The Role of cognitions in pain and depression

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The Role of cognitions in pain and depression
Litwins, Nola
Publication Date:
Physical Description:
v, 65 leaves : ; 29 cm.


Subjects / Keywords:
Chronic pain ( jstor )
Clinical psychology ( jstor )
Cognition ( jstor )
Cognitive psychology ( jstor )
Dysthymic disorder ( jstor )
Emotionality ( jstor )
Low back pain ( jstor )
Pain ( jstor )
Pain perception ( jstor )
Psychology ( jstor )
Adaptation, Psychological ( mesh )
Attitude ( mesh )
Chronic Disease -- psychology ( mesh )
Cognition ( mesh )
Data Interpretation, Statistical ( mesh )
Department of Clinical and Health Psychology thesis Ph.D ( mesh )
Depression -- psychology ( mesh )
Dissertations, Academic -- College of Health Professions -- Department of Clinical and Health Psychology -- UF ( mesh )
Facial Pain -- psychology ( mesh )
Pain -- psychology ( mesh )
Pain Measurement ( mesh )
Pain Threshold ( mesh )
Psychological Tests ( mesh )
Research ( mesh )
bibliography ( marcgt )
non-fiction ( marcgt )


Thesis (Ph.D.)--University of Florida, 1996.
Bibliography: leaves 56-64.
General Note:
General Note:
Statement of Responsibility:
by Nola Litwins.

Record Information

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University of Florida
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University of Florida
Rights Management:
Copyright [name of dissertation author]. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
Resource Identifier:
002287247 ( ALEPH )
49346579 ( OCLC )
ALP0400 ( NOTIS )

Full Text








I would like to express my appreciation to Mike

Robinson for his guidance, his never-ending patience and

always having an open door. I would also like to thank Rus

Bauer, Eileen Fennell, Cyd Strauss and Chuck Vierck for

their support. Additionally, a special note of thanks

should be extended to Dr. Henry Gremillion, Director of the

Facial Pain Center, who graciously worked my data collection

into his busy schedule. Finally, I would like to thank my

husband, Robert, for designing the pain rating device and

for his support and patience.



ACKNOWLEDGEMENTS.............................. ii

ABSTRACT....................................... iv

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

COGNITIONS AND PAIN ........................... 10


METHOD................... ............... .... 22

Subjects....... ...... .................... 22
Procedure ................................ 24
Measures .................................... 27

RESULTS...................................... .. 31

DISCUSSION ........................ ............. 36

APPENDIX ........................... ........... 48

REFERENCES..................................... 56

BIOGRAPHICAL SKETCH ........................... 65


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



Nola M. Litwins

Chairman: Michael E. Robinson, Ph.D.
Major Department: Clinical and Health Psychology

The use of negative thoughts has been associated with

lower pain tolerance, higher pain ratings and increased

rates of depression among chronic pain patients. Fifty-eight

adult chronic pain patients, recruited from the Facial Pain

Center at the University of Florida, were asked to

participate in a study investigating the role of cognitions

in pain. Subjects completed the Beck Depression Inventory

(BDI), Inventory of Negative Thoughts in Response to Pain

(INTRP), and Pain Beliefs and Perceptions Inventory (PBPI)

prior to participation in the cold pressor task. Following

the cold pressor pretest to obtain a baseline tolerance,

subjects were randomly assigned into either a positive self-

statement training (PSST) or negative self-statement

training (NSST) group. It was hypothesized that subjects in

the PSST group would have greater increases in tolerance,

threshold and pain ratings from pretest to posttest than

subjects in the NSST group. A repeated measures

Multivariate Analysis of Variance (MANOVA) was significant

at p < .10. A repeated measures Analysis of Variance

(ANOVA) using Pain Sensitivity Range (PSR) was significant

at p < .02. Numerous variables were suggested to enhance the

strength of this relationship. These included extending the

amount of time allotted for training and rehearsal of

strategies, increasing subjects' self-efficacy, and allowing

subjects to use preferred styles of coping. Depression was

not found to be correlated with any pain variables. This is

consistent with some recent literature which suggests a

reexamination of current methods of assessing depression

(e.g., BDI) in chronic pain patients.


Incidence rates of depression among chronic pain

patients have been estimated to be anywhere from 10% to 100%

(Magni et al., 1994; Pilowsky et al., 1977; Romano & Turner,

1985; Turkington, 1980). Atkinson et al. (1991) reported

that in 58% of patients with chronic low back pain the first

episode of major depression followed the onset of pain.

Several models have been developed to explain the existence

of such a relationship, including the idea that pain is

actually a form of masked depression. These individuals

present with physical symptoms which cannot be explained

adequately on a medical basis and depression-related

explanations are thought to be most likely. Report of

depressed mood is usually absent; however, patients may

report neurovegetative symptoms of depression, such as sleep


This concept of the 'pain-prone patient', first

described by Engel (1959), suggests that certain individuals

display psychodynamic features similar to depression-prone

individuals. For these individuals, pain functions as

punishment resulting from guilt over aggressive impulses.

Pain, then, reduces the severity of the depression by

weakening the guilt. The pain-prone patient is

characterized by the presence of continuous pain, denial of

emotional and interpersonal difficulties, inability to

tolerate success or happiness and depressive symptoms of

anhedonia and sleep disturbances (Blumer & Heilbronn, 1982).

Empirical evidence supporting this concept is lacking.

However, patients have been described as having a social

history characterized by a working class background and

being raised under difficult circumstances requiring

assumption of responsibility at an early age. Alcoholism is

common among family members and patients may begin working

at an early age, usually in physically strenuous jobs. They

then work steadily until a relatively minor injury leaves

them incapacitated. Adequate physical findings to account

for the pain or its intensity are frequently absent and,

thus, they may meet the criteria for somatoform pain

disorder (Harness & Rome, 1989).

Rather than focusing on unconscious mechanisms, such as

those described in the 'pain-prone' patient, behavioral

models of depression have focused on the role of lack of

positive reinforcement for adaptive behaviors. Similarly,

operant models of pain focus on the behavior, rather than on

the pain itself. In fact, nociception is not seen as

necessary or sufficient for these behaviors to develop.

In this model, chronic pain occurs in a social context

and is shaped by the behavior of others. Pain behaviors are

seen as being negatively reinforced by environmental factors

such as attention, financial reward or avoidance of aversive

behaviors (Fordyce, 1976). The development of depression in

chronic pain patients then is seen as resulting from an

interaction of these two factors. Thus, an individual may

find himself or herself receiving increased attention for

pain behaviors and avoiding previously held

responsibilities, while at the same time receiving little

positive reinforcement for independent activities. These

patients would become hypervigilant for somatic distress

signals, which through social reinforcement, would be

maintained (Boureau et al., 1991).

The use of the tricyclic antidepressants in the

treatment of chronic pain patients has often been cited as

evidence for models which hypothesize that similar

neurochemical mechanisms are involved in both disorders. It

has been suggested that depression is associated with

decreased monoamine activity monoaminee theory). Tricyclic

antidepressants work primarily by blocking re-uptake of

serotonin (5-HT) and norepinephrine, and have been linked to

both affective disorders and the modification of pain

perception (Hendler, 1982). However, it is unlikely that

availability of the neurotransmitter is solely responsible

for relief of depressive symptoms. Administration of

antidepressants leads to almost immediate increases in

neurotransmitters at the synapse; however, clinical

improvement of symptoms may take 3 to 6 weeks to emerge.

