Disability and Rehabilitation, 2009; 31(19): 1605–1613

RESEARCH PAPER

The complex interplay between pain intensity, depression, anxiety and

catastrophising with respect to quality of life and disability

BJÖRN BÖRSBO1,2, MICHAEL PEOLSSON1,3 & BJÖRN GERDLE1,4

1
Rehabilitation Medicine, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping, Sweden,
2
Clinical Department of Rehabilitation Medicine, County Hospital Ryhov, Jönköping, Sweden, 3School for Technology and
Disabil Rehabil Downloaded from informahealthcare.com by Michigan University on 10/30/14

Health, Royal Institute of Technology, Stockholm, Sweden, and 4Pain and Rehabilitation Centre, University Hospital,
Linköping, Sweden

Accepted December 2008

Abstract
Purpose. To identify subgroups of patients with chronic pain based on the occurrence of depression, anxiety and
catastrophising and the duration of pain and pain intensity. In addition to this, the relationship between the subgroups with
respect to background variables, diagnosis, pain-related disability and perceived quality of life are investigated.
For personal use only.

Methods. This study used 433 patients with chronic pain including 47 patients with spinal cord injury-related pain, 150 with
chronic whiplash associated disorders and 236 with fibromyalgia. The participants answered a postal questionnaire that
provided background data, pain intensity and duration and psychological and health-related items.
Results. On the basis of depression, anxiety, catastrophising, pain intensity and duration, we identified subgroups of
patients with chronic pain that differed with respect to perceived quality of life, disability and diagnosis. The psychological
factors, especially depression, significantly influenced perceived quality of life and disability. Pain intensity and duration play
a minor role with respect to quality of life, although pain intensity is associated to perceived disability.
Conclusions. The results of this study highlight the importance of not looking at patients with chronic pain as a homogenous
entity. A detailed assessment, including psychological factors with emphasis on depressive symptoms, might be essential for
planning and carrying through treatment and rehabilitation.

Keywords: Chronic pain, catastrophising, depression, anxiety, quality of life, disability

Introduction [5,6] proposes that elements of personal vulnerability

Chronic pain has a negative impact on quality of life
[1]. The development and maintenance of chronic
pain is a complex interplay of biological, psycholo-
gical and social factors and context. The bio-psycho-
social model of chronic pain [2] can explain the
framework of these processes. The complex interplay
includes psychological factors such as depression,
catastrophising and anxiety.
Depression is a predictor of disability in patients
with chronic pain in long-time follow-up studies [3].
There is also a relationship between depression and
poorer self-reported functional activity among per-
sons with chronic pain [4]. Different models of the
association between chronic pain and depression
have been suggested. The diathesis-stress model
(diathesis) interact with stresses (e.g., pain itself,
result of losses) or threats to wellbeing to create
depression.
Catastrophising has been defined as an exaggerated
negative orientation toward pain stimuli and pain
experience [7]. There is evidence for associations
between catastrophising and heightened pain, in-
creased pain behaviour, heightened disability, low
quality of life, increased use of health care services
and analgesic medication [8,9].
Anxiety is a co-morbidity to chronic pain with
incidence rates between about 15 and 40% [10]; co-
morbidity also exist between mood and anxiety
disorders [11,12]. Several studies have found pain
conditions more strongly associated with several
anxiety disorders than with depression [13,14].

