Puin, 26 (1986) 141-151

Elsevier

141

PA1 00939

Clinical Section Rmie w A rticle

A Classification System of Cognitive Coping Strategies for Pain

Ephrem Fernandez

Department of Clinical Psychology, Ohio State University, 1885 Neil Avenue Mall, Columbus,

OH 43210-1222 (U.S.A.)

(Received 5 September 1985, revised received 23 January 1986, accepted 6 February 1986)

Summary

Cognitive strategies have received considerable interest in pain management,

alongside the traditional approaches of physical intervention and behavior modifica- tion. However, the literature on these strategies is ridden with inconsistencies of terminology that present major difficulties in the conceptualization and evaluation

of different strategies. A new classification scheme is hence proposed in which these strategies are grouped into 3 broad categories: imagery, self-statements and atten- tion-diversion - which are further divided into a total of 10 subcategories.

Examples are drawn from the literature to illustrate the use of each strategy. The new classification system offers a comprehensive nomenclature for the identification of cognitive coping strategies for pain and provides a basis for guiding research on the relative efficacy of different cognitive strategies in pain management.

Introduction

It is widely acknowledged that psychological variables exert a significant in- _. _ _ _ _^_

fluence on pain [46,66,68j. Among these variabies impiicated are anxiety [5,26j,

predictability [2,56], perceived controllability [9,22], attention [8,42], personality attributes [41,57], and socio-cultural factors [58,69]. Inasmuch as psychological factors influence pain, it should be possible to alleviate pain by manipulating such factors. ‘Cognitive strategies’ represent one such major approach to the manage- ment of pain.

0304-3959/86/%03.50 0 1986 Elsevier Science Publishers B.V. (Biomedical Division)

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‘Cognitive strategies’ as part of a trimodal system of pain management

As illustrated in Table I, ‘cognitive strategies’ may be seen as part of a trimodal system of pain management that also includes “behavioral manipulation’ and ‘physical intervention.’ Based on Jaremko 1301 and Turk and Genest [65], cognitive strategies refer to techniques that influence pain through the medium of one’s thoughts or cognitions. The cognitive strategy of pain control is a covert one and it may be self-initiated. Examples are imagery, self-statements and attention-diversion.

Behavioral manipulations refer to techniques which alter pain through the modification of overt action or a combination of behaviors and cognitions. They are initially at least, under some degree of external control (e.g., the hypnotist or the biofeedback therapist). As indicated in Table I, this degree of external control varies with the particular kind of behavioral manipulation employed: in the case of operant conditioning, control may be largely in the hands of the therapist, whereas in the case of perceived controllability, the subject may experience a greater degree of independent self-control.

Finally, the trimodal system of pain management includes ‘physical intervention.’ In contrast to the cognitive and behaviorai methods, the medium of intervention here is the body, and control is largely external to the subject (as in the case of physiotherapy, chemotherapy and surgery).

TABLE I

THE TRIMODAL SYSTEM OF PAIN MANAGEMENT

1. Cognitiue strategies: involving thoughts, cognitions, private events; self-initiated. (i) Imagery, fantasy, e.g., Horan et al. 1291. (ii) Self-statements, e.g.. Wort~ngton (71f. (iii) Attention-~v~ion, e.g., Kanfer and Goldfoot 1331.

2. Behavioural manipuiations: involving actions, behaviors, public events, externally manipulated.

High external control (i) Hypnosis, e.g., Hilgard [25]. (ii) Gperant conditioning, e.g, Fordyce [20]. (iii) Modeling, e.g., Craig and Prkachin [lb]. (iv) Biofeedback, Nouwen and Solinger 1491.

Luwj external control (i) Expectancy, placebos, e.g., Scott and Leonard [SZ]. (ii} Perceived controllability, e.g., Corah and Boffa 1141. (iii) Attribution, e.g., Nisbett and Schachter [48]. (iv) Cognitive dissonance, e.g., Zimbardo et al. 1741.

3. Physical interoention: directly involving body; completely under external control. (i) Physical relaxation, physiotherapy, e.g., Grzesiak [23]. (ii) Concurrent tactile stimulation, e.g., Higgins et al. [24]. (iii) Transcutaneous electrical stimulation, e.g., Dorsch and Ruhle 1171. (iv) Acupuncture, e.g., Bowsher et al. [lo]. (v) Pharmacological agents, e.g., Merskey and Hester [45]. (vi) Surgery, e.g., Fairman [19].

