Abstract
Purpose
The cognitive mediation hypothesis describes the influence of psychological factors on the relationship between pain and depression such as cognitions of catastrophizing and help-/hopelessness. More recent research also emphasizes the role of suppression of negative thoughts and experiences such as pain. However, there is little research investigating direct and indirect effects of these contrasting cognitions.
Method
A total of 164 acute and sub-acute non-specific back pain patients participated in this study. Pain intensity, depression, and pain-related cognitions were measured using questionnaires, such as the Beck Depression Inventory and the Kiel Pain Inventory. Data were analyzed using structural equation modeling.
Results
The results of the path analysis support the hypothesis that cognitive coping strategies have a mediating effect on pain and depression. Consistent with previous research, we found that pain had no direct relation with depression. Help-/hopelessness had a direct path to depression, whereas catastrophizing had an indirect effect via increased help-/hopelessness. The current results also indicate that thought suppression mediated the relationship between pain and depression via both direct and indirect effects.
Conclusion
Cognitive mediators, such as help-/hopelessness, catastrophizing, and thought suppression, have a significant impact on depression in patients with acute and sub-acute back pain. The current results may aid in the optimization of treatments for these patients by focusing attention toward the modification of dysfunctional cognitive pain-coping strategies.
Similar content being viewed by others
References
Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J Pain. 2006;10:287–333.
Raspe H, Matthis C, Croft P, O’Neill T. Variation of back pain between countries: the example of Britain and Germany. Spine. 2004;29:1017–21.
Schmidt CO, Raspe H, Pfingsten M, Hasenbring M, Basler HD, Eich W, et al. Back pain in the German adult population. Spine. 2007;32:2005–11.
Webb R, Brammah T, Lunt M, Urwin M, Allison T, Symmons D. Prevalence and predictors of intense, chronic, and disabling neck and back pain in the UK general population. Spine. 2003;28:1195–20.
Bair MJ, Wu J, Damush TM, Sutherland JM, Kroenke K. Association of depression and anxiety alone and in combination with chronic musculoskeletal pain in primary care patients. Psychosom Med. 2008;70:890–7.
Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity. Arch Intern Med. 2003;163:2433–45.
Gallagher RM, Verma S. Managing pain and comorbid depression: a public health challenge. Semin Clin Neuropsychiatry. 1999;4:203–20.
Currie SR, Wang J. Chronic back pain and major depression in the general Canadian population. Pain. 2004;107:54–60.
Nicholas MK, Linton SJ, Watson PJ, Main CJ. Early identification and management of psychological risk factors (“yellow flags”) in patients with low back pain: a reappraisal. Phys Ther. 2011;91(5):737–53.
Vlaeyen JWS, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;85:317–32.
Pincus T, Vogel S, Burton AK, Santos R, Field AP. Fear avoidance and prognosis in back pain: a systematic review and synthesis of current evidence. Arthritis Rheum. 2006;54(12):3999–4010.
Gore M, Sadosky A, Stacey BR, Tai KS, Leslie D. The burden of chronic low back pain: clinical comorbidities, treatment patterns, and health care costs in usual care settings. Spine. 2012;37(11):E668–77.
Fishbain DA, Gao J, Lewis JE, Bruns D, Meyer LJ, Disorbio JM. Prevalence comparisons of somatic and psychiatric symptoms between community nonpatients without pain, acute pain patients, and chronic pain patients. Pain Med. 2014;16:37–50.
Banks SM, Kerns RD. Explaining high rates of depression in chronic pain: a diathesis-stress framework. Psychol Bull. 1996;119:95–110.
Fishbain DA, Cutler R, Rosomoff HL, Rosomoff RS. Chronic pain associated depression: antecedent or consequence of chronic pain? A review. Clin J Pain. 1997;13:116–37.
Lindsay PG, Wyckoff M. The depression-pain syndrome and its response to antidepressants. Psychosomatics. 1981;22:571–3.
Linton SJ, Bergbom S. Understanding the link between depression and pain. Scand J Pain. 2011;2:47–54.
Rudy TE, Kerns RD, Turk DC. Chronic pain and depression: toward a cognitive-behavioral mediation model. Pain. 1988;35:129–40.
Klasen BJ, Brüggert J, Hasenbring M. Role of cognitive pain coping strategies for depression in chronic back pain. Path analysis of patients in primary care. Schmerz. 2006;20:398–410.
Hasenbring MI, Verbunt JA. Fear-avoidance and endurance-related responses to pain: new models of behaviour and their consequences for clinical practice. Clin J Pain. 2010;26:747–53.
