THE RELATIONSHIP BETWEEN PAIN APPRAISALS AND COPING STRATEGY USE AND ADAPTATION TO CHRONIC LOW BACK PAIN A DAILY DIARY STUDY

Transcription

1 THE RELATIONSHIP BETWEEN PAIN APPRAISALS AND COPING STRATEGY USE AND ADAPTATION TO CHRONIC LOW BACK PAIN A DAILY DIARY STUDY by LYNDA D. GRANT B.A., Northeastern College, NJ M.A., Simon Fraser University, 1987 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF EDUCATION (Department of Counselling Psychology) THE UNIVERSITY OF BRITISH COLUMBIA October 7, 1997 Lynda D. Grant, 1997

2 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that. copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department The University of British Columbia Vancouver, Canada Date OcV l^/q7 DE-6 (2/88)

3 11 ABSTRACT Data from daily diaries were used to examine the relationships between daily pain appraisals (Catastrophizing, Self-Efficacy, and perceived control over pain) and coping strategy use (Distraction, Ignoring Pain, Praying and Hoping, and Reinterpreting Pain Sensation) and nighttime negative mood and pain intensity for 88 women (mean age years, SD 11.90) with chronic low back pain who were not attending a specialized pain treatment program. These relationships were examined at two levels using the Hierarchical Linear Modeling program (Bryk & Raudenbush, 1992). The first level of analyses examined whether pain appraisals and coping strategy use during the day predicted levels of nighttime depressed and anxious mood, and pain. This analysis was based on 30 days of monitoring for each participant. The second level of analyses examined whether these daily processes could be predicted by psychosocial and functional variables important to the experience of chronic pain. This analysis was based on the Mutidimensional Pain Inventory (Kerns, Turk, & Rudy, 1985) completed prior to participants beginning the daily monitoring. There were four major findings in this study. First, pain appraisals were more predictive of negative mood and pain intensity than coping strategy use, with Catastrophizing the strongest predictor of depressed and anxious mood, and control the strongest predictor of pain intensity. Second, general affective distress predicted higher levels of negative mood on a daily basis. Third, women who

4 perceived their pain to be interfering a great deal in their lives were more anxious on a daily basis. Fourth, punishing spousal responses predicted nightly negative mood and pain more than solicitous or distracting spousal responses. These results are similar to findings based on patients attending pain treatment programs. This suggests that some of the same processes identified in clinical pain patients may apply to low back pain sufferers in the community who are comparable to study participants. The implications of these findings for pain research and treatment are discussed.

5 IV TABLE OF CONTENTS ABSTRACT TABLE OF CONTENTS LIST OF TABLES LIST OF FIGURES ACKNOWLEDGMENTS ii iv vii ix x INTRODUCTION 1 REVIEW OF THE LITERATURE 9 Adaptation 9 Stress 12 Appraisal 15 Critique 21 Coping 30 Critique 33 Coping Self-Statements Subscale 35 Increased Behavioral Activities Subscale 35 Reinterpreting Pain Sensation and Praying and Hoping Subscales 36 Ignoring Pain and Diverting Attention Subscales 36 Pain Duration 42 Summary 43 HYPOTHESES 48 The Relationship Between Daily Nighttime Depressed Mood, Nighttime Anxious Mood, and Nighttime Pain Intensity, Appraisals, and Coping Strategy Use 48 Hypothesis 1 48 The Relationship Between the MPI Subscales and Daily Responses to Pain 49 Hypothesis 2 49 Exploratory Analyses 50 Exploratory Analyses 1 50 Exploratory Analyses 2 50 Exploratory Analyses 3 50

6 V METHOD 51 Design 51 Participants 51 Measures 53 Coping Strategy Questionnaire 54 Catastrophizing 55 Perceived Control Over Pain 56 Self-Efficacy 57 State-Trait Personality Inventory - Anxiety and Depression Subscales 58 Pain intensity Multidimensional Pain Inventory 60 McGill Pain Questionnaire 65 Procedure 67 Data Analyses 68 Missing data 68 Preliminary Analyses 69 Analyses of Diary Data: Hierarchical Linear Models 70 Steps in HLM Model Building 75 Null Model 75 Level-1 Models 76 Level-2 Models '...77 Interaction Effects 78 RESULTS 79 Completers Versus Non-Completers Comparability 79 Descriptive Statistics 80 Means, standard deviations, and Cronbach's alphas for the daily variables 80 Correlations for the Daily Variables and the Time 1 MPI 82 Comparisons With Selected Pain Populations on the MPI and MPQ 86 Main Analyses 87 Overview 87 Null Models Nighttime depressed mood 90 Level-1 analyses 90 Level-2 analyses 95 Nighttime anxious mood 101 Level-1 analyses 101 Level-2 analyses 105

7 vi Nighttime pain intensity Ill Level-1 analyses Ill Level-2 analyses 116 Exploratory Analyses of the Interaction Effects DISCUSSION 125 Predicting Daily Negative Mood and Pain 126 Appraisals 126 Coping Strategy Use 128 The Role of Psychosocial and Functional Variables on Daily Responses to Pain 133 Conclusions 138 Limitations of the Study 139 Research Implications 143 Clinical Implications 145 REFERENCES 147 APPENDICES Appendix A: Summary Tables of the Literature Review 158 Appendix B: Demographic Questionnaire and Data Summary 176 Appendix C: Consent Form 185 Appendix D: Equations for the HLM Models 187 Appendix E: Completers Versus Non-Completers Data 192 Appendix F: Correlations for Days 15 and 30, and Comparisons With Clinical Pain Studies 196 Appendix G: Results of the HLM Level-2 Analyses for the MPI Functional and Interpersonal Subscales 205 Appendix H: Tables and Figures for the Significant Interactions 208 Appendix I: Examples of Questions For Each of The Multi-Item Measures 215

