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Cognitive factors and persistent pain: A glimpse into pandora's box

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Abstract

Conventional models of persistent pain have tended to be dichotomous in nature, with pain viewed as either physically or psychologically based. Inadequacies inherent in both of these views have resulted in alterative conceptualizations that focus on the integration of biomedical with cognitive, affective, and behavioral factors. During the past decade there has been a proliferation of research designed to examine the relative contributions of individuals' attitudes, beliefs, appraisals, self-perceptions, and coping strategies to the perception, experience, and response to noxious sensations as well as treatment, and how these are modified as a result of treatment. In this paper a cognitive—behavioral conceptualization of persistent pain is described and contrasted with sensory, psychogenic, motivational, and operant conditioning models. A number of cognitive assessment procedures and recent research on the role of cognitive schemata, cognitive processes, and ongoing cognition in chronic pain are briefly summarized. The central importance of negative cognition — “catastrophizing” — is emphasized. Once pandora's cognitive box has been opened, a range of important issues must be addressed or one may be consumed by unbridled enthusiasm for the development of instruments and correlational research. Several caveats regarding current research on cognitive mediators are raised, namely, confounds among the cognitive measures that have proliferated and between cognitive measures and measures of mood states, generalizability of results based on pain clinic samples, and adherence to “patient uniformity myths.”

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References

  • American Psychiatric Association (1987).Diagnostic and statistical manual (3rd rev. ed. Washington, DC: Author.

    Google Scholar 

  • Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change.Psychological Review, 84 191–215.

    Google Scholar 

  • Bandura, A., O'Leary, A., Taylor, C. B., Gauthier, J., & Gossard, D. (1987). Perceived self-efficacy and pain control—opioid and nonopioid mechanisms.Journal of Personality and Social Psychology, 53 563–571.

    Google Scholar 

  • Bandura, A., Taylor, C. B., Williams, S. L., Meffort, I. N., & Barchas, J. D. (1985). Catecholamine secretion as a function of perceived coping self-efficacy.Journal of Consulting and Clinical Psychology, 53 406–414.

    Google Scholar 

  • Black, R. G. (1975). The chronic pain syndrome.Surgical Clinics of North America, 55 999–1011.

    Google Scholar 

  • Blanchard, E. B. (1987). Long-term effects of behavioral treatment of chronic headache.Behavior Therapy, 18 375–385.

    Google Scholar 

  • Block, A. R., Kremer, E. F., & Gaylor, M. (1980). Behavioral treatment of chronic pain: The spouse as a discriminative cue for pain behaviors.Pain, 2 243–252.

    Google Scholar 

  • Blumer, D., & Heilbronn, M. (1982). Chronic pain as a variant of depressive disease. The pain-prone disorder.Journal of Nervous and Mental Disease, 9170 381–406.

    Google Scholar 

  • Boden, S. D., Davis, D. O., Dina, T. S., Patronas, N. J., & Wiesel, S. W. (1990). Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects.Journal of Bone and Joint Surgery, 72-A 403–408.

    Google Scholar 

  • Boston, K., Pearce, S. A., & Richardson, P. H. (1990). The Pain Cognitions Questionnaire.Journal of Psychosomatic Research, 34 103–109.

    Google Scholar 

  • Bradley, L. A., Young, L. C., Anderson, K. O., Turner, R. A., Aguelo, C. A., McDaniel, L. K., Pisko, E. J., Semble, E. L., & Morgan, T. M. (1987). Effects of psychological therapy on pain behavior of rheumatoid arthritis patients: Treatment outcome and six-month follow up.Arthritis and Rheumatism, 30 105–114.

    Google Scholar 

  • Cairns, D., & Pasino, J. (1977). Comparison of verbal reinforcement and feedback in the operant treatment of disability of chronic low back pain.Behavior Therapy, 8 621–630.

    Google Scholar 

  • Chaves, J. F., & Brown, J. M. (1987). Spontaneous cognitive strategies for the control of clinical pain and stress.Journal of Behavioral Medicine, 10 263–276.

    Google Scholar 

  • Cioffi, D. (1991). Beyond attentional strategies: A cognitive-perceptual model of somatic interpretation.Psychological Bulletin, 109 25–41.

    Google Scholar 

  • Council, J. R., Ahern, D.K., Follick, M. J., & Kline, C. L. (1988). Expectancies and functional impairment in chronic low back pain.Pain, 33 323–331.

