Ethnic differences in pain coping: factor structure of the coping strategies questionnaire and coping strategies questionnaire-revised.

Coping has been examined extensively in the pain literature, although coping instruments have been typically validated in clinical populations with little ethnic diversity. This study examined the factor structure of the Coping Strategies Questionnaire (CSQ) and the CSQ-Revised (CSQ-R) in 650 healthy male and female African American (44%) and white (56%) subjects and explored associations of coping to health and pain-related measures. Factor analyses revealed 6 components for each ethnic group, accounting for comparable amounts of variance and resembling previously reported CSQ subscales. Internal consistency for both ethnic groups was acceptable (0.72-0.91). There were significant main effects for ethnicity on 4 of the CSQ-R scales (P < .05). No ethnic differences in pain or health variables emerged, although when split into high-pain versus minimal-pain groups, differences were revealed on catastrophizing. Results indicate that the factor structure of the CSQ-R in healthy adults is similar to clinical populations and is comparable across African American and white subjects. Group differences on CSQ-R scales suggest potentially important ethnic influences on pain coping. These findings support the use of the CSQ-R to assess coping in African Americans and in healthy young adults. Additional clinical research is needed to determine the practical importance of group differences in pain coping. PERSPECTIVE: Coping has been examined extensively in the pain literature, although coping instruments typically have been validated in clinical populations with little ethnic diversity. This study examines the factor structure of the CSQ-Revised in an ethnically diverse population and supports the use of the CSQ-R to assess coping in African Americans and in healthy young adults.     

Pain beliefs and the use of cognitive-behavioral coping strategies.

Patients' beliefs about chronic pain, such as how long it will last and whether it is a mysterious experience, have been shown to be related to compliance with treatment programs. The present study examined whether these pain beliefs related to a specific component of pain management, namely the frequency of use and the perceived effectiveness of cognitive and behavioral coping strategies. One hundred twenty chronic pain patients were administered the Pain Beliefs and Perceptions inventory (PBAPI) and the Coping Strategies questionnaire (CSQ). A cluster analysis of 2 pain beliefs (that pain is enduring and that pain is mysterious) was conducted revealing 3 distinct subgroups of patients based upon these 2 beliefs. Multivariate analysis of variance was used to detect whether the use of cognitive-behavioral pain coping strategies differed in patients in the 3 pain beliefs subgroups. The results indicated that patients belonging to the group characterized by the belief that pain was enduring and mysterious were less likely to use cognitive coping strategies (e.g., reinterpretation of pain sensation), more likely to catastrophize, and less likely to rate their coping strategies as effective in controlling and decreasing pain than patients believing their pain to be understandable and of short duration. The implications of these results for understanding the patient's choice of and compliance with treatment and coping efforts is discussed.     

Dimensions of pain-related cognitive coping: cross-validation of the factor structure of the Coping Strategy Questionnaire

Previous research has demonstrated a relationship between cognitive pain coping activity and adjustment in pain patients. The empirically derived dimensions of coping activity, as measured by scales from the Coping Strategy Questionnaire (CSQ), however, have varied across investigations. The purpose of this investigation was to determine both the content and number of dimensions of the CSQ and to explore the potential moderating influence that sociodemographic and patient history variables may have on the latent structure of the CSQ. A total of 620 patients from 5 different chronic pain patient samples were used to assess the generalizability of the dimensions across samples. Confirmatory factor analytic procedures identified a 3-factor solution in most of the samples that was robust across various demographic characteristics. Two factors appeared particularly robust: one reflected conscious use of cognitive coping strategies (with high loadings on ignoring pain and coping self-statements) and another reflected self-efficacy beliefs concerning pain (with high loadings on ability to control and decrease pain). A third factor, which was somewhat less stable, appeared to reflect avoidance of pain by attention to non-pain-related mental activity (with high loadings on diverting attention and praying and hoping). Scales reflecting catastrophizing cognitions and behavioral coping strategies did not consistently load on the above dimensions. Issues concerning the conceptualization and measurement of pain-related cognitive coping dimensions are discussed.     

