Jooumo/ of Psychosomatic Research. Vol. 34. No. I, pp. 103-109, 1990. Printed m Great Britain.
THE PAIN COGNITIONS
0
OOZZ-3!?29/90 s3.00 + .I0 1990 Pergamon Press plc
QUESTIONNAIRE
K. BOSTON,* S. A. PEARCE?and P. H. RICHARDSON$ (Received 21 March 1989; accepted in revised form 20 July 1989) Abstract-This paper reports the development of the Pain tered to 90 mixed chronic pain patients and an exploratory positive factors. Significant associations were observed measures of pain severity and mood. No clear relationship pain or mood variables. The implications of these findings pain are discussed.
Cognitions Questionnaire. This was adminisfactor analysis revealed two negative and two between scores on the negative factors and emerged, however, for positive cognitions and for the assessment and treatment of chronic
INTRODUCTION
THE ROLE of cognitions in clinical pain experience is not yet fully understood and empirical evidence demonstrating the effectiveness of cognitive methods of pain control remains equivocal [l, 21. This may partly be due to the inadequacies of the measuring instruments used and the difficulties in classifying cognitive strategies [3]. Recent research has focused on the role of coping strategies in adjustment to chronic pain. Rosenstiel and Keefe [4] developed a Coping Strategies Questionnaire to assess the spontaneous use of six different cognitive coping strategies and two behavioural strategies in coping with pain. They found that patients high on cognitive coping and suppression were more likely to report functional impairment than those low on this strategy. Those high on helplessness were significantly more depressed and more anxious than individuals low on this strategy. Diverting attention and praying was associated with higher levels of pain and more functional impairment. A further finding was that the tendency to catastrophize was related to poorer emotional adjustment. Using the Coping Strategies Questionnaire (CSQ), Keefe, Caldwell, Queen et al. [5] performed a second factor analysis and investigated the relation of pain coping strategies to pain, health status and psychological distress in osteoarthritic patients. One of the factors to emerge from this second analysis of the CSQ was labelled pain control and rational thinking. In contrast with the findings of the previous study, they found that patients high on pain control and rational thinking, a positive coping strategy, reported lower levels of pain, better health status and lower levels of psychological distress than those low on this factor. Brown and Nicassio [6] developed a questionnaire for the assessment of active vs passive coping strategies for chronic pain patients suffering from rheumatoid arthritis. The results suggested that those using active coping strategies reported less pain, less depression, less functional impairment and higher general self-efficacy. *Shrodells Psychiatric Unit, Watford General Hospital, Watford, Herts, U.K. TUniversity College London, Gower Street, London WCIE 6BT; Honorary Clinical Psychologist, Whittington Hospital London N19, U.K. IAcademic Unit of Psychiatry, UMDS St Thomas’s Campus, London SE1 7EH, U.K. 103
104
K. BOSTON et al.
Those using passive coping strategies reported greater depression, greater pain and flare-up, greater functional impairment, and lower general self-efficacy. The overall picture concerning the relationship between cognitions and pain thus remains unclear. Moreover the studies cited are limited by the fact that the questionnaire items which have aimed to assess cognitive strategies have all been derived from laboratory studies or from the view of pain professionals and not from a chronic pain population. It has not therefore been possible to investigate the role of spontaneously occurring positive and negative cognitions in chronic pain populations. The aim of this study was to develop an instrument for the assessment of pain cognitions spontaneously generated by chronic pain patients. This was then used to assess the occurrence of positive and negative cognitions in a heterogeneous pain population and to investigate the relationship between these cognitions and measures of pain, mood and functional limitation.
METHOD
Item selection for the questionnaire was achieved following semi-structured interviews with an initial sample of 23 chronic pain patients. For the main study a sample of 90 chronic pain patients was interviewed on a single occasion when they completed a newly developed cognitions questionnaire and a number of other measures of pain and mood.
