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Effects of Coping Statements on Experimental Pain in Chronic Pain Patients

Permanent Link: http://ufdc.ufl.edu/UFE0041682/00001

Material Information

Title: Effects of Coping Statements on Experimental Pain in Chronic Pain Patients
Physical Description: 1 online resource (44 p.)
Language: english
Creator: Roditi, Daniela
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2010

Subjects

Subjects / Keywords: catastrophizing, coping, expectancies, experimental, positive, response
Clinical and Health Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: EFFECTS OF COPING STATEMENTS IN EXPERIMENTAL PAIN IN CHRONIC PAIN PATIENTS By Daniela Roditi Catastrophizing has been well-established in the literature as a cognitive mediator in the pain experience and a predictor of the pain experience as indicated by heightened pain sensations and lower thresholds for pain for catastrophizers. Relatively few studies have investigated the direct relationship between positive cognitions and pain. The present study measured the effects of response expectancies (catastrophizing self-statements and positive coping self-statements) on cold pressor-induced pain. Participants were 58 adult chronic pain patients with current facial pain. It was hypothesized that catastrophizing would lead to a decrease in pain endurance whereas positive coping would lead to an increase in pain endurance. It was also hypothesized that catastrophizing would lead to an increase in peak pain intensity whereas positive coping would lead to a decrease in peak pain intensity. Participants signed a consent form explaining possible risks associated with the experiment. The University of Florida Institutional Review Board approved the procedures and protocols of the study. A cold pressor apparatus was used to induce pain in participants. A pressure sensitive bladder/transducer was used to measure pain intensity. Pain endurance was determined by calculating the difference between tolerance and threshold. At pretest, participants submerged their non-dominant hand in the cold pressor. Pain endurance and peak pain intensity measurements were recorded. Participants underwent random assignment to a catastrophizing group or a positive coping group. Participants chose one coping statement from a given list to use as a coping strategy during the test phase. ANCOVA results indicated a significant effect of coping on pain endurance after controlling for pretest pain endurance, F(1, 36) = 5.525, p < .05. Manipulation of coping explained 13.3% of the variance in test phase pain endurance. On average, participants employing catastrophizing statements as a coping strategy experienced significantly lower pain endurance (M = 35.53, SD = 39.71) compared to participants employing positive coping statements (M = 73.70, SD = 86.14). However, the type of coping statement (group assignment) used had no significant influence on peak pain intensity measurements. Most previous work showing a coping-pain relationship cannot confirm causality of the relationship. The results of this research show that manipulation of coping causes changes in pain behavior. This provides a mechanism for considering how response expectancies mediate pain endurance in clinical settings, ultimately leading to more effective treatment options.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Daniela Roditi.
Thesis: Thesis (M.S.)--University of Florida, 2010.
Local: Adviser: Robinson, Michael E.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2010
System ID: UFE0041682:00001

Permanent Link: http://ufdc.ufl.edu/UFE0041682/00001

Material Information

Title: Effects of Coping Statements on Experimental Pain in Chronic Pain Patients
Physical Description: 1 online resource (44 p.)
Language: english
Creator: Roditi, Daniela
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2010

Subjects

Subjects / Keywords: catastrophizing, coping, expectancies, experimental, positive, response
Clinical and Health Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: EFFECTS OF COPING STATEMENTS IN EXPERIMENTAL PAIN IN CHRONIC PAIN PATIENTS By Daniela Roditi Catastrophizing has been well-established in the literature as a cognitive mediator in the pain experience and a predictor of the pain experience as indicated by heightened pain sensations and lower thresholds for pain for catastrophizers. Relatively few studies have investigated the direct relationship between positive cognitions and pain. The present study measured the effects of response expectancies (catastrophizing self-statements and positive coping self-statements) on cold pressor-induced pain. Participants were 58 adult chronic pain patients with current facial pain. It was hypothesized that catastrophizing would lead to a decrease in pain endurance whereas positive coping would lead to an increase in pain endurance. It was also hypothesized that catastrophizing would lead to an increase in peak pain intensity whereas positive coping would lead to a decrease in peak pain intensity. Participants signed a consent form explaining possible risks associated with the experiment. The University of Florida Institutional Review Board approved the procedures and protocols of the study. A cold pressor apparatus was used to induce pain in participants. A pressure sensitive bladder/transducer was used to measure pain intensity. Pain endurance was determined by calculating the difference between tolerance and threshold. At pretest, participants submerged their non-dominant hand in the cold pressor. Pain endurance and peak pain intensity measurements were recorded. Participants underwent random assignment to a catastrophizing group or a positive coping group. Participants chose one coping statement from a given list to use as a coping strategy during the test phase. ANCOVA results indicated a significant effect of coping on pain endurance after controlling for pretest pain endurance, F(1, 36) = 5.525, p < .05. Manipulation of coping explained 13.3% of the variance in test phase pain endurance. On average, participants employing catastrophizing statements as a coping strategy experienced significantly lower pain endurance (M = 35.53, SD = 39.71) compared to participants employing positive coping statements (M = 73.70, SD = 86.14). However, the type of coping statement (group assignment) used had no significant influence on peak pain intensity measurements. Most previous work showing a coping-pain relationship cannot confirm causality of the relationship. The results of this research show that manipulation of coping causes changes in pain behavior. This provides a mechanism for considering how response expectancies mediate pain endurance in clinical settings, ultimately leading to more effective treatment options.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Daniela Roditi.
Thesis: Thesis (M.S.)--University of Florida, 2010.
Local: Adviser: Robinson, Michael E.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2010
System ID: UFE0041682:00001


