Pain Medicine 2011; 12: 314–321 Wiley Periodicals, Inc. Ethnicity, Catastrophizing, and Qualities of the

Pain Experiencepme_1015 314..321

Lacy A. Fabian, PhD,* Lynanne McGuire, PhD,† Conclusions. To better explicate our findings, we Burel R. Goodin, PhD,† and Robert R. Edwards, described the context in which these findings ‡ PhD occurred following a “who, what, where, when, and Downloaded from https://academic.oup.com/painmedicine/article/12/2/314/1855752 by guest on 27 September 2021 why” approach. This approach provides an efficient *Centers for Public Health Research and Evaluation, description of how our findings align with previous Battelle Memorial Institute, Maryland; research, while identifying future research that should clarify the theoretical underpinnings of †Department of Psychology, University of Maryland, catastrophizing and pain and also inform clinical intervention. Baltimore County, Baltimore, Maryland; Key Words. Pain; Pain Quality; Catastrophizing; ‡Department of Anesthesiology, Perioperative and Sex; Ethnicity Pain Medicine, Harvard Medical School, Center, Brigham & Women’s Hospital, Introduction Chestnut Hill, Massachusetts, USA Recent research investigating relations between ethnicity Reprint requests to: L. Fabian, PhD, Centers for Public and pain has produced few firm generalizations, in part Health Research and Evaluation, Battelle, Suite 200, because ethnicity and pain are multidimensional con- 6115 Falls Rd., Baltimore, MD 21209, USA. Tel: structs that vary by individual and are shaped by culture. 410-372-2731; Fax: 614-458-0661; E-mail: Despite the complexities inherent in the study of ethnicity [email protected]. and pain, several reviews of this literature have been undertaken and published. A review by Edwards and col- leagues [1], addressed laboratory and clinical studies of ethnic differences in pain whereby two key, yet general, Abstract themes emerged: 1) findings from laboratory-based studies suggest greater sensitivity to experimental pain Objective. It is generally well established that cata- stimuli among African Americans compared with Cauca- strophizing exerts a potent influence on individuals’ sians, and 2) higher levels of pain and disability have been experience of pain and accompanying emotional reported among African Americans relative to Caucasian distress. Further, preliminary evidence has shown patients that were treated for a variety of acute and per- that meaningful differences among various pain rel- sistent pain conditions. Ethnic differences in pain are evant outcomes (e.g., pain ratings, endogenous pain becoming well-documented; however, explaining these inhibitory processes) can be attributed to individu- differences is more challenging. als’ ethnic background. The mechanisms that might explain ethnic differences in pain outcomes are How one copes with pain consistently predicts important unclear, and it remains to be fully established clinical outcomes, including pain severity and disability [2]. whether the relation between ethnicity and pain One of the most robust predictors of pain outcomes is response may be indirectly affected by pain catastrophizing [3], which is defined as a negative emo- catastrophizing. tional and cognitive response to pain that involves elements of magnification, helplessness, and pessimism. Traditional Design. In the current study, we examined differ- conceptualizations have suggested that catastrophizing is ences in pain responses by ethnicity among healthy, a relatively enduring mode of responding either directly to a young adults (N = 62), and attempted to determine painful experience or in anticipation of such an experience whether such an ethnicityÐpain relation was medi- [3]. Contrary to trait conceptualization, more recent views ated by catastrophizing using the standard Pain have regarded catastrophizing as also a potentially modi- Catastrophizing Scale (PCS) and a modified version fiable, situation-specific cognitive style [4]. Several studies of the PCS reflecting situational catastrophizing have examined what has come to be termed “standard” during a cold pressor task. (i.e., trait conceptualization) vs “situational” (i.e., situation- specific conceptualization) catastrophizing processes in Results. Results showed that pain responses relation to experimental pain outcomes [5,6]. Although a varied by ethnicity, as did reported catastrophizing. review of the methodology for assessing standard vs situ- Catastrophizing mediated the relation between eth- ational catastrophizing is beyond the scope of the current nicity and affective and sensory pain responses. study, results from previous investigation preliminarily