In order to elicit cognitions experienced by pain patients 23 chronic pain patients attending the pain clinic at St Thomas’s Hospital were asked ‘What do you find yourself thinking at times when you are in pain?’ 193 pain-related thoughts were elicited. These were reduced to 60 items by eliminating repetitive and idiosyncratic responses. The 60 items were then rated by 12 clinical psychologists in terms of their adaptive or maiadaptive function. Only items with 100% agreement were chosen for the final questionnaire which consisted of 15 positive (i.e. putatively adaptive) and I5 negative (i.e. maladaptive) items. In the finished questionnaire each item was presented with a four point scale anchored, not at all, sometimes, often. and most of the time (scored 0. I. 2. 3. respectively). Main .trudJ, Su~jwt.s. Ninety chronic pain patients suffering pain of at least six months duration were recruited during routine pain clinic appointments at St Thomas’s or the Whittington Hospitals. The mean age of the patients was 51.8 yr (SD = 16.5). Sixty-eight per cent of the patients were female and 32% were male. Fifty-nine per cent of the sample were married, 18% were single, 23% were widowed, divorced or separated and 25% of the patients lived alone. The mean duration of time since pain onset was 5.16 yr (median = 3.00 yr; so = 7.8). Pain locations were: multiple sites (33%) head and shoulders (IO%), chest and abdomen (8%). back (18%). upper and lower limbs (19%), and other e.g. anal, testicular (12%). The mean score of the sample on the Modified Zung Depression Rating Scale (see ‘Measures’ Section) was 49.47 (SD 6.2) and the mean state anxiety score (STAI) at the time of testing was 47.47 (SD 11.9). The mean total pain behaviour checklist score for the sample was 109.54 (SD 35.9). Mean pain intensity ratings on the NRS 101 were 46.62 (sb 23.8) for current pain and 67.35 (SD 20.5) for the average of the last week. Measures. Subjects were asked to Indicate the duration of their current episode of pain in months, and its location. Pain intensity, distress and behavioural disruption over the last week and at present were rated by subjects on a 101 point numerical rating scale (NRSIOI) (71. Pain behaviours were assessed by means of the Pain Behaviour Checklist (PBC) [S]. Patients also completed the Modified Zung Depression Inventory [9] and the Spielberger STAI-XI. a measure of current anxiety [IO]. Prowdure. Whilst waiting for a medical appointment subjects were invited to take part in a study investigating the experience of long term pain. Subjects were assured of confidentiality and assured that their responses would not be made available to their doctors. After giving consent patients were left to complete the questionnaires on their own. The investigator was available to answer queries and checked each set of completed questionnaires in the presence of the subject.
The Pain Cognitions
Questionnaire
105
RESULTS
The cumulative proportions of subjects responding ‘often’ or ‘most of the time’ to 25 of the 30 questionnaire items are presented in Table I, along with their rank order in terms of frequency of endorsement (low rank equals high frequency of endorsement). The remaining five items were not included in the factor solution (see below) and hence are excluded from the table. The nine most frequently endorsed items were positive in content and the nine least frequently endorsed items were all negative. The responses on the cognitions questionnaire were subjected to a principal components analysis with orthogonal rotation using the Varimax procedure. The first five factors (see Table I) accounted for 47% of the variance. Subsequent factors were not considered since they accounted for less than 5% of the variance. Items were included in a factor if they loaded above 0.45 on it and were not correlated at that level with any other factor. Factor one, accounting for 18% of the variance consists of eight items which appear to be mainly active positive coping strategies, including distraction and self-reassurance. Factor two accounted for 11% of the variance. Items loading highly on this factor appear to indicate a sense of hopelessness. Factor three accounted for 6.5% of the variance. Items loading on this factor appear similar to those on factor two but suggest a sense of helplessness in relation to their condition. Factor four also accounted for 6.5% of the variance. The four items loading primarily on this factor convey an impression of passive optimism. Factor 5 accounted for just 5% of the variance. The items loading on it are psychologically inconsistent and the factor was therefore excluded from the final solution. For each factor the individual scores (1, 2, 3 or 4) of items loading above 0.45 on that factor were summed to yield a total factor score. Items with negative loadings were scored with reverse polarity (4, 3, 2, 1). The internal consistency of the resultant scales was examined using Cronbach’s alpha and the reliability coefficients were as follows: Factor la.80; Factor 24.80; Factor 34.66; Factor 4-0.72. Pearson product moment correlations were computed between each of the factor scores and all other continuous variables. No significant correlations were obtained for the relationship between age, chronicity or pain duration for any of the factors (in all cases r < 0.20, df = 96, p > 0.05). Correlations between factor scores and all other measures of pain and mood are displayed in Table II. Only correlation coefficients which are significant at the five per cent level are given in the table. Scores on Factor 1 (active positive coping) were significantly negatively correlated with current pain distress and pain-related behavioural disruption over the past week. Scores on Factors 2 (hopelessness) and 3 (helplessness) were significantly positively correlated with all pain measures excluding current pain intensity. Scores on Factor 4 (support and trust) were significantly positively correlated with total pain behaviour checklist scores. Spielberger anxiety scores were significantly correlated with all four factor scores (positively with the ‘negative’ factors 2 and 3, and negatively with the positive ones-l and 4). Scores on the Modified Zung depression inventory were related clearly only to Factor 3 where they showed a significant positive correlation. In view of the strong associations between all factor scores and patients current anxiety levels, partial correlations were computed between factor scores and pain
