Jwrnol o/ F’sy~hosomalrc Resenrch. Vol. 34. No Prmted m Great Bntain.
CHRONIC
I, pp. 117-122, 1990.
0022-3999190 $3.00 + 00 7: 1990 Pergamon Press plc
LOW BACK PAIN PATIENT AND SPOUSE
S. SAARIJ~RVI,*M. T. HYYPP& V. LEHTINENand
E. ALANEN
(Receiced 3 May 1989; accepted in recited form 24 August 1989) Abstract-Marital adjustment, psychological distress, health attitudes and prevalence of musculoskeletal pain symptoms were studied and compared between 63 chronic low back pain (CLBP) patients and their spouses. The CLBP patients experienced somatization significantly more than their spouses, while other psychological distress scores did not reveal statistically significant differences between the couples. The CLBP patients experienced significantly more feelings of guilt at having pain than their spouses. The patients experienced significantly more internal control, while their spouses experienced more external locus control of health. The female spouses had had significantly more musculoskeletal pain symptoms in neck and shoulders during the past week than the male spouses. The prevalence of musculoskeletal pain symptoms in the CLBP patients did not differ significantly between sexes. The results of this study are compared to population studies where the same methods have been used.
INTRODUCTION
THEREis a growing interest in the relationship between the family and matital issues associated with chronic pain. It is assumed that family characteristics and behavior contribute to chronic pain and that they may influence the success of the outcome. Comprehensive reviews on this matter have recently been published [IA]. The earliest reports on the family life of chronic pain patients showed that they often had marital and sexual problems [5,6]. There are also reports which suggest that marital satisfaction in chronic pain patients and their spouses is high and correlates positively with pain, i.e. spouses who are satisfied with their marriage might be more likely to perpetuate the pain by reinforcing pain behavior [7-91. The emotional distress of the spouse, i.e. depression or anxiety, has been shown to relate to the emotional distress of the chronic pain patient [lo, 111. The high prevalence of pain symptoms has also been reported in the spouses of chronic pain patients [5,9]. Most of the above mentioned studies have been carried out on patients who have sought help at pain clinics. Patient selection may cause bias by focusing on the negative effects of chronic illness on the family. Recently it has been shown that persistent pain sufferers in a speciality pain clinic and in a family practice clinic are different on many pain behavior and emotional variables, and that persistent pain sufferers in the general population have a better prognosis than those who are referred to pain clinics [12]. As part of a large Finnish population study, Mini-Finland Health Survey, Joukamaa [13] compared 220 subjects reporting low back pain and their 101 controls. Sexual problems were more common among subjects with low back pain than among *Address for correspondence: Peltolantie 3, SF-20720 Turku,
The Rehabilitation Finland.
Research
117
Centre
of the Social Insurance
Institution,
118
S. SAARIJ~RVIet al.
their controls. However, in terms of overall marital adjustment no differences were noted. One-fifth of both groups reported marital conflict and dissatisfaction. Independently of research strategies the common conclusion has been that family factors play a crucial role in the maintenance and perpetuation of pain behavior, and that participation of the spouse in rehabilitation programs might be useful [l-4]. The purpose of the present study was to clarify how satisfied CLBP patients, who present themselves in primary health care, and their spouses are in their relationships? How much strain do they experience? What kind of health locus of control and attitudes to pain and health issues do they have? The objective of this study is to compare CLBP patients with their own spouses. METHODS Suhiects The CLBP patients were recruited from the communal ptimary health care centers in the city of Turku. They had been selected by general practitioners in health care centres and they had already participated in another study, in which the effectiveness of educational physiotherapy had been examined. This present study was carried out in combination with the one year follow-up of the earlier study. The CLBP patients came to the Rehabilitation Research Centre (RRC) of the Social Insurance Institution in Turku. A physiatrist examined the functional status of the patients, and they were asked to participate in the present study. The patients were fully informed about the nature of the study protocol which had been approved by the Ethical Committees of the Turku University Central Hospital and the RRC. The etiology of CLBP did not influence patient selection. The inclusion criteria of the study were the following: (1) the patient was married and/or was cohabiting together with his/her spouse; and (2) the CLBP was still a problem causing difficulties in the activities of daily living; (3) if the patient had been operated on for a herniated disc, over 3 months should have elapsed since the operation; (4) the patient or the spouse should not have a disease causing more handicap or disability than the CLBP. One hundred and seventy-five CLBP patients attended the RRC. and 98 of them met the above inclusion criteria (20 cases were excluded due to the 4th criterium). In 63 cases both spouses were willing to participate in this study. Among the compliant CLBP patients 31 were men and 32 women. The age of the patients ranged from 23 to 64 yr, the mean was 46.9 and the SD was 8.8 yr. The age of the spouses ranged from 22 to 68 yr, the mean was 47.1 and the so was 9.6 yr. The duration of CLBP varied from 13 to 108 months, the mean was 22 and the so was 20.4 months, The duration of their relationship varied from 1 to 36 yr, the mean was 18.7 and the SD was 1 I .6 yr. 35 pairs refused to parttcipate in the study. Among them 25 index persons were women and IO were men. The age of them varied from 29 to 59 yr. the mean was 44.0 yr, and the SD was 8.6 yr. The duration of low back pain varied from 13 to 108 months, the mean was 21.5 months and the SD was 24.4 months.
