The Psychophysiological impact of marital interactions upon spouses of chronic pain patients

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The Psychophysiological impact of marital interactions upon spouses of chronic pain patients
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Thesis (Ph.D.)--University of Florida, 1990.
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Bibliography: leaves 87-91.
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by Daniel B. Stampler.
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Vita.

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THE PSYCHOPHYSIOLOGICAL IMPACT OF MARITAL INTERACTIONS
UPON SPOUSES OF CHRONIC PAIN PATIENTS









BY

DANIEL B. STAMPLER


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


1990

























Copyright 1990

by

Daniel B. Stampler


















To my parents














ACKNOWLEDGEMENTS

I would like to acknowledge the contributions of a

number of individuals. Foremost, I would like to thank

Hugh Davis, Ph.D., for his guidance and support throughout

my graduate training, for providing me the opportunity to

work in his laboratory, and for creating the unique

collaborative environment for this project. I would like

to thank Jeffrey Cassisi, Ph.D., for his knowledge and

assistance in technical matters, for his energy and

interest in this project and my career development, and

for establishing the various contacts needed to facilitate

this project. I would like to extend my appreciation to

Michael MacMillan, M.D., for allowing me the opportunity

to attend his busy clinics and recruit subjects from his

patient population. I would also like to thank Warren

Rice, Ph.D., for facilitating subject recruitment through

the V.A. I would like to thank Eileen Fennell, Ph.D., and

Michael Creary, Ph.D., for their comments and suggestions

regarding this research. Finally, I would like to thank

Anita Saloman and Candace Valenstein for their valuable

assistance.















TABLES OF CONTENTS

ACKNOWLEDGEMENTS...................................... iv

LIST OF TABLES................ ........................ vi

ABSTRACT............................................... vii

INTRODUCTION............................................ 1

The Role of the Family and Marriage in Chronic Pain... 3
The Impact of Chronic Pain on the Marriage and the
Spouse............. ............................... .... 7
Spouse Psychophysiology and Responses to Chronic Pain. 14
Experimental Hypotheses................................ 15

METHODS ................................................ 18

Subjects. ............................................. 18
Measures......................................................... 18
Procedures.. ........................................... 21

RESULTS......................... ........................ 24

Data Analyses.......................................... 24
General Characteristics................................. 25
Pain and Symptom Characteristics...................... 25
Marital Characteristics of Chronic Pain............... 29
Spouse Psychophysiology.............................. 34

DISCUSSION............................................. 51

Interpreting Autonomic Arousal......................... 54
Gender Differences in Satisfaction-Mediated Arousal... 58
Additional Characteristics of Chronic Pain Marriages.. 60
Concluding Comments.. ................................ 65

APPENDIX A: DETAILED EXPERIMENTAL PROTOCOL............. 67

APPENDIX B: NONCOPYRIGHTED MATERIALS................... 73

APPENDIX C: RAW DATA................................... 79

REFERENCES.......... ...... .... .......................... 87

BIOGRAPHICAL SKETCH.................................... 92














LIST OF TABLES


Table Page
1 Means and Standard Deviations of Selected
Characteristics of Chronic Pain Couples......... 26

2 Prevalence of Patient and Spouse Marital
Satisfaction by Gender in Chronic Pain Couples.. 29

3 Intercorrelations of Marital and Pain Variables
for All Spouses and by Spouse Gender............. 33

4 Stepwise Regression Model for Spouse Skin
Conductance When Listening to the Pain
Presentation.................................... 38

5 Spouse Skin Conductance Reactivity by Level of
Spouse Marital Satisfaction Under Experimental
Conditions....................................... 38

6 Stepwise Regression Model for Female Spouse
Skin Conductance When Listening to the Pain
Presentation................................... 39

7 Stepwise Regression Model for Spouse Skin
Conductance When Responding to the Pain
Presentation................................... 41

8 Stepwise Regression Model for Female Spouse
Skin Conductance When Responding to the Pain
Presentation. .. ............. ................... 43

9 Stepwise Regression Model for Spouse Heart Rate
When Listening to the Pain Presentation.......... 45

10 Spouse Heart Rate Reactivity by Level of Patient
Marital Satisfaction Under Experimental
Conditions....................................... 45

11 Stepwise Regression Model for Male Spouse Heart
Rate When Listening to the Pain Presentation.... 46

12 Stepwise Regression Model for Spouse Heart Rate
When Responding to the Pain Presentation........ 48

13 Stepwise Regression Model for Male Spouse Heart
Rate When Responding to the Pain Presentation... 49














Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

THE PSYCHOPHYSIOLOGICAL IMPACT OF MARITAL INTERACTIONS
UPON SPOUSES OF CHRONIC PAIN PATIENTS

By

Daniel B. Stampler

August 1990

Chairman: Hugh Davis, Ph.D.
Major Department: Clinical and Health Psychology

The purpose of this investigation was to describe the

characteristics of chronic pain marriages, examine the

psychophysiological impact of marital interactions about

chronic pain, and explore a psychophysiological

explanation for the maintenance of maladaptive spousal

responses to pain. Solicitous responses were considered

maladaptive since they tend to reinforce pain. Twenty-six

chronic pain couples engaged in a series of structured

marital interactions about neutral and pain topics while

being monitored for skin conductance (SC) and heart rate

(HR) activity. Marital satisfaction and spouse

solicitousness were proposed to mediate spouse reactivity

when spouses passively listened and actively responded to

patient pain presentations. It was proposed that

satisfied spouses would display empathic reactivity when

listening to the pain and solicitous spouses would


vii








attentuate their arousal when responding to the pain.

This attenuation of arousal was presumed to reinforce

spouse solicitiousness.

There was strong support for the role of marital

satisfaction. Spouse satisfaction mediated SC reactivity

while patient satisfaction mediated HR reactivity. The

more satisfied the couple, the more empathic and attentive

the spouse when listening to the pain and less reactive

the spouse when responding to the pain. Dissatisfied

spouses were autonomically deactivated when listening to

the pain yet more reactive when responding to the pain.

Gender differences also emerged. Spouse satisfaction

mediated SC in female spouses while patient satisfaction

mediated HR in male spouses. In both cases, the wife's

satisfaction mediated spouse reactivity. There was no

evidence for a psychophysiological explanation for the

maintenance of maladaptive spousal responses to chronic

pain. However, adaptive "distracting" responses were

associated with HR accelerations when male spouses

responded to the pain. These HR increases may reflect the

distracting husband's inattention to the wife's pain.

In general, the wives of patients appeared most

vulnerable in chronic pain marriages. They were more

prone to marital dissatisfaction than male spouses or the

patients themselves. Also, engaging in more adaptive

responses to pain was related to more somatic distress in

wives. Dissatisfied wives were more depressed, less


viii








empathic as listeners, and more reactive as responders to

their husband's pain. Directions for future research were

addressed.














INTRODUCTION

The study of chronic pain has been traditionally

approached in terms of the medical model with the focus on

the afflicted individual. The initial emphasis was placed

on the physical aspects of tissue injury or disease

process and the subjective experience of unpleasant

sensation. What has proven elusive with the phenomenon of

pain, in both its acute or chronic form, is the lack of

correspondence often observed between the extent of

organic pathology and the amount or quality of pain

experienced (Melzack, 1983). Indeed, many chronic pain

conditions, particularly the low back varieties, have no

discernible physical basis (Dolce & Raczynski, 1985). The

unidimensional sensory model of chronic pain has given way

to more comprehensive models which incorporate

psychological, psychosocial, and psychophysiological

constructs.

The introduction of psychological variables to the

study of chronic pain has broadened the perspective from

which to conceptualize the development and maintenance of

chronic pain. For instance, the diathesis-stress model

described by Turk and Flor (1984) suggests that chronic

pain can result from the interaction of a predisposing

organic or psychological condition with the occurrence of








personally relevant stressful events. Thus, in the

myofascial (i.e., soft tissue) pain patient with

inadequate coping abilities, recurrent or intensive

aversive stimulation is proposed to lead to painful muscle

spasm. From this approach, treatment typically involves

the acquisition of coping strategies to reduce stress and

tension levels in order to better manage the antecedents

and consequences of the pain.

Although the conceptualization of chronic pain has

broadened, assessment and treatment activities have tended

to focus on the individual patient. The familial context

in which the pain evolved and currently exists has been,

until more recently, somewhat overlooked (Flor & Turk,

1985). In recent years, increasing attention has been

devoted to the impact of chronic pain upon family members

and the role of the family in the development,

maintenance, and treatment of chronic pain. Particular

interest has been given to the role of the spouse in

chronic pain.

The influence of the family in health and illness can

not be ignored or underestimated. Despite the advances of

modern medicine and the expansion of the formal health

care system, the family continues to serve as primary unit

of health care and maintenance (Litman, 1974; Pratt,

1976). The family is a principal source of beliefs and

attitudes about health and illness as well as expected

responses to physical symptoms (Gochman, 1985). With








respect to chronic pain, the theoretical perspective has

been expanding to incorporate the marital and family

dimensions (Roy, 1985).

The purpose of this investigation is to elucidate the

marital dimension of chronic pain. The aim is to describe

and examine the characteristics of marital relationships

which are associated with chronic pain conditions. This

research also explores the psychophysiological impact upon

spouses of pain-related marital interactions as well as a

psychophysiological explanation for the maintenance of

spousal responses which serve to perpetuate chronic pain

conditions.

As an introduction, the literature regarding the role

of the family and marriage in the development and

maintenance of chronic pain as well as the research on the

impact of chronic pain on the marriage and spouse will be

presented. A model for the relationship between spouse

psychophysiology and spousal responses to chronic pain

will be discussed. More specific statements of the

hypotheses will follow.

The Role of the Family and Marriage in Chronic Pain

There is a considerable amount of evidence indicating

that the families of chronic pain patients, both family of

origin and current family, have a greater prevalence of

pain problems than families of non-pain patients (Gentry,

Shows, & Thomas, 1974; Merskey, 1965; Mohamed, Weisz, &

Waring, 1978; Violon & Giurgea, 1984). This finding








suggests that the family unit may provide a variety of

sources for the development and maintenance of chronic

pain in one or more of its members. There are numerous

perspectives from which to conceptualize the family's role

in chronic pain.

The psychodynamic perspective views chronic pain as a

somatic expression of unresolved psychic conflict stemming

from early childhood experiences. This viewpoint is

exemplified by the work of Engel (1959) who developed the

concept of the "pain-prone personality." Pain-proneness

was said to result from early childhood experiences of

neglect and abuse and to reflect the expression of

internalized aggression and guilt. The family of origin

is thus seen as central to the development of a chronic

pain personality.

The systems perspective views chronic pain in terms

of its role within the family context. The family is seen

as a network of relationships where the functioning of

each member is partly dependent upon the functioning of

other members. Symptoms which develop in the family

context are believed to serve a stabilizing role in the

family system. The systems approach to chronic illness

has been discussed by Haley (1963) and Waring (1982).

Haley (1963) proposed that behavior is always multilevel

communication, and that illness behavior is no exception.

An expression of pain can reflect a subjective feeling

state, yet also communicate a desire to avoid intimacy or








to shift tasks and responsibilities to others. Waring

(1982) stated that pain and suffering can serve a mutual

care-giving function in couples deficient in mature

expressions of intimacy. In both cases, the pain serves

to stabilize a dysfunctional relationship within the

family or marriage.

The behavioral perspective views chronic pain as the

product of modeling influences and/or the conditioning of

pain behavior. Observational learning can account for the

acquisition of behaviors associated with pain (e.g.,

complaining, seeking reassurance and attention, utilizing

health care systems). As noted above, there is

substantial evidence of familial modeling influences for

chronic pain patients. Modeling influences can also

account for spousal responses to pain behavior, such as

care-giving responses (Kremer, Seiber, & Atkinson, 1985).

Families can teach its members how to respond to pain in

others as well as how to express it.

The operant conditioning model of chronic pain has

been described by Fordyce (1976). According to this

model, the experience of pain manifests itself in some

form of behavior which, over time, can become subject to

the effects of conditioning. Pain behaviors can come

under the control of reinforcement contingencies which

perpetuate the chronic pain condition. Chronic pain may

be maintained by pain-contingent attention and sympathy,

avoidance of undesirable activities, and other pain








reinforcing events. Wellness behaviors, such as activity

and independence of function, may or may not be reinforced

by the contingencies in the patient's environment and may,

in fact, be actively discouraged. In such fashion, pain

and disability can be maintained and fostered even when

the initial cause of pain has been resolved. On the other

hand, the occurrence of pain-contingent punishment, such

as the withholding of attention, can serve to discourage

the chronicity of pain behaviors.

Fordyce's (1976) operant approach may easily operate

within the context of the marriage. The primary care-

giver for the chronic pain patient is often the spouse.

Since the manner in which care-giving functions are

performed can have a significant impact upon pain

expression, the spouse can play a key role in the

maintenance of chronic pain and dysfunction. The

"solicitous" or overprotective spouse may serve as a

consistent and reliable source of reinforcement for pain

behavior by providing desirable consequences when the

patient exhibits pain and by withholding such rewards when

the patient appears healthy and functional. On the other

hand, the "nonsolicitous" spouse may serve as an

unreliable source of pain-contingent reinforcement and may

only show friendly concern when the patient is functional.

Numerous anecdotal reports support the notion that

the spouse can contribute to the maintenance of chronic

pain (Fordyce, 1976; Khatami & Rush, 1978; Maruta,








Osborne, Swanson, & Halling, 1981). Flor, Kerns, and Turk

(1987) showed that spouse reinforcement of pain was

significantly related to both perceived pain and activity

levels of chronic pain patients. The best predictor of

patient's pain and activity levels was the patient's

perception of spousal responses to chronic pain. Block,

Kremer, and Gaylor (1980) provided evidence that the

solicitous spouse can serve as a discriminative cue for

pain behavior. They interviewed twenty married chronic

pain patients who were told that their spouse or a neutral

observer was viewing them through a one-way mirror. The

patients who had described their spouses as nonsolicitous

reported significantly lower pain levels in the spouse-

observer condition compared to the neutral-observer

condition. The patients who had described their spouses

as solicitous reported higher levels of pain in the

spouse-observer condition compared to the neutral-observer

condition.

When solicitous spouse behaviors occur with

regularity in response to pain, one would suspect that

these behaviors are also maintained within the

environment. In considering factors which might maintain

spousal responses to pain, one should consider the impact

of chronic pain on the marriage and the spouse.

The Impact of Chronic Pain on the Marriage and the Spouse

By virtue of its intractable nature, chronic pain has

ample time to affect the functioning of the marriage.








When a spouse develops chronic pain, routine marital and

family interaction patterns can become disrupted. Roy

(1988) noted that role changes and role conflicts may

arise, such as dependency in the family provider or the

inability to engage in traditional role responsibilities.

