Full text of DOI:10.1207/S15327558IJBM0802_02

INTERNATIONAL JOURNAL OF BEHAVIORAL MEDICINE, 8(2), 103–115
Copyright © 2001, Lawrence Erlbaum Associates, Inc.
A Comparative Study of Coping
Among Women With Fibromyalgia,
Neck/Shoulder and Back Pain
Mia Mellegård, Giorgio Grossi, and Joaquim J. F. Soares
Passive coping strategies for pain (e.g., catastrophizing) have been implicated in
the development and maintenance of chronic pain conditions such as
fibromyalgia (FM). Catastrophizing may thus be independently associated with
FM, controlling for pain parameters such as intensity and complexity. This
cross-sectional study compared coping strategies for pain (Coping Strategies
Questionnaire; CSQ) among women with FM (n = 81), neck/shoulder pain (n =
76), and back pain (n = 131). Sociodemographics and pain parameters were also
assessed. FM patients reported stronger pain intensity, higher consumption of
analgesics and sedatives, and higher disability than the other patients did. They
also reported higher scores for the CSQ subscales—diverting attention,
catastrophizing, praying/hoping, and pain behaviors—and lower scores for
self-efficacy beliefs. Multivariate analyses controlling for relevant confounders
ruled out most differences in coping strategies between groups, with the excep-
tion of diverting attention and pain behaviors. The results indicate that passive
coping is not independently related to FM, but is, rather, dependent on a more
general dysfunction due to pain.
Key words: coping, fibromyalgia, neck/shoulder pain, back pain
Neck/shoulder and back pain are the most common musculoskeletal disorders in
the Western world today. For example, 50% to 80% of the general population
have experienced an episode of back pain during their lifetime (Nachemson,
Mia Mellegård and Joaquim J. F. Soares, Centre for Mental Health, Department of Public Health
Sciences, Division of Social Medicine, Karolinska Institute, Stockholm, Sweden; Giorgio Grossi,
National Institute for Psychosocial Factors and Health, Stockholm, Sweden.
Correspondence concerning this article should be addressed to Mia Mellegård, Centre for Mental
Health, Box 175 33, S–118 91 Stockholm, Sweden. E-mail: mia.mellegard@smd.sll.se

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MELLEGÅRD, GROSSI, SOARES
1991; Skovron 1992). In 90% of the cases the pain resolves within 3 to 4
months, but 2% to 10% of the patients develop chronic conditions (Snook &
Jensen, 1984; Spengler et al., 1986). Fibromyalgia (FM) is not as frequent as
neck/shoulder and back pain, but affects 2% to 4% of the general population and
accounts for 12% to 20% of patients visiting rheumatic disease clinics, with a
dominance among women (Forseth & Gran, 1992; Jacobsson, Lindgärde, &
Manthorpe, 1989; Raspe, Baumgartner, & Wolfe, 1993; Wolfe & Hawley, 1994;
Wolfe et al., 1995; Wolfe et al., 1990).
FM is a syndrome characterized by tender point pain (i.e., at least 11 of 18
specific sites of deep muscle tenderness) and widespread musculoskeletal pain
(upper and lower body) of 3 months duration or longer. The tender points are as-
sociated with characteristic symptoms such as general muscular pain, stiffness,
fatigue, and nonrestorative sleep (Wolfe, 1986, 1989; Wolfe et al., 1990). Other
frequent symptoms include irritable bowel syndrome, headache, psychological
distress, and marked functional disability (Bengtsson, Bäckman, Lindblom, &
Skogh, 1994; McCain, 1994; Yunus, Masi, & Aldag, 1989; Yunus, Masi,
Calabrao, Miller, & Feigenbaum, 1981). In addition, the patient often experi-
ences anxiety and feelings of despondency and hopelessness (Bengtsson, 1994;
McCain, 1994; Wolfe et al., 1990; Yunus, 1989). The disorder usually begins at
the age of 20 to 40 (“Consensus Document on Fibromyalgia,” 1993) and the
course is chronic with few, and generally transitory, remissions (Bengtsson et
al., 1994; Felson & Goldberg, 1986; Hawley & Wolfe, 1991; Hawley, Wolfe, &
Cathey, 1988; Ledingham, Doherty, & Doherty, 1993; Nørregard et al., 1993).
