Psychosocial factors associated with chronic pain in adolescents

A number of psychosocial factors have been associated with the onset, exacerbation and/or maintenance of chronic pain in adolescents. The present study was conducted to evaluate the relative importance of vulnerability, reinforcement, and modeling. We compared 222 adolescents with chronic pain and no documented physiological etiology (headache, back, limb and abdominal pain) with 148 controls and their (respectively 183 vs. 127) parents. Analyses showed that adolescents with chronic pain are more vulnerable in terms of neuroticism, negative fear of failure, and (less) experienced social acceptance. Contrary to our expectations, the chronic pain group experienced less reinforcement for their pain behavior by both parents and peers than the control group. While the number of pain models was higher in the chronic pain group, no differences were found between their parents and those of the adolescents without chronic pain in pain experience, pain parameters, and pain coping. Regression analyses on the contribution of psychosocial factors to chronic pain and its parameters sustained the positive relation between vulnerability, (less) pain reinforcement, pain models and coping with pain. Furthermore, we also found evidence that gender differences have to be taken into account.     

Sex differences in perceptions of pain coping strategy usage

Sex differences are generally found in the perception and experience of pain, with women reporting more intense and frequent pain than men. One reason why such differences may occur has been linked to socially-acquired gender-role expectations associated with pain. Although there is evidence that men and women report using different pain coping strategies, we do not know the extent to which gender-specific expectations are associated with pain-related coping. The current study sought to examine this in more detail by administering a standard pain coping measures on three separate occasions, but with different instructions. Hundred and twenty two participants (57 male, 65 female) were asked to complete the coping measure as themselves, then again as they would expect the typical man and the typical woman to complete it. Results indicated that there were no significant differences between men and women in their own self-reported usage of pain coping strategies. However, there was general evidence to suggest that there are differences in stereotypical views of how men and women are thought to cope with pain. Furthermore, sex differences were also found in how participants viewed their own coping behaviours in comparison to that of the typical man and typical woman. These results confirm that alongside pain, men and women hold different gender-specific expectations with respect to certain pain coping strategies. Future research is required to examine whether these different coping expectations influence an individuals own choice of strategy, and whether this in turn affects actual pain experiences.     

Influences of gender role and anxiety on sex differences in temporal summation of pain.

Previous research has consistently shown moderate to large differences between pain reports of men and women undergoing experimental pain testing. These differences have been shown for a variety of types of stimulation. However, only recently have sex differences been demonstrated for temporal summation of second pain. This study examined sex differences in response to temporal summation of second pain elicited by thermal stimulation of the skin. The relative influences of state anxiety and gender role expectations on temporal summation were investigated. Asymptomatic undergraduates (37 women and 30 men) underwent thermal testing of the thenar surface of the hand in a temporal summation protocol. Our results replicated those of Fillingim et al indicating that women showed increased temporal summation compared to men. We extended those findings to demonstrate that temporal summation is influenced by anxiety and gender role stereotypes about pain responding. When anxiety and gender role stereotypes are taken into account, sex is no longer a significant predictor of temporal summation. These findings highlight the contribution of social learning factors in the differences between sexes' pain perception. PERSPECTIVE: Results of this study demonstrate that psychosocial variables influence pain mechanisms. Temporal summation was related to gender role expectations of pain and anxiety. These variables explain a significant portion of the differences between men and women's pain processing, and may be related to differences in clinical presentation.     

Epidemiology, co-morbidity, and impact on health-related quality of life of self-reported headache and musculoskeletal pain--a gender perspective.