Both spouses came to the RRC together and filled out the questionnaires for the study, independently but with the aid of a nurse. (1) The Marital Questionnaire, which consisted of (a) fourteen items from Dyadic Adjustment Scale (DAS). The reliability for the entire 32-item scale has shown to be high (0.96). The correlation with the LockeeWallace Marital Adjustment Test scale was 0.86 among married respondents [14]. It has been shown that while the DAS measures dyadic adjustment reliably the majority of 32 items are unnecessary and it has been suggested that fewer items are enough to get reliable information of adjustment [15]. The inter-item correlations varied between 0.574.77 in our sample. (b) Six items were derived from the Marital Communication Inventory (MCI). The reliability of the MCI has shown to be high (0.93) [16]. In a Finnish validity study those items distinguished well between good and poor communication between spouses [I 71. The inter-item correlations varied between 0.634.81 in our sample. (c) One direct question on overall marital happiness was also included. The alternatives were very happy, happy. neither happy nor unhappy. unhappy, or very unhappy. (2) The Brief Symptom Inventory (BSI); a shortened version of SCL-90-R [18], covers psychological distress symptoms. i.e. somatization. depression, anxiety, phobic anxiety, hostility and obsessivrecompulsive traits. Both test retest and internal consistency reliabilities of the BSI have shown to be very good [IX].
lcyl uau10~ ueyl alow paDuapadxa osje Laql .(g()@o = d) swayed &J’J3 apXuaj aqi ueql u!ed %U!AB~ le y!n% a1oI.u pawa!ladxa sluagcd da13 aIt3.u aqL ‘[OWIOD IeuJalxa alow pawa!ladxa sasnods .yaql al!qM ‘sasnods +aq] ueql ~O.IIUODIIXIXWI! aJ0u.I L[~UIJXJU%!SpaDuapadxa swaged da73 aqJ ‘(II alqeL) sasnods $aqi ueql alow Lpue3y!u8!s u!ed Ou!Aeq I&?l[!n% JO s8uqaaj alow passaldxa sluaged da73 aqL sapnrwv
yipqi
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luapnlS aql dq paPqn3[%?3 a.~a~ sa~ua~ag!p xas u! sa~1e3y!u8!S .asnods UMO Jaq/s!y q]!~ paJeduro3 SBM iuayd da13 haha leql sueam qxq~ ‘Isal-1 palFed aq) Aq pa,e[n3pD aJaM sasnods aql pue sluaged da73 aql uaamlaq sawaJay!p Jo3 (so.0 r d [aha aql le) sanpzr\-d p23ysgzls au 3uogeyap pJepuels pue sueaw se pa]uasaJd aJe elea 3asLpJue pzys!lels 11” JOJ pasn SEM LJeJqg p3ysgels svs aqL
.[rz] atqeldawe aq 01 umoqs uaaq seq I! JO A$q!qe!qaJ aql pue ‘sapluno3 XPJON u! asn aA!sualxa u! SF aJ!euuo!]sanb s!qL .s/(ap uai\as Ised aq, %uyp yXq Jarno1 pue Jaddn u! puz ‘sJaplnoqs pue ~3au u! sruolduh u!ud JO a3uaJJnmo aq] JO suogsanb aql paqdde am Kpnls s!q, UI .sruojdwLs ~ela~ayso~nmuu JO s!si(leue aql JOJ (0~s) a+uuo!lsanb ~!PJON paz!pmpualS aqL (p) .sasnods aql 10~ pawasald osp2 SBM ‘suo!wy~poru lq8ys qly ‘ap3S apnyj)jf aqL ‘[61] swayed da73 u! E8.0 01 IL’O ILIO~Jpay% slawq3 aql JO 61yqeqaJ aq= Tua[qoJd u!k?d aql %uyuanyu! SJO~XJ Ieq8oIoqchd JO aweldamv pue ‘rualqoJd qlleaq aql %qu~amo3 uo!~mI~.~o~u~qJ!M $uaw$uawo3 ‘sa~)poq]ne aJv3 q)[eaq u! a3uapyuo3 ‘q!nO pue luawqyund ‘aJn)nJ aql u! qly :aJaM (qzea u! scual! 5) srual!Jo sJalsn[D Jaqlo aql .[oz] LJoluaAuI 1oJluo3 JO sn307 ql[vaH aql uroq pan!Jap aJaM ‘a3ueq3 pue ~OJ~UO~p3uJalu! ‘1owIo3 Ieuralxa ‘(Jalsnl3 DaAa u! sruay 5) srual! JO slalsn[3 aaJq1 ‘[61] sluaged uyd c+orqD JOJ pado[aAap Qe!3ads aps s!qJ yed pm ql[eaq 8uyJamo3 sapn$!m? pm SJaqaq ‘slq%noql slaA.03 ap3S apnl!llV aq.L (E) ‘a’!