Psychological characteristics make a significant contribution to the develop-
ment of chronic disability due to musculoskeletal pain. According to the
fear-avoidance model (Waddell, Newton, Henderson, Somerville, & Main,
1993), there are individual differences in the perception of fear in response to
pain. Besides experiencing severe pain, some patients also perceive a strong fear
of pain. The patients often attempt to manage this fear by coping strategies,
which are geared to avoiding activities perceived as potentially painful. Pain
coping strategies refer to thoughts and actions patients adopt to manage pain and
its effects (e.g., Jensen & Linton, 1991; Katz, Ritvo, Irvine, & Jackson, 1996).
Coping with pain can be classified into cognitive, including pain management
techniques (e.g., distraction); and behavioral strategies, referring to actions for
managing pain (e.g., taking pain medication; Fernandez, 1986). Further, they
can reflect active or passive styles (e.g. Snow-Turek, Norris, & Tan, 1996). Ac-
tive coping (e.g., problem solving), involves attempts to relieve or control pain,
or to function in spite of it. Passive coping (e.g., praying/hoping) generally en-
tails the tendency to avoid activity, rely on others, or take pain medication to re-
duce pain. Helplessness and catastrophizing thoughts also characterize the
passive coping style (Nicholas, Wilson, & Goyen, 1992). Passive coping may
lead to physical inactivity, which in turn, is followed by physical deterioration,

GENDER DIFFERENCES IN COPING
105
for example, loss of muscular strength and mobility. These are often experi-
enced as new symptoms and act to reinforce physical and social inactivity with
deleterious effects on the mental and physical health of patients (Waddell et al.,
1993).
Generally weak associations have been found between active coping and adap-
tation to pain (e.g., Brown & Nicassio, 1987). Passive coping, mainly
catastrophizing, has consistently been associated with greater pain (Brown,
Nicassio, & Wallston, 1989; Flor & Turk, 1988; Keefe, Brown, Wallston, &
Caldwell, 1989), depression (Brown, et al., 1989; Parker et al., 1989; Sullivan &
D’Eon, 1990; Snow-Turek et al., 1996), disability (Parker et al., 1989), and poorer
psychological adjustment (Brown et al., 1989; Manne & Zautra, 1990; Parker et
al., 1989; Snow-Turek et al., 1996).
Passive coping may thus facilitate chronification of symptoms. The extent to
which passive coping may be implicated in the development of widespread pain
conditions, for example FM, secondary to a well-localized musculoskeletal pain
condition, for example neck/shoulder or back pain, remains to be elucidated. One
possible mediator between psychosocial factors (e.g., coping) and chronic, wide-
spread pain can be the activation of so-called trigger points (TPs). TPs consist of
tissue that has been damaged at an earlier stage and later on react to new strain. By
engaging surrounding tissue they can contribute to the creation of new TPs.
Groups of TPs can be involved in a negative spiral whereby physical or psycholog-
ical stress or both initiate a motor or physiological response, which in turn leads to
activation of TPs and to a localized response (pain, weakness). This may then lead
to the activation of nearby TPs and contribute to the spreading and intensifying of
the pain (Sola, 1984). Several other plausible physiological mechanisms can be
found in the literature (e.g., Hägg, 1991; Indahl, Kaigle, Reikerås, & Holm, 1997;
Lundberg et al., 1994; Schleifer & Ley, 1994).
Catastrophizing may be linked to all these mechanisms by increased physical
and mental levels of stress. It could thus be argued that the propensity to react to
pain with passive coping may be a vulnerability factor for the development or
maintenance of FM or both. If this is the case, FM patients would be expected to
report a more frequent use of passive coping strategies for pain than other patient
groups; for example, with back pain and neck/shoulder pain, independently of pain
parameters such as intensity, duration, and use of medication. If, on the other hand,
passive coping is a function of a more severe clinical picture, differences in pas-
sive coping between patient groups would be ruled out in multivariate analyses
controlling for pain parameters. We present a cross-sectional study designed to in-
vestigate differences in pain parameters and pain coping strategies among FM,
neck/shoulder, and back pain patients. FM patients were expected to report a
greater use of passive coping strategies for pain, independently of their clinical
picture. The clinical picture was compared between the three groups to see if any
differences could be found.

