Coping with fibromialgia: Usefulness of the Chronic Pain Coping Inventory-42 Javier Garcia-Campayo a,b, * , Aida Pascual a,b , Marta Alda c,d , Monica Teresa Gonzalez Ramirez e a Department of Psychiatry, Miguel Servet University Hospital, Avda Gomez Laguna 52, 4D, 50.009 Zaragoza, Spain b University of Zaragoza, Spain c Department of Psychiatry, Alcan ˜iz Hospital, Alcan ˜iz, Teruel, Spain d Grupo Aragone ´s de Investigacio ´ n en Atencio ´ n Primaria, Red de Actividades Preventivas y Promocio ´ n de la Salud (REDIAPP) (G03/170), Instituto Aragone ´s de Ciencias de la Salud, Spain e Faculty of Psychology, Autonomous University of Nuevo Leon, Mexico Received 4 November 2006; received in revised form 14 February 2007; accepted 20 February 2007 Abstract There are few studies on coping with fibromyalgia (FM). The aim of the present study was to assess the usefulness of a Spanish version of the Chronic Pain Coping Inventory-42 (CPCI-42) in patients with FM. A random sample (N = 402) of patients with FM was obtained from the Fibromyalgia Association of Aragon, Spain. Patients were assessed with the CPCI-42, the Fibrofatigue Scale (FFS), the EuroQol-5D (EQ-5D), and the Hospital Anxiety and Depression Scale (HADS). The psychometric properties of the CPCI-42 were valid and factor analyses supported the eight-factor structure described in patients with chronic pain. Illness-focused coping strategies (i.e., guarding, resting, and asking for assistance) were strongly correlated with each other, positively correlated with disability and depression, and negatively correlated with quality of life, indicating construct validity. Seeking social support was weakly correlated with any other scale or outcome, confirming it belongs to a different group of coping strategies. The well- ness-focused group of coping strategies was the most incoherent group. Task persistence correlated with illness-focused strategies and negative outcomes, indicating that it should be included in the illness-focused group. However, other wellness-focused strate- gies, including relaxation, exercise, and coping self-statements, were correlated with each other, negatively correlated with depres- sion, and positively correlated with quality of life. Future research directions and clinical implications are discussed. Ó 2007 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. Keywords: Coping; Fibromyalgia; Validation; CPCI 1. Introduction Coping may be defined as ‘‘the purposeful use of cog- nitive and behavioral techniques to manage demands that are perceived as stressful or taxing the resources of the individual’’ (Lazarus and Folkman, 1984). Cer- tain types of coping, such as the use of coping self-state- ments, are associated with better physical and psychological functioning among patients with chronic pain. Other coping strategies, such as pain contingent rest, guarding (Kleinke, 1992; Boothby et al., 1999), and catastrophizing (Tennen et al., 2006), appear to be related to poorer functioning. A variety of coping measures have been developed to address the need for reliable and valid assessment of pain coping responses, including the Vanderbilt Pain Management Inventory (VPMI; Brown and Nicassio, 1987), the Coping Strategies Questionnaire (CSQ; 0304-3959/$32.00 Ó 2007 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.pain.2007.02.013 * Corresponding author. Tel.: +34 076 25 36 21; fax: +34 976 25 40 06. E-mail address: [email protected](J. Garcia-Campayo). www.elsevier.com/locate/pain Pain 132 (2007) S68–S76
Transcript
www.elsevier.com/locate/pain
Pain 132 (2007) S68–S76
Coping with fibromialgia: Usefulness of theChronic Pain Coping Inventory-42
Javier Garcia-Campayo a,b,*, Aida Pascual a,b, Marta Alda c,d,Monica Teresa Gonzalez Ramirez e
a Department of Psychiatry, Miguel Servet University Hospital, Avda Gomez Laguna 52, 4D, 50.009 Zaragoza, Spainb University of Zaragoza, Spain
c Department of Psychiatry, Alcaniz Hospital, Alcaniz, Teruel, Spaind Grupo Aragones de Investigacion en Atencion Primaria, Red de Actividades Preventivas y Promocion de la Salud (REDIAPP) (G03/170),
Instituto Aragones de Ciencias de la Salud, Spaine Faculty of Psychology, Autonomous University of Nuevo Leon, Mexico
Received 4 November 2006; received in revised form 14 February 2007; accepted 20 February 2007
Abstract
There are few studies on coping with fibromyalgia (FM). The aim of the present study was to assess the usefulness of a Spanishversion of the Chronic Pain Coping Inventory-42 (CPCI-42) in patients with FM. A random sample (N = 402) of patients with FMwas obtained from the Fibromyalgia Association of Aragon, Spain. Patients were assessed with the CPCI-42, the Fibrofatigue Scale(FFS), the EuroQol-5D (EQ-5D), and the Hospital Anxiety and Depression Scale (HADS). The psychometric properties of theCPCI-42 were valid and factor analyses supported the eight-factor structure described in patients with chronic pain. Illness-focusedcoping strategies (i.e., guarding, resting, and asking for assistance) were strongly correlated with each other, positively correlatedwith disability and depression, and negatively correlated with quality of life, indicating construct validity. Seeking social supportwas weakly correlated with any other scale or outcome, confirming it belongs to a different group of coping strategies. The well-ness-focused group of coping strategies was the most incoherent group. Task persistence correlated with illness-focused strategiesand negative outcomes, indicating that it should be included in the illness-focused group. However, other wellness-focused strate-gies, including relaxation, exercise, and coping self-statements, were correlated with each other, negatively correlated with depres-sion, and positively correlated with quality of life. Future research directions and clinical implications are discussed.� 2007 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
