Advertisement

International Journal of Behavioral Medicine

, Volume 25, Issue 2, pp 207–214 | Cite as

Mild Depression in Low Back Pain: the Interaction of Thought Suppression and Stress Plays a Role, Especially in Female Patients

  • Kerstin Konietzny
  • Omar Chehadi
  • Irmgard Streitlein-Böhme
  • Herbert Rusche
  • Roland Willburger
  • Monika Ilona Hasenbring
Article

Abstract

Purpose

Mild depression has been shown as a precursor and as a consequence of low back pain, even in early phases of acute or subacute pain. Chronic daily life stress as well as dysfunctional pain-related cognitions such as thought suppression (TS) seem to play a role in the pain-depression cycle; however, the mechanisms of these associations are less understood. Experimentally induced TS, conceived as the attempt to directly suppress sensations such as pain, has been shown to paradoxically cause a delayed and non-volitional return of the suppressed thoughts and sensations and to increase affective distress. These dysfunctional processes are supposed to increase under high cognitive load, such as high stress.

Method

In the present cross-sectional study, we for the first time sought to examine a possible interaction between habitual TS and stress on depression in N = 177 patients with subacute low back pain (SLBP), using the following questionnaires: Subscale Thought Suppression from Avoidance-Endurance Questionnaire, Beck Depression Inventory, and Kiel Interview of Subjective Situation. A three-way ANOVA was conducted with two groups of TS (high/low), stress (high/low) and sex as independent factors and depression as dependent.

Results

Results indicated a significant three-way interaction with highest depression scores in female patients showing high TS and high stress. Overall main effects for sex and stress indicated higher depression in women and in highly stressed patients.

Conclusion

Our findings support the hypothesis that TS heightens depressive mood under conditions of high cognitive load especially in female patients with SLBP indicating a special vulnerability for depressive mood in women with SLBP.

Keywords

Depression Coping behavior Low back pain Life stress Sex differences Suppression 

Notes

Acknowledgments

This study was supported by a research grant from the German Research Foundation (Deutsche Forschungsgemeinschaft: HA 1684) awarded to MIH. We further thank Nina Kreddig for providing helpful comments.

Compliance with Ethical Standards

Funding

This study was supported by a research grant from the German Research Foundation (Deutsche Forschungsgemeinschaft: HA 1684) awarded to MIH.

Conflict of Interest

The authors have no conflict of interest to declare.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