Marital adjustment may also suffer due to social

isolation, communication difficulties, and impaired sexual

functioning (Hudgens, 1979). While the findings indicate

that marriages in which one partner has chronic pain are

full of strife, Roy (1988) pointed out that the studies to

date provide only a fragmentary picture of the disruptive

effects of chronic pain on marriage.

Marital Satisfaction

Chronic pain has been shown to impact significantly

upon the patient's marital adjustment. In Maruta and

Osborne's (1978) sample of 66 chronic pain patients, over

30% reported deterioration in marital adjustment and 60%

reported deterioration in sexual adjustment. Merskey and

Boyd (1978) compared 141 chronic pain patients with or

without organic pathology associated with the pain and

discovered that the nonorganic group presented with more

pre-morbid personality problems and more ongoing marital

difficulties. Mohamed et al. (1978) compared 26 depressed

persons with or without complaints of pain and found that

the depressed pain group evidenced more marital

difficulties. Kreitman, Sainsbury, Pierce, and Costain

(1965) reported similar findings.








Marital satisfaction has also been studied in chronic

pain couples. Kerns and Turk (1984) examined 30 chronic

pain patients and their spouses and reported significant

marital dissatisfaction in over half of the sample. Flor

et al. (1987) reported that 34% of 32 chronic pain

patients and 59% of their spouses were dissatisfied with

their marriages. Maruta et al. (1981) examined 50 couples

and found that, despite similarly favorable ratings prior

to pain onset, 82% of patients rated their marriage as

"average" or "above average" six months after pain onset

while 54% of their spouses rated their marriage as "below

average." In all, 65% of spouses reported deterioration

in satisfaction. Ahern and Follick (1985) examined 117

spouses of chronic pain patients. Over 35% rated their

marriages overall as maladjusted and 40% reported

significant dissatisfaction with specific areas of their

marital functioning. Patients' functional impairment,

particularly in the psychosocial realm, predicted spouses'

marital satisfaction better than either the patients' or

spouses' emotional distress. The spouses were more likely

to become dissatisfied with the relationship when the

patient became more withdrawn and socially isolated.

In summary, a substantial proportion of couples with

a chronic pain patient evidence marital difficulties.

Flor et al. (1987) and Maruta et al. (1981) further note

that spouses tend to view their marriages less favorably

than their ill partners. One can speculate that secondary








gain due to reinforcement of sick role behavior could

account for these findings. The disruptive effects of

chronic pain on marital satisfaction may become asymmetric

when the patient has an excuse for dysfunction and an

overprotective spouse who takes over responsibilities at

the expense of his/her own satisfaction in the marriage.

Spouse Symptomatology

The refractory nature of chronic pain can have an

adverse impact on the somatic and psychological well-being

of the patient's spouse (Rowat, 1985) as well as the

patient (Turk, Rudy, & Flor, 1985). Shanfield, Heiman,

Cope, and Jones (1979) reported significant symptomatic

distress in 44 spouses using the Symptom Check List-90.

In addition to an elevation on the global symptom index,

spouses obtained high scores on scales of depression,

anxiety, hostility, somatization, and interpersonal

sensitivity. Mohamed et al. (1978) found that the spouses

of their depressed pain group exhibited more pain problems

than the spouses of their depressed group. Flor, Turk,

and Scholz (1987) also discovered evidence of physical

symptoms in 58 spouses of chronic pain patients. The

spouses of maritally dissatisfied patients had more

physical symptoms than spouses of maritally satisfied

patients; these spouses also tended to be less supportive

of their partners, more depressed, and less maritally

satisfied themselves. A subsample of 20 spouses was








compared to 20 spouses of diabetic patients and evidenced

significantly more pain-related symptoms.

Rowat and Knafl (1985) interviewed 40 spouses about

their perceptions and experiences regarding the pain

problem, its impact on marital life, and its management.

Approximately 83% reported having experienced some form of

health disturbance (e.g., physical, emotional, or social)

which they attributed directly to their partner's chronic

pain condition. These symptoms included depression,

nervousness, neurovegetative distress, headaches, and

social restriction and isolation. Forty percent (40%)

expressed a sense of helplessness with regard to how to

manage the pain problem while 25% described managing the

home environment as the way they attempt to exert control

over the pain.

Rowat and Knafl (1985) divided their sample into high

versus low distress spouses on the basis of symptomatology

and number of life areas affected by the pain problem.

One striking difference between these groups was that the

high distress spouses (80% female) primarily adopted the

role of "protector-advocate" with their partners while the

low distress spouses (60% male) reported using more

avoidance or ignoring behaviors. The role of "protector"

involved shielding the patient from undue stress and

potentially painful activities. As earlier noted, such

solicitous behavior can have pain-reinforcing

consequences. These latter results are in contrast to








Flor et al. (1987) who found symptomatic spouses to be

less supportive of their partners.

In summary, there is mixed evidence regarding how the

impact of chronic pain marriages upon spouses, in terms of

symptomatology, relates to marital adjustment and spousal

responses to chronic pain.

Spouse Psychophysiology

In addition to somatic and psychological

consequences, chronic pain in a marital partner can also

have a psychophysiological impact on the spouse. Berger

(1962) demonstrated that observers respond physiologically

when viewing displays of pain or emotion in others.

Observers have been shown to respond to expressions of

pain with increases in skin conductance (Berger, 1962),

and facial electromyography (Vaughan & Lanzetta, 1981),

and with decreases in heart rate (Craig & Lowery, 1969).

Block (1981) referred to these bodily reactions as

evidence of "psychophysiological empathy" because these

responses reflect an emotional reaction to the plight of

another person.

Block (1981) examined the autonomic effects of pain

displays on the spouses of 16 male chronic pain patients.

The spouses were psychophysiologically monitored while

they viewed a series of brief videotaped segments of

painful and neutral facial displays of their marital

partners and confederate performers. The spouses also








provided pain intensity ratings of the various displays as

well as marital satisfaction scores.

The spouses exhibited greater increases in skin

conductance to the pain displays, whether emitted by their

marital partners or the performers. More interestingly,

satisfied spouses showed greater increases in skin

conductance to the painful displays of their partners than

did dissatisfied spouses, even though both groups

perceived the facial expressions as similarly painful.

Block's (1981) results support the notion of a

psychophysiological empathic response to signs of distress

and further suggests that the magnitude of this response

varies directly in relation to the level of marital

satisfaction. Satisfied spouses appear more vulnerable to

aversive psychophysiological reactions in response to

their partners' pain; less satisfied spouses appear less

empathic to similarly perceived pain.

Block (1981) speculated that the overt responses of

spouses may be influenced by their physiological state,

that is, spouses may respond in ways to reduce their

aversive state of arousal. One way in which spouses can

reduce this source of aversive feeling is to provide

comfort when their partners are in pain. Since such

spousal responses have been shown to influence chronic

pain behavior (Fordyce, 1976), spousal autonomic responses

to expressions of pain could provide a mechanism for the

spousal maintenance of chronic pain. Unfortunately, no








data on solicitous spouse behaviors were collected by

Block (1981).

Spouse Psychophysioloqy and Responses to Chronic Pain

Roy (1982) stated that there is a need for empirical

validation of the various models and mechanisms proposed

to explain maladaptive spouse responses to chronic pain.

The mechanism presented by Block (1981) involves the

removal of an aversive stimulus. Solicitous, care-giving

responses were suggested to reduce unpleasant

physiological arousal brought about by expressions of pain

and suffering. Marital satisfaction was proposed to

mediate the degree of arousal. With respect to this

model, Kremer et al. (1985) stated that the task for

research is to identify how these reactive spouses respond

to their partners and whether these ways of responding

reduce any unpleasant arousal.

Indeed, the relationship between spouse

solicitousness and spouse psychophysiology has not been

investigated. Moreover, the relationship between spouse

solicitousness and spouse marital satisfaction is not

definitive. Kremer et al. (1985) reported that solicitous

spouse behaviors were more prevalent in satisfied

marriages. In contrast, Flor et al. (1987) did not find

an association between pain-reinforcing behaviors and

spouse satisfaction. Clearly, all three variables need to

be studied in one investigation.








To date, marital satisfaction and psychophysiological

reactivity to a marital partner in pain have been related

in only one investigation. Block (1981) used videotaped

presentations of the patient in pain. A live interaction

would lend validity to the notion that the partner's pain

leads to an empathic response in the satisfied spouse.

Furthermore, a live interaction would allow the spouse the

opportunity to respond to his/her partner and to his/her

own physiology; the solicitous spouse could be presumed to

reduce his/her autonomic arousal.

Experimental Hypotheses

The marital characteristics of chronic pain were

examined for the following hypotheses:

1.) There will be a substantial proportion of

marital distress and dissatisfaction in both patients and

spouses. Gender differences in marital satisfaction were

also examined with no specific predictions.

2.) Spousal responses to chronic pain behavior will

be related to patient pain and symptom variables. For

example, spouse solicitousness will correlate positively

with pain severity, pain duration, and patient symptom

distress. Spouse solicitousness will also be positively

related to patient marital satisfaction as Flor et al.

(1987), among others, have shown that patients with

reinforcing spouses are more satisfied with their

relationships despite reporting more intense pain.








3.) The associations between spouse symptom

distress, spouse solicitousness, and spouse marital

satisfaction were examined to clarify their relationships.

As mentioned previously, Rowat and Knafl (1985) found

distressed spouses to be more "protective" of their

partners while Flor et al. (1987) found distressed spouses

to be less "supportive" as well as less maritally

satisfied. The evidence for the relationship between

spouse satisfaction and solicitousness has been mixed.

The psychophysiology of marital interactions about

the chronic pain were examined for the following

hypotheses:

1.) Spouses who are more maritally satisfied, more

solicitous, or both, will exhibit greater autonomic

reactivity when listening to their partners describe their

pain problem than spouses who are lower in these

variables.

2.) Spouses who are more maritally satisfied, more

solicitous, or both, will exhibit lesser autonomic

reactivity when responding to and discussing their

partners' pain problem than spouses who are lower in these

variables.

While it is proposed that spouse marital satisfaction

and solicitousness are related to spouse psychophysiology,

it is not known which variable will be most predictive of

spouse autonomic reactivity under the experimental

conditions. The predictive power of other variables, such





17


as pain duration and severity, spouse symptom distress,

spouse age, spouse gender, marriage duration, and patient

marital satisfaction will also be considered in the

analyses. It is conceivable that these variables could be

more relevant mediators of spouse psychophysiology.














METHODS

Subjects

Twenty-six chronic low back pain patients and their

spouses who attend the Orthopaedics Clinic or Neurological

Surgery Clinic at Shands Teaching Hospital or the Veterans

Administration Medical Center in Gainesville, Florida,

were recruited for this investigation. To be eligible to

participate in the study, each patient must have had a

history of chronic low back pain exceeding six months in

duration and a diagnosis from their physician of a chronic

pain syndrome in the lower back region. In addition, the

spouse must have been willing and able to participate in

the study. The age range was limited to 18-65 years.

Also, potential subjects who showed obvious cognitive

impairment, severe psychopathology, or an inability to

read or speak English were excluded from the study. The

couples received a $40 fee for their participation.

Measures

In addition to the collection of demographic

information, the following measures were obtained from

patients and spouses:

Marital Adjustment Test (MAT)

The MAT is a widely used, validated, and reliable

self-report measure of marital adjustment and satisfaction








(Locke & Wallace, 1959). The MAT contains 15 items which

assess various aspects of marriage, such as communication,

affection, sexual compatibility, social activities, and

value differences, with the total score reflecting overall

satisfaction with the marriage.

West Haven-Yale Multidimensional Pain Inventory (WHYMPI)

The WHYMPI is a 52-item comprehensive, self-report

measure of the impact and experience of pain. This

instrument has psychometric utility for pain assessment

(Kerns, Turk, & Rudy, 1985). The WHYMPI is composed of 12

empirically derived scales divided into three sections.

The first section (20 items) is designed to assess impact

of pain on the patient's life (e.g., life interference,

support, pain severity, control, and negative mood). The

second section (14 items) is designed to assess the

patient's perceptions of the range of behavioral responses

of significant others to his/her expressions of pain

(e.g., solicitous responses, punishing responses, and

distracting responses). The third section (18 items)

examines the extent to which the patient participates in

common daily activities (e.g., household chores, outdoor

work, activities away from home, and social activities).

The patients completed the WHYMPI whereas the spouses

provided ratings of their perceptions of patient pain

severity using a scale similar in content to the pain

severity scale from the WHYMPI.








Symptom Checklist-90 Revised (SCL-90)

The SCL-90 is a 90-item self-report measure of

psychological symptom patterns. This instrument has sound

psychometric properties (Derogatis, 1983). Each item is

rated on a five-point scale from no distress to extreme

distress. The SCL-90 contains nine primary symptom scales

(e.g., somatization, depression, anxiety, hostility,

obsessive-compulsive, interpersonal sensitivity, phobic

anxiety, paranoid ideation, and psychoticism) as well as

three summary scales of overall psychological distress

(e.g., global symptom index, positive symptom distress

index, and the positive symptom total).

Follow-Up Questionnaire

The quality of the marital interactions was assessed

with a series of six-point rating scales. Specifically,

patients and spouses rated the how natural and typical the

various marital interactions were as well as how "neutral"

the mutually chosen neutral topic was for them.

Autonomic Measures

Skin conductance (SC) and heart rate (HR) measures

were collected continuously throughout each experimental

condition. Skin conductance was measured with 10mm

Beckman electrodes attached to the thenar and hypothenar

eminences of the left palmar surface (Venables & Christie,

1973). A water soluble transmission gel (KY Jelly) was

applied to the electrodes as a contact medium and the

electrode sites were prepared with distilled water. The








SC signal was processed through a Coulbourn Skin

Conductance Coupler (S71-22).

Heart rate was measured with a photoplethysmographic

sensor placed on the center portion of the distal phalanx

of the left index finger. The HR signal was processed

through a Coulbourn Pulse Monitor Optical Densitometer

(S71-40) and a Coulbourn Tachometer (S77-26).

Both SC and HR signals were relayed through a

Coulbourn 8-bit, analog-to-digital convertor (L25-08) to

Labtech Notebook software on an AT compatible personal

computer. The data were sampled at two hertz and stored

on disc for later reduction and analysis in Lotus 1-2-3

and PC-SAS (Version 6.03).

Procedures

Chronic pain couples were recruited either by mail or

in person during a routine clinic visit. The couples were

asked whether they would be willing to participate in a

study of the impact of chronic back pain on marital and

family life. They were told that the study was not part

of their treatment and that their decision to take part or

not to take part would in no way affect any present or

future treatment at Shands Teaching Hospital or the

Veterans Administration Medical Center. If the couple

expressed interest, the study was briefly explained. When

there were patients in the clinic who expressed interest

but were not accompanied by a spouse, future contact was








made to include the spouse in the decision to participate

in the study.

