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Memories of parental rearing and perceived self-image in groups of chronic pain patients
European Journal of Pain 9 (2005) 277–284 www.EuropeanJournalPain.com
Memories of parental rearing and perceived self-image in groups of chronic pain patients Ha˚kan Nordin a, Martin Eisemann
b,*
, Jo¨rg Richter
c
a
Division of Psychiatry, Central Hospital of Rogaland, Norway Department of Psychology, University of Tromsø, N-9007 Tromsø, Norway University Hospital of Psychiatry and Psychotherapy, University of Rostock, Germany b
c
Received 22 February 2004; accepted 13 July 2004 Available online 14 August 2004
Abstract Objectives: The aim of this study was to analyze the relationships between perceived parental rearing styles as determining factors of self-image in chronic pain patients, and to test the hypothesis of two different groups inherent to the pain sample. Methods: In this study, 152 patients with chronic pain participated. The sample was divided into two groups by means of hierarchical cluster analysis on the Minnesota multiphasic personality inventory, version 2. Cluster 1 comprised 116 individuals (44 men and 72 women) with a ‘‘conversion V’’ MMPI-2 profile, and cluster 2 comprised 21 individuals (5 men and 16 women) with a ‘‘general elevated’’ MMPI-2 profile. The patients were investigated by means of the structural analysis of social behavior (SASB), the Giessen test (GT), the locus of control scale (LOC) and the EMBU questionnaire (My memories of parental upbringing). Results: The results show significant associations between memories of parental rearing and self-image as adults and are in line with results from previous studies describing two psychologically different groups inherent to chronic pain patients. Conclusions: The significant differences between healthy controls, pain patients and between clusters of pain patients on parental rearing scales, and the significant relationship between memories of parental rearing and self-image provide therapists with a special approach to the treatment of chronic pain patients in accordance to social cognitive theories and the psychodynamic theoretical construct of introjection as an early process in the development of self-images. 2004 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Ltd. All rights reserved. Keywords: Parental rearing; Self-image; Chronic pain; Minnesota multiphasic personality inventory, version 2; Cluster analysis
1. Introduction The relationship between chronic pain and various aspects of the self were investigated in several studies over the last three decades (Kopel and Arkowitz, 1975; Rosenstiel and Keefe, 1983; Jensen et al., 1991; Strahl et al., 2000; Asgari and Nicholas, 2001). Introjection is a primitive and unconscious process of internalization
*
Corresponding author. Tel.: +47 77646279; fax: +47 77645610. E-mail address: [email protected] (M. Eisemann).
where e.g., attitudes, behavior and/or values of important persons in our environment early in life become a part of us and thus a part of our identity. In its benign form, founded in love and warmth, it is an important part of constructive coping later in life. On the other hand, in its malign form, expressed by, e.g., rejection or aggression, the consequence or the primitive defence, could be to internalize the qualities of the abuser, in terms of an ‘‘identification with the aggressor’’ (McWilliams, 1994, p. 109). McWilliams further stated that ‘‘If we lose any of the people whose image we have internalised, whether by death, separation, or rejection, not
1090-3801/$30 2004 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ejpain.2004.07.004
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only do we feel that our environment is poorer for their absence in our lives but we also feel that we are somehow diminished, that an part of our self has died, . . . When mourning is avoided, unconscious self-criticism takes its place’’. Parental rearing represents one of the major factors within the comprehensive vulnerability model of the development of psychopathological manifestations suggested by Perris (1994). He argued in his framework that, ‘‘. . . not only disturbances of information-processing capacity, but also the development of basically dysfunctional meaning structures, or dysfunctional working models of self and environment to which informationprocessing disturbances, obviously contribute’’ (Perris, 1994, p. 19) must be taken into account. The relationships between early parental rearing and later psychopathology was empirically demonstrated in several studies (Wind and Silvern, 1994; Richter and Eisemann, 2001; Andersson and Eisemann, 2003); for a comprehensive overview on this topic, see Perris (1994). Armentrout (1975) studied these associations in 83 male and 43 female students by means of the ChildÕs report of parental behavior inventory in combination with the Minnesota multiphasic personality inventory (MMPI) and found significant relationships between the validity scale F and the clinical MMPI scales D, Pd, Pt, Sc and Si and more severe parental rejection and severe covert psychological parental control. McCrae and Costa took a contrary opinion (1988). They found just modest correlations between parental attitudes and personality factors in a study of 619 men and women, and concluded that parental rearing seems to be of minor impact than traditionally supposed. This in mind it is expected that behaviors of parents toward rearing of children should affect significantly their later success and failure in life, health and pathology, coping strategies and self-image, self-efficacy, selfesteem and self-construct, etc. Several studies were performed to investigate the relationships between parental rearing and self-esteem/self-image in samples of healthy people. Buri et al. (1992) demonstrated that parental nurturance is a robust predictor of self-esteem in adolescence and early adulthood in sample of 784 subjects. Hagarty et al. (2002) investigated the relationship between early experiences and sense of belonging in adulthood in 362 community college students. The results showed that perceived caring by both parents was positively influencing the experience of sense of belonging as adults. A negative relationship was found with overprotection of father. Solomon and Serres (1999) reported low self-esteem and low school marks among children who had been victims of verbal aggression by parents from an investigation of 140 ten years-old children. Furthermore, Morvitz and Motta (1992) found relationships between childrenÕs perception of maternal and paternal acceptance, academic achievement and
self-esteem. Perceived inter-parental conflicts and inconsistencies in rearing styles and authoritarianism were significantly negatively correlated to self-esteem among 122 young adults (Pawlak and Klein, 1997) and parenting styles were the best predictors of self-esteem. Selfesteem emerged as the most powerful predictor of happiness in a study of Furnham and Cheng (2000) concerning the relationship between perceived parental behavior, self-esteem and happiness in a sample of non-clinical late adolescents and young adults. Furthermore, maternal authoritativeness was one of the most powerful predictors of self-esteem, and also the single direct predictor when maternal and paternal rearing styles were investigated together. Relationships between various self-constructs and the experience of pain (Lipchik et al., 1993; Lorig et al., 1999, 2001), as well as relationships between self-constructs and treatment outcome were frequently reported. Coughlin et al. (2000) found in an intervention study that it is essential to successful pain management that patientsÕ self-efficacy in their control over pain becomes increased and the external attributions become decreased. Binzer et al. (2003) reported no significant differences between somatic and psychogenic pain patients concerning perceive parental rearing, locus of control and several personality measurements in an investigation of 51 non-depressed patients with chronic pain. In a study by Nordin et al. (2004a), performing hierarchial cluster analysis, using Euclidean distance, on the MMPI-2 validity and clinical scales, in a sample of chronic pain patients, two almost identical clusters were found for both sexes. The major cluster corresponded to the classical ‘‘conversion-V’’ profile, and the minor to the ‘‘general elevated profile’’. By means of discriminant analysis 100% of the variance was explained in both the male and female samples. Subsequently, Nordin et al. (2004b) investigated differences in self-image in the same sample of chronic pain patients. Cluster 1 (conversionV) patientsÕ self-image was mainly characterized by self-affirm and self-love and cluster 2 (general elevated) by self-blame, self-attack and self-neglect. The significant differences between patients characterized by differing personality profiles (MMPI-2 profiles), was defined by Benjamin (1996), in terms of e.g., friendliness, flexible and openness, well-focused cognitive styles, the ability to maintain social relationships, and between patients and healthy subjects in terms of e.g., spontaneity and self pleasure. No associations were found between selfimage and medical diagnosis and just a weak relationship between experience of physical trauma and the self-neglect scale of the SASB self-image scales. The result suggested that the self and its development were independent of the medical condition (Nordin et al., 2004b). However, several investigations supported the assumption that the same factors, which affect psycho-
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logical disturbances and/or life satisfaction, seem to determine the perception of somatic disorders, e.g., pain. Portegijs et al. (1996) found significant relationships between deprivation of parental care and somatization. Benjamin et al. (1994) confirmed the importance of maternal factors in a study of 72 infants and concluded that non-optimal parenting may contribute to less effective coping strategies and this, in turn, might represent a substantial background factor in the development of chronic pain. According to the theories of early social experiences and the development of the self, and the results of the previous studies by Nordin et al. (2004a,b) and from other studies, e.g., those mentioned above, the present investigation aimed to study the relationships between perceived parental rearing and self-images in chronic pain patients. We hypothesized that: 1. There are significant relationships between parental rearing and self-image in chronic pain patients. It is expected that negative parental attitudes like rejection and/or overprotection are associated to negative selfimages and that positive parental rearing attitudes such as emotional warmth are associated with positive self-images. 2. There are significant differences between patients groups based on MMPI-2 clusters. It is expected that patients characterized by a conversion-V profile have more positive memories of parental rearing than patients characterized by a general elevated profile in terms of more parental emotional warmth and less rejection and overprotection. 3. There are significant differences between the pain sample and healthy subjects. Assumingly, pain patients have more experiences of parental rejection and overprotection than healthy subjects.
