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Psychosomatic Medicine 61:341-345 (1999)
© 1999 American Psychosomatic Society

ORIGINAL ARTICLES

Measuring Counterdependency in Patients With Chronic Pain

Robert J. Gregory, MD and Sarah L. Berry, BS

From the Outpatient Psychiatry Consultation Program, SUNY Health Science Center, Syracuse, New York.

Address reprint requests to: Robert J. Gregory, MD, Associate Professor of Psychiatry, Director, Outpatient Psychiatry Consultation Program, SUNY Health Science Center, 750 East Adams St., Syracuse, NY 13210.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
OBJECTIVE: Some reports have characterized patients with chronic pain as counterdependent, that is, having emotional suppression, idealization of relationships, strong work ethic, a caregiver role-identity, and self-reliance. However, research has been hampered because formal measures of these traits have been lacking. In this article, we describe a five-item self-report questionnaire, the Counterdependency Scale (CDS), designed to elicit each of these traits on a Likert scale.

METHODS: The CDS was administered to 150 consecutive patients evaluated in an outpatient psychiatry consultation program.

RESULTS: CDS scores were normally distributed and had significant interitem correlations and test-retest reliability (r = 0.68). As expected, subjects with chronic pain (N = 100) had higher mean CDS scores than those without chronic pain (t = 5.6, p = .000). CDS scores were independent of demographic variables and measures of anxiety, depression, alexithymia, and somatic amplification.

CONCLUSIONS: These results suggest that counterdependency can be described by a distinct and measurable cluster of traits associated with chronic pain.

Key Words: counterdependency • pain • alexithymia • scale • depression

Abbreviations: CDS = Counterdependency Scale; BSI = Brief SymptomInventory; TAS-20 = Twenty-Item Toronto Alexithymia Scale; SSAS = Somatosensory Amplification Scale; MMPI = MinnesotaMultiphasic Personality Inventory.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
"Anyone whose mind is taken up by the hundred and one tasks of sick-nursing which follow one another in endless succession over a period of weeks and months will adopt a habit of suppressing every sign of his own emotion" (1). Freud made this observation when discussing his treatment of Elisabeth von R., a woman with chronic leg pain. Since that time, other investigators have reported that many patients with chronic pain have a cluster of traits characterized by emotional suppression, idealization of relationships, strong work ethic, a caregiver role-identity, and self-reliance.

In a case series of patients with chronic traumatic pain, Ford (2) noted that patients tended to start work in childhood and take on excessive responsibility. Coen and Sarno (3) described emotional inhibition with avoidance of conflict in a case series of patients with chronic back pain.

Controlled studies have had similar findings. Pilowsky and Bassett (4) compared 114 patients at a pain clinic with 53 psychiatric inpatients with depression using an illness behavior questionnaire. Among the pain patients, they found that "the salient feature was denial of both affective disturbance and life problems." Maruta et al. (5) compared the academic and work histories of 26 depressed psychiatric inpatients with those of 26 age- and sex-matched inpatients having lower back pain. They reported that the pain patients had less formal education but were likely to start work at an earlier age.

In a 13-month longitudinal study of 46 amputees, Parkes (6) discovered that the development of phantom limb pain correlated with personality traits of compulsive self-reliance, rigidity, and emotional suppression. Blumer and Heilbronn (7) documented detailed social and occupational histories in 129 pain clinic patients whose pain did not appear to have a somatic basis and in a comparison group of 30 patients diagnosed with rheumatoid arthritis. They reported that the "pain-prone" patients were significantly more likely to idealize spousal relationships and to have "ergomania" with work beginning at an early age, chronic overtime, and work without vacations.

To our knowledge, Barsky (8) was the first investigator to use the term "counterdependent" to summarize the personality characteristics of patients with chronic pain. Further research, however, has been limited by the lack of a validated scale or questionnaire that quantifies counterdependent traits. In the study reported here, we examined the use of the CDS, a five-item self-rated questionnaire, among patients seen for outpatient psychiatric consultation. Each item on the scale was designed to elicit each of the five counterdependency traits identified in the abovementioned studies of chronic pain populations: emotional suppression, idealization of relationships, strong work ethic, caregiver role-identity, and self-reliance (see Table 1 ). Patients rate their agreement with each item on a five-point Likert scale with "strongly agree" and "strongly disagree" as the end points.