SEM
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S. SAARIJ~RVIet
120
TABLE L-PSYCHOLOGICAL
al.
DISTRESSOF THE CLBP THEIRspousFs
PATIENTS AND
CLBP
patients Somatization Depression Anxiety Phobic anxiety Hostility Obsessive-Compulsive
(n = 63)
Spouses (n = 63)
1.2 0.8 0.8 0.3 0.8 1.1
0.9 0.7 0.8 0.3 0.8 1.2
(0.7) (0.7) (0.6) (0.5) (0.6) (0.8)
pain is dependent on chance (p = 0.03). In the spouses in health attitudes were noted. Musculoskeletal
symptoms
during
p
(0.7) (0.5) (0.6) (0.4) (OS) (0.7)
0.01 0.42 0.95 0.91 0.82 0.42
no significant
sex differences
the past week
The female spouses had experienced significantly more often pain symptoms during the past week in neck (53%) than the male spouses (16%) (p = 0.002), and in shoulders (66% vs 38%) (p = 0.02). In the prevalence of pain symptoms in upper or lower back no significant sex differences were noted. In the CLBP patients no significant sex differences in the occurrence of pain symptoms in different sites were found. DISCUSSION
Both the CLBP patients and their spouses expressed high marital satisfaction. The finding of marital congruency is in accordance with recent reports [8,22]. In a Finnish population sample in which marital happiness was assessed with the same overall assessment question as in this study, 58% of men, and 59% of women regarded their marriage as happy or very happy [23]. The assessments of marital happiness were higher in the study sample. In this respect, it must be noted that the willingness of the couples to participate in the present study alredy speaks for their positive marital relationship. It is possible that those CLBP patients (n = 35) who fulfilled the inclusion criteria but refused to participate may have had more conflicts in their marriages. This is the major limitation of our study because we assume that marital satisfaction is associated with psychological distress and with health attitudes of CLBP patients. But we thought that the only reliable way to assess marital TABLE [I.-HEALTH
ATTITUDESOF THE CLBP
PATIENTSA&D THEIKSPOUSES CLBP
Faith in the future Punishment and guilt Confidence in health care authorities Contentment with information concerning the health problem Acceptance of psychological factors influencing the pain problem External control Internal control Chance
patient (n = 63)
Spouse (n = 63)
2.6 1.5 3.2 3.4 2.2 I.9 2.5 I.9
2.6 1.1 3.1 3.5 2.1 2.3 2.1 1.7
(0.6) (0.5) (0.5) (0.6) (0.6) (0.4) (0.5) (0.5)
(0.5) (0.2) (0.5) (0.5) (0.6) (0.5) (0.5) (0.5)
” 0.94 0.0001 0.20 0.28 0.27 0.0001 0.0001 0.10
Chronic
low back pain patient
121
and spouse
adjustment was that both spouses together came to the RRC and an independent answering to the questionnaires was guaranteed. In the present study somatization was the only statistically significant indicator of psychological distress which distinguished the CLBP patients from their spouses, i.e. the CLBP patients experienced more somatization than their spouses. There were no significant sex differences in somatization in the CLBP patients, while in the spouses women somatized more than men. Psychological distress scores in the BSI of the CLBP patients and their spouses, especially somatization, depression, anxiety and hostility seemed to be somewhat higher than in a Finnish population sample of people with same civil status and at the same age group (Kronholm E., pers. commun.). As compared with the community norms, the scores of the Health Locus of Control in the CLBP patients were at the same level as in a Finnish population sample of people with same civil status and at the same age group (Mattlar C.