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In short, cognitive strategies, behavioral manipulations and physical intervention differ from one another in terms of the point of entry in treatment: in the first of these, the point of entry is the mind, in the second it is behavior, and in the third it is the body, An adjunct is the varying degree of external control, with cognitive strategies per~tting more autonomy in their implementation than behavioral manipulations which in turn require less external control than physical methods of treatment.

Classifying cognitive strategies

A major difficulty in reviewing the literature on cognitive m~agement of pain is the terminological inconsistency. Several authors have employed different terms in referring to the same strategies. An example is the strategy of isolating a non-painful feature of a noxious stimulus to focus on (e.g., focusing on the thermal properties of cold pressor pain): Blitz and Dinnerstein [S] have referred to this as ‘dissociation,’ Craig et al. [15] merely refer to it as ‘focused attention.’ Similarly, what is termed ‘rationalization’ by Jaremko [30] is vaguely termed ‘cognitive reappraisal’ by Langer et al. [38]; and that which Beers and Karoly [6] label ‘incompatible imagery’ is classed as ‘selective attention’ by Thelen and Frey [64], while Spanos et al. [54] refer to it simply as ‘a strategy inconsistent with pain.’

The problems attendant upon such inconsistencies suggest the need for a stan- dardized classification system for cognitive strategies. Any meaningful evaluation of the comparative effectiveness of different strategies depends on the availability of such a standardized system. More importantly, classification is integral to funda- mental conceptual clarity in this area. In response to these needs, a taxonomy was developed permitting the identification and assignment of all cognitive coping strategies for pain, to formally designated classes (see Table II).

The classification scheme is hierarchical, and the distinctions made are primarily nominal, and in a few instances, continuous. As shown, the various cognitive strategies may be classified into 3 broad divisions, namely, imagery, self-statements, and attention-diversion. These in turn are divided into subcategories each of which will be described and illustrated with reference to documented studies. However, no attempt is made to evaluate these studies or to discuss the treatment efficacy of the strategies used. Extensive reviews already exist on this subject 163,671.

Imagery Imagery strategies revolve around the production of particular images with

pain-attenuating potential. These comprise (incompatible) imagery of events incon- sistent with pain, and transformative imagery which seeks to modify specific features of the very pain experience. Incompatible imagery in turn subdivides into incompatible emotive imagery and incompatible sensory imagery.

Incompatible emotive imagery is designed to elicit emotions of affective reactions inconsistent with pain. As indicated in Table II, one documented example of such imagery is found in a study by Westcott and Horan [70] in which subjects under

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TABLE II

CLASSIFICATION OF COGNITIVE COPING STRATEGIES FOR PAIN

Strategy Description Example

Incompatible imagq

Incompatible emotive

imagery

Incompatible sensory

imagery

~ransf~~~~t~v~ images

Contextual transfor-

mation

Stimulus-transforma-

tive imagery

Response-transforma-

tive imagery

Se~-statgme~t~

Coprng self-statements

Stress inoculation

Imagery that arouses certain emo-

tions (e.g., mirth, self-assertion,

anger and humor) which recipro-

cally inhibit pain

During cold-pressor stimulation,

subjects imagining themselves in

an argument with a professor who

has unfairly failed them. Westcott

and Horan 1701

Imagery of ‘pure’ visual, auditory, Imagining a hot day in the desert,

or other sensations, with no neces- while undergoing cold-pressor

sary link to particular emotions pain, Spanos et al. [54]

Imaginative transformation of the

context or setting in which the

pain occurs

Imaginative transformation of the

stimulus features producing pain

Imaginative transformation (or re-

labeling) of the sensations arising

from noxious stimulation, without

reference to the concept of pain

A set of rational-emotive type

statements that subjects rehearse

within themselves in trying to cope

with different stages of the pain

experience

Reinterpretatiue self-statements

Denial SelEverbahzation, denying the ex-

istence of pain

Self-verbalization, emphasizing on- ly positive aspects of the experi-

ence

In the process of ischemic pain in

the arm. imagining oneself as a

spy, shot in the arm, and escaping

from enemy agents who pursue

one down a tortuous mountain

road, Knox [36]

In a clinical case of abdominal pain, visualizing the sensations as

caused by tightening steel bands

that can be loosened. Levendusky

and Pankratz [40]