Keywords: Coping; Fibromyalgia; Validation; CPCI
1. Introduction
Coping may be defined as ‘‘the purposeful use of cog-nitive and behavioral techniques to manage demandsthat are perceived as stressful or taxing the resourcesof the individual’’ (Lazarus and Folkman, 1984). Cer-tain types of coping, such as the use of coping self-state-
0304-3959/$32.00 � 2007 International Association for the Study of Pain. P
ments, are associated with better physical andpsychological functioning among patients with chronicpain. Other coping strategies, such as pain contingentrest, guarding (Kleinke, 1992; Boothby et al., 1999),and catastrophizing (Tennen et al., 2006), appear to berelated to poorer functioning.
A variety of coping measures have been developed toaddress the need for reliable and valid assessment ofpain coping responses, including the Vanderbilt PainManagement Inventory (VPMI; Brown and Nicassio,1987), the Coping Strategies Questionnaire (CSQ;
J. Garcia-Campayo et al. / Pain 132 (2007) S68–S76 S69
Rosenstiel and Keefe, 1993) and the Chronic Pain Cop-ing Inventory (CPCI; Jensen et al., 1995). The VPMIdoes not include assessment of specific coping strategies.The CSQ is widely used to measure pain coping. How-ever, it is more heavily weighted towards cognitive,rather than behavioral, coping strategies (Hadjistavro-poulos et al., 1999). Additionally, although many stud-ies have demonstrated a strong relationship betweenthe catastrophizing scale and patient adjustment, theother CSQ subscales are not consistently associated withmeasures of patient adjustment (Boothby et al., 1999;De Good and Tait, 2001).
The CPCI assesses behavioral and cognitive pain cop-ing strategies, such as exercise, guarding, resting, andcoping self-statements, that are targeted in many multi-disciplinary pain management programs, and it has beenshown to have valid psychometric properties (Jensenet al., 1995). Additional validation of the CPCI was pro-vided by Hadjistavropoulos et al. (1999), who conducteda principal component analysis that supported the origi-nal subscale structure. Romano et al. (2003) developedan abbreviated, 42-item version of the CPCI (CPCI-42) that has several advantages over the original CPCI,such as increased professional acceptance and facilita-tion of repeated assessments of coping processes overtime, without sacrificing psychometric properties.
Fibromyalgia (FM) is a chronic pain condition char-acterized by musculoskeletal aches, pain, and stiffnessand exaggerated tenderness at characteristic sites (Wolfeet al., 1990). There are few studies on coping with FM(Nicassio et al., 1995; Martin et al., 1996; Hallbergand Carlsson, 1998; Nielson et al., 2001; Raak et al.,2003; Nielson and Jensen, 2004). The aim of the presentstudy was to assess the applicability of a Spanish versionof the CPCI-42 to patients with FM, a specific subsam-ple of patients with chronic pain, by measuring its psy-chometric properties (i.e., internal consistency, test–retest reliability, construct validity).
2. Methods
2.1. Subjects
Sample size was calculated according to the recommended10:1 ratio of number of subjects to number of test items (Kline,1998). The sample was comprised of consecutive patients withFM recruited from the Fibromyalgia Association of Aragon,who were assessed at the Somatoform Disorders/FibromyalgiaUnit at Miguel Servet University Hospital, Zaragoza, Spain, in2005. The final study sample consisted of 402 patients (361women and 41 men), aged 22-64 (mean 45.3 ± 6.8 years), allself-described as White European. In order to be included inthe study, patients had to fulfill the American College of Rheu-matology criteria for primary FM (Wolfe et al., 1990), accord-ing to a diagnosis made by a Spanish National Health Servicerheumatologist. When a patient was simultaneously diagnosedwith FM and chronic fatigue syndrome (CFS), FM symptoms
(e.g., pain) had to be the predominant symptom from thepatient’s point of view. In 41 cases, CFS symptoms predomi-nated, resulting in patient exclusion from the study. Of 406potential subjects, four (1%) declined to participate. On aver-age, the patients who participated in the study had sufferedfrom FM for 8.7 years (range 1–22 years), and 185(46%) hadbeen granted an invalidity pension. The study questionnairesand protocol were approved by the Ethical Committee of theregional health authority, and the patients signed a consentform attesting to their willingness to participate.
