- Email: [email protected]
Examining the interaction effects of coping style and brief interventions in the treatment of postsurgical pain
279
Pain, 20 (1984) 279-291 Elsevier
PA1 00689
Examining the Interaction Effects of Coping Style and Brief Interventions in the Treatment of Postsurgical Pain L.E. Scott 1 and G.A. Clum 152 Henderson Hall, Virginia Polytechnic Institute and State University, Blacksburg, VA 24061 (U.S.A.) (Received 16 January 1984, accepted 29 May 1984)
Summary The present study sought to ameliorate two major deficiencies in the literature on treating response to surgery, viz., (1) the failure to compare clearly delineated treatments, alone and in combination; and (2) the failure to examine treatment X coping style interactions. Information imparting and brief relaxation were examined in this study as they interacted with an avoidance-sensitization coping style. No differences were found between treatments or coping styles. Sensitizers, on the other hand, were found to profit most from the relaxation training. Avoiders appeared to do well when they were left alone. The interaction effect was demonstrated for both self-report measures of pain and a behavioral measure of potency of medications ingested. The effects on self-report of pain were more evident on the second postsurgical day than on the fourth postsurgical day. The results indicate that brief relaxation training, often the only kind available to the medical psychologist dealing with surgical patients, is best confined to patients with a sensitizing coping style. Further, the results of this study, in conjunction with a reanalysis of previous studies, cast considerable doubt on information imparting when presented alone as a viable technique for reducing the distress consequent on surgery.
’ Reprint requests should be sent to Linda E. Scott, University Counseling Services, Virginia Polytechnic Institute and State University, Blacksburg, VA 24061, U.S.A.
0304-3959/84/$03.00
Q 1984 Elsevier Science Publishers
B.V
280
Introduction A major concern in managing medical patients is the amount of pain and distress they will experience as a result of the medical procedures. Previous studies have shown that the patients who are sensitizers * tend to have the poorest postsurgical recovery (61. Avoiders *, however, may have a poorer recovery when presented with preparatory information [7]. Some studies [18,23] have attempted to reduce postsurgical discomfort by decreasing anxiety or by changing the patient’s method of coping with the pre- and postoperative environment (i.e., by providing information about procedures and methods of dealing with them). We will now examine in a selective review: (1) the efficacy of information imparting and relaxation techniques in reducing clinical pain and anxiety; and (2) the interaction of type of intervention and method of coping, as it relates to pain and anxiety reduction. Information imparting has been found to be both helpful [8,13] and harmful [1,18] with respect to pain and discomfort. This conflicting evidence is apparently due to the use of different types of information, the context in which it is presented, and individual variability in response to preparatory information. For instance, Egbert et al. [8] devised a multicomponent program that provided patients with information about the procedures and sensations to be expected, as well as instruction in relaxation, controlled breathing and careful movement. Patients in the instruction group received one-half the number of analgesics as compared to controls, and were released an average of 2.7 days earlier. Johnson [13] found that a detailed description of the specific sensory characteristics of the pain to be experienced, prior to the induction of ischemic pain, significantly reduced the amount of distress reported by subjects. Conversely, Langer et al. [18] found preparatory information to be ineffective as a means of reducing pain and recovery time. However, preparatory information, in this instance, consisted only of general information about procedures, possible complications, and locations of pain. Langer et al. proposed that the information may have served to sensitize the patients to the discomforting aspects of the impending surgery, Further support for this notion is provided by Kanfer and Goldfoot [16] who have demonstrated that the presentation of a negative set, prior to a measure of pain tolerance, using the cold-pressor test, significantly increases discomfort ratings and reduces pain tolerance. The negative set condition consisted of specific information about the expected intensity, location, and nature (i.e., cramping) of the pain. It also appears that the relationship between information and response to stress is mediated by individual coping styles. Andrew [l], in an examination of the interac-
* Researchers in this area have frequently used the avoidance-sensitization dimension to describe individual differences in dealing with stressful situations [6,25] (i.e., coping styles). Generally, avoiders respond to threat with blocking and denial. They report low anxiety and deal with stress by denying its potential threat or refusing to think about it. Sensitizers are generally described as vigilant, overtly anxious, and alert to threat. They actively seek information about a stressor as a means of preparing to experience it.
281
tion between preparatory information and three levels of coping style, found information to be helpful to non-specific defenders (individuals with coping styles that involve both avoidance and sensitization), but detrimental to individuals who displayed denial as their characteristic defense. Averill [3], in a review of literature on stress and pain reduction, concludes that the relationship between information and alleviation of distress is a complex one. He noted that if information is to be beneficial, the specific situation or the individual’s coping style must allow for a positive appraisal of the impending harm. Information cannot be presumed to have an ‘inoculatory’ effect as Janis [12] has suggested. Evidence of the effectiveness of brief-duration relaxation training in the reduction of postsurgical pain and anxiety is also equivocal, with some research supportive [9] and other research negative [4,23]. One possible explanation for the discrepancy may be that relaxation techniques are effective only with patients who display certain with an information-seeking style of personality characteristics, e.g., individuals coping. Other studies have also suggested that the success of an intervention may be a function of the patient’s characteristic coping style. Shipley et al. [25], for example, examined the relationship between anxiety during an endoscopic exam and the number of viewings of a videotape of the procedure, administered prior to the exam. There was a decrease in heart rate as a direct function of the number of exposures for the sensitizers. Avoiders, however, produced an inverted U-shaped relationship between heart rate and exposures, with one viewing producing the highest heart rate. The authors concluded that one exposure may have conflicted with the avoiders characteristic style of coping and fear was reduced only by three exposures. In a follow-up study [24], with patients who had undergone endoscopic examination once before, tape viewing resulted in decreased anxiety in sensitizers and had no effect or increased anxiety in avoiders. The authors concluded that sensitizers should be prepared extensively and that avoiders may respond best when left alone. The Shipley et al. studies [24,25] suggest that information about surgical procedures may have negative effects for indi~duals with an avoidant coping style. Delong [7], in a study similar to that of Andrew [l], looked at the effect of type of information and coping style on recovery from surgery. Two types of information were given: (1) detailed and specific information about the hospital stay and procedures involved and, (2) general information about the hospital. Patients in the middle group, who were neither extreme avoiders nor sensitizers, showed the fastest recovery from surgery. Sensitizers demonstrated a better recovery when given specific information than when given general information. Avoiders had the slowest recovery. Delong [7] concluded that avoiders may have blocked the information and thus did not prepare themselves adequately for the upcoming stress. The purpose of the present study was to evaluate the effect of two intervention strategies, relaxation training, and information giving, separately and in combination, on levels of postoperative pain and anxiety. An important question to be resolved was whether these two types of treatment would be differentially effective for individuals with different types of coping style (i.e., sensitizers vs. avoiders). On the basis of previous research, it was h~othesized that sensitizers would report less
282
pain and anxiety when trained in relaxation than sensitizer controls or than sensitizers provided with information. Avoiders were expected to respond to information with increased anxiety wfien compared to avoider controls. Finally, avoiders given information were expected to experience more pain and anxiety than sensitizers given information.
