The clinician effect on "objective" technical components of the electrodiagnostic consultation.

OBJECTIVE: To examine the impact of clinician factors on technical data within an electrodiagnostic consultation for low-back pain and spinal stenosis. DESIGN: Examiner differences on single-segment paraspinal mapping scores and other findings were examined in a prospective, masked, double-controlled trial involving 150 people aged 55-80 yrs who were selected for no symptoms, back pain, or possible spinal stenosis. RESULTS: Unmasked clinicians were more variable than masked physicians (F2,219 = 4.808, P =or<0.01) and gave lower scores to people they felt had mechanical back pain. The percentage of inadequate segmental scores differed among clinicians (0-16.6%, F8,226 = 4.170, P < 0.001), with fellows having more difficulty than faculty (11.76 +/- 32.38% vs. 0.75 +/- 8.67%) (t233 = 3.753, P < 0.001). Correction of clinician bias improved the relationship between paraspinal score and subjects' ability to walk (weighted regression R = 0.129, B = -0.047, P < 0.001; unweighted regression R = 0.090, B = -0.045, P < 0.001). CONCLUSIONS: Objective testing is adversely affected by clinician factors including prejudgment, experience, and individual idiosyncrasies. Less variation is found in more codified procedures. For electrodiagnostic consultation, correction of variability improves the relationship of test results to disability.

Pain catastrophizing and neural responses to pain among persons with fibromyalgia.

Pain catastrophizing, or characterizations of pain as awful, horrible and unbearable, is increasingly being recognized as an important factor in the experience of pain. The purpose of this investigation was to examine the association between catastrophizing, as measured by the Coping Strategies Questionnaire Catastrophizing Subscale, and brain responses to blunt pressure assessed by functional MRI among 29 subjects with fibromyalgia. Since catastrophizing has been suggested to augment pain perception through enhanced attention to painful stimuli, and heightened emotional responses to pain, we hypothesized that catastrophizing would be positively associated with activation in structures believed to be involved in these aspects of pain processing. As catastrophizing is also strongly associated with depression, the influence of depressive symptomatology was statistically removed. Residual scores of catastrophizing controlling for depressive symptomatology were significantly associated with increased activity in the ipsilateral claustrum (r = 0.51, P < 0.05), cerebellum (r = 0.43, P < 0.05), dorsolateral prefrontal cortex (r = 0.47, P < 0.05), and parietal cortex (r = 0.41, P < 0.05), and in the contralateral dorsal anterior cingulate gyrus (ACC; r = 0.43, P < 0.05), dorsolateral prefrontal cortex (r = 0.41, P < 0.05), medial frontal cortex (r = 0.40, P < 0.05) and lentiform nuclei (r = 0.40, P < 0.05). Analysis of subjects classified as high or low catastrophizers, based on a median split of residual catastrophizing scores, showed that both groups displayed significant increases in ipsilateral secondary somatosensory cortex (SII), although the magnitude of activation was twice as large among high catastrophizers. Both groups also had significant activations in contralateral insula, SII, primary somatosensory cortex (SI), inferior parietal lobule and thalamus. High catastrophizers displayed unique activation in the contralateral anterior ACC, and the contralateral and ipsilateral lentiform. Both groups also displayed significant ipsilateral activation in SI, anterior and posterior cerebellum, posterior cingulate gyrus, and superior and inferior frontal gyrus. These findings suggest that pain catastrophizing, independent of the influence of depression, is significantly associated with increased activity in brain areas related to anticipation of pain (medial frontal cortex, cerebellum), attention to pain (dorsal ACC, dorsolateral prefrontal cortex), emotional aspects of pain (claustrum, closely connected to amygdala) and motor control. These results support the hypothesis that catastrophizing influences pain perception through altering attention and anticipation, and heightening emotional responses to pain. Activation associated with catastrophizing in motor areas of the brain may reflect expressive responses to pain that are associated with greater pain catastrophizing.

Yohimbine treatment of organic erectile dysfunction in a dose-escalation trial.