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1 EFFECTS OF COP ING STATEMENTS ON EXPERIMENTAL PAIN IN CHRONIC PAIN PATIENTS By DANIELA RODITI A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGRE E OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2010

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2 2010 Daniela Roditi

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3 To everyone who has inspired, encouraged, and supported me throughout my lifetime in all personal, academic and professional achievements making this milestone possible

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4 ACKNOWLEDGMENTS I am greatly thankful to my mentor, Dr. Michael E. Robinson, for his continuing and unwavering support and guidance throughout the development of this project from the beginning to the end. Additi onally, I would like to recognize as the members of my supervisory committee Dr. Stephen Boggs Dr. Glenn Ashkanazi, and Dr. Russe l l Bau e r Lastly I would like to recognize my family, friends, and colleagues for their support throughout this project.

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5 T ABLE OF CONTENTS page ACKNOWLEDGMENTS ...............................................................................................................4 LIST OF TABLES ..........................................................................................................................7 LIST OF FIGURES ........................................................................................................................8 ABSTRACT ....................................................................................................................................9 CHAPTER 1 INTRODUCTION .................................................................................................................11 Coping 11 Catastrophizing .............................................................................................................11 Positive Coping Self Statements ...............................................................................12 Response Expectancies .....................................................................................................12 Previous Coping Research ................................................................................................13 Current Study .......................................................................................................................14 2 MATERIALS AND METHODS ...........................................................................................15 Procedure ..............................................................................................................................15 Participants ...........................................................................................................................16 Apparatuses ..........................................................................................................................17 Measures ..............................................................................................................................17 Demographics ...............................................................................................................17 Coping Statements .......................................................................................................18 Pain Threshold ..............................................................................................................18 Pain Tolerance ..............................................................................................................18 Pain Endurance .............................................................................................................18 Pain Intensity .................................................................................................................19 3 RESULTS ..............................................................................................................................24 Descri ptive Analyses ...........................................................................................................24 First Hypothesis ....................................................................................................................24 Second Hypothesis ..............................................................................................................26 4 D ISCUSSION .......................................................................................................................30 Clinical Implications .............................................................................................................34 Methodological Limitations and Future Research Directions .......................................35

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6 5 SUMMARY ............................................................................................................................38 LIST OF REFERENCES ............................................................................................................40 BIOGRAPHICAL SKETCH ........................................................................................................44

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7 LIST OF TABLES Table page 2 1 Demographic variables of total sample ( N = 58) ................................................. 19 2 2 List of Catastrophizing Self Statem ents .............................................................. 20 2 3 List of Positive Coping Self Statements .............................................................. 21 3 1 ANOVA results of comparison between two coping groups ............................... 27 3 2 Mean PSR and Peak Pain Intensity Measurements of Catastrophizing and Positive Self Statement (PSS) Group s ............................................................... 29

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8 LIST OF FIGURES Figure page 2 1 Experimental Procedure Flowchart ..................................................................... 22 2 2 Cold Pressor Apparatus. Taken in 2010 in the Center for Pain Research laboratory ........................................................................................................... 23 3 1 Effects of coping manipulation on PSR. ............................................................. 28

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9 Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of t he Requirements for the Degree of Master of Science EFFECTS OF COPING STATEMENTS IN EXPERIMENTAL PAIN IN CHRONIC PAIN PATI E NTS By Daniela Roditi M ay 2010 Chair: Michael E. Robinson Major: Psychology Catastrophizing has been well established in the literature as a cognitive mediator in the pain experience and a predictor of the pain experience as indicated by heightened pain sensations and lower thresholds for pain for catastrophizers. Relatively few studies have investigated the direct relationship betw een positive cognitions and pain. The present study measured the effects of response expectancies (catastrophizing self statements and positive coping self statements) on cold pressor induced pain. Participants were 58 adult chronic pain patients with cur rent facial pain. It was hypothesized that catastrophizing would lead to a decrease in pain endurance whereas positive coping would lead to an increase in pain endurance. It was also hypothesized that catastrophizing would lead to an increase in peak pain intensity whereas positive coping would lead to a decrease in peak pain intensity. Participants signed a consent form explaining possible risks associated with the experiment. The University of Florida Institutional Review Board approved the procedures and protocols of the study. A cold pressor apparatus was used to induce pain in participants. A pressure sensitive bladder/transducer was used to measure pain

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10 intensity. Pain endurance was determined by calculating the difference between tolerance and threshold. At pretest, participants submerged their nondominant hand in the cold pressor. Pain endurance and peak pain intensity measurements were recorded. Participants underwent random assignment to a catastrophizing group or a positive coping group. Participants chose one coping statement from a given list to use as a coping strategy during the test phase. ANCOVA results indicated a significant effect of coping on pain endurance after controlling for pretest pain endurance, F (1, 36) = 5.525, p < .05. Manipulation of coping explained 13.3% of the variance in test phase pain endurance. On average, participants employing catastrophizing statements as a coping strategy experienced significantly lower pain endurance (M = 35.53, SD = 39.71) compared to participants employing positive coping statements (M = 73.70, SD = 86.14). However, the t ype of coping statement (group assignment) used had no significant influence on peak pain intensity measurements. Most previous work showing a coping pain relationship cannot conf irm causality of the relationship. The results of this research show that manipulation of coping causes changes in pain behavior. This provides a mechanism for considering how response expectancies mediate pain endurance in clinical settings, ultimately leading to more effective treatment options.

