assessment of pain cognitions in cancer patients with chronic pain

© U.S. Cancer Pain Relief Committee, 2001 0885-3924/01/$–see front matterPublished by Elsevier, New York, New York PII S0885-3924(01)00354-2

Vol. 22 No. 5 November 2001 Journal of Pain and Symptom Management 911

Original Article

Assessment of Pain Cognitions in Cancer Patients with Chronic Pain

Rianne de Wit, PhD, Frits van Dam, PhD, Marie-José Litjens, RN, MSN,and Huda Huijer Abu-Saad, RN, PhD

Division of Psychosocial Research and Epidemiology (R.d.W., F.v.D., M.-J.L.,) The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam; Department of Medical Psychology and Psychotherapy (R.d.W.), Erasmus University, Rotterdam; Pain Expertise Center (R.d.W.), University Hospital Rotterdam, Rotterdam; Faculty of Psychology (F.v.D.), University of Amsterdam, Amsterdam; and Department of Nursing Science (H.H.A.-S.), University of Maastricht, Maastricht, The Netherlands

Abstract

Although reports suggest that beliefs about pain play an important role in the adjustment and pain experience of non-cancer patients, the impact of cognitions on the pain experience is unknown in cancer patients. This study examined the factor structure, reliability, and validity of the Pain Cognition List–Experimental version, a measure developed to assess patients’ self-statements about pain and the extent to which patients are effective in dealing with the pain. The Pain Cognition List–Experimental version was administered to 313 cancer patients during hospitalization. Confirmatory factor analysis was conducted to evaluate the adequacy of fit for the original five factors. Because of a failure to replicate the factors, exploratory factor analysis was conducted, finding the factors Pain Impact, Social Comparison, Acquiescence, and Outcome Efficacy. The internal consistency for the factor Pain Impact was high (r

�

0.89), while the other three factors showed low reliability. The factor Catastrophizing, usually an important factor in non-cancer patients, did not emerge. No differences were found across sex. The factors Pain Impact and Acquiescence provided evidence for concurrent validity. Patients with district nursing showed higher scores on the factors Pain Impact and Acquiescence, and higher scores on Pain Impact and Acquiescence were associated with higher pain intensity scores. This study was an attempt to evaluate pain cognitions and beliefs in cancer patients. It is concluded that the Pain Cognition List for non-cancer patients cannot be easily used in cancer pain patients and that evaluation of pain cognitions in cancer patients is useful. Health care providers evaluating pain in cancer patients with chronic pain need to be aware of the impact pain cognitions have on patients’ pain experience. Although more research is needed, measuring pain cognitions should be considered.

J Pain Symptom Manage 2001; 22:911–924

. © U.S. Cancer Pain Relief Committee, 2001.

Key Words

Pain cognition, pain beliefs, psychological assessment, cancer pain, Pain Cognition List

Address reprint requests to:

Rianne de Wit, PhD, University Hospital Rotterdam, Pain Expertise Center-Dijkzigt Hospi-tal, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.

Accepted for publication: January 25, 2001.

912 de Wit et al. Vol. 22 No. 5 November 2001

Introduction

Cancer pain has characteristics of bothchronic and acute pain. Like acute pain, can-cer pain is directly associated with tissue dam-age. When cancer pain persists and worsens, itcan serve as a sign of the progression of dis-ease,

1,2

and can produce feelings of hopeless-ness and helplessness, emotional distress, andmight have a negative impact on coping tech-niques. Cancer pain is best described as a com-plex, multidimensional model. Pain, and espe-cially cancer pain, is not only a nociceptive,physical experience, but involves affective, cog-nitive, behavioral, and sociocultural dimen-sions. The cognitive dimension refers to theway patients think of their pain and what thepain means for them, in terms of thoughts, be-liefs, attitudes, and self-efficacy expectations.Beliefs about pain are assumed to play an im-portant role in the process of coping by influ-encing both the initiation of coping strategiesand a person’s level of adjustment. The way apatient copes with pain is influenced by thethoughts about their pain and what the painmeans for them. Although the role of cogni-tions in clinical pain experience is not fully un-derstood, pain cognitions may partly be re-sponsible for dysfunction, and may influencethe outcome of treatment. Judgments of self-efficacy, perceived pain control, and catastro-phizing with respect to pain seem to constitutepain appraisals that are important in the ad-justment to chronic pain.

Although a considerable body of knowledgeexists on the role of pain cognitions in non-cancer patients, only a few studies in cancerpain patients have shown that pain beliefs areassociated with pain intensity.

3–5

Arathuzik

3

found that cognitive and emotional factors ap-peared to play a central role in the response topain and in the coping methods used to dealwith pain. Arathuzik

4

found that a cognitive-behavioral intervention can change the ability todecrease pain. Zimmerman et al.

5

found a rela-tionship between pain intensity and psycholog-ical status. Cancer patients with pain weremore anxious, depressed, and hostile, and hadmore somatic complaints than patients whowere not in pain. Turk and associates

6

foundthat patients with cancer-related pain reportedsignificantly higher levels of cognitive and be-havioral fear-responses to pain than did pa-

tients with non-cancer pain. The meaning pa-tients ascribe to their pain may differ fromperceiving pain as a challenge (“I am going tofight as long as I can”), as an enemy (“It is likebeing attacked”), or as a punishment (“Why isGod punishing me?”).

