Social Support in Urologic Chronic Pelvic Pain Syndrome: The StressBuffering Model and Gender Differences
by
Jessica V. Ginting
A thesis submitted to the Graduate Program in Psychology
in conformity with the requirements for
the degree of Doctor of Philosophy
Queen’s University
Kingston, Ontario, Canada
(November, 2013)
Copyright ©Jessica V. Ginting, 2013
Abstract
Chronic pain is recognized for its intra- and interpersonal stress, with greater
social support being associated with better patient outcomes. Urologic Chronic Pelvic
Pain Syndromes (UCPPS) are pain-associated conditions that are prevalent across genders
and are strongly associated with diminished quality of life (QOL). To date, no genderbased research has examined such supportive behaviours in UCPPS samples. One model,
the stress-buffering model of social support, suggests people with greater support within
their proximal (e.g., marriage) and distal (e.g., physician) social environment may be
protected from negative stressor impact (i.e., pain). Due to their strong associations with
poorer QoL, I hypothesized catastrophizing and perceived pain control as important
intrapersonal cognitive variables to also consider in such relations between pain and
patient QoL. In this dissertation, I examined several research questions using two selfreport studies: 1) Are there gender differences in social support for people with UCPPS?;
2) Does social support moderate the relationship between pain and patient outcome
variables and are there gender differences in this effect?; and 3) If social support
moderates the relationship between pain and outcomes, is this effect further moderated by
cognitive variables and/or gender?
In Studies 1 and 2, women with IC/PBS endorsed higher levels of solicitous and
distracting spouse responses to pain behaviour than did men with CP/CPPS.
Additionally, in Study 2 women reported greater support from friends than did men. In
regard to moderation effects in Study 1, distracting spouse responses buffered the
relationships between patient pain and mental QoL, and between pain and disability.
ii
However, spouse solicitousness had a detrimental effect on the relationship between
patient pain and mental QoL but only at low levels of catastrophizing in the patient. The
genders did not differ in the effect of spouse responses to pain behaviour in Study 1, and
Study 1 results with respect to the stress-buffering role of distracting spouse responses
were not replicated in Study 2. In Study 2, sources of social support from outside of the
marriage also did not have a stress-buffering effect on the relationship between pain and
patient outcome. Of the models reviewed, no one current model for understanding the
role of social support or catastrophizing in chronic pain was sufficient to account for the
findings reported in these studies. However, a dyadic emotion regulation perspective is
suggested with implications for marital therapy with couples with chronic pain.
iii
Acknowledgements
Dean, thank you for taking me on as a graduate student—for something that
neither one of us had planned on, it worked out pretty well! Thanks for your words of
encouragement and believing in me.
Thank you to my committee members for their patience and contribution in this
process. Additionally, thank you to all participants who participated in these studies and
other centres involved with data collection. And a special thanks to Dr. Nickel, Karen,
Dale and all at CAUR.
To my clinical cohort, I couldn’t have asked for a better group of people with
whom to share the joys and misery of grad school.
Thanks also go out to my labmates Annie, Laura and Mary. Laura, thanks for
being such a great host on my visits to Kingston.
Nate, you lived through this dissertation with me, and there are no words to
describe how thankful I am for your support and motivation through all of this. Thank
you for adding balance to my life.
To my family and friends, thanks for your continued support through this (very)
long process. I’m greatful to have such wonderful people that add fun and laughter to my
life.
iv
Table of Contents
Abstract…………………………………………………………………………………… ii
Acknowledgements………………………………………………………………………. iv
List of Tables…………………………………………………………………………….. ix
List of Figures…………………………………………………………………………….. x
Chapter 1: General Introduction…………………………………………………………...1
Current Perspectives of Pain ........................................................................................... 2
Interpersonal aspects of pain. ..................................................................................... 4
Intrapersonal psychological aspects of pain. .............................................................. 8
Summary and Critique of Previous Research ............................................................... 11
Chapter 2: Literature Review……………………………………………………………. 13
Psychological Research in UCPPS ............................................................................... 16
Gender Differences in Social Support ..................................................................... 21
Overview of Current Studies ........................................................................................ 25
Chapter 3: Study 1 - Spouse Responses to Pain Behaviour, Catastrophizing, and
Perceived Control Over Pain as Moderators in the Relationship Between Pain and Patient
Outcome in Men and Women with Urologic Chronic Pelvic Pain Syndrome…………...27
Abstract………………………………………………………………………………….. 28
Introduction……………………………………………………………………………… 29
Present Study ................................................................................................................ 35
v
Methods…………………………………………………………………………………..38
Participants ................................................................................................................... 38
Male sample ............................................................................................................. 39
Female sample.......................................................................................................... 39
Measures ....................................................................................................................... 40
Procedure ...................................................................................................................... 45
Results…………………………………………………………………………………… 46
Preliminary Analyses .................................................................................................... 46
Bivariate Correlations ................................................................................................... 49
Research Question 1: Are There Gender Differences in Reported Spousal Responses to
Pain Behaviour Between Women with IC/PBS and Men with CP/CPPS? .................. 53
Research Questions 2 and 3: Do spouse responses to pain behaviour moderate the
relationship between pain and patient outcome and is there a gender difference? If
spouse responses to pain behavior moderate the relationships between pain and
outcomes, do cognitive variables (e.g., perceived control over pain, catastrophizing)
influence the stress-buffering effect of spouse responses and are there gender
differences in the aforementioned effects? ................................................................... 54
Discussion……………………………………………………………………………….. 58
Limitations and Directions for Future Research ........................................................... 67
Conclusion .................................................................................................................... 70
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Chapter 4: Study 2 - Spouse Responses to Pain Behaviour, Catastrophizing, and Different
Sources of Social Support as Moderators of Relationship Between Pain and Patient
Outcome in Men and Women with Urogenital Chronic Pelvic Pain Syndrome…….…...72
Abstract………………………………………………………………………………….. 73
Introduction……………………………………………………………………………… 74
Present Study ................................................................................................................ 77
Methods…………………………………………………………………………………..78
Participants ................................................................................................................... 78
Measures ....................................................................................................................... 79
Procedure ...................................................................................................................... 81
Results…………………………………………………………………………………… 82
Preliminary Analyses .................................................................................................... 82
Bivariate Correlations ................................................................................................... 87
Research Question 1: Are there gender differences in reported spousal responses to
pain behaviour and social support from family, friends and physician between women
with IC/PBS and men with CP/CPPS? ......................................................................... 92
Research Questions 2 and 3: Does social support moderate the relationship between
pain and patient outcome variables and are there gender differences in this effect?
Does social support continue to moderate the relationship between pain and patient
outcome when catastrophizing is included as a potential moderator and are there
gender differences in this effect? .................................................................................. 93
vii
Discussion……………………………………………………………………………….. 94
Limitations of the Present Research ........................................................................... 100
Conclusions................................................................................................................. 103
Chapter 5: General Discussion………………………………………………………….105
Theoretical Implications ............................................................................................. 105
Future Directions ........................................................................................................ 112
Clinical Implications ................................................................................................... 117
Summary and Conclusions ......................................................................................... 118
References………………………………………………………………………………122
Appendix………………………………………………………………………………..139
viii
List of Tables
Table 1.1: Demographics and t-Tests for Gender Differences in Study 1 Variables. ....... 47
Table 1.2: Bivariate Correlations Among Study Variables in Overall Sample. ................ 51
Table 1.3: Bivariate Correlations Among Study Variables Separated by Gender ............ 52
Table 1.4: Gender Differences in Spouse Responses to Pain Behaviour .......................... 53
Table 2.1: Demographics and T-tests for Gender Differences in Study 2 Variables……..82
Table 2.2: T-tests for Differences Between Full Study 1 and Study 2 Samples ................. 85
Table 2.3: Mean Differences Between Women with IC/PBS in Study 1 vs. Study 2 .......... 86
Table 2.4: Mean Differences Between Men with CP/CPPS in Study 1 vs. Study 2 ........... 86
Table 2.5: Correlations Among Study Variables in Overall Study 2 Sample .................... 89
Table 2.6: Correlations Among Study Variables Separated by Gender ............................ 90
Table 2.7: Gender Differences in Social Support .............................................................. 93
ix
List of Figures
Figure 1.1. The relationship between pain (SF-MPQ) and mental QoL at low levels of
catastrophizing. .................................................................................................................. 56
Figure 1.2. The relationship between pain (SF-MPQ) and mental QoL. ......................... 57
Figure 1.3. The relationship between pain (SF-MPQ) and disability (PDI). .................... 58
x
Chapter 1: General Introduction
This series of studies is focused on understanding how social support perceived by
a patient suffering from a chronic pain condition can potentially act to buffer the negative
impact of pain. What follows in this chapter (Chapter 1) is a review of what pain “is,”
how it has been considered in the relevant research, and an illustration of some of the
important variables (i.e., social support, cognitive variables) and models relevant to
patient pain and QOL. Following this, in Chapter 2, I will review the psychological
research in Urologic Chronic Pelvic Pain Syndromes and the gender differences in social
support, and I will provide an overview of the present line of research. Chapters 3 and 4
contain the respective studies followed by the General Discussion in Chapter 5.
What is Pain?
The most common definition of pain suggests it is "an unpleasant sensory and
emotional experience associated with actual or potential tissue damage, or described in
terms of such damage" (Bonica, 1979, p. 250). Pain serves as an important warning
signal of disease or injury and is much more than a process of neural transmission and
sensory transduction. Pain is complex involving emotions, culture, experience, sensation,
and even spirituality. Pain is typically described as chronic when it lasts longer than three
months since pain onset (Turk & Okifuji, 2001), but some researchers suggest the
modification from acute to chronic is the 12-month mark (Spanswick & Main, 2000).
Beyond duration, chronic pain also differs from acute pain in that it is often referred to as
a disease state of the central nervous system. In such a disease state, a sensitization or
1
wind-up process amplifies neural responses to the initial painful stimuli altering the usual
function of neural mechanisms.
According to (Schopflocher, Taenzer, & Jovey, 2011), a survey of a representative
sample across Canada indicated 18.9% of Canadians suffer from chronic pain (i.e., pain
lasting ≥ 6 months). Moreover, LaChapelle (2004) reports that up to 80% of physician
visits in Canada are for issues resulting from pain. Chronic pain costs more than cancer,
heart disease, and HIV combined, with estimated direct health care costs greater than $6
billion per year and productivity costs related to job loss and sick days at $37 billion per
year. In a three-month span, 32% of all Canadians reported suffering losses of income,
used sick days, reported reductions in workplace productivity, or lost jobs as a result of
pain (Angus Reid Research for the Canadian Pain Society: March 4-7, 2011).
The impact of chronic pain cannot be considered only in economic terms; it also has a
significant impact on patient’s lives. Patients with chronic pain may be socially,
vocationally, and interpersonally disabled. Pain is considered an area of healthcare that
remains undertreated (Craig, 2009) and takes a significant psychological toll on patients
(Tang & Crane, 2006). Pain that is poorly assessed and chronic in nature is not only
common and costly to Canadians, but it is also associated with a lower quality of life than
other chronic diseases including chronic lung or heart disease (Choinière et al., 2010).
Current Perspectives of Pain
Modern models of pain suggest pain is not entirely a sensory experience, and
identical painful stimulation (i.e., same experimental pain applied by pressure or
temperature) does not produce identical reports of pain and distress across research
2
participants and clinical patients alike. Pain varies between people and is influenced by
their subjective meanings of situation, attention, and other personal appraisals (Sullivan et
al., 2001).
A biomedical model applied to the understanding and treatment of pain with no
consideration of psychological and social factors is incomplete. As suggested by Sullivan
and colleagues (2001) above, the research showing that psychosocial factors are
significant in determining pain-related outcomes is extremely strong (Clay et al., 2010;
Gatchel, Peng, Peters, Fuchs, & Turk, 2007; Katz et al., 2012; Tripp, Nickel, Wong, et al.,
2012; Turk & Okifuji, 2002) and is viewed as necessary in both research and the
provision of care to individuals with chronic pain (Hadjistavropoulos et al., 2011).
According to the biopsychosocial model, determinants of pain-related outcomes consist of
three dimensions: biology, psychology, and the social context. In a biopsychosocial
model of pain, biological aspects of chronic illness (e.g., changes in muscles, joints, or
nerves generating nociceptive input) affect psychological factors (e.g., catastrophizing,
helplessness) and the social context of the individual (e.g., social activity, activity of daily
living, interpersonal relationships) and vice-versa (see Figure 1).
Interpersonal aspects of pain. Pain research has been critiqued as being largely
focused on the intrapersonal processes (i.e., biological and psychological) and less so on
the interpersonal processes (i.e., social context) of the biopsychosocial model
(Hadjistavropoulos et al., 2011). Historically, research examining interpersonal processes
in pain was largely motivated by the operant model of pain, which emphasizes the role of
3
Biology
Well-being
Psychology
Social Context
Figure 1. Determinants of pain-related outcomes (reproduced from Hadjistavropoulos, et
al., 2011).
reinforcement processes in the development and maintenance of pain behaviour, and
subsequently pain-related outcomes (Fordyce, 1976; Fordyce, Shelton, & Dundore,
1982). Spouse responses to pain behaviour as reinforcement processes have primarily
been investigated within this literature because the marital relationship, in comparison to
other close relationships, provides the most opportunities for operant learning. Spouse
responses to pain behaviour have classically been conceptualized as solicitous (e.g., “tries
to get me to rest,” “does some of my chores”), distracting (e.g., “tries to get me involved
in some activity”) and negative (e.g., "gets angry with me"; Kerns, Turk, & Rudy, 1985).
Solicitous and distracting spouse responses to pain behaviour are associated with higher
levels of pain and disability in individuals with chronic pain (Leonard, Cano, & Johansen,
2006). However, studies have not been able to demonstrate a causal relationship between
spouse responses to pain behaviour and disability as experimental manipulation of such
4
variables are unfeasible and would be unethical. Observational studies do suggest that
spouse responses to pain behaviour can maintain pain and disability (Romano, Jensen,
Turner, Good, & Hops, 2000; Romano et al., 1992; Romano et al., 1995). For example,
in couples with a chronic pain sufferer, solicitous spouse responses are associated with
higher levels of verbal and nonverbal pain behaviours (Romano et al., 2000; Romano et
al., 1992). However, counter to predictions of the operant model, correlational studies
have also demonstrated positive associations between negative spouse responses to pain
behaviour and reports of emotional distress, disability, and pain (Boothby, Thorn,
Overduin, & Ward, 2004; Cano, Gillis, Heinz, Geisser, & Foran, 2004).
Social support is also considered part of the social context of chronic pain. The
benefits of social support have been demonstrated, indicating that social support is
associated with greater well-being (Cohen & Wills, 1985). The stress-buffering model of
social support asserts that social support “ "buffers" (protects) persons from the
potentially pathogenic influence of stressful events” (Cohen & Wills, 1985, p. 310). This
model suggests that social support enhances efficacy, esteem, and confidence, and thus
the individual feels that he or she can cope with a particular stressor (Bova, 2001). The
stress-buffering model of social support has been most heavily examined within the
depression literature, with prospective studies providing minimal support (Burton, Stice,
& Seeley, 2004; Zimmerman, Ramirez-Valles, Zapert, & Maton, 2000). However,
studies examining other outcomes (e.g., health-related quality of life, marital satisfaction,
reactivity to stress, job burnout), some of which were cross-sectional and others were
longitudinal, provide support of this model (Carlsson, Bjorvatn, Engebretsen, Berglund,
5
& Natvig, 2004; Lee et al., 2006; O'Donovan & Hughes, 2007; Olstad, Sexton, &
Sogaard, 2001; Unger, Jacobs, & Cannon, 1996; Xanthopoulou et al., 2007).
It has been suggested that the degree of life threat and functional impairment may
also determine which types of support are beneficial (Penninx et al., 1998). For example,
individuals who are faced with a life-threatening disease may benefit most from
emotional support, as it may prevent depressive symptoms (Penninx et al., 1998).
Whereas an individual who suffers from a condition that renders him or her physically
unable to carry out daily functions may benefit most from instrumental support (Penninx
et al., 1998). As such, Penninx and colleagues suggest that the stress-buffering effects of
social support may be disease specific, as coping strategies that focus on the emotional
distress caused by a disease may be most successful in diseases that cannot be managed
by individual or medical intervention. Therefore, the stress-buffering model of social
support is especially relevant in chronic pain research.
Within the chronic pain literature, social support has been examined as spousal
responses to pain behaviour. More recent conceptualizations of spouse solicitousness and
distracting responses suggest a positive valence for these responses (Cano, Barterian, &
Heller, 2008), whereas traditional operant conceptualizations suggest a negative valence
(Fordyce, 1976). However, the valence of spouse responses to pain behaviour continues
to be up for debate. A recent study on chronic low back pain patients suggests that
solicitous spouse responses may have a dual role (Campbell, Jordan, & Dunn, 2012). In
this cross-sectional study, for individuals with low levels of depressive symptoms, partner
solicitous responses were associated with disability, whereas this relationship was not
6
significant for individuals with high levels of depressive symptoms. Campbell and
colleagues (2012) argued that because depressive symptoms were strongly associated
with higher levels of disability, solicitous spouse responses might have an operant effect
of increasing disability and a buffering effect on depressive symptoms. This stressbuffering effect of spouse solicitousness is consistent with previous studies that
demonstrated a buffering effect of solicitous spouse responses on depressive symptoms
(Goldberg, Kerns, & Rosenberg, 1993; Kerns, Haythornthwaite, Southwick, & Giller,
1990).
A factor analysis conducted by Cano and colleagues (2008) showed that solicitous
and distracting spouse responses loaded onto the same factor, which the authors labelled
as solicitousness, whereas negative spouse responses to pain behaviour loaded onto a
factor representing invalidation or lack of validation. According to these results,
solicitous and distracting spouse responses to pain behaviour may be conceptualized as
social support, whereas negative spouse responses are conceptualized as lack thereof.
However, a recent qualitative study demonstrated that none of the observed spouse
response categories were rated exclusively as positive or negative, including responses
traditionally conceptualized as punishing responses to pain behaviour (Newton-John &
Williams, 2006). Overall, preliminary data suggest that solicitous and distracting spouse
responses may share a similar valence, and negative spouse responses to pain behaviour
are of the opposite valence. However, most research indicates that spouse responses to
pain behaviour are associated with a variety of negative psychosocial and physical
outcomes such as increased depression and anxiety, physical and psychosocial disability,
7
pain catastrophizing, and greater pain severity in the identified patient (Buenaver,
Edwards, & Haythornthwaite, 2007; Cano, Gillis, et al., 2004; Cano, Johansen, & Franz,
2005; Cano, Weisberg, & Gallagher, 2000).
Intrapersonal psychological aspects of pain. It is clear that following
nociceptive input the perception or interpretation of pain occurs. Therefore, an
individual’s adaptive and/or maladaptive pain interpretation is not solely based on
objective reality but also on one’s idiosyncratic interpretations of reality (Turk, 2002).
These interpretations are highly subject to long-held core beliefs about one’s ability to
manage pain. Research shows that pain appraisals (i.e., pain catastrophizing) are
prominent in poor experimental and clinical pain outcomes (Sullivan et al., 2001).
Catastrophizing is a negative cognitive-affective appraisal process that consists of
magnification, helplessness, and rumination (Sullivan, Bishop, & Pivik, 1995).
Rumination and magnification may be related to primary appraisal processes whereby an
individual focuses on and exaggerates the threat value of a painful stimuli. Whereas
helplessness may be related to secondary appraisal processes whereby an individual
negatively evaluates his or her ability to cope effectively (i.e., self-efficacy) with the
painful stimuli (Sullivan et al., 1995). Catastrophizing is thought to contribute to fear,
leading to avoidance or escape activity associated with pain (Vlaeyen & Linton, 2000),
and it is robustly and positively associated with pain (Heyneman, Fremouw, Gano,
Kirkland, & Heiden, 1990; Jensen, Turner, Romano, & Karoly, 1991; Keefe, Brown,
Wallston, & Caldwell, 1989; Sullivan & D'Eon, 1990).
8
Alternatively, catastrophizing may be conceptualized as an inability to suppress or
inhibit pain-related cognitions (Van Damme, Crombez, & Eccleston, 2002, 2004). Van
Damme and colleagues demonstrated that pain catastrophizers were unable to consolidate
disconfirming evidence that pain cues were not necessarily followed by pain experiences.
This tendency may not be unique to high catastrophizers and may be common to all painrelated negative mental sets (e.g., fear of pain, pain anxiety). An alternative perspective,
the communal coping model of pain catastrophizing, states that catastrophizing, and the
resulting pain expression, may actually be a means of garnering social support (Sullivan
et al., 2001; Sullivan, Tripp, & Santor, 2000).
Sullivan and colleagues (2000) suggest that the adaptiveness of catastrophizing
may be contextually determined. Pain duration or chronicity is suggested to form part of
this context. In a sample of individuals with musculoskeletal pain, higher catastrophizing
was found to be associated with greater perceptions of pain-specific spousal support only
in individuals with shorter pain durations, suggesting that catastrophizing may be
adaptive in earlier stages of disease progression and becomes maladaptive in later stages
(Cano, 2004). Cano hypothesized that in the earlier stages of pain duration,
catastrophizing serves as a distress signal and need for support. In later stages,
catastrophizing may become maladaptive as others’ responses become increasingly
negative in reaction to the individual’s inability to divert his or her attention from pain or
the realization that previous attempts to help have not been successful. However, a direct
test of this hypothesis has not been undertaken.
9
Self-efficacy may also be involved in secondary appraisal processes of stress and,
thus, may be a part of the psychological determinants of well-being in individuals with
pain. I speculate that evaluations of self-efficacy may contribute to feelings of
helplessness if the individual believes that he or she does not have the skills to manage
with the situation/stressor at hand. In the chronic pain literature, two types of selfefficacy have been studied -- functional self-efficacy (i.e., one’s confidence in his or her
ability to perform specific activities) and self-efficacy for managing pain or perceived
control of pain. Higher levels of self-efficacy have been associated with lower levels of
depressive symptoms, pain intensity, and disability in various pain samples (Beckham,
Rice, Talton, Helms, & Young, 1994; Lorig, Chastain, Ung, Shoor, & Holman, 1989; J.
A. Turner, Ersek, & Kemp, 2005; Woby, Roach, Urmston, & Watson, 2007). Patients
with greater self-efficacy tend to engage in more effective self-care, which is ultimately
associated with better psychological outcomes (McCormick, 1997; Webster & Brennan,
1998). For example, in a sample of rheumatoid arthritis patients, individuals with greater
self-efficacy were more likely to engage in active coping strategies (e.g., task persistence,
exercise, diversion of attention from pain), whereas individuals with lower self-efficacy
were more likely to engage in passive coping strategies (e.g., resting, guarding; Brown &
Nicassio, 1987). Further, active coping was found to predict better outcomes at 6-months
follow-up, whereas passive coping predicted poorer outcomes (Brown & Nicassio, 1987).