Lethem J, Slade PD, Troup JDG, Bentley G. Outline of a fear-avoidance model of exaggerated pain perception. Behav Res Ther. 1983;21:401–8.
Vlaeyen JWS, Kole-Snijders AMJ, Boeren RGB, van Eek H. Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain. 1995;62:363–72.
Vlaeyen JWS, Linton SJ. Fear-avoidance model of chronic musculoskeletal pain: 12 years on. Pain. 2012;153:1144–7.
Hasenbring MI, Chehadi O, Titze C, Kreddig N. Fear and anxiety in the transition from acute to chronic pain: there is evidence for endurance besides avoidance. Pain manag. 2014;4(5):363–74.
Cook AJ, Brawer PA, Vowles KE. The fear-avoidance model of chronic pain: validation and age analysis using structural equation modelling. Pain. 2006;121:195–206.
Keefe FJ, Rumble ME, Scipio CD, Giordana LA, Perri LM. Psychological aspects of persistent pain: current state of the science. J Pain. 2004;5:195–211.
Sullivan MJL, D’Eon J. Relation between catastrophizing and depression in chronic pain patients. J Abnorm Psychol. 1990;99:260–3.
Jensen MP, Tuner JA, Romano JM, Karoly P. Coping with chronic pain: a critical review of the literature. Pain. 1991;47:249–83.
Sullivan MJL, Stanish W, Waite H, Sullivan M, Tripp DA. Catastrophizing, pain, and disability in patients with soft-tissue injuries. Pain. 1998;77:253–60.
Sullivan MJL, Bishop SR, Pivik J. The pain catastrophizing scale: development and validation. Psychol Assess. 1995;7:524–32.
Abramson LY, Seligmann MEP, Taesdale J. Learned helplessness in humans: critique and reformulation. J Abnorm Psychol. 1978;87:49–74.
Abramson L, Metalsky G, Alloy L. Hopelessness depression: a theory-based subtype of depression. Psychol Rev. 1989;96:358–72.
Seligman ME. Helplessness: on depression, development, and death. San Francisco: Freeman; 1975.
Hasenbring M. The Kiel Pain Inventory-Manual. Three questionnaire scales for assessment of pain-related cognitions, emotions and coping-strategies. Bern: Huber Verlag; 1994.
Hasenbring M. Attentional control of pain and the process of chronification. Prog Brain Res. 2000;129:525–34.
Lazarus RS, Folkman S. Stress appraisal, and coping. New York: Springer; 1984.
Keefe FJ, Lumley M, Anderson T, Lynch T, Carson KL. Pain and emotion: new research directions. J Clin Psychol. 2001;57(4):587–607.
Lumley MA, Cohen JL, Borszcz GS, Cano A, Radcliffe AM, Porter LS, et al. Pain and emotion: a biopsychosocial review of recent research. J Clin Psychol. 2011;67(9):942–68.
Rusu AC, Hasenbring MI. Multidimensional pain inventory derived classifications of chronic pain: evidence for maladaptive pain-related coping within the dysfunctional group. Pain. 2008;134:80–90.
Hasenbring MI, Hallner D, Rusu AC. Endurance-related pain responses in the development of chronic back pain. In: Hasenbring MI, Rusu AC, Turk DC, editors. From acute to chronic back pain. Risk factors, mechanisms, and clinical implications. New York: Oxford University Press; 2012. p. 295–314.
Wegner DM, Schneider D, Carter SR, White TL. Paradoxical effects of thought suppression. J Pers Soc Psychol. 1987;53:5–13.
Sullivan MJL, Rouse D, Bishop S, Johnston S. Thought suppression, catastrophizing, and pain. Cogn Ther Res. 1997;21:555–68.
Wegner DM. You cannot always think what you want: problems in the suppression of unwanted thoughts. In: Zanna M, editor. Advances in experimental social psychology. San Diego: Academic; 1992. p. 193–225.
Wegner DM. Ironic processes of mental control. Psychol Rev. 1994;101:34–52.
Cioffi D, Holloway J. Delayed costs of suppressed pain. J Pers Soc Psychol. 1993;64:274–82.
Goubert L, Crombez G, Eccleston C, Devulder J. Distraction from chronic pain during a pain-inducing activity is associated with greater post-activity pain. Pain. 2004;110:220–7.
Keogh E, Bond FW, Hanmer R, Tilston J. Comparing acceptance- and control-based coping instructions on the cold-pressor pain experiences of healthy men and women. Eur J Pain. 2005;9:591–8.
