Attentional and Interpretational Biases Toward Pain-Related Stimuli in Children and Adolescents: ASystematic Review of the Evidence

This review investigated whether youth exhibit attention or interpretation biases toward pain-related information and whether such biases are more pronounced in youth with chronic pain. Three databases were searched to identify studies that assessed attention or interpretation biases using an accepted experimental paradigm. Ten studies were identified, 8 examining attentional biases and 2 examining interpretation biases. As in the adult literature, there was no evidence of attentional biases toward pain in youth without chronic pain. Three studies investigating youth without chronic pain found evidence for relationships between catastrophizing or anxiety and indicators of vigilance or avoidance (in 2 cases, for youth with low self-reported attentional control). For attentional biases, 5 studies compared youth with and without chronic pain. Two of these studies measured cortical correlates and found evidence of neurologic activity indicating a bias in orienting to pain-related stimuli. Three studies examined biases toward pain-related words or pictures. Of those, 2 found evidence of biases at subliminal presentation times, indicating vigilance (although 1 only after a stressful task). For supraliminal presentations, 1 study found evidence of avoidance, one of difficulty disengaging, and one of general slowing of responses. Only 1 study compared youth with and without pain for interpretation bias in adolescents, and interpretation biases were greater for youth with chronic pain. As with attention, no evidence for interpretation biases were found in youth without chronic pain. Overall, there is weak evidence to support vigilance in youth with chronic pain compared with those without. However, whether pain affects the subsequent deployment of attention is unclear. There is no evidence for biases toward pain in youth without chronic pain, but evidence suggests that anxiety or catastrophizing and attentional control may moderate pain-related attentional biases. There is also weak evidence of interpretation bias in youth with chronic pain compared with those without.

Fear of Pain, Pain Catastrophizing, and Acute Pain Perception: Relative Prediction and Timing of Assessment

Pain-related fear and catastrophizing are important variables of consideration in an individual's pain experience. Methodological limitations of previous studies limit strong conclusions regarding these relationships. In this follow-up study, we examined the relationships between fear of pain, pain catastrophizing, and experimental pain perception. One hundred healthy volunteers completed the Fear of Pain Questionnaire (FPQ-III), Pain Catastrophizing Scale (PCS), and Coping Strategies Questionnaire-Catastrophizing scale (CSQ-CAT) before undergoing the cold pressor test (CPT). The CSQ-CAT and PCS were completed again after the CPT, with participants instructed to complete these measures based on their experience during the procedure. Measures of pain threshold, tolerance, and intensity were collected and served as dependent variables in separate regression models. Sex, pain catastrophizing, and pain-related fear were included as predictor variables. Results of regression analyses indicated that after controlling for sex, pain-related fear was a consistently stronger predictor of pain in comparison to catastrophizing. These results were consistent when separate measures (CSQ-CAT vs PCS) and time points (pretask vs “in vivo”) of catastrophizing were used. These findings largely corroborate those from our previous study and are suggestive of the absolute and relative importance of pain-related fear in the experimental pain experience.

Perspective

Although pain-related fear has received less attention in the experimental literature than pain catastrophizing, results of the current study are consistent with clinical reports highlighting this variable as an important aspect of the experience of pain.     

State Versus Trait: Validating State Assessment of Child and Parental Catastrophic Thinking About Children's Acute Pain

Pain catastrophizing has emerged as one of the most robust predictors of child pain outcomes. Although assessments of state (ie, situation-specific) pain catastrophizing in children and parents are often used, their psychometric properties are unknown. This study aimed to assess factor structure, reliability, and predictive validity of state versions of Pain Catastrophizing Scales for children and parents relative to corresponding trait versions for child and parental pain-related outcomes. Data were pooled from 8 experimental pain studies in which child and/or parent state catastrophizing (measured immediately before application of a pain stimulus) and trait catastrophizing were assessed in community-based samples of children aged 8 to 18 years (N = 689) and their parents (N = 888) in Dutch or English. Exploratory factor analyses were conducted to examine the underlying factor structure of the state versions of the Pain Catastrophizing Scale for parents/children, revealing a single factor solution that explained 55.53% of the variance for children and 49.72% for parents. Hierarchical linear regression analyses were used to examine relative influence of state versus trait catastrophizing on child and parent pain-related outcomes. Child and parent state catastrophizing were significantly associated with child pain intensity, child state anxiety and parental distress. State catastrophizing scores showed stronger associations than trait scores for most outcomes.