Correspondence: Björn Börsbo, Clinical Department of Rehabilitation Medicine, County Hospital Ryhov, Jönköping SE-551 85, Sweden. Tel: þ46707922161.
Fax: þ4636322622. E-mail: bjorn.borsbo@liu.se
ISSN 0963-8288 print/ISSN 1464-5165 online ª 2009 Informa UK Ltd.
DOI: 10.1080/09638280903110079
 1606 B. Börsbo et al.
Patients with anxiety disorders reported the highest
pain intensity and interference and the lowest general
activity level in fibromyalgia [15]. Pain-related anxiety
includes physiological, cognitive, behavioural and
affective manifestations of anxiety within the context
of pain [16]; a relationship between pain-related
anxiety and disability is expected [17]. Anxiety
sensitivity (AS) is the fear of arousal-related bodily
sensations arising from beliefs that these sensations
have harmful consequences [18]. Anxiety sensitivity
has been closely associated with negative pain
experiences in acute and chronic settings [19,20].
The interplay between psychological factors has
been addressed in several studies. Cook et al. [21]
analysing psychological factors in diverse chronic
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pain conditions found that fear is a mediator between
catastrophising and perceived disability, depression
and pain. The duration of pain has been suggested to
be an essential aspect of the relationship between
psychological components and function in muscu-
loskeletal pain [22]. In a scientific as well as in a
clinical context, it has been found suitable and
advantageous to try to subgroup patients with
chronic pain [23–26].
There is a need for further studies investigating the
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importance and interplay between factors that per se
have been shown to influence the perceived quality of
life and disability in chronic pain respectively. Do the
influencing variables differ for quality of life versus
disability? Is there any dominating factor or combi-
nation of factors?
With these questions in mind, this study aims to
identify subgroups based on the occurrence of
depression, anxiety, catastrophising and the degree
of pain intensity and duration and to investigate how
the subgroups differed with respect to background
variables, diagnosis, pain-related disability and per-
ceived quality of life.
Materials and methods
Materials
Eight hundred ninety-one patients at the rehabilita-
tion clinics at Linköping University Hospital and
County Hospital Ryhov in Jönköping from 2002
through 2004 were invited to participate, i.e., after
assessment and/or treatment at the three clinics. The
inclusion criteria were chronic pain (43 month), the
diagnoses spinal cord injury (SCI)-related pain,
fibromyalgia (FM) and chronic whiplash associated
disorders (WAD). The patients were selected from
case records. The diagnoses, settled by experienced
clinicians, were obtained from the case records. They
were asked by letter to participate and the patients
who chose to participate received a questionnaire
covering background data, psychological and health-
related items. Patients who did not return the
questionnaire were reminded twice before they were
indicated as dropouts. The whole questionnaire was
appended to the letter with the reminder.
Of 891 invited patients, we received 325 returned
questionnaires after the first letter with the ques-
tionnaire, after the first reminder 77 questionnaires
and after the second reminder 32 questionnaires.
One patient did not satisfy the inclusion criteria and
was excluded.
Thus, a total of 433 patients – including 47
patients with SCI-related pain, 150 with WAD and
236 with Fibromyalgia – participated.
The Research Ethics Committee of the University
of Linkoping, Sweden approved the study (Dnr:
M70-05).
Methods
The questionnaire included the following items and
instruments. Swedish validated versions were used.
(References given below present the questionnaires
and studies of psychometrical properties):
. Age, gender and background data.
. Pain intensity ratings of nine predefined anatomi-
cal regions. For the rating of pain intensity, a
visual analogue scale (VAS) was used; the scale
was a 100 mm long with defined end points (‘no
pain’ and ‘worst pain imaginable’), but without
marks in between (results in cm). All the
questions regarding pain concerned the previous
7 days. The rating of the most painful region was
used (VAS-max) [27,28].
. Pain Regions Index (PRI). Number of the above
pre-defined anatomical regions associated with
pain with a possible range of 0–9.
. Anxiety Sensitivity Index (ASI) is a 16-item self-
reported questionnaire. Each item asks about the
amount of fear the participant experiences in
regard to bodily sensations commonly associated
with anxiety. Participants are asked to rate each
item on a 5-point Likert-like scale ranging from
very little (0) to very much (4). The ratings on the
16 items are summed for a total ranging from 0 to
64. Studies have found support for test–retest
reliability, criterion validity and construct validity
(e.g., support for the distinction between AS and
trait anxiety) [18,29].
. Pain Anxiety Symptoms Scale-20 (PASS-20) is a
short version of the 40-item PASS that measures
fear and anxiety responses specific to pain. The
PASS-20 has four 5-item subscales that measure
avoidance, fearful thinking, cognitive anxiety
and physiological responses to pain. Participants
 Identification of subgroups in patients with chronic pain
rate each item on a 6-point scale ranging from