314 Ethnicity, Catastrophizing and Pain suggest that assessment of situational catastrophizing (i.e., sion and acute illness, respectively. These participants’ the assessment of current catastrophic thinking during an data were omitted leaving a final sample of 62 partici- experimental pain task) better predicts individuals’ propen- pants. Participants were healthy college students (61% sity to report pain and distress during experimental acute women) ranging in age from 18 to 25 years with an pain induction than standard catastrophizing [7,8]. average Body Mass Index (M = 22.1, SD = 3.01). The Whether standard and situational catastrophizing repre- sample was racially diverse; 18% African American, 24% sent the same construct, differing aspects of the same Asian/Pacific Islander, 42% Caucasian, 3% Hispanic, 2% construct or separate constructs altogether remains Native American, and 11% Other (racial classifications unclear and is currently a topic of debate. adhered to prior guidelines and not the current census guidelines implemented in Census 2000). Potential partici- To our knowledge, the inter-relations among ethnicity, stan- pants completed screening questionnaires to determine Downloaded from https://academic.oup.com/painmedicine/article/12/2/314/1855752 by guest on 27 September 2021 dard and situational catastrophizing, and pain reports have their eligibility for the study. Participants were required to not been previously examined in an experimental context. be physically and psychologically healthy, without a history Further, the literature is inconsistent with some studies of persistent pain and without current pain. Criteria for showing no ethnic differences in pain reports [9] and mixed exclusion included: 1) age less than 18 or over 45 years; results in the use of pain coping strategies including 2) ongoing problems; 3) diagnosed with catastrophizing [10]. Inconsistencies within the ethnicity hypertension or taking medication for blood pressure; 4) and pain literature may be at least partially attributable to circulatory disorders; 5) history of cardiac events; 6) unexplored and/or inconsistent assessment of the various history of metabolic disease or neuropathy; 7) pregnant; 8) qualities of pain-related study outcomes (e.g., affective– currently using prescription analgesics, tranquilizers, anti- motivational vs sensory–discriminative dimensions of pain depressants, or other centrally acting agents; 9) use of reporting) Pain-related outcomes such as tolerance and nicotine; 10) use of prescription medication; and 11) psy- ratings of pain unpleasantness may primarily reflect the chiatric disorders (e.g., ). affective–motivational dimension of pain, while pain thresh- old and ratings of pain intensity may be more strongly Ethics associated with sensory–discriminative aspects of the experience [11]. It has been theorized that ethnic differ- The study was approved by the University’s institutional ences in pain response may be most prominent for the review board. Participants completed written informed affective–motivational dimension of pain [12,13]; however, consent prior to initiation of study procedures and were ethnic differences in the sensory–discriminative aspects of compensated for their participation. pain perception have been reported [14]. Therefore, addi- tional examination of ethnic differences in relation to affec- tive and sensory dimensions of pain response is warranted. Study Design

Ethnic groups with minority status may be more prone to Participants were paired with experimenters of the same engaging in negative coping strategies such as catastro- sex to minimize the effects of experimenter sex on partici- phizing, which could affect their pain perception and sub- pants’ report of pain [15]. Prior to pain testing, participants sequent reports of painful experiences. The current study completed the Pain Catastrophizing Scale (PCS) using examined the association between ethnicity, standard and standard instructions and a measure of depressive symp- situational catastrophizing, and affective and sensory toms. Next, pain testing involved repeated immersions of dimensions of pain perception in a multi-ethnic sample of the dominant hand into a cold water bath for a maximum self-identified Caucasians, African Americans, and Asian/ total duration of 420 seconds. Similar to Dixon and col- Pacific Islanders. Specifically, the following questions were leagues [7], participants were encouraged to keep their examined: 1) Are there significant ethnic differences in the hand immersed for at least 2 minutes during the final cold report of pain across various dimensions of pain quality water immersion, but were told they could remove their (e.g., affective and sensory); 2) Are there significant ethnic hand at any time. Pain testing was immediately followed differences in the report of standard and situational pain by completion of pain ratings and the situational PCS, with catastrophizing; and 3) Does standard and/or situational modified instructions that directed participants to report catastrophizing mediate the relation between ethnicity and on catastrophizing with respect to the cold pressor pain the report of pain in response to experimental noxious just experienced. stimulation. Lastly, results of this study were addressed in a discussion offering an approach for the advancement of Assessment catastrophizing and pain theory. Pain Testing Methods The Cold Pressor Task (CPT), a cold water acute pain Participants stimulus, was administered using a circulating cold water bath (ThermoNeslab RTE17, Portsmouth, NH) maintained A total of 64 participants qualified for participation in the at a temperature of 4°C. Participants completed five cold study. Two participant sessions were discontinued prior to water immersions. The first four immersions were for a the completion of pain testing due to apparent hyperten- maximum duration of 60 seconds, with 60–120 seconds