Does fear of pain moderate the effects of sensory focusing and distraction on cold pressor pain in pain-free individuals?

The present study investigated the influence of sensory focusing and distraction on pain tolerance and self-reported pain intensity in healthy female university students ranking high or low in pain-related fear. Pain was induced experimentally by means of a cold pressor test. Results showed that individuals high in pain-related fear groups had greater pain intensity ratings than those low in pain-related fear groups. A planned comparison analysis showed that distraction produced reduced pain ratings only in low fearful individuals, whereas sensory focusing led to reduced pain ratings only in high fearful individuals. Self-report measures of anxiety sensitivity, pain vigilance, and pain catastrophizing were positively associated with pain intensity, but, except for pain vigilance, no meaningful association was found between these measures and pain tolerance. Implications of the results and directions for future research are provided. PERSPECTIVE: In the management of chronic pain, distraction might be especially useful in low fearful individuals. Learning to focus on the sensory aspects (ie, monitoring) of the pain experience might be beneficial for high fearful individuals.     

Lower-Order Pain-Related Constructs Are More Predictive of Cold Pressor Pain Ratings than Higher-Order Personality Traits

Pain is a debilitating condition affecting millions each year, yet what predisposes certain individuals to be more sensitive to pain remains relatively unknown. Several psychological factors have been associated with pain perception, but the structural relations between multiple higher- and lower-order constructs and pain are not well understood. Thus, we aimed to examine the associations between pain perception using the cold pressor task (CPT), higher-order personality traits (neuroticism, negative affectivity, trait anxiety, extraversion, positive affectivity, psychoticism), and lower-order pain-related psychological constructs (pain catastrophizing [pre- and post-], fear of pain, anxiety sensitivity, somatosensory amplification, hypochondriasis) in 66 pain-free adults. Factor analysis revealed 3 latent psychological variables: pain- or body-sensitivity, negative affect/neuroticism, and positive affect/extraversion. Similarly, pain responses factored into 3 domains: intensity, quality, and tolerance. Regression and correlation analyses demonstrated that: 1) all the lower-order pain constructs (fear, catastrophizing, and hypochondriasis) are related through a single underlying latent factor that is partially related to the higher-order negative-valence personality traits; 2) pain- or body-sensitivity was more strongly predictive of pain quality than higher-order traits; and 3) the form of pain assessment is important—only qualitative pain ratings were significantly predicted by the psychological factors.PerspectiveConsistent with the biopsychosocial model, these results suggest multiple pain-related psychological measures likely assess a common underlying factor, which is more predictive of qualitative than intensity pain ratings. This information may be useful for the development and advancement of pain assessments and treatments while considering the multidimensional nature of pain.     

Factor Structure and Psychometric Properties of the Resilience Scale in a Spanish Chronic Musculoskeletal Pain Sample

The concept of resilience is receiving increasing attention in the field of chronic pain. It has been shown to play a protective role in patients with osteoarthritis, fibromyalgia, and rheumatoid arthritis. Despite this finding, no resilience measurements have been validated in chronic pain populations. The Resilience Scale (RS) is a well-known instrument that has been used to assess resilience in studies conducted in the general population. When used in chronic pain samples, this scale presented the highest internal consistency compared to other resilience scales. The main aim of this study was to provide data on the factor structure, reliability, and validity of the RS in a sample of chronic musculoskeletal pain patients (n = 300). Factor analyses revealed a single-factor solution of 18 items (RS-18), which accounted for 52.43% of the total variance of this scale. The RS-18 shows good reliability (internal consistency and stability) and construct validity. This scale has the advantage of excluding items closely related to functional disability and impairment. Furthermore, the RS-18 significantly correlated with several pain-related variables (ie, catastrophizing, pain acceptance, active and passive pain coping, anxiety, depression, pain-related anxiety, disability, functioning, impairment, and pain intensity). Clinicians and researchers are thus provided with a valid and reliable instrument to assess resilience in chronic pain populations.     