    Google Scholar 

  • Deyo, R. A. (1986). The early diagnostic evaluation of patients with low back pain.Journal of General Internal Medicine, 1 328–338.

    Google Scholar 

  • Dolce, J. J., Crocker, M. F., & Doleys, D. M. (1986). Prediction of outcome among chronic pain patients.Behaviour Research and Therapy, 24 313–319.

    Google Scholar 

  • Dolce, J. J., Doleys, D. M., Raczynski, J. M., Lossie, J., Poole, L., & Smith, M. (1986). The role of self-efficacy expectancies in the prediction of pain tolerance.Pain, 27 261–272.

    Google Scholar 

  • Doleys, D. M., Crocker, M., & Patton, D. (1982). Response to patients with chronic pain to exercise quotas.Physical Therapy, 62 1111–1115.

    Google Scholar 

  • Dufton, B. D. (1989). Cognitive failure and chronic pain.International Journal of Psychiatry in Medicine, 19 291–297.

    Google Scholar 

  • Engel, G. L. (1959). ‘Psychogenic’ pain and the pain-prone patient.American Journal of Medicine, 26 899–918.

    Google Scholar 

  • Estlander, A.-M., & Harkapaa, K. (1989). Relationship between coping strategies, disability and pain levels in patients with chronic low back pain.Scandinavian Journal of Behavior Therapy, 18 59–69.

    Google Scholar 

  • Fernandez, E., & Turk, D. C. (1989). The utility of cognitive coping strategies for altering pain perception: A meta-analysis.Pain, 38 123–135.

    Google Scholar 

  • Flor, H., Birbaumer, N., & Turk, D. C. (1990). The psychobiology of chronic pain.Advances in Behaviour Research and Therapy, 12 47–84.

    Google Scholar 

  • Flor, H., & Turk, D. C. (1988). Chronic back pain and rheumatoid arthritis: Predicting pain and disability from cognitive variables.Journal of Behavioral Medicine, 11 251–265.

    Google Scholar 

  • Flor, H., Turk, D. C., & Birbaumer, N. (1985). Assessment of stress-related psychophysiological responses in chronic back pain patients.Journal of Consulting and Clinical Psychology, 53 354–364.

    Google Scholar 

  • Flor, H., Turk, D. C., & Rudy, T. E. (1989). Relationship of pain impact and significant other reinforcement of pain behaviors: The mediating role of gender, marital status and marital satisfaction.Pain, 38 45–50.

    Google Scholar 

  • Fordyce, W. E. (1976).Behavioral methods for chronic pain and illness. St. Louis: Mosby.

    Google Scholar 

  • Gauthier, J., Cote, L., & Drolet, M. (1985). Migraine and blood volume pulse biofeedback: How does clinical improvement relate to self-efficacy?Canadian Psychology, 25. (Abstract No. 167)

  • Gil, K. M., Williams, D. A., Keefe, F. J., & Beckham, J. C. (1990). The relationship of negative thoughts to pain and psychological distress.Behavior Therapy, 21 349–362.

    Google Scholar 

  • Gross, R. T., & Collins, F. K. (1981). On the relationship between anxiety and pain: A methodological confounding.Clinical Psychology Review, 1 375–386.

    Google Scholar 

  • Herman, E., & Baptiste, S. (1981). Pain control: Mastery through group experience.Pain, 10 79–86.

    Google Scholar 

  • Heyneman, N. E., Fremouw, W. J., Gano, D., Kirkland, F., & Heiden, L. (1990). Individual differences in the effectiveness of different coping strategies for pain.Cognitive Therapy and Research, 14 63–77.

    Google Scholar 

  • Hijzen, T. H., Slangen, S. L., & Van Houweligew, H. C. (1986). Subjective clinical and EMG effects of biofeedback and splint treatment.Journal of Oral Rehabilitation, 13 529–539.

    Google Scholar 

  • Holroyd, K. A., & Andrasik, F. (1982). Do the effects of cognitive therapy endure? A two-year follow-up of tension headache sufferers treated with cognitive therapy or biofeedback.Cognitive Therapy and Research, 6 325–333.

    Google Scholar 

  • Holroyd, K. A., Penzien, D. B., Hursey, K. G., Tobin, D. L., Rogers, L., Holm, J. E., Marcille, P. J., Hall, J. R., & Chila, A. G. (1984). Change mechanisms in EMG biofeedback training: Cognitive change underlying improvements in tension headache.Journal of Consulting and Clinical Psychology, 52 1039–1053.