8 LIST OF TABLES Table 1. Means and Standard Deviations for the MPI Subscales for Time 1 and Time 2 and Cronbach's alphas for Time 1 64 Table 2. Means, Standard Deviations, and Cronbach's Alphas for the Daily variables for days 1, 15, and Table 3. Pearson-Product Moment Correlation matrix of Demographic and Daily Variables for Day 1 83 Table 4. Pearson-Product Moment Correlation Matrix for Time 1 MPI, Demographic, and Daily Variables for Day 1 84 Table 5. HLM Results for the Null Models for Nighttime Depressed Mood, Nighttime Anxious Mood, and Nighttime Pain Intensity.. 89 Table 6. Level-1 HLM Analyses of the Effects of Morning Depressed Mood, the Three Pain Appraisals, and Distraction, Ignoring Pain, and Praying and Hoping on Nighttime Depressed Mood 91 Table 7. Level-2 HLM Results for Nighttime Depressed Mood. The Relationships Between the MPI Functional Subscales and the Level-1 Intercepts and Morning Depressed Mood Slope 97 Table 8. Level-2 HLM Results for Nighttime Depressed Mood. The Relationships Between the MPI Interpersonal Subscales and the Level-1 Intercepts and Morning Depressed Mood Slope 99 Table 9. Level-1 HLM Analysis of the Effects of Morning Anxious Mood, the Three Pain Appraisals, and Distraction, Ignoring Pain, and Praying and Hoping on Nighttime Anxious Mood 102 Table 10. Level-2 HLM Results for Nighttime Anxious Mood. The Relationships Between the MPI Functional Subscales and the Level-1 Intercepts and Morning Anxious Mood Slope 107 Table 11. Level-2 HLM Results for Nighttime Anxious Mood. The Relationships Between the MPI Interpersonal Subscales and the Level-1 Intercepts and Morning Anxious Mood 110

9 Table 12. Level-1 HLM Analysis of the Effects of Morning Pain Intensity, the Three Pain Appraisals, and the Four Coping Strategies for Nighttime Pain Intensity 113 Table 13. Level-2 HLM Results for Nighttime Pain Intensity. The Relationships Between the MPI Functional Subscales and the Level-1 Intercepts and Morning Pain Intensity Slope 117 Table 14. Level-2 HLM Results for Nighttime Pain Intensity. The Relationships Between the MPI Interpersonal Subscales and the Level-1 Intercepts and Morning Pain Intensity Slope 120

10 ix LIST OF FIGURES Figure 1. Graphic Representation of HLM Level-1 Analyses 72 Figure 2. Graphic Representation of HLM Level-2 Analyses 74

11 ACKOWLEDGEMENTS I would like to thank Bonita Long, my dissertation supervisor, for her support during the preparation of this thesis. Her dedication to her students, her thoroughness, and her desire to learn and stretch herself has contributed greatly to my personal and scholastic development. I would also like to thank the members of my committee, Ken Craig and Anita DeLongis. Their knowledge and expertise greatly strengthened this research study. Additional thanks are extended to Doug Willms for sharing his statistical expertise in HLM, and to the 88 women whose willingness to give so much time to complete the questionnaires made this project possible. Last, but certainly not least, I would like to thank my husband, Ron Gibson. He has never wavered in his support and encouragement, despite having to take on the additional tasks and burdens that are required of a student's spouse. This Ph.D has been very much of a team effort.

12 1 CHAPTER ONE Introduction Adaptation to pain is considered to be a multidimensional phenomena that involves a broad range of psychosocial and functional variables (Turk & Rudy, 1988). These include perceptions of pain severity, interference of pain on life, psychological well-being, social support, ability to control pain, and functional abilities. Although most people with chronic pain adapt well to their condition (Jensen, Turner, Romano, & Karoly, 1991), a certain proportion of sufferers do not and find their pain both emotionally and physically disabling. These people are responsible for the largest percentage of annual pain related work days lost, health care costs, and compensation payments (Nachemson, 1984). Consequently, the identification of factors that help or hinder peoples' abilities to adapt to chronic pain may help us understand the wide variation in response to pain, and increase our clinical abilities to assist those who are not adapting well. Thus, the purpose of this study was to examine the relationships between daily pain appraisals and coping strategy use and nighttime negative mood and pain, and whether these daily processes were predicted by psychosocial and functional variables important to the experience of chronic pain. Over the past 10 years there has been a noticeable increase in research focused on chronic pain and adaptation. Recently, models of stress and coping

