|Year : 2015 | Volume
| Issue : 1 | Page : 8-14
Psychological experiences of patients with chronic pain: A qualitative study
Samaneh Talaei, Hasan Labbaf, Seyed Akbar Nilipour Tabatabayi, Majid Barekatain
Department of Management, Shakhes Pajouh Research Institute, Esfahan University, Esfahan, Iran
|Date of Web Publication||17-Dec-2014|
Department of Management, Shakhes Pajouh Research Institute, Esfahan University, Esfahan
Source of Support: None, Conflict of Interest: None
Background: Depression and anxiety are major health problems among chronic pain sufferers across the lifespan. Patients with high levels of depression and anxiety are likely to express fearful feeling in response to physical sensations or when stumble upon stressors or pain. Aim: The aims of this study were to identify depression and anxiety among different types of chronic pain patients, and to explore the experiences and consequences of depression and anxiety in the patient's life through a qualitative study. Materials and Methods: Thirty-seven chronic pain patients from pain clinic and neurology clinic, Universiti Kebangsaan Malaysia Medical Center, were participated in an interview for self-reported data collection. All subjects suffer from chronic pain complain of headache, shoulder, back and knee pain. The data were analyzed using interpretative phenomenological analysis. Result: Results showed that chronic pain patients with high anxiety and depression responded more fear toward their environment and underwent negative relationship with their family and others. The results also indicated that depression and anxiety problems present as the psychological elements of worry, preoccupation, rumination, and avoidance. Conclusion: Identifying depression and anxiety that accompany the discomfort during pain may help increase the intensity of pain. Management of psychological factors during pain may include increased rates of return to work, reductions in health care costs, and increased health-related quality-of-life. In addition, feeling worry about family and feeling depressed, these situations affect the emotional and physical intimacy among family members.
Keywords: Anxiety, chronic pain, depression
|How to cite this article:|
Talaei S, Labbaf H, Nilipour Tabatabayi SA, Barekatain M. Psychological experiences of patients with chronic pain: A qualitative study. Int J Health Syst Disaster Manage 2015;3:8-14
|How to cite this URL:|
Talaei S, Labbaf H, Nilipour Tabatabayi SA, Barekatain M. Psychological experiences of patients with chronic pain: A qualitative study. Int J Health Syst Disaster Manage [serial online] 2015 [cited 2020 Jan 26];3:8-14. Available from: http://www.ijhsdm.org/text.asp?2015/3/1/8/147137
| Introduction|| |
Psychological factors have been considered to be important in the onset, severity, aggravation, and maintenance of pain.  A psychological study found that if pain could not be explained by physical causes, then the source of this pain may be related to psychological factors.  In clinic practice, pain persists to be attributed to psychological causes, when physical findings are lacking, and when pain continues despite medical intervention.  Clinically, pain persists to be attributed to psychological causes, when physical findings are lacking, and when pain continues despite medical intervention.  Psychological research on pain based largely on dualistic conceptions, with the mind, separated from the body, in attempts to understand the reason of pain. , Among the psychological factors related to chronic pain, depression, and anxiety commonly occur as a result of chronic pain and needs treating to improve the quality-of-life. ,
Meanwhile, depression, anxiety, and somatization are the mental disorders in primary healthcare that are most frequently examined by scholars.  Depression is a serious problem among patients who complain of chronic pain, and it can be a combination of physical disability and threaten of emotional well-being.  Some studies ,, have shown a higher prevalence of depression among clinical chronic pain samples, compared with the general population. Depression and pain symptoms are highly prevalent conditions faced by primary care physicians and specialists.  In addition, assessment in elderly people showed that treating depression can improve pain and pain-related disabilities. ,
Wurzman et al.  reported on the association of major depressive disorder with chronic pain conditions. Asghari et al.  has suggested that the psychological factors are important in understanding, managing, and treating disability with depression among chronic pain patients. McCullough , mentioned that the emotional signs of depression included depressed mood, anhedonia, disinterest, or feeling of guilt, hopelessness, and helplessness. Somatic symptoms also include other factors that are constituents of depression such as sleeplessness, loss of appetite, loss of weight, dry mouth, and constipation. 
