Pain self-efficacy moderates the association between pain and somatization in a community sample

Petri Karkkola; Sanna Sinikallio; Niko Flink; Kirsi Honkalampi; Matti Kuittinen

doi:10.1515/sjpain-2018-0052

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Pain self-efficacy moderates the association between pain and somatization in a community sample

Petri Karkkola , Sanna Sinikallio , Niko Flink , Kirsi Honkalampi and Matti Kuittinen

Published/Copyright: September 21, 2018

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From the journal Scandinavian Journal of Pain Volume 19 Issue 1

Abstract

Background and aims

Pain is a common condition. However, only a minority of people experiencing pain develop a chronic pain problem. Factors such as somatization, pain self-efficacy and lack of psychological well-being affect the risk of pain chronicity and pain-related disability. However, research on protective pain-related psychological factors in populations without chronic pain is scarce. We aim to examine if pain self-efficacy attenuates the associations between pain and both anxiety and somatization in a community sample.

Methods

In a cross-sectional study, 211 participants from a community sample responded to measures of average pain over the last 3 months, anxiety, somatization, and pain self-efficacy. The possibility of moderation effects were tested with a series of regression analyses.

Results

The association between pain and anxiety was not moderated by pain self-efficacy. In contrast, pain self-efficacy moderated the relation of pain and somatization. The interaction explained 3% of the variance in somatization, in addition to the independent effects of pain and self-efficacy (F(1,207)=5.65, p<0.025). Among those in the bottom quartile of pain self-efficacy, the association between pain and somatization was moderate or strong (r=0.62, p<0.01), whereas for those in the top quartile the association was modest (r=0.11, p>0.05).

Conclusions

The results are partly consistent with the hypothesis that pain self-efficacy attenuates the associations between pain and pain chronification risk factors in a relatively healthy community sample. Should further preferably longitudinal studies replicate the findings, the role pain self-efficacy as a protective factor needs to be explicated in theoretical models of pain chronification.

Implications

The findings are consistent with the notion that clinicians should promote patient’s pain self-efficacy in acute and sub-acute pain conditions especially when the individual is prone to somatization. However, more prominent clinical implications require studies with longitudinal designs.

Keywords: pain; anxiety; somatization; self-efficacy

1 Introduction

Pain is a common experience. The global mean for 1-year prevalence of neck pain is 25% [1] and for low back pain nearly 40% [2]. The burden of these conditions, measured in years lived with a disability, is high [3, 4]. Pain is often related to psychological symptoms [5] and sleep disturbance [6]. In Europe, approximately 19% of adults experience chronic pain [7], which affects well-being and healthcare use [8].

A minority of people who experience pain develop a debilitating pain condition [9]. Until recently, discussions about the dynamics of recovery and protective factors have been scarce [10, 11]. Positive affect and optimism have been suggested to prevent pain chronification as they promote the pursuit of subjectively valued life goals [12]. In addition to positive affect [13], resilience [14] has moderated associations between pain and emotional outcomes, thus potentially acting as a protective factor. To our knowledge, the only pain-specific moderating factor that has been examined is pain acceptance [15].

Self-efficacy concerns what a person believes they can do with their cognitive, social, emotional and behavioural skills to achieve goals in certain domains or situations [16]. Self-efficacy may affect health status, motivation and an adherence to prescribed regimens [17], thus potentially affecting the ability to achieve goals that are otherwise hindered by illness or incapacity. Pain-related self-efficacies have been defined, for example, as a person’s belief in their ability to control pain or associated negative emotions, or to function despite the pain [18]. The latter form of self-efficacy has been particularly associated with low functional impairment [19]. For example, it has predicted less avoidance coping [20] and an increased probability of remaining at work despite recurring pain [21]. It has been associated with positive change in pain management interventions [22, 23] and in primary care [24]. Thus, self-efficacy beliefs on functioning despite pain constitute a plausible protective factor that motivates the continuance of the pursuit of valued goals. We aim to examine whether a person’s self-efficacy to function despite their pain attenuates the association between pain and the two non-pain-specific factors of somatization and anxiety in a community sample. Although speculative, it has been suggested that more pain-specific symptoms may only be relevant in chronic pain contexts [25].