never (0) to always (5). Reliability analyses with
PASS-20 indicate good internal consistency akin
to the PASS-40. Psychometric analyses reveal
good convergent, discriminant, predictive and
construct validity [30,31].
. Hospital Anxiety and Depression Scale (HADS) is a
self-rating scale in which the severity of anxiety
and depression is rated on a 4-point scale. Seven
questions are related to anxiety and seven to
depression, both with a score range of 0–21. A
score of 7 or less indicates a non-case, a score of
8–10 a doubtful case and 11 or more a definite
case. The instrument is widely used in clinical
practice and research. Investigations have shown
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that the HADS is a psychometrically sound
instrument. In this study, we used both subscales
[32,33].
. The Pain Catastrophising Scale (PCS) is a 13-item
self-report measure designed to assess cata-
strophic thoughts or feelings accompanying the
experience of pain. Respondents are asked to
reflect on past painful experiences and to indicate
the degree to which each of the 13 thoughts or
feelings are experienced when in pain. The
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questionnaire uses a 5-point scale ranging from
0 (not at all) to 4 (all the time). Subscales for
rumination, magnification and helplessness plus
a total score are added up. In this study, we used
the total score [7,34].
. Quality of Life Scale (QOLS-S) is composed of 16
items that together describe the quality of life
concept: (i) material comforts; (ii) health; (iii)
relationships with parents, sibling and other
relatives; (iv) having and rearing children; (v)
close relationships with spouse or significant
others; (vi) close friends; (vii) helping and
encouraging others, participating in organisa-
tions, volunteering; (viii) participating in political
organisations or public affairs; (ix) learning; (x)
understanding yourself; (xi) work; (xii) expres-
sing yourself creatively; (xiii) socialising; (xiv)
reading, music or watching entertainment; (xv)
participating in active recreation; and (xvi)
independence, being able to do things for
yourself. A seven-point satisfaction scale is used.
Clients estimated their satisfaction with their
current situation. A higher total score shows
higher satisfaction. The item scores are added to
a total score, ranging from 16 to 112 [35,36].
. The Pain Disability Index (PDI) is a 7-item self-
report instrument based on a 10-point scale that
assesses perception of the specific impact of pain
on disability that may preclude normal or desired
performance of a wide range of functions, such as
family and social activities, sex, work, life-support
(sleeping, breathing, eating) and daily living
1607
activities. The PDI has shown good reliability and
validity in several studies [37,38].
Statistics
All statistical evaluations were made using the sta-
tistical packages SPSS (version 15.0; SPSS, Chicago,
IL) and SIMCA-Pþ (version 11.1; Umetrics Inc.,
Umeå, Sweden). Results in the text and tables are
generally given as mean values + one standard
deviation (+1SD). For univariate comparisons
between groups, analysis of variance (ANOVA) was
used for all variables except gender and diagnosis,
where the Chi2-test square was used.
A cluster analysis (based on the K-means algo-
rithm) was used to identify subgroups of patients.
The cluster analysis was made using the variables for
depression (HADS-D), anxiety (HADS-A, PASS,
ASI), catastrophising (PCS) and pain (intensity
according to VAS and pain duration). Our criteria
when performing the cluster analysis where: a
substantial number of persons in each subgroup, an
approximate equal distribution of persons in the
subgroups and a clinically manageable number of
subgroups. Four clusters (subgroups) fulfilled these
criteria. Cluster based on five and six subgroups
resulted in less demarcated clusters and, thus did not
contribute to the informative value of the analysis.
The obtained clusters were compared using ANOVA
and Chi2 -test with respect to the other variables to
uncover differences in the other variables (i.e.,
background variables, diagnosis, spreading of pain,
disability and quality of life).
Principal component analysis (PCA) using SIM-
CA-P was used to extract and display systematic
variation in a data matrix and is a multivariate cor-
relation analysis. A component consists of a vector
of numerical values between –1 and 1 (referred to as
loadings) and obtained significant components are
uncorrelated. Variables that have high loadings (with
positive or negative sign) on the same component are
inter-correlated. Items with high loadings (ignoring
the sign) are considered to be of large or moderate
importance for the component under consideration.
Partial least squares or projection to latent
structures (PLS) were used to regress one or several
Y-variables using several other variables (X-vari-
ables) [39]. The variable influence on projection
(VIP) gives information about the relevance of each
X-variable and each Y-variable pooled over all
dimensions. Thus the VIP parameter gives informa-
tion about the relevance of each X variable, both for
the X- and Y-model parts. X-variables with a VIP
1.0 influence the model the most. The PLS
regression coefficients may be re-expressed as a
regression model and express the influence of each
X-variable on Y in each single component. In this
 1608 B. Börsbo et al.