315 Fabian et al. between immersions, and the final immersion was for a administered immediately following the completion of the maximum duration of 180 seconds. final cold water immersion and the instructions asked participants to refer to the pain experienced during the cold water immersions when answering the questions Standard and Situational Pain Catastrophizing pertaining to pain-related catastrophizing. In the current study, the internal consistency of the total standard PCS The standard PCS [16] is a 13-item scale that assesses score prior to pain testing was good (Cronbach’s catastrophic thinking in response to pain. The standard a=0.82), and the internal consistency of the situational PCS assesses catastrophic pain-related cognitive- score immediately after pain testing was excellent (Cron- emotional processes by asking participants to recall their bach’s a=0.92). experiences during past occurrences of pain. In the Downloaded from https://academic.oup.com/painmedicine/article/12/2/314/1855752 by guest on 27 September 2021 current study, as is typically done in experimental pain studies, the standard PCS was administered prior to the Depressive Symptoms initiation of the laboratory pain task and was considered an assessment of individuals’ tendency to engage in pain- The Beck Depression Inventory (BDI) [18] is a self-report related catastrophizing. The PCS total score, calculated measure that consists of 21-items rated on a four-point by summing the 13-item responses, provides a good Likert-type scale (0–3), with higher scores reflecting more index of the catastrophizing construct through the inclu- severe symptoms. The BDI was administered to partici- sion of the highly correlated subscales of helplessness, pants prior to pain testing to assess the frequency and rumination, and magnification. Higher scores on the severity of a variety of cognitive, affective, physiological, PCS are indicative of greater pain-related catastrophizing and motivational symptoms of depression [18]. The BDI [17]. Subsequently, the situational PCS used the same has well-established psychometric properties [18]. In the 13-items as the standard PCS, with modified instructions current study, the internal consistency of the BDI was and item wording (see Figure 1). The situational PCS was adequate (Cronbach’s a=0.73).

Standard PCS Situational PCS Instructions: Using the following scale, please Instructions: Using the following scale, please indicate the degree to which you have these indicate the degree to which you had these thoughts thoughts and feelings when you are and feelings while you were experiencing the experiencing pain. cold water pain, when it was most painful.

I worry all the time about whether it will end. I worried all the time about whether it would end.

I feel I can't go on. I felt I couldn't go on.

It's terrible and I think it's never going to get It was terrible and I thought it was never going to any better. get any better.

It's awful and I feel that it overwhelms me. It was awful and I felt that it overwhelmed me.

I feel I can't stand it anymore. I felt I couldn't stand it anymore.

I become afraid that the pain will get worse. I became afraid that the pain would get worse.

I keep thinking of other painful events. I kept thinking of other painful events.

I anxiously want the pain to go away. I anxiously wanted the pain to go away.

I can't seem to get it out of my mind. I couldn't seem to get it out of my mind.

I keep thinking about how much it hurts. I kept thinking about how much it hurt.

I keep thinking about how badly I want the pain I kept thinking about how badly I wanted the pain to stop. to stop.

There's nothing I can do to reduce the intensity There's nothing I could do to reduce the intensity of of the pain. the pain.

I wonder whether something serious may I wondered whether something serious might happen. happen.

Figure 1 Standard Pain Catastrophizing Scale (PCS) compared with the situational PCS.