Somatization is a tendency to experience and communicate somatic distress and symptoms unaccounted for by pathological findings, to attribute them to physical illness and to seek medical help for them [26]. Somatization has been associated with healthcare use [27], fear-avoidance strategies [28] and risk of pain chronicity, and disability [29]. It may amplify transient pain sensations, making them more persistent [30]. We propose that pain accompanied by low self-efficacy is associated with higher somatization symptoms, whereas high self-efficacy attenuates the association as, through the facilitation of goal pursuit, it may decrease somatic distress and the need to communicate symptoms, attribute them to illness, or seek medical help.

Anxiety symptoms are common in people with chronic pain [5]. The relationship between pain and anxiety is probably bidirectional [31]. Furthermore, anxiety and pain are associated in the general population [32]. Pain may disrupt activities by capturing attention and directing it towards new priorities that concern threat detection, a key factor in anxiety symptomology [33], and choice of behaviour, often characterised by avoidance [34]. In the present study, we hypothesise that high pain self-efficacy attenuates the association between pain and anxiety as it promotes goal pursuit and provides counter-evidence for the intrusive effects of pain or directs attention away from pain experiences, thus decreasing the need for threat detection and avoidance.

2 Methods

2.1 Participants and procedure

The participants (n=217) comprised unpaid volunteers from a Finnish community sample. The inclusion criteria were a minimum age of 18 years and fluency in Finnish. Six participants were excluded due to excessive missing data, most often concerning average pain over the last 3 months or pain self-efficacy. Four participants had omitted one item on one of the study measures, and the missing data were replaced with the sample mean. Demographic characteristics are presented in Table 1.

Table 1:

Demographic characteristics.

	Mean (SD)	Number (%)
Age (years)	38.00 (15.58)
Sex
Men		80 (38)
Women		129 (61)
Unknown		2 (1)
Marital status
Single		75 (36)
Married/domestic partnership		116 (55)
Divorced		15 (7)
Widowed		5 (2)
Employment status
Employed full time		109 (52)
Employed part time		28 (13)
Student		44 (21)
Unemployed		10 (5)
Retired		18 (8)
Unknown		2 (1)

Sample size – 211. SD=standard deviation.

The participants were recruited as part of a research methodology course by undergraduate students of psychology from the School of Educational Sciences and Psychology at the University of Eastern Finland. Data were collected from multiple sites such as workplaces, various public locations, and events. After receiving information about the study and providing their written consent, the participants anonymously completed a background questionnaire and measurements for the study variables and returned the forms to the students in sealed envelopes. The study protocol was approved by the Research Ethics Committee of the University of Eastern Finland.

2.2 Measures

2.2.1 Average pain over the last 3 months

Average pain over the last 3 months was measured with one item from the Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) [35, 36]. The participants were asked to rate their average pain over the last 3 months using a numerical rating scale (0=“not at all”, 10=“very painful”).

2.2.2 Anxiety

Anxiety was assessed using the Anxiety scale (ANX) from the Symptom Checklist-90 (SCL-90) [37]. The participants assessed their anxiety symptoms with 10 items on a scale of 0 (“not at all”) to 4 (“very much”). The mean was used as the scale score, ranging from 0 to 4. Higher scores reflect greater anxiety. The Finnish SCL-90 has been validated in both the general population and for psychiatric patients with adequate psychometric properties [38, 39]. The internal consistency (Cronbach’s α) for the scale in this sample was 0.82.

2.2.3 Somatization

Somatization was assessed using the Somatization scale (SOM) from the SCL-90 [37]. The participants reported cardiovascular, gastrointestinal and respiratory symptoms on a scale of 0 (“not at all”) to 4 (“very much”). The scale was scored without the items that referred to pain to prevent pain problems from inflating associations between pain and somatization [40]. Somatization scores, calculated as the mean of item scores, can range from 0 to 4. Higher scores reflect greater somatization. The internal consistency (Cronbach’s α) of the scale in this sample was 0.78.

