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cute Pain (2009) 11, 113—120

ffects of cognitive pain coping strategies andocus of control on perception of cold pressorain in healthy individuals: Experimental study

atasa Jokic-Begica,∗, Dragutin Ivaneca, Dragana Markanovicb

Department of Psychology, Faculty of Humanities and Social Sciences University of Zagreb,uciceva 3, 10000 Zagreb, CroatiaFaculty of Philosophy, University J.J. Strossmayer, Osijek, Croatia

eceived 30 March 2009; received in revised form 2 October 2009; accepted 5 October 2009vailable online 1 November 2009

KEYWORDSInternal—externalcontrol;Pain measurement;Experimental;Students;Time perception

SummaryBackground: The aim of the present study was to determine the effectiveness of thecoping strategies — distraction and redefining — on pain experience in individualswith internal vs. external locus of control.Method: The participants were exposed to pain induced by cold pressor procedure.Pain tolerance, pain intensity, and objective and subjective duration of pain weremeasured in three different situations. In the control situation, the participantsdid not use any cognitive pain coping strategy. In two other situations, they useddistraction and redefining strategies, respectively.Results: Internally- and externally-oriented participants did not differ in pain tol-erance, pain intensity ratings, and subjective duration of painful stimulation in anyof the three situations. The use of cognitive pain coping strategies increased paintolerance in both groups in comparison with the control situation. In both situations,the participants underestimated the duration of pain tolerance. There was no dif-ference between the effectiveness of distraction and redefining strategies on paintolerance and pain intensity ratings.

Conclusion: Cognitive pain coping strategies increase the duration of pain toleranceirrespective of the individual’s locus of control, but have no effect on pain intensityrating.© 2009 Elsevier B.V. All r

ain perception is a resultant of a complex inter-ction of neurophysiological, psychological and

∗ Corresponding author. Tel.: +385 1 6120 089;ax: +385 1 6120 037.

E-mail address: njbegic@fzg.hr (N. Jokic-Begic).

366-0071/$ — see front matter © 2009 Elsevier B.V. All rights reseoi:10.1016/j.acpain.2009.10.003

ights reserved.

socio—cultural factors [1]. According to the biopsy-chosocial model, experience of pain is modulated

by individual differences in cognitive, affective,behavioural, and social factors [2].

Pain interrupts and demands attention [3]. Aspain and attentional task draw on the same lim-

rved.

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ited attentional resources, focusing of attention oncompeting stimuli should lead to fewer attentionalresources being allocated to the painful stimulus[4]. Consequently, pain tolerance would increase[5] and the experience of the stimulus as painfulwould be reduced [4].

Instruction in attentional coping strategies isoften used in experimental and clinical manage-ment of acute pain [6]. The two most frequentlyused pain coping strategies are distraction andfocused attention.

Distraction is defined as a deflection of attentionfrom a primary stimulus (e.g., painful experience)to an alternative stimulus. It is often used as apain coping strategy in everyday situations and incognitive-behavioural therapy of chronic pain [7,8].Many experimental studies have found distractionto be effective in healthy control subjects [3,9—11],although some studies produced different results[12]. Despite its intuitive appeal, the findings ofclinical and experimental research remain incon-clusive.

As opposed to distraction strategy, in redefin-ing strategy the attention is focused on a painfulstimulus in a non-distressing manner. Leventhal etal. [13] suggested that sensory focus strategies,which include redefining, work by intercepting ordisrupting sensation-distress associations. In somecontexts, sensory focus strategies result in greatertolerance, lower distress, and/or lower pain inten-sity ratings than distraction-based interventions[6].

Comparison of effectiveness of these twostrategies has produced ambiguous results, whichdepended on various factors including the type ofpainful stimulus, duration of pain tolerance, mea-sure of tolerance, and some trait characteristics,such as locus of control [6].

