Sex-specific effects of pain-related anxiety on adjustment to chronic pain

OBJECTIVE: Considerable research indicates that both high levels of anxiety and female sex are associated with increased sensitivity to experimental pain and greater experience of clinical pain. In general, however, previous research has not investigated the joint effects of sex and anxiety on pain responses. A single previous laboratory-based study indicated that anxiety was inversely related to pain thresholds among men but not among women. The present study examined the relation between pain-related anxiety and adjustment to chronic pain in a sex-dependent manner. DESIGN AND SETTING: A total of 215 (114 women, 101 men) chronic pain patients referred to a multidisciplinary treatment center completed questionnaires assessing anxiety and adjustment to chronic pain. RESULTS: Results generally supported the previous laboratory-based finding indicating that an inverse relation between anxiety and adjustment to chronic pain was present only among male patients. Although male patients with high pain-related anxiety reported greater pain severity, greater interference of pain, and lower levels of daily activity than male patients with low anxiety, this effect was not present among female patients. Moreover, the effects of pain-related anxiety on adjustment to chronic pain were not attributable to either hypervigilance or use of passive coping strategies. Potential explanations and implications for the present findings are discussed.     

Possible selves in chronic pain: self-pain enmeshment, adjustment and acceptance

The aim of this study was to test whether enmeshment of self and pain predicted adjustment (depression and acceptance) in a chronic pain population. 89 chronic pain patients completed standardized self-report measures of depression and acceptance and generated characteristics describing their current actual self, hoped-for self and feared-for self, and made judgments about the degree to which their future possible selves (hoped-for and feared-for) were dependent on the absence or presence of pain, i.e. enmeshed with pain. Hierarchical multiple regression analyses showed that after accounting for the influence of demographics (age, gender), pain characteristics and the degree of role interference attributable to pain, the proportion of hoped-for self characteristics that could be achieved even with the presence of pain predicted the magnitude of depression and acceptance scores. The findings are discussed with reference to the enmeshment hypothesis and theories of self-discrepancy, self-regulation and hopelessness.     

Psychosocial factors and adjustment to chronic pain in persons with physical disabilities: a systematic review

Jensen MP, Moore MR, Bockow TB, Ehde DM, Engel JM. Psychosocial factors and adjustment to chronic pain in persons with physical disabilities: a systematic review.

Objective

To systematically review the research findings regarding the associations between psychosocial factors and adjustment to chronic pain in persons with physical disabilities.

Data Sources

A key word literature search was conducted using articles listed in PubMed, PsychInfo, and CINAHL up to March 2010, and manual searches were made of all retrieved articles to identify published articles that met the review inclusion criteria.

Study Selection

To be included in the review, articles needed to (1) be written in English, (2) include adults with a physical disability who report having pain, (3) include at least 1 measure of a psychosocial predictor domain, (4) include at least 1 criterion measure of pain or patient functioning, and (5) report the results of associations between the psychosocial factors and criterion measures used in the study. Twenty-nine studies met the inclusion criteria.

Data Extraction

Three reviewers tabulated study details and findings.

Data Synthesis

The disability groups studied included spinal cord injury (SCI), acquired amputation, cerebral palsy (CP), multiple sclerosis (MS), and muscular dystrophy (MD). Psychosocial factors were shown to be significantly associated with pain and dysfunction in all disability groups. The psychosocial factors most closely associated with pain and dysfunction across the samples included (1) catastrophizing cognitions; (2) task persistence, guarding, and resting coping responses; and (3) perceived social support and solicitous responding social factors. Pain-related beliefs were more strongly associated with pain and dysfunction in the SCI, CP, MS, and MD groups than in the acquired amputation group.

Conclusions

The findings support the importance of psychosocial factors as significant predictors of pain and functioning in persons with physical disabilities. Clinical trials to test the efficacy of psychosocial treatments for pain and dysfunction are warranted, as are studies to determine whether psychosocial factors have a causal influence on pain and adjustment in these populations.     

Sex differences in adolescent chronic pain and pain-related coping

Sex differences exist in pain and the strategies used to cope with pain. Although it is has been proposed that such differences become apparent around puberty, somewhat surprisingly very little research has specifically investigated sex as a moderator of pain within adolescents. The primary aim of the current study was to investigate sex differences in pain and coping within a group of 46 male and 115 female adolescent chronic pain sufferers. All were aged between 11 and 19 years and had been referred to the Pain Management Unit at the Royal National Hospital for Rheumatic Diseases, United Kingdom. Patients completed a battery of measures including pain experiences and a pain coping questionnaire. No sex differences were found in pain chronicity, although males and females did differ in self-reported pain experiences (females reported higher pain). Sex differences were also found in coping behaviours. Females used more social support, positive statements and internalizing/catastrophizing, whereas males reported engaging in more behavioural distraction. Of these strategies internalizing/catastrophizing was found to mediate the relationship between sex and pain. This suggests that not only do sex differences exist in the pain experiences and pain-coping strategies of adolescents with chronic pain, but that internalizing/catastrophizing may be an important mechanism in understanding such differences. More research examining potential sex differences in children and adolescents is recommended.     

