Waddell’s Symptoms as Correlates of Vulnerabilities Associated with Fear–Anxiety–Avoidance Models of Pain: Pain-Related Anxiety, Catastrophic Thinking, Perceived Disability, and Treatment Outcome

Introduction Fear–anxiety–avoidance models of chronic pain emphasize psychological constructs as key vulnerabilities for the development and maintenance of disabling chronic pain. Complementarily, Waddell described physical signs and symptoms thought inconsistent with anatomic and pathologic disease patterns that might function as indications of pain-related psychological distress. Research has not supported using Waddell’s signs due to low inter-rater reliability and limited associations with psychological distress; however, these findings are equivocal. Similarly, theorists have suggested that endorsement of Waddell’s symptoms may indicate psychological distress; however, the precedent research has not included the psychological constructs described in fear–anxiety–avoidance models as vulnerability factors for the development and maintenance of chronic pain. Methods Participants for the current study were patients (n = 68; 35% women) with chronic low back pain involved in a multi-disciplinary work-hardening program provided by a third-party insurer. Patients endorsing more than two of Waddell’s symptoms were compared with those who did not on demographic variables as well as established self-report psychological measures, measures of perceived disability, functional capacity, and treatment outcome. Results Patients endorsing more than two of Waddell’s symptoms reported higher levels of depressive symptoms, pain-related anxiety, fear, catastrophizing, and pain intensity. Unexpectedly, there were no significant differences in functional capacity. Similar differences were found between those who did and did not return to work. Conclusions While Waddell’s symptoms must still be interpreted judiciously, they may provide much needed cross-disciplinary utility as indicators that more detailed psychological assessment is warranted. Comprehensive implications and directions for future research are discussed.     

Brief fear of negative evaluation scale-revised

Rodebaugh et al. [2004: Psychol Assess 2:169-181] recently performed a confirmatory factor analysis (CFA) on the Brief Fear of Negative Evaluation scale (BFNE; Leary, 1983: Psychol Bull 9:371-375]. Their study resulted in the emergence of a two-factor solution comprising straightforwardly worded items and reverse-worded items. They concluded by recommending use of only the straightforwardly worded items in the BFNE. Our intent in this study was to evaluate this recommendation through replication and extension. Participants included 385 undergraduates from the Universities of Regina and Houston, who provided responses to a questionnaire battery including either the BFNE or a revision utilizing straightforwardly worded versions of the reverse-worded items (BFNE-II). A CFA of the BFNE, using the two-factor model proposed by Rodebaugh et al., supported their conclusion that the reverse-worded items comprise a separate, methodologically based factor. However, CFA of the BFNE-II resulted in an acceptable unitary model that conforms to the theoretical basis for the BFNE, without risking loss of sensitivity from item removal. Additional analyses suggest use of the BFNE-II rather than a shortened form.     

Health care utilization by United Nations peacekeeping veterans with co-occurring, self-reported, post-traumatic stress disorder and depression symptoms versus those without

It remains to be determined whether patients with comorbid post-traumatic stress disorder (PTSD) and depression use more health care resources than do those without. United Nations peacekeeping veterans from Canada were divided into four groups, i.e., PTSD alone (n = 23), depression alone (n = 167), comorbid PTSD and depression (n = 119), and neither (n = 164), and compared with respect to total number of visits to any health care professional in the past year. Analysis of variance revealed that the groups significantly differed in total visits. Post hoc analyses indicated that veterans with co-occurring PTSD and depression symptoms had more visits than did those in the other groups and that veterans with PTSD symptoms alone and depression symptoms alone had more visits than did those with neither PTSD nor depression. Additional analyses revealed that veterans with co-occurring PTSD and depression symptoms made more visits to general practitioners, specialists, pharmacists, and mental health professionals than did the others. Future research directions and implications for treatment planning are discussed.     