7

In chronic non-cancer pain, it is generallyagreed that the meaning assigned to pain canplay an important role in the experience ofpain and in the response to treatment. Severalstudies have demonstrated the impact of paincognition on patients’ pain experience, disabil-ity, distress, non-adherence, and outcome oftreatment.

6,8–17

Particularly, catastrophizing hasbeen associated most strongly with depression,poorer adjustment, and higher intensity ofpain.

11,18–24

Studies on catastrophizing havebeen conducted primarily in chronic nonma-lignant pain.

Several studies have demonstrated that treat-ment of cancer pain is often inadequate.

25,26

Ward et al.

27

found that higher concerns werecorrelated with higher levels of pain. The im-pact of pain cognition on patients’ cancer painexperience, however, remains unknown.

28

Whatever importance pain cognition may havein the multidimensional model of cancer pain,the patient is best treated when these aspectsare not neglected in the treatment of pain. Abetter understanding of the role of pain cogni-tions might have important implications forthe treatment of cancer pain.

In the past two decades, over one dozen in-struments have been developed to measure thecognitions, beliefs, and attributions patientshave about the cause of the pain and their self-efficacy expectations, for example, the CognitiveError Questionnaire,

29,30

Pain Cognitions Ques-tionnaire,

8

Cognitive Evaluative Questionnaire,

31

Survey of Pain Attitudes,

32–34

Pain-Related Con-trol Scale,

11,35

Pain Beliefs Questionnaire,

10

PainBeliefs and Perceptions Inventory;

16,36,37

Pain In-formation and Beliefs Questionnaire,

38

Pain Cat-astrophizing Scale,

39,40

Inventory of NegativeThoughts in Response to Pain,

41

and Pain Cogni-tion List–Experimental version.

42

Although a variety of self-report measuresare nowadays available, most measures havenot been used extensively in different researchsettings, the scales show considerable overlap,not all measures have been psychometricallywell-constructed, and some measures haveshown disappointing results regarding validity

Vol. 22 No. 5 November 2001 Assessment of Pain Cognitions in Cancer Patients 913

aspects.

43

In only a few studies, psychometricproperties of the various measures to assesspain cognitions have been compared.

22,34

Of all measures available, only the Pain Cog-nition List–Experimental version developedby Vlaeyen

42,44

has been developed in theDutch language. The Pain Cognition List hasonly been studied in chronic nonmalignantpain patients,

44

and was recently further vali-dated in an extended population diagnosedwith e.g., back pain, fibromyalgia, complexregional pain syndrome, and rheumatoid ar-thritis.

45

Vlaeyen et al. define pain cognition as “anyverbalized evaluation related to both an evalua-tion of the pain and an evaluation of the extentto which the person is effective in dealing withthe pain.”

46

Pain cognition focuses on connota-tions related to pain, in terms of attributionsand self-efficacy expectations. Self-efficacy ex-pectations are based on Bandura’s theory ofbehavioral change,

47,48

while attributions arebased on the coping theory of Roskies and Laz-arus.

49

Cognitions or thoughts (beliefs, ap-praisals, or expectations) patients have regard-ing their pain should be distinguished fromcoping, which can be described as purposefulefforts to manage pain.

9

The way patients copewith their pain is influenced by their thoughtsabout pain and what pain means for them,which is partly based on the information thatpatients received.

The present study represents an effort to val-idate a questionnaire measuring pain cogni-tions in cancer patients with chronic pain. Be-cause the Pain Cognition List consisted of anexperimental version and has only been stud-ied in chronic nonmalignant pain patients, thepsychometric properties of the Pain CognitionList–Experimental version were investigated.The purpose of the present study was twofold.First, the psychometric properties of the PainCognition List–Experimental version were de-scribed. By means of confirmatory factor analy-sis, the factor structure, reliability, and validityaspects of the Pain Cognition List, as originallydescribed by Vlaeyen and associates,

46

was rep-licated. To validate the factor structure in can-cer pain patients, an exploratory factor analysiswas conducted to find the best fit. Second, theoccurrence of cognitions in cancer patientswith chronic pain was assessed, and the associa-tion with sociodemographic variables, medical

variables, pain variables, and quality of life wasinvestigated.

Methods

Design and Patient Population

The study presented here was part of alarger study on the effects of a Pain EducationProgram, with a follow-up of two months. Thecurrent study was part of a prospective, longitu-dinal, randomized trial in which the effects of atailored “Pain Education Program” were inves-tigated. A detailed description of the Pain Edu-cation Program is given elsewhere.

50

The patients in this study were admitted tothe Antoni van Leeuwenhoek Hospital/TheNetherlands Cancer Institute, a specializedcancer hospital in Amsterdam, the Nether-lands. Patients who provided informed consentwere enrolled in the study if they met the fol-lowing criteria: 1) pain related to cancer, orcancer therapy; 2) a pain duration of at leastone month; 3) a life expectancy of at leastthree months (assessed by physicians); 4) ableto read and speak Dutch; 5) accessible by tele-phone; and 6) not residing in nursing home orretirement home. Based on the assumptionthat patients who required district nursing af-ter postdischarge would differ from patientswithout district nursing with regard to the abil-ity to perform daily activities, housing, andliving conditions, and pain complaints expe-rienced, patients with and without districtnursing were distinguished.

Procedure

Patients who met the inclusion criteria wereapproached to participate in the study. Datawere collected from the medical record andfrom interviews with patients who were willingto complete the informed consent form. Theinterview was conducted by nurses 3–4 days af-ter admission. Data collection included infor-mation on patient demographics, medical vari-ables, pain experience and pain treatment,quality of life, and patients’ pain cognitions.Patients who were not able to fill in the 77-itemPain Cognition List–Experimental version ontheir own received help from a nurse.