In cold-pressor pain, dissociating

the ‘coldness’ from the ‘pain’ and

focusing only on the former, Blitz

and Dinnerstein [g]

Subjects in ischemic pain resorting

to coping statements such as “You

can meet the challenge,’ ‘ You were

supposed to expect the pain to rise, just keep it under control,’

Meichenbaum and Turk 1431

Thinking of ‘radiant heat pain’ as

being pleasurable and the experi-

ence as being enjoyable, Neufeld

[471

Psychology undergraduates during cold-pressor stimulation, thinking

of the course credit they would

receive for participation in the ex-

periment, Jaremko [30]

145

TABLE II (continued)

Strategy Description Example

Passive distraction

Active attention- diversion

Diverting attention away from the Viewing slides during a cold-pres- pain, and passively redirecting it to sor test, Kanfer and Gddfoot 1331 a distractor stimulus Diverting attention away from the Engaging in mental problem-solv- pain, and directing it to the active ing, tasks, during cold-pressor performance of a distractor task stimulation, Brncato [ll]

cold pressor stimulation generated images of anger associated with an imagined argument with a professor who had unfairly failed them in an exam and befriended a cheater. Si~larly, images of ~self-assertiveness,’ ‘pride’ and ‘mirth’ may be exploited as emotive imagery incompatible with pain [39].

By contrast, incompatible sensory imagery centers around images of ‘pure’ visual, auditory or other sensations incompatibly with pain but with no necessary link to particular emotions. As indicated in Table IT, imagining a hot day in the desert while undergoing cold pressor pain [54] is one example of this strategy. Similar imagery of ‘hot days’ to produce incompatibility with cold pressor pain have been employed by Blitz and Dinnerstein [8], Jaremko 1301, Jaremko et al. [31] and Ladouceur and Carrier [37]. Use of pleasant imagery to produce incompatibility with pain has also been reported [13,62,72]. Clinically, this imagery has often assumed the form of pleasant images of ‘blue skies,’ ‘grassy meadows’ and ‘gentle warmth’ to ameliorate dental pain [29] and the pain of c~ldbirth [27&l].

The second set of imagery strategies, transformative imagery, is designed to alter specific features of the pain experience. First, it may assume the form of contextual transfo~ation in which the context or setting of the pain is altered in ima~nation. A classic example as reported in Table II is found in the Knox 1361 study in which subjects administered forearm ischemic pain imagined themselves as spies shot in the arm and escaping from enemy agents down a tortuous mountain road. In another study by Jaremko et al. 1311, ischemic pain was managed by imagining the pain as occurring in the context of exertion during sports. Finally, in a clinical study by Langer et al. [38], male surgical patients using contextual transformation as part of a wider treatment regimen, were required to imagine themselves playing an exciting football game during which they sustained a minor cut; female patients in the same condition imagined themselves receiving a similar cut in the process of finishing dinner preparations for a large group of people.

Tr~sformative imagery may also be such that the aspects of the situation being transformed are features of the stimulus producing pain (stimulus-transformative imagery). The clinical example referred to in Table II, involving the visualization of abdominal pain as caused by tightening steel bands that could be loosened, is a well-known example.

146

Finally, transformative imagery may also take the form of response-transforma- tive imagery involving the imagination of response states that usually originate from the noxious stimulation itself, but which are dissociable from the ensuing pain. Thus, in the case of cold pressor stimulation, the subject is typically directed to

focus on the ‘numbness’ or just the ‘coldness’ of the stimulated limb [8,18,53].

Transformative imagery of numbness or insensitivity has also been used toward the alleviation of pressure pain 13,121. The relabeling of responses to noxious stimula- tion in terms of a whole array of objective sensations such as numbness, pressure or

pulsations has also been explored in studies by Ahles et al. [l], McCaul and Haughtvedt [42], Rybstein-Blinchik [SO], Rybstein-Blinchik and Grzesiak [St] and Scott and Barber [52]. In all these cases. reference to the notion of pain is avoided

al together.

The next major class of cognitive strategies involves periodic rehearsing of key statements to oneself during the pain experience. Self-statements as these are termed, may be of the ‘coping’ or ‘reinterpretative’ kind.