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MELLEGÅRD, GROSSI, SOARES
MATERIALS AND METHODS
Patients
The sample consisted of 288 female patients, aged 18 to 64 years, with FM (n =
81), neck/shoulder pain (n = 76), and back pain (n = 131). Patients were recruited
to the study while seeking help for pain at primary care and physiotherapy centers,
in a catchment area in the southwest of Stockholm. Analysis of variances
(ANOVAs) and chi-square tests (χ2) showed no significant differences between
the three patient groups with regard to age, marital status, education, or ethnic
background. The mean age of the sample was 46±11 years. Twenty-five percent
had a high educational level (i.e., university), 69% were married/cohabited, and
24% had an ethnic background (Table 1).
Measures
Demographics and sick leave. A sociodemographic questionnaire was
used to assess age, education, ethnic background (i.e., whether the patient was of
an ethnic origin other than Swedish), and marital status. Sick-leave duration dur-
ing the past 12 months (i.e., no sick leave, 1–30 days sick leave and >30 days
TABLE 1
Sociodemographic Data for Patients With FM, Neck/Shoulder Pain and Back Pain
Neck/Shoulder Pain
FM (%)
(%)
Back Pain (%)
M
SD
M
SD
M
SD
Age (years)
Education
47.2
9.1
45.4
10.9
44.8
11.6
Mandatory
High School
University
Other education
Marital status
Single
27
32
16
6
33.3
39.5
19.8
7.4
16
32
24
4
21.1
42.1
31.6
5.3
39
49
31
12
29.8
37.4
23.7
9.2
(130)
16.9
68.5
11.5
3.1
13
52
15
1
(76)
24
52
16.0
64.2
18.5
1.2
10
57
8
13.2
75.0
10.5
1.3
22
89
15
4
Married/cohabit
Divorced/separated
Widow/er
1
Ethnic backgroundd
Yes
31.6
68.4
17
59
22.4
77.6
33
98
25.2
74.8
No
an = 81. bn = 76. cn = 131. dWhether the patient was of an ethnic origin other than Swedish.

GENDER DIFFERENCES IN COPING
107
sick leave) was also measured. The patients were also asked to complete the fol-
lowing measures. All questionnaires were preceded by instructions.
Pain variables. The Pain Questionnaire (Arnér, 1984; Carlsson, 1984) was
used to collect data on pain duration, frequency, complexity (i.e., one or several
types of pain), and intensity (least to worst through a visual analogue scale (VAS)
graded from 0 (no pain) to 10 (worst conceivable pain). Intake of analgesics and
sedatives (regularly, occasionally, and never) were also assessed. Finally, disabil-
ity was evaluated by an index consisting of 15 items (yes or no answers) about dif-
ferent aspects of disability related to pain, mobility, and social life, where a high
score corresponds to high disability. Cronbach for the disability index was .84. Re-
liability and validity for the entire Pain Questionnaire are reported in Arnér and
Carlsson.
Coping strategies questionnaire. The Coping Strategies Questionnaire
(CSQ; Rosenstiel & Keefe, 1983) assessed the patients’ coping abilities. It consists
of 44 items measuring the extent to which respondents engage in six different cog-
nitive and two behavioral pain coping strategies. The cognitive coping strategies
include (a) diverting attention (thinking of things that serve to distract one from the
pain), (b) reinterpreting pain sensations (imagining the pain as a different sensa-
tion, e.g., heat, or as a sensation that appears outside the body), (c) coping self-state-
ments (telling oneself that one can cope with pain, no matter how bad it gets), (d) ig-
noring pain sensations (denying that the pain hurts or affects one in any way), (e)
praying/hoping (telling oneself to hope and pray that the pain will get better some-
day), and (f) catastrophizing (negative self-statements, negative beliefs about fu-
ture, catastrophizing thoughts and ideations). The two behavioral coping strategies
include (a) increasing behavioral activities (engaging in activities that divert one’s
attention from the pain) and (b) pain behaviors (overt pain behaviors that reduce
pain sensations, such as taking analgesics). The perceived effectiveness of the cop-
ing efforts was rated with two items: control over pain and ability to decrease pain.
