Putting the psychosocial back into biopsychosocial:
Serious injury, pain and cognition
Part 2: Evidence supporting SCIAM
Ashley Craig and James Middleton
John Walsh Centre for Rehabilitation Research, Kolling Institute of Medical Research
Sydney Medical School-Northern, The University of Sydney, NSW Australia
1
Age, sex, pain, bladder/ bowel
dysfunction, tiredness, pressure
areas, TBI, time since injury,
injury level, medications
Cognitions: Specific selfefficacy, pain catastrophisation,
perceptions of vulnerability and
benefit, meaning
Behaviours: Adaptive
(pacing, self-management)
and maladaptive (alcohol
abuse, withdrawal)
Positive
adjustment
Biological/ medical
factors
Personality,
pre-morbid
mental
health and
cognitive
function,
general selfefficacy,
fatigue
Psychological factors
Appraisal and
reappraisal
Social, environmental,
political, cultural and
religious factors
Participation in
valued social
roles, adapting
to changing
health
Coping strategies
Psychological
morbidity,
relationship
breakdown
Resilience and
motivational process
Negative
adjustment
Employment, legislative framework,
social support, social barriers and
mobility, QOL
Moderators
Mediators
Outcome
The SCI Adjustment Model
Middleton, J., & Craig, A. (2008). Psychological challenges in treating persons with spinal cord injury. In A. Craig
and Y. Tran (Eds.). Psychological dynamics associated with spinal cord injury rehabilitation: New directions and
best evidence. New York: Nova Science Publishers.
Pain catastrophisation involves an exaggerated and negative
cognitive-affective response to one’s pain.
Higher pain catastrophisation is related to altered attention,
anticipation, and heightened emotional responses to pain
(Flor et al., 1993; Quartana et al., 2009; Sullivan et al., 1995).
Model for the integrative study of pain catastrophising (From: Quartana, P.
J., Campbell, C. M., & Edwards, R. R. (2009). Pain catastrophizing: a critical review. Expert
Review of Neurotherapeutics, 9(5), 745-758.
Pain intensity as a function of depressive mood up to 12
months post injury (6 months post discharge) in adults
with SCI (Craig, Middleton et al )
Pain catastrophisation as a function of depressive mood up to 12
months post injury in adults with SCI (Craig, Middleton et al )
Pain catastrophisation was assessed using the Pain Related Self-statement Scale
Catastrophisation domain developed by Flor et al., (1993)
Pain catastrophisation as a function of anxiety up to 12 months
post injury in adults with SCI (Craig, Middleton et al )
Pain catastrophisation was assessed using the Pain Related Self-statement Scale
Catastrophisation domain developed by Flor et al., (1993)
Self-efficacy has been defined as ‘the belief in one’s capabilities to
organize and execute the courses of action required to produce given
attainments’ (Bandura, 1997)
Self-efficacy involves an assessment of the extent to which a person
perceives they can control their behaviour, lives and daily outcomes
Self-efficacy protects against the impact of chronic pain
Pain intensity and self-efficacy were shown to contribute to the development of
disability and depression in patients with chronic pain.
Specifically, a poor belief in one’s ability to manage pain was a significant
predictor of pain related disability and depressive mood
Arnstein, P. et al., (1999). Self efficacy as a mediator of the relationship between pain intensity,
disability and depression in chronic pain patients Pain, 80, 483–491.
Chronic pain influences mood (and mood influences pain)
(Greater time since injury associated with lower pain)
TIME SINCE
INJURY
-0.31
CHRONIC PAIN
0.50
DEPRESSIVE
MOOD
Craig, A., Tran, Y., Siddall, P., Wijesuriya, N., Lovas, L., Bartrop, R., & Middleton, J. (2013).
Developing a model of associations between chronic pain, depressive mood, chronic fatigue
and self-efficacy in people with spinal cord injury. The Journal of Pain, 14, 911-920.
Self-efficacy mediates/ buffers this effect of pain on mood
SELF-EFFICACY
-0.47
-0.54
TIME SINCE
INJURY
-0.31
CHRONIC PAIN
0.32
DEPRESSIVE
MOOD
Craig, A., Tran, Y., Siddall, P., Wijesuriya, N., Lovas, L., Bartrop, R., & Middleton, J. (2013).