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an mean duration of pain 10.5 ± 9.5 years, range 1.5– 33 years. The patients were admitted to the Department of Rehabilitation Medicine at the of the University Hospital of Umea˚, Sweden for a two days examination due to lack of response to traditional treatments or due to the problem of vague and/or complex diagnosis. The psychological assessment was carried out at day one. The participants were orally informed about the study in a group meeting at the department, given written information and signed their agreement to participate in the study. The research ethics committee, Umea˚ University, Sweden, approved the project. 2.2. Measures 2.2.1. Structural analysis of social behavior The structural analysis of social behavior (SASB) has three foci: identification, recapitulation and introjection, which represent three different types of internalization of early important others according to psychoanalytical theory. In accordance with the aim of this investigation, we applied exclusively the part related to introjection. It consists of 36 questions which should be rated by the subject on a scale from 0 to 100, with 0 = not at all and 100 = perfectly. The results were computed into eight clusters describing different parts of the internalised self (see Fig. 1). Each cluster consists of four to five questions. The SASB model was constructed on two axes: The horizontal describing the continuum self-love to the right and self-hate to the left is named affiliation, and the vertical with emancipation on the top and control in the bottom is named interdependence (Benjamin, 1974 – see Fig 1). Analyses confirmed the structure of SASB and its reliability as high in normal samples (Benjamin, 1974, 1996). 2.3. Locus of control
2. Method
Eisemann et al. (1988) developed the locus of control scale (LOC). It consists of 40 items to be answered
2.1. Subjects 2.1.1. Chronic pain sample In this study, 171 patients suffering from chronic pain participated. The sample was divided into two groups based on results of a hierarchial cluster analysis (Nordin et al., 2004a). Patients of cluster 1, 145 individuals (53 men and 92 women) were characterized by a ‘‘conversion V’’ MMPI-2 profile and patients of cluster 2, 26 individuals (5 men and 21 women) were characterized by a ‘‘general elevated’’ MMPI-2 profile. The mean age of the cluster 1 patients was 38.8 ± 10.28 years, range 18–66 years and the mean duration of pain 6.6 ± 6.7 years, range 10 month to 25 years. In cluster 2, the mean age was 40 ± 11.81 years, range 21–66 and
1. Self-emancipate 8.Self-neglect
2. Self-affirm
7. Self-attack
3. Active-self-love
6. Self-blame
4. Self-protect 5. Self-control
Fig. 1. The labels of the eight introjections of the SASB clusters (Benjamin, 1996).
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according to a 4-point forced-choice Likert scale format: (1) strongly agree, (2) agree, (3) disagree and (4) strongly disagree. The scale is scored in the external direction, i.e. the higher the score, the more external the LOC. This scale was preferred because it was developed to measure adult clinical samples in contrast to others (Eisemann et al., 1988). Furthermore, this LOC includes 10 items measuring social desirability which is regarded as a confounding variable. Test–retest reliability was rs = 0.74 for the LOC total score and rs = 0.76 for the social desirability score (Eisemann et al., 1988).
tion of the original longer measure’’ (Arrindell et al., 2001). 2.6. Diagnosis Information about diagnosis was obtained from medical records. The diagnoses had been made by experienced specialists in rehabilitation medicine and classified into categories as headache (4.4%), neck pain (37.9%), back pain (21.9%), pain from limbs (12.4%), myalgia (14.6%), according to general pain (3.6%) and unspecified pain (5.2%).
2.4. The Giessen test 3. Statistical analyses The theoretical foundation of the Giessen test (GT) was influenced by psychoanalytical theory and psychosocial research, especially by Mead and Kelly (Beckman and Richter, 1975). The GT contains 40 items of a bipolar format each with seven response alternatives, constituting the scales: social response, dominance, self-control, underlying mood, permeability and social potency. The test–retest reliability scores were between 0.65 and 0.76. When developing the test, greater emphasis was placed on achieving high validity than on maximally homogenous scales (Beckman and Richter, 1975). Subsequently, external validity was found to be acceptable when correlating the GT scales with the NEO personality inventory (Gunzelmann et al., 2002). 2.5. The EMBU Perceived parental rearing behavior was assessed by the short form of the EMBU (Swedish acronym for my memories of upbringing) developed from the original 81-item Swedish version (Perris et al., 1980) by Arrindell et al. (2001). The s-EMBU is a 23-item inventory with 4point Likert type scales, to be answered separately for father and mother. A factor analyses yielded three factors: (1) Rejection – implying a parental rearing characterized by physical punishment, rejection of the subject and an individual, hostility, derogation, etc.; (2) Emotional warmth – giving warm and loving attention, helping the subject, aiding through problems, able to confide in the parent, etc.; and (3) Overprotection – protection from negative experiences, high degree of intrusiveness, high expectancy to know all about the subject, imposement of strict regulations and demanding unquestioning obedience to them, etc. Validity and reliability was found to be acceptable, alpha scores ranged from 0.75 to 0.87 for the various scales (Arrindell et al., 2001). Notable is that ‘‘The s-EMBU can thus be recommended with confidence as a functional equivalent to the early 81-item version when the clinical and/or research context does not adequately permit the applica-
The data were analyzed using the Statistical Package for the Social Sciences (SPSS Inc., 1999). Multivariate analysis of variance (MANOVA), adjusted for Bonferroni, were calculated for interaction between gender, clusters and diagnosis as fixed factors and all of the EMBU scales as dependent factors. The MANOVA were also computed with gender and clusters as independent factors and the self-image and EMBU scales as dependent. Mann–Whitney U-test for comparison of means were computed for the EMBU scales according to gender in each MMPI-2 clusters and between clusters. StudentÕs t-tests were computed to test for mean differences of EMBU scales between clusters and the comparison group, 461 healthy Swedish subjects from Arrindell et al. (2001). Linear multiple regression analyses, stepwise method, were calculated for analysing the relationship between EMBU scales as independent and self-image factors of the GT, the SASB, and the LOC scales, as dependent variables, within both pain-related personality clusters. Discriminant analyses were performed to test for multivariate differences between the clusters based on EMBU scales. In addition, partial correlations were calculated between the self-image scales and the EMBU scales separately for the personality clusters controlling for social desirability, affecting the correlations exclusively in the patient groups.