106
K. BOSTON et al.
TABLE I.-ROTATED
Factor
Factor
Factor
Factor
Factor
1
2
3
4
5
FACTOR, LOADINGSAND RESPONSEFREQUENCIESFOR THE PAIN C~CNI~IONS QUESTIONNAIREADMINISTERED TO90 CHRONIC PAIN PATIENTS Factor loadings
Rank order
0.642
% Often or most of time
Original valence
12
36.70
POS
0.631
4
58.90
POS
0.592 0.569
7 16
53.40 27.80
POS POS
0.561
2
60.00
POS
0.518
10
45.60
POS
0.517
11
36.70
POS
I
63.30
POS
0.743
18
22.20
NEG
0.665 0.601
20 19
17.70 20.00
NEG NEG
0.594
14
34.50
NEG
0.502
13
35.50
NEG
0.693
22
11.10
NEG
0.633
23
10.00
NEG
0.600
24
10.00
NEG
0.576
25
7.80
NEG
0.647
8
52.30
POS
_ -0.555 _ -0.539
17 21
25.50 11.20
NEG NEG
0.501
5
56.60
POS
0.601
6
54.40
POS
0.489
15
34.40
NEG
0.489
9
51.10
NEG
0.452
3
58.90
POS
Reassure yourself that you can get used to being in pain. Reassure yourself that you can cope now because you have coped in the past. Accept the pain to an extent. Think of something pleasant rather than concentrate on the pain. Think of things to do to distract yourself from the pain. Make a conscious effort to think the pain away. Reassure yourself that you are not generally unhappy. Tell yourself that you must be optimistic. Think about not being able to go on putting up with the pain. Want not to wake up in the morning. Find yourself thinking that you have given up all hope. Think that you might become a burden to your family and friends. Ask what you have done to deserve this pain. Think that there is no-one there to care about you. Think that further treatment will cause more pain. Think that others pressurise you to do things you can’t. Think that the doctors might start to dislike you. Remind yourself of the support and encouragement you get from others. Expect there to be no relief at all. Blame the doctor (or hospital or operation) for your condition. Trust the doctors and believe that they can do something. Remind yourself that you have to be positive about the pain. Think anxiously about the things that bring on the pain. Think that it is unfair that you can’t do the things you used to do. Think that you won’t let the pain get the better of you.
Rank order refers to ranked frequency POS = positive: NEG = negative.
of endorsement
of the item.
The Pain Cognitions
Questionnaire
107
TABLEII.--CORRELATIONS BETWEEN FACTOR SCORES ANDMEASURES OFPAIN AND MOOD ANDPAR~LNCORRELATIONS (WITHANXIETY PARTIALLED our) Factor 1 Positive: distraction/ reassurance
Correl. Pain intensity (now) Pain intensity (Past week) Pain distress (now) Pain distress (Past week) Behavioural disruption (past week) Pain behaviour total (PBC) Anxiety (STAI) Depression (ZUNG)
NS NS -0.26* NS -0.37t
-E7$ NS
Factor 2 Negative: hoplessness
Partial Correl.
Correl.
Partial Correl.
Factor 3 Negative: helplessness
Correl.
Partial Correl.
Factor 4 Positive: support/trust
Correl.
Partial Correl.
NS NS NS NS NS
NS 0.25; 0.26* 0.29* 0.38t
NS NS NS NS NS
NS 0.21* 0.25* 0.21* 0.28*
NS NS NS NS NS
NS NS NS NS NS
NS NS NS NS NS
NS
-0.22* 0.523 NS
NS
- 0.24* 0.461 0.26*
NS
-0.24* -0.22* NS
0.31
+p < 0.05. tp < 0.01. $p < 0.001. anxiety levels, partial correlations were computed between factor scores and pain scores with anxiety as a covariate (see Table II). On Factors 1, 2 and 3 the resulting correlations were all reduced in size, none remaining statistically significant. The relationship between Factor 4 and total pain behaviour became marginally stronger when current anxiety was partialled out (r = 0.31, df = 96, p = 0.05).
DISCUSSION
Analysis of the present findings indicated that the most commonly reported cognitive responses to pain were positive in nature. The nine most frequently reported responses were positive, whilst the nine least frequently reported ones were negative. If these results are taken at face value this would suggest that the common clinical impression that chronic pain patients use predominantly negative coping strategies is erroneous. Instead it would appear that they may engage in positive strategies and that these are proving unsuccessful. Alternatively it is possible that the use of positive coping strategies has little overall bearing on the experience of pain. It may be, however, that the greater reporting of positive strategies in this study reflects a response bias or social desirability effect. Patients attending pain clinics may attempt to show that they are doing everything possible to help themselves. On balance we feel this is unlikely since patients taking part in the study were reassured that their answers to the questionnaire would not be made available to their doctors. In addition the clinical impression of patients attending pain clinics suggests the converse, that they usually emphasize how difficult it is to cope with the pain and hence how much they need help. The principal components analysis of responses to the pain cognitions questionnaire produced four interpretable factors. These comprise two negative and two positive factors. The negative factor labelled hopelessness appears to be comprised of items indicating a pessimistic view of the patients ability to cope with pain. The
108
K.