Method Subjects The subject population consisted of surgical patients admitted to Lewis Gale Hospital in Salem, Virginia. Of the 64 total patients, 41 were cholecystectomy patients, 19 abdominal hysterectomy, and 4 vaginal hysterectomy. Nine of the cholecystectomy patients were male. Four of the women were black and one was Indian. Ages ranged from 19 to 70 years with a mean age of 43. None of the patients had a medical history or organic brain damage, mental retardation, and/or other significant psychological disturbances. Patients were referred in the order that they were scheduled for surgery and were approached if they were physically well enough to complete the measures. Of the 72 patients who initially agreed to participate, eight did not complete the study. Two were excluded since their surgery was canceled. Two patients were unable to understand the measures, one was rescheduled for another type of surgery, and another had requested an electrical stimulator for pain relief. Two patients did not wish to continue with the study: one because her surgeon requested that his patients no longer be included in the study, and the other because of significant psychofogical distress unrelated to our procedures. Measures The McGill Pain Questionnaire (MPQ). The MPQ scales used in this study as dependent measures included the sensory, affective, and evaluative scales, a total score (PRi), a measure of the level of pain at the time of testing (PPI) and a retrospective measure of pain at its worst [22]. The STAI [26] is comprised of two State-Trait Anxiety Inventory (STAZ). self-report scales to measure state anxiety and trait anxiety. Only the state anxiety scale was used in this study. This scale consists of 20 statements designed to provide an index of the patient’s feelings at the time of testing. Coping process meamre. Cohen and Lazarus [6] developed a structured interview to assess a patient’s coping style, specific to the surgery situation. Each patient was asked about his/her emotional state, the amount of information he/she had about the upcoming surgery, what other information he/she may want to know, etc. Each interview was audiotaped and later rated by two advanced clinical psychology graduate students. Ratings were based on specific criteria provided by Cohen and Lazarus f6]. Avoidance and sensitization were treated as a dimension on a scale from 1 to 10, with higher ratings (8-10) representing a sensitizing process, low ratings (l-3) reflecting an avoidant strategy, and a middle range (4-7) for patients who
283
reflect both strategies, but do not emphasize either. The correlation between the two sets of independent ratings was +0.817 for this study. Analgesics administered. The number of analgesics received during the postoperative course was tabulated from the medical records after each patient was discharged. Two methods of tabulating these medications were used. First, the number demerol, dilaudid), combination narcotic of narcotic analgesics (i.e., morphine, analgesics (i.e., Tylenol No. 3, percodan, percocet) and non-narcotic analgesics (i.e., Tylenol, aspirin) were counted. This count represented the number of times a particular type of medication was administered, regardless of dosage. Second, a potency measure was tabulated for each patient. This represents the equivalent dosages of narcotic analgesics received, based on morphine sulfate as the comparison measure. The potency measure was based on equivalent dosage data presented by Gebhart [lo]. Procedures and treatments Patients scheduled for cholecystectomy or abdominal hysterectomy were contacted on the afternoon prior to surgery. After signing a consent form which briefly explained the purpose of the study, the examiner answered questions concerning the consent form, the experimenters involved, or the use of the data, without discussing hypotheses or types of treatments. Each patient in a treatment group was told that he/she would be given information that would help him/her cope more effectively with the distress and discomfort associated with surgery. Patients in the control group were told that the purpose of the study was to gather information about how different people respond to surgery. At that time, each patient answered the coping process interview questions and their responses were audiotaped. Patients were told that their responses were taped in order to save time during the data-gathering process. Next, the STAI state anxiety form and the McGill Pain Questionnaire were administered. At this point in the preoperative session, patients were presented with the materials and/or information corresponding to the group to which they were assigned. Patients were assigned to groups in a random fashion, in sequential order (R, I, RI, C). There was a minor divergence from this ordering in the later stages of data collection in order to equalize age and type of surgery across treatment groups. This random assignment to groups resulted in an approximately equal number of each coping style, based on median split into two groups (l-5 and 6-10) in each of 8 cells. There were 9 subjects in the relaxation treatment sensitizers (6-10) group, and 7 subjects in the relaxation treatment avoiders (l-5) group. Relaxation training (R). Each patient in this group was read a narrative explaining the relationship between tension and discomfort. The relaxation strategy was described as an effective technique for reducing tension and discomfort. The examiner then read the relaxation instructions to each patient, as the patient practiced the strategy for 10 min. The strategy was that developed by Benson [5], which instructs the patient to focus on his breathing to achieve a deep level of relaxation. Each patient was then instructed to practice the strategy at least 3 times per day or whenever they were feeling tense or in discomfort. Each patient was given a typed
284
copy of the rationale and instructed to refer to it as often as needed. During the postoperative sessions, the examiner discussed the patient’s response to surgery, asked them how many times they had practiced the relaxation strategy, and encouraged patients to practice it as often as possible. Information (I). Each patient in this group was read a narrative describing in detail the procedures they would have to undergo prior to surgery, the location, quality, and type of discomfort usually experienced by patients undergoing cholecystectomy or hysterectomy, and the sensations associated with medications typicaIly administered. Patients were told that the experiences described are typical and that they should not be surprised when they experience similar discomforts. The narrative was based on that used by Johnson et al. [15], and Wilson [27] with minor adjustments for different procedures used in the hospital in this study. Four of the hysterectomy patients were scheduled for possible vaginal hysterectomies. Two of these patients received information. These patients were read the same narrative, but told that in the event they did have the vaginal procedure, they would not have incisional pain, but rather some mild to moderate cramping postoperatively. In the postoperative sessions, the examiner discussed the patient’s response to surgery, inquired if there were any surprises with respect to their experiences, and reread the portion of the information narrative describing the postoperative sensations and procedures. Relaxation training and information (RI). Patients in this group received the relaxation training and information described for the relaxation and information groups above. Control (C). Patients in this group completed the interview, state anxiety scale, and pain measures. The examiner talked with the patient briefly about his/her feelings about surgery, how he/she liked the hospital, etc., without offering any information or suggestions related to the surgery. In the postoperative sessions, the examiner inquired about the patient’s response to surgery, feelings about the hospital, how many visitors they have had, and when they expected to go home. Patients in all groups were revisited on the second (counting the day after surgery as the first postoperative day) and fourth postoperative days and completed the pain measures and the state anxiety measure. Patients also received the treatments described above, corresponding to the group to which they had been assigned, after completing the self-report measures on pain and anxiety. After each patient was discharged his/her medical records were examined and the number and type of analgesics administered during the postoperative period, from the day of surgery until discharge, was tabulated.
