Sandra J. Waters

Pain Catastrophizing and Pain-Related Fear in Osteoarthritis Patients: Relationships to Pain and Disability

This study examined the degree to which pain catastrophizing and pain-related fear explain pain, psychological disability, physical disability, and walking speed in patients with osteoarthritis (OA) of the knee. Participants in this study were 106 individuals diagnosed as having OA of at least one knee, who reported knee pain persisting for six months or longer. Results suggest that pain catastrophizing explained a significant proportion (all Ps < or = 0.05) of variance in measures of pain (partial r(2) [pr(2)] = 0.10), psychological disability (pr(2) = 0.20), physical disability (pr(2) = 0.11), and gait velocity at normal (pr(2) = 0.04), fast (pr(2) = 0.04), and intermediate speeds (pr(2) = 0.04). Pain-related fear explained a significant proportion of the variance in measures of psychological disability (pr(2) = 0.07) and walking at a fast speed (pr(2) = 0.05). Pain cognitions, particularly pain catastrophizing, appear to be important variables in understanding pain, disability, and walking at normal, fast, and intermediate speeds in knee OA patients. Clinicians interested in understanding variations in pain and disability in this population may benefit by expanding the focus of their inquiries beyond traditional medical and demographic variables to include an assessment of pain catastrophizing and pain-related fear.

Gender differences in pain, coping, and mood in individuals having osteoarthritic knee pain: a within-day analysis.

&NA; This study examined gender differences in prospective within‐day assessments of pain, pain coping, and mood in men and women having OA, and analyzed gender differences in dynamic relations between pain, mood, and pain coping. A sample of 64 women and 36 men diagnosed as having pain due to osteoarthritis of the knee(s) rated their pain, pain coping, and mood two times each day (once in the afternoon and once in the evening) for 30 days using a booklet format. Two gender differences were found in between person‐analyses: women used more problem focused coping than men, and women who catastrophized were less likely than men to report negative mood. Several within‐day and across‐day gender differences were noted. First, women were much more likely to show a significant increase in pain over the day. Second, men were more likely than women to experience an increase in coping efficacy over the day. Third, men were more likely than women to use emotion‐focused coping when their mood was more negative. Finally, men were more likely than women to experience an increase in negative mood and a decrease in positive mood in the morning after an evening of increased pain. Taken together, these findings underscore the importance of obtaining multiple daily assessments when studying gender differences in the pain experience.

Anger and persistent pain: current status and future directions.

Persons having persistent pain often report feeling angry (Zimmerman et al., 1996). These angry feelings can be directed at themselves, others, or their life situation (Okifuji et al., 1999). Anger is an important emotion because it can exacerbate pain. Theories of pain such as the gate control theory and neuromatrix theory maintain that intense negative emotions such as anger can increase pain by altering descending and central pain modulation systems (Melzack, 1991; Rumelhart and McClelland, 1986). In addition to exacerbating pain, anger can complicate pain management efforts by disrupting relationships with health care providers, thereby interfering with medical or surgical treatments for persistent pain. Furthermore, persons with persistent pain who are having difficulties coping with anger often experience problems with marriage partners, family, friends, and co-workers. In 1995, Fernandez and Turk (1995) wrote an influential review of research on anger in persons having persistent pain. Since publication of that review paper, a number of new studies have been published on this topic. The purpose of this paper is to highlight recent research on anger and pain and to discuss its implications. In this paper, we describe concepts used in anger research, highlight representative clinical studies on anger and pain, discuss biopsychosocial mechanisms of anger-pain relationships, and discuss treatment implications of this research.

Laboratory pain perception and clinical pain in post-menopausal women and age-matched men with osteoarthritis: relationship to pain coping and hormonal status

&NA; The present study examined relationships between pain coping, hormone replacement therapy, and laboratory and clinical pain reports in post‐menopausal women and age‐matched men with osteoarthritis. Assessment of nociceptive flexion reflex threshold was followed by an assessment of electrocutaneous pain threshold and tolerance. Participants rated their arthritis pain using the Arthritis Impact Measurement Scales. To assess pain coping, participants completed measures of emotion‐focused coping, problem‐focused coping, and pain catastrophizing. Results indicated that women were more likely than men to report using emotion‐focused pain strategies, and that emotion‐focused coping was associated with more arthritic pain and lower electrocutaneous pain tolerance. Correlations between coping measures and pain reports revealed that catastrophizing was associated with greater arthritis pain and lower pain threshold and tolerance levels. However, catastrophizing was not related to nociceptive flexion reflex threshold, suggesting that the observed relationship between catastrophizing and subjective pain does not rely on elevated nociceptive input. A comparison of men (n=58), post‐menopausal women receiving hormone replacement therapy (n=32), and post‐menopausal women not receiving hormone replacement therapy (n=42) revealed no significant group differences in arthritis pain, electrocutaneous pain threshold or tolerance, or nociceptive flexion reflex threshold. Thus, older adults with osteoarthritis do not exhibit the pattern of sex differences in response to experimental pain procedures observed in prior studies, possibly due to the development of disease‐related changes in pain coping strategies. Accordingly, individual differences in clinical and experimental pain may be better predicted by pain coping than by sex or hormonal differences.