Yohimbine has had questionable effects in men with organic erectile dysfunction. We conducted this study to better define the population of men responsive to yohimbine, because tobacco was thought to affect a regimen of yohimbine more than other risk factors. We measured nocturnal penile tumescence with the RigiScan monitor, hormone profiles, answers to the Florida Sexual Health Questionnaire, and clinical responses at baseline and after two different doses of yohimbine in 18 nonsmoking men with erectile dysfunction. Of the 18 men, nine (50%) were successful in completing intercourse in more than 75% of attempts. The yohimbine responders were men with less severe erectile dysfunction as manifested by improved increased rigidity on RigiScan testing, higher Florida Sexual Health Questionnaire scores, and slightly higher levels of serum testosterone. Yohimbine is an effective therapy to treat organic erectile dysfunction in some men with erectile dysfunction.

Functional capacity evaluations in persons with spinal disorders: predicting poor outcomes on the Functional Assessment Screening Test (FAST).

This study determines how performance on the simple, low exertion Functional Assessment Screening Test (FAST) relates to performance on more extensive physical and psychological testing. One hundred eighty-eight persons with chronic back disability and 17 spine healthy volunteers underwent the FAST (three 2-min static tests [kneeling, stooping, and squatting] and two 5-min tests [repetitive stooping and repetitive twisting while standing]), the Progressive Isoinertial Lifting Evaluation (PILE), trunk extension endurance, submaximal bicycle ergometry, and psychological profiles. All FAST components were completed by 88% of spine healthy subjects, but only by 19.7% (n = 37) of the back patients. Internal consistency for overall test performance was 0.82 (alpha coefficient). Back pain noncompleters had poorer performance on the PILE and trunk extension endurance despite similar cardiovascular fitness and perceived exertion during testing. They had more dysfunctional coping mechanisms, pain avoidance, depression, and self-reported disability. Since performance on nonstrenuous testing is so poor, and psychosocial variables relate strongly to test performance, extensive Functional Capacity Evaluations may not be necessary or valid in assessing the physical performance of this population of chronic back pain patients.

Outcomes after surgery for thoracic outlet syndrome.

PURPOSE: This study determined whether there is an association between psychological and socioeconomic characteristics and the long-term outcome of operative treatment for patients with sensory neurogenic thoracic outlet syndrome (N-TOS). METHODS: Clinical records, preoperative psychological testing results, and long-term follow-up questionnaire data were reviewed for consecutive patients who underwent surgery for N-TOS from 1990 to 1999. Multivariate logistic regression models were developed as a means of identifying independent risk factors for postoperative disability. RESULTS: Operative decompression of the brachial plexus via a supraclavicular approach was performed for upper extremity pain and paresthesia with no mortality and minimal morbidity in 170 patients. After an average follow-up period of 47 months, 65% of patients reported improved symptoms, and 64% of patients were satisfied with their operative outcome. However, 35% of patients remained on medication, and 18% of patients were disabled. Preoperative factors associated with persistent disability include major depression (odds ratio [OR], 15.7; P =.02), not being married (OR, 7.9; P =.04), and having less than a high school education (OR, 8.1; P =.09). CONCLUSION: Operative decompression was beneficial for most patients. Psychological and social factors, including depression, marital status, and education, are associated with self-reported disability. The impact of the preoperative treatment of depression on the outcome of TOS decompression should be studied prospectively.

Negative affect, self-report of depressive symptoms, and clinical depression: relation to the experience of chronic pain.

OBJECTIVE: The goal of this study was to examine the relative importance of global affective distress, self-report of depressive symptoms, and presence or absence of major depression to the experience of chronic pain. SETTING: A multidisciplinary pain program at a university medical center was the setting for this study. PATIENTS: Subjects in this study were 211 consecutive patients with chronic pain. OUTCOME MEASURES: Pain duration, compensation, and litigation status were controlled for in the statistical analyses, as each correlated significantly with at least one of the measures of affect. Global affective distress was assessed using the Global Severity Index (GSI) from the Brief Symptom Inventory. The Beck Depression Inventory and the Center for Epidemiological Studies Depression Scale were used as measures of self-report of depressive symptoms. Presence or absence of major depression was based on DSM-IV criteria. RESULTS AND CONCLUSIONS: The GSI, Beck Depression Inventory, and Center for Epidemiological Studies Depression Scale were significantly correlated with each measure of the experience of pain, although clinical depression was only significantly related to self-reported disability and negative thoughts about pain. The self-report measures of depression maintained their relation to the dependent measures when the somatic items from the scales were removed, suggesting that the relations were not spuriously due to the influence of pain symptoms on the scales. When examining the unique contribution of each variable to the experience of pain (by simultaneously controlling for the other measures of affect), the GSI was uniquely related to the sensory and affective components of pain. Self-report of depressive symptoms was more highly related to a measure of the evaluative component of pain and uniquely related to self-reported disability and negative thoughts about pain. The results are discussed within the context of theoretical models of the relation between pain and affect, and suggestions for future research are presented.

