300 Pain Management
of Pain: •[Pain] is unquestionably a sensation in a part or
parts of the body but it is also always unpleasant and there-
fore also an emotional experienceŽ (Merskey, 1986). The
central and interactive roles of sensory information and af-
fective state are supported by an overwhelming amount of
evidence (Fernandez & Turk, 1992). The affective compo-
nents of pain include many different emotions, but they are
primarily negative emotions. Depression and anxiety have
received the greatest amount of attention in chronic pain
patients; however, anger has recently received considerable
interest as an important emotion in chronic pain patients.
Depression
Clinical data suggest that from 40% to 50% of chronic pain
patients suffer from signi“cant depression (Banks & Kerns,
1996). In the majority of cases, depression appears to be re-
actions, although some have suggested that chronic pain is a
form of •masked depression,Ž whereby patients use pain to
express their depressed mood because they feel it is more ac-
ceptable to report pain than to acknowledge depression.
Although this may be true in a small number of cases, the re-
search on this topic does not suggest that depression precedes
the development of chronic pain (Turk & Salovey, 1984).
It is not surprising that a large number of chronic pain
patients are depressed. It is interesting to ponder the other
side of the coin. Given the nature of the symptom and the
problems created by chronic pain, why is it that all such pa-
tients are notdepressed? We (Okifuji et al., 2000; Turk,
Okifuji, & Scharff, 1995) examined this question and deter-
mined that patients• appraisals of the effects of the pain on
their lives and of their ability to exert any control over the
pain and their lives mediated the pain-depression link. That
is, those patients who believed that they could continue
to function despite their pain, and who believed that they
could maintain control despite their pain, did not become
depressed.
Anger
Anger has been widely observed in people with chronic pain
(Schwartz, Slater, Birchler, & Atkinson, 1991). Pilowsky and
Spence (1976) reported •bottled-up angerŽ in 53% of chronic
pain patients. Kerns, Rosenberg, and Jacob (1994) noted that
the internalization of angry feelings was strongly related to
measures of pain intensity, perceived interference, and re-
ported frequency of pain behaviors. Summers and colleagues
(Summers, Rapoff, Varghess, Porter, & Palmer, 1991) exam-
ined patients with spinal cord injuries and found that anger
and hostility were powerful predictors of pain severity.
Moreover, even though chronic pain patients in psychother-
apy might present an image of themselves as even-tempered,
88% of the patients treated acknowledged their feelings
of anger when these were explicitly sought (Corbishley,
Hendrickson, Beutler, & Engle, 1990).
Frustrations related to persistence of symptoms, limited
information on etiology, and repeated treatment failures
along with anger toward employers, the insurance, the health
care system, family members, and themselves, all contribute
to the general dysphoric mood of these patients. The effects
of anger and frustration on exacerbation of pain and treat-
ment acceptance has not received much attention, but it
would be reasonable to expect that the presence of anger may
serve as a complicating factor, increasing autonomic arousal
and blocking motivation and acceptance of treatments ori-
ented toward rehabilitation and disability management rather
than cure, which are often the only treatments available for
chronic pain (Fernandez & Turk, 1995).
It is important to be aware of the central role of negative
mood in chronic pain patients because it is likely to affect
treatment motivation and compliance with treatment recom-
mendations. For example, patients who are anxious may fear
engaging in what they perceive as demanding activities;
patients who are depressed and who feel helpless may have
little initiative to comply; and patients who are angry with
the health care system are not likely to be motivated to re-
spond to recommendations from yet another health care
professional.Cognitive FactorsA great deal of research has been directed toward identifying
cognitive factors that contribute to pain and disability. These
studies have consistently demonstrated that patients attitudes,
beliefs, and expectancies about their plight, themselves, their
coping resources, and the health care system affect reports of
pain, activity, disability, and response to treatment.Beliefs about PainPeople respond to medical conditions in part based on their
subjective ideas about illness and their symptoms. Health
care providers working with chronic pain patients are aware
that patients having similar pain histories and reports of pain
may differ greatly in their beliefs about their pain. Behavior
and emotions are in”uenced by interpretations of events and
expectations, rather than solely by objective characteristics
of the event itself. Thus, pain, when interpreted as signifying
ongoing tissue damage or a progressive disease, is likely to