BACKGROUND: Headache and musculo-skeletal pain are major public health problems. Substantial proportions of the general population report that they experience pain problems that affect their work, daily living and social life. Epidemiological studies have consistently shown that the prevalence of most pain conditions is higher in women than in men. DESIGN: Cross-sectional survey in the county of Uppland, Sweden, 1995. Five thousand four hundred and four completed the questionnaire (response rate=68%). In these analyses for persons aged 20-64 years 4506 were included. RESULTS: Back pain (22.7%) and shoulder pain (21.0%) were the most commonly reported medical problems in the population with pain in arms/legs (15.7%) in fifth and headache (12.5%) in eight place. Major gender differences were found. The prevalence of pain conditions, especially headache, was higher among women. Women reported more severe pain. Co-morbidity between pain conditions and psychiatric and somatic problems was higher among women. Health-related quality of life (SF-36) differed by gender and type of pain condition. The physical dimensions of HRQoL were more affected by headache among men; psychological dimensions were more affected among women. Among both men and women, pain conditions were associated with poorer socioeconomic conditions and life-style factors but there were gender differences. Education and unemployment were important only among men while economical difficulties, half-time work and being married were associated with pain among women. Obesity, early disability retirement, long time sick-leave and lack of exercise were associated with pain conditions generally. Factors associated with pain conditions were unevenly distributed between genders. CONCLUSION: There are major differences between men and women in the prevalence and severity of self-reported pain in the population. Biological factors may explain some of the differences but the main explanation is presumably gender disparities in work, economy, daily living, social life and expectations between women and men. Although improved working conditions are of importance, deeper societal changes are needed to reduce the inequities in pain experiences between women and men.     

Gender differences in pain, coping, and mood in individuals having osteoarthritic knee pain: a within-day analysis

This study examined gender differences in prospective within-day assessments of pain, pain coping, and mood in men and women having OA, and analyzed gender differences in dynamic relations between pain, mood, and pain coping. A sample of 64 women and 36 men diagnosed as having pain due to osteoarthritis of the knee(s) rated their pain, pain coping, and mood two times each day (once in the afternoon and once in the evening) for 30 days using a booklet format. Two gender differences were found in between person-analyses: women used more problem focused coping than men, and women who catastrophized were less likely than men to report negative mood. Several within-day and across-day gender differences were noted. First, women were much more likely to show a significant increase in pain over the day. Second, men were more likely than women to experience an increase in coping efficacy over the day. Third, men were more likely than women to use emotion-focused coping when their mood was more negative. Finally, men were more likely than women to experience an increase in negative mood and a decrease in positive mood in the morning after an evening of increased pain. Taken together, these findings underscore the importance of obtaining multiple daily assessments when studying gender differences in the pain experience.     

Sex, gender, and pain: Women and men really are different

Sex-related differences in the experience of both clinical and experimentally induced pain have been widely reported. Specifically, females are at greater risk for developing several chronic pain disorders, and women exhibit greater sensitivity to noxious stimuli in the laboratory compared with men. Several mechanisms have been proposed to account for these sex differences. Psychosocial factors such as sex role beliefs, pain coping strategies, mood, and pain-related expectancies may underlie these effects. In addition, there is evidence that familial factors can alter pain responses, and these intergenerational influences may differ as a function of sex. Sex hormones are also known to affect pain responses, which may mediate the sex differences. Although the magnitude of these effects has not been well characterized, there are potentially important practical implications of sex differences in pain responses. These implications are discussed, and directions for future research are delineated.     

Psychosocial contributions to sex-correlated differences in pain

Sex-correlated differences in pain perception and behavior have been reported in several studies. Where such differences are found, they are most often in the direction of girls and women reporting more pain than is reported by boys and men. Although biologic, psychologic, and sociocultural factors act interdependently to influence pain responding, most efforts to explain sex-correlated differences in pain have focused on first-order biologic differences between the sexes. The current paper discusses empirical and theoretical literature addressing gender role socialization, cognitive factors, and affective factors associated with sex-correlated differences in pain. We affirm that there is convincing evidence that such psychosocial factors must be taken into account in research on sex-correlated differences in pain. We contend that the use of the dichotomous variable sex as a proxy for presumed biologic aspects of being female or male may obscure the contribution to sex-correlated differences that could be ascribed to the ways in which women and men are socialized with respect to pain perception and pain reporting.     

Psychosocial Factors and Prediction of Headaches in College Adults

The current study evaluated psychosocial variables that may contribute to the experience of headache in college adults. One hundred ninety-nine participants, 103 women and 96 men, completed head pain logs for 4 weeks after completing measures assessing psychosocial variables. Multiple regression analyses indicated that level of emotional functioning, perception of stress, and gender were predictive of future headache frequency, intensity, and duration. Family history and health habits did not predict headache activity. These findings are consistent with research investigating psychosocial variables and headache activity.     