Empirical subgroups of the Coping Strategies Questionnaire-Revised: a multisample study.

OBJECTIVE: The purpose of this study was to examine the dimensions of coping, measured by the subscales of the new revised Coping Strategies Questionnaire (CSQ-R) using factor analysis, and to perform cluster analysis on these factors to explore the existence of distinct subgroups. No published studies have identifed subgroups of chronic pain patients based on the use of CSQ coping strategies. SOURCE: A sample of 419 chronic low back pain patients from a multidisciplinary pain rehabilitation clinic and a sample of 556 chronic pain patients of mixed pain etiology presenting for treatment at an anesthesia pain clinic were used to establish reliability of factors and clusters. RESULTS: Both samples yielded very similar two-factor solutions, with initial solutions accounting for 67.1% and 69.1% of the total variance. The factors were characterized as cognitive coping and distraction. Three homogeneous subgroups were then identified that consisted of a group high on cognitive coping, a group with low overall ratings of response CSQ-R items in general, and a group with frequent endorsement of catastrophizing and distraction-related items. CONCLUSION: This paper is the first to report empirically derived subgroups from scores on the CSQ or CSQ-R. In addition, the three clusters were significantly different across measures of pain, psychological distress, and levels of physical functioning, demonstrating validity for the clusters.

Empirical test of the factor structure of the West Haven-Yale Multidimensional Pain Inventory.

OBJECTIVE: Although the West Haven-Yale Multidimensional Pain Inventory (MPI) is frequently used in clinical evaluation and research with chronic pain patients, few studies have reported item-level factor analyses. After performing such an analysis, Bernstein et al. (Spine 1995;20:956-63) reported lack of independence between the solicitous and distracting response scales in section II as well as the activities away from home and social activities scales in section III. They suggested that the combination of these scales would improve the internal structure of the MPI. The purpose of this study was to perform a confirmatory factor analysis testing whether the MPI would be improved by the consolidation of these scales. In addition, a third, empirical model was generated for comparison with the West Haven-Yale and Bernstein models. DESIGN: This study used exploratory and confirmatory factor analysis on two independent samples of chronic pain patients (n = 472 and n = 346) to test hypotheses regarding the factor structure of the MPI. RESULTS AND CONCLUSION: Principal axis factor analysis resulted in an empirical model that suggested that the primary psychometric problem of the MPI was lack of item-factor discrimination for several items. When the three models were tested using confirmatory factor analysis, improvement in model fit occurred when cross loading items were excluded. Nevertheless, the goodness of fit of original factor structure was adequate, suggesting it would be premature to suggest changes in this instrument.

Assessing depression among persons with chronic pain using the Center for Epidemiological Studies-Depression Scale and the Beck Depression Inventory: a comparative analysis.

OBJECTIVE: This study examined the ability of two self-report questionnaires, the Beck Depression Inventory (BDI) and the Center for Epidemiological Studies-Depression Scale (CES-D), to discriminate between chronic pain patients with and without major depression. Since previous research has suggested that medical conditions such as chronic pain can influence the endorsement of items that measure neurovegetative symptoms of depression, the accuracy of each of these questionnaires was also assessed eliminating these items. SUBJECTS: These included 132 consecutive patients with chronic pain, 44 of whom were diagnosed as suffering from major depression according to DSM-IV criteria. METHODS: Patients were administered a battery of questionnaires that included the CES-D and BDI. They were also interviewed by a clinical psychologist to determine the presence or absence of major depression. RESULTS: Both questionnaires were able to discriminate significantly between persons with and without major depression. Removal of the somatic items on each questionnaire did not improve their accuracy. Discriminant function analysis revealed an optimal cut-off score of 21 for the BDI, and 27 for the CES-D. Overall hit rates at these cut-offs for the two questionnaires were comparable, while the CES-D had somewhat better sensitivity (81.8% vs. 68.2%). Conversely, the BDI had slightly better specificity (78.4% vs. 72.7%). CONCLUSION: The results suggest that both questionnaires have good predictive validity among chronic pain patients, and decisions regarding the use of one questionnaire rather than the other may depend upon the goals of the user and the setting within which the questionnaire is used.