2.2. Translation of the CPCI-42
Permission to translate and validate the CPCI-42 wasobtained from the original authors (Romano et al., 2003).Two native Spanish speakers, who were aware of the objectiveof the CPCI-42, first translated the CPCI-42 to Spanish. Then,two native-English speakers, who were not familiar with theCPCI-42, performed a back-translation from Spanish to Eng-lish. Any discrepancies between the Spanish and English trans-lators were resolved by agreement. The original and back-translated English versions were judged equivalent by a thirdnative English speaker. The Spanish version was judged tobe an accurate translation of the original English version.The final Spanish version was approved by the originalauthors. Members of our group have substantial experiencetranslating psychometric questionnaires to Spanish and vali-dating them (Garcıa-Campayo et al., 1996, 2005, 2006; SanzCarrillo et al., 2002).
2.3. Measures
2.3.1. CPCI-42
The CPCI (Jensen et al., 1995) is a 65-item, self-report ques-tionnaire that requires patients to report the frequency of useof particular behavioral and cognitive strategies to cope withpain. The strategies are grouped into eight subscales thatinclude guarding, resting, asking for assistance, relaxation,task persistence, exercise/stretch, seeking social support, andcoping self-statements. The subscales had high internal consis-tency, test–retest reliability, and concurrent validity in a sam-ple of chronic pain patients (Jensen et al., 1995). The CPCI,a 42-item abbreviated version of the CPCI, had good psycho-metric properties (Romano et al., 2003). The CPCI-42 was val-idated in a group of patients with FM in the present study.
2.3.2. Fibromyalgia Impact Questionnaire (FIQ)
The FIQ is a 10-item self-report questionnaire that mea-sures the health status of patients with FM (Burckhardtet al., 1991). The first item focuses on the patient’s ability toperform physical activities. The following two items requirethe patient to indicate the number of days in the past weekthey felt good and how many days of work he or she missed.The remaining seven items concern the ability to work, pain,fatigue, morning tiredness, stiffness, anxiety, and depressionand are measured with the visual analogue scale (VAS). Inthe present study we used a Spanish version of the FIQ thathas been translated and validated (Rivera and Gonzalez,2004).
S70 J. Garcia-Campayo et al. / Pain 132 (2007) S68–S76
2.3.3. FFS
The FFS measures the health status and outcome ofpatients with FM and CFS (Zachrisson et al., 2002). It wasdesigned to assess the components and characteristics of healththat are most affected by these disorders. The FFS contains 12observer-rated items that assess symptom severity. Based onthe information obtained in a clinical interview, each item isscored from 0 (absence of the symptom) to 6 (maximal degreeof the symptom). To aid scoring, a short description (anchor-ing point) is given to scores 0, 2, 4, and 6. If a patient’s condi-tion falls between anchoring points, a score of 1, 3, or 5 (whichare not defined) is assigned. Our group developed and vali-dated a Spanish version of the FFS (Garcia-Campayo et al.,2006).
2.3.4. HADS
The HADS (Zigmond and Snaith, 1983) is a self-reportscale that screens for the presence of depression and anxietyin patients with organic disorders. It comprises 14 items thatare rated on a 4-point Likert-type scale, and it is appropri-ate for use in community and hospital settings. Two sub-scales, HADS-Dep and HADS-Anx, independently assessdepression and anxiety. The HADS was validated in a Span-ish population (Tejero et al., 1986). HADS was selected foruse in the present study because it is considered one of thebest questionnaires for assessing depression and anxiety inpatients (APA, 2000).
2.3.5. EQ-5D
EQ-5D is a standardized instrument that measures healthoutcome and is applicable to a wide range of conditions andtreatments. It provides a simple, descriptive profile and asingle index value for health status. The EQ-5D was origi-nally designed to complement other instruments, such asthe 36-item Short-Form Health Status Survey (SF-36), Not-tingham Health Profile (NHP), or disease-specific question-naires, but it is now increasingly used as a stand-alonemeasure. EQ-5D combines the EuroQol descriptive systemand the EuroQol VAS. The EuroQol VAS measures self-rated health status on a 0-100 graduated VAS (Brookset al., 2003). The EQ-5D covers five dimensions of health,including mobility, self-care, usual activities, pain/discom-fort, and anxiety/depression. Each dimension is character-ized at three levels (i.e., no problems, some moderateproblems, extreme problems). A measure of health statusis defined by combining one level from each of the fivedimensions. In the present study, we used a validated Span-ish version of the EQ-5D (Badıa et al., 1999).