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11 CHAPTER 1 INTRODUCTION Coping Lazarus and Folkman (1984) best defined coping as an active effort to manage or control a perceived stressor. Nev ertheless, there is no universally agreed upon operational definition of what constitutes a coping strategy or a universally agreed upon way to classify the several different coping strategies that have been identified. A frequently used classification sys tem within the context of chronic pain centers around the dichotomy of active versus passive coping. Passive coping includes those strategies in which one surrenders control or withdraws from the pain (Van Damme, Crombez, & Eccleston, 2008) Conversely, active coping strategies are those involving an attempt to control or manage the pain or to persevere regardless of the experienced pain (Van Damme, et al., 2008) The present study will focus specifically on catastrophizing and positive coping self statements which are two types of coping strategies representing passive coping and active c oping, respectively Catastrophizing Catastrophizing is the tendency to exaggerate the negative outcomes of a situation (Turner, Jensen, & Romano, 2000) More specifically, pain catastrophizing is characterized by pessimistic cognitions leading to exaggerations and negative expectations of the pain experience such as heightened pain perceptions. It involves elements of helplessness and pessimism as captured by the catastrophizing subscale of the Coping Strategies Questionnaire (Rosenstiel & Keefe, 1983) Within the aforementioned classification system catastrophizing is a type of passive coping (Van Damme, et al., 2008) Catastrophizing has been well established in the literature as a

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12 cognitive mediator in the pain experience and a predictor of the pain experience as i ndicated by heightened pain sensations and lower thresholds for pain for catastrophizers (George & Hirsch, 2008; Keefe, et al., 2000; Sullivan, Rodgers, & Kirsch, 2001; Sullivan, Thorn, Rodgers, & Ward, 2004) Research also suggests a positive correlation between catastrophizing and depression exists in chronic pain patients (Lee, Wu, Lee, Cheing, & Chan, 2008; Lopez Lopez, Montorio, Izal, & Velasco, 2008; Sullivan & D'Eon, 1990; Turner, et al., 2000) Despite the wealth of literature regarding catastrophizing and pain, most research has been correlational supporting the notion of an antecedent relationship but not a causal one (Roth, Low ery, & Hamill, 2004; Severeijns, Vlaeyen, van den Hout, & Weber, 2001; Sullivan, et al., 2001; Sullivan, et al., 2004) Positive Coping Self Statements Positive coping self statements are those which encourage the individual to persist despite pain or to reassess the situation in a more positive light. Relatively few studies have investigated the direct relationship between positive cognitions and pain. Some research has found that higher use of coping self statements was predictive of higher perceptions of control over pain (Haythornthwaite, Menefee, Heinberg, & Clark, 1998) Moreover, it has been suggested that positive coping self statements interact with level of pain intensity (Jensen & Karoly, 1991; Jensen, Turner, & Romano, 1992) There is some indication that positive coping self statements are correlated with fewer depressive symptoms (Walker, Smith, Garber, & Claar, 2005) Response Expectancies Response expectancies have been defined in the literature as nonvolitional responses to events (Kirsch, 1985) These are differentiated from Rotters social

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13 learning theory concept of outcome expectancies by virtue of being automatic rather than meditated responses as is t he case with outcome expectancies (Kirsch, 1985; Rotter, 1954) In addition, response expectancies have been typically differentiated by their virtue of being self confirming. It has been suggested that response expectancies may be a mechanism by which psychotherapy produces change for the patient (Milling, Reardon, & Carosella, 2006) In particular, Milling et al posit that response expectancies may produce analgesia in pain treatments by creating a cognitive set in which the indiv idual being treated comes to expect reductions in pain (2006) Therefore, we propose that response expectancies and voluntary cognitive efforts need not be mutually exclusive concepts. It seems as though the cognitive set believed to be responsible for analgesic relief in pain tr eatments exemplifies this proposition. If a cognitive set is established, it is no longer an automatic, nonvolitional response but rather a deliberate, effortful process. Furthermore, if theory regarding response expectancies is expanded to include both n on volitional and volitional expectations, then we hold that these can be manipulated by altering existing or creating new cognitive sets in which a person expects either diminished pain or increased pain. Therefore, a possible mechanism by which expectanc ies can be manipulated is via alteration of coping self statements. Positive self statements can be induced in participants to produce a change of expectations of a more favorable outcome. Likewise catastrophizing statements may be a mechanism by which ex pectancies can be negatively manipulated, resulting in pessimistic expectations for a worse outcome. Previous Coping Research Previous research found that preexisting catastrophizing predicted higher pain intensity in an experimental task on children and adolescents whereas preexisting

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14 positive coping self statements predicted lower pain intensity (Lu, Tsao, Myers Kim, & Zeltzer, 2007) Research by Severeijns et al. found that although catastrophizing was successfully manipulated in participants in the experimental group condition, it did not moderate the pain experience as neither pain expectancy levels, nor ex perienced peak pain intensity levels, nor pain tolerance differed significantly from those of participants in the control group condition (2005) It is important to further investigate the relationship between catastrophizing and pain as well as positive coping and pain using an experimental research design in order to infer a causal relationship between cognitions and pain experience. Cu rrent Study The present study aimed to build on the current literature on catastrophizing and pain and positive coping and pain from an experimental perspective by directly manipulating the constructs in a sample of adult chronic pain patients. Most previous studies have not directly manipulated catastrophizing or positive coping and findings from studies that have done so are not consistent with the hypothesized theory (Lu, et al., 2007; Severeijns, et al., 2005) T he primary aims were to evaluate the effects of catastrophizing and positive coping on Pain Sensitivity Range (PSR) and peak pain intensity measurements during experimentally induced pain using the cold pressor task. It was hypothesized that catastrophizing would lead to a decrease in pain endurance as measured by PSR whereas positive coping would lead to an increase in pain endurance as measured by PSR. It was also hypothesized that catastrophizing would lead to an increase in peak pain intensity measurements whereas positive coping would lead to a decrease in peak pain intensity measurements.