BOSTON el al.
other negative factor labelled helplessness appears to consist of items that indicate an external focus and passivity. A clear pattern of positive correlations emerged between scores on the two negative factors and measures of pain intensity, distress and behavioural disruption over the previous week. Scores on the pain hopelessness factor were also significantly correlated with depression. It would therefore appear that there is a clear association between the report of negative cognitions and both the intensity, and affective dimensions of pain. A less clear picture emerges for the relationship between positive cognitions and pain severity measures. Significant correlations emerged between the support and trust factor and both anxiety, and the pain behaviour checklist: the greater the perception of support, the greater the pain behaviour. Hence there is some evidence to suggest that the adoption of this passive coping style leads to a greater susceptibility to behavioural disruption. Conversely the active coping scores (Factor 1) are significantly negatively correlated with pain distress and behavioural disruption. The observation of two factors apparently active and passive in nature and the pattern of their correlations with pain measures is reminiscent of the findings of Brown and Nicassio [6] who found active coping styles to be correlated with better adjustment. The interpretation of these findings is complicated by the observation that scores on each of the cognitive factors and on the pain measures were significantly correlated with anxiety. The possibility therefore exists that the significant correlations that emerged between factor scores and pain measures were an artefact of anxiety. This interpretation is supported by the results of the partial correlations. Alternatively it may be that the correlations provide information about the cognitive and affective aspects of chronic pain. Pain is a multidimensional experience including an affective element. It is therefore not surprising that explicit measures of affect (viz. STAT) are related to measures of pain. This problem of the confounding of measures of pain and anxiety has been described elsewhere [ 1 I]. Hence rather than dismissing the correlations between pain measures and factor scores as artefacts of anxiety it could be concluded that where significant effects of anxiety are observed this indicates the close relationship between the cognitions measured by the factor and affective distress. It follows that the coping strategies concerned are more closely related to affective distress than pain intensity. One important practical implication of the results of this study concerns the form of cognitiveebehavioural treatment that is likely to be most appropriate for this patient group. In the application of cognitive methods to chronic pain patients one assumption has generally been that methods should aim to increase the use of positive coping strategies [ 121. The results presented here suggest that pain patients are already using positive strategies and that their use may be unrelated to the severity of the pain problem. This observation plus the greater correlations between pain and negative cognitions, would suggest that cognitive methods might be more effective if they were aimed at reducing the frequency of use of negative strategies rather than increasing the rate of use of positive strategies. Such a conclusion would be in agreement with the findings from some previous studies. Both Chaves and Brown [13] and Rosenstiel and Keefe [4] suggest that successful coping is a consequence of avoiding catastrophizing cognitions. This is further supported by Turner and Clancy [14] who showed during cognitive-behavioural treatment that
The Pain Cognitions
Questionnaire
109
reductions in catastrophizing were significantly related to reductions in pain intensity and physical impairment. In summary we have described the initial development of an instrument for the assessment of pain-related cognitions which may prove to be a valuable tool for the assessment of patients prior to cognitive treatment as well as for the evaluation of cognitive treatments for pain. REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
PEARCE S. A review of cognitive-behavioural methods for the treatment of chronic pain. Jpsychosom Res 1983; 27: 43140. LINTON SJ. Behavioural remediation of chronic pain: a status report. Pain 1986; 24: 125-141. FERNANDEZ E. A classification system of cognitive coping strategies for pain. Pain 1986; 26: 141~151. ROSENSTIEL AK, KEEFE FJ. The use of coping strategies in chronic low back pain patients. Relationships to the patient characteristics and current adjustments. Pain 1983; 17: 3344. KEEFE FJ, CALDWELL DS, QUEEN KT, GIL KM, MARTINEZ S, CRISS~N JE, OGDEN W, NUNLEY J. Pain coping strategies in osteoarthritis patients. J consult clin Psycho1 1987; 55: 208-212. BROWN GK, NICA~~IO PM. The development of a questionnaire for the assessment of active and passive coping strategies in chronic pain patients. Pain 1987; 31: 5345. JENSENMP, KAROLY P, BRAVERS. The measurement of clinical pain intensity. Pain 1986; 27: 117~126. PHILLIPS C, HUNTER M. Pain bchaviour in headache sufferers. Behuv Anal Modif 1981; 4: 257-266. MAIN CJ, WADDELL G. ‘The detection of psychological abnormality using four simple scales’. Curren/ Concepfs in Pain, Vol. 2, pp. 10-16. 1984. SPIELBERGERCD, GORUSH RL, LUSHENERN. Mum&for the Stale-Trait Anxiety Inventory, Consulting Psychologists Press: Palo Alto, 1970. GROWSRT, COLLINS FK. On the relationship between anxiety and pain: a methodological confounding. Clin Psycho1 Rev 1981; 1: 375-386. TURK DC, MEIC~NBAUM D, GENFX TM. Pain and Behavioral Medicine: A Cognitive-Behavioral Perspective, New York: Guilford Press, 1983. CHAWS FF, BROWN J. Self-generated strategies for control of pain and stress. Paper presented at Meefing of the American Psychological Associaion, Toronto, Ontario, 1978. TURNER JA, CLANCY S. Strategies for coping with chronic low back pain: relationship to pain and disability. Pain 1986; 24: 355-364.