2.4. Procedures
Patients diagnosed with FM who fulfilled the inclusion cri-teria were invited to participate in the study, until the requirednumber of participants was reached. Those who agreed to par-ticipate completed the questionnaires. Twelve (3%) sets ofquestionnaires were excluded due to incomplete or illegibledata. For a subsample of 88 patients, CPCI-42 test–retest reli-ability for the 2-week to 1-month follow-up interval wasevaluated.
2.5. Data analysis
Construct validity of the CPCI-42 questionnaire was esti-mated by confirmatory factor analysis (Thomsom, 2004).The initial model was based on the eight-factor modelobtained from a previous exploratory factor analysis (Romanoet al., 2003). Each of the 42 observed variables was initiallyassumed to be associated with the factor variable that had itslargest factor loading from the varimax rotation result of theexploratory factor analysis. Thus, each observed variable wasassumed, initially, to be associated with one and only one ofthe eight factor variables, whereas each factor variable wasassumed to be associated with the observed variables thathad their largest factor loadings.
Internal consistency was assessed using Cronbach’s acoefficient. Test–retest reliability, evaluated with Pearsoncorrelation coefficients, was assessed for the 2-week to 1-month follow-up interval. Criterion validity of the CPCI-42 was examined by calculating the correlations of theCPCI-42 subscales with the measures of the health statusof patients with FM according to the clinician (measuredwith FFS) or the patient (measured with FIQ), depressionand anxiety (assessed by HADS), and quality of life (mea-sured by the EQ-5D).
All statistical analyses were performed with SPSS software,version 13 (SPSS Inc., Chicago, Illinois) except for the confir-matory factory analysis, which was carried out with LISRELsoftware, version 8.30 (Scientific Software International, Inc.Lincolnwood, Illinois). As in a prior study (Truchon et al.,2006), a v2/degrees of freedom (df) ratio <3.0, a comparativefit index (CFI) >0.90, a standardized root-mean-square resid-ual (SRMR) 60.08, and root-mean-square error of approxi-mation (RMSEA) <0.08 or ideally, <0.05 were used toevaluate model fit.
3. Results
3.1. Confirmatory factor analysis of the Spanish version
of CPCI-42
Individual item-scale correlations are presentedin Table 1. In general, fit indices were satisfactory.For example, v2/df = 3.1, RMSEA (90% confidenceinterval (CI)) = .059 (.057–.061), SRMR = 0.08, andCFI = 0.81. However, it should be noted that factorialstructures with more than five indicators per factor aredifficult to confirm, and the CFI and the RMSEA areaffected by the number of items (Floyd and Widaman,1995). Except for item 33 (use of self-hypnosis to relax),the item-scale correlation ranged from 0.34 to 0.79.Based on the weak item-scale correlation (0.21) the itemwas excluded from analyses, including those described inthe remaining tables.
3.2. Descriptive statistics
Table 2 presents means, standard deviations, andranges of the CPCI-42 scale factors and the other mea-
Pattern/structure coefficients of free parameters are in bold. All other pattern coefficients fixed to zero are not shown. Structure coefficients (innormal text) represent the correlation between an item and the factors.Guard, guarding; Rest, resting; Ask, asking for assistance; Relax, relaxation; Task, task persistence; Exe, exercise/stretching; CSS, coping self-
statements; SSS, seeking social support.
J. Garcia-Campayo et al. / Pain 132 (2007) S68–S76 S71
sures used in the study. It can be seen that the sample iscomprised of patients with FM, who were disabled anddepressed with a poor quality of life and low levels ofanxiety.
3.3. Internal consistency
Table 3 shows the internal consistency (Cronbach’s acoefficient) of the CPCI-42. It is widely accepted that acoefficients of P0.70 indicate adequate to excellent
internal consistency. For all of the CPCI-42 subscales,the Cronbach’s a coefficient was >0.70 (Jensen, 2003).
3.4. Test–retest reliability
Table 3 shows the test–retest reliability (Pearson’scorrelation) coefficients of a subset of patients(N = 88) for the 2-week to 1-month follow-up interval.The coefficients range from 0.65 to 0.82. CoefficientsP0.70 indicate adequate to excellent test–retest
a These data were obtained after removing item 33 (use of self-hypnosis to relax) from the relaxation subscale.
S72 J. Garcia-Campayo et al. / Pain 132 (2007) S68–S76
reliability. The majority of subscales had test–retestcoefficients >0.70 (Jensen, 2003).
