Table of Contents  
Year : 2018  |  Volume : 1  |  Issue : 2  |  Page : 48-53

Fear of negative evaluation and social well-being in patients with multiple sclerosis: The moderating role of disease duration

1 Department of Nursing, Social Determinants of Health Research Center, Qazvin University of Medical Sciences, Qazvin, Iran
2 Taylor's Business School, Faculty of Business and Law, Taylor's University, Jalan Taylors, Subang Jaya, 47500 Subang Jaya, Selangor, Malaysia
3 Department of Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
4 The Melbourne Graduate School of Education, The University of Melbourne, Melbourne, Australia

Date of Web Publication29-Oct-2018

Correspondence Address:
Dr. Saeed Pahlevan Sharif
Taylor's Business school, Taylor's University, Jalan Taylors, 47500 Subang Jaya, Selangor
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/SHB.SHB_23_18

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Introduction: Diagnosis of multiple sclerosis (MS) can be accompanied by fear of negative evaluation (FNE). Emerging MS symptoms and FNE affect patients' health in dimensions including social well-being (SWB). The purpose of this study was to investigate the relationship between FNE and SWB among Iranian patients with MS. In addition, the moderating role of disease duration on this relationship was examined. Methods: In this descriptive correlational study, 200 MS patients were recruited from two clinics in Qazvin, Iran, through convenience sampling. Participants completed a demographic questionnaire, the Brief FNE Scale, and the SWB Questionnaire. Results: Mean scores for FNE and SWB were 35.12 ± 13.39 and 100.11 ± 9.81, respectively. We did not find a significant relationship between FNE and SWB (b = 0.092, P = 0.321). However, there was a statistically significant positive association between the duration of the disease and SWB (b = 0.928, P = 0.001). Moreover, there was a statistically significant interaction between the duration of the disease and FNE in predicting SWB (b = −0.025, P = 0.049). Conclusion: The study showed that the strength of the relationship between FNE and SWB depends on the disease duration. More specifically, FNE predicts well-being in patients with longer disease duration but not in patients with shorter disease duration.

Keywords: Disease duration, fear of negative evaluation, moderation, multiple sclerosis, social well-being

How to cite this article:
Soleimani MA, Sharif SP, Yaghoobzadeh A, Allen KA. Fear of negative evaluation and social well-being in patients with multiple sclerosis: The moderating role of disease duration. Soc Health Behav 2018;1:48-53

How to cite this URL:
Soleimani MA, Sharif SP, Yaghoobzadeh A, Allen KA. Fear of negative evaluation and social well-being in patients with multiple sclerosis: The moderating role of disease duration. Soc Health Behav [serial online] 2018 [cited 2023 Oct 1];1:48-53. Available from:

  Introduction Top

Multiple sclerosis (MS) is a common chronic, progressive neurological disability characterized by the demyelination of the central nervous system.[1] The average age of onset is around 18 to 30 years.[2] MS is twice as prevalent in females compared to males.[3] Patients with MS are often diagnosed during a busy and productive stage of their lives with respect to family, work, and social commitments.[4] MS can influence sensory, motor, perceptual, and cognitive ability in patients.[5] Other health-related physical symptoms such as fatigue, bladder and bowel disorders, pain, visual impairment, problems with balance, spasms, and sexual disorders may also impact on the lives of these patients.[6],[7] MS involves restricted movement which limits patients' engagement in daily tasks as well as social activities. It seems that the disability and disease progression of MS has a profound impact on the lives of patients. Following that, it leads to fear of negative evaluation (FNE) and reduction in social health. Disability and disease progression has a role in decreasing the patients' perceived quality of life.[8],[9]

FNE is described by McLean and Woody as a central feature of social anxiety. It is the fear of scrutiny from others and usually involves a fear of social situations, particularly public speaking.[10] Therefore, FNE involves anxiety, expectations, and negative judgment of others about one's self.[11]