Bias effects in three common self-report pain assessment measures.

OBJECTIVE: Past research has shown response biases to influence the accuracy of results from self-report measures. In pain assessment, where a percentage of patients have financial and other reasons to minimize or exaggerate psychological disturbance, it becomes especially important to identify the influence of response bias in self-report of adjustment. This study investigated the susceptibility of three commonly used self-report pain assessment measures to response bias. DESIGN: This study used a within-subjects (asymptomatic subjects) design with two experimental conditions and nonequivalent control group (chronic pain patients). SUBJECTS: Experimental group: 40 students enrolled in an occupational therapy program at a major southeastern United States university. CONTROL GROUP: 200 subjects referred to a multidisciplinary pain clinic at a major teaching hospital. MEASURES: Coping Strategies Questionnaire, Multidimensional Pain Inventory, and Pain Beliefs and Perceptions Inventory. RESULTS: With few exceptions, asymptomatic subjects scored significantly differently on these measures while portraying themselves as either coping well or coping poorly. In addition, when using the "coping poorly" response set, asymptomatic subjects reproduced scores similar to those of symptomatic chronic pain patients. CONCLUSION: The susceptibility to manipulation appeared constant across the three measures, a finding that highlighted the difficulties clinicians and researchers encounter in accurate interpretation of results from these measures in the absence of validity indicators. This study also emphasizes the ease with which subjects with sufficient motivation can present themselves in an untruthful and manipulative manner and can generate scores that are, on their own, difficult to distinguish from those of a group of typical chronic pain patients.

The Coping Strategies Questionnaire: a large sample, item level factor analysis.

OBJECTIVE: The Coping Strategies Questionnaire (CSQ), a measure of coping in chronic pain patients, was subjected to item-level exploratory factor analysis. SUBJECTS: A sample of 965 chronic pain patients were used in the analysis. RESULTS: Principal components analysis using a varimax rotation procedure identified nine factors that accounted for 54.5% of the variance. Of these nine factors, the first five represent subscales of the original CSQ subscales. The catastrophizing subscale replicated with significant loadings for all six original items, and ignoring sensations replicated with five of six items. Factors representing reinterpreting pain sensations, coping self-statements, and diverting attention subscales also appeared. The items from the praying and hoping subscale split into separate praying and hoping factors (factors 6 and 8). When reliability coefficients were calculated, factors 7 through 9 had unacceptably low internal consistency and thus were not considered stable factors. Correlations between factors 1 through 6 and other measures of psychological and physical functioning were calculated in the construct validation portion of this study. Previously found relationships were replicated in that the correlations between CSQ factor scores and measures of pain, depression, and disability were in the same direction in this data set as those previously reported.

The relationship between symptoms of post-traumatic stress disorder and pain, affective disturbance and disability among patients with accident and non-accident related pain.

Recent studies have reported a high prevalence of symptoms of post-traumatic stress disorder (PTSD) among individuals with chronic pain. Studies suggest that persons with pain and PTSD also display higher levels of affective disturbance. In the present study we examined self-reports of pain, affective disturbance, and disability among pain patients with and without symptoms of PTSD. Patients without PTSD symptoms were further subdivided into persons whose pain was the result of an accident or insidious in onset. Thus, three groups were examined: (1) persons with accident related pain and high PTSD symptoms (Accident/High PTSD); (2) persons with no or few symptoms of PTSD whose pain was accident related (Accident/Low PTSD); and (3) patients whose pain was not accident related and did not have PTSD symptoms (No Accident). No Accident patients were older than persons with accident related injuries, and both accident related pain groups were more likely than No Accident patients to be involved in litigation or receiving compensation. Thus, these variables were controlled for in the statistical analyses. Self-report of pain was also included as a covariate in the analyses examining group differences in affective disturbance and disability. Accident/High PTSD patients displayed higher levels of self-reported pain compared to the other two groups. The Accident/High PTSD group also had the highest levels of affective disturbance. Both accident groups tended to report greater disability compared to patients whose pain was not accident related. These findings suggest that PTSD symptoms in chronic pain patients are associated with increased pain and affective distress. Accident related pain, even without the presence of PTSD symptoms, appears to be associated with greater disability. The results indicate that the identification and treatment of PTSD symptoms in refractory pain patients may be a critical albeit subtle factor in the effective management of suffering and disability in this population.

