Background

There are different ways to cope with pain, and there are different ways to regulate emotions associated with chronic diseases. Because most patients with chronic diseases are unable to ‘solve’ their persisting pain conditions by themselves (in terms of recovery or repair) and to find distance to negative emotions associated with pain, they have to find strategies to adapt to a long-lasting course of disease.Coping Styles Used by Chronic Health Disorder Sufferers.  Patients have to find ways to maintain physical, emotional and spiritual health despite of often long-lasting courses. Thus, patients’ coping with chronic pain is an ongoing process which includes appraisals of stress, cognitive, behavioural, and emotional coping responses, and subsequent reappraisals of stress.

One of the most frequently used concept on adaptation strategies of patients with chronic pain diseases differentiates active and passive coping [1,2]. Active coping (i.e., problem solving, including collecting information and refocusing on the problem, or regulation of emotion by focusing attention on the emotional response aroused by the stressor) is associated with less pain, less depression, less functional impairment, and higher general self-efficacy, while passive coping (i.e., avoidance and escape) is correlated with reports of greater depression, greater pain and flare-up activity, greater functional impairment, and lower general self-efficacy [1]. Although the importance of decreasing maladaptive and encouraging adaptive coping responses is emphasized by innovative treatment programs for chronic pain, one nevertheless has to ask which adaptive coping strategies were of relevance for the patients.

A recent meta-analysis found that among older adults with persistent pain, the most frequently reported coping strategies were Task Persistence (maintaining activity, for example despite fluctuations of pain intensity), Pacing (activity avoidance), and Coping Self-Statements (a form of conditioning to put a stop for example to thoughts that lead to anxiety etc. and to replace them with rational thoughts); the least frequently used strategies were Asking for Assistance and Relaxation [3]. Findings from that study suggest useful coping strategies clinicians could explore with individual patients [3]. Coping Styles Used by Chronic Health Disorder Sufferers.

Our own study results suggest that most patients with chronic diseases use adaptive coping strategies which can be differentiated according to the utilization of external resources of health control (i.e., Trust in Medical Help; Search for Information and Alternative Help; Trust in Divine Help) and internal sources (i.e., Conscious Way of Living; Positive Attitudes; Reappraisal: Illness as Chance) [4,5]. Particular the cognitive reappraisal strategy was of outstanding relevance. It deals with patients’ interpretation of disease as an opportunity, a hint to change life, and reflect upon what is essential in life. Because of this reflection, patients may alter their goals, change aspects of life or behaviour, and may see their situation as a chance for personal growth (transformation). However, the subjective meaning of illness is influenced by intrapersonal, disease-related and environmental factors [6]. These interpretations of illness may have an influence on preferences in decision-making and choice of coping strategies.

In this report, we intended to analyze which adaptive coping strategies referring to the concept of ‘locus of health control’ (in terms of external or internal resources), were of relevance for patients with chronic pain conditions, and how these strategies were associated with patients’ life satisfaction and interpretation of illness. Our hypothesis was that particularly the adaptive coping strategies referring on the internal resources are associated with life satisfaction, while positive interpretations of illness (such as challenge or value) are related to reappraisal processes.

Methods

Measures

Adaptive coping strategies in response to chronic pain conditions were measured with the AKU questionnaire (AKU is an acronym of the German translation of “Adaptive Coping with Disease”), which was designed to identify adaptive coping styles, such as to create favourable conditions, search for information, medical support, religious support, social support, initiative spirit, and positive (re)interpretation of disease [4,5,7]. The underlying concept of the instrument refers to internal and external loci of disease/health control based on the work of Rotter [8,9] and Levenson [10]. The questionnaire was re-validated recently in a sample of 6,963 individuals, and we were able to approve the 6 factorial structure of the 28-item instrument which had a good internal consistency (Cronbach’s alpha = 0.867; difficulty index 0.67) [5], i.e.:

▪ Trust in Divine Help in response to disease addresses non-organized intrinsic religiosity as an external transcendent resource to cope (i.e., trust in a higher power which carries through; strong belief that God will help; faith is a strong hold, even in hard times; pray to become healthy again; live in accordance with religious convictions). Coping Styles Used by Chronic Health Disorder Sufferers.

