Coping Flashcards
The outcome of pain mediated by?
More than 30 years ago, the gate control theory of
pain showed that how much we are hurt or damaged
does not bear a one-to-one relationship with
how much pain we experience; nociception and
pain are not the same (Melzack & Wall, 1965).
Nociception is the activation of peripheral sensory
fibers when tissue is damaged or is about to be
damaged.
Pain is a sensory or emotional experience
associated with or described in terms of tissue
damage (Merskey & Bogdale,1994).
Cognitive factors (attention and perception of control over pain), as well as the immediate environment (people or context) effect pain experience.
Lazarus and Folkman (1962)
Stress - Appraisal - coping - Reappraisal of outcomes
Pain (chronic or acute) can be considered as a classical ‘stressor’.
Primary appraisal - Evaluation of an event/situation with respect to personal wellbeing.
Stress appraisal of challenges and threats
Suffering with ongoing pain as a Challenge – how to cope with the pain ans get though the day
Threat - Is it going to get worse?
Secondary appraisal - Consider coping options and evaluation of resources to overcome a stressful situation
Internal (e.g., will power, inner strength)
External (e.g., health services, family support)
An individuals evaluation of resources, and perceived ability/inability to cope can cause very different psychological outcomes
Emotion-focused coping:
Used when we feel like we have little control over situation.
Aims at alleviation of emotional distress
o Avoiding – ‘I’m not going to school’
o Distancing yourself from the emotion ‘I’m not stressed, it doesn’t matter’
o Acceptance – ‘I failed the exam, but I still have 4 other subjects’
o Seeking emotional support from your partner
Can also lead to negative behaviours including selective attention (ignoring issue), and behaviours e.g., Alcohol or aggression to vent anger
Problem-focused coping:
Used when we feel some control of situation to manage the source of stress.
o Define the problem,
o Generate alternative solutions
o Learning new skills to manage stressor
o Reappraising
Problem-focused coping actually serves to increase resources and therefore beneficially affects the secondary appraisal
Reappraisal: New information from environment can ‘feedback’ to effect primary and secondary appraisals
Can increase or decreases the stress pressure
May be influenced by coping approaches (e.g., Problem focused coping utilises active reappraisal).
Coping is a fluid, dynamic process involving the ongoing interaction between appraisals and reappraisals
Assessment of pain coping
Coping Strategies Questionnaire (CSQ, Rosentiel and Keefe, 1983)
Self-report instrument 50 items using 7-point Likert scales
6 coping dimensions and 2 behavioural dimensions
The Chronic Pain Coping Inventory (Jensen and Turner, Pain, 1995).
Vanderbilt Pain Management Inventory (Brown and Nicassio, 1987)
Attentional distraction
Example: “If possible, I would try and read a book or magazine to take my mind off the pain” (Boothby, 1999)
Mixed findings for effects of attentional refocusing on chronic pain :
van Lankveld et al. (1994): use of distraction correlated with well-being
Evidence for success of distraction for chronic pain IS POOR, this contrasts with acute pain, which shows a strong effect.
Roelofs et al. (2006): used electronic diary to evaluate effects of attentional distraction on pain – no effects seen
Affleck et al. (1992) found negative correlation between pain levels and attentional distraction in patients with comparatively low pain; those with strong pain showed a positive correlation.
Robinson et al. (1997): distraction predicted greater pain and interference
Hope and prayer
• Prayer and hope can affect pain:
• 1. as a distraction
• 2. inducing positive emotion/outlook
• 3. by strengthening social contacts and support
• 4. by inducing a relaxed, meditative state
o 2-4 link to resilience and acceptance later
Dimensions of spiritual experience are associated with serotonin binding
in the neocortex (Borg et al., Am. J. Psych., 160: 1965-1969, 2003)
Mixed support - some evidence that there can actually be negative consequences.
Hill et al. (1995) : more disability and pain severity
Robinson et al. (1997) : greater life interference
Ribbentrop at al. (2005): positive spirituality in pain patients was related to improved mental health negative spirituality was related to poor health outcomes and greater mortality
Reinterpreting pain
Example: “I do not think of it as pain but rather as a dull or warm feeling”
(Boothby, 1999)
Positive effects of reinterpretation:
Kuile et al.(1995) : patients after a hypnosis therapy program showed less pain if they used reinterpretation
Dozois et al. (1995): no correlation with disability
Hill et al. et al.(1995) : or with pain severity
Robinson et al. (1997): no correlations with pain outcomes either
Unless part of a fuller therapeutic program, reinterpreting pain does not seem to be an effective coping strategy
Positive self-statements
Example: “I see it is a challenge and don’t let bother me” (Boothby, 1999)
positive effects of positive self-statements:
Hill (1993): negative correlation with pain severity
van Lankveld et al. (1994): negative correlation with depression
Lack of correlations:
Dozois et al. (1996): Robinson et al. (1997): no correlation with different pain outcomes
Mixed findings. Some limited evidence for positive self-statements on pain and pain outcomes, but a number of studies have not found any associations.