The effects of depression and chronic pain on psychosocial and physical functioning.

OBJECTIVE: The present study employed causal modeling to examine the impact of somatic and cognitive symptoms of depression on the functioning of patients with chronic pain. DESIGN: Path analyses were conducted to determine whether pain level is directly related to the psychosocial and physical dimensions of functional status or whether this relationship is mediated by depression. SETTING: Subjects were recruited from a facial pain clinic at the University of Florida, an outpatient clinic associated with a tertiary-care health center. PATIENTS: Subjects were 70 patients with chronic pain, 53 of whom had primary facial pain. MAIN OUTCOME MEASURES: All subjects completed a packet of self-report questionnaires, including the Beck Depression Inventory, McGill Pain Questionnaire, and Sickness Impact Profile. RESULTS: Results of path analyses indicated that both somatic and cognitive symptoms of depression significantly correlate with psychosocial functioning even after controlling for the effects of pain level, trait anxiety, and trait anger. Somatic symptoms of depression were significantly correlated with physical functioning after pain level, anxiety and anger were controlled. CONCLUSIONS: This study indicates that depression is directly related to both the physical and the psychosocial functioning of facial pain patients, while self-reported level of pain is not. A better understanding of the impact of depression on chronic pain and the relationship of these two disorders could lead to improved assessment and treatment of chronic pain disorders.

A time series analysis of the relationship between ambulatory EMG, pain, and stress in chronic low back pain.

Twenty-one subjects with chronic back pain (CBP) participated in an ambulatory electromyography (EMG) monitoring study to ascertain the relationships between muscle activity, physical activity, psychosocial stress, and pain. A time-series analysis approach was adopted to investigate both immediate and lagged associations between these variables in an attempt to determine potential causal relationships. Results for group relationships showed a significant relationship between physical activity and pain, self-report of stress and pain, but no relationship between EMG activity and pain. A lagged relationship between physical activity and pain was found, suggesting a causal relationship between physical activity and pain. However, no time lag was observed between stress and pain, hence no causal relationship can be elucidated. Analysis at the individual level indicated stronger relationships between several combinations of these variables, highlighting the need to consider the heterogeneity of the CBP population and etiology of CBP. The use of ambulatory monitoring of pain, stress, and EMG is suggested as one avenue to further explore the population's heterogeneity.

Relationship between MMPI-2 cluster profiles and surgical outcome in low-back pain patients.

The purpose of this study was to investigate back surgery outcome differences based on Minnesota Multiphasic Personality Inventory-2 (MMPI-2) profile types. Four homogenous subgroups were found from a hierarchical cluster analysis of 201 MMPI-2 profiles. These four clusters consisted of a Depressed-pathological profile, a conversion V profile (V-type), a neurotic Triad profile, and a within normal limit (WNL) profile. Patients in the WNL and Triad subgroups reported significantly more satisfaction with postsurgical improvement than did patients in the Depressed-pathological or V-type subgroups. The Triad subgroup also gave a more favorable subjective rating of surgical outcome than did patients in the Depressed-pathological or V-type subgroups. These groups also differed on measures of work status and nonwork-related physical activity levels but not on indices of pain.

Pain and anxiety during burn dressing changes: concordance between patients' and nurses' ratings and relation to medication administration and patient variables.

Few studies have examined the various factors related to pain during burn dressing changes. Patients' and nurses' ratings of pain and tension were obtained during 107 burn dressing changes among 11 burned patients. As found in previous studies, there was little concordance between nurses' and patients' ratings. Both nurses' and patients' ratings of pain were positively related to amount of analgesic medications administered, whereas amounts were inversely related to patients' reports of pain in a subsample of dressing changes in which anxiolytics were administered. However, these relationships failed to reach statistical significance. Multiple regression analyses revealed that ratings of tension during the procedure were significantly related to overall and worst pain, whereas amount of analgesics and anxiolytics given, postburn day, and total body surface area were not. Exploratory correlations suggested that ability to accurately discriminate between painful episodes, social desirability, and trait anxiety may be factors that significantly influence self-report of pain and might be worthwhile to study more systematically in the future. Implications for burn pain control and suggestions for future research are presented.

