sullivan feb 2000

7/26/2019 Sullivan Feb 2000

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Cognitive Therapy and Research, Vol. 24, No. 1, 2000, pp. 121-134

Gender Differences in Pain and Pain Behavior:The Role of Catastrophizing

Michael J. L. Sullivan,1,3 Dean A. Tripp,2 and Darcy Santor1

This research examined gender differences in catastrophizing and pain in 80 healthstudents (42 women, 38 men) who participated in an experimental pain procedurParticipants completed the Pain Catastrophizing Scale (PCS; Sullivan, Bishop Pivik, 1995) prior to immersing one arm in ice water for 1 minute. Participants welater interviewed to assess the strategies they used to cope with their pain. Independeraters examined videotape records and coded participants pain behavior during anfollowing the ice water immersion. Results showed that women reported more inten

pain and engaged in pain behavior for a longer period of time than men. When PCscores were statistically controlled, gender was no longer a significant predictor pain or pain behavior. For women, the helplessness subscale of the PCS contributeunique variance to the prediction of pain and pain behavior. For men, none of the PCsubscales contributed unique variance to the prediction of pain and pain behavioDiscussion addresses the social learning factors that may contribute to gender diffeences in pain. Discussion also addresses the limitations and clinical implications the findings.

KEY WORDS: pain; pain behavior; catastrophizing; gender differences.

There is a growing literature suggesting that gender is an important determinaof pain experience (Lautenbacher & Rollman, 1993; Levine & De Simone, 199Unruh, 1996). The findings of several clinical and experimental investigations sugest that women experience more frequent and more intense pain than men (CrooRideout, & Browne, 1984; Lautenbacher & Rollman, 1993; Taylor & Curran, 1985

Currently, the factors that contribute to gender differences in pain experience aunclear. The primary purpose of the present research was to examine the ro


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122 Sullivan, Tripp, and Sant

GENDER DIFFERENCES IN CLINICAL PAIN

Although research findings have been mixed, the available literature generalsupports a relation between gender and pain. Numerous studies have shown th

women are more likely than men to experience pain in response to a variety medical conditions and aversive medical procedures (see Unruh, 1996, for a reviewFor example, women report more frequent tension and migraine headaches thamen (Rasmussen, 1993; Rasmussen & Breslau, 1993). Women report more frquent and intense musculoskeletal pain than men (Andersson, Ejlertsson, Lede& Rosenberg, 1993; Hasvold & Johnsen, 1993). Pain due to arthritic conditiosuch osteoarthritis, rheumatoid arthritis, and fibromyalgia is also reported mofrequently by women than men (Verbrugge, Lepkowski, & Konkol, 1991).

Women also differ from men in their behavioral responses to pain. For exampwomen report more health care utilization than men (Taylor & Curran, 1985; VoKorff, Wagner, Dworkin, & Saunders, 1991). In several studies, women have beeshown to take more sick days than men in response to pain, and women are molikely than men to go on short-term disability following the onset of a pain-relatecondition (Crook, 1993; Hertzberg, 1985; Taylor & Curran, 1985; Verbrugge, 1985

Although the clinical pain literature can provide useful insights on the relatiobetween gender and pain, the results of clinical studies examining gender differencin pain and pain-related behavior can be difficult to interpret. For example, gende

related differences in comfort with help seeking may yield gender difference reports of pain and disability, and yet be unrelated to actual pain experiencInterpretive difficulties also arise when one considers the lack of consistency reported findings on gender differences in clinical pain. Several investigations havfailed to show evidence of gender differences in clinical pain (Faull & Nicol, 198Larson, 1991; Lester, Lefebre, & Keefe, 1994; Manahan et al. 1985). It is possibthat self-selection or referral biases associated with different clinical settings mainfluence the probability of detecting gender differences in pain experience. Heter

geneity of samples with respect to the nature and severity of the condition givinrise to pain may also decrease the power to detect gender differences. To circumvethese interpretive difficulties, investigators have attempted to examine the relatiobetween gender and pain experience in asymptomatic individuals in response experimental pain procedures.

