Behavioral Pain Coping Research Articles

The role of coping flexibility in chronic pain adjustment: Preliminary analysis

IntroductionWhile a body of research has evidenced the role of pain coping in chronic pain adjustment, the role of coping flexibility in chronic pain adjustment has received little research attention. Coping flexibility can be conceptualized with two dimensions, cognitive and behavioral. The cognitive dimension of coping flexibility (or coping appraisal flexibility) refers to one's appraisal of pain experience when changing coping strategies whereas the behavioral dimension of coping flexibility denotes the variety of coping responses individuals use in dealing with stressful demands.ObjectiveThe aim of this paper is to present preliminary findings on the role of coping flexibility in chronic pain adjustment by assessing 3 competing models of pain coping flexibility (see Figs. 1–3).MethodsPatients with chronic pain (n = 300) completed a battery of questionnaire assessing pain disability, discriminative facility, need for closure, pain coping behavior, coping flexibility, and pain catastrophizing. The 3 hypothesized models were tested using structural equation modeling (SEM). In all models tested, need for closure and discriminative facility were fitted as the dispositional cognitive and motivational factors respectively underlying the coping mechanism, whereas pain catastrophizing and pain intensity were included as covariates.ResultsResults of SEM showed that the hierarchical model obtained the best data-model fit (CFI = 0.96) whereas the other two models did not attain an accept fit (CFI ranging from 0.70–0.72).ConclusionOur results lend tentative support for the hierarchical model of pain coping flexibility that coping variability mediated the effects of coping appraisal flexibility on disability.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Cognitive‐Behavioral Treatment for Comorbid Insomnia and Osteoarthritis Pain in Primary Care: The Lifestyles Randomized Controlled Trial

To assess whether older persons with osteoarthritis (OA) pain and insomnia receiving cognitive-behavioral therapy for pain and insomnia (CBT-PI), a cognitive-behavioral pain coping skills intervention (CBT-P), and an education-only control (EOC) differed in sleep and pain outcomes. Double-blind, cluster-randomized controlled trial with 9-month follow-up. Group Health and University of Washington, 2009 to 2011. Three hundred sixty-seven older adults with OA pain and insomnia. Six weekly group sessions of CBT-PI, CBT-P, or EOC delivered in participants' primary care clinics. Primary outcomes were insomnia severity and pain severity. Secondary outcomes were actigraphically measured sleep efficiency and arthritis symptoms. CBT-PI reduced insomnia severity (score range 0-28) more than EOC (adjusted mean difference = -1.89, 95% confidence interval = -2.83 to -0.96; P < .001) and CBT-P (adjusted mean difference = -2.03, 95% CI = -3.01 to -1.04; P < .001) and improved sleep efficiency (score range 0-100) more than EOC (adjusted mean difference = 2.64, 95% CI = 0.44-4.84; P = .02). CBT-P did not improve insomnia severity more than EOC, but improved sleep efficiency (adjusted mean difference = 2.91, 95% CI = 0.85-4.97; P = .006). Pain severity and arthritis symptoms did not differ between the three arms. A planned analysis in participants with severe baseline pain revealed similar results. Over 9 months, CBT of insomnia was effective for older adults with OA pain and insomnia. The addition of CBT for insomnia to CBT for pain alone improved outcomes.

Pain Catastrophizing: An Updated Review

Pain catastrophizing has been described for more than half a century which adversely affects the pain coping behavior and overall prognosis in susceptible individuals when challenged by painful conditions. It is a distinct phenomenon which is characterized by feelings of helplessness, active rumination and excessive magnification of cognitions and feelings toward the painful situation. Susceptible subjects may have certain demographic or psychological predisposition. Various models of pain catastrophizing have been proposed which include attention-bias, schema-activation, communal-coping and appraisal models. Nevertheless, consensus is still lacking as to the true nature and mechanisms for pain catastrophizing. Recent advances in population genomics and noninvasive neuroimaging have helped elucidate the known determinants and neurophysiological correlates behind this potentially disabling behavior.