2.2.4 Pain self-efficacy

Pain self-efficacy was assessed using the Pain Self-Efficacy Questionnaire (PSEQ) [41]. The PSEQ is a 10-item measure of pain-related self-efficacy. Using a 7-point scale from 0 (“not at all confident”) to 6 (“completely confident”), the participants rated their confidence in their ability to perform various activities despite their pain. Scores can range from 0 to 60, with higher scores indicating stronger self-efficacy beliefs. The Finnish PSEQ has been validated in a sample of rehabilitation intervention participants with good psychometric properties [42]. The internal consistency (Cronbach’s α) of the scale in this sample was 0.94.

2.3 Data analysis

The IBM SPSS Statistics 23 program by International Business Machines Corporation (Armonk, NY, USA) was used for all statistical analyses. The PROCESS macro [43] was used to test for moderator effects. The utilization of PROCESS was based on the availability of heteroscedasticity-consistent standard errors [44].

The number and percentage (for categorical variables) and means and standard deviations (for continuous variables) for the study variables are presented for descriptive purposes. We computed the intercorrelations of the study variables and performed two series of regression analyses. Anxiety and somatization, respectively, were the dependent variables. Average pain over the last 3 months was entered first. Next, pain self-efficacy was entered. The average pain×pain self-efficacy interaction term was entered at the final step. The scores were all non-centred raw scores. The probability of Type I error was controlled by the Bonferroni correction; a p-value of 0.025 (0.05/2) was chosen as the level of significance in the regression analyses. To illustrate significant moderation effects, we present figures with correlations between average pain over the last 3 months and the independent variable for the lowest and highest quartile of pain self-efficacy.

3 Results

3.1 Sample characteristics

Table 1 displays the demographic characteristics of the sample. The mean age was 38.0 years. There were more women (61%) than men (38%). Most participants were married or in a domestic partnership (55%), and most either worked full time (52%) or were studying (21%).

Participants had experienced, on average, only mild pain over the last 3 months and mild current anxiety symptoms or somatization. The participants’ pain self-efficacy was high (see Table 2).

Table 2:

Means and standard deviations of the study variables.

	Mean (SD)
Average pain over the last 3 months (ÖMPSQ) (0–10)	2.70 (2.31)
Anxiety (SCL-90 ANX) (0–4)	0.42 (0.42)
Somatization (SCL-90 SOM) (0–4)	0.45 (0.47)
Pain self-efficacy (PSEQ) (0–60)	46.57 (10.37)

SD=standard deviation; ÖMPSQ=Örebro Musculoskeletal pain screening questionnaire; SCL-90 ANX=symptom checklist-90 anxiety; SCL-90 SOM=Symptom Checklist-90 somatization; PSEQ=pain self-efficacy questionnaire.

3.2 Moderating effects of pain self-efficacy

Intercorrelations between the study variables are listed in Table 3. Average pain was moderately associated with anxiety and somatization, but not significantly with pain self-efficacy. Anxiety and somatization were strongly associated, and both had a statistically significant association with pain self-efficacy.

Table 3:

Correlations between study variables.

	1	2	3	4
1. Average pain over the last 3 months (ÖMPSQ)	1	0.33^b	0.42^b	−0.10
2. Anxiety (SCL-90 ANX)		1	0.71^b	−0.18^a
3. Somatization (SCL-90 SOM)			1	−0.24^b
4. Pain self-efficacy (PSEQ)				1

ÖMPSQ=Örebro Musculoskeletal pain screening questionnaire; SCL-90 ANX=symptom checklist-90 anxiety; SCL-90 SOM=symptom checklist-90 somatization; PSEQ=pain self-efficacy questionnaire.
^a p<0.05 ^bp<0.01.