3.5. Criterion validity
We measured the relationship between the CPCI-42and measures of health status of patients with FM,according to the clinician (measured with the FFS) orthe patient (measured with the FIQ), depression andanxiety (assessed by HADS), and quality of life (mea-sured by the EQ-5 D). All of these measures wereexpected to be related to patient coping. We calculatedPearson product–moment correlation coefficients, whichare summarized in Table 4. Because of the large numberof coefficients computed in the analyses, the a level wasset to P < 0.01 to control for the possibility of Type Ierrors when interpreting the results. The guarding, rest-ing, and asking for assistance subscales were positiveand significantly correlated with depression and disabil-ity, as measured with the FIQ or FFS and negative and
Table 3Cronbach’s a coefficients and test–retest reliabilities (95% CI) of CPCI-42 subscales
Cronbach’s a(N = 402)
Test–retest r
(N = 88)
Subscales
Guarding .73–.76–.79 .77–.80–.83Resting .70–.73–.76 .68–.71–.74Asking for assistance .84–.87–.90 .72–.75–.78Relaxationa .73–.76–.79 .73–.76–.79Task persistence .71–.74–.77 .69–.72–.75Exercise/stretch .81–.84–.87 .68–.71–.74Seeking social support .78–.81–.84 .70–.73–.76Coping self-statements .77–.80–.83 .74–.77–.80
a These data were obtained after removing item 33 (use of self-hypnosis to relax) from the relaxation subscale.
significantly correlated with quality of life, as measuredby the EQ-5D. Task-persistence was positive and signif-icantly correlated with depression and disability. Theseeking social support subscale was weakly correlatedwith any other measure. Relaxation, exercise/stretching,and coping self-statements were positive and signifi-cantly correlated with quality of life and negative andsignificantly correlated with depression.
3.6. Correlation of subscales
The guarding, resting, and asking for assistance sub-scales were positive and significantly correlated witheach other. Task-persistence was positive and signifi-cantly correlated with those subscales but weakly corre-lated with the remaining subscales. The seeking socialsupport subscale was weakly correlated with any othersubscale. Relaxation, exercise/stretching, and copingself-statements were positive and significantly correlatedwith each other and weakly correlated with guarding,resting, asking for assistance, and task-persistence(Table 5).
4. Discussion
The present study was performed to assess the utilityof the CPCI-42 questionnaire on a sample of patientswith FM, a specific subtype of patients with chronicpain. The CPCI-42 is expected to be of great value formonitoring the effectiveness of psychological treatmentsfor FM, since one of the primary goals of any treatmentis to improve patients’ coping with their condition.Moreover, use of the abbreviated version of the inven-tory facilitates repeated measures over time.
The importance of this study is that it is the first timethat CPCI-42, one of the most commonly used question-naires for assessing coping with chronic pain, has beenapplied to FM, a prevalent chronic pain disease. Inaddition, our study provides an instrument for assessingcoping in Spanish-speaking countries. Our study hassome limitations. For instance, we did not compareCPCI-42 to objective measures of coping, such as behav-ioral observations of coping or reports of cognitive cop-ing during structured or standardized situations.However, those data were obtained when the originalCPCI questionnaire was validated (Jensen et al., 1995).Also, we translated and validated the CPCI-42, and atthe same time we applied it to a new population,patients with FM.
It is not clear if our findings differ from previous stud-ies because of differences in population (patients withchronic pain and patients with FM) or to language, orcultural. However, our previous experience validatingFM questionnaires (Garcia-Campayo et al., 2006) isthat cultural/idiomatic differences between the UnitedStates and Spain are minimal in this context. Thus, dif-
Seeking social support .06 .09 �.09 .12 .05Coping self-statements �.07 �.09 �.31** �.11 .21**
FIQ, Fibromyalgia Impact Questionnaire; FSS, Fibrofatigue Scale; HADS, Hospital Anxiety and Depression Scale; HADS-dep, depression subscaleof the HADS; HADS-anx, anxiety subscale of the HADS; EQ-5D, EuroQol-5D.
* P < 0.01.** P < 0.001.
J. Garcia-Campayo et al. / Pain 132 (2007) S68–S76 S73
ferences between our findings and those of other studiesare most likely due to different study populations.Regarding the usefulness of applying the CPCI-42 topatients with FM, the confirmatory factor analysis indi-cated that the CPCI-42 scales were conceptually homo-geneous and confirm the validity of the scalesconstructed by Jensen et al. (1995).
The present study confirmed the factorial structure ofthe CPCI-42. Our results, and those of others (Jensenet al., 1995; Hadjistavropoulos et al., 1999; Tan et al.,2001; Truchon and Cote, 2005) with the CPCI andRomano et al. (2003) with the CPCI-42, support theeight-factor structure of the CPCI in general, and theCPCI-42 in particular. However, we have extended thefindings to a Spanish-speaking population with FM.
One important difference between the Spanish andEnglish versions of the CPCI-42 is that item number33 (use of self-hypnosis to relax) in the Spanish versionshowed weak item-scale correlation and indicates theneed to review the formulation of this item or eliminateit from the Spanish version of the questionnaire. Wepropose eliminating this item because self-hypnosis israrely used as a coping strategy by Spanish patients withFM or chronic pain.