316 Ethnicity, Catastrophizing and Pain

Pain Measures measures it was dropped from further analysis, though the means and standard deviations for the sample are The short-form McGill Pain Questionnaire (SF-MPQ) [19] is reported in Table 1. a self-report measure that consists of 15-items rated on a four-point Likert-type scale, with higher scores indicating Covariates. Sex differences in pain catastrophizing greater pain. The SF-MPQ allows quantitative, multidi- and pain responses have been well researched, with mensional pain ratings to be obtained in a brief period of females often reporting more clinical and experimental time [19]. The SF-MPQ was given immediately after pain pain [23–25] and catastrophic cognitions [26,27] than testing and included instructions that asked the partici- males when exposed to experimental acute pain. Further- pant to report on the pain experienced during the cold more, in some cases, greater catastrophizing has been water pain procedures. The sensory and affective pain shown to account for observed sex differences in clinical Downloaded from https://academic.oup.com/painmedicine/article/12/2/314/1855752 by guest on 27 September 2021 scale scores were used. The SF-MPQ is reliable and valid, pain reports [24]. Depressive symptoms are also related and is commonly used in clinical and research applications to pain and catastrophizing [28,29]. Therefore, sex and [19,20]. In the current study, the internal consistency of depressive symptoms were included as covariates in the SF-MPQ sensory pain score (Cronbach’s a=0.76) analyses. and affective pain score (Cronbach’s a=0.84) were adequate to good. Additionally, participants completed a pain intensity rating using a numerical rating scale (NRS). Results Participants rated pain intensity on a scale of 0 (no pain) to 100 (most intense pain imaginable) immediately prior to Pain Relevant Responses: Ethnicity Differences removal of their hand from the cold water bath during the final CPT immersion. Pain intensity is suggested to Average pain responses were assessed for the total approximate a sensory rating of pain [21]. Total pain expo- sample and across ethnicity and sex (see Table 1). Using sure, a more objective indicator of pain, was assessed as a MANCOVA, main effects of ethnicity, controlling for sex the total time in seconds of hand immersion in the cold and depressive symptoms, on the SF-MPQ affective sub- water bath (420 seconds maximum duration over five scale, SF-MPQ sensory subscale, and pain intensity NRS immersions). Among the four pain measures, the inter- during acute pain were examined. African Americans and correlations were moderate and ranged from 0.45 to 0.62; Asian/Pacific Islanders, who did not significantly differ however, total pain exposure was only associated with the from each other, reported significantly greater pain inten- pain intensity rating (r[61] 0.26, P 0.045). sity than Caucasians (pain intensity during acute pain: =- = 2 [F (3, 79) = 3.60, P = 0.035], hp = 0.133). Statistics Catastrophizing in Response to Acute Pain: MANCOVA, ANCOVAs and regression analyses were Ethnicity Differences used to examine the three research questions. A MANCOVA with pain responses as outcomes was used Two ANCOVAs, for standard and situational catastrophiz- to examine the main effects of ethnicity, controlling for ing, were used to examine whether each catastrophizing sex and depressive symptoms, with pain responses. report varied by ethnicity, controlling for sex and depres- ANCOVAs, for standard and situational catastrophizing sive symptoms (see Table 2). Standard catastrophizing did were used to examine the main effects of ethnicity, con- not significantly vary by ethnicity (P = 0.90). Situational trolling for sex and negative affect, with catastrophizing. catastrophizing did significantly vary by ethnicity, such that Finally, Baron and Kenny’s [22] guidelines were followed African Americans reported greater situational catastroph- for the mediation analyses to clarify ethnicity differences in izing than Asian/Pacific Islanders and Caucasians, who pain responses. Specifically, catastrophizing was pro- 2 did not differ (F [3, 79] = 4.35, P = 0.019, hp = 0.156). posed to mediate the effect of ethnicity in predicting pain responses. The racial categories examined were African Americans (n = 11), Asian/Pacific Islanders (n = 15), and Catastrophizing as a Mediator of the Relation of Caucasians (n = 26); to examine differences in ethnicity Ethnicity with Pain post hoc t-test comparisons were used. Participants from other ethnicities (i.e., Hispanic, n = 2; Native American, Multiple regression analyses were completed to determine n = 1; and Other, n = 7) were dropped given sample size whether pain catastrophizing mediated differences in pain constraints. responses across ethnicity, controlling for sex and depres- sive symptoms. Mediation analyses for the standard PCS The first two analyses hold general data assumptions, with were not performed given the findings in hypothesis two attention to normality and compound symmetry or sphe- that standard catastrophizing did not differ by ethnicity. ricity particularly relevant to guard against inflated Type 1 Using Sobel’s test [22], the situational PCS total score error. Though the data were roughly normal (i.e., was a significant mediator of the relation of ethnicity with skewness/SE of skewness < 3), total pain exposure was SF-MPQ affective subscale (t[56] = 2.15, P = 0.03) and significantly skewed. A base 10 log transformation was the rating of pain intensity (t[56] = 2.01, P = 0.045), but used, but this approach did not normalize the data, there- not the SF-MPQ Sensory subscale (t[56] = 1.79, fore given its limited association with the other three pain P = 0.073) (see Table 3).