Psychosocial factors associated with pain intensity, pain-related interference, and psychological functioning in persons with multiple sclerosis and pain

Biopsychosocial models of chronic pain that recognize psychological and environmental factors as important aspects of adjustment to pain have been proposed for understanding chronic pain and related suffering in persons with multiple sclerosis (MS), but such models have not been empirically tested. The objective of this study was to test such a model by evaluating the associations of several psychosocial variables (i.e., pain-related catastrophizing, perceived social support, pain beliefs, and pain coping) with pain intensity, pain interference with functioning, and psychological functioning in persons with chronic pain and MS, after controlling for demographic and disease-related factors. Participants were 125 community-dwelling persons with MS and pain who completed a mailed questionnaire that included measures of pain intensity and interference, psychological functioning, catastrophizing, social support, and pain beliefs and coping. The psychosocial variables accounted for an additional 25% of the variance in average pain intensity after controlling for demographic and disease-related variables (p<.001). These variables explained an additional 22% of the variance in pain-related interference (p<.001) and 43% of the variance in psychological functioning (p<.001), after adjusting for demographic and MS-related variables and average pain intensity. Catastrophizing was consistently and independently associated with all criterion measures, whereas social support, pain beliefs, and pain coping were associated with some criterion measures but not others. The results provide empirical support for a biopsychosocial understanding of chronic pain in MS and suggest that specific psychosocial factors (e.g., catastrophizing) may be important regarding adjustment to pain in persons with MS.     

Emotional adjustment and chronic pain

Previous work has suggested that patients with organic lesions causing pain may show as much emotional disturbance as patients with pain but without lesions. This study examined 141 chronic pain patients for their life experience, both currently and premorbidly, in terms of upbringing, neurotic traits and personality disturbance. Patients with an organic cause for pain reported significantly less family disturbance in childhood, less premorbid personality problems and less neurotic traits than patients who did not have any organic cause for their pain. The data provide support for the view that a significant proportion of the emotional disturbance associated with chronic pain is a secondary effect. Adjectives used to describe pain and factors causing exacerbation and relief of pain, although overlapping, also differed in the two groups.     

Educational achievement and chronic pain disability: mediating role of pain-related cognitions

OBJECTIVE: This study examined the relation between level of educational achievement (LOE) and the clinical morbidity associated with chronic pain. SETTING: a multidisciplinary pain rehabilitation program located within a university hospital. PATIENTS: Two hundred ninety-nine consecutive patients with chronic spinal pain, average age 39.6 years (SD = 10.7) and with an average duration of pain of 41.9 months (SD = 51.6). OUTCOME MEASURES: Age, duration of pain, sex, and compensation and litigation status were controlled for in the statistical analysis because each was found to be significantly associated with LOE. Pain intensity was assessed by the McGill Pain Questionnaire. Affective distress was assessed by the Global Severity Index from the Brief Symptom Inventory. Severity of depressive symptoms was derived from scores from the Center for Epidemiological Studies-Depression Scale. Pain beliefs and pain coping strategies were assessed by the Survey of Pain Attitudes and the Coping Strategies Questionnaire, respectively. Finally, self-report of pain-related disability was assessed by the Pain Disability Index. RESULTS AND CONCLUSIONS: After controlling for relevant covariates, LOE was unrelated to pain intensity, severity of depressive symptoms, or affective distress, but was inversely related to self-reported disability. Persons with lower LOEs possessed a greater belief that pain is a "signal of harm," unrelated to emotional experience, disabling and uncontrollable. They also endorsed more passive and maladaptive coping strategies, including a tendency to catastrophize about their pain. Path analysis indicated that, after controlling for the influence of both the belief that pain is a "signal of harm" and catastrophizing on the association between LOE and disability, this relation loses statistical significance. These results suggest that pain-related cognitions mediate the relation between LOE and pain disability and that persons with lower LOEs are more likely to develop maladaptive pain beliefs and coping strategies.     

Expressive dimensions of pain catastrophizing: An observational study in adolescents with chronic pain

Investigated was the relationship between pain catastrophizing and pain intensity in adolescents suffering from chronic pain (n = 38) and the extent to which they expressed communicative pain and pain-related protective behaviours. Adolescents were observed on video performing a 2-Min Walk Test (2MWT). Behaviours were coded on videotape. The adolescents’ verbalizations about the 2MWT were also rated by their parents. Analyses revealed that higher levels of catastrophic thinking about pain were associated with higher levels of facial pain expressions and verbalizations about their pain experience, beyond the effects of age, gender, pain duration and pain intensity. Pain-related protective behaviours did not vary with the adolescents’ level of pain catastrophizing, but varied with pain intensity. The findings corroborate the functional distinctiveness of different types of pain behaviours. The results are discussed in terms of the processes linking (1) catastrophizing to communicative pain behaviours and (2) pain to pain-related protective behaviours.     