4. Results When comparing means of the EMBU factors by gender for the clusters of the MMPI-2, no significant differences were found for cluster 1, whereas significant differences were found for maternal Ôemotional warmthÕ among the group of cluster 2 (z = 2.082; p = 0.037) in terms of higher scores for men. No significant main effect was found for diagnosis, in a model with gender,
H. Nordin et al. / European Journal of Pain 9 (2005) 277–284
clusters and diagnosis as fixed factors and EMBU scales as dependent. When calculating MANOVA, the m/f scale was excluded due to its lack of clinical relevance in this context, in order to obtain a significant model. Results of the MANOVA concerning self-image scales, showed significant main effects for gender (PillaiÕs Trace = 0.22; F(14/ 100) = 1.99; p = 0.026; g2 = 0.218 – based on significant differences in the factors social response, self-blame, self-attack, and self-neglect) and for clusters (PillaiÕs Trace = 40; F(14/100) = 4.69; p = 0.000; g2 = 0.40 – based on significant differences in the factors social response, underlying mood, permeability, self-affirm, active-self-love, self-blame, self-attack, self-neglect and LOC). Furthermore, regarding self-image scores, significant interaction for clusters · gender occurred (PillaiÕs Trace = .20; F(14/100) = 1.82; p = 0.046; g2 = 0.20 – based on social response and self-attack). When searching for differences on parental rearing (the EMBU scales), significant main effects emerged for clusters (PillaiÕs Trace = 0.12; F(6/128) = 2.96; p = 0.01; g2 = 0.12 – based on maternal rejection, maternal emotional warmth and overprotection – both parents). The results also showed an significant interaction between gender · clusters (PillaiÕs Trace = 0.17; F(6/ 128) = 2.01; p = 0.024; g2 = 0.09 – based on maternal rejection and emotional warmth). When using parental rearing and self-image in a more comprehensive model, the results revealed significant main effects for gender (PillaiÕs Trace = 0.20; F(14/ 100) = 1.93; p = 0.045; g2 = 0.20 – based on maternal rejection, maternal emotional warmth, active-self-love, self-blame, self-attack and self-neglect). For clusters, a significant main effect appeared (PillaiÕs Trace = 0.43; F(14/100) = 5.40; p = 0.000; g2 = 43 – based on rejection – mother, overprotection – father, overprotection – mother, underlying mood, permeability, self-affirm, active-self-love, self-blame, self-attack, self-neglect and LOC). The interaction term between gender · clusters showed significant effects (PillaiÕs Trace = 0.21; F(14/ 100) = 1.93; p = 0.031; g2 = 0.21 – based on emotional warmth – mother, self-blame and self-control). By means of discriminant analysis, based on the EMBU scales as independent variables, 81.3% of patients could be correctly classified into the MMPI-2 clusters. In Table 1, partial correlations, controlling for social desirability, between the EMBU factors and the selfimages scales, showed significant positive relationship between the Emotional warmth scales of both parents and a positive, healthy self-image for cluster 1. Furthermore, for cluster 1-patients, the EMBU scale overprotection – father related positively to healthy self-image scales as measured by the SASB and the GT. In cluster 2, rejection from both parents yielded a significant negative relationships with positive self-images and paternal
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rejection, supported internal LOC. Overprotectionscores of mothers yielded no significant relationships in any of the clusters. The multiple regression analysis (stepwise) with all of the EMBU scales as independent variables and each of the self-images scales as dependent variables revealed explained amounts of variances in the SASB self-images scales self-emancipate, self-affirm, active-self-love, selfprotect, self-control, the GT scales self-control, permeability and social potency ranging between 4% and 7% in the group of cluster 1-patients. Paternal overprotection explained 36% of the variance in the GT scale social potency and paternal rejection explained 20% in the LOC, in cluster 2-patients. Patients of the group of the ‘‘conversion-V’’ cluster reported, on average, significantly more parental emotional warmth and lower parental rejection and overprotection compared to the ‘‘general elevated’’ group (Table 2). When comparing EMBU means of cluster 1 with healthy subjects significant differences were found for all scales, except for the scale Overprotection – father, with generally lower scores for the cluster 1pain patients. The comparison of means between cluster 2 and healthy subjects revealed significant differences on the scales Emotional warmth for both parents in terms of lower scores for pain patients, overprotection – mother and rejection – mother, in terms of higher scores for cluster 2-pain patients compared to healthy subjects.
5. Discussion As several studies have shown, there are significant relationships between parental rearing and psychopathology later in life, and even between parental rearing attitudes and somatization and pain in adults (Wind and Silvern, 1994; Richter and Eisemann, 2001; Andersson and Eisemann, 2003; Lipchik et al., 1993; Lorig et al., 1999, 2001). The objectives of this study were to investigate relationships between perceived parental rearing measured by the EMBU questionnaire and various kinds of self-images measured by the SASB, the GT and the LOC in two groups of chronic pain patients characterized by differences in personality-profiles emerged from hierarchial cluster analysis of the MMPI-2 (Nordin et al., 2004a). Cluster 1 for both genders, the ‘‘conversion-V’’ profile suggested vague physical complaints, which might increase under stress. Severe anxiety and depression were usually absent. Cluster 2, the ‘‘general elevated’’ profile for both genders, was characterized by feeling overwhelmed by anxiety, tension and depression. These patients perceived difficulties in concentration and decision-making, and functioned on a low level of efficiency (Butcher and Williams, 1996; Nordin et al., 2004a).
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Table 1 Partial correlations, controlled for Social Desirability, between factors of the SASB, the GT, and the LOC with the EMBU factors by MMPI-2 pain cluster groups Cluster Giessen test Social response
Emotional warmth (father)
Emotional warmth (mother)
Over-protection (father)
Over-protection (mother)
Rejection (father)
Rejection (mother)
1 2
0.18 0.23
0.04 0.22
0.23* 0.03
0.04 0.09
0.07 0.02
0.00 0.17
Dominance
1 2
0.06 0.16
0.10 0.09
0.07 0.05
0.08 0.31
0.15 0.32
0.07 0.25
Self-control
1 2
0.10 0.15
0.03 0.30
0.13 0.07
0.16 0.17
0.04 0.30
0.07 0.28
Underlying mood
1 2
0.03 0.18
0.06 0.11
0.11 0.19
0.08 0.26
0.08 0.05
0.02 0.23
Permeability
1 2
0.22* 0.23
0.24* 0.16
0.18 0.17
0.17 0.32
0.01 0.17
0.01 0.05
Social potency
1 2
0.22* 0.10
0.24* 0.16
0.03 0.21
0.10 0.01
0.11 0.58*
0.06 0.28
0.05 0.03
0.25* 0.26
0.05 0.20
0.04 0.16
0.00 0.02
Structural analysis of social behavior Self-emancipate 1 0.17 2 0.02 Self-affirm
1 2
0.25* 0.12
0.11 0.10
0.13 0.02
0.01 0.07
0.07 0.02
0.04 0.12
Active-self-love
1 2
0.22* 0.19
0.07 0.04
0.03 0.41
0.05 0.27
0.01 0.04
0.02 0.10
Self-protect
1 2
0.22* 0.21
0.27** 0.28
0.21* 0.26
0.00 0.45
0.07 23
0.28** 0.55*
Self-control
1 2
0.17 0.29
0.26** 0.14
0.05 0.28
0.08 0.04
0.03 0.11
0.20* 0.01
Self-blame
1 2
0.07 0.24
0.05 0.25
0.02 0.03
0.07 0.19
0.06 0.11
0.00 0.36
Self-attack
1 2
0.15 0.04
0.07 0.03
0.04 0.10
0.03 0.07
0.13 0.04
0.02 0.09
Self-neglect
1 2
0.06 0.28
0.09 0.28
0.00 0.16
0.04 0.01
0.03 0.05
0.08 0.30
LOC
1 2
0.03 0.18
0.00 0.33
0.11 0.02
0.04 0.18
0.12 0.44*
0.03 0.33
* **
p < .05. p < 0.01.