These two items were summed up in an index of self-efficacy.
The CSQ items are graded from 0 to 6, with a high score representing a more
frequent use of coping strategies. The Swedish version of the CSQ, has a satisfac-
tory internal consistency, that is, alphas ranging from .70 to .80 (Jensen & Linton,
1993).
Design and Procedure
The design was cross-sectional. Diagnoses were established by general practitioners
or rheumatologists. Neck/shoulder and back pain were assessed according to the
Swedish version of the ICD–9 (Socialstyrelsen, 1987). FM was diagnosed according

108
MELLEGÅRD, GROSSI, SOARES
to the American College of Rheumatology (ACR) criteria (Wolfe et al., 1990), that
is, widespread pain (upper and lower body) of 3 months’ duration or longer in com-
bination with tenderness at 11 or more of the 18 specific tender point sites on digital
palpation or by use of a dolorimeter with a force of 4 kg. No reliability tests were
conducted on the diagnoses. All patients were volunteers and gave their informed
consent to participate in the study. Confidentiality was guaranteed. Ethical com-
mittee approval was sought and given.
Statistical Analysis
Differences between the diagnostic groups in terms of sociodemographics, pain-re-
lated data, coping, and disability were evaluated by chi-square tests (χ2) and
ANOVAs with the post hoc Tukey HSD and the Bonferroni correction tests. The
associations between diagnoses and coping were examined by means of multiple
linear regressions, controlling for possible confounders. All tests were two-tailed
and the alpha level of p < .05 was used for all the analyses.
RESULTS
Pain Characteristics
There was an overall significant difference between the three groups (Table 2) re-
garding pain intensity, F(2, 275) = 11.58, p < .0001) and duration, F(2, 270) =
10.83, p < .0001). Post hoc tests showed that FM patients had higher pain intensity
and longer pain duration (all, p <.0001), compared with the two other diagnoses.
Further, chi square tests indicated that the FM patients experienced their pain as
more frequent, χ2 (8) = 70.15, p < .0001 and complex than the other patients groups;
that is, had different types of pain, χ2 (2) = 18.09, p < .0001). In addition, they con-
sumed more analgesics, χ2 (4) = 16.93, p < .01 and sedatives, χ2 (4) = 43.30, p <
.0001. Finally, an overall significant difference between the diagnostic groups was
observed in terms of perceived disability, F(2, 279) = 66.89, p < .0001). Post hoc
tests revealed that patients with FM felt more disabled than neck/shoulder (p <
.0001) and back pain patients (p < .0001).
Coping
Our hypothesis stated that the FM patients would have a poorer ability to cope with
pain (e.g., more catastrophizing) than neck/shoulder and back pain patients.
The ANOVAs (Table 3) provided support for the hypothesis with respect to
praying/hoping, F(2, 284) = 8.40, p < .0001, and catastrophizing, F(2, 285) =
14.69, p < .0001. Post hoc tests demonstrated that the differences could be at-

GENDER DIFFERENCES IN COPING
109
TABLE 2
Clinical Characteristics of Patients With FM, Neck/Shoulder and Back Pain
FMa
Neck/Shoulder Painb
Back Painc
M
Characteristics
n
M
SD
12
n
M
SD
n
SD
Pain intensity (0–100)
76 85.43
Pain duration (months) 73 65.6
74
72
73.49
28.5
17
65.9
128
128
130
75.52
31.8
20
44.3
60.8
Sick-leave
75
No sick-leave
1-30 days
>30 days
7
10
58
9.3
13.3
77.3
22
32
22
28.9
42.1
28.9
43
46
41
33.1
35.4
31.5
Pain complexity (type)
One type
Several types
Pain frequency
All the time
10
71
12.3
87.7
32
44
42.1
57.9
128
30.3
13.2
21.1
30.3
5.3
43
86
33.3
66.7
52
16
8
4
1
64.2
19.8
9.9
4.9
1.2
23
10
16
23
4
25
14
51
25
13
19.5
10.9
39.8
19.5
10.2
All the timed
Almost all the time
Almost every day
Almost every week
Use of analgesics
Regularly
28
39
14
34.6
48.1
17.3
9
37
30
11.8
48.7
39.5
25
64
42
19.1
48.9
32.1
Occasionally
Never
Use of sedatives
Regularly
Occasionally
Never
19
16
44
24.1
20.3
55.7
2
9
2.6
11.8
85.5
4
10
117
5.51
3.1
7.6
89.3
3.40
65
4.55
Disability (0–15)
75 10.45
3.05
3.86
an = 81. bn = 76. cn = 131. dExcept 1 hr or so immediately after treatment.