The Relationship between Happiness during Pregnancy,And Labor Pain Coping Behaviors

Background: Happiness is accounted for one of the psychological health criteria, and is considered as one of the six fundamental emotions- in human beings. Labor pain is also considered as one of the exclusive experiences, which demands pregnant women�s ability to cope with it. Happiness may give this potential ability to the pregnant women to apply skillful coping methods to tolerate the labor pain, but there is no registered evidence about this relationship. Aim: To determine the relationship between happiness during pregnancy and labor pain coping behaviors. Method: In this correlational study 80 low risk pregnant women, in the 36 � 40 weeks of pregnancy, who have referred to Omolbanin Hospital for prenatal care were selected using convenience sampling. Demographic information and the level of happiness were measured during pregnancy using Oxford Happiness Questionnaire. Labor pain coping behaviors were measured during contractions, and each half an hour from the dilatation of 3�5 cm till delivery using Labor Pain Coping Behaviors Observation Form. Data were analyzed with SPSS version 16 using Kruskal-Wallis, One- way ANOVA, Mann-Whitney tests and Spearman and Pearson correlation coefficients. Results: The frequency of low, medium and high level of happiness was 11.3, 72.5, and 16.2 respectively. Also, 16.3 of the pregnant women showed unfavorable, 50 acceptable, and 33.7 favorable labor pain coping behaviors. The results of Spearman�s correlation test revealed that there was a significant relationship between pregnancy happiness and the mean score of labor pain coping behaviors, (p = 0.000, and r = 0.444), i.e. higher levels of happiness during pregnancyis associated with more favorable labor pain coping behaviors. Conclusion: The parturient's behavior during labor indicates her level of emotion. So in parturient�s clinical management, in addition to physiological signs and clinical examinations these two issues should be considered as well.

Adaptation and Initial Validation of the BRCS in an Elderly Spanish Sample

Resilience is understood as a dynamic process encompassing positive adaptation within the context of adversity. This study examined the validity of the Brief Resilient Coping Scale (BRCS), a 4-item measure designed to capture tendencies to cope with stress in a highly adaptive manner, in an elderly Spanish population. A total of 133 elderly people from an association of retired persons in Valencia (Spain) provided the responses for the validation study. The factorial validity of the scale was tested using confirmatory factor analysis, with a single dimension of resilience with adequate fit indexes emerging from this analysis. The BRCS has adequate internal consistency both at the scale and item levels. The criterion-related validity of the scale was established by correlating resilient coping with measures of coping resources and psychological well-being. The correlations with measures of personal coping resources (e.g., optimism, helplessness, self-efficacy), pain-coping behaviors, and psychological well-being were in the expected direction, and were statistically significant and large. In conclusion, the adaptation into Spanish of the BRCS seems to be a reliable and valid measure of resilient coping in the elderly population, and it could potentially be used in both clinical practice and research in the elderly.

Cerebral Activation and Catastrophizing During Pain Anticipation in Patients With Fibromyalgia

Anticipation of pain influences its cerebral processing and dysfunctional cognitive style like catastrophizing correlates with the severity of pain. Patients with fibromyalgia syndrome (FMS) exhibit higher levels of catastrophizing, increased attention to pain, and augmented cerebral pain processing. Therefore, alteration in cerebral processing during anticipation of experimental pain and its relation to catastrophizing are the main focus of the study. Functional magnetic resonance imaging of the brain was acquired during the time of pain anticipation with announcement of its intensity or not in 12 patients with FMS and 14 healthy controls. Within a two-factorial model (factors "group" and "session"), the main effect of group and the interaction effect were tested in a whole-brain analysis. In addition, activation of the periaqueductal gray (PAG) was analyzed in a region-of-interest analysis. Patients with FMS generally displayed greater catastrophizing behavior (p = .003) but not during the anticipation of the experimental pain (p > .16). Furthermore, patients showed greater activation of the dorsolateral prefrontal cortex (p = .05), the PAG (p = .04), and the posterior parietal cortex (p = .03) during the anticipation of pain, independent of the pain coping behavior during anticipation. The lack of difference in catastrophizing during the experimental pain suggests independent coping mechanisms during experimental and clinical pain. Regarding the importance of the frontal cortex and the PAG in the descending pain modulation system, it seems reasonable to assume that these functional changes related to the context of stimulus presentation may contribute to central sensitization in FMS.