-E., Helenius H., pers. commun.). The spouses expressed more external and less internal control than in the population sample. This discrepancy may reflect the caretaking attitudes of the spouses. The CLBP patients, and especially men experienced guilt at having pain. This observation gives some support to the concept of ‘pain-proneness’ [24,25], according to which either conscious or unconscious guilt is essential for the psychodynamics of pain patients, and that pain may represent self punishment. The observed sex difference may be due to the cultural expectancies and gender-related coping strategies [26], i.e. for men especially it seems to be difficult to accept the limitations of their functional capacity and to cope with the negative feelings associated with pain [27]. The spouses, and especially women had often experienced musculoskeletal pain symptoms during the past week. This finding is consistent with earlier reports in which frequent pain complaints in the spouses of chronic pain patients have been observed [5,9]. In a Finnish community sample of people with same civil status and at the same age group women had significantly more pain symptoms in neck and shoulders than men and this kind of sex difference was not found in pain symptoms in upper and lower back (Jarvisalo J., Knuts L.-R., pers. commun.). However, in the CLBP patients no significant sex differences in pain symptoms in different pain sites were observed. It may be that the CLBP patients are more sensitive to experiencing pain in other sites too. Because CLBP seems to affect both spouses, e.g. in the form of increased psychological distress, it could be helpful in the rehabilitation of CLBP patient to meet the couple in conjoint sessions. The aim of these discussions should be in helping the couple to cope better with their life situation, and, thereby also coping with chronic pain and its affective covariates in a more effective way [28]. Acknowled~rmenrs-This
study was supported
by a grant from the Social Insurance
Institution,
Finland.
REFERENCES
1. 2.
ROY R. Marital and family issues in patients with chronic PAYNE B, NORFLEETMA. Chronic pain and the family.
pain. Psychother Psychosom 1982; 37: I-12. A Review. Pain 1986; 26: l-22.
122 3.
4. 5. 6. I. 8.
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TURK DC, FLOR H, RUDY TE. Pain and families. 1. Etiology, maintenance, and psychosocial impact. Pain 1987; 30: 3-27. FLOR H, TURK DC, RUDY TE. Pain and families. II. Assessment and treatment. Pain 1987; 30: 2945. MOHAMED SN, WEISZ GN, WARING EM. The relationship of chronic pain to depression, marital adjustment and family dynamics. Pain 1978; 5: 285-292. MARUTA T, OSBORNED, SWANXIN DW, HALLING JM. Chronic pain patients and spouses. Marital and sexual adjustment. Mayo Clin Proc 1981; 56: 307-310. BLOCK AR, BOYER SR. The spouse’s adjustment to chronic pain: cognitive and emotional factors. Sot Sri & Med 1984; 19: 1313~1318. KREMER EF, SIEBERW, ATKINSON JH. Spousal perpetuation of chronic pain behavior. Znt J Fam Ther 1985;
9. 10.
7: 258-270.
FLOR H. TURK DC, SCHOLZ BG. Impact of chronic pain on the spouse: marital, emotional and physical consequences. J psychosom Res 1987; 31: 63-71. SHANFIELDSB, HEIMANN EM, COPE DN. JONES J. Pain and marital relationship: psychiatric distress. Pain 1979;
Il. 12. 13.
14. 15.
J Marriage
16. 17. 18. 19. 20. 21.
22.
7: 343-351,
AHERN DK, ADAMS AE, FOLIXK MJ. Emotional and marital disturbance in spouses of chronic low back pain patients. Clin J Puin 1985; 1: 69-74. CROOK J, WEIR R, TUNKS E. An epidemiological follow-up survey of persistent pain sufferers in a group family practice and specialty pain clinic. Pain 1989; 36: 49-61. JOUKAMAAM. Low Back Pain and Psychological Factors. A Social-psychratric Study of the Population of Working Age. Publications of the Social Insurance Institution, Finland, AL: 28: Turku, 1986. In Finnish with an English summary. SPANIER GB. Measuring dyadic adjustment: New scales for assessing the quality of marriage and similar dyads. J Marriage Fam 1976; 38: 15-28. SHARPLEY CF, CROSS DG. A psychometric evaluation of the Spanier Dyadic Adjustment Scale. Fam
Acta psychiat 23.
24. 25. 26.
I
stand
1987; 75:
166-170.
TOLKKI-NIKRONEN M. Less expectations--less disappointments. Acta Unit~ersifaris Tamperensis. Ser A, VoI 191. Tampere 1985. In Finnish with an English summary. BLUMER D, HEILBRONN M. Chronic pain as a variant of depressive disease. J New Ment Dis 1982