Interestingly, in a community sample, general self-efficacy and health-related selfefficacy were found to be differentially associated with outcome variables (W. J. Taylor,
Dean, & Siegert, 2006). Individuals were divided into three groups: no pain, pain present
10
for less than 12 months, and pain present for 12 months or longer. Health-related selfefficacy, but not general self-efficacy, was associated with health-related QoL in all
groups. Both health-related and general self-efficacy were associated with psychological
distress in all groups. The authors suggest that given these associations were not
dependent on presence or chronicity of pain that self-efficacy may predate the
development of pain and are likely influenced by factors other than pain itself.
Summary and Critique of Previous Research
The preceding literature review suggests a role for social support and cognitive
factors (i.e., catastrophizing and perceived control over pain) in predicting adjustment to
chronic pain. Few published studies report on the stress-buffering role of spouse
responses to pain behaviour, with studies primarily reporting that solicitous spouse
responses have a stress-buffering effect on depressive symptoms (Campbell et al., 2012;
Goldberg et al., 1993; Kerns et al., 1990). However, with respect to the roles of social
support and cognitive variables in chronic pain, our knowledge is primarily based on
bivariate correlations, which do not allow for the consideration of interpersonal alongside
intrapersonal variables. Both intra- and interpersonal factors are of great importance in
our understanding of chronic pain, and it is acknowledged that the best management of
chronic pain employs a multidisciplinary and biopsychosocial approach (Gatchel et al.,
2007).
The primary purpose of this research was to examine the moderating effect of
social support (i.e., stress-buffering model) on the relationships between pain and patient
outcomes (i.e., mental and physical QoL, disability, and depressive symptoms) and to
11
examine if the moderating effect of social support was further qualified by intrapersonal
variables (i.e., catastrophizing and perceived control over pain). Documenting such
relationships would further inform existing psychosocial treatment models for couples
with chronic pain (Saarijarvi, Lahti, & Lahti, 1989; Saarijarvi, 1991; Saarijarvi,
Rytokoski, & Alanen, 1991; Saarijarvi, Alanen, Rytokoski, & Hyyppa, 1992; Keefe,
Caldwell, Baucom, & Salley, 1996; Keefe et al., 1999; Keefe, Blumenthal, Baucom,
Affleck, Waugh, Caldwell et al., 2004).
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Chapter 2: Literature Review
The stress-buffering model of social support was examined in individuals
suffering from Urologic Chronic Pelvic Pain Syndromes (UCPPS). UCPPS are chronic
conditions with acute symptom flare-up episodes and pain that is mild to moderate
(Association of Reproductive Health Professionals, 2008). However, for many
individuals, pain is constant, severe, and usually associated with bladder filling (Warren
et al., 2008) and only temporarily relieved by voiding. Similar to other painful chronic
conditions, UCPPS pain does not correspond strongly with medical findings (Deyo &
Weinstein, 2001; Egan & Krieger, 1997). Chronic Prostatitis/Chronic Pelvic Pain
Syndrome (CP/CPPS) in men and Interstitial Cystitis/Painful Bladder Syndrome
(IC/PBS) predominantly in women are two such syndromes that manifest overlapping
symptom profiles of urogenital pain (Hanno, Landis, Matthews-Cook, Kusek, & Nyberg,
1999; Krieger, Nyberg, & Nickel, 1999; Litwin et al., 1999b; Schaeffer, Datta, et al.,
2002) and voiding symptoms of urgency and frequency (Nickel, 2002; van de Merwe et
al., 2008). Although their aetiology is unknown, IC/PBS and CP/CPPS have a similar
pathogenesis, and the two syndromes represent urogenital manifestations of regional or
systemic abnormalities rather than organ-specific syndromes (i.e., bladder or prostate;
Moldwin, 2002; Pontari, 2006).
A prostatitis diagnosis is common and accounts for as many as 8% of urology
outpatient visits in the United States and almost 3% in Canada (Nickel, Downey, Nickel,
& Clark, 2002). For many men, symptoms peak at 35-65 years of age (Collins, Stafford,
O'Leary, & Barry, 1999). The adult North American prevalence of Chronic
13
Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) is variable but is estimated between
2-16% across community dwelling and other samples (Nickel, Downey, Hunter, & Clark,
2001; Nickel, Teichman, Gregoire, Clark, & Downey, 2005). In a North-American male
adolescent sample, 8.3% reported experiencing CP/CPPS-like symptoms (Tripp, Nickel,
Ross, Mullins, & Stechyson, 2009), and an African adolescent male sample indicated
13.3% (Tripp, Nickel, Pikard, & Katz, 2012). Unfortunately, CP/CPPS symptoms do not
routinely remit, and in community-based samples, 66% of patients continue experiencing
symptoms one year later (Nickel et al., 2002), with newer studies suggesting no change in
symptoms over two years (Tripp, Nickel, Shoskes, & Koljuskov, 2013). Furthermore,
treatment successes for CP/CPPS is bleak, with strategies based on sequential
monotherapies considered suboptimal for many patients (Nickel, Downey, Ardern, Clark,
& Nickel, 2004). The QoL of individuals with CP/CPPS is greatly affected by their
symptoms and is comparable to individuals suffering severe congestive heart failure,
diabetes, myocardial infarction, unstable angina, hemodialysis-dependent end-stage renal
disease, or active Crohn’s disease (McNaughton Collins et al., 2001; Wenninger, Heiman,
Rothman, Berghuis, & Berger, 1996).
Estimated prevalences of Interstitial Cystitis/Painful Bladder Syndrome (IC/PBS)
range from 8 per 100000 to 510 per 100000 (Lukban et al, 2001), whereas symptoms
suggestive of IC/PBS are estimated to range from 3300 to 11200 per 100000 (Clemens et
al., 2005). Disease progression may initiate with presence of urgency and frequency,
followed by pain, and this progression may develop over the course of 2 years (Curhan,
Speizer, Hunter, Curhan, & Stampfer, 1999). Typically, symptoms have an onset
14
between the ages of 20 and 40, and many report symptoms after an acute episode of
bacterial cystitis (Clemens, Joyce, Wise, & Payne, 2007). IC/PBS is almost exclusively
diagnosed in women, with a female to male ratio of 9:1 (Clemens et al., 2007).
Biomedical treatments for IC/PBS that target and repair the bladder lining are often
ineffective (Peters, 2012).
UCPPS differ from other chronic pain conditions in that it presents a greater
degree of uncertainty owing to its unknown pathology, frequent socially awkward
symptoms (urgency to urinate resulting in need for constant access to a bathroom), and
lack of controllability regarding exacerbation (Nickel, 2002). There is a degree of
comfort afforded by the ability to apply heat to the lower back or rub a sore hand, but in
the case of UCPPS, the pain is located in areas including the pelvic area, genitalia, or the
bladder, which are much more difficult to intervene. Therefore, there may be an
increased reliance on psychosocial variables such as social support to improve QoL.
Although researchers have investigated social support in UCPPS or related
samples (e.g., Warwick, Joseph, Cordle, & Ashworth, 2004; Nickel et al., 2008), and in
other pain conditions such as chronic low back pain (Goldberg et al., 1993), rheumatoid
arthritis (Revenson & Majerovitz, 1990), and osteoarthritis (Cano, 2004), much remains
unknown beyond bivariate relationships between social support and factors such as QoL.
Sampling UCPPS may be important because researchers purport that associations
between marital processes, pain severity, disability, and psychological distress may differ
depending on the chronic pain samples recruited (Leonard et al., 2006; Penninx et al.,
1998). For example, perceived spousal solicitousness was correlated with higher pain
15
intensity among low back pain patients, but the reverse was true for patients with sickle
cell disease and arthritis (Anderson & Rehm, 1984).
Psychological Research in UCPPS
Sufferers of CP/CPPS and IC/PBS frequently report depressive symptoms (Novi
et al., 2005; Pontari et al., 2005), marital discord (Michael, Kawachi, Stampfer, Colditz,
& Curhan, 2000), disability (Azevedo et al., 2005; Nickel et al., 2008), diminished QoL
(Michael et al., 2000; Tripp, Nickel, Landis, Wang, & Knauss, 2004), and comorbid
medical conditions (e.g., allergies, sinusitis, irritable bowel syndrome; Clemens, Brown,
Kozloff, & Calhoun, 2006; Nickel et al., 2010a).
Depression and stress. In a phenotyping study of women with IC/PBS, patients
reported diminished physical QoL, greater pain, sleep problems, depression,
catastrophizing, anxiety, and stress (Nickel et al., 2010b). In another study, 13% of men
with CP/CPPS compared to 4% of otherwise healthy men met criteria for a mental health
diagnosis (Clemens et al., 2006). Furthermore, 23% of women with IC/PBS versus 3% of
otherwise healthy women met criteria for a mental health diagnosis (Clemens et al.).
Indeed, approximately 35% of women with IC/PBS had a probable current depressive
disorder (Watkins et al., 2011), and depending on the measure used, approximately 1017% of patients scored in the moderate-severe depression range (Rothrock, Lutgendorf,
Hoffman, & Kreder, 2002). With respect to men with CP/CPPS, the average study
participant reported levels of depression below the cut off for clinical depression (Tripp et
al., 2006).
16
Not only do individuals with UCPPS report psychological distress, but symptoms
also appear to be exacerbated by stress. For example, women with IC/PBS report
symptom flare up under periods of acute stress, including increased bladder pain and
urinary urgency (Koziol, Clark, Gittes, & Tan, 1993; Lutgendorf, Kreder, Rothrock,
Ratliff, & Zimmerman, 2000). Additionally, as IC/PBS disease severity increased, the
relationships between stress, urgency, and pain became more pronounced. (Rothrock,
Lutgendorf, Kreder, Ratliff, & Zimmerman, 2001).
Pain and QoL. UCPPS urinary symptoms and pain have significant relationships
with functioning and QoL. For women with IC/BPS, greater symptom severity (i.e.,
frequency, urgency, and pain) is associated with poorer physical and social functioning,
as well as poorer mental health (Rothrock et al., 2002). In a psychosocial phenotyping
study of women with IC/PBS, pain was the strongest predictor of physical QoL, whereas
social support, depression, catastrophizing, and stress significantly predicted diminished
mental QoL (Nickel et al., 2010b). With respect to men with CP/CPPS, urinary
symptoms and pain-contingent rest (i.e., resting to cope with pain) have been found to be
significant predictors of physical QoL, even after controlling for robust predictors such as
pain and catastrophizing (Nickel et al., 2008). Similarly, urinary symptoms, paincontingent rest, and pain significantly predicted disability (Tripp et al., 2006).
In Tripp and colleagues’ (2012) study of women’s IC/PBS pain locations,
approximately 25% of the sample endorsed pain in primary sites only (i.e., vagina, lower
abdomen, lower back, pelvis, and buttocks), and almost equal proportions of the sample
reported pain in primary IC/PBS sites plus one to three additional locations, or four to
17
nine additional locations, or greater than nine additional locations (Tripp, Nickel, Wong,
et al., 2012). The authors suggested that the increasing level of pain locations endorsed by
these patients may mean that IC/PBS pain is centrally mediated rather than a visceral
nerve abnormality involving only the bladder. Individuals reporting pain in greater than
three additional locations also reported higher sensory pain, greater affective pain, and
higher depressive symptoms.
Catastrophizing. The examination of intrapersonal factors (i.e., catastrophizing)
has also indicated that variables beyond disease-specific markers play an important role in
determining UCPPS patient outcomes. Various interpersonal coping strategies by women
with IC/PBS, like venting of negative emotions, was associated with greater depression
and poorer mental QoL, whereas seeking instrumental support (i.e., asking for assistance
with activities or duties) was associated with less depression (Rothrock, Lutgendorf, &
Kreder, 2003). In the first study examining pain catastrophizing in CP/CPPS,
catastrophizing was associated with greater disability, depression, urinary symptoms, and
pain (Tripp et al., 2006). Catastrophizing has a strong association with poorer UCPPS
mental health. Even when disease specific symptoms were controlled, catastrophizing
continued to predict depressive symptoms and QoL in women with IC/PBS (Rothrock et
al.) and pain severity in men with CP/CPPS (Tripp et al., 2006). Another recent study of
men with CP/CPPS suggested that the helplessness dimension of catastrophizing (e.g.,
“it’s terrible and I think it is never going to get any better”) is particularly salient in
predicting poorer mental health status beyond other competing psychosocial variables in
the analyses (Nickel et al., 2008).
18
Stable pain symptoms combined with non-curative medical therapies may cause
or assist in the development of helplessness in these men, resulting in poorer mental
health. Indeed, helplessness is likely a product of feeling unempowered to make positive
changes in one’s ability to manage pain (Sullivan et al., 1995). In a sample of Canadian
adolescent males reporting Chronic Prostatitis-like symptoms, catastrophizing
magnification of pain (e.g., “I keep thinking of other painful events”) was the lone
predictor of poorer adolescent QoL when statistically controlling for pain and urinary
status (Tripp et al., 2009). Taken together, catastrophizing appears to play a consistent
role in symptom progression and impact, and these preliminary data suggest that different
components of catastrophizing are salient predictors in various stages of symptom
progression.
UCPPS catastrophizing research has also informed a phenotyping classification
system recommended for physicians to direct appropriate therapy. Shoskes and
colleagues (2009) proposed an empirically derived 6-point clinical phenotyping system
consisting of Urinary symptoms, Psychosocial dysfunction, Organ-specific findings,
Infection, Neurologic/systemic, and Tenderness of muscle (UPOINT). In particular,
criteria for inclusion in the psychosocial domain consist of clinical depression and/or
evidence of catastrophizing (helplessness, hopelessness). Catastrophizing is a suggested
target of intervention because it is linked to symptom propagation. Indeed, a
psychotherapy model has been proposed and tested for UCPPS psychosocial risk factors
(e.g., depressed mood, social support, catastrophizing; Tripp, Nickel, & Katz, 2011).
CP/CPPS symptom scores and negative QoL impact were significantly reduced at end of
19
treatment, and the mean baseline scores showed significant linear reductions for pain,
disability, and catastrophizing. Although positive changes were observed in depressive
symptoms and social support, these changes were not significant.
Social support. No research with a specific focus on social support has been
conducted in UCPPS. Studies that have reported findings on social support have reported
associations only between social support and mental QoL (Nickel et al., 2010b). A
qualitative study on women with chronic pelvic pain (not necessarily IC/PBS) conducted
by Warwick and colleagues (2004) is the most in-depth examination of social support in a
related sample to date. Warwick and colleagues interviewed 8 women attending a
secondary care service meeting the inclusion criteria of having continuous or intermittent
pain in the pelvic or lower abdominal region that had lasted for at least 6 months and was
not exclusively associated with sexual intercourse or menstruation. The women were
asked how others (i.e., partner, family member, friends, others who have had chronic
pelvic pain, doctors, nurses, and acquaintances and strangers) have been helpful or
unhelpful since the onset of their pain. Emotional and practical support from close others
were valued, and women expressed a need for sustained and enduring support.
Furthermore, provision of support while maintaining autonomy was of great importance.
Summary. UCPPS are significant health problems in North America, if not
internationally. Psychosocial research on UCPPS is still in its early stages and largely
consists of bivariate relationships between psychosocial predictors and patient outcome.
Catastrophizing has been demonstrated as an important predictor in UCPPS impact, and
some data also suggest a role for social support. Historically, UCPPS has been
20
understood and treated within a biomedical model, but more recent conceptualizations of
UCPPS such as the UPOINT system have incorporated empirically supported
psychosocial variables and suggest a biopsychosocial approach with respect to treatment
(Shoskes et al., 2009). Relative to other domains in the UPOINT system, the
psychosocial domain is much less established, and thus, further research is needed in this
particular domain to advance the UPOINT system.
Gender Differences in Social Support
An examination of social support would not be complete without discussion of
gender differences. In the general social support literature, theorists propose that gender
differences exist in social support provision for various reasons. First, women prefer to
be support providers (Fausto-Sterling, 1985), whereas other theorists suggest that social
role expectations for women lead them to be providers of nurture and support (Barbee et
al., 1993). Yet other theorists focus on how cultural and relational dynamics lead women
to be more supportive (Wood, 1994). Based on the aforementioned ideas, the support gap
hypothesis (SGH) suggests that women receive less support from their husbands than
husbands receive from their wives (Belle, 1982). Additionally, spousal support is
suggested to be such an important source of social support that the availability of support
from outside of a marital relationship does not adequately compensate for low levels of
spousal support (Coyne & DeLongis, 1986; Lieberman, 1982).
A large body of research has been generated by the support gap hypothesis, but
the evidence is mixed and somewhat confusing (Pasch, Bradbury, & Davila, 1997; Schulz
& Schwarzer, 2004; Schwarzer & Gutierrez-Dona, 2005; Verhofstadt, Buysse, & Ickes,
21
2007; Xu & Burleson, 2001). Primary SGH support comes from studies examining
gender differences in emotional support or the expressions of love, empathy, and concern,
with these studies finding that women provide more emotional support than men do
(Antonucci & Akiyama, 1987; Burda, Vaux, & Schill, 1984; Huston-Hoburg & Strange,
1986; Vaux, 1985). In a sample of cancer surgery patients, women reported a decline in
social support over time, whereas men reported relatively stable levels of emotional
support (Luszczynska, Boehmer, Knoll, Schulz, & Schwarzer, 2007; Schulz &
Schwarzer, 2004). Moreover, male partners also reported providing less emotional
support at 1-month post surgery than did female partners (Luszczynska et al., 2007). This
“support gap” might also be related to age, with Schwarzer and Guttierrez-Dona (2005)
finding that the support gap is minimal or non-existent in younger participants, and the
support gap increased with age, with older women receiving much lower levels of spousal
support than their male counterparts. In contrast, Verhofstadt and colleagues (2007)
found that women provide more emotional support than men do but only according to
self-reports, whereas this difference was absent when observational data were considered.
Additionally, Xu and Burleson (2001) reported that the support gap hypothesis was most
consistent with gender differences in desired social support; women reported higher
levels of desired social support from their spouses than men desired from their spouses.
Schwarzer and Guttierrez-Dona (2005) speculated that the support gap might be a result
of “marriage burn out;” that is, as time passes in the relationship, the higher levels of
support desired by the female partner takes a toll on their male partner, leading to
diminished provision of social support. Although a recent study showed that men were
22
more likely to respond solicitously than women were (Newton-John & Williams, 2006),
men’s supportive responses are accompanied by negativity (Neff & Karney, 2005),
further contributing to gender differences in the effect of social support.
There is limited evidence that the SGH applies to forms of support other than
emotional support. Other types of support discussed in this literature include esteem
support (i.e., expressions of respect, validation, and confidence that bolster another’s selfconcept), network support (i.e., generation of feelings of social connection through
expressions that create a sense of belonging), tangible support (i.e., provision of material
assistance such as goods, or services), and informational support (i.e., expressions that
provide facts, advice, and appraisals regarding the situation of concern). Men provide
more tangible support and are preferred by others as sources of tangible and informational
supports (Barbee, Gulley, & Cunningham, 1990). Although these differences were noted,
other studies have not found differences in support types across men and women
(Goldsmith & Dun, 1997; Pasch et al., 1997).
Gender differences in social support within the context of chronic pain are much
less delineated, but the extant literature does indicate gender differences in the
psychological (Sullivan et al., 2001) and social (Newton-John & Williams, 2006)
determinants of pain-related outcomes. As such, these gender differences may signify
differential outcomes for men and women suffering similar chronic pain conditions and
suggest different therapeutic targets for men and women with chronic pain and their
spouses.
23
Gender differences in the relationship between social support and depression, pain
severity, and marital satisfaction have been reported (Cano et al., 2000). For instance,
negative spousal responses are related to elevated depression and pain severity, and
poorer marital satisfaction in men and women. However, the relationship between
depression and negative spousal responses was significantly stronger for men than
women, whereas the relationship between negative spousal responses and marital
satisfaction was stronger for women than men. Further, distracting spousal responses
were associated with both increased pain severity and marital satisfaction but only in
men. Lastly, solicitous spousal responses were related to marital satisfaction in both men
and women, but the relationship was significantly stronger in women. However, given
limited research on gender differences in spousal support in chronic pain, these
differences noted by Cano et al. (2000) may not replicate in different pain samples.
Further contributing to gender differences in spousal responses to pain behaviour
are gender differences in catastrophizing. Women score higher than men do on measures
of catastrophizing, and they display more pain behaviour than men (Sullivan et al., 2001).
In light of the communal coping model, women are thought to maximize their opportunity
for support via increased expressions of pain, whereas men may minimize such potential
opportunities (Sullivan, 2012). Furthermore, in comparison to low catastrophizers,
individuals who engage in high levels of catastrophizing also perceive others’ pain as
more intense (Sullivan, Martel, Tripp, Savard, & Crombez, 2006), suggesting the
possibility that high catastrophizers might be better able to recognize and respond to pain
24
behaviours (e.g., solicitous spouse responses to reduce expressions of distress; M. J. L.
Sullivan, 2012).
Overview of the Current Line of Studies
The two studies presented in the current dissertation addressed several gaps in the
social support in chronic pain literature. First, spousal responses to pain behaviour were
examined within a context rather than in isolation by including intrapersonal variables
important to chronic pain (i.e., catastrophizing and perceived control over pain). Second,
in Study 2, I expanded chronic pain social support research by examining sources of
social support outside of the marital relationship (i.e., support from friends, family, and
physicians). Third, I also investigated gender differences in the influence of social
support in the prediction of pain-related outcomes. Although gender differences in social
support have been researched extensively, gender differences in the impact of social
support have not been examined in chronic pain.
The results of two questionnaire-based studies are reported in this dissertation.
The primary objective in Study 1 was to investigate the moderating effect of spouse
responses to pain behaviour on the relationship between pain and patient outcome.
Additionally, I examined if this moderating effect was further moderated by gender or
intrapersonal variables (i.e., catastrophizing or perceived control over pain).
The initial objective in Study 2 was to provide a replication of Study 1, as well as
examining the moderating effect of additional sources of social support (i.e., support from
friends, family, and physicians) on the relationship between pain and patient outcome.
Similar to Study 1, I also examined if the moderating effect of different sources of
25
support was further moderated by gender or intrapersonal variables. Given that the
operant theory of pain has been the primary perspective in examining the role of others in
the maintenance of pain and disability, spouses have been at the centre of this research
with little attention to sources of social support outside of the marital relationship.