Appendix A contains a detailed, verbatim account of

the experimental protocol. Essentially, the couple was

led to a waiting area where informed consent was obtained

and the questionnaires were completed. Following the

questionnaire period, the couple was led to the

experimental room and familiarized with its contents. The

psychophysiological sensors were presented to the couple

and attached as described. Following a five-minute

habituation period, the couple engaged in a series of

structured interactions. The first set of interactions

involved a mutually chosen neutral topic. For the first

90 seconds, the patient talked about the topic while the

spouse listened. When signaled, the spouse was allowed to

respond and engage in a two-way discussion of the topic

for three minutes. The second set of interactions

involved the impact of the chronic pain on daily life.

Similarly, for the first 90 seconds, the patient talked

about the pain while the spouse listened. When signaled,

the spouse was allowed to respond and engage in a two-way

discussion of the pain for three minutes. Thus, there

were four conditions during which the couples interacted

about neutral and pain topics. From the perspective of

the spouses of chronic pain patients, these conditions

were "neutral-listen," "neutral-respond," "pain-listen,"

and "pain-respond." Following the interactions, patients





23


and spouses completed ratings of the quality of the

marital interactions. When the experiment was completed,

the couple was debriefed about the purposes of the study

and paid $40 for their time and effort.














RESULTS

For clarity, the term "spouse" in the following text

refers to the spouse of the pain patient and not to the

patient him/herself.

Data Analyses

Most of the self-report data were analyzed using two-

way analysis of variance procedures (ANOVA) with patient

status (patient/spouse) and gender (male/female) as

grouping factors. Where appropriate, one-way ANOVAs were

performed to examine gender differences within the patient

and spouse groups (e.g., pain duration, spouse

solicitousness). Pearson correlations between selected

variables were also performed. Unless otherwise noted,

the .05 alpha level is assumed.

The psychophysiological data were analyzed using

stepwise regression procedures to determine the relevant

variables (e.g., marital satisfaction) which best

predicted autonomic reactivity under experimental

conditions. Additional stepwise regressions were

performed to examine gender differences in spouse

psychophysiological reactivity. One-way ANOVAs were

performed to examine group differences in autonomic

reactivity with respect to relevant predictor variables

(e.g., satisfied versus dissatisfied spouses).








General Characteristics

The means and standard deviations of the various

characteristics of patients and spouses are presented in

Table 1. The patients were almost evenly divided by

gender with 54% male (n=14) and 46% female (n=12);

conversely, spouses were represented by slightly more

females. There were no significant age differences

between patients and spouses, between husbands and wives,

or between the sexes in each group (F(3,48)=0.54, ns;

overall M=42.5 years). Similarly, the mean education

levels of marital partners were equivalent (F(3,48)=0.63,

ns; overall M=12.7 years). Marital duration for the

chronic pain couples averaged 13.2 years. There were no

significant differences in marital duration when patients

were male rather than female (F(1,48)=0.09, ns).

Pain and Symptom Characteristics

Mean pain duration in patients was six years. Pain

chronicity in male patients was about three years longer

than in female patients; however, this difference was not

statistically significant (E(1,24)=0.83, ns). In 73% of

the marriages, the pain complaint originated after the

couple was married.

The pain severity ratings provided by patients and

spouses (who rated their partners) were statistically

equivalent (F(1,48)=0.16, ns), averaging 4.28 and 4.15,

respectively, on a six-point scale. These ratings were

slightly above the norms provided by the WHYMPI for















Table 1. Means and Standard Deviations of Selected
Characteristics of Chronic Pain Couples


Variable


Patient


Spouse


SEX (% male)
AGE (years)
EDUC (years)
MDUR (years)
PDUR (years)
a __


53.8%
42.0 (9.1)
12.8 (2.3)
13.2 (11.2)
6.0 (7.9)


46.2%
42.9 (9.5)
12.7 (2.0)
13.2 (11.2)
ib


PRAT- 4.28 (1.15) 4.15 (1.17)
GSI 65 4c (8.8) 60.5c (10.2)
PSDI 63s6d (8.6) 56.9d (9.5)
SOM 68.0d (6.7) 56.7 (9.8)
MAT 107 (32.1) 103 (27.4)
PUNa 1.80 (1.60)
SOLa 3.94 (1.27)
DISa 2.71 (1.34)
-------------------------------------------------------


Patient


Variable


Male


Spouse


Female


Male


Female


43.2 (11.9)
12.3 (2.1)
12.8 (10.4)

4.17b(1.1)
62.5 (9.9)
54.0 (9.5)
56.2 (9.5)
107 (24)
1.79 (1.62)
3.76 (1.42)
2.56 (1.47)


42.7 (7.3)
13.1 (1.8)
13.7 (12.4)

4.14b(1.28)
58.8 (10.4)
59.4 (9.0)
57.1 (10.4)
99 (31)
1.81 (1.66)
4.14 (1.11)
2.90 (1.19)


- ------- -- -- --- --- --- c--- --- d---------~
a 0-6 point scale b Spouse-rated c <.07 d <.01

EDUC=Education, MDUR=Marital Duration, PDUR=Pain Duration,
PRAT=Pain Severity Rating, GSI=Global Symptom Index,
PSDI=Positive Symptom Distress Index, SOM=Somatization,
MAT=Marital Adjustment Test, PUN=Punishing Responses,
SOL=Solicitous Responses, DIS=Distracting Responses.


44.1
13.1
12.8
7.3
4.19
65.1
62.7
69.0
109


AGE
EDUC
MDUR
PDUR
PRATa
GSI
PSDI
SOM
MAT
PUNa
SOLa
DISa


(8.2)
(3.0)
(10.4)
(9.8)
(1.33)
(11.2)
(7.2)
(8.0)
(28)


39.6
12.3
13.7
4.5
4.39
65.8
64.6
66.9
105


(9.7)
(1.0)
(12.4)
(5.2)
(0.94)
(5.2)
(10.2)
(5.0)
(38)








chronic pain patients. Patient-rated and spouse-rated

pain severity were moderately correlated, r=+0.64, also

suggesting that the marital partners viewed pain severity

similarly. There were no gender effects (F(1,48)=0.07,

ns) or interaction effects (F(1,48)=0.11, ns) for pain

severity ratings.

The Global Symptom Index (GSI) from the SCL-90 is a

summary score representative of a variety of cognitive and

emotional symptoms. A near-significant difference in mean

GSI scores for patients and spouses (F(1,48)=3.43, E<.07)

was found. The mean GSI scores for patients and spouses

were 65.4 and 60.5, respectively, both of which were below

the clinical range. There were no gender effects

(E(1,48)=0.34, ns) or interaction effects (F(1,48)=0.42,

ns) for GSI scores. Patient GSI scores were positively

correlated with both patient-rated and spouse-rated pain

severity, r=+0.64 and r=+0.55, respectively, indicating a

moderate relationship between patient pain severity and

patient global symptom distress. Spouse GSI scores were

not correlated with pain severity ratings.

The Positive Symptom Distress Index (PSDI) is a

summary score representative of the intensity of symptoms

endorsed by the respondent. The mean PSDI scores for

patients and spouses were 63.6 and 56.9, respectively.

This group difference was statistically significant

(F(1,48)=7.17, E<.01) and indicated that the patients'

symptomatology was more intense than their spouses'








symptomatology. There were no gender effects

(F(1,48)=2.14, ns) or interaction effects (F(1,48)=0.51,

ns) for PSDI scores. Patient PSDI scores were positively

correlated with both patient-rated and spouse-rated pain

severity, r=+0.55 and r=+0.40, respectively, indicating a

moderate association between patient pain severity and

patient symptom intensity. Spouse PSDI scores were not

correlated with pain severity ratings.

The sole symptom subscale on the SCL-90 on which

patients and spouses differed significantly was the

Somatization subscale (F(1,48)=23.16, p<.0001). The

patients attained a mean score of 68 compared to the

spouse mean score of 56.7, indicating that the patients

suffered from more somatic-physical symptoms than spouses.

There were no gender effects (F(1,48)=0.06, ns) or

interaction effects (f(1,48)=0.4, ns) for SOM scores.

Patient SOM scores were positively correlated with both

patient-rated and spouse-rated pain severity, r=+0.49 and

r=+0.47, respectively, indicating a moderate association

between patient pain severity and patient somatization.

Spouse SOM scores were not correlated with pain severity

ratings.

Marital partners did not differ significantly on the

remaining symptom subscales which included depression,

anxiety, hostility, and interpersonal sensitivity.









Marital Characteristics of Chronic Pain

Marital Satisfaction

A substantial proportion of patients and spouses

reported marital dissatisfaction and maladjustment.

Nearly 27% of the patients and 42% of their spouses scored

in the dissatisfied range on the MAT (MAT<100). When

patient and spouse marital adjustment were examined by

gender, the percentage of dissatisfied marital partners

ranged from 50% in female spouses to 33% in both male

spouses and female patients to 21% in male patients.

Thus, the wives of chronic pain patients evidenced the

greatest prevalence of marital dissatisfaction in chronic

pain marriages (see Table 2).


Table 2. Prevalence of Patient and Spouse Marital
Satisfaction by Gender in Chronic Pain Couples
-------------------------------------------
Level of Patients Spouses
Marital -----------------------------
Satisfaction Male Female Male Female
--------------------------------------------------
Satisfied 78.6% 67.0% 67.0% 50.0%
Dissatisfied 21.4% 33.0% 33.0% 50.0%
--------------------------------------------------


When examining marital satisfaction by couple, 54% of

the couples were conjointly satisfied in their marriages

while 23% were conjointly dissatisfied. In accordance,

the correlation between patient and spouse MAT was

r=+0.53. About 19% of the marriages consisted of a

satisfied patient and dissatisfied spouse. In these

disjointly satisfied couples, 80% of the dissatisfied

spouses were female. In contrast, half of the








dissatisfied spouses in conjointly dissatisfied couples

were female and half of the satisfied spouses in

conjointly satisfied couples were female. Thus, the

couples in which only one partner was maritally satisfied

were characterized by a satisfied male patient and a

dissatisfied wife. As further evidence for gender

differences in marital satisfaction, the correlation

between patient and spouse MAT differed by spouse gender.

When the spouses were male, r=+0.78 indicating more

conjoint marriages; when the spouses were female, the

association was nonsignificant, reflecting the prevalence

of dissatisfied wives married to satisfied patients.

When examining group differences in mean MAT scores,

there were no significant differences found by patient

status (F(1,48)=0.23, ns), gender (F(1,48)=0.53, ns), or

their interaction (F(1,48)=0.85, ns). The mean MAT scores

for patients and spouses were 107 and 103, respectively,

suggesting relative satisfaction overall. When these

groups were further examined by gender, the mean MAT

scores ranged from 99 in female spouses to 109 in male

patients, though none of the differences between means

were significant.

Marital Satisfaction and Symptom Distress

Marital satisfaction in patients and spouses was not

associated with the symptom scales of the SCL-90 with the

exception of a significant negative correlation between

female spouse satisfaction and depression, r=-0.68, and a








near-significant negative correlation between female

spouse satisfaction and global symptom distress, r=-0.50,

E<.07. Thus, dissatisfied wives of chronic pain patients

were more depressed and perhaps more globally distressed

than satisfied wives.

Marital satisfaction in patients and spouses was not

associated with pain severity ratings (provided by patient

or spouse). There were also no significant differences in

pain severity ratings when grouped by satisfaction level.

Thus, satisfied and dissatisfied spouses perceived similar

levels of pain severity in patients. Also, satisfied and

dissatisfied patients experienced similar levels of pain.

Spousal Responses to Chronic Pain

The spouse's typical manner of responding to the

patient's chronic pain behavior was measured by the WHYPMI

subscales of punishing (PUN), solicitous (SOL), and

distracting (DIS) responses. The mean score for SOL was

3.94, which exceeded one standard deviation above the

WHYPMI norm for solicitous responding. The mean scores

for PUN (M=1.80) and DIS (M=2.71) exceeded the norms

within one standard deviation. There were no gender

differences in mean scores for PUN (F(1,24)=0.0, ns), SOL

(F(1,24)=0.56, ns), or DIS (F(1,24)=0.41, ns), indicating

that husbands and wives of chronic pain patients did not

differ in the amount of punishing, solicitous, and

distracting responses toward the pain.








The intercorrelations between PUN, SOL, and DIS are

presented in Table 3. The variable SOL was negatively

correlated with PUN, r=-0.39, and positively correlated

with DIS, r=+0.48. Thus, spouses who responded more

solicitously to their partner's chronic pain behavior also

tended to respond in a less punishing and more distracting

manner. When examined by gender, these correlations did

not reach significance.

Spousal Responses and Pain Variables

The variables PUN, SOL, and DIS were not associated

with pain duration or the patient's rating of pain

severity, suggesting that spousal responses to chronic

pain were not implicated in pain chronicity or severity

(see Table 3). Spouse-rated pain severity was positively

correlated with DIS, r=+0.51, indicating that the more

pain the spouse perceives, the more distracting the spouse

is in response to the pain (or vice versa). This

relationship held for female spouses, r=+0.67, but for not

male spouses. The variables PUN, SOL, and DIS were also

not associated with the activity scales from the WHYPMI,

suggesting that spousal responses to pain were also not

related to the level of patient dysfunction.

Spousal Responses and Symptom Distress

The variables PUN, SOL, and DIS were not associated

with GSI, PSDI, or SOM in either patient or spouse groups,

suggesting that spousal responses to chronic pain are not

related to patient or spouse symptomatology. However, SOM
















Table 3. Intercorrelations of Marital and Pain Variables
for All Spouses and by Spouse Gender
-------------------------------------------------------
All Spouses
-------------------------------------------------------
MAT1 MAT2 PUN SOL DIS PRAT1 PRAT2 PDUR
-------------------------------------------------------
MAT1 ~
MAT2 +0.53 -
PUN -0.44 -0.39 ~
SOL ns +0.39 -0.39 ~
DIS ns +0.53 ns +0.48
PRAT1 ns ns ns ns +0.51 ~
PRAT2 ns ns ns ns ns +0.64
PDUR ns ns ns ns ns ns ns
---------------------------------------------
Male Spouses
-------------------------------------------------------
MAT1 MAT2 PUN SOL DIS PRAT1 PRAT2 PDUR
-------------------------------------------------------
MAT1
MAT2 +0.78
PUN -0.74 ns
SOL ns ns ns
DIS ns ns ns ns
PRAT1 ns ns ns ns ns ~
PRAT2 ns ns ns ns ns +0.70
PDUR ns ns ns ns ns ns ns
-------------------------------
Female Spouses
-------------------------------------------------------
MAT1 MAT2 PUN SOL DIS PRAT1 PRAT2 PDUR
-------------------------------------------------------
MAT1
MAT2 ns
PUN ns ns
SOL ns ns ns
DIS ns +0.78 ns ns
PRAT1 ns ns ns ns +0.67
PRAT2 ns ns ns ns ns +0.61
PDUR ns ns ns ns ns ns ns
---------------------------------------------
D<.05
MATl=Spouse Marital Satisfaction, MAT2=Patient Marital
Satisfaction, PUN=Punishing Responses, SOL=Solicitous
Responses, DIS=Distracting Responses, PRAT1=Spouse-Rated
Pain Severity, PRAT2=Patient-Rated Pain Severity,
PDUR=Pain Duration.








and PSDI scores for wives of patients were correlated with

DIS (r=+0.59 and r=+0.65, respectively) suggesting that

the more somatic the wife, the more distracting she is in

response to the pain (or vice versa). The variables SOL

and PUN were not associated with GSI, SOM, or PSDI scores

for either gender.