Measures

Pain cognition

was measured by means of thePain Cognition List–Experimental version.

42,44


The original Pain Cognition List–Experimen-tal version, consisting of 77 items, was used inthis study. The Pain Cognition List–Experi-mental version describes the factors Pain Im-pact, Catastrophizing, Outcome Efficacy, Ac-quiescence, and Reliance on Healthcare. Thequestionnaire consists of 5-point Likert self-report items with answer categories: total agree-ment, relative agreement, neither agreementnor disagreement, relative disagreement, andtotal disagreement. The 77-item version hasbeen tested by Vlaeyen and associates

44

in astudy of 188 chronic nonmalignant patients.

44

Preliminary analyses led to elimination of 27items that were either too skewed, correlatedwith more than one factor, or did not signifi-cantly correlate with one of the subscales. Aftertesting, 50 items remained, consisting of fivefactors. The first factor, Pain Impact, describesthe impact the pain has on the patients’ func-tioning by means of items such as: “I feel lessand less capable of doing something.” The sec-ond factor, Catastrophizing, describes the aver-sive aspect of the pain experience by means ofitems such as “The word pain frightens me.”Outcome Efficacy, the third factor, representsthe patient’s expectation that a given behaviorwill lead to certain outcomes. An example ofthis factor is: “Relaxation exercises decreasethe pain.” The fourth factor, Acquiescence, de-scribes a certain passivity and the expectationthat responding in a different way is futile andunnecessary by means of questions such as “Ithink the best thing to do is to wait and seewhat happens.” The last factor, Reliance onHealthcare, shows the expectation that changeis possible, but can only be brought about byothers. An example of the last factor is “Some-body must be able to help me.” Results showedthat the five factors accounted for 39.9% of thetotal variance, internal consistency rangedfrom 0.61–0.88, and test–retest reliabilityranged from 0.42 to 0.92. In a subsequentstudy, the Pain Cognition List consisting of 50items was further validated in an extendedpopulation of more than 900 patients.

51,52

A re-vised factor structure provided support forfour factors with 39 items accounting for35.4% of the variance. The internal consis-tency ranged from 0.64 to 0.88. The intercorre-lations between the factors ranged from 0.01 to0.45, and the test–retest reliability ranged from0.51–0.73. The former factors Catastrophizing

and Reliance on Healthcare correspondedclosely to the original factors. The factor PainImpact was partly modified. The new factorthat emerged was labeled Optimism, describ-ing the positive attitude of the patients despitetheir pain complaints. The factor Outcome Ef-ficacy emerged in a somewhat different way,and was newly labeled Internal Control. Inter-nal Control describes the extent to which paincan be influenced. The original factor Acquies-cence was not confirmed in the revised version.Finally, the factor Pain Disability emerged, de-scribing the impact the pain has on the pa-tients’ functioning. It is concluded that theoriginal reported factor structure could onlybe partly replicated.

Sociodemographic

data included, for example,sex, age, education, and employment. Medicalvariables consisted of variables such as type ofcancer, time since diagnosis, disease stage (lo-cal, regional, metastatic, or unknown), andcancer treatment (surgery, chemotherapy, ra-diotherapy, hormonal therapy, other, or notherapy).

Pain experience

was measured by means of theDutch Language Version of the McGill PainQuestionnaire (MPQ-DLV). This measure con-sists of a self-report instrument including painlocation. Furthermore, the McGill Pain Ques-tionnaire describes the sensory dimension(range 0–36), affective dimension (range 0–15),evaluative dimension (range 0–12), as well asthe total score (range 0–63), and the totalnumber of words chosen (range 0–20). Reli-ability and validity of the questionnaire havebeen established.

53–56

Pain intensity

was assessed on an 11-point Nu-merical Rating Scale ranging from 0 to 10 inwhich 0 represents “no pain” and 10 “pain asbad as you can imagine.” Patients were askedto indicate Present Pain Intensity, AveragePain Intensity in the past 24 hours, and WorstPain Intensity. The Numeric Rating Scale hasbeen demonstrated to be a reliable and validmeasure of pain intensity.

57

Quality of life

was measured by means of theEuropean Organization for Research andTreatment of Cancer Core Quality of LifeQuestionnaire (EORTC QLQ-C30

�

3). TheEORTC QLQ-C30

�

3 contains 5 functioningscales (physical functioning, cognitive func-tioning, role functioning, emotional function-ing, and social functioning); physical symptom


scales (fatigue and malaise, nausea and vomit-ing, and pain); several single-item symptommeasures (constipation, dyspnea, difficultywith sleeping, appetite loss, diarrhea, and fi-nancial impact); overall perceived health sta-tus; and global quality of life. The functioningand quality of life scales range from 0 to 100with higher values indicating a higher value offunctioning and quality of life; the symptomscales range from 0 to 100 with higher valuesindicating more symptoms or difficulties. TheEORTC QLQ-C30

�

3 has demonstrated ac-ceptable levels of reliability and validity.

58

Pharmacological

pain treatment

was evaluatedby assessing the pharmacological pain treat-ment received. Name, dose, frequency of non-opioids and opioids, route, and schedule ofadministration were established. This was cate-gorized into the “three-step analgesic ladder”of the World Health Organization, in whichstep 1 represents nonopioids, step 2 “weak”opioids, and step 3 “strong” opioids.