Locus of control, a concept developed by Rot-ter within his social learning theory, is defined asa perceived source of factors influencing individ-ual’s behaviour management and causing whateverhappens to an individual, including success and fail-ure [14]. A person attributes causes to differentoutcomes along the internal—external dimension.Individuals who believe they can control and deter-mine most events in their environment are atthe internal end of the continuum. They attributethe outcomes of their behaviour to their owncapabilities, efforts, or other characteristics, i.e.,they have an internal locus of control. Unlike

them, individuals who believe the outcomes oftheir behaviour are determined by fate, chance,luck, someone else’s influence, or other forcesoutside themselves have an external locus ofcontrol.

N. Jokic-Begic et al.

Higher levels of internality correlate with higherpain tolerance and more positive response to pain[15]. Individuals with high external locus of con-trol have stronger physiological responses to pain,show more negative emotional reactions to pain,and usually rate pain as more intense [16—18] thanindividuals with high internal locus of control. Theperception of control in an aversive situation is agood predictor of pain tolerance, but not of painintensity, pain threshold, or heart rate [19].

The question remains of whether the locus ofcontrol plays a role in the effectiveness of cog-nitive pain coping strategies, i.e., whether somestrategies are more appropriate for individuals withinternal orientation and other for individuals withexternal orientation.

The aim of the present study was to deter-mine the effectiveness of two coping strategies— distraction and redefining — in toleratingexperimentally caused acute pain. The hypothesiswas that the redefining strategy would be moreeffective in internally- than externally-orientedindividuals because it involves perceived control.In externally-oriented individuals, distraction isexpected to be more effective because it is inaccordance with their belief in external behaviourcontrol. The objective duration of pain tolerance,pain intensity, and subjective duration of pain weremeasured to test the hypothesis that the strat-egy taking more attention would also result in theunderestimation of pain duration and pain intensityand consequently increase pain tolerance.

1. Participants and method

1.1. Participants

Ninety-six psychology students from the ZagrebUniversity School of Humanities and Social Sci-ences participated in the study. The students wereselected from the total number of psychology stu-dents (N = 249) on the basis of their results on TheInternal—External Locus of Control Scale or RI-Escale. Those whose scores were within the top orbottom 25% were included in the study and dividedin two groups. Students who scored in the bottom25%, i.e., those who scored 1—7 points, on the RI-E scale were included in the externally-orientedgroup (n = 47), and those who scored in the top 25%,i.e. those who scored 15—21 points, on the RI-Escale were included in the internally-oriented group

(n = 49). Low scores theoretically corresponded toan external locus of control, whereas high scorescorresponded to an internal locus of control. Exclu-sion criteria were use of analgesics, exposure to

Pain coping strategies in healthy adults

physical activity immediately before testing, illnessat the time of testing, or illness that could be aggra-vated by testing (e.g., vasculitis or scleroderma).The final sample consisted of 82 women and 14 men,with mean age of 20.7 ± 2.2 years (range, 18—30years).

The participants were explained that the pur-pose of the study was to determine how differentpersons perceive and tolerate pain. All studentsincluded in the study provided their informedconsent. The study was approved by the EthicsCommittee of the Zagreb University School ofHumanistic and Social Sciences.

1.2. Instruments

1.2.1. The internal—external locus of controlscale or RI-E scale [20]RI-E scale is a 29-item forced-choice scale used fordetermining the general locus of control. The itemsare binary variables scored as 0 or 1, and the totalscore is the sum of scores on 23 items (six itemsare intended to conceal the real purpose of inves-tigation). Theoretical score range is 0—23, withhigher scores indicating higher level of externality.Translation and adaptation of RI-E scale to Croat-ian and the evaluation of its metric characteristicshad been performed previously [20]. The results inour sample (N = 249; mean score, 11.1 ± 4.2; range,1—21) showed normal distribution and Cronbach’salpha was 0.74.

