The impact of threatening information about pain on coping and pain tolerance.
ABSTRACT This study examined the impact of threatening information on coping and pain tolerance in a healthy adult sample. Prior to engaging in a Cold Pressor Test (CPT), 121 college students were randomly assigned to one of three conditions: a threat condition in which they read an orienting passage warning them about symptoms and consequences of frostbite (pain as a signal for nociception), a reassurance condition in which they read an orienting passage about the safety of the CPT (pain independent of nociception), or a control condition in which no orienting passage was read before the experimental task. Only 15.6% of participants in the threat group completed the CPT to its 4-minute duration, compared with 55.6% in the reassurance group and 45.2% of those in the control group. Even though groups did not differ on level of reported pain, threatened participants catastrophized more about the pain and reported less use of cognitive coping strategies (reinterpreting pain sensations, ignoring pain, diverting attention away from pain to other experiences, and using coping self-statements) than other respondents. A path analysis indicated that the relation between threat and pain tolerance was fully mediated by catastrophizing and cognitive coping. Together, findings suggest that pain appraised as threatening contributes to a specific pattern of coping responses associated with a reduced capacity to bear pain.
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ABSTRACT: BACKGROUND: Pain is a major ailment that motivates individuals to look for treatment. Despite its enormous clinical relevance, very little is known about the factors that influence our preference of an analgesic (or pain-relieving treatment). The current study investigated the influence of the information regarding the probability and the magnitude of the expected analgesic effect on preference of analgesic options. METHODS: Twenty-four healthy volunteers were instructed to imagine pain across different scenarios and choose between two hypothetical analgesics that differed in their probabilities to successfully relieve pain and the magnitude of their expected analgesic effects. The conservative analgesic was more reliable but less potent than the radical analgesic, whereas the radical analgesic was less reliable but more potent than the conservative analgesic. RESULTS: Consistent with the predictions of prospect theory, a larger proportion of the participants chose the radical analgesic when the overall probability of both analgesics decreased, and when the potency of the radical analgesic was expected to be stronger relative to the conservative analgesic. At the individual level, individuals' relative imagined pain relief (radical analgesic/conservative analgesic) predicted their preference for the radical analgesic. CONCLUSIONS: Our findings revealed that preference of analgesic options is mediated by the overall probability of analgesic effect and the relative potency of analgesics. The expected relief one imagines to obtain from analgesics would guide preference. The findings highlight the importance for clinicians to understand how patients subjectively frame the probability and magnitude factors related to decision making in medical context.European journal of pain (London, England) 09/2012; · 3.37 Impact Factor
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ABSTRACT: The aims of this study were: 1) to examine race and sex differences in primary pain appraisals and catastrophizing; 2) to test the unique ability of race, sex, primary pain appraisals, and catastrophizing to predict experimental pain outcomes; and 3) to conduct mediational analyses testing pain appraisals and catastrophizing as explanatory mechanisms for race and sex differences in pain. One hundred and fifty-five college students at The University of Alabama completed a cold pressor experimental pain task and a questionnaire battery. Statistical methods included multivariable regression models and nonparametric bootstrapping methods for tests of mediation. African-Americans reported higher catastrophizing and had lower pain tolerance than white Americans. Males demonstrated higher challenge appraisals, lower pain intensity, and longer pain tolerance. Challenge appraisals were positively related to pain tolerance, threat/harm appraisals were inversely related to pain tolerance, and pain catastrophizing was positively related to both pain intensity and pain unpleasantness. Pain catastrophizing partially mediated race differences in pain tolerance and mediated sex differences in intensity, whereas primary pain appraisals did not significantly mediate race or sex differences in pain variables. Primary appraisals and catastrophizing appear to be separable constructs related to different aspects of the pain experience. PERSPECTIVE: This study found that important race and sex differences exist in relation to pain appraisals and catastrophizing, and that these cognitive variables play unique roles in different aspects of the pain experience. Cognitive-behavioral therapies for pain may be enhanced by including a focus on both pain appraisals and pain catastrophizing.The journal of pain: official journal of the American Pain Society 01/2011; 12(5):563-72. · 3.78 Impact Factor
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ABSTRACT: The field of pain medicine has shifted from multidisciplinary rehabilitation to procedure-focused interventional pain medicine (IPM). Considerable controversy exists regarding the efficacy of IPM and its more narrow focus on nociception as an exclusive target of pain treatment. This topical review aims to examine pain research and treatment outcome studies that support a biopsychosocial model of pain, and to critique the clinical practice of IPM given its departure from the premises of a biopsychosocial model. A modern definition of pain and findings from clinical and basic science studies indicate that pain-related psychological factors are integral to pain perception. The clinical viability of IPM is challenged based upon its biomedical view of peripheral nociception as a primary source of pain and the potential of this viewpoint to foster maladaptive pain attributions and discourage the use of pain coping strategies among chronic pain patients. IPM should adopt a biopsychosocial perspective on pain and operate within a framework of multidisciplinary pain rehabilitation to improve its effectiveness.Translational behavioral medicine. 03/2012; 2(1):106-16.