Analyzing chronic low back pain: the relative contribution of pain coping strategies

Sixty-two chronic low back pain patients were administered the Coping Strategies Questionnaire (CSQ) to assess the frequency of use and perceived effectiveness of a variety of cognitive and behavioral pain coping strategies. Analysis of individual variables revealed that CSQ factors, gender, physical examination findings, and chronicity of pain had significant effects on one or more of a series of pain, psychological distress or behavioral measures. To assess the relative contribution of each of these variables hierarchical stepwise regression analyses were carried out. These analyses revealed that the Helplessness factor of the CSQ explained 50% of the variance in psychological distress (Global Severity Index of the SCL-90R), and 46% of the variance in depression (Beck Depression Inventory). Patients scoring high on this CSQ factor had significantly higher levels of psychological distress. None of the demographic or medical status variables explained a significant proportion of variance in the psychological distress measures. The Diverting Attention and Praying factor of the CSQ explained a moderate (9%), but significant amount of variance in pain report. Patients scoring high on this factor had higher scores on the McGill Pain Questionnaire. Coping strategies were not strongly related to pain behavior measures such as guarding or uptime. A consideration of pain coping strategies may allow one to design pain coping skills training interventions so as to fit the needs of the individual low back pain patient.     

Einfluss einer Motivationsintervention auf die Bewältigung chronischer Schmerzen

Background

For effective self-management of chronic pain changes of cognitive and behavioral attitudes are required. The readiness to change can be described within the framework of the transtheoretical model (TTM) and is facilitated through motivational interviewing. This prospective study evaluated the effectiveness of brief motivational interviewing by telephone for the variables self-efficacy, cognitive and behavioral coping and psychological strain through chronic pain over a period of 9 months.

Methods

Different questionnaires, the self-efficacy expectations (ASES-D), cognitive, behavioral coping and psychological strain through chronic pain (FESV) and the German version of the pain stages of change questionnaires (PSOCQ), the FF-STABS were distributed to 147 patients at a rehabilitation clinic (indications: fibromyalgia syndrome, rheumatoid arthritis, ankylosing spondylitis). The intervention group participants received 3 telephone calls at intervals of 2 months with a follow-up time of 9 months after first study admission. At the end of the study 91 patients were enrolled for analysis (drop out rate 38%). To evaluate the effects of treatment nonparametric-analysis for longitudinal data was used.

Results and conclusion

The analysis showed significant positive effects in the intervention group for cognitive coping (U-value ?2.423; p=0.015 group × time-effect) and for coping with emotional strains of chronic pain (subscale anxiety: U-value ?2.3618; p=0.018; subscale anger: U-value 2.8638; p=0.004; group × time-effect). No significant effects were shown for self-efficacy expectations and behavioral coping with pain. Further explorative analysis of subgroups revealed slightly better treatment effects for patients with rheumatoid arthritis and ankylosing spondylitis than for those with fibromyalgia syndrome.     

Pain coping strategies in a Dutch population of chronic low back pain patients

The use of strategies for coping with chronic pain was assessed by means of the Coping Strategy Questionnaire (CSQ) in a Dutch sample of 108 chronic low back pain (LBP) patients referred for behavioral treatment. The 3 factors of the CSQ were related to measurements of behavioral and emotional adjustment to LBP above and beyond the effects of demographic and medical status variables. Especially patients high on the factor Helplessness reported higher levels of pain, functional impairment, anxiety, depression and psychoneuroticism, while patients high on the factor Perceived Control reported lower levels of pain, functional impairment and also manifested a higher level of uptime. The causal role of coping strategies in adjustment to pain, the selectivity of focusing on LBP patients selected through referral and implications for pain management are discussed.     

How chronic pain patients cope with pain: Relation to treatment outcome in a multidisciplinary pain clinic

One hundred male and 100 female chronic pain patients in a multidisciplinary pain clinic completed a 34-item Pain Coping Questionnaire (PCQ). Factor analysis identified four pain coping factors: self-management, helplessness, social support, and medical remedies. Multiple-regression analyses were conducted to determine the relation between PCQ factors and measures of adjustment at admission to the pain program as well as admission to discharge changes in adjustment measures. The following concepts relevant to coping with chronic pain were defined: cognitive strategies, self-efficacy, helplessness, catastrophizing, and cognitive distortion. Suggestions were made for integrating these concepts in the development of scales for assessing strategies for coping with chronic pain.     