13 2 have been called upon to explain adaptational differences among chronic pain sufferers (Jensen & Karoly, 1991; Keefe et al., 1987). One of the models used most frequently is Lazarus's transactional model of stress and coping (Lazarus & Folkman, 1984). Within this model, pain is the stressor, and pain appraisals (personal judgments about pain) and coping strategies (purposeful efforts to manage the pain) are believed to play a central role in how well people adapt to pain. There is a substantial literature supporting the relationship between pain specific appraisals and adaptation to chronic pain. Catastrophizing, perceived control over pain, and self-efficacy judgments are three appraisals that have been shown to be most central to adaptation (Jensen & Karoly, 1991). Catastrophizing appraisals are defined as frequent negative and worrying thoughts about pain and the prognosis for the future (Turner, 1991). They have been shown to have significant positive associations with pain intensity (Flor & Turk, 1988; Hill, 1993; Keefe, Browne, Wallston, & Caldwell, 1989; Romano, Turner, Syrjala, & Levy, 1987), anxiety and depression (Hill, 1993; Keefe et al., 1989; McCracken & Gross, 1933; Romano et al., 1987), and functional limitations (Flor & Turk, 1988, Reesor & Craig, 1988). Appraisals of perceived control over pain have been found to be positively associated with physical activity (Spinhoven, Ter Kuile, Linssen, & Gazendam,

14 3 1989) and better psychological functioning (Jensen & Karoly, 1991), and negatively associated with pain intensity (Spinhoven et al., 1989; Spinhoven & Linssen, 1991), and depression, anxiety, and poorer psychological functioning (Affleck, Tennen, Pfeiffer, & Fifield, 1987; Keefe, et al., 1989; Keefe & Williams, 1990). Self-efficacy appraisals have shown significant positive relationships with the amount of exercise and physical activity people engage in (Council, Ahern, Follick, & Kline, 1988; Dolce, Crocker, & Doleys, 1986; Dolce, Crocker, Moletteire, & Doleys, 1986), and the frequency of coping strategy use (Jensen, Turner, & Karoly, 1991). Self-efficacy appraisals for pain, functioning, and the ability to manage non-arthritis symptoms have all been shown to be significantly and negatively correlated with pain intensity, depression, and disability for arthritis patients (Lorig, Chastain, Ung, Shoor, & Holman, 1989; O'Leary, Shoor, Lorig, & Holman, 1988; Regan, Lorig, & Thorensen, 1988). A substantial number of studies have examined the relationship between coping strategy use and adaptation. One of the most frequently used measures of coping with pain is the Coping Strategy Questionnaire (CSQ; Rosentiel & Keefe, 1983). However, factor analytic studies of the CSQ have failed to find a reliable factor structure, or consistent relationships between individual factors and adaptational outcomes (Hill, 1993; Jensen, Turner, & Romano, 1994; Spinhoven &

15 4 Lissen, 1991). Studies using the individual CSQ subscales have shown more promising results, although the results have been somewhat weak and are not always consistent. Taken as a whole, these studies suggest that coping strategy use is related to psychological and physical functioning, pain intensity, and interference of pain on life (Hill, 1993; Jensen & Karoly, 1991; Keefe & Williams, 1990; Romano et al., 1987). In summary, there is evidence that the appraisals of Catastrophizing, perceived control over pain, and Self-Efficacy, and coping strategy use are associated with adaptation to chronic pain. However, we are still left with at least three unanswered questions. First, what is the daily relationship between pain appraisals and coping strategy use and responses to pain such as depression, anxiety, and pain intensity? A sub-component of this question is how independent are the appraisals and the coping strategies in their ability to predict adaptation to pain when they are considered together in the analysis? Second, what is the relationship between these daily processes and psychosocial and functional variables important to the experience of chronic pain? Third, are the relationships identified in the literature similar for non-clinical pain populations, which are the vast majority of chronic pain sufferers (Sternbach, 1986)? Part of the reason for these gaps in our knowledge is due to methodological issues such as retrospective recall and cross-sectional data collection methods, the tendency to use

16 5 unidimensional measures of the pain experience, and the almost exclusive reliance on clinical pain populations. The use of retrospective recall data collection methods, where participants are asked to remember what they did or thought over a number of days or weeks, and then summarize this temporal experience into one response creates concerns about measurement error. A number of authors have expressed concern about recall error and bias, as well as responses that are confounded by person or situational variables that are unique to the time of measurement (Affleck, Urrows, Tennen, & Higgins, 1992; DeLongis, Hemphill, & Lehman, 1992; Epstein, 1986; Stone & Kennedy-Moore, 1992; Wethington & Kessler, 1993). The reliance on cross-sectional research designs creates a number of difficulties. First, Lazarus and Folkman (1894) emphasize that the coping process is best understood as an ongoing interaction with the environment rather than a static event. One or few measurement points do not allow for the examination of the variation in the relationship between appraisals and coping strategy use and same day responses to pain, or how these daily processes relate to overall adaptation. Second, even though the coping process is variable, the importance of some stability in this process to psychological well-being and social functioning is also recognized (Folkman, 1992; Lazarus, 1990). Cross-sectional designs can not

17 6 identify these more stable processes that occur in responses over time (Epstein, 1986). The most common methods of assessing adaptation to pain in the chronic pain literature have been based on the concepts of psychological well-being and psychopathology, especially anxiety and depression (Jensen, Turner, Romano, & Karoly, 1991; Turk & Rudy, 1992). However, some authors have argued that this is a unidimensional conceptualization of the pain experience, and not sufficient to represent the midtidimensionality of this complex phenomena (Turk & Rudy, 1988). These researchers suggest that pain studies need to examine a wide range of psychosocial and functional variables important to the experience of chronic pain (Kerns, Turk, & Rudy, 1985; Turk & Rudy, 1988). The almost exclusive use of clinical pain populations (i.e., those attending specialized pain treatment programs) creates a number of difficulties. First, there is evidence to suggest that these patients are more depressed, have higher levels of pain intensity, and use more social withdrawal as a response to pain than chronic pain sufferers in the general community (Crooks, Rideout, & Browne, 1984). These findings suggest that we should be cautious about generalizing research results obtained from participants actively involved in pain treatment programs to non-clinical pain populations.