1.2.2. Verbal fluency test [21]The test measures spontaneous production of thewords. Participants were asked to verbally generateas many nouns beginning with a particular letter aspossible within 1 min. In Croatian language, mostwords begin with letters F, A, S, K, L, or P, sothese were the letters used in the task. After 1 min,the investigator would instruct the participant torepeat the task using another letter. The purposeof this strategy was distraction.

1.2.3. List of positive self-statementsThe list consists of 15 self-statements that areeither confronting or reinterpretative. Confrontingstatements emphasize the ability of an individualto tolerate discomfort (e.g., ‘‘I am brave’’ or ‘‘Thishurts, but I have the control’’ or ‘‘Doesn’t matterhow cold it is, I can stand it’’), whereas rein-terpretative statements negate or underestimatediscomfort (e.g. ‘‘It’s not that bad,’’ or ‘‘There are

worst things than this,’’ or ‘‘The water is pleasantlycool’’). Participants were asked to read and chooseone or more proposed statements or think of theirown statements to use during the test. They could

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say the statements aloud or silently. The purposeof this strategy was to redefine the pain. Duringthe test, the list of positive self-statements was onthe wall in full view of the participant.

1.2.4. Pain intensity scaleThe scale is used for pain intensity rating. Partici-pants rated the intensity of pain at the end of thetest on a scale from 0 (no pain) to 10 (the strongestpossible pain).

1.2.5. Subjective duration of pain toleranceIn each situation, participants were asked to esti-mate the duration of pain tolerance in secondsimmediately after the completion of the procedure.

1.2.6. Apparatus for cold pressor testAcute pain was induced by the cold pressorprocedure. A special apparatus was constructedconsisting of a freezer (50 × 65 × 75 cm) with acapacity of 120 L, a water circulation pump, and anarmrest. The freezer was filled with water whosetemperature was maintained at 2 ◦C. The watertemperature was measured by a thermometer, andthe water circulation pump prevented the warmingof the water around the immersed arm. The arm-rest for the forearm and hand was immersed intothe water up to the point where the whole forearmwas under the water. A counterweight, connectedto the armrest, would lift the armrest to the start-ing position when the participant took the arm outof the water. A switch on the armrest was connectedto a stopwatch, which was activated when the arm-rest was immersed into the water and stopped whenthe armrest returned to the starting position. Thepain tolerance, i.e., time during which the partici-pant could hold his or her dominant hand immersedin the cold water, was measured in seconds. Partic-ipant’s estimate of the duration of pain tolerancewas recorded retrospectively.

1.3. Method

The study was performed in a laboratory at theDepartment of Psychology, Zagreb University Schoolof Humanistic and Social Sciences, during a wintersemester. Each participant was tested individuallyand exposed to three different experimental situa-tions (dependent part of the design).

In the control situation, the participant wasinstructed to immerse the dominant hand and fore-arm into cold water and keep it immersed as long

as possible, i.e., to take the hand and forearm outof the water only when pain becomes unbearable.The procedure was limited to 300 sec for ethicalreasons, but the participants were not aware of

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the time limitation. The participant could see theinvestigator, but conversation during the procedurewas not allowed. After the participant interruptedthe procedure, the investigator recorded the dura-tion of pain tolerance. Each participant was thenasked to rate the intensity of pain on the 0—10 scaleand estimate the time during which he or she tol-erated the pain (the participant could not see thestopwatch).

In the second situation, the pain tolerance wasmeasured in the same way, but the participantswere engaged in the verbal fluency task (controlledassociations), which served as a distraction strat-egy. Before the cold pressor test, the investigatordescribed the technique that could help the par-ticipant endure the discomfort caused by the coldwater and explained the task. The participant wasgiven the first letter immediately after he or sheimmersed the dominant forearm and hand into thewater and asked to say as many nouns beginningwith that letter as possible. After 1 min, the partic-ipant was given another letter and the procedurewas repeated until the participant or the investiga-tor interrupted the measurement. If the participanttried to talk to the investigator, he or she wasinstructed to continue with the task. After the mea-surement, the participant was asked to estimatepain tolerance and pain intensity and interviewedabout the experience.