The Relationship of Pain Catastrophizing to Heightened Feelings of Distress

This study examined pain catastrophizing in individuals experiencing chronic pain conditions. Total score on the Pain Catastrophizing Scale (PCS) was examined, along with its relationship to several clinical scales of the Minnesota Multiphasic Inventory–Second Edition to answer the question of which scale would have the strongest relationship with total score on the PCS. These three scales have been most commonly implicated in chronic pain conditions. Overall results supported the importance of pain catastrophizing in helping to create heightened feelings of distress. Individuals higher in catastrophizing tend to experience increased pain, distress, anxiety, and depression with lower levels of functioning. A quick measure of catastrophizing is supported that will allow the professional more knowledge of the role of pain in the individual's condition and how pain-related thoughts may modify their quality of life.     

Pain-Related Fear,Pain Intensity and Function in Individuals With Chronic Musculoskeletal Pain: A Systematic Review and Meta-Analysis

Pain-related fear is considered a strong psychological predictor for both chronic pain and disability. The aims of this study were to systematically review and critically appraise the concurrent association and the predictive value of pain-related fear affecting both pain intensity and disability in individuals with chronic musculoskeletal pain (MSK). PubMed, AMED, CINAHL, PsycINFO, PubPsych, and the grey literature were searched from inception to January 2019. Observational studies reporting cross-sectional and longitudinal associations between pain-related fear and pain intensity and/or disability were included. The GRADE criteria judged whether the overall quality and strength of the evidence was high or low in terms of risk of bias, inconsistency, indirectness, imprecision and publication bias. Seventy observational studies (97% cross-sectional) were included with a total sample of 15,623 individuals (63.56% females) with chronic MSK. Pain-related fear is composed of fear of pain, pain-related anxiety, and fear-avoidance beliefs. Greater levels of fear of pain, pain-related anxiety, and fear-avoidance beliefs were significantly associated with greater pain intensity and disability. However, the quality and strength of the evidence was very low owing to the imprecision of results, risk of bias, indirectness, and publication bias were common across the included studies. Despite these limitations, these findings highlight the potential role that pain-related fear may play in chronic MSK and disability. The field would benefit from research using higher quality studies and longitudinal designs.PerspectiveThis article presents promising results about the concurrent association between pain-related fear and both pain intensity and disability in individuals with chronic MSK. Nevertheless, the overall quality and strength of the evidence was very low in terms of risk of bias, indirectness, imprecision, and publication bias. Thus, the findings should be taken with caution, and further research is needed.PROSPERO: CRD42018082018     

Sensory,Affective, and Catastrophizing Reactions to Multiple Stimulus Modalities: Results from the Oklahoma Study of Native American Pain Risk

Native Americans (NAs) have a higher prevalence of chronic pain than any other U.S. racial/ethnic group; however, little is known about the mechanisms for this pain disparity. This study used quantitative sensory testing to assess pain experience in healthy, pain-free adults (n = 137 NAs (87 female), n = 145 non-Hispanic whites (NHW; 68 female)) after painful electric, heat, cold, ischemic, and pressure stimuli. After each stimulus, ratings of pain intensity, sensory pain, affective pain, pain-related anxiety, and situation-specific pain catastrophizing were assessed. The results suggested that NAs reported greater sensory pain in response to suprathreshold electric and heat stimuli, greater pain-related anxiety to heat and ischemic stimuli, and more catastrophic thoughts in response to electric and heat stimuli. Sex differences were also noted; however, with the exception of catastrophic thoughts to cold, these finding were not moderated by race/ethnicity. Together, findings suggest NAs experience heightened sensory, anxiety, and catastrophizing reactions to painful stimuli. This could place NAs at risk for future chronic pain and could ultimately lead to a vicious cycle that maintains pain (eg, pain → anxiety/catastrophizing → pain).PerspectiveNAs experienced heightened sensory, anxiety, and catastrophizing reactions in response to multiple pain stimuli. Given the potential for anxiety and catastrophic thoughts to amplify pain, this characteristic may place them at risk for pain disorders and could lead to a vicious cycle that maintains pain.     