The results of the regression analyses are presented in Table 4. Using anxiety as the dependent variable, the results show a direct effect of average pain over the last 3 months on anxiety in the first step (t=4.08, p<0.025) and a direct negative effect of pain self-efficacy over and above average pain in the second step (t=−2.37, p<0.025). In the third step, the interaction term was not statistically significant.

Table 4:

Results of the regression analyses with self-efficacy as moderator.

Step	R ²	R ² change	F change	β	t
Dependent variable: anxiety
Average pain over the last 3 months	0.11	0.11	25.33^a	0.33	4.08^a
Self-efficacy	0.13	0.02	5.04^a	−0.15	−2.37^a
Pain intensity×self-efficacy	0.15	0.02	4.17	−0.64	−1.88
Dependent variable: somatization
Average pain over the last 3 months	0.18	0.18	44.68^a	0.42	4.92^a
Self-efficacy	0.21	0.04	10.25^a	−0.20	−3.49^a
Pain intensity×self-efficacy	0.24	0.03	5.65^a	−0.78	−2.38^a

^a p<0.025.

Using somatization as the dependent variable, average pain over the last 3 months had a direct effect on somatization in the first step (t=4.92, p<0.025). Pain self-efficacy had a direct negative effect on somatization over and above average pain in the second step (t=−3.49, p<0.025). In the third step, the average pain×pain self-efficacy interaction term was statistically significant (F(1,207)=5.65, p<0.025), indicating moderation. The interaction explained 3% of the variance in somatization, over and above average pain and self-efficacy. Among those in the bottom quartile of pain self-efficacy, the association between average pain over the last 3 months and somatization was moderate or strong (r=0.62, p<0.01). For those in the top quartile of pain self-efficacy, the association was modest and statistically non-significant (r=0.11, p>0.05). This interaction is presented in Fig. 1.

Fig. 1:

Associations of pain with somatization for different levels of pain self-efficacy.

4 Discussion

The findings were partially consistent with the hypothesis that high pain self-efficacy moderates the negative effects of average pain over the last 3 months, even in a relatively healthy community sample. We observed a moderator effect, suggesting that high pain self-efficacy attenuates the association between perceived pain and somatization.

4.1 Moderating effect on somatization

To our knowledge, this is the first study to examine the moderating effect of pain self-efficacy on the association between pain and somatization. Furthermore, the effect was observed in a community sample. As somatization is consistently elevated in chronic pain samples [5], increases the risk of low back pain chronicity [29], and is associated with seeking health care [27], the result is interesting from both a scientific and a clinical perspective.

It has been suggested that pain interference in day-to-day activities could trigger the adverse responses regarding affects, disability and chronicity [10]. However, factors that contribute to the pursuit of valued goals may protect against pain chronification and subsequent disability [11, 12]. Pain self-efficacy, defined as the confidence to function despite pain, is negatively associated especially with functional impairment [19]. As a motivational factor, pain self-efficacy could, via goal-setting and other active self-regulatory strategies [16], decrease somatic distress and the need to communicate symptoms, attribute them to illness, or seek medical help, as pain self-efficacy predicts better outcomes related to pain management interventions [23], work [21], and coping [20].

Pain self-efficacy is not the only potential pain-related factor that promotes goal pursuit. For example, pain acceptance has been found to moderate the relationship of pain and negative affect in a chronic pain sample [15]. It is noteworthy that the most common pain acceptance measure comprises subscales that assess the degree of engagement in activities regardless of pain, and the willingness to experience pain [45, 46]. It appears that engagement in activity despite pain (component of pain acceptance) and the confidence to function despite pain (pain self-efficacy) are related but not identical phenomena that should be studied together as potential protective factors.

The interaction explained 3% percent of additional variance over and above average pain over the last 3 months and self-efficacy. It is expected that in a community sample displaying mild pain symptoms, the possible effect would be of modest magnitude. For example, in a sample suffering from chronic pain, interactions including pain intensity and positive affect contributed an additional variance of up to 9%, depending on the outcome variables [13].

