M EASURES

4.2.1 Pain

4.2.1.1 Pain localization, duration and intensity

A pain map was used to localize all pains. There was one front view and one rear view on which to draw the pain sites. The duration of all chronic pain was elicited and a grid was offered to mark pain for consecutive decades. The current pain intensity was measured with two 10–cm Visual Analogue Scales (VAS; McDowell and Newell 1996). On the first VAS (pain max) patients were asked to rate their maximal experienced pain (0= “no pain” to 10= “worst pain one can imagine”) and on the second VAS (pain min) their minimal experienced pain (0= “no pain” to 10= “worst pain one can imagine”). Pain intensity was the mean of pain max and pain min.

4.2.1.2 Pain disability

The Pain Disability Scale (PDS) in this study was based on a pain disability scale used in most of the pain clinics in northern Finland. The Pain Disability Index (PDI) (Pollard 1984, Tait et al. 1987) is a reliable measure of pain disability (Grönblad et al. 1994, Tait and Chibnall 2005). Culturally and geographically, however, the study populations lived in a rather different atmosphere than where the PDI was developed and tested (St. Louis, USA). We therefore felt obligated to conduct a pilot study with 103 pain clinic outpatients (A. Saariaho and T. Saariaho, unpublished data). The pain patients perceived strange expressions in items #1 (e.g. driving the children to school), #3 (e.g.

parties, theater, concerts, dining out), #4 (e.g. housewife or volunteer worker) and #7 (Life-Support Activity) in PDI. The correlation between PDS and PDI was high (r=.81) and both PDS and PDI were strongly associated with BDI-II (r=.56 and r=.58 respectively) and pain intensity (VAS, r=.62 and r=.62 respectively). The results of this pilot data supported the use of PDS in this cultural setting to estimate pain disability.

The Pain Disability Scale (PDS) was developed for this study. It is a 9-item self-report scale consisting of seven direct statements: “My pain is disturbing my sleep”, “… my hobbies”, “… my sex life”, “… my work”, “… my ability to move”, “… my economy”, “… my social contacts”, and two inverted statements: “I can enjoy life despite my pain”, “I can control my pain”. All the items

were self-reported on a 4-point Likert-type scale: 0 = not at all; 1 = to some extent; 2 = significantly; 3 = very much. The total score (range 0-27) reflects the overall level of pain disability. A score of 0-4 indicates ‘no disability’, a score of 5-13 ‘mild disability’, a score of 14-22

‘remarkable disability’ and a score of 23-27 ‘severe disability’. The reliability of the PDS was estimated in both samples by computing Cronbach’s alphas. The lowest acceptable alpha value can be regarded as 0.70. The alphas for the PDS scales were 0.83 in the pain patient group and 0.89 in the control group. In both cases the alpha levels were well above 0.70, indicating adequate reliability.

4.2.2 Early maladaptive schemas

Both groups completed the Finnish version of the extended Young Schema Questionnaire - short form (=YSQ-S2-extended, Appendix). It consists of two parts as follows:

1) YSQ-S2 is a 75 -item self-report, likert-type questionnaire (Young and Brown 2003b), where a value of 1 means “Completely untrue of me” and a value of 6 means

“Describes me perfectly”. Higher values describe stronger schema valence and a more maladaptive core belief. Every EMS consists of five items. Also, if two or more of these five items are rated 5 or 6, the patient has a meaningful schema (www.schematherapy.com/id111.htm), which signifies that the schema exists and is of importance in the patient's life and may have an effect on behaviour (Young et al.

2003). The YSQ-S2 is designed to assess 15 EMSs and to provide a total score reflecting the level of each EMS. The 15 subscales are as follows: Emotional Deprivation = ED, Abandonment/ Instability = AB, Mistrust/ Abuse = MA, Defectiveness/ Shame = DS, Social Isolation/ Alienation = SI, Dependence/

Incompetence = DI, Vulnerability to Harm or Illness = VH, Enmeshment/

Undeveloped self = EM, Failure = FA, Entitlement/ Grandiosity = ET, Insufficient Self-control/ Self-discipline = IS, Subjugation = SB, Self-sacrifice = SS, Emotional Inhibition = EI, Unrelenting standards/ Hypercriticalness = US. The construct validity (Welburn et al. 2002) and reliability of YSQ-S2 in clinical and research use (Waller et al. 2001) have been established.

2) When the data collection started (2004) the theoretical development of SFT was proposed to be composed of 18 EMSs but there was no short version of the YSQ

available including all 18 EMS subscales (the 15 EMSs already mentioned and Approval-seeking/ Recognition-seeking = AS, Negativity/ Pessimism = NP, Punitiveness = PU; Young et al. 2003). We (A. Saariaho and T. Saariaho) therefore made a pilot study with a different pain patient sample which completed all the AS, NP and PU EMS items from the YSQ-L3a (Young and Brown 2003a) Finnish version.