study, the variable of importance for explaining Y
was primarily identified by a VIP value 1.0 and
secondarily by the regression coefficient in relation to
Y. Multiple linear regression (MLR) could have been
an alternative method for the prediction, but it
assumes that the regressors (X-variables) are inde-
pendent and only one Y-variable at a time can be
predicted. If multicollinearity (high correlations)
occurs among the X-variables, the calculated regres-
sion coefficients become unstable and their inter-
pretability breaks down [39]. PLS and PCA also have
the advantages that it makes it possible to blend
interval and ordinal data [40].
Two concepts – R2 and Q2 – are further used to
describe the results in PCA and PLS. R2 describes
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the goodness of fit: the fraction of sum of squares of
all the variables explained by a principal component.
Q2 describes the goodness of prediction: the fraction
of the total variation of the variables that can be
predicted by a principal component using cross
validation methods. Outliers were identified using
the two powerful methods available in SIMCA-P:
score plots in combination with Hotelling’s T2
(identifies strong outliers) and distance to model in
X-space (DModX) (identifies moderate outliers).
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The proportion of missing data for each variable
were: sex (0%), gender (0%), HADS-D (2.1%),
HADS-A (1.4%), PCS (5.8%), PASS-20 (8.8%),
ASI (8.3%), pain duration (6.3%), pain intensity
max (0.2%), different diagnoses (0 %), PRI (0.5%),
PDI (6.0%) and QOLS (3.0%). In all statistical
analysis, p  0.05 (two-tailed) was regarded as
significant.
Results
Identification of subgroups and their relations to disability
and quality of life
A PCA-analysis was performed to identify and
exclude different types of outliers. Two outliers were
excluded (results not shown).
In the cluster analysis the following standardised
input variables were used: depression (HADS-D),
anxiety (HADS-A, PASS, ASI), catastrophising
(PCS) and pain (intensity according to VAS and
pain duration). On the basis of the predetermined
criteria for optimum number of clusters (see
statistics) the cluster analysis identified four clusters
(subgroups) (Table I, upper part). Clusters based on
five and six subgroups resulted in less demarcated
clusters and, thus did not contribute to the informa-
tive value of the analysis. As intended, the four
subgroups differed significantly on all scales.
The first group (n ¼ 101), here called the ‘most
favourable’1 group, was characterised by relatively
low pain intensity and short pain duration. The
scores on depression, anxiety and catastrophising
scales were low. Group 2 (n ¼ 85), here called the
‘long-time/favourable’ group, had by far the longest
pain duration and relatively high pain intensity. They
scored relatively low on depression, anxiety and
catastrophising. Group 3 (n ¼ 150), here called the
‘short-time/worse’ group, was the group with the
shortest duration of pain and with intermediary pain
intensity. The scores for depression, anxiety and
catastrophising were generally relatively high. The
fourth group (n ¼ 95), here called the ‘worst off’
group, scored highest on pain intensity and had a
relatively long duration of pain. The scores on the
psychological factors were the highest of the four
groups.
The identified subgroups were then investigated
for possible differences concerning background
variables (age and gender), diagnosis (WAD, FM
and SCI), spreading of pain (PRI), pain-related
disability (PDI) and quality of life (QOLS) (Table I,
lower part). All subgroups differed significantly on all
these variables except for gender.
The ‘most favourable’ subgroup scored low on
disability and the score on perceived quality of life
was high. PRI, generalisation of pain, was relatively
lower than all the other subgroups. This group
contained the relatively highest proportion of persons
with SCI and pain and the lowest proportion with
FM. The ‘long-time/favourable’ group scored rela-
tively low on disability and relatively high on life
quality variables. In this group, a large number of
people had FM and SCI. The ‘short-time/worse’
subgroup showed a relatively high disability score,
and the perceived quality of life was relatively low.
The ‘worst off’ group showed the highest disability
and the lowest scores on perceived quality of life.
The last two subgroups contained a high proportion
of persons with WAD.
In conclusion, with respect to the outcome
variables disability and quality of life, there is a
correlation to the psychological variables depression,
anxiety and catastrophising. That is, individuals that
scored low on psychological items showed a better
perceived quality of life and less pain-related
disability: the higher score on psychological vari-
ables, the lower quality of life and higher disability
(Table I). For the pain variables (VASmax and pain
duration), there is neither clear correlation to
disability and quality of life, according to the four
subgroups, nor is there a correlation between
generalisation of pain and psychological factors.
A principal component analysis (PCA) was made
to further investigate the multivariate correlation
pattern (R2 ¼ 0.69; Q2 ¼ 0.34) (details not shown).
This confirmed the results from the cluster analyses
(data not shown) that perceived disability and quality
 Identification of subgroups in patients with chronic pain 1609