Results The data analyses consisted of analyses of covariance, in a 2 X 4 with 2 levels of coping style and 4 levels of treatment, and with type age, and race as covariates. Coping style ratings were divided into 2 a median split, with subjects rated as 6 or above assigned to level 1
factorial design, of surgery, sex, levels, based on (sensitizers) and
285
those rated as 5 or below assigned to level 2 (avoiders). This split into 2 levels of coping style resulted in an essentially equal sample size for each cell, with 9 subjects in level 1 of the relaxation group and 7 subjects in level 2. Since eight of the patients were released early, prior to the collection of the data on day 4, the analyses for the fourth postoperative day were based on unequal cell frequencies. Planned comparisons between levels of coping style and treatment were performed to examine the source of the interaction effects. Comparisons were calculated using adjusted cell means, and a cell size of eight. For comparisons involving variables collected the fourth postoperative day, the harmonic mean cell size [17] of seven, was used in the calculation of F values for each comparison. Main effects and interactions Treatment groups were not compared on presurgical levels of pain since, with few exceptions, gallbladder and hysterectomy patients are pain-free in the preoperative period. Treatment effects and interactions on postoperative day 2. A summary of the means and standard deviations on self-report anxiety and pain measures as well as significant differences between these values are given in Table I. There were no significant main effects for treatment on any of the dependent measures on the second postoperative day. There was a significant interaction between coping style and treatment (F = 3.64, P < 0.05) for state anxiety. Examination of the planned comparisons between adjusted cell means revealed that sensitizers in the relaxation group were less anxious than those in the relaxation plus information group (F = 8.31, P -C0.01). Sensitizers receiving relaxation did not differ on anxiety from sensitizers in the control group or the information group. There were no differences across treatments for avoiders, with respect to state anxiety. There was a significant interaction between coping style and treatment (F = 3.99, P < 0.01) for the evaluative scale of the McGill. Examination of the planned comparisons revealed a significant difference between sensitizers and avoiders in the information (F = 4.36, P < 0.05) group with sensitizers reporting more pain. Sensitizers in the relaxation group reported significantly less pain than sensitizers in the information (F = 6.79, P -C 0.05) and relaxation plus information (F = 5.29, P c 0.05) groups. The coping style by treatment interaction for the miscellaneous scale of the McGill Pain Questionnaire approached significance (P -C0.10). Planned comparisons revealed a significant difference between sensitizers and avoiders (F = 6.99, P < 0.05) in the information group. Sensitizers reported more pain than avoiders. Also, sensitizers in the relaxation group reported significantly less pain on the miscellaneous scale than sensitizers in the information only group (F = 7.19, P < 0.01). There were no differences across treatments for avoiders, for this scale. On the second postoperative day, patients were asked to rate the worst pain they had experienced postoperatively, on the l-5 scale used for the PPI. There was a significant interaction between coping style and treatment for this self-report measure (F = 2.66, P < 0.05). Sensitizers in the relaxation group reported less pain than sensitizers in all other groups, significantly less than the controls (F = 6.94, P -C0.05)
I
1.4J.k 1.9
Sensitizers Avoiders
Present pain index
Note:
2.9 h.’ 3.9
Sensitizers Avoiders
Worst pain
Mean values with the same letter denote
significant
’
3.3 4.6
Sensitizers Avoiders
Miscellaneous pain
differences.
2.1 2.0
3.8 3.6
1.1 1.4 0.5 I.5
1.3 f.g 3.4s
3.4 2.7
2.9 2.7
0.8 3.3
0.8 2.9
Sensitizers Avoiders
Affective pain
2.9 hs 1.4b
16.6 14.6
1.5 1.9
0.96 ‘,* 2.6
Sensitizers Avoiders
Evaluative
pain
8.6 8.5
10.2 15.8
Sensitizers Avoiders
Sensory pain
36.2 38.5
5.7 11.6
Information x
S.D.
1.3 0.9
0.6 1.2
2.6 3.9
3.8 2.5
1.4 1.6
8.4 6.2
1.9 9.9
S.D.
GROUPS
Relaxation
group
FOR TREATMENT
x
Treatment
DEVIATIONS
32.4 a 41.1
AND STANDARD
Sensitizers Avoiders
MEANS
State anxiety
Dependent measures
ADJUSTED
TABLE STYLE:
2.5’ 1.6
4.0 3.2
3.8 2.9
’
2.0 0.9 r
2.7 d 1 .o
16.7 10.9
46.4 A 32.9
X
Relaxation + information
x COPING
0.8 0.5
1.1 0.5
3.3 3.5
1.4 1.2
1.6 0.83
6.3 2.8
1.4 9.3
S.D.
DAY 2
2.5 k 2.1
4.1 h 3.6
3.3 4.4
2.2 3.3 e
2.3 2.5
14.8 18.0
36-t 35.5
Z
Control
POSTOPERATIVE
1.3 1.7
1.3 1.1
2.8 4.0
1.6 4.6
1.5 1.7
6.7 10.8
11.1
1.0
S.D.
Sensitizers Avoiders
Sensitizers Avoiders
Combination drugs
Potency of drugs
7.0 d 8.4
3.0 0.6 a
7.2 11.9
x
Relaxation
4.0 3.3
3.4 1.5
5.1 4.7
S.D.
a.b.c
12.1 d 11.3
4.3 6.0
10.7 9.1
X
6.6 4.5
3.1 5.6
7.9 5.4
S.D.
x COPING STYLE
Information
GROUPS
Note: Mean values with the same letter denote significant differences.
Sensitizers Avoiders
FOR TREATMENT
Treatment groups
DEVIATIONS
Narcotic analgesics
Dependent measures
MEANS AND STANDARD
TABLE II
5.6 2.2 b
7.1 7.3
10.2 7.6
x
Relaxation + information
CUMULATIVE
4.8 3.4
4.8 2.5
2.9 3.5
S.D.
4.0 2.2 c
9.6 7.6
11.2 7.5
X
5.7 5.1
4.5 3.0
4.0 5.1
S.D.
INDEXES
Control
MEDICATION
288
and those in the relaxation plus information group ( F = 5.49, P < 0.05). There were no differences across treatments for avoiders. with respect to worse pain experienced. Finally, on the PPI, sensitizers in the relaxation group reported significantly less pain than sensitizers in the relaxation plus information group (F = 4.14. P < 0.05) or sensitizer controls (F = 4.22, P < 0.05). Also, avoiders in the relaxation plus information group reported significantly less pain on the affective scale than avoider controls (F = 4.01. P -C 0.05). Thus, sensitizers did better with relaxation than sensitizers receiving one of the other conditions on 5 of 7 dependent measures. Avoiders in the information plus relaxation group were better than avoider controls or avoiders receiving information on only 1 of 7 dependent measures. Finally. sensitizers given information did poorer than avoiders receiving information on 2 of the 7 dependent measures. Dependent measures for postoperative day 4. There were no significant main effects or interactions for any of the measures of pain and anxiety for the fourth postoperative day. Planned comparisons revealed significant effects for the PPI and the affective and miscellaneous scales of the McGill Pain Questionnaire. There were no significant comparisons between means for any of the other measures collected on day 4. Avoiders in the information group were reporting significantly more pain on the PPI than avoider controls ( F = 5.23, P < 0.05). For the affective scale, sensitizers reported significantly less pain in the relaxation group than in the relaxation plus information group (F = 5.75, P < 0.05). Avoiders in the information groups reported significantly less pain than avoider controls (F = 5.29, P < 0.05). On the miscellaneous scale, avoiders reported less pain in the information (F = 5.74, P < 0.05) and relaxation plus information (F = 4.49, P < 0.05) groups than avoider controls. Medication
measures of postoperative pain
Means and standard deviations on the medication measures as well as significant differences between these values are given in Table II. There were no significant main effects or interactions for any of the medication measures of pain, tabulated for the entire postoperative period. Planned comparison between adjusted cell means, however, revealed that avoiders in the relaxation group (F = 4.48, P < 0.05) and in the control group (F = 4.63, P < 0.05) requested significantly less combination medications than avoiders in the information group. Avoiders in the relaxation group also received significantly less combination medications than avoiders in the information group (F = 9.25, P -C 0.01). Also, with respect to potency of narcotic analgesia, sensitizers in the relaxation group received significantly less narcotic analgesia than sensitizers in the information group (F = 4.67, P < 0.05). Discussion Contrary to expectations, relaxation alone, information
there were no significant treatment alone, or the two in combination
effects. Neither was an effective
289
treatment for postoperative pain or anxiety. It is possible, however, that the treatments provided in this study may have been too brief to provide an adequate test of their effectiveness for patients irrespective of their coping style. Most authors, for instance, use more extensive training in relaxation techniques [11,12]. The main purpose of this study was to examine the relationship between the patient’s coping style and his/her response to treatment. The overall goal of such an approach is to be able to match the treatment with the needs of the individual patient. As predicted, there were differences between the responses of sensitizers and avoiders to the interventions provided. Sensitizers benefited most from relaxation training alone. This effect exists both for self-report of pain and, in one instance (comparing information alone with relaxation), potency of narcotic analgesia. Although in some cases not significantly, sensitizers receiving relaxation training reported lower anxiety and less pain and used less pain medication than the control group, information group, or relaxation and information group, on every dependent measure. Apparently, even with brief relaxation strategies, sensitizers are able to utilize such strategies to reduce postsurgical anxiety and pain. This data is important because of the typically brief periods medical psychologists have between hospital admission and time of surgery. On the basis of the present data, relaxation approaches would be most efficiently confined to the patient who is a sensitizer. Avoiders did not benefit from any of the treatments in a consistent fashion. The data suggests that avoiders may do as well or better when spared the presurgical preparations, at least of the types examined here. This is consistent with the findings of DeLong [7] who reported that avoiders presented with information recovered more slowly and Shipley et al. [24,25] who concluded that avoiders do quite well when their defenses are not disturbed. The questionable utility of preparatory information As previously reported, preparatory information has been promoted by some authors [12,15]. Others [2,18,19] have shown that information can also be detrimental, causing subjects to focus attention on the discomfort or perceive greater threat in the situation. Proponents of information giving have suggested that prior preparation for a stressor allows an individual to rehearse the upcoming event cognitively and develop strategies for coping with the stress [12]. Shipley et al. [25] also suggest that prior exposure to a stressful stimulus can promote desensitization to that experience but note that the utility of prior information depends on the individual’s characteristic coping style. Although there was a minimal effect on self-report of pain, information imparting was found to significantly increase medication usage in the avoider group. This is consistent with Andrew’s [l] finding for avoiders, even though she provided more general information than used here. These results appear at first to conflict with studies that have reported positive effects for patient preparation. However, most of the previous studies used treatments with multiple components, which cannot be compared with the information that was provided in the current study [8]. Additionally, Johnson et al. [14,15], who used information identical to the type provided in this study, failed to demonstrate any effect for information giving on indices of pain or medication usage. The only
290
effect demonstrated in these two studies was a reduction in length of stay in the hospital. It is clear, therefore, that the assumption of a demonstrated positive effect for information giving is inaccurate when the available clinical studies are closely examined.