Effects of day-to-day affect regulation on the pain experience of patients with rheumatoid arthritis

Abstract Individual differences in the regulation of affect are known to impact pain and other symptoms in rheumatoid arthritis. However, no studies have yet used a rigorous daily diary methodology to address the question of whether current pain is reduced when positive or negative affects are effectively regulated. We used a prospective, repeated daily sampling design to infer the regulation of affect from day‐to‐day changes in affect intensity and examined how these changes in affect were prospectively related to pain from rheumatoid arthritis. Ninety‐four adult patients diagnosed with rheumatoid arthritis completed daily measures of pain and positive and negative affect over a period of 30 days. Information on demographic and disease status variables was collected during a medical evaluation. Results of hierarchical linear model analyses indicated that the regulation of both positive and negative affect from the prior day to the current day predicted significantly greater decreases in pain that day, resulting in up to a 28% reduction in pain intensity. These findings were partly influenced by disease status and demographic variables. This study suggests that the day‐to‐day regulation of negative and positive affect is a key variable for understanding the pain experience of individuals with rheumatoid arthritis and is a potentially important target for intervention.

Effects of coping skills training and sertraline in patients with non-cardiac chest pain: a randomized controlled study.

&NA; Non‐cardiac chest pain (NCCP) is a common and distressing condition. Prior studies suggest that psychotropic medication or pain coping skills training (CST) may benefit NCCP patients. To our knowledge, no clinical trials have examined the separate and combined effects of CST and psychotropic medication in the management of NCCP. This randomized clinical trial examined the separate and combined effects of CST and antidepressant medication (sertraline) in participants with non‐cardiac chest pain. A sample of individuals diagnosed with NCCP was randomly assigned to one of four treatments: (1) CST plus sertraline (CST + sertraline), (2) CST plus placebo (CST + placebo), (3) sertraline alone, or (4) placebo alone. Assessments of pain intensity, pain unpleasantness, anxiety, pain catastrophizing, depression, and physical disability were collected prior to treatment, and at 10‐ and 34‐weeks following randomization. Data analyses revealed that CST and sertraline either alone or in combination significantly reduced pain intensity and pain unpleasantness. The combination of CST plus sertraline may have the greatest promise in that, when compared to placebo alone, it not only significantly reduced pain but also pain catastrophizing and anxiety. Overall, these findings support the importance of further research on the effects of CST and sertraline for non‐cardiac chest pain.

Pain catastrophizing in patients with noncardiac chest pain: relationships with pain, anxiety, and disability.

Objective: To examine the contributions of chest pain, anxiety, and pain catastrophizing to disability in 97 patients with noncardiac chest pain (NCCP) and to test whether chest pain and anxiety were related indirectly to greater disability via pain catastrophizing. Methods: Participants completed daily diaries measuring chest pain for 7 days before completing measures of pain catastrophizing, trait anxiety, and disability. Linear path model analyses examined the contributions of chest pain, trait anxiety, and catastrophizing to physical disability, psychosocial disability, and disability in work, home, and recreational activities. Results: Path models accounted for a significant amount of the variability in disability scales (R2 = 0.35 to 0.52). Chest pain and anxiety accounted for 46% of the variance in pain catastrophizing. Both chest pain (β = 0.18, Sobel test Z = 2.58, p < .01) and trait anxiety (β = 0.14, Sobel test Z = 2.11, p < .05) demonstrated significant indirect relationships with physical disability via pain catastrophizing. Chest pain demonstrated a significant indirect relationship with psychosocial disability via pain catastrophizing (β = 0.12, Sobel test Z = 1.96, p = .05). After controlling for the effects of chest pain and anxiety, pain catastrophizing was no longer related to disability in work, home, and recreational activities. Conclusions: Chest pain and anxiety were directly related to greater disability and indirectly related to physical and psychosocial disability via pain catastrophizing. Efforts to improve functioning in patients with NCCP should consider addressing pain catastrophizing. NCCP = noncardiac chest pain.