Multidimensional Pain Inventory derived classifications of chronic pain: evidence for maladaptive pain-related coping within the dysfunctional group

This study examines maladaptive pain-related fear-avoidance and endurance coping in subgroups of patients with chronic back pain. Hypotheses were derived from the avoidance-endurance model of pain [Hasenbring M. Attentional control of pain and the process of chronification. In: Sandkühler J, Bromm B, Gebhart GF, editors. Progress in pain research, vol. 129. New York: Elsevier; 2000. p. 525-34.], which assumes that endurance coping (cognitive, behavioral tendency to endure severe pain to finish current activities irrespective of pain increases) leads to overuse of muscles, joints, and discs with an increase of pain as long-term consequence. Participants were 120 patients referred for treatment of chronic pain to General Practices. They were classified as 'dysfunctional-DYS' (15.8%), 'interpersonally distressed-ID' (10.8%), and 'adaptive copers-AC' (61.7%) based on the Multidimensional Pain Inventory [Kerns RD, Turk DC, Rudy TE. The West Haven-Yale Multidimensional Pain Inventory (WHYMPI). Pain 1985;23:345-56.] and compared on measures of pain-related fear-avoidance coping (anxiety/depression; help-/hopelessness; catastrophizing; avoidance of social/physical activity) and endurance coping (positive mood; thought suppression; endurance behavior) using the Kiel Pain Inventory [Hasenbring M. The Kiel Pain Inventory-Manual. Three questionnaire scales for assessment of pain-related cognitions, emotions and copying strategies. Bern:Huber; 1994.]. Multivariate analysis of variance indicated that groups differed significantly for pain-related fear-avoidance and endurance coping, even after control for pain intensity and depression. Univariate effects revealed that patients classified as DYS reported more anxiety/depression, help-/hopelessness, and catastrophizing than did those classified as AC. Furthermore, the DYS group showed more thought suppression compared to AC; however, subgroups did not differ significantly with regard to avoidance of social and physical activity, and endurance behavior. Further, DYS as well as ID group showed more non-verbal pain behavior compared to AC, which refers to the special role of operant conditioning. Implications are considered for further investigation of endurance coping to provide a more comprehensive assessment and treatment for subgroups of chronic pain patients.     

Coping and convalescence course after lumbar disk operations

BACKGROUND: Aim of the present prospective longitudinal study was the statistical foundation and thus further replication of recent findings of Hasenbring [13], who postulated a significant importance of specific, within the psychological pain research long neglected pain coping strategies as risk factors concerning pain chronification: appeals to "stick it out" on the cognitive level and endurance strategies on the behavioural level. METHODS: In contrast to Hasenbring's heterogeneous chronic pain patients sample (first plus repeated surgical or conservative treatment) the present 82 low back pain patients with acute radicular pain and simultaneous lumbar disc prolapse all underwent first time lumbar nucleotomy. Prior to treatment we conducted an extensive psychological and neurological examination. The psychological tests included a general depression scale (Allgemeine Depressionsskala; ADS) and the Kiel Pain Inventory (KPI). Based on these scales a cluster analysis was performed, which allocated patients to four distinct groups resembling the group structure ascertained by Hasenbring [12, 13]: A first group of patients characterized by a positive mood and marked endurance strategies (n=7); another cluster with depressive mood and simultaneous cognitive appeals to stick it out (n=10); a third group of emotionally depressed patients who preferably applied social and physical avoidance strategies in their coping with chronic pain (n=29), plus a last cluster without any psychological risk factors (n=26). RESULTS: As treatment outcome criteria to evaluate the quality of the convalescence process six months later we assessed the pain intensity (11-point self-rating scale), the ability to work, and whether the patients had applied for early retirement or not. Results showed no significant differences in pain intensity between the groups at the 6-month follow up. Concerning the two other outcome variables the two clusters characterized by cognitive or behavioural endurance tendencies turned out to be high risk groups: At the 6-month follow up patients of both groups seemed less likely to return to work. The patients typified by endurance strategies and positive mood had more often applied for early retirement than those patients without psychological risk factors. DISCUSSION: These results corroborate the finding that this subgroup of chronic low back pain patients might indeed carry a bad prognosis and call for further research into this area, especially with regard to rehabilitation potential and facilities of reintegration into working life.     