GENDER DIFFERENCES IN EXPERIMENTAL PAIN

Research has revealed significant gender differences in pain experience t id f i t l i d I f th l


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Gender, Catastrophizing and Pain 1

applied to the Achilles tendon (M 28.7 pounds per square inch) than wome(M 15.9 pounds per square inch). It has also shown that women have lower pathresholds for pressure applied to fingers and toes (Brennum, Kjeldsen, Jensen, Jensen, 1989), and to a wide range of muscle groups (Fisher, 1987; Jensen, Rasmu

sen, Pedersen, Lous, & Olesen (1992).Feine, Bushnell, Miron, and Duncan (1991) examined gender differences response to a noxious heat stimuli in a sample of young adults consisting of 20 womand 20 men. Subjects were asked to rate the intensity of pain they experienced frothermal electrodes placed on their upper lip. Results showed that women rated thheat stimulus as more painful than men. Interestingly, women also showed modiscrimination between heat stimuli of varying intensities than men (see also Gookasian, 1980). Weisenberg, Tepper, and Schwarzwald (1995) have recently reportelower pain tolerance in women in response to immersing one arm in a containof ice water. In the latter study women also reported higher levels of anxiety thamen and obtained lower scores on a measure of perceived ability to cope with pa(i.e., self-efficacy).

Although the results of the investigations described above suggest that, acroa variety of painful stimuli, women report higher levels of pain than men, severinvestigations have failed to detect significant gender differences in pain (Clark Mehl, 1971; Harkins & Chapman, 1977; Kenshalo, 1986; Lautenbacher & Stria1991; Neri & Aggazani, 1984; Sullivan, Bishop, & Pivik, 1995; Sullivan, Rous

Bishop, & Johnston, 1997). The basis for the inconsistencies in findings is uncleaLautenbacher and Rollman (1993) have suggested that certain types of painfstimulation such as pressure pain or electric shock may be more likely to revegender differences than heat or cold. Levine and De Simone (1991) have suggestethat the sex of the experimenter may be a significant factor determining observegender differences in pain. It has also been suggested that sample sizes are frequenttoo small to detect gender differences (Sullivan et al. 1995).

The inconsistencies in findings highlight the possibility that a correlate

gender, as opposed to gender itself, may be the variable that accounts for thobserved relation between gender and pain experience. Cross-study variations pain-related correlates of gender may exaggerate gender differences in some circumstances and obscure them in others. There is a basis for predicting that genddifferences in catastrophizing may mediate the relation between gender and pain eperience.

THE ROLE OF CATASTROPHIZING

Cli i l d i t l i ti ti h h th t t t hi i


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concept that comprised three related components: rumination, magnification, anhelplessness (Sullivan et al. 1995, study 1). Sullivan et al. (1995) suggested thrumination and magnification may be related to primary appraisal processes wheindividuals may focus on and exaggerate the threat value of a painful stimuli (c

Lazarus & Folkman, 1984). Helplessness may be related to secondary appraisprocesses where individuals negatively evaluate their ability to deal effectively wipainful stimuli.

Research has shown that women engage in catastrophic thinking to a greatdegree than men. Sullivan et al. (1995, study 1) reported that women obtainehigher scores than men on the rumination and helplessness subscales of the PaCatastrophizing Scale (PCS; Sullivan et al. 1995). No gender differences were founfor the magnification subscale of the PCS. These findings have been replicated a recent re-examination of the psychometric properties of the PCS (Osman, BarrioKopper, Hauptmann, Jones, & ONeill, 1997). Research on coping with chronpain has also shown that women are more likely to catastrophize than men (JenseNygren, Gamberale, Goldie, & Westerholm, 1994).

The present study examined the role of catastrophizing in mediating the relatiobetween gender and pain experience. Men and women were asked to immerse onarm in a container of ice water and to provide ratings of their pain experiencParticipants were videotaped during the procedure to allow for coding of pabehaviors. The following predictions were made:

1. Women will report higher levels of pain than men in response to ice wter immersion.

2. Women will display more pain behavior than men in response to ice wter immersion.

3. Women will score higher than men on the measure of catastrophizing.4. When levels of catastrophizing are statistically controlled, the relation b

tween gender and pain will no longer be significant.

This study also explored the relations among gender, coping, and pain, anexamined the components of catastrophizing that were most strongly associatewith heightened pain experience in women and men.