Masedo AI, Esteve MR. Effects of suppression, acceptance, and spontaneous coping on pain tolerance, pain intensity and distress. Behav Res Ther. 2007;45:199–209.
Beck AT. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561–71.
Beck AT, Steer RA, Garbin MG. Psychometric properties of the Beck Depression Inventory: twenty-five years later. Clin Psychol Rev. 1988;8:77–100.
First MB, Spitzer RL, Gibbon M, Williams JBW. Structured clinical interview for DSM-IV axis I disorders. Arlington: American Psychiatric Publishing; 1997.
Williams A, Richardson PH. What does the BDI measure in chronic pain? Pain. 1993;55:259–66.
Novy DM, Nelson DV, Berry LA, Averill PM. What does the Beck Depression Inventory measure in chronic pain? A reappraisal. Pain. 1995;61(2):261–70.
Geisser ME, Roth RS, Robinson ME. Assessing depression among persons with chronic pain using the Center for Epidemiological Studies-Depression Scale and the Beck Depression Inventory: a comparative analysis. Clin J Pain. 1997;13:163–70.
Turner JA, Romano JM. Self‐report screening measures for depression in chronic pain patients. J Clin Psychol. 1984;40(4):909–13.
Love AW. Depression in chronic low back pain patients: diagnostic efficiency of three self‐report questionnaires. J Clin Psychol. 1987;43(1):84–9.
Hasenbring M, Hallner D, Rusu AC. Fear-avoidance- and endurance-related responses to pain: development and validation of the Avoidance-Endurance Questionnaire (AEQ). Eur J Pain. 2009;13(6):620–8.
Rosenstiel AK, Keefe FJ. The use of coping strategies in chronic low back pain patients: relationship to patient characteristics and current adjustment. Pain. 1983;17(1):33–44.
Verra ML, Angst F, Lehmann S, Aeschlimann A. Translation, cross-cultural adaptation, reliability, and validity of the German version of the Coping Strategies Questionnaire (CSQ-D). J Pain. 2006;7(5):327–36.
Turner JA, Aaron LA. Pain-related catastrophizing: what is it? Clin J Pain. 2001;17(1):65–71.
Sullivan MJL, Thorn B, Haythornthwaite JA, Keefe F, Martin M, Bradley LA, et al. Theoretical perspectives on the relation between catastrophizing and pain. Clin J Pain. 2001;17:52–64.
Hasenbring M, Marienfeld G, Kuhlendahl D, Soyka D. Risk factors of chronicity in lumbar disc patients. Spine. 1994;19:2759–65.
Schulz-Kindermann F, Hennings U, Ramm G, Zander AR, Hasenbring M. The role of biomedical and psychosocial factors for the prediction of pain and distress in patients undergoing high-dose therapy and BMT/PBSCT. Bone Marrow Transplant. 2002;29:341–51.
Pollard CA. Preliminary validity study of the pain disability index. Percept Mot Skills. 1984;59(3):974.
Tait RC, Pollard CA, Margolis RB, Duckro PN, Krause SJ. The Pain Disability Index: psychometric and validity data. Arch Phys Med Rehabil. 1987;68:438–41.
Chibnall JT, Tait RC. The Pain Disability Index: factor structure and normative data. Arch Phys Med Rehabil. 1994;75(10):1082–6.
Tait RC, Chibnall JT, Krause S. The Pain Disability Index: psychometric properties. Pain. 1990;40(2):171–82.
Dillmann U, Nilges P, Saile H, Gerbershagen HU. Assessing disability in chronic pain patients. Schmerz. 1994;8:100–10.
Kline RB. Principles and practice of structural equation modeling. 2nd ed. New York: The Guilford Press; 2005.
Schumacker R, Lomax R. A beginners guide to structural equation modelling, 2nd Edition. Lawrence Erlbaum Associates, 2004.
Jackson DL. Revisiting sample size and number of parameter estimates: some support for the N:q hypothesis. Struct Equ Model. 2003;10:128–41.
Corp IBM. IBM SPSS statistics for Windows, version 22.0. Armonk: IBM Corp; 2013.
Arbuckle JL. Amos version 7.0. Chicago: SPSS; 2006.
Byrne BM. Structural equation modelling with Amos: basic concepts, applications and programming. New Jersey: Lawrence Erlbaum Associates; 2001.
Browne MW, Cudeck R. Alternative ways of assessing model fit. In: Bollen KA, Long JS, editors. Testing structural equation models. Newbury Park: Sage; 1993. p. 136–62.