Table I. Cluster analysis based on the scales of depression (HADS-D), anxiety (HADS-A, PASS, ASI), pain intensity (VAS) and pain
duration.

Subgroups, Mean (SD)

Group 1 ‘most Group 2 ‘long-time/ Group 3 ‘short-time/ Group 4 ‘worst off’

Variables favourable’ (n ¼ 101) favourable’ (n ¼ 85) worse’ (n ¼ 150) (n ¼ 95) p-value

Stand. variables
HADS-D 3.6 (2.6) 6.8 (3.1) 8.9 (3.4) 11.9 (3.7) 50.001*
HADS-A 3.3 (2.3) 6.8 (3.1) 8.3 (3.0) 14.3 (2.9) 50.001*
PCS.total 10.2 (6.4) 16.5 (7.9) 22.0 (6.0) 36.6 (6.6) 50.001*
PASS. total 28.7 (11.5) 40.8 (11.2) 52.3 (9.1) 70.4 (13.2) 50.001*
ASI 8.8 (5.9) 16.8 (8.8) 21.6 (8.5) 39.3 (10.5) 50.001*
Pain duration (months) 96.0 (60.2) 246.4 (66.8) 85.5 (38.8) 116.0 (81.9) 50.001*
VAS. max 64.6 (22.5) 80.3 (13.8) 77.6 (16.2) 85.6 (13.2) 50.001*
Background variables
Gender (% men) 18.8 15.3 18.0 21.1 0.796
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Age (years) 41.3 (8.6) 45.9 (6.6) 41.3 (9.1) 41.0 (8.8) 50.001*
Diagnosis (% within diagnosis)
WAD 22.0 6.7 44.0 27.3 50.001*
FM 20.5 26.9 31.2 21.4 50.001*
SCI 42.6 25.6 23.4 8.5 50.001*
Diagnosis (% within cluster)
WAD 32.7 11.8 44.0 43.2 50.001*
FM 47.5 74.1 48.7 52.6 50.001*
SCI 19.8 14.1 7.3 4.2 50.001*
PRI 6.4 (2.5) 7.8 (1.8) 7.4 (1.9) 7.6 (1.9) 50.001*
Pain disability index (PDI) 27.2 (12.4) 35.0 (10.3) 39.2 (8.7) 45.4 (10.0) 50.001*
Quality of life (QOLS) 85.2 (14.1) 78.2 (12.6) 70.9 (13.3) 63.1 (15.7) 50.001*
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The four identified clusters have been compared with respect to the variables and scales below the dotted line: background data, diagnosis,
pain generalisation, disability and quality of life. Mean values (+one standard deviation, SD) are reported. For statistical comparison of the
clusters, analysis of variance (ANOVA) was used for all variables except gender and diagnosis, where the Chi2-test square was used. p-values
are given.
VASmax, maximum pain intensity ratings according to visual analogue scale; PRI, Pain Regions Index; ASI, Anxiety Sensitivity Index;
PASS-20, Pain Anxiety Symptoms Scale-20; HADS, Hospital Anxiety and Depression Scale; PCS, The Pain Catastrophizing Scale; QOLS-
S, Quality of Life Scale; PDI, The Pain Disability Index; WAD, Whiplash associated disorders; FM, fibromyalgia; SCI, spinal cord injury.

of life correlated to the psychological variables
(depression, anxiety and catastrophising), but not
to the pain variables (pain intensity and pain
duration).
Regressions of disability and quality of life
(VIP ¼ 0.99), PASS (VIP ¼ 0.98), HADS-A (VIP ¼
0.98), ASI (VIP ¼ 0.92), VAS max (VIP ¼ 0.45) and
pain duration (VIP ¼ 0.25). Hence, the most im-
portant variable for the outcome of quality of life was
depression followed by PCS, PASS and HADS-A at
the boundary of importance (VIP 1.0).