METHOD

Participants

F t t d 38 h ll d i I t d t P h l


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Apparatus

A cold pressor apparatus was used consisting of an insulated container, measuing 30 40 30 cm, divided into two compartments separated by a wire mesThe entire container was filled with water, and one compartment was filled wi

ice. The other compartment was equipped with a moveable armrest used to immera participants arm in the ice water. Water temperature was maintained at 2 4C. Participants were videotaped during the procedure using a Hitachi VM-2300VHS video camera positioned behind a one-way mirror. Participants were awathat they were being videotaped, but they could not see the video camera.

Measures

The Pain Catastrophizing Scale (PCS; Sullivan et al. 1995)

The PCS is a self-report measure of catastrophic thinking associated with pathat consists of 13 items describing different thoughts and feelings that individuamay experience when they are in pain. The PCS instructions ask participants reflect on past painful experiences, and to indicate the degree to which they experenced each of 13 thoughts or feelings when experiencing pain, on 5-point scalwith the endpoints (0) not at all and (4) all the time. The PCS yields a total scoand three subscale scores assessing rumination, magnification, and helplessnesThe PCS has been shown to have high internal consistency (coefficient alphas: totPCS 0.87, rumination 0.87, magnification 0.66, helplessness 0.78; Sullivaet al. 1995).

Pain

An 11-point Likert-type rating scale was positioned on the wall directly front of the participants. Participants gave verbal reports of their current pain bchoosing numbers between (0) no pain and (10) extreme pain.

Pain Behavior

Initially, our intent was to classify participants pain behaviors according the system described by Keefe and Block (1982) for use in chronic pain patienduring physical examination (i.e., guarding, rubbing, grimacing, sighing). Howevethe pain behavior coding system required some modification to account for the foc(e.g., pain in the immersed arm) and the constraints (e.g., immobility) associated withe cold pressor procedure. After extensive pilot testing, the following pain behavi

categories and criteria were derived:

1 A ti i l i th i d ( d d l f th i d f ll i th


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narrowed eyes, tightened lips, and corners of the mouth pulled back clenched.

4. Vocalizationsgrunting, gasping, or sighing.

Two judges blind to the experimental hypotheses independently coded th

videotapes. Judges provided a frequency count and recorded the duration of eacof the four categories of pain behaviors both during the ice water immersion anthe 3-minute period following the immersion. For the classification of pain behaviorthe mean percentage agreement for the two judges across the four categories w84%. Disagreements were resolved through discussion. For the duration of pabehaviors, the mean correlation for the two judges ratings across the four categoriwas r 0.91. Due to the low frequency of pain behaviors across categories,composite index of pain behavior duration was derived by summing duration acro

pain behavior categories.Coping Interview

At the end of the session, participants were interviewed concerning the wathey tried to cope with the pain of the cold pressor procedure. Participants werasked the following questions, What thoughts or feelings did you experience durinthe ice water immersion? How did you try to cope with the pain you weexperiencing? and Did you engage in any mental strategy or did you do anythinto control or decrease your pain? The coping interview was similar to that usein previous research on coping with cold pressor pain (Spanos et al. 1979; Sullivaet al. 1995).

Two judges who were blind to the experimental hypotheses transcribed particpants responses to the interview, and coded responses into one of eight copincategories. Coping categories included (1) coping self-statements (I told myselcould do this.), (2) distraction (I tried to think of other things, like studying what I had to do tomorrow.), (3) suppression (I tried not to think about thpain.); (4) relaxation (I tried to breathe deeply and relax.), (5) sensory focu

(I thought mostly about how my arm was feeling.); (6) reinterpreting sensation(I tried to think of it as cooling down on a hot day.), and (7) catastrophizing (couldnt believe that it could hurt so much.). After reviewing participants rsponses, one additional category was included: (8) No thoughts (I didnt thinabout anything.). Responses were first unitized according to thematic content ansentence structure, and were then classified into one of the coping categories. Meapercentage inter-rater agreement across coping categories was 78% with a rangof 66% (suppression) and 100% (no thoughts). Only one participant reported usin

sensory focus and relaxation and both coders agreed on the classification.