Emerging MS symptoms, concerns about body image, and FNE affect patients' health across several domains, including social well-being (SWB) and mental health.[12] SWB refers to the health of an individual's relationships with others and with society. It includes factors such as social prosperity, social adaptation, social cohesion, social acceptance, and social participation. SWB has been found to influence FNE, especially in a chronic condition such as MS.[13] In addition, the mental health of patients with MS can be adversely affected.[14] Mental health can be threatened due to loss of work, social isolation, and a change in social roles (e.g., as a caregiver). Therefore, mental health and SWB are related.[15],[16],[17],[18]

Research has reported that when chronic disease severity was low, participants' perceptions of negative reactions were not related to their FNE scores. However, by increasing disease severity, FNE scores increasingly predicted perceived reactions.[19] In other words, perceptions of negative reactions and evaluation were greatest among high FNE participants who were also the most severe cases. Thus, as symptoms become more observable, patients with a greater fear of being evaluated negatively become increasingly distressed.[19],[20],[21] Moreover, other studies have supported the link between high social approval and FNE in chronic conditions.[22],[23] Hence, the psychological distress reported by MS patients appears to be tied to the extent to which the symptoms are observable and patients' concerns about how symptoms are perceived and evaluated by other people.[24],[25]

The purpose of this study was to examine the relationship between FNE and SWB among Iranian patients with MS. We hypothesized that higher FNE would be associated with a decrease in SWB in a sample of patients with MS. Second, we sought to determine if the relationship between FNE- and SWB-dependent disease duration (time since diagnosis) in the same sample. Thus, we postulated that the disease duration moderates the relationship between FNE and SWB in MS patients.

  Methods Top


A descriptive cross-sectional correlational design was used to examine the relationship between FNE and SWB. The study population consisted of MS patients who were recruited to the two neurologic clinics in Qazvin, Iran, between June and September 2016. The inclusion criteria were as follows: (1) willingness to participate in the study, (2) a diagnosis of MS confirmed by a neurologist, (3) to not be in the acute phase of disease, (4) absence of acute disorders or other chronic diseases, and (5) ability to communicate with researcher. To ensure sufficient statistical power of the test, the required sample size for performing regression analysis was calculated using power analysis. The current study required a minimum of 200 participants assuming α = 0.05, power = 80%, and f2 = 0.08.[21]


The questionnaire consisted of three parts: demographic variables, Brief Version of FNE Scale (FNES), and SWB Scale. Demographic questions were used to elicit information about patients' age, sex, marital status, educational level, socioeconomic status, main income resource, age of onset of MS, and duration of the disease. Furthermore, perceived social support was measured using an analog scale ranging from 0 to 10 (0 = the least, 10 = the most).

Brief fear of negative evaluation scale

Developed by Leary, this questionnaire requires respondents to rate the degree to which each of 12 statements applies to them on a five-point Likert scale (e.g., “I am afraid others will not approve of me” and “I am afraid that people will find fault with me”) ranging from 1 (not at all characteristic of me) to 5 (extremely characteristic of me). Items 2, 4, 7, and 10 are reversed score.[26] A high FNES score indicates more FNE.

This instrument has demonstrated good validity and reliability in an Iranian Population.[27] Content validity of the present scale was approved by a panel which consisted of five experts (two nursing doctorates, two psychiatrists, and one clinical psychologist). For this study, internal consistency reliability, using Cronbach's alpha, was 0.93.

Social well-being questionnaire

Designed by Keyes, it is a five-dimensional self-administered questionnaire comprising 33 items (e.g., “I believe that the progress of society has stopped,” “My behavior affects the behavior of other people in the community,” and “that I feel that there is nothing in society which is worth participating in”). The social well-being questionnaire (SWBQ) items are scored on a five-point Likert scale where 1 stands for “completely disagree” and 5 stands for “completely agree.” The dimensions of SWBQ are social integration (1, 11, 13, 20, 22, 29, and 33), social acceptance (6, 8, 14, 19, 23, 27, and 31), social actualization (5, 7, 15, 17, 18, 25, and 30), social contribution (3, 4, 24, 26, 28, and 32), and social coherence (2, 9, 10, 12, 16, and 21). Items 1, 2, 5, 6, 7, 9, 10, 12, 14, 15, 19, 21, 23, 24, 25, 26, 27, 29, 32, and 33 are reverse scored. The possible range of the total score of the SWBQ is 33–165. Higher scores of the questionnaire reflect more well-adjusted SWB.[28] Validity and reliability of SWBQ were confirmed in different studies.[29],[30] In the present study, a survey of experts was considered to ensure content validity of the questionnaire. Internal consistency reliability, using Cronbach's alpha, for each domain was social integration (α = 0.78), social acceptance (α = 0.68), social actualization (α = 0.72), social contribution (α = 0.78), and social coherence (α = 0.56). Cronbach's alpha for total SWB was 0.76.