This line of research has implications for non-medical management strategies
specific to UCPPS (i.e., the psychosocial domain of the UPOINT system). Additionally,
this line of research contributes to our knowledge of the social context within which
UCPPS occurs.
26
Chapter 3: Study 1
Spouse Responses to Pain Behaviour, Catastrophizing, and Perceived Control Over Pain
as Moderators in the Relationship Between Pain and Patient Outcome in Men and Women
with Urologic Chronic Pelvic Pain Syndrome
27
Abstract
Research on the role of social support is needed to inform the biopsychosocial
model and its related treatments for Urologic Chronic Pelvic Pain Syndromes (UCPPS).
Spousal support, operationalized here as spouse responses to pain, is a key predictor in
the outcome of chronic pain, and its impact has yet to be examined in the adjustment of
women with Interstitial Cystitis/Painful Bladder Syndrome (IC/PBS) and men with
Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS). To determine the
moderating effect of spouse responses to pain behaviour, and if this effect is further
qualified by gender and/or cognitive variables (i.e., catastrophizing and perceived control
over pain), this study examined regression models predicting the outcomes of mental and
physical quality of life (QoL), disability, and depressive symptoms. Ninety-six women
with IC/PBS and 188 men with CP/CPPS completed questionnaires of demographics,
depressive symptoms, disability, QoL and a measure of perceived spousal responses to
their pain. Distracting spouse responses to pain behaviour buffered the relationships
between pain and mental QoL and between pain and disability. Of note, this effect was
neither qualified by gender nor cognitive variables. Additionally, solicitous spouse
responses strengthened the relationship between pain and mental QoL but only at low
levels of catastrophizing, and there were no gender differences in this effect.
28
Introduction
Social support has long been considered a crucial aspect of successful stress
management. The stress-buffering hypothesis, which suggests that social support
diminishes the negative impact of physical or psychosocial stress (Cohen & Wills, 1985),
has direct relevance to the social support in chronic pain literature. Individuals who
experience chronic pain are faced with a consistent health/life stressor that increases
demand for support from one’s social support network.
The current study focuses on the moderating role of spousal social support on the
relationship between pain and pain-related outcomes given the frequency of contact and
intimacy of the relationship. When social support is considered positive, it is associated
with improvements in physical health (Cunningham & Barbee, 2000; Sarason, Sarason, &
Gurung, 1997), mental health (Cohen & Wills, 1985; Schwarzer & Leppin, 1992), and
marital satisfaction (Conger, Rueter, & Elder, 1999; Pasch & Bradbury, 1998; Saitzyk,
Floyd, & Kroll, 1997).
Social Support and Pain
In pain research, social support often has been examined as spouse responses to
pain behaviour within the context of an operant model of pain. The three major
categories of spousal responses to patient pain behaviour are: solicitous (e.g., “tries to get
me to rest,” “does some of my chores”), distracting (e.g., “tries to get me involved in
some activity”), and negative or punishing (e.g., “gets angry with me”) as measured by
the West Haven-Yale Multidimensional Pain Inventory (MPI; Kerns et al., 1985).
According to the operant model of pain, solicitous and distracting responses to pain
29
behaviour should reinforce and subsequently increase pain behaviours, whereas negative
responses to pain behaviour should punish and subsequently decrease pain behaviour
(Fordyce, 1976). The literature has been somewhat at odds with these hypotheses,
demonstrating that all three types of spouse responses to pain behaviour are associated
with a variety of negative psychosocial and physical outcomes, such as increased
depression and anxiety, physical and psychosocial disability, pain catastrophizing, and
greater pain severity in the identified patient (Buenaver et al., 2007; Cano, Gillis, et al.,
2004; Cano et al., 2005; Cano et al., 2000).
A series of studies employing observational methods in interactions between
individuals with chronic pain and their spouses have provided evidence in support of an
operant model of pain, suggesting a sequential relationship between spouse responses to
pain behaviour and pain behaviour (Romano et al., 2000; Romano et al., 1992; Romano et
al., 1995). In videotaped interactions, individuals with chronic musculoskeletal pain and
their partners, as well as matched control couples, performed a series of household
activities (e.g., sweeping floor). Individuals with chronic pain were more likely to display
verbal and nonverbal pain behaviours following solicitous spouse behaviours than were
individuals without chronic pain (Romano et al., 1992). In a separate publication using
the same sample, solicitous spouse responses to pain behaviour were found to predict
higher levels of reported disability, but the authors did not assess other types of spouse
responses and, therefore, could not account for their effect (Romano et al., 1995). In a
later study, Romano et al. (2000) found that the rate of verbal and nonverbal pain
behaviour was significantly and positively associated with the rate of spouse solicitous
30
behaviours (Romano, et al., 2000). Furthermore, negative spouse responses to pain
behaviour were negatively associated with the rate of nonverbal pain behaviour after
controlling for solicitous spouse responses (Romano et al., 2000). Of note, distracting
spouse responses were not assessed in any of the aforementioned studies. This line of
research suggests that spouse responses to pain behaviour are important in the
maintenance of pain and disability and are important to consider even after controlling for
biological indicators of pain severity.
Although the stress-buffering hypothesis is particularly relevant to chronic pain,
the effects of spouse responses to pain behaviour on pain-related outcomes within the
context of the stress-buffering hypothesis are rarely examined (Holtzman, Newth, &
Delongis, 2004). Spousal responses to pain behavior can buffer the relationship between
the patient perceived interference of pain and depression (Goldberg et al., 1993). In this
particular study, Goldberg and colleagues combined the support scale of the West HavenYale Multidimensional Pain Inventory with the spouse responses to pain behaviour scale
by summing standardized scores. However, a more recent study by Cano and colleagues
(2008) suggested that negative spouse responses to pain behaviour loads on to a factor
representing validation and invalidation, which was qualitatively distinct from the factor
on to which solicitous and distracting spouse responses loaded. Therefore, combining the
different types of spouse responses to pain behaviour into one variable is problematic.
Studies examining general social support show satisfaction with support has a
stress-buffering effect. For example, in a community sample of individuals with
rheumatoid arthritis, higher support satisfaction earlier in the day buffered the relationship
31
between catastrophizing reported earlier in the day and subsequent negative affect (i.e.,
symptoms of anxiety and depression; Holtzman & Delongis, 2007). To consolidate
discrepant results regarding social support, Turk, Kerns, and Rosenberg (1992) speculated
that negative and positive spouse responses to pain behaviour may not be opposite ends of
a continuum but rather have effects on different outcomes. Positive responses to pain
behaviour appear to be more influential on the outcomes of pain severity and disability,
whereas negative responses appear to be more influential in determining depressive
symptoms. However, no studies have reported findings on the moderating effects of
spouse responses on the relationship between chronic pain and pain-related outcomes.
Gender Differences in Social Support
A discussion of the benefits of social support would be insufficient without
acknowledgement of the support gap hypothesis (SGH), which is the notion that women
receive less social support from their husbands than men receive from their wives (Belle,
1982). Much of the research examining the SGH has been conducted on non-clinical
samples, with mixed results (Pasch et al., 1997; Verhofstadt et al., 2007; Xu & Burleson,
2001). Few gender differences in social support have been reported within the pain
literature but in the opposite direction of the SGH, and these gender differences were
dependent on type of social support and who reported the social support (i.e., spouse vs.
individual with chronic pain; Newton-John & Williams, 2006). In Newton-John and
Williams (2006), husbands and wives of individuals with chronic pain were provided with
a set of vignettes in which the partner with pain expresses some form of pain behaviour.
Spouses selected vignettes that they had experienced and indicated how they would
32
normally respond to each situation. Individuals with chronic pain then were given the
pain vignettes selected by their respective spouse and indicated how their spouse would
normally respond to each situation. In comparison to female spouses, male spouses
identified fewer pain-related interactions. Based on the self-report of spouses, husbands
responded more solicitously (i.e., provided help) than did wives (41% vs. 28% of
provided responses). However, based on the reports of individuals with chronic pain,
there was no gender difference in solicitous spouse responses. Interestingly, based on
reports of individuals with chronic pain, husbands offered help more frequently than did
wives (14% vs. 9%). The distinction between providing and offering help was made
based on the presumption that the individual with chronic pain has the opportunity to
refuse help when it is offered as opposed to when it is provided.
Other studies also have reported gender differences in associations between
spouse responses and pain-related outcomes. In a study of individuals with benign
musculoskeletal pain, negative spouse responses to pain behaviour were associated with
higher levels of pain severity and interference of pain in daily living but only for men
(Burns, Johnson, Mahoney, Devine, & Pawl, 1996). However, Fillingim and colleagues
(2003) found that differences in observed associations were dependent on the type of data
collected (i.e., self-report vs. more objective functional or behavioural measures). For
men, high spousal solicitousness was associated with greater self-reported disability, and
the association between spousal solicitousness and reported pain severity appeared to be
more consistent for men. However, for women but not men, self-reported activity level,
functional performance, and pain tolerance were associated with solicitous spouse
33
responses. The authors concluded that spousal solicitousness appears to be more strongly
associated with self-report measures in men and with more objective functional or
behavioural measures in women. However, overall reports of gender differences in
relationships among marital variables (i.e., satisfaction, spouse responses to pain
behaviour), pain severity, and depression are scarce within the chronic pain literature, as
researchers rarely examine data collected from men separately from data collected from
women within the same study (Cano et al., 2000; Fillingim, Doleys, Edwards, & Lowery,
2003).
Integration of Inter- and Intrapersonal Variables
A biopsychosocial approach to pain is the standard for research and treatment.
Therefore, an examination of the effects of social support without consideration of
intrapersonal variables is simply incomplete (Hadjistavropoulos et al., 2011). Pain
catastrophizing and perceived control over pain are two variables of importance due to
their positive and negative associations with the pain (Hill, 1993; Keefe & Williams,
1990; Strong, Ashton, Cramond, & Chant, 1990; Sullivan et al., 2001).
Cognitive processes such as catastrophizing are also important predictors in
diminished quality of life. Quality of life is more associated with the person’s beliefs
about pain than with the intensity of the pain itself (Lame, Peters, Vlaeyen, Kleef, &
Patijn, 2005). Indeed, within a heterogeneous chronic pain sample, pain catastrophizing
was the most prominent predictor of poorer QoL, and the associations between
catastrophizing and the physical aspects of QoL (i.e., physical functioning, role
limitations physical, bodily pain) were stronger than the association between pain
34
intensity and QoL (Lame et al., 2005). These findings were later corroborated in a study
of men with Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS), indicating
catastrophizing as the single strongest predictor of pain experience over and above
urinary and depressive symptoms (Tripp et al., 2006).
Additionally, perceived control over pain is shown to be associated with patient
functioning. For example, improvement in functioning was related to increased perceived
control over pain in a multidisciplinary treatment study (Jensen, Turner, & Romano,
2007). Self-efficacy, a construct related to perceived control over pain, also accounts for
a significant portion of the variance in disability even after controlling for pain (Ayre &
Tyson, 2001).
Present Study
The current study examines gender differences in social support in UCPPS, as
previous research has primarily examined the support gap hypothesis within non-clinical
samples. Research indicates women are more responsive with respect to social support
provision in times of stress (Neff & Karney, 2005), suggesting possible gender
differences in social support in the presence of chronic pain. Spouse responses to pain
behaviour have primarily been examined within a negative context of reinforcing pain
behaviour and have not been examined as a buffer of the impact of pain. Additionally,
the role of spouse responses to pain behaviour has most frequently been examined in
bivariate correlations without consideration of intrapersonal/cognitive variables. Given
the importance of the biopsychosocial model in chronic pain, examining interpersonal
variables (i.e., social support) within the context of intrapersonal variables (i.e., cognitive)
35
is crucial to furthering our understanding of adjustment to chronic pain and also increases
ecological validity.
Therefore, my objectives in the present research were to extend previous research
on gender differences in social support with Urologic Chronic Pelvic Pain Syndromes and
to test the stress-buffering hypothesis of social support, as applied to spousal responses to
pain behaviour. Social factors may be relatively more important moderators of pain
experience in women (Fillingim et al., 2003), but studies reporting gender differences in
the role of social support in pain are rare.
The second aim of the present study was to determine if the effect of spouse
responses to pain behaviour are further moderated by gender or intrapersonal variables
(i.e., catastrophizing, perceived control over pain).
As such, the following research questions were posed along with related
hypotheses:
1.1. Are there gender differences in reported spousal responses to pain behaviour?
Hypothesis 1.1: Consistent with previous research (Newton-John & Williams,
2006), women were expected to report higher levels of solicitous
responses. No predictions were made with respect to distracting and
negative responses, as previous research has not examined gender
differences in these spouse responses.
1.2. Do spouse responses to pain behaviour moderate (i.e., buffer) the relationships
between pain and patient outcomes and are there gender difference in this
effect?
Hypothesis 1.2a: I predicted that both solicitous and distracting responses would
buffer the relationships between pain and depressive symptoms
and between pain and mental QoL (Cano, Barterian & Heller,
36
2008; Campbell, Jordan & Dunn, 2012). I predicted that the
stress-buffering effect of solicitous and distracting spouse
responses would be stronger for men with CP/CPPS than women
with IC/PBS given that husbands’ supportive responses are also
accompanied by expressions of negativity (Neff & Karney, 2005).
Hypothesis 1.2b: I predicted that solicitous and distracting spouse responses
would strengthen the relationships between pain and disability and
between pain and physical QoL (Campbell et al., 2012) and that
the relationships between pain and disability and between pain
and physical QoL would be stronger for women (Neff & Karney,
2005).
Hypothesis 1.2c: I also predicted that negative spouse responses would strengthen
the relationships between pain and each outcome variable (i.e.,
mental and physical QoL, disability, depressive symptoms). No
predictions regarding gender differences of the effect of negative
spouse responses, as previous research has not commented on
these differences.
1.3. If spouse responses to pain behavior moderate the relationships between pain
and outcomes, is this effect further moderated by cognitive variables (e.g.,
perceived control over pain, catastrophizing) and/or gender?
Hypothesis 1.3a: At low levels of catastrophizing, I predicted that solicitous or
distracting spouse responses would buffer the relationships
between pain and depressive symptoms and between pain and
mental QoL. In contrast, at high levels of catastrophizing,
solicitous or distracting spouse responses should not buffer the
relationships between pain and depressive symptoms and between
pain and mental QoL. Gender differences were not predicted, as
research has not previously examined these higher order
interactions.
Hypothesis1. 3b: At both low levels and high levels of catastrophizing, I
predicted that solicitous or distracting spouse responses would not
buffer the relationships between pain and disability and between
pain and physical QoL, but this relationship would be stronger at
high levels of catastrophizing. Gender differences were not
predicted.
37
Hypothesis 1.3c: At both low levels and high levels of catastrophizing, consistent
with the stress-buffering hypothesis, I predicted that negative
spouse responses would not buffer the relationships between pain
and outcomes (i.e., mental and physical QoL, disability,
depressive symptoms), and that the relationships would be
stronger at high levels of catastrophizing. Gender differences
were not predicted.
Hypothesis 1.3d: At high levels of perceived control over pain, I predicted that
solicitous and distracting spouse responses would buffer the
relationships between pain and depressive symptoms and between
pain and mental QoL. In contrast, at low levels of perceived
control over pain, I predicted that solicitous and distracting spouse
responses would buffer the relationships between pain and
depressive symptoms and between pain and mental QoL.
Additionally, I predicted that the relationships between pain and
depressive symptoms and between pain and mental QoL would be
weaker at high levels of perceived control over pain. Gender
differences were not predicted.
Hypothesis 1.3e: At low levels of perceived control over pain, I predicted that
solicitous and distracting spouse responses would increase the
strength of relationships between pain and disability and between
pain and physical QoL in comparison to high levels of perceived
control over pain. Gender differences were not predicted.
Hypothesis 1.3f: At both low levels and high levels of perceived control over pain,
consistent with the stress-buffering hypothesis, I predicted that
negative spouse responses would not buffer the relationships
between pain and outcomes (i.e., mental and physical QoL,
disability, depressive symptoms), and that the relationships would
be stronger at low levels of perceived control over pain. Gender
differences were not predicted.
Method
Participants
Data were drawn from two existing data sets: one collected from male patients
suffering from CP/CPPS and the other from female patients suffering from IC/PBS. All
38
patients were previously diagnosed with their respective syndrome in outpatient tertiary
care specialty clinics in Urology.
Male sample. For the male sample, 253 men diagnosed with CP/CPPS were
recruited from an existing cohort enrolled in the NIH (National Institutes of Health)
Chronic Prostatitis Cohort (CPC) Study from seven North American tertiary care clinical
centers (6 U.S., 1 Canada, see Appendix; Schaeffer, Landis, et al., 2002). These patients
met the NIH definition for CP/CPPS, which is described as pain in the pelvic region for 3
of the last 6 months, in the absence of pathogenic bacteria (Krieger et al., 1999). For the
current study only men who reported having a spouse or partner were included. Of this
larger sample, 188 men met this criterion. The mean age of these men was 48.4 years
(SD = 10.8), with 76% reporting current employment, and 90% reported education of
high school or more. The ethnicity of this sample was primarily white (91%), with 4%
African-American, 2% Asian, 1% American Indian, and 2% other.
Female sample. The female patient sample diagnosed with IC/PBS was recruited
from three North American NIH-funded centers (i.e., Queen's University, Canada; Loyola
University, IL, USA; University of Rochester, USA; Tripp, Nickel, Fitzgerald, et al.,
2009). These patients fulfilled the diagnostic criteria described in the US National
Institutes of Health Interstitial Cystitis Database Study (Hanno et al., 1999) and the
definition described at the US National Institutes of Health Urological Chronic Pelvic
Pain Consensus Symposium (Nickel, 2008). Although not available at the time, most
patients would have fulfilled the criteria for diagnosis of BPS/IC outlined in the recently
published American Urological Association guidelines (Hanno et al., 2011) as well as
39
European Society for the Study of Interstitial Cystitis and European Association of
Urology definition of BPS (Fall et al., 2010; van de Merwe et al., 2008). A total of 120
women were recruited, of which 96 reported having a spouse or partner. These women
had a mean age of 50.6 years (SD=13.89). Ninety-seven percent reported education of
high school or more, and 46% were employed. The majority of participants were
Caucasian (94%), with 2% African-American, 2% Asian, and 2% Hispanic.
Measures
Demographics questionnaire. All participants provided information on age, race
(American Indian, Asian, Hispanic or Latino, Black/African American, Native
Hawaiian/Pacific Islander, White), level of education (less than high school, high school
or GED, some college or university, graduate professional after college/university), and
whether living with a spouse or partner.
Multidimensional Pain Inventory (MPI). The MPI (Kerns et al., 1985) is a 52item inventory that assesses psychosocial variables associated with pain. It consists of
three sections, but for the current study, only scores on section II of the MPI were used.
Section II assesses the responses of a spouse to communications of pain as identified by
the respondent (3 subscales: solicitous responses, distracting responses, and negative
responses). For each item, respondents indicate from 0 (never) to 6 (very often) how
often their significant other responds to them when in pain. Scores for each subscale are
the mean of the subscale items, with a range of 0 to 6. Kerns et al. (1985) report internal
consistency of .78 for the solicitous responses scale, with a two-week test-retest reliability
coefficient of .89. Internal consistency for the MPI for the current study was good ( =
40
.83), as was internal consistency for the individual subscales (negative  = .81, solicitous
 = .87, distracting  = .79)
Survey of Pain Attitudes – Control Scale (SOPA-C). The SOPA-C (Jensen,
Karoly, & Huger, 1987) is a 10-item scale that assesses each respondent’s perceived
control over their own pain, with scores ranging from 0 to 40. Scores higher than 26 are
within the adaptive range, whereas scores between 4 and 26 (inclusive) are within the
subclinical range, and scores below 4 are in the clinical range. Example items include,
“There are times when I can influence the amount of pain I feel,” and “The amount of
pain I feel is out of my control.” Responses are rated from 0 (very untrue) to 4 (very
true). The control scale has shown adequate internal consistency, r = .71 (Jensen, Turner,
& Romano, 1994) and 6-week test-retest reliability, r = .68 (Jensen, Turner, Romano, &
Lawler, 1994). In the current study, internal consistency was also found to be acceptable
( = .78).
Center for Epidemiological Studies Depression Scale (CES-D). The CES-D
(Radloff, 1977) is a 20-item inventory assessing depressive symptoms within the last
week in the general population with an emphasis on mood; scores range from 0 to 60.
Example items include: “I had trouble keeping my mind on what I was doing,” and “My
sleep was restless.” A standard threshold of 16 or greater has been used to classify
depressed outpatients (Weissman, Sholomskas, Pottenger, Prusoff, & Locke, 1977),
whereas a cutoff of 27 is suggested for individuals with chronic pain (Geisser, Roth, &
Robinson, 1997b). Radloff reports internal consistency for the general population and
patient samples of .84-.90 and test-retest reliability of .48-.67. The CES-D correlates
41
highly with clinician-rating measures of depression, such as the Hamilton Depression
Rating Scale and global ratings (Radloff, 1977), and the CES-D has better sensitivity in
chronic pain patients than does the Beck Depression Inventory (Geisser, Roth, &
Robinson, 1997a). Internal consistency in the current study was good ( = .88).
Short-Form McGill Pain Questionnaire (SF-MPQ). The SF-MPQ (Melzack,
1987) consists of 15 word descriptors of pain that assess sensory and affective qualities of
pain and overall pain intensity. Eleven descriptors represent the sensory dimension of
pain experience (e.g., throbbing, stabbing, gnawing), and four descriptors represent the
affective dimension (e.g., tiring-exhausting, fearful). Each descriptor is rated on a 4-point
intensity scale ranging from 0 (none) to 3 (severe), and the items are summed to provide
the Pain Rating Index Total (PRIT), with scores ranging from 0 to 45. Higher scores on
the PRIT indicate greater overall pain. The SF-MPQ is a reliable and valid measure
commonly used in clinical pain applications (Melzack, 1987). Wright et al. (2001) report
internal consistencies of .70 for both subscales. A study of the Norwegian translation of
the SF-MPQ suggests a change of greater than 5 on the 0-45 scale is clinically significant
(Strand, Ljunggren, Bogen, Ask, & Johnsen, 2008). For the current study, internal
consistency of items included in the PRIT was excellent ( = .90).