Perceptions of pain in women with headache: a laboratory investigation of the influence of pain-related anxiety and fear

The present study compared the responses of women with headache (chronic tension-type, n = 27; migraine, n = 27) and controls (n = 27) to an acute pain laboratory task, the cold pressor test. Participants' pain perception (i.e., threshold and tolerance) and their fear/anxiety associated with pain were assessed during days 1, 2, or 3 of menses. Analyses pertaining to participants' responses to the cold pressor test (ie, pain threshold and tolerance) failed to show statistically significant group differences, even when covarying pain-related anxiety/fear. Analyses did, however, reveal significant group differences between migraineurs and controls in cognitive anxiety. Correlational analyses also revealed that cognitive anxiety, somatic anxiety, fear, and escape/avoidance were all significantly correlated with pain tolerance in the group with chronic tension-type headache, but not in the other two groups. Subsequent multiple regressions, however, showed that the relationship between anxiety and pain tolerance was primarily a function of somatic anxiety. These results suggest that headache frequency plays a role in mediating the relationship between fear of pain and pain tolerance and that the models by Lethem and colleagues and McCracken may be relevant for understanding tension headache sufferers' responses to head pain.     

A prospective study of acceptance of pain and patient functioning with chronic pain

Acceptance of chronic pain is emerging as an important concept in understanding ways that chronic pain sufferers can remain engaged with valued aspects of life. Recent studies have relied heavily on cross-sectional investigations at a single time point. The present study sought to prospectively investigate relations between acceptance of chronic pain and patient functioning. A sample of adults referred for interdisciplinary treatment of severe and disabling chronic pain was assessed twice, an average of 3.9 months apart. Results showed that pain and acceptance were largely unrelated. Pain at Time 2 was weakly related to measures of functioning at Time 2. On the other hand, acceptance at Time 1 was consistently related to patient functioning at Time 2. Those patients who reported greater acceptance at Time 1 reported better emotional, social, and physical functioning, less medication consumption, and better work status at Time 2. These data suggest that willingness to have pain, and to engage in activity regardless of pain, can lead to healthy functioning for patients with chronic pain. Treatment outcome and process studies may demonstrate the potential for acceptance-based clinical methods for chronic pain management.     

Sexuality and sexual adjustment of patients with chronic pain

Purpose: To describe sexual functioning and its relationship with psychological measures in chronic pain patients.

Method: It is a self report survey with a convenience sample. Seventy consenting chronic pain patients responded to a questionnaire. Mean age was 49-9 years (range 29–74); mean pain duration was 146–7 months (range 6–624). Participants endorsed a wide variety of pain conditions.

Instruments used: (1) Derogatis Inventory of Sexual Functioning; (2) Multidimensional Pain Inventory; (3) Center for Epidemiological Studies Depression Scale; (4) Multidimensional Health Locus of Control; (5) Hopkins Symptom Check List; (6) Vanderbilt Pain Management Inventory; (7) Coping Strategies Questionnaire.

Results: Sixty-six per cent of patients were interested in sex, 50% were satisfied with current sexual partner and 20% considered current sexual life to be adequate. Over 70% fantasized at least once a month. Only 44% experienced normal arousal during intercourse; 33% practiced masturbation and 47 % were involved in sexual intercourse or oral sex at least once a month. The majority were dissatisfied with orgasmic activities. No relationship was found between pain severity, duration, frequency and sexual functioning. A relationship was found between disability status, age and several psychological variables and various domains of sexual functioning.

Conclusions: Sexual problems are common in chronic pain patients. Patients who reported symptoms of depression and distress had more sexual problems.     

Selective attention to pain-related information in chronic musculoskeletal pain patients

Cognitive-behavioural models of chronic pain contend that appraisals of harm affect the individual's response to pain. It has been suggested that fear of pain and/or anxiety sensitivity predispose individuals to chronicity. According to this view, pain is maintained through hypervigilance towards painful sensations and subsequent avoidance. The present study investigates the nature of cognitive biases in chronic pain patients. A sample of 169 consecutive patients referred to a specialist pain management centre participated in the study. Questionnaires measuring different aspects of pain and a computerised version of the Dot-Probe Task were administered. Four types of words related to different dimensions of pain and matched, neutral words were used as stimuli. Reaction times in response to the stimuli were recorded. A factorial design 3 x 4 x 2 x 2 and ANOVAs were employed to analyse the data. Chronic pain patients showed a cognitive bias to sensory pain words relative to affective, disability, and threat-related words. However, contrary to expectations, those high in fear of pain responded more slowly to stimuli than those less fearful of pain. These results suggest that patients with chronic pain problems selectively attend to sensory aspects of pain. However, selective attention appears to depend upon the nature of pain stimuli. For those who are highly fearful of pain they may not only selectively attend to pain-related information but have difficulty disengaging from that stimuli. Theoretical and clinical implications of the data are discussed.     