Conclusions The results of this study suggest several conclusions that should be explored in further studies of patients in clinical settings. First, it appears that relaxation training alone is the most effective technique, of those examined here, for the reduction of postoperative pain and anxiety in sensitizers. This is apparently the case because of the anxiety-reducing effect of the technique and the fact that it encourages redirection of attention away from discomforts. Further study should examine the effect of more extensive training in the relaxation technique prior to surgery. Secondly, avoiders appear to do quite well on their own in a situation where a positive outcome is expected. Further research should examine the effect of avoidance strategies in situations where outcome is more likely to be difficult. Third, information giving alone does not appear to be beneficial to either sensitizers or avoiders. One likely explanation for this effect is that information contributes to further sensitization to discomforts for sensitizers and conflicts with avoidant processes in avoiders. Further study should determine if exposure to information, such as more extensive preoperative preparation, would promote habituation for sensitizers.
References 1 Andrew, J.M., Recovery from surgery, with and without preparation instruction, for three coping styles, J. Personality sot. Psychol., 15 (1970) 223-226. 2 Auerbach, SM. and Kendall, P.C., Sex differences in anxiety response and adjustment to dental surgery: effects of general vs. specific preoperative information, J. clin. Psychol., 34 (1978) 309-313. 3 Averill, J.R., Personal control over aversive stimuli and its relationship to stress, Psychol. Bull., 80 (1973) 286-303. 4 Bafford, D.C., Progressive relaxation as a nursing intervention: a method of controlling pain for open-heart surgery patients, Commun. Nurs. Res., 8 (1977) 284-290. 5 Benson, H., The Relaxation Response, William Morrow, New York, 1975. 6 Cohen, F. and Lazarus, R.S., Active coping processes, coping dispositions, and recovery from surgery, Psychosom. Med., 35 (1973) 375-389. 7 DeLong, R.D., Individual differences in patterns of anxiety arousal, stress-relevant information and recovery from surgery, Unpublished doctoral dissertation, University of California, Los Angeles, CA, 1970. 8 Egbert, L.D., Battit, G.E., Welch, C.E. and Bartlett, M.D., Reduction of postoperative pain by encouragement and instruction of patients, New Engl. J. Med., 270 (1964) 825-827. 9 Flaherty, G.G. and Fitzpatrick, J.J., Relaxation training to increase comfort level of postoperative patients: a preliminary study, Nurs. Res., 27 (1978) 352-355. 10 Gebhart, G.F., Narcotic and non-narcotic analgesics for relief of pain. In: A. Jacox (Ed.), Pain: a Source Book for Nurses and other Health Professionals, Little, Brown and Co., Boston, MA, 1977, pp. 227-262.
291
11 Cessel, A.H. and Alderman, M.H. Management of myofascial pain dysfunction syndrome of the temporomandibular joint by tension control training, Psychosomatics, 12 (1971) 302-309. 12 Janis, I.L., Psychological Stress: Psychoanalytic and Behavioral Studies of Surgical Patients, Wiley, New York, 1958. 13 Johnson, J.E., Effects of accurate expectations about sensations on the sensory and distress components of pain, J. Personality sot. Psychol., 27 (1973) 261-275. 14 Johnson, J.E., Fuller, S.S., Endress, M.P. and Rice, V.H., Altering patients response to surgery: an extension and replication, Res. Nurs. Hlth, 1 (1978) 111-121. 15 Johnson, J.E., Rice, V.H., Fuller, S.S. and Endress, M.P. Sensory information, instruction in a coping strategy, and recovery from surgery, Res. Nurs. Hlth, 1 (1978) 4-17. 16 Kanfer, F.H. and Goldfoot, D.A., Self-control and tolerance of noxious stimulation, Psychol. Rep., 18 (1966) 79-85. 17 Keppel, G., Design and Analysis: a Researcher’s Handbook, Prentice-Hall, Englewood Cliffs, NJ, 1973. 18 Langer, E.J., Janis, I.L. and Wolfer, J., Reduction of psychological stress in surgical patients, J. exp. sot. Psychol., 11 (1975) 155-165. 19 Leventhal, H., Brown, D., Shacham, S. and Engquist, G., Effects of preparatory information about sensations, threat of pain, and attention on cold pressor distress, J. Personality sot. Psychol., 37 (1979) 688-714. 20 Martinez-Urrutia, A., Anxiety and pain in surgical patients, J. consult. clin. Psychol., 43 (1975) 437-442. 21 McAmmond, D.M., Davidson, P.O. and Kovitz, D., A comparison of the effects of hypnosis and relaxation training on stress reactions in a dental situation, Amer. J. clin. Hypn., 13 (1971) 233-242. 22 Melzack, R., The McGill Pain Questionnaire: major properties and scoring methods, Pain, 1 (1975) 277-299. 23 Pickett, C. and Glum, G.A., Comparative treatment strategies and their interaction with locus of control in the reduction of postsurgical pain and anxiety, J. consult. clin. Psychol., 50 (1982) 439-442. 24 Shipley, R.H., Butt, J.H., Honvitz, B. and Farbry, J.E., Preparation for a stressful medical procedure: effect of amount of stimulus pre-exposure and coping style, J. consult. clin Psychol., 46 (1978) 499-507. 25 Shipley, R.H., Butt, J.H. and Horwitz, E.A., Preparation to re-experience a stressful medical examination: effect of repetitious videotape exposure and coping style, J. consult. clin. Psychol., 47 (1979) 485-492. 26 Spielberger, C.D., Gorsuch, R.L. and Lushene, R.E., The State-Trait Anxiety Inventory, Consulting Psychologists Press, Los Angeles, CA, 1974. 27 Wilson, F., Behavioral preparation for surgery: benefit or harm ?, J. behav. Med., 4 (1981) 79-102.