Pain Disability Index (PDI). The PDI (Pollard, 1984) assesses the extent to
which chronic pain interferes with a person’s ability to engage in various life activities
(Pollard, 1984). For each of seven categories of life activity (Family/Home
Responsibility, Recreation, Social Activity, Occupation, Sexual Behaviour, Self-Care,
and Life Support Activity), patients rate their level of disability on a numeric rating scale
42
ranging from 0 (no disability) to 10 (total disability); scores range from 0 to 70. Higher
scores on the PDI indicate higher pain-related disability, and patients with high PDI
scores report more psychological distress, more pain, and more restriction of activities
than do patients with low PDI scores. Internal consistency of the PDI is reported at .86
demonstrating that the PDI has high internal consistency (Sullivan et al., 1995; Tait,
Chibnall, & Krause, 1990). A recent study of chronic back pain patients suggest that a
change between 8.5 and 9.5 in PDI total score is clinically significant (Soer, Reneman,
Vroomen, Stegeman, & Coppes, 2012). Internal consistency for this scale in the current
study was excellent ( = .90).
The Pain Catastrophizing Scale (PCS). The PCS (Sullivan et al., 1995) is a 13item instrument that assesses three components of catastrophizing: Rumination (e.g., I
can’t stop thinking about how much it hurts), Magnification (e.g., I worry that something
serious may happen), and Helplessness (e.g., There is nothing I can do to reduce the
intensity of the pain). Each item is rated on a scale ranging from 0 (not at all) to 4 (all the
time), with total scores ranging from 0 to 52 and higher scores representing higher levels
of pain catastrophizing. Initial studies show catastrophizing to predict levels of pain and
distress reported in response to pain inductions (Sullivan et al., 1995). In applied settings,
PCS scores have been associated with pain, disability, and employment status among
patients with intractable musculoskeletal pain (Sullivan, Stanish, Waite, Sullivan, &
Tripp, 1998). Internal consistencies of .93 for the total PCS, and .91 for the Rumination
subscale, .75 for Magnification, and .87 for the Helplessness subscale have been reported,
all indicative of a high internal consistency (Osman et al., 1997). Internal consistency for
43
the scale was excellent in the current study ( = .94). A score of 30 represents clinically
relevant levels of catastrophizing (Sullivan, 2009), and a reduction of 38-44% in
catastrophizing scores is associated with return to work and low pain severity following
treatment .
MOS Short Form Quality of Life Questionnaire (SF-12). Health-related
quality of life was assessed using the Medical Outcomes Study Short Form 12 (Ware,
Kosinski, & Keller, 1996). Using 12 items, two SF-12 subscales can be computed -- the
Physical Component Summary (SF12-PCS) and the Mental Component Summary (SF12MCS). The SF-12 is a generic measure and does not target a specific age or disease
group. The mean is set at 50 (range 0-100; higher scores indicate better QOL) for both
the SF12-MCS and SF12-PCS scores in the general population. Ware, Snow, Kosinski,
and Gandek (1993) suggest that a 5-point difference on a MOS scale is clinically
significant. Internal consistency was good ( for SF12-PCS = .81,  for SF12-MCS =
.83).
The NIH-Chronic Prostatitis Symptom Index (NIH-CPSI). The NIH-CPSI is
a commonly used 13-item questionnaire for the assessment of symptom severity in men
with CP/CPPS. For each item, score ranges are 0–1 (6 items), 0–3 (2 items), 0–5 (3
items), 0–6 (1 item), and 0–10 (1 item), with a range for the NIH-CPSI total score of 0–43
points. Higher scores represent greater symptom severity. This measure demonstrates
excellent test-retest reliability ranging from .83 to .93 over a two-week period, and good
internal consistency (Litwin et al., 1999a). The validation sample reported a mean total
44
score of 19.5. Scale items demonstrated good internal consistency in the current study (
= .84).
Interstitial Cystitis Symptom Index/Interstitial Cystitis Problem Index
(ICSI/ICPI). The ICSI/ICPI (O'Leary, Sant, Fowler Jr, Whitmore, & Spolarich-Kroll,
1997) assesses the most important voiding and pain symptoms of IC/PBS, as well as the
extent to which these symptoms are problematic. The ICSI consists of 4 items, each rated
on a scale of 0 (not at all) to 5 (almost always/usually) with total scores ranging from 0 to
20. The ICPI also consists of 4 items, with each item rated on a scale of 0 (no problem)
to 4 (big problem) with total scores ranging from 0 to 16. Scale items demonstrated
acceptable internal consistency, ICPI  = .78, ICPI  = .71.
Procedure
Male sample. Following approval from institutional review boards, study
materials were sent by mail, including a consent form, demographic sheet, and study
measures. Participants signed the consent before completing their measures. The
measures took approximately 35-45 minutes to complete, and completed packages were
returned in a postage-paid envelope to the research centers.
Men with CP/CPPS from an existing cohort (N=488) enrolled in the NIH Chronic
Prostatitis Cohort (CPC) Study (see Appendix A; Schaeffer, Landis, et al., 2002) were
contacted, and approximately 52% (n = 253) of participants agreed to participate in the
present study. Men who decided to participate in the present study had previously
reported lower rates of prostatitis symptoms (i.e., pain, voiding, impact symptoms; p <
.05), a better quality of life (i.e., both physically and mentally; p < .05), longer time of
45
diagnosis (1.6 years; p < .05), being older by 4 years (p < .05), more likely to be White (p
< .05), and better educated (p < .05), and more likely to be living with a spouse/
cohabitating partner (p<.05; Tripp et al., 2006). Of the 253 participants, 188 reported
having a partner or spouse, and only these participants were included in the present study.
Female sample. Female participants were recruited by letter invitation after
approval from the respective ethics boards. Adult women with a clinical diagnosis of
IC/PBS were identified as eligible for participation during their routine clinical care.
Materials were sent by mail, including a consent form, demographic sheet, and study
measures. The participants read and signed the consent before completing their measures.
The measures took approximately 35-45 minutes to complete, and completed packages
were returned in a postage-paid envelope to the research centers. A total of 120 women
participated in this survey (Tripp, Nickel, Fitzgerald, et al., 2009). Of these 120 women,
the responses of 5 were not included because of incomplete data for 15% of their
measures. Of the remaining 115 participants, 96 reported having a partner or spouse, and
only these participants were included in the present study.
Results
Preliminary Analyses
Men in the current study reported a mean score of 16.5 on the NIH-CPSI, which is
comparable to that reported in the development study of the NIH-CPSI (total score range:
0-43; Litwin et al., 1999a). Additionally, women in the current study reported a mean
score of 10.6 and 12 on the ICPI and ICSI, respectively, and this is similar to other
46
reported IC/PBS samples (score range: 0-16; Sirinian, Azevedo, & Payne, 2005).
Unfortunately, mean scores were not reported in the validation study of the ICSI/ICPI.
Chi-square tests of independence were conducted to determine if there was a
relationship between gender and categorical demographic variables (i.e., ethnicity,
education level, and employment status; see Table 1.1 for the proportions). The chisquare was significant for employment status, 2(3) = 32.55, p < .001, and education
level, 2(4) = 124.65, p < .001, but not for ethnicity, 2(1)= 0.29, p = .59. Women were
less likely to be employed, more likely to be unemployed and more likely to be on
disability than men. With respect to education level, women were less likely to have high
school education, more likely to have a college/university degree and more likely to have
a graduate or professional degree than men.
Table 1.1
Demographics and t-Tests for Gender Differences in Study 1 Variables.
CP/CPPS
%
Employment Status
Employed
Unemployed
Retired
On Disability
Ethnicity
White
African-American
Asian
American Indian
Other
Education
Less than high school
High school
IC/PBS
%
76.5
4.3
15.0
4.2
2
p
32.55
<.001
0.29
.59
124.65
<.001
45.8
13.5
21.9
18.8
91
4
2
1
2
94
2
2
0
2
9.6
55.1
3.1
18.8
47
Some University
University/College
Graduate
Graduate or
Professional Degree
35.3
25.0
0
37.5
0
15.6
CP/CPPS
M (SD)
(min.-max.)
IC/PBS
M (SD)
(min.-max.)
48.38 (10.77)
(23.54-84.86)
SF-MPQ (0-45)
Measure
(range)
t(282)
p
50.56 (13.82)
(21-83)
-1.47
.144
7.16 (6.73)
(0-29)
13.71 (9.54)
(0-42)
-6.70
<.001
SOPA-C (0-40)
19.59 (5.05)
(0-33)
18.01 (8.65)
(0-37)
1.93
.054
PCS (0-52)
15.53 (9.75)
(0-43)
21.68 (12.13)
(0-50)
-4.62
<.001
CES-D (0-60)
16.03 (6.38)
(0-33)
19.00 (12.04)
(1-48)
-2.72
.007
PDI (0-70)
12.88 (13.09)
(0-61)
28.27 (15.32)
(0-63)
-8.84
<.001
SF-12 PCS (0-100)
47.87 (9.51)
(15.26-63.11)
34.63 (7.99)
(17.35-55.64)
11.67
<.001
Age
SF-12 MCS (0-100)
47.37 (10.13)
44.45 (13.66)
2.03
.043
(18.24-65.29)
(18.13-67.72)
Note. SF-MPQ = Short-Form McGill Pain Questionnaire; PDI = Pain Disability Index;
PCS = Pain Catastrophizing Scale; CES-D = Centre for Epidemiological Studies
Depression Scale; SOPA-C = Survey of Pain Attitudes-Control Scale; SF-12 PCS =
Physical Component Subscale of the Medical Outcomes Study Short Form 12; SF-12
MCS = Mental Component Subscale of the Medical Outcomes Study Short Form 12.
Using independent-samples t tests, the two genders were compared on
demographics (i.e., age) and study variables of interest (see Table 1.1). To control for
Type I error, a Bonferroni correction was employed, and thus a p level of .006 was used
(.05/8). In comparison to men, women reported higher levels of pain, catastrophizing,
48
and disability and lower physical QoL. The differences in pain, disability, and physical
QoL were also considered to be clinically significant.
Both men and women had a mean catastrophizing score below clinically
significant relevant levels and reported subclinical levels of depressive symptoms
according to guidelines suggested for individuals with chronic pain. Although men and
women scored below clinically significant levels of catastrophizing, the gender difference
in catastrophizing is considered clinically significant (Scott, Wideman, & Sullivan, 2013).
As well, both men and women reported levels of perceived control over pain within the
subclinical range (Jensen, Karoly, & Huger, 1987). Men with CP/CPPS reported mental
and physical QoL within half a standard deviation below the mean of the normative
sample. Women with IC/PBS reported mental QoL similar to the normative sample, but
they reported physical QoL approximately 1.5 standard deviations below the mean of the
normative sample.
Bivariate Correlations
Pearson correlations for the overall sample were calculated for all variables of
interest and are displayed in Table 1.2. A conservative p value of .001 was used (.05/45).
Solicitous, distracting, and negative spouse responses to pain behaviour were associated
with higher levels of disability. Only negative spouse responses to pain behaviour were
significantly associated with depressive symptoms, mental QoL, and catastrophizing. In
contrast, solicitous and distracting spouse responses were significantly associated with
physical QoL and pain.
49
Examining the correlations by gender indicates that for men with CP/CPPS (lower
half of Table 1.3), higher reports of solicitous spouse responses to pain behaviour were
associated with poorer physical QoL and greater disability. Unlike the CP/CPPS group,
in the IC/PBS group (upper half of Table 1.3), solicitous spouse responses were not
significantly related to any of the outcome variables of interest (i.e., depressive
symptoms, physical or mental QoL, disability). Distracting spouse responses to pain
behaviour were not associated with any of the outcome variables in either group. In both
the IC/PBS and the CP/CPPS groups, higher negative spouse responses to pain behaviour
were associated with higher levels of depressive symptoms. However, in the CP/CPPS
group, higher negative spouse responses were also associated with poorer physical and
mental QoL and disability. In sum, negative spouse responses are most consistently
related to outcomes in men with CP/CPPS.
50
Table 1.2
Bivariate Correlations Among Study Variables in Overall Sample.
1. SR
2. DR
3. NR
4. SF12-PCS
5. SF12-MCS
6. PDI
7. CES-D
8. PCS
9. SF-MPQ
10. SOPA-C
1
.65*
-.19*
-.34*
-.10
.34*
.06
.16
.32*
-.03
2
3
4
5
6
7
8
9
.01
-.19*
-.12
.21*
.09
.17
.19*
.05
-.18
-.28*
.25*
.29*
.29*
.14
-.06
.18
-.66*
-.23*
-.29*
-.50*
.12
-.42*
-.72*
-.46*
-.35*
-.02
.46*
.51*
.62*
-.17
.51*
.40*
-.09
.48*
-.17
-.16
Note. SR = Solicitous spouse responses; DR = Distracting spouse responses; NR = Negative spouse Responses; SF12-PCS = SF-12
Physical Component Scale; SF12-MCS = SF-12 Mental Component Scale; PDI = Pain Disability Index; CES-D = Centre for
Epidemiological Studies Depression Scale; PCS = Pain Catastrophizing Scale; SF-MPQ = Short-Form McGill Pain Questionnaire;
SOPA-C = Survey of Pain Attitudes-Control Scale.
*p < .001.
51
Table 1.3
Bivariate Correlations Among Study Variables Separated by Gender
1. SR
2. DR
3. NR
4. SF12-PCS
5. SF12-MCS
6. PDI
7. CES-D
8. PCS
9. SF-MPQ
10. SOPA-C
1
.67*
-.12
-.25*
-.11
.25*
.08
.11
.19
.03
2
.60*
.10
-.17
-.11
.16
.10
.11
.12
.07
3
-.36*
-.15
-.26*
-.26*
.28*
.28*
.27*
.13
.12
4
-.02
-.01
-.10
.23*
-.61*
-.23*
-.16
-.41*
-.06
5
.00
-.10
-.30
-.03
-.41*
-.65*
-.40*
-.38*
-.18
6
.16
.15
.25
-.45*
-.42*
.37*
.43*
.56*
.10
7
-.07
.04
.32*
-.13
-.78*
.53*
.33*
.34*
.22
8
.02
.16
.33*
-.22
-.49*
.48*
.65*
.44*
.20
9
.27
.19
.16
-.37*
-.28
.53*
.41*
.42*
.14
10
.02
.07
-.22
.27
.09
-.36*
-.25
-.47*
-.34*
-
Note. Correlations below diagonal are for men, above diagonal for women. SR = Solicitous spouse responses; DR = Distracting
spouse responses; NR = Negative spouse Responses; SF12-PCS = SF-12 Physical Component Scale; SF12-MCS = SF-12 Mental
Component Scale; PDI = Pain Disability Index; CES-D = Centre for Epidemiological Studies Depression Scale; PCS = Pain
Catastrophizing Scale; SF-MPQ = Short-Form McGill Pain Questionnaire; SOPA-C = Survey of Pain Attitudes-Control Scale.
* p<.001.
52
Research Question 1: Are There Gender Differences in Reported Spousal Responses to
Pain Behaviour Between Women with IC/PBS and Men with CP/CPPS?
A mixed-design ANCOVA was conducted to address this research question. The withinsubjects factor was spouse responses to pain behaviour, and the between-subjects factor was
gender. Pain, physical QoL, catastrophizing, and disability were included as covariates, as the
two genders differed on these measures (see Table 1.1). There was no main effect of gender,
F(1, 278) = 1.81, p = .18, nor spouse responses to pain behavior, F(2, 556) = 2.55, p = .08.
There was a significant interaction between gender and spouse responses to pain behavior, F(2,
277) = 7.35, p = .001, with women reporting higher levels of solicitous, t(282) = 7.47, p < .001,
and distracting, t(282) = 2.86, p = .004, spouse responses than men did. However, men and
women did not differ in reported levels of negative spouse responses to pain behavior, t(282) =
0.96, p = .65.
Table 1.4
Gender Differences in Spouse Responses to Pain Behaviour
CP/CPPS
M(SD)
(min.-max.)
1.94 (1.51)
(0-6)
IC/PBS
M(SD)
(min.-max.)
3.22 (1.69)
(0-6)
DR (0-6)
1.38 (1.34)
(0-6)
NR (0-6)
0.89 (1.10)
(0-6)
Measure (range)
SR (0-6)
t(282)
7.47
p
< .001
1.89 (1.51)
(0-5.75)
2.86
.004
0.97 (1.29)
(0-6)
0.45
.653
Note. SR = solicitous spouse responses; DR = distracting spouse responses; NR = negative
spouse responses
53
Research Questions 2 and 3: Do Spouse Responses to Pain Behaviour Moderate the
Relationship Between Pain and Patient Outcome and Is There a Gender Difference? If
Spouse Responses to Pain Behavior Moderate the Relationships Between Pain and
Outcomes, Do Cognitive Variables (e.g., perceived control over pain, catastrophizing)
Influence the Stress-Buffering Effect of Spouse Responses and Are There Gender
Differences in the Aforementioned Effects?
General Linear Model analysis was conducted using SPSS 18 (Chicago, IL). This
approach was selected because the data consisted of continuous predictor variables and multiple
dependent outcome variables. The dependent variables were patient outcomes of physical QoL,
mental QoL, disability, and depressive symptoms. The predictors were gender (women with
IC/PBS = -1; men with CP/CPPS = 1); pain (SF-MPQ); and solicitous, distracting, and negative
spouse responses. Four-way interaction terms involving gender, pain, a spouse response variable
(i.e., solicitous or distracting or negative responses), and an intrapersonal variable (i.e.,
catastrophizing or perceived control over pain), and their associated lower order interaction
terms were included. Because interaction terms were included in the models, all continuous
predictors were centered to reduce multicollinearity between the main effect and product terms
(Aiken & West, 1991). In these analyses, if the highest-order interaction was significant, then
follow-up analyses were conducted for this interaction only. If the highest-order interaction was
not significant, then only lower order interactions involving pain and one of the spouse response
variables were examined. Simple slopes analyses of significant interactions were also conducted
as necessary as outlined below.
54
Contrary to predictions, gender did not significantly interact with any interaction terms
involving pain and a spouse response variable, ps > .10. There was a significant interaction
between pain and solicitous responses, F(3, 708) = 4.11, p = .007, and between pain and
distracting responses, F(3, 708) = 6.79, p < .001, but the interaction between pain and negative
responses was not significant, F(3, 708) = 1.91, p = .13. The interaction between pain and
distracting responses predicted mental QoL, B = 0.32, t(282) = 2.91, p = .004, and disability, B
= -0.38, t(282) = -3.16, p = .002. However, the interaction between pain and solicitous
responses was qualified by a marginally significant three-way interaction among pain, solicitous
responses, and catastrophizing, F(3, 708) = 2.37, p = .07. The interaction among pain, solicitous
responses to pain behavior, and catastrophizing predicted only mental QoL, B = 0.01, t(282) =
2.01, p = .04. Simple slopes analyses for interactions were conducted as detailed below (i.e.,
three-way followed by two-way interactions).
Interaction among pain, solicitous responses, and catastrophizing (3-way
interaction). At high (i.e., 1 SD above the mean) and mean levels of catastrophizing , the
interaction between pain and solicitous responses was not significant for mental QoL, B = 0.08,
t(282) = 0.86, p = .39, and B = -0.07, t(282) = -0.77, p = .44, respectively. At low
catastrophizing (i.e., 1 SD below the mean), the interaction between pain and solicitous
responses was marginally significant for mental QoL, B = -0.22, t(282) = -1.61, p = .10.
Contrary to predictions, at low catastrophizing and high solicitous responses, higher pain was
associated with lower mental QoL (see Figure 1.1), B = -0.67, t(282) = -2.72, p = .007.
Additionally, at low catastrophizing and mean or low levels of solicitous responses, pain was not
55
significantly associated with mental QoL, B = -0.30, t(282) = -1.33, p = .19, and B = 0.07,
t(282) = 0.19, p = .85, respectively.
60
Predicted Mental QoL
50
40
30
High SR*
Mean SR
20
Low SR
10
0
Min
Max
SF-MPQ
Figure 1.1. The relationship between pain (SF-MPQ) and mental QoL at low levels of
catastrophizing.
*p <.05
Interaction between pain and distracting spouse responses (2-way interaction).
Prediction of mental QoL. Consistent with predictions, pain was not significantly
associated with mental QoL at high levels (i.e., 1 SD above the mean) of distracting spouse
responses to pain behaviour (see Figure 1.2), B = 0.08, t(282) = 0.40, p = .69. Additionally,
56
higher pain was associated with lower mental QoL at mean, B = -0.38, t(282) = -2.73, p = .007,
and low (i.e., 1 SD below the mean) distracting responses, B = -0.83, t(282) = -3.71, p < .001.
60
Predicted Mental QoL
50
40
30
High DR
Mean DR*
20
Low DR*
10
0
Min
Max
SF-MPQ
Figure 1.2. The relationship between pain (SF-MPQ) and mental QoL.
*p < .05
Prediction of disability. Consistent with predictions, pain was not significantly
associated with disability at high (i.e., 1 SD above the mean) distracting spouse responses, B =
0.07, t(282) = 0.33, p = .74. However, higher pain was associated with higher levels of disability
at mean, B = 0.61, t(282) = 4.01, p < .001, and low (i.e., 1 SD below the mean) distracting
responses, B = 1.16, t(282) = 4.67, p < .001.
57
80
70
Predicted PDI
60
50
40
High DR
Mean DR*
30
Low DR*
20
10
0
Min
Max
SF-MPQ
Figure 1.3. The relationship between pain (SF-MPQ) and disability (PDI).
*p < .05
Discussion
The primary aims of Study 1 were to examine gender differences in social support in a
novel chronic pain sample (i.e., UCPPS), and to explore whether the stress-buffering effect of
social support was dependent upon gender and/or cognitive variables (i.e., pain catastrophizing
or control over pain).
Research Question 1: Are There Gender Differences in Reported Spousal Responses to
Pain Behaviour Between Women with IC/PBS and Men with CP/CPPS?
58
Women perceived higher levels of solicitous and distracting spouse responses to pain
behaviour even after controlling for pain, physical QoL, catastrophizing, and disability.
However, men and women reported similar levels of negative spouse responses to pain
behaviour. These gender differences are contrary to the support gap hypothesis but consistent
with research indicating men provide more solicitous responses than women in response to their
partner’s pain (Newton-John & Williams, 2006). Therefore, results of the current study suggest
that the support gap hypothesis is not applicable even in a clinical sample.
However, a finer grained analysis may support the support gap hypothesis. Neff and
Karney (2005) reported that although men and women did not differ in the amount of social
support they provided to their spouse, in comparison to men, women provided more support on
days that their spouse experienced greater stress. Women also desire more social support than
men (Xu & Burleson, 2001), suggesting that perhaps women communicate this desire resulting
in increased reports of perceived social support by women. Data from the current study do
indicate that women scored higher on pain catastrophizing, which is speculated as a form of pain
communication and social-support seeking (Sullivan, 2012). Therefore, it may not be an issue of
gender differences in responsiveness, but individuals who request more support simply get more
support.