Further Evaluation of the Motivational Model of Pain Self-Management: Coping with Chronic Pain in Multiple Sclerosis

Growing evidence suggests that motivation to engage in pain-coping strategies is a key predictor of how well a person adjusts to pain. According to the Motivational Model of Pain Self-Management, readiness to engage in pain self-management behaviors is influenced by beliefs about the importance of the behavior (importance) and the ability to carry out the behavior (self-efficacy). The purpose of this study was to test the Motivational Model of Pain Self-Management for exercise and task persistence pain-coping behaviors in a sample of 114 individuals with multiple sclerosis and chronic pain. Measures included the Multidimensional Pain Readiness to Change Questionnaire-2 and measures of importance, self-efficacy, and coping behavior duration. Tests of mediation were conducted with two path analyses, one for each coping behavior. The effects of importance and self-efficacy beliefs on coping behaviors were mediated or partially mediated by readiness to engage in those behaviors. These findings provide support for the Motivational Model of Pain Self-Management and have important implications for the development of treatments for chronic pain.

Effects of expectancies and coping on pain-induced motivation to smoke.

The prevalence of tobacco smoking among persons with recurrent pain is approximately twice that observed in the general population. Smoking has been associated with the development and exacerbation of several chronically painful conditions. Conversely, there is both experimental and cross-sectional evidence that pain is a potent motivator of smoking. A recent study provided the first evidence that laboratory-induced pain could elicit increased craving and produce shorter latencies to smoke (Ditre & Brandon, 2008). To further elucidate interrelations between pain and smoking, and to identify potential targets for intervention, in the current study, we tested whether several constructs derived from social-cognitive theory influence the causal pathway between pain and increased motivation to smoke. Smokers (N = 132) were randomly assigned to 1 of 4 conditions in this 2 x 2 between-subjects experimental design. Results indicated that manipulations designed to (a) challenge smoking-related outcome expectancies for pain reduction and (b) enhance pain-related coping produced decreased urge ratings and increased latencies to smoke, relative to controls. An unexpected interaction effect revealed that although each manipulation was sufficient to reduce smoking urges, the combination was neither additive nor synergistic. These findings were integrated with those of the extant literature to conceptualize and depict a causal pathway between pain and motivation to smoke as moderated by smoking-related outcome expectancies and mediated by the use of pain coping behaviors.

Will This Patient Develop Persistent Disabling Low Back Pain?

Low back pain is extremely common. Early identification of patients more likely to develop persistent disabling symptoms could help guide decisions regarding follow-up and management. To systematically review the usefulness of individual risk factors or risk prediction instruments for identifying patients more likely to develop persistent disabling low back pain. Electronic searches of MEDLINE (1966-January 2010) and EMBASE (1974-February 2010) and review of the bibliographies of retrieved articles. Prospective studies of patients with fewer than 8 weeks of low back pain from which likelihood ratios (LRs) were calculated for prediction of persistent disabling low back pain for findings attainable during the clinical evaluation. Two authors independently assessed studies and extracted data to estimate LRs. A total of 20 studies evaluating 10,842 patients were identified. Presence of nonorganic signs (median [range] LR, 3.0 [1.7-4.6]), high levels of maladaptive pain coping behaviors (median [range] LR, 2.5 [2.2-2.8]), high baseline functional impairment (median [range] LR, 2.1 [1.2-2.7]), presence of psychiatric comorbidities (median [range] LR, 2.2 [1.9-2.3]), and low general health status (median [range] LR, 1.8 [1.1-2.0]) were the most useful predictors of worse outcomes at 1 year. Low levels of fear avoidance (median [range] LR, 0.39 [0.38-0.40]) and low baseline functional impairment (median [range] LR, 0.40 [0.10-0.52]) were the most useful items for predicting recovery at 1 year. Results were similar for outcomes at 3 to 6 months. Variables related to the work environment, baseline pain, and presence of radiculopathy were less useful for predicting worse outcomes (median LRs approximately 1.5), and a history of prior low back pain episodes and demographic variables were not useful (median LRs approximately 1.0). Several risk prediction instruments were useful for predicting outcomes, but none were extensively validated, and some validation studies showed LRs similar to estimates for individual risk factors. The most helpful components for predicting persistent disabling low back pain were maladaptive pain coping behaviors, nonorganic signs, functional impairment, general health status, and presence of psychiatric comorbidities.

