Self-efficacy and outcome expectancies: relationship to chronic pain coping strategies and adjustment

Recent studies suggest that coping strategies play an important role in adjustment to chronic pain. Identification of factors that influence coping could potentially help clinicians facilitate the use of adaptive coping strategies by pain patients. According to social learning theory, self-efficacy beliefs (judgments regarding one's capabilities) and outcome expectancies (judgments regarding the consequences of behaviors) are significant determinants of coping behavior. This study tested hypotheses derived from social learning theory by examining the contributions of these beliefs to the prediction of coping behavior in chronic pain patients. One hundred and fourteen chronic pain patients completed measures of health-related dysfunction, pain severity, use of 8 coping strategies, and outcome and self-efficacy expectancies regarding these coping strategies. In support of social learning theory, and consistent with research in other areas, the patients' beliefs regarding their capabilities were strongly related to reported coping efforts. Beliefs about the consequences of coping efforts and their interaction with beliefs about capabilities were generally unrelated to coping. These results suggest that treatment should emphasize the actual practice and use of adaptive coping strategies over education about their outcome.     

Do beliefs, coping, and catastrophizing independently predict functioning in patients with chronic pain?

Physical and psychosocial disability in patients with chronic pain have been shown to be associated with patients' pain-related beliefs, tendency to catastrophize, and pain coping strategy use. However, little is known about whether beliefs, catastrophizing, and coping strategies are independently associated with patient adjustment. Identification of specific beliefs, cognitive responses, and coping strategies strongly and independently associated with physical and psychosocial functioning would suggest the importance of targeting those variables for modification in treatment. One hundred sixty-nine patients entering a multidisciplinary pain treatment program completed measures of pain, beliefs, coping, catastrophizing, physical disability, and depression. Principal components analyses were used to create belief and coping components, which were then entered in multiple regression analyses predicting physical disability and depression. Belief scores significantly and independently predicted both physical disability and depression, after controlling for age, sex, pain intensity, catastrophizing, and coping. Coping scores significantly and independently predicted physical disability, but not depression, whereas catastrophizing independently predicted depression, but not physical disability. These findings suggest the importance of targeting specific pain-related beliefs and coping strategies, as well as catastrophizing, for modification in the treatment of patients with chronic pain.     

Empirical subgroups of the Coping Strategies Questionnaire-Revised: a multisample study.

OBJECTIVE: The purpose of this study was to examine the dimensions of coping, measured by the subscales of the new revised Coping Strategies Questionnaire (CSQ-R) using factor analysis, and to perform cluster analysis on these factors to explore the existence of distinct subgroups. No published studies have identifed subgroups of chronic pain patients based on the use of CSQ coping strategies. SOURCE: A sample of 419 chronic low back pain patients from a multidisciplinary pain rehabilitation clinic and a sample of 556 chronic pain patients of mixed pain etiology presenting for treatment at an anesthesia pain clinic were used to establish reliability of factors and clusters. RESULTS: Both samples yielded very similar two-factor solutions, with initial solutions accounting for 67.1% and 69.1% of the total variance. The factors were characterized as cognitive coping and distraction. Three homogeneous subgroups were then identified that consisted of a group high on cognitive coping, a group with low overall ratings of response CSQ-R items in general, and a group with frequent endorsement of catastrophizing and distraction-related items. CONCLUSION: This paper is the first to report empirically derived subgroups from scores on the CSQ or CSQ-R. In addition, the three clusters were significantly different across measures of pain, psychological distress, and levels of physical functioning, demonstrating validity for the clusters.     