tributed to a more frequent use of praying/hoping by the FM patients versus
neck/shoulder (p < .5) and back pain patients (p < .0001). Similar results were
obtained for FM patients versus back pain and neck/shoulder pain patients re-
garding catastrophizing (p < .0001) and p <.05, respectively). An overall signifi-
cant difference was shown between the diagnostic groups concerning the coping
strategies pain behaviors, F(2, 285) = 13.19, p < .0001 and diverting attention,
F(2, 285) = 14.27, p < .0001. The differences were related to higher scores for
these coping strategies among FM patients (all post hoc tests p < .0001). Finally,
an overall difference in scores for self-efficacy beliefs was observed between
the groups, F(2, 257) = 5.57, p < .01, which according to post hoc testing was
due to lower scores on self-efficacy beliefs for FM patients compared to back
pain patients (p < .01).

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MELLEGÅRD, GROSSI, SOARES
Multivariate Analyses
A series of multiple linear regression analyses was performed to investigate the as-
sociations between diagnostic groups and coping strategies after adjustment for
confounders. In these analyses, diagnostic groups, age, and ethnic background
were used as independent variables together with those variables that were found to
TABLE 3
Coping Strategies Among Patients With FM, Neck/Shoulder Pain and Back Pain
Fibromyalgiab
Neck/Shoulder Painc
Back Paind
Coping Strategiesa
M
SD
M
SD
M
SD
Diverting attention
15.51
5.14
6.16
6.10
6.21
7.22
7.00
8.95
5.61
4.99
2.13
10.76
3.83
18.49
13.32
9.78
6.30
5.42
7.73
6.37
6.70
7.37
7.43
5.38
2.05
11.04
4.95
18.44
13.28
8.79
11.61
15.73
16.26
6.71
6.92
5.69
8.49
8.14
7.17
7.87
7.94
6.16
2.32
Reinterpreting pain sensations
Coping self statements
Ignoring sensations
17.22
11.77
12.83
15.94
18.12
19.17
5.52
Praying/hopinge
Catastrophising
9.09
Increased behavioural activities
Pain Behaviours
Self-efficacy believesf
16.28
14.64
6.41
aThe CSQ-items are graded from 0–6, with a high score representing a more frequent use of coping
strategies. bn = 81. cn = 76. dn = 131. eFor Fibromyalgia, n = 80. fFor Fibromyalgia n = 54; for back pain n
= 130.
TABLE 4
Multiple Linear Regression Analysis of the Associations Between FM,
Neck Pain and the Coping Strategies Diverting Attention and Pain Behaviors
Predictors
Diverting Attention Std. β
Pain Behaviors Std. β
Age
.119
.054
.200*
.034
.080
.117
.039
–.057
.000
.105
–.001
.139
.099
.029
–.045
.203*
.099
.129
.062
.294**
.054
–.060
–.022
.011
Ethnic background
FM patients
Back pain patients
Disability
Sick leave
Use of analgesics
Use of sedatives
Pain frequency
Pain duration
Pain intensity
R2
.241
.241
Adjusted R2
*p < .05. **p < .001.