Averill et al.  illustrated that among chronic pain patients, depression affected single patients more than those who were married. Depression among single patients could be related to loss of attention, no buffer against negative thinking, hopelessness, and lack of financial support.  Therefore, family relationship, emotional and financial support from the family, could reduce the depression among chronic pain patients , better treatment of depression, requires increased attention to strengthen patients' relationships with comorbidity medical conditions. 
Besides, anxiety is defined as an unpleasant state that is related to apprehension, fear, distress, or discomfort, which is also associated with heightened pain perception, increased risk to physical health, and prolongation of the pain experience.  Anxiety is a response conditioned by a signal of danger. Pain is interpreted as danger, and the usual response is anxiety. , Perception of pain severity and the fear of anxiety impact significantly on fear of pain, and fear of pain extensively affect headache and avoidance behavior.  According to Hoff and Morgan,  avoidance behavior may interfere with the necessary participation in treatment to returning to the previous state of activity. In patients with chronic pain, if anxiety becomes the usual response, it may develop their experience of avoidance behavior with anxiety due to pain during movement. 
Hoff and Morgan  reported that patients who experienced chronic pain have anxiety and patients with anxiety often have a higher frequency of pain complains. They illustrated that the anxiety could occur before increased pain problem or following the development of pain. In addition, Sternbach  revealed that somatic symptoms include vertigo, diffused abnormal sensation, increased muscle tension, headache, tachycardia, and tachypnea, and chest or abdominal pain attributed to anxiety. McWilliams et al.,  noted that attempt to improve the treatment of anxiety disorders may require pain management. Therefore, the objective of this study was to identify depression and anxiety among different types of chronic pain patients, and to explore the experiences and consequences of depression and anxiety in the patient's life through a qualitative study.
| Materials and Methods|| |
This research was designed to collect self-reported data from participants using a qualitative research procedure for data collection and analysis. The study groups consisted of 37 patients were represented by both genders (15 males and 22 females) with chronic pain under follow-up at pain and neurology clinic, in Universiti Kebangsaan Malaysia Medical Center from December 2010 until March 2011.
Thirty-seven participants comprised 15 (14.54%) males and 22 (59.46%) females; all afflicted with chronic pain. In the present study, data were collected from pain clinic and neurology clinic, in Universiti Kebangsaan Malaysia Medical Centre. To confirm the number of samples that is appropriate for this study, the Mason  saturation theory was used for this purpose.
The instrument comprised of two parts, questions pertaining to demographic information of the participants, and an interview guide. The interview guide contained 21 open-ended questions developed for the purpose of this study. It was based on literature reviews with the aim of trying to understand and identify which psychological factors related with chronic pain among adult patients were most experienced by the patients.
The interviews were administrated in the meeting-room at the pain clinic and neurology clinic, in University Kebangsaan Malaysia, where the location was very private and quiet. Appointments were arranged with patient participants for the interviews, after obtaining the approval of the chief officer at each clinic. This was done after obtaining the approval of the chief officers at each clinic. To provide the participants with the maximum opportunity to guide them with the direction of the interviews, the study used an open-ended questioning approach. This method is known to provide opportunities to the participants to elaborate on topics introduced by the researcher, and then the participants were given full freedom to discuss aspects of their experiences with chronic pains, that they felt appropriate.