Still it is possible on days of UCPPS symptom flare-ups that husbands and wives differ in
their responsiveness to their partner’s pain or men and women with UCPPS request different
amounts of social support. A daily diary study documenting days of symptom flare-ups would
be an important area for future research to further clarify the application of the support gap
hypothesis in UCPPS.
59
Research Questions 2 and 3: Do Spouse Responses to Pain Behaviour Moderate the
Relationship Between Pain and Patient Outcome? If Spouse Responses to Pain Behavior
Moderate the Relationships Between Pain and Outcomes, is this Effect Further Moderated
by Cognitive Variables (e.g., perceived control over pain, catastrophizing) and/or Gender?
Although there were no gender differences, the stress-buffering hypothesis was
supported, indicating that both men and women suffering from UCPPS equally benefit from
social support. That is, distracting spouse responses buffered the relationships between pain and
disability and between pain and mental QoL, and this effect was not dependent upon gender or
cognitive variables. As well, the effect of solicitous spouse responses on the relationship
between pain and mental QoL was moderated by catastrophizing, such that at high levels of
catastrophizing, spouse solicitousness did not influence the relationship between pain and mental
QoL (e.g., pain was negatively associated with mental QoL). Contrary to the stress-buffering
hypothesis, at low levels of catastrophizing, solicitous spouse responses moderated the
relationship between pain and mental QoL such that the relationship between pain and mental
QoL was only significant (and negative) at high levels of solicitous spouse responses. The
distracting behavior finding is discussed in the next section, followed by a discussion of the
solicitous spouse responses finding.
Interaction between pain and distracting spouse responses. Although the moderating
role of distracting spouse responses to pain behaviour is consistent with the stress-buffering
hypothesis, the stress-buffering hypothesis does not suggest how distracting responses attenuate
the negative impact of pain. Findings from the current study may be best understood within the
60
context of cognitive models of pain that predict attention and subsequent emotional processing of
sensory information results in distress (McCaul & Malott, 1984). That is, distraction buffers the
negative effect of pain by occupying attentional resources and preventing the processing of the
pain experience. This speculation is based on the notion that humans have a finite attentional
capacity. In direct contrast, pain catastrophizing has the opposite effect of distraction and floods
attentional capacity with pain-related sensory and emotionally-charged (i.e., fear) information,
acting to amplify the negative impact of pain through rumination and magnification processes.
Spousal attempts to distract the individual with chronic pain (e.g., “Reads to me;” “Talks
to me about something else to take my mind off the pain;” “Tries to involve me in some
activity;” “Encourages me to work on a hobby”) may provide the individual with “mental
breaks” from ruminating cognitive and sensory pain processes, allowing individuals to
experience meaningful contact with their spouse in spite of pain. In a related study, task
persistence (i.e., ignoring pain and continuing an activity despite pain) is also shown to be
associated with lower levels of disability (Ersek, Turner, & Kemp, 2006). Therefore, the
distracting behavior provided by spouses may be one of the methods individuals with chronic
pain engage in to assist them in ignoring their pain.
There is mixed evidence of the efficacy of distraction on pain reduction with some
researchers reporting pain reduction (Damme, Crombez, Wever, & Goubert, 2008; McCaul &
Malott, 1984; Miron, Duncan, & Catherine Bushnell, 1989; Petrovic, Petersson, Ghatan, StoneElander, & Ingvar, 2000; Tracey et al., 2002; Valet et al., 2004), and some researchers reporting
no effect (Hodes, Rowland, Lightfoot, & Cleeland, 1990; McCaul, Monson, & Maki, 1992). Of
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note, most research on pain reduction efficacy for distraction was conducted with non-clinical
samples using experimentally induced pain and laboratory distraction tasks.
In one reported study of individuals with chronic low back pain, the distraction group
(i.e., participants were instructed to press a button as quickly as possible in response to a tone)
did not experience less pain when compared to the non-distraction controls during a lifting task
(i.e., lifting and holding a 5.5 kg bag for 60 s; Goubert, Crombez, Eccleston, & Devulder, 2004).
In contrast, an evaluation of attention management as treatment for chronic pain indicated
strategies including brief relaxation, use of imagery, and distraction towards external objects
resulted in reduced pain intensity and pain-related interference in a sample of chronic pain
patients (Elomaa, Williams, & Kalso, 2009).
Evidence with respect to the efficacy of distraction on pain reduction in clinical samples
is not clearly delineated, but contrasting results reported by Goubert and colleagues and by
Elomaa and colleagues suggest that the type of distracter is important. That is, distracters that
counter the stress response (e.g., relaxation via use of imagery) may be more effective than
distracters that simply occupy attentional resources (i.e., pressing a button in response to tone).
It may also be that distraction, as assessed in this study as form of spousal engagement, may act
as a viable distracter in an interpersonal manner.
Researchers hypothesize the efficacy of distraction may be dependent on affectivemotivational characteristics of the distracters (Eccleston & Crombez, 1999; Verhoeven et al.,
2010). According to this perspective, the allocation of attention is determined by whether or not
information is goal-relevant. Only one published study to date has examined the influence of the
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affective-motivational characteristics of distracters on pain reduction, and the authors did not
find supporting evidence. Verhoeven and colleagues reported individuals reported similar levels
of pain regardless if they were presented with a motivated distraction task (i.e., reward and
punishment for task performance) or distraction task only (i.e., no reward or punishment for task
performance).
Here, it is important to note that laboratory distraction tasks differ from distracting spouse
responses. In the laboratory, distraction tasks comprise of button-pressing in the presence of
predetermined stimuli and performance is assessed by reaction time. In contrast, the MPI
assesses interpersonal distraction or engagement in an enjoyable activity (e.g., “Talks to me
about something else to take my mind off the pain”). Therefore, the MPI assesses distracters that
may be more salient with respect to affective-motivational characteristics when compared with
button-pressing distracters in the laboratory. Distraction assessed in an interpersonal manner
may act to help regulate the pain experience, as it has desirable affective-motivational
characteristics including emotional closeness and enjoyment from pleasurable activities with
people you have meaningful relations with.
Of note, Verhoeven and colleagues (2010) have recently reported that the effect of
distraction may be moderated by catastrophizing, such that individuals high in catastrophizing
reported lower levels of pain intensity than the control group but only when presented with the
motivated distraction task. In contrast, and despite differences in measures used and sample
characteristics, both the current study and Goubert et al. (2004) found the effect of distraction
was not moderated by catastrophizing in individuals with chronic pain. Furthermore, the mean
catastrophizing score of participants in the current study was below clinical significance and may
63
account for the absence of a moderating effect of catastrophizing on the role of distracting
responses, as the level of catastrophizing may have been insufficient to occupy attentional
resources. However, if indeed the mean level of catastrophizing insufficiently occupied
attentional resources, one would not expect catastrophizing to moderate the effect of spouse
solicitousness, but it did moderate the effect. Distraction may very well be an important
component of adjustment to chronic pain in UCPPS, and in the particular case of distracting
spouse responses to patient pain, the stress-buffering effect of distracting spouse responses is not
dependent upon one’s level of catastrophizing.
Interaction among pain, solicitous spouse responses, and catastrophizing. As noted
above, the effect of solicitous spouse responses was moderated by level of catastrophizing.
Following the cognitive resource model for pain again, when catastrophizing is high, a pain
sufferer uses attentional resources attending to and processing painful sensory information
leaving insufficient attentional resources to attend to and/or process solicitous spouse responses.
Therefore, when catastrophizing is high, solicitous spouse responses do not act as a moderator of
the relationship between pain and mental QoL. In contrast, when catastrophizing is low,
attentional resources are available to process solicitous spouse responses. Speculatively, the
emotional processing of solicitous responses may then reinforce one’s beliefs and attitudes about
pain and therefore, increase the strength of the relationship between pain and mental QoL.
Indeed attitudes and beliefs about pain are associated with adjustment (Jensen, Turner, &
Romano, 2007; Moseley, 2004). However, a test of such a mechanism could not be conducted in
the current study. Therefore, one possible area for future research is to examine if attitudes and
64
beliefs about pain mediate the moderating effect of solicitous spouse responses on the
relationship between pain and mental QoL.
Alternatively, according to the communal coping model of catastrophizing high
catastrophizers’ expressive pain displays serve a communicative function to maximize the
probability that distress will be managed within a social or interpersonal context (Sullivan et al.,
2000). Research does support this notion; high catastrophizers exhibit more pain behaviour
during a cold-pressor task when there was someone present to receive their pain communication
(e.g., M. J. L. Sullivan, Adams, & Sullivan, 2004). Therefore, an alternative explanation for the
negative relationship between pain and mental QoL at high levels of catastrophizing is that
individuals who are highly distressed by their pain also tend to catastrophize to communicate
their distress. However, researchers suggest catastrophizing may serve a communal coping
function only in situations involving acute pain, as prolonged expressions of distress in the
situation of chronic pain may actually result in negative responses from others (Buenaver et al.,
2007; Cano, 2004). Unfortunately, pain duration was not assessed in the current sample, and
therefore, comparisons cannot be made among the sample in the current study with samples
reported by Buenaver et al. or Cano.
Pain may be associated with poorer mental QoL when spouse solicitousness is high
because the patient may interpret spouse solicitousness negatively. When individuals with
chronic pain do not seek social support (i.e., are low on catastrophizing) but continue to receive
it in the form of spouse solicitousness, the unsolicited social support may actually undermine
their efforts to develop coping strategies, acting to exacerbate the impact of pain on mental QoL.
Evidence from the general social support literature does suggest invisible support (i.e., social
65
support that the provider reported enacting, but the recipient does not report receiving) is more
effective in promoting adjustment than visible support (i.e., social support that the recipient
reported receiving; Bolger & Amarel, 2007; Bolger, Zuckerman, & Kessler, 2000). Researchers
speculate that visible social support has a paradoxical negative effect because support recipients
feel burdensome and incompetent (Bolger & Amarel, 2007; Bolger et al., 2000). In the current
study, visible social support in the form of spouse solicitousness may have had an especially
negative impact when individuals with chronic pain do not request such social support (i.e.,
individuals are low on pain catastrophizing). Furthermore, individuals with chronic pain rate
spouse responses that involve providing or offering help most frequently as negative in
comparison to responses that involve task persistence (Newton-John & Williams, 2006).
Gender Differences
It is surprising gender differences in the moderating role of spouse responses to pain
behaviour were not observed in the current study, as the pain literature provides evidence for
gender differences in pain catastrophizing (see review by Sullivan et al., 2001), and solicitous
spouse responses to pain behaviour (Fillingim et al., 2003; McWilliams, Dick, Bailey, Verrier, &
Kowal, 2012; Newton-John & Williams, 2006), both in clinical and non-clinical samples. Also,
preliminary analyses in the current study showed that women with IC/PBS reported higher levels
of pain, catastrophizing, and disability and lower levels of physical QoL than did men with
CP/CPPS. The aforementioned gender differences are consistent with research indicating that
women with osteoarthritis report higher pain severity and disability but inconsistent with
research on other types of musculoskeletal pain (i.e., back pain, fibromyalgia) and cancer pain,
which has limited evidence of gender differences (see review by Fillingim, King, Ribeiro66
Dasilva, Rahim-Williams, & Riley, 2009). Results from the current study suggest that despite
differences in the aforementioned variables, spouse responses to pain behaviour do not
differentially moderate the relationship between pain and outcome across men and women with
UCPPS.
Limitations and Directions for Future Research
The current study was the first to examine gender differences in the influences of spousal
responses to pain behaviour, catastrophizing, and perceived control over pain in UCPPS.
Although there are a number of strengths including examination of both inter- and intrapersonal
pain variables, there are also a number of limitations.
Participants in the present study may not represent the general IC/PBS and CP/CPPS
population, and more importantly, their spouses may not represent the general population of their
respective spouses. Men with CP/CPPS presented in the current study were drawn from a
subsample (n = 253) of men enrolled in the NIH Chronic Prostatitis Cohort Study (N = 488).
Differences were previously noted between survey responders and non-responders that impact
data generalizability (e.g., symptom severity, QoL; Tripp et al., 2006). Additionally, samples
used in the current study were not ethnically diverse primarily consisting of European Canadians
and Americans. However, that said the findings specific to these samples can be further
supported by replication studies including more diverse samples with respect to ethnicity,
socioeconomic status, and employment, as these are important predictors of health (Braveman,
Cubbin, Egerter, Williams, & Pamuk, 2010). As well, much of the literature in UCPPS is
conducted on samples sharing very similar profiles in regard to demographics and symptoms
(e.g., Berry et al., 2011; Clemens et al., 2005; Tripp et al., 2013).
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Data were also collected from tertiary-care patients, where it can be expected that patients
will have longer symptom duration and more medical treatments and diagnostic experiences in
comparison to individuals in primary care (Turner, et al., 2002). There is also the issue of
generalizability of these data to non-treatment seekers who are suffering from UCPPS. Nontreatment seeking chronic pain patients may have better emotional and physical self-regulatory
skills and potentially superior social support as indicated by lower levels of distress (Vera,
Michael, & Jeff, 2000). However, research in this area is intended to inform treatment models
intended for individuals who are currently distressed.
In the current study, reports of spousal responses were provided by the patient, not selfreports from their spouses, which is argued as a necessary method in many studies due to time
and resource limits. However, there is mixed evidence with respect to congruence between
patient and spouse reports of spouse responses to pain behaviour. Some researchers have
reported patients perceive fewer solicitous responses (Lousberg, Schmidt, & Groenman, 1992;
Williamson, Robinson, & Melamed, 1997), and greater punishing responses (Williamson et al.,
1997), whereas other researchers have not found differences in solicitous or negative spouse
responses (Cano, Johansen, & Geisser, 2004) or distracting spouse responses (Williamson et al.,
1997). However, patients’ perceptions of their spouses’ behavior may account for a larger
proportion of the variance in pain-related outcomes when compared to spouses’ self-reports
(Flor, Kerns, & Turk, 1987). Thus, although corroborating information from the non-identified
spouse may be ideal, it is not suggested as necessary. However, future research examining the
moderating effect of social support should examine social support both from the perspective of
the spouse and the individual with chronic pain.
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Additionally, the current study was cross-sectional, and therefore, directionality of
relationships cannot be concluded—plausible directions of relationships have been discussed
above. However, it is the first study to examine the relationships among pain, social support, and
pain-related outcomes in men and women with UCPPS, which will provide the basis for future
research in this area to advance our understanding of the role of social support in UCPPS.
Longitudinal or sequential examination of the relationships among pain, social support, and painrelated outcomes will be important in facilitating our understanding of the mechanisms involved
in predicting adjustment to chronic pain.
Lastly, the current study examined social support only from spouses and does not
comment on the role of social support from other sources. Although spousal support is
especially relevant relative to other sources of support, women with chronic pain may seek more
social support and use a wider range of coping strategies than men and use more problem
solving, positive self-statements, and palliative behaviours than men (Unruh, Ritchie, &
Merskey, 1999). The use of social support networks also vary across men and women such that
men tend to participate in more activity-focused relationships and women maintain more
emotionally intimate relationships (Belle, 1987; Flaherty & Richman, 1989). More recent
studies also suggest that women feel and express more emotion with people outside of their
marriages than men (Monin et al., 2010). Furthermore, women are more likely to mobilize
social supports in times of stress, and men’s mobilization of support is primarily focused on their
wives. As such, future research should examine sources of social support outside of the marriage
and how support from other sources (e.g., healthcare providers, family, friends) may influence
the relationship between pain and patient adjustment.
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Conclusions
This novel study indicated the support gap hypothesis (i.e., men receive more support
from their spouses than women receive from their spouses) is not applicable to spouse responses
to pain behaviour in men and women with UCPPS. Moreover, the evidence suggests the
opposite is true: women suffering from UCPPS receive more social support from their partners
than men with UCPPS receive from their partners. Furthermore, different types of spousal
support have different effects on the relationships between pain and outcomes, and the effect of
spouse responses can be dependent on catastrophizing. That is, distracting spouse responses
buffered the relationships between pain and disability and between pain and mental QoL.
However, solicitous spouse responses strengthened the relationship between pain and mental
QoL but only when catastrophizing was low. These results are consistent with literature
emphasizing the role of catastrophizing and solicitous spouse responses to pain behaviour in the
prediction of outcomes in individuals with chronic pain (e.g.,Boothby et al., 2004). Contrary to
the stated hypotheses, the stress-buffering effect was not more apparent in men with CP/CPPS
than in women with IC/PBS.
Although it is premature to implicate specific methods or targets for psychosocial
interventions for UCPPS, the data do suggest distracting and solicitous spouse responses and
catastrophizing as potential targets for psychosocial interventions for individuals with UCPPS.
Moreover, solicitous spouse responses may be especially detrimental to individuals with chronic
pain who score low on catastrophizing. Further research is needed to clarify the relationship
among pain, social support, catastrophizing, and patient outcomes in individuals with UCPPS.
The influence of other sources of social support is of particular interest given demonstrated
70
gender differences in the utilization of social networks and, thus, may bring to light more gender
differences in the influence of social support, which is the focus of Study 2.
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Chapter 4: Study 2
Spouse Responses to Pain Behaviour, Catastrophizing, and Different Sources of Social Support
as Moderators of Relationship Between Pain and Patient Outcome in Men and Women with
Urogenital Chronic Pelvic Pain Syndrome
72
Abstract
Spouse responses to pain behaviour were previously examined as moderators of the
relationship between pain and outcomes in men and women with UCPPS. Given the noted
gender differences in the general social support literature, gender differences in the moderating
effect of spouse responses were also examined, but no gender differences were found in Study 1.
To extend Study 1, sources of social support outside of the romantic relationship were examined
as some research indicates that men and women use their social support networks for different
purposes, suggesting that social support from outside of the marriage may be more important in
the prediction of pain-related outcomes in women than men. Two different regression models
were tested: 1) to replicate Study 1, catastrophizing along with spouse responses were examined
as moderators of the relationship between pain and outcome; and 2) catastrophizing along with
support from family, friends, and physician were examined as moderators of the relationship
between pain and outcome. Eighty-six men with CP/CPPS and 113 women with IC/PBS
completed self-report measures assessing demographics, depressive symptoms, disability, QoL, a
measure of spousal responses to their pain, and measures assessing social support from family,
friends, and physician. Although gender differences in solicitous and distracting spouse
responses to pain behaviour were replicated, results regarding the prediction of pain-related
outcomes were not replicated. There were gender differences in social support from friends,
with women reporting higher levels of support from their friends, but sources of social support
from outside of the romantic relationship did not moderate the association between pain and
outcome.
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Introduction
No gender differences were found in Study 1 in the moderating effect of spouse
responses to pain behaviour and catastrophizing on the relationships between pain and painrelated outcomes (i.e., mental and physical QoL, disability, and depressive symptoms). As
discussed in Study 1, perhaps greater gender-based differences would become apparent when
examining other sources of support. A significant body of research suggests, in comparison to
men, women’s responses to stress are better characterized as “tending and befriending” (i.e.,
nurturing and affiliation; S. E. Taylor et al., 2000; Turton & Campbell, 2005). According to
these authors, seeking social support is more prevalent in the stress regulation of women.
Moreover, the marital relationship tends to be more central to the well-being of men than women
(Dykstra & de Jong Gierveld, 2004), suggesting that sources of support outside of the spousal
relationship may be more significant to well-being for women. These suggestions provide some
of the impetus for a deeper examination of sources of social support, which may be important in
clarifying such gender differences in chronic pain.
How do men and women benefit from different sources of social support? In a middleaged cohort study, men’s mental health was predicted by support from the closest person
(Stansfeld, Rael, Head, Shipley, & Marmot, 1997), whereas women benefitted more from a
combination of support sources (Fuhrer, Stansfeld, Chemali, & Shipley, 1999). Additionally,
support from one’s partner was negatively associated with depression for men, but for women it
was their friend and family support that provided some protection against depression (Schwarzer
& Gutierrez-Dona, 2005). Similarly, in a study of healthy adults, social support from family and
74
friends buffered the negative impact of relationship strain on life satisfaction and positive mood
but only for women (Walen & Lachman, 2000).
In a recent study of late middle-aged men and women, the authors examined gender
differences in the association between social support and depressive symptoms (Fiori & Denckla,
2012). Specifically, they examined support obtained from non-kin (i.e., friends, neighbours, or
coworkers) and kin (i.e., sons or daughters [19 and older], parents, brothers or sisters, and other
relatives). Men and women were then separately grouped into three groups, individuals who
reported support from: kin only, non-kin only, and both kin and non-kin. Notably, social support
from spouses was not included in their analyses. The authors reported a significant effect of
source(s) of support on depressive symptoms in women but not in men. Women who reported
receiving support from both kin and non-kin had the lowest depressive symptoms, and there was
a trend showing individuals who reported support from kin only had lower depressive symptoms
than individuals reporting support from non-kin only. However, the authors did not test if men
and women differed in depressive symptoms within each support source group (i.e., kin only,
non-kin only, and both kin and non-kin). Considering the research outlined, the source of social
support is suggested to be important in predicting health-related outcomes, and that varied
sources of social support may be more salient for women than men.
It is possible that differences in the role of type of social support and source of social
support are due to the measurement of social support. Social support may be conceptualized in
several ways. In the pain literature, social support is conceptualized as responses to pain
behavior (e.g., solicitous, distracting, negative, etc.). In the general social support literature,
there are several categories of social support (e.g., instrumental/tangible, emotional, esteem,
75
etc.), and social support can also be assessed with respect to perceived availability and received,
amount/frequency, and satisfaction with social support. As such, there are discrepancies with
respect to gender differences and what is helpful for whom with respect to social support, but
what is clear is that social support appears to benefit individuals across cultures, genders, and
health conditions (see reviews by Kim, Sherman, & Taylor, 2008; Uchino, 2006).
Social support can be viewed within an operant theory of pain (Flor et al., 1987; Gil,
Keefe, Crisson, & Van Dalfsen, 1987; Romano et al., 2000; Romano et al., 1992). This
application of operant theory suggests that through learning mechanisms, pain behaviours are
influenced by social responses, particularly responses of partners in intimate relationships
(Fordyce, 1976). As such, within the pain literature, there is limited research available
distinguishing between different sources of support. For example, the rheumatoid arthritis
literature indicates social support from family and friends is positively associated with improved
QoL (Minnock, Fitzgerald, & Bresnihan, 2003).