59,60

Non-pharmacological pain treatment was mea-sured by summing the number of times pa-tients used techniques such as heat, cold,massage, relaxation, and distraction to re-lieve pain.

Statistical Analysis

Analyses were carried out using the statisticalpackage SPSS for Windows version 7.5. Statisti-cal significance was at

P

�

.05 level, two-tailed.In the analyses, all reverse-scored items on thepain Cognition List were recorded. Means,standard deviations, and frequencies were esti-mated to describe the patient population.Comparisons were made using Student’s

t

-tests.Internal consistency (reliability) of the PainCognition List–Experimental version was as-sessed by Cronbach’s alpha coefficients.

Construct validity, the degree to which an in-strument measures the construct under investi-gation, was assessed by: (1) factor analysis; (2)correlations between subscale scores; (3) cor-relations between the Pain Cognition List andsociodemographic variables, (e.g., age, sex);(4) correlations between the Pain CognitionList and variables regarding pain, pain inten-sity, quality of life, and use of non-pharmaco-logical pain treatment (concurrent validity);and (5) the degree to which a measure candistinguish between subgroups (known-groupcomparisons).

The internal structure of the Pain CognitionList–Experimental version was assessed throughfactor analyses. First, confirmatory factor analy-sis was conducted. In a confirmatory factoranalysis, the relations between variables arespecified a priori and based on previous re-search. The aim is to confirm the fit betweenthe previous found model and the actual struc-tural model in the current data set.

61

In case ofan unsatisfying fit a new exploratory factoranalysis with oblique (Oblimin) rotation wasbeen carried out. Multitrait Analysis Program(MAP), a technique based on the examinationof item-scale correlations, was used to examinethe internal structure.

62

Kaiser Meyer Olkinmeasure of sampling adequacy was performedto determine whether the data were appropri-ate for an exploratory factor analysis.

63

Itemsthat were not quasi-normal distributed becauseof skewness

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1 or

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1 were deleted for fromanalyses. Oblique rotation rather than orthog-onal rotation was selected because the objec-tive was to obtain factors that were correlatedand theoretically meaningful. Factors wereidentified until the eigenvalue fell below 1.0.Items were included in the factor if theyloaded

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0.40 on either, but not both, factors.Of those items having high factor loadings ontwo factors, correlations between the item andthe factor were calculated. When the correla-tion coefficients differed less than 0.05, theitem was excluded. When the difference wasmore than 0.05, the item was assigned to thefactor with which it correlated most highly.

To demonstrate validity, correlations amongthe factors and data regarding sociodemo-graphic variables, medical variables, pain, qual-ity of life, pain knowledge, and pain treatmentwere described by means of Pearson product-moment correlations.

Results

Patient Characteristics

A total of 383 patients satisfied the selectioncriteria. Seventy patients (18%) declined to par-ticipate in the study for the following reasons:48 patients (69%) found the study too burden-some, 15 patients (21%) were not motivated,and 7 patients (10%) were too ill. Of the 313participating patients, 63% were female (

n

�

196). The mean age was 56 years (SD

�

12),and almost three-fourths of the patients was


married (74%). Of the patients, 41% had loweducation corresponding to primary schooland lower vocational training, 33% had lowlevel of secondary school and intermediate vo-cational training, and 26% had high levels ofsecondary school, college graduate, or univer-sity. Only 12% of the patients (

n

�

38) was em-ployed.

Patients suffered from cancer of differentsites (Table 1), most frequently in an advancedstage (58%). Although various cancer treat-ments were provided, no anticancer treatmentwas provided in 22% of the patients. Pain in theabdominal region and in the lower back regionwas reported most frequently. The mean painduration was 14 months (SD

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33, range

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1–324 months). Patients’ Present Pain Intensitywas on average 3.3 (SD

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2.3), the Average

Pain Intensity was 4.9 (SD

�

2.1), and theWorst Pain Intensity was 7.7 (SD

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2.1). In to-tal, 88% of the patients were prescribed anal-gesics: 72% received non-opioids (WHO step1), 38% received “weak” opioids (WHO step2), and 36% received “strong” opioids (WHOsteps 3/4).

Feasibility of the Pain Cognition List–Experimental Version

In the hospital, patients were asked to fill inthe Pain Cognition List–Experimental versioneither on their own or, in case patients wereconfined to bed, they were read the items ofthe questionnaire and could answer orally. Formost of our patients, the questionnaire wasread aloud by the nurse and about 10% ofthem reacted emotionally. In order to allow for

Table 1

Characteristics of the Study Population

No. of patients (%)

Type of Cancer (

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100%)Lip, oral cavity, and pharynx 18 (5.8)Digestive organs and peritoneum 38 (12.1)Respiratory and intrathoracic organs 34 (10.9)Breast 94 (30.0)Bone, connective tissue, and skin 43 (13.7)Genitourinary organs 74 (23.6)Other (e.g., non-Hodgkin’s lymphoma) 35 (11.2)

Extent of DiseaseLocal 45 (14.4)Regional 60 (19.2)Metastatic 182 (58.1)Unknown 9 (2.9)Not applicable 17 (5.4)

Cancer Treatment (

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100%)None 70 (22.4)Surgery 56 (17.9)Chemotherapy 118 (37.7)Radiotherapy 58 (18.5)Hormonal therapy 28 (8.9)Other and unknown 21 (6.7)

Pain Location (

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100%)Head, face mouth 66 (21.1)Breast, thoracic region 64 (20.4)Upper shoulder and upper limbs 91 (29.1)Abdominal region 124 (39.6)Lower back, lumbar spine, sacrum, coccyx 122 (39.0)Lower limbs 85 (6.5)Anal, perianal, and genital region 17 (5.4)Everywhere 2 (0.1)

Source of Cancer Pain (

�

100%)Direct tumor involvement 242 (77.3)Cancer therapy 75 (24.0)Associated with cancer disease 21 (6.7)Unknown 14 (4.5)


patients’ emotional reactions, it is advised toadminister the Pain Cognition List in the pres-ence of a nurse.