Each of the interviews lasted about 40 to 50 min, and all the interviews were tape-recorded. To validate that the interview process ran smoothly, one research assistant was also asked to be present during the interview. She was asked to sit next to the interviewer to help in administrative matters, such as inserting and changing the tapes, managing the tape recorder, and copying important statements as much as possible into the notebook. Meanwhile, participants were guaranteed anonymity, in that they were given permission to withdraw at any time during the interview.
| Result|| |
The data were analyzed following interpretative phenomenological analysis (IPA) method so as to create a comprehensive account of themes and subthemes that have significance in the original text.  All interviews were recorded and transcribed verbatim. The first step in the analysis involved repeated reading of the transcripts and annotated descriptions on each transcript regarding key phrases and processes. These descriptions included summaries of contents, connections between different aspects of the transcript and initial interpretations. Within each transcript, the notes were condensed to produce initial themes, with care being taken to ensure that these themes were consistent with the data. When this process had been repeated with each transcript, the resulting sets of initial themes were examined to identify recurrent patterns across the transcripts producing a final set of superordinate themes at the end of the process. The links between the themes and data set were rechecked at this stage. Finally, the themes were reorganized in such a way as to produce a logical and coherent research narrative [Figure 1].
Descriptio n of the themes and sub-themes
The raw data showed enormous richness in describing each theme of the reasons for chronic pain, as experienced by the interviewees. The interpretative process conducted on the raw data resulted in the development of two themes. These themes included anxiety symptoms and feeling depressed and frustration.
The IPA method further divides each major theme into several subthemes. As shown in [Table 1], the six subthemes revealing anxiety symptoms consist of: (i) Worry about family, (ii) worry about future, (iii) losing the family, (iv) trembling hands and sweaty palms, (v) stress, and (vi) nervousness. Feeling depressed, and frustration as them will explain about how patients suffer of chronic pain.
Under this theme, patients explained that the chronic pain was attributed to anxiety toward family members, future, and stress around them. This anxiety was based on what the patients perceived as the consequences of an anticipated recurrent of chronic pain. Most of the patients expressed that they felt worried regarding family members, futures, and prolonged pain. Moreover, some patients mentioned that feelings such as, worrying during daily life activity was attributed to the pain. This theme seems to be supported by the finding of Gliatto  which noted that anxiety disorders, particularly panic disorder, occur more frequently in patients with chronic pain.
Worried about family
0Worried about family is seen as a kind of anxiety manifested in the presence of a persistently painful condition. Patient's relationship with the members of their family may lead them to feel worried. Patients also explained that fear of unexpected happening to the family member was related to their feeling worried. This subtheme seems to find support from Gliatto's  study that anxiety disorders occur more frequently in patients with chronic pain. The following excerpts from patients are shown as examples, a 47-year-old male patient reported that he was always worried about the family and could not accept if anything terrible happened to them:
Too much worry always for my family. Cannot accept any terrible or bad thing happened to them.
Majority of the patients reported that they worried about their families. Patients expressed feeling of having to worry about their family because they feared in case something bad happened to them. Some patients reported of feeling worry about family because of strong emotion and relationship with them all the time. Therefore, patients seem to have negative interpretations of supporting family members in the future due to chronic pain. This result of present study is similar to the findings of Greenberg and Burns  that anxiety among individuals with chronic pain may be considered as integral part of the general negative affect which suffered by chronic pain patients. This study would suggest that family members may rely on patients during the pain, offering to help and taking extra burdens to reduce the feeling worry.
Worry about future
In this subtheme, patients explained that feeling worried about the future may lead to physical illness or emotional problem. Patients also reported about their specific thought and emotion as the impact of pain on their future. Patients worried about their ability to engage in daily activities and their relationship with family members in the future. These thoughts and emotions of worry about the future were common negative feelings among chronic pain patients. Result from the study shows that patients have negative expectations about the effect of their pain on their future. This subtheme seemed to be similar to that of Winterowd et al.,  which indicated that negative, unrealistic thought and beliefs usually occur as a result of having chronic pain. As an example, a female patient aged 53-year-old reported of feeling worried during moment of pain. During the period of pain, she worried about how the pain was making her worried about the future:
When I was sick, I feel worry about my future.