References

  1. 1.
    Poole H, White S, Blake C, Murphy P, Bramwell R. Depression in chronic pain patients: prevalence and measurement. Pain Pract. 2009;9:173–80. doi: 10.1111/j.1533-2500.2009.00274.x.CrossRefPubMedGoogle Scholar
  2. 2.
    Haggman S, Maher CG, Refshauge K. Screening for symptoms of depression by physical therapists managing low back pain. Phys Ther. 2004;84:1157–66.PubMedGoogle Scholar
  3. 3.
    Dilling H, Mombour W, Schmidt MH, Schulte-Markwort E, Remschmidt H, editors. Internationale Klassifikation psychischer Störungen: ICD-10 Kapitel V (F) klinisch-diagnostische Leitlinien. 10th ed. Bern: Hogrefe; 2015.Google Scholar
  4. 4.
    Balague F, Mannion AF, Pellise F, Cedraschi C. Clinical update: low back pain. Lancet. 2007;369:726–8. doi: 10.1016/S0140-6736(07)60340-7.CrossRefPubMedGoogle Scholar
  5. 5.
    Hasenbring M, Marienfeld G, Kuhlendahl D, Soyka D. Risk factors of chronicity in lumbar disc patients. A prospective investigation of biologic, psychologic, and social predictors of therapy outcome. Spine. 1994;19:2759–65.CrossRefPubMedGoogle Scholar
  6. 6.
    Melloh M, Elfering A, Käser A, Salathé CR, Barz T, Aghayev E, et al. Depression impacts the course of recovery in patients with acute low-back pain. Behav Med. 2013;39:80–9. doi: 10.1080/08964289.2013.779566.CrossRefPubMedGoogle Scholar
  7. 7.
    Linton SJ. A review of psychological risk factors in back and neck pain. Spine. 2000;25:1148–56.CrossRefPubMedGoogle Scholar
  8. 8.
    Atkinson JH, Slater MA, Grant I, Patterson TL, Garfin SR. Depressed mood in chronic low back pain: relationship with stressful life events. Pain. 1988;35:47–55.CrossRefPubMedGoogle Scholar
  9. 9.
    Turk DC, Okifuji A, Scharff L. Chronic pain and depression: role of perceived impact and perceived control in different age cohorts. Pain. 1995;61:93–101.CrossRefPubMedGoogle Scholar
  10. 10.
    Hasenbring M. Endurance strategies—a neglected phenomenon in the research and therapy of chronic pain? Schmerz. 1993;7:304–13. doi: 10.1007/BF02529867.CrossRefPubMedGoogle Scholar
  11. 11.
    Hasenbring MI, Hallner D, Rusu AC. Fear-avoidance- and endurance-related responses to pain: development and validation of the avoidance-endurance questionnaire (AEQ). Eur J Pain. 2009;13:620–8. doi: 10.1016/j.ejpain.2008.11.001.CrossRefPubMedGoogle Scholar
  12. 12.
    Hasenbring M, Rusu AC, Turk DC, editors. From acute to chronic back pain: risk factors, mechanisms, and clinical implications. Oxford, New York: Oxford University Press; 2012.Google Scholar
  13. 13.
    Wegner DM, Schneider DJ, Carter SR, White TL. Paradoxical effects of thought suppression. J Pers Soc Psychol. 1987;53:5–13.CrossRefPubMedGoogle Scholar
  14. 14.
    Wegner DM. Ironic processes of mental control. Psychol Rev. 1994;101:34–52.CrossRefPubMedGoogle Scholar
  15. 15.
    Cioffi D, Holloway J. Delayed costs of suppressed pain. J Pers Soc Psychol. 1993;64:274–82.CrossRefPubMedGoogle Scholar
  16. 16.
    Masedo AI, Esteve RM. Effects of suppression, acceptance and spontaneous coping on pain tolerance, pain intensity and distress. Behav Res Ther. 2007;45:199–209.CrossRefPubMedGoogle Scholar
  17. 17.
    Purdon C. Thought suppression and psychopathology. Behav Res Ther. 1999;37:1029–54.CrossRefPubMedGoogle Scholar
  18. 18.
    Klasen BW, Brüggert J, Hasenbring M. Role of cognitive pain coping strategies for depression in chronic back pain. Path analysis of patients in primary care. Schmerz. 2006;20:398, 400-2, 404-6 passim. doi: 10.1007/s00482-006-0470-y.CrossRefPubMedGoogle Scholar
  19. 19.
    Aldao A, Nolen-Hoeksema S, Schweizer S. Emotion-regulation strategies across psychopathology: a meta-analytic review. Clin Psychol Rev. 2010;30:217–37. doi: 10.1016/j.cpr.2009.11.004.CrossRefPubMedGoogle Scholar
  20. 20.
    Hülsebusch J, Hasenbring MI, Rusu AC. Understanding pain and depression in back pain: the role of catastrophizing, help−/hopelessness, and thought suppression as potential mediators. IntJ Behav Med. 2015; doi: 10.1007/s12529-015-9522-y.