    Google Scholar 

  • Ingram, R. E., Atkinson, J. H., Slater, M. A., Saccuzzo, D. P., & Garfin, S. R. (1990). Negative and positive cognition in depressed and nondepressed chronic-pain patients.Health Psychology, 9 300–314.

    Google Scholar 

  • Jensen, M. P., Karoly, P., & Huger, R. (1987). The development and preliminary validation of an instrument to assess patients' attitudes toward pain.Journal of Psychosomatic Research, 31 393–400.

    Google Scholar 

  • Keefe, F. J., Caldwell, D. S., Williams, D. A., Gil, K. M., Mitchell, D., Robertson, C., Martinez, S., Nunley, J., Beckham, J., & Helms, M. (1990). Pain coping skills training in the management of osteoarthritic knee pain: A comparative study.Behavior Therapy, 21 49–62.

    Google Scholar 

  • Keefe, F. J., & Williams, D. A. (1989). New directions in pain assessment and treatment.Clinical Journal of Pain, 2 549–568.

    Google Scholar 

  • Keefe, F. J., & Williams, D. A. (1990). A comparison of coping strategies in chronic pain patients in different age groups.Journal of Gerontology: Psychological Sciences, 45 P161-P165.

    Google Scholar 

  • Kerns, R. D., Turk, D. C., Holzman, A. D., & Rudy, T. E. (1986). Comparison of cognitive-behavioral and behavioral approaches to the outpatient treatment of chronic pain.Clinical Journal of Pain, 1 195–203.

    Google Scholar 

  • Kores, R. C., Murphy, W. D., Rosenthal, T. L., Elias, D. B., & North, W. C. (1990). Predicting outcome of chronic pain treatment via a modified self-efficacy scale.Behaviour Research and Therapy, 28 5–169.

    Google Scholar 

  • Kotarba, J. A. (1983).Chronic Pain: Its social dimensions. Beverly Hills, CA: Sage.

    Google Scholar 

  • Lefebvre, M. F. (1981). Cognitive distortion and cognitive errors in depressed psychiatric and low back pain patients.Journal of Consulting and Clinical Psychology, 49 517–525.

    Google Scholar 

  • Leventhal, H., Meyer, D., & Nerenz, D. (1980). The common-sense representations of illness danger. In S. Rachman (Ed.),Contributions to medical psychology (Vol. 2, pp. 7–30). New York: Pergamon Press.

    Google Scholar 

  • Litt, M. D. (1988). Self-efficacy and perceived control: Cognitive mediators of pain tolerance.Journal of Personality and Social Psychology, 54 149–160.

    Google Scholar 

  • Lorig, K., Chastain, R. L., Ung, E., Shoor, S., & Holman, H. R. (1989). Development and evaluation of a scale to measure perceived self-efficacy in people with arthritis.Arthritis and Rheumatism, 32 37–44.

    Google Scholar 

  • Martin, P. R., Nathan, P. R., Milech, D., & Van Keppel, M. (1989). Cognitive therapy vs. self-management training in the treatment of chronic headaches.British Journal of Clinical Psychology, 28 347–361.

    Google Scholar 

  • Melzack, R. (1986). Neurophysiological foundations of pain. In R. A. Sternbach (Ed.),The psychology of pain (2nd ed.). New York: Raven Press.

    Google Scholar 

  • Melzack, R., & Casey, K. L. (1968). Sensory, motivational, and central control determinants of pain: A new conceptual model. In D. Kenshalo (Ed.),The skin senses (pp. 423–443). Springfield, IL: Thomas.

    Google Scholar 

  • Melzack, R., & Wall, P. D. (1965). Pain mechanisms: A new theory.Science, 150 971–979.

    Google Scholar 

  • Melzack, R., & Wall, P. D. (1983).The challenge of pain. New York: Basic Books.

    Google Scholar 

  • Miller, S. M. (1981). Controllability and human stress: Methods, evidence, and theory.Behaviour Research and Therapy, 17 287–304.

    Google Scholar 

  • Moore, J. E., & Chaney, E. F. (1985). Outpatient group treatment of chronic pain: Effects of spouse involvement.Journal of Consulting and Clinical Psychology, 53 326–334.

    Google Scholar 

  • Nachemson, A. L. (1976). The lumbar spine: An orthopedic challenge.Spine, 1 59–71.

    Google Scholar 

  • Newton, C. R., & Barbaree, H. E. (1987). Cognitive changes accompanying headache treatment: The use of a thought-sampling procedure.Cognitive Therapy and Research, 11 635–652.

