Results

Pain as emotion. Pain is primarily experienced as present in the body and it has been traditionally considered as a predominantly biological event (Turk & Okifuji, 2002). However,

pain is never solely a bodily phenomenon (Good, 1992). Pain is simultaneously bodily experience and mental-emotional experience as it is impossible to separate the notion of

aversiveness from the construct of pain (Jackson, 1994), also due to its frequent association with comorbid psychiatric issues or emotional suffering (Chiesa & Serretti, 2011). Many agree that a sensory experience would not be pain if there were no perception of emotional distress. Pain, therefore, should be considered an emotional experience (Craig, 1995). According to Craig (1999), “emotional distress serves not only as a component of pain, but it may also be an issue because of its presence in anticipation of pain, as a consequence of pain, a cause of pain or represent a concurrent problem with independent sources” (p.335).

Anxiety, depression, and anger. Although there are several affective factors (mainly negative emotions) associated with pain, the three emotions that are most frequently associated with chronic pain are anxiety, fear, depression, and anger (Flor & Turk, 2011; Tunks, Crook, &

Weir, 2008).

Anxiety and fear. Patients suffering from chronic pain often feel worried and anxious.

Anxiety is intensified when they cannot find a cause for the pain or when the uncertainty about their prognosis or fear of future disability hits them (Gatchel et al., 2007). People with chronic pain also worry about receiving verification of their pain from others. For example, some patients whose chronic pain condition is caused by work-related injury experience extreme levels of anxiety. This anxiety is often caused by worries that in order to receive compensation for their injury and treatment, they have to “prove” that their pain is “real”, which often involves going through a legal process and potentially experiencing insults to their dignity (Olender, 1962).

Fear of anticipated pain related to physical activities often causes avoidance behavior, which leads to inactivity resulting in greater disability (Gatchel et al., 2007). Results from several studies that have shown that “fear of movement and fear of (re)injury are better predictors of functional limitation than biological parameters or even pain severity and duration” (Crombez, Vlaeyen, & Heuts, 1999; Turk, Robinson, & Burwinkle, 2004; Vlaeyen, Kole-Snijders, Rotteveel,

et al., 1995, as cited in, Gatchel, 2007, p. 599). Fear also has a direct impact on physical symptoms by increasing muscle tension and physiological arousal.

Anxiety, fear, and fear-avoidance behavior are all related and together play an important role in the pain experience. It is important that effective chronic pain treatment addresses these factors (Gatchel, 2007).

Depression. Depressive symptoms are frequently encountered in individuals with chronic pain; on the other hand, depressed patients often complain about various types of pain (King, 1997). The prevalence and mortality of depression in chronic patients is high. It is reported that 50% of chronic pain patients develop major depression within five years from its onset, and the suicidal rate among patients with prolonged pain and depression has been reported to be as high as 10 to 15% (Kulich & Andrew, 2006). Research findings suggest that there is a complex relationship between pain and depression and this relationship has been under constant debate in terms of causality (Main & Spanswick, 2000). Depression not only intensifies pain (Craig, 1999), but also is a significant predictor of pain (Affleck et al, 1991; Doan & Wadden, 1989; Magni et al, 1998). Studies have shown that even though chronic pain and depression are separate phenomena and independent processes, the two share several characteristics and there is a possibility for mutual influence between them (Beutler et al., 1986; Brown, 1990; Crisson &

Keefe, 1988). At this time, the mechanism underlying the relationship between chronic pain and depression is not well understood (Giesecke et al., 2005).