The impact of threatening information about pain
on coping and pain tolerance
Todd Jackson1*, Laurie Pope2, Takeo Nagasaka2, April Fritch2,
Tony Iezzi3and Hong Chen4
1School of Psychology, James Cook University, Australia
2Psychology Department, University of Wisconsin – Superior, USA
3Psychology Department, London Health Sciences Centre, UK
4Psychology Department, Southwest China Normal University, China
This study examined the impact of threatening information on coping and pain
tolerance in a healthy adult sample. Prior to engaging in a Cold Pressor Test (CPT), 121
college students were randomly assigned to one of three conditions: a threat condition
in which they read an orienting passage warning them about symptoms and
consequences of frostbite (pain as a signal for nociception), a reassurance condition in
which they read an orienting passage about the safety of the CPT (pain independent of
nociception), or a control condition in which no orienting passage was read before the
experimental task. Only 15.6% ofparticipants in the threat groupcompleted the CPT to
its 4-minute duration, compared with 55.6% in the reassurance group and 45.2% of
those in the control group. Even though groups did not differ on level of reported pain,
threatened participants catastrophized more about the pain and reported less use of
cognitive coping strategies (reinterpreting pain sensations, ignoring pain, diverting
attention away from pain to other experiences, and using coping self-statements) than
other respondents. A path analysis indicated that the relation between threat and pain
tolerance was fully mediated by catastrophizing and cognitive coping. Together, findings
suggest that pain appraised as threatening contributes to a specific pattern of coping
responses associated with a reduced capacity to bear pain.
Various investigators have implicated pain beliefs and coping as influences on physical
and psychological functioning (e.g. Buer & Linton, 2002; Crombez, Vlaeyen, Heuts, &
Lysens, 1999; Geisser, Robinson, & Riley, 1999; Turner, Jensen, & Romano, 2000),
compliance with treatment regimens (e.g. DeGood & Tait, 2001), and risk of acute pain
turning into chronic pain and disability (e.g. Gatchel & Ecker, 1999). Nonetheless, past
work has generally assessed effects of either appraisal or coping on outcomes, failing
to evaluate their combined impact or effects of appraisal on subsequent coping
*Correspondence should be addressed to Todd Jackson, School of Psychology, James Cook University, Townsville, QLD 4811,
Australia (e-mail: firstname.lastname@example.org).
British Journal of Health Psychology (2005), 10, 441–451
q 2005 The British Psychological Society
(Thorn, Rich, & Boothby, 1999). In addition, many researchers have focused narrowly
on aspects of pain appraisal such as perceptions of control and self efficacy, neglecting
interpretations of the meaning of pain as a threat or challenge (Haythornthwaite &
Although self-reported appraisals of threat have been linked to reduced tolerance for
experimental pain (Stanford, Kersh, Thorn, Rich, & Ward, 2002), increases in disability
and avoidance of maximal physical performance (Crombez et al., 1999; Geisser & Roth,
1998), to our knowledge, only two studies have attempted to experimentally
manipulate appraisals of noxious stimuli. Following from pioneering work on appraisal
(e.g. Lazarus, 1966), Neufeld (1970) assessed tolerance for a radiant heat stimulus
applied to the forearms of 12 college students after first manipulating instructional sets
about the stimulus. Increased tolerance was observed when participants used a denial
instructional set (i.e. thinking of the sensation as pleasurable and the experience as
enjoyable) compared to intellectualization or neutral instructional sets. Unfortunately,
instructional sets used in Neufeld’s study confounded appraisal with coping, given that
denial and intellectualization are not merely appraisals or evaluations about the nature
of a stressor and/or one’s resources but instead reflect ‘effortful’ coping strategies
(e.g. Folkman & Moskowitz, 2004; Lazarus, 1999). More recently, Friedman, Thompson,
and Rosen (1985) found uncomfortable sensations associated with cold water
immersion were tolerated significantly longer when they were ascribed to non-
damaging processes (i.e. instructional sets ‘normalizing’ sensations or framing them as
novel) compared with a control condition lacking particular instructions. In a follow-up
study, repeated exposure to cold water – used to demonstrate the safety of the
procedure – increased tolerance even though reported pain did not decrease. These
authors concluded that decreased tolerance of control group subjects was due to
relatively higher levels of threat, not decreased sensation. Unfortunately, this inference
was unfounded because threat was not directly manipulated in the instructional sets
used in the study. Given weaknesses in past experimental research, clarification is still
needed regarding relations between appraisals of threat and pain tolerance.