THE PAIN COGNITIONS
0
OOZZ-3!?29/90 s3.00 + .I0 1990 Pergamon Press plc
QUESTIONNAIRE
K. BOSTON,* S. A. PEARCE?and P. H. RICHARDSON$ (Received 21 March 1989; accepted in revised form 20 July 1989) Abstract-This paper reports the development of the Pain tered to 90 mixed chronic pain patients and an exploratory positive factors. Significant associations were observed measures of pain severity and mood. No clear relationship pain or mood variables. The implications of these findings pain are discussed.
Cognitions Questionnaire. This was adminisfactor analysis revealed two negative and two between scores on the negative factors and emerged, however, for positive cognitions and for the assessment and treatment of chronic
INTRODUCTION
THE ROLE of cognitions in clinical pain experience is not yet fully understood and empirical evidence demonstrating the effectiveness of cognitive methods of pain control remains equivocal [l, 21. This may partly be due to the inadequacies of the measuring instruments used and the difficulties in classifying cognitive strategies [3]. Recent research has focused on the role of coping strategies in adjustment to chronic pain. Rosenstiel and Keefe [4] developed a Coping Strategies Questionnaire to assess the spontaneous use of six different cognitive coping strategies and two behavioural strategies in coping with pain. They found that patients high on cognitive coping and suppression were more likely to report functional impairment than those low on this strategy. Those high on helplessness were significantly more depressed and more anxious than individuals low on this strategy. Diverting attention and praying was associated with higher levels of pain and more functional impairment. A further finding was that the tendency to catastrophize was related to poorer emotional adjustment. Using the Coping Strategies Questionnaire (CSQ), Keefe, Caldwell, Queen et al. [5] performed a second factor analysis and investigated the relation of pain coping strategies to pain, health status and psychological distress in osteoarthritic patients. One of the factors to emerge from this second analysis of the CSQ was labelled pain control and rational thinking. In contrast with the findings of the previous study, they found that patients high on pain control and rational thinking, a positive coping strategy, reported lower levels of pain, better health status and lower levels of psychological distress than those low on this factor. Brown and Nicassio [6] developed a questionnaire for the assessment of active vs passive coping strategies for chronic pain patients suffering from rheumatoid arthritis. The results suggested that those using active coping strategies reported less pain, less depression, less functional impairment and higher general self-efficacy. *Shrodells Psychiatric Unit, Watford General Hospital, Watford, Herts, U.K. TUniversity College London, Gower Street, London WCIE 6BT; Honorary Clinical Psychologist, Whittington Hospital London N19, U.K. IAcademic Unit of Psychiatry, UMDS St Thomas’s Campus, London SE1 7EH, U.K. 103
104
K. BOSTON et al.
Those using passive coping strategies reported greater depression, greater pain and flare-up, greater functional impairment, and lower general self-efficacy. The overall picture concerning the relationship between cognitions and pain thus remains unclear. Moreover the studies cited are limited by the fact that the questionnaire items which have aimed to assess cognitive strategies have all been derived from laboratory studies or from the view of pain professionals and not from a chronic pain population. It has not therefore been possible to investigate the role of spontaneously occurring positive and negative cognitions in chronic pain populations. The aim of this study was to develop an instrument for the assessment of pain cognitions spontaneously generated by chronic pain patients. This was then used to assess the occurrence of positive and negative cognitions in a heterogeneous pain population and to investigate the relationship between these cognitions and measures of pain, mood and functional limitation.
METHOD
Item selection for the questionnaire was achieved following semi-structured interviews with an initial sample of 23 chronic pain patients. For the main study a sample of 90 chronic pain patients was interviewed on a single occasion when they completed a newly developed cognitions questionnaire and a number of other measures of pain and mood.