Anger. The unbearable pain itself may cause extreme anger and frustration in chronic pain patients. Even though the causal relationship between anger and pain is unknown, clinical

evidence has shown that anger is significantly associated with pain intensity (Gaskin et al., 1992), perceived interference and frequency of pain behaviors (Kerns et al., 1994), the affective

component of pain (Fernandez & Milbourn, 1994) and emotional distress in chronic pain patients (Duckro, Chibnall, & Tomizic, 1995), as well as their families (Schwartz et al, 1991). Okifuji and colleagues’ (1999) study found that chronic pain patients’ anger and frustration related to

persistence of symptoms, unknown etiology, repeated treatment failures as well as anger toward employers, insurers, healthcare providers, family and themselves contribute to a general

dysphoric mood. An interesting finding is that approximately 70% of the sample reported that the target of their anger is themselves. The reason for this self-directed anger was their inability to alleviate their symptoms and to move on with their lives. This finding raises a significant concern when one considers the following two phenomena: a) internalization of the angry feelings is strongly related to measures of pain intensity, perceived interference and frequency of pain behaviors (Kerns et al., 1994), and b) the tendency of individuals with pain to inhibit the expression of anger is related to pain severity and overt pain behaviors (Hatch et al., 1991).

Pain versus suffering. Long lasting pain that has lost its functional meaning

accompanied by emotional and social distress takes the pain to a different realm of suffering (Loeser, 1982). Suffering is angst of an order different from pain as it includes “the emotional responses that are triggered by nociception or some other aversive event associated with it, such as fear or depression” (Gatchel et al., 2007, p.582). When people’s pain enters the realm of suffering, the concept of remedy becomes not cure or fix but healing. Egnew (2009) states that when an individual is suffering from chronic illness of a type that is beyond medicine, the

suffering has to be transcended through holistic healing, and healing may occur regardless of cure, restoration of health, continued illness or impairment.

2.1.3.3 Cognitive aspects of pain. Cognition (i.e. thoughts, beliefs and appraisals) is another important psychological factor that influences the experience of pain. According to Flor and Turk (2011), “patients’ attitudes, beliefs, and expectancies about their plight, themselves, their coping resources, and the health care system affect their reports of pain, activity, disability, and response to treatment” (p.71). Common pain beliefs which cause maladaptive effect in pain coping are identified as believing that “Pain is a signal of damage, activity should be avoided when one has pain, pain leads to disability, pain is uncontrollable, and pain is a permanent condition” (Jensen, Turner, Romano, & Lawler, 1994; Turner et al., 2000, as cited by Gatchell et

al., 2007, p. 602). These beliefs about pain and the meaning an individual ascribes to pain can significantly affect his or her mood and behavioral responses to pain, leading to maladaptive coping, increased suffering and greater disability.

Catastrophizing. The construct of pain catastrophizing which is defined as “the tendency to focus on and exaggerate the threat value of painful stimuli and negatively evaluate one's ability to deal with pain” (Keefe, Rumble, Scipio, Giordano, & Perri, 2004) is recognized as one of the most significant contributors to the experience of pain. Picavet et al. (2002) describes the mechanism of pain catastrophizing as follows:

Persons, who catastrophically misinterpret pain, are likely to become fearful of pain, which results in at least two processes. First, pain-related fear is associated with avoidance behaviors and the avoidance of movement and . . . . rewarding activities such as work, leisure, and family. Second, pain related fear is associated with increased bodily awareness and pain hypervigilance [which is]

known to be associated with increased pain levels and hence might exacerbate the painful experience. (p. 1028)

Clinical studies suggest that an excessively negative orientation toward pain (pain catastrophizing) coupled with fear of movement or re-injury is closely related to the etiology of chronic pain and associated disability (Fritz, George, & Delitto, 2001; Picavet, Vlaeyen &

Schouten, 2002; Vlaeyen & Linton, 2000). A study by Sorbi and colleagues (2006) reported that catastrophizing was the strongest pain predictor (as cited in Flor & Turk, 2011). Several other studies identified that a significant percentage of the variance in pain and disability were

accounted for by catastrophizing along with other cognitive factors such as helplessness, adaptive coping, and resourcefulness (Flor & Turk, 1988; Flor, Behle, & Birbaumer, 1993). Flor and Turk (2011) concluded that “what appears to distinguish low from high pain tolerant individuals is their cognitive processing, catastrophizing thoughts and feelings that precede, accompany, and follow aversive stimulation” (p. 77).