Recently, Eccleston and Crombez (1999) have contended that because pain is the
archetypal signal for danger, the possibility of imminent pain shifts attention towards
pain and makes escape a priority, especially when pain is appraised as threatening.
Supporting these claims, Dawson, Schell, Beers, and Kelly (1982) found larger task
interference when a visual stimulus signalled the occurrence of a noxious
electrocutaneous stimulus than when a visual stimulus signalling the absence of a
noxious stimulus. Similarly, Crombez, Eccleston, Baeyens, and Eelen (1998a, 1998b)
observed greater disruption in task performance immediately after the onset of a low
intensity electrocutaneous stimulus among participants threatened with randomly
delivered high intensity stimuli compared with those not so threatened. Notably, the
threat manipulation disrupted task performance at the onset of the stimulus but
dissipated shortly thereafter. That is, with the threat of intense pain, attention shifted
towards the object of threat (i.e. the electrocutaneous stimulus). After the stimulus was
appraised as non-threatening, attention returned to the primary task.
While these studies suggest that pain appraised as a potential threat demands
attention, other correlational research has examined how pain appraisals are related to
coping (e.g. Unruh, Ritchie, & Merskey, 1999; Williams & Keefe, 1991). Williams and
Keefe observed that chronic pain patients who believed their pain was mysterious and
permanent catastrophized more about pain and used fewer cognitive coping strategies
than patients who believed their pain was of shorter duration and understandable.
Todd Jackson et al.442
Unruh et al. found pain appraised as threatening had a positive association with
catastrophizing and negative associations with cognitive and behavioural distraction
among community volunteers.
Due to the use of non-experimental designs and participant self-selection into
appraisal groups, unmeasured variables (e.g. self esteem, locus of control, and
neuroticism) cannot be dismissed as potential causes of both appraisal and coping
responses in these investigations. Therefore, associations between appraisal and coping
must be regarded as tentative. However, still other investigators have related certain
patterns of coping with the emergence of pain problems and other negative outcomes.
According to Eccleston and Crombez (1999), fear of pain and catastrophic thinking
about pain produce a general hyper-vigilance for pain and a priming of escape
behaviour. In other words,people threatened by pain havepropensities to catastrophize
about pain, engage in less cognitive coping, and show reduced tolerance during
exposure. Indeed, considerable data suggests that catastrophizing about pain instead of
ignoring, distracting, reinterpreting, or using coping self-statements, predicts reduced
pain tolerance (e.g. Geisser, Robinson, & Pickren, 1992; McCracken, Goetsch, &
This experiment examined the impact of threat appraisal on both pain coping
strategies and tolerance for the Cold Pressor Test (CPT). It was hypothesized that
persons led to appraise the CPT as threatening would be less likely to complete or
tolerate the task compared with those assured of its safety and those not led to view the
CPTin any particular way. Furthermore, compared with respondents in reassurance and
control conditions, those in the threat condition were expected to report reduced task-
specific self-efficacy, heightened catastrophizing, and decreased use of specific
cognitive strategies (i.e. reinterpretation, ignoring, diverting attention, and coping
self-statements). Finally, based on separate lines of tentative evidence suggesting that (1)
threat appraisals predict certain ways of coping and (2) patterns of coping can predict
pain tolerance, we hypothesized increases in catastrophizing and decreases in cognitive
coping would mediate the association between exposure to threatening information
and reduced pain tolerance.
Participants were 121 college undergraduates (77 female, 44 male) recruited from
classes at the University of Wisconsin – Superior and given course credit for
participation. The sample ranged between 18 and 39 years of age (M ¼ 20:66,
SD ¼ 3:46), and was predominantly single (92.6%) and Caucasian (93.4%). Exclusion
criteria included presence of a pain condition, circulatory disorder, diabetes,
hypertension, Raynaud’s disease, a heart condition, previous cold injury, problems
with blood clotting, skin condition, or the use of medications for these conditions. Two
potential participants were given alternate research for extra credit because they met
After arriving for their appointments, respondents read and signed informed consent
and medical release forms. They completed a demographic data sheet and were
Threat, coping, and pain tolerance443
instructed by one of four experimenters (2 female, 2 male) how to provide ratings of
current pain level. Next, the experimenter stated that participants would answer
questions at this point, after which they were required to follow strictly standardized
instructions until after the experiment finished.