In this subtheme, patients expressed that they were overly worried about something that might happen in the future. They worried about the pain and the possibility of something terrible happening to them in the future. In terms of worry, some patients may experience relationship problem among family members which could then lead to being concerned about their future.
Losing the family
This is described as one of the anxiety symptoms which patients reflected their feeling about their family. Some patients reported feeling worried because they have lost a family member in the past. Other patients also reported that they were dependent on the families, and their anxiety was linked to the fear of losing a family member in the future. As an example, a 71-year-old female patient expressed her worry of the loss of her daughter:
I am very upset to lose my daughter.
Another patient, a 21-year-old female expressed that she worried about losing her parents. She seemed to have very close relationship with her father which made her anxious if something bad might happen to him.
I really worry about my father [ ] I'm afraid that maybe something bad will happen to him, because without him my life is nothing .
In this subtheme, some patients reported that having a history of family loss and the fear of losing another family member contributed to anxiety. These patients reported feeling of fear, anxiousness, and helplessness when they think about any loss that might happen within their family. MacDonald and Kingsbury  similarly found that people with the anxious attachment style show noticeable behaviors such as heightened anxiety in response to separation and conflict in close relationships, increased rejection sensitivity, and preoccupation with relationships in general compared with those with secure attachments.
Trembling hands and sweaty palms
Anxiety is signaled by the sensations of sweaty palms, a pounding heart, and trembling hands.  Some patients described of having trembling hands and sweaty palms due to pain, stress, anxiety, and nervousness. The following excerpt about trembling hands and sweaty palms was expressed by 22-year-old female patient experienced sweaty palms due to headache. She reported:
When the pain comes, my hand will sweat; my palm always sweats when the migraine come.
Only few patients (six female and one male) reported of sweaty palms and shivering hand. For these patients, the obvious reason for their trembling hands and sweaty palms were the pain, anxiety, and stress. According to Erickson,  anxiety in chronic pain is associated with physical symptoms, including sweating, muscular tension, nausea, dizziness, heart palpitations, and diarrhea.
Patients reported that there is an association between stress and their pain experience. The majority of the patients expressed their emotions that accompanied stress was apparent to chronic pain. Moreover, according to some patients, there seemed to be consistent tendency to experience stress as somatic symptoms. Chronic pain patients also mentioned that stress is related with an increased pain. For example, a 43-year-old male patient said that the pain was related to his stress. He complained from severe pain on his back during the time of stress. He said:
I feel pain after stress or sometimes when I am in stress about something, one side of my back start with heavy pain.
More than half of the patients reported that the stress contributed to their pain. Each patient explained how the pain increased as if they were being in stress. Stressful situations can be showed as challenges related to the pain experience. Similarly, in relation to this finding, Gabbard  reported that the pain causes stress, stress exacerbates pain, and personal belief about stressor influence subsequent thoughts, emotions, and behaviors.
Patients reported that the pain was due to nervousness because of being in crowded places and the company of noisy people. Among the chronic pain patients, only three patients were reluctant to participate in a crowded place. As an example, one female patient aged 40 years described that pain severity was related to the feeling of nervousness from many people being around her. She said:
I don't like too many people around. I get upset, the headache will get worse.
The result showed few patients (three chronic headache) attributed their pain and nervousness to the unquiet place and noisy people. In addition, headache and nervousness may contribute to feeling of avoidance due to ambient noise and many people being around. The result of the current study is similar to the finding of Merikangas et al.,  which indicate that recurrent headache is associated with major depression, ambivalence affective disorder, anxiety disorders, and sociophobia.