Ignoring pain
Example: “I tell myself it does not hurt” (Boothby, 1999)
• No correlations between pain outcome measures and ignoring pain:
• Dozois et al. (1996) physical disability
• Hill (1993) psychosocial dysfunction
• Hill et al. (1995) pain severity
• Little evidence for effects of ignoring pain on pain severity and pain-related outcomes
Catastrophising
- Pain catastrophising relates to greater pain, depression, anxiety, and life interference (Lecture 5)
- Catastrophising (helplessness, anxiety) is a passive pain coping mechanisms which correlates with pain, depression, and disability in chronic pain patients (Samwel et al., Clin.J. Pain, 2006).
Catastrophising as a ‘coping’ mechanism is likely to contribute to more negative outcomes.
MUsic
Cepeda et al. (Cochrane Lib., 2010) analysed effects of music on acute and chronic pain using meta-analysis of 54 studies
Across various types of clinical and acute pain, moderate effect for less pain in music conditions. Importantly, chronic pain appeared to show a stronger effect size than acute pain, however only 2 studies for chronic pain compared to 11 for acute pain.
After surgery, patients required significantly less morphine when listening music compared to unexposed patients.
Music evidence provides some support for a potential coping effect of distraction – perhaps a specific form linked to positive affect and optimism– link to resilience later!
Methodological problems in pain coping research
Most of the studies are cross-sectional, typically correlating one coping questionnaire with a set of outcome measures (pain severity, depression, disability).
This leads to a problem with circularity : was a positive correlation e.g. between hoping and praying and clinical pain due to rebound of pain following this coping, or was it due to particularly strong pain urging a person to pray?
Lack of longitudinal studies to compare samples of coping mechanisms and pain outcomes over years
A compromise: day-by-day variations in the level of coping, pain, depression and other measures (Affleck et al., 1996; Keefe et al., 1987)
Pain acceptance
Coping = active effort to control pain; however, acceptance of pain appears to correlate better with decreased pain and improved functioning (McCracken et al., J. Behav. Med., 2007)
Acceptance:
1) willingness to experience pain,
2) to continue healthy life activities anyway!
Chronic Pain Acceptance Questionnaire (McCracken et al., 2004)
20-item questionnaire to measure levels of acceptance
Two factors of pain acceptance (Vowles et al., Pain, 2008)
o Factor 1: Activity engagement
o Factor 2: Pain willingness
Acceptance of pain predicts pain-related outcomes independently of coping measures (McCracken and Eccleston, Pain, 2003)
Analysis was performed in 230 chronic pain patients using CPAQ, CPQ and other measures.
Acceptance predicted lower pain, disability, depression and pain-related anxiety.
Interestingly, none of the coping strategies showed association with pain except for praying and hoping which showed a positive relationship with pain and low adjustment.
(Veehof et al., 2011,)
Meta-analysis of 19 studies aiming at effects of acceptance in chronic pain patients
Weak-moderate effects for acceptance were observed in:
pain, depression, anxiety, physical wellbeing, quality of life
These effects were comparable to effect sizes for cognitive behavioural therapy which may also be useful for improving acceptance (Vowel et al., 2007)
Resilience
Pain acceptance works well, but we want to move on and have other more active actions
Resilience: a novel concept in evaluation of coping with chronic pain
Resilience individuals = continuing functioning and facilitated recovery in the presence of pain (Sturgeon and Zautra, 2010)
Resilience manifests in 3 outcomes:
Facilitated recovery – resilient individuals regain equilibrium fast after a stressful event
Sustainability – perseverance in desired actions, goal pursuits, and social engagement
Growth – realisation and understanding own capacities, ability to follow life goals under adverse conditions
Mechanisms of Resilience (Sturgeon and Zautra, 2010)
• Optimism, Purpose in life – striving for goals, Pain acceptance, Emphasis on positive emotions, Preference of active coping - function in spite of presence of pain, engage in physical activity, Resilience through social support –utilise support network
Vulnerability contributes to worsened physical and psychological functioning in response to stress.
Can be related to diminished coping resources
Can be influenced by various factors:
o fitness and good (mental and physical) health
o social support
o material resources
Sturgeon and Zautra, 2010
Resilience modifies the relationship between pain and pain outcomes through coping mechanisms and acceptance i.e., resilience links all of the concepts we have discussed.
Implications for treatment of pain:
Implications for Resilience:
Smith et al., J. Pain, 2009
Habituation to repeated heat pain stimuli (in healthy people). For highly resilience patients habituation occurs quicker.
Ferreira et al., 2007
Optimism in chronic pain patients is related to lower level of pain and depression.
Purpose in Life – faster recovery after a knee surgery (Smith and Zautra, Int. J. Behav. Med., 2004)