Coping with persistent pain: a comparison of persistent pain sufferers in a specialty pain clinic and in a family practice clinic

Coping has been defined as an effort to manage external and internal demands and conflicts that tax or exceed a person's resources. This paper examines the types of coping strategies used by two groups of persistent pain sufferers: one from a family practice clinic and the other from a specialty pain clinic. The relationship between the use of different types of coping strategies and adjustment was determined. The two study groups of persistent pain sufferers differed significantly from each other on many of the indices developed to tap adjustment but did not differ on any of the Billings and Moos original categories of coping strategies. When a factor analysis of coping items was performed, 5 valid clusters relevant to the chronic pain patient samples were determined. The factor the authors entitled 'adversarialness' with the qualities of dysphoric withdrawal, avoidant behavior and catastrophizing was found to explain adjustment defined by several indices. The authors conclude that it may be important to help persistent pain sufferers to alter their attitudes and behavior that tend toward catastrophizing, avoidance and withdrawal, rather than simply concentrate on trying to teach them techniques for 'coping with stress.'     

Analyzing pain in rheumatoid arthritis patients. Pain coping strategies in patients who have had knee replacement surgery.

This study used the Coping Strategies Questionnaire (CSQ) to investigate pain coping strategies in 52 rheumatoid arthritis patients who reported having knee pain 1 year or more following knee replacement surgery. Data analysis revealed that, as a group, these patients were active copers in that they reported frequent use of a variety of pain coping strategies. Pain coping strategies were found to be related to measures of pain and adjustment. Patients who rated their ability to control and decrease pain high and who rarely engaged in catastrophizing (i.e., who scored high on the Pain Control and Rational Thinking factor of the CSQ) had much lower levels of pain and psychological disability than patients who did not. Coping strategies were not found to relate to age, gender, obesity status or disability/compensation status. Taken together, these results suggest that an analysis of pain coping strategies may be helpful in understanding pain in arthritis patients who have pain following joint replacement surgery.     

Quality of life in chronic pain is more associated with beliefs about pain, than with pain intensity.

OBJECTIVES: The objectives of this study were to investigate pain cognitions and quality of life of chronic pain patients referred to a multi-disciplinary university pain management clinic and to search for predictors of quality of life. METHODS: A heterogeneous group of 1208 chronic pain patients referred to the Maastricht university hospital pain clinic participated in this cross-sectional study. At the initial assessment, all patients completed a set of questionnaires on demographic variables, cause, location, pain intensity (McGill pain questionnaire, MPQ), pain coping and beliefs (pain coping and cognition list, PCCL), pain catastrophising (pain catastrophising scale, PCS) and eight dimensions of quality of life (Rand-36). RESULTS: The results showed that the present sample of heterogeneous pain patients reported low quality of life on each domain and significantly lower scores than has been found in previous studies with other Dutch chronic pain populations. Patients with low back pain and multiple pain localisations experienced most functional limitations. Women reported more pain, more catastrophising thoughts about pain, more disability and lower vitality and general health. When tested in a multiple regression analysis, pain catastrophising turned out to be the single most important predictor of quality of life. Especially social functioning, vitality, mental health and general health are significantly associated with pain catastrophising. CONCLUSIONS: Patients from a multi-disciplinary university pain clinic experience strikingly low quality of life, whereby low back pain patients and patients with multiple pain localisations have the lowest quality of life. Pain catastrophising showed the strongest association with quality of life, and stronger than pain intensity.     