In order to elicit cognitions experienced by pain patients 23 chronic pain patients attending the pain clinic at St Thomas’s Hospital were asked ‘What do you find yourself thinking at times when you are in pain?’ 193 pain-related thoughts were elicited. These were reduced to 60 items by eliminating repetitive and idiosyncratic responses. The 60 items were then rated by 12 clinical psychologists in terms of their adaptive or maiadaptive function. Only items with 100% agreement were chosen for the final questionnaire which consisted of 15 positive (i.e. putatively adaptive) and I5 negative (i.e. maladaptive) items. In the finished questionnaire each item was presented with a four point scale anchored, not at all, sometimes, often. and most of the time (scored 0. I. 2. 3. respectively). Main .trudJ, Su~jwt.s. Ninety chronic pain patients suffering pain of at least six months duration were recruited during routine pain clinic appointments at St Thomas’s or the Whittington Hospitals. The mean age of the patients was 51.8 yr (SD = 16.5). Sixty-eight per cent of the patients were female and 32% were male. Fifty-nine per cent of the sample were married, 18% were single, 23% were widowed, divorced or separated and 25% of the patients lived alone. The mean duration of time since pain onset was 5.16 yr (median = 3.00 yr; so = 7.8). Pain locations were: multiple sites (33%) head and shoulders (IO%), chest and abdomen (8%). back (18%). upper and lower limbs (19%), and other e.g. anal, testicular (12%). The mean score of the sample on the Modified Zung Depression Rating Scale (see ‘Measures’ Section) was 49.47 (SD 6.2) and the mean state anxiety score (STAI) at the time of testing was 47.47 (SD 11.9). The mean total pain behaviour checklist score for the sample was 109.54 (SD 35.9). Mean pain intensity ratings on the NRS 101 were 46.62 (sb 23.8) for current pain and 67.35 (SD 20.5) for the average of the last week. Measures. Subjects were asked to Indicate the duration of their current episode of pain in months, and its location. Pain intensity, distress and behavioural disruption over the last week and at present were rated by subjects on a 101 point numerical rating scale (NRSIOI) (71. Pain behaviours were assessed by means of the Pain Behaviour Checklist (PBC) [S]. Patients also completed the Modified Zung Depression Inventory [9] and the Spielberger STAI-XI. a measure of current anxiety [IO]. Prowdure. Whilst waiting for a medical appointment subjects were invited to take part in a study investigating the experience of long term pain. Subjects were assured of confidentiality and assured that their responses would not be made available to their doctors. After giving consent patients were left to complete the questionnaires on their own. The investigator was available to answer queries and checked each set of completed questionnaires in the presence of the subject.
The Pain Cognitions
Questionnaire
105
RESULTS
The cumulative proportions of subjects responding ‘often’ or ‘most of the time’ to 25 of the 30 questionnaire items are presented in Table I, along with their rank order in terms of frequency of endorsement (low rank equals high frequency of endorsement). The remaining five items were not included in the factor solution (see below) and hence are excluded from the table. The nine most frequently endorsed items were positive in content and the nine least frequently endorsed items were all negative. The responses on the cognitions questionnaire were subjected to a principal components analysis with orthogonal rotation using the Varimax procedure. The first five factors (see Table I) accounted for 47% of the variance. Subsequent factors were not considered since they accounted for less than 5% of the variance. Items were included in a factor if they loaded above 0.45 on it and were not correlated at that level with any other factor. Factor one, accounting for 18% of the variance consists of eight items which appear to be mainly active positive coping strategies, including distraction and self-reassurance. Factor two accounted for 11% of the variance. Items loading highly on this factor appear to indicate a sense of hopelessness. Factor three accounted for 6.5% of the variance. Items loading on this factor appear similar to those on factor two but suggest a sense of helplessness in relation to their condition. Factor four also accounted for 6.5% of the variance. The four items loading primarily on this factor convey an impression of passive optimism. Factor 5 accounted for just 5% of the variance. The items loading on it are psychologically inconsistent and the factor was therefore excluded from the final solution. For each factor the individual scores (1, 2, 3 or 4) of items loading above 0.45 on that factor were summed to yield a total factor score. Items with negative loadings were scored with reverse polarity (4, 3, 2, 1). The internal consistency of the resultant scales was examined using Cronbach’s alpha and the reliability coefficients were as follows: Factor la.80; Factor 24.80; Factor 34.66; Factor 4-0.72. Pearson product moment correlations were computed between each of the factor scores and all other continuous variables. No significant correlations were obtained for the relationship between age, chronicity or pain duration for any of the factors (in all cases r < 0.20, df = 96, p > 0.05). Correlations between factor scores and all other measures of pain and mood are displayed in Table II. Only correlation coefficients which are significant at the five per cent level are given in the table. Scores on Factor 1 (active positive coping) were significantly negatively correlated with current pain distress and pain-related behavioural disruption over the past week. Scores on Factors 2 (hopelessness) and 3 (helplessness) were significantly positively correlated with all pain measures excluding current pain intensity. Scores on Factor 4 (support and trust) were significantly positively correlated with total pain behaviour checklist scores. Spielberger anxiety scores were significantly correlated with all four factor scores (positively with the ‘negative’ factors 2 and 3, and negatively with the positive ones-l and 4). Scores on the Modified Zung depression inventory were related clearly only to Factor 3 where they showed a significant positive correlation. In view of the strong associations between all factor scores and patients current anxiety levels, partial correlations were computed between factor scores and pain