Also, examination of the role of both pre- and post-synaptic

receptor sites has led to information which is inconsistent

with the original theory. For instance, increased

availability of serotonin leads to down-regulation of

receptors, making the system less sensitive to monoaminergic

stimulation, rather than more sensitive as originally

hypothesized (Hollandsworth, 1990).

Serotonin has also been linked to pain perception and

can either be algesic or analgesic depending on the point in

the nervous system at which it is released. Direct tissue

damage leads to increased serotonin production, which is

capable of activating nociceptors, receptors activated by

painful stimuli. Additionally, serotonin causes pain when

applied to a human blister base and can potentiate pain

induced by bradykinin, an endogenous peptide which initiates

pain (Campbell et al., 1989). However, it has been

hypothesized that it is depletion of brain serotonin in the

dorsal raphe nucleus, which may account for hypersensitivity

to both pain and depression (Sternbach, 1976). Serotonin

depletion is associated with heightened perception of pain

(Hampf, 1989); whereas, augmentation leads to reduction in

pain perception.

It appears that decreased availability of serotonin

may, in part, be responsible for pain and depression

individually. Recently, evidence has been found which may

link the co-occurrence of these disorders. Dietary

deficiencies of tryptophan, the biochemical precursor to

serotonin, alter pain sensitivities by decreasing neuronal

opiate response due to a lowered concentration of serotonin

(Haze, 1991). Also, depletion of plasma tryptophan has been

found to eliminate the analgesic effect of morphine on

tolerance to cold pressor pain (Abbott et al., 1992). More

detailed analysis of the role of opioid receptors, including

the role of endorphins, may shed light on the interaction

between mood and pain perception.

Evidence supporting the role of serotonin in pain and

depression is promising; however, there are a number of

factors which need to be investigated before this

relationship is clear. For instance, serotonin levels are

elevated, rather than depleted, in migraine patients

(Kreisberg, 1988) suggesting that all types of chronic pain

may not have the same biological basis. Additionally,

receptor subtype and location may influence the expression

of drugs that interact with them. Ritanserin, a serotonin

antagonist, which acts on 5-HT2 receptors, has been shown to

have both analgesic and antidepressant effects (Nappi et

al., 1990), which is inconsistent with the notion that

increases in serotonin lead to these effects. Additionally,

interaction between serotonergic and adrenergic systems

makes it difficult to examine these neurotransmitters


In addition to neurotransmitter imbalances, many

patients with depressive disorder have an excess secretion

of cortisol, which fails to be suppressed in response to

exogenous administration of dexamethasone (Reus, 1988).

France et al. (1984) found that chronic pain patients who

also met DSM-III criteria for major depression were

dexamethasone non-suppressors. However, these results were

not confirmed using a sample of fibrositis patients (Hudson

et al., 1976), casting doubt on the significance of the

dexamethasone suppression test. Additionally, the increased

number of false positive results, such as those found in

individuals diagnosed with dementia and schizophrenia,

suggests further caution in interpreting these findings.

Fields (1991) has proposed a cognitive neurobiological

model which integrates biological evidence for pain and

depression with psychological factors. This model includes

sensory, affective and evaluative components of pain. The

sensory component results from nociceptor stimulation in

peripheral tissues, which leads to activation of pain

pathways. Activation in the peripheral nerve transmits

impulses by means of the spinothalamic tract to the

ventrobasal thalamus and then to the somatosensory cortex.

Additionally, the pain modulating pathway, with nuclei in

the periaqueductal gray, can be activated by opioids and is

associated with opiate receptors.

Fields contends that there is evidence for bi-

directional control of pain transmission. Cells in the

medulla, known as off-cells, are inhibitory neurons to pain

and account for analgesic effects of morphine. Another

class of cells in the medulla, on-cells, have a facilitating

effect on pain transmission. These cells are inhibited by

administration of opiates; however, their firing rates

increase to a rate that is higher than the pre-opiate rate

in the presence of an opiate antagonist. In this context,

the pain transmission system can be driven in the absence of

peripheral stimulation by a noxious stimulus.

The affective component is activated by the same

peripheral nociception as the sensory component, but then

follows different pathways. It is thought that these

pathways probably diverge from the somatosensory cortex and

involve projections into the hypothalamus, medial thalamus,

frontal cortex and limbic system. This activation of the

affective pathway can lead to changes in mood, such as


The evaluative component of this model relates to the

meaning that individuals apply to the pain. Cognitive

strategies developed as a result of an individual's

interpretation of their pain can affect pain intensity, thus

making it appear milder or more severe than the nociceptive

input alone. Thus, according to this model, the

relationship of pain and depression can be explained by

these three components. Nociception alone can lead to

activation of both sensory and affective pathways, leading

to changes in sensory perception and mood, so that pain

alone may lead to dysphoria. Furthermore, pain transmission

can occur in the absence of painful stimuli and can be

mediated by an individual's affect and cognition. Thus, the

mere expectation that a stimulus will cause pain is enough

to activate pain pathways.

Such cognitive factors have been important in the

development of theories and treatment programs relevant to

both pain and depression. Cognitive evaluation of a

situation influences an individual's ability to cope with

the stressful event (Lazarus & Folkman, 1984). Coping,

then, involves not only what a person does in response to a

stressor, but what a person thinks and says to

himself/herself. Additionally, a person's belief in his/her

own effectiveness influences whether he/she will attempt to

cope with the situation (Bandura, 1977).

Beck (1967) contends that depression is the result of

systematic negative distortions in cognitive processes which

yield a negative view of the self, the world and the future.

These distortions may involve overgeneralization,

personalization, selective abstractions and dichotomous

thinking. Similarly, pain patients who are faced with daily

pain may develop distorted appraisals of their pain leading

to a pattern of negative cognitions. For instance, an

individual's pain at any given moment may lead to the notion

that they will be unable to participate in activities for

the entire day overgeneralizationn).

The next section will provide an overview of studies

investigating the role of these negative cognitions in the

development of depression in chronic pain.


Studies in this area have addressed a number of issues

including what characteristics contribute to the development

of depression in pain patients, whether cognitive

distortions are related solely to the pain experience or

more global in nature, and whether distortions are related

to pain intensity or severity. A commonly cited study by

Lefebvre (1981) examined cognitive distortions in depressed

and non-depressed pain patients, depressed psychiatric

patients and non-depressed patients without low back pain

(LBP). The Cognitive Error Questionnaire (CEQ) was used to

measure the extent to which individuals utilize cognitive

errors. The CEQ consists of a series of vignettes followed

by a cognition reflecting a cognitive error. Subjects are

then asked to make a rating ranging from "almost exactly

like I would think" to "not at all like I would think." The

CEQ is composed of a General scale and a scale with themes

relating to individuals with low back pain (LBP).

Depressed non-pain patients had higher Beck Depression

Inventory (BDI) scores than depressed pain patients.