18 7 This study sought to address these methodological issues in several ways. First, data were collected via daily diaries for 30 days. Daily diaries are selfreport instruments that are completed one or more times a day over a period of days or weeks. They are designed to pick up day-to-day variations in participants' responses to pain, as well as more stable patterns of responding. This type of data collection typically yields stronger predictive validity as it greatly reduces the recall period, thereby reducing recall error and increasing reports of prevalence of coping responses (Bolger, DeLongis, Kessler, & Schilling, 1989; DeLongis, Folkman, & Lazarus, 1988; Suls, Wan, & Blanchard, 1994; Verbrugge, 1980). Second, psychosocial and functional variables, measured by the Multidimensional Pain Inventory (MPI; Kerns et al., 1985), were also examined to see whether they predicted the daily pain processes identified in the daily diary analyses. Third, participants were recruited for the study via media advertisements from the community rather than from specialized pain clinics. I expected to find that (a) higher levels of negative mood at night would be associated with higher levels of catastrophic thinking and the use of Praying and Hoping coping strategies during the day, whereas lower levels of negative mood would be associated with higher levels of Self-Efficacy and control appraisals, and the more frequent use of Distraction and Ignoring Pain coping strategies; (b) higher levels of pain intensity at night would be associated with higher levels of

19 8 catastrophic thinking and the use of Praying and Hoping, Distraction, and Ignoring Pain coping strategies during the day, whereas lower levels of pain would be associated with higher levels of Self-Efficacy and control appraisals; and (c) people who generally perceived themselves to be adapting well to their pain from a psychosocial and functional perspective would report lower levels of negative mood and pain intensity on a daily basis. There is also some suggestion in the literature that there may be interaction effects between pain appraisals and pain intensity, and coping strategy use and pain intensity. Estlander and Harkapaa (1989) found that chronic pain patients engaged in significantly higher levels of catastrophizing when experiencing increased levels of pain, and Jensen and Karoly (1991) found that control appraisals had a significant positive effect on activity levels only when their interaction with lower levels of pain intensity was taken into account. Both of these studies also found that the use of more active coping strategies appeared to increase during lower levels of pain, and the use of more passive strategies increased during higher levels of pain. Because so few studies have examined these types of relationship, I included them in this study for exploratory purposes only.

20 9 CHAPTER TWO Review of the Literature In order to understand more clearly the relationships between pain appraisals, coping strategy use, overall adaptation, and daily responses to pain, I review the relevant conceptual and empirical literature on adaptation to chronic pain. First, I provide an overview of the theoretical constructs that form the basis for this research project. Second, I review research on how these constructs pertain to adaptation to chronic pain. Finally, I discuss the limitations of our current procedures for examining adaptation to chronic pain. Richard Lazarus is recognized as a leader in the field of stress and coping. His emphasis on complex mental processes has advanced our understanding of how people cope with stressful events. His cognitive-affective, transactional, process-oriented conceptualization of stress and coping has been widely adopted within the chronic pain and coping literature (Jensen, Turner, Romano, & Karoly, 1991). Four constructs from Lazarus's stress and coping model that relate to chronic pain are reviewed: adaptation, stress, appraisal, and coping. Adaptation As Lazarus states, no matter how appraisals and coping processes are defined or conceptualized, their primary task is to affect adaptational outcomes (Lazarus & Folkman, 1984). In the chronic pain literature, the most common

21 10 methods of assessing adaptation have been based on the concepts of psychological well-being and psychopathology, especially anxiety and depression (Jensen, Turner, Romano, & Karoly, 1991; Turk& Rudy, 1992). Recently, some researchers have been calling for an abandonment of this type of unidimensional conceptualization. They argue that it is not sufficient to represent the multidimensionality of the complex phenomena of pain (Turk & Rudy, 1988). Kerns et al. (1985) developed the Multidimensional Pain Inventory (MPI) in order to address the above issue. The MPI is a multifactor instrument designed to measure a broad domain of psychosocial and functional variables important to the experience of chronic pain. The MPI functional subscales are: Life Control, Pain Severity, Interference, Affective Distress, Support, and General Activity Level. The MPI interpersonal subscales are: Punishing Responses, Solicitous Responses, and Distracting Responses. With regards to the MPI functional subscales, Life Control has been found to be negatively related to measures of catastrophizing and helplessness, rs = -.62 and -.65, respectively, p_ <.01 (Flor & Turk, 1988), and depression, r = -.44, p <.01 (Turk, Okifuji, & Schaff, 1995). Pain Severity has shown positive correlations with catastrophizing, r =.37, p<.01, and negative correlations with control over pain, r = -.39, p <.01 (Geisser, Robinson, & Henson, 1994). For arthritis patients, General Activity Level has been found to be positively associated with self-