Developing a model of associations between chronic pain, depressive mood, chronic fatigue
and self-efficacy in people with spinal cord injury. The Journal of Pain, 14, 911-920.
However, self-efficacy has no influence on fatigue
Chronic pain and depressive mood related to higher fatigue (and vice versa)
SELF-EFFICACY
-0.47
-0.54
TIME SINCE
INJURY
-0.31
CHRONIC PAIN
0.32
0.52
DEPRESSIVE
MOOD
0.40
FATIGUE
Craig, A., Tran, Y., Siddall, P., Wijesuriya, N., Lovas, L., Bartrop, R., & Middleton, J. (2013).
Developing a model of associations between chronic pain, depressive mood, chronic fatigue
and self-efficacy in people with spinal cord injury. The Journal of Pain, 14, 911-920.
Evidence suggests self-efficacy protects against negative mood
in adults with SCI
Craig, A., et al., (2013). The influence of self-efficacy on mood states in people with spinal cord injury.
ISRN Rehabilitation, vol. 2013, 1-6.
Age, sex, pain, bladder/ bowel
dysfunction, tiredness, pressure
areas, TBI, time since injury,
injury level, medications
Specific self-efficacy, pain
catastrophisation, perceptions
of vulnerability and benefit,
meaning
Adaptive (pacing, selfmanagement) and
maladaptive (alcohol abuse,
withdrawal)
Positive
adjustment
Biological/ medical
factors
Personality,
pre-morbid
mental
health and
cognitive
function,
general selfefficacy,
fatigue
Psychological factors
Appraisal and
reappraisal
Social, environmental,
political, cultural and
religious factors
Participation in
valued social
roles, adapting
to changing
health
Coping strategies
Psychological
morbidity,
relationship
breakdown
Resilience and
motivational process
Negative
adjustment
Employment, legislative framework,
social support, social barriers and
mobility, QOL
Moderators
Mediators
Outcome
The SCI Adjustment Model
Middleton, J., & Craig, A. (2008). Psychological challenges in treating persons with spinal cord injury. In A. Craig
and Y. Tran (Eds.). Psychological dynamics associated with spinal cord injury rehabilitation: New directions and
best evidence. New York: Nova Science Publishers.
Mood as a function of cognitive performance in adults with
SCI (From: Craig, Guest, Tran, & Middleton. (submitted). Cognitive impairment
and mood states following spinal cord injury)
Research findings using the MSES
Quality of life and SCI (Middleton, J., Tran, Y., & Craig, A. (2007).
Relationship between quality of life and self-efficacy in persons with spinal cord
injuries. Archives Physical Medicine and Rehabilitation, 88, 1643-1648.)
Self-efficacy is related to higher quality of life in adults with SCI
High and low self-efficacy (SE) across SF-36 QOL domains compared to
Australian norms
Source: Middleton, Craig & Tran (2007). Archives Phys Med Rehab, 88, 1643-1648
90
80
QOL SF-36
70
60
50
40
Those with
high selfefficacy
different to
Australian
norms in
three
physical
domains
30
20
phys fn
phys role
pain
Aust norms
health
vitality
low SE SCI
social fn
emot fn
High SE SCI
mental
health
High and low self-efficacy (SE) across SF-36 QOL domains compared to
Australian norms
Source: Middleton, Craig & Tran (2007). Archives Phys Med Rehab, 88, 1643-1648
90
80
QOL SF-36
70
60
50
40
30
20
phys fn
phys role
pain
Aust norms
health
vitality
low SE SCI
social fn
emot fn
High SE SCI
mental
health
Those with
low selfefficacy
different to
the other
two groups
in all
domains
p<.05
CONCLUSIONS
Findings from research are continuing to transform and shape
SCIAM
This model improves our understanding of how people with injury
adjust over time
It provides direction for improving psychosocial interventions for
adults with serious injury like SCI
It provides a basis for predicting those who will have trouble with
adjustment over time
Thank you