Spousal Responses and Marital Satisfaction

Spousal responses to chronic pain were significantly

related to marital satisfaction (see Table 3). Patient

MAT was positively correlated with SOL, r=+0.39, and DIS,

r=+0.53, and negatively correlated with PUN, r=-0.39.

Thus, satisfied patients had less punishing and more

solicitous and distracting spouses. These relationships

did not hold when examined by spouse gender, except for a

positive correlation between patient MAT and DIS for

female spouses, r=+0.78.

Spouse MAT was negatively associated with PUN,

r=-0.44, but was not associated with either SOL or DIS.

Thus, satisfied spouses were less punishing in response to

the pain. This relationship held for male spouses,

r=-0.74, but not for female spouses.

Spouse Psvchophysiology

Dependent Measures

The autonomic measures of skin conductance (SC) and

heart rate (HR) were analyzed separately with stepwise

regression procedures. For each autonomic measure, two

dependent measures were examined which reflected the








spouse's autonomic reactivity to pain presentations under

listening and responding conditions.

To derive these dependent measures, the mean SC and

HR of spouses during each of the four conditions (i.e.,

"neutral-listen," "neutral-respond," "pain-listen," and

"pain-respond") were obtained. The spouse's autonomic

reactivity to listening to the patient's pain presentation

was derived by subtracting the spouse's autonomic activity

during the "neutral-listen" condition from the spouse's

autonomic activity during the "pain-listen" condition.

Thus, each autonomic measure reflected how much more or

less aroused the spouse was when presented with the pain

topic compared to the neutral topic.

The spouse's autonomic reactivity to responding to

the patient's pain was derived by subtracting the change

in the spouse's autonomic reactivity during the "neutral"

conditions (i.e., the change from the "listen" phase to

the "respond" phase) from the corresponding change in the

spouse's autonomic reactivity during the "pain"

conditions. Thus, each autonomic measure reflected how

much more or less aroused the spouse was when responding

to the pain topic compared to the neutral topic.

Since the dependent measures reflected change in

autonomic activity from one condition to another, the

magnitude of change could be partly determined by the

initial psychophysiological levels which from change was

measured. This phenomenon is referred to as the law of








initial values (Andreassi, 1980) which states that the

higher the initial level, the smaller the increase (or

larger the decrease) in psychophysiological reactivity to

a stimulus. Similarly, the lower the initial level, the

larger the increase (or smaller the decrease) in

reactivity.

To determine whether the law of initial values

applied to the present data, correlations between the

magnitude of change (e.g., "pain-listen" minus "neutral-

listen") and initial levels (e.g., "neutral-listen") were

obtained for each of the dependent measures. For three of

the four dependent measures, the correlations were not

statistically significant, suggesting that the law of

initial values did not apply to these measures. For the

remaining dependent measure, spouse SC reactivity to

listening to the pain, there was a significant negative

correlation. The initial level of SC activity (i.e.,

during "neutral-listen") was included in the appropriate

stepwise regression, along with the other hypothesized

variables, and was not found to be a significant predictor

of spouse SC reactivity to pain under listening

conditions. Thus, the law of initial values did not

appear to have any untoward effects on the data.

Manipulation Check

The subjects provided ratings of the quality of the

marital interactions in order to confirm whether the

interactions were natural and typical of their usual style








of interacting and whether the neutral interactions were

indeed neutral. Both patients and spouses rated the

neutral discussion as neutral, with mean ratings of 5.7

and 5.2, respectively, on a six-point scale. Patients and

spouses also rated the neutral discussion as natural

(M=5.2 and M=5.0, respectively), and the pain discussion

as natural (M=5.1 and M=5.2, respectively) and typical of

their usual interactions about pain (M=4.6 and M=4.8,

respectively). Furthermore, patients and spouses rated

the patient's pain description as typical of the way the

patient usually describes the impact of pain on daily

living (M=5.2 and M=5.3, respectively).

Predicting Spouse Skin Conductance Reactivity to Listening
to the Patient's Pain Presentation

The stepwise regression for spouse SC reactivity is

presented in Table 4. The most predictive variable of

spouse SC reactivity to listening to the patient's pain

presentation was spouse marital satisfaction, which

accounted for 20% of the variance in SC change. The more

satisfied the spouse, the more aroused s/he was when

listening to the pain presentation; the more dissatisfied

the spouse, the less aroused s/he was when listening to

the pain presentation. Satisfied spouses showed a mean SC

change of +0.20 micromhos (uMHOs) while dissatisfied

spouses showed a mean SC change of -0.44 uMHOs. This

group difference in SC reactivity was statistically

significant (F(1,24)=6.42, p<.02). Table 5 contains the

mean changes in spouse SC under experimental conditions.









Table 4. Stepwise Regression Model for Spouse Skin
Conductance When Listening to the Pain Presentation

Step Variable Partial R2 Model R2 F <

1 Spouse Marital Satisfaction .20 .20 6.16 .02
2 Patient Marital Satisfaction .18 .38 6.57 .02
3 Spouse Age .12 .50 5.12 .04
---------------------------------------------------------



Table 5. Spouse Skin Conductance Reactivity by Level of
Spouse Marital Satisfaction Under Experimental Conditions
----------------------------------------------------------
Level of Spouse
Marital Satisfaction Listena Respondb
----------------------------------------------------------
Satisfied +0.20 (0.29) +0.06 (0.37)
Dissatisfied -0.44 (0.94) +0.50 (0.71)
----------------------------------------------------------
Units in micromhos a R<.02 b E<.05


The second most predictive variable was patient

marital satisfaction, which accounted for an additional

18% of the variance in SC change. The more dissatisfied

the patient, the more aroused the spouse was when

listening to the pain presentation; the more satisfied the

patient, the less aroused the spouse was when listening to

the pain presentation.

The third most predictive variable was spouse age,

which accounted for an additional 12% of the variance in

SC change. The older the spouse, the more aroused s/he

was when listening to the pain presentation; the younger

the spouse, the less aroused s/he was when listening to

the pain presentation.

None of the other variables (i.e., spousal responses

to chronic pain, pain severity and duration, spouse









symptom distress, and marital duration) were significantly

predictive of spouse SC reactivity to listening to the

pain presentation.

Female spouses. The stepwise regression for female

spouse SC reactivity is presented in Table 6. The most

predictive variable of wives' SC reactivity to listening

to husbands' pain presentation was wives' marital

satisfaction, which accounted for 57% of the variance in

SC change. The more satisfied the wife, the more aroused

she was when listening her husband's pain presentation;

the more dissatisfied the wife, the less aroused she was

when listening to her husband's pain presentation.

Satisfied wives showed a mean SC change of +0.29 uMHOs

while dissatisfied wives showed a mean SC change of -0.45

uMHOs. This group difference in SC reactivity was

statistically significant (E(1,12)=8.1, R<.02).


Table 6. Stepwise Regression Model for Female Spouse Skin
Conductance When Listening to the Pain Presentation
----------------------------------------------------
Step Variable Partial R2 Model R2 F
-----------------------------------------------------
1 Spouse Marital Satisfaction .57 .57 15.9 .002
----------------------------------------------------


None of the other variables, including spousal

responses to chronic pain, were significantly predictive

of wives' SC reactivity to listening to the husbands' pain

presentation.

Male spouses. In contrast to the findings for

spouses as a whole, none of the variables, including








marital satisfaction, were significantly predictive of

husbands' SC reactivity to listening to the wives' pain

presentation.

Skin conductance summary: listening conditions. The

primary variable mediating the spouse's level of SC

arousal when s/he listened to the patient's pain

presentation was the spouse's level of satisfaction in the

marriage. Maritally satisfied spouses were more

autonomically aroused than maritally dissatisfied spouses.

When the patient was also satisfied (i.e., conjointly

satisfied marriage), SC arousal was attenuated; when the

patient was dissatisfied (i.e., disjointly satisfied

marriage), SC arousal was accentuated.

Upon further examination, the mediating role of

marital satisfaction occurred only among the wives of

chronic pain patients, not the husbands. The more

satisfied the wife was in the marriage, the more aroused

she was when hearing about her husband's pain; the more

dissatisfied the wife, the more unaroused she was (i.e.,

autonomic deactivation). For husbands of female chronic

pain patients, the relationship between marital

satisfaction and SC arousal was not significant. The

husband's SC arousal was not mediated by how satisfied he

was in the marriage (or by any other of the variables

under consideration).

The variables representing the spouse's typical

manner of responding to chronic pain, such as solicitous









or punishing responding, were not shown to mediate SC

arousal when the spouse listened to the patient's pain

presentation. Thus, solicitous spouses did not

necessarily experience increased SC arousal when hearing

about their partners' pain.

Predicting Spouse Skin Conductance Reactivity to
Responding to the Patient's Pain Presentation

The stepwise regression for spouse SC is presented in

Table 7. The most predictive variable of spouse SC

reactivity to responding to and discussing the patient's

pain presentation was spouse marital satisfaction, which

accounted for 20% of the variance in SC change. The more

satisfied the spouse, the less aroused s/he was when

responding to the pain presentation; the more dissatisfied

the spouse, the more aroused s/he was when responding to

the pain presentation. Satisfied spouses showed a mean SC

change of +0.06 uMHOs while dissatisfied spouses showed a

mean SC change of +0.50 uMHOs (see Table 5). This group

difference in SC reactivity was statistically significant

(E(1,24)=4.25, E<.05).


Table 7. Stepwise Regression Model for Spouse Skin
Conductance When Responding to the Pain Presentation
----------------------------------------------------------
Step Variable Partial R2 Model R2 F D<
----------------------------------------------------------
1 Spouse Marital Satisfaction .20 .20 5.85 .03
2 Patient Marital Satisfaction .13 .33 4.63 .05
3 Spouse Symptom Distress .09 .42 3.44 .08
----------------------------------------------------------


The second most predictive variable was patient

marital satisfaction, which accounted for an additional








13% of the variance in SC change. The more dissatisfied

the patient, the less aroused the spouse was when

responding to the pain presentation; the more satisfied

the patient, the more aroused the spouse was when

responding to the pain presentation.

The third most predictive variable was spouse symptom

distress, which accounted for an additional 9% of the

variance in SC change. The more symptomatic the spouse,

the less aroused s/he was when responding to the pain

presentation; the less symptomatic the spouse, the more

aroused s/he was when responding to the pain presentation.

None of the other variables, including spousal

responses to chronic pain, were significantly predictive

of spouse SC reactivity to responding to and discussing

the pain presentation.

Female spouses. The stepwise regression for female

spouse SC reactivity is presented in Table 8. The most

predictive variable of wives' SC reactivity to responding

to and discussing the husbands' pain presentation was

wives' marital satisfaction, which accounted for 38% of

the variance in SC change. The more satisfied the wife,

the less aroused she was when responding to her husband's

pain presentation; the more dissatisfied the wife, the

more aroused she was when responding to her husband's pain

presentation. Satisfied wives showed a mean SC change of

+0.12 uMHOs while dissatisfied wives showed a mean SC

change of +0.78 uMHOs. This group difference in SC









reactivity approached statistical significance (F(1,12)=

4.04, R<.07).


Table 8. Stepwise Regression Model for Female Spouse Skin
Conductance When Responding to the Pain Presentation
----------------------------------------------------------
Step Variable Partial R2 Model R2 F
-------------------------------------------------------
1 Spouse Marital Satisfaction .38 .38 7.25 .02
----------------------------------------------------------


None of the other variables, including spousal

responses to chronic pain, were significantly predictive

of wives' SC reactivity to responding to and discussing

the husbands' pain presentation.

Male spouses. In contrast to the findings for

spouses as a whole, none of the variables, including

marital satisfaction, were significantly predictive of

husbands' SC reactivity to responding to and discussing

the wives' pain presentation.

Skin conductance summary: responding conditions. The

primary variable mediating the spouse's level of SC

arousal when s/he responded to and discussed the patient's

pain presentation was the spouse's level of satisfaction

in the marriage. Maritally dissatisfied spouses were more

autonomically aroused than maritally satisfied spouses.

When the patient was also dissatisfied (i.e., conjointly

dissatisfied marriage), SC arousal was attenuated; when

the patient was satisfied (i.e., disjointly satisfied

marriage), SC arousal was accentuated.








Upon further examination, the mediating role of

marital satisfaction occurred only among the wives of

chronic pain patients, not the husbands. The more

dissatisfied the wife was in the marriage, the more

aroused she was when responding to her husband's pain; the

more satisfied the wife, the less aroused she was. For

husbands of female chronic pain patients, the relationship

between marital satisfaction and SC arousal was not

significant. The husband's SC arousal was not mediated by

how satisfied he was in the marriage (or by any other of

the variables under consideration).

The variables representing the spouse's typical

manner of responding to chronic pain behavior, such as

solicitous or punishing responding, were not shown to

mediate SC arousal when the spouse discussed the patient's

pain presentation. Thus, solicitous spouses did not

necessarily experience decreased SC arousal when

responding to their partners' pain.

Predicting Spouse Heart Rate Reactivity to Listening to
the Patient's Pain Presentation

The stepwise regression for spouse HR reactivity is

presented in Table 9. The most predictive variable of

spouse HR reactivity to listening to the patient's pain

presentation was patient marital satisfaction, which

accounted for 21% of the variance in HR change. The more

satisfied the patient, the less aroused the spouse was

when listening to the pain presentation; the more

dissatisfied the patient, the more aroused the spouse was









when listening to the pain presentation. Spouses of

satisfied patients showed a mean HR change of -0.9 beats

per minute (BPM) while spouses of dissatisfied patients

showed a mean HR change of +4.1 BPM. This group

difference in HR reactivity approached statistical

significance (F(1,24)= 2.95, p<.10). Table 10 contains

the mean changes in spouse HR under experimental

conditions.


Table 9. Stepwise Regression Model for Spouse Heart Rate
When Listening to the Pain Presentation
----------------------------------------------------------
Step Variable Partial R2 Model R2 F
----------------------------------------------------------
1 Patient Marital Satisfaction .21 .21 6.24 .02
----------------------------------------------------------



Table 10. Spouse Heart Rate Reactivity by Level of
Patient Marital Satisfaction Under Experimental Conditions
----------------------------------------------------------
Level of Patient
Marital Satisfaction Listena Respondb
----------------------------------------------------------
Satisfied -0.9 (3.6) +0.5 (3.3)
Dissatisfied +4.1 (11.4) -2.9 (6.3)
----------------------------------------------------------
Units in beats per minute a E<.10 b E<08


None of the other variables, including spousal

responses to chronic pain, were significantly predictive

of spouse HR reactivity to listening to the pain

presentation.