Ethical considerations

The study was approved by the associated Qazvin University of Medical Sciences Ethics Committee (IR.QUMS.REC.1394.219). All participants were informed about the voluntary nature of participation, with the option to withdraw from the study at any time. We also guaranteed the confidentiality of the participants' personal information. In addition, we obtained a written informed consent from each participant.

Statistical analysis

The Statistical Package for the Social Sciences (SPSS), version 20 (SPSS, IBM Corp., Armonk, NY, USA) and PROCESS were used for data analysis. Descriptive statistics for numerical variables were displayed as means with standard deviation (SD) and n (%) for categorical variables. Correlations between FNE with SWB scores and its dimensions were assessed using Pearson correlation when P values were adjusted using Bonferroni correction. To perform the correlation analysis, normality assumption was assessed. Multiple regression analysis using Hayes' approach (2013) was used to assess the moderation effect model where SWB as the dependent variable was regressed on FNE as the independent variable, disease duration as the moderator, and the interaction of FNE and disease duration. All variables in the model were continuous. PROCESS uses grand mean centering to make the results interpretable. To do so, the independent variable (FNE) and the moderator (disease duration) are standardized. Next, the independent variable, moderator, and their interaction are included in the model. Finally, the multiple regression analysis is conducted and regression coefficients and their P values are estimated.

  Results Top

[Table 1] shows the participants' demographic characteristics. The sample was mainly female (n = 150, 75%). Among the participants, 122 (61%) patients reported their marital status as married, while 67 (33.5%) of them indicated that they were single. With regard to educational level, 64.5% of the sample had college-level degrees.
Table 1: Demographic characteristics of the study participants

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[Table 2] shows the results of Pearson correlation analysis on the relationship between FNE and SWB dimensions after controlling for the effect of sex, age, socioeconomic status, and perceived social support. As it is shown, this study did not find any significant relationship between FNE and SWB (r = −0.079, P = 0.494). Similarly, the relationship between FNE and social integration (r = −0.068, P = 0.281), social acceptance (r = −0.010, P = 0.776), social contribution (r = 0.153, P = 0.142), and social coherence (r = 0.022, P = 0.676) was not significant at 0.05. However, FNE had a statistically significant negative association with social actualization (r = −0.275, P < 0.001).
Table 2: Pearson correlation of fear of negative evaluation and social well-being

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The results of performing multiple regression analysis after controlling for the effect of sex, age, socioeconomic status, and perceived social support are shown in [Table 3]. This study did not find any significant relation between FNE and SWB (b = 0.092, P = 0.321). However, there was a statistically significant positive association between disease duration and SWB (b = 0.928, P < 0.001). Moreover, the results provided support for the moderating role of disease duration on the association between FNE and SWB (b = −0.025, P = 0.049). Specifically, for the medium level of disease duration (6.270 years), the relationship between FNE and SWB was not statistically significant (b = −0.062, P = 0.239). When the disease duration was shorter by 1 SD (1.91 years), the association between FNE and SWB became weaker (b = 0.045, P = 0.543). However, for individuals with a disease duration which was 1 SD above the mean (i.e., 10.635 years), the negative relationship between FNE and SWB was statistically significant (b = −0.170, P = 0.028). Thus, disease duration moderated the association between FNE and SWB such that FNE was negatively associated with SWB for those with longer, but not shorter, disease duration.
Table 3: Moderation results

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  Discussion Top

This study was conducted to examine the relationship between FNE and SWB in a sample of Iranian MS patients. Initial Pearson correlations indicated no significant relationship between these variables. Contrary to the present results, Leary et al. demonstrated a negative correlation between FNE and SWB among patients with psoriasis.[19] Furthermore, other studies that represented people who with chronic disease score highly on measures of approval motivation, public self-consciousness, self-monitoring, social anxiety, and FNE are found to be more highly motivated to obtain social approval and are more afraid of receiving disapproval than people who score lower on each of these variables.[22],[31] Thus, our initial hypothesis was not supported; however, this may be due to the differences in disease duration among participants of the study. However, these studies, which found a statistically significant relation, did not report disease severity.