Perceived control and self-efficacy. Perceived control refers to “the belief that one can exert influence on the duration, frequency, intensity or unpleasantness of pain” (Gatchell et al.,

2007, p.603). Prolonged experience of pain often causes learned helplessness in patients due to their disability and dependency on medication or other people (Weisenberg, 1999). Some laboratory-based studies have shown that when people have some degree of control over pain stimulation, it reduces their stress and increases pain tolerance (Weisenberg, 1984, 1989, as cited in Weisenberg, 1999). When one’s perceived control over their pain is strong, he or she is able to modify the meaning of the pain stimulus which may directly affect threat appraisal, consequently decreasing the intensity and unpleasantness of pain and increase pain tolerance (Bandura et al., 1987). A study has shown that internal locus of control is associated with better coping with pain while an external orientation (i.e., chance or luck) to control of pain was associated with

maladaptive coping (Crisson & Keefe, 1998).

A related concept to the perceived control is self-efficacy, which refers to personal judgment of how well a person believes they can perform specific behaviors in particular situations (Bandura, 1977). The significance of self-efficacy to one’s ability to manage chronic pain conditions has been demonstrated (Jensen, Turner, & Romano, 1991; Kate R. Lorig, Peter D.

Mazonson, & Halsted R. Holman, 1993). Studies on chronic pain have reported that self-efficacy is associated negatively with pain intensity, disability and depressive symptoms, and positively with use of pain coping strategies and better outcomes for managing pain (Arnstein, Caudillb, Mandlea, Norrisa, & Beasley, 1999; Bandura, O’Leary, Taylor, Gauthier, & Gossard, 1987;

Borsbo, Peolsson, & Gerdle, 2008).

Coping vs. Acceptance. The individual’s specific ways of dealing with pain, adjusting to pain, and reducing the pain and distress caused by pain, are known as coping strategies. Coping is spontaneous and intentional, and it includes overt strategies (i.e., resting, medication) and covert strategies (i.e., distracting oneself from pain, seeking information, and problem solving) (Turk &

Monarch, 2002).

In chronic pain management, coping takes two forms - active coping and acceptance (Esteve, Ramírez-Maestre, & López-Martínez, 2007; Goldman, 2010; McCracken & Eccleston,

2003). Active coping refers to directed actions by an individual in pain to control their own pain and to function in spite of any pain that they are experiencing (Esteve et al., 2007). Active coping has been associated with physical activity levels (Snow-Turek, Norris, & Tan, 1996), higher levels of social interaction (Strahl, Kleinknecht, & Dinnel, 2000), and lower levels of depression (Esteve et al., 2007). However, some experts have argued that, while coping with chronic pain experience was understood as to conquer, master, or triumph over adversity, the attempt to control something that is fundamentally uncontrollable which indeed means analgesia, may be considered as a form of avoidance (McCracken & Eccleston, 2003). From this view, the concept of acceptance has been proposed as an effective adaptation effort to chronic pain. Acceptance of chronic pain has been defined as “living with pain without reaction, disapproval, or attempts to reduce or avoid it” (McCracken & Eccleston, 2003). A number of studies suggest that among the many psychological factors, acceptance of pain is one of the most powerful predictors of adaptive coping for patients with chronic pain (McCracken, 1999; Borsbo, Gerdle, & Peolsson, 2010).

Greater acceptance of chronic pain is associated with less pain, depression, pain-related anxiety and behavioral problems (Bach and Hayes, 2002; Jacobson et al., 2000; Kabat-Zinn et al., 1985;

Linehan, 1993; McCracken & Eccleston, 2003). Recently another term “approach” coping is proposed. Approach coping refers to “the person’s cognitive and behavioral orientation to chronic pain” (Sturgeon & Zautra, 2010, p. 108) which stands in contrast to both efforts to directly solve the problem or avoidance behavior.