state or a manifestation of stable vulnerability. Traditional perioperative models have been based on state anxiety around threat of surgery, anaesthesia and uncertainty[5,37]. But this is a useful perspective and may cause us to lose personality traits. State and trait anxiety have been differentiated in psychology for a long time[38]. This distinction is not always clear in perioperative research. Thus, clinicians may interpret high preoperative anxiety as a transient response, when it may actually reflect a more persistent pattern of threat appraisal and emotion regulation.

Another issue is the relationship between pain and anxiety. Many clinical models propose a direct effect of anxiety on pain. Studies do show a relationship between the two but newer evidence suggests a more complex pattern[9,11]. Anxiety and pain may share some common mechanisms, for example, threat appraisal and attentional bias. They may take different routes as well. Emotional reactivity can mainly lead to increase anxiety. Vigilance and bodily monitoring can increase the perception of pain even if emotional distress is not very high[39,40]. Therefore, a simple linear model cannot account for differences in the surgical care of patients.

The research design limits the present knowledge. A lot of the studies are cross sectional. It is unknown if personality traits can predict anxiety and pain, or if the distress of surgery influences patient-reported personality. Common method variance and social desirability bias might also be a concern with self-report measures[21]. Personality tools like the Ten-Item Personality Inventory are short and easy to use, but only give a broad picture of complex traits[19,41,42]. A practical challenge for researchers is that clinical tools need to be brief, but theory testing requires more detailed measures.

Then there is culture. The meaning of anxiety, emotional stability, conscientiousness and pain expression may differ between cultural groups[43-46]. Cross-cultural adaptation procedures have been suggested[20] but measurement invariance is not always tested in many studies. Cultural norms may affect patients’ ways of expressing fear, pain and trust in doctors and coping with medical uncertainty. Results from one culture cannot be directly applied to another culture.

New technologies have their pros and cons too. More dynamic data can be obtained from ecological momentary assessment and biosignal monitoring[24,25]. These data, however, still need interpretation by clear psychological theory. Cortisol and autonomic responses also reflect complex mind-body processes, making it difficult to separate the role of personality from other biological and contextual factors[22]. These issues demonstrate the need for a more integrated framework.

A TRAIT-BASED PRECISION PSYCHOLOGICAL FRAMEWORK

In this review, we propose a precision psychological framework of traits. The central idea is that preoperative anxiety is a cognitive appraisal process determined by a trait. Personality traits function as upstream variables. They affect perception of surgical threat, emotion regulation, attention and interpretation of bodily sensations.

The framework is conceptualised as a dual-path model. One path is affective-regulatory. Low emotional stability along this pathway increases threat appraisal, emotional reactivity, and difficulties in emotion regulation. Higher preoperative anxiety is associated with these processes. The other is cognitive-attentional. In this pathway, traits such as conscientiousness can increase vigilance, monitoring of procedures, and attention to bodily sensations. These processes may increase anticipation of pain and perception of pain. The two paths are related but not identical. This is consistent with overlap of anxiety and pain in some patients and a more dissociated presentation in others.

Cognitive appraisal is the vital link between personality and perioperative outcomes. Cognitive appraisal theory proposes that emotional reactions are not only based on events themselves, but also on the way people interpret these events[47]. A patient who feels that surgery is out of control and threatening may become more anxious. If a patient feels surgery is manageable, they may have less distress. Emotional regulation then determines whether the first assessment is enhanced or diminished[48]. Attentional focus matters as well. A patient might interpret bodily sensations as normal signs of recovery or as signs of danger.

The framework also includes physiological and contextual factors. Psychological processes can interact with autonomic activation and endocrine stress reactions, and facilitate anxiety or pain perception[49,50]. Culture, previous surgical experience, clinical communication and hospital environment may also modify the influence of personality traits on patient responses. The perioperative outcomes are thus the product of an interaction between the personality traits, the cognitive-emotional mechanisms, the physiological responses and the clinical context.

An important concept in this framework is psychological calibration. This implies the customisation of communication, information and psychological support according to the patient’s main cognitive-emotional profile. High threat sensitivity may require help to reduce uncertainty, increase perceived control and provide emotional reassurance. Clear procedural information and realistic expectations for recovery may be necessary for highly vigilant patients. This approach goes beyond one-size-fits-all anxiety management and promotes more individualised care around perioperative care. These pathways and their inter-relationships are visualised in Figure 1. The model of trait-based precision psychological model of pre-operative anxiety is introduced.

Figure 1 Trait-based precision psychological framework of preoperative anxiety. ANS: Autonomic nervous system.