In this study, the duration of the disease had a moderating effect on the relationship between FNE and SWB. More specifically, disease duration seemed to strengthen the negative association between FNE and SWB. Thus, patients with longer disease duration who also had a higher level of FNE experienced lower SWB. Moreover, the results of the study indicated that physical symptoms such as weakness, disability, impaired coordination, and walking movement can affect the FNE among MS patients. These symptoms will be aggregate by the relapse occurrence of the disease.[32] In addition, body image, self-esteem, and confidence are reported as other factors influencing FNE.[33],[34] Therefore, the later stages of MS and its associated changes in physical appearance may contribute to decrease in SWB because of stigmatization by and social isolation from others. On the other hand, poor social skills and poor physical appearance are observable signs that contribute to the stigmatization of individuals.[35] In addition, physical changes associated with the later stages of MS, poor social skills, and poor physical appearance may contribute to social isolation.[36],[37] Thus, the experience of negative evaluation can lead to avoidant-type behaviors in patients.[38]

Although cultural nuances can affect the disability experience of MS patients, the chronic nature of disease is the same in all populations. In MS, the relapse of the disease depends on age and the duration of the disease.[39] Each relapse may involve different signs and symptoms. Relapse experiences occur in different dimensions of health, including physical, mental, and social dimensions. As illness progresses, the disability also increases. Manouchehrinia et al. reported that there was a moderate correlation between disability and disease duration and between disability and age.[40] In addition, there are certain symptoms in these patients which are less likely to be diagnosed. For example, cognitive fatigue in MS is underrecognized.[41] In chronic disease, the severity of disability can be a barrier to participating in social activities.[42] Thus, SWB of patients with complete disability may be impaired compared with patients who are at an early stage of the disease.

Limitations and future research

The study is limited by its descriptive nature and a convenience sample of self-selected Iranian patients with MS. This disease is also quite different among races. Therefore, the generalizability cannot be made for other countries. Therefore, findings cannot be generalized, and causation cannot be established. Furthermore, the cross-sectional nature of this descriptive study limits the ability to understand change over time. A future study could assess the longitudinal outcomes related to the key variables of interest in the present study (e.g., SWB and FNE) and how they relate to emerging symptoms among MS patients. Given the global prevalence of MS, this is an important issue for future research.

  Conclusion Top

No significant negative correlation was found between FNE and SWB in MS patients. The result of the current research showed that the duration of the disease had a moderating effect on the association between FNE and SWB. Limited studies are available that directly assess the relationship between these two main variables in chronic condition. With regard to the outcomes of chronic disease on different dimension of health, it seems examining these variables and evaluating other moderating factors to be important in other chronic condition.


The authors would like to express their gratitude to the patients who bravely participated in this study. We gratefully acknowledge the Yasaman Hatef Matbue and Elahe Kabiri for your collaboration in this study. This work was supported by the National Institutes of Health (grant numbers 728, 2016).

Financial support and sponsorship

This work was supported by the National Institutes of Health (grant numbers 728, 2016). Deputy for Research and Technology of Qazvin University and Medical Sciences (No. P.62) too.

Conflicts of interest

There are no conflicts of interest.