Feeling depressed and frustrated
In this theme, patients reported how the duration of pain was extremely frustrating and depressing on them. Some patients expressed that they were feeling depressed about their future because of their illness. Some patients were also feeling frustrated due to an insufficient response from medical treatment and their disability during the time of pain. Loss of physical function and the uncertainty of the duration of pain also contributed to the patients feeling of frustration. This finding is similar to that of Averill et al.  which reported that longer pain duration among chronic patients was found to be related to depression. Chronic pain patients often report their feeling of frustration, because they could not cope with the problems they encountered, especially when they faced poor social support. As an example, a male patient aged 57 reported that he could not do his daily activities properly and felt tiredness during the time of pain. He mentioned that the most difficult part of his life was related to the pain:
I cannot work well, I feel tired (during a moment of pain) happen to me sometimes. Most problems in my life are about the pain.
Another patient, a 28-year-old female, expressed her feeling about frustration because she was young, yet she was not feeling healthy due to her pain. She explained her feeling as follows:
I am still young, but my health is not good [ ] I have to take the medicine.
Patients reported feeling depressed and frustrated which are associated to the pain. This result is in accordance with that of previous research by McCullough  which stated the emotional signs of depressed people included a depressed mood, anhedonia, feeling guilty, hopelessness, and helplessness. In the present study, the patients mentioned their feeling of being depressed and frustrated, related to their disability in daily activities during moment of pain. Koleck et al.  reported that emotional distress, in the form of helplessness, hopelessness, and negative beliefs, was the most important factor related to chronic pain. In addition, elderly patients were feeling frustrated and depressed about having to bear prolonged pain and using medication. This study suggests that feeling of frustration with the persistence of pain may contribute to the psychological forms of depression. In terms of chronic pain, feeling depressed is considered the consequence of persistent pain. ,
| Discussion|| |
The total sample comprised 24 (64.87%) Malays (8 males and 16 females), 9 (24.32%) Chinese (4 males and 5 females), 3 (8.11%) Indians (1 male and 2 females), and 1 (2.70%) Iraqi. Moreover, in terms of chronic pain complaints, 24 patients (64.87%) reported of headache, 5 patients (13.51%) expressed shoulder pain, 3 patients (8.11%) had back pain, and 5 patients (13.51%) complained of knee pain.
The verbal descriptor scale was used to provide a method to rate patients' pain based on the word descriptors.  The participants described the pain they experienced during the last 2 weeks (until the date of the interview) as follows. Only one patient (2.70%) reported no pain, while 7 patients (18.92%) had mild pain, 4 patients (10.81%) experienced moderate pain, and 25 patients (67.57%) experienced severe pain. Only 1 male patient (2.70%) reported on the background of his illness and history of his nose surgery that he had during his adolescence.
According to the above-mentioned finding and based on the interview guide which was analyzed by IPA, the loss of health was the source for feeling depressed and frustrated. Despite the abundance of recent literature, their psychological connection to chronic pain is still somewhat unclear. Further research is needed to understand how to relief these psychological factors associated to chronic pain and its related unpleasant experience. The result of the present study has shown that feeling depressed and anxiety symptoms are the most common correlates of pain.
The loss of health was the source for feeling depressed and frustrated. Patients explained feelings depressed, and frustration was related to uncertainty of pain duration, disability during the time of pain, loss of physical functions, and poor response to medical treatment. Depression is related to physical illness and duration of pain persistence. , As a noted by Averill et al.,  depression is a more common complaint in people with chronic pain than those without it.
In this study, some chronic pain patients expressed that they worried about their future because of their illness, and they may get depressed more often. At other times, they may feel frustrated, and they can feel lonely, even if they have family members around them. Chronic pain patients reported that they prefer to be alone during moment of pain; but, this seemed to affect or reduce their close relationship with family members or other people. This feeling may contribute to the patient feeling depressed with prolonged chronic pain.
This result, it was shown that the loss of physical function and reduced daily living activity may be associated with the patient feeling depressed or frustrated during moments of pain. In addition, the combination of chronic pain and depression is associated with high rates of disability, problematic with social or economic condition, and high utilization of health care resources.  The present study suggests that feeling depressed and frustration may diminish the patients' interest to do daily activities or continue their communication with family members.