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  		Table 1. Items of the CDS and the Specific Trait Each Item Elicits
 
Several questions were addressed in this study: (1) Do such diverse counterdependency traits, as elicited by the CDS, correlate with one another? (2) Are counterdependency traits stable over time? (3) Are counterdependency traits more common among patients who have chronic pain? (4) Is counterdependency a unique and distinct set of traits as compared with standardized measures of anxiety, depression, alexithymia, and somatic amplification?


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
The study population included 150 consecutive patients referred to the Outpatient Psychiatry Consultation Program of the SUNY Health Science Center, Syracuse, New York. Sources of referral included a general medicine clinic (N = 80), primary care physicians in the community (N = 40), and a pain treatment center (N = 30). One hundred patients suffering from chronic pain (defined as daily pain over the last 6 months) were compared with 50 patients without pain. The location of pain in most patients (N = 58) was restricted to the back and/or extremities and caused by injury or muscle strain. Mean duration of pain was 7.6 ± 7.2 years. Patients having a primary psychotic disorder, cognitive impairment, or inability to complete questionnaires were excluded from the study.

DSM-IV diagnoses and social, developmental, and occupational histories were obtained in semistructured psychiatric interviews by a board-certified psychiatrist (R.J.G.). Patients referred to the outpatient consultation program were also administered a series of questionnaires before each interview, including the BSI for anxiety and depression, TAS-20, SSAS, and CDS.

The BSI is a symptom checklist derived from the Hopkins Symptom Checklist (SCL-90) and has been shown to have good validity and reliability (9). The Toronto Alexithymia Scale and its two modified versions, TAS-R and TAS-20, are currently the most commonly used and best researched measures of alexithymia (10, 11). High rates of alexithymia have been found in patients with posttraumatic stress disorder, eating disorders, panic disorder, and substance use disorders (12). Studies of patients with chronic pain have produced mixed results (13, 14), with some evidence that alexithymia in this population is largely determined by the degree of comorbid anxiety and depression (14, 15).

As originally conceived by Barsky et al. (16), somatic amplification refers to a tendency in hypochondriacal patients to scrutinize their bodies for somatosensory input and then to amplify and misinterpret the sensation as representing a pathological process. The SSAS was designed and validated to measure this concept (17). Although somatic amplification has been used by cognitive theorists to conceptualize psychological factors in chronic pain (18), initial studies have not demonstrated elevated SSAS scores in chronic pain populations (14, 19).

The CDS was developed after clinical observations that a large subgroup of patients with chronic pain did not follow patterns of dependency, neediness, and depression frequently cited in the literature (20–22). This subgroup also seemed not to score highly on more recently developed measures of alexithymia and somatic amplification (14). Instead, these patients seemed to minimize emotional distress, to describe idealized, shallow relationships with stereotypical roles, and to lead overly productive lives until the development of their pain syndrome. Initially, 20 scale items were created to capture these personality traits. Of the 20 items, five were selected on the basis of interitem reliability and correlation with chronic pain. These five items were then used in the present study and constitute the CDS.

On approval of our institutional review board, data from interviews and questionnaires were entered into a computer database for analysis using Statistica software (Statistica, Tulsa, OK). Between-group differences were assessed by unpaired t tests for parametric variables and by {chi}2 analysis with the Yates correction for nonparametric variables. Interitem correlations were assessed by Pearson product moment correlation coefficients. Linear regression analyses were performed to ascertain the predictors of CDS scores.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
The most common psychiatric diagnosis assigned was major depression (N = 68). Subjects were more likely to be white (N = 127), female (N = 107), and married (N = 55) with a mean age of 43.2 ± 12.0 years. The mean level of education was 12.0 ± 2.1 years, and most subjects (N = 107) had a stable work history (history of full-time employment for at least two consecutive years). Fifty-three subjects admitted to physical or sexual abuse in childhood. Of these variables, only stable work history was more common among subjects with chronic pain ({chi}2 = 7.6, df = 1, p < .01).

CDS scores had a normal distribution among the 150 subjects. Most items were significantly correlated with one another (Table 2 ). As outlined in Table 3 , item-to-scale correlations were all highly significant. Cronbach’s {alpha} (0.57) was consistent with the low number of items on the scale.