  21. 21.
    Wegner DM, Erber R. The hyperaccessibility of suppressed thoughts. J Pers Soc Psychol. 1992;63:903–12.CrossRefGoogle Scholar
  22. 22.
    Wegner DM, Erber R, Zanakos S. Ironic processes in the mental control of mood and mood-related thought. J Pers Soc Psychol. 1993;65:1093–104.CrossRefPubMedGoogle Scholar
  23. 23.
    Wenzlaff RM, Bates DE. Unmasking a cognitive vulnerability to depression: how lapses in mental control reveal depressive thinking. J Pers Soc Psychol. 1998;75:1559–71.CrossRefPubMedGoogle Scholar
  24. 24.
    Schoofs D, Preuss D, Wolf OT. Psychosocial stress induces working memory impairments in an n-back paradigm. Psychoneuroendocrinology. 2008;33:643–53. doi: 10.1016/j.psyneuen.2008.02.004.CrossRefPubMedGoogle Scholar
  25. 25.
    Beevers C, Meyer B. Thought suppression and depression risk. Cognit Emot. 2004;18:850–67.CrossRefGoogle Scholar
  26. 26.
    Wenzlaff RM, Luxton DD. The role of thought suppression in depressive rumination. Cogn Ther Res. 2003;27:293–308. doi: 10.1023/A:1023966400540.CrossRefGoogle Scholar
  27. 27.
    Wegner DM, Zanakos S. Chronic thought suppression. J Pers. 1994;62:616–40.CrossRefPubMedGoogle Scholar
  28. 28.
    Blumberg SJ. The white bear suppression inventory: revisiting its factor structure. Personal Individ Differ. 2000;29:943–50.CrossRefGoogle Scholar
  29. 29.
    Robichaud M, Dugas MJ, Conway M. Gender differences in worry and associated cognitive-behavioral variables. J Anxiety Disord. 2003;17:501–16.CrossRefPubMedGoogle Scholar
  30. 30.
    Rassin E. The white bear suppression inventory (WBSI) focuses on failing suppression attempts. Eur J Pers. 2003;17:285–98. doi: 10.1002/per.478.CrossRefGoogle Scholar
  31. 31.
    Imhof M, Schulte-Jakubowski K. The white bear in the classroom: on the use of thought suppression when stakes are high and pressure to perform increases. Soc Psychol Educ. 2015;18:431–42. doi: 10.1007/s11218-015-9301-2.CrossRefGoogle Scholar
  32. 32.
    Piccinelli M, Wilkinson G. Gender differences in depression. Critical review Br J Psychiatry. 2000;177:486–92.CrossRefPubMedGoogle Scholar
  33. 33.
    Rustøen T, Wahl AK, Hanestad BR, Lerdal A, Paul S, Miaskowski C. Gender differences in chronic pain—findings from a population-based study of Norwegian adults. Pain Manag Nurs. 2004;5:105–17. doi: 10.1016/j.pmn.2004.01.004.CrossRefPubMedGoogle Scholar
  34. 34.
    von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007:1453–7.Google Scholar
  35. 35.
    National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management. 2016:NICE guideline (NG59).Google Scholar
  36. 36.
    Hasenbring MI, Hallner D, Klasen B, Streitlein-Bohme I, Willburger R, Rusche H. Pain-related avoidance versus endurance in primary care patients with subacute back pain: psychological characteristics and outcome at a 6-month follow-up. Pain. 2012;153:211–7.CrossRefPubMedGoogle Scholar
  37. 37.
    Beck AT. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561–71.CrossRefPubMedGoogle Scholar
  38. 38.
    Kammer D. Eine Untersuchung der psychometrischen Eigenschaften des deutschen Beck-Depressionsinventars (BDI). Diagnostica. 1983;29:48–60.Google Scholar
  39. 39.
    Beck AT, Steer RA, Carbin MG. Psychometric properties of the Beck depression inventory: twenty-five years of evaluation. Clin Psychol Rev. 1988;8:77–100. doi: 10.1016/0272-7358(88)90050-5.CrossRefGoogle Scholar
  40. 40.
    Geisser ME, Roth RS, Robinson ME. Assessing depression among persons with chronic pain using the Center for Epidemiological Studies-Depression Scale and the Beck Depression Inventory: a comparative analysis. Clin J Pain. 1997;13:163–70.CrossRefPubMedGoogle Scholar
  41. 41.
    Pincus T, Burton AK, Vogel S, Field AP. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine. 2002;27:20.CrossRefGoogle Scholar
  42. 42.
    Hasenbring M, Marienfeld G, Ahrens S, Soyka D. Chronic pain factor in patients with lumbar disc herniation. Schmerz. 1990;4:138–50. doi: 10.1007/BF02527877.CrossRefPubMedGoogle Scholar