Maladaptive Cognitions and Chronic Pain: Epidemiology, Neurobiology, and Treatment

Maladaptive cognitions are widespread and play a significant role in the development of chronic pain. (1) Catastrophizing seems to increase the risk of chronicity. In the laboratory it amplifies temporal summation of pain with repeated stimulation and delays the disengagement of attention from pain. In neuroimaging it is associated with increased activation in regions of the cortex involved in attention, the aversiveness of pain, and possibly pain intensity. (2) Fearful anticipation of pain seems to pre-activate brain regions involved in both the sensory and emotional intensity of pain and primes a stronger initial pain response. It may lead to abnormal patterns of muscle recruitment that, speculatively, may predispose to injury. (3) Belief that normal activity should be avoided seems to promote unnecessary long-term disability in nonspecific low back pain. Extreme guarding may intensify pain through loss of inhibition from motor cortex. (4) Educational programs targeting maladaptive beliefs have shown benefit in the primary prevention of chronic back pain in both pain-free and acute pain populations. In established chronic pain, cognitive-behavioral therapy has shown efficacy in improving pain intensity, coping and pain behaviors when compared with usual treatment. (5) Possible future research directions and clinical implications are discussed.

Development and Validation of the Emotional Intimacy Scale

Although many measures have been developed to capture elements of social support, only a few include an assessment of emotional intimacy. Emotional intimacy involves a perception of closeness to another that allows sharing of personal feelings, accompanied by expectations of understanding, affirmation, and demonstrations of caring. The 5-item Emotional Intimacy Scale (EIS) was developed to assess the emotional intimacy component in one close relationship. A sample of 90 women with rheumatoid arthritis was used to assess the reliability and validity of the scale. Internal consistency and test-retest reliability for a 6-week period were .88 and .85, respectively. To assess construct validity, significant, positive correlations were obtained between the EIS and measures of social support, self-efficacy, perceived health competence, reappraisal coping behaviors, life satisfaction, and positive affect. Significant negative correlations were obtained between the EIS and perceived stress levels, helplessness, negative pain coping behaviors, pain, and fatigue. In support of criterion-related validity, the EIS predicted outcomes from an intervention program. To further assess criterion-related validity, scores on the EIS and helplessness predicted scores on two indicators of psychological well-being that measured positive affect and life satisfaction. The EIS is a brief measure of emotional intimacy with good psychometric properties.

Partner-Guided Cancer Pain Management at the End of Life: A Preliminary Study

This preliminary study tested the efficacy of a partner-guided cancer pain management protocol for patients who are at the end of life. Seventy-eight advanced cancer patients meeting criteria for hospice eligibility and their partners were randomly assigned to a partner-guided pain management training intervention, or usual care control condition. The partner-guided pain management training protocol was a three-session intervention conducted in patients' homes that integrated educational information about cancer pain with systematic training of patients and partners in cognitive and behavioral pain coping skills. Data analyses revealed that the partner-guided pain management protocol produced significant increases in partners' ratings of their self-efficacy for helping the patient control pain and self-efficacy for controlling other symptoms. Partners receiving this training also showed a trend to report improvements in their levels of caregiver strain. Overall, the results of this preliminary study suggest that a partner-guided pain management protocol may have benefits in the context of cancer pain at the end of life. Given the significance of pain at the end of life, future research in this area appears warranted.

Testing a Model of Pain Appraisal and Coping in Children With Chronic Abdominal Pain.

This prospective study of children with recurrent abdominal pain (N=133; ages 8--15 years) used path analysis to examine relations among dispositional pain beliefs and coping styles, cognitions and behavior related to a specific pain episode, and short- and long-term outcomes. Children believing they could not reduce or accept pain appraised their episode-specific coping ability as low and reported passive coping behavior. Dispositional passive coping had direct effects on both episode-specific passive coping and long-term symptoms and disability. Accommodative coping (acceptance and self-encouragement) was associated with reduced episode-specific distress, which itself predicted reduced depressive symptoms 3 months later. Results suggest that coping-skill interventions for children with chronic pain should target reductions in passive coping and consider the potential benefits of accommodative coping strategies.