Table 5Correlation of different CPCI-42 subscales
Guarding Resting Ask assist Relaxa
Guarding X 0.45** 0.41** 0.04Resting X X 0.43** 0.12Asking for assistance X X X 0.11Relaxation X X X XTask-persistence X X X XExercise/stretch X X X XSeeking social support X X X XCoping self-statements X X X X
*P < 0.05.Ask assist, asking for assistance; Task persist, task persistence; Exercise, e
seeking social support.** P < 0.01.
Regarding construct validity, according to Jensenet al. (1995) there are two families of coping strategies.One includes strategies, such as task persistence, relaxa-tion, exercise/stretching, and coping self-statements,that are wellness focused and are encouraged in psycho-logical treatment. The other includes strategies, such asguarding, resting, and asking for assistance, that are ill-ness focused and discouraged in psychological treat-ment. A final strategy, seeking social support, isneither encouraged nor discouraged in psychologicaltreatment and was thought to belong to another familyof coping strategies. In a confirmatory factor analysis ofthe French version of the CPCI in patients with chronicpain, Truchon et al. (2006) confirmed the illness-focusedcoping group, although this was not possible for thewellness-focused group. In the present study, the seekingsocial support scale was weakly correlated with othersubscales, confirming that it belongs to a different,unidentified group of coping strategies. In addition,seeking social support was only weakly correlated withfunctional measures, which is consistent with its beingneither encouraged nor discouraged in treatment. Thesubscales belonging to the illness-focused group of strat-egies were positive and significantly correlated with each
tion Task persist Exercise Seeking social Coping self
S74 J. Garcia-Campayo et al. / Pain 132 (2007) S68–S76
other as well as with depression and disability as mea-sured by the FIQ and FFS. The subscales were negativeand significantly correlated with quality of life as mea-sured by the EQ-5D. Wellness focused and illnessfocused families of coping strategies demonstrated con-struct validity.
The wellness-focused group (i.e., task persistence,relaxation, exercise/stretching, and coping self-state-ments) of strategies was the most incoherent group, asreported by Truchon and Cote (2005). One of the strat-egies, task-persistence, was positive and significantlycorrelated with depression and disability and weaklycorrelated with quality of life. This strategy would,therefore, is more consistent with the illness-focusedstrategies. However, the other three strategies of thewellness-focused group are positive and significantlycorrelated with quality of life and negative and signifi-cantly correlated with depression, although they didshow a weak correlation with disability. These threestrategies significantly correlated with each other, butweakly with task persistence. Thus, while it is doubtfulthat task persistence should be targeted by treatmentprograms, relaxation, exercise/stretching, and copingself-statements may alleviate depression and improvequality of life, but not necessarily the ability to function.The cross-sectional design of the study does not allowconclusions to be drawn.
It does not seem appropriate to label the groups ofcoping strategies illness focused and wellness focusedbecause they were not inverse and significantly corre-lated. Rather, they were weakly correlated (except fortask persistence, which was positive and significantlycorrelated with the illness-focused strategies and shouldprobably be included in this group).
In their CPCI predictive validity study, Truchon andCote (2005) found that the wellness-focused group ofstrategies weakly correlated with measures of positiveoutcome. The authors proposed two explanations forthis. First, the same person can simultaneously applycontradictory coping strategies; and second, the copingstrategies included in the wellness-focused group arenot necessarily adaptive strategies. The latter explana-tion may have important consequences because, apartfrom requiring complete rebuilding the CPCI, it wouldnecessitate reconsideration of psychotherapies thatemphasize the use of wellness-focused coping strategies.In our study of patients with FM, the wellness-focusedgroup of strategies correlated with better quality of lifeand less depression. Therefore, at least for patients withFM and with the limitations of a cross-sectional study,the three wellness-focused strategies of relaxation, exer-cise/stretching, and coping self-statements appear to beuseful and deserve to be emphasized in psychologicaltreatment.
The psychometric properties of the Spanish versionof the CPCI-42 are valid. Regarding internal consis-
tency, Cronbach’s a coefficient was consistently higherthan 0.70, as was the case with test–retest reliabilitycoefficients. According to a recent guide on the valida-tion of questionnaires, coefficients between 0.70 and0.90 are considered adequate (Jensen, 2003). Thesevalues are higher than those found in the originalCPCI-42 validation study (Romano et al., 2003).The reason for this may be that in the original study,patients began psychological treatment during thetest–retest interval, and treatment may have modifiedthe patients’ coping strategies. Our patients did notreceive any new treatment during the test–retest inter-val. A similar finding was reported by Truchon andCote (2005) who studied the predictive validity ofthe CPCI. That study confirmed the validity of indi-vidual subscales and the overall factorial structure ofthe CPCI described by previous authors (Jensenet al., 1995; Hadjistavropoulos et al., 1999; Tanet al., 2001; Romano et al., 2003; Truchon and Cote,2005). Finally, the criterion validity of the CPCI-42was coherent with illness-focused and seeking socialsupport subscales but raised doubts about the crite-rion validity of the wellness-focused strategies.