Coping self-statements make no attempt to modify nociceptive input, but em- phasize the person’s ability to withstand the pain. They have been used primarily in the context of a treatment regimen known as ‘stress insulation’ 143). A different set

of statements is usually employed at each stage of the pain experience (e.g., ‘You

can develop a plan to deal with it’ during the preparatory stage, ‘Relax, you’re in control’ during the confronting stage, ‘Just keep it manageable,’ during the critical stage, and also reinforcing statements such as ‘good, you did it’ at the concluding stage). Such statements have formed the subject of investigation in studies by Horan et al. 1281, Klepac et al. 1351, Worthington (711 and Worthington and Shumate [73].

While coping self-statements make no attempt to modify nociceptive input, reinterpretative self-statements are aimed at negating the unpleasant aspects of nociceptive stimulation. This typically incorporates the use of defense mechanisms

such as denial or rationalization. Denial-oriented reinterpretative self-statements may for instance require subjects to deny the harmful and unpleasant features of radiant heat stimulation and even regard it as pleasurable 1471. Rationalization-ori- ented reinterpretative self-statements may require subjects to think of positive

aspects of a pain experiment such as the course credit obtainable [30], or in the case of surgical patients, the compensatory aspects of the painful experience, like receiving extra care and attention, and improving in health [38].

Attention-dicersion

The third and final group of cognitive strategies, attention-diversion, deals with

the directing of attention to a non-noxious event or stimulus in the immediate environment in order to achieve distraction from concurrent pain. This ranges on a continuum from a passive redirecting of attention to a distractor stimulus (passive distraction), to active attention-diversion that requires more complex and involved interaction with the distractor as is necessitated in the performance of a distractor task.

147

Passive distraction, thus, may merely involve the use of scenic slides as a visual distractor from pain [7,33,34,42]. Alternatively, auditory stimuli have been employed to distract subjects from pain [21,44]. Clinically, passive distraction has often taken the form of focusing on conspicuous ‘dots’ presented as a distractor from childbirth pains [59-611.

The active attention-diversion, which involves a more complex interaction with the distractor, is usually promoted by active performance of some competing task during pain. Thus, Barber and Cooper [4] had subjects add aloud, and Beers and Karoly [6] had subjects count backwards from 1000 in steps of 3, as a means of achieving distraction from pain. More ‘involved’ tasks are reported by Brucato [ll] who presented a range of mathematical problems to subjects in cold pressor pain, and by Spanos et al. [55] who required subjects to perform a pursuit rotor task during cold pressor stimulation.

Critical appraisal of the new taxonomy

It is apparent from the foregoing section that the proposed classification system is fairly comprehensive in nature. None of the cognitive strategies reported in the pain literature has been found to resist classification in this new scheme. This attests to the usefulness of the taxonomy. The features of each category are clearly stated and supplemented with illustrative examples, so as to facilitate unambiguous identification of strategies. The various categories within the taxonomy are for all practical purposes, mutually exclusive; even in the few instances where common elements obtain in different strategies, these elements are combined in different proportions or emphasized to varying degrees, thus preserving class distinctiveness. It seems arguable, however, that some of the categories (particularly the ‘attention- diversion’ group) may be too broad or are capable of further subdivision. Perhaps future work can address this deficiency by building on the basic framework provided here, with a view to fashioning an all-embracing system that is also well differentiated within.

A further note may be added regarding the place of cognitive strategies in the treatment of pain. Jessup et al. [32] have pointed out that such strategies are often subsumed within behavioral inte~entions (like biofeedback) that remedy pain. Other extensive reviews have concluded that cognitive strategies by themselves, are also effective in attenuating pain [63,66]. However, most of these findings have been restricted to experimentally induced pain. The potential of cognitive strategies for clinical pain yet remains to be determined.

Conclusion

The proposed system of classification has much potential value for the study of cognitive coping strategies for pain. It offers a clear and instructive nomenclature for conceptualizing and referring to the gamut of such strategies. It further repre-

148

sents some sort of framework for the meaningful comparison of strategies, with regard to treatment efficacy. Finally, the systematic classification of strategies on the basis of their unique features, or combinations of features, may also permit insight into mediating processes responsible for the differential effects of various strategies on the pain experience. In sum, it is felt that this new classification scheme holds much promise for guiding the research and very conceptualization of cognitive strategies in pain management.

Acknowledgement

Parts of this paper were presented at the annual meeting of The Midwestern Psychological Association on May 4, 1984.

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