We had hypothesized that there were (1) significant relationships between parental rearing and self-image; (2) there were significant differences between the MMPI-2 clusters and (3) there were significant differences between pain patients and healthy subjects regarding perceived parental rearing attitudes. The interpretation of our results were limited by: (a) lack of control group of healthy subject; (b) the small
number of men in cluster 2 (five individuals) not allowing us to draw conclusions about gender. We investigated possible differences between the EMBU scales according to medical diagnosis and gender. The result showed no significant relationships with regards to diagnosis which is in line with the studies by Binzer et al. (2003) and Nordin et al. (2004b) reporting no significant differences on the self-image scales across
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Table 2 Mann–Whitney U-test for comparisons of means between EMBU scales, and MMPI-2 clusters and StudentÕs t-test for comparisons of means between clusters and healthy subjects
Emotional warmth (father) Emotional warmth (mother) Overprotection (father) Overprotection (mother) Rejection (father) Rejection (mother)
Cluster 1 M (SD)
Cluster 2 M (SD)
Healthy M (SD)
15.24 (4.30) 16.64 (3.91) 16.57 (3.01) 17.95 (3.36) 8.01 (2.30) 7.74 (2.40)
13.10 (3.53) 12.47 (5.13) 18.14 (4.86) 21.30 (6.32) 9.42 (2.37) 11.57 (5.51)
16.42 (4.08) 17.75 (3.75) 16.82 (4.06) 19.07 (4.38) 9.24 (2.53) 9.21 (2.34)
Cluster 1 vs. 2 z/p 2.29* 3.40*** 1.21 2.40* 3.64*** 3.29***
Cluster 1 vs. healthy, df: 593 t/p
Cluster 2 vs. healthy, df: 421 t/p
3.24*** 3.33*** 0.76 3.13*** 5.71*** 7.11***
3.66*** 6.43*** 1.44 2.22* 0.32 4.09***
p < 0.05. p < 0.01. *** p < 0.001. *
**
the groups of chronic pain patients according to medical diagnosis. The results suggested that important psychological factors in chronic pain, e.g., self-image or LOC and experiences of parental rearing were independent of medical diagnosis, assuming that psychological factors are stretching over medical diagnosis and impact every-day life. Consequently, it should be more important to focus on perceived self-image in treatment, than on single diagnosis. The only gender difference found in the MMPI-2 cluster 2 should be regarded as tentative given the small sample size. The strong discriminant power of the EMBU on MMPI-2 clusters underlines results from previous studies (Nordin et al., 2004a,b) suggesting that there are at least two qualitative different groups according to psychological variables among chronic pain patients, and indicate the power of parental rearing behavior on later psychopathology. Furthermore, significant relationships were found between the EMBU scales and the selfimage scales. The EMBU measures memories of parental upbringing in three dimensions; emotional warmth, overprotection and rejection – separately for the mother and the father. In this study, especially the scale emotional warmth, for both parents, was associated with positive self-image from both the GT and the SASB in cluster 1, the ‘‘conversion-V’’ group. Not surprisingly, the rejection scores showed associations with more negative self-images in both clusters. Contrary to most studies, Overprotection was found positively (father) or not (mother) related to self-image scores. Except for the last finding, the results were in line with reports from earlier studies (Morvitz and Motta, 1992; Solomon and Serres, 1999; Pawlak and Klein, 1997). As expected the cluster 2-patients, the ‘‘general elevated’’ MMPI-2 group, scored lower on the emotional warmth scales and higher on the overprotection (mother) and rejection scales compared to cluster 1 and the comparison group. Thus, the results suggest a higher degree of parental caring attitudes associated with physical punishment and hostility among cluster 2 pain patients compared with cluster 1 and healthy sub-
jects. The result for the cluster 2 patients indicate an almost direct copying process between perceived parental upbringing attitudes and dominant self-images as presented by Nordin et al. (2004b). The results support and underline theories of early social learning for the development of the self, as stressed by e.g., Buri et al. (1992); McWilliams (1994); Perris (1994); Hagarty et al. (2002) or Benjamin (2003, pp. 48–58). The average scores of the cluster 1-patients were located between those of cluster 2-patients and the compared healthy subjects group. However, the result contrasts that of Binzer et al. (2003), suggesting that there were no significant mean differences between patients and controls concerning parental rearing. Interestingly and unexpected, the patients of cluster 1 generally scored lower than comparisons on all EMBU scales. This could be interpreted as a sign of detachment or low-attachment, parental rearing style, but demands further investigation for a more convincing explanation. It must be noted that the associations are not convincing due to the low degree of predictive power of the EMBU and the few significant correlations, indicating the influence of later life events and/or other important persons on the perceived self-image. However, the hypothesis of differences between clusters and between clusters and healthy subjects could be accepted. In summary, the results of our investigation showed significant relationships between memories of parental rearing style and perceived self-images related to personality profiles according to MMPI-2. Additionally, we found some evidence that child upbringing can be regarded as an underlying factor for the perception of chronic pain. Consequently, our results support previous conclusions that there are similar factors which are determining perception of and/or coping with psychiatric and somatic disorders (Portegijs et al., 1996; Benjamin et al., 1994). The significant differences from a healthy group (see Arrindell et al. (2001)) and between clusters on parental rearing and the significant relationship between memories of parental rearing and selfimage provide therapists with a special approach in
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the treatment of chronic pain, in accordance to the social cognitive theories and the psychodynamic theoretical construct of introjection as an early process in the development of self-images. These results underline the importance of establishing trusting therapeutic relations for unfolding the characteristics of early and later interpersonal relationships and their impact on adaptive and maladaptive behavior. References Andersson P, Eisemann M. Parental rearing and individual vulnerability to drug addiction: a controlled study in a Swedish sample. Nord J Psychiatry 2003;57:147–56. Armentrout JA. Repression-sensitization and MMPI correlates of retrospective reports of parental child-rearing behaviors. J Clin Psychol 1975;31:444–8. Arrindell WA, Richter J, Eisemann M, Garling T, Ryde´n O, Hansson SB, et al.. The short EMBU in East-Germany and Sweden: a cross-cultural factorial validity extension. Scand J Psychol 2001;42:157–60. Asgari A, Nicholas MK. Pain self-efficacy beliefs and pain behaviour. A prospective study. Pain 2001;94:85–100. Benjamin LS. Structural analysis of social behavior. Psychol Rev 1974;81:392–425. Benjamin LS. A clinician-friendly version of the interpersonal circumplex: structural analysis of social behavior (SASB). J Pers Ass 1996;66:248–66. Benjamin LS. Interpersonal diagnosis and treatment of personality disorders. second ed.. New York: The Guilford Press; 2003. Beckman D, Richter HE. Der Giessen-test. Bern: Huber; 1975. Binzer M, Almay B, Eisemann M. Chronic pain disorder associated with psychogenic versus somatic factors: a comparative study. Nord J Psychiatry 2003;57:61–6. Buri JR, Murphy P, Richtsmeier LM, Komar KK. Stability of parental nurturance as a salient predictor of self-esteem. Psychol Rep 1992;71:535–43. Butcher JN, Williams CL. Essentials of MMPI-2 and MMPI – an interpretation. Minneapolis: University of Minnesota Press; 1996. Coughlin AM, Badura AS, Fleischer TD, Guck TP. Multidisciplinary treatment of chronic pain patients: its efficacy in changing patient locus of control. Arch Phys Med Rehabil 2000;81:739–40. Eisemann M, Perris C, Palm U, Palm A, Perris H. LOC – presentation of a swedish instrument for asssessing locus of control. In: Perris C, Eisemann M, editors. Cognitive psychotherapy – an update. Umea: DOPUU Press; 1988. p. 41–5. Furnham A, Cheng H. Perceived parental behaviour, self-esteem and happiness. Soc Psychiatr Epidemiol 2000;35:463–70. Gunzelmann T, Schumacher J, Bra¨hler E. Normierung des GiessenTests fu¨r u¨ber 60-Ja¨hrige. Z Gerontol Geriat 2002;35:13–20. Hagarty BM, Williams RA, Oe H. Childhood antecedents of adult sense of belonging. J Clin Psychol 2002;58:793–801.