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15 CHAPTER 2 MATERIALS AND METHOD S Procedure Participants signed a consent form explaining possible risks associated with the experiment and were all assured that they could withdraw from the study at any time without negative consequences if they chose to. The University of Florida Institutional Review Board approved the procedures and protocols of the study. In the pretest, all participants submerged their nondominant hand, palm facing down, in the cold pressor apparatus. Participants were instructed to say pain when they first experienced pain (to measure pain threshold) and to keep their hand submerged in the cold water as long as possible (to measure pain tolerance). Pain sensitivity r anges were subsequently determined for each participant by calculating the difference between pain tolerance time and pain threshold time Pain intensity measurements were recorded as indicated by the pressure sensitive bladder/trans ducer. Participants were instructed to press the pressure sensitive bladder/transducer to indicate the level of pain intensity throughout the duration o f the cold pressor task. Only peak pain intensity measurements were used for data analyses. Participant s were randomly assigned to one of two groups: catastrophizing self statements or positive coping self statements. Participants in each group were asked to rehearse statements from the designated lists and instructed to choose one statement, repeated aloud, to use as a coping strategy for the duration of the cold pressor task during the test phase In the test phase participants repeated the cold pressor task following the same protocol as the pretest with the addition of the chosen coping strategy repeated aloud.

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16 Pain threshold and pain tolerance were reassessed. New pain intensity measurements were recorded as indicated by the pressure sensitive bladder/transducer. Upon completion of the test phase participants were debriefed concerning the nature of the study. All participants received information regarding appropriate coping strategies in the management of chronic pain. Figure 21 shows a flowchart diagram of the experimental procedures. Participants Adult chronic pain patients ( N = 58) with current fac ial pain stemming from temporomandibular disorders (TMD) were recruited from the Parker Mahan Facial Pain Center at the University of Florida. Eligibility criteria excluded all those with pain duration shorter than six months, those with pain related to malignant process, those with upper extremity pain, and those with history of severe cardiovascular disease. The mean age of the sample was 39.3 0 (range 1865, SD = 11.68) years. Forty nine participants were female and nine were male. Primary diagnoses included myofascial pain syndrome, bruxism, noxious occlusion, degenerative arthritis, fibromyalgia, and disk displacement. Participants had a mean education level of 13.88 years ( SD = 1.90). The mean duration of pain was 97.69 ( SD = 95.74) months. The majority of participants were married (38), 15 were single, 4 were divorced, and 1 was widowed. The sample was predominantly Caucasian (56); the remaining participants were African American (2). Thirty seven participants were currently employed; the remaining twenty one were currently unemployed. Table 21 provides demographic information for the total sample of facial pain patients.

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17 Apparatuses A cold pressor apparatus was used to induce pain in participants. It consisted of a 2.5 cubic foot thermal cooler divided by a fitted screen. One side of the apparatus contained cold water whereas the other side contained ice. Water circulated from one side to the other via a dc bilge pump allowing for water to remain at a constant temperature range of 1 3 degrees Celsius. T he 1 3 degree variation in the water temperature in the cold pressor is within standard parameters for a cold pressor task. Figure 22 displays a picture of a cold p ressor a pparatus used to induce pain in participants. A pressure sensitive bladder/transduc er was used to measure individual ratings of pain intensity in response to the cold pressor apparatus. The pressure sensitive bladder consisted of a blood pressure monitor inflation device linked to a computer via a pressure transducer (an HC11 micropr oc es sor) allowing for analog to digital conversion. The device required 20 lbs. of force to reach a maximum voltage of 5 volts. No subjects were able to maximize this pressure/voltage, thus eliminating the possible confound of ceiling effects. The resolution of the processor allowed for measurement sensitivity to increments of .01 volts. M easures Demographics A self report questionnaire was used to gather demographic information from all participants. Questions inquired about participants age, sex, race/ e th nicity, marital status, years of education attained, employment status, pain duration, and primary pain diagnosis

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18 Coping S tatements A list of catastrophizing statements was derived from the Coping Strategies Questionnaire CSQ CAT subscale (Ros enstiel & Keefe, 1983) and a list of positive coping statements was created by using statements opposite of the catastrophizing statements generated Table 22 reports the list of catastrophizing self statements given to participants in the negative coping group. Table 23 reports the list of positive coping self statements given to participants in the positive coping group. Pain Threshold Pain threshold was determined by the amount of time elapsed from initial immersion of hand into the cold pressor appar atus to the moment participants verbally indicated they felt pain. Pain Tolerance Pain tolerance was determined by the amount of time elapsed from initial immersion of hand into the cold pressor apparatus to the moment participants removed their hand from the cold pressor. A limit of 300 seconds was set for tolerance at which point participants were asked to remove their hand due to risk of injury. A total of ten participants reached the tolerance limit at one or both of the testing phases. Pain E ndurance P ain sensitivity ranges were determined for each participant by calculating the difference between tolerance and threshold. PSR was used as a measure of pain endurance and has been found to be a more stable measure of pain than pain tolerance (Wolff, 1986) Thus, this was selected as the dependent variable to preclude bias derived from prepain perception often inherent in threshold and tolerance ratings.