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  		Table 2. Intercorrelations Among CDS Itemsa
 

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  		Table 3. Psychometric Characteristics of the CDS (N = 150)
 
To assess the stability of counterdependency traits over time, 30 subjects were randomly selected during a follow-up visit for readministration of the CDS at a median time interval of 53 days from initial CDS completion. Initial and final CDS scores were significantly correlated for each item, with an overall correlation coefficient of 0.68 (Table 3).

The mean CDS score was 2.78 ± 0.80 for the chronic pain group and 2.03 ± 0.73 for the comparison group (t = 5.6, df = 148, p = .000). Table 4 outlines the social and demographic determinants of CDS scores. Among these variables, only a stable work history predicted CDS scores for subjects with chronic pain. However, this relationship no longer reached statistical significance when responses to item 3 were controlled for in analyses of covariance (F = 1.53, df = 97, p = .220).


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  		Table 4. Linear Regression Analysis of the CDS and Sociodemographic Characteristics
 
Table 5 demonstrates the relationship between counterdependency and measures of alexithymia, somatic amplification, anxiety, and depression. CDS scores seem to be independent of these other measures.


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  		Table 5. Linear Regression Analysis of the CDS and Psychological Measures
 
Other analyses were performed in the chronic pain group to determine whether pain location or the assignment of a DSM-IV diagnosis is predictive of counterdependency traits. In logistic regression analyses, CDS scores were not significantly predicted by diagnoses of major depression (r = 0.09), personality disorder (r = 0.10), or somatoform disorder (r = 0.07). An analysis of variance of CDS scores and pain location revealed that subjects having pain only in their backs and/or extremities (N = 58) had significantly higher CDS scores than patients with head, abdominal, or multiple-site pain (F = 13.6, df = 98, p = .000). With stepwise regression, pain location in the back and/or extremities and stable work history together accounted for 14% of the variance in CDS scores.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
The results of this study support those from previous studies demonstrating counterdependency traits in a subgroup of patients with chronic pain. The strong interitem correlations of the CDS lend support to the concept of counterdependency as a distinct cluster of traits that is stable over time. Counterdependency as measured by the CDS also seems to be independent of other psychological measures that have been applied to chronic pain populations.

There was considerable interest in and controversy surrounding personality characteristics of patients with chronic pain before the 1980s. Often it was assumed that pain fulfilled unconscious needs for guilt or masochism (20, 21) or served as a release for emotional pain (22). Indeed, some of the pain patients in our study group seemed to fit this profile. Unlike the counterdependent patients, they often sought excessive medical attention, exhibited emotional lability and hostility, and met criteria for a somatoform disorder.

The more rigorous studies examining personality traits of patients with chronic pain have focused on application of the MMPI and discovery of the so-called "Conversion V" MMPI profile, that is, elevation of the hypochondriasis and hysteria scales with a lesser elevation of the depression scale. This pattern has been able to differentiate chronic pain patients from patients having acute pain (23). Results of studies attempting to correlate the Conversion V profile with treatment outcomes have been mixed (24). This profile has been criticized in that the hypochondriasis and hysteria scales are largely somatic symptom checklists. There is also one study showing modest reductions in hypochondriasis and hysteria scale scores with improvement in pain, indicating that these scales may represent nonspecific symptoms associated with coping with a chronic illness instead of preexisting personality traits (25).

Because of these and other concerns about the validity and utility of the Conversion V profile, research into personality characteristics of patients with chronic pain, including counterdependency, diminished in the 1980s. Much of the focus of psychological research has shifted to behavioral and cognitive aspects of chronic pain, such as helplessness, pessimism, and catastrophic fears (26). Treatment approaches within this theoretical model have focused on relaxation and biofeedback techniques, decreasing reinforcement of pain behaviors, and promoting more positive cognitions (27).

It is possible that counterdependency promotes chronic pain through cognitive mechanisms. Because of their reliance on productivity and autonomy to support self-esteem, counterdependent patients may perceive a greater threat from a disabling pain syndrome, which, in turn, may enhance pain perception and promote chronicity (28). On the other hand, the answer may simply be that persons who work longer hours are more likely to get injured.

Research on counterdependency has been hampered by the lack of a scale or measure for this trait. The development of the CDS is the first step toward meeting this need. Future research should include the development of a more comprehensive scale that elaborates on each of the five dimensions of counterdependency to increase internal reliability. Potential overlap of counterdependency characteristics with obsessive-compulsive personality traits is another area of exploration.

Received for publication July 16, 1998.

Revision received December 11, 1998.


   REFERENCES
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 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
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