Pain, 20 (1984) 279-291 Elsevier
PA1 00689
Examining the Interaction Effects of Coping Style and Brief Interventions in the Treatment of Postsurgical Pain L.E. Scott 1 and G.A. Clum 152 Henderson Hall, Virginia Polytechnic Institute and State University, Blacksburg, VA 24061 (U.S.A.) (Received 16 January 1984, accepted 29 May 1984)
Summary The present study sought to ameliorate two major deficiencies in the literature on treating response to surgery, viz., (1) the failure to compare clearly delineated treatments, alone and in combination; and (2) the failure to examine treatment X coping style interactions. Information imparting and brief relaxation were examined in this study as they interacted with an avoidance-sensitization coping style. No differences were found between treatments or coping styles. Sensitizers, on the other hand, were found to profit most from the relaxation training. Avoiders appeared to do well when they were left alone. The interaction effect was demonstrated for both self-report measures of pain and a behavioral measure of potency of medications ingested. The effects on self-report of pain were more evident on the second postsurgical day than on the fourth postsurgical day. The results indicate that brief relaxation training, often the only kind available to the medical psychologist dealing with surgical patients, is best confined to patients with a sensitizing coping style. Further, the results of this study, in conjunction with a reanalysis of previous studies, cast considerable doubt on information imparting when presented alone as a viable technique for reducing the distress consequent on surgery.
’ Reprint requests should be sent to Linda E. Scott, University Counseling Services, Virginia Polytechnic Institute and State University, Blacksburg, VA 24061, U.S.A.
0304-3959/84/$03.00
Q 1984 Elsevier Science Publishers
B.V
280
Introduction A major concern in managing medical patients is the amount of pain and distress they will experience as a result of the medical procedures. Previous studies have shown that the patients who are sensitizers * tend to have the poorest postsurgical recovery (61. Avoiders *, however, may have a poorer recovery when presented with preparatory information [7]. Some studies [18,23] have attempted to reduce postsurgical discomfort by decreasing anxiety or by changing the patient’s method of coping with the pre- and postoperative environment (i.e., by providing information about procedures and methods of dealing with them). We will now examine in a selective review: (1) the efficacy of information imparting and relaxation techniques in reducing clinical pain and anxiety; and (2) the interaction of type of intervention and method of coping, as it relates to pain and anxiety reduction. Information imparting has been found to be both helpful [8,13] and harmful [1,18] with respect to pain and discomfort. This conflicting evidence is apparently due to the use of different types of information, the context in which it is presented, and individual variability in response to preparatory information. For instance, Egbert et al. [8] devised a multicomponent program that provided patients with information about the procedures and sensations to be expected, as well as instruction in relaxation, controlled breathing and careful movement. Patients in the instruction group received one-half the number of analgesics as compared to controls, and were released an average of 2.7 days earlier. Johnson [13] found that a detailed description of the specific sensory characteristics of the pain to be experienced, prior to the induction of ischemic pain, significantly reduced the amount of distress reported by subjects. Conversely, Langer et al. [18] found preparatory information to be ineffective as a means of reducing pain and recovery time. However, preparatory information, in this instance, consisted only of general information about procedures, possible complications, and locations of pain. Langer et al. proposed that the information may have served to sensitize the patients to the discomforting aspects of the impending surgery, Further support for this notion is provided by Kanfer and Goldfoot [16] who have demonstrated that the presentation of a negative set, prior to a measure of pain tolerance, using the cold-pressor test, significantly increases discomfort ratings and reduces pain tolerance. The negative set condition consisted of specific information about the expected intensity, location, and nature (i.e., cramping) of the pain. It also appears that the relationship between information and response to stress is mediated by individual coping styles. Andrew [l], in an examination of the interac-
* Researchers in this area have frequently used the avoidance-sensitization dimension to describe individual differences in dealing with stressful situations [6,25] (i.e., coping styles). Generally, avoiders respond to threat with blocking and denial. They report low anxiety and deal with stress by denying its potential threat or refusing to think about it. Sensitizers are generally described as vigilant, overtly anxious, and alert to threat. They actively seek information about a stressor as a means of preparing to experience it.
281
tion between preparatory information and three levels of coping style, found information to be helpful to non-specific defenders (individuals with coping styles that involve both avoidance and sensitization), but detrimental to individuals who displayed denial as their characteristic defense. Averill [3], in a review of literature on stress and pain reduction, concludes that the relationship between information and alleviation of distress is a complex one. He noted that if information is to be beneficial, the specific situation or the individual’s coping style must allow for a positive appraisal of the impending harm. Information cannot be presumed to have an ‘inoculatory’ effect as Janis [12] has suggested. Evidence of the effectiveness of brief-duration relaxation training in the reduction of postsurgical pain and anxiety is also equivocal, with some research supportive [9] and other research negative [4,23]. One possible explanation for the discrepancy may be that relaxation techniques are effective only with patients who display certain with an information-seeking style of personality characteristics, e.g., individuals coping. Other studies have also suggested that the success of an intervention may be a function of the patient’s characteristic coping style. Shipley et al. [25], for example, examined the relationship between anxiety during an endoscopic exam and the number of viewings of a videotape of the procedure, administered prior to the exam. There was a decrease in heart rate as a direct function of the number of exposures for the sensitizers. Avoiders, however, produced an inverted U-shaped relationship between heart rate and exposures, with one viewing producing the highest heart rate. The authors concluded that one exposure may have conflicted with the avoiders characteristic style of coping and fear was reduced only by three exposures. In a follow-up study [24], with patients who had undergone endoscopic examination once before, tape viewing resulted in decreased anxiety in sensitizers and had no effect or increased anxiety in avoiders. The authors concluded that sensitizers should be prepared extensively and that avoiders may respond best when left alone. The Shipley et al. studies [24,25] suggest that information about surgical procedures may have negative effects for indi~duals with an avoidant coping style. Delong [7], in a study similar to that of Andrew [l], looked at the effect of type of information and coping style on recovery from surgery. Two types of information were given: (1) detailed and specific information about the hospital stay and procedures involved and, (2) general information about the hospital. Patients in the middle group, who were neither extreme avoiders nor sensitizers, showed the fastest recovery from surgery. Sensitizers demonstrated a better recovery when given specific information than when given general information. Avoiders had the slowest recovery. Delong [7] concluded that avoiders may have blocked the information and thus did not prepare themselves adequately for the upcoming stress. The purpose of the present study was to evaluate the effect of two intervention strategies, relaxation training, and information giving, separately and in combination, on levels of postoperative pain and anxiety. An important question to be resolved was whether these two types of treatment would be differentially effective for individuals with different types of coping style (i.e., sensitizers vs. avoiders). On the basis of previous research, it was h~othesized that sensitizers would report less
282
pain and anxiety when trained in relaxation than sensitizer controls or than sensitizers provided with information. Avoiders were expected to respond to information with increased anxiety wfien compared to avoider controls. Finally, avoiders given information were expected to experience more pain and anxiety than sensitizers given information.