Validation of the Chronic Pain Coping Inventory

The Chronic Pain Coping Inventory (CPCI; Jensen, M.P., Turner, J.A., Romano, J.M. and Strom, S.E., The Chronic Pain Coping Inventory: development and preliminary validation, Pain, 60 (1995) 203–216) is a recently developed questionnaire comprising eight main subscales that measure coping strategies that are frequently targeted for change in interdisciplinary pain treatment programs. Preliminary research, carried out by the developers of the CPCI, supports the reliability and validity of the scale. The purpose of the present study was to further examine the validity of the CPCI independently. In the present study, 210 patients were administered the CPCI, along with the Coping Strategies Questionnaire (CSQ; Rosenstiel, A.K. and Keefe, F.J., The use of coping strategies in low back pain patients: relationship to patient characteristics and current adjustment, Pain, 17 (1983) 33–44; Riley III, J.L. and Robinson, M.E., CSQ: five factors or fiction? Clin. J. Pain, 13 (1997) 156–162), and the Multidimensional Pain Inventory (MPI; Kerns, R.D., Turk, D.C. and Rudy, T.E., The West Haven-Yale Multidimensional Pain Inventory (WHYMPI), Pain, 23 (1985) 345–356) as part of a pre-admission screening. Principal components analysis with oblique rotation was performed on the 64 main CPCI scale items. An eight-factor solution was identified as most appropriate. The original subscales were generally supported, however, some modifications to scoring of subscales were suggested. As a second step in the study, the relationship between the modified CPCI subscales and the CSQ subscales were examined and their relative ability to predict concurrent adjustment to pain (MPI subscales) was assessed. Results indicated that CPCI subscales tap coping constructs that are conceptually different than the CSQ subscales. Several CPCI subscales were also found to be significantly and uniquely related to measures of concurrent adjustment, even after taking CSQ subscales and demographic and pain-related variables into account. These results suggest the CPCI is a valuable tool, above and beyond established coping measures, in the clinical assessment and research of pain. Directions for future research are discussed.     

Depression and functional disability in chronic pediatric pain.

OBJECTIVES: The primary aim of this study was to describe pain characteristics, coping strategies, depression, and functional disability in children and adolescents with chronic pain and to examine potential factors that are associated with functional disability in a pediatric pain population. The secondary aim of this study was to compare functional disability in two chronic pain conditions: localized musculoskeletal pain and chronic daily headaches. SUBJECTS: The participants in this study were 73 pediatric pain patients with a variety of chronic pain conditions. Subjects in the second part of the study were a subset of patients (N = 44) from the pain clinic sample with chronic localized musculoskeletal pain and a subset of patients (N = 38) from the headache center of the same hospital who had chronic daily headaches. DESIGN: Patients completed self-report measures of pain intensity, depression, coping strategies, coping efficacy, and functional disability. RESULTS: Results indicated that chronic pain had a substantial impact on the children's lives and that depression was strongly associated with functional disability. Maladaptive coping was correlated with depression and disability; however, maladaptive coping was not independently associated with functional disability. A comparison between the two groups found significant differences in pain intensity and functional disability. The localized musculoskeletal pain group reported higher levels of disability and more difficulty coping than the chronic daily headache group. CONCLUSIONS: The implications for treatment of chronic pain in children are discussed with an emphasis on greater attention to developmental issues and their relation to coping, emotional functioning, and disability in pediatric pain. Further research examining differences in coping and disability between different pediatric pain groups is also warranted.     

Psychological, behavioral, and family characteristics of pediatric patients with chronic pain: a 1-year retrospective study and cluster analysis

OBJECTIVES: There has been a longstanding recognition that adult patients with chronic pain are not a homogenous population and that there are subgroups of patients who report high levels of distress and interpersonal difficulties as well as subgroups of patients who report little distress and high functioning. The purpose of the present study was to attempt to identify similar subgroups in a pediatric chronic pain population. METHODS: The sample consisted of 117 children with chronic pain and their parents who were assessed in a multidisciplinary pain clinic during 2001. Participants completed a set of psychologic self-report questionnaires, as well as demographic and pain characteristic information. A cluster analysis was conducted to identify 3 distinct subgroups of patients to replicate similar studies of adult chronic pain sufferers. RESULTS: Overall, mean scores were within population norms on measures of distress and family functioning, with somatic symptoms at a level of clinical significance. The cluster analysis identified the 3 subgroups that were strikingly similar to those identified in adult chronic pain populations: one with high levels of distress and disability, another with relatively low scores on distress and disability, and a third group that scored in between the other 2 on these measures but with marked low family cohesion. DISCUSSION: The similarity of these subgroups to the adult chronic pain population subgroups as well as implications for future studies are discussed.     