317 Fabian et al.

Discussion 26) = The objective of the present study was to examine ethnic differences in various reports of pain quality (i.e., affective and sensory) and standard (i.e., recall thoughts and feel- ings during past experiences of pain) and situational (i.e., recall thoughts and feelings of an experimental pain task just experienced) pain catastrophizing. Additionally, we examined catastrophizing as a potential mediator of the relation between ethnicity and pain responses to clarify one potential mechanism for explaining ethnicity Downloaded from https://academic.oup.com/painmedicine/article/12/2/314/1855752 by guest on 27 September 2021 15) Caucasian (n

= differences in pain reporting.

First, pain responses were examined. African Americans and Asian/Pacific Islanders, who did not differ from each other, reported greater pain intensity than Caucasians. Asian/Pacific Islanders (n The findings provide evidence that reports of various quali- ties of pain differentially vary across ethnicity, which neces- sitates identification of potential mechanisms such as catastrophizing to explain the relation. Therefore, we examined catastrophizing, and we found that only situ- ational catastrophizing varied by ethnicity, with African Americans reporting greater catastrophizing than Asian/

11) Pacific Islanders and Caucasians, who did not differ. To

= our knowledge, no research has examined how pain

African American (n quality and standard and situational catastrophizing reports vary by ethnicity. Research suggests that racial differences in pain responses may be associated with ethnicity-related differences in catastrophizing. Chibnall and colleagues [30] examined differences in pain catas-

24) trophizing in African Americans and Caucasians with low- = back injuries. Even after controlling for socio-economic status, African Americans showed greater catastrophiz- ing. The present study showed similar findings in a healthy sample of African Americans, in that African Americans reported greater situational catastrophizing and pain than other ethnicities. It is possible that ethnicity, as a social construct, is merely a marker for the myriad other factors 38) Male (n that influence differences in pain responses (e.g., access = to or perceived racism). Thus, caution must be used when interpreting the findings as strictly a function of Numerical Rating Scale.

= ethnicity [9].

Finally, we performed mediation analyses to determine if catastrophizing would mediate the relation of ethnicity with pain responses. Standard catastrophizing was not a mediator given lack of variability across ethnicities. Situ- ational catastrophizing was a significant mediator for 62) Female (n

= affect and rating of pain intensity but not sensory pain. The shifting presence and absence of mediation highlight the complexity, and potentially limited use, of catastrophizing Total (N Mean SD Mean SD Meanas SD a mechanism Meanfor SD explaining Mean ethnicity SD differences Mean SD in the report of various qualities of pain. Others report that coping strategies such as prayer differ across ethnicities as does the use of such pain-reducing strategies to control pain in undergraduates not experiencing chronic

Pain relevant responses by sex and ethnicity pain [10], suggesting that certain coping strategies may Short-Form McGill Pain Questionnaire; NRS

= be appropriate for certain pain qualities. Additionally, one

0.05. study with African Americans, Hispanics, and Caucasians < with chronic pain did not find ethnic differences in pain P Table 1 Variable * SF-MPQ SF-MPQ AffectiveSF-MPQ SensoryPain Intensity NRSTolerance 2.95 16.16 80.21 3.23 8.18 26.77 165.72 3.86 19.81 90.08 34.33responses, 3.49 20.47 7.07 159.59 65.00 11.12 40.36 1.67 with 28.55 175.17 6.52 2.28 slight, 18.75 93.09* 21.45 though 5.55 149.73 11.79 5.85 statistically 3.23 51.67 93.20* 18.59 165.82 3.53 9.10 non-significant, 8.30 28.46 65.00* 3.72 174.46 13.53 33.33 2.04 16.47 6.99 2.76