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19 Pain I ntensity Peak pain intensity was determined by the selecting the highest voltage pain intensity measurement as indicated by the pressure sensitive bladder/transducer. Table 2 1. Demographic variables of total sample ( N = 58) Demographic variables n % years or mo nths Gender Males 9 15.52% Females 49 84.48% Mean Age (in years) 39.30 ( SD = 11.68) Ethnicity Caucasian 56 96.55% African American 2 3.45% Marital Status Married 38 65.52% Divorced 4 6.90% Widowed 1 1.72% Single 15 25.86% Me an Years of Education 13.88 ( SD = 1.90) Employment Employed 37 63.79% Unemployed 21 36.21% Mean Pain Duration (in months) 97.69 ( SD = 95.74)

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20 Table 2 2. List of Catastrophizing Self Statements 7 Catastrophizing Statements This is terrible. This is never going to get better. This is overwhelming. I cannot control the pain This is worse than I thought. I cant stand it anymore. I feel like I cant go on.

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21 Table 2 3. List of Positive Cop ing Self Statements 7 Positive Coping Statements One step at a time, I can handle it. I just have to remain focused on the positives. It will be over soon. I can control the pain It won't last much longer. This isn't as bad as I thought. No matter how bad it gets, I can do it.

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22 Informed Consent Signed Pretest: Cold Pressor Task Random Group Assignment PSR calculated and recorded Catastrophizing Self Statements Group Posit ive Self Statements Group Test phase: Cold Pressor Task using selected Coping strategy Test phase: Cold Pressor Task using selected Coping strategy PSR Calculated and recorded Peak Pain Intensity recorded PSR Calculated and recorded Peak Pain Intensity recorded Deb riefing Debriefing Rehearsal of Statements Rehearsal of Statements Figure 21. Experimental Procedure Flowchart

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23 Figure 22. Cold Pressor Apparatus. Taken in 20 10 in the Center for Pain Research laboratory

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24 CHAPTER 3 R ESULTS The statistical analyses conducted to evaluate the hypotheses for this research project were analyzed using the Statistical Package for Social Sciences (SPSS) An alpha level of .05 was used for all statistical tests. V a riables were examined on a li st wise basis for each hypothesis ; thus, excluding from the analyses participants for whom data from va r iables of interest were missing Descriptive Analyses A comparison of the catastrophizing self statements group and the positive coping self statements group was conducted to assess for any significant differences among demographic variables between the two groups. Levenes test results were nonsignificant for the variables examined: age, race, number of years of education attained, employment status, du ration of pain, and pretest pain endurance; thus we fail ed to reject the assumption of homogeneity of variances. Results of a one way independent ANOVA revealed that on average, participants in the catastrophizing self statements group did not differ significantly from participants in the positive self statements group along the dimensions of age, race, number of years of education attained, employment status, duration of pain, or pretest pain endurance. Table 31 reports Levenes statistics, F statistics, means, standard deviations, and probability values for the variables analyzed. First Hypothesis Pain Endurance In the analyses of our first hypothesis, of the initial 58 participants, only the data from 39 participants were used. Data from the remaining participants were excluded as PSRs could not be calculated because participants either reached the maxim um

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25 tolerance time of 300 seconds or did not indicate pain and, thus, threshold time could not be determined. Among those participants excluded from t he analyses, 9 were assigned to the catastrophizing group and 10 to the positive self statements group. Betweengroup analyses reveal ed participants did not differ among demographic variables (see Table 31 ). On average, participants employing catastrophizing statements as a coping strategy experienced a 20.05 second decreased PSR (pretest M = 55.58, SD = 72.45, test phase M = 35.53, SD = 39.71) and participants employing positive coping self statements showed a 12.15 second increase in PSR (pretest M = 6 1.55, SD = 87.32, test phase M = 73.70, SD = 86.14), as shown in Figure 3 1. To test the effect of coping statement manipulation an ANCOVA with test phase PSR as the dependent variable and pretest PSR as the covariate was performed. Results indicated that after controlling for pre manipulation PSR, post manipulation PSR differed between the two coping statement groups. Results indicated a significant effect of coping on PSR after controlling for pretest PSR, F (1, 36) = 5.525, p < .05. Manipulation of coping explained 13.3% of the variance in test phase PSR (see Table 3 2 ). It should be noted that our findings did not reveal any withingroup effects. Paired samples t tests indicated that although the positive coping self statements and the catastrophizing s elf statements groups differ ed significantly from one another at test phase (betweengroups effect), each groups endurance at test phase was not significantly different from the mean at pretest, t (19) = 1.05, p = .305, d = .33 and t(18) = 1.54, p = .140, d = .59, respectively. Therefore, the post intervention difference represents the combination of smaller withingroup endurance effects in opposite

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26 directions (as hypothesized). The absence of statistically significant withingroup differences is likely a function of an underpowered sample size. Nevertheless, d = .33 and d = .59 represent small to medium and medium effect sizes, and suggest these findings might represent meaningful relationships. Of note, there were no significant betweengroup PSR differ ences at pretest, t (45) = .065, p = .948. Second Hypothesis Peak Pain Intensity In the analysis of our second hypothesis, of the initial 58 participants, only the data from 50 participants were used. Data from the remaining participants were excluded as no pain intensity measurements were recorded for them. On average, participants employing catastrophizing statements as a coping strategy did not experience a significant change in test phase peak pain intensity (pretest M = 1.81, SD = .20, test phase M = 1.86, SD = .29) compared to participants employing positive coping self statements (pretest M = 1.83, SD = .18, M = 1.83, SD = .19). To test the effect of coping statement manipulation an ANCOVA with test phase peak pain intensity measurement as the depe ndent variable and pretest peak pain intensity measurement as the covariate was performed. Results indicated that after controlling for premanipulation peak pain intensity measurement, post manipulation peak pain intensity measurement did not differ signi ficantly between the two coping statement groups. Results indicated a nonsignificant effect of coping on peak pain intensity measurement after controlling for pretest peak pain intensity measurement, F (1, 47) = .705, p > .05 (see Table 3 2 ).