Cognitive factors and the experience of pain and suffering in older persons

Cognitive factors are thought to play an important mediational role between pain and consequent levels of suffering, yet there has been little investigation of these issues in older chronic pain patients. The present study sought to examine the reliability and validity of the Pain Locus of Control (PLOC) scale when used with older patients, to explore age differences in PLOC orientation, and examine the relationship between cognitive beliefs and levels of pain and suffering. 169 older patients attending a pain management clinic completed a comprehensive psychometric battery prior to admission. Principal components analysis replicated the original factor structure of the PLOC previously identified in young adult samples, suggesting that older patients adopt the same underlying constructs of control. The internal item consistency of the 36 item scale was shown to be very good to excellent. Older adults endorsed a higher chance locus of control, but this orientation was amenable to change following a cognitive-behavioural treatment program. PLOC orientation was related to use of coping strategies, levels of pain and depression, functional and psychosocial impact as well as compliance with treatment protocols. Stepwise regression analysis revealed that self perceived interference from pain and internal PLOC were the best predictors of depressive symptoms in older adults. In combination, these findings suggest that cognitive factors are of importance in older chronic pain patients and extend the relevance of cognitive-behavioural models of pain across the entire adult age spectrum.     

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.     

Health locus of control, gender differences and adjustment to persistent pain

Locus of control (LOC) beliefs, long thought important in adjustment to persistent pain, were studied among 160 subjects (67 males and 93 females) referred to a comprehensive pain rehabilitation program. The subscale structure of the Multidimensional Health Locus of Control (MHLC) was factorially replicated in our sample. Three unique MHLC profile clusters were identified for both males and females. Among men, cluster assignment was related to age only. The younger male patients reported a stronger internal attributional style. Older male patients relied more heavily on both chance and powerful other factors. Among women, cluster assignment was related to the use of coping strategies. For example, patients with high internal scores only, reflecting a strong internal orientation towards self-management of health care needs, were more likely to utilize Information-Seeking, Self-Blame, and Threat Minimization coping strategies than patients with high scores on both the Internal and Powerful Other factors. It appears that the presence of both Internal and Powerful Other health attributional styles is associated with less frequent use of cognitive self-management techniques. In understanding the LOC scores it is important to rely on pattern analysis of scores. Implications for clinical treatment are discussed.     

Qualitätssicherung in der Therapie chronischen Schmerzes

The present paper is one of a series of publications, reviewing German instruments for psychological assessment of pain. Their main focus is on the results of a task force on quality testing for each subject. This paper describes and comments on methods regarding self-reporting of pain cognitions and both cognitive and behavioral strategies for coping with pain. Concerning pain cognitions one focus is on patients' attributions of causes of pain and the modes of controlling pain (subjective pain model). The other focus is on instruments recording "pain beliefs" in the sense of dysfunctional congitions associated with the experience of pain. Each instrument was examined with reference to approved psychometric criteria, empirical foundation and clinical relevance. It was noted that several instruments are deficient in their psychometric criteria and their empirical foundations. We used these data as a basis to elaborate a specific and differential recommendation. A similar procedure was followed with instruments for the assessment of pain-related coping strategies. According to our research there are two subgroups of coping instruments, one more specifically for cognitive coping with pain, and the other combined with behavioral coping strategies. Once again, we elaborated a specific and differential recommendation, giving priority to instruments taking account of both cognitive and behavioral dimensions of coping with pain.     

Coping and Management Techniques Used by Chronic Low Back Pain Patients Receiving Treatment From Chiropractors

ObjectivesThe purpose of this study was to describe coping strategies (eg, mechanisms, including self-treatment) that a person uses to reduce pain and its impact on functioning as reported by patients with chronic low back pain who were seen by doctors of chiropractic and how these coping strategies vary by patient characteristics.MethodsData were collected from a national sample of US chiropractic patients recruited from chiropractic practices in 6 states from major geographical regions of the United States using a multistage stratified sampling strategy. Reports of coping behaviors used to manage pain during the past 6 months were used to create counts across 6 domains: cognitive, self-care, environmental, medical care, social activities, and work. Exploratory analyses examined counts in domains and frequencies of individual items by levels of patient characteristics.ResultsA total of 1677 respondents with chronic low back pain reported using an average of 9 coping behaviors in the prior 6 months. Use of more types of behaviors were reported among those with more severe back pain, who rated their health as fair or poor and who had daily occurrences of pain. Exercise was more frequent among the healthy and those with less pain. Female respondents tended to report using more coping behaviors than men, and Hispanics more than non-Hispanics.ConclusionPersons with chronic back pain were proactive in their coping strategies and frequently used self-care coping strategies like those provided by chiropractors in patient education. In alignment with patients’ beliefs that their condition was chronic and lifelong, many patients attempted a wide range of coping strategies to relieve their pain.     