However, these 2 groups did not show significantly different

levels of general cognitive distortion. Depressed pain

patients endorsed errors related to catastrophizing,

overgeneralization and selective abstraction significantly

more strongly than depressed non-pain patients. LBP

cognitive distortion, which are specifically related to a

person's back pain, was not as strongly associated with

depression as general cognitive distortion. Lefebvre

concluded that depressed pain patients distort about general

life experiences to about the same degree as their depressed

non-pain counterparts.

Several studies by Smith and colleagues (Smith et al.,

1986; Smith et al., 1988; Smith et al., 1990) have also

utilized the CEQ to examine cognitive distortions in LBP and

rheumatoid arthritis (RA) patients. Previous examinations

of MMPI profiles suggested that LBP patients with elevations

on Depression (D) demonstrated 2 profiles. One is

characteristic of somatization, with elevations on

Hypochondriasis (Hs) and Hysteria (Hy). The other is

characteristic of general distress, with elevations on

Psychasthenia (Pt) and Schizophrenia (Sc). Smith et al.

(1986) found that general and LBP cognitive distortions were

significantly related to elevations on D, Pt and Sc,

concluding that cognitive distortion is a correlate of

general cognitive distress, but not of somatization. Both

types of distortion were also found to account for

significant amounts of self-report and interview-rated

depression independent of disease severity in a sample of RA

patients (Smith et al., 1988).

Much of the pain-depression literature has focused on

what factors may mediate the pain-depression relationship in

an attempt to determine why some individuals are more

susceptible to developing depression while experiencing

chronic pain. Using the Automatic Thoughts Questionnaire

(ATQ) (Hollon & Kendall, 1980) and the Positive Automatic

Thoughts Questionnaire (ATQ-P) (Ingram & Wisnicki, 1988),

Ingram et al. (1990) examined the role of both positive and

negative cognitions and depression in chronic pain patients.

Not surprisingly, depressed patients reported significantly

more negative thoughts than non-depressed pain patients or

controls. These negative thoughts were associated with the

presence of depression, regardless of pain intensity. Of

interest is the finding that non-depressed pain patients

report significantly more positive thoughts than depressed

pain patients or normals. This suggests that high levels of

positive thoughts may serve as a buffer for emotional

distress resulting from chronic pain.

Chronic pain patients are often viewed as a homogenous

group, even though the characteristics of these patients can

vary greatly. Although low back pain and RA patients are

frequently studied as a group, chronic pain samples have

been shown to be quite heterogeneous. Gil et al. (1990)

developed the Inventory of Negative Thoughts in Response to

Pain (INTRP) to examine the relation of negative thinking

patterns to pain and psychological distress in 3 pain

populations: sickle cell disease (SCD), RA and chronic pain.

Factor analysis of this measure yielded three factors:

Negative Self-Statements, Negative Social Cognitions and

Self-Blame. Patients scoring high on the INTRP had higher

levels of depression, anxiety, somatization, obsessive-

compulsiveness, interpersonal sensitivity, paranoid ideation

and psychoticism. Chronic pain patients scored

significantly higher on Negative Self-Statements than SCD or

RA patients. Additionally, chronic pain patients scored

significantly higher on Negative Social Cognitions than RA

patients and reported lower levels of control over negative

thoughts than did SCD patients.

Passive coping strategies such as catastrophizing have

been related to higher levels of depression (Brown et al.,

1989; Keefe & Williams, 1990; Weickgenant et al., 1993) and

higher reports of pain intensity (Wilkie & Keefe, 1991;

Turner & Clancy, 1986). Catastrophizing refers to an

individual's tendency to overexaggerate negative aspects of

a situation and is most commonly measured by the Coping

Strategies Questionnaire (CSQ) (Rosenstiel & Keefe, 1983),

which assesses the extent to which subjects report using 6

cognitive and 2 behavioral coping strategies when they felt

pain. The catastrophizing subscale is designed to measure

negative self-statements and catastrophizing thoughts.

Patients scoring high on this scale demonstrate higher

levels of functional impairment, higher ratings of pain and

higher levels of depression (Keefe et al., 1989).

Catastrophizing scores are able to predict long-term

depression after controlling for initial level of depression

(Keefe et al., 1990).

The use of catastrophizing has also been associated

with lower pain tolerance (Spanos et al., 1979). Pain

tolerant individuals (able to endure 5 minutes of cold

pressor task) were less likely than pain-sensitive

individuals (able to tolerate for an average of 60 seconds)

to use catastrophizing as a coping strategy (Geisser et al.,

1992). Although, there is current debate over whether

catastrophizing by itself is a predictor of depression or

merely a symptom of depression (Jensen et al., 1991; Affleck

et al., 1992; Sullivan and D'Eon, (1990), a recent study by

Geisser et al. (1994) found that catastrophizing played a

significant role in mediating the relationship between

evaluative and affective aspects of pain.

In addition to a person's negative cognitions,

attributions of successes and failures have also been

hypothesized as a contributing factor in the development of

depression (Abramson et al., 1978). According to this

theory, success is attributed to specific, unstable,

external factors; whereas, failure is attributed to global,

stable and internal factors. Depression in chronic pain

patients has been found to be related to an internal,

stable, global style for negative events only (Love, 1988).

Additionally, depressed pain patients are more likely to

endorse negative self-attributions than non-depressed pain

patients (Holzberg et al., 1993).

These studies suggest that the cognitive aspects of

pain and depression may provide important suggestions to the

development of treatment programs which adequately address

both issues. Distortions were not found to be specific to

pain. Rather depressed pain patients were found to be

similar to depressed non-pain patients in their use of

cognitive distortions and errors. This is consistent with a

cognitive-behavioral approach to depression, which would

maintain that such individuals are likely to adopt negative

patterns of viewing many areas of their life. These

distortions appear to account for depression independently

of disease severity or pain intensity. Additionally,

cognitive distortions may be related to psychological

distress in general, and not just depression.

Previous studies investigating the role of negative

thoughts in pain patients have been retrospective in nature.

The main purpose of the study will be to assess the role of

cognitions in pain through the implementation of self-

statement training (SST), using either negative or positive

cognitions during the cold pressor task. Cold pressor pain

is produced by immersion of a limb in very cold water. It

produces severe pain that increases quickly and is tolerated

for a relatively short period of time (Gracely, 1989). If


negative thoughts are related to pain tolerance in chronic

pain patients then it should be possible to manipulate those

thoughts in such a way as to increase a patient's tolerance

to the painful stimuli. This appears to be the first step

in the larger task of addressing the role of cognitions and

depression in pain patients, which this study will not

directly address. This next section will provide a general

review of self-statement training, with emphasis on studies

relating to cold pressor pain.


In order to assess the role of self-verbalization and

pain tolerance, it is first necessary to introduce stress

inoculation training (SIT). Developed by Meichenbaum

(1977), SIT has been successfully used in the management of

pain and its principles are commonly incorporated into self-

statement training programs. Meichenbaum (1977) proposed

three phases: education, rehearsal, and application

training. During the education phase of SIT, participants

are provided with a conceptual framework for understanding

the nature of the individual's response to stressful events.

Melzack and Wall's three factor conceptualization of pain

(sensory-discriminative, motivational-affective and

cognitive-evaluative) is often presented during this time

(Melzack, 1973). Subjects are encouraged to view their

response as a series of phases consisting of preparing for

the stressor, confronting or handling the stressor, possibly

being overwhelmed by the stressor and self-reinforcement for

successful coping.