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27 Table 3 1. ANOVA results of comparison between two coping groups Demographic Variables n Levene's statistic p F statistic p Mean SD Age 2.36 0.13 0.72 0.79 Positive Coping 29 38.93 10.69 Catastrophizing 29 39.76 12.77 Race 1.72 0.20 0.40 0.53 Posi tive Coping 29 1.03 0.19 Catastrophizing 29 1.10 0.56 Years of Education attained 0.00 0.96 0.01 0.95 Positive Coping 29 13.86 1.77 Catastrophizing 29 13.90 2.04 Employment Status 0.29 0.60 0.07 0.79 Positive Coping 29 0.62 0.49 Catastrophizing 29 0.66 0.48 Pain Duration (in months) 0.01 0.91 1.43 0.24 Positive Coping 29 82.69 105.38 Catastrophizing 29 112.69 84.20 Pretest PSR (in seconds) 0.23 0.63 0.00 0.95 Positive Coping 23 56.91 82.14 Catastr ophizing 24 58.46 79.63

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28 Figure 31. Effects of coping manipulation on PSR. Note: Mean pain sensitivity ranges in seconds. Error bars represent standard error.

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29 Table 32 Mean PSR and Peak Pain Intensity Measurements of Catastrophizing and Positive Self Statement (PSS) Group s ________________________________________________________________________ Mean Standard deviation ___________________ ___________________ Group Pretest Test phase Pr etest Test phase ________________________________________________________________________ PSR ( n = 39) Catastrophizing 55.58 35.53* 72.45 39.71 PSS 61.55 73.70* 87.32 86.14 ________________________________________________________________________ Peak Pain Intensity Measurement ( n = 50) Catastrophizing 1.81 1.86 .20 .29 PSS 1.83 1.83 .18 .19 ________________________________________________________________________ Note. Maximum PSR = 300 seconds. Maximum Peak Pain Intensity = 5 volts. Means marked with an asterisk differ at p < .05. ANCOVA results indicated that after controlling for premanipulation PSR, post manipulation PSR differed between the two coping statement groups. Results indicated a significant effect of coping on PSR after controlling for pretest PSR, F (1, 36) = 5.525, p < .05. Manipulation of coping explained 13.3% of the variance in test phase PSR.

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30 CHAPTER 4 DISCUSSION By manipulating the use of coping strategies we were able to evaluate the effects of catastrophizing and positive coping self statements on pain endurance (PSR) and peak pain intensity during experimentally induced pain. As indicated in the results section, the catastrophizing and positive coping self statements groups differed post in tervention. Examination of Figure 3 1 and of the withingroup effect sizes suggest s that the post interventions differences resulted from smaller nonsignificant within groups effects in opposite directions (as hypothesized). The direction of these finding s supports extant literature stating catastrophizing is a mediator in the pain experience (Edwards, Haythornthwaite, Sullivan, & Fillingim, 2004; Keefe, et al., 2000; Sullivan, et al., 2001; Sullivan, et al., 2004; T urner, Holtzman, & Mancl, 2007) Furthermore, using random assignment and the experimental manipulation of coping statements, results support a causal relationship between coping self statements and pain perception. Specific evidence suggesting catastrophizing uniquely contributes to decreases in pain endurance is inconclusive. Although several research findings have not found catastrophizing to uniquely affect pain tolerance time there are some research findings supporting this notion (France, et al., 2004) It is possible that when several mediators and predictors of pain are evaluated, shared variance (e.g. negative affect, fear of pain) eclipses the unique contribution of catastrophizing (Hirsh, George, Bialosky, & Robinson, 2008; Hirsh, George, Riley, & Robinson, 2007) More work on the unique contributions of negative and positive coping, and negative mood measures is warranted.

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31 Additionally, it is important to highlight that although our results are not applicable to a direct numerical translation to changes in clinical pain endurance, the magnitude of raw chang e produced by our manipulation is substantial. Specifically, participants in the catastrophizing self statements group experienced a 56.43% decrease in endurance (20.05 seconds) and those in the positive self statements group experienced a 16.49% increased endurance (12.15 seconds). We propose that such a change would be of great clinical significance if similar cha nges were to occur in a clinical setting. This study adds to the body of literature by furthering the hypothesis of an antecedent relationship between catastrophizing and decreased pain endurance and positive coping. Additionally, it adds to the current body of literature by demonstrating the effects (changes in pain endurance) of experimental manipulation of coping strategies. These findings lend support for this being a potential causal association between coping strategy and pain endurance. It is possibl e that the use of PSR as a measure of pain endurance is a viable explanation for why we successfully found effects of coping on the pain experience in light of the divergent findings in the extant literature regarding pain tolerance time (France, et al., 2004; Lu, et al., 2007; Severeijns, et al., 2005) Whereas other measures of tolerance do not measure the time period of experienced pain and instead measure the time point at which pain becomes unbearable, our measure of endurance includes only the time period during which one is coping with experienced pain by excluding the time period prior to threshold; a subtle but potentially important difference. This explanation would suggest that effects of pain endurance oug ht to be considered in future research alongside the more commonly used measures of pain threshold and pain tolerance.