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Prior to the pain procedure, participants completed the PCS. To regulate artemperature, participants immersed their dominant arm in a container of rootemperature water for 5 minutes. Participants were then instructed to place thearm on the moveable armrest of the cold pressor apparatus, to lower their ar

into the ice water, and to keep their arm immersed for a period of 1 minute. Thewere signaled, by a voice on a tape recording, to give two verbal ratings of thecurrent level of pain at 30-second intervals during the water immersion. At the enof 1 minute, they were signaled to remove their arm from the ice water. Participanwere videotaped for an additional 3 minutes following removal of their arm frothe cold pressor.

RESULTS

Pain Ratings

As shown in Table I, men and women did not differ significantly in the paratings they provided during the room temperature water immersion, t(78) 0.4(ns). However, during the ice water immersion, men reported significantly less pathan women, t(78) 2.2, p 0.05.

Pain Behavior

During the ice water immersion, women displayed pain behaviors for signicantly longer duration than men, t (78) 2.5, p 0.01. During the 3 minutfollowing the ice water immersion, women continued to display pain behavior foa longer duration than men, t(78) 2.5, p 0.01.

The total number of different occurrences of pain was marginally higher fwomen (M 3.0, SD 1.3) than for men (M 2.5, SD 1.2), t (78) 1

p

0.07. Chi-square analyses revealed that the probability of displaying specifipain behaviors did not vary as a function of gender.

Table I. Pain Ratings and Pain Behavior During and After the IceWater Immersion

Men Women(N 38) (N 42) p

Pain ratings 2.1 (1.0) 2.0 (1.1) ns

(room temperaturewater immersion)Pain ratings 6.3 (1.7) 7.2 (1.5) 0.05


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Table II.Components of Catastrophizing as a Function of Gender

Men WomenCatastrophizing (N 38) (N 42) p

PCS Total 17.6 (10.3) 26.6 (10.4) 0.001PCS Rumination 7.3 (3.8) 10.7 (3.2) 0.001PCS Magnification 3.7 (2.7) 4.0 (2.2) nsPCS Helplessness 6.9 (4.8) 11.7 (5.6) 0.001

Note: Numbers in parentheses are standard deviations. PCS Pain Catastrophizing Scale.

Catastrophizing

Consistent with previous research (Osman et al. 1997; Sullivan et al. 199

study 1), men scored significantly lower on the total score of the PCS than womet(78) 3.8, p 0.001. As shown in Table II, men scored significantly lower othe rumination, t (78) 4.3, p 0.001, and the helplessness, t (78) 4.1, p 0.001, subscales of the PCS. There were no gender differences on the magnificatiosubscale of the PCS, t(78) 1.1, (ns).

Correlations between the different subscales of the PCS and the pain measurwere computed separately for men and women (Table III). For both men anwomen, the rumination (men, r .49, p 0.05; women, r .44, p 0.05) an

helplessness (men, r .48, p 0.05; women, r .56, p 0.01) subscales of thPCS were significantly correlated with pain ratings during the ice water immersioThe magnification subscale was correlated with pain ratings during the ice watimmersion for men (r .48, p 0.05) but nor for women (r .25, ns). Dire

Table III. Correlations Between PCS subscales and Pain Measuresfor Men and Women

Pain ratings and pain behavior

Room temp. Ice water Pain beh.Men (N 38) immersion immersion duration

PCS Total 0.18 0.53a 0.33a

Rumination 0.30 0.49a 0.41a

Magnification 0.04 0.48a 0.09Helplessness 0.17 0.48a 0.34a

Pain ratings and pain behavior

Room temp. Ice water Pain beh.Women (N 42) immersion immersion duration

PCS total 0.19 0.51a 0.34a

Rumination 0.21 0.44a 0.22


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regression analyses revealed that, for women, the helplessness subscale contributethe greatest proportion of unique variance to the prediction of pain (semi particorr .43,p 0.001). For men, none of the subscales contributed significant uniquvariance to the prediction of pain, and among the three subscales, helplessne

contributed the lowest proportion of unique variance to the prediction of pain (sempartial corr 0.002, ns).The helplessness subscale was significantly correlated with duration of pa

behavior for both men (r .34, p 0.05) and women (r .41, p 0.01). Thrumination subscale was significantly correlated with duration of pain behavior fomen (r .41,p 0.05) but not for women (r .22, ns). The magnification subscawas not correlated with duration of pain behavior for either men or women.