Sex,gender, coping,and self‐efficacy: Mediation of sex differences in pain perception in children and adolescents

Sex differences in pain perception have been reported in an expanding literature based on adult samples in epidemiological as well as laboratory studies. Especially with respect to the latter, studies with children and adolescents do not consistently show that females report higher pain ratings and display lower pain tolerance than males. The first aim of the presented studies is to comparably examine sex differences in children and adolescents based on experimental and questionnaire approach indices of pain perception. The second aim is to examine the contribution of three prominent psychosocial factors (gender‐role expectations, coping with pain, and pain self‐efficacy) to these sex differences. In Study 1, a total of 118 children and adolescents from grades 5 to 9 were tested with the Cold Pressor Task (CPT) and a Pain Perception Questionnaire. In Study 2, 148 participants additionally reported on their gender‐role expectations, coping with pain, and pain self‐efficacy. Although the results reveal only medium‐sized correlations between the CPT and the questionnaire measures, both measures indicate substantial sex differences in pain perception in both studies. In Study 2, sex differences are also present for masculinity, femininity, catastrophizing as well as pain self‐efficacy. However, while the relation between sex and the CPT rating is partially mediated by pain self‐efficacy, catastrophizing partially mediates the relation between sex and the questionnaire based pain ratings. The results of both studies are discussed with respect to the difference between experimental assessments of pain perception and assessments by questionnaire in children and adolescents.     

Bridging the gap between pain and gender research: A selective literature review

Evidence suggests that males and females differ with respect to the perception and experience of pain. Much of this work focuses on biological factors, yet it is also acknowledged that psychosocial issues are important. Within humans, socially and culturally constructed meanings of being and acting as a man or a woman should help us understand sex‐related differences in pain. However, such an approach has not been widely adopted, partly because of problems conveying sex and gender concepts. We argue here for an assimilation of gender studies concepts into pain research as a means of developing our understanding of the psychosocial influences on pain in men and women. In order to bridge the gap between gender studies and pain, we draw on theoretical developments in such gender concepts, and illustrate their application to pain. We make use of Doise's [Doise W. Levels of explanation in social psychology [Mapstone E, Trans.]. Cambridge (UK): Cambridge University Press. 1986 [original work published 1982]] meta‐theoretical model of levels of explanation in social psychology to show how gender may be conceptualized at an intra‐individual, situational, positional and ideological level of analysis. We then selectively review existing gender and pain research using these different levels of explanation. In doing so we also highlight that by considering the gender conceptualizations underpinning such studies we are able to point to directions for future research. We conclude by arguing that this approach opens up a new avenue for pain researchers, which we hope will further our understanding of this interesting phenomena.     

Gender,coping and the perception of pain

Research consistently indicates that gender differences exist in pain perception, with females typically reporting more negative responses to pain than males. It also seems as if males and females use and benefit from different coping strategies when under stress; females seem to prefer emotion-focused coping, whereas males prefer sensory-focused coping. Unfortunately, experimental research that examines such differences in the context of pain has not yet been adequately investigated. The aim of the current study was, therefore, to determine whether gender differences would be found in the effect that sensory-focused and emotion-focused coping instructions have on cold pressor pain experiences. Participants consisted of 24 male and 26 female healthy adults, all of whom reported no current pain. A consistent pattern of effects was found, over both behavioural and self-report measures of pain. Compared to females, males exhibited less negative pain responses when focusing on the sensory component of pain (i.e. increased threshold, tolerance and lower sensory pain). Furthermore, compared to sensory focusing, emotional focusing was found to increase the affective pain experience of females. Together these results confirm that important differences exist between men and women in the effects pain coping instructions have on the experience of pain. The implications of such findings for research and practice are discussed.     