Cognitive coping strategies are introduced to the

subject during the rehearsal phase. Participants learn to

monitor negative and self-defeating statements and replace

them with positive coping statements. Subjects are

encouraged to generate their own statements for use during a

stressful situation. Additionally, subjects are trained in

procedures, such as relaxation, which will decrease

physiologic arousal. Finally, subjects are encouraged to

use their coping skills during a stressful situation in the

application training phase.

It is not yet clear which components of SIT are most

effective in increasing pain tolerance. Girodo and Wood

(1979) assigned 70 undergraduates to one of four conditions:

SIT rationale while hypnotized, rationale while awake,

hypnotic induction only and simple instructions to repeat

self-statements before posttesting. These authors found an

increase in duration scores from pretest to posttest but no

significant differences between groups. Self-statements and

hypnosis were independently capable of reducing perceptions

of cold pressor pain. Subjects who received instructions to

use self-statements alone coped no better than controls,

although they reported the same number and frequency of

self-statements as other groups. This suggests that self-

statement training is enhanced by the provision of

information relating to the efficacy of self-statement

training in pain management.

Vallis (1984) performed a complete component analysis

of SIT using cold pressor pain and 80 undergraduate females.

All conditions which included skills acquisition

demonstrated a significant increase in tolerance as a

function of training (without corresponding increases in

amount of reported discomfort). The education-alone

condition, which used the 3 factor conceptualization of

Melzack and Wall, also demonstrated significant improvement

in tolerance. Additionally, data from unstructured

questionnaires indicated that treatment led to decreases in

the use of catastrophizing strategies, from pre-treatment to

post-treatment, although it is unclear how this was


Worthington (1978) used 90 female undergraduates and

cold pressor to examine pleasant versus neutral imagery,

choice (allowed to chose own imagery) versus yoked

(instructed to use imagery of subject they were yoked to)

and pre-planned explicit self-verbalization versus no self-

verbalization. The use of pleasant imagery did not lead to

greater tolerance than the use of neutral imagery. Subjects

who had a choice of imagery had greater tolerance gains than

the subjects to whom they were yoked. Subjects who heard

pain conceptualized as a 3 stage process and then explicitly

planned self-verbalizations that they intended to use during

each stage had greater tolerance gains than subjects who

only heard the conceptualization and then repeated it back

to the experimenter (no self-verbalization). However, there

were no changes in self-report of pain intensity.

Shumate and Worthington (1987) examined the

effectiveness of and self-verbalizations using positive

self-verbalization (PSV) (planned positive task-relevant

self-instructions), negative self-verbalizations (NSV)

(trained to identify and refute maladaptive thoughts),

combined self-talk (combination of positive and negative

self-verbalization groups), and information (provided with

information regarding pain). Positive self-verbalization

training was effective in increasing positive thoughts in

both PSV only and combination groups. Likewise, NSV

training was effective in decreasing negative thoughts in

NSV only and combination groups. Increases in cold-pressor

tolerance were associated with increased positive self-talk,

regardless of experimental condition. Reports of pain and

emotional distress were not decreased by cognitive

techniques. However, subjects reported a decrease in

maximum pain felt during posttest irrespective of group


This review has attempted to focus on those studies

examining self-statement training in the context of SIT.

Although experimental procedures may be varied, these

studies provide evidence that self-statements are effective

in reducing cold-pressor pain and lead to increased

tolerance. Additionally, the use of self-statements has

been found to lead to decreases in the use of

catastrophizing. However, the use of these statements does

not seem to affect patient ratings of pain intensity.


The studies reviewed here have tended to use

undergraduate students as subjects. SST used during this

study was developed based on the recommendations and

findings of these studies. The current study used pain

patients as subjects in an attempt to determine how these

patients react to a painful experimental stimulus and what

role their cognitions play in their coping.



Subjects were 58 adult chronic pain patients recruited

from the Parker Mahan Facial Pain Center at the University

of Florida. All subjects were between age 18 and 65 and had

current facial pain resulting from TMD. Typical primary

diagnoses included myofascial pain syndrome,

bruxism/clenching, noxious occlusion, fibromyalgia,

degenerative arthritis and disk displacement. Seventeen

subjects (29%) reported headaches as a secondary diagnosis.

Patients were approached in clinic prior to their

appointment and asked to participate in a study

investigating the role of cognitions and pain. Individuals

meeting the following criteria were excluded from

participation in the study: a) pain related to a malignant

process, such as cancer -- 0 subjects excluded; b) pain

duration of less than 6 months -- 5 subjects; c) pain in the

upper extremities -- 25 subjects; and d) history of severe

cardiovascular disease -- 1 subject.

Demographic information can be found in Table 1. The

average age at time of study was 39.3 (ES = 11.7). Average

pain duration reported was 97.7 months (SD = 95.7).

Demographic Information for PSST and NSST Samples


Variable n n

Females 25 24
Males 4 5

Right 27 26
Left 2 3

White 28 28
Black 1 0
Other 0 1

Single 7 8
Married/living together 18 20
Divorced 3 1
Widowed 1 0

EDUCATION (in years)
<12 1 0
12 10 10
12-16 18 17
>16 0 2

Employed 18 17
Not-employed 11 12

Treatments for pain prior to presentation in the clinic can

be found in Table 2.


Part I: Pretest. Prior to participation in the cold-

pressor task, subjects completed a consent form which

outlined the procedures of the study. Subjects were allowed

to decline participation at any time during the procedure.

Additionally, subjects were administered the Beck Depression

Inventory (BDI), Pain Beliefs and Perceptions Inventory

(PBPI), Inventory of Negative Thoughts in Response to Pain

(INTRP) and the demographic questionnaire. The cold-pressor

apparatus consisted of a cooler fitted with a screened

divider. This cooler was filled with cold water and ice was

placed in one side of the device. The water was circulated

using a dc bilge pump, which maintained the water at a

constant temperature of 1-4 degrees Celsius.

Subjects were seated in a comfortable chair, given a

brief description of the procedure, and asked to remove all

jewelry and watches from their non-dominant hand. They were

instructed to place this hand with the palm facing down in

the compartment not containing ice, so that the top of the

water was midway between their wrist and elbow. Subjects

were instructed to say 'pain' at the point at which they

first experienced pain, and then to keep their hand in the

water for as long as possible. Subjects were asked to make

pain ratings at 10 second intervals during the task using a

Table 2

Treatments Received Prior to Facial Pain Clinic Evaluation

Treatment %

Medication 41

Splints 34

Physical Therapy/Massage 33

Surgery 15

Braces 12

Extractions/Root canals 10

Chiropractor 10

Injections/Nerve blocks 9

Biofeedback/Psychological 9

Acupuncture 7


No Treatment 15

*Subjects may be in more than one category


pain rating device, described elsewhere. Prior to beginning

the pretest subjects completed a current pain VAS (CP I).

The experimenter recorded pain threshold and tolerance in

seconds. Subjects maintaining their hand in the water at

300 seconds were asked to remove it. Immediately following

the task, subjects were asked to make pain ratings using

VAS-intensity (Sensory I) and VAS-unpleasantness (Affect I)


Part II: Posttest. Subjects were randomly assigned to

either the Positive Self-Statement Training (PSST) group or

Negative Self-Statement Training (NSST) group. Both groups

were provided a rationale supporting the use of either

positive or negative coping statements in the management of

pain. This was followed by rehearsal of statements chosen

by the subject from a pre-determined list. Subjects were

then asked to choose one statement to use during the task.