In conclusion, the present study confirms the validpsychometric properties of the Spanish version of theCPCI-42 in patients with FM. However, we proposechanging the name of the Spanish version to Abbrevi-ated Version CPCI, due to the fact that it is comprisedof only 41 items, since item 33 was eliminated. Addi-tionally, the study raises doubts about the validity ofthe wellness-focused strategies because they were posi-tively correlated with illness-focused subscales andweakly correlated or positively correlated with dysfunc-tional outcomes. It is possible that in patients with FMand chronic pain the wellness-focused strategies are notrelated to successful rehabilitation (Truchon and Cote,2005). New research studies on the predictive value ofcoping strategies in FM patients in particular, andpatients with chronic pain in general, are necessary toconfirm this point.
Acknowledgements
The authors thank the Asociacion Aragonesa de Fi-bromialgia (ASAFA) for its collaboration. This workhas been possible thanks to the grant 05/2185 ‘‘Trata-miento cognitivo-conductual de pacientes con trastornode somatizacion abreviado (SSI 4,6) en atencion pri-maria’’ from Fondo de Investigaciones Sanitarias(FIS). Madrid.
Appendix A
Spanish version of the CPCI-42. (Item 33 has beenruled out) Sample of some items.
J. Garcia-Campayo et al. / Pain 132 (2007) S68–S76 S75
Durante la semana pasada, ¿cuantos dıas utilizo cadauna de las siguientes estrategias, al menos una vez al dıa,para afrontar su dolor?
NOTA: Puede haber utilizado algunas de estasestrategias en dıas en los que no tenıa dolor, para preve-nir o minimizar el dolor en el futuro.
Por favor, indique el numero de dıas en que utilizocada estrategia para el dolor, tuviese o no dolor en esemomento.
Numero de dıas
1. Ignore el dolor
0 1 2 3 4 5 6 7 2. Me tome un descanso 0 1 2 3 4 5 6 7 3. Conseguı apoyo de
un amigo
0 1 2 3 4 5 6 7
4. Pedı a alguien quehiciese algo por mı
0
1 2 3 4 5 6 7
5. Me recorde a mı mismoque las cosas podıan serpeores
0
1 2 3 4 5 6 7
6. Conseguı apoyo de unmiembro de mi familia
0
1 2 3 4 5 6 7
7. Simplemente continuehaciendo lo que hacıa
0
1 2 3 4 5 6 7
8. Evite actividades
0 1 2 3 4 5 6 7 9. Me fui a mi cuarto a
descansar
0 1 2 3 4 5 6 7
10. Me tumbe en el sofa
0 1 2 3 4 5 6 7
Copyright� Psychological Assessment Resources, Inc. (PAR). Furtherreproduction is prohibited without permission from PAR, Inc.
References
American Psychiatric Association. Handbook of Psychiatric Mea-sures. Washington, DC: American Psychiatric Association,2000.
Badıa X, Roset M, Montserrat S, Herdman M, Segura A. The Spanishversion of EuroQol: a description and its application. Med Clin(Barc) 1999;112:79–85.
Boothby JL, Thorn BE, Stroud MW, Jensen MP. Coping with pain.In: Gatchel RJ, Turk DC, editors. Psychosocial factors in pain:critical perspectives. New York, NY: Guilford Press; 1999. p.343–59.
Brooks R, Rabin RE, De Charro F, editors. The measurementand validation of a health status using EuroQol-5D: aEuropean perspective. Basel (Switzerland): Kluwer AcademicPublishers; 2003.
Brown GK, Nicassio PM. Development of a questionnaire for theassessment of active and passive coping strategies in chronic painpatients. Pain 1987;31:53–64.
Burckhardt CS, Clark SR, Bennet RM. The Fibromialgya ImpactQuestionnaire: development and validation. J Rheumatol1991;18:728–33.
DeGood DE, Tait RC. Assessment of pain beliefs and pain coping. In:Turk DC, Melzac R, editors. Handbook of Pain Assessment. 2nded. New York; NY: Guildford Press; 2001. p. 320–41.
Floyd FJ, Widaman KF. Factor analysis in the development andrefinement of clinical assessment instruments. PsychologicalAssessment 1995;7:286–99.
Garcia-Campayo J, Pascual A, Alda M, Marzo J, Magallon R, Fortes S.The Spanish version of the Fibrofatigue Scale: validation of aquestionnaire for the observer’s assessment of fibromyalgia andchronic fatigue syndrome. Gen Hosp Psychiatry 2006;28:154–60.