Another common symptom among chronic pain patients was anxiety. Anxiety was found to be common among chronic pain patients and was significantly associated with chronic pain.  In this present study, anxiety was expressed as a consistent worrying about the situation in the future or family, feeling stressed, nervousness, and the fear of losing family members. Patients were concerned about their thoughts on things that may or may not happen.
Most of the patients explained their experiences as being worried about their future, and they worried about their family members. Thus, chronic pain and disability during moments of pain may be associated to feeling worry about the future. These feelings may contribute to close a relationship of patients with their family members. Malay families are close with each other in family life activities. Family members are always involved in common activities that help build and support family bonds.  This study suggests that this close relationship among family members may be the reason for patients to be worried about their inability to take a part in daily activities and support the family during moments of pain.
More than half of the patients linked pain with stress. Stress, like other situations such as feeling worried about the future and the family, and nervousness can be associated with chronic pain. Some patients reported that the first experiences with chronic pain were associated with stress. This study suggests that these negative feelings can contribute to anxiety and may be extended to cover both of the emotional and physical aspects of chronic pain conditions.
| Conclusion|| |
In summary, the combination of depression and anxiety is associated with worse clinical outcomes during moments of pain. Thus, chronic pain often leads to anxiety, depression, and disability. Concern over poor health and fear of an uncertain future health can lead patients into search of solutions to the problems of chronic pain. The use of family emotional support may be helpful to determine when there was a change in behavior and level of function associated with the mood disorder versus the pain itself.
According to the results of the current research, we can suggest that deeper understanding of anxiety symptoms and depression can improve the quality-of-life among adults suffering from chronic pain. The findings of this research could provide useful information for pain clinics as well as in designing pain management intervention and health promotion programs. Implementation of the anxiety symptoms theme and relevant sub-theme which elicited in the current research may be one of the helpful tools in pain management.
| Acknowledgments|| |
We are grateful to the staff in charge at the pain clinic and neurology clinic of University Kebangsaan Malaysia Medical Centre and to all the participants in this study who generously spared some of their time to be interviewed.
| References|| |
Gamsa A. The role of psychological factors in chronic pain. II. A critical appraisal. Pain 1994;57:17-29.
Barlow DH, Durand VM. Abnormal Psychology: An Integrative Approach. Belmont, CA: Cengage Learning; 2012. p. 138.
Kupers RC, Konings H, Adriaensen H, Gybels JM. Morphine differentially affects the sensory and affective pain ratings in neurogenic and idiopathic forms of pain. Pain 1991;47:5-12.
Ligthart L, Gerrits MM, Boomsma DI, Penninx BW. Anxiety and depression are associated with migraine and pain in general: An investigation of the interrelationships. J Pain 2013;14:363-70.
Ellegaard H, Pedersen BD. Stress is dominant in patients with depression and chronic low back pain. A qualitative study of psychotherapeutic interventions for patients with non-specific low back pain of 3-12 months′ duration. BMC Musculoskelet Disord 2012;13:166.
Kirmayer LJ, Robbins JM, Dworkind M, Yaffe MJ. Somatization and the recognition of depression and anxiety in primary care. Am J Psychiatry 1993;150:734-41.
Faucett JA. Depression in painful chronic disorders: The role of pain and conflict about pain. J Pain Symptom Manage 1994;9:520-6.
Aguglia E, Carlino D, De Vanna M. Psychopathological aspects of pain. Neurol Croat 2006;55:46-52.
Asghari A, Julaeiha S, Godarsi M. Disability and depression in patients with chronic pain: Pain or pain-related beliefs? Arch Iran Med 2008;11:263-9.
Currie SR, Wang JL. Chronic back pain and major depression in the general Canadian population. Pain 2004;107:54-60.
Teh CF, Reynolds CF 3 rd
, Cleary PD. Quality of depression care for people with coincident chronic medical conditions. Gen Hosp Psychiatry 2008;30:528-35.