Further validation of the chronic pain coping inventory

Multidisciplinary treatment programs for chronic pain typically emphasize the importance of decreasing maladaptive and encouraging adaptive coping responses. The Chronic Pain Coping Inventory (CPCI), developed to assess coping strategies targeted for change in multidisciplinary pain treatment, is a 64-item instrument that contains 8 subscales: Guarding, Resting, Asking for Assistance, Relaxation, Task Persistence, Exercising/Stretching, Coping Self-Statements, and Seeking Social Support. A previous validation study with 210 patients in a Canadian academic hospital setting supported an 8-factor structure for the CPCI. The current study was undertaken to validate the CPCI among 564 veterans with a more extended history of chronic pain. Patients completed the study questionnaires before multidisciplinary treatment. A confirmatory factor analysis was used to examine the factor structure of the 64-item CPCI. A series of hierarchical multiple regression analyses were performed with depression, pain interference, general activity level, disability, and pain severity as the criterion variables and the 8 CPCI factors as the predictor variables, controlling for pain severity and demographic variables. The confirmatory factor analysis results strongly supported an 8-factor model, and the regression analyses supported the predictive validity of the CPCI scales, as indicated by their association with measures of patient adjustment to chronic pain. Perspective This article validated the 8-factor structure of the CPCI by using a confirmatory factor analysis and a series of linear regressions. The results support the applicability and utility of the CPCI in a heterogeneous population of veterans with severe chronic pain treated in a tertiary teaching hospital. The CPCI provides an important clinical and research tool for the assessment of behavioral pain coping strategies that might have an impact on patient outcomes.

Pain catastrophizing and interpersonal problems: a circumplex analysis of the communal coping model

Using the circumplex model of interpersonal behavior [Handbook of research methods in clinical psychology, 1982], this study tested the communal coping model of catastrophizing (CCM) in a large ( N=179) sample of patients with irritable bowel syndrome (IBS), a common, benign chronic pain disorder associated with significant painful extraintestinal comorbidity (e.g. headache, low back pain). Patients completed the Coping Strategies Questionnaire, the Brief Symptom Inventory, and the Inventory of Interpersonal Problems. The main findings were: (1) individuals who reported higher levels of catastrophizing described greater interpersonal problems; (2) the interpersonal problems described by catastrophizers fell within the friendly and friendly submissive quadrants of the circumplex supporting the notion that they have an interpersonal style demanding support and care-taking [Pain 103 (2003) 151]; (3) the pain coping behavior most strongly associated with interpersonal problems was catastrophizing; and (4) the relationship between interpersonal problems and catastrophizing remained after removing the influence of general symptomatic distress (i.e. an overall tendency to complain of psychological problems in general). In general, data provide evidence supporting the interpersonal distinctiveness of pain catastrophizing as postulated by the CCM. Advantages of a circumplex model and of interpersonal theory for understanding and testing the CCM are discussed.

The Development and Psychometric Evaluation of the Brief Resilient Coping Scale

This article introduces the Brief Resilient Coping Scale (BRCS), a 4-item measure designed to capture tendencies to cope with stress in a highly adaptive manner. Two samples of individuals with rheumatoid arthritis (ns = 90 and 140) provide evidence for the reliability and validity of the BRCS. The BRCS has adequate internal consistency and test-retest reliability. Convergent validity of the scale is demonstrated by predictable correlations with measures of personal coping resources (e.g., optimism, helplessness, self-efficacy), pain coping behaviors, and psychological well-being. Resilient coping, as assessed by the BRCS, also buffers the effects of high levels of arthritis-related and non-arthritis-related stressors on depressive symptoms. The sensitivity of the BRCS to changes associated with a cognitive-behavioral intervention is also demonstrated. The BCRS may be useful for identifying individuals in need of interventions designed to enhance resilient coping skills.

Predictors of improvement in a cognitive-behavioral intervention for women with rheumatoid arthritis.