To experimentally manipulate appraisal, participants were randomly assigned to one
of three groups: a control group in which no orienting passage was read prior to the
CPT, a reassurance group in which an orienting passage describing the safety of the CPT
(indicating pain can be independent of nociception) was read before the task, or a threat
group in which an orienting passage described symptoms of frostbite (tingling,
numbness, loss of feeling, and reduced mobility) and its effects (e.g. waxy skin, and, in
serious cases, skin turning blue, gangrene, and amputation). This scenario was selected
because some symptoms of frostbite (e.g. numbing, pain, and tingling) are similar to
sensations experienced during immersion in ice water. As such, it was plausible that
people reading this information might attribute pain as a signal for possible nociception
or view the safety of the task as uncertain. Each orienting passage encouraged
participants to leave their hand in the ice water for as long as possible but to remove it if
sensations became too uncomfortable. Each orienting passage was factual and 180
words in length (see Appendix).
Just before engaging in the CPT, all participants completed a short self-efficacy scale
(SES). Next, they immersed their non-writing hand in a container of room temperature
water for about 15 seconds to stabilize skin temperature. Finally, volunteers immersed
the same hand in cold water maintained at 2–58C for as long as they could, with
reiteration that they could withdraw their hand at any point without penalty. Water
temperature, measured by a digital thermometer, was recorded immediately after
participants removed their hand from the ice water. A CPT was terminated after 240
seconds, if participants had not done so beforehand.
Following the CPT, participants completed a modified Coping Strategies
Questionnaire (CSQ) in another room. In a brief post-experiment interview, those in
appraisal conditions were asked for reactions to the orienting passage they read and
details they recalled from the passage. Because the threat group may have attributed
pain sensations to a pathological process (i.e. frostbite), disclosure of research purposes
and manipulations occurred immediately after the interview to reduce the length of
possible distress they experienced to about 15 minutes. After debriefing, a feedback
sheet describing symptoms, causes, and treatment of frostbite was provided along with
contact information for the principal investigator. Most respondents (97.5%) requested
the findings, a summary of which was e-mailed to them after data analyses.
Data was requested for gender, age, marital status, ethnicity, height and weight, annual
visits to health care professionals, and total prescription medications.
Task specific self-efficacy
A 7-item SES was created to examine efficacy in coping with the CPT. The items assessed
perceived confidence in coping, certainty in tolerating the task, and control of
performing well during the CPT on a 5-point scale between not at all and very much.
The alpha coefficient for this scale was a ¼ :91.
Todd Jackson et al.444
Coping Strategies Questionnaire (CSQ; adapted from Rosenstiel & Keefe, 1983)
Five ignoring pain items (e.g. ‘During the CPT, I ignored the pain’), seven
reinterpreting pain items (‘: : :imagined the pain was outside my body’), six diverting
attention items (e.g. ‘: : :tried to think of something pleasant’), five coping self-
statements items (e.g. ‘: : :told myself to be brave and carry on’), and four
catastrophizing items (e.g. ‘: : :thought the pain was awful and overwhelming’) from
the CSQ assessed coping with the CPT. Items from CSQ increasing behaviour and
praying/hoping subscales were omitted because their content did not apply well to the
experimental situation. CSQ items were rated on a 6-point Likert scale between 1
(never did that) and 6 (very often did that). Internal consistencies for CSQ subscales
ranged between a ¼ :80 for coping self-statements and a ¼ :90 for catastrophizing.
Pain tolerance and current pain level
Pain tolerance was operationalized as total time (to the nearest 100th of a second) that a
participant’s hand remained immersed in the ice water. After each 30 seconds during
immersion, participants provided verbal ratings of current pain on a 0–10 point scale
with 0 as no pain at all and 10 as very high level of pain. Following past research (e.g.
Geisser et al., 1992; Jackson, Iezzi, Gunderson, Nagasaka, & Fritch, 2002), an average
rating of pain was also calculated as the sum of individual ratings divided by the number
of 30-second intervals completed.
Passage recall and perceived threat
After the CPT, participants in the experimental conditions were asked to recall any
information they could about the orienting passage they had read and to rate the extent
to which they found the CPT threatening on a 3-point scale (0 ¼ not at all,
1 ¼ somewhat, 2 ¼ very).