Of the 313 participating patients, 21 patients(6.7%) did not fill in the Pain Cognition List: 6patients died before discharge, 6 patients didnot return the questionnaire by mail, 8 pa-tients considered filling in the questionnairetoo burdensome, and 1 patient considered thequestionnaire too long. In addition to thesepatients, 4 patients were excluded from furtheranalyses because of missing values that con-sisted of 8 or more of the 77 items (

�

10%). Pa-tients with less than 8 missing values were in-cluded in the analyses by recoding the missingitem to “neither agreement nor disagreement”(score 3). Altogether, the analyses were per-formed on 288 patients (92%).

Replication of the Confirmatory Factor Analysis

A replication study of the Pain CognitionList–Experimental version was carried out toevaluate the five-factor structure. The originalstructure, as tested by Vlaeyen and associates,

44

consisted of the factors Pain Impact (17 items),Catastrophizing (17 items), Outcome Efficacy(7 items), Acquiescence (4 items), and Relianceon Healthcare (5 items). Results of exploratoryprincipal component factor analysis with Ob-lique rotation showed that the five-factor struc-ture could not be replicated. An examination ofthe eigenvalues, however, suggested a four-fac-tor instead of a five-factor structure. When forc-ing the initial five-factor structure, Kaiser’s mea-sure of sampling was unsatisfactorily high. Ofthe 50 items, 7 were not normally distributed,and 5 items loaded on more than one factorwhile the correlation coefficient difference wasless than 0.05. The factors Outcome Efficacy,Acquiescence, and Reliance on Healthcare

showed marginal levels of reliability: 0.59, 0.55,and 0.43, respectively. The inter-factor correla-tions were high (r

�

�

0.08 to 0.53), meaningsome overlap between the factors. Table 2 pre-sents the mean and standard deviations for thePain Cognition List subscales and total score.

It is concluded that the five-factor structurewas not confirmed in this population of cancerpain patients. The obvious difference in thefactor structure needs to be further explored.Although the differences may, in part, be dueto differences in patient population, questionsare also raised about the psychometric quali-ties of the Pain Cognition List.

Results of the Exploratory Factor Analysis

In subsequent analyses, the factor structureof the original 77-item Pain Cognition List wasanalyzed to find the best fit. Based on the ex-amination for skewness (

�

1 or

�

1), 15 itemswere deleted from further analyses. Because oflinear dependency, meaning that a variablecan be perfectly explained by another vari-able, 7 items were deleted in sequence of theirmultiple R. To determine whether the datawere appropriate for an explanatory factoranalysis, Kaiser Meyer Olkin was calculated as0.82, which can be valued as “meritorious.”

63

Based on the scree plot, an examination of theeigenvalues suggested a modified model withfour factors. Thirty-four items finally remainedand constituted the Pain Cognition List forCancer patients. The four factors accountedfor a total of 39% of the variance. Results ofthe factor analysis are given in Table 3. Factor1, Pain Impact, accounted for 20% of the vari-ance. This factor, primarily concerning the im-pact the pain has on the patients’ functioning,consisted of 22 items. High scores on this fac-tor indicate that patients think that their be-

Table 2

Summary Statistics of the Confirmatory Factor Analysis for the Subscales of the Pain CognitionList–Cancer Patients

Scale intercorrelations

Factor No. of items Scale mean SD Cronbach’s alpha 1 2 3 4

Exploratory factor analysisPain Impact (1) 17 46.3 13.3 0.86Catastrophizing (2) 17 49.5 13.3 0.83 0.53

a

Outcome Efficacy (3) 7 21.6 5.3 0.59

�

0.29

a

0.02Acquiescence (4) 5 13.7 3.8 0.55 0.16

a

0.35

a

�

0.08Reliance on Health Care (5) 4 19.3 3.4 0.43

�

0.38

a

�

0.15

a

0.19

a

�

0.14

b

a

P

�

0.001.

b

P

�

0.01.


havior is not effective in dealing with theirpain. The 4 items of factor 2, Social Compari-son, accounted for 8% of the variance. Pa-tients with high scores on this factor relativizetheir situation by comparing their situationwith others. The third factor, Acquiescence,includes 4 items resembling a certain degreeof passivity and accounted for 6% of the vari-ance. This factor describes the locus of con-trol that people experience over their pain.Patients with high scores on this factor have acertain degree of passivity and the expectationthat responding in a different way will nothelp to decrease their pain. The last factor,Outcome Efficacy, includes 4 items represent-ing the expectancy that a given behavior will

lead to a decrease in pain intensity; this factoraccounted for 5% of the variance.

Table 4 presents summary statistics for thefour factors and the total scale structure. TheCronbach’s alpha coefficient for Pain Impactwas high (r

�

0.89), while the other threescales demonstrated low reliability estimates:0.51, 0.59, and 0.53, respectively. The findingof low internal consistency of the factors So-cial Comparison, Acquiescence, and Out-come Efficacy might be partly due to the smallnumber of items representing the factors.The means of scale intercorrelations indicatethat each scale provides unique informationand is factorially distinct. The intercorrela-tions ranged from

�

0.05 to 0.08, suggestingthat each scale is tapping a separate factor.