In the third situation, a redefining strategy wasused. The participants were instructed to use pos-itive self-statements. Before the cold pressor test,the participant was instructed to read the proposedstatements and to use them in an autosuggestivemanner during the hand immersion. The participantcould choose whether to say the statements aloudor silently. The list of statements was available onthe wall in full view of the participant.

The order of experimental situations was fixed.All participants were first exposed to the controlsituation, so that baseline values of dependentvariables could be measured. The second situationinvolved the distraction strategy, and the third oneinvolved the redefining strategy.

The order of the situations was not randomizedfor two reasons. First, a randomized order wouldnot allow us to measure the baseline values in allparticipants. Second, we believe that there wouldbe no serial effects, because intensive painful stim-ulation was used.

The interval between the exposures to coldwater in each situation was 1—5 days. Physico-

chemical conditions during the cold pressor testwere constant. Dependent variables were pain tol-erance and subjectively estimated duration of pain.Pain tolerance was measured both objectively (time

N. Jokic-Begic et al.

during which a participant could cope with thepain) and subjectively (pain intensity rating). Theinvestigator was unaware of a participant’s groupallocation.

After the measurements had been completed,the participants were contacted and fully explainedthe purpose of the study.

1.4. Statistical analysis

Normal distribution of results in each experimen-tal situation was tested with Kolmogorov—Smirnovtest. For both groups of participants, the distri-bution of pain tolerance in all three situationssignificantly deviated from normal. The reason wasthe time limitation of pain tolerance. Many partici-pants reached the time limit of 300 s, i.e., the pointat which the measurement was stopped. The per-centage of such participants ranged from 29.2% to60.8%.

Estimated pain intensity in externally-orientedgroup in the control situation showed a signifi-cant deviation from normal distribution. Therefore,non-parametric statistical tests were used in dataanalysis. Estimated duration of hand immersionwas used as an indicator of focusing on the stim-ulus. The difference between the objective andsubjective duration of pain tolerance was used inanalysis as an error in duration estimate. If the dif-ference was positive, the objective duration waslonger than the subjective duration of pain toler-ance. The difference between the internally- andexternally-oriented groups in each dependent vari-able in each experimental situation was tested withMann—Whitney U test. The difference in valuesof each dependent variable in the three experi-mental situations was assessed with Friedman test(�2 test). The difference between the situationswhere distraction and redefining strategies wereused was determined with Wilcoxon signed rankstest. Due to the small number of male participants,we did not analyse the data for men and womenseparately.

Statistical analysis was performed with Statisti-cal Package for the Social Sciences ver. 16.0 (SPSSInc., Chicago, IL, USA) for Microsoft Windows. Thelevel of statistical significance was set at p < 0.05.

2. Results

No significant difference was found in pain toler-

ance, pain intensity, and subjective duration of paintolerance between the internally- and externally-oriented group in any of the three experimentalsituations.

Pain coping strategies in healthy adults 117

Fig. 1 Duration of pain tolerance in internally-oriented(open bars) and externally-oriented (gray bars) partici-prr

ptwwd(pwsdet

s(it

Fvoer

Fig. 3 The difference between the objective and sub-jective duration of pain tolerance in internally-oriented(open bars) and externally-oriented (gray bars) par-ticipants in three different experimental situations.Positive median values indicate subjectively underes-timated duration of pain tolerance. Negative medianvtq

i(dtsirH

ants in three different experimental situations. The barsepresent median values, and whiskers represent quartileange.

Cognitive pain coping strategies used by thearticipants had a significant influence on painolerance (�2

2 = 77.3; p < 0.001). In comparisonith the control situation, pain tolerance timeas almost 2 min longer in the situations whereistraction and redefining strategies were usedp < 0.001 for both) for both groups of partici-ants (Fig. 1). No difference in pain tolerance timeas found between the distraction and redefining

ituations (p = 0.160). Also, no difference in painuration was found between the internally- andxternally-oriented groups in any of the experimen-al situations.