  References Top

Orasanu B, Frasure H, Wyman A, Mahajan ST. Sexual dysfunction in patients with multiple sclerosis. Mult Scler Relat Disord 2013;2:117-23.  Back to cited text no. 1
Tavakol M, Yusefi S. A study of the demographic characteristics of patients MS. J Bioeth 2012;3:79-100.  Back to cited text no. 2
Mackenzie IS, Morant SV, Bloomfield GA, MacDonald TM, O'Riordan J. Incidence and prevalence of multiple sclerosis in the UK 1990-2010: A descriptive study in the general practice research database. J Neurol Neurosurg Psychiatry 2014;85:76-84.  Back to cited text no. 3
Masoudi R, Mohammadi I, Ahmadi F, Hasanpour-Dehkordi A. The effect of self-care program education based on Orem's theory on mental aspect of quality of life in multiple sclerosis patients. Iran J Nurs 2009;22:53-64.  Back to cited text no. 4
Ghanbari S, Ghasemzade R. Experience of multiple sclerosis patients about leisure time activities. Qual Res Health Sci 2012;1:15-26.  Back to cited text no. 5
Jadidmilani M. Physical health in people with multiple sclerosis. Paper presented at the The 7th International Congress of Multiple Sclerosis; 2010. p. 32.  Back to cited text no. 6
Turekca S, Schultheis M, Sunderaraman P. B-89Comparison of driving performance, cognition, and physical symptoms in individuals with multiple sclerosis and healthy controls. Arch Clin Neuropsychol 2014;29:570.  Back to cited text no. 7
Ghafari S, Ahmadi F, Nabavi SM, Memarian R, Kazemnejad A. Effect of applying progressive muscle relaxation technique on fatigue in multiple sclerosis patients. Shahrekord Univ Med Sci 2008;10:61-8.  Back to cited text no. 8
Merghatikhoei E, Qaderi K, Amini L, Haghani H. Study on sexual behavior and quality of life of women with multiple sclerosis referred to Iran MS society in Tehran in 2010. Iran J Obstet Gynecol Infertil 2012;15:7-14.  Back to cited text no. 9
McLean PD, Woody SR. Anxiety Disorders in Adults: An Evidence-Based Approach to Psychological Treatment. Oxford: Oxford University Press; 2001.  Back to cited text no. 10
Watson D, Friend R. Measurement of socialevaluative anxiety. Consult Clin Psychol 1969;33:448-57.  Back to cited text no. 11
Agha-Bagheri H, Mohammad-Khani P, Emrani S, Farahmand V. The efficacy of mindfulness-based cognitive therapy group on the increase of subjective well-being and hope in patients with multiple sclerosis. J Clin Psychol 2012;4:23-31.  Back to cited text no. 12
Arfee Eynaldyn R. The Relationship between Leisure and Social Health about Check Youth 15 to 23 Years, city Bostanabad. Allameh Tabatabai; 2010.  Back to cited text no. 13
World Health Organization. International Classification of Impairments, Disabilities, and Handicaps. Geneva: World Health Organization; 1980.  Back to cited text no. 14
Pugliatti M, Rosati G, Carton H, Riise T, Drulovic J, Vécsei L, et al. The epidemiology of multiple sclerosis in Europe. Eur J Neurol 2006;13:700-22.  Back to cited text no. 15
Janardhan V, Bakshi R. Quality of life in patients with multiple sclerosis: The impact of fatigue and depression. J Neurol Sci 2002;205:51-8.  Back to cited text no. 16
Hakim EA, Bakheit AM, Bryant TN, Roberts MW, McIntosh-Michaelis SA, Spackman AJ, et al. The social impact of multiple sclerosis – A study of 305 patients and their relatives. Disabil Rehabil 2000;22:288-93.  Back to cited text no. 17
Walsh A, Walsh PA. Love, self-esteem, and multiple sclerosis. Soc Sci Med 1989;29:793-8.  Back to cited text no. 18
Leary MR, Rapp SR, Herbst KC, Exum ML, Feldman SR. Interpersonal concerns and psychological difficulties of psoriasis patients: Effects of disease severity and fear of negative evaluation. Health Psychol 1998;17:530-6.  Back to cited text no. 19
Williams KC, Falkum E, Martinsen EW. Fear of negative evaluation, avoidance and mental distress among hearing-impaired employees. Rehabil Psychol 2015;60:51-8.  Back to cited text no. 20
Cohen J, Cohen P, West SG, Aiken LS. Applied Multiple Regression/Correlation Analysis for the Behavioral Sciences. 3rd ed. Mahwah, New Jersey: Lawrence Erlbaum, Routledge; 2003.  Back to cited text no. 21