Female spouses. In contrast to the findings for

spouses as a whole, none of the variables, including

marital satisfaction, were significantly predictive of









wives' HR reactivity to listening to the husbands' pain

presentation.

Male spouses. The stepwise regression for male

spouse HR reactivity is presented in Table 11. The most

predictive variable of husbands' HR reactivity to

listening to wives' pain presentation was wives' marital

satisfaction, which accounted for 36% of the variance in

HR change. The more satisfied the wife, the less aroused

the husband was when listening to the wife's pain

presentation; the more dissatisfied the wife, the more

aroused the husband was when listening to the wife's pain

presentation. Husbands of satisfied wives showed a mean

HR change of +1.0 BPM while husbands of dissatisfied wives

showed a mean HR change of +6.8 BPM. This group

difference in HR reactivity was not statistically

significant (F(1,10)=1.23, ns).


Table 11. Stepwise Regression Model for Male Spouse Heart
Rate When Listening to the Pain Presentation
----------------------------------------------------------
Step Variable Partial R2 Model R2 F R<
----------------------------------------------------------
1 Patient Marital Satisfaction .36 .36 5.63 .04
----------------------------------------------------------


None of the other variables, including spousal

responses to chronic pain, were significantly predictive

of husbands' HR reactivity to listening to the wives' pain

presentation.

Heart rate summary: listening conditions. The

primary variable mediating the spouse's level of HR








arousal when s/he listened to the patient's pain

presentation was the patient's level of satisfaction in

the marriage. In addition, the mediating role of marital

satisfaction occurred only among the husbands of chronic

pain patients, not the wives. The more satisfied the

female patient, the less aroused her husband was when

hearing about her pain; the more dissatisfied the female

patient, the more aroused the husband was. For wives of

male chronic pain patients, the relationship between

marital satisfaction and HR arousal was not significant.

The wife's HR arousal was not mediated by how satisfied

the husband was in the marriage (or by any other of the

variables under consideration).

The variables representing the spouse's typical

manner of responding to chronic pain behavior, such as

solicitous or punishing responding, were not shown to

mediate HR arousal when the spouse listened to the

patient's pain presentation.

Predicting Spouse Heart Rate Reactivity to Responding to
the Patient's Pain Presentation

The stepwise regression for spouse HR reactivity is

presented in Table 12. The most predictive variable of

spouse HR reactivity to responding to and discussing the

patient's pain presentation was patient marital

satisfaction, which accounted for 23% of the variance in

HR change. The more satisfied the patient, the more

aroused the spouse was when responding to the pain

presentation; the more dissatisfied the patient, the less








aroused the spouse was when responding to the pain

presentation. Spouses of satisfied patients showed a mean

HR change of +0.5 BPM while spouses of dissatisfied

patients showed a mean HR change of -2.9 BPM (see Table

10). This group difference in HR reactivity approached

statistical significance (F(1,24)=3.36, p<.08).


Table 12. Stepwise Regression Model for Spouse Heart Rate
When Responding to the Pain Presentation
----------------------------------------------------------
Step Variable Partial R2 Model R2 F
----------------------------------------------------------
1 Patient Marital Satisfaction .23 .23 7.33 .02
----------------------------------------------------


None of the other variables, including spousal

responses to chronic pain, were significantly predictive

of spouse HR reactivity to responding to and discussing

the pain presentation.

Female spouses. In contrast to the findings for

spouses as a whole, none of the variables, including

marital satisfaction, were significantly predictive of

wives' HR reactivity to responding to and discussing the

husbands' pain presentation.

Male spouses. The stepwise regression for male

spouse HR reactivity is presented in Table 13. The most

predictive variable of husbands' HR reactivity to

responding to and discussing the wives' pain presentation

was wives' marital satisfaction, which accounted for 50%

of the variance in HR change. The more satisfied the

wife, the more aroused the husband was when responding to









the wife's pain presentation; the more dissatisfied the

wife, the less aroused the husband was when responding to

the wife's pain presentation. Husbands of satisfied wives

showed a mean HR change of -1.2 BPM while husbands of

dissatisfied wives showed a mean HR change of -4.4 BPM.

This group difference in HR reactivity, however, was not

statistically significant (E(1,10)=1.22, ns).


Table 13. Stepwise Regression Model for Spouse Heart Rate
When Responding to the Pain Presentation
---------------------------------------------------------
Step Variable Partial R2 Model R2 F <
----------------------------------------------------------
1 Patient Marital Satisfaction .50 .50 10.0 .01
2 Spouse Distracting Responses .16 .66 4.20 .07
----------------------------------------------------------


The second most predictive variable was husbands'

distracting responses to pain behavior, which accounted

for an additional 16% of the variance in HR change.

Distracting responses are behaviors which aim to distract

the patient from the experience of chronic pain. The more

distracting the husband is in response to pain behavior,

the more aroused he was when responding to the wife's pain

presentation; the less distracting the husband, the less

aroused he was when responding to the wife's pain

presentation.

None of the other variables, including spousal

responses to chronic pain, were significantly predictive

of husbands' HR reactivity to responding to and discussing

the wives' pain presentation.








Heart rate summary: responding conditions. The

primary variable mediating the spouse's level of HR

arousal when s/he responded to and discussed the patient's

pain presentation was the patient's level of satisfaction

in the marriage. In addition, the mediating role of

marital satisfaction occurred only among the husbands of

chronic pain patients, not the wives. The more satisfied

the female patient, the more aroused her husband was when

responding to her pain; the more dissatisfied the female

patient, the less aroused the husband was. For wives of

male chronic pain patients, the relationship between

marital satisfaction and HR arousal was not significant.

The wife's level of HR arousal was not mediated by how

satisfied the husband was in the marriage (or by any other

of the variables under consideration).

For husbands, their manner of responding to chronic

pain (specifically, distracting responding) was also shown

to mediate HR arousal during discussion of the wife's pain

presentation. The more distracting the husbands, the more

aroused they were when responding to the wives' pain.














DISCUSSION

The purpose of this investigation was to describe the

characteristics of chronic pain marriages, examine the

psychophysiological impact of marital interactions about

chronic pain, and explore a psychophysiological

explanation for the maintenance of maladaptive spousal

responses to chronic pain.

In this investigation, two variables were proposed to

have roles in the psychophysiological impact upon spouses

of marital interactions about chronic pain. Spouse

marital satisfaction and solicitousness were proposed to

mediate the spouse's autonomic arousal when listening and

responding to the patient's pain presentation. Maritally

satisfied and/or solicitous spouses were proposed to

manifest more autonomic reactivity when passively

listening to the pain presentation and less reactivity

when actively responding to the pain. The proposed model

suggested that maritally satisfied spouses would display

more "empathic" autonomic responses to their partners'

plight and that solicitous spouses would attenuate their

arousal when allowed to respond to their partners' pain.

The present results strongly support the role of

marital satisfaction in mediating spouse psychophysiology,

but not the role of spousal responses to chronic pain. In








addition, gender differences in satisfaction-mediated

autonomic arousal were discovered. Thus, while marital

satisfaction was implicated in spouse psychophysiological

reactivity during marital interactions about chronic pain,

there was no support for a psychophysiological explanation

for maladaptive spousal responses to chronic pain.

The support for the role of marital satisfaction

represents a conceptual replication of earlier findings

(Block, 1981) which used brief videotaped stimuli of male

pain patients presented to wives who were being monitored

for autonomic reactivity. The present investigation used

in vivo interactions of chronic pain couples and studied

both husbands and wives of patients, allowing for the

discovery of gender differences. The present results were

similar to Block's (1981) findings in that satisfied

spouses responded with greater SC arousal to patient pain

than dissatisfied spouses (who perceived similar levels of

pain); spouse satisfaction also accounted for a similar

amount of the variance in SC arousal and none of the

variance in HR arousal. Block (1981) had found that

spouse HR also increased to patient pain displays,

suggesting an overall arousal response. In the present

study, spouse HR responses were mediated by patient

marital satisfaction whereby only the spouses of

dissatisfied patients showed such HR accelerations to pain

presentations. When the patients were satisfied, their

spouses showed HR decelerations.








Levenson and Gottman (1983) used psychophysiological

data obtained during marital interactions to predict

current levels of marital satisfaction. Their composite

measure of psychophysiological "linkage" or temporal

interrelatedness between partners accounted for over 60%

of the variance in the couple's marital satisfaction. In

the present study, the predictive strength of marital

satisfaction with regard to changes in psychophysiological

arousal was moderate overall and, in two instances, it

exceeded 50% of the variance in autonomic reactivity. The

female spouse's marital satisfaction predicted 57% of the

variance in her SC reactivity when she listened to her

husband describe his pain; the female patient's marital

satisfaction predicted 50% of the variance in the male

spouse's HR reactivity when he responded to her pain. As

Levenson and Gottman (1983) similarly noted about their

findings, the strength of these interrelations between

psychophysiology and marital satisfaction is greater than

is usually obtained between observable behavior and

marital satisfaction.

The lack of support for the connection between spouse

solicitousness and autonomic reactivity suggest that

marital overprotection of the pain patient does not

influence and is not influenced by the spouse's

physiological state. Similar statements can be made

regarding spousal punishing responses and the wife's

distracting responses. Distracting husbands were found to








evidence higher HR when responding to the pain. A

limitation in these data with regard to spousal responses

to pain is that questionnaire measures quantifying the

spouse's typical manner of responding to pain were used to

represent spousal responses during the interactions.

Perhaps if the spouses' actual behaviors were codified

along the relevant dimensions, significant relationships

with spouse psychophysiology would have emerged. At

present, there are no available coding systems for spousal

responses to chronic pain.

Interpreting Autonomic Arousal: Empathy and Attention

The autonomic measure of SC is often interpreted as

indicative of the emotional reactivity of the organism

(Andreassi, 1980) and supportive evidence exists showing

autonomic reactivity in observers of persons in distress

(Bandura & Rosenthal, 1966; Berger, 1962; Block, 1981;

Craig & Lowery, 1969, Craig & Wood, 1969). One

interpretation of SC arousal under these circumstances is

that it represents an empathic response. Empathy has been

defined as "an emotional state elicited by and congruent

with the perceived welfare of someone else" (Batson &

Coke, 1983, p.419) whereby witnessing another person in

undesirable circumstances can lead to an aversive

emotional reaction in the observer. In the present study,

the magnitude of SC arousal in spouses was associated with

the level of spouse satisfaction in the marriage. Thus,

satisfied spouses were more empathic when listening to








their partners describe the pain's impact on their daily

lives. In contrast, dissatisfied spouses were unempathic

toward their partners' pain (i.e., they evidenced SC

deactivation). Whether spouses were more empathic because

they were more maritally satisfied or spouses perceived

themselves as more satisfied because they respond

empathically to their partners remains unaddressed.

In addition to SC reactivity, empathic spouses showed

HR deceleration to the pain presentation when their

partners were also satisfied in the marriage. Cardiac

deceleration has been shown to accompany "empathic

listening" and to reflect facilitated "mental intake" of

environmental stimuli (Lacey, 1959). Thus, satisfied

patients had more attentive spouses when they presented

them with the pain's impact on daily living. Dissatisfied

patients had less attentive spouses who exhibited cardiac

acceleration to the pain presentation, reflective of

"mental rejection" of environmental stimuli (Lacey &

Lacey, 1974). Once again, the issue remains whether

spouses were more attentive because patients were more

satisfied or patients were more satisfied because their

spouses are more attentive to their problems.

When the autonomic measures of SC and HR are

considered together, spouses in conjointly satisfied

marriages were more empathic and attentive to the

patient's pain whereas spouses in conjointly dissatisfied

marriages were less empathic and attentive to the pain.








In disjointly satisfied marriages comprising satisfied

patients and dissatisfied spouses (the most common

asymmetric pattern) the spouses were attentive, though

less empathic to the pain. Indeed, the more satisfied the

patient, the less empathic the dissatisfied spouse.

Researchers have suggested that witnessing another

person in distress produces aversive emotional arousal

(i.e., empathy) in the potential helper who then acts to

reduce this arousal through being helpful (Batson & Coke,

1983). Block (1981) and others (Kremer et al., 1985) have

suggested that such a mechanism could account for

solicitousness in spouses of chronic pain patients. The

data provided no support for this contention. The

principal variables which mediated spouse emotional

reactivity during responding to the pain were spouse and

patient marital satisfaction.

Satisfied spouses evidenced less incremental SC

arousal than dissatisfied spouses. While satisfied

spouses were more aroused (i.e., empathic) as passive

observers of pain, they were less reactive as active

participants in pain-related interactions. None of the

characteristic spousal responses to chronic pain were

predictive of these changes in arousal, suggesting that

responding to the pain (in any fashion) may, in itself,

lessen the magnitude of arousal in satisfied spouses. In

contrast, dissatisfied spouses were unaroused (i.e.,

unempathic) as passive observers of pain, yet more








vulnerable to emotional reactivity when required to

respond to the pain and discuss its impact on daily

living. For dissatisfied spouses, dealing with the pain

created the arousal.

One could speculate that satisfied spouses would be

more prone to engage the patient about the pain due to

their empathic reactivity as listeners and tempered

reactivity as responders whereas dissatisfied spouses

would be more prone to not engage (or disengage from) the

patient due to their lack of empathic reactivity as

listeners and more intense reactivity as responders. More

fine-grained research on the sequential nature of pain-

related marital interactions could bear upon this

question. For instance, Levenson and Gottman (1983) have

shown there is more negative affect reciprocity and

psychophysiological linkage between dissatisfied marital

partners during conflictual interactions. Similar results

may occur for dissatisfied or disjointly satisfied chronic

pain couples during discussions about chronic pain. The

pain-related discussions of more satisfied couples may not

be as marked by the exchange of negative affect or the

interrelatedness of aversive arousal.

Spouse HR during responding to the pain was also

mediated by patient marital satisfaction. The spouses of

satisfied patients were less attentive when responding to

the pain presentation than spouses of dissatisfied

patients. This lack of attentiveness may actually be








adaptive since it was also associated with distracting

responses toward the pain (e.g., encouraging nonpain

activities) in male spouses. The husbands who typically

distract their wives from the experience of pain were less

attentive when actively responding to the pain. Greater

attention to the pain may prevent the spouse's use of

distraction when dealing with the pain complaint.

Gender Differences in Satisfaction-Mediated Arousal

In addition to establishing the mediating role of

marital satisfaction, the present results also established

gender differences in how marital satisfaction mediates

the psychophysiological impact of pain-related

interactions upon spouses. Specifically, spouse marital

satisfaction mediated SC arousal in wives only and patient

marital satisfaction mediated HR arousal in husbands only.

In each case, it was the wives' marital satisfaction which

mediated the spouses' psychophysiology.