Method Subjects The subject population consisted of surgical patients admitted to Lewis Gale Hospital in Salem, Virginia. Of the 64 total patients, 41 were cholecystectomy patients, 19 abdominal hysterectomy, and 4 vaginal hysterectomy. Nine of the cholecystectomy patients were male. Four of the women were black and one was Indian. Ages ranged from 19 to 70 years with a mean age of 43. None of the patients had a medical history or organic brain damage, mental retardation, and/or other significant psychological disturbances. Patients were referred in the order that they were scheduled for surgery and were approached if they were physically well enough to complete the measures. Of the 72 patients who initially agreed to participate, eight did not complete the study. Two were excluded since their surgery was canceled. Two patients were unable to understand the measures, one was rescheduled for another type of surgery, and another had requested an electrical stimulator for pain relief. Two patients did not wish to continue with the study: one because her surgeon requested that his patients no longer be included in the study, and the other because of significant psychofogical distress unrelated to our procedures. Measures The McGill Pain Questionnaire (MPQ). The MPQ scales used in this study as dependent measures included the sensory, affective, and evaluative scales, a total score (PRi), a measure of the level of pain at the time of testing (PPI) and a retrospective measure of pain at its worst [22]. The STAI [26] is comprised of two State-Trait Anxiety Inventory (STAZ). self-report scales to measure state anxiety and trait anxiety. Only the state anxiety scale was used in this study. This scale consists of 20 statements designed to provide an index of the patient’s feelings at the time of testing. Coping process meamre. Cohen and Lazarus [6] developed a structured interview to assess a patient’s coping style, specific to the surgery situation. Each patient was asked about his/her emotional state, the amount of information he/she had about the upcoming surgery, what other information he/she may want to know, etc. Each interview was audiotaped and later rated by two advanced clinical psychology graduate students. Ratings were based on specific criteria provided by Cohen and Lazarus f6]. Avoidance and sensitization were treated as a dimension on a scale from 1 to 10, with higher ratings (8-10) representing a sensitizing process, low ratings (l-3) reflecting an avoidant strategy, and a middle range (4-7) for patients who
283
reflect both strategies, but do not emphasize either. The correlation between the two sets of independent ratings was +0.817 for this study. Analgesics administered. The number of analgesics received during the postoperative course was tabulated from the medical records after each patient was discharged. Two methods of tabulating these medications were used. First, the number demerol, dilaudid), combination narcotic of narcotic analgesics (i.e., morphine, analgesics (i.e., Tylenol No. 3, percodan, percocet) and non-narcotic analgesics (i.e., Tylenol, aspirin) were counted. This count represented the number of times a particular type of medication was administered, regardless of dosage. Second, a potency measure was tabulated for each patient. This represents the equivalent dosages of narcotic analgesics received, based on morphine sulfate as the comparison measure. The potency measure was based on equivalent dosage data presented by Gebhart [lo]. Procedures and treatments Patients scheduled for cholecystectomy or abdominal hysterectomy were contacted on the afternoon prior to surgery. After signing a consent form which briefly explained the purpose of the study, the examiner answered questions concerning the consent form, the experimenters involved, or the use of the data, without discussing hypotheses or types of treatments. Each patient in a treatment group was told that he/she would be given information that would help him/her cope more effectively with the distress and discomfort associated with surgery. Patients in the control group were told that the purpose of the study was to gather information about how different people respond to surgery. At that time, each patient answered the coping process interview questions and their responses were audiotaped. Patients were told that their responses were taped in order to save time during the data-gathering process. Next, the STAI state anxiety form and the McGill Pain Questionnaire were administered. At this point in the preoperative session, patients were presented with the materials and/or information corresponding to the group to which they were assigned. Patients were assigned to groups in a random fashion, in sequential order (R, I, RI, C). There was a minor divergence from this ordering in the later stages of data collection in order to equalize age and type of surgery across treatment groups. This random assignment to groups resulted in an approximately equal number of each coping style, based on median split into two groups (l-5 and 6-10) in each of 8 cells. There were 9 subjects in the relaxation treatment sensitizers (6-10) group, and 7 subjects in the relaxation treatment avoiders (l-5) group. Relaxation training (R). Each patient in this group was read a narrative explaining the relationship between tension and discomfort. The relaxation strategy was described as an effective technique for reducing tension and discomfort. The examiner then read the relaxation instructions to each patient, as the patient practiced the strategy for 10 min. The strategy was that developed by Benson [5], which instructs the patient to focus on his breathing to achieve a deep level of relaxation. Each patient was then instructed to practice the strategy at least 3 times per day or whenever they were feeling tense or in discomfort. Each patient was given a typed
284
copy of the rationale and instructed to refer to it as often as needed. During the postoperative sessions, the examiner discussed the patient’s response to surgery, asked them how many times they had practiced the relaxation strategy, and encouraged patients to practice it as often as possible. Information (I). Each patient in this group was read a narrative describing in detail the procedures they would have to undergo prior to surgery, the location, quality, and type of discomfort usually experienced by patients undergoing cholecystectomy or hysterectomy, and the sensations associated with medications typicaIly administered. Patients were told that the experiences described are typical and that they should not be surprised when they experience similar discomforts. The narrative was based on that used by Johnson et al. [15], and Wilson [27] with minor adjustments for different procedures used in the hospital in this study. Four of the hysterectomy patients were scheduled for possible vaginal hysterectomies. Two of these patients received information. These patients were read the same narrative, but told that in the event they did have the vaginal procedure, they would not have incisional pain, but rather some mild to moderate cramping postoperatively. In the postoperative sessions, the examiner discussed the patient’s response to surgery, inquired if there were any surprises with respect to their experiences, and reread the portion of the information narrative describing the postoperative sensations and procedures. Relaxation training and information (RI). Patients in this group received the relaxation training and information described for the relaxation and information groups above. Control (C). Patients in this group completed the interview, state anxiety scale, and pain measures. The examiner talked with the patient briefly about his/her feelings about surgery, how he/she liked the hospital, etc., without offering any information or suggestions related to the surgery. In the postoperative sessions, the examiner inquired about the patient’s response to surgery, feelings about the hospital, how many visitors they have had, and when they expected to go home. Patients in all groups were revisited on the second (counting the day after surgery as the first postoperative day) and fourth postoperative days and completed the pain measures and the state anxiety measure. Patients also received the treatments described above, corresponding to the group to which they had been assigned, after completing the self-report measures on pain and anxiety. After each patient was discharged his/her medical records were examined and the number and type of analgesics administered during the postoperative period, from the day of surgery until discharge, was tabulated.
Results The data analyses consisted of analyses of covariance, in a 2 X 4 with 2 levels of coping style and 4 levels of treatment, and with type age, and race as covariates. Coping style ratings were divided into 2 a median split, with subjects rated as 6 or above assigned to level 1
factorial design, of surgery, sex, levels, based on (sensitizers) and
285
those rated as 5 or below assigned to level 2 (avoiders). This split into 2 levels of coping style resulted in an essentially equal sample size for each cell, with 9 subjects in level 1 of the relaxation group and 7 subjects in level 2. Since eight of the patients were released early, prior to the collection of the data on day 4, the analyses for the fourth postoperative day were based on unequal cell frequencies. Planned comparisons between levels of coping style and treatment were performed to examine the source of the interaction effects. Comparisons were calculated using adjusted cell means, and a cell size of eight. For comparisons involving variables collected the fourth postoperative day, the harmonic mean cell size [17] of seven, was used in the calculation of F values for each comparison. Main effects and interactions Treatment groups were not compared on presurgical levels of pain since, with few exceptions, gallbladder and hysterectomy patients are pain-free in the preoperative period. Treatment effects and interactions on postoperative day 2. A summary of the means and standard deviations on self-report anxiety and pain measures as well as significant differences between these values are given in Table I. There were no significant main effects for treatment on any of the dependent measures on the second postoperative day. There was a significant interaction between coping style and treatment (F = 3.64, P < 0.05) for state anxiety. Examination of the planned comparisons between adjusted cell means revealed that sensitizers in the relaxation group were less anxious than those in the relaxation plus information group (F = 8.31, P -C0.01). Sensitizers receiving relaxation did not differ on anxiety from sensitizers in the control group or the information group. There were no differences across treatments for avoiders, with respect to state anxiety. There was a significant interaction between coping style and treatment (F = 3.99, P < 0.01) for the evaluative scale of the McGill. Examination of the planned comparisons revealed a significant difference between sensitizers and avoiders in the information (F = 4.36, P < 0.05) group with sensitizers reporting more pain. Sensitizers in the relaxation group reported significantly less pain than sensitizers in the information (F = 6.79, P -C 0.05) and relaxation plus information (F = 5.29, P c 0.05) groups. The coping style by treatment interaction for the miscellaneous scale of the McGill Pain Questionnaire approached significance (P -C0.10). Planned comparisons revealed a significant difference between sensitizers and avoiders (F = 6.99, P < 0.05) in the information group. Sensitizers reported more pain than avoiders. Also, sensitizers in the relaxation group reported significantly less pain on the miscellaneous scale than sensitizers in the information only group (F = 7.19, P < 0.01). There were no differences across treatments for avoiders, for this scale. On the second postoperative day, patients were asked to rate the worst pain they had experienced postoperatively, on the l-5 scale used for the PPI. There was a significant interaction between coping style and treatment for this self-report measure (F = 2.66, P < 0.05). Sensitizers in the relaxation group reported less pain than sensitizers in all other groups, significantly less than the controls (F = 6.94, P -C0.05)
I
1.4J.k 1.9
Sensitizers Avoiders
Present pain index
Note:
2.9 h.’ 3.9
Sensitizers Avoiders
Worst pain
Mean values with the same letter denote
significant
’
3.3 4.6
Sensitizers Avoiders
Miscellaneous pain
differences.