Validation of the coping with health, injuries, and problems scale in a chronic pain sample

OBJECTIVE: The Coping with Health, Injuries, and Problems (CHIP) Scale is a self-report instrument that is designed for diverse patient populations to provide measures of emotion-focused (e.g., emotional preoccupation) and task-oriented (e.g., palliative, instrumental, distraction) responses to injury. The present investigation assessed the factor structure, reliability, and validity of the measure in patients (n = 203) with chronic musculoskeletal pain. METHOD: Patients were administered questionnaires, including the CHIP Scale, and measures of pain coping strategies, adjustment, and personality. RESULTS: The factor structure, with one exception, was replicable, and the subscale reliabilities were acceptable. The subscales related in predictable ways to other similar questionnaires, to pain adjustment, and to personality. CONCLUSION: Overall, the CHIP Scale is both reliable and valid in assessing responses to chronic pain. Researchers and clinicians who want to use a psychometrically sound measure of response to illness that is applicable across diverse patient populations are encouraged to consider this measure.     

The relationship of adult attachment dimensions to pain-related fear, hypervigilance, and catastrophizing

Despite the prominence of fear-avoidance models of chronic pain, there is a paucity of research regarding the origins of pain-related fear. Based on the premise that insecure attachment could be a developmentally based origin of elevated fear of pain, associations between adult attachment dimensions and constructs included in fear-avoidance models of chronic pain were investigated. Consistent with Bartholomew and Horowitz's [Bartholomew K, Horowitz LM. Attachment styles among young adults: a test of a four-category model. J Pers Soc Psychol 1991;61:226-44.] model, attachment was conceptualized as being comprised of a model of self dimension (i.e., degree of anxiety regarding rejection based on beliefs of personal unworthiness) and a model of others dimension (i.e., degree of interpersonal mistrust and discomfort with interpersonal closeness). A large university student sample free of chronic pain (N=278) completed a measure of adult romantic attachment (i.e., Experiences in Close Relationships Questionnaire; [Brennan KA, Clark CL, Shaver PR. Self-report measurement of adult attachment: an integrative overview. In: Simpson JA, Rholes WS, editors. Attachment theory and close relationships. New York: The Guilford Press, 1998. p. 46-76.]), the Fear of Pain Questionnaire-III [McNeil DW, Rainwater AJ. Development of the fear of pain questionnaire - III. J Behav Med 1998;21:389-410.], the Pain Vigilance and Awareness Questionnaire [McCracken LM. Attention to pain in persons with chronic pain: a behavioural approach. Behav Ther 1997;28:271-84.], and the Pain Catastrophizing Scale [Sullivan MJ, Bishop SR, Pivik J. The pain catastrophizing scale: development and validation. Psychol Assess 1995;7:24-532.]. It was hypothesized that insecure attachment would be positively associated with reports of pain-related fear, hypervigilance, and catastrophizing and that the model of self dimension would be the attachment variable most strongly associated with these variables. Correlation and multiple regression analyses supported these hypotheses. The model of self dimension had significant positive associations with each of the fear-avoidance constructs. The model of others dimension had a significant positive association with pain catastrophizing, but was not significantly associated with fear of pain and pain hypervigilance. Future research directions and potential clinical implications are discussed.     

Hypervigilance and attentional fixedness in chronic musculoskeletal pain: consistency of findings across modified stroop and dot-probe tasks.

Results from modified Stroop and dot-probe tasks have provided mixed evidence regarding attentional biases for sensory and affect pain stimuli in chronic pain patients. No studies have compared the same groups of chronic pain and healthy control participants on both tasks. We tested 36 patients with chronic musculoskeletal pain and 29 healthy control subjects on the modified Stroop and dot-probe tasks. Stimuli comprised affect pain, sensory pain, physical catastrophe, and neutral words. There was no evidence to suggest differential processing of threat cues by patients and control subjects on the modified Stroop task. All participants did, however, show differential processing of affect pain words. This was evident on both masked and unmasked presentation formats. There were no significant interactions between clinical status and threat word type observed for any of the indices of selective attention derived from the dot-probe task, but all participants had difficulty disengaging attention from affective pain and health catastrophe words. Findings were not influenced by individual differences in mood, anxiety, or fear of pain. Correlational analyses of the standard (unmasked) Stroop interference index and dot-probe indices of selective attention revealed a consistent lack of significant association, suggesting that the 2 tasks might be measuring different phenomena. Taken together, these findings provide evidence that chronic pain patients and healthy control participants do not differ in the way they attend to threatening linguistic stimuli. PERSPECTIVE: Some patients with chronic pain might have trouble paying attention to anything other than the affective components of pain and associated catastrophic health consequences. Interventions that specifically target this attentional fixedness might facilitate shifting attention to other targets and thereby reduce pain-specific anxiety and fear.