Strategies for coping with chronic low back pain: Relationship to pain and disability

Seventy-four chronic low back pain patients in a study assessing the effectiveness of group outpatient cognitive-behavioral and operant behavioral treatment completed the Coping Strategy Questionnaire (CSQ) and measures of pain, depression, and functional disability pre- and post-treatment. The previously reported factor structure of the CSQ was generally replicated, and significant associations were found between use of ignoring and reinterpretation strategies and downtime, between use of attention diversion strategies and pain intensity, and between tendency to catastrophize and physical and psychosocial impairment. Both treatments resulted in significant changes in types of coping strategies used to deal with pain. Increased use of praying and hoping strategies was significantly related to decreases in pain intensity. Decreased catastrophizing was also significantly related to decreases in pain intensity, as well as to decreases in physical and psychosocial impairment.     

Coping with chronic pain: a comparison of two measures

Cognitive-behavioral models of chronic pain hypothesize that how a person copes with pain influences how well he or she adjusts to the pain. Several measures have been developed to assess pain coping, but no studies have yet examined whether these measures are complementary or redundant. In the current study, two pain coping measures (the Chronic Pain Coping Inventory, CPCI, and the Coping Strategies Questionnaire, CSQ) were completed by a large number (N=564) of primarily male veterans referred to a chronic pain program. Regression analyses indicated that the CPCI scales did not contribute unique variance to the prediction of depression over and above the CSQ scales. The CSQ Catastrophizing scale was the single most powerful predictor of depression, although several other CSQ scales (Coping Self-Statements, Diverting Attention, and Increasing Behavioral Activities) also contributed. Both the CPCI and the CSQ contributed unique variance to the prediction of disability, although the CPCI scales appear to be more strongly related to disability than the CSQ scales. The CPCI Guarding scale was the single most powerful predictor of disability of all the coping responses assessed in this study. Other scales predicting disability were the CPCI Seeking Social Support, the CSQ Catastrophizing, and the CSQ Increasing Behavioral Activities. While both CSQ and CPCI contribute unique but modest variance to the prediction of pain severity, the CSQ Catastrophizing scale was the single most powerful predictor of pain severity. The findings of this study are consistent with cognitive-behavioral models of pain. Future research will need to determine whether changes in coping responses (catastrophizing and guarding, in particular) merely reflect, or actually influence, adjustment to chronic pain. In the meantime, clinicians would be wise to give these coping responses particular attention in chronic pain programs.     

Behavioral treatment of chronic low back pain. I. Relation of coping strategy use to outcome.

The clinical relevance of strategies to cope with pain was assessed by means of the Coping Strategy Questionnaire (CSQ). This was presented to a sample of 53 low back pain patients in The Netherlands, who had agreed to participate in a treatment outcome study of a group program consisting of education about pain and a training in relaxation and imaginative pain coping strategies. A baseline period of 10 weeks was followed by 10 weekly therapy sessions. At posttreatment, improvement in measurements of reported pain intensity and behavioral and emotional adjustment to pain correlated significantly with (changes in) coping strategy use. However, at the 6-month follow-up, only pain reduction appeared to be significantly related to pretreatment-follow-up changes on CSQ scores for Perceived Control. It is concluded that a judgment about one's capability to control pain may be as important as the specific pain coping strategies used.     

The relationship of personality variables and patient recruitment to pain coping strategies and psychological distress in tension headache patients.

The relationship of personality variables and patient recruitment to pain coping strategies and psychological distress was assessed in a Dutch sample of 111 chronic tension headache patients. Using the Coping Strategy Questionnaire (CSQ), high scores on the factor of helplessness proved to be associated with psychological distress. In particular, patients who manifested neuroticism and hostility as personality traits and who were referred for treatment by physicians achieved higher scores on the factor of helplessness. Patients who reported a lower level of pain intensity manifested a higher perceived control of pain. Patients who reported shorter daily pain periods indicated a lower level of active coping with pain. It is concluded that future research must be more attentive to the complex interactions between personality variables, environmental factors, and the coping demands posed by the nature of the pain problem.