Table 3

Factor Structure of the Pain Cognition List for Cancer Patients

Item Description Factor 1 Factor 2 Factor 3 Factor 4

Factor 1. Pain Impact (22 items)21 I think I can manage for myself in daily life very well 0.6620 My attitude has not been influenced a great deal by my pain 0.657 I have diversion enough to keep the pain bearable 0.65

29 I think I have learned how to deal/cope with the pain 0.6123 The pain does not keep me from enjoying my life 0.6140 In the past I could get caught up in (all sorts of) nice things,

but the pain is making that impossible for me now 0.6022 It looks like my pain comes to the front every time 0.5914 I think I am actively engaged 0.5842 When I am busy doing something I can forget my pain 0.5874 I feel less and less capable of doing something 0.556 Whenever I feel pain or not, I always do what I had planned to do 0.545 I feel handicapped by my pain 0.54

43 Because of my pain, I don’t feel I’m a fit person anymore 0.5371 I feel powerless against the pain 0.5366 I have become physically weaker and weaker 0.5034 Pain will drive me crazy one day 0.481 My thoughts are concentrated on pain all the time 0.48

72 The word “pain” frightens me 0.4776 I cannot live without pain-killers 0.4539 I think I live very tense 0.4346 I think I can influence my pain in a positive way 0.4261 I have become to feel psychologically weaker 0.41

Factor 2. Social Comparison (4 items)25 I like to talk with people who have the same problems as me,

because I can learn a lot from them0.62

26 I often think: “Why is this happening to me?” 0.5762 I find it important to talk a lot with my partner/family/friends

about my pain 0.5368 Somebody must be able to help me 0.42

Factor 3. Acquiescence (4 items)48 I think I must learn to live with the pain 0.6559 I think the best thing to do is to wait and see what happens 0.6163 I think I will never get rid of this pain 0.6044 I think there is nothing I can do against my pain 0.55

Factor 4. Outcome Efficacy (4 items)52 I think tension increases the pain 0.5949 Relaxation exercises decrease the pain 0.5850 I think the pain is a signal that I should take it easy 0.5512 I think psychological factors have to do with my pain too 0.50


Relationships of Pain Cognition List for Cancer Patients to Sociodemographic Variables

Analyses were conducted to determine how pa-tients’ pain cognition was related to sociodemo-graphic variables, such as sex, age, and level ofeducation (Table 5). Some previous studies havefound significant correlations for the relation-ship between pain cognitions and sex,

9,34

whereasothers10,11,31 have found no significant correla-tions with regard to pain cognitions and sex.

Our results showed no significant differencesacross sex for all factors. Based on research, nosignificant correlations were hypothesized forthe relationship between pain cognitions andage.8–11,46 In this study, Pearson product-moment correlations showed that older patientswere more passive in the way they respond tothe pain than younger patients (r � 0.33, P �0.01). Age had a slight but significant correla-tion with Pain Impact (r � 0.14, P � 0.01) andSocial Comparison (r � �0.19, P � 0.01), butnot with Outcome Efficacy. Regarding education,it was hypothesized that higher educated patientswould respond less passively and score higher onOutcome Efficacy than lower educated patients.The results showed that higher educated patientshad lower scores on Acquiescence (r � �0.31,P � 0.01), meaning a lower degree of passivity.Pain Impact, Social Comparison, and OutcomeEfficacy, however, were not significantly corre-lated with patients’ level of education.

Concurrent-related validity refers to the de-gree to which an instrument can distinguish in-dividuals who differ on some other criterionmeasured or observed at the same time; resultsare given in Table 6. Only those correlationswith r � 0.25 (P � 0.01) are considered ofpractical clinical significance.

Several studies have shown that pain dura-tion and pain cognitions are not strongly re-lated.8–11,24,31,37 In congruence with these re-sults, the present study showed there were nosignificant correlations for the relationship be-tween pain duration and the several factors ofthe Pain Cognition List. In some studies nega-tive pain-related cognitions have been associ-ated with greater pain intensity,13,21 while otherstudies showed no significant correlations.10,34

In our study, higher pain intensity scores weresignificantly related to Pain Impact (r � 0.30),while the sensory category of the McGill PainQuestionnaire was r � 0.19 correlated to PainImpact.

Furthermore, both the affective and evalua-tive pain dimension of the McGill Pain Ques-tionnaire were expected to be related to pa-tients’ pain cognitions. Our study showed thatthe affective and evaluative categories of theMcGill Pain Questionnaire were significantlycorrelated to Pain Impact (r � 0.48, and r �0.35, respectively), but not with the other paincognition factors.

It was hypothesized that the functioning sub-scales of the Quality of Life questionnairewould be significantly correlated with the sub-scales of the Pain Cognition List, with cognitivefunctioning being correlated most highly withthe subscales of the Pain Cognition List. Ourresults showed that all functioning subscaleswere significantly related to Pain Impact (r ��0.25 to �0.54), indicating that the higher thevalue on the functioning scales and globalquality of life, the higher the pain impact.