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32 A second aim was to examine the effects of catastrophizing and positive coping on peak pain intensity measurements. Results did not support our hypothesis. The manipulation of coping strategies did not affect peak pain intensity measurements signifying participants did not experience heightened pain upon employing catastrophizing coping strategies nor did they experience a decrease in pain upon employing positive self statements as coping strategies. Interestingly, although our findings did not support such a relationship, the positive relationship between catastrophizing and heightened pain sensations is widely supported in the extant liter ature (George & Hirsch, 2008; Keefe, et al., 2000; Picavet, Vlaeyen, & Schouten, 2002; Sullivan, et al., 2001; Sullivan, et al., 2004) Taken together these findings suggest that the manipulation of coping strategies led participants in our sample to endure pain differentially despite the fact that they were experiencing the same peak pain intensity as they were prior to the manipulation of coping. Interestingly, this lends support for the theory that expectations, r ather than demand characteristics, may be the underlying mechanism responsible for the changes in pain endurance. If, indeed, demand characteristics induced by the statements were responsible for the changes observed at test phase then both, pain endurance and pain intensity measurements, should have changed. Instead our results show that the only change was participants willingness to endure pain regardless of experiencing the same peak intensity of pain. Nevertheless, it is a possibility that demand char acteristics motivated participants in the positive coping self statements group to endure pain for a longer period of time and participants in the catastrophizing self statements group for a shorter duration of time. Participants, therefore, may have simpl y been behaving in a manner consistent with the

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33 way they believed the experimenter expected them to behave. It remains to be determined if the failure to affect peak pain intensity is a function of the manner in which peak pain intensity was obtained in this study, or if cognitive strategies more strongly operate on more tonic pain, or the endurance of pain. The pressure sensitive bladder/transducer we employed allowed for precise .5 second resolution of pain intensity, and unlike other pain intensity measu rements, it did not ask participants to rely on retrospective assessment or cumulative averages of their pain in order to rate it. Therefore, it is possible that the absence of a cognitive component in measurement unique to pain may partially account for t he lack of coping manipulation effects on peak pain intensity. Response expectancies have been found to have a significant concordant influence on the pain experience (Baker & Kirsch, 1991; Sullivan, et al., 2001) There is support for the theory that response expectancies partially mediate the relation between catastrophizing and the pain experience and it is likely that response expectancies may also mediate the relation between optimism and the pain experience (Sullivan, et al., 2001) Although there are mixed findings in the literature, opt imism has been found to partially mediate pain intensity in cancer patients and in laboratory induced pain (Geers, Wellman, Helfer, Fowler, & France, 2008) Recent literature reveals that the placebo effect is an example of how expectancies may influence and determine the pain experience (Pollo, et al., 2001; Vase, Robinson, Verne, & Price, 2003) Similarly, we assumed that presenting participants with self statements of poor pain coping (catastrophizing) or increased pain coping (positive expectations) would generate underlying pain expectations responsible for the changes in PSR. Consistent with the

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34 observed effect of catastrophizing and pain in this study, negative expectations have been found to be unique contributors to a heightened pain experience (Mon tgomery & Bovbjerg, 2004; Sullivan, et al., 2001) Unfortunately, research exploring positive expectations and their relationship to pain experience is scarce in comparison and findings are often inconclusive. Research has tended to focus predominately on negative contributors to the pain experience almost to the exclusion of positive protective factors in the pain experience. Therefore, although there is some evidence re garding the association between negative and positive expectations, pessimism and opti mism, and decreased pain, additional research in this area is warranted. Clinical Implications As aforementioned our results are not applicable to a direct translation to changes in clinical pain endurance; nevertheless, the changes produced by our manipulation reflect changes commonly obtained through efficacious clinical interventions While cognitive behavioral therapy (CBT) interventions may vary substantially, CBT interventions generally include common components such as psychoeducation, relaxation techniques, training in effective coping strategies, and cognitive restructuring specifically targeting dysfunctional/unrealistic thoughts. In the context of chronic pain interventions, CBT has been found to be efficacious (Morley, Eccleston, & Williams, 1999) although the exact components that lead to successful outco mes have yet to be discerned. It has been suggested that, perhaps, the improvement of self efficacy may be one of the principal common factors driving successful outcomes (Turk, Swanson, & Tunks, 2008) Therefore, a possible mechanism by which self efficacy can be increased is through the attainment of favorable expecta tions (i.e. positive self statements) and the reduction of pessimistic expectations (i.e. catastrophizing self statements ).

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35 Research in a sample of chronic headache sufferers revealed that CBT interventions aimed at reducing catastrophizing and adopting cognitive coping strategies (positive self statements regarding ability to manage headaches ) alongside behavioral coping strategies revealed that this intervention led to significant improvements headache experience marked by reductions in the headache frequency and peak intensity, the reductio n of catastrophizing and significant increases in headache management self efficacy as measured by self report assessments (Thorn, et al., 2007) Changes were maintained a t post treatment and 12 month follow up (Thorn, et al., 2007) Our findings coupled with clinical intervention findings suggest that painrelief expectations are highly ame nable to change and are responsive to painspecific cognitive behavioral treatments in select patient populations. Methodological Limitations and Future Research Directions The generalizability of the findings in this study is limited to our sample. A des ign limitation includes the absence of a neutral control group as the pre post design is subject to pretest sensitization. The absence of a specific manipulation check prevents us from conclusively knowing if our manipulation of coping was responsible for the changes in pain endurance. However, it should be taken into account that participants were instructed to verbalize and repeat aloud the coping strategy they selected throughout the test phase therefore ensuring participants were at least partially cogn itively engaging in the particular strategy (via awareness and verbalization). As previous findings in CBT research suggest, it is a plausible explanation that participants expectations for pain relief or ability to endure pain changed as a function of the manipulation of coping (Jensen, Turner, & Romano, 2001; Smeets, Vlaeyen, Kester, & Knottnerus, 2006; Turner, Dworkin, Mancl, Huggins, & Truelove, 2001; Turner, Mancl, &