There is also a significant association between healthcare provider contact and chronic
pain (Blyth, March, Brnabic, & Cousins, 2004; Von Korff, Wagner, Dworkin, & Saunders,
1991), implying physicians may be a significant source of formal social support. Lanza and
colleagues (1993) suggest support from healthcare providers is unique and cannot be substituted
with support from informal sources, such as friends and family (Dakof & Taylor, 1990; DunkelSchetter, 1984). Additionally, the general view is quality of the physician-patient relationship
and physician empathy has a positive influence on patient outcomes (Hojat et al., 2011; Street,
Makoul, Arora, & Epstein, 2009). Greater patient satisfaction is important, because it is
associated with significantly decreased pain and disability (Hurwitz, Morgenstern, & Yu, 2005).
76
Varied sources of social support are also known to influence mental health outcomes in
older adults. In healthy older adults, the absence of social support from family or friends is
damaging for mental health (Takahashi, Tamura, & Tokoro, 1997), whereas having contact with
both friends and family appears to be beneficial (Dupertuis, Aldwin, & Bossâ, 2001).
Additionally, in adults aged 50 years and older, social support from spouses, friends, and adult
children have been found to be associated with lower levels of depressive symptoms in
descending order of importance (Dean, Kolody, & Wood, 1990).
Present Study
Within the pain literature, spouses are recognized as providers of behavioural
reinforcement given their frequency of contact with the patient suffering from pain. As such,
there is limited research regarding other sources of social support in chronic pain. The
accumulating research on non-clinical samples suggests sources of support other than one’s
intimate partner can have a significant impact on health outcomes (Fiori & Denckla, 2012;
Fuhrer et al., 1999; Schwarzer & Gutierrez-Dona, 2005; Stansfeld et al., 1997; Walen &
Lachman, 2000). Therefore, Study 2 was designed to replicate and also extend the models
originally hypothesized in Study 1 by investigating the role of sources of social support outside
of the romantic relationship (i.e., friends, family and physician support) in individuals with
UCPPS.
Research questions and hypotheses novel to Study 2:
2.1. Are there gender differences in reported social support from family, friends, and
physician?
77
Hypothesis 2.1: Consistent with previous research on gender differences in use of
social support networks and seeking social support, women were
predicted to report higher levels of support from family, friends, and
physician than men.
2.2. Does social support moderate the relationship between pain and patient outcome
variables and are there gender differences in this effect?
Hypothesis 2.2: I predicted that social support from family, friends, and physician
would buffer the relationships between pain and each outcome
variable (i.e., mental and physical QoL, disability, depressive
symptoms). I predicted that the stress-buffering effect of social
support from family, friends, and physician would be stronger for
women than men given previous research indicating that social
support is more prevalent in the stress regulation of women (Taylor et
al., 2000; Turton & Campbell, 2005).
2.3. If social supports from other sources buffer the relationships between pain and
outcomes, is this effect further moderated by catastrophizing and/or gender?
Hypothesis 2.3: At low levels of catastrophizing, I predicted that social support
from family, friends, or physician would buffer the relationships
between pain and outcome variables. At high levels of
catastrophizing, I predicted that social support from family or
friends or physician would not buffer the relationships between pain
and outcome variables.
Method
Participants
Male sample. For the male sample, 91 men diagnosed with CP/CPPS were recruited
from 5 North American tertiary care clinical centers (3 U.S. centres: The Smith Institute for
Urology, Cleveland Clinic, Los Angeles Infertility & Prostatitis Medical Group, and 1 Canadian
centre: Kingston General Hospital). These patients met the NIH definition for CP/CPPS, which
78
is described as pain in the pelvic region for 3 of the last 6 months, in the absence of pathogenic
bacteria (Krieger, et al., 1999). Of the 91 men, 5 were excluded as greater than 20% of their data
was missing on central study measures (e.g., MPI, CES-D, PDI). Therefore, 86 men were
included in the current analyses.
Female sample. A total of 113 women with IC/PBS were recruited from 5 North
American tertiary care clinical centers (3 U.S. centres: The Smith Institute for Urology,
University of Rochester Medical Centre, University Urology, and 2 Canadian centres:
Sunnybrook Health Sciences and Kingston General Hospital). These patients fulfilled the
diagnostic criteria described in the US National Institutes of Health Interstitial Cystitis Database
Study (Hanno, Landis, Matthews-Cook, Kusek, & Nyberg, 1999) and the definition described at
the US National Institutes of Health Urological Chronic Pelvic Pain Consensus Symposium
(Nickel, 2008). Although not available at the time, patients fulfilled the criteria for diagnosis of
BPS/IC outlined in the recently published American Urological Association guidelines (Hanno et
al., 2011) as well as European Society for the Study of Interstitial Cystitis and European
Association of Urology definition of BPS (Fall et al., 2010; van de Merwe, et al., 2008). Onehundred and ten women were included in the analyses, as 3 women were excluded due to greater
than 20% of their data missing on central study measures.
Measures
Demographics questionnaire. All participants provided information on age, ethnicity
(Caucasian/White, Hispanic or Latino, Aboriginal, Asian or Pacific Islander, Black/AfricanAmerican/African-Canadian, Other), level of education, whether living with a spouse or partner,
79
employment status, time since diagnosis of UCPPS, and other physical or mental health
conditions.
The Multidimensional Scale of Perceived Social Support (MSPPS; Zimet, Dahlem,
Zimet, & Farley, 1988) includes 12 reliable and valid items assessing support. This measure
assesses one’s perception of availability of social support from friends, family, and significant
others. For the current study, only the friends and family subscales were used. Each item is
rated on a scale from 1 (very strongly disagree) to 7 (very strongly agree); range for each
subscale is 4 to 28. Mean scores in the validation sample were 5.80 for family and 5.85 for
friends. Cronbach’s alpha was .93 for family and .94 for friends.
Patient Satisfaction Questionnaire Short-Form (PSQ-18; Marshall & Hays, 1994).
The PSQ-18 is a measure of patient satisfaction with their health care. The 18 items assess
technical quality, interpersonal manner, communication, time spent with Doctor, general
satisfaction, financial aspects, and accessibility and convenience. Each item is rated on a scale of
1 (strongly agree) to 5 (strongly disagree), with 9 items reversed scored, such that higher scores
indicate higher levels of satisfaction. Internal consistency in the current study was excellent (  =
.93).
The following measures were described in detail in Study 1. Therefore, only internal
consistencies were reported for the following measures. The Short-Form McGill Pain
Questionnaire (SF-MPQ) was used to assess pain, and in the current study, scale items
demonstrated excellent internal consistency ( = .91). The Multidimensional Pain Inventory
(MPI) was used to assess spouse responses to pain behaviour, and subscale items demonstrated
acceptable to good internal consistency (Negative  = .84, Solicitous  = .85, Distracting  =
80
.70). The Center for Epidemiological Studies Depression Scale (CES-D) was used to assess
depressive symptoms and scale items demonstrated excellent internal consistency in the current
study ( = .93). The Pain Disability Index (PDI) was used to assess extent of disability, and
internal consistency of the PDI in the current study was excellent ( = .92). The Pain
Catastrophizing Scale (PCS) was used to assess pain-related catastrophizing and demonstrated
excellent internal consistency in the current study ( = .95). The MOS Short Form Quality of
Life Questionnaire (SF-12) was used to assess mental and physical QoL and has demonstrated
scale validity and reliability (Ware, Kosinski, & Keller, 1996). The SF-12 physical component
scale and mental component scale demonstrated good internal consistency ( = .84 and  = .82,
respectively). The NIH-Chronic Prostatitis Symptom Index (NIH-CPSI) was used to assess
symptom severity in men with CP/CPPS. In the current study, internal consistency was good (
= .86). Interstitial Cystitis Symptom Index/Interstitial Cystitis Problem Index (ICSI/ICPI) was
used to assess voiding and pain symptoms of IC/PBS as well as the extent to which these
symptoms are problematic; scale items demonstrated acceptable to good internal consistency
(ICSI  = .72, ICPI  = .82).
Procedure
Following approval from the institutional review boards, men with urologist-diagnosed
CP/CPPS and women with urologist-diagnosed IC/PBS were invited to participate by study
personnel. Participants were provided with a combined letter of information and consent form
and were given the opportunity to ask questions. Individuals agreeing to participate completed
the questionnaire package and returned the package to their respective research centre by mail
using postage-paid envelopes provided to participants. Participants were also provided with a
81
contact phone number should they have any questions. Participants were instructed to sign the
consent form, which was returned with their completed measures. The measures required
approximately 30-45 minutes to complete.
Results
Preliminary Analyses
Men in the current sample reported a mean NIH-CPSI score of 22.79 (SD = 10.29; range
of possible scores = 0-43), which is comparable to the validation sample (Litwin et al., 1999a).
Similar to other reported samples (e.g., Sirinian et al., 2005), the current sample women reported
a mean ICSI score of 12.66 (SD = 4.55; range of possible scores = 0-16) and mean ICPI score of
10.83 (SD = 4.02; range of possible scores = 0-16).
Table 2.1
Demographics and T-tests for Gender Differences in Study 2 Variables.
CP/CPPS
%
Employment Status
Employed
Unemployed
Retired
On Disability
Ethnicity
Caucasian
Other
Hispanic
Asian
Black/AfricanCanadian
Education
Less than high school
IC/PBS
%
64.7
2.4
23.5
9.4
2
p
25.05
<.001
1.34
.25
0.68
.71
38.5
8.3
16.5
36.7
96.5
3.5
0
0
92.7
2.8
1.8
0.9
0
1.8
3.5
2.7
82
High School
GED
University/College
Degree
Graduate or
Professional Degree
Vocational Education
Measure (range)
Age
Relationship length (in
years)
Time since diagnosis
CES-D (0-60)
SF-MPQ (0-45)
PDI (0-70)
PCS (0-52)
SF-12 PCS (0-100)
SF-12 MCS (0-100)
15.0
0
20.2
1
53.5
50.5
23.3
4.7
21.1
4.5
M (SD)
(min.-max.)
52.8 (11.47)
(26-73)
23.27 (13.37)
(1.5-51.50)
5.71 (6.16)
(0.1-37)
16.64 (11.11)
(0-46)
13.2 (9.82)
(0-39)
22.94 (16.89)
(0-70)
20.06 (10.79)
(0-50)
41.58 (10.73)
(12.93-61.28)
44.51 (10.76)
(20.79-66.30)
M (SD)
(min.-max.)
47.75 (14.04)
(20-75)
19.63 (14.18)
(0.2-49.58)
7.29 (6.21)
(0-33)
21.67 (13.68)
(0-58)
18.01 (11.09)
(0-45)
34.13 (17.88)
(0-66)
24.95 (13.63)
(0-52)
35.52 (10.62)
(18.74-58.61)
41.72 (12.67)
(16.38-69.01)
t
(194)
-2.68a
p
.007
-1.60b
.112
1.73c
.086
2.84
.004
3.17
.002
4.45
<.001
2.81
.006
-3.94
<.001
-1.63
.105
Note. CES-D = Centre for Epidemiological Studies Depression Scale; SF-MPQ = Short-Form
McGill Pain Questionnaire; PDI = Pain Disability Index; PCS = Pain Catastrophizing Scale;
PSQ-18 = Patient Satisfaction Questionnaire Short-Form; SF-12 PCS = Physical Component
Subscale of the Medical Outcomes Study Short Form 12; SF-12 MCS = Mental Component
Subscale of the Medical Outcomes Study Short Form 12; SR = Solicitous Spouse Responses; DR
= Distracting Spouse Responses; NR = Negative Spouse Responses.
a
df=191, bdf=149, cdf=184
83
Study 2 samples. A chi-square test of independence was conducted to determine if there
was a relationship between gender and categorical demographic variables (i.e., ethnicity,
education level, and employment status; see Table 2.1 for the proportions). Due to low expected
cell counts, education was divided into 3 groups (vocational education/high school or less,
university degree, graduate or professional degree), and ethnicity was dichotomized (Caucasian
and other). A 2 test of independence indicated that education, 2(2) = 0.68, p = .71, and
ethnicity, 2(1) = 1.34, p = .25 were unrelated to gender. However, there was a relationship
between gender and employment status, 2 (3) = 25.05, p < .001, such that more women than
men indicated they were on disability.
Using independent-samples t tests, the two genders were compared on demographics
(i.e., age, relationship length, time since diagnosis) and study variables of interest (see Table
2.1). To control for Type I error, a Bonferroni correction was employed, and thus a p level of
.005 was used (.05/9).
Unlike Study 1, in comparison to men, women reported higher levels of depressive
symptoms. Similar to Study 1, using a conservative cutoff for clinically significant depression in
individuals with pain (Geisser et al., 1997b), neither men nor women with UCPPS reported
clinically significant depressive symptoms. Additionally, consistent with Study 1, women
reported higher levels of pain and disability and lower levels of physical QoL, such that the
gender difference was also considered clinically significant for disability (Soer et al., 2012) and
physical QoL (Ware, Snow, Kosinski, & Gandek, 1993). Similar to Study 1, neither gender met
the cutoff for clinically significant catastrophizing (Sullivan, 2009). Generally, gender
differences observed in Study 1 were also found in Study 2.
84
Study 1 vs. Study 2 sample comparisons. To determine whether the two study samples
were comparable, a series of t tests were conducted. A Bonferroni correction was used (0.5/6) to
reduce the probability of Type I errors; therefore, a p level of .008 was used. Of note, the sample
in Study 2 reported lower physical and mental QoL, higher pain and higher disability (see Table
2.2).
Table 2.2
T-tests for Differences Between Full Study 1 and Study 2 Samples
Age
Physical QoL
Mental QoL
SF-MPQ
PDI
CES-D
Study 1
M (SD)
49.11 (11.91)
43.29 (10.96)
46.40 (11.50)
9.38 (8.37)
18.09 (15.66)
17.04 (8.81)
Study 2
M (SD)
49.97 (13.10)
38.18 (11.06)
42.95 (11.92)
15.90 (10.80)
29.22 (18.28)
19.47 (12.83)
t
(478)
-0.72
5.00
3.16
-7.11
-6.95
-2.30
p
.469
<.001
.002
<.001
<.001
.022
Note. QoL = Quality of Life; SF-MPQ = Short-Form McGill Pain Questionnaire; PDI = Pain
Disability Index; CES-D = Centre for Epidemiological Studies Depression Scale.
T-tests were conducted to compare women with IC/PBS from Study 1 with women in
Study 2 (see Table 2.3) and similarly for men with CP/CPPS (see Table 2.4). A Bonferroni
correction was also used for these analyses, resulting in p < .006 (.05/8) and p < .007 (.05/7) for
women and men, respectively. Women from the two studies were similar with the exception of
pain; individuals from Study 2 reported higher levels of pain. In contrast, men from the two
studies differed on a number of measures; men from Study 2 were older, reported lower physical
QoL, higher pain, higher disability, and higher CP/CPPS symptom severity. Differences in pain,
85
NIH-CPSI scores and disability also reached clinical significance (Propert et al., 2006; Soer et
al., 2012; Strand et al., 2008).
Table 2.3
Mean Differences Between Women with IC/PBS in Study 1 vs. Study 2
Age
Physical QoL
Mental QoL
SF-MPQ
PDI
CES-D
ICPI
ICSI
Study 1
Women
M (SD)
50.56 (13.82)
34.63 (7.99)
44.45 (13.66)
13.71 (9.54)
28.27 (15.32)
19.00 (12.04)
10.57 (3.86)
12.03 (4.58)
Study 2
Women
M (SD)
47.75 (13.98)
35.52 (10.62)
41.72 (12.67)
18.01 (11.09)
34.13 (17.88)
21.67 (13.68)
10.83 (4.02)
12.66 (4.55)
t
(204)
p
1.45
-0.68
1.45
-2.99
-2.53
-1.48
-0.47
-0.99
.149
.497
.139
.003
.012
.138
.640
.322
Note. QoL = Quality of Life; SF-MPQ = Short-Form McGill Pain Questionnaire; PDI = Pain
Disability Index; CES-D = Centre for Epidemiological Studies Depression Scale.
Table 2.4
Mean Differences Between Men with CP/CPPS in Study 1 vs. Study 2
Age
Physical QoL
Mental QoL
SF-MPQ
PDI
CES-D
NIH-CPSI
Study 1
Men
M (SD)
48.38 (10.77)
47.71 (9.55)
47.39 (10.12)
7.16 (6.73)
12.88 (13.09)
16.04 (6.38)
16.52 (8.66)
Study 2
Men
M (SD)
52.80 (11.34)
41.57 (10.73)
44.51 (10.76)
13.20 (9.82)
22.94 (16.88)
16.64 (11.11)
22.79 (10.29)
t
(272)
p
-3.10
4.74
2.15
-5.17
-4.89
-0.47
-5.02*
.002
<.001
.033
<.001
<.001
.639
<.001
Note. QoL = Quality of Life; SF-MPQ = Short-Form McGill Pain Questionnaire; PDI = Pain
Disability Index; CES-D = Centre for Epidemiological Studies Depression Scale.
86
Bivariate Correlations
Pearson correlations for the overall sample were calculated for all variables of interest
and are displayed in Table 2.5. A p value of .001 was used given the large number of
correlations. Of the different types of spouse responses, only solicitous spouse responses to pain
behaviour were associated with poorer physical QoL, whereas only negative spouse responses to
pain behaviour were associated with poorer mental QoL. Both solicitous and negative spouse
responses to pain behaviour were associated with higher levels of disability. Of the three types
of spouse responses, only negative spouse responses to pain behaviour were associated with
higher levels of depressive symptoms. All three types of spouse responses to pain behaviour
were associated with higher levels of catastrophizing. Interestingly, of the three types of spouse
responses, only solicitous spouse responses to pain behaviour were associated with higher pain.
Support from family and friends were associated with higher mental QoL, lower disability, lower
depressive symptoms, and lower catastrophizing. However, only support from friends was
associated with lower levels of pain. Interestingly, lower support from physicians was associated
with poorer physical QoL but was not associated with mental QoL, disability, or depressive
symptoms.
Examining the correlations by gender indicates that for men with CP/CPPS (lower half of
Table 2.6), higher reports of solicitous spouse responses to pain behaviour were associated with
higher levels of disability and pain. Similarly, for women with IC/PBS (upper half of Table 2.6),
higher reports of solicitous spouse responses to pain behaviour were associated with higher pain
and also with lower physical QoL. For men with CP/CPPS, distracting spouse responses to pain
behaviour were associated with higher disability and higher pain. However, for women with
87
IC/PBS, distracting spouse responses to pain behaviour were not significantly associated with
other variables. For men with CP/CPPS, higher levels of negative spouse responses to pain
behaviour were associated with lower physical QoL, lower mental QoL, higher disability, higher
depressive symptoms, higher catastrophizing, and higher pain. However, for women with
IC/PBS, negative spouse responses to pain behaviour were significantly associated with lower
mental QoL, higher depressive symptoms, and higher catastrophizing.
For both men and women with UCPPS, negative spouse responses to pain behaviour
were most consistently associated with pain-related outcomes (i.e., physical and mental QoL,
disability, and depressive symptoms) when compared to solicitous and distracting spouse
responses to pain behaviour. Support from family was associated with higher levels of mental
QoL and lower levels of depressive symptoms for both men and women with UCPPS. For
women with IC/PBS, support from family was also associated with lower catastrophizing, and
for men with CP/CPPS, support from family was also associated with lower disability. Support
from friends was associated with higher mental QoL, lower disability, lower depressive
symptoms, lower catastrophizing, and lower pain for both men and women with UCPPS.
Support from physicians was associated with higher mental QoL and lower depressive symptoms
but only in men with CP/CPPS.
88
Table 2.5
Correlations Among Study Variables in Overall Study 2 Sample
1. SR
2. DR
3. NR
4. SF12-PCS
5. SF12-MCS
6. PDI
7. CES-D
8. PCS
9. SF-MPQ
10. Rel.
Length
11. Time Dx
12. MSPSS
Family
13. MSPSS
Friends
14. PSQ-18
1
.66*
-.27*
-.28*
-.09
.24*
.10
.19
.28*
2
3
4
5
6
7
8
9
10
11
12
13
-.17
-.11
-.07
.11
.04
.16
.12
-.10
-.27*
.17
.29*
.25*
.13
.23*
-.72*
-.47*
-.49*
-.60*
-.57*
-.78*
-.58*
-.46*
.65*
.71*
.74*
.64*
.55*
.66*
-
.02
.07
-.05
.01
.34*
-.24*
-.28*
-.23*
-.20
-
.02
-.01
.12
-.21*
.11
.04
-.03
-.05
.04
.27*
-
.24*
.16
-.43*
.08
.39*
-.17
-.38*
-.16
-.09
.15
-.09
-
.12
.17
-.21*
.04
.40*
-.20*
-.38*
-.20*
-.20*
.06
.04
.51*
-
.25*
.17
-.20*
-.15
.08
.11
-.05
.00
.03
.02
-.07
.30*
.27*
Note. SR = Solicitous spouse responses; DR = Distracting spouse responses; NR = Negative spouse Responses; SF12-PCS = SF-12
Physical Component Scale; SF12-MCS = SF-12 Mental Component Scale; PDI = Pain Disability Index; CES-D = Centre for
Epidemiological Studies Depression Scale; PCS = Pain Catastrophizing Scale; SF-MPQ = Short-Form McGill Pain Questionnaire;
Rel. Length = Relationship Length; Time Dx = Time since diagnosis; MSPSS = Multidimensional Scale of Perceived Social Support;
PSQ-18 = Patient Satisfaction Questionnaire.