Coping with Pain

The frequencies of different coping strategies reported by men and womeduring the postimmersion interview are presented in Table IV. Due to the modesample size, and the relative infrequency of spontaneously initiated coping stratgies, gender analyses could be performed on only six of the eight coping categorieChi-square analyses (or Fishers exact test when expected frequencies were lethan 5) were used to examine the relation between gender and coping. Distractiowas the most frequently reported coping strategy but did not vary significantly

a function of gender. Four men and no women reported having no thoughts duing the ice water immersion, 2 4.6, p 0.05. Twenty-three women and 1men reported catastrophizing thoughts during the ice water immersion, 2 3p 0.06. No other differences approached statistical significance.

There were few significant relations between coping strategy use and paexperience. Experiencing no thoughts during the ice water immersion was inversecorrelated with duration of pain behavior,r .25,p 0.05. Reinterpreting pasensations was inversely, but not significantly, correlated with pain ratings durinthe ice water immersion, r 0.13, ns. Reports of catastrophic thinking wesignificantly correlated with pain ratings during the ice water immersion, r .2p 0.01.

Mediational Hypotheses

Baron and Kenny (1986) suggest using three regression equations to test meditional hypotheses: (1) regressing the mediator (catastrophizing) on the independe

Table IV. Coping Strategies Reported During the Postimmersion Interview

Men Women 2 p


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variable (gender), (2) regressing the dependent variable (pain) on the independevariable (gender), and (3) regressing the dependent variable (pain) on both thindependent variable (gender) and the mediator (catastrophizing). It is argued thif the independent variable no longer has any effect at all when the mediator

controlled, a mediational hypothesis is supported (see also Holmbeck, 1997).The results of the first regression analysis revealed that gender was a significapredictor of level of catastrophizing,R 0.40,F(1, 18) 15.1,p 0.001. A seconregression analysis revealed that gender was a significant predictor of pain intensitR 0.24,F(1, 78) 4.8,p 0.05. When gender and catastrophizing were enteresimultaneously as independent variables, catastrophizing (beta 0.55,p 0.001but not gender (beta 0.01, p 0.85) contributed significant unique variance the prediction of pain ratings.

The mediating role of catastrophizing was also examined for duration of pabehavior. The first regression analysis was identical to the one above showing thgender was a significant predictor of level of catastrophizing. A second regressioanalysis revealed that gender was a significant predictor of pain behaviour, R0.30, F (1, 78) 8.2, p 0.005. When gender and catastrophizing were enteresimultaneously as independent variables, catastrophizing (beta 0.35,p 0.005but not gender (beta 0.16, p 0.13) contributed significant unique variance the prediction of pain behavior. The results of these analyses support the positiothat catastrophizing mediates the relation between gender and pain, and gend

and pain behavior.

DISCUSSION

In the present study, women reported more intense pain and displayed pabehavior for longer duration than men in response to a cold pressor procedurWomen also scored higher on a measure of catastrophic thinking than men. Whe

level of catastrophizing was statistically controlled, gender no longer contributesignificantly to the prediction of pain intensity or duration of pain behavior.

The processes that give rise to gender differences in catastrophizing are as yunclear. A number of investigators have discussed catastrophizing as a traitlikvariable, citing findings showing that levels of catastrophizing are stable acroperiods ranging from 2 to 8 months (Keefe et al. 1989; Sullivan et al. 1995). Otherhowever, have suggested that catastrophizing can be readily changed by instructinindividuals to use more adaptive coping strategies (Spanos et al. 1981; Vallis, 1984

If catastrophizing is a traitlike variable, it may arise as a function of social learninforces that give rise to other gender-typed traits (e.g., expressiveness versus instrt lit ) If t t hi i i it ti ll d t i d th


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a maladaptive response to stressful situations (Nolen-Hoeksema, 1987, 1993). contrast, Unruh (1996) has suggested that women may attend to pain sooner thamen because the illness, disease, or condition giving rise to pain may result in mointerference of gender-related social roles. Pain may have implications for women

ability to meet household, parenting, and occupational responsibilities. For mepain may only be of significance if it threatens to interfere with occupational resposibilities.