The Coping Strategies Questionnaire and chronic pain adjustment: a conceptual and empirical reanalysis.

OBJECTIVE: Some studies have found significant relations between both the factor scores and subscales of the Coping Strategies Questionnaire (CSQ) and various measures of adjustment to chronic pain. In their review of the literature on coping with chronic pain, Jensen et al. (Pain 1991;47:249-83) suggest that conceptual overlap between the subscales may inflate these observed correlations. In the present study, we examine the factor structure of the CSQ subscales which reflect coping, excluding the CSQ subscales which measure appraisal or activity. We then examine the relationship between the CSQ factors and subscales and pain adjustment, while controlling for selected variables. DESIGN AND SUBJECTS: One hundred fifty-two chronic pain patients were administered the CSQ. Seventy-three were also administered the Multidimensional Pain Inventory (MPI). Adjustment to chronic pain was defined based on patients' cluster membership on the MPI and responses to the Interference, Pain Severity, and Negative Affect subscales. SETTING: Tertiary care center. RESULTS: Multiple regression analyses revealed that the Pain Avoidance factor was positively related to pain severity, interference, and MPI cluster membership. In addition, the catastrophizing subscale was positively related to negative affect and MPI cluster membership even when controlling for level of depression, ability to decrease pain was related to lower levels of pain severity, and ability to control pain was related to MPI cluster membership. Neither the Conscious Cognitive Coping factor nor the Increasing Activities subscale was related to the adjustment measures. Follow-up analyses revealed that the Praying/Hoping subscale appeared to account for the relationship between pain avoidance and adjustment. CONCLUSION: The results suggest that praying/hoping and catastrophizing are related to poorer adjustment to chronic pain, that ability to control and decrease pain are related to better adjustment, and that catastrophizing appears to be a separate construct from depression. The results also suggest that the individual CSQ subscales may have greater utility in terms of examining coping, appraisals, and pain adjustment compared to the composite scores.

Multivariate cluster analysis of the MMPI-2 in chronic low-back pain patients.

OBJECTIVE: The purpose of our study was to investigate whether Minnesota Multiphasic Personality Inventory-2 cluster solutions of chronic low-back pain patients would replicate those found in previous research with the Minnesota Multiphasic Personality Inventory. SETTING: A multidisciplinary pain clinic in the southeastern United States. PATIENTS: The subjects were 201 chronic low-back pain patients who had suffered a work-related back injury. OUTCOME MEASURES: The Minnesota Multiphasic Personality Inventory-2. RESULTS: We found four relatively homogeneous subgroups of chronic low-back pain patients that were similar to those identified by previous researchers using data collected with the Minnesota Multiphasic Personality Inventory. CONCLUSION: These findings indicate that interpretations of the Minnesota Multiphasic Personality Inventory-2 should parallel those of the Minnesota Multiphasic Personality Inventory for chronic low-back pain patients. They further suggest that the results of Minnesota Multiphasic Personality Inventory-based studies are also applicable to Minnesota Multiphasic Personality Inventory-2.

The relationship of cognitive distortion to depression in chronic pain: the role of ambiguity and desirability in self-ratings.

OBJECTIVE: This study attempts to clarify the relationship between depression and the cognitions of chronic pain patients. It was hypothesized that the ambiguity and desirability of self-rated traits would significantly predict level of depression. DESIGN: The study incorporated a correlational design in which subjects rated a number of traits as they pertained to themselves and completed questionnaires on negative affect and pain. SETTING: Subjects were recruited from a Spine Program and the Orthopaedic Clinic, at a tertiary care facility at the University of Florida. SUBJECTS: Fifty-eight chronic pain patients, two thirds of whom had primary back pain, were recruited for the study. OUTCOME MEASURE(S): All subjects completed a Beck Depression Inventory and McGill Pain Questionnaire, and rated themselves on 28 traits characterized by the dimensions of desirability and ambiguity. RESULTS: A hierarchical regression analysis indicated that the subjects' self-ratings on ambiguous negative traits significantly predicted level of depression. CONCLUSIONS: Patients with chronic pain are more likely to acknowledge undesirable traits in themselves when they have higher levels of depression when the pain level was controlled. These findings may have important implications for the cognitive-behavioral treatment of chronic pain patients.