There was no significant difference in pain inten-

ity between the three experimental situations�2

2 = 2.46; p = 0.290), i.e., both groups of partic-pants had similar ratings of pain intensity in allhree experimental situations (Fig. 2).

ig. 2 Subjective estimate of pain intensity (medianalues) in internally-oriented (open bars) and externally-riented (gray bars) participants in three differentxperimental situations. Whiskers represent quartileange.

ortttotgs

3

Wiioowtadiw

alues, if present, would indicate subjectively overes-imated duration of pain tolerance. Whiskers indicateuartile range.

Subjective duration of pain tolerance was signif-cantly different in three experimental situations�2

2 = 22.42; p < 0.001). The error in estimateduration of pain, defined as the difference betweenhe objective and subjective duration of pain, wasignificantly smaller in the control situation thann the situations where distraction (p < 0.001) oredefining strategies (p = 0.003) were used (Fig. 3).owever, no difference in estimated durationf pain was found between the distraction andedefining situations (p = 0.061). These results showhat the participants estimated the duration of painolerance more correctly in the control situationhan in the situations where they used distractionr redefining strategies. No difference in subjec-ive duration of pain was found between the tworoups of participants in any of the experimentalituations.

. Discussion

e found that pain tolerance was significantlyncreased in situations where cognitive pain cop-ng strategies were used. This finding confirmedur hypothesis that both internally- and externally-riented participants would tolerate pain longerhen using a cognitive pain coping strategy. Pain

olerance was significantly longer when distraction

nd redefining strategies were used. The medianuration of pain tolerance of 300 s in both exper-mental situations where pain coping strategiesere used suggests that half of participants in

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each group reached the upper limit of endurance.These results confirm the previous findings thatcognitive coping strategies can increase pain tol-erance [22—24] and pain threshold [22,24—26]. Inall three situations, both groups of participantsrated the pain intensity equally, i.e., around 7,which is relatively strong pain. This result wasexpected, though, because the cold pressor proce-dure is known to induce pain of very high intensity.Although the use of different cognitive strategiesextended the time during which such intense painwas tolerated, it did not influence the ratings ofpain intensity. At first, this finding does not seemto be logical, but it was to be expected becauseof the analgesic effect produced by cognitive paincoping strategies. Similar pain intensity ratings inall three experimental situations indicate that theparticipants experienced pain of the same intensity,but that it took significantly longer for such pain tobe induced by cold water hand immersion in situ-ations where distraction and redefining strategieswere used.

Finally, the participants significantly underesti-mated the duration of pain tolerance in all threeexperimental situations, regardless of their locusof control. We believe that participants under-estimated the time spent on the task in eachsituation, because the task required some amountof their attention. Other investigators reportedsimilar results [27—29].

Rather unexpectedly, internally- and externally-oriented participants in our study did not differ inpain experience as expected. In the control situ-ation, which served as a baseline measurement,both groups had their hands immersed in cold waterfor the same period of time, both groups esti-mated the time during which they tolerated thepain equally long, and both groups rated the painequally intense. These results are not consistentwith previous findings reported in the literature,which show that the individuals with internal locusof control respond to pain more positively then theindividuals who believe their experiences are con-trolled by various external factors [15,18,19,30].However, a few investigators did not find the asso-ciation between locus of control and response topain [31].