Ginsburg IH, Link BG. Feelings of stigmatization in patients with psoriasis. J Am Acad Dermatol 1989;20:53-63.  Back to cited text no. 22
Ginsburg IH, Link BG. Psychosocial consequences of rejection and stigma feelings in psoriasis patients. Int J Dermatol 1993;32:587-91.  Back to cited text no. 23
Jean VM, Beatty WW, Paul RH, Mullins L. Coping with general and disease-related stressors by patients with multiple sclerosis: Relationships to psychological distress. Mult Scler 1997;3:191-6.  Back to cited text no. 24
Jones SM, Amtmann D. The relationship of age, function, and psychological distress in multiple sclerosis. Psychol Health Med 2015;20:629-34.  Back to cited text no. 25
Leary MR. A brief version of the fear of negative evaluation scale. Pers Soc Psychol Bull1983;9:371-5.  Back to cited text no. 26
Tavoli A, Melyani M, Bakhtiari M, Ghaedi GH, Montazeri A. The brief fear of negative evaluation scale (BFNE): Translation and validation study of the Iranian version. BMC Psychiatry 2009;9:42.  Back to cited text no. 27
Keyes CL. Social well-being. Soc Psychol Q1998;61:121-40.  Back to cited text no. 28
Mozaffari N, Dadkhah B, Shamshiri M, Mohammadi MA, Dehghan Nayeri N. The status of social well-being in Iranian nurses: A cross- sectional study. J Caring Sci 2014;3:239-46.  Back to cited text no. 29
Darabinia M, Heidari Gorji AM, Hosseini Karnami H. Examining social health and its related factors among Iranian medical students. J Caring Sci 2018;7:47-51.  Back to cited text no. 30
Jobling RG. Psoriasis – A preliminary questionnaire study of sufferers' subjective experience. Clin Exp Dermatol 1976;1:233-6.  Back to cited text no. 31
Benedict RH, Wahlig E, Bakshi R, Fishman I, Munschauer F, Zivadinov R, et al. Predicting quality of life in multiple sclerosis: Accounting for physical disability, fatigue, cognition, mood disorder, personality, and behavior change. J Neurol Sci 2005;231:29-34.  Back to cited text no. 32
Begley CM, White P. Irish nursing students' changing self-esteem and fear of negative evaluation during their preregistration programme. J Adv Nurs 2003;42:390-401.  Back to cited text no. 33
Vander Wal JS, Thomas N. Predictors of body image dissatisfaction and disturbed eating attitudes and behaviors in African American and Hispanic girls. Eat Behav 2004;5:291-301.  Back to cited text no. 34
Corrigan P. How stigma interferes with mental health care. Am Psychol 2004;59:614-25.  Back to cited text no. 35
Robens S, Fox E, Grose J, Gunn H, Freeman J. Social isolation amongst severely impaired people with multiple sclerosis (MS): choice, control and identity. Paper Mult Scler J 2014;20:968-9.  Back to cited text no. 36
Feinstein A. An examination of suicidal intent in patients with multiple sclerosis. Neurology 2002;59:674-8.  Back to cited text no. 37
Kent G. Understanding the experiences of people with disfigurements: An integration of four models of social and psychological functioning. Psychol Health Med 2000;5:117-29.  Back to cited text no. 38
Glassock RJ. Therapy of relapsing minimal-change disease in adults: A new approach? Kidney Int 2013;83:343-5.  Back to cited text no. 39
Manouchehrinia A, Westerlind H, Kingwell E, Zhu F, Carruthers R, Ramanujam R, et al. Age related multiple sclerosis severity score: Disability ranked by age. Mult Scler 2017;23:1938-46.  Back to cited text no. 40
Ramamurthy G, Ranganathan LN, Kanthimathinathan S, Govindarajan S, Maheswari EU, Marimuthu J, et al. Cognitive Fatigue in Multiple Sclerosis: Correlation Between Objective and Subjective Measures (P4. 401). AAN Enterprises; 2018.  Back to cited text no. 41
Soleimani MA, Negarandeh R, Bastani F, Greysen R. Disrupted social connectedness in people with Parkinson's disease. Br J Community Nurs 2014;19:136-41.  Back to cited text no. 42


  [Table 1], [Table 2], [Table 3]


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