  43. 43.
    Hasenbring M, Hallner D, Rusu AC. Endurance-related pain responses in the development of chronic back pain. In: Hasenbring M, Rusu AC, Turk DC, editors. From acute to chronic back pain: risk factors, mechanisms, and clinical implications. Oxford, New York: Oxford University Press; 2012. p. 295–314.CrossRefGoogle Scholar
  44. 44.
    Hasenbring M, Kurtz B, Marienfeld G. Erfahrungen mit dem Kieler Interview zur subjektiven Situation (KISS). In: Brähler E, Dahme B, Klapp BF, Davies-Osterkamp S, Jacobi P, Koch-Gromus U, et al., editors. Psychosoziale Onkologie. Berlin: Springer Berlin Heidelberg; 1989. p. 68–85. doi: 10.1007/978-3-642-74986-5_6.CrossRefGoogle Scholar
  45. 45.
    Hasenbring M, Klasen B, Schaub C, Hallner D. KISS-BR. Kieler Interview zur subjektiven Situation – Belastungen/Ressourcen. In: Schumacher J, Klaiberg A, Brähler E, editors. Diagnostische Verfahren zu Lebensqualität und Wohlbefinden. Göttingen: Hogrefe; 2003. p. 189–91.Google Scholar
  46. 46.
    Sudhaus S, Fricke B, Schneider S, Stachon A, Klein H, von Düring M, Hasenbring M. The cortisol awakening response in patients with acute and chronic low back pain. Relations with psychological risk factors of pain chronicity. Schmerz. 2007;21:202–204, 206-11. doi: 10.1007/s00482-006-0521-4.CrossRefPubMedGoogle Scholar
  47. 47.
    Schulz-Kindermann F, Hennings U, Ramm G, Zander AR, Hasenbring M. The role of biomedical and psychosocial factors for the prediction of pain and distress in patients undergoing high-dose therapy and BMT/PBSCT. Bone Marrow Transplant. 2002;29:341–51. doi: 10.1038/sj.bmt.1703385.CrossRefPubMedGoogle Scholar
  48. 48.
    Shultz S, Averell K, Eickelman A, Sanker H, Donaldson MB. Diagnostic accuracy of self-report and subjective history in the diagnosis of low back pain with non-specific lower extremity symptoms: a systematic review. Man Ther. 2015;20:18–27.CrossRefPubMedGoogle Scholar
  49. 49.
    Grebner M, Breme K, Rothoerl R, Woertgen C, Hartmann A, Thomé C. Coping und Genesungsverlauf nach lumbaler Bandscheibenoperation. Schmerz. 1999;13:19–30. doi: 10.1007/s004829900011.CrossRefPubMedGoogle Scholar
  50. 50.
    Hallner D, Hasenbring M. Classification of psychosocial risk factors (yellow flags) for the development of chronic low back and leg pain using artificial neural network. Neurosci Lett. 2004;361:151–4. doi: 10.1016/j.neulet.2003.12.107.CrossRefPubMedGoogle Scholar
  51. 51.
    Rommel O, Kley RA, Dekomien G, Epplen JT, Vorgerd M, Hasenbring M. Muscle pain in myophosphorylase deficiency (McArdle’s disease): the role of gender, genotype, and pain-related coping. Pain. 2006;124:295–304. doi: 10.1016/j.pain.2006.04.017.CrossRefPubMedGoogle Scholar
  52. 52.
    Scholich SL, Hallner D, Wittenberg RH, Rusu AC, Hasenbring MI. Pilot study on pain response patterns in chronic low back pain. The influence of pain response patterns on quality of life, pain intensity and disability. Schmerz. 2011;25:184–90. doi: 10.1007/s00482-011-1023-6.CrossRefPubMedGoogle Scholar
  53. 53.
    Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale: Erlbaum; 1988.Google Scholar
  54. 54.
    Tabachnick BG, Fidell LS. Using multivariate statistics. 4th ed. Boston, Mass. [u.a.]: Allyn and Bacon; 2001.Google Scholar
  55. 55.
    Field A. Discovering statistics using IBM SPSS statistics. 4th ed. SAGE: Los Angeles; 2015.Google Scholar
  56. 56.
    Schmider E, Ziegler M, Danay E, Beyer L, Bühner M. Is it really robust? Methodology. 2010;6:147–51. doi: 10.1027/1614-2241/a000016.CrossRefGoogle Scholar
  57. 57.
    IBM Corporation. IBM SPSS Statistics for Windows: version 23.0. Armonk: IBM Corporation; 2015.Google Scholar
  58. 58.
    Szasz PL. Thought suppression, depressive rumination and depression: a mediation analysis. Journal of Evidence-Based Psychotherapies. 2009;9:199–209.Google Scholar
  59. 59.
    Garland EL, Brown SM, Howard MO. Thought suppression as a mediator of the association between depressed mood and prescription opioid craving among chronic pain patients. J Behav Med. 2016;39:128–38. doi: 10.1007/s10865-015-9675-9.CrossRefPubMedGoogle Scholar
