The way you think about pain is related to the way you cope
Posted Nov 27 2008 11:59am
Cognitive appraisal and coping in chronic pain patients
Carmen Ramírez-Maestre, Rosa Esteve and Alicia E. López
I’m interested in coping approaches in people with chronic pain, as you might have guessed! Despite my criticism that the current coping measures such as the Vanderbilt Pain Management Inventory represent clinicians ideas of coping rather than those derived from what patients say and do, there is some evidence that certain types of coping are associated with better function as measured by the Impairment and Functioning Inventory (Ramírez-Maestre and Valdivia, 2003). At least in this study.
Anyway, this particular study looked at appraisal style, and its relationship with coping (and function).
Participants: 122 patients with musculoskeletal chronic pain who attended the Clinical Pain Unit at the Carlos Haya Hospital in Málaga (Spain). Individuals were considered eligible for the study if they had experienced pain for at least 6 months, and were not being treated for a terminal illness. Participants included in the study were in their mid-fifties, mainly female, mostly educated to primary school level, and over 80% were not working at the time of the study. Most of the participants had ‘widespread’ pain, with low back pain being the next most common single pain site. All of the participants were using medication to manage their pain.
Measures: Cognitive Appraisal Inventory for chronic pain patients (Ramírez-Maestre et al., 2005). This is a 31 item, 3 sub-scale measure to assess the type of appraisal that patients make about the situation of suffering chronic pain. The three subscales are harm or loss appraisal, threat appraisal, or challenge appraisal.
Vanderbilt Pain Management Inventory (Brown and Nicassio, 1987) is an 18 item, 2 sub-scale measure of active and passive coping strategies.
• Active strategies: Handling the pain or carry on functioning despite the pain.
• Passive strategies: Strategies giving control over pain to another person or allowing pain to adversely affect other areas of the subject’s life.
A spanish-translation of the McGill Pain Inventory was used to to describe pain.
Impairment and Functioning Inventory for chronic pain patients (Ramírez-Maestre and Valdivia, 2003) was used to measure disability. This is a 19 item, 4 sub-scale self-report measure of household activity, independent functioning, social activities and leisure activities.
Method: Nearly 20% of the participants didn’t read, so the measures were applied via interview at the first visit to the Pain Management Centre.
Findings: Using structural equation modelling (which I still haven’t got my head around completely, but here is a powerpoint called ‘Fun with Structural Equation Modelling’!) the researchers took the responses from each of the questionnaires and did some awesome mathematics, and came up with a diagram (which I can understand!) describing the statistical relationships between these variables.
Basically, the authors developed a series of hypotheses about the relationships they might find between variables. They then used statistical modelling to determine whether in fact these relationships held good.
What did they find? The authors found that the model below fit the data best.
What does this mean? Well, the closer the number in the white boxes is to 1, the closer the relationship - either positive or negative.
So, they found that harm appraisal was related to passive coping, and passive coping was related to higher pain intensity and greater functional impairment. The relationship between passive coping and disability as measured in this study wasn’t very strong.
The appraisal of threat had two relationships. The first was to passive coping and the second to active coping. People with higher levels of appraisal of harm reported higher levels of passive coping and lower levels of active coping.
The challenge appraisal also had two statistically significant relationships: higher levels of challenge were associated with lower levels of passive coping and higher levels of active coping.
In terms of coping, passive appraisal had a significant relationship with two variables - to pain and impairment, not function, while active appraisal had a significant relationship with daily functioning.
What are the implications of this? Well, let’s get the proviso’s out of the way first. All of the measures are self-report, so we don’t know what people actually do in real life. Also, people probably change the type of coping they use in different circumstances and over the duration of their chronic pain - the design of this study means that a cross-section of people were used, and it may not represent any of the dynamic relationship between coping and appraisal.
Now, onto the good stuff. Ramírez-Maestre, Esteve & Lópe state that ‘Cognitive appraisal refers to the ongoing way in which individuals define and evaluate relationships with their environment as well as the significance of these relationships to their well-being.’ This study demonstrates that indeed, ‘cognitive appraisals of pain can indirectly predict the level of functioning, impairment, and pain intensity of pain’.
If daily activity and impairment are considered as indicators of chronic pain patients’ health, adjustment, quality of life, and well-being, as suggested by many authors, then this study confirms that cognitive appraisals of pain, due to the mediating role of passive coping, influence the level of functioning and impairment.
This of course, suggests that if we can help people reconceptualise their situation as a challenge rather than a threat or harmful, they may move from using passive coping strategies to active coping strategies. I’m not so sure - these were people who had no exposure to pain management strategies,the people who viewed their pain as a challenge and used active coping strategies arrived at this approach on their own. We don’t know whether another variable influenced this, or why they didn’t use passive coping, we simply know there is a relationship between viewing pain as a challenge and using active coping strategies. So that’s another research study needed!
I’m really interested in how the people who did view their pain as a challenge and used active coping came about this approach. I’m also interested that despite these people having lower levels of disability, they were still seeking treatment. I wonder if people who don’t seek treatment show the same characteristics. It would be great to see a further study using the same method with people who are not seeking treatment - would they show the same relationships?
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C RAMIREZMAESTRE, R ESTEVE, A LOPEZ (2008). Cognitive appraisal and coping in chronic pain patients European Journal of Pain, 12 (6), 749-756 DOI: 10.1016/j.ejpain.2007.11.004 Anarte MT, Ramı´rez-Maestre C, Lo´pez AE, Esteve R. Evaluacio´n de estrategias de afrontamiento, nivel de funcionamiento y edad en personas con dolor cro´nico oncolo´gico y benigno. Benalma´dena: IV Congreso de la Sociedad Espan˜ola del Dolor; 1999.
Brown GK, Nicassio PM. Development of a questionnaire for the assessment of active and passive coping strategies in chronic pain patients. Pain 1987;31:53–64.
Ramı´rez-Maestre C, Esteve R, Lo´pez AE. Development of an inventory to assess cognitive appraisal in patients with chronic pain. In: Budapest: 8th European conference on psychological assessment; 2005.
Ramı´rez-Maestre C, Valdivia Y. Evaluacio´n del funcionamiento diario en pacientes con dolor cro´ nico. Psicol Conduct 2003;11:283–91.