The influence of pain-related comorbidities on pain intensity and pain-related psychological distress in patients presenting with musculoskeletal pain

BackgroundMusculoskeletal pain (MSP) is the largest contributor to chronic pain and frequently occurs alongside other medical comorbidities.ObjectiveExplore the relationships between the presence of pain-related comorbidities, pain intensity, and pain-related psychological distress in patients with MSP.MethodsA longitudinal assessment of individuals 18–90 years old in the Midwestern United States beginning a new episode of physical therapy for MSP. Electronic medical records were assessed the full year prior for care-seeking of diagnoses for pain-related comorbidities (anxiety, metabolic disorder, chronic pain, depression, nicotine dependence, post-traumatic stress disorder, sleep apnea, and sleep insomnia). Pain intensity and pain-related psychological distress (Optimal Screening for Prediction of Referral and Outcome - Yellow Flags tool) were captured during the physical therapy evaluation. Generalized linear models were used to assess the association between pain intensity, psychological distress, and pain-related co-morbidities. Models were adjusted for variables shown in the literature to influence pain.Results532 participants were included in the cohort (56.4% female; median age of 59 years, Interquartile Range [IQR]:47, 69). Comorbid depression (beta coefficient (β) = 0.7; 95%CI: 0.2, 1.2), spine versus lower extremity pain ((β = 0.6; 95%CI: 0.1, 1.1), and prior surgery (β = 0.8, 95%CI: 0.3, 1.4) were associated with higher pain intensity scores. No pain-related comorbidities were associated with pain-related psychological distress (yellow flag count or number of domains). Female sex was associated with less pain-related psychological distress (β = −0.2, 95%CI: −0.3, −0.02).ConclusionsDepression was associated with greater pain intensity. No comorbidities were able to account for the extent of pain-related psychological distress.     

Role loss and emotional adjustment in chronic pain

Chronic pain interrupts behaviour, interferes with functioning, and may affect a person's identity: their sense of self. We tested whether loss of role and personal attributes and current and past self-concept differentiation, predicted adjustment as indexed by measures of depression. Chronic pain patients (n=80) completed measures of pain (MPQ), disability (PDI), depression and anxiety (BDI, HADS). Measures of role and attribute loss and self-concept differentiation were derived from a Role-Attribute Test in which participants identified four social roles in four domains (friendship, occupation, leisure, family) and nominated two personal attributes in each role prior to pain onset and current. Participants reported mean losses of 3.38 roles, and 6.97 attributes. Greater losses were observed in friendship, occupation and leisure domains compared with the family domain. Multiple regression analyses revealed that after controlling for demographic and clinical differences, role and attribute loss predicted depression scores. There was no evidence that depression was associated with past self-concept differentiation. The results are discussed with reference to the methodology used and the relevance of self-identity to understand adjustment to chronic pain.     

Psychosocial subgroups in persons with spinal cord injuries and chronic pain

Widerström-Noga EG, Felix ER, Cruz-Almeida Y, Turk DC. Psychosocial subgroups in persons with spinal cord injuries and chronic pain.

Objectives

To define adaptational subgroups in people with chronic pain and spinal cord injury (SCI), and to compare these subgroups with respect to demographic factors, level of injury, functional independence, pain disability, depressed mood, social support, and life satisfaction.

Design

Interviews.

Setting

Veterans Affairs medical center and The Miami Project to Cure Paralysis.

Participants

Persons with SCI and chronic pain (N=190).

Interventions

Not applicable.

Main Outcome Measure

The Multidimensional Pain Inventory, SCI version.

Results

Cluster analysis revealed 3 subgroups: (1) dysfunctional (34.6% of all participants), characterized by higher pain severity, life interference, and affective distress scores, and lower levels of life control and activities scores; (2) interpersonally supported (33.0% of participants), characterized by moderately high pain severity, and higher life control, support from significant others, distracting responses, solicitous responses, and activities scores; and (3) adaptive copers (32.4% of participants), characterized by lower pain severity, life interference, affective distress, support from significant others, distracting responses, solicitous responses, activities and higher life control scores. Compared with the dysfunctional subgroup, the interpersonally supported subgroup reported significantly greater social support and life satisfaction and less pain disability and emotional distress, despite moderately high pain severity.

Conclusion

Three subgroups, independent of sex, pain duration, and functional status, were identified. Although severe pain significantly decreases life satisfaction after SCI, its impact is moderated by perceived social support.