Gender role expectations of pain mediate sex differences in cold pain responses in healthy Libyans

Previous studies found a relationship between response to experimentally‐induced pain and scores for the gender role expectations of pain (GREP) questionnaire. Findings were similar in individuals from America, Portugal and Israel suggesting that gender role expectations may be universal. The aim of this study was to translate and validate Arabic GREP using Factor Analysis and to investigate if sex differences to cold‐pressor pain in healthy Libyan men and women are mediated through stereotypical social constructs of gender role expectations and/or pain‐related anxiety. One hundred fourteen university students (58 women) underwent two cycles of cold pressor pain test to measure pain threshold, tolerance, intensity, and unpleasantness. Participants also completed the Arabic GREP questionnaire and the Pain Anxiety Symptom Scale‐Short form (PASS‐20). It was found that Libyan men had higher pain thresholds and tolerances than women (mean difference, 95% CI: threshold = 4.69 (s), ?0.72 to 10.1, p = 0.005; tolerance = 13.46 (s), 0.5–26.4, p = 0.018). There were significant differences between sexes in 6 out of 12 GREP items (p < 0.004 after Bonferonni adjustment). The results of mediational analysis showed that GREP factors were the mediators of the effects of sex on pain threshold (z = ?2.452, p = 0.014 for Self Sensitivity); (z = ?2.563, p = 0.01, for Self Endurance) and on pain tolerance (z = ?2.538, p = 0.01 for Self Endurance). In conclusion, sex differences in response to pain were mediated by gender role expectations of pain but not pain‐related anxiety.     

Gender differences in treatment-seeking chronic headache sufferers

OBJECTIVE: To identify gender differences within a group of patients seeking treatment for chronic headache. Previous studies of the general population have reported differences in headache symptoms, frequency, disability, and psychological distress, with women affected with more severe and disabling symptoms than men. This study evaluated these features in a population seeking treatment. METHODS: Two hundred fifty-eight consecutive patients with headache attending a university headache clinic were evaluated with questionnaires about headache symptoms and psychological distress. Comparisons between men and women were made for headache symptoms, severity, frequency, trigger factors, comorbid depression and anxiety, and response to treatment. RESULTS: There were no gender differences in headache symptoms, frequency, severity, and duration. Headache triggers were gender-specific, with men more likely to endorse exercise and women more likely to endorse stress and exposure to odors. Psychological comorbidity was similar among men and women seeking treatment, with a mean Beck Depression Inventory score of 10 and a mean Spielberger trait anxiety score of 39 for both men and women. Disability was greater in men, with 46% reporting restrictions in activities more than 3 days per week because of headache compared with 29% of women. In addition, men were more likely to contribute headache control to external figures than women. CONCLUSIONS: Patients seeking treatment for chronic headache do not have the same gender-specific differences that have been reported in general population surveys. Men who seek treatment for headache are more likely to have significant disability, and are equally likely to have symptoms of depression and anxiety as women who seek treatment. Clinical and research investigations of headache triggers need to be gender-specific.     

Gender differences in variables associated with psychosocial adjustment to a burn injury

The purpose of this study was to determine whether variables associated with psychosocial adjustment to a burn injury vary by gender. Male and female burned subjects (N = 260) were compared on their functional disability, disfigurement, coping responses, social resources, and psychosocial adjustment to a burn injury. Both men and women had adjusted psychosocially to their burn injury. Less functional disability (r = .57, p less than .001) for men and greater problem-solving (r = .57, p less than .001) for women were the most important variables in explaining psychosocial adjustment to a burn injury. In the future, researchers need to be cognizant of gender differences and consider men and women as separate populations.     

Schmerzmedizin aus einer interkulturellen und geschlechterspezifischen Perspektive

Cultural setting and sex and gender of the patient are important factors affecting the occurrence, severity, clinical course and prognosis of pain and pain-related diseases. Intercultural differences in the perception and verbal expression of symptoms and emotional function are fundamental and it is important to realize these differences in order to understand patients with a migration background. A trusting doctor-patient relationship is generally very sensitive and it is even more difficult to establish when differences in the cultural background impair mutual understanding. Regarding sex and gender there is evidence that females are more susceptible to developing chronic pain conditions, experience more severe pain and respond differently to pain therapy; however, results of recent studies indicate that females are not that different to males when comparing several modalities of experimental pain (although some differences exist). Similarly, sex and gender differences in postoperative pain seem to exist but the differences are relatively small when pain scores are compared. Other aspects, such as the response to analgesics and role of psychosocial factors should be addressed when sex and gender aspects are studied. Similarly, sex and gender differences in the prevalence of chronic pain exist but the results of some studies, e.g. those controlling for confounders, are not very clear. Research is needed to delineate the role of specific aspects affecting sex and gender differences and the underlying mechanisms (e.g. reduced inhibitory control, hormones, psychological aspects and social factors). Altogether, we need to open our minds to some intercultural and sex and gender aspects in the clinical setting. For sex and gender differences we may need a more biopsychosocial approach to understand the underlying differences and differentiate between sex and gender and sex and gender-associated aspects for acute and chronic pain.     