Relationship of MMPI cluster type, pain coping strategy, and treatment outcome.

The purposes of the present study of chronic pain patients were to (a) assess whether cognitive and behavioral coping style is related to personality factors, (b) assess how coping styles differ across personality types, and (c) assess how outpatient interdisciplinary intervention affects the coping styles of various personality types. Four MMPI clusters (Depression/Pathological, V-type, Marginal Depression, and Marginal V-type) were derived using a hierarchical clustering procedure. Seventy subjects also completed the Coping Strategies Questionnaire before and after a 3-week outpatient pain management program. Pretreatment analyses indicated the Depression/Pathological and Marginal Depression groups used diverting attention less than either V-type group. The V-type group reported using praying/hoping significantly more than either of the marginal groups. At posttreatment the Depression/Pathological group used catastrophizing significantly more than either of the marginal groups. Results of pre-post analyses indicated that the Depression/Pathological group increased their use of diverting attention, reinterpreting pain sensations, and ignoring pain sensations, while decreasing catastrophizing. The V-type group increased their use of reinterpreting pain sensations, while decreasing praying/hoping and catastrophizing. Neither of the Marginal subtypes showed significant pre-post changes in coping strategies. These results suggest that different personality types use different pain coping strategies prior to multidisciplinary treatment. Groups showing more severe psychological distress, perhaps related to an underlying personality disorder, displayed greater changes in coping strategies with treatment, but remained more dysfunctional after treatment. These findings suggest that the alteration of coping strategies may be an important treatment effect needing more individualization to maximize treatment response.(ABSTRACT TRUNCATED AT 250 WORDS)     

Self-efficacy for managing pain is associated with disability, depression, and pain coping among retirement community residents with chronic pain.

Little is known about cognitive and behavioral factors that influence older adults' adjustment to chronic pain. The objective of this study was to investigate the relationship of self-efficacy for managing pain to reports of pain intensity, pain-related disability, depressive symptoms, and pain coping strategy use among 140 retirement community residents (88% female; age mean = 81.7, range 66-99 years) with chronic pain. The 8-item Arthritis Self-Efficacy Scale, modified to specify pain rather than arthritis, demonstrated good psychometric characteristics (Cronbach alpha = .89, minimal floor and ceiling effects, and validity) in this sample. Controlling for age, gender, and pain intensity, self-efficacy was associated significantly and negatively with pain-related disability and depressive symptoms (P values < .001), and positively with use of pain coping strategies previously found to be associated with better outcomes (task persistence, exercise/stretch, coping self-statements, activity pacing; P values < .05). Self-efficacy for managing pain appears to be important in the adjustment of older adults with pain. Research is needed to determine whether interventions designed to increase self-efficacy improve quality of life and prevent functional declines in this population. PERSPECTIVE: Among retirement community residents (mean age of 82 years) with chronic pain, higher self-efficacy for managing pain is associated with less disability and depression and with the use of pain coping strategies related to better adjustment. This suggests the potential value of interventions to increase self-efficacy in this population.     