GENDER DIFFERENCES IN COPING
111
TABLE 5
Multiple Linear Regression Analysis of the Associations
Between FM and Back Pain Regarding Coping Strategy Diverting Attention
Predictors
Std. β
Age
.119
.054
.172*
.030
.080
.117
.039
–.057
.000
.105
–.001
.139
.139
Ethnic background
FM patients
Neck pain patients
Disability
Sick leave
Use of analgesics
Use of sedatives
Pain frequency
Pain duration
Pain intensity
R2
Adjusted R2
*p < .05. **p < .001.
be unevenly distributed between groups, that is, disability, sick leave, use of anal-
gesics and sedatives, pain frequency, duration, and frequency. The coping vari-
ables praying/hoping, catastrophizing, pain behaviors, diverting attention, and
self-efficacy were treated as dependent measures. The associations between diag-
nostic groups and praying/hoping, catastrophizing, and self-efficacy were ruled out
by the introduction of confounders. However, the diverting attention strategy was
used more often by FM patients than neck pain patients (std. β = .20, p < .05; Table
4) and back pain patients (std. β = .172, p < .05; Table 5). FM patients also used
more pain behaviors than the neck pain patients did (std. β = .203, p < .05). Among
the confounders, use of analgesics was positively associated with scores for pain
behaviors (std. β = .294, p < .001).
DISCUSSION
This cross-sectional investigation studied differences in coping strategies be-
tween patients with three different pain conditions, that is, FM, back pain, and
neck/shoulder pain. FM patients were hypothesized to manifest more passive
coping than the other groups, also after taking relevant confounders into consid-
eration. The patients with FM had a poorer clinical picture than the other patient
groups. They had had their pain much longer and experienced it as more fre-
quent, intensive, and complex. In addition, they consumed more analgesics and
sedatives, felt more disabled, and had been on sick leave longer. The results con-

112
MELLEGÅRD, GROSSI, SOARES
cerning differences in the use of coping strategies between the three diagnostic
groups were, in part, consistent with our hypothesis. FM used more of the pas-
sive coping strategies—praying/hoping and catastrophizing—but also more di-
verting attention and pain behavior than the other patients. They also reported
lower scores for self-efficacy beliefs than back patients. With the exception of
diverting attention and pain behaviors, the differences in coping strategies were
ruled out when relevant confounders were taken into consideration. An explana-
tion of these results is that the high levels of passive coping displayed by FM pa-
tients are not related to an enduring propensity toward maladaptive responses to
pain but, rather, to a generally greater physical disability.
Further analyses conducted separately among the three diagnostic groups re-
vealed that diverting attention was related to longer pain duration among FM pa-
tients, and to use of analgesics among patients with neck/shoulder pain. The
importance of this cognitive coping strategy for patients’ adaptation is, however,
unclear. Diverting attention has been described as an adaptive coping strategy by
some authors (e.g., Martin et al., 1996), and as a maladaptive one by others (e.g.,
Nicassio, Schoenfeld-Smith, Radojevic, & Schuman, 1995). In our sample of
FM patients it was largely unrelated to pain parameters, thus any conclusions of
its’ effectiveness are unwarranted.
The pain behaviors’ subscale of the CSQ measures overt behaviors aimed at
managing pain, that is, taking medication, resting, walking, relaxing, taking hot
showers or baths, and using electric pads. Based on the item content of this scale,
the associations with use of analgesics and sedatives observed among patients with
neck/shoulder pain, and FM, respectively, could thus be expected. Among FM pa-
tients, pain behaviors were performed more frequently by those with a foreign eth-
nic background, indicating that they are more prone toward overt behavioral
coping with pain than Swedes. Also in the FM group, pain behaviors were related
to less frequent pain. This may indicate that pain behaviors may be efficacious in
decreasing the frequency of pain in this patient group.
The study has a number of limitations that must be acknowledged. For instance,
the questions about use of medications and the pain behaviors’ subscale of the CSQ
have very similar content, and therefore not surprisingly show strong associations.
Obviously, the main limitation of this study consists of the cross-sectional design,
whichprecludescausalinterpretationsoftheresults.Inspiteoftheselimitations,the
findingsextendourknowledgeaboutthedifferentialcopingmodesamongthestud-
ied patient groups in failing to show independent relations between FM and passive
coping. Rather, FM patients greater use of catastrophizing and praying/hoping was
attributable to a greater impact of pain on physical functioning.
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