318 Ethnicity, Catastrophizing and Pain

Table 2 Standard and situational PCS catastrophizing in response to acute pain, by sex and ethnicity

African American Asian/Pacific Caucasian Total (N = 62) Female (n = 38) Male (n = 24) (n = 11) Islanders (n = 15) (n = 26)

Variable Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD

PCS 15.90 8.21 17.24 8.24 13.79 7.84 18.73 8.03 17.33 9.51 14.62 8.35 PCS† 20.76 11.86 24.21 10.64 15.29 11.84 31.64* 10.47 22.07* 10.07 17.73* 11.53

* P < 0.05. Downloaded from https://academic.oup.com/painmedicine/article/12/2/314/1855752 by guest on 27 September 2021 † Situational measure. PCS = Pain Catastrophizing Scale. differences in standard catastrophizing [9]. Such a finding simple approach to systematically examine our findings in suggests that ethnic differences in pain may change from comparison to past research is the “who, what, where, acute to chronic pain experiences, and possibly, that when, and why” approach. standard and situational catastrophizing are assessing different constructs. Who? Populations experiencing acute or chronic pain, even healthy populations, have shown associations Overall, we examined healthy adults’ pain and cata- between catastrophizing and pain responses. strophizing in a laboratory setting with standard and situational assessment to better understand differences What? There has also been considerable validation of in reports of pain by ethnicity. We found support that what information catastrophizing reports suggest about catastrophizing with a situational focus and varying the pain experience (e.g., that it is a negative experience qualities of pain were differentially related to ethnicity. We made up of thoughts marked by helplessness, rumination, also found that ethnicity differences in varying types of and/or magnification). pain reports were at least partially mediated by situational catastrophizing. Where? Measurement of catastrophizing has been done in laboratory, hospital and home environments with find- A key charge of current research is to develop the theory ings all supporting its relation to pain, despite the varied underlying catastrophizing and its relation to pain. A influences these settings may have.

Table 3 Models of situational pain catastrophizing mediating the association of ethnicity with pain responses, controlling for depressive symptoms and sex

SF-MPQ Affective SF-MPQ Sensory Pain Intensity NRS Variable bbb

Step 1† Sex 0.34* 0.50** 0.28* African Americans‡ NS NS 0.32* Asian/Pacific Islanders‡ 0.34* 0.26* 0.30* Full Model: R2 = 0.23*, f 2 = 0.30 R2 = 0.39***, f 2 = 0.64 R2 = 0.34*, f 2 = 0.52 Step 2‡ Sex 0.33* 0.33* 0.33* African Americans‡ NS NS NS Asian/Pacific Islanders‡ 0.38** 0.38** 0.38** Full Model: R2 = 0.29*, f 2 = 0.41 R2 = 0.29*, f 2 = 0.41 R2 = 0.29*, f 2 = 0.41 Step 3‡ PCS 0.61*** 0.43** 0.55** Sex NS 0.36** NS African Americans‡ NS NS 0.31* Asian/Pacific Islanders‡ NS NS NS Full Model: R2 = 0.53***, f 2 = 1.13 R2 = 0.52***, f 2 = 1.08 R2 = 0.55***, f 2 = 1.22

* P < 005. ** P < 0001. *** P < 00001. † BDI was not significant at any step in the models. ‡ Ethnicity was dummy coded as two variables, the first compared African Americans with Caucasians and the second compared Asian/Pacific Islanders with Caucasians. PCS = Pain Catastrophizing Scale; BDI = Beck Depression Inventory; SF-MPQ = Short-Form McGill Pain Questionnaire; NRS = Numerical Rating Scale; NS = nonsignificant.