Analyses of post-test interview data found 4.6% of the threat condition and 6.7% of
reassurance condition recalled nothing of the passage they read, indicating that most
participants attended to this information. Threat group participants rated the CPT as
more threatening (M ¼ 1:40, SD ¼ 0:62) than did those in the reassurance condition
group (M ¼ 0:48, SD ¼ 0:55), Fð1; 83Þ ¼ 51:81, p , :0001. Three threat group
participants viewed the frostbite passage as a manipulation used to frighten them, not
a realistic threat and one reassurance group participant was clearly not reassured,
stating her fear increased after reading of short-term discomfort in the passage. Because
passages did not differ in the degree to which they generated such unambiguously
undesirable effects, x2ð2Þ ¼ 1:13, p , :57, data from these four participants was
retained in subsequent analyses.
There were no differences between conditions for gender of participant, x2ð2Þ ¼ 2:03,
p , :36, or tester, x2ð2Þ ¼ 0:22, p , :80, age, Fð2; 116Þ ¼ 0:80, p , :45, education,
Fð2; 118Þ ¼ 2:59, p , :08, body mass index, Fð2; 115Þ ¼ 1:02, p , :36, health care
Threat, coping, and pain tolerance445
visits, Fð2; 118Þ ¼ 0:99, p , :37, prescription drugs, Fð2; 118Þ ¼ 0:92, p , :40, or
water temperature during immersion, Fð2; 118Þ ¼ 0:22, p , :80.
Only seven of the 45 (15.6%) participants in the threat group completed the CPT
compared with 25 of the 45 (55.6%) reassured participants, and 14 of the 31 (45.2%)
control participants, x2ð2Þ ¼ 16:18, p , :0001. The threat group also had a lower mean
pain tolerance time than either of the other groups, even though conditions did not
differ on reported pain at each 30-second interval or on average reported pain (Table 1).
A multivariate analysis of variance (MANOVA) assessed between-groups differences
for measures of self-efficacy and coping. A significant effect was obtained,
Fð14; 224Þ ¼ 2:28, p , :006, warranting examination of individual measures. Perhaps
because most respondents were from northern Wisconsin and had past experiences
tolerating cold temperature, groups did not differ on self-efficacy. However, the threat
group reported more catastrophizing and less use of reinterpretation, ignoring and
coping self statements than control participants as well as less diverting attention than
reassured participants (Table 1). The threat group also reported marginally less use of
reinterpretation, p , :08, and coping self-statements, p , :10 than the reassurance
group. In contrast, reassured participants (who had been assured the CPT was safe but
not explicitly instructed to cope in any particular way such as using denial) did not differ
for control condition participants on any of the research measures.
Table 1. Descriptive and univariate statistics for pain perception, self efficacy and coping between
research conditions (N ¼ 121)
VariableThreat (T)Reassurance (R) Control (C)F Comparisons
143.8 (78.3)179.6 (76.4)191.4 (66.7)4.39t , C**
t , R*
t , C*
t , R*
t , C*
t , C**
t . C**
Average current paina
30 seconds (N ¼ 121)
60 seconds (N ¼ 105)
90 seconds (N ¼ 98)
120 seconds (N ¼ 90)
150 seconds (N ¼ 79)
180 seconds (N ¼ 71)
210 seconds (N ¼ 57)
240 seconds (N ¼ 46)
Coping self statements
*p , :05;**p , :02;
aDifferences in pain tolerance, and current pain levels were calculated in separate analyses but are
reported, for convenience, with other between-conditions comparisons in Table 1.
Todd Jackson et al.446
Finally, a path analysis evaluated the hypothesis that coping would mediate the
relation threat and pain tolerance. Two data transformations were done to facilitate this
analysis. First, given that reassurance and control groups did not differ on any measure,
they were combined into a single group. Transforming the three experimental
conditions (threat vs. reassurance vs. control) into two conditions (threat vs. non-
threat), permitted the inclusion of a dichotomous group variable to standard regression
equations. Second, a factor analysis with principal axis factoring was performed on CSQ
items to assess whether the number of coping factors could be simplified for the path
analysis. The analysis generated six factors, although all CSQ items loaded highest on
one of the first two factors, both of which were interpretable. The first factor (labelled
cognitive coping), consisted of all but one item from the Diverting, Ignoring, Re-
interpretation, and Coping Self-statement Scales, accounting for 27.21% of the total CSQ
variance. These items had an alpha coefficient of a ¼ :90. The second factor
(catastrophizing), accounted for 14.25% of the CSQ variance, and was comprised all four
catastrophizing subscale items. In addition, the ignore pain item (‘I didn’t pay much
attention to it’) loaded negatively on catastrophizing but was dropped because it also
had a substantial positive loading on cognitive coping.