106
K. BOSTON et al.
TABLE I.-ROTATED
Factor
Factor
Factor
Factor
Factor
1
2
3
4
5
FACTOR, LOADINGSAND RESPONSEFREQUENCIESFOR THE PAIN C~CNI~IONS QUESTIONNAIREADMINISTERED TO90 CHRONIC PAIN PATIENTS Factor loadings
Rank order
0.642
% Often or most of time
Original valence
12
36.70
POS
0.631
4
58.90
POS
0.592 0.569
7 16
53.40 27.80
POS POS
0.561
2
60.00
POS
0.518
10
45.60
POS
0.517
11
36.70
POS
I
63.30
POS
0.743
18
22.20
NEG
0.665 0.601
20 19
17.70 20.00
NEG NEG
0.594
14
34.50
NEG
0.502
13
35.50
NEG
0.693
22
11.10
NEG
0.633
23
10.00
NEG
0.600
24
10.00
NEG
0.576
25
7.80
NEG
0.647
8
52.30
POS
_ -0.555 _ -0.539
17 21
25.50 11.20
NEG NEG
0.501
5
56.60
POS
0.601
6
54.40
POS
0.489
15
34.40
NEG
0.489
9
51.10
NEG
0.452
3
58.90
POS
Reassure yourself that you can get used to being in pain. Reassure yourself that you can cope now because you have coped in the past. Accept the pain to an extent. Think of something pleasant rather than concentrate on the pain. Think of things to do to distract yourself from the pain. Make a conscious effort to think the pain away. Reassure yourself that you are not generally unhappy. Tell yourself that you must be optimistic. Think about not being able to go on putting up with the pain. Want not to wake up in the morning. Find yourself thinking that you have given up all hope. Think that you might become a burden to your family and friends. Ask what you have done to deserve this pain. Think that there is no-one there to care about you. Think that further treatment will cause more pain. Think that others pressurise you to do things you can’t. Think that the doctors might start to dislike you. Remind yourself of the support and encouragement you get from others. Expect there to be no relief at all. Blame the doctor (or hospital or operation) for your condition. Trust the doctors and believe that they can do something. Remind yourself that you have to be positive about the pain. Think anxiously about the things that bring on the pain. Think that it is unfair that you can’t do the things you used to do. Think that you won’t let the pain get the better of you.
Rank order refers to ranked frequency POS = positive: NEG = negative.
of endorsement
of the item.
The Pain Cognitions
Questionnaire
107
TABLEII.--CORRELATIONS BETWEEN FACTOR SCORES ANDMEASURES OFPAIN AND MOOD ANDPAR~LNCORRELATIONS (WITHANXIETY PARTIALLED our) Factor 1 Positive: distraction/ reassurance
Correl. Pain intensity (now) Pain intensity (Past week) Pain distress (now) Pain distress (Past week) Behavioural disruption (past week) Pain behaviour total (PBC) Anxiety (STAI) Depression (ZUNG)
NS NS -0.26* NS -0.37t
-E7$ NS
Factor 2 Negative: hoplessness
Partial Correl.
Correl.
Partial Correl.
Factor 3 Negative: helplessness
Correl.
Partial Correl.
Factor 4 Positive: support/trust
Correl.
Partial Correl.
NS NS NS NS NS
NS 0.25; 0.26* 0.29* 0.38t
NS NS NS NS NS
NS 0.21* 0.25* 0.21* 0.28*
NS NS NS NS NS
NS NS NS NS NS
NS NS NS NS NS
NS
-0.22* 0.523 NS
NS
- 0.24* 0.461 0.26*
NS
-0.24* -0.22* NS
0.31
+p < 0.05. tp < 0.01. $p < 0.001. anxiety levels, partial correlations were computed between factor scores and pain scores with anxiety as a covariate (see Table II). On Factors 1, 2 and 3 the resulting correlations were all reduced in size, none remaining statistically significant. The relationship between Factor 4 and total pain behaviour became marginally stronger when current anxiety was partialled out (r = 0.31, df = 96, p = 0.05).
DISCUSSION
Analysis of the present findings indicated that the most commonly reported cognitive responses to pain were positive in nature. The nine most frequently reported responses were positive, whilst the nine least frequently reported ones were negative. If these results are taken at face value this would suggest that the common clinical impression that chronic pain patients use predominantly negative coping strategies is erroneous. Instead it would appear that they may engage in positive strategies and that these are proving unsuccessful. Alternatively it is possible that the use of positive coping strategies has little overall bearing on the experience of pain. It may be, however, that the greater reporting of positive strategies in this study reflects a response bias or social desirability effect. Patients attending pain clinics may attempt to show that they are doing everything possible to help themselves. On balance we feel this is unlikely since patients taking part in the study were reassured that their answers to the questionnaire would not be made available to their doctors. In addition the clinical impression of patients attending pain clinics suggests the converse, that they usually emphasize how difficult it is to cope with the pain and hence how much they need help. The principal components analysis of responses to the pain cognitions questionnaire produced four interpretable factors. These comprise two negative and two positive factors. The negative factor labelled hopelessness appears to be comprised of items indicating a pessimistic view of the patients ability to cope with pain. The
108
K.