▪ Trust in Medial Help addresses patients’ reliance on an external medical source of health control (i.e., trust in the therapeutic potentials of modern medicine, take prescribed medicaments, follow advises of medicals, full confidence in doctors and therapists).

▪ Search for Information and Alternative Help refers to external sources providing additional information or alternative help (i.e., thoroughly informed about disease; get thorough information how to become healthy again; find people which can help; search for alternative ways of healing).

▪ Conscious Way of Living addresses cognitive and behavioural strategies in terms of internal powers and virtues (i.e., healthy diet; physical fitness; living consciously; keep away harmful influences; change life to get well).

▪ Positive Attitudes refers to internal cognitive and behavioural strategies (i.e., realization of shelved dreams and wishes; resolving cumbering situations of the past; take life in own hands; doing all that what pleases; positive thinking; avoiding thinking at illness).

▪ Reappraisal: Illness as Chance addresses a reappraisal attitude referring to cognitive processes of life reflection (i.e., reflect on what is essential in life; illness has meaning; illness as a chance for development; appreciation of life because of illness).

The items of the AKU were scored on a 5-point scale from disagreement to agreement (0 – does not apply at all; 1 – does not truly apply; 2 – don’t know; 3 – applies quite a bit; 4 – applies very much). The sum scores were referred to a 100% level (transformed scale score). Scores > 50% indicate high agreement or utilization of coping strategy, while scores < 50% indicate low usage of respective strategy.

The questionnaire holds 3 independent items, which did not contribute to the primary AKU item pool. They made up an independent scale termed Escape from illness (i.e., fear what illness will bring; would like to run away from illness; when I wake up, I don’t know how to face the day”, which addresses a passive (avoidance-escape) coping style [4,5,7], while the AKU questionnaire differentiates active adaptive coping styles. It was confirmed recently that Escape correlated strongly with depression, with disease appraisals such as ‘weakness/failure’ and ‘punishment’, and negatively with life satisfaction [11]. The items were scored on a 5-point scale from disagreement to agreement.

To measure how the patients interpret their disease, we used the ‘Interpretation of Illness Questionnaire’ (IIQ) [12] which refers to the work of the Canadian psychiatrist Lipowski [13].Coping Styles Used by Chronic Health Disorder Sufferers.  The 8-item instrument has satisfactory internal consistency (Cronbach’s alpha = 0.730) and involves guilt-associated negative interpretations (i.e., punishment, weakness), fatalistic negative interpretations (i.e., adverse interruption of life/loss, threat/enemy), strategy-associated interpretations (i.e., relieving break from the demands of life, call for help), and positive interpretations of disease (i.e., challenge, value) [12]. The items were scored on a 5-point scale from disagreement to agreement (0 – does not apply at all; 1 – does not truly apply; 2 – don’t know; 3 – applies quite a bit; 4 – applies very much), and are referred to a 100% level (4 “regularly” = 100%).

Life satisfaction was measured with the Brief Multidimensional Life Satisfaction Scale (BMLSS) [14]. The eight items of the BMLSS refer to intrinsic dimensions (Myself, Overall Life), social dimensions (Friendships, Family life), external dimension (Work, Where I live), and the perspective dimension (Financial Situation, Future Prospects). All items were scored on a 7-point scale from dissatisfaction to satisfaction (0 – Terrible; 1 – Unhappy; 2 – Mostly dissatisfied; 3 – Mixed (about equally satisfied and dissatisfied); 4 – Mostly satisfied; 5 – Pleased; 6 – Delighted). The Life Satisfaction sum score was referred to a 100% level (transformed scale score). Scores > 50% indicate high life satisfaction, while scores < 50% indicate low satisfaction.

Results