Prior to the path analysis, correlation coefficients were calculated to assess relations
between Threat Group (threatened vs. non-threatened), catastrophizing, cognitive
coping, and pain tolerance. With the exception of a non-significant association between
the catastrophizing and cognitive coping factors, r ¼ 2:14, p , :12, all bivariate
correlations were statistically significant. Based on Darlington’s (1990) recommen-
(i.e. standardized regression coefficients) between measures, and t-tests evaluated the
statistical significance of path coefficients. In the first regression equation, Threat Group
was regressed on catastrophizing. Cognitive coping was the criterion predicted by
catastrophizing in Step 1 and by group in Step 2 of the second regression. Pain tolerance
was the criterion with cognitive coping in Step 1, catastrophizing in Step 2, and group in
Figure 1. Path analysis of relations between threat, copin, g and pain tolerance (N ¼ 121).
Threat, coping, and pain tolerance 447
Step 3 of the final prediction equation. Figure 1 indicates coping fully mediated the
relation between exposure to threatening information and pain tolerance. Threatened
participants were more likely than others to catastrophize about pain and report
reductions in cognitive coping, although the two coping dimensions remained relatively
independent of one another. In turn, cognitive coping and catastrophizing each made
unique contributions to pain tolerance, while group failed to add significantly to the
prediction of tolerance. Together, the three predictors accounted for Adj. R2¼ :33,
F(3,117) ¼ 21.06, p , :0001, of the variance in pain tolerance.
This experiment clearly implicates appraisals of threat as an influence on reduced
tolerance for cold pressor pain and use of specific pain coping strategies. Participants
warned with potentially threatening information about frostbite (i.e. pain as a signal for
nociception) were less likely to tolerate or complete the CPT compared with those
reassured of its safety and control participants who read no orienting passage. This
difference was apparent despite the absence of group differences on ratings of current
pain levels throughout the task. Thus, appraisals of threat, not increases in pain,
predicted decreases in pain tolerance, a conclusion that echoes the past work of
Friedman et al. (1985).
The proposition that coping would mediate the relation between threat appraisals
and pain tolerance was supported by the results of a path analysis. Participants exposed
to threatening information before the CPT were more likely to catastrophize (view the
pain as terrible and overwhelming), even though they did not report more pain than the
other participants did. Threatened participants were also less likely than those not
exposed to threat to endorse cognitive coping strategies including mental diversion,
re-interpretation of sensations, coping self statements, or simply ignoring pain. In turn,
their increased tendency to catastrophize and reduced use of cognitive coping each
contributed to threatened participants’ relatively lower tolerance for cold pressor pain.
Together, these results suggest not only that pain appraised as a threat demands
attention (Eccleston & Crombez, 1999), but also that perceived threat predicts a specific
pattern of coping responses that may play a role in reducing the capacity to bear pain.
Although past correlational research (e.g. Unruh et al., 1999; Williams & Keefe, 1991)
has implied as much, use of random assignment and the manipulation of threatening
information in this experiment provides more convincing evidence that threat
appraisals, and not unmeasured person variables or self-selection of groups, has a critical
role in how people cope with and, ultimately, tolerate pain.
Sullivan, Tripp, and Santor (2000) point out that catastrophizing in and of itself is not
maladaptive. In fact, when pain signals impending or actual tissue damage,
catastrophizing may be more adaptive than ignoring, reinterpreting, or ‘grinning and
bearing’ the experience. In such potential crises, intervention seems warranted and
catastrophizing can prompt appropriate medical care. On the other hand, somewhat
analogous to the hypothesis that panic disorder results from catastrophic
misinterpretations of normal bodily sensations (Clark, 1986), when pain is ‘benign’
and does not signal nociception, threat-based appraisals may be less adaptive,
contributing to rumination and magnification that can foster helplessness, disability,
and/or unwarranted medical attention (DeGood & Tait, 2001; Sullivan et al., 2000),
outcomes observed in many patients with genuine pain that reflects neither potential
nor ongoing tissue damage.
Todd Jackson et al.448
While replications are required with clinical samples, the present findings suggest
that for some patients, becoming aware of meanings they ascribe to ongoing pain and
critically re-evaluating them when necessary, may have implications for improving
coping and increasing function. Williams and Keefe(1991) havenoted that patientswho
do not understand the nature of their pain may not view training in coping and self-
control skills as appropriate. In some cases, learning to recognize ongoing pain as not
automatically indicative of harm or impending damage may be an important early
treatment goal. Strategies such as graded exposure have potential utility for challenging
exaggerated expectations about pain intensity and risk of reinjury that sometimes
correspond with patients’ avoidance of daily activity (e.g. Crombez et al., 1999).
Despite its implications, the main limitations of this study must be acknowledged.