Table 4Summary Statistics of the Exploratory Factor Analysis for the Subscales of the Pain Cognition List–Cancer Patients

Scale intercorrelations

Factor No. of items Scale mean SD Cronbach’s alpha 1 2 3

Confirmatory factor analysesPain Impact (1) 22 61.4 17.3 0.89Social Comparison (2) 4 12.4 3.7 0.51 0.08Acquiescence (3) 4 12.3 4.0 0.59 0.07 �0.03Outcome Efficacy (4) 4 10.9 3.6 0.53 �0.01 �0.05 �0.03

Table 5Relationship Between the Pain Cognition

List–Cancer Patients and Gender

FactorMale Mean

(SD)Female Mean

(SD) P

Pain Impact (1) 60.8 (18.8) 61.8 (16.5) nsa

Social Comparison (2) 12.2 (3.7) 12.5 (3.7) nsAcquiescence (3) 12.5 (4.0) 12.1 (3.9) nsOutcome Efficacy (4) 11.1 (3.7) 10.8 (3.7) ns

anot significant.


However, cognitive functioning was not mosthighly correlated with Pain Impact.

Finally, the number of nonpharmacologicalpain treatments was significantly correlatedwith Acquiescence. The higher the number ofnonpharmacological pain treatments used byour patients, the lower the patients’ scores onAcquiescence.

In cancer patients with chronic pain, inde-pendent clinical variables that are expected todiscriminate between subgroups of patients aredifficult to define. The responses of patientsfor whom district nursing was necessary in thehome setting were compared with those ofpatients for whom no district nursing wasneeded. Results showed that patients with dis-trict nursing were more often female (P �0.05), older (P � 0.001), differed in marital sta-tus (P � 0.05) and in having a profession (P �0.05), differed with regard to the location of theprimary tumor (P � 0.05) and differed in typeof treatment (P � 0.001). Results regarding thecognitions subscale showed that patients withdistrict nursing differed from patients without

district nursing with regard to Pain Impact (P �0.001), and Acquiescence (P � 0.05), meaningthat patients who needed district nursing inthe home setting showed more behavior thatwas not effective in dealing with the pain,showed a higher degree of passivity, and scoredhigher on the total scale compared to patientsfor whom district nursing was not deemed nec-essary (Table 7).

Discussion and ConclusionThe impact of cognitions on the pain experi-

ence in cancer patients has hardly been stud-ied. The Pain Cognition List–Experimentalversion, measuring patients’ self-statementsabout the pain and the extent to which patientsare effective in dealing with the pain, was de-veloped in the Dutch language, but tested onlyin Dutch non-cancer pain patients. In thepresent study, the factor structure, reliability,and validity of the Pain Cognition List–Experi-mental version was studied in cancer patientswith chronic pain.

Table 6Correlations Between the Pain Cognition List–Cancer Patients and Pain Variables, Pain

Treatment, and Quality of Life

Pain impact

Social comparison Acquiescence

Outcome efficacy

Pain duration �0.02 �0.04 0.16a 0.04Present pain intensity 0.30a 0.02 0.15a �0.02McGill pain questionnaire

Pain Rating Index-Sensory 0.19a 0.08 0.06 0.02Pain Rating Index-Affective 0.48a 0.17a 0.03 �0.07Pain Rating Index-Evaluative 0.35a 0.18a 0.05 0.00

Quality of LifePhysical functioning �0.44a 0.08 �0.13 0.06Role functioning �0.42a 0.01 �0.12 0.08Cognitive functioning �0.25a �0.03 0.00 0.02Emotional functioning �0.46a �0.23a �0.02 �0.16a

Social functioning �0.32a �0.05 0.12b �0.01Global quality of life �0.54a 0.06 �0.08 �0.01

Non-pharmacological pain treatment �0.06 0.09 �0.29a �0.17a

aP � 0.01; two-tailed.bP � 0.05.

Table 7Relationship Between Pain Cognition List for Cancer Patients and District Nursing Care

FactorWith District Nursing

Mean (SD)Without District Nursing

Mean (SD) P

Pain impact (1) 66.4 (19.1) 59.0 (15.9) �0.001Social Comparison (2) 12.1 (3.5) 12.5 (3.8) nsa

Acquiescence (3) 12.9 (4.2) 11.9 (3.8) �0.05Outcome Efficacy (4) 10.7 (3.8) 11.0 (3.6) ns

anot significant.


Based on previous research,44 a confirmatoryfactor analysis was conducted to compare thefit between the previous model studied in non-cancer pain patients and the actual structureamong variables in a cancer pain population.The results showed an unsatisfying fit. An ex-ploratory factor analysis showed that the fourfactors Pain Impact, Social Comparison, Acqui-escence, and Active Coping explained 39% ofthe variance. Compared to the original factorstructure reported by Vlaeyen and associates,44

and Nooyen-Haazen and associates,45 a differ-ent structure was found in the present study.The main finding was that the factor Catastro-phizing, focusing on the aversive aspect of thepain experiences, did not emerge as a factor.Items like “I often think back to the days whenI had no pain,” “I consider myself as an un-lucky person,” “I think that fate hit me,” and “Iconsider myself to be a hopeless case” did notload on any factor. This is striking because ca-tastrophizing thinking styles are found to bemost strongly associated with increased pain innon-cancer pain patients. When comparingthe results of our study with those of Vlaeyenand associates,44 only 6 of the 17 items, origi-nally representing the factor Catastrophizing,were loading on one of the scales: 5 itemsloaded on the factor Pain Impact, and 1 itemon the Social Comparison. When comparingthe results of the present study with those ofNooyen-Haazen and associates,45 only 6 of the16 items emerged. Items loading on the factorsSocial Comparison, Acquiescence, and Out-come Efficacy were only partly found in theoriginal factor structure.