22 11 efficacy for symptoms other than arthritis, r =.26, g <.01, and negatively associated with the use of more dependent types of coping strategies, r = -.21, p <.01 (Regan et al., 1988). Interference of pain on life has demonstrated positive relationships with catastrophizing, r =.52, p <.01 (Geisser, Robinson, & Henson, 1994) and depression, r =.27, p <.01 (Turk et al., 1995), and negative relationships with the perception of ability to decrease pain, r = -. 19, p_ <.05 (Geisser, Robinson, & Henson, 1994) With regards to the MPI interpersonal subscales, Schwartz, Slater, and Birchler (1996) found that Punishing Responses accounted for 12% of the variance in the prediction of increased average pain, 15% of the variance for increased functional impairment, and 15% of the variance for increased psychosocial impairment. Kerns et al. (1991) found that this subscale accounted for 12% of the variance for increased affective distress. Kerns et al. (1991) found that the Solicitous Responses subscale accounted for 3% of the variance in increased help-seeking behaviour and 5% of the variance in increased pain behaviour. Lousberg, Schmidt, and Groenman (1992) found that patients who perceived their spouses to be solicitous reported greater increases in pain when their spouses were observing them than patients with non-solicitous spouses, F(l,36) = 4.69, p_ <.01. Flor, Turk, and Rudy (1989) found this subscale correlated moderately with Pain Impact, which was a composite score of the MPI

23 12 Pain Severity and Pain Interference subscales, r =.45, rj <.01, and accounted for 35% of the variance in increased marital satisfaction. In contrast, Schwartz et al. (1996) and Burns et al. (1996) found no relationship between Solicitous Responses and poorer adaptation to pain. Finally, the Distracting Responses subscale has accounted for 6% of the variance in the prediction of increased pain behaviour, and 5% of the variance in increased help-seeking behaviour (Kerns et al., 1991). Distracting Responses have also been found to be significantly and positively related to pain severity (Kerns et al., 1990). In summary, adaptation to chronic pain is a complex phenomena that includes psychological, social, and functional components. The MPI has shown utility in assessing these components for clinical pain populations. The results suggest that people who perceive themselves to be functioning well, both personally and interpersonally, report lower levels of affective distress and pain intensity. Stress Lazarus defines stress as "a relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and as endangering well-being" (Lazarus & Folkman, 1984, p. 19). Consequently, stress is not the result of the property of a person or the

24 13 environment, but the product of the relationship between the two. This definition recognizes the multifactorial nature of the stress process. The relationship between pain and stress has been recognized for a number of years, either from the perspective of pain as a stressor or as a symptom of increased stress. A number of authors have postulated that the strain of living with daily pain and the physical limitations this may impose can lead to physical and psychological distress in and of itself, and create an increased vulnerability to further increases in stress and decreases in personal resources (Turner, 1991). Turner, Clancy, and Vitaliano (1987) studied community residents who were recruited by offering them a behavioural treatment program for chronic low back pain. Even though these participants were only mildly distressed and disabled by their pain, 35% of them identified pain as the primary stressor in their lives, and believed that pain required them to hold back from doing what they wanted. A number of studies have identified a relationship between stressful life events or daily hassles and a variety of pain problems (De Benedittis, Lorenzetti, & Pieri, 1990; Feuerstein, Suit, & Houle, 1985; Holm, Holroyd, Hursey, & Penzien, 1986). In one of the largest studies, questions concerning stress and pain were included in a nation wide survey of over 1,000 people in the United States (Sternbach, 1986). Strong associations were found between common pain problems, such as headaches and back pain, and stress (assessed by asking "How

25 14 often do you feel under great stress?") and daily hassles (i.e., a quarrel, argument, fuss; a difficulty, problem, trouble). Stress was voluntarily mentioned by respondents as a major contributor to the pain of headaches, backaches, stomach pain, and menstrual pains, but not for joint or dental pains. Sternbach concluded that the greater the daily stress and hassles, the greater the incidence and severity of the pain problems reported. Flor, Turk, and Birnaumer (1985) investigated the pschophysiological responses of chronic low back pain patients in response to stress. They found that patients responded with abnormal back muscle reactivity to personal stressors, and exhibited prolonged delay returning to baseline levels. This muscular reactivity is important as increased muscle tension is known to be associated with increased pain (Turk & Holzman, 1986). Collectively, these studies suggest that greater pain may be a consequence of increased stress. Consequently, pain intensity is viewed as a measure of stress in this study. However, individual responses to particular events vary widely. Whether a specific person-environment relationship is judged as stressful, and how this relationship is responded to, depends on appraisal and coping processes that mediate this relationship (Lazarus & Folkman, 1984).