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Memories of parental rearing and perceived self-image in groups of chronic pain patients Ha˚kan Nordin a, Martin Eisemann
b,*
, Jo¨rg Richter
c
a
Division of Psychiatry, Central Hospital of Rogaland, Norway Department of Psychology, University of Tromsø, N-9007 Tromsø, Norway University Hospital of Psychiatry and Psychotherapy, University of Rostock, Germany b
c
Received 22 February 2004; accepted 13 July 2004 Available online 14 August 2004
Abstract Objectives: The aim of this study was to analyze the relationships between perceived parental rearing styles as determining factors of self-image in chronic pain patients, and to test the hypothesis of two different groups inherent to the pain sample. Methods: In this study, 152 patients with chronic pain participated. The sample was divided into two groups by means of hierarchical cluster analysis on the Minnesota multiphasic personality inventory, version 2. Cluster 1 comprised 116 individuals (44 men and 72 women) with a ‘‘conversion V’’ MMPI-2 profile, and cluster 2 comprised 21 individuals (5 men and 16 women) with a ‘‘general elevated’’ MMPI-2 profile. The patients were investigated by means of the structural analysis of social behavior (SASB), the Giessen test (GT), the locus of control scale (LOC) and the EMBU questionnaire (My memories of parental upbringing). Results: The results show significant associations between memories of parental rearing and self-image as adults and are in line with results from previous studies describing two psychologically different groups inherent to chronic pain patients. Conclusions: The significant differences between healthy controls, pain patients and between clusters of pain patients on parental rearing scales, and the significant relationship between memories of parental rearing and self-image provide therapists with a special approach to the treatment of chronic pain patients in accordance to social cognitive theories and the psychodynamic theoretical construct of introjection as an early process in the development of self-images. 2004 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Ltd. All rights reserved. Keywords: Parental rearing; Self-image; Chronic pain; Minnesota multiphasic personality inventory, version 2; Cluster analysis
1. Introduction The relationship between chronic pain and various aspects of the self were investigated in several studies over the last three decades (Kopel and Arkowitz, 1975; Rosenstiel and Keefe, 1983; Jensen et al., 1991; Strahl et al., 2000; Asgari and Nicholas, 2001). Introjection is a primitive and unconscious process of internalization
*
Corresponding author. Tel.: +47 77646279; fax: +47 77645610. E-mail address: [email protected] (M. Eisemann).
where e.g., attitudes, behavior and/or values of important persons in our environment early in life become a part of us and thus a part of our identity. In its benign form, founded in love and warmth, it is an important part of constructive coping later in life. On the other hand, in its malign form, expressed by, e.g., rejection or aggression, the consequence or the primitive defence, could be to internalize the qualities of the abuser, in terms of an ‘‘identification with the aggressor’’ (McWilliams, 1994, p. 109). McWilliams further stated that ‘‘If we lose any of the people whose image we have internalised, whether by death, separation, or rejection, not
1090-3801/$30 2004 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ejpain.2004.07.004
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only do we feel that our environment is poorer for their absence in our lives but we also feel that we are somehow diminished, that an part of our self has died, . . . When mourning is avoided, unconscious self-criticism takes its place’’. Parental rearing represents one of the major factors within the comprehensive vulnerability model of the development of psychopathological manifestations suggested by Perris (1994). He argued in his framework that, ‘‘. . . not only disturbances of information-processing capacity, but also the development of basically dysfunctional meaning structures, or dysfunctional working models of self and environment to which informationprocessing disturbances, obviously contribute’’ (Perris, 1994, p. 19) must be taken into account. The relationships between early parental rearing and later psychopathology was empirically demonstrated in several studies (Wind and Silvern, 1994; Richter and Eisemann, 2001; Andersson and Eisemann, 2003); for a comprehensive overview on this topic, see Perris (1994). Armentrout (1975) studied these associations in 83 male and 43 female students by means of the ChildÕs report of parental behavior inventory in combination with the Minnesota multiphasic personality inventory (MMPI) and found significant relationships between the validity scale F and the clinical MMPI scales D, Pd, Pt, Sc and Si and more severe parental rejection and severe covert psychological parental control. McCrae and Costa took a contrary opinion (1988). They found just modest correlations between parental attitudes and personality factors in a study of 619 men and women, and concluded that parental rearing seems to be of minor impact than traditionally supposed. This in mind it is expected that behaviors of parents toward rearing of children should affect significantly their later success and failure in life, health and pathology, coping strategies and self-image, self-efficacy, selfesteem and self-construct, etc. Several studies were performed to investigate the relationships between parental rearing and self-esteem/self-image in samples of healthy people. Buri et al. (1992) demonstrated that parental nurturance is a robust predictor of self-esteem in adolescence and early adulthood in sample of 784 subjects. Hagarty et al. (2002) investigated the relationship between early experiences and sense of belonging in adulthood in 362 community college students. The results showed that perceived caring by both parents was positively influencing the experience of sense of belonging as adults. A negative relationship was found with overprotection of father. Solomon and Serres (1999) reported low self-esteem and low school marks among children who had been victims of verbal aggression by parents from an investigation of 140 ten years-old children. Furthermore, Morvitz and Motta (1992) found relationships between childrenÕs perception of maternal and paternal acceptance, academic achievement and