Battle of the Appraisals: Pain-Related Injustice Versus Catastrophizing as Mediators in the Relationship Between Pain Intensity and 3-Month Outcomes in Adolescents with Chronic Pain

Pain appraisals are closely tied to pain and functional outcomes. Pain-related injustice and pain catastrophizing appraisals have both been identified as important cognitive-emotional factors in the pain experience of youth. Although pain-related injustice and catastrophizing have been linked to worse pain outcomes – as primary predictors and intermediary variables – little is known about whether they operate as independent or parallel mediators of the relationship between pain and functioning in youth. We tested pain-related injustice and catastrophizing appraisals as candidate mediators of the relationship between baseline pain intensity and 3-month functional outcomes in adolescents. Youth with chronic pain (N = 89, 76% female, 89% White, average age = 15 years) completed measures assessing pain intensity, pain-related injustice, and catastrophizing at baseline, as well as measures assessing functional disability and overall quality of life 3 months later. Multiple mediation analyses indicated that injustice mediated the relationship between pain intensity and 3 month quality of life. Exploratory analyses of specific quality of life domains indicated that injustice mediated the relationship between pain intensity and 3 month emotional functioning, whereas catastrophizing mediated the relationship between pain intensity and 3 month social functioning. The findings suggest these pain-related appraisals play different intermediary roles in the relationships among pain and future psychosocial outcomes.PerspectivePain-related injustice and catastrophizing appraisals play different intermediary roles in the relationships among pain and future psychosocial outcomes in youth with chronic pain. Treatments targeting pain-related injustice appraisals in pediatric populations are needed to complement existing treatments for catastrophizing.     

Situational Versus Dispositional Measurement of Catastrophizing: Associations With Pain Responses in Multiple Samples

Catastrophizing is widely recognized as an important risk factor for adverse pain-related outcomes. However, questions remain surrounding the details of its assessment. In particular, recent laboratory studies suggest that evaluation of “situational” catastrophizing (ie, catastrophizing measured during or directly after the administration of noxious stimulation) may provide information distinct from that obtained by standard, or “dispositional” measures, which assess individuals' recall of catastrophizing in daily life. However, comparatively little research has systematically investigated the interrelationships and properties of these 2 different forms of pain-related catastrophizing. The current study evaluated both situational and dispositional catastrophizing measures within multiple samples: healthy individuals (N = 84), patients with painful temporomandibular joint disorders (TMD; N = 48), and patients with painful arthritis (N = 43). All participants first completed the Pain Catastrophizing Scale (PCS), and then underwent psychophysical pain testing, which included heat, cold, and pressure pain. Participants then completed a situational catastrophizing measure with reference to the laboratory pain he/she had just undergone. Situational catastrophizing scores were not significantly correlated with dispositional PCS scores in the healthy participants and arthritis patients, though they were associated in TMD patients. Situational catastrophizing was more strongly associated with experimental pain responses than dispositional PCS scores for the healthy subjects and arthritis patients. In general, higher levels of situational catastrophizing were associated with lower pain thresholds and higher pain ratings across all 3 samples. The findings highlight the importance of multidimensional assessment of pain-related catastrophizing, and suggests a role for measuring catastrophizing related to specific, definable events.PerspectiveThis study adds to a growing literature examining catastrophizing. Our findings highlight the potential importance of the multidimensional assessment of pain-related catastrophizing, and suggest a role for measuring catastrophizing related to specific, definable events.     

Time-course of attentional bias for pain-related cues in chronic daily headache sufferers

This study investigated attentional biases for linguistic pain-related stimuli in individuals suffering from chronic headaches and healthy controls. Attentional bias was assessed using a visual probe (also reported as dot probe in previous investigations) task which presented pain-related (sensory and affective) and neutral words at two exposure duration conditions, 500 and 1250 ms. The results indicated that individuals suffering from chronic headaches showed a significantly greater attentional bias at 1250 ms compared to the controls, which indicates a bias in maintained attention to pain cues in this group. No significant differences between groups were found in attentional bias scores at the shorter stimulus duration of 500 ms, which instead correlated significantly with trait anxiety. Results are discussed in relation to research into pain-related and anxiety-related biases in initial orienting and maintained attention.     