26 15 Appraisal Cognitive-affective appraisal is an evaluative process through which people assess what is at stake in a particular encounter (primary appraisal) and what coping resources and options they have available in order to remedy the situation (secondary appraisal). These appraisals are then modified (i.e., reappraisals) according to any new information from the environment, the person, or both (Lazarus & Folkman, 1984). Appraisal is a phenomenological experience through which people come to understand the meaning of what is happening to them and how their sense of personal well-being may be affected. Consequently, appraisals determine how a person will adapt to a particular event because these self-assessments influence the amount of stress experienced as well as cognitive and behavioural coping responses. Stress and responses to the stressor depend more on inferential meanings about what is happening than on what actually happens, therefore, individual variations in response to stressors are to be expected. Appraisals are hypothesized to affect adaptation to chronic pain in three ways. First, maladaptive appraisals about the experience of pain, personal efficacy, or both may be associated with depression, inactivity, and increased sensitivity to physiological processes (Turk & Holzman, 1986). Second, appraisals are thought to impact adaptation by influencing the type of coping

27 16 strategies people engage in (Jensen, Turner, & Romano, 1991). Finally, appraisals may influence adherence and response to pain management treatment (DeGood & Shutty, 1992). Lazarus has been criticized for ignoring the impact of dispositional tendencies in his transactional theory (Ben-Porath & Tellegen, 1990; Costa & McCrae, 1990). However, he argues that he has always contended that appraisals are influenced by these more global beliefs as they establish the basis of the relationship between the person and the environment. He states that what he classifies as person variables (i.e., commitments and beliefs) are actually dispositional factors (Lazarus, 1990; Lazarus & Folkman, 1984). However, he also believes that in order to understand the coping process, situation specific appraisals should be a primary focus of study. DeGood and Shutty (1992) support this view, and state that the investigation of highly specific beliefs about pain has the greatest potential for clinical application. Catastrophizing, perceived control over pain, and self-efficacy judgments are three appraisals that have been shown to be most central to adaptation (Jensen & Karoly, 1991). Presented in Table A of Appendix A is a tabulated summary of the general findings of studies that have examined the relationship between these appraisals and adaptation to chronic pain. Prior to discussing the results of these studies, the rationales for treating catastrophizing as a separate construct from

28 17 depression, as well as classifying it as an appraisal rather than a coping strategy are given. Then, the samples and criterion measures are described in order to put the results into context. There has been some debate in the literature as to whether catastrophizing, which is defined as having frequent negative and worrying thoughts about pain and the prognosis for the future (Turner, 1991), is a just a symptom of depression, or whether it is representative of a separate construct (Jensen, Turner, Romano, & Karoly, 1991). Sullivan and D'Eon (1990) studied the relationship between the Coping Strategy Questionnaire (CSQ; Rosentiel & Keefe, 1983) subscales, which include a measure of Catastrophizing, and depression, as measured by the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). Using hierarchical regression analysis, the authors found that the CSQ subscales accounted for 16% of the variance in the depression scores. However, when the Catastrophizing subscale was removed, the remaining subscales accounted for only 3% of the variance in depression scores. The authors concluded that since only the Catastrophizing scale was significantly and positively associated with depression, catastrophizing and depression were most likely not separate constructs. In response to the Sullivan and D'Eon (1990) article, Haaga (1992) points out that their results could just as easily be interpreted as indicating that although a

29 18 positive correlation between catastrophizing and depression has a very high probability, this does not make them indistinguishable constructs. He argues that Sullivan and D'Eon (1990) use an "all-or-none" decision making approach. That is, catastrophizing about pain is either a unique construct or symptomatic of depression. Haaga (1992) states that the CSQ Catastrophizing subscale and the BDI may be measures of constructs that are positively, but not perfectly, correlated. He advocates taking a more continuous variable approach to the question of construct distinction, rather than Sullivan and D'Eon's (1990) dichotomous approach. Using path analysis, Geisser, Robinson, Keefe, and Weiner (1994) examined whether catastrophizing and depression predicted different dimensions of the pain experience. Catastrophizing was measured by the CSQ, depression by the BDI (Beck et al., 1961), and pain experience by the McGill Pain Questionnaire (MPQ; Melzack, 1975). The MPQ was designed to measure three major psychological dimensions of pain: sensory-discriminative, motivational-affective, and cognitive-evaluative. Patients' scores on the CSQ Catastrophizing subscale and the BDI were included in three path analyses predicting scores on either the Sensory, Affective, or Evaluative subscales of the MPQ. The path coefficient between BDI scores and the MPQ Sensory subscale was statistically significant, t(82)=2.0, p_< 05, but the path coefficients between the BDI and the MPQ

30 19 Evaluative and Affective subscales were not. On the other hand, although the path coefficient between Catastrophizing and the MPQ Sensory subscale was not significant, the paths between Catastrophizing and the MPQ Affective and Evaluative subscales were, t(82)=2.8, p<01, and t(82)=2.4, p<.05, respectively. Geisser et al. (1994) concluded that these results lend support to the hypothesis that catastrophizing and depression are separate constructs. Further evidence for this hypothesis is provided by studies that found that catastrophizing was related to pain intensity and functional impairment, even after controlling for depression (Keefe et al., 1989; Romano et al., 1987). Based on the arguments put forward by Haaga (1992) and the research findings described above, it is reasonable to assume that catastrophic appraisals about pain may be important in the understanding of adaptation to chronic pain. Consequently, it was treated as a separate construct in this research project. Some authors have argued that even though the CSQ Catastrophizing subscale is included in a measure of coping, it should be considered an appraisal rather than a coping strategy because of the way in which the questions are phrased (Jensen & Karoly, 1991; Jensen, Turner, Romano, & Karoly, 1991; Turner, 1991). They contend that this type of phraseology assesses the degree to which people worry and display negative thinking in response to pain (e.g., "It is awful and I feel that it overwhelms me") rather than the degree to which people