Flor H, Fydrich T, Turk DC. Efficacy of multidisciplinary pain treatment centers: A meta-analytic review. Pain 1992;49:221-30.
Valente MA, Ribeiro JL, Jensen M. Coping, depression, anxiety, self-efficacy and social support: Impact on adjustment to chronic pain. Escritos Psicol 2009;2:8-17.
Wurzman R, Jonas W, Giordano J. Chronic pain and depression: A spectrum disorder. Pain Practitioner 2008;18:20.
McCullough PK. Geriatric depression: Atypical presentations, hidden meanings. Geriatrics 1991;46:72-6.
Hooten WM, Timming R, Belgrade M, Gaul J, Goertz M, Haake B, et al
. Assessment and management of chronic pain. ICSI 2012;16:8-17.
Averill PM, Novy DM, Nelson DV, Berry LA. Correlates of depression in chronic pain patients: A comprehensive examination. Pain 1996;65:93-100.
Keostler AJ, Doleys DM. The psychology of pain. In: Tollison CD, Satterthwait JR, Tollison JW, editors. Practical Pain Management. 3 rd
ed. New York: Lippincott Williams and Wilkins; 2002. p. 33.
Greenberg J, Burns JW. Pain anxiety among chronic pain patients: Specific phobia or manifestation of anxiety sensitivity? Behav Res Ther 2003;41:223-40.
Hallowel AI. The social function of anxiety in a primitive society. Am Sociol Rev 1941;6:869-81.
Norton PJ, Asmundson GJ. Anxiety sensitivity, fear, and avoidance behavior in headache pain. Pain 2004;111:218-23.
Hoff LA, Morgan BD. Psychiatric and Mental Health Essentials in Primary Care. New York: Routledge; 2011. p. 201-2.
Sternbach RA. Psychological aspect of chronic pain. Clin Orthop Relat Res J 1977;129:15-155.
McWilliams LA, Cox BJ, Enns MW. Mood and anxiety disorders associated with chronic pain: An examination in a nationally representative sample. Pain 2003;106:127-33.
Mason M. Sample size and saturation in PHD using qualitative interviews. Forum Qual Soz Forsch Forum Qual Soc Res 2010;11:1215-22.
Smith JA, Jarman M, Osborn M. Doing interpretative phenomenological analysis. In: Murray M, Chamberlain K, editors. Qualitative Health Psychology: Theories and Method London: Sage Publication; 1999. p. 218-40.
Gliatto MF. Generalized anxiety disorder. Am Fam Physician 2000;62:1591-600, 2.
Winterowd C, Beck AT, Gruene D. Cognitive Therapy with Chronic Pain Patient. New York: Springer; 2003. p. 11.
MacDonald G, Kingsbury R. Does physical pain augment anxious attachment? J Soc Pers Relat 2006;23:291.
Erlbuan, L. Inner Strengths:
Contemporary Psychotherapy and Hypnosis for Ego-Strengthening. New Jersey: Mahwah; 1999. p. 251.
Erickson B. Depression, anxiety, and substance use disorder in chronic pain. Tech Reg Anesth Pain Manag 2005;9:200-3.
Merikangas KR, Angst J, Isler H. Migraine and psychopathology: Results of the Zurich cohort study of young adults. Archives General Psychiatry 1990;47:849-53.
Koleck M, Mazaux JM, Rascle N, Bruchon-Schweitzer M. Psycho-social factors and coping strategies as predictors of chronic evolution and quality of life in patients with low back pain: A prospective study. Eur J Pain 2006;10:1-11.
D′arcy YM. Chronic pain management. New York: Springer Publishing; 2011.p. 34
Hanim JF, Melati S. Risk and protective behaviors of family with youth misbehaviors in a collectivist society: Implications for family counseling. Couns Psychother Health 2008;4:134-61.