The present study is the first to show that women display more pain behaviothan men in response to an experimental pain procedure. Although several clinicinvestigations have reported that women are more likely than men to engage invariety of illness behaviors such as health care visits, medication intake, and timoff work, previous research has not examined the relation between gender and pabehavior in response to experimental pain procedures (Unruh, 1996).

Both pain behaviors and illness behaviors have been discussed in terms of therole in minimizing pain, and communicating distress (Bonica, 1977; Fordyce, 197Keefe, Bradley, & Crisson, 1990; Keefe & Gil, 1986). The communicative functioof pain behavior may be particularly relevant to explaining gender differences pain behavior. Recent theory and research suggest that women are more likethan men to adopt a communal and emotionally expressive orientation towadealing with stress situations (Coyne & Fiske, 1992; Endler & Parker, 1994; Lyons Sullivan, 1998; Lyons, Sullivan, Ritvo, & Coyne, 1995). Through heightened displa

of distress and by communicating an inability to deal effectively with a painfsituation, women may be maximizing the probability that potential caregivers ocompanions will maintain proximity or offer support or assistance. Converselwhen men adopt a stoic presentation during painful situations, they may minimizthe probability that others will offer support or assistance.

Women did not differ from men in their repertoire of coping strategies. Oththan catastrophizing, the only coping strategy that revealed gender differences whaving no thoughts during the ice water immersion. Four men reported having n

thoughts during the ice water immersion, and these men also reported less pathan women. One possibility is that the individuals who reported having no thoughmay have been engaging in denial of their cognitive experience as well as deniof their pain experience. Alternately, having no thoughts may be adaptive insofas it reduces the probability of experiencing catastrophic thoughts (Turk & Rud1992; Spanos et al. 1979).

Proceeding from the assumption that the primary goal of coping is to reducdistress, then the clinical implications of the present study are clear. Given th

catastrophizing accounts for gender differences in pain experience, and catastrophiing is associated with increased physical and emotional distress in response i f l ti l ti i t ti h ld b i d t d i t t hi i


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and/or individuals who catastrophize prefer an interpersonal or communal approato coping, then reducing catastrophizing may not be an appropriate target of intevention. The expression of distress may be a necessary component of an interpesonal or communal approach to coping. Specifically, expressions of distress sign

the need for assistance (Lyons et al. 1995; Lyons & Sullivan, in press). If interpesonal goals are primary, then an argument can be made for the adaptiveness catastrophizing in coping with pain. It is also important to note that, to the extethat catastrophizing is associated with expressions of distress and help-seekinbehavior, it may be quite adaptive in facilitating the early detection and treatmeof illness. This line of reasoning suggests that the relative adaptiveness of catastropizing may be contextually determined.

It may be premature to make strong statements about the nature of intervetions best suited for alleviating the physical and emotional distress of individuawho catastrophize, and indeed, whether catastrophizing itself should be a target intervention. The literature that is emerging suggests that, in order to maximizthe impact of interventions for pain control, it will be necessary to devote moattention to understanding the goals of coping with pain, and to elucidating thcontextual factors that impact on these goals. If men and women have differegoals when faced with aversive situations, they will likely also differ in the thoughand behaviors that are initiated to attain those goals. Further research examininthe determinants of catastrophizing may facilitate the development of interventio

that can be tailored to individual needs.Finally, caution is warranted in generalizing the present findings beyond th

experimental context within which they were generated. The study sample consisteof healthy, well-educated students who tend to be underrepresented in clinicsamples. In addition, the cold pressor procedure used in the present study diffein many ways (e.g., degree of threat/harm, duration of experience, interferenwith activities) from painful experiences that individuals face in their day-to-dalives, and also from the painful experiences that lead them to seek out medic

assistance. Replication with a clinical sample would be required before the theorecal or clinical implications of the present findings can be discussed with confidenc

ACKNOWLEDGMENTS

The authors thank Mr. Mark Ryer and Ms. Heather Waite for their assistancin data collection and coding. The authors also thank Drs. Joyce DEon, Ma

Lynch, Anita Unruh, and three anonymous reviewers for their comments onprevious version of the paper. This research was supported by a grant from thSocial Sciences and Humanities Research Council of Canada


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