self-esteem. Perceived inter-parental conflicts and inconsistencies in rearing styles and authoritarianism were significantly negatively correlated to self-esteem among 122 young adults (Pawlak and Klein, 1997) and parenting styles were the best predictors of self-esteem. Selfesteem emerged as the most powerful predictor of happiness in a study of Furnham and Cheng (2000) concerning the relationship between perceived parental behavior, self-esteem and happiness in a sample of non-clinical late adolescents and young adults. Furthermore, maternal authoritativeness was one of the most powerful predictors of self-esteem, and also the single direct predictor when maternal and paternal rearing styles were investigated together. Relationships between various self-constructs and the experience of pain (Lipchik et al., 1993; Lorig et al., 1999, 2001), as well as relationships between self-constructs and treatment outcome were frequently reported. Coughlin et al. (2000) found in an intervention study that it is essential to successful pain management that patientsÕ self-efficacy in their control over pain becomes increased and the external attributions become decreased. Binzer et al. (2003) reported no significant differences between somatic and psychogenic pain patients concerning perceive parental rearing, locus of control and several personality measurements in an investigation of 51 non-depressed patients with chronic pain. In a study by Nordin et al. (2004a), performing hierarchial cluster analysis, using Euclidean distance, on the MMPI-2 validity and clinical scales, in a sample of chronic pain patients, two almost identical clusters were found for both sexes. The major cluster corresponded to the classical ‘‘conversion-V’’ profile, and the minor to the ‘‘general elevated profile’’. By means of discriminant analysis 100% of the variance was explained in both the male and female samples. Subsequently, Nordin et al. (2004b) investigated differences in self-image in the same sample of chronic pain patients. Cluster 1 (conversionV) patientsÕ self-image was mainly characterized by self-affirm and self-love and cluster 2 (general elevated) by self-blame, self-attack and self-neglect. The significant differences between patients characterized by differing personality profiles (MMPI-2 profiles), was defined by Benjamin (1996), in terms of e.g., friendliness, flexible and openness, well-focused cognitive styles, the ability to maintain social relationships, and between patients and healthy subjects in terms of e.g., spontaneity and self pleasure. No associations were found between selfimage and medical diagnosis and just a weak relationship between experience of physical trauma and the self-neglect scale of the SASB self-image scales. The result suggested that the self and its development were independent of the medical condition (Nordin et al., 2004b). However, several investigations supported the assumption that the same factors, which affect psycho-
H. Nordin et al. / European Journal of Pain 9 (2005) 277–284
logical disturbances and/or life satisfaction, seem to determine the perception of somatic disorders, e.g., pain. Portegijs et al. (1996) found significant relationships between deprivation of parental care and somatization. Benjamin et al. (1994) confirmed the importance of maternal factors in a study of 72 infants and concluded that non-optimal parenting may contribute to less effective coping strategies and this, in turn, might represent a substantial background factor in the development of chronic pain. According to the theories of early social experiences and the development of the self, and the results of the previous studies by Nordin et al. (2004a,b) and from other studies, e.g., those mentioned above, the present investigation aimed to study the relationships between perceived parental rearing and self-images in chronic pain patients. We hypothesized that: 1. There are significant relationships between parental rearing and self-image in chronic pain patients. It is expected that negative parental attitudes like rejection and/or overprotection are associated to negative selfimages and that positive parental rearing attitudes such as emotional warmth are associated with positive self-images. 2. There are significant differences between patients groups based on MMPI-2 clusters. It is expected that patients characterized by a conversion-V profile have more positive memories of parental rearing than patients characterized by a general elevated profile in terms of more parental emotional warmth and less rejection and overprotection. 3. There are significant differences between the pain sample and healthy subjects. Assumingly, pain patients have more experiences of parental rejection and overprotection than healthy subjects.
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an mean duration of pain 10.5 ± 9.5 years, range 1.5– 33 years. The patients were admitted to the Department of Rehabilitation Medicine at the of the University Hospital of Umea˚, Sweden for a two days examination due to lack of response to traditional treatments or due to the problem of vague and/or complex diagnosis. The psychological assessment was carried out at day one. The participants were orally informed about the study in a group meeting at the department, given written information and signed their agreement to participate in the study. The research ethics committee, Umea˚ University, Sweden, approved the project. 2.2. Measures 2.2.1. Structural analysis of social behavior The structural analysis of social behavior (SASB) has three foci: identification, recapitulation and introjection, which represent three different types of internalization of early important others according to psychoanalytical theory. In accordance with the aim of this investigation, we applied exclusively the part related to introjection. It consists of 36 questions which should be rated by the subject on a scale from 0 to 100, with 0 = not at all and 100 = perfectly. The results were computed into eight clusters describing different parts of the internalised self (see Fig. 1). Each cluster consists of four to five questions. The SASB model was constructed on two axes: The horizontal describing the continuum self-love to the right and self-hate to the left is named affiliation, and the vertical with emancipation on the top and control in the bottom is named interdependence (Benjamin, 1974 – see Fig 1). Analyses confirmed the structure of SASB and its reliability as high in normal samples (Benjamin, 1974, 1996). 2.3. Locus of control
2. Method
Eisemann et al. (1988) developed the locus of control scale (LOC). It consists of 40 items to be answered
2.1. Subjects 2.1.1. Chronic pain sample In this study, 171 patients suffering from chronic pain participated. The sample was divided into two groups based on results of a hierarchial cluster analysis (Nordin et al., 2004a). Patients of cluster 1, 145 individuals (53 men and 92 women) were characterized by a ‘‘conversion V’’ MMPI-2 profile and patients of cluster 2, 26 individuals (5 men and 21 women) were characterized by a ‘‘general elevated’’ MMPI-2 profile. The mean age of the cluster 1 patients was 38.8 ± 10.28 years, range 18–66 years and the mean duration of pain 6.6 ± 6.7 years, range 10 month to 25 years. In cluster 2, the mean age was 40 ± 11.81 years, range 21–66 and
1. Self-emancipate 8.Self-neglect
2. Self-affirm
7. Self-attack
3. Active-self-love
6. Self-blame
4. Self-protect 5. Self-control
Fig. 1. The labels of the eight introjections of the SASB clusters (Benjamin, 1996).
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according to a 4-point forced-choice Likert scale format: (1) strongly agree, (2) agree, (3) disagree and (4) strongly disagree. The scale is scored in the external direction, i.e. the higher the score, the more external the LOC. This scale was preferred because it was developed to measure adult clinical samples in contrast to others (Eisemann et al., 1988). Furthermore, this LOC includes 10 items measuring social desirability which is regarded as a confounding variable. Test–retest reliability was rs = 0.74 for the LOC total score and rs = 0.76 for the social desirability score (Eisemann et al., 1988).
tion of the original longer measure’’ (Arrindell et al., 2001). 2.6. Diagnosis Information about diagnosis was obtained from medical records. The diagnoses had been made by experienced specialists in rehabilitation medicine and classified into categories as headache (4.4%), neck pain (37.9%), back pain (21.9%), pain from limbs (12.4%), myalgia (14.6%), according to general pain (3.6%) and unspecified pain (5.2%).