The finding that internally- and externally-oriented groups did not differ significantly in paintolerance in two experimental situations wherecognitive pain coping strategies were used sug-gests that both pain control techniques were

equally useful for both groups. We expected theredefining technique to be more appropriate forthe internally-oriented individuals due to theirtendency to perceive the problems as poten-

N. Jokic-Begic et al.

tially controllable, and the distraction task to bemore useful to the externally-oriented individualsbecause they tend to perceive the experiences asless controllable and more often use non-adaptivecoping strategies. A few studies among patientswith chronic pain [32—34] implied that effective-ness of a particular cognitive pain coping strategydepends on the individual’s locus of control; how-ever, our study results did not show that the samelogic may be applied in case of acute pain. Rather,it seems that different cognitive factors and cogni-tive interpretation in general play more importantrole in acute pain experience than specific cognitivepain coping techniques.

Our study also shows the importance of expecta-tion in pain perception. Our study participants wereinformed that both strategies would help them incoping with pain. This awareness could have con-tributed to the lack of difference between thetwo experimental situations where distraction andredefining strategies were used. Had we not toldthe participants anything about the possible effectsof the strategies, the obtained results could havebeen different, i.e., similar to those obtained byMarino et al. [35], who found decreased efficiencyof coping strategies when the participants had beentold that the strategies would not help them incoping with the pain. Therefore, it seems that thechoice of a particular pain coping strategy is lessimportant than how efficient we think it would be,which is in accordance with Bandura’s self-efficacymodel [36].

There are some limitations to our study. First,the participants were psychology students. Thefact that they were all young and healthy couldhave biased the results toward higher pain toler-ance than if the participants had been selectedfrom general population. In addition, the study wasconducted under laboratory conditions at the Uni-versity Department of Psychology, which is a safeenvironment. The participant’s feeling of safetycould have influenced pain tolerance time. There-fore, we recommend that future studies be basedon a sample of general population to obtain thevariability in baseline pain tolerance. We also didnot have a gender balance in our sample. How-ever, there was no difference between male andfemale participants in significant variables. In ouropinion, different proportion of male and femaleparticipants in our study did not affect the results,although future studies should aim at achieving abetter gender balance in the sample.

Second, the time limitation strongly influencedthe results, but the duration of the test had tobe limited for ethical reasons. Third, there is apossibility that our hypothesis was statistically sup-

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Pain coping strategies in healthy adults

ported only in part, because of some difficultieswith Rotter RI-E scale. The reliability of the scalein our study was high and similar to the reliabil-ity obtained in other studies [20,37,38]. However,the scale measures global locus of control, so it ispossible that it is less predictive in specific situ-ations. Fourth, objective control over the use ofpain coping strategies was not possible. Partici-pants’ engagement in the distraction task could becontrolled, but it was not possible to control theirengagement in redefining strategy and assess towhat extent they followed the given instructions.Although most participants in post-experimentalinterview said they had no difficulties with the tech-nique used, some might not have been telling thetruth. Fifth, it should be noted that there is apossibility that the obtained differences betweenthe experimental situations were more the resultof interaction between the experimenter and par-ticipant than the result of the strategies used, asthese were mutually confounding. To exclude sucha possibility, the control situation had to includean amount of interaction between the experi-menter and participant similar to that in othertwo situations. However, if the interaction in thecontrol situation was increased, it would proba-bly not be possible to measure the baseline valuesof dependent variables. This methodological lim-itation could partially be improved by reducingthe interaction between the experimenter and par-ticipant in all three situations, e.g., by leavingthe participant alone in the room and by usinga computer for giving tasks and recording theanswers. Finally, it is possible that speaking aloudwas itself a distraction, even when participantsused redefining strategy, which was assumed tobe the mechanism underlying the increased paintolerance.

Our study has important practical considera-tions. The use of different cognitive pain copingsstrategies significantly extends the duration of paintolerance, which could be useful in some med-ical procedures accompanied by pain (dentistry,surgery, or invasive diagnostic procedures). Ourstudy participants did not use any cognitive paincoping strategy on their own accord, but wereinstructed to do so. Similarly, health professionalscould teach the patients who are about to undergoa painful medical procedure how to use cognitivestrategies that would help them cope with pain.

Conflict of interest

All authors give a statement that there is no conflictof interest.

[

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