    Google Scholar 

  • Nicassio, P. M., Wallston, K. A., Callahan, L. F., Herbert, M., & Pincus, T. (1985). The measurement of helplessness in rheumatoid arthritis. The development of the Arthritis Helplessness Index.Journal of Rheumatology, 12 462–467.

    Google Scholar 

  • Nisbett, R. E., & Ross, L. D. (1980).Human inference: Strategies and shortcomings of informal judgment. New York: Prentice-Hall.

    Google Scholar 

  • Nouwen, A., & Solinger, J. W. (1979). The effectiveness of EMG biofeedback training in low back pain.Biofeedback and Self-Regulation, 4 103–111.

    Google Scholar 

  • O'Leary, A., Shoor, S., Lorig, K., & Holman, H. R. (1988). A cognitive-behavioral treatment for rheumatoid arthritis.Health Psychology, 7 527–544.

    Google Scholar 

  • Osterweis, M., Kleinman, A., & Mechanic, D. (1987).Pain and disability: Clinical, behavioral, and public policy perspectives. Washington, DC: National Academy Press.

    Google Scholar 

  • Parker, J. C., Frank, R.G., Beck, N. C., Smarr, K. L., Buescher, K. L., Philips, L. R., Anderson, S. K., & Walker, S. E. (1988). Pain management in rheumatoid arthritis patients: A cognitive-behavioral approach.Arthritis and Rheumatism, 31 593–601.

    Google Scholar 

  • Parker, J. C., Smarr, K. L., Buescher, K. L., Philips, L. R., Frank, R. G., Beck, N. C., Anderson, S. K., & Walker, S. E. (1989). Pain control and rational thinking. Implications for rheumatoid arthritis.Arthritis and Rheumatism, 32 984–990.

    Google Scholar 

  • Philips, H. C. (1987). Avoidance behaviour and its role in sustaining chronic pain.Behaviour Research and Therapy, 25 273–279.

    Google Scholar 

  • Reesor, K. A., & Craig, K. D. (1988). Medically incongruent chronic back pain: Physical limitations, suffering, and ineffective coping.Pain, 32 35–45.

    Google Scholar 

  • Romano, J. M., Turner, J. A., Syrjala, K. L., & Levy, R. L. (1987). Coping strategies of chronic pain patients: Relationship to patient characteristics and functioning.Pain, Suppl 4 S416. (Abstract No. 802)

    Google Scholar 

  • Rosenstiel, A. K., & Keefe, F. J. (1983). The use of coping strategies in low back pain patients: Relationship to patient characteristics and current adjustment.Pain, 17 33–40.

    Google Scholar 

  • Rowe, M. L. (1969). Low back pain industry: A position paper.Journal of Occupational Medicine, 161–169.

  • Schmidt, A. J. M. (1985a). Performance level of chronic low back pain patients in different treadmill test conditions.Journal of Psychosomatic Research, 29 639–646.

    Google Scholar 

  • Schmidt, A. J. M. (1985b). Cognitive factors in the performance of chronic low back pain patients.Journal of Psychosomatic Research, 29 183–189.

    Google Scholar 

  • Schwartz, D. P., DeGood, D. E., & Shutty, M. S. Jr. (1985). Direct assessment of beliefs and attitudes of chronic pain patients.Archives of Physical Medicine and Rehabilitation, 66 806–809.

    Google Scholar 

  • Segal, Z. V., & Shaw, B. F. (1988). Cognitive assessment: Issues and methods. In K. Dobson (Ed.),Handbook of cognitive-behavioral therapies (pp. 32–50). New York: Guilford Press.

    Google Scholar 

  • Shutty, M. S., Jr., & DeGood, D. E. (1990). Patient knowledge and beliefs about their pain and its treatment.Rehabilitation Psychology, 35 43–54.

    Google Scholar 

  • Slater, M. A., Hall, H. F., Atkinson, J. H., & Garfin, S. R. (1991). Pain and impairment in chronic back pain: Validation of the Pain and Impairment Relationship Scale (PAIRS).Pain, 44 51–56.

    Google Scholar 

  • Smith, T. W., Follick, M. J., Ahern, D. K., & Adams, A. (1986). Cognitive distortion and disability in chronic low back pain.Cognitive Therapy and Research, 10 201–210.

    Google Scholar 

  • Smith, T. W., Peck, J. R., Milano, R. A., & Ward, J. R. (1988). Cognitive distortion in rheumatoid arthritis: Relation to depression and disability.Journal of Consulting and Clinical Psychology, 56 412–416.