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36 Aaron, 2006) Nevertheless, the absence of s uch a manipulation check tempers a causal inference regarding the effect of changing expectations as the mechanism for change (increased/decreased endurance) in the pain experience. Another design limitation is that experimenters were not blinded to the c ondition or the hypotheses. However, because the data were collected using objective time measurements and electronic/mechanical devices it is unlikely this would introduce experimenter bias. Furthermore, it is possible that the cold pressor task was not an optimal analog of chronic clinical pain and that other pain induction strategies would have been more appropriate. Of note, there is no evidence of systematic variance due to variation in the water temperature in the cold pressor and, thus, no concern of confound effects. As noted in the materials and methods section, the temperature variation is within standard parameters of the cold pressor task It should also be noted that no data are available regarding the reliability and validity of the pressure se nsitive bladder/transducer used to measure pain intensity. This precludes comparison of our obtained measurements with those obtained from existing well established methodology for measuring pain intensity such as Visual Analog Scale (VAS). Our reliance on PSR as a measure of pain endurance strongly reduced our sample size from 58 to 39, excluding 19 participants for whom PSR could not be calculated. The reduction in sample size may have rendered our study underpowered and may influence the validity of our results. Nonetheless, it should be noted that the exclusion of participants was not selective as the two groups did not differ significantly in betweengroup analyses of demographic variables. In evaluating our results, it is important to consider the br evity and limited scope of our coping manipulation strategy.

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37 Thus, it is suggested that further experimental research be conducted on the effects of catastrophizing and positive coping in the pain experience using more diverse chronic pain samples as well as different pain manipulation strategies. Additional measures of expectation, both situational and dispositional, are important to further understand the potential of expectancies as a mechanism in pain coping strategies, both positive and negative. Lastl y, it would be of interest to assess preexisting coping predispositions prior to pretest and test phase in order to allow for potenti al associations between habitual (baseline) coping response predispositions and the effects of experimental manipulation o f coping Assessing pre existing coping predispositions would also allow experimenters to discern if there are differential results when participants are assigned to a coping condition contradicting their habitual coping style as compared to being assigned to a coping condition that is consistent with their preferred coping strategy repertoire.

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38 CHAPTER 5 SUMMARY This study investigated the effects of chronic pain patients response expectancies on pain endurance and peak pain intensity measurements during an experimental pain task. Response expectancies were manipulated by manipulating participants coping behaviors to induce catastrophizing or positive coping following pain experimentally induced using a coldpressor. Fifty eight participants were asked to complete the cold pressor task (immersion of nondominant hand in a bath of cold water) as part of the pretest. Ensuing pain endurance and perceived peak pain intensity measurements were established. Participants selected a coping statement (either a catastrophizing self statement or a positive coping self statement depending on random group assignment) from a list of seven self statements. Using their selected coping statement, participants repeated the cold pressor task during the test phase. Pain endurance and peak pain intensity measurements were subsequently reestablished. Whereas during the pretest participants pain endurance and peak pain intensity ratings did not differ, participants assigned to the positive coping self statement condition endur ed pain for a significantly longer duration of time during the test phase as compared to participants assigned to the catastrophizing self statement condition. Interestingly, peak pain intensity ratings were not affected by the manipulation of participants coping response as there were no differences between the groups measurements from pretest to test phase. Collectively, these results indicate that the manipulation of participants coping responses led to them to endure pain differentially during the tes t phase despite experiencing the same intensity of pain as experienced during the pretest. These results suggest that the manipulation of response

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39 expectancies via the manipulation of coping strategies is responsible for changes in the pain experience as i ndicated by the changes in pain endurance observed in this study.

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44 BIOGRAPHICAL SKETCH Daniela Roditi was born in Mexico City, Mexico. She is the daughter of Alberto Roditi and Gabriela Dominguez. Daniela has a younger sister, Ana Laura R oditi, and an older brother, Guillermo Roditi. Daniela graduated summa cum laude from Stetson University in May 2008 with a Bachelor of Arts in psychology and a minor in health care issues. She is currently residing in Gainesville, Florida and is pursuing a doctorate in clinical and health psychology at the University of Florida. Danielas research interests include coping behaviors, response expectancies, and the use of analgesic placebos Daniela is currently furthering her clinical training experience i n various settings. Her clinical experience includes conducting pediatric neuropsychological assessments, structured comprehensive assessments specific to populations of people with anxiety disorders, a range of medical psychology assessments and conducti ng psychological assessments with children. Daniela is also currently involved in a randomized controlled clinical trial comparing the effects of different cognitive behavioral therapies in a sample of fibromyalgia patients. Current volunteer experiences i nclude providing free brief therapy at a local community center for residents of the community in need of psychological services. Danielas aspirations within the field of clinical health psychology include an academic career that involves a balance of teaching and clinical research opportunities.