Fahland RA, Kohlmann T, Hasenbring M, Feng YS, Schmidt CO. Which route leads from chronic back pain to depression? A path analysis on direct and indirect effects using the cognitive mediators catastrophizing and helplessness/hopelessness in a general population sample. Schmerz. 2012;26:685–91.
Crombez G, Eccleston C, van Damme S, Vlaeyen JWS, Karoly P. Fear-avoidance model of chronic pain. The next generation. Clin J Pain. 2012;28:475–83.
Leeuw M, Goossens MEJB, Linton SJ, Crombez G, Boersma K, Vlaeyen JWS. The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med. 2006;30:77–94.
Pincus T, Smeets RJEM, Simmonds MJ, Sullivan MJL. The fear avoidance model disentangled: improving the clinical utility of the fear avoidance model. Clin J Pain. 2010;26:739–46.
Johnson MH. How does distraction work in the management of pain? Curr Pain Headache Rep. 2005;9(2):90–5.
Najmi S, Riemann BC, Wegner DM. Managing unwanted intrusive thoughts in obsessive-compulsive disorder: relative effectiveness of suppression, focused distraction, and acceptance. Behav Res Ther. 2009;47:494–503.
Wenzlaff RM, Luxton DD. The role of thought suppression in depressive rumination. Cogn Ther Res. 2003;27(3):293–308.
Hasenbring MI, Hallner D, Klasen B, Streitlein-Böhme I, Willburger R, Rusche H. Pain-related avoidance versus endurance in primary care patients with subacute back pain: psychological characteristics and outcome at a 6-month follow-up. Pain. 2012;153(1):211–7.
Aldao A, Nolen-Hoeksema S, Schweizer S. Emotion-regulation strategies across psychopathology: a meta-analytic review. Clin Psychol Rev. 2010;30:217–37.
Kennedy-Moore E, Watson JC. Expressing emotion: myths, realities, and therapeutic strategies. New York: Guilford; 1999.
Hayes SC, Strosahl K, Wilson KG. Acceptance and commitment therapy: an experiential approach to behavior change. New York: Guildford; 1999.
Barnow S. Emotionregulation and psychopathology. Psychol Rundsch. 2012;63(2):111–24.
Reid KJ, Harker J, Bala MM, Truyers C, Kellen E, Bekkering GE, et al. Epidemiology of chronic non-cancer pain in Europe: narrative review of prevalence, pain treatments and pain impact. Curr Med Res Opin. 2011;27(2):449–62.
Scholich SL, Hallner D, Wittenberg RH, Hasenbring MI, Rusu AC. The relationship between pain, disability, quality of life and cognitive-behavioural factors in chronic back pain. Disabil Rehabil. 2012;34(23):1993–2000.
Kovacs FM, Abraira V, Zamora J, Gil del Real Teresa M, Llobera J, Fernández C, et al. Correlation between pain, disability, and quality of life in patients with common low back pain. Spine. 2004;29:206–10.
Kovacs FM, Abraira V, Zamora J, Fernández C, Spanish Back Pain Research Network. The transition from acute to subacute and chronic low back pain: a study based on determinants of quality of life and prediction of chronic disability. Spine. 2005;30:1786–92.
Kovacs FM, Muriel A, Abriaira V, Medina JM, Castillo Sanchez MD, Olabe J, et al. The influence of fear avoidance beliefs on disability and quality of life is sparse in Spanish low back pain patients. Spine. 2005;30:E676–82.
Pincus T, Burton AK, Vogel S, Field AP. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine. 2002;27(5):E109–20.
Linton SJ. A review of psychological risk factors in back and neck pain. Spine. 2000;25(9):1148–56.
Acknowledgments
This study was supported by a research grant from the German Research Foundation (DFG: HA 1684) awarded to MIH.
The manuscript was edited by American Journal Experts. Costs of this service were incurred by the authors’ department (Department of Medical Psychology and Medical Sociology, Ruhr-University Bochum).
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
All procedures followed in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all patients being included in the study.
Conflict of Interest
The authors declare that they have no competing interests.
Rights and permissions
About this article
Cite this article
Hülsebusch, J., Hasenbring, M.I. & Rusu, A.C. Understanding Pain and Depression in Back Pain: the Role of Catastrophizing, Help-/Hopelessness, and Thought Suppression as Potential Mediators. Int.J. Behav. Med. 23, 251–259 (2016). https://doi.org/10.1007/s12529-015-9522-y
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12529-015-9522-y