Garcıa Campayo J, Sanz Carrillo C, Lou S, Ibanez JA, Alda M.Validation of the Spanish version of the SCOFF questionnaire forthe detection of eating disorders in primary care. J Psychosom Res2005;59:51–5.
Garcıa-Campayo J, Sanz-Carrillo C, Perez-Echeverrıa MJ, Campos R,Lobo A. Screening of somatization disorder: validation of theSpanish version of the Othmer and deSouza test. Acta PsychiatrScand 1996;94:411–5.
Hallberg LR, Carlsson SG. Anxiety and coping in patients withchronic work-related muscular pain and patients with fibromyal-gia. Eur J Pain 1998;2:309–19.
Jensen MP. Questionnaire validation: a brief guide for readers of theresearch literature. Clin J Pain 2003;19:345–52.
Jensen MP, Turner JA, Romano JM, Strom SE. The Chronic PainCoping Inventory: development and preliminary validation. Pain1995;60:203–16.
Kline RB. Principles and practices of structural equation modelling.In: Kenny DA, editor. Methodology in the social sciences. NewYork: The Guilford Press; 1998.
Kleinke CL. How chronic pain patients cope with pain: relation totreatment outcome in a multidisciplinary pain clinic. Cognit TherRes 1992;16:669–85.
Lazarus RS, Folkman S. Stress, appraisal, and coping. New York,NY: Springer; 1984.
Martin MY, Bradley LA, Alexander RW, Alarcon GS, Triana-Alexander M, Aaron LA, et al. Coping strategies predict disabilityin patients with primary fibromyalgia. Pain 1996;68:45–53.
Nicassio PM, Schoenfeld-Smith K, Radojevic V, Schuman C. Paincoping mechanisms in fibromyalgia: relationship to pain andfunctional outcomes. J Rheumatol 1995;22:1552–8.
Nielson WR, Jensen MP, Hill ML. An activity pacing scale for thechronic pain coping inventory: development in a sample of patientswith Fibromyalgia Syndrome. Pain 2001;89:111–5.
Nielson WR, Jensen MP. Relationship between changes in coping andtreatment outcome in patients with Fibromyalgia Syndrome. Pain2004;109:233–41.
Raak R, Hurtig I, Wahren LK. Coping strategies and life satisfactionin subgrouped fibromyalgia patients. Biol Res Nurs2003;4:193–202.
Rivera J, Gonzalez T. The Fibromyalgia Impact Questionnaire: avalidated Spanish version to assess the health status in women withfibromyalgia. Clin Exp Rheumatol 2004;22:554–60.
Romano JM, Jensen MP, Turner JA. The chronic pain copinginventory-42: reliability and validity. Pain 2003;104:65–73.
Rosenstiel AK, Keefe FJ. The use of coping strategies in chronic lowback pain patients: relationship to patient characteristics andcurrent adjustment. Pain 1993;17:33–44.
Sanz Carrillo C, Garcıa-Campayo J, Rubio A, Santed MA, MontoroM. Validation of the Spanish version of the Perceived StressQuestionnaire. J Psychosom Res 2002;52:167–72.
Tan G, Jensen MP, Robinson-Whelen S, Thornby JI, Monga TN.Coping with chronic pain: a comparison of two measures. Pain2001;90:127–33.
Tejero A, Guimera EM, Farre JM, Peri JM. Clinical use of HADS inpsychiatric simples: a sensitivity, reliability and validity study (inSpanish). Rev Dep Psiquiatr Fac Med Barc 1986;13:233–8.
Tennen H, Affleck G, Zautra A. Depression history and coping withchronic pain: a daily process analysis. Health Psychol 2006;25:370–9.
S76 J. Garcia-Campayo et al. / Pain 132 (2007) S68–S76
Thomsom B. Exploratory and confirmatory factor analysis. Wash-ington, DC: American Psychological Association; 2004.
Truchon M, Cote D. Predictive validity of the Chronic Pain Inventoryin subacute low back pain. Pain 2005;116:205–12.
Truchon M, Cote D, Irachabal S. The chronic pain coping inventory:confirmatory factor analisis of the French version. BMC Muscu-loskeletal Disord 2006;7:1–9.
Wolfe F, Smythe HA, Yunus MB, Bennet RM, Bombardier C,Goldenberg DL. The American College of Rheumatology 1990
criteria for the classification of fibromyalgia. Report ofthe Multicenter Criteria Committee. Arthritis Rheum1990;33:160–72.
Zachrisson O, Regland B, Jahreskog M, Kron M, GottfriesCG. A rating scale for fibromyalgia and chronic fatiguesyndrome (the Fibrofatigue scale). J Psychosomatic Res2002;52:501–9.
Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale.Acta Psychiatr Scand 1983;67:361–70.