2.4. The Giessen test 3. Statistical analyses The theoretical foundation of the Giessen test (GT) was influenced by psychoanalytical theory and psychosocial research, especially by Mead and Kelly (Beckman and Richter, 1975). The GT contains 40 items of a bipolar format each with seven response alternatives, constituting the scales: social response, dominance, self-control, underlying mood, permeability and social potency. The test–retest reliability scores were between 0.65 and 0.76. When developing the test, greater emphasis was placed on achieving high validity than on maximally homogenous scales (Beckman and Richter, 1975). Subsequently, external validity was found to be acceptable when correlating the GT scales with the NEO personality inventory (Gunzelmann et al., 2002). 2.5. The EMBU Perceived parental rearing behavior was assessed by the short form of the EMBU (Swedish acronym for my memories of upbringing) developed from the original 81-item Swedish version (Perris et al., 1980) by Arrindell et al. (2001). The s-EMBU is a 23-item inventory with 4point Likert type scales, to be answered separately for father and mother. A factor analyses yielded three factors: (1) Rejection – implying a parental rearing characterized by physical punishment, rejection of the subject and an individual, hostility, derogation, etc.; (2) Emotional warmth – giving warm and loving attention, helping the subject, aiding through problems, able to confide in the parent, etc.; and (3) Overprotection – protection from negative experiences, high degree of intrusiveness, high expectancy to know all about the subject, imposement of strict regulations and demanding unquestioning obedience to them, etc. Validity and reliability was found to be acceptable, alpha scores ranged from 0.75 to 0.87 for the various scales (Arrindell et al., 2001). Notable is that ‘‘The s-EMBU can thus be recommended with confidence as a functional equivalent to the early 81-item version when the clinical and/or research context does not adequately permit the applica-
The data were analyzed using the Statistical Package for the Social Sciences (SPSS Inc., 1999). Multivariate analysis of variance (MANOVA), adjusted for Bonferroni, were calculated for interaction between gender, clusters and diagnosis as fixed factors and all of the EMBU scales as dependent factors. The MANOVA were also computed with gender and clusters as independent factors and the self-image and EMBU scales as dependent. Mann–Whitney U-test for comparison of means were computed for the EMBU scales according to gender in each MMPI-2 clusters and between clusters. StudentÕs t-tests were computed to test for mean differences of EMBU scales between clusters and the comparison group, 461 healthy Swedish subjects from Arrindell et al. (2001). Linear multiple regression analyses, stepwise method, were calculated for analysing the relationship between EMBU scales as independent and self-image factors of the GT, the SASB, and the LOC scales, as dependent variables, within both pain-related personality clusters. Discriminant analyses were performed to test for multivariate differences between the clusters based on EMBU scales. In addition, partial correlations were calculated between the self-image scales and the EMBU scales separately for the personality clusters controlling for social desirability, affecting the correlations exclusively in the patient groups.
4. Results When comparing means of the EMBU factors by gender for the clusters of the MMPI-2, no significant differences were found for cluster 1, whereas significant differences were found for maternal Ôemotional warmthÕ among the group of cluster 2 (z = 2.082; p = 0.037) in terms of higher scores for men. No significant main effect was found for diagnosis, in a model with gender,
H. Nordin et al. / European Journal of Pain 9 (2005) 277–284
clusters and diagnosis as fixed factors and EMBU scales as dependent. When calculating MANOVA, the m/f scale was excluded due to its lack of clinical relevance in this context, in order to obtain a significant model. Results of the MANOVA concerning self-image scales, showed significant main effects for gender (PillaiÕs Trace = 0.22; F(14/ 100) = 1.99; p = 0.026; g2 = 0.218 – based on significant differences in the factors social response, self-blame, self-attack, and self-neglect) and for clusters (PillaiÕs Trace = 40; F(14/100) = 4.69; p = 0.000; g2 = 0.40 – based on significant differences in the factors social response, underlying mood, permeability, self-affirm, active-self-love, self-blame, self-attack, self-neglect and LOC). Furthermore, regarding self-image scores, significant interaction for clusters · gender occurred (PillaiÕs Trace = .20; F(14/100) = 1.82; p = 0.046; g2 = 0.20 – based on social response and self-attack). When searching for differences on parental rearing (the EMBU scales), significant main effects emerged for clusters (PillaiÕs Trace = 0.12; F(6/128) = 2.96; p = 0.01; g2 = 0.12 – based on maternal rejection, maternal emotional warmth and overprotection – both parents). The results also showed an significant interaction between gender · clusters (PillaiÕs Trace = 0.17; F(6/ 128) = 2.01; p = 0.024; g2 = 0.09 – based on maternal rejection and emotional warmth). When using parental rearing and self-image in a more comprehensive model, the results revealed significant main effects for gender (PillaiÕs Trace = 0.20; F(14/ 100) = 1.93; p = 0.045; g2 = 0.20 – based on maternal rejection, maternal emotional warmth, active-self-love, self-blame, self-attack and self-neglect). For clusters, a significant main effect appeared (PillaiÕs Trace = 0.43; F(14/100) = 5.40; p = 0.000; g2 = 43 – based on rejection – mother, overprotection – father, overprotection – mother, underlying mood, permeability, self-affirm, active-self-love, self-blame, self-attack, self-neglect and LOC). The interaction term between gender · clusters showed significant effects (PillaiÕs Trace = 0.21; F(14/ 100) = 1.93; p = 0.031; g2 = 0.21 – based on emotional warmth – mother, self-blame and self-control). By means of discriminant analysis, based on the EMBU scales as independent variables, 81.3% of patients could be correctly classified into the MMPI-2 clusters. In Table 1, partial correlations, controlling for social desirability, between the EMBU factors and the selfimages scales, showed significant positive relationship between the Emotional warmth scales of both parents and a positive, healthy self-image for cluster 1. Furthermore, for cluster 1-patients, the EMBU scale overprotection – father related positively to healthy self-image scales as measured by the SASB and the GT. In cluster 2, rejection from both parents yielded a significant negative relationships with positive self-images and paternal
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rejection, supported internal LOC. Overprotectionscores of mothers yielded no significant relationships in any of the clusters. The multiple regression analysis (stepwise) with all of the EMBU scales as independent variables and each of the self-images scales as dependent variables revealed explained amounts of variances in the SASB self-images scales self-emancipate, self-affirm, active-self-love, selfprotect, self-control, the GT scales self-control, permeability and social potency ranging between 4% and 7% in the group of cluster 1-patients. Paternal overprotection explained 36% of the variance in the GT scale social potency and paternal rejection explained 20% in the LOC, in cluster 2-patients. Patients of the group of the ‘‘conversion-V’’ cluster reported, on average, significantly more parental emotional warmth and lower parental rejection and overprotection compared to the ‘‘general elevated’’ group (Table 2). When comparing EMBU means of cluster 1 with healthy subjects significant differences were found for all scales, except for the scale Overprotection – father, with generally lower scores for the cluster 1pain patients. The comparison of means between cluster 2 and healthy subjects revealed significant differences on the scales Emotional warmth for both parents in terms of lower scores for pain patients, overprotection – mother and rejection – mother, in terms of higher scores for cluster 2-pain patients compared to healthy subjects.
5. Discussion As several studies have shown, there are significant relationships between parental rearing and psychopathology later in life, and even between parental rearing attitudes and somatization and pain in adults (Wind and Silvern, 1994; Richter and Eisemann, 2001; Andersson and Eisemann, 2003; Lipchik et al., 1993; Lorig et al., 1999, 2001). The objectives of this study were to investigate relationships between perceived parental rearing measured by the EMBU questionnaire and various kinds of self-images measured by the SASB, the GT and the LOC in two groups of chronic pain patients characterized by differences in personality-profiles emerged from hierarchial cluster analysis of the MMPI-2 (Nordin et al., 2004a). Cluster 1 for both genders, the ‘‘conversion-V’’ profile suggested vague physical complaints, which might increase under stress. Severe anxiety and depression were usually absent. Cluster 2, the ‘‘general elevated’’ profile for both genders, was characterized by feeling overwhelmed by anxiety, tension and depression. These patients perceived difficulties in concentration and decision-making, and functioned on a low level of efficiency (Butcher and Williams, 1996; Nordin et al., 2004a).
