Although the findings may not be as generalizable to a clinic population or those with more severe acute illnesses, it was interesting to note that those with chronic conditions were more likely to use a combination of various and varied coping responses to manage their condition and adjust their lifestyle accordingly.
Brown and Nicassio (1987) classified coping strategies as either active or passive, based upon their relationship to levels of pain severity and psychosocial functioning. On the one hand, active strategies were defined as efforts by the patient to function despite the pain and include positive coping self-statements, pacing, positive social comparisons, regular exercise, distraction, seeking social support and task persistence (Gatchel & Turk 1996).
On the other hand, passive strategies reflected a tendency to relinquish control and depend upon others and have been found to include pain-contingent rest (i.e. rest taken in response to the level of pain experienced), guarding, wishful thinking, avoidance of activity, catastrophizing, and the use of sedative hypnotic medication. Brown and Nicassio (1987) noted that whilst active coping strategies were related to reduced pain severity, lower levels of depression and less
functional impairment, the reverse applied to passive coping strategies. Whilst passive strategies may be appropriate in some instances, particularly with regard to acute episodes, in chronic pain without comorbidity, passive strategies are often viewed as ‘maladaptive’. However, as previously discussed, the coping strategies used in any given situation are dependent upon contextual factors and the individual’s appraisal of these. Therefore, a passive strategy in one instance may be in fact be adaptive in another. The skill is to know what is appropriate for each individual’s situation at any given time (Richardson & Poole 2001).
Catastrophizing, defined as ‘an exaggerated negative orientation toward pain stimuli and pain experience’ (Sullivan et al. 1998, p. 253), has consistently been found to be significantly related to heightened pain severity in a wide variety of chronic pain conditions (Sullivan et al. 2001) and has also been found to be related to lower pain thresholds and pain tolerance levels in normal(McCracken & Eccleston 2003). Although there is debate as to whether catastrophizing is best characterized as an appraisal rather than a coping response (e.g. Jensen et al. 1991, Sullivan et al. 2001), it has been found that reducing catastrophic thoughts is useful in terms of increasing adjustment to osteoarthritis pain (Keefe et al. 1990, Severeijns et al. 2001).
Lethem et al. (1983) developed a fear avoidance model of chronic pain where catastrophizing leads to fear of pain, leading in turn to avoidance of activity, hypervigilance, depression and disuse resulting in disability. Fear-avoidance beliefs and fear of movement/(re)injury in particular have been shown to be strong predictors of physical performance and pain disability (Waddell et al. 1993, Crombez et al. 1998, Vlaeyen et al. 2002). Therefore, reducing catastrophizing through education and coping skills training and increasing activity according to this model, will reduce depression and disability. Although Geisser et al. (1999) argued that rather than reduce the use of unhelpful passive strategies the use of helpful active strategies should be encouraged.
Coping is influenced by a number of factors including mood, disability, beliefs, other symptomatology, level of support in the marital relationship and locus of control, i.e. the extent to which individuals believe that they are in control of outcomes and the extent to which they believe in chance or misfortune (Skevington 1995). Patients who are most adaptive are those who have strong internal beliefs, strong beliefs in the powers of others such as health professionals and weak beliefs in chance. Pain beliefs may affect treatment outcomes and patients’ beliefs about their illness affect their attitudes to coping skills, adherence and compliance with treatment, e.g. if patients believe they are not in control of their condition, they are less likely to adhere to a self-management program (Williams & Keefe 1991). In addition, they may believe that a certain course of treatment is effective and another ineffective. Several authors have suggested that coping strategies may be an important mediator between pain and depression and thus disability in low back pain (e.g. Waddell et al. 1993, Gatchel & Turk 1999).
Coping skills can be developed by teaching cognitive techniques such as problem solving, correction of distorted cognitions by education and encouraging physical activity (Harding & Williams 1995). The provision of information is important in that it enhances perceived control about pain and thus anxiety and distress is reduced (Arntz & Schmidt 1989).
A broad range of coping styles should be taught as what may be effective in reducing pain for one individual (adaptive) on one occasion, may not be on another, or for a different individual. Richardson and Poole (2001) suggest that assessment of coping styles could identify the type of coping that leads to a positive outcome for the individual patient in terms of facilitating adaptation to their condition. Coping strategies are reviewed in the second part of this paper.
Perceived self-efficacy (i.e. an individual’s belief that they can succeed at something they want to do) is closely related to coping ability. Perceived control and higher self-efficacy have been shown to be positively related to lower levels of state anxiety and greater use of more adaptive coping strategies (i.e. task-orientated rather than emotion-focused coping), which in turn have been positively related to psychological and functional outcome measures (Scharloo & Kaptein 1997). Any treatment of chronic pain related to the development of coping strategies and anxiety reduction should therefore also include strategies to increase self-efficacy.
- Adams, Nicola, Poole, Helen & Clifford Richardson; Psychological approaches to chronic pain management: part I; Journal of Clinical Nursing; Mar 2006; Vol. 15; Issue 3.
Personal Reflection Exercise #7
The preceding section contained information about chronic pain management and psychological approaches part I. Write three case study examples regarding how you might use the content of this section in your practice.
QUESTION 16
What is one of the most researched variables of pain that influences pain intensity and physical / psychosocial disability? To select and enter your answer go to Test.