CLINICAL AND TRANSLATIONAL IMPLICATIONS

This framework is of practical importance for surgical care. The usual treatments for anxiety include routine information, sedation or standard reassurance. These approaches can be helpful to some patients, but they may not address the particular psychological process that makes each patient anxious. Clinicians can use a personality-informed approach to identify patients who are vulnerable due to emotional reactivity, threat sensitivity, vigilance, or weak regulation.

Brief screening tools can be incorporated into the preoperative assessment to screen for anxiety symptoms and relevant personality profiles[19]. It is not for the sake of labelling patients. The goal is to inform communication and support. Preoperative interventions targeted to the patient characteristics can reduce anxiety and improve postoperative outcome as shown in previous studies[51]. Thus, personality-informed strategies may permit more precise perioperative care.

Psychological calibration can also help clinicians and patients communicate. Messages for patients with high threat sensitivity may need to highlight safety, control, and support. Patients who are strong monitors may require detailed explanations of surgery, anaesthesia and recovery. Personalised communication may increase satisfaction, reduce anxiety, and improve cooperation in perioperative care[52,53]. Table 1 provides examples of personality-informed strategies for perioperative intervention.

Table 1 Personality-informed perioperative intervention strategies.

Personality trait	Core processing tendency	Typical presentation	Recommended communication strategy
Low emotional stability (high neuroticism)	High threat sensitivity and negative cognitive bias (e.g., catastrophizing)	Elevated anxiety, risk amplification, negative interpretation	Emphasize safety and controllability, reduce uncertainty, provide guided cognitive support
High conscientiousness	High vigilance and information monitoring	Strong focus on details, repeated attention to procedures and bodily changes	Provide structured, step-by-step information, clarify procedures and expectations
High emotional stability	Adaptive emotional regulation and balanced appraisal	Lower anxiety, stable coping	Provide standard communication and routine explanation

Non-pharmacological interventions also fall under this framework. Cognitive-behavioral strategies, relaxation training, and mindfulness-based interventions can be used to reduce anxiety and help regulate stress responses[26,54]. A trait-based model could help us to know which intervention is more appropriate to which patient. For example, training in emotion regulation might be beneficial for patients with low emotional stability. The structured information may be more useful to patients with high vigilance.

Barriers to clinical use will persist. Preoperative consultations tend to be brief. Some clinicians may lack psychological assessment training. Some hospitals may not have the resources for psychological care. For future translation, therefore, brief tools, simple decision pathways, and teamwork among surgeons, anaesthesiologists, psychologists and behavioural medicine specialists will be required[55]. Digital health tools can also help by monitoring patient states and providing real-time, personalised support[24,25].

FUTURE RESEARCH DIRECTIONS

Future research may apply longitudinal and experimental designs to better elucidate causal pathways. Prospective studies may track patients from preoperative evaluation to postoperative recovery. These studies can assess personality traits as predictors of anxiety, pain and behavioural outcomes over time[56-59]. We also need randomised trials to see whether personality-informed interventions are better than standard care.

Researchers should also employ analytical methods that capture the complexity of the model. Structural equation modelling, multilevel modelling, and network analysis are useful to test mediation, moderation, and dynamic links between personality traits, cognitive appraisal, emotion regulation, physiological stress, and perioperative outcomes[60]. These methods are more appropriate than simple linear models for the study of interacting psychological processes.

Future work should combine psychological, physiological and digital data. Personality traits may be related to stress and pain responses and may be explained by cortisol, heart rate variability, inflammatory markers, and neuroimaging[22,49,50]. Ecological momentary assessment and wearable monitoring can detect real-time changes in anxiety and physiological arousal[24,25]. Machine learning may help to predict patient risk and suggest personalised care, but researchers also need to address privacy, bias and access issues[61].

Research should further include various cultural and clinical contexts. Measurement invariance testing is needed to test whether personality, anxiety and pain constructs work the same way across groups[20]. Future research should explore coping style, health beliefs, emotional intelligence and resilience as these may interact with personality traits and influence perioperative responses.

CONCLUSION

Preoperative anxiety should not be viewed as a transient emotional response to surgical stress. The evidence reviewed here suggests that stable personality traits affect patient appraisal of surgical threat, emotion regulation, and attention to bodily signals. These processes influence both anxiety and pain, but may do so through partially distinct pathways. The proposed trait-based framework points to the inadequacies of standardised perioperative management. It supports a movement toward individualised care recognising differences in emotional reactivity, vigilance and cognitive processing. A practical framework for aligning communication and intervention with patient-specific profiles is the concept of psychological calibration. Further research is needed to explore longitudinal designs, integrated physiological markers, and personalised intervention evaluation. A better understanding of perioperative psychology may improve patient experience and clinical outcomes.