خشم در درد مزمن: تحقیق اهداف و شدت خشم

The study was designed to assess the frequency and intensity of patients' anger directed toward various potential targets and how intensity of anger toward different targets was related to the chronic pain experience. Ninety-six chronic pain patients who were referred for a comprehensive evaluation completed questionnaires to assess their levels of anger, pain, distress, and disability. Approximately 70% of the participants reported to have angry feelings. Most commonly, patients reported to be angry with themselves (74%) and health care professionals (62%). The relevance of anger to chronic pain experience seemed to vary across targets. Anger toward oneself was significantly associated with pain and depression, whereas only overall anger was significantly related to perceived disability. The results suggest that anger should be conceptualized as a multifactorial construct. In addition to presence, intensity, and expression of anger, targets of anger may be important to better understand psychological adaptation to chronic pain.

The role of affective factors in the experience of pain has received a great deal of attention over the past few decades. The significance of affect has been incorporated within the definition of pain formulated by the International Association for the Study of Pain [1] in which pain is defined as a sensory and emotional experience. In research evaluating emotion in chronic pain, the greatest amount of attention has been devoted to depression and anxiety. Anger as an emotional feature in chronic pain has received relatively little empirical investigation, although anecdotally chronic pain patients are observed to exhibit high levels of anger and hostility 2, 3 and 4. Several empirical studies provide preliminary support for the association between anger and pain intensity 5 and 6, unpleasantness of pain [7], affective component of pain [8], and emotional distress in chronic pain patients 3, 9 and 10 as well as families of chronic pain patients [4]. Kerns and associates [11] found that the suppressed feelings of anger accounted for a significant portion of the variance in pain intensity, perceived interference, and frequency of pain behaviors. These preliminary investigations have focused primarily on the intensity and expression of anger in chronic pain patients. There seems to be a growing consensus that a substantial majority of chronic pain patients experience a significant level of anger. Anger in chronic pain has been considered by some to be attributable to enduring personality dispositions associated with unconscious conflicts [12], whereas others have suggested that anger may be a reaction to the presence of recalcitrant symptoms that have been unsubstantiated by objective medical findings and unrelieved by medical treatments [2]. There is some evidence supporting the latter hypothesis. For example, a laboratory study [13] demonstrated that mere anticipation of pain was sufficient to provoke angry behavioral responses in healthy individuals. Using the crosslagged design with a clinical sample, Arena et al. [14] found that an increase in pain tends to precede anger, directly contradicting the anger–somatization association. The relatively fruitless debate over the cause–effect relationship between anger and pain is reminiscent of the arguments on the associations between pain and depression (see ref. 15). To refine our understanding of the association between anger and pain beyond this debate, several investigators have begun to examine individual differences in how anger is expressed. In an early study, Pilowsky and Spence [16] found that chronic pain patients are less willing to express anger compared with out-patient medical patients. Similarly, individuals with chronic pain problems appear to inhibit their anger compared to pain-free, healthy individuals 17 and 18. Furthermore, inhibition of anger seems to contribute to aversiveness of the chronic pain experience. Inhibition of anger has been found to be related to pain severity and overt pain behaviors [11] as well as to increased emotional distress 10 and 19. Denial of anger also seems to be common among chronic pain patients. However, awareness of anger should not be confused with anger expression. For example, Corbishely et al. [20] observed that chronic pain patients tend to show strong reservation about expressing socially undesirable emotions that could create interpersonal conflict. For these individuals, it appears that expression of the emotion is under conscious control. They are aware of their anger but choose not to express it. On the other hand, some chronic pain patients may lack awareness of their angry feelings and have increased difficulties in recognizing and reporting these feelings [21]. Fernandez and Turk [2] recently proposed that the specificity of targets toward which patients experience angry feelings may be important in understanding of the relationship between pain and anger. When a pain sufferer is angry, there are a range of possible targets (e.g., employer, insurance company, health care providers). The presence of intensity of anger toward different targets may be differentially related to the chronic pain experience. That is, there may be some targets of anger that are more relevant to the chronic pain experience than others. Thus, one of the purposes of the present study was to delineate the prevalence and intensity of anger toward a set of specific targets. In addition, the relationship between pain and anger directed toward various targets was evaluated. Another important issue regarding anger concerns gender differences. There is growing literature suggesting the presence of important differences in the ways that men and women respond to pain [22]. Moreover, in Western cultures, there appear to be social conventions regarding the expression of anger. In general, it seems acceptable for men to display angry feelings, whereas women are socialized to avoid overt expression of anger. However, research investigating gender differences in anger expression has revealed equivocal results. Some studies report that women report significantly higher levels of generalized anger than males (e.g., ref. 23), some report the opposite results 3, 24 and 25, and still others report no gender differences in anger expression 26 and 27. In the chronic pain population, some studies note that male patients seem to acknowledge angry feelings more readily than do female patients 3 and 25. In contrast, other investigators [28] suggest that there may be substantial variability within groups of men and women. There seems to be a subgroup of women who do outwardly express anger, whereas some male patients may suppress their anger. Considering these inconsistent results in the literature, a second purpose of the present study was to compare the prevalence and intensity of anger directed toward different targets for men and women.