They were instructed to repeat this statement aloud during

the posttest.

Training for both groups took approximately 7-8

minutes. As in the pretest, subjects completed a current

pain VAS (CP II) immediately prior to participation in the

posttest. Upon completion of the posttest, subjects

completed VAS Intensity (Sensory II) and VAS Unpleasantness

(Affect II), and VAS ratings of clinical pain (CLP) and

rationale effectiveness.

Following participation, all subjects were debriefed

concerning the nature of the study. Special consideration

was given to providing the NSST group with information

regarding the use of appropriate coping statement for the

management of pain (See appendix for all scripts).


Beck Depression Inventory (BDI) (Beck & Steer. 1987).

The BDI is a 21-item questionnaire which measures presence

and severity of depression. It contains questions

concerning depressive symptoms, such as feelings of guilt

and worthlessness, irritability, social withdrawal, sleep

and appetite disturbances and quality of mood. Each item

consists of 4 statements which rate symptoms in severity

from 0 (least severe) to 3 (most severe). Sums of all items

yield a total score which may range from 0 to 63. Test-

retest reliability ranges are .48 .86 for psychiatric

samples and .60 .83 for non-psychiatric samples. Internal

consistency is .86 and .81 for psychiatric and non-

psychiatric samples, respectively.

Inventory of Negative Thoughts in Response to Pain

(TNTRP) (Gil et al., 1990). This 21-item questionnaire

assesses subjects' responses to pain flare-ups. Respondents

indicate on a 5-point Likert scale how frequently they have

negative thoughts during flare-ups. These cognitions fall

into three categories: negative self statements, negative

social cognitions and self-blame. Cronbach's coefficient

alphas range from .73 to .91, suggesting that each of the

scales possesses satisfactory internal consistency.

Pain Beliefs and Perceptions Inventory (PEPT) (Williams

and Thorn. 1989). This 16-item questionnaire assesses

beliefs which have developed as the result of persistent

pain. These beliefs may differ from previously held

cultural or personal beliefs about pain. The PBPI is

composed of 4 belief scales. Mystery measures the belief

that pain is a mysterious, aversive event that is poorly

understood. Self-blame assesses the degree to which

patients believe that they are to blame for their pain. The

remaining 2 belief scales, Permanence and Constancy, were

originally one scale (Time) which described the belief that

pain is and will be an enduring part of life (Williams, et

al., 1994). Constancy is concerned with temporal aspects of

pain, such as whether it is constant or remittent.

Permanence assesses the degree to which a patient has

accepted pain as a permanent part of life. Respondents are

asked to indicate how closely they agree with each statement

by using a 4 point Likert scale (-2, -1, 1, 2) ranging from

strongly disagree to strongly agree.

In addition to the above questionnaires, subjects were

asked to complete a questionnaire containing information on

demographic variables, such as age, race, education, and

marital status. Additionally, subjects were asked to report


information concerning diagnosis, pain duration and severity

and medication use at time of appointment.

Pain measures. Pain threshold was measured as the

amount of time it took the subject to report pain during the

cold-pressor task. Pain tolerance was defined as the total

amount of time subjects maintained their hand in the water.

Pain sensitivity range (PSR) was defined as tolerance minus

threshold for each trial. A series of visual analog scales

(VAS) were used to obtain ratings for pain (intensity,

unpleasantness, current pain and clinical pain) and

effectiveness of rationale. All VAS scales were 10 cm. in

length with verbal anchors. For example, VAS-intensity

assessed subjects' ratings of pain intensity and range from

"no pain at all" to "worst imaginable pain." Subjects were

asked to make a mark on the line which best represented

their experience.

Typically, in studies assessing pain perception,

subjects make oral pain ratings at 10 second intervals. Due

to the verbal nature of the intervention (repeating a

statement aloud), this was viewed as a possible confound.

Therefore, a pain rating device using a pressure sensitive

bladder was used to obtain pain ratings during the task.

Subjects pressed on the bladder using their dominant hand.

The bladder was connected to an air pressure sensor

(transducer) through a small tube. Air pressure was

converted to a voltage level by means of an analog to


digital converter housed within an HC11 microprocessor.

Data was downloaded to a laptop computer for later analysis.

This device required 20 pounds of pressure to reach a

maximum voltage of 5 volts. This provided an added benefit

of eliminating possible ceiling effects seen in the use of

anchored VAS scales.


Standard techniques were used to compute each

individual's scores on the BDI, PBPI and the INTRP.

Statistical Package for the Social Sciences (SPSS) was used

to analyze the data. Group comparisons were first conducted

to determine if the two groups differed significantly from

one another on the demographic and pain variables. Chi

square analyses were used to analyze categorical variables

(gender, race, education, marital status, and handedness).

Independent samples t-tests were used to compare age, pain

duration, weekly pain (number of days per week subject

experiences pain), daily pain (number of hours during day

that pain episodes last), threshold, tolerance and VAS

ratings. Results revealed that groups differed

significantly on rationale effectiveness t (56) = 6.44, p <

.0001. All other comparisons were non-significant. Means

and standard deviations for pain variables can be found in

Table 3. Means and standard deviations for psychosocial

variables can be found in Table 4.

The primary hypothesis being addressed by this study

was that subjects in the PSST group would have greater

increases in tolerance, threshold and pain ratings from

pretest to posttest than subjects in the NSST group. A

Table 3

Means and Standard Deviations for Pain Variables


Variable Mean SD Mean SD

Durations (months) 82.69 105.38 112.69 84.20

Weekly Pain 5.78 1.62 6.86 .45
Daily Pain 8.03 5.04 10.98 8.69

Current Pain I 2.92 2.53 4.22 3.08
Current Pain II 3.08 2.65 3.83 3.20

Sensory I 6.24 2.04 6.09 2.76
Sensory II 6.71 1.47 6.54 2.69

Affective I 7.37 1.97 7.44 2.27
Affective II 7.29 1.81 7.71 2.26

Peak I (volts) 1.81 .18 1.78 .20
Peak II (volts) 1.81 .20 1.83 .28

Threshold I (sec) 49.03 55.72 71.07 96.84
Threshold II (sec) 52.76 60.96 86.55 101.38

Tolerance I (sec) 94.17 90.52 119.45 119.06
Tolerance II (sec) 118.41 104.65 111.10 107.27

PSR I (sec) 45.14 76.50 48.38 75.59
PSR II (sec) 65.66 87.90 24.55
Clinical Pain 4.27 2.96 4.33 3.42

Effectiveness 7.08 2.33 2.76



Table 4

Means and Standard Deviations for Psvchosocial Variables

Measure Mean SD

BDI TOTAL 11.98 7.92
Cognitive 5.84 4.35
Somatic 6.14 4.37

Constancy 1.75 4.24
Permanence -.55 4.17
Mystery 2.00 3.92
Self-Blame -4.07 2.35

Negative Self-
Statements .93 .69
Negative Social
Cognitions 1.44 .81
Self-Blame .77 .80


repeated measures Multivariate Analysis of Variance (MANOVA)

was used to test this hypothesis. Three dependent variables

were used: threshold, tolerance and peak pain ratings. No

main effects were found to be significant. A group by time

interaction was found (3,54) = 2.66, p = .057. PSR scores

were calculated to assess subjects' sensitivity to the

painful stimulus. A repeated measures Analysis of Variance

(ANOVA) using these scores revealed a group by time

interaction, (3,54) = 6.15, p < .02. No main effects were

found to be significant.