  60. 60.
    Gijsbers van Wijk CM, Huisman H, Kolk AM. Gender differences in physical symptoms and illness behavior. A health diary study. Soc Sci Med. 1999;49:1061–74.CrossRefPubMedGoogle Scholar
  61. 61.
    Hammen C. Stress and depression. Annu Rev Clin Psychol. 2005;1:293–319. doi: 10.1146/annurev.clinpsy.1.102803.143938.CrossRefPubMedGoogle Scholar
  62. 62.
    McGonagle KA, Kessler RC. Chronic stress, acute stress, and depressive symptoms. Am J Community Psychol. 1990;18:681–706.CrossRefPubMedGoogle Scholar
  63. 63.
    Hammen C, Davila J, Brown G, Ellicott A, Gitlin M. Psychiatric history and stress: predictors of severity of unipolar depression. J Abnorm Psychol. 1992;101:45–52.CrossRefPubMedGoogle Scholar
  64. 64.
    Bouteyre E, Maurel M, Bernaud JL. Daily hassles and depressive symptoms among first year psychology students in France: the role of coping and social support. Stress Health. 2007;23:93–9.CrossRefGoogle Scholar
  65. 65.
    Wolf TM, Elston RC, Kissling GE. Relationship of hassles, uplifts, and life events to psychological well-being of freshman medical students. Behav Med. 1989;15:37–45. doi: 10.1080/08964289.1989.9935150.CrossRefPubMedGoogle Scholar
  66. 66.
    Burks N, Martin B, Martin MA. Every day’s problems and life change events: ongoing versus acute sources of stress. J Hum Stress. 1985;11:27–35.CrossRefGoogle Scholar
  67. 67.
    Matud MP. Gender differences in stress and coping styles. Personal Individ Differ. 2004;37:1401–15. doi: 10.1016/j.paid.2004.01.010.CrossRefGoogle Scholar
  68. 68.
    Lebe M, Hasenbring MI, Schmieder K, Jetschke K, Harders A, Epplen JT, et al. Association of serotonin-1A and -2A receptor promoter polymorphisms with depressive symptoms, functional recovery, and pain in patients 6 months after lumbar disc surgery. Pain. 2013;154:377–84. doi: 10.1016/j.pain.2012.11.017.CrossRefPubMedGoogle Scholar
  69. 69.
    Beevers CG, Wenzlaff RM, Hayes AM, Scott WD. Depression and the ironic effects of thought suppression: therapeutic strategies for improving mental control. Clinical Psycholgy: Science and Practice. 1999;6:133–48.Google Scholar
  70. 70.
    Linton SJ, Bergbom S. Understanding the link between depression and pain. Scand J Pain. 2011;2:47–54. doi: 10.1016/j.sjpain.2011.01.005.CrossRefGoogle Scholar
  71. 71.
    Wiesenfeld-Hallin Z. Sex differences in pain perception. Gend Med. 2005;2:137–45.CrossRefPubMedGoogle Scholar
  72. 72.
    Munce SEP, Stewart DE. Gender differences in depression and chronic pain conditions in a national epidemiologic survey. Psychosomatics. 2007;48:394–9. doi: 10.1176/appi.psy.48.5.394.CrossRefPubMedGoogle Scholar
  73. 73.
    Pincus T, Vogel S, Burton AK, Santos R, Field AP. Fear avoidance and prognosis in back pain: a systematic review and synthesis of current evidence. Arthritis Rheum. 2006;54:3999–4010. doi: 10.1002/art.22273.CrossRefPubMedGoogle Scholar
  74. 74.
    Sieben JM, Vlaeyen JWS, Portegijs PJM, Verbunt JA, van Riet-Rutgers S, Kester ADM, et al. A longitudinal study on the predictive validity of the fear-avoidance model in low back pain. Pain. 2005;117:162–70. doi: 10.1016/j.pain.2005.06.002.CrossRefPubMedGoogle Scholar

Copyright information

© International Society of Behavioral Medicine 2017

Authors and Affiliations

  • Kerstin Konietzny
    • 1
  • Omar Chehadi
    • 1
  • Irmgard Streitlein-Böhme
    • 2
  • Herbert Rusche
    • 3
  • Roland Willburger
    • 4
  • Monika Ilona Hasenbring
    • 1
  1. 1.Department of Medical Psychology and Medical Sociology, Faculty of MedicineRuhr-University of BochumBochumGermany
  2. 2.Department of General Medicine, Faculty of MedicineUniversity of FreiburgFreiburgGermany
  3. 3.Department of General Medicine, Faculty of MedicineRuhr-University of BochumBochumGermany
  4. 4.Department of Orthopedics, Elisabeth HospitalRuhr-University of BochumBochumGermany

Personalised recommendations