*p<.001
89
Table 2.6
Correlations Among Study Variables Separated by Gender
1
1. SR
2. DR
3. NR
4. SF12PCS
5. SF12MCS
6. PDI
7. CES-D
8. PCS
9. SF-MPQ
10. Rel.
Length
11. Time
Dx
12. MSPSS
Family
13. MSPSS
Friends
14. PSQ-18
.74*
-.05
2
.58*
.06
3
-.42*
-.29*
-
4
-.25
.04
-.03
5
-.05
-.03
-.24
6
.09
-.06
.07
7
.03
-.07
.27
8
.12
.09
.20
9
.21
.00
.08
-.16
-.20
-.23
-
.25
-.67*
-.46*
-.44*
-.07
-.08
-.34*
.16
-
-.61*
-.80*
.24
.04
.17
.25
.22
.12
.19
.22
.37*
.38
.37*
.25
-.72*
-.41*
-.51*
-.59*
-.49*
-.74*
-.40*
-.25
.62*
.72*
.72*
.16
.23
0
-.09
.24
.02
.13
.22
-.25
.15
.14
-.41*
-.04
.04
.01
.05
10
0
.03
-0.1
11
-0.05
-0.13
0.08
12
.29*
0.16
-.45*
13
0.11
.19
-.23
14
.18
.14
-.13
-.56*
.01
-0.15
0.05
0.14
-.13
-.67*
-.56*
.38*
.23
.32*
.34*
.04
.65*
.45*
.38*
.68*
.71*
.64*
.72*
.62*
.65*
-
-.29
-.33*
-.29
-.29
-0.06
-0.17
-0.14
-0.12
-0.18
-.29*
-.20
-0.15
-.25
-.34*
-.25
-.27*
.08
-.05
-.03
.00
-.10
-.15
-.06
.03
-
.33*
0.16
0.15
.00
-.05
.09
.19
.05
.27
.22
-
-0.05
0.02
-.12
.17
.51*
-.23
-.57*
-.13
-.06
.19
-0.2
-
.50*
.29*
-.18
.07
.59*
-.35*
-.60*
-.26
-.24
.02
-0.03
.52*
-
.21
-.28
.03
.28
-.10
-.26
-.13
-.12
.20
-.14
.31
.22
-
Note. Correlations below diagonal are for men, above diagonal for women. SR = Solicitous spouse responses; DR = Distracting
spouse responses; NR = Negative spouse Responses; SF12-PCS = SF-12 Physical Component Scale; SF12-MCS = SF-12 Mental
90
Component Scale; PDI = Pain Disability Index; CES-D = Centre for Epidemiological Studies Depression Scale; PCS = Pain
Catastrophizing Scale; SF-MPQ = Short-Form McGill Pain Questionnaire; Rel. Length = Relationship Length; Time Dx = Time since
diagnosis; MSPSS = Multidimensional Scale of Perceived Social Support; PSQ-18 = Patient Satisfaction Questionnaire.
*p<.001
91
Research Question 1: Are there gender differences in reported spousal responses to pain
behaviour and social support from family, friends, and physician between women with
IC/PBS and men with CP/CPPS?
Two mixed-design ANCOVAs were conducted to address this research question. In the
first ANCOVA the within-subjects factor was spouse responses to pain behaviour, whereas in the
second ANCOVA the within-subjects factor was source of social support (i.e., family, friends,
physician), and the between-subjects factor was gender for both ANCOVAs. Depressive
symptoms, pain, disability, and physical QoL were included as covariates, as the two genders
differed on these measures (see Table 2.1).
In the first ANCOVA, the main effect of gender, F(1, 190) = 8.70, p = .004, was
qualified by an interaction between gender and spouse response to pain behaviour, F(2, 380) =
10.31, p < .001. As expected, follow-up analyses indicated women reported higher levels of
solicitous spouse responses and distracting spouse responses than did men (see Table 2.7).
Consistent with Study 1, men and women did not differ in reported levels of negative spouse
responses to pain behavior.
In the second ANCOVA, the main effect of gender, F(1, 190) = 17.01, p < .001, was
qualified by an interaction between gender and source of social support, F(2, 380) = 9.42, p <
.001. Consistent with predictions, in comparison to men, women reported higher levels of social
support from their friends. However, contrary to predictions men and women did not differ in
social support from family or their physician.
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Table 2.7
Gender Differences in Social Support
Measure (range)
SR (0-6)
DR (0-6)
NR (0-6)
MSPSS Family
(4-28)
MSPSS Friends
(4-28)
PSQ-18 (0-5)
Gender Difference?
CP/CPPS
IC/PBS
M (SD)
M (SD)
(min.-max.) (min.-max.)
2.86 (1.37) 3.92 (1.53)
(0-6)
(0-6)
1.91 (1.11)
2.5 (1.44)
(0-4)
(0-5.25)
1.27 (1.36)
1.1 (1.3)
(0-6)
(0-5.75)
21.84 (6.47) 22.68 (6.3)
(4-28)
(4-28)
17.33 (7.41) 20.69 (7.18)
(4-28)
(5-28)
3.27 (0.70) 3.81 (0.81)
(1.33-4.56)
(1.17-5)
Study 1
Study 2
.354
Yes; women
higher
Yes; women
higher
No
Yes; women
higher
Yes; women
higher
No
0.98
.327
N/A
No
3.36
<.001
N/A
4.77
.001
N/A
Yes; women
higher
No
t(194)
5.07
p
.001
3.29
.001
-0.93
Research Questions 2 and 3: Does social support moderate the relationship between pain
and patient outcome variables and are there gender differences in this effect? If social
support buffers the relationships between pain and outcomes, is this effect further
moderated by catastrophizing and/or gender?
Replication of Study 1. The General Linear Model (GLM) analysis was conducted
using SPSS 18 (Chicago, IL). This approach was selected because the data consisted of
continuous predictor variables and multiple dependent outcome variables (i.e., mental and
physical QoL, depressive symptoms, and disability). The dependent variables were patient
outcomes of physical QoL, mental QoL, disability, and depressive symptoms. The predictors
were gender (women with IC/PBS = -1; men with CP/CPPS = 1); pain (SF-MPQ); and
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solicitous, distracting, and negative spouse responses. Additionally, four-way interaction terms
involving gender, pain, a spouse response variable (i.e., solicitous or distracting or negative
responses), and catastrophizing and their associated lower order interaction terms were included.
Because interaction terms were included in the models, all continuous predictors were centered
to reduce multicollinearity between the main effect and product terms (Aiken & West, 1991). In
this set of analyses, if the highest-order interaction was significant, then follow-up analyses were
conducted for this interaction only. If the highest-order interaction was not significant, then only
lower order interactions involving pain and one of the spouse response variables were examined.
None of the interaction terms of interest were significant, ps > .17. Therefore, Study 2 failed to
replicate results reported in Study 1.
Study 2 model with social support from other sources as moderators. A similar
GLM analysis was conducted in SPSS as outlined above. The predictors were gender (women
with IC/PBS = -1; men with CP/CPPS = 1); pain (SF-MPQ); and social support from family,
friends, and physician. Additionally, four-way interaction terms involving gender, pain, a source
of social support (i.e., family, friend, physician), and catastrophizing and their associated lower
order interaction terms were included. None of the interaction terms of interest were significant,
ps > .26. Therefore, the new hypotheses tested in Study 2 were not supported.
Discussion
The objectives of the current study were to replicate findings from Study 1 and extend
Study 1 by examining sources of support other than one’s spouse (i.e., family, friends, and
physician). Gender differences in the levels of reported spouse responses to pain behaviour were
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replicated, but the models predicting disability, depressive symptoms, and mental and physical
QoL were not replicated.
Research Question 1: Are there gender differences in reported spousal responses to pain
behaviour and social support from family, friends and physician between women with
IC/PBS and men with CP/CPPS?
Despite noted differences between samples across the two studies, gender differences in
spouse responses to pain behaviour were consistent. Consistent with predictions, in both Studies
1 and 2 women reported higher levels of solicitous and distracting spouse responses than did
men. As discussed in Study 1, this finding is consistent with reports that men provide more
tangible support than women (Barbee et al., 1990). However, findings are inconsistent with the
support gap hypothesis (SGH; Belle, 1982), which states that men receive more social support
from their wives than women receive from their husbands. There is some suggestion that the
support gap is minimal or nonexistent in early marriage and increases with age (Schwarzer &
Gutierrez-Dona, 2005). Men and women in the current sample were equivalent in age and
reported similar relationship lengths of approximately 20 plus years, suggesting the likelihood of
a support gap. Evidence from recent observational studies suggest the SGH may be too
simplistic and suggests the importance of considering gender role socialization when examining
gender differences in social support provision (Verhofstadt & Devoldre, 2012; Verhofstadt &
Weytens, 2013). In these studies, masculine people reported providing higher levels of tangible
support, and feminine individuals reported higher levels of emotional support provision. The
SGH was supported only in couples in which at least one spouse was stereotypically masculine
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or feminine. Masculinity and femininity are, therefore, important constructs to examine in future
studies regarding gender differences in social support in UCPPS. Such research would clarify
treatment recommendations regarding spousal support.
Consistent with previous research indicating that women are more likely to seek, use, and
receive social support (e.g., Day & Livingstone, 2003; S. E. Taylor et al., 2000; R. J. Turner &
Marino, 1994), women with IC/PBS also reported higher levels of support from friends. Some
researchers suggest that men and women use their social support networks differently such that
men tend to participate in more activity-focused relationships and women maintain more
emotionally intimate relationships (Belle, 1987; Flaherty & Richman, 1989). If men do not use
their network for social support, then it could be argued that their perceived availability of social
support from outside of the romantic relationship is lower for this very reason.
In the current study, men and women reported similar levels of social support from
family. This finding is inconsistent with research demonstrating that women receive more social
support from their family when compared to men (e.g., Umberson, Chen, House, Hopkins, &
Slaten, 1996). However, others suggest that gender differences in support from family members
also depends on the gender of the family member (Monin, Clark, & Lemay, 2008). In a sample
of American college students, female-female family relationships were most supportive and
male-male family relationships were least supportive (Monin et al.). In male-female family
relationships, men felt more supported than in their same-gender family relationships, but
women felt less supported than in their same-gender family relationships. Unfortunately, the
gender of various social support sources was not assessed in the current study and would be an
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important variable to consider in future research in this area. Perhaps the sample in the current
study referred both to men and women in their family rather than a specific family member when
responding to items on the MSPSS, resulting in similar levels of support reported by men and
women.
Research Questions 2 and 3: Does social support moderate the relationship between pain
and patient outcome variables and are there gender differences in this effect? If social
support buffers the relationships between pain and outcomes, is this effect further
moderated by catastrophizing and/or gender?
Replication of Study 1. Models predicting various pain related outcomes were not
successfully replicated in Study 2. As previously noted, the two samples differed on a number of
variables, suggesting participants in Study 2 have higher pain and disability, as well as lower
mental and physical QoL. Of note, with the exception of mental QoL, all of the differences were
also clinically significant. As such, at higher pain severity, as is the case in the Study 2 sample
compared to Study 1, pain may be the only predictor of outcome. Examination of bivariate
correlations in the two studies indicates that the magnitude of associations between pain and each
outcome variable was slightly larger in Study 2 than in Study 1. Therefore, failure to replicate
results from Study 1 may be due to sample differences, as previously noted. Alternatively, the
effects in Study 1 were small in magnitude, were drawn from a larger sample, and may not be as
common in smaller samples.1
1
Partial eta-squared for significant interactions in Study 1 ranged from .01 to .03. Participant recruitment was
discontinued in Study 2 because the pool of potential participants had been exhausted, and there were no additional
sites that could be recruited within a reasonable time to increase the sample size and, therefore, power.
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Extension of study 1. A model including social support from family, friends, and
physician to predict various pain-related outcomes to extend Study 1 was tested, and gender
differences were expected to become more apparent by examining sources of social support
outside of the romantic relationship. However, no significant results for these analyses were
produced in Study 2.
As noted in the general introduction, one significant issue in the social support literature
is the multiple conceptualizations of social support that may underlie some of the inconsistencies
in the social support findings. In much of that literature, the most frequent distinction has been
made between perceived and received social support. Perceived support is the perception that
support would be available if needed, whereas received support refers to supportive behaviours
that are provided by sources of social support (Uchino, 2009). In comparison to received
support, perceived support is more consistently related to beneficial health outcomes (HoltLunstad, Smith, & Layton, 2010).
In the current study, both measures of perceived (i.e., MSPSS) and received (i.e., MPI,
PSQ) support were used. The failure to replicate findings with respect to the role of spouse
responses to pain behaviour and non-significant findings with respect to physician support is
perhaps case in point regarding variability in the association between received support and health
outcomes. However, perceived support from family and friends did not moderate the
relationship between pain and outcome in the current study. It is possible that spouses or
intimate partners are the most important sources of social support in individuals with chronic
pain who have spouses or intimate partners. Research does suggest that social support from
outside of the marriage does not compensate for lack of a supportive marriage (in either
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individuals who are single or are maritally dissatisfied; Coyne & DeLongis, 1986; Holt-Lunstad,
Birmingham, & Jones, 2008), suggesting a unique benefit of spousal support. However, further
replication is necessary, as this study was the first to examine the stress-buffering role of various
sources of social support in individuals with chronic pain.
It is also important to note that much of the literature reviewed in this thesis is drawn
from the general social support literature or from the medical literature associated with chronic
pain conditions other than UCPPS. Perhaps the replication of gender differences in the effect of
sources of social support was not successful because the UCPPS samples examined were
characteristically distinct from the other chronic pain populations. Studies typically examine one
pain condition (e.g., musculoskeletal pain, rheumatoid arthritis) and do not compare the role of
social support across different chronic pain conditions. This area is one for future research. For
example, future studies comparing UCPPS with rheumatoid arthritis and musculoskeletal pain in
regard to social support benefit would be interesting.
Alternatively, gender differences in the stress-buffering effect of social support from
various sources may not have been observed because the positive effect of social support may
have been diluted by the detrimental effect of conflict that comes with increased involvement
with one’s social support network. For example, Turner (1994) found that in a sample of
physically disabled adults, the protective effects of social support on depressive symptoms was
partially negated by the detrimental effect of conflict. This finding was corroborated in a
national probability sample indicating that both social support and social strain predicted wellbeing, but social support exerted a stronger effect (Walen & Lachman, 2000). Therefore, the
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negative aspects or stressors associated with one’s social support network would be important to
consider in examining the effects of the positive aspects of social support in the future.
Limitations and Future Directions
A number of limitations are present in the current study. As noted in Study 1, the current
sample may not be representative of the general IC/PBS and CP/CPPS population and their
spouses. Although the current sample was similar to other reported samples with respect to
UCPPS symptoms severity (Litwin et al., 1999a; Sirinian et al., 2005), the majority of
participants in Study 2 had a university/college degree, was Caucasian and employed and most
participants had been diagnosed with their condition for at least 1 year. Individuals who are on
disability may need more social support, but it is uncertain if they would benefit to the same
extent as individuals who continue to be gainfully employed. Moreover, the role of social
support may change over the course of chronic pain, with social support in the earlier course of
chronic pain being more important in predicting later adjustment (Evers, Kraaimaat, Geenen,
Jacobs, & Bijlsma, 2003; Strating, Suurmeijer, & Van Schuur, 2006). Future studies should
examine social support in individuals with UCPPS-like symptoms and/or individuals newly
diagnosed with UCPPS to determine the role of social support from various sources in predicting
adjustment to chronic pain.
Although the benefit of social support is consistent across cultures (e.g., Morling,
Kitayama, & Miyamoto, 2003), there may be cultural differences in how people seek and receive
social support from their networks (Kim et al., 2008). For example, in a recent review Kim and
colleagues (2008) reported that Asians and Asian Americans are more likely to benefit from
forms of social support that do not involve explicit disclosure of stressful events and feelings of
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distress. These differences would have implications for interventions targeted for couples coping
with chronic pain. However, it appears that psychosocial correlates of IC/PBS are consistent
across Hispanics, African-Americans, and Caucasians (Link et al., 2008). Nonetheless, inclusion
of participants diverse in ethnicity/culture, employment status, and marital satisfaction would be
important in future research.
In retrospect, another limitation of the current study may have been the use of different
types of social support measures. A distinction between perceived and received social support
has been made in the literature, with some evidence suggesting that perceived support is
positively associated with well-being, whereas received support is negatively or unrelated to
well-being (Kaul & Lakey, 2003; Reinhardt, Boerner, & Horowitz, 2006; Wethington & Kessler,
1986). The MPI and PSQ-18 are measures of received support (e.g., “when I am in pain, my
significant other asks me what he/she can do to help,” “when I go for medical care, they are
careful to check everything when treating and examining me”), whereas the MSPSS is a measure
of perceived support (e.g., “I can count on my friends when things go wrong”). An examination
of bivariate correlations indicate that perceived support (i.e., social support from family and
friends) was more strongly associated with pain and outcomes examined in the current study than
was received support (i.e., social support from physicians), but neither perceived nor received
support buffered the relationship between pain and outcome in the current study. Additionally,
whereas the MPI specifically examined spousal support within the context of pain/UCPPS and
participants completed the PSQ-18 in relation to their urologist, the MSPSS was not specific to
pain. Future studies should examine perceived support from various sources specifically within
the context of chronic pain.
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Indeed, other types of social support (e.g., emotional [i.e., expressions of love, empathy,
and concern], tangible [i.e., provision of material assistance], informational [i.e., expressions that
provide facts, advice, and appraisals of situations]) received from other sources were not
examined in the current study and may shed further light on gender differences in the effect of
social support from various sources. Examining the social support-pain literature suggests that
there is a significant range in the amount of social supports provided at least by spouses of
individuals with chronic pain (Newton-John & Williams, 2006). Both individuals with pain and
their spouses reported that spouses responded most frequently by providing help (i.e., behaviours
aimed at either relieving pain or decreasing pain-related distress), followed by observe only (i.e.,
observing and monitoring in response to witnessing pain behaviour) and offer help (i.e., asking if
help is needed thereby allowing the individual with pain to decline the offer). Newton-John and
Williams (2006) reported all other response categories (e.g., discourage pain talk, express
frustration) were rarely endorsed. Preliminary evidence suggests gender differences in what is
preferred with respect to social support in chronic pain, with women preferring solicitude and
activity direction more than men (McWilliams et al., 2012). Future research examining social
support in chronic pain should assess satisfaction with various types of social support provided
by various sources and how satisfaction with various types of social support predicts pain-related
outcomes.
The gender of the source of social support (i.e., family, friends, physician) was not
assessed in the current study and would be of interest, as it may influence the types of social
support enacted (Barbee et al., 1990; Verhofstadt et al., 2007). Studies examining the
characteristics of spouses and/or other sources of social support would also provide a better
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context within which pain and adjustment to pain is experienced. For example, low
catastrophizers perceive less intense pain in others (Sullivan et al., 2006), suggesting that low
catastrophizers are less likely to provide social support or provide less effective forms of social
support.
Directionality of relationships cannot be concluded given the cross-sectional design of
the current study. However, causality can be concluded only via experimental design, which
cannot be pursued in this line of research while continuing to meet ethical standards in human
research. Studies 1 and 2 represent the first studies to simultaneously examine the moderating
role of social support and catastrophizing in the relationship between pain and outcome, as well
as gender differences, in men and women with UCPPS. Although a direct replication was not
reported, there was some consistency of findings across the two studies, despite clinically
significant differences across the samples used.
Conclusions
Results from Study 2 provides corroborating evidence that the support gap hypothesis is
not applicable in men and women with UCPPS, and in fact, women receive more social support
from their partners than men receive from their partners. Additionally, women also receive more
social support from their friends than men do. However, the stress-buffering effect of distracting
spouse responses and amplifying effect of solicitous spouse responses and catastrophizing were
not replicated. Perceived or received social support from one’s romantic partner, family, friend,
or physician does not buffer the negative impact of pain in individuals who report higher pain
severity—participants in Study 2 reported higher pain than participants in Study 1. These results
suggest that the benefit of social support has limits, such that it loses efficacy at higher pain
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severity. Social support can be assessed in many ways and requires further examination in
predicting adjustment to chronic pain.
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Chapter 5: General Discussion
The objectives of this set of studies were to examine the stress-buffering hypothesis of
social support in the relationship between pain and pain-related outcomes in men with CP/CPPS
and women with IC/PBS, and to determine if gender differences exist in this effect. Spousal
social support and social support from other sources were examined alongside intrapersonal
variables, such as pain catastrophizing and perceived control over pain, in their role in
determining pain-related outcomes across the two studies. The results suggest that there are
stress-buffering effects for spousal support, but these effects were not replicated, and there were
no gender differences in the moderating role of spousal support. These studies suggest that no
one theory or model examined in the current dissertation sufficiently predicted the data on the
role of social support or catastrophizing in UCPPS, perhaps suggesting the need for a new
framework to examine these relations.
In the following sections a discussion of related theories and associated research is
offered with directions for future research suggested to allow for a better integration of the
stress-buffering model for social support and catastrophizing as a form of cognitive appraisal and
the communal coping model for catastrophizing. This is a timely discussion because
conceptualizations of catastrophizing and spouse responses to pain behaviour are now
converging on a theoretical framework emphasizing empathy, intimacy, emotional closeness and
emotion regulation in couples with chronic pain (Cano et al., 2008; Goubert et al., 2005; Issner,
Cano, Leonard, & Williams, 2012; Leong, Cano, & Johansen, 2011; Sullivan, 2012).
Theoretical Implications
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The biopsychosocial model and self-regulation of chronic pain. The biopsychosocial
model of chronic pain is a general model implicating biological, psychological, and social factors
in determining pain-related outcomes. Within this broad conceptualization many different
perspectives may be considered in delineating how each factor may contribute to adjustment.
Findings from the current dissertation suggest that the stress-buffering model for social support
does not adequately account for the role of social support in UCPPS as it only predicts that social
support can diminish the negative impact of stress but does not suggest how social support has
this effect.
As discussed in the general introduction, the idea of pain as an exclusive sensory or
physiological experience is outdated, with decades of research demonstrating the significant
influence of psychosocial factors in the experience of pain (e.g., Clay et al., 2010; Gatchel et al.,
2007). A biopsychosocial model suggests that the pain experience is multi-faceted and
comprises three dimensions: 1) sensory-discriminative; 2) affective-motivational; and 3)
cognitive-evaluative. The sensory and affective dimensions of pain are highly responsive to each
other, and supported by parallel neural systems whereby persistent pain appears to be mediated
by neural plasticity or sensitization particularly in the medial pain system (responsible for the
affective-motivational dimension of pain; Lumley et al., 2011). The relationship between the
sensory component of pain and a persons’ affective state has been demonstrated in laboratory
pain studies. For example, experimental induction of negative emotions (e.g., anxiety) results in
increased pain severity during a cold pressor task (Carter et al., 2002). Additionally, more
intense pain experience and lower pain tolerance were reported in a sample of chronic back pain
patients listening to sad music, whereas a happy mood induction resulted in lower pain ratings
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and greater pain tolerance (Tang et al., 2008). The relationship between emotions and pain is so
strong that several population-based longitudinal studies have actually found that depressed,
pain-free individuals are on average two times more likely to develop chronic musculoskeletal
pain than non-depressed, pain-free individuals (Carroll, Cassidy, & Cote, 2004; Larson, Clark, &
Eaton, 2004; Magni, Moreschi, Rigatti-Luchini, & Merskey, 1994).
Self-regulation has long been suggested as an essential component of psychological
interventions for pain ultimately with the aim of altering the physiological experience of pain via
altering the psychological (i.e., stress, emotion) experience of pain. Rooted in Melzack & Wall’s
(1965) gate control theory of pain, self-regulatory strategies including biofeedback and
relaxation training were the earliest of such interventions. The research reviewed above suggests
not only are the sensory and affective components of pain inextricably linked but emotions and
affective experience in general are strongly linked to pain. Therefore, what regulates one can
ultimately regulate the other and influence adjustment to chronic pain. As such, an emotion/pain
regulation perspective may be best suited in advancing our understanding of the role of social
support in determining adjustment to chronic pain.