Most notably, although the data supported the proposition that coping mediates
relations between threat appraisals and subsequent pain tolerance, coping was assessed
after completion of the CPT. Therefore, it is possible that coping strategies endorsed
were affected not only by appraisal but also by degree of pain tolerance. Given the lack
of experimental research linking threat appraisals with specific approaches to pain
coping, the use ofan established, widely used coping scale (Rosenstiel & Keefe, 1983) in
this study provides a foundation for further work that might clarify these relations by
assessing coping in ‘real’ time with strategies such as ‘think-aloud’ protocols. Second,
given the nature of the research sample (i.e. healthy adults), attempted replications are
warranted with diverse age and ethnic/cultural groups, and persons with acute and
ongoing pain. Finally, this investigation does not explain how or why appraisal, coping,
and pain interact over extended time intervals. For obvious ethical reasons,
experimental manipulations involving appraisal and exposure to noxious stimuli must
be brief and safe. Therefore, the use of innovative methods such as prospective diary
keeping, (e.g. Affleck, Urrows, Tennen, & Higgins, 1992; Keefe, Affleck, Lefebvre, &
Starr, 1997), with populations such as patients recovering from surgery, those having
experienced recent injuries, and persons living with ongoing pain, may foster
understanding of how pain appraisal and coping unfolds over longer periods of time.
of Wisconsin – Superior, Superior, WI, USA. Tony Iezzi, Department of Psychology, London Health
University, Chongqing, China. Faculty Development and Foundation Fellow grants from the
University of Wisconsin – Superior supported this study. We thank Gary Sherman, Hal Bertilson,
David Carroll, and Beverly Lim for their assistance in data collection and anonymous reviewers for
helpful feedback on an earlier draft of this paper.
Affleck, G., Urrows, S., Tennen, H., & Higgins, P. (1992). Daily coping with pain from rheumatoid
arthritis: Patterns and correlates. Pain, 51, 221–229.
Buer, N., & Linton, S. J. (2002). Fear-avoidance beliefs and catastrophizing: Occurrence and risk
factor in back pain and ADL in the general population. Pain, 99, 485–492.
Clark, D. M. (1986). A cognitive approach to panic. Behavior Research & Therapy, 24, 461–470.
Crombez, G., Eccleston, C., Baeyens, F., & Eelen, P. (1998a). Attention disruption is enhanced by
the threat of pain. Behavior Research and Therapy, 36, 195–204.
Threat, coping, and pain tolerance 449
Crombez, G., Eccleston, C., Baeyens, F., & Eelen, P. (1998b). When somatic information threatens,
catastrophic thinking enhances attention interference. Pain, 75, 187–198.
Crombez, G., Vlaeyen, J., Heuts, P. H., & Lysens, R. (1999). Pain-related fear is more disabling than
pain itself: Evidence on the role of pain-related fear in chronic back pain disability. Pain, 80,
Darlington, R. B. (1990). Regression and linear models. New York: McGraw-Hill.
Dawson, M. E., Schell, A. M., Beers, J. R., & Kelly, A. (1982). Allocation of cognitive processing
during human autonomic classical conditioning. Journal of Experimental Psychology:
General, 111, 273–295.
DeGood, D. E., & Tait, R. C. (2001). Assessment of pain beliefs and coping. In D. C. Turk & R.
Melzack (Eds.), Handbook of pain assessment: Second edition (pp.320–345). New York:
Eccleston, C., & Crombez, G. (1999). Pain demands attention: A cognitive–affective model of the
interruptive function of pain. Psychological Bulletin, 125(3), 356–366.
Folkman, S., & Moskowitz, J. T. (2004). Coping: Pitfalls and promise. Annual Review of
Psychology, 55, 745–775.
Friedman, H., Thompson, R. B., & Rosen, E. F. (1985). Perceived threat as a major factor in
tolerance for experimentally induced cold-water pain. Journal of Abnormal Psychology,
Gatchel, R. J., & Ecker, J. (1999). Psychosocial predictors of chronic pain and response to
treatment. In R. J. Gatchel & D. C. Turk (Eds.), Psychosocial factors in pain: Critical
perspectives (pp.412–434). New York: Guilford.
Geisser, M. E., Robinson, M. E., & Pickren, W. E. (1992). Differences in cognitive coping strategies
among pain-sensitive and pain-tolerant individuals on the cold-pressor test. Behavior Therapy,
Geisser, M. E., Robinson, M. E., & Riley, J. R., III. (1999). Pain beliefs, coping, and adjustment to
chronic pain: Let’s focus more on the negative. Pain Forum, 8, 161–168.