In the next step, using two different analyses, we Discussion

regressed disability (PDI) and quality of life (QOLS)
using the scales HADS, PASS, ASI, pain intensity
and pain duration as regressors. The significant
regression (R2 ¼ 0.45; Q2 ¼ 0.44) of PDI showed that
the following variables in descending order were
important: HADS-D (VIP ¼ 1.30), PASS (VIP ¼
1.10), PCS (VIP ¼ 1.06), VAS max (VIP ¼ 1.06),
HADS-A (VIP ¼ 0.96), ASI (VIP ¼ 0.94) and pain
duration (VIP ¼ 0.18). Hence, the most important
(VIP 1.0) variables for the outcome of disability
were depression, pain anxiety, catastrophising and
pain intensity.
When QOLS was regressed (R2 ¼ 0.45;
2
Q ¼ 0.44), the following variables in descending
order were important: HADS-D (VIP ¼ 1.73), PCS
Major findings
Using cluster analysis based on depression, anxiety,
catastrophising and pain intensity and duration, it
was possible to identify four large subgroups of
patients that differed with respect to perceived
quality of life, disability and diagnosis. The psycho-
logical factors, and especially depression, had a
crucial association with perceived quality of life and
disability. Pain intensity and duration play a minor
role for quality of life, although pain intensity
correlates relatively more to disability. The three
pain diagnoses were not symmetrically distributed
within the four clusters.
 1610 B. Börsbo et al.
Identification of subgroups and their relations to disability
and quality of life
In patients referred to specialised pain clinics, the
psychological factors significantly correlate with
quality of life and disability. Typically, the higher
the patients scored these variables, the lower the
scores on quality of life and the higher the scores on
disability. In the present study, not surprisingly,
there is one subgroup (subgroup 1, the ‘most
favourable’) that scored low on both psychological
and pain variables and also exhibited the best
situation according to quality of life and disability.
Another expected subgroup (subgroup 4, the ‘worst
off’) scored high on psychological variables and pain
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intensity (notably not the longest pain duration of the
subgroups) and showed the worst situation with
respect to quality of life and disability. These results
agree with several other studies [8,17,41]. However,
the pain variables intensity and duration did not
completely follow the same pattern as the psycholo-
gical variables. Subgroup 2 (the ‘long-time/favour-
able’) is interesting: although the subjects in this
group scored high on pain intensity and had by far
the longest duration of pain, they scored relatively
For personal use only.
low on the psychological factors. This group
exhibited a relatively good situation according to
quality of life and disability. Hence, if psychological
factors are kept low, persons with high pain intensity
for a long time seems in this cross-sectional study to
have a fair chance to live a life with relatively good
quality. This must of course be confirmed in
prospective studies. Giesecke et al. [42] identified,
in a study of patients with fibromyalgia, a subgroup
with high tenderness, low depression/anxiety, low
catastrophising and high pain control. However,
there were no significant differences to other
subgroups with regard to self-reported pain or
perceived level of physical functioning in their study.
This subgroup of patients with chronic pain (the
‘long-time/favourable’) in several aspects resemble the
subgroup adaptive copers identified by Turk and
Rudy among patients referred to an outpatient pain
clinic [43]. A possible explanatory mechanism,
referring to the diathesis stress model [6,44], is that
individuals in the ‘long-time/favourable’ subgroup are
able to cope with the stress of living with chronic pain
and its consequences. They therefore do not react
with depression and anxiety, factors that in turn
should have worsened disability and decreased the
perceived of quality of life.
In contrast to the ‘long-time/favourable’ subgroup,
subgroup 3 (the ‘short-time/worse’) exhibited the
lowest rating of pain intensity and a relatively short
duration of pain, but scored high on all the
psychological variables. Their quality of life was
low and they scored high disability. Referring
speculatively to the temporal diathesis-stress model,
persons in this subgroup might experience greater
stress from a relatively low pain intensity and shorter
pain duration, and therefore develop psychological
symptoms that in turn enhance the negative impact
on disability and quality of life.
The asymmetrical distribution of the different
diagnoses (WAD, FM and SCI) in the four
subgroups suggests that there might be some
diagnosis-related factor related to how individuals
cope with chronic pain. The occurrence of trauma,
as in WAD and SCI, and the situation of con-
comitant neurological impairment, as in SCI, may
play a role. These findings call for further studies.
Regressions of disability
Depression was the variable that showed the highest
correlation with disability. This finding confirms the
findings from previous studies. In patients with
chronic low back pain, high levels of self-report of
depression and higher pain levels significantly pre-
dicted disability and the higher levels of self-reported