Correlation coefficients were calculated to determine

the relationship between pre-test threshold and tolerance

times and psychosocial variables. Results can be found in

Table 5. Pre-test tolerance and threshold were not found to

be correlated significantly with any psychosocial variables.

Depression, as measured by the BDI total score, was

significantly correlated with all INTRP scales and PBPI

Permanence. Individual scales for INTRP and PBPI were

intercorrelated. PBPI Permanence was significantly

correlated with INTRP Negative Self-statements and Social

Cognitions. PBPI Self-Blame was significantly correlated

with INTRP Negative Self-statements and Self-blame.











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The hypothesis that subjects in the PSST group would

have significant increases in tolerance, threshold, and pain

ratings during the cold pressor from pretest to posttest was

partially confirmed by this study. The repeated measures

MANOVA was significant at p < .10 and the repeated measures

ANOVA using PSR scores was significant at Q < .02. Analysis

of data obtained from the ANOVA reveal changes in pain

perception in the proposed directions, with PSST subjects

increasing their time from pretest to posttest and NSST

subjects decreasing their time.

An important consideration of any study is whether the

constructs being examined are valid. Three major constructs

were examined in this study: threshold, tolerance and pain

ratings. Threshold emphasizes the discrimination of

nociceptive quality, assessing at what point a stimulus is

perceived as painful. Tolerance is an expression of

unwillingness to receive more intense stimulation. Harris

and Rollman (1988), using a multi-trait, multi-method

procedure found that threshold and tolerance, while related,

do not tap identical components and each has validity as a

trait. These remain fairly consistent within an individual,

when exposed to different pain induction methods. The

definitions of tolerance and threshold used in this study

are consistent with those of other studies in the literature

and are viewed as appropriate.

The pain rating device used in the study is novel. As

previously stated, this device was seen as superior to those

used in previous studies, in that it would eliminate ceiling

effects and make it possible to report pain ratings without

interference to the verbal intervention. However, its

validity has not been determined and, therefore, it is not

possible at this point to assess the device's potential as a

valid measure of pain ratings. The sampling rate of the

microprocessor allowed for the recording of over 180

increments between the baseline voltage of 1.5 volts and

maximum possible rating of 5 volts. It is possible this

high sampling rate, coupled with demands of the pressure

sensor, which required 20 pounds of pressure to reach 5

volts, made it difficult to demonstrate a group difference

due to the small variability in ratings over time.

The hypothesis related to pain ratings proves difficult

to examine. Two theories have been proposed. It has been

reported that increased tolerance leads to increased reports

of pain (Williams & Kinney, 1991). It has also been

suggested in the literature that cognitive interventions,

such as those used here, do not effect pain ratings

(Worthington, 1978). Of the two groups, the PSST group was

hypothesized to have increases in tolerance times from

pretest to posttest. Therefore, it was hypothesized that

PSST pain ratings would increase, due to the increased

length of exposure to the painful stimulus, in comparison to

the NSST group. However, it could also be argued that the

NSST group would have increases in their pain ratings due to

the negative cognitions. If both of these postulates are

true then there would be no difference between the groups.

Clearly further examination of this measure is needed and no

definite conclusions can be drawn.

Perceived control is the belief that one has at one's

disposal a response that can influence the aversiveness of

an event (Thompson, 1981). Keefe and Brown (1980) have

proposed that pain patients' perceptions of their ability to

control their pain decrease as they move from the acute, to

the pre-chronic and finally chronic phases. This study did

not control for patients' belief that they could impact

their pain. Crisson and Keefe (1988) report that patients

who hold a chance orientation to control (e.g., believe that

chance is responsible for their pain) felt more helpless to

deal with their pain.

Litt (1988) has suggested that cognitive strategies

designed to modify pain tolerance should be effective to the

extent that they enhance self-efficacy expectations. Self-

efficacy refers to one's confidence in his or her ability to

behave in such a way as to produce a desirable outcome

(Bandura, 1977). Comparing relaxation training, cognitive

coping skills and a pain irrelevant task, Cassens et al.

(1988) found relaxation and cognitive treatments to only be

effective when they were accompanied by positive feedback.

In his study, Litt (1988) found the longest tolerance times

were observed in subjects who perceived high control over

their situation and had high confidence in their ability to

use that control. The question then arises Does the

current study change subjects' perceptions of their ability

to control their pain?

Subjects in both the PSST and NSST groups are told that

the strategy that they are being instructed to use "may be

effective" in increasing their tolerance to pain. This

suggests that the lack of difference between the groups

could be related to the fact that both groups believe that

they will be able to control their pain using the statements

assigned to them. However, a significant difference was

noted between the groups for subjects' report of the

effectiveness of the rationale, with subjects in the NSST

group rating their intervention as significantly less

effective than subjects in the PSST group, t (56) = 6.44, p

< .0001. Thus, self-efficacy theory would suggest that

individuals in the NSST group would likely have lower

ratings of self-efficacy than their PSST counterparts and

therefore the difference between the two groups should have

been enhanced.

Research suggests that an individual's choice of coping

statements is important in the management of pain (Beers &

Karoly, 1979; Turk & Rudy, 1986). However, some previous

studies have not found the use of self-statements alone to

be effective in managing pain (Hacket & Horan, 1980;

Worthington & Shumate, 1981). Closer examination of the

Worthington and Shumate article revealed that the

intervention was used by only 26% of the subjects in that

condition. In fact, it has been noted that difficulties in

the assessment of cognitive approaches to pain arise because

subjects spontaneously use their own cognitive coping

strategies when faced with noxious stimulation (Tan, 1982).

This study attempted to alleviate this problem by having

subjects state aloud the coping statements to ensure that

they were using only the coping mechanisms required by the

study. However, it may not have capitalized on subjects use

of their own preferred coping strategies.

Using a meta-analysis, Dush et al. (1983) found that

self-statement training alone is not as effective as when it

is combined with other modalities. This is consistent with

the trends in our data which show that the PSST group did

increase their tolerance times, while those in the NSST

group decreased their tolerance times, from pretest to

posttest. However, the difference was not found to be

significant and would have likely been enhanced by the

addition of other coping strategies, such as relaxation or

possibly even allowing subjects to choose their own coping


Distraction has been found to be an effective means of

enhancing tolerance to cold pressor stimulation (Williams &

Kinney, 1991). It is possible that with an acute pain

stressor, the use of negative coping statements does not

prove to be a disadvantage over positive statements due to

the distraction component it provides. Anecdotally, when

asked to make ratings of the effectiveness of the rationale,

subjects in the NSST group would often comment that it

helped to distract them, but was not very effective in

helping them to deal with the pain. McCaul and Malott

(1984) reported that distraction is effective for dealing

with acute pain, especially laboratory pain.

What contribution do psychological variables such as

depression, anxiety or the use of negative thoughts

contribute to the measurement of tolerance and threshold?