One- and two-item measures of pain beliefs and coping strategies

Pain-related beliefs and pain coping strategies are central components of current cognitive-behavioral models of chronic pain, and have been found in numerous studies to be associated significantly with psychosocial and physical disability. However, the length of most measures of pain-related beliefs and coping restricts the ability of clinicians and researchers to perform a thorough assessment of these variables in many situations. The availability of very brief versions of existing scales would make possible the assessment of a range of important pain beliefs and coping strategies in settings where subject or patient assessment burden is an issue. In this study, one- and two-item versions of the subscales of several commonly used measures of pain beliefs and coping strategies were developed using both rational and empirical procedures. The findings support the validity of these brief subscales. The appropriate use and limitations of these measures are discussed.     

Changes after multidisciplinary pain treatment in patient pain beliefs and coping are associated with concurrent changes in patient functioning

Little is known about how patient functioning changes after completion of multidisciplinary pain programs, and what factors are associated with such changes when they occur; for example, whether improvement or deterioration in functioning corresponds to changes in patient beliefs and coping during this period. The objective of this study was to examine the extent to which changes in patient pain and functioning were associated with changes in beliefs and coping after multidisciplinary pain treatment. Patients with chronic pain (N=141) completed outcome (pain, functioning) and process (beliefs, catastrophizing, coping) measures at the end of multidisciplinary pain treatment and 12 months posttreatment. On average, patients reported similar levels of pain at both times, but showed a small worsening in disability and depression outcomes between posttreatment and follow-up, which were associated significantly with concurrent changes in the process measures. In particular, increased belief in oneself as disabled by pain, catastrophizing, and increased use of resting, guarding and asking for assistance in response to pain were linked with increased disability and depression. Decreased perceived control over pain was also consistently associated with worsening of these outcomes. The results highlight the potential importance of specific pain-related beliefs and coping responses in long-term patient pain and adjustment. Research is needed to determine whether booster interventions after the end of intensive multidisciplinary treatment that target these beliefs and coping responses improve long-term outcomes.     

An empirical assessment of pain beliefs

Pain beliefs represent patients' own conceptualizations of what pain is and what pain means for them. Such beliefs may be discordant with current scientific understanding and may serve to adversely affect compliance with modern methods of chronic pain treatment. This study attempts to assess several of the core dimensions around which pain beliefs develop and examines the relationship between pain beliefs and behavioral manifestations of the pain experience. An empirically and factorially derived product of this study, the Pain Beliefs and Perceptions Inventory (PBAPI) assess 3 dimensions of pain beliefs: (1) self-blame, (2) perception of pain as mysterious, and (3) beliefs about the duration of pain. These core pain beliefs were found to be predictive of subjective pain intensity, multidisciplinary chronic pain treatment compliance, poor self-esteem, somatization and psychological distress, and associated with attributions about health locus of control.     

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 chronic pain: a critical review of the literature.

A growing number of investigators have used models of stress and coping to help explain the differences in adjustment found among persons who experience chronic pain. This article reviews the empirical research which has examined the relationships among beliefs, coping, and adjustment to chronic pain. Although preliminary, some consistent findings are beginning to emerge. For example, patients who believe they can control their pain, who avoid catastrophizing about their condition, and who believe they are not severely disabled appear to function better than those who do not. Such beliefs may mediate some of the relationships between pain severity and adjustment. Although coping strategies appear to be associated with adjustment in chronic pain patients, methodological problems limit conclusions regarding the strength and nature of this association. Our recommendations for future research include the development of coping and belief measures which: (1) do not confound different dimensions (e.g., coping, beliefs, and adjustment) in the same measure; (2) assess specific (rather than composite) constructs; (3) are psychometrically sound; and (4) assess behavioral coping strategies more objectively. We also recommend a greater use of experimental research designs to examine causal relationships among appraisals, coping, and adjustment.     