Visuospatial and Verbal Memory in Chronic Pain Patients: An Explorative Study

Abstract:   Cognitive bias, such as selective memory for pain-related information, is frequently observed in chronic pain patients and is assessed mostly using verbal material. Beside word lists, the current study used photographs of people presenting pain behaviors to assess memory bias in chronic pain patients. Chronic pain patients were hypothesized to show better recall of pain-related words and pictures as compared to pain-free controls. Twenty-eight female chronic neck patients and 28 pain-free female controls completed two computerized pictorial memory games and two word recall tasks. Patients and controls performed equally well in the neutral pictorial memory game. In the pain-related game, patients performed significantly worse than controls. No significant differences were found in the word recall task. The result is discussed in terms of cognitive avoidance.     

Pain catastrophizing influences the use and the effectiveness of distraction in schoolchildren

Distraction is an intuitive way of coping with pain and is often used in children's pain treatment programs. However, empirical evidence concerning the effectiveness of distraction is equivocal. One potential explanation might be that distraction does not work for everyone in every situation. In the current series of studies, we examined the role of pain catastrophizing as an influencing factor of distraction effectiveness. In the first study, we investigated the use of pain coping strategies (including distraction) in schoolchildren (N = 828, aged 8–18 years) by means of a questionnaire. Results indicated that children with higher levels of pain catastrophizing reported using less distraction strategies in daily life than children with lower levels of pain catastrophizing. In the second study, a subsample (N = 81, aged 9–18 years) performed a painful cold pressor task (CPT) (12 °C). Participants were randomly assigned to a distraction group, in which an attention‐demanding tone‐detection task was performed during the CPT, or a control group, in which no distraction task was performed. Results showed that participants in the distraction group were engaged in the distraction task, and reported to have paid less attention to pain than participants in the control group. However, distraction was ineffective in reducing cold pressor pain, and even intensified the pain experience in high catastrophizing children. Caution may be warranted in using distraction as a ‘one size fits all’ method, especially in high catastrophizing children.     

Psychologic Influence on Experimental Pain Sensitivity and Clinical Pain Intensity for Patients with Shoulder Pain

Pain-related fear and pain catastrophizing are 2 central psychologic factors in fear-avoidance models. Our previous studies in healthy subjects indicated that pain-related fear, but not pain catastrophizing, was associated with cold pressor pain outcomes. The current study extends previous work by investigating pain-related fear and pain catastrophizing in a group of subjects with shoulder pain, and included concurrent measures of experimental and clinical pain. Fifty nine consecutive subjects seeking operative treatment of shoulder pain were enrolled in this study (24 women, mean age = 50.4, SD = 14.9). Subjects completed validated measures of pain-related fear, pain catastrophizing, and clinical pain intensity and then underwent a cold pressor task to determine experimental pain sensitivity. Multivariate regression models used sex, age, pain-related fear, and pain catastrophizing to predict experimental pain sensitivity and clinical pain intensity. Results indicated that only pain-related fear uniquely contributed to variance in experimental pain sensitivity (β = ?.42, P < .01). In contrast, sex (β = ?.29, P = .02) and pain catastrophizing (β = .43, P < .01) uniquely contributed to variance in clinical pain intensity. These data provide additional support for application of fear-avoidance models to subjects with shoulder pain. Our results also suggest that pain-related fear and pain catastrophizing may influence different components of the pain experience, providing preliminary support for recent theoretical conceptualizations of the role of pain catastrophizing.PerspectiveThis study provided additional information on how specific psychological variables potentially influence experimental and clinical pain. In this sample of subjects with shoulder pain, we replicated findings from our previous studies involving healthy subjects, as fear of pain was uniquely associated with experimental pain sensitivity. In contrast, pain catastrophizing emerged as the sole psychological variable related to clinical pain intensity.     