A remarkable 57% percent of the variance in wives'

empathic (SC) reactivity was predictable from their level

of satisfaction in the marriage. When wives were

satisfied and adjusted in the relationship, they "felt

for" their husbands who were describing the impact of the

pain on their lives. When wives were unhappy in the

marriage, they felt little toward their husbands' plight.

The nonpatient husbands' empathic response was less clear-

cut. Though many "felt for" their wives in pain, their

marital satisfaction had little to do with their empathic








reactivity. The emotional activation of dissatisfied

spouses when responding to the pain was also manifested in

wives only. Relationship quality was simply not an

important factor in the male spouses' emotional reactivity

to their wives' pain.

For male spouses, marital satisfaction was found to

mediate their attentiveness, rather than their

emotionality, toward the pain. In addition, their own

satisfaction in the relationship was not an important

factor. It was their wives' marital satisfaction which

was implicated in their attentiveness toward the pain.

The more satisfied the wife, the more attentive the

husband when presented with the pain and less attentive

when dealing with the pain. The female spouses'

attentiveness toward the pain had little to do with the

quality of the marriage.

The wife's marital satisfaction was thus the primary

mediator of emotionality in female spouses and

attentiveness in male spouses. These findings appear

consistent with the tenor of research on gender and

relationships. In general, women are more likely to

engage in socioemotional behaviors in relationships than

men who tend to be more instrumental or task-oriented in

relationships (Maccoby, 1990). Wives appear more finely

attuned to the quality of emotional interchange in a

marriage than do husbands and reflect this awareness in

changes in their marital satisfaction over time (Levenson








& Gottman, 1985). The instrumental nature of the men's

approach to relationships may be reflected in the

husband's relative attentiveness to the satisfied wife's

plight under listening conditions and inattentiveness and

adaptiveness (e.g., distracting responses) to her pain

under responding conditions. In fact, Lacey (1959)

likened the acceleration or deceleration of the heart to

an "instrumental act" of the person which either hindered

or facilitated attentional processes.

Finally, the primacy of the wife's satisfaction for

the psychophysiological responsivity of the spouse in

marital interactions about chronic pain suggests that it

is the wife who governs the impact of salient events in

the marriage. Gottman and Krokoff (1989) have proposed

that wives serve as the manager of conflict in marriage

whereby wives are more inclined to confront troublesome

issues whereas husbands are more conflict-avoidant. In

the present data, the wives appear to mediate their own

emotionality and their husbands' attentiveness to an

important and troublesome issue.

Additional Characteristics of Chronic Pain Marriages

With regard to the role of the spouse in the

maintenance of chronic pain, there was no confirmation for

the proposed relationship between spousal responses to

chronic pain (i.e., punishing, solicitous, and distracting

responses) and patient pain, symptom, or dysfunction

variables. Although it has been shown elsewhere (Fordyce,








1976) that operant behavioral principles apply to the

maintenance of chronic pain within the marital context,

the data did not support the notion that chronic pain is

influenced by the reinforcing or punishing aspects of

spousal behavior toward pain. The closest the data came

was a positive relationship between the spouse's

perception of pain severity in the patient and the

spouse's distracting responses when the patient is in

pain. The lack of support for the role of spousal

responses in chronic pain may explain their weak role in

spouse psychophysiological reactivity during marital

interactions about chronic pain.

Regarding the impact of chronic pain on the marriage,

the data concurred with previous findings of a substantial

prevalence of marital dissatisfaction among chronic pain

couples. Approximately 46% of the couples had at least

one dissatisfied marital partner and half of these couples

were conjointly dissatisfied. A majority of the marriages

however were well-adjusted. The results also confirmed

prior findings (Flor et al., 1987; Maruta et al., 1981)

that the spouses of chronic pain patients have a larger

prevalence of marital dissatisfaction than the patients.

When considering spouse gender, there were further

differences in marital adjustment. The wives of chronic

pain patients were more vulnerable to marital

dissatisfaction than the husbands of patients; and, the

more dissatisfied the wife, the more depressed and








symptomatic she was as well. Moreover, the marriages in

which only one partner was satisfied were predominantly

characterized by the satisfied male patient married to the

dissatisfied wife. As mentioned earlier, these disjointly

satisfied marriages tended to have less empathic wives who

become autonomically activated when responding to the

patient's pain.

Spousal responses to chronic pain were related to

marital satisfaction in predicted directions and may

account for the noted asymmetries in marital satisfaction.

The chronic pain patients with more solicitous, more

distracting, and less punishing spouses were more

satisfied in their marriages. This scenario makes sense

in that patients who are reinforced and not punished by

their spouses for sick role behavior would be quite

content with marital circumstances. Maritally satisfied

spouses were less punishing, though not necessarily more

(or less) solicitous or distracting toward the pain. This

situation also makes sense in that dissatisfied spouses

would seem more likely to respond to pain in a punishing

or negative fashion; also, overprotective spouses may not

necessarily be pleased with marital circumstances,

especially if their responses contribute to the patient's

sick role. Taken together, punishing responses were

associated with conjointly dissatisfied marriages whereas

solicitous and distracting responses were associated with

marriages comprising satisfied patients and either








satisfied or dissatisfied spouses. Thus, while most

couples (77%) were symmetric with respect to level of

marital satisfaction, the asymmetric or disjointly

satisfied marriages were more likely to have a

dissatisfied spouse rather than a dissatisfied patient.

The relationship which emerged between spouse

symptomatology and spousal responses to chronic pain may

account for the gender asymmetries in marital

satisfaction. As reported earlier, Rowat and Knafl (1985)

found that highly symptomatic spouses, mostly wives, were

more overprotective of the patient while Flor et al.

(1987) found an inverse association. The present results

showed no significant relationship between symptom

distress and solicitousness in spouses. Instead, it was

the distracting wives who were found to have more somatic

distress and symptom intensity; distracting wives also had

more satisfied husbands. Thus, "adaptive" spouse

behaviors aimed at distracting the patient from the

experience of pain (e.g., encouraging nonpain activities),

rather than "maladaptive" responses aimed at

overprotecting the patient from the pain, were associated

with aversive symptomatology in wives as well as marital

satisfaction in their husbands. The benefit to male

patients in terms of relationship satisfaction comes at

the expense to wives in terms of somatic distress. This,

perhaps, contributes to the prevalence of dissatisfied

wives in disjointly satisfied chronic pain marriages.








Previous studies have shown spouses of chronically

ill to report numerous somatic complaints (Klein, Dean, &

Bogdonoff, 1967; Shanfield et al., 1979). Block (1981)

suggested that the satisfied spouses' heightened empathic

responses to pain may predispose them to develop

psychophysiological difficulties. Since it was the wives

whose marital satisfaction mediated their empathic

reactivity, their vulnerability to somatic distress might

be accounted for by their psychophysiological reactivity.

The present data, however, provided no evidence to support

this notion.

First, spouses did not report significant

symptomatology on the SCL-90. Second, spouse GSI scores

were not predictive of autonomic reactivity to pain

presentations. Moreover, satisfied wives, who displayed

empathic reactions, were less globally symptomatic than

dissatisfied wives, who displayed unempathic reactions.

Perhaps, then, it is the dissatisfied wives' greater

activation when responding to the pain complaint which

predisposes them to develop greater symptom distress. The

evidence contraindicated this as well. Spouse GSI scores

were associated with less, not more, SC arousal when

spouses responded to the pain. The symptomatic spouses

had lower SC arousal under these circumstances.

Therefore, heightened autonomic reactivity during pain-

related interactions was not implicated in somatic

difficulties in the spouses of chronic pain patients.








Concluding Comments

The emerging picture of the chronic pain marriage

looks rather disheartening for the wives of chronic pain

patients. Wives were more prone to marital

dissatisfaction than their husbands who were more likely

to be satisfied in the relationship. Also, engaging in

more "adaptive" responses to pain was related to greater

somatic distress in wives. The term adaptive is qualified

because spousal responses to chronic pain were not found

to be significantly related to patient pain and symptom

variables. Dissatisfied wives were also found to be

rather unempathic toward their husbands' pain and more

autonomically reactive when attempting to deal with their

partners' pain. These responses were accentuated when the

husbands were satisfied in the relationship.

Finally, there was no compelling evidence to suggest

that the spouse's psychophysiological arousal during

marital interactions about chronic pain is implicated in

perpetuating maladaptive spousal responses to chronic

pain. Further detailed examination of spousal behavior

during pain-related marital interactions may establish

such relationships in future research.
















APPENDIX A

DETAILED EXPERIMENTAL PROTOCOL














DETAILED EXPERIMENTAL PROTOCOL


Introduction to Prospective Subjects

Prospective subjects were given with the following

introduction of the study:

I am a researcher working with the doctors in this
clinic on a research project. We are involved in a
study of the way the families of people with chronic
pain cope with everyday stresses and problems. We
are looking both for couples who are coping pretty
well and couples who are having difficulty coping.
We are offering couples $40 for their participation.
This study is not part of your treatment and your
decision to take part or not will in no way affect
your treatment at this hospital. If you are willing,
I can tell you more about the study and what you
would do.

The study will involve two basic activities, filling
out some brief questionnaires and taking part in some
brief conversations. The entire procedure takes
about 90 minutes. The questionnaires will ask about
physical symptoms, mood and feelings, and marital
life. The conversations will be about everyday
topics, some of which are normal problems for
families with a member who has chronic pain. While
you are talking about these topics, we will measure
heart rate and perspiration. This is done with
sensors taped to the surface of the skin. These
sensors are harmless and are commonly used in the
clinics here in the hospital. We will also videotape
part of the session. All the information that you
provide will be kept confidential.

Lab Instructions
When a couple arrived at the laboratory, they were led to

the waiting area. After the initial greetings, the

experimenter stated:









This is a study of the way the families of people
with chronic pain deal with everyday stresses and
problems. The study involves two basic activities,
filling out some brief questionnaires and taking part
in some brief conversations about neutral topics and
the impact of the chronic pain problem on daily
living. During these conversations, we will measure
heart rate and perspiration with sensors taped to the
surface of the skin. I have an informed consent form
for you to read and sign. Feel free to ask
questions.

We will start with each of you completing some
questionnaires. Your responses will be kept
confidential. It is important that you be as open
and honest as possible in completing them. It is
also important that you do not discuss, comment on,
or look at each other's questionnaire items. Please
read and follow all directions carefully. I will
gladly answer any questions you might have.

Following the questionnaire period, the couple was led to

the experimental room. In this room, there were a pair of

straight back chairs in one corner facing each other about

two feet apart. On a small table nearby were two small

lights which were used as cues during the session. In the

opposite corner on top of a cabinet was a video camera.

The couple was told:

This is the room where the rest of the experiment
will take place. As you can see, there are cords
along the wall near the chairs you will be seated in.
These are used to transmit the information from the
sensors to the equipment in the room next door.
During most of the experiment, I will be in the room
next door. Since there are no windows between the
rooms, we have a camera over there so I can see what
is going on. We will also record portions of the
conversations. We will be able to talk with each
other over this intercom. You don't need to touch it
in order to speak or hear me.

The psychophysiological sensors were then presented to the


couple with the following statement:








These are sensors to measure your heart rate and
perspiration. They will be taped to the surface of
your skin. They are harmless and you will not feel
their activity.

After the sensors were attached, the couple was instructed

to sit in the chairs. They were told:

Please sit up comfortably in the chairs and face each
other without crossing your arms and legs. During
the conversations, when these lights are on, it is
important that you keep relatively still so that you
do not disturb the sensors. Between the
conversations, you can shift as necessary to get
comfortable.

Before we start, I want to check the equipment to see
if all the connections are working right. Afterward,
we will start with the first conversation which will
be about a neutral topic. I will give you further
instructions later on.

Following the five-minute habituation period, the couple

engaged in a series of structured interactions described

below.

Neutral-Listen and Neutral-Respond Interactions

The couple was told:

For this first conversation, we would like you to
discuss a relatively neutral or irrelevant topic. We
want to collect some measures when you are having a
discussion about a nonproblematic issue. Please try
to keep the conversation as natural, relaxed, and
problem-free as possible.

Now let's choose the topic that you will discuss. I
would like you both to think of an activity or place
that is agreeable to both of you and is not an area
of conflict in the marriage. What would that be?
OK, this will be the topic of the conversation."

The patient was given the following instruction:

[name], for the next couple minutes, I want you to
describe [the topic] to your spouse. You can be as
descriptive as you want, just so long as you keep
talking. Try to keep your presentation as natural
and relaxed as possible.








The spouse was then instructed with the following:

[name], for the first part of the task, I just want
you to listen to the description. Later on, after I
signal you, you will have a chance to respond and
discuss the topic freely with your spouse. Remember
to keep the conversation as natural and relaxed as
possible.

Then to both spouses:

OK, you will notice that there are two small lights
here. I will signal you with the white light when to
begin the first part of the task where [patient]
talks and [spouse] listens. A couple of minutes
later, I will signal you with the yellow light when
to begin discussing the topic together in a neutral
and relaxed fashion. Are there any questions?

The couple engaged in the "neutral-listen" interaction for

90 seconds followed immediately by the "neutral-respond"

interaction which lasted three minutes. During the

interactions, the couple's psychophysiological activity

was recorded.

Pain-Listen and Pain-Respond Interactions

The couple was told:

For this next conversation, we would like you to
discuss the chronic pain problem and its impact on
your daily lives. You might talk about the physical
sensations of the pain, the thoughts or emotions
associated with the pain, or the various limitations
which result from the pain condition.

The patient was given the following instruction:

[name], for the next couple of minutes, I want you to
describe your pain difficulties to your spouse in
your usual way of talking about them.

The spouse was then instructed with the following:

[name], for the first part of the task, I just want
you to listen to the description. Later on, after I
signal you, you will have a chance to respond and
discuss these difficulties freely with your spouse in
your usual way of talking about them.








Then to both spouses:

OK, I will signal with the white light when to begin
the first part of the task where [patient] talks and
[spouse] listens. A couple of minutes later, I will
signal you with the yellow light when to begin
discussing the pain difficulties together in your
usual way of talking about them. Are there any
questions?

The couple engaged in the "pain-listen" interaction for 90

seconds followed immediately by the "pain-respond"

interaction which lasted three minutes. During the

interactions, the couple's psychophysiological activity

was recorded. When the experiment was completed, the

couple received $40 for their time and effort.
















APPENDIX B

NONCOPYRIGHTED MATERIALS















INFORMED CONSENT TO PARTICIPATE IN RESEARCH


J. HILLIS MILLER HEALTH CENTER
UNIVERSITY OF FLORIDA
GAINESVILLE, FLORIDA 32610

You are asked to volunteer as a participant in a research
study. This form is designed to provide you with
information about this study and to answer any of your
questions.


1. TITLE OF RESEARCH STUDY

Stress, Chronic Illness, and Marriage

2. PROJECT DIRECTORS

Names: Hugh Davis, Ph.D., Jeffrey E. Cassisi, Ph.D., and
Michael MacMillan, M.D.