NEWS SECTION

Different types of integrated management programmes have lately been introduced in the treatment of Whiplash Associated Disorders (WAD). In this study regular primary care physiotherapy and physiotherapy management with integrated components of cognitive-behavioural origin was compared in an experimental group study. The predictive value of self-efficacy was also addressed. Thirty-three patients with chronic WAD were included in the trial. Results revealed no significant differences between groups in self-ratings of disability or pain intensity. However, among the self-reported benefits of treatment, patients in the experimental group reported significantly less pain than did the comparison group. At three months follow-up the experimental group also reported better performance of daily activities. Between group differences in the coping repertoire were found at pre-, post-, and three-month follow-up. Generally, patients with high self-efficacy reported less use of "maladaptive" and passive coping style than patients with low self-efficacy, at all times. In conclusion cognitive behavioural components can be useful in physiotherapy treatment for patients with chronic WAD, but their contributions are not yet fully understood. Self-efficacy is related to patients' use of different coping styles. Positive long-term outcomes in WAD-patients could therefore be improved by enhancing patients' self-efficacy and by teaching them to use active, adaptive coping strategies.     

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.     

Perceived social support and coping responses are independent variables explaining pain adjustment among chronic pain patients.

The purpose of the present study was to test a hypothetical model of the relationships between perceived social support, coping responses to pain, pain intensity, depressed mood, and functional disability (functional status and functional impairment) in a population of patients with chronic pain in a Spanish Clinical Pain Unit. It was postulated that social support and pain coping responses both independently influence reported pain intensity, depressed mood, and functional disability. Analyses were performed by Structural Equation Modelling. The results indicated that satisfaction with social support is significantly associated with a depressed mood and pain intensity, but not with functional disability. Although this effect is independent of the use of active coping responses by patients, there is a modest but significant relationship between social support and passive coping strategies, indicating that higher levels of perceived social support are related to less passive pain coping strategies. The findings underscore the potential importance of psychosocial factors in adjustment to chronic pain and provide support for a biopsychosocial model of pain. PERSPECTIVE: This article tested a hypothetical model of the relationships between social support, pain coping, and chronic pain adjustment by using Structural Equation Modelling. The results indicate that perceived social support and pain coping are independent predictors of chronic pain adjustment, providing support for a biopsychosocial model of pain.     

Angina pectoris in type A and type B cardiac patients

The type A behavior pattern is characterized by excessive competitive drive, a sense of time urgency, enhanced aggressiveness, hostility and a persistent desire for recognition. Type A behaviour is widely recognized as a risk factor in coronary heart disease. This study investigated whether type As and Bs differ in their experience of pain and pain coping efforts. A group of type A (n = 35) and a group of type B (n = 19) cardiac disease patients served as subjects. All subjects underwent diagnostic treadmill testing and were compared on a variety of pain measures. There were no differences between type As and Bs in age, sex, presence of state or trait anxiety or severity of cardiac disease. Type A patients, however, were much more likely than type Bs to be classified on the New York Heart Association (NYHA) functional angina scale as having more severe pain and functional limitation. Type As were also less likely to use pain coping strategies to deal with their pain. Those who assess pain and functional impairment in cardiac patients using the NYHA scale should be aware that type A personality characteristics may affect their assessments. Type A patients who tend to make little use of pain coping strategies may benefit from systematic training in pain control methods. Additional research is needed to examine whether type A-B differences in pain and pain coping strategies may affect risks of coronary morbidity and mortality.     

Der Beitrag kognitiver Schmerzverarbeitung zur Depressivität bei Rückenschmerzpatienten

Background

The concurrent occurrence of chronic pain syndromes and depressive symptoms is a commonly observed phenomenon. The aim of the present study was to illuminate the mediating role of specific cognitive pain coping strategies as a connective link between pain and depression.

Methods

A total of 122 chronic and chronic recurrent simple back pain patients were examined in view of the connection between pain, cognitive pain coping strategies, and depression.

Results

The results of the path analysis support the assumption of a mediating effect of cognitive coping strategies between pain and depression (GFI = 0.99; AGFI = 0.96). It could be shown, that cognitive coping mediates the link between pain and depression in back pain patients.

Conclusion

The results give further support for the cognitive mediation hypothesis and enhance it by pointing out the role of specific pain-related cognitive appraisals.