A systematic literature review of 10 years of research on sex/gender and pain perception – Part 2: Do biopsychosocial factors alter pain sensitivity differently in women and men?

This systematic review summarizes the results of 10 years of laboratory research on pain and sex/gender. An electronic search strategy was designed by a medical librarian to access multiple databases. A total of 172 articles published between 1998 and 2008 were retrieved, analyzed, and synthesized. The second set of results presented in this review (129 articles) examined various biopsychosocial factors that may contribute to differences in pain sensitivity between healthy women and men. The results revealed that the involvement of hormonal and physiological factors is either inconsistent or absent. Some studies suggest that temporal summation, allodynia, and secondary hyperalgesia may be more pronounced in women than in men. The evidence to support less efficient endogenous pain inhibitory systems in women is mixed and does not necessarily apply to all pain modalities. With regard to psychological factors, depression may not mediate sex differences in pain perception, while the role of anxiety is ambiguous. Cognitive and social factors appear to partly explain some sex-related differences. Finally, past individual history may be influential in female pain responses. However, these conclusions must be treated with much circumspection for various methodological reasons. Furthermore, some factors/mechanisms remain understudied in the field. There is also a need to assess and improve the ecological validity of findings from laboratory studies on healthy subjects, and perhaps a change of paradigm needs to be considered at this point in time to better understand the factors that influence the experience of women and men who suffer from acute or chronic pain.     

Why do women have back pain more than men? A representative prevalence study in the federal republic of Germany

OBJECTIVES: In comparison with men, women have a healthier lifestyle, are more rarely overweight, have less stressful occupations, or are not employed outside the home. The "gender pain bias" is the fact that women nevertheless have a higher prevalence of back pain. This paper looks at the possible underlying reasons for this as yet unexplained gender difference, using Stokols' socioecological health model as a basis. METHODS: The first National Health Survey for the Federal Republic of Germany was carried out from October 1997 to March 1999. It comprised a representative total sample of 5315 persons between the ages of 20 and 64. The participants took part in a medical examination and answered a self-report form. chi test and logistic regression analyses were used to investigate correlations between self-reported low back pain and gender-specific biopsychobehavioral and sociophysical environmental factors. RESULTS: Seven-day back pain prevalence in the Federal Republic of Germany is 32% for men and 40% for women. Prevalences are significantly higher for overweight subjects, persons with a marked somatization tendency or a low level of social support, physically inactive individuals, smokers, elderly subjects, the nonemployed, "blue collar workers" and lower socioeconomic groups. From a multivariate perspective, however, none of these factors reduces (and hence sufficiently explains) the gender difference. Factoring in the gender-specific somatization tendency reduces the odds ratios of women versus men from 1.42 to 1.23. DISCUSSION: In view of the gender difference in pain prevalence, which remains stable despite a multivariate perspective, there is clearly a need for more research into the reasons underlying the gender difference. We believe that future studies should look at rarely investigated constructs such as "sex role expectancies," "anxiety," "ethnicity," and "family history" and take anatomic differences in muscle strength into account.     

Epidemiological and clinical characteristics with psychosocial aspects of tension-type headache in Turkish college students

We investigated the prevalence and clinical characteristics of tension-type headache (TTH), psychosocial factors contributing to the onset and aggravation of headache and coping mechanisms of individuals in a young population in Turkey. The sample consisted of 2226 university students, aged 7 to 21 years old. A self-administered questionnaire inquiring about epidemiological and clinical features of headache was filled out by participants. TTH diagnosis was determined in accordance with the International Headache Society Criteria of 1988. The prevalence of TTH was 20.35% (25.54% for women and 14.25% for men). 43.7% of headache sufferers had one or more stressful life events before the onset of headache and stress was the most frequent aggravating factor of headache (52%). Resting (58.1%) was the most common coping style. In conclusion, TTH is not a rare condition in Turkish young people and psychosocial factors are always taken into consideration for diagnosis and treatment of TTH.