A randomized, controlled trial of emotional disclosure in rheumatoid arthritis: Can clinician assistance enhance the effects?

&NA; Emotional disclosure by writing or talking about stressful life experiences improves health status in non‐clinical populations, but its success in clinical populations, particularly rheumatoid arthritis (RA), has been mixed. In this randomized, controlled trial, we attempted to increase the efficacy of emotional disclosure by having a trained clinician help patients emotionally disclose and process stressful experiences. We randomized 98 adults with RA to one of four conditions: (a) private verbal emotional disclosure; (b) clinician‐assisted verbal emotional disclosure; (c) arthritis information control (all of which engaged in four, 30‐min laboratory sessions); or (d) no‐treatment, standard care only control group. Outcome measures (pain, disability, affect, stress) were assessed at baseline, 2 months following treatment (2‐month follow‐up), and at 5‐month, and 15‐month follow‐ups. A manipulation check demonstrated that, as expected, both types of emotional disclosure led to immediate (post‐session) increases in negative affect compared with arthritis information. Outcome analyses at all three follow‐ups revealed no clear pattern of effects for either clinician‐assisted or private emotional disclosure compared with the two control groups. There were some benefits in terms of a reduction in pain behavior with private disclosure vs. clinician‐assisted disclosure at the 2‐month follow‐up, but no other significant between group differences. We conclude that verbal emotional disclosure about stressful experiences, whether conducted privately or assisted by a clinician, has little or no benefit for people with RA.

The association of perceived stress, contextualized stress, and emotional eating with body mass index in college-aged Black women

A growing body of literature supports the association between adverse stress experiences and health inequities, including obesity, among African American/Black women. Adverse stress experiences can contribute to poor appetite regulation, increased food intake, emotional eating, binge eating, and sedentary behavior, all of which can contribute to weight gain and obesity. Most research studies concerning the effect of psychological stress on eating behaviors have not examined the unique stress experience, body composition, and eating behaviors of African American/Black women. Even fewer studies have examined these constructs among Black female college students, who have an increased prevalence of overweight and obesity compared to their counterparts. Therefore, the aim of the current study is to examine the associations among emotional eating, perceived stress, contextualized stress, and BMI in African American female college students. All participants identified as African American or Black (N=99). The mean age of the sample was 19.4 years (SD=1.80). A statistically significant eating behavior patterns×perceived stress interaction was evident for body mass index (BMI) (β=0.036, S.E.=.0118, p<.01). In addition, a statistically significant eating behavior patterns×contextualized stress interaction was observed for BMI (β=0.007, S.E.=.0027, p=.015). Findings from this study demonstrate that the stress experience interacts with emotional eating to influence BMI. Based on these findings, culturally relevant interventions that target the unique stress experience and eating behavior patterns of young African American women are warranted.

The effects of written emotional disclosure and coping skills training in rheumatoid arthritis: A randomized clinical trial

OBJECTIVE Two psychological interventions for rheumatoid arthritis (RA) are cognitive-behavioral coping skills training (CST) and written emotional disclosure (WED). These approaches have developed independently, and their combination may be more effective than either one alone. Furthermore, most studies of each intervention have methodological limitations, and each needs further testing. METHOD We randomized 264 adults with RA in a 2 × 2 factorial design to 1 of 2 writing conditions (WED vs. control writing) followed by 1 of 2 training conditions (CST vs. arthritis education control training). Patient-reported pain and functioning, blinded evaluations of disease activity and walking speed, and an inflammatory marker (C-reactive protein) were assessed at baseline and 1-, 4-, and 12-month follow-ups. RESULTS Completion of each intervention was high (>90% of patients), and attrition was low (10.2% at 12-month follow-up). Hierarchical linear modeling of treatment effects over the follow-up period, and analyses of covariance at each assessment point, revealed no interactions between writing and training; however, both interventions had main effects on outcomes, with small effect sizes. Compared with control training, CST decreased pain and psychological symptoms through 12 months. The effects of WED were mixed: Compared with control writing, WED reduced disease activity and physical disability at 1 month only, but WED had more pain than control writing on 1 of 2 measures at 4 and 12 months. CONCLUSIONS The combination of WED and CST does not improve outcomes, perhaps because each intervention has unique effects at different time points. CST improves health status in RA and is recommended for patients, whereas WED has limited benefits and needs strengthening or better targeting to appropriate patients.