Emotion regulation is the process by which we influence which emotions we have, and
how and when we experience emotions (Gross, 1998). Emotions can also be regulated in a dyad;
that is, involving a partner (e.g., therapist, spouse, friend) who provides assistance (i.e., social
support) with the regulation of an affective experience. Emotion dysregulation occurs when an
individual is simultaneously unable to accept an emotional experience and change it effectively
(Fruzetti & Iverson, 2006) and may be facilitated by problematic responses of others to
expressions of emotions, wants, thoughts and goals (Fruzetti & Iverson, 2006). Validation and
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invalidation are responses that moderate high emotional arousal, where validation is the
communication of acceptance and understanding, and invalidation is the communication of
rejection or failure to understand the experiences of the other (Fruzetti & Iverson, 2006). There
is some suggestion that negative spouse response to pain behaviour is a form of invalidation, but
it is unclear how solicitous and distracting spouse responses to pain behaviour load onto
validation and invalidation (Cano et al., 2008). However, Cano and colleagues’ study was the
first of its kind, and replication of this work has yet to be published.
The communal coping model of catastrophizing. According to the communal coping
model of catastrophizing, the pain expressions of high catastrophizers maximize the probability
that distress will be managed within a social/interpersonal context (Sullivan et al., 2001), thereby
implying that catastrophizing may be a means of dyadic regulation through emotional disclosure
and/or expression of need for social support. Findings from Study 1 suggest that catastrophizing
may be an important part of dyadic regulation of pain and emotion, as demonstrated by the
strong and negative association between pain and mental QoL at high levels of catastrophizing.
Some evidence suggests that pain duration may help determine the extent to which
catastrophizing may be adaptive. In a study by Cano (2004) higher levels of catastrophizing
were associated with higher levels of solicitous spouse responses to pain behaviour and were not
significantly associated with general spousal support but only in the short term. In the long-term,
high catastrophizing was not significantly associated with solicitous spouse responses, but rather
it was associated with lower levels of general spousal support. Of note, Cano reported the
interaction between catastrophizing and pain duration and the main effect of pain duration did
not significantly predict distracting or negative spouse responses, suggesting that catastrophizing
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does not necessarily lead to expressions of frustration or hostility by one’s spouse in prolonged
situations of pain (i.e., chronic pain). Rather, catastrophizing in the long term leads to a decline
in the provision of general spousal support, but is unrelated to the provision of pain-specific
support. These findings were corroborated by Buenaver and colleagues (2007), who found that
catastrophizing was most strongly associated with solicitous spouse responses at shorter pain
durations, but they also found that the interaction between pain duration and catastrophizing was
not significant in predicting punishing responses. Pain duration was not examined in the current
dissertation in the moderation analyses and was approximated in Study 2 using time since
diagnosis (an underestimation of pain duration—this data was not collected in Study 1). Results
from Study 2 do not provide conclusive evidence suggesting catastrophizing becomes
maladaptive over time, but one possible area for investigation is the interpersonal context within
which catastrophizing occurs.
Interpersonal models of depression suggest that individuals with depression behave in
ways that actively and negatively shape their interpersonal environments resulting in
interpersonal rejection (Coyne, 1976). Research in the pain literature provides some evidence
that similar processes occur in the lives of individuals with chronic pain. For example, high
catastrophizers report receiving less social support from others (Boothby et al., 2004; Buenaver
et al., 2007), and they also feel “entitled” to more support than they receive (Cano, Leong,
Heller, & Lutz, 2009). Analyses of observational data also revealed that high levels of support
entitlement were associated with greater invalidation responses from spouses (Cano et al., 2009),
suggesting that high catastrophizers behave in ways that lead to interpersonal rejection. Results
from Study 1 indicated higher pain was associated with lower mental QoL at high levels of
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catastrophizing. One possible mechanism of this relationship is through invalidation, resulting in
failure to regulate pain and emotions and poorer mental QoL.
Research on catastrophizing suggests that high catastrophizers display more
communicative pain behaviours and use fewer coping strategies only in the presence of an
observer (Sullivan et al., 2004). Sullivan and colleagues (2004) also reported high
catastrophizers indicated higher pain intensity than low catastrophizers during the cold pressor
task regardless of the presence of an observer, suggesting that high catastrophizers were less
effective in employing coping strategies. As such, it appears that high catastrophizers require
social support to supplement their own efforts in managing their pain-related distress as they may
have poorer self-regulatory mechanisms. This suggestion is consistent with research
demonstrating a relationship between catastrophizing and insecure and anxious attachment styles
in both pain-free and clinical samples (Meredith, Strong, & Feeney, 2006; Tremblay & Sullivan,
2010). In response to emotionally distressing or challenging situations, individuals with insecure
and anxious attachment are guided by “rules that direct attention toward distress and attachment
figures in a hypervigilant manner that inhibits the development of autonomy and selfconfidence” (Kobak & Sceery, 1988, p. 142). However, the relationship between catastrophizing
and poor self-regulation remains speculative as no published research has directly examined
whether high catastrophizers exhibit poor self-regulation, nor does any research report whether
catastrophizing predicts the efficacy of self-regulatory approaches to pain management (i.e.,
biofeedback, relaxation training, hypnotherapy, and mindfulness).
Although not directly supported by data in the current dissertation, based on research
reviewed it is speculated that the communal coping model of catastrophizing is qualified by the
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context within which it occurs (e.g., attachment style of the couple, spouse’s pain
catastrophizing). Further research is required to determine the circumstances under which
catastrophizing is an effective means of dyadic emotion and pain regulation.
UPOINT. The UPOINT system (Shoskes et al., 2009) for guiding treatment of UCPPS
consists of six domains: urinary symptoms, psychosocial dysfunction, organ-specific findings,
infection, neurologic dysfunction, and tenderness of muscles. The domain of primary concern in
regard to this thesis is that of psychosocial dysfunction, which includes “maladaptive” cognitive
coping strategies such as catastrophizing as a potential therapeutic target. However, given recent
discussions of catastrophizing in the pain literature that a perspective of catastrophizing as purely
a cognitive variable is inadequate (Sullivan, 2012), the view of catastrophizing as categorically
maladaptive is outdated. Rather, it may be that the interpersonal context of catastrophizing
determines the extent to which it is adaptive or maladaptive. In his recent review of
catastrophizing, Sullivan (2012) states that cognitive conceptualizations of catastrophizing do not
comment on interpersonal processes related to support seeking, communication, and validation,
all of which are characteristic of the experience of high catastrophizers.
Sullivan also suggested that cognitive models tended to “pathologize” catastrophizing,
although catastrophizing is demonstrated to be present in many healthy individuals without
emotional disorders, once again suggesting that it may be the social responses to catastrophizing
that determine whether or not it is adaptive. Therefore, with respect to the psychosocial domain
of the UPOINT system, an assessment of catastrophizing alone would be described as inadequate
and the inclusion of one’s spouse and the dyadic patterns of perceived social support is
recommended to determine what, if indeed any, type of psychological intervention is indicated.
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However, much remains unknown regarding helpful social responses to catastrophizing, and this
is one of the important areas for future research discussed below.
Future Research
Within the biopsychosocial model of pain, it is suggested here that the role of social
support and catastrophizing may be best considered within a framework of dyadic emotion and
pain regulation. More research is needed to determine the relationships among catastrophizing,
social support, validation and invalidation, as this will help to determine what types of responses
successfully regulate the pain experience.
The current line of research can be extended in a number of ways. One possible area for
future research is to use pain vignettes as described by Newton-John and Williams (2006)
whereby individuals with chronic pain would read the vignettes and describe how their spouse,
friend, and a designated family member would normally respond to the described pain situation.
As this will generate a large amount of data for qualitative analysis, it is proposed that only
individuals with chronic pain participate and be separated into 3 groups: one group that will
respond to the vignettes with respect to their spouse’s responses, friend’s responses, and family
member’s responses. This research will allow us to determine if different sources of support
provide different types of support, how much variance there is in the types of support provided
within each source and if there are gender differences. This would extend previous research
indicating that men and women use their social support networks differently (Belle, 1987;
Flaherty & Richman, 1989) by applying it to individuals with chronic pain.
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Future research can also more closely examine spouse responses to pain behaviour, as it
has been demonstrated that spouses provide a wider array of responses to pain behaviour than
evaluated by the MPI (Newton-John & Williams, 2006). The Pain Response Preference
Questionnaire (PRPQ; McWilliams, Saldanha, Dick, & Watt, 2009) was developed based on the
results of the Newton-John and Williams study and is currently the most exhaustive measure of
spouse responses to pain. However, this measure is still in the validation stages, and it remains
to be confirmed whether the measure is comprised of 3 factors (i.e., solicitude, suppression and
activity direction) or 4 factors (i.e., solicitude, suppression, management and encouragement).
Nonetheless, the PRPQ would allow for the assessment of responses to pain not previously
assessed, and an exploratory factor analysis is suggested for the PRPQ to determine the
relationship of its factors with validation and invalidation, both pertinent to emotion regulation.
Using methods reported by Cano and colleagues (2008), couples with chronic pain (or more
specifically with UCPPS) would participate in marital interactions regarding the impact of pain
on their lives. Videotaped interactions would then be coded for validating and invalidating
behaviours, and exploratory factor analyses would then be conducted along with PRPQ scales.
This research would help to determine what types of spouse responses are likely to facilitate
emotion regulation, as it is presently unclear how different types of spouse responses should be
conceptualized within an emotion regulation perspective (i.e., which responses are validating and
which are invalidating).
Daily diary studies are also suggested to determine what spouse responses to pain
behaviour look like in vivo as well as to examine the role of empathic effort. Empathic effort
(i.e., perception that one’s partner is motivated to understand) is more strongly associated with
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women’s relationship satisfaction than men’s relationship satisfaction (Cohen, Schulz, Weiss, &
Waldinger, 2012), and therefore, may have differential predictive value in determining outcomes
across men and women with UCPPS. Spouses' maladaptive attributions for events in their
relationship are influenced by levels of marital satisfaction, such that distressed spouses are more
likely than nondistressed spouses to see their partners’ negative actions as intentional and
selfishly motivated (Bradbury & Fincham, 1990; Epstein, Baucom, & Kendall, 1993; Fincham,
1994). Applying this to the social support in chronic pain research, negative spouse responses or
expressions of anger and frustration may not necessarily result in pain and emotion dysregulation
in the individual with chronic pain if perceived empathic effort is high.
The diary study suggested above could be completed using smartphones whereby
individuals with chronic pain would be prompted a number of times daily and asked if they had
expressed pain to their spouses in the previous hours, and if so, to describe how their spouse
responded and also rate their pain and negative affect pre- and post-spouse response. These data
could then be analyzed qualitatively. This type of research would provide a more ecologically
valid assessment of how spouses respond to pain and would also allow us to determine how
accurately current spouse inventories represent spouse responses to pain. As well, we would be
able to determine if empathic effort mediates the interaction between negative spouse responses
and marital satisfaction in the prediction of emotion regulation (operationalized as change in
level of negative affect pre-post spouse responses). Ideally observational studies would be best
to allow for an objective assessment of spouse responses to pain behaviour. However, it would
be difficult to get an ecologically valid situation of UCPPS pain in the lab; unlike low back pain,
for example, there are no specific tasks that we could reproduce in the lab without being
114
unethical (e.g., causing flare up with caffeine or spicy food, etc.). An alternative to a daily diary
study would be an observational study of experimentally induced pain (e.g., cold pressor task) in
individuals with UCPPS.
Of note, intrapersonal characteristics of spouses were not assessed in the current
dissertation. This would be an important area for future research, as these characteristics will
influence how and under what conditions spouses respond to their partners’ pain, thus regulating
the pain experience. Information including spouses’ level of catastrophizing and pain status are
of particular interest. For example, low catastrophizers have been shown to perceive less intense
pain in others (Sullivan et al., 2006), suggesting that low catastrophizers are less likely to
validate a partner’s pain experience. Additionally, Gauthier and colleagues (2011) found that the
highest levels of pain behaviour were observed when high catastrophizing chronic pain patients
were married to low catastrophizing spouses. Gauthier et al. (2011) hypothesized that high
catastrophizers had to increase the “volume” of their pain communication to compensate for their
low catastrophizing spouse’s tendency to underestimate pain. Of note, Gauthier and colleagues
(2011) assessed spouses’ catastrophizing about their own pain and not their partners’ pain. It is
possible that spouses who catastrophize about their partners’ pain may be more sensitive to their
partners’ expression of pain and more likely to express validation than spouses who do not
catastrophize about their partners’ pain. However, a recent study reported by Leonard and
colleagues (2013) suggests that higher catastrophizing about a partner’s pain does not necessarily
result in better empathy. Therefore, further research is required to examine the role of spouse
catastrophizing about their own pain and their partner’s pain.
115
In addition to catastrophizing, partners who do not have a pain history may be less likely
to empathize thus preventing effective emotion regulation. Johansen and Cano (2007) reported
that sadness observed during a recorded marital interaction was related to fewer depressive
symptoms and less pain only when both members of a couple reported pain, suggesting that
partners with pain are better able to regulate their partner’s experience of pain, which may be a
reflection of their interpersonal empathy for others’ pain. Using self-report data, a multiple
moderator model could be examined to determine the relationship between pain and outcome,
such that when spouse catastrophizing is low and pain history is absent, pain is associated with
poorer outcomes. It is also suggested that both spouse’s catastrophizing about their own pain
and catastrophizing about their partner’s pain are assessed to determine if there are differential
effects between the two variables. Examination of spousal characteristics will help to inform
treatment models that are tailored to the couple rather than the individual with chronic pain.
Empathic accuracy is another spouse characteristic suggested for future research.
Empathic accuracy is the extent to which one can accurately infer a partner’s thoughts and
feelings during an interaction (Ickes & Simpson, 1997); therefore, it is important in determining
how spouses respond to regulate their partner’s pain experience. Empathic accuracy is thought
to be important in everyday non-conflictual and non-threatening interactions, as it enhances
relationship quality. However, in relationship-threatening situations empathic accuracy
engenders strong negative feelings toward one’s partner contributing to relationship
dissatisfaction. In such situations less accuracy has actually been demonstrated to be related to
increased relationship satisfaction (Simpson, Orina, & Ickes, 2003), which has been termed
“motivated inaccuracy”. That is, in order to preserve the relationship, the perceiver is motivated
116
to not attend to the emotions or assume their partner’s thoughts and emotions are less negative
than they really are.
Presently, only one published study has examined empathic accuracy in couples with a
chronic pain sufferer (Leonard et al., 2013). Leonard and colleagues reported that spouses’
perception of their partner’s pain severity was associated with lower empathic accuracy but only
at longer pain durations. The authors interpreted this finding as spouses of individuals with
severe chronic pain become less empathically accurate over time because they are discouraged
that their partner’s pain has not improved. However, Leonard and colleagues (2013) did not
account for marital satisfaction in their analyses. It is possible that empathic accuracy decreases
over time, but only for individuals with low marital satisfaction (i.e., for spouses who perceive
their partner’s pain as threatening). Using methods described by Cohen and colleagues (2012),
empathic accuracy in videotaped marital interactions of couples with a chronic pain sufferer
could be tested in a multiple moderation analyses to determine if marital satisfaction moderates
the interaction between pain severity and pain duration in predicting empathic accuracy. This
research would help inform interventions aimed at couples with a chronic pain sufferer with low
marital satisfaction.
Clinical Implications
The clinical implications discussed here remain speculative given the relative novelty of
research in the role of social support and catastrophizing in chronic pain within an emotion
regulation perspective. Additionally, given the number of unmeasured factors (e.g., spouse
variables including pain history and catastrophizing) the application of findings in clinical
intervention is limited. Furthermore, clinical significance was not assessed in the current study
117
and therefore, it is unclear whether spousal support buffers the negative impact of pain to a
clinically meaningful extent. With that said results from the current dissertation suggest that
distraction in the form of engaging the individual with chronic pain in pleasurable activities or in
conversation may facilitate regulation of the pain experience. With respect to solicitous spouse
responses, results from the current dissertation suggest that too much solicitousness can be
harmful especially when individuals with chronic pain are low in catastrophizing (i.e., do not
request social support). However, the right amount of spouse solicitousness can help to reduce
distress. Additionally, using cognitive behavioural therapy and assertive communication skills,
couples in which one spouse experiences chronic pain can be taught to improve their
communication by being explicit with one another regarding intentions of provided social
support and interpretation of social support to facilitate improved provision of social support
(Keefe et al., 1996, 1999).
Results of the current line of research also suggest that catastrophizing is important in
predicting adjustment to chronic pain. It is recommended that catastrophizing be more
thoroughly assessed in couples with a chronic pain sufferer by also examining how spouses
respond to their partner’s catastrophizing, and the exploration of benefits and disadvantages of
catastrophizing for the partner with chronic pain. Such an approach would provide a better
context for catastrophizing within each couple, as it is currently unclear what determines
catastrophizing as adaptive or maladaptive.
Summary and Conclusions
The current studies shed light on the role of social support in men and women with
UCPPS. The studies reported in this dissertation were the first to examine the stress-buffering
118
role of social support within the context of intrapersonal variables (e.g., catastrophizing and
perceived control over pain) and also the first studies to examine the support gap hypothesis
within a chronic pain sample. The studies suggest that the support gap hypothesis is not
applicable in UCPPS and future studies need to examine other variables including
catastrophizing in relation to possible gender differences in social support. Although not
replicated in Study 2, Study 1 suggests that the role of solicitous spouse responses to pain
behaviour is dependent on catastrophizing, such that high levels of spouse solicitousness
strengthens the relationship between pain and mental QoL only when catastrophizing is low.
Additionally, results of Study 1 indicate that distracting spouse responses buffer the negative
impact of pain and the role of distracting spouse responses requires further investigation in the
chronic pain literature. Although the concept of distraction in the pain literature is far from
novel, few publications in the pain literature focus on the role of spousal distraction. Future
study designs need to examine distracters that also act to regulate the pain experience to further
clarify the potential benefits of distraction in chronic pain. Results from Study 1 also suggest
that the stress-buffering hypothesis of social support is much too simplistic as it does not
consider the context within which supportive transactions occur nor does it suggest how social
support can be of benefit.
An additional objective of the current research was also to determine gender differences
in the role of social support. Results from the current studies suggest that there are no gender
differences in the role of social support in individuals with UCPPS. Gender differences are
rarely reported in the social support chronic pain literature either due to non-significant findings
or gender was not a variable of interest to the researcher. Given gender differences in seeking
119
and providing social support, as well as gender differences in pain communication, gender
continues to be a variable of interest in the examination of pain regulation. Much remains
unknown regarding what is helpful in determining long-term adjustment, and what gender
differences exist (if any). The current studies suggest that despite possible gender differences in
received social support, social support operates similarly in men and women with UCPPS.
Longitudinal studies may be important with respect to advancing our knowledge in this
particular area, but cross-sectional studies are valuable in determining the critical variables to be
examined in longitudinal studies.
What is apparent from these studies is the importance of examining chronic pain within
its interpersonal context, as it shapes the experience of pain and emotions associated with
chronic pain. Although the interpersonal context within which chronic pain is experienced has
long been considered an important determinant of outcomes, most empirically supported
psychological interventions for chronic pain are solely focused on the individual with pain.
Research suggests that couples with a chronic pain sufferer could benefit from interventions
aimed at both partners, rather than just the individual with pain (Leong et al., 2011). Not only
does the pain and relationship literature emphasize the importance of the interpersonal context of
pain, but a recent review of catastrophizing by Sullivan (2012) also places great emphasis on
examining pain catastrophizing in its interpersonal context. In line with this, researchers such as
Cano and colleagues (Cano et al., 2008) specifically suggest examining spouse responses to pain
behaviour in light of emotion regulation and empathy theories. Social support and
catastrophizing were discussed within a dyadic pain and emotion regulation context and several
120
directions for future research were suggested to inform the biopsychosocial model of chronic
pain.
121
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Appendix
Chronic Prostatitis Collaborative Research Network (CPCRN) Study Group Northwestern
University:
Anthony J. Schaeffer, MD Principal Investigator (PI); Charles L. Bennett, MD, PhD; Wade
Bushman, MD, PhD; Elizabeth A. Calhoun, PhD; Alisa Erika Koch, MD; Robert B. Nadler, MD;
Mary Healy, RN; Marylin Dopona
Brigham and Women’s Hospital: Michael P. O’Leary, MD, MPH (PI); Debra Rhodes, MD:
Judith Spolarich-Kroll, BA; Alex Adler
Massachusetts General Hospital: Mary McNaughton Collins, MD, MPH; Michael J. Barry,
MD
Queen’s University: J. Curtis Nickel, MD (PI); Dean A. Tripp, PhD; Dale Ardern, RN; Janet
Clark, ACP; Joseph Downey, MSc
Temple University: Michel A. Pontari, MD (PI); Michael R. Ruggieri, PhD; Linda Kish, BA;
Sharon Filer-Maerten, BS
University of California, Los Angeles: Mark S. Litwin, MD, MPH Principal Investigator (PI);
Scott I. Zeitlin, MD; Yining Xie, MD
University of Maryland: Richard B. Alexander, MD Principal Investigator (PI); Sathibalan
Ponniah, PhD; Cindy S. Lowder, MS, RN; Kim Burton
University of Mississippi: Jackson E. Fowler, Jr, MD (PI); Rachael Tapley, RHIA; Anne
Dautenhahn
Cleveland Clinic, Fort Lauderdale: Daniel Shoskes, MD (PI); Kim Thomas
Martin Luther King Hospital: Nand S. Datta, MD (PI); Mary Ellen Raimo; Kawajalen Mervin
University of Arizona: Craig V. Comiter, MD (PI); Pat Conrad
University of Pennsylvania School of Medicine: J. Richard Landis, PhD Principal Investigator
(PI); Kathleen J. Propert, ScD; John T. Farrar, MD; Harold I. Feldman, MD, MS; Denise Cifelli,
BS; Stephen Durborow, BS; Lori Fanelli, BA; Xueyou Hu, MS; Lee Randall, BA; Jill S. Knauss,
MS; Randy Hildebrand, MS; Gina Norwood, BS; Marie Durborow; Christopher Helker, RN,
MPH
The National Institute of Diabetes and Digestive and Kidney Disease (NIDDK): John W.
Kusek, PhD (Project Officer); Leroy M. Nyberg, PhD, MD
139