Many studies have found catastrophizing to be related to

depression and to decreased tolerance times. Correlation

coefficients were calculated to determine the relationship

between pretest tolerance and threshold times and

psychosocial variables (e.g., BDI, INTRP, PBPI). Tolerance

and threshold were not found to be correlated significantly

with any psychosocial variables. This is consistent with a

study by Boureau et al. (1991) which found no correlation

between the BDI and pain measures when assessing nociceptive

reflex in chronic pain patients. However, it raises some

interesting questions about the use of paper and pencil

instruments to measure depression and pain in chronic pain

patients. Scores on the BDI are often elevated in these

patients due to increased somatic complaints (Williams &

Richardson, 1993) and it has been suggested that the cut-off

score be increased to identify depression in these patients

(Turner & Romano, 1984). Paper and pencil measures (BDI,

INTRP, PBPI) were intercorrelated, suggesting that they are

measuring related aspects.

Although there is currently a large group of literature

suggesting a higher than normal rate of incidence of

depression within the chronic pain population, additional

studies have found a weak relationship (Garron & Leavitt,

1983; Kerns et al., 1983; Pilowsky et al., 1977). When

depression is reported among chronic pain patients, it is

typically expressed as mild depressive symptoms rather than

meeting the criteria for major depressive disorder

(Skevington, 1993). It has been suggested that chronic pain

and depression are best seen as independent phenomena due to

the difficulties in making definitive statements about the

extent and nature of their relationship (Craig, 1989).

Anxiety is often the primary emotional reaction to an

acute pain experience. In fact, autonomic arousal patterns

are similar in both pain and anxiety and may be difficult to

distinguish (Gross & Collins, 1981) and increased levels of

anxiety are related to increased reports of pain (Cornwall &

Donderi, 1988; Jamison et al., 1987). No attempt was made

to control for anxiety in this study; however, it is

possible that subjects in this study experienced little

anxiety regarding the painful experience. By the second

trial, subjects are familiar with the sensations of cold

pressor and recognize that they can remove their hand from

the apparatus at any time, thus terminating the stressor.

Second, subjects who found the prospect of cold pressor pain

to be too overwhelming and, therefore, anxiety producing

most likely opted not to participate rather than to be

exposed to such emotional, as well as physical discomfort.

No attempt was made in this study to control for

potential physiological variables which may have contributed

to the outcome. For example, high blood pressure has been

found to be correlated with diminished pain sensitivity

(Ditto et al., 1993). It is also unclear what impact the

physiologic effects of prolonged pain on the nervous system

might have with regard to threshold and tolerance. There

are at least two theories which attempt to explain chronic

pain patients' response to pain. Adaptation theory

hypothesizes that pain patients evaluate pain within the

context of their previous experience, predicting that they

would have higher thresholds than controls because of their

extensive history dealing with pain. The opposing theory,

postulates that pain patients should demonstrate lower pain

thresholds due to their hypervigilance to somatic distress


Studies have found support for both the adaptation

model (Cohen et al., 1983; Naliboff et al., 1981; Zamir &

Shuber, 1981) and the hypervigilance model (Malow et al.,

1980; Malow & Olson, 1981). It has been suggested that

discrepancies between these studies could be explained by

the differences in methods being used (Cohen et al., 1983).

Designs supporting the adaptation model used repeated

presentations of radiant heat, while Malow's studies used a

focal pressure stimulator which applied a constant pressure,

leading to steady increases in pain intensity. Without

comparison to a control group, it is unclear what role these

theories play in this sample. However, the current study

using the cold pressor would seem to be more similar to

those using the focal pressure stimulator.

Finally, some comments should be made about the sample

itself. This sample was predominantly white and well-

educated. It was comprised of a 5:1 ratio of females to

males. This is consistent with the literature which reports

that although gender differences for TMD symptoms are absent

in a non-clinical population (Glass et al., 1993), females

comprise the largest proportion in clinical settings

(Southwell et al., 1990). The basis for this inconsistency

remains speculative.

The findings of this study have implications for both

the clinician and researcher. The trend toward significance

of the MANOVA and the significant finding regarding pain

perception indicates that a relationship exists between the

use of coping statements and tolerance. Numerous

applications are possible for strengthening this

relationship. It appears that increasing the time available

for training may be most important clinically. Learning

theory suggests that patterns of behavior, including

cognitive coping, are developed over time as the result of

numerous environmental factors (e.g., positive

reinforcement) and may be difficult to change. Subjects in

this study demonstrated a broad range of pain duration from

6 months to 45 years, with mean duration of 97.7 months.

The use of positive coping statements may require not only

the learning of new skills for dealing with a painful

experience, but the unlearning of old maladaptive patterns.

Obviously, one hopes to have available a sufficient amount

of time to work with a patient on developing these new

strategies. Experimentally, increasing the time available

for training would appear to have benefits as well.

Increasing both the time allotted for self-statement

training and the number of trials would have the benefit of

building more rapport with the patient and insuring that the

patient has adequate competency in the use of self-



This additional training time may also serve to enhance

a patient's feelings of self-efficacy in coping with their

pain. Future research examining the role of negative vs.

positive cognitions which include a self-efficacy component,

such as providing patients in both groups with negative or

positive feedback, would allow further examination of not

only the importance of such feedback, but also allow for a

better understanding of cognitive coping strategies.

Several studies suggest that matching a patient's

intervention with their preferred coping style may be more

effective in dealing with a stressful procedure (Auerbach et

al., 1976; Martelli et al., 1987; Shipley et al., 1979).

The distinction between relevant vs. irrelevant strategies

for pain appears to be important, with relevant strategies

leading to increases in pain threshold (Spanos et al., 1975)

and lower ratings of pain intensity (Rybstein-Blinchik,

1979). The intervention used in this study was purposely

brief and limited to simple sentences of roughly the same

length. Statements were presented in a forced choice format

so that subjects were not allowed to incorporate their own

means of coping. Clinically, of course, one would want to

maximize a patient's coping response so that patients would

have a variety of coping statements from which to choose.

Experimentally this could be achieved by providing a broader

range of statements which are more specifically related to

the painful experience and allowing patients to use more


than one statement during the task. Alternatively,

subjects could generate a list of statements, either alone

or in conjunction with the experimenter, to be used during

the task.

Finally, combining self-statements with other

modalities, such as relaxation training or even biofeedback,

would prove to be beneficial. This could easily be

incorporated into self-statement training through the use of

verbal prompts for relaxation.



"In a few minutes, I'm going to ask you to participate

in a study which examines how individuals cope with pain by

having you place your hand in some ice water. You may

decline to participate at any time during the procedure

without penalty."

*Determine non-dominant hand.

*Ask subject to remove all jewelry and watches from non-

dominant hand.

"In a minute, we will begin the task. When I tell you,

please place your left/right hand in the ice chest so that

your palm is facing down and the water comes midway between

your wrist and elbow. During the task, you will use this

device to indicate ratings of pain or discomfort. Think

about it like this. When the bulb is resting in your hand,

it indicates that you feel no pain at all. When the bulb is

squeezed as hard and firm as possible, that would indicate

worst imaginable pain. There are lots of points in between.