2.1 2.0
3.8 3.6
1.1 1.4 0.5 I.5
1.3 f.g 3.4s
3.4 2.7
2.9 2.7
0.8 3.3
0.8 2.9
Sensitizers Avoiders
Affective pain
2.9 hs 1.4b
16.6 14.6
1.5 1.9
0.96 ‘,* 2.6
Sensitizers Avoiders
Evaluative
pain
8.6 8.5
10.2 15.8
Sensitizers Avoiders
Sensory pain
36.2 38.5
5.7 11.6
Information x
S.D.
1.3 0.9
0.6 1.2
2.6 3.9
3.8 2.5
1.4 1.6
8.4 6.2
1.9 9.9
S.D.
GROUPS
Relaxation
group
FOR TREATMENT
x
Treatment
DEVIATIONS
32.4 a 41.1
AND STANDARD
Sensitizers Avoiders
MEANS
State anxiety
Dependent measures
ADJUSTED
TABLE STYLE:
2.5’ 1.6
4.0 3.2
3.8 2.9
’
2.0 0.9 r
2.7 d 1 .o
16.7 10.9
46.4 A 32.9
X
Relaxation + information
x COPING
0.8 0.5
1.1 0.5
3.3 3.5
1.4 1.2
1.6 0.83
6.3 2.8
1.4 9.3
S.D.
DAY 2
2.5 k 2.1
4.1 h 3.6
3.3 4.4
2.2 3.3 e
2.3 2.5
14.8 18.0
36-t 35.5
Z
Control
POSTOPERATIVE
1.3 1.7
1.3 1.1
2.8 4.0
1.6 4.6
1.5 1.7
6.7 10.8
11.1
1.0
S.D.
Sensitizers Avoiders
Sensitizers Avoiders
Combination drugs
Potency of drugs
7.0 d 8.4
3.0 0.6 a
7.2 11.9
x
Relaxation
4.0 3.3
3.4 1.5
5.1 4.7
S.D.
a.b.c
12.1 d 11.3
4.3 6.0
10.7 9.1
X
6.6 4.5
3.1 5.6
7.9 5.4
S.D.
x COPING STYLE
Information
GROUPS
Note: Mean values with the same letter denote significant differences.
Sensitizers Avoiders
FOR TREATMENT
Treatment groups
DEVIATIONS
Narcotic analgesics
Dependent measures
MEANS AND STANDARD
TABLE II
5.6 2.2 b
7.1 7.3
10.2 7.6
x
Relaxation + information
CUMULATIVE
4.8 3.4
4.8 2.5
2.9 3.5
S.D.
4.0 2.2 c
9.6 7.6
11.2 7.5
X
5.7 5.1
4.5 3.0
4.0 5.1
S.D.
INDEXES
Control
MEDICATION
288
and those in the relaxation plus information group ( F = 5.49, P < 0.05). There were no differences across treatments for avoiders. with respect to worse pain experienced. Finally, on the PPI, sensitizers in the relaxation group reported significantly less pain than sensitizers in the relaxation plus information group (F = 4.14. P < 0.05) or sensitizer controls (F = 4.22, P < 0.05). Also, avoiders in the relaxation plus information group reported significantly less pain on the affective scale than avoider controls (F = 4.01. P -C 0.05). Thus, sensitizers did better with relaxation than sensitizers receiving one of the other conditions on 5 of 7 dependent measures. Avoiders in the information plus relaxation group were better than avoider controls or avoiders receiving information on only 1 of 7 dependent measures. Finally. sensitizers given information did poorer than avoiders receiving information on 2 of the 7 dependent measures. Dependent measures for postoperative day 4. There were no significant main effects or interactions for any of the measures of pain and anxiety for the fourth postoperative day. Planned comparisons revealed significant effects for the PPI and the affective and miscellaneous scales of the McGill Pain Questionnaire. There were no significant comparisons between means for any of the other measures collected on day 4. Avoiders in the information group were reporting significantly more pain on the PPI than avoider controls ( F = 5.23, P < 0.05). For the affective scale, sensitizers reported significantly less pain in the relaxation group than in the relaxation plus information group (F = 5.75, P < 0.05). Avoiders in the information groups reported significantly less pain than avoider controls (F = 5.29, P < 0.05). On the miscellaneous scale, avoiders reported less pain in the information (F = 5.74, P < 0.05) and relaxation plus information (F = 4.49, P < 0.05) groups than avoider controls. Medication
measures of postoperative pain
Means and standard deviations on the medication measures as well as significant differences between these values are given in Table II. There were no significant main effects or interactions for any of the medication measures of pain, tabulated for the entire postoperative period. Planned comparison between adjusted cell means, however, revealed that avoiders in the relaxation group (F = 4.48, P < 0.05) and in the control group (F = 4.63, P < 0.05) requested significantly less combination medications than avoiders in the information group. Avoiders in the relaxation group also received significantly less combination medications than avoiders in the information group (F = 9.25, P -C 0.01). Also, with respect to potency of narcotic analgesia, sensitizers in the relaxation group received significantly less narcotic analgesia than sensitizers in the information group (F = 4.67, P < 0.05). Discussion Contrary to expectations, relaxation alone, information
there were no significant treatment alone, or the two in combination
effects. Neither was an effective
289
treatment for postoperative pain or anxiety. It is possible, however, that the treatments provided in this study may have been too brief to provide an adequate test of their effectiveness for patients irrespective of their coping style. Most authors, for instance, use more extensive training in relaxation techniques [11,12]. The main purpose of this study was to examine the relationship between the patient’s coping style and his/her response to treatment. The overall goal of such an approach is to be able to match the treatment with the needs of the individual patient. As predicted, there were differences between the responses of sensitizers and avoiders to the interventions provided. Sensitizers benefited most from relaxation training alone. This effect exists both for self-report of pain and, in one instance (comparing information alone with relaxation), potency of narcotic analgesia. Although in some cases not significantly, sensitizers receiving relaxation training reported lower anxiety and less pain and used less pain medication than the control group, information group, or relaxation and information group, on every dependent measure. Apparently, even with brief relaxation strategies, sensitizers are able to utilize such strategies to reduce postsurgical anxiety and pain. This data is important because of the typically brief periods medical psychologists have between hospital admission and time of surgery. On the basis of the present data, relaxation approaches would be most efficiently confined to the patient who is a sensitizer. Avoiders did not benefit from any of the treatments in a consistent fashion. The data suggests that avoiders may do as well or better when spared the presurgical preparations, at least of the types examined here. This is consistent with the findings of DeLong [7] who reported that avoiders presented with information recovered more slowly and Shipley et al. [24,25] who concluded that avoiders do quite well when their defenses are not disturbed. The questionable utility of preparatory information As previously reported, preparatory information has been promoted by some authors [12,15]. Others [2,18,19] have shown that information can also be detrimental, causing subjects to focus attention on the discomfort or perceive greater threat in the situation. Proponents of information giving have suggested that prior preparation for a stressor allows an individual to rehearse the upcoming event cognitively and develop strategies for coping with the stress [12]. Shipley et al. [25] also suggest that prior exposure to a stressful stimulus can promote desensitization to that experience but note that the utility of prior information depends on the individual’s characteristic coping style. Although there was a minimal effect on self-report of pain, information imparting was found to significantly increase medication usage in the avoider group. This is consistent with Andrew’s [l] finding for avoiders, even though she provided more general information than used here. These results appear at first to conflict with studies that have reported positive effects for patient preparation. However, most of the previous studies used treatments with multiple components, which cannot be compared with the information that was provided in the current study [8]. Additionally, Johnson et al. [14,15], who used information identical to the type provided in this study, failed to demonstrate any effect for information giving on indices of pain or medication usage. The only
290
effect demonstrated in these two studies was a reduction in length of stay in the hospital. It is clear, therefore, that the assumption of a demonstrated positive effect for information giving is inaccurate when the available clinical studies are closely examined.