Geisser, M. E., & Roth, R. S. (1998). Knowledge of and agreement with pain diagnosis: Relation to
pain beliefs, pain severity, disability, and psychological distress. Journal of Occupational
Rehabilitation, 8, 73–88.
Haythornthwaite, J. A., & Heinberg, L. J. (1999). Coping with pain: What works, under what
circumstances, and in what ways? Pain Forum, 8, 172–175.
Jackson, T., Iezzi, T., Gunderson, J., Nagasaka, T., & Fritch, A. (2002). Gender differences in pain
perception: The mediating role of self-efficacy beliefs. Sex Roles, 47, 561–569.
Keefe, F. J., Affleck, G., Lefebvre, J. C., & Starr, K. (1997). Pain coping strategies and copingefficacy
in rheumatoid arthritis: A daily process analysis. Pain, 69, 35–42.
Lazarus, R. S. (1966). Psychological stress and the coping process. New York: McGraw-Hill.
Lazarus, R. S. (1999). Stress and emotion: A new synthesis. New York: Springer.
McCracken, L. M., Goetsch, V. L., & Semenchuk, E. M. (1998). Coping with pain produced by
physical activity in persons with chronic low back pain: Immediate assessment following a
specific pain event. Behavioral Medicine, 24, 29–34.
Neufeld, R. W. J. (1970). The effect of experimentally altered cognitive appraisal on pain
tolerance. Psychonomic Science, 20, 106–107.
Rosenstiel, A. K., & Keefe, F. J. (1983). The use of coping strategies in chronic low back pain
patients: Relationship to patient characteristics and current adjustment. Pain, 17, 33–44.
Stanford, S., Kersh, B., Thorn, B., Rich, M. A., & Ward, L. C. (2002). Psychosocial mediators of sex
differences in pain responsivity. Journal of Pain, 3, 58–64.
Sullivan, M. J. L., Tripp, D. A., & Santor, D. (2000). Gender differences in pain and pain behavior:
The role of catastrophizing. Cognitive Therapy and Research, 24, 121–134.
Thorn, B. E., Rich, M. A., & Boothby, J. L. (1999). Pain beliefs and coping attempts: Conceptual
model building. Pain Forum, 8, 169–171.
Turner, J. A., Jensen, M. P., & Romano, J. M. (2000). Do beliefs, coping, and catastrophizing
independently predict functioning in patients with chronic pain? Pain, 85, 115–125.
Todd Jackson et al.450
Unruh, A. M., Ritchie, J., & Merskey, H. (1999). Does gender affect appraisal of pain and pain
coping strategies? Clinical Journal of Pain, 15(1), 31–40.
Williams, D. A., & Keefe, F. J. (1991). Pain beliefs and the use of cognitive-behavioral coping
strategies. Pain, 46, 185–190.
Received 10 August 2003; revised version received 3 July 2004
Potential threat orienting passage
Before we begin, carefully read the following information about exposure to cold water.
Prolonged exposure to freezing temperature can lead to frostbite. Frostbite is an
injury to the body that is caused by freezing. Frostbite causes a loss of feeling and colour
in affected areas of your body. Often it affects your fingers or hands. Warning signs
include sensations of tingling, throbbing, pain, and numbness in your exposed limbs,
flesh that becomes discoloured or turns blue, and unusually firm or waxy skin.
Avictim is often unaware that frostbite has occurred until someone else points it out
because the frozen tissues are numbed. However, frostbite can permanently damage
your body tissue. Severe cases can lead to Gangrene and amputation of limbs.
Keep this warning in mind. We would like you to try to leave your hand in the cold
water for as long as you can. However, please feel free to withdraw your hand at any
point, without penalty, especially if discomfort becomes too high.
Complete the items on the next page and then we will begin the experiment.
Reassurance orienting passage
Before we begin, carefully read the following information about exposure to cold water.
The CPT is a safe and effective experimental procedure. Our review of the literature
indicates well over 1,500 experiments have used the CPT with various populations
including young children, pregnant women, elderly people, college students, and
personswith chronicmedical conditions,hence supporting its popularity and safetyas a
method for studying pain perception. The procedure is harmless, except for those
persons having the medical conditions listed in your consent form.
You may experience short-term discomfort or pain during and shortly after the
experiment, but the procedure is safe because the water temperature has not fallen
below the freezing point and because exposure is short-term.
Keep this assurance in mind. We would like you to try to leave your hand in the cold
water for as long as you can. However, please feel free to withdraw your hand at any
point, without penalty, especially if discomfort becomes too high.
Complete the items on the next page and then we will begin the experiment.
Threat, coping, and pain tolerance 451