Several reasons might explain this result.First, an explanation for finding differences infactor structure might be due to methodologi-cal weaknesses. Although the Pain Impact sub-scale was shown to be powerful, low alpha coef-ficients were found for the factors SocialComparison, Acquiescence, and Outcome Effi-cacy. The low correlations indicate a need forfurther revision of the Pain Cognition Ques-tionnaire for cancer patients. The Pain Cogni-tion List is further limited by the fact that itoriginally consisted of 77 items, of which only34 items remained in the final analysis. Sinceonly 34 items in this data set loaded on fourfactors, 43 items were removed. A second ex-planation might be that some of the items(e.g., relaxation exercises decrease the pain)

seem to measure pain coping rather than painbeliefs. Originally, the questionnaire was sup-posed to measure cognitions (attributes andexpectations). However, of all factors that arisefrom the second factor analysis, it is debatablewhether the fourth factor Outcome Efficacydoes in fact measure pain cognitions. In agree-ment with Jensen et al.,64 we believe that differ-ent dimensions should not be confounded infuture studies.

A third explanation might be that cancer pa-tients present different pain cognitions com-pared to non-cancer pain patients. It is reason-able to assume that cancer pain patients placegreater emphasis on the physical aspects ofpain than non-cancer pain patients. Conse-quently, cancer patients might focus more onthe sensory components of the pain and lesson other aspects of the pain experience. Can-cer patients know the cause of their pain and,thus, they can deal with their pain complaints,whereas non-cancer patients in pain frequentlycannot identify the source of pain. As a result,the degree of catastrophizing might differ be-tween these two groups of pain patients. Can-cer patients might focus more on the nocicep-tive components of the pain and less on theaversive aspects of the pain experience. Thatcancer and non-cancer pain patients behavedifferently was suggested by Turk and associ-ates,6 finding that cancer patients appeared tothink and worry more about pain, avoid activi-ties, and generally feel more hopeless than pa-tients with non-cancer related pain. However,until well-established, convenient, valid, andreliable measures are available to assess pa-tients’ pain cognitions, the difference mightalso be explained by other reasons. From this,it can be concluded that pain cognitions incancer pain patients cannot be easily com-pared with those in non-cancer pain patients.

Given the results of our study, only the factorPain Impact meets criteria for use in clinicalpractice. The factors Social Comparison, Ac-quiescence, and Outcome Efficacy contributedonly in a limited way. The internal consistencyfor the factor Pain Impact was high, while theother three factors showed low reliability.

Although the psychometric properties of thePain Cognition List are disappointing, thefinding that cancer pain patients seem to differmeaningfully from non-cancer pain patients isimportant. Further research is needed to inves-


tigate whether the factor structure as found inthe present study can be confirmed in anothercancer pain population. We also need to evalu-ate whether differences between cancer andnon-cancer pain patients can be replicated. Be-cause cancer pain patients seem to react differ-ently than non-cancer pain patients, whetheror not pain cognitions influence pain intensityand adequacy of pain treatment needs furtherstudy. Knowledge about the role of pain cogni-tions related to outcome of pain treatment isvaluable because it may enhance treatment ef-fectiveness. However, as long as no valid andreliable Pain Cognition List is available, paincognitions should only be studied in a researchsetting rather than in a clinical setting. Fur-thermore, the test–retest reliability of the PainCognition List should be determined in futureresearch. By means of longitudinal data,changes in pain cognitions over time need tobe established. It is also necessary to establishwhether certain patients are more able tochange their pain cognitions than others.

Pain cognitions, albeit important in under-standing patients’ pain behavior, are difficultto conceptualize. There are no simple short in-struments that can capture this concept. Con-sequently, the Pain Cognition List is not a sim-ple instrument that is easily self-administered.Some patients found it a burden to completethe questionnaire. Therefore, it is advised tohave the questionnaire filled in during a con-sultation, so that patients can be helped if nec-essary, and completeness can be checked im-mediately.

Initial support for the validity of the PainCognition List for cancer patients is providedonly for the factor Pain Impact. Although theresults suggest that this measure has potentialfor understanding variance in cancer pain, un-certainty with regard to the clinical signifi-cance of the use of the Pain Cognition List willremain until more research is completed. Fur-ther developmental work is needed on theoriginal factor structure of the experimentalversion of the Pain Cognition List to assurethat the structure as found in non-cancer pa-tients is different in a cancer pain population.In the absence of a well-validated measure toevaluate patients’ pain cognitions, there is noreason for the use of measuring pain cognitionin clinical practice. Based on the results, thereis a first indication that pain cognitions do in-

fluence pain intensity. Whether different paincognitions are associated with outcomes ofpain treatment remains unclear. By investigat-ing the predictive value of pain cognitions re-garding changes in adequacy of pain treat-ment, we can establish the relation betweenpain cognitions and the degree of pain reduc-tion in the long term.

AcknowledgmentsThis study was supported by a grant from the

Dutch Cancer Society (grant NKI 92-469). Theauthors thank all patients for their coopera-tion. We extend special thanks to the nursingdepartments of The Netherlands Cancer Insti-tute/Antoni van Leeuwenhoek Hospital fortheir participation in the study. The authorsthank Anneke van Buuren, Karin van derHeijden, Gerleen Leenhouts, Simone Loon-stra, and Linda Zandbelt for recruiting and in-terviewing the patients, and Dr. J.W.S. Vlaeyenfor his valuable contribution.

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