Conclusions The results of this study suggest several conclusions that should be explored in further studies of patients in clinical settings. First, it appears that relaxation training alone is the most effective technique, of those examined here, for the reduction of postoperative pain and anxiety in sensitizers. This is apparently the case because of the anxiety-reducing effect of the technique and the fact that it encourages redirection of attention away from discomforts. Further study should examine the effect of more extensive training in the relaxation technique prior to surgery. Secondly, avoiders appear to do quite well on their own in a situation where a positive outcome is expected. Further research should examine the effect of avoidance strategies in situations where outcome is more likely to be difficult. Third, information giving alone does not appear to be beneficial to either sensitizers or avoiders. One likely explanation for this effect is that information contributes to further sensitization to discomforts for sensitizers and conflicts with avoidant processes in avoiders. Further study should determine if exposure to information, such as more extensive preoperative preparation, would promote habituation for sensitizers.
References 1 Andrew, J.M., Recovery from surgery, with and without preparation instruction, for three coping styles, J. Personality sot. Psychol., 15 (1970) 223-226. 2 Auerbach, SM. and Kendall, P.C., Sex differences in anxiety response and adjustment to dental surgery: effects of general vs. specific preoperative information, J. clin. Psychol., 34 (1978) 309-313. 3 Averill, J.R., Personal control over aversive stimuli and its relationship to stress, Psychol. Bull., 80 (1973) 286-303. 4 Bafford, D.C., Progressive relaxation as a nursing intervention: a method of controlling pain for open-heart surgery patients, Commun. Nurs. Res., 8 (1977) 284-290. 5 Benson, H., The Relaxation Response, William Morrow, New York, 1975. 6 Cohen, F. and Lazarus, R.S., Active coping processes, coping dispositions, and recovery from surgery, Psychosom. Med., 35 (1973) 375-389. 7 DeLong, R.D., Individual differences in patterns of anxiety arousal, stress-relevant information and recovery from surgery, Unpublished doctoral dissertation, University of California, Los Angeles, CA, 1970. 8 Egbert, L.D., Battit, G.E., Welch, C.E. and Bartlett, M.D., Reduction of postoperative pain by encouragement and instruction of patients, New Engl. J. Med., 270 (1964) 825-827. 9 Flaherty, G.G. and Fitzpatrick, J.J., Relaxation training to increase comfort level of postoperative patients: a preliminary study, Nurs. Res., 27 (1978) 352-355. 10 Gebhart, G.F., Narcotic and non-narcotic analgesics for relief of pain. In: A. Jacox (Ed.), Pain: a Source Book for Nurses and other Health Professionals, Little, Brown and Co., Boston, MA, 1977, pp. 227-262.
291
11 Cessel, A.H. and Alderman, M.H. Management of myofascial pain dysfunction syndrome of the temporomandibular joint by tension control training, Psychosomatics, 12 (1971) 302-309. 12 Janis, I.L., Psychological Stress: Psychoanalytic and Behavioral Studies of Surgical Patients, Wiley, New York, 1958. 13 Johnson, J.E., Effects of accurate expectations about sensations on the sensory and distress components of pain, J. Personality sot. Psychol., 27 (1973) 261-275. 14 Johnson, J.E., Fuller, S.S., Endress, M.P. and Rice, V.H., Altering patients response to surgery: an extension and replication, Res. Nurs. Hlth, 1 (1978) 111-121. 15 Johnson, J.E., Rice, V.H., Fuller, S.S. and Endress, M.P. Sensory information, instruction in a coping strategy, and recovery from surgery, Res. Nurs. Hlth, 1 (1978) 4-17. 16 Kanfer, F.H. and Goldfoot, D.A., Self-control and tolerance of noxious stimulation, Psychol. Rep., 18 (1966) 79-85. 17 Keppel, G., Design and Analysis: a Researcher’s Handbook, Prentice-Hall, Englewood Cliffs, NJ, 1973. 18 Langer, E.J., Janis, I.L. and Wolfer, J., Reduction of psychological stress in surgical patients, J. exp. sot. Psychol., 11 (1975) 155-165. 19 Leventhal, H., Brown, D., Shacham, S. and Engquist, G., Effects of preparatory information about sensations, threat of pain, and attention on cold pressor distress, J. Personality sot. Psychol., 37 (1979) 688-714. 20 Martinez-Urrutia, A., Anxiety and pain in surgical patients, J. consult. clin. Psychol., 43 (1975) 437-442. 21 McAmmond, D.M., Davidson, P.O. and Kovitz, D., A comparison of the effects of hypnosis and relaxation training on stress reactions in a dental situation, Amer. J. clin. Hypn., 13 (1971) 233-242. 22 Melzack, R., The McGill Pain Questionnaire: major properties and scoring methods, Pain, 1 (1975) 277-299. 23 Pickett, C. and Glum, G.A., Comparative treatment strategies and their interaction with locus of control in the reduction of postsurgical pain and anxiety, J. consult. clin. Psychol., 50 (1982) 439-442. 24 Shipley, R.H., Butt, J.H., Honvitz, B. and Farbry, J.E., Preparation for a stressful medical procedure: effect of amount of stimulus pre-exposure and coping style, J. consult. clin Psychol., 46 (1978) 499-507. 25 Shipley, R.H., Butt, J.H. and Horwitz, E.A., Preparation to re-experience a stressful medical examination: effect of repetitious videotape exposure and coping style, J. consult. clin. Psychol., 47 (1979) 485-492. 26 Spielberger, C.D., Gorsuch, R.L. and Lushene, R.E., The State-Trait Anxiety Inventory, Consulting Psychologists Press, Los Angeles, CA, 1974. 27 Wilson, F., Behavioral preparation for surgery: benefit or harm ?, J. behav. Med., 4 (1981) 79-102.