31 20 use these thoughts as a strategy for coping with pain. Because this line of reasoning appears logical, and the face validity of this scale supports it being used as an appraisal measure, it was used in this manner in this study. Sample sizes for the studies reviewed in Table A in Appendix A ranged from 14 to 223, with a median of 88 participants. The percentage of female, compared with male participants, ranged from 47% to 100%, with a median of 57%. For those studies that reported mean pain duration the range was 1.8 to 13.2 years, with a median of 8 years. One study examined phantom limb pain, 39% examined primarily back pain patients, 26% examined patients with some type of arthritis, and 30% examined mixed pain type patients. All of the participants were receiving some kind of pain treatment either at specialized pain clinics, physiotherapy clinics, or rheumatology practices. Adaptational measures used in these studies can generally be classified into four main categories. Psychological adaptation was assessed via measures of depression, anxiety, general mood, or personality/psychopathology inventories. Behavioural adaptation was assessed through measures of medication use, exercise and activity levels, functional limitations, professional service utilization, nonorganic signs, and observed pain behaviours. The impact of pain on the person's life was assessed via stress and satisfaction with life scales, and by measures of

32 21 perceived interference of pain on work, home, and interpersonal activities. Finally, pain intensity was measured via various types of analogue scales. Critique. The results indicate that the CSQ Catastrophizing subscale demonstrates a consistent relationship with adaptation, and that the more a person catastrophized about pain the more physically and psychologically distressed he or she is. Catastrophizing has been found to be positively associated with pain intensity (Flor & Turk, 1988; Hill, 1993; Keefe et al., 1989; Romano et al., 1987), anxiety (McCracken & Gross, 1993), depression (Hill, 1993; Keefe et al, 1989; Romano et al., 1987), and interference with life activities and functional limitations (Flor & Turk, 1988; Hadjistavropoulos & Craig, 1994; Reesor & Craig, 1988). Catastrophizing has also been found to be predictive of depression, pain intensity, and functional impairment for up to 6 months (Keefe et al., 1989). Consistent relationships have also been found between the appraisals of perceived control over pain and adaptational outcomes. Research findings indicate that the more control people believe they have over pain, the less psychologically and physically distressed they are. Control appraisals have demonstrated negative relationships with depression, anxiety, and poorer psychological functioning (Affleck et al., 1987; Jensen & Karoly, 1991; Keefe et al., 1989; Keefe & Williams 1990), pain intensity (Spinhoven et al., 1989; Spinhoven & Linnsen, 1991), functional limitations, and low activity levels (Spinhoven et al., 1989).

33 22 There is also some indication that appraisals of control influence the type of coping strategies people engage in. Higher levels of perceived control over pain have been found to be positively related to the use of relaxation strategies (Affleck et al., 1992; Jensen, Karoly, & Huger, 1987), and negatively related to the use of emotional expression as a method for managing pain (Affleck et al., 1992). The concept of self-efficacy refers to appraisals concerning one's capabilities to successfully execute the behaviour required to produce a specific outcome (Bandura, 1986, 1997). It does not refer to personality characteristics or global traits that operate across situations, independent of contextual factors (Strecher, DeVillis, Backer, & Rosenstock, 1986). Self-efficacy is also different from self-esteem, which is an evaluation of self-worth rather than an appraisal about specific capabilities in specific situations (Strecher et al., 1986). As can be seen from the results presented in Table A in Appendix A, there is evidence that higher levels of perceived self-efficacy are associated with better adaptation to chronic pain. Self-efficacy for exercise appraisals have shown a positive relationship with actual engagement in physical movement and exercise (Council et al., 1988; Dolce, Crocker, & Doleys, 1986; Dolce, Crocker, Moletteire, & Doleys, 1986). Self-efficacy for coping is positively related to the frequency of coping strategy use (Jensen, Turner, Romano, & Karoly, 1991). Selfefficacy for pain, physical functioning, and managing symptoms is negatively

34 23 associated with pain intensity, depression, and disability for arthritis patients (Lorig & Holman, 1993; Lorig et al, 1989; O'Leary et al., 1988; Regan et al., 1988). In summary, there is evidence that pain specific catastrophizing, perceived control over pain, and self-efficacy appraisals are associated with adaptational outcomes. Specifically, the results suggest that these pain appraisals are related to (a) short- and long-term adaptation, (b) psychological well-being, (c) perceived pain intensity, (d) the types of pain coping strategies people engage in, and (e) functional impairment and exercise levels. Despite the consistency of these findings, we are still left with at least two unanswered questions: (a) What are the relationships between Catastrophizing, perceived control over pain, and self-efficacy appraisals, daily responses to pain such as anxiety, depression, pain intensity, and overall psychosocial and functional adaptational outcomes? and (b) Are the relationships identified in the literature similar for non-clinical pain populations? With regards to the first question, a problem with current research findings is that the vast majority of the studies reviewed used a cross-sectional research design. Respondents were asked to report on their appraisals at a specific point in time, or to remember what their appraisals were over days, weeks, or an unspecified period of time, and then summarize this temporal experience into one

