Now that we understand what self-efficacy and pain self-efficacy is, we can start building up an understanding of how it affects patient outcomes for people with chronic pain. If pain self-efficacy is an important aspect in chronic pain outcomes, what are those outcomes, and why are they affected?
In this section, we look at two common outcomes found in chronic pain patients: depression and disability. Chronic pain increases a person's susceptibility to both of these conditions, for a variety of reasons. A common factor found to impact both of these outcomes (both in severity and likelihood) is pain self-efficacy.
Depression is unfortunately common in people with chronic pain, with about 70% of chronic pain patients qualifying for a depression diagnosis
As stated in a previous article of mine, research shows that about 75% of
depression patients experience chronic/reoccurring pain (Lepine, 2004), and 60% of chronic pain patients
report significant depressive symptoms (Bair, 2003).
This is a major overlapping issue for pain and, consequently, it gets a lot of
attention in research and medicine. There are many factors that likely
contribute to the overlap and researchers want to identify those interlinking
causes. One identified factor is that of pain self-efficacy.
General self-efficacy already has an impact on any individual’s predisposition to depression
(Mukhtar, 2010), but pain
self-efficacy is a particularly strong predictor of depression for people with chronic
pain. A sense of helplessness in situations (termed 'learned helplessness') is a major part of the thought patterns that lead to depression. Feeling unable to manage pain is a meaningful loss of control. For example, individuals who reported similar levels of pain but differed
in their pain self-efficacy, also differed later in their lives in whether they
became disabled or depressed. It was not the only factor that led to the
difference between groups, but it was a strong mediator between chronic pain
and later depression and disability (Arnstein, 1999). Meaning the
self-efficacy these people felt in regards to their pain affected their
likeliness to develop major depressive disorder.
In another study that examined pain self-efficacy and depression, the same correlation was found between a weak sense of pain self-efficacy and higher proclivity towards depression. This study controlled for pain intensity (meaning the factor was accounted for, its impact quantified, and the effect removed) and still found the same correlation. The study also investigated how the use of pain coping strategies (such as task persistence, coping self-statements, pacing) was associated with pain self-efficacy. Patients who used pain coping strategies were more likely to have a strong sense of pain self-efficacy and a lower incidence of major depression
(Turner, 2005). Based on the results of their study,
the researchers suggest that not only is pain self-efficacy protective against
depression, but that cognitive behavioral and self-management treatments to
teach coping strategies could help improve pain self-efficacy.
These observations make sense when we think back to a common cause of depression: a feeling of helplessness. When individuals are able to master this feeling and overcome it, replacing it with a confident belief in their ability to manage their pain, they are less likely to fall victim to this avenue to depression. By developing a strong sense of pain self-efficacy, a person can feel in control over an otherwise distressing challenge.
As mentioned above, a chronic pain patient with a lower sense of pain self-efficacy is more likely to become disabled by their pain. This may appear to be obvious, common knowledge; on the surface, it sounds like a higher pain would result in both lower pain self-efficacy and higher likeliness for disability. But when controlling for pain severity, the finding remains. In a 2001 study by Asghari and Nicholas, higher pain self-efficacy beliefs were found to lower avoidance behaviors for challenging tasks and reduce disability associated with pain, regardless of the severity of pain the subjects were in
(Ashari, 2001). This suggests that confronting
challenging tasks and believing in the capacity to complete them despite the
pain is beneficial in trying to minimize disability associated with a painful
condition. And remember, pain self-efficacy is not dependent on the ability to succeed. Rather, it is persistence
in the face of failure or success and a centered focus on the task at hand.
Another study that examined the relationship between pain self-efficacy and disability also included the quality ‘fear avoidance’. Fear avoidance is what it sounds like—the avoidance of activities due to fear. A model called the ‘Fear-Avoidance Model’ was developed to help explain how a type of chronic pain developed despite the absence of a disease/permanent injury. It argues that fear avoidance prevents the use of the body and creates a cycle that leads to debilitating pain and disability. However, in this study, it was shown that self-efficacy had a greater impact on disability than fear avoidance
(Denison, 2004). Meaning, based on their findings, they
argued that a lack of belief for pain self-efficacy has a larger impact on
disability severity than the avoidance of activities associated with pain.
What’s particularly interesting about this finding, is that the beliefs that
might impact performance of activities seemed to have a greater impact than the
actual execution or avoidance of activities.
Disability from pain cannot always be avoided and these studies do not ignore the significant role that pain intensity plays. Neither these researchers nor I are arguing that a weak sense of pain self-efficacy is the sole cause of disability from debilitating pain. What I am trying to say is that it can help protect against eventual disability and offers some amount of buffer against disability, regardless of the severity of pain a person is in. It will benefit both your confidence in and ability to manage the challenges that pain presents. After all, the first step of ability is the belief in a capability to execute it.
Pain self-efficacy has also been found to have an interacting relationship with pain intensity/severity. Numerous studies found that while severity of pain could affect the strength of an individual’s sense of pain self-efficacy, the effect was not limited to one direction. Individuals with a strong sense of pain self-efficacy are better able to manage their pain and report less pain severity. The difference has been observed not only in similarly diagnosed individuals, but also in patients that were taught coping mechanisms to improve their pain self-efficacy. Thus, developing pain self-efficacy can lower the severity of pain experienced.
***The research explaining and supporting the connection between Pain Self-Efficacy and Pain Severity comprise the next post, Power of Belief: Part III (as there is a lot to cover!)***