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Table 1 Partial correlations, controlled for Social Desirability, between factors of the SASB, the GT, and the LOC with the EMBU factors by MMPI-2 pain cluster groups Cluster Giessen test Social response
Emotional warmth (father)
Emotional warmth (mother)
Over-protection (father)
Over-protection (mother)
Rejection (father)
Rejection (mother)
1 2
0.18 0.23
0.04 0.22
0.23* 0.03
0.04 0.09
0.07 0.02
0.00 0.17
Dominance
1 2
0.06 0.16
0.10 0.09
0.07 0.05
0.08 0.31
0.15 0.32
0.07 0.25
Self-control
1 2
0.10 0.15
0.03 0.30
0.13 0.07
0.16 0.17
0.04 0.30
0.07 0.28
Underlying mood
1 2
0.03 0.18
0.06 0.11
0.11 0.19
0.08 0.26
0.08 0.05
0.02 0.23
Permeability
1 2
0.22* 0.23
0.24* 0.16
0.18 0.17
0.17 0.32
0.01 0.17
0.01 0.05
Social potency
1 2
0.22* 0.10
0.24* 0.16
0.03 0.21
0.10 0.01
0.11 0.58*
0.06 0.28
0.05 0.03
0.25* 0.26
0.05 0.20
0.04 0.16
0.00 0.02
Structural analysis of social behavior Self-emancipate 1 0.17 2 0.02 Self-affirm
1 2
0.25* 0.12
0.11 0.10
0.13 0.02
0.01 0.07
0.07 0.02
0.04 0.12
Active-self-love
1 2
0.22* 0.19
0.07 0.04
0.03 0.41
0.05 0.27
0.01 0.04
0.02 0.10
Self-protect
1 2
0.22* 0.21
0.27** 0.28
0.21* 0.26
0.00 0.45
0.07 23
0.28** 0.55*
Self-control
1 2
0.17 0.29
0.26** 0.14
0.05 0.28
0.08 0.04
0.03 0.11
0.20* 0.01
Self-blame
1 2
0.07 0.24
0.05 0.25
0.02 0.03
0.07 0.19
0.06 0.11
0.00 0.36
Self-attack
1 2
0.15 0.04
0.07 0.03
0.04 0.10
0.03 0.07
0.13 0.04
0.02 0.09
Self-neglect
1 2
0.06 0.28
0.09 0.28
0.00 0.16
0.04 0.01
0.03 0.05
0.08 0.30
LOC
1 2
0.03 0.18
0.00 0.33
0.11 0.02
0.04 0.18
0.12 0.44*
0.03 0.33
* **
p < .05. p < 0.01.
We had hypothesized that there were (1) significant relationships between parental rearing and self-image; (2) there were significant differences between the MMPI-2 clusters and (3) there were significant differences between pain patients and healthy subjects regarding perceived parental rearing attitudes. The interpretation of our results were limited by: (a) lack of control group of healthy subject; (b) the small
number of men in cluster 2 (five individuals) not allowing us to draw conclusions about gender. We investigated possible differences between the EMBU scales according to medical diagnosis and gender. The result showed no significant relationships with regards to diagnosis which is in line with the studies by Binzer et al. (2003) and Nordin et al. (2004b) reporting no significant differences on the self-image scales across
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Table 2 Mann–Whitney U-test for comparisons of means between EMBU scales, and MMPI-2 clusters and StudentÕs t-test for comparisons of means between clusters and healthy subjects
Emotional warmth (father) Emotional warmth (mother) Overprotection (father) Overprotection (mother) Rejection (father) Rejection (mother)
Cluster 1 M (SD)
Cluster 2 M (SD)
Healthy M (SD)
15.24 (4.30) 16.64 (3.91) 16.57 (3.01) 17.95 (3.36) 8.01 (2.30) 7.74 (2.40)
13.10 (3.53) 12.47 (5.13) 18.14 (4.86) 21.30 (6.32) 9.42 (2.37) 11.57 (5.51)
16.42 (4.08) 17.75 (3.75) 16.82 (4.06) 19.07 (4.38) 9.24 (2.53) 9.21 (2.34)
Cluster 1 vs. 2 z/p 2.29* 3.40*** 1.21 2.40* 3.64*** 3.29***
Cluster 1 vs. healthy, df: 593 t/p
Cluster 2 vs. healthy, df: 421 t/p
3.24*** 3.33*** 0.76 3.13*** 5.71*** 7.11***
3.66*** 6.43*** 1.44 2.22* 0.32 4.09***
p < 0.05. p < 0.01. *** p < 0.001. *
**
the groups of chronic pain patients according to medical diagnosis. The results suggested that important psychological factors in chronic pain, e.g., self-image or LOC and experiences of parental rearing were independent of medical diagnosis, assuming that psychological factors are stretching over medical diagnosis and impact every-day life. Consequently, it should be more important to focus on perceived self-image in treatment, than on single diagnosis. The only gender difference found in the MMPI-2 cluster 2 should be regarded as tentative given the small sample size. The strong discriminant power of the EMBU on MMPI-2 clusters underlines results from previous studies (Nordin et al., 2004a,b) suggesting that there are at least two qualitative different groups according to psychological variables among chronic pain patients, and indicate the power of parental rearing behavior on later psychopathology. Furthermore, significant relationships were found between the EMBU scales and the selfimage scales. The EMBU measures memories of parental upbringing in three dimensions; emotional warmth, overprotection and rejection – separately for the mother and the father. In this study, especially the scale emotional warmth, for both parents, was associated with positive self-image from both the GT and the SASB in cluster 1, the ‘‘conversion-V’’ group. Not surprisingly, the rejection scores showed associations with more negative self-images in both clusters. Contrary to most studies, Overprotection was found positively (father) or not (mother) related to self-image scores. Except for the last finding, the results were in line with reports from earlier studies (Morvitz and Motta, 1992; Solomon and Serres, 1999; Pawlak and Klein, 1997). As expected the cluster 2-patients, the ‘‘general elevated’’ MMPI-2 group, scored lower on the emotional warmth scales and higher on the overprotection (mother) and rejection scales compared to cluster 1 and the comparison group. Thus, the results suggest a higher degree of parental caring attitudes associated with physical punishment and hostility among cluster 2 pain patients compared with cluster 1 and healthy sub-
jects. The result for the cluster 2 patients indicate an almost direct copying process between perceived parental upbringing attitudes and dominant self-images as presented by Nordin et al. (2004b). The results support and underline theories of early social learning for the development of the self, as stressed by e.g., Buri et al. (1992); McWilliams (1994); Perris (1994); Hagarty et al. (2002) or Benjamin (2003, pp. 48–58). The average scores of the cluster 1-patients were located between those of cluster 2-patients and the compared healthy subjects group. However, the result contrasts that of Binzer et al. (2003), suggesting that there were no significant mean differences between patients and controls concerning parental rearing. Interestingly and unexpected, the patients of cluster 1 generally scored lower than comparisons on all EMBU scales. This could be interpreted as a sign of detachment or low-attachment, parental rearing style, but demands further investigation for a more convincing explanation. It must be noted that the associations are not convincing due to the low degree of predictive power of the EMBU and the few significant correlations, indicating the influence of later life events and/or other important persons on the perceived self-image. However, the hypothesis of differences between clusters and between clusters and healthy subjects could be accepted. In summary, the results of our investigation showed significant relationships between memories of parental rearing style and perceived self-images related to personality profiles according to MMPI-2. Additionally, we found some evidence that child upbringing can be regarded as an underlying factor for the perception of chronic pain. Consequently, our results support previous conclusions that there are similar factors which are determining perception of and/or coping with psychiatric and somatic disorders (Portegijs et al., 1996; Benjamin et al., 1994). The significant differences from a healthy group (see Arrindell et al. (2001)) and between clusters on parental rearing and the significant relationship between memories of parental rearing and selfimage provide therapists with a special approach in
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