Phone: (904) 392-9761

3. THE PURPOSE OF THE RESEARCH

The purpose of our research is to study the effects
of stress on marriage where one spouse has a chronic
illness. We are interested in the everyday things that
you and your spouse find stressful. Research suggests
that when a spouse has a chronic health problem, changes
occur in the way the couple handles things. These changes
can help us understand how the couple reacts to and copes
with chronic illness.

4. PROCEDURES FOR THIS RESEARCH

First, you will complete questionnaires regarding
mood and physical symptoms, marital adjustment, and
interpersonal style. A series of conversations in which
you and your spouse will discuss neutral topics and
problem areas will follow. These discussion topics will
be mutually chosen by you and your spouse. During these
discussions, we are interested in measuring heart rate,
perspiration, and low back muscle tension. Before you
begin, sensors will be taped to different locations on
your back, arms, and hands. Following the discussions,
you will complete another brief questionnaire. The entire
procedure is expected to take about two hours.









All the information that you provide will be kept in
the strictest confidence and protected to the limits of
the law. Your name will not be linked to any information
you give and your identity will not be known in any form
of publication based on this research.

5. POTENTIAL RISKS OR DISCOMFORTS

If you wish to discuss these or any other discomforts
you may experience, you may call the Project Director
listed in #2 of this form.

The potential risks associated with this research are
neglible. The conversation topics are similar to those
encountered in everyday situations. You may choose to
stop participation at any point during the experiment.
The back, arm, and hand sensors are used in clinic
situations and are considered safe. Following the removal
of the sensors, a few people may experience a temporary
mild irritation of the skin from the sensor paste and
tape.

6. POTENTIAL BENEFITS

The results from this research project will be used
to better understand the social context of chronic illness
and improve clinical assessment and treatment approaches
which often ignore social influences. Also, you and your
spouse will be paid $40.00 for your time and effort.

7. GENERAL CONDITIONS

I understand that I will X /will not receive
money for my participation in this study. If I am
compensated, I will receive $20.00 ($40 total per couple).

I understand that I will /will not X be
charged additional expenses for my participation in this
study. If I am charged additional expenses these will
consist of N/A .

I understand that I am free to withdraw my/my child's
consent and discontinue participation in this research
project at any time without this decision affecting my/my
child's medical care. If you have any question regarding
your rights as a subject, you may phone 392-3063.

In the event of my/my child's sustaining a physical
injury which is proximately caused by this experiment, no
professional medical care received at the J. Hillis Miller
Health Center exclusive of hospital expenses will be
provided me without charge. This exclusion of hospital
expenses does not apply to patients at the Veterans








Administration Medical Center (VAMC) who sustain physical
injury during participation in VAMC-approved studies. It
is understood that no form of compensation exists other
than those described above.

I also understand that the University of Florida and
the Veterans Administration Medical Center will protect
the confidentiality of my records to the extent provided
by Law. The Study Sponsor, Food and Drug Administration
or either Institutional Review Board may ask to review my
records, however the records will remain confidential as
only a number and initial will be used.

7. Signitures

I have fully explained to the nature and
purpose of the above-described procedure and the benefits
and risks that are involved in its performance. I have
answered and will answer all questions to the best of my
ability. I may be contacted at telephone




Signiture of Principle or Co-Priniciple Date
Investigator Obtaining Consent


I have been fully informed of the above-described
procedure with its possible benefits and risks and I have
received a copy of this description. I have given
permission of my/my child's participation in this study.




Signiture of Patient or Subject or Date
Relative or Parent or Guardian (specify)




Signiture of Child (7 to 17 years of age) Date


Signiture of Witness


Date









GENERAL INFORMATION FORM


Today's Date:

Name: Study#:

Age: Sex:

Education: Occupation:

Date of Marriage:

Number of dependent children:

Number of previous marriages:


Patient Section

Doctor: STH#:

Height: Weight:

Duration of pain (in months):

Nature of pain complaint (briefly describe):




Number of prior surgeries (briefly describe):




List prescribed medications:




Other significant health problems (if any):




Spouse Section

Significant health problems (if any):


List prescribed medications:









FOLLOW-UP QUESTIONNAIRE


1. How neutral was the discussion about the "neutral"
topic?

1 2 3 4 5 6
Not at all Very Much


2. How natural was the discussion about the neutral topic?

1 2 3 4 5 6
Not at all Very Much



3. How typical was the description of the pain problem?

1 2 3 4 5 6
Not at all Very Much



4. How typical was the discussion about the pain problem?

1 2 3 4 5 6
Not at all Very Much



5. How natural was the discussion about the pain problem?

1 2 3 4 5 6
Not at all Very Much



6. How severe is the pain problem as a marital problem?

1 2 3 4 5 6
Not at all Very Much



7. How much new understanding did you gain about the pain
problem?
1 2 3 4 5 6
None at all Very Much
















APPENDIX C

RAW DATA















RAW DATA


---------------------- PATIENTS -----------------------


Variable


N Mean


AGE 26 42.000 9.059
EDUCATION 26 12.769 2.320
MARITAL DURATION 26 158.096 133.906
# DEPENDENT CHILDREN 26 1.461 1.475
PRIOR MARRIAGES 26 0.692 0.735
HEIGHT 26 68.461 3.613
WEIGHT 26 174.615 40.873
PAIN DURATION 26 72.038 95.377
# SURGERIES 26 1.076 1.598
MARITAL SATISFACTION 26 107.000 32.113
INTERFERENCE 26 4.296 1.043
SUPPORT 26 4.538 1.499
PAIN SEVERITY 26 4.282 1.150
LIFE CONTROL 26 3.711 1.436
NEGATIVE MOOD 26 3.551 1.327
PUNISHING RESPONSES 26 1.798 1.601
SOLICITOUS RESPONSES 26 3.935 1.272
DISTRACTING RESPONSES 26 2.711 1.335
HOUSEHOLD CHORES 26 2.876 1.372
OUTDOOR WORK 26 1.576 1.564
ACTIVITIES 26 2.480 1.199
SOCIAL ACTIVITIES 26 2.028 1.025
SOMATIZATION 26 68.038 6.731
OBSESSIVE-COMPULSIVE 26 61.076 10.287
INTERPERSONAL SENSITIVITY 26 60.384 12.162
DEPRESSION 26 65.461 10.591
ANXIETY 26 59.153 13.129
HOSTITILY 26 60.923 12.092
PHOBIA 26 51.423 13.248
PARANOIA 26 53.961 12.021
PSYCHOTICISM 26 60.000 9.797
GLOBAL SYMPTOM INDEX 26 65.423 8.759
POSITIVE SYMPTOM DISTRESS 26 63.576 8.551
POSITIVE SYMPTOMS 26 61.961 7.825
FOLLOW-UP Q1 25 5.680 0.476
FOLLOW-UP Q2 25 5.240 0.830
FOLLOW-UP Q3 25 5.200 0.866
FOLLOW-UP Q4 25 4.640 1.439
FOLLOW-UP Q5 25 5.080 1.187
FOLLOW-UP Q6 25 3.640 1.577
FOLLOW-UP Q7 25 3.320 1.842


Std Dev















--------------------- FEMALE PATIENTS ------------------


Variable


N Mean


AGE 12 39.583 9.737
EDUCATION 12 12.333 0.984
MARITAL DURATION 12 164.291 149.200
# DEPENDENT CHILDREN 12 1.416 1.505
PRIOR MARRIAGES 12 0.583 0.668
HEIGHT 12 65.416 2.539
WEIGHT 12 148.166 37.944
PAIN DURATION 12 53.583 61.950
# SURGERIES 12 1.166 1.642
MARITAL SATISFACTION 12 104.583 37.850
INTERFERENCE 12 4.430 1.178
SUPPORT 12 4.695 1.480
PAIN SEVERITY 12 4.390 0.941
LIFE CONTROL 12 3.333 1.512
NEGATIVE MOOD 12 4.055 1.100
PUNISHING RESPONSES 12 1.812 1.655
SOLICITOUS RESPONSES 12 4.138 1.105
DISTRACTING RESPONSES 12 2.895 1.194
HOUSEHOLD CHORES 12 3.316 1.371
OUTDOOR WORK 12 0.516 0.581
ACTIVITIES 12 2.708 1.376
SOCIAL ACTIVITIES 12 2.291 1.157
SOMATIZATION 12 66.916 4.962
OBSESSIVE-COMPULSIVE 12 61.000 7.122
INTERPERSONAL SENSITIVITY 12 63.916 7.501
DEPRESSION 12 66.333 7.691
ANXIETY 12 60.916 10.049
HOSTITILY 12 62.833 7.744
PHOBIA 12 51.583 12.500
PARANOIA 12 54.583 13.041
PSYCHOTICISM 12 63.583 6.302
GLOBAL SYMPTOM INDEX 12 65.750 5.189
POSITIVE SYMPTOM DISTRESS 12 64.583 10.139
POSITIVE SYMPTOMS 12 63.000 5.239
FOLLOW-UP Q1 11 5.818 0.404
FOLLOW-UP Q2 11 5.181 0.873
FOLLOW-UP Q3 11 5.090 0.943
FOLLOW-UP Q4 11 4.909 1.136
FOLLOW-UP Q5 11 5.272 0.904
FOLLOW-UP Q6 11 3.818 1.662
FOLLOW-UP Q7 11 3.818 1.537


Std Dev
















---------------------- MALE PATIENTS ------------


Variable


N Mean


AGE 14 44.071 8.222
EDUCATION 14 13.142 3.034
MARITAL DURATION 14 152.785 124.822
# DEPENDENT CHILDREN 14 1.500 1.506
PRIOR MARRIAGES 14 0.785 0.801
HEIGHT 14 71.071 1.940
WEIGHT 14 197.285 28.201
PAIN DURATION 14 87.857 116.887
# SURGERIES 14 1.000 1.617
MARITAL SATISFACTION 14 109.071 27.586
INTERFERENCE 14 4.182 0.941
SUPPORT 14 4.405 1.558
PAIN SEVERITY 14 4.190 1.332
LIFE CONTROL 14 4.035 1.336
NEGATIVE MOOD 14 3.119 1.388
PUNISHING RESPONSES 14 1.785 1.616
SOLICITOUS RESPONSES 14 3.760 1.418
DISTRACTING RESPONSES 14 2.553 1.471
HOUSEHOLD CHORES 14 2.500 1.305
OUTDOOR WORK 14 2.485 1.580
ACTIVITIES 14 2.285 1.037
SOCIAL ACTIVITIES 14 1.803 0.878
SOMATIZATION 14 69.000 8.009
OBSESSIVE-COMPULSIVE 14 61.142 12.672
INTERPERSONAL SENSITIVITY 14 57.357 14.679
DEPRESSION 14 64.714 12.820
ANXIETY 14 57.642 15.514
HOSTITILY 14 59.285 14.973
PHOBIA 14 51.285 14.328
PARANOIA 14 53.428 11.547
PSYCHOTICISM 14 56.928 11.357
GLOBAL SYMPTOM INDEX 14 65.142 11.162
POSITIVE SYMPTOM DISTRESS 14 62.714 7.205
POSITIVE SYMPTOMS 14 61.071 9.627
FOLLOW-UP Q1 14 5.571 0.513
FOLLOW-UP Q2 14 5.285 0.825
FOLLOW-UP Q3 14 5.285 0.825
FOLLOW-UP Q4 14 4.428 1.650
FOLLOW-UP Q5 14 4.928 1.384
FOLLOW-UP Q6 14 3.500 1.556
FOLLOW-UP Q7 14 2.928 2.017


Std Dev















------------------------- SPOUSES ------------------------


Variable


N Mean


AGE 26 42.923 9.524
EDUCATION 26 12.692 1.954
MARITAL DURATION 26 158.096 133.906
# DEPENDENT CHILDREN 26 1.346 1.468
PRIOR MARRIAGES 26 0.500 0.761
MARITAL SATISFACTION 26 103.000 27.447
PAIN SEVERITY 26 4.153 1.174
SOMATIZATION 26 56.653 9.781
OBSESSIVE-COMPULSIVE 26 58.153 8.911
INTERPERSONAL SENSITIVITY 26 57.769 12.271
DEPRESSION 26 61.269 8.469
ANXIETY 26 55.346 11.492
HOSTITILY 26 58.153 10.887
PHOBIA 26 47.884 12.741
PARANOIA 26 56.961 14.029
PSYCHOTICISM 26 57.384 12.878
GLOBAL SYMPTOM INDEX 26 60.500 10.151
POSITIVE SYMPTOM DISTRESS 26 56.923 9.456
POSITIVE SYMPTOMS 26 59.846 9.849
FOLLOW-UP Q1 25 5.160 1.143
FOLLOW-UP Q2 25 4.960 1.059
FOLLOW-UP Q3 25 5.320 0.900
FOLLOW-UP Q4 25 4.840 1.178
FOLLOW-UP Q5 25 5.160 0.800
FOLLOW-UP Q6 25 4.000 1.080
FOLLOW-UP Q7 25 3.000 1.825
SC NEUTRAL-LISTEN 26 4.062 3.800
SC NEUTRAL-RESPOND 26 4.052 3.605
SC PAIN-LISTEN 26 3.993 3.481
SC PAIN-RESPOND 26 4.230 3.519
SC "LISTENING" 26 -0.070 0.712
SC "RESPONDING" 26 0.247 0.570
HR NEUTRAL-LISTEN 26 74.764 11.179
HR NEUTRAL-RESPOND 26 75.841 10.349
HR PAIN-LISTEN 26 75.229 11.777
HR PAIN-RESPOND 26 75.905 9.672
HR "LISTENING" 26 0.465 6.733
HR "RESPONDING" 26 -0.402 4.486
---------------------------------------------------------


Std Dev















---------------------- FEMALE SPOUSES -------------------


Variable


N Mean


AGE 14 42.714 7.321
EDUCATION 14 13.071 1.817
MARITAL DURATION 14 152.785 124.822
# DEPENDENT CHILDREN 14 1.357 1.549
PRIOR MARRIAGES 14 0.500 0.854
MARITAL SATISFACTION 14 99.428 30.856
PAIN SEVERITY 14 4.142 1.278
SOMATIZATION 14 57.071 10.351
OBSESSIVE-COMPULSIVE 14 56.142 10.294
INTERPERSONAL SENSITIVITY 14 55.714 13.309
DEPRESSION 14 59.785 8.833
ANXIETY 14 53.714 9.522
HOSTITILY 14 58.142 11.561
PHOBIA 14 48.071 12.206
PARANOIA 14 57.785 12.638
PSYCHOTICISM 14 58.285 12.922
GLOBAL SYMPTOM INDEX 14 58.785 10.386
POSITIVE SYMPTOM DISTRESS 14 59.428 8.967
POSITIVE SYMPTOMS 14 57.714 10.535
FOLLOW-UP Q1 14 5.285 0.825
FOLLOW-UP Q2 14 5.000 1.037
FOLLOW-UP Q3 14 5.500 0.650
FOLLOW-UP Q4 14 4.785 1.121
FOLLOW-UP Q5 14 4.928 0.916
FOLLOW-UP Q6 14 4.071 1.206
FOLLOW-UP Q7 14 3.142 2.070
SC NEUTRAL-LISTEN 14 4.650 4.495
SC NEUTRAL-RESPOND 14 4.487 4.233
SC PAIN-LISTEN 14 4.570 4.320
SC PAIN-RESPOND 14 4.862 4.374
SC "LISTENING" 14 -0.079 0.608
SC "RESPONDING" 14 0.455 0.679
HR NEUTRAL-LISTEN 14 77.647 12.738
HR NEUTRAL-RESPOND 14 78.675 10.966
HR PAIN-LISTEN 14 75.992 11.256
HR PAIN-RESPOND 14 78.205 10.744
HR "LISTENING" 14 -1.653 3.795
HR "RESPONDING" 14 1.180 3.521
---------------------------------------------------------