The assessment of pain coping and pain-related cognitions in children and adolescents: current methods and further development.

Pain coping and pain-related cognitions are considered important for the understanding of chronic pain in children. Based on a systematic literature search, 4 instruments were identified that assess a range of pain coping strategies and one questionnaire focusing on pain-related cognitions. Three of these tools have good psychometric quality. Yet, only the Pain Coping Questionnaire (PCQ) has been widely used across different pain conditions and by several international research groups. We designed the Pain-Related Cognitions Questionnaire for Children (PRCQ-C) as an abbreviated German version of the PCQ. Factorial, construct, and external validity were tested in a sample of 401 children and adolescents (7-18 years) comprising 253 school children and 148 children having recurrent pain. The proposed 3 subscales, "catastrophizing," "problem-solving," and "positive self-statements," were confirmed, all having good internal consistency and retest reliability. No age and only marginal gender differences were observed. Catastrophizing was associated with dysphoric mood, trait anxiety, and current pain activity. Subgroups of pain patients differed with regard to catastrophizing and positive self-statements. PERSPECTIVE: The PRCQ-C is a brief instrument for the assessment of pain-related cognitions in children and adolescents. It supports the validity of the PCQ, demonstrates its use in an abbreviated version and extends its international availability.     

Pain catastrophizing is related to temporal summation of pain but not temporal summation of the nociceptive flexion reflex

Pain catastrophizing is associated with enhanced temporal summation of pain (TS-Pain). However, because prior studies have found that pain catastrophizing is not associated with a measure of spinal nociception (nociceptive flexion reflex [NFR] threshold), this association may not result from changes in spinal nociceptive processes. The goal of the present study in healthy participants was to examine the relationship between trait (traditional) and state (situation-specific) pain catastrophizing and temporal summation of NFR (TS-NFR) and TS-Pain. A secondary goal was to replicate prior findings concerning relationships between catastrophizing and NFR threshold, electrocutaneous pain threshold, and sensory and affective ratings of electrocutaneous stimuli. All analyses controlled for depression symptoms, pain-related anxiety, and participant sex. As expected, multiple regression analyses indicated that neither trait nor situation-specific catastrophizing was associated with NFR threshold, but that situation-specific catastrophizing was associated with pain ratings. Multilevel linear growth models of TS data indicated that situation-specific catastrophizing was associated with TS-Pain but not TS-NFR. Trait catastrophizing was not related to TS-Pain or TS-NFR. Together, these results confirm prior studies that indicate that catastrophizing enhances pain via supraspinal processes rather than spinal processes. Moreover, because catastrophizing was associated with TS-Pain but not TS-NFR, caution is warranted when using pain ratings to infer temporal summation of spinal nociceptive processes.     

Pain Catastrophizing and Negative Mood States After Spinal Cord Injury: Transitioning From Inpatient Rehabilitation Into the Community

Chronic pain is prevalent in people with spinal cord injury (SCI). We investigated how chronic pain intensity and catastrophizing varies in adults with SCI during inpatient rehabilitation up to 12 months postinjury after transitioning into the community. Eighty-eight participants with SCI were assessed for pain intensity and catastrophizing, depressive mood states, and cognitive performance. Participants were divided into subgroups of clinically elevated depressive mood and anxiety versus those with normal mood state levels. The rate of clinically elevated pain catastrophizing was 22.5% at 12 months postinjury. Participants with elevated anxiety reported significantly higher pain intensity 12 months postinjury. Participants with clinically elevated depressive mood and anxiety reported significantly elevated pain catastrophizing 12 month postinjury. Findings indicate those with elevated depressive mood states will be more likely to have high levels of pain and engage in cognitive appraisals involving pain-related catastrophizing. Importantly, however, risk of increased pain intensity and catastrophizing occurred only after transitioning into the community, when personal resources will be severely challenged. Implications of these results for models of pain catastrophizing are discussed and it is concluded there is a need for ongoing support in the community to develop self-management skills and strategies that strengthen social support networks.

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.