Now let's take some time to practice, so that you can have

an accurate feel of how the bulb works. Place the bulb in

your hand like this and squeeze it so that you can feel the

varying degrees of tension." (Give practice trials). "Be

careful that you do not cover up the hole on the end of the

bulb. During the task, I will be asking you to make ratings

of your pain or discomfort using the bulb. Each time you

hear me say 'rating' squeeze the bulb to indicate your level

of pain or discomfort at that time. Remember that when it

is resting in your hand that indicates no pain.

The bulb helps you to indicate your level of discomfort

at times during the task. I'd also like you to indicate

when you first feel pain by saying the word 'pain' out loud

so that I can hear you, then keep your hand in the water for

as long as you can before removing it. After the procedure

I'll ask you some information about your experience during

the task."

*Ask subject if he/she has any questions, repeat if


*Rating of current pain VAS.

** Following procedure, administer pain ratings -I.


"In a few minutes, you will be asked to repeat the cold

pressor task in the same manner as before, but this time I'd

like you to try some techniques which many people find

helpful when faced with a painful experience.

What you say to yourself during a painful event can

affect the way you experience pain. Positive thoughts can

help you to feel better about your ability to deal with a


painful experience. For instance, if you focus on positive

thoughts, such as 'This is not that bad. I can do this. I

am almost through.' you will be able to perceive the pain

as more manageable and more easily endured. By focusing on

these positive thoughts, you will have a more realistic view

of your situation and may be more able to deal with the

difficult experience of the painful task.

We would like you to repeat a statement out loud which

focuses on positive thoughts, so that the painful experience

can be made less intense and more easily endured.

Here is a list of statements which people have found

effective in coping with pain." *Present note card to


"Please follow along with me, as I read them out loud."

*Read statements from note card.

"One step at a time, I can handle it.

I just have to remain focused on the positives.

It won't last much longer.

No matter how bad it gets, I can do it.

It will be over soon.

This isn't as bad as I thought."

"Please pick one statement that you'd like to use for

practice. Now imagine that you are getting ready to place

your hand in the ice chest. Practice saying this statement

out loud so that I can hear you. Say the statement at a pace

which is comfortable for you." *Repeat using new statement.

"We are just about ready to begin. Please pick one

statement that you'd like to use during the task. (Record

statement on data sheet). Please use only that statement by

repeating it out loud during the task. Say the statement

at a pace that is comfortable for you. Continue to use the

statement until you remove your hand from the water. Once

again, I will also be asking you make pain ratings using the

bulb. Each time you hear me say 'rating' squeeze the bulb

to indicate your level of discomfort or pain at that moment.

Also, remember to indicate when you first feel pain by

saying the word 'pain' out loud so that I can hear you.

Then keep your hand in the water for as long as you can

before removing it."

*Rating of current pain VAS-II.

*After completion of task, administer pain-ratings-II,

rating of clinical pain and effectiveness of rationale VAS.

*Do debriefing.


"In a few minutes, you will be asked to repeat the cold

pressor task in the same manner as before, but this time I'd

like you to try some techniques which many people find

helpful when faced with a painful experience.

What you say to yourself during a painful event can

affect the way you experience pain. For instance, your

natural tendency might be to focus on negative thoughts

regarding the pain, such as 'This is terrible, I can't take

this anymore, This is the worst thing I've ever

experienced'. By focusing on what comes naturally and

allowing yourself to experience those negative thoughts, you

will have a more realistic view of your situation and may be

more able to deal with the difficult experience of the

painful task.

We would like you to repeat a statement out loud which

focuses on negative feelings, so that the painful experience

can be made less intense and more easily endured.

Here is a list of statements which people have found

effective in coping with pain." *Present note card to


"Please follow along with me, as I read them out loud."

*Read statements from note card.

"This is terrible.

This is never going to get better.

I can't stand it anymore.

This is overwhelming.

I feel like I can't go on.

This is worse than I thought.

I cannot control the pain."

"Please pick one statement that you'd like to use for

practice. Now imagine that you are getting ready to place

your hand in the ice chest. Practice saying this statement

out loud so that I can hear you. Say the statement at a

pace which is comfortable for you." *Repeat with new


"We are just about ready to begin. Please pick one

statement that you'd like to use during the task. (Record

statement on data sheet). Please use only that statement by

repeating it out loud during the task. Say the statement

at a pace that is comfortable for you. Continue to use the

statement until you remove your hand from the water. Once

again, I will also be asking you make pain ratings using the

bulb. Each time you hear me say 'rating' squeeze the bulb

to indicate your level of discomfort or pain at that moment.

Also, remember to indicate when you first feel pain by

saying the word 'pain' out loud so that I can hear you.

Then keep your hand in the water for as long as you can

before removing it."

*Rating of current pain VAS-II.

*After completion of task, administer pain-ratings-II,

rating of clinical pain and effectiveness of rationale VAS.

*Do debriefing.


"You have just participated in a study which is

examining the role of cognitions or thoughts during a

painful experience. This study involved the use of two

groups of individuals. Half of the subjects say positive

statements during the cold pressor task and the other half

say negative statements during the cold pressor task. You

were in the ____ group.

Many studies in the literature now are investigating

the role of such statements in pain management. It has been

found that what we say to ourselves may influence our

experience and report of pain. In particular, the use of

catastrophizing has been found to be related to decreased

tolerance to pain. Catastrophizing refers to an

individual's tendency to overexaggerate the negative aspects

of a situation."

PSST group "You were asked to say statements which were the

opposite of catastrophizing thoughts. The use of positive

thoughts such as those that you were asked to choose from

have been found to be an effective means of coping with a

painful situation. If you would like any more information

regarding the use of such thoughts or about this study, I

would be happy to provide that for you now."

NSST group "You were asked to say statements which were

similar to catastrophizing thoughts. The use of negative

thoughts such as those that you were asked to choose from

have not been found to be an effective means of coping with

a painful situation. It is believed that it is more

effective to use positive thoughts which emphasize coping

and control over the situation. So for instance instead of

saying 'This is terrible', you might say 'This isn't as bad

as I thought' or instead of saying 'I can't stand this

anymore or this is overwhelming', you might say 'I am in

control of the pain, I can handle it.' If you would like

any more information regarding the use of such thoughts or

about this study, I would be happy to provide that for you



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Nola Litwins was born in raised in West Palm Beach,

Florida. She received her undergraduate degree in

psychology in December, 1988, her Master of Science degree

in May, 1993 and her Ph.D in August, 1996, all from the

University of Florida. Her predoctoral internship was

completed at the Dallas Veterans Administration Medical

Center. She plans to practice psychology in Dallas, Texas.

Her area of interest is medical psychology.

I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor o Philosophy.

Michael Robinson, Chair
Associate Professor of
Clinical and Health Psychology

I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philosophy.

Iussell Bauei
Professor of Clinical and Health

I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philosophy.

Eileen Fennell
Professor of Clinical and Health

I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Do.tor of Philosophy.

Cyd trauss
Clinical Associate Professor of
Clinical and Health Psychology

I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adeae te, i -copeand quality, as
a dissertation for the degr

Charles Vi k
Professor Neurosciee

This dissertation was submitted to the Graduate Faculty
of the College of Health Professions and was accepted as
partial fulfillment of the requirements for the degree of
Doctor of Philosophy.

August, 1996
Dean, College of Health Professions

Dean, Graduate School

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