depression (but not higher pain levels) significantly
predicted lower levels of observed physical perfor-
mance [45]. In this study, where the disability level is
self-reported, pain intensity correlates significantly
with the outcome of disability. In a study of
subgroups of patients with chronic WAD, subgroups
with high pain intensity differed from subgroups with
low pain intensity mainly in life quality variables
referring to physical functioning [46].
Of the anxiety variables, only pain anxiety (PASS)
correlated significantly with disability, a finding that
agrees with McCracken et al. [47] who showed that
disability was most strongly correlated with the
more specific pain-related fear measures (i.e., Fear-
Avoidance Beliefs Questionnaire or PASS) as com-
pared to a more general measure of anxiety (i.e., the
Fear of Pain Questionnaire or the trait form of the
Spielberger Trait Anxiety Inventory). The impor-
tance of pain-related anxiety on disability could be
viewed within the context of the fear avoidance
model and a large number of mainly cross-sectional
studies have shown that pain-related fear is one of the
most potent predictors of observable physical per-
formance and self-reported disability (for a review
see [48]). The catastrophising variable showed a
significant association with disability. Catastrophis-
ing has consistently been associated with disability in
patients with chronic pain [49] and has also been
considered as a precursor of pain-related fear [50].
In summary, when regressing disability, one might
apply the diathesis-stress model that includes
disability (Figure 1) [51]. Catastrophising and
anxiety sensitivity may be understood as diathesis
 Identification of subgroups in patients with chronic pain
Figure 1. The diathesis-stress model, modified from Pincus and
Williams [51].
(pre-existing, semi-dormant characteristics of the
individual). Pain and disability may be understood
Disabil Rehabil Downloaded from informahealthcare.com by Michigan University on 10/30/14
as stressors leading to depression and/or anxiety and
starting a vicious cycle. In this cross-sectional study,
we are only able to confirm the presence and relative
importance of the different factors and we were
unable to express a definite opinion on temporal
pathways.
Regressions of quality of life
For personal use only.
Depression was also the outmost dominant variable
in the cross-sectional regression of perceived quality
of life. The consequence of depression for quality of
life was demonstrated in previous studies [46]. In
this study, with different pain diagnoses, catastro-
phising and anxiety contributes to some extent
(borderline significant correlations) but this does
not change the picture of depression being the
crucial factor for perceived quality of life.
Interestingly, duration of pain seems to have a
minor association with both disability and quality of
life. This confirms the result from the cluster analysis
where the ‘long-time/good’ subgroup showed a
relatively advantageous situation addressing disabil-
ity and quality of life, a finding that contradicts
Boersma and Linton’s study. They found that the
time point in the development of a musculoskeletal
pain problem might be an essential aspect of the
importance of the relationship between psychological
components and function [22]. However, they
studied the first years after onset of pain; our study
group included patients with very long pain duration
where one might expect a more consolidated state on
influencing patterns from psychological factors.
Methodological considerations
The patients were selected from two clinics that
specialise in handling severe chronic pain conditions.
Hence future studies should investigate patients
in an earlier stage. Furthermore, our study is a
1611
cross-sectional study, which makes it impossible to
make any statement about causality. The return rate
of the questionnaires was low. The non-responding
individuals exhibited a gender bias: the study group
was 18.4% male and the non-responding group was
31.1% male. This might affect the results. However,
in the cluster analysis of the study group, there was
no significant gender difference.
Conclusions
On the basis of depression, anxiety, catastrophising,
pain intensity and duration, we managed to identify
subgroups of patients with chronic pain who differed
with respect to perceived quality of life, disability and
distribution of diagnosis. The psychological factors
(especially depression) showed a relatively strong
correlation with perceived quality of life and disability.
Pain intensity and duration had a minor role for quality
of life in the cross-sectional perspective, whereas pain
intensity contributes more to the outcome of perceived
disability. Further studies should investigate the
temporal processes and causality and the difference
in diagnostic groups. The results of this study highlight
the importance of not regarding chronic pain patients
as a homogenous entity.
Acknowledgements
We thank Futurum, the Academy for Healthcare,
County Council, Jönköping, for their grant.
Note
1. Note that the labels of the subgroups must be seen in a relative
context, i.e., we investigated patients with complicated chronic
pain conditions referred to specialised clinics.
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