    Google Scholar 

  • Smith, T. W., Peck, J. R., & Ward, J. R. (1990). Helplessness and depression in rheumatoid arthritis.Health Psychology, 9 377–389.

    Google Scholar 

  • Spanos, N. P., Horton, C., & Chaves, J. F. (1975). The effects of two cognitive strategies on pain threshold.Journal of Abnormal Psychology, 84 677–68.

    Google Scholar 

  • Stein, M. J., Wallston, K. A., Nicassio, P. M., & Castner, N. M. (1988). Correlation of clinical classification schema for the arthritis helplessness subscale.Arthritis and Rheumatism, 31 876–881.

    Google Scholar 

  • Sullivan, M., & D'Eon, J. L. (1990). Relation between catastrophizing and depression in chronic pain patients.Journal of Abnormal Psychology, 99 260–263.

    Google Scholar 

  • Thompson, S. C. (1981). Will it hurt less if I can control it? A complex answer to a simple question.Psychological Bulletin, 90 89–101.

    Google Scholar 

  • Turk, D. C. (1990). Customizing treatment for chronic pain patients: Who, what and why?Clinical Journal of Pain, 6 255–270.

    Google Scholar 

  • Turk, D. C., & Flor, H. (1987). Pain > pain behaviors: Utility and limitations of the pain behavior construct.Pain, 31 277–295.

    Google Scholar 

  • Turk, D. C., Meichenbaum, D., & Genest, M. (1983).Pain and behavioral medicine: A cognitive-behavioral perspective. New York: Guilford Press.

    Google Scholar 

  • Turk, D. C., & Rudy, T. E. (1986). Assessment of cognitive factors in chronic pain: A worthwhile enterprise?Journal of Consulting and Clinical Psychology, 54 760–768.

    Google Scholar 

  • Turk, D. C. & Rudy, T. E. (1988). Toward an empirically derived taxonomy of chronic pain patients: Integration of psychological assessment data.Journal of Consulting and Clinical Psychology, 56 233–238.

    Google Scholar 

  • Turk, D. C., & Rudy, T. E. (1990). Neglected factors in chronic pain treatment outcome studies — Referral patterns, failure to enter treatment, and attrition.Pain, 43 7–26.

    Google Scholar 

  • Turk, D. C., & Rudy, T. E. (1991). Neglected topics in the treatment of chronic pain patients — Relapse, noncompliance, and adherence enhancement.Pain, 44 5–28.

    Google Scholar 

  • Turk, D. C., Rudy, T. E., & Salovey, P. (1986). Implicit modes of illness: Description and validation.Journal of Behavioral Medicine, 2 453–474.

    Google Scholar 

  • Turner, J. A., & Clancy, S. (1986). Strategies for coping with chronic low back pain: Relationship to pain and disability.Pain, 24 355–362.

    Google Scholar 

  • Turner, J. A., & Clancy, S. (1988). Comparison of operant behavioral and cognitive-behavioral group treatment for chronic low back pain.Journal of Consulting and Clinical Psychology, 56 261–266.

    Google Scholar 

  • Vlaeyen, J. W. S., Geruts, S. M., Kole-Snijders, A. M., Schuerman, J. A., Groenman, N. H., & Van Eek (1990). What do chronic pain patients think of their pain? Towards a pain cognition questionnaire.British Journal of Clinical Psychology, 29 383–394.

    Google Scholar 

  • Weisel, S. E., Tsourmas, N., Feffer, H., et al. (1984). A study of computer assisted tomography in the incidence of positive CAT scans in an asymptomatic group of patients.Spine, 2 549–551.

    Google Scholar 

  • Williams, D. A., & Thorn, B. E. (1989). An empirical assessment of pain beliefs.Pain, 36 351–358.

    Google Scholar 

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  1. Pain Evaluation and Treatment Institute, University of Pittsburgh School of Medicine, Baum Boulevard at Craig Street, 15213, Pittsburgh, Pennsylvania, USA

    Dennis C. Turk & Thomas E. Rudy

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  1. Dennis C. Turk
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Preparation of this paper was supported in part by grant 2R01AR38698 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases, and grant 2R01DE07514 from the National Institute of Dental Research.

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Turk, D.C., Rudy, T.E. Cognitive factors and persistent pain: A glimpse into pandora's box. Cogn Ther Res 16, 99–122 (1992). https://doi.org/10.1007/BF01173484

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