Std Dev















---------------------- MALE SPOUSES -------------


Variable


N Mean


AGE 12 43.166 11.945
EDUCATION 12 12.250 2.094
MARITAL DURATION 12 164.291 149.200
# DEPENDENT CHILDREN 12 1.333 1.435
PRIOR MARRIAGES 12 0.500 0.674
MARITAL SATISFACTION 12 107.166 23.490
PAIN SEVERITY 12 4.165 1.096
SOMATIZATION 12 56.166 9.504
OBSESSIVE-COMPULSIVE 12 60.500 6.640
INTERPERSONAL SENSITIVITY 12 60.166 11.011
DEPRESSION 12 63.000 8.045
ANXIETY 12 57.250 13.625
HOSTITILY 12 58.166 10.555
PHOBIA 12 47.666 13.884
PARANOIA 12 56.000 16.022
PSYCHOTICISM 12 56.333 13.316
GLOBAL SYMPTOM INDEX 12 62.500 9.931
POSITIVE SYMPTOM DISTRESS 12 54.000 9.534
POSITIVE SYMPTOMS 12 62.333 8.762
FOLLOW-UP Q1 11 5.000 1.483
FOLLOW-UP Q2 11 4.909 1.136
FOLLOW-UP Q3 11 5.090 1.136
FOLLOW-UP Q4 11 4.909 1.300
FOLLOW-UP Q5 11 5.454 0.522
FOLLOW-UP Q6 11 3.909 0.943
FOLLOW-UP Q7 11 2.818 1.537
SC NEUTRAL-LISTEN 12 3.376 2.828
SC NEUTRAL-RESPOND 12 3.545 2.800
SC PAIN-LISTEN 12 3.319 2.136
SC PAIN-RESPOND 12 3.492 2.107
SC "LISTENING" 12 -0.059 0.845
SC "RESPONDING" 12 0.005 0.272
HR NEUTRAL-LISTEN 12 71.401 8.328
HR NEUTRAL-RESPOND 12 72.535 8.897
HR PAIN-LISTEN 12 74.338 12.802
HR PAIN-RESPOND 12 73.222 7.849
HR "LISTENING" 12 2.938 8.582
HR "RESPONDING" 12 -2.250 4.917


Std Dev















------------------DISSATISFIED SPOUSES---------------


Variable


NEUTRAL-LISTEN
NEUTRAL-RESPOND
PAIN-LISTEN
PAIN-RESPOND
"LISTENING"
"RESPONDING"
NEUTRAL-LISTEN
NEUTRAL-RESPOND
PAIN-LISTEN
PAIN-RESPOND
"LISTENING"
"RESPONDING"


N Mean

11 5.415
11 5.220
11 4.970
11 5.276
11 -0.444
11 0.500
11 72.278
11 72.409
11 73.607
11 72.746
11 1.330
11 -0.994


Std Dev

5.214
4.954
4.794
4.851
0.939
0.708
9.464
8.260
13.028
8.052
9.944
6.151


------------------- SATISFIED SPOUSES -------------------


Variable


N Mean


SC NEUTRAL-LISTEN 15 3.070 1.970
SC NEUTRAL-RESPOND 15 3.196 1.955
SC PAIN-LISTEN 15 3.276 1.979
SC PAIN-RESPOND 15 3.462 1.953
SC "LISTENING" 15 0.204 0.290
SC "RESPONDING" 15 0.062 0.367
HR NEUTRAL-LISTEN 15 76.588 12.279
HR NEUTRAL-RESPOND 15 78.358 11.246
HR PAIN-LISTEN 15 76.418 11.085
HR PAIN-RESPOND 15 78.222 10.351
HR "LISTENING" 15 -0.168 3.051
HR "RESPONDING" 15 0.031 2.904
---------------------------------------------------------


Std Dev















----------- SPOUSES OF DISSATISFIED PATIENTS----------


Variable


SC NEUTRAL-LISTEN
SC NEUTRAL-RESPOND
SC PAIN-LISTEN
SC PAIN-RESPOND
SC "LISTENING"
SC "RESPONDING"
HR NEUTRAL-LISTEN
HR NEUTRAL-RESPOND
HR PAIN-LISTEN
HR PAIN-RESPOND
HR "LISTENING"
HR "RESPONDING"


N Mean

7 1.681
7 1.710
7 1.718
7 1.925
7 0.035
7 0.180
7 69.127
7 69.817
7 73.188
7 70.941
7 4.064
7 -2.941


Std Dev

0.948
0.978
1.113
1.096
0.400
0.351
9.473
9.523
16.911
9.437
11.364
6.333


------------- SPOUSES OF SATISFIED PATIENTS-----------


Variable


SC NEUTRAL-LISTEN
SC NEUTRAL-RESPOND
SC PAIN-LISTEN
SC PAIN-RESPOND
SC "LISTENING"
SC "RESPONDING"
HR NEUTRAL-LISTEN
HR NEUTRAL-RESPOND
HR PAIN-LISTEN
HR PAIN-RESPOND
HR "LISTENING"
HR "RESPONDING"


N Mean

19 4.940
19 4.915
19 4.831
19 5.078
19 -0.108
19 0.272
19 76.841
19 78.061
19 75.981
19 77.734
19 -0.860
19 0.532


Std Dev

4.092
3.849
3.696
3.738
0.803
0.638
11.258
9.960
9.752
9.334
3.610
3.340














REFERENCES


Andreassi, J.L. (1980). Psychophysiology: Human behavior
and physiological response. New York: Oxford
University Press.

Ahern, D.K., & Follick, M.J. (1985). Distress in spouses
of chronic pain patients. International Journal of
Family Therapy, 2, 247-257.

Bandura, A., & Rosenthal, T.L. (1966). Vicarious classical
conditioning as a function of arousal level. Journal
of Personality and Social Psychology, 3, 54-62.

Batson, C.D., & Coke, J.S. (1983). Empathic motivation of
helping behavior. In J.T. Cacioppo & R.E. Petty
(Eds.), Social psychophysiology: A sourcebook
(pp.417-433). New York: Guilford Press.

Berger, S.M. (1962). Conditioning through vicarious
instigation. Psychological Bulletin, 69, 450-466.

Block, A.R. (1981). An investigation of the response of
the spouse to chronic pain behavior. Psychosomatic
Medicine, 43, 415-422.

Block, A.R., Kremer, E.F., & Gaylor, M. (1980). Behavioral
treatment of chronic pain: The spouse as a
discriminative cue for pain behavior. Pain, 9,
243- 252.

Craig, K.D., & Lowery, H. (1969). Heart rate components of
conditioned vicarious autonomic responses. Journal of
Personality and Social Psychology, 11, 381-387.

Craig, K.D., & Wood, K. (1969). Psychophysiological
differentiation of direct vicarious affective
arousal. Canadian Journal of Behavioral Science, 1,
98-105.

Derogatis, L.R. (1983). SCL-90-R administration, scoring,
and procedures manual-II for the revised version.
Towson, MD: Clinical Psychology Research.

Dolce, J.J., & Radczynski, J.M. (1985). Neuromuscular
activity and electromyography in painful backs:
Psychological and biomechanical models in assessment
and treatment. Psychological Bulletin, 97, 502-520.








Engel, G.L. (1959). Psychogenic pain and the pain-prone
patient. American Journal Of Medicine, 26, 899-918.

Flor, H., Kerns, R.D., & Turk, D.C. (1987). The role of
spouse reinforcement, perceived pain, and activity
levels of chronic pain patients. Journal of
Psychosomatic Research, 31, 251-259.

Flor, H., & Turk, D.C. (1985). Chronic illness in an adult
family member: Pain as a prototype. In D.C. Turk &
R.D. Kerns (Eds.), Health, illness, and families: A
life-span perspective (pp. 255-278). New York: Wiley-
Interscience.

Flor, H., Turk, D.C., & Scholz, O.B. (1987). Impact of
chronic pain on the spouse: Marital, emotional and
physical consequences. Journal of Psychosomatic
Research, 31, 63-71.

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

Gentry W.D., Shows, N.D., & Thomas, M. (1974). Chronic low
back pain: a psychological profile. Psychosomatics,
15, 174-177.

Gochman, D.S. (1985). Family determinants of children's
conceptions of health and illness. In D.C. Turk &
R.D. Kerns (Eds.), Health, illness, and families: A
life-span perspective (pp. 23-50). New York: Wiley-
Interscience.

Gottman, J.M., & Krokoff, L.J. (1989). Marital interaction
and satisfaction: A longitudinal view. Journal of
Consulting and Clinical Psychology, 57, 47-52.

Haley, J. (1963). Marriage therapy. Archives of General
Psychiatry, 8, 213-234.

Hudgens, A.J. (1979). A family oriented treatment of
chronic pain. Journal of Marital and Family Therapy,
5, 67-78.

Kerns, R.D., & Turk, D.C. (1984). Chronic pain and
depression: mediating role of the spouse. Journal of
Marriage and the Family, 46, 845-852.

Kerns, R.D., Turk, D.C., & Rudy, T.E. (1985). The West
Haven-Yale Multidimensional Pain Inventory (WHYMPI).
Pain, 23, 345-356.








Khatami, M., & Rush, A.J. (1978). A pilot study of the
treatment of outpatients with chronic pain: Symptom
control, stimulus control, and social systems
intervention. Pain, 5, 163-172.

Klein, R., Dean, A., & Bogdonoff, M. (1967). The impact of
illness upon the spouse. Journal of Chronic Disease,
20, 241-248.

Kreitman, N., Sainsbury, P., Pierce K., & Costain, W.R.
(1965). Hypochondriasis and depression in outpatients
at a general hospital. British Journal of Psychiatry,
111, 607-615.

Kremer, E.F., Sieber, W., & Atkinson, J.H. (1985). Spousal
perpetuation of chronic pain behavior. International
Journal of Family Therapy, 7, 258-270.

Lacey, J.I. (1959). Psychophysiological approaches to the
evaluation of psychotherapeutic process and outcome.
In E.A. Rubinstein & M.B. Parloff (Eds.), Research in
psychotherapy (pp.160-207). Washington, D.C.:
American Psychological Association.

Lacey, J.I., & Lacey, B.C. (1974). On heart rate and
behavior: A reply to Elliot. Journal of Personality
and Social Psychology, 30, 1-18.

Levenson, R.W., & Gottman, J.M. (1983). Marital
interaction: Physiological linkage and affective
exchange. Journal of Personality and Social
Psychology, 45, 587-597.

Levenson, R.W., & Gottman, J.M. (1985). Physiological and
affective predictors of change in relationship
satisfaction. Journal of Personality and Social
Psychology, 49, 85-94.

Litman, T.J. (1974). The family as a basic unit in health
and medical care: A social behavioral overview.
Social Science and Medicine, 8, 495-519.

Locke, H.J., & Wallace, K.M. (1959). Short marital
adjustment and prediction tests: Their reliability
and validity. Marriage and Family Living, 21, 251-
255.

Maccoby, E.E. (1990). Gender and relationships: A
developmental account. American Psychologist, 45,
513-520.

Maruta, T., & Osbourne, D. (1978). Sexual activity in
chronic pain patients. Psychosomatics, 19, 531-537.








Maruta, T., Osborne, D., Swanson, D.W., & Halling, J.M.
(1981). Chronic pain patients and spouses: Marital
and sexual adjustment. Mayo Clinic Proceedings, 56,
307-310.

Melzack, R. (1983). Pain measurement and assessment. New
York: Ravens Press.

Merskey, H. (1965). Psychiatric patients with persistent
pain. Journal of Psychosomatic Research, 9, 299-309.

Merskey, H., & Boyd, D. (1978). Emotional adjustment and
chronic pain. Pain, 5, 173-178.

Mohamed, S.N., Weisz, G. M., & Waring, E.M. (1978). The
relationship of chronic pain to depression, marital,
and family dynamics. Pain, 5, 285-292.

Pratt, L. (1976). Family structure and effective health
behavior. The energized family. Boston: Houghton-
Mufflin.

Rowat, K.M. (1985). Assessing the "chronic pain family."
International Journal of Family Therapy, 7, 284-296.

Rowat, K.M., & Knafl, K.A. (1985). Living with chronic
pain: The spouse's perspective. Pain, 23, 259-271.

Roy, R. (1982). Marital and family issues in patients with
chronic pain: A review. Psychotherapy and
Psychosomatics, 37, 1-12.

Roy, R. (1985). The interactional perspective of pain
behavior in marriage. International Journal of Family
Therapy, 1, 271-283.

Roy, R. (1988). Impact of chronic pain on marital
partners: systems perspective. In R. Dubner, G.F.
Gebhart, & M.R. Bond (Eds.), Proceedings of the Vth
World Congress on Pain (pp. 286-297). Amsterdam:
Elsevier Science Publishers.

Shanfield, S.B., Heiman, E.M., Cope, D.N., & Jones, J.R.
(1979). Pain and the marital relationship:
Psychiatric distress. Pain, 7, 343-351.

Turk, D.C., & Flor, H. (1984). Etiological theories and
treatment for chronic back pain. II. Psychological
models and interventions. Pain, 19, 209-233.

Turk, D.C., Rudy, T.E., & Flor, H. (1985). Why a family
perspective for pain? International Journal of Family
Therapy, 2, 223-234.








Vaughn, K., & Lanzetta, J. (1981). The effect of
modification of expressive displays on vicarious
emotional arousal. Journal of Experimental Social
Psychology, 17, 16-30.

Venables, P.H., & Christie, M.J. (1973). Mechanisms,
instrumentation, recording techniques and
quantification of responses. In W.F. Prokasy & D.C.
Raskin (Eds.), Electrodermal activity in
psychological research (pp. 1-124). New York:
Academic Press.

Violon, A., & Giurgea,D. (1984). Familial models for
chronic pain. Pain, 18, 199-203.

Waring, E.M. (1982). Conjoint marital and family therapy.
In R. Roy & E. Tunks (Eds.), Chronic pain:
Psychosocial factors in rehabilitation (pp. 59-83).
Baltimore: Williams & Wilkins.




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