The mean of every item was calculated and the five highest valued items from every subscale were included in the YSQ-S2-extended as follows (in parentheses there is a reference of the 7 EMS items which are included in the YSQ-S3; Young 2005):

“It is important to me to be liked by almost everyone I know” (AS76)

“Accomplishments are most valuable to me if other people notice them” (AS77)(YSQ-S3-item #34)

“I find it hard to set my own goals, without taking into account how others will respond to my choices”

(AS78)

“When I look at my life decisions, I see that I made most of them with other people’s approval in mind”

(AS79)

“Lots of praise and compliments make me feel like a worthwhile person” (AS80) (YSQ-S3-item #88)

“Even when things seem to be going well, I feel that it is only temporary” (NP81) (YSQ-S3-item #17)

“If something good happens, I worry that something bad is likely to follow” (NP82) (YSQ-S3-item #35)

“You can’t be too careful; something will almost always go wrong” (NP83) (YSQ-S3-item #53)

“I focus more on the negative aspects of life and of events than on the positive” (NP84)

“People close to me consider me a worrier” (NP85)

“If I don’t try my hardest, I should expect to lose out” (PU86) (YSQ-S3-item #36)

“There is no excuse if I make a mistake” (PU87)

“People who don’t “pull their own weight” should get punished in some way” (PU88)

“If I don’t do the job, I should suffer the consequences” (PU89) (YSQ-S3-item #54)

“I often think about mistakes I’ve made and feel angry with myself” (PU90)

The original English version of the YSQ-S2 has been in clinical use in Finland for several years and the 15 aforementioned additional items (AS, NP, PU) were translated into Finnish by a group of counsellors and the whole questionnaire was back-translated blind into English by another bilingual group. An authorised translator checked the original and back-translated versions. A group of counsellors then assessed both the syntax and the cultural interpretations of each item. The original items appeared in the same order as in the YSQ-S2.

The abbreviation YSQ-S2-extended refers in this text to this Finnish version with 18 EMSs and 90 schema items.

4.2.3 Depressiveness

The assessment of depression among chronic pain patients poses a problem because of the symptom overlap between depression and chronic pain. The Beck Depression Inventory (BDI; Beck et al.

1961, 1979) is one of the most popular self-report scales, and designed to measure the intensity of depressive symptoms in psychiatric populations. However, the BDI has been criticized for being too sensitive to the somatic symptoms of chronic pain patients and hence, misleading by yielding excessive presence of depressiveness (Williams and Richardson 1993). More specifically, Morley et al. (2002) concluded that the BDI cannot measure depression in chronic pain patients. On the other hand, among Finnish pain patients (Kuusinen 2004), the BDI was shown to be a reliable measure to assess depressiveness. Kuusinen (2004) supported the use of both factors of BDI (i.e. BDISOM and BDIPSY) in assessing depression among chronic pain patients.

The Beck Depression Inventory-Second Edition (BDI-II, Beck et al. 1996) is a revision of the BDI. The original version was revised to reflect the diagnostic criteria of the Diagnostic and Statistical Manual for Mental Disorders-Forth Edition (American Psychiatric Association, 1994).

Three studies have tested the psychometric properties of the BDI-II among chronic pain patient samples (Poole et al. 2006, Harris and D'Eon 2008, Corbière et al. 2011). Poole et al. (2006) used both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) with a split sample method in a total of 1227 chronic pain patients. They confirmed a two-factor model, namely 'negative thoughts' and 'behaviour' with 18 items (the items pessimism, appetite changes and interest in sex were not included in the model). They suggested that chronic pain patients have a different pattern of item endorsement from psychiatric patient groups. Chronic pain patients scored higher on the behaviour than on the negative thoughts factor. Harris and D'Eon (2008) confirmed a three-factor model, namely 'negative attitude', 'performance difficulty' and 'somatic elements' with all 21 items included in the model. All the three aforementioned factors contributed to a second-order factor (BDI-II). Their results supported the use of the BDI-II for assessing depressive symptoms in both women and men with chronic pain. They too, found that chronic pain patients scored less on the cognitive symptoms of depression as depressed individuals without chronic pain.

Corbière et al. (2011) confirmed a three-factor model of BDI-II (cognitive, somatic and affective factors) among chronic pain patients with musculoskeletal disorders. Importantly, patients receiving medical services for depression scored higher on every factor. Eighty percent of the participants gave ‘pain’ or ‘pain and state of mind’ as the perceived cause of depressive symptoms. They, too, suggested the use of all 21 items of the BDI-II in evaluating depression among chronic pain patients.

Depressiveness was assessed with the BDI-II, also validated in Finnish language (Beck et al.

2004). All the items were self rated from 0 to 3 and summed to get a score range from 0 to 63 and higher values indicating more severe depressive symptoms. A score of 0-13 indicates minimal depressiveness (the individual faces normal ‘ups and downs’), a score of 14-19 indicates mild, a score of 20-28 moderate and a score of 29-63 severe depressive symptoms. The results of the studies by Harris and D'Eon (2008) and Corbière et al. (2011) supported the use of BDI-II total score for assessing depressive symptoms.