BOSTON el al.
other negative factor labelled helplessness appears to consist of items that indicate an external focus and passivity. A clear pattern of positive correlations emerged between scores on the two negative factors and measures of pain intensity, distress and behavioural disruption over the previous week. Scores on the pain hopelessness factor were also significantly correlated with depression. It would therefore appear that there is a clear association between the report of negative cognitions and both the intensity, and affective dimensions of pain. A less clear picture emerges for the relationship between positive cognitions and pain severity measures. Significant correlations emerged between the support and trust factor and both anxiety, and the pain behaviour checklist: the greater the perception of support, the greater the pain behaviour. Hence there is some evidence to suggest that the adoption of this passive coping style leads to a greater susceptibility to behavioural disruption. Conversely the active coping scores (Factor 1) are significantly negatively correlated with pain distress and behavioural disruption. The observation of two factors apparently active and passive in nature and the pattern of their correlations with pain measures is reminiscent of the findings of Brown and Nicassio [6] who found active coping styles to be correlated with better adjustment. The interpretation of these findings is complicated by the observation that scores on each of the cognitive factors and on the pain measures were significantly correlated with anxiety. The possibility therefore exists that the significant correlations that emerged between factor scores and pain measures were an artefact of anxiety. This interpretation is supported by the results of the partial correlations. Alternatively it may be that the correlations provide information about the cognitive and affective aspects of chronic pain. Pain is a multidimensional experience including an affective element. It is therefore not surprising that explicit measures of affect (viz. STAT) are related to measures of pain. This problem of the confounding of measures of pain and anxiety has been described elsewhere [ 1 I]. Hence rather than dismissing the correlations between pain measures and factor scores as artefacts of anxiety it could be concluded that where significant effects of anxiety are observed this indicates the close relationship between the cognitions measured by the factor and affective distress. It follows that the coping strategies concerned are more closely related to affective distress than pain intensity. One important practical implication of the results of this study concerns the form of cognitiveebehavioural treatment that is likely to be most appropriate for this patient group. In the application of cognitive methods to chronic pain patients one assumption has generally been that methods should aim to increase the use of positive coping strategies [ 121. The results presented here suggest that pain patients are already using positive strategies and that their use may be unrelated to the severity of the pain problem. This observation plus the greater correlations between pain and negative cognitions, would suggest that cognitive methods might be more effective if they were aimed at reducing the frequency of use of negative strategies rather than increasing the rate of use of positive strategies. Such a conclusion would be in agreement with the findings from some previous studies. Both Chaves and Brown [13] and Rosenstiel and Keefe [4] suggest that successful coping is a consequence of avoiding catastrophizing cognitions. This is further supported by Turner and Clancy [14] who showed during cognitive-behavioural treatment that
The Pain Cognitions
Questionnaire
109
reductions in catastrophizing were significantly related to reductions in pain intensity and physical impairment. In summary we have described the initial development of an instrument for the assessment of pain-related cognitions which may prove to be a valuable tool for the assessment of patients prior to cognitive treatment as well as for the evaluation of cognitive treatments for pain. REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
PEARCE S. A review of cognitive-behavioural methods for the treatment of chronic pain. Jpsychosom Res 1983; 27: 43140. LINTON SJ. Behavioural remediation of chronic pain: a status report. Pain 1986; 24: 125-141. FERNANDEZ E. A classification system of cognitive coping strategies for pain. Pain 1986; 26: 141~151. ROSENSTIEL AK, KEEFE FJ. The use of coping strategies in chronic low back pain patients. Relationships to the patient characteristics and current adjustments. Pain 1983; 17: 3344. KEEFE FJ, CALDWELL DS, QUEEN KT, GIL KM, MARTINEZ S, CRISS~N JE, OGDEN W, NUNLEY J. Pain coping strategies in osteoarthritis patients. J consult clin Psycho1 1987; 55: 208-212. BROWN GK, NICA~~IO PM. The development of a questionnaire for the assessment of active and passive coping strategies in chronic pain patients. Pain 1987; 31: 5345. JENSENMP, KAROLY P, BRAVERS. The measurement of clinical pain intensity. Pain 1986; 27: 117~126. PHILLIPS C, HUNTER M. Pain bchaviour in headache sufferers. Behuv Anal Modif 1981; 4: 257-266. MAIN CJ, WADDELL G. ‘The detection of psychological abnormality using four simple scales’. Curren/ Concepfs in Pain, Vol. 2, pp. 10-16. 1984. SPIELBERGERCD, GORUSH RL, LUSHENERN. Mum&for the Stale-Trait Anxiety Inventory, Consulting Psychologists Press: Palo Alto, 1970. GROWSRT, COLLINS FK. On the relationship between anxiety and pain: a methodological confounding. Clin Psycho1 Rev 1981; 1: 375-386. TURK DC, MEIC~NBAUM D, GENFX TM. Pain and Behavioral Medicine: A Cognitive-Behavioral Perspective, New York: Guilford Press, 1983. CHAWS FF, BROWN J. Self-generated strategies for control of pain and stress. Paper presented at Meefing of the American Psychological Associaion, Toronto, Ontario, 1978. TURNER JA, CLANCY S. Strategies for coping with chronic low back pain: relationship to pain and disability. Pain 1986; 24: 355-364.