If future studies were to support the moderating effect, the role of self-efficacy as a protective factor should be explicated. Further research, preferably longitudinal, in both the general population and in chronic pain samples is necessary to establish the moderating effect.

The findings have some clinical implications. Supporting and promoting the patient’s confidence in their functioning despite pain is recommended, including in acute and sub-acute pain conditions. This may be especially important with individuals who are prone to somatization. However, although pain self-efficacy can be increased during interventions for people suffering from chronic pain [47, 48], more research on supporting pain self-efficacy in non-chronic pain populations is needed.

4.2 Lack of a moderating effect on anxiety

The lack of a moderating effect of pain self-efficacy on the association between pain intensity and anxiety may initially seem surprising. Several factors have buffered the effects of pain on depression [14] or on negative affect [13]. However, previous studies have examined people suffering from chronic pain.

The most basic explanation is that while pain is common in the general population, pain-related self-efficacy is not an important protective factor in relation to anxiety symptoms. Moderate or severe anxiety symptomology is also associated with many non-pain-related life events [49] and personality traits [50]. In contrast, it is likely that somatization has a more direct connection to common pain experiences. Anxiety is perhaps too broad an outcome measure compared to more pain-specific factors such as pain catastrophizing or fear of pain. The hypothesised buffering effect in the chronic pain population remains an open question and warrants further research.

However, it is also possible that despite high intercorrelations, anxiety and somatization have fundamental differences regarding the dynamics of pain and pain-self-efficacy. Somatization directs attention to somatic distress and motivates a person to seek medical help [26], whereas anxiety is about threat detection and avoidance [33]. It is possible that the avoidance motivated by anxiety directs a person’s efforts towards goals that are not particularly facilitated by pain self-efficacy, thus making it impossible for self-efficacy to provide counter-evidence of the intrusive effects of pain regarding the avoided or abandoned goals now being associated with pain. Nevertheless, all these hypothetical mechanisms need to be further studied.

4.3 Study limitations

The study has some limitations. Firstly, the cross-sectional design rules out causal conclusions. The results are partially consistent with the buffering hypothesis but do not refute alternative interpretations. Secondly, in our sample, anxiety, somatization, and pain intensity were all low. This makes the detection of moderator effects more difficult, although this is more or less inevitable in a community sample. Thirdly, anxiety and somatization are related both conceptually and empirically [26]. As they correlate strongly and have virtually identical associations with pain and pain self-efficacy in the present study, it may be doubtful whether one provides any incremental information over the other. However, they may have different dynamics regarding pain and pain self-efficacy, and their moderating roles differed. Nevertheless, in further studies the potential protective role of pain self-efficacy should be examined with more variable risk factors, including pain-specific measures. Fourthly, our sample was not representative, but was a convenience sample. The generalisability of our results is unknown. This calls for replications using different kinds of participants, both with and without pronounced pain. Finally, it is not known how stable pain self-efficacy is in the transitions between different pain conditions (e.g. from acute pain to sub-acute pain). If pain self-efficacy is unstable, it may not be a reliable protective factor.

5 Conclusions

Interestingly, pain self-efficacy moderated the association between pain intensity and somatization in a community sample. Attempts at replications should be made with samples of different pain conditions. Providing that the effect is observed and the person’s pain self-efficacy is found to be at least moderately stable, pain self-efficacy should be considered a protective factor in the process of pain chronification.

Authors’ statements
Research funding: There was no funding for this study.
Conflict of interest: The authors declare no potential conflicts of interest.
Informed consent: After receiving information about the study, the participants provided written consent.
Ethical approval: The study protocol was approved by the Research Ethics Committee of the University of Eastern Finland.

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Received: 2018-03-09

Revised: 2018-08-20

Accepted: 2018-08-21

Published Online: 2018-09-21

Published in Print: 2019-01-28

Articles in the same Issue

https://doi.org/10.1515/sjpain-2018-0052

Keywords for this article

pain; anxiety; somatization; self-efficacy