319 Fabian et al.

When? These measurements were originally focused in a 2 Turk DC, Okifuji A. Psychological factors in chronic general way with emphasis on prior experiences with pain, pain: Evolution and revolution. J Consult Clin Psychol but more recent research has emphasized situational 2002;70:678–90. measurement, as it may be more related to pain [16]. 3 Sullivan MJ, Thorn B, Haythornthwatie JA, et al. Theo- Why? Suggested mechanisms for the effects of catastro- retical perspectives on the relation between catastro- phizing on pain have varied from emotional to physiologi- phizing and pain. Clin J Pain 2001;17:52–64. cal [31–34]. These past findings focus on developing an understanding of catastrophizing as it relates to pain more 4 Thorn BE, Clements KL, Ward LC, et al. Personality broadly, but show little focus on how catastrophizing factors in the explanation of sex differences in pain relates to specific types of reported pain (e.g., affective or catastrophizing and response to experimental pain. Downloaded from https://academic.oup.com/painmedicine/article/12/2/314/1855752 by guest on 27 September 2021 sensory). Clin J Pain 2004;20:275–82.

There are, however, several notable limitations to the 5 Goodin B, McGuire L, Allshouse M, et al. Associa- current study. First, the power to detect effects with rel- tions between catastrophizing and endogenous pain- evant outcomes was minimal given the sample size. inhibitory processes: Sex differences. J Pain 2009;10: However, these findings are similar to previous research 180–90. [30,35] with the added benefit that potential confounds may be minimized given that the current sample was 6 Litt MD, Shafer D, Napolitano C. Momentary mood comprised of healthy young adults attending college. and coping processes in TMD pain. Health Psychol Second, the ability to generalize these findings to chronic 2004;23:354–62. pain populations or those experiencing different types of pain is limited given that the study examined healthy 7 Dixon KE, Thorn BE, Ward LC. An evaluation of young adults in an acute pain setting only. Finally, previous sex differences in psychological and physiological research has shown that situational catastrophizing is only responses to experimentally-induced pain: A path moderately associated with standard catastrophizing analytic description. Pain 2006;112:188–96. measurement, and is more relevant to current sensory and affective pain responses [7,8]. However, situational cata- 8 Edwards RR, Campbell CM, Fillingim RB. Catastroph- strophizing may more closely approximate general dis- izing and experimental pain sensitivity: Ony in vivo tress following the pain experience, so it is necessary to reports of catastrophic cognitions correlate with pain clarify the validity of the construct, given its apparent rel- responses. J Pain 2005;6:338–9. evance to ethnicity differences across pain qualities. 9 Edwards RR, Moric M, Husfeldt B, Buvanendran A, Conclusion Ivankovich O. Ethnic similarities and differences in the chronic pain experience: A comparison of African Future researchers should place priority on further explain- American, Hispanic, and Caucasian patients. Pain ing the contextual elements involved in their assessments Med 2005;6:88–98. of catastrophizing and explicating the qualities of pain reports. Catastrophizing is a stable predictor of pain in a 10 Hastie BA, Riley RL, Fillingim RB. Ethnic differences variety of settings that is readily modifiable [36–39]. Par- and responses to pain in healthy young adults. Pain ticular treatment models may be more appropriate for Med 2005;6:61–71. addressing certain aspects of pain. To identify how the contextual modifications affect catastrophizing and ulti- 11 Price DD. Psychological Mechanisms of Pain and mately the varied qualities of pain, a more systematic Analgesia. Seattle: IASP Press; 1994. presentation of the context must be examined, with par- ticular attention to the type of pain response under study. 12 Edwards RR, Fillingim RB. Ethnic differences in thermal pain response. Psychosom Med 1999;61: Acknowledgments 346–54.

This work was supported by grants from the National 13 Riley JL, Wade JB, Myers CD, et al. Racial/ethnic Institutes of Health (R21AT003250-01A1 (to L.M.), differences in the experience of chronic pain. Pain K23AR051315-01 (to R.R.E.), R21NS48593 (to R.R.E.), 2002;100:291–8. and by a URA from the UMBC office of the provost (to M.A.). We would also like to thank Mr Mark Allshouse for 14 Campbell C, Edwards R, Fillingim R. Ethnic differences the data collection. No authors have any conflict of interest in responses to multiple experimental pain stimuli. Pain regarding this work. 2005;1:20–6.

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