35 24 response. This type of data collection is problematic for three reasons. First, although examining the relationship between current appraisals and current experience allows for the exploration of their correlational relationship, it is a point-in-time "snapshot" of the process, and does not allow for the examination of the variation in the daily relationships between appraisals and same day adaptational outcomes, or how these daily processes relate to overall adaptation to pain. Lazarus emphasizes that cognitions and behaviours are best understood as part of ongoing interactions with the environment rather than static events. That is, appraisals initiate coping efforts, which impact the person-stressor relationship, which then leads to reappraisal and further coping efforts and reappraisals (Lazarus & Folkman, 1984). The effects of this ongoing interaction are thought to occur over time, and cross-sectional designs that rely on one or few assessment points may miss important aspects of this interaction and lead to conclusions that are erroneous or incomplete (DeLongis et al., 1992). Second, cross-sectional designs do not allow for the identification of what Epstein (1986) calls "threads of stability and generality" (p. 1201) that occur in behaviour across time. Even though Lazarus advocates assessing appraisals and coping responses from a situation specific contextual model (Lazarus & Folkman, 1984), the importance to psychological well-being and social functioning of having some stability in coping processes over occasions and time is also

36 25 recognized (Folkman, 1992; Lazarus, 1990). By repeatedly assessing responses over situations and time these stable aspects of the coping process can be identified (Folkman, 1992). Third, cross-sectional designs generally ask respondents to retrospectively recall days or weeks of pain appraisals, which runs the risk of measurement error. Generally, the literature suggests that people are not particularly good at remembering past events, moods, or cognitions (Cohen, 1987; DeLongis et al., 1992; Wethington & Kessler, 1993). Epstein (1986) also argues that the results of cross-sectional designs can be confounded by person and/or situational variables that are unique to the point in time that the measures are taken. Participants may respond for a variety of reasons in a way that is unrepresentative of their more usual way of responding, or there may be current aspects of the situation that are influencing their responses. These variables could contribute to measurement error and decrease the reliability and generalizability of the findings. There is some indication in the pain literature that specific conditions associated with the time of recall can influence recall accuracy. As far as I am aware, researchers have not examined accuracy of recall for the pain specific appraisals of catastrophizing, perceived control, or self-efficacy. However, research in other areas indicates that memory for the experience of pain can be flawed. For example, there is some evidence that memory for pain intensity is

37 26 subject to distortion. Linton and Melin (1982) studied 12 chronic pain patients referred to a pain treatment program. Participants rated their level of pain on an 101-point Likert scale prior to starting treatment, and then re-rated their preadmission pain 3 to 11 weeks later at the end of treatment. Eleven of the 12 patients significantly overestimated their pre-treatment pain levels, and the amount of overestimation was unrelated to overall improvement in pain levels during the treatment program. Memory for pain may also be pain state dependent. Eich, Reeves, Jaeger, and Graff-Radford (1985) asked patients to recall pain levels they had reported 1 week prior to this assessment point. They found that when present pain intensity was high, patients with chronic headaches rated their maximum, usual, and minimum levels of prior pain as being more severe than their hourly pain diaries indicated. When their present pain intensity was low, these same patients remembered all three levels of prior pain as being less severe than they actually were. These are crucial issues when examining pain correlates. By collecting data via multiple measurement points across participants, situations, and time, these unique person or situational components can be minimized and the more broad, crpss-situational pain-appraisal-adaptation processes are more likely to be identified.

38 27 With regards to the second question concerning whether research findings would be similar for non-clinical pain populations, one of the reasons for this gap in our knowledge is that all of the studies reviewed have focused on clinical pain populations, i.e., participants who were attending some kind of pain treatment program. This creates two difficulties. First, clinical pain patients may not be representative of the larger population of chronic pain sufferers. Studies that compared chronic pain patients involved in active pain treatment programs with chronic pain sufferers in the general community have found differences. Crook et al. (1984) conducted telephone surveys of 90 community residents suffering from persistent pain but not attending any pain clinic, and 48 people who had attended active treatment at a local university pain clinic during the previous 6 months and who were still experiencing persistent pain. Persistent pain was defined as "often troubled by pain" and "noteworthy pain in the last 2 weeks." The authors found no difference between the groups on pain duration or type of pain problem. However, the pain clinic group reported significantly higher levels of pain intensity, utilization of health services, somatic symptoms, depression, and psychosocial and functional impairment, and were more frequently unemployed as a consequence of pain. The authors concluded that chronic pain patients who attend pain clinics are not representative of individuals in the general population who also have chronic pain but are not referred to such clinics.

39 28 In contrast, Toomey, Mann, Abahsian, Carnike, and Hernandez (1993) found little difference between 28 outpatient pain patients being treated by a variety of medical specialists and 48 patients attending an outpatient pain clinic. The only significant finding was that the pain clinic patients demonstrated lower "powerful others" scores as measured by the Pain Locus of Control Scale, which is a measure the authors developed by revising the Multidimensional Health Locus of Control Scale (Wallston & Wallston, 1978). The authors interpreted this result as indicating that the pain clime patients felt less predictable control over pain than medical clinic patients. The contradictory findings in these two studies may be due to the differences in the populations studied. One of the major differences between the samples was that in the Crook et al. (1984) study only 30% of the community pain sufferers had consulted a physician in the previous 2 weeks, compared to 68% of the pain clinic patients. In the Toomey et al. (1993) study, although the medical clinic patients were not attending a pain clinic, they were receiving on-going active pain treatment from medical specialists. It may be that patients who attend specialized pain programs and patients who are actively being treated by a medical specialist experience higher levels of pain and affective distress, and cope less well than pain sufferers not receiving such treatment. Although it is difficult to draw definitive conclusions from such a small number of studies, there seems to be