In this article we present a secondary analysis of data from a brief cognitive-behavioral intervention for women with rheumatoid arthritis that resulted in significant overall improvements in personal coping resources, pain coping behaviors, psychological well-being, and fatigue. Not every participant, however, improved during the intervention. Establishing predictors of improvement in brief interventions is important to optimize the cost-effective use of these resources. In search of predictors of improvement, we examined demographic and background variables, personal coping resources, pain coping behaviors, and social support. Both linear and quadratic effects were analyzed, comparing baseline measures to both immediate postintervention and 3-month follow-up outcomes using standardized indexes ofpredictors and criteria variables. After removing the effects of baseline scores on the outcomes index, significant predictors of improvement included length of time since diagnosis, personal coping resources, and maladaptive and adaptive pain coping behaviors. Both linear and quadratic effects were found, although this varied as a function of type of predictor.

The negative effect of decreasing the level of activity in coping with pain in rheumatoid arthritis: an increase in psychological distress and disease impact.

The objective of this study was to analyze the effect of coping with pain in rheumatoid arthritis (RA) on subsequent changes in psychological distress and disease impact. A sample of 109 randomly selected RA patients was asked to participate in a longitudinal study. Patients were measured at baseline and after 3 years. Both measurements were completed in 80 patients. At each assessment the following variables were assessed: disease activity, pain, physical and psychological distress, disease impact, and coping. The relation between coping with pain at baseline and subsequent changes in psychological distress and disease impact was analyzed using stepwise regression. Disease status variables assessed at baseline and after 3 years were entered in the regression analysis as control variables. Results show that cognitive coping with pain at baseline was not related to subsequent changes in psychological distress or disease impact. On the other hand, behavioral pain coping assessed at baseline was related to subsequent changes in psychological distress and disease impact. "Decreasing activity" was related to an increase in self-reported psychological distress and disease impact after controlling for disease status at both assessments. It was concluded that cognitive pain coping did not predict any subsequent changes in psychological distress or disease impact. "Decreasing activity" as a behavioral pain coping style has a negative effect on subsequent changes in psychological distress and disease impact.

Children with cognitive impairment: parent report of pain and coping.

Information about pain in children with cognitive impairment is lacking. To gather pain-relevant information in this population, parents of 145 children with borderline to profound cognitive impairment were interviewed regarding their children's pain expression, experience, treatment, and coping behavior. Descriptions of pain expression and coping behavior were associated with the level of cognitive impairment. Children with mild to moderate cognitive impairment were more likely to be described as directly communicating their pain and exhibiting procedural coping strategies similar to those observed in children without cognitive impairments. More than half of the parents reported that their children experienced pain differently than did children without cognitive impairment, with the majority perceiving decreased pain sensitivity and greater pain tolerance. Finally, one third of parents felt that their children's pain was treated differently than that of other children. Half of these parents believed that health care providers had difficulties assessing and treating their children's pain. Results contribute to the developing foundation of information about pain in this special pediatric population.

Coping styles of headache sufferers.

Psychological factors are important in the chronification and aggravation of headaches. We studied 90 patients suffering from migraine, chronic daily headache (CDH) evolved from migraine, and episodic or chronic tension-type headache (TTH). Emotional, cognitive, and behavioral pain coping were assessed using the Kiel Pain Inventory (KPI), Beck's Depression Inventory, the State-Trait-Anxiety Inventory, and Quality of Life Questionnaire. In addition, the clinical course of headache was analyzed using a validated headache diary. The results were as follows. Firstly, the KPI is reliable internally for the assessment of pain-coping strategy employment among headache patients. Secondly, migraine sufferers were characterized by pronounced psychological abnormalities during the headache phase, demonstrating a less adaptive coping behavior. This was in contrast to the TTH patients, who showed more general distress manifesting in elevated anxiety and lower quality of life. The only factor which appeared to be essential for differentiating between migraine and TTH was the intensity of headache. Thirdly, chronic TTH and CDH evolved from migraine demonstrated more pronounced psychological disabilities and more severe clinical courses of headaches than episodic TTH or nontransformed migraine. The predictor variable for transformation of migraine was impairment of well-being/quality of life, and for transformation of TTH, the frequency of headaches and depression. Finally, analgesic misuse seems to be less important for chronification and transformation of headaches than the degree of psychological disability. This study draws attention to the role of psychological factors in the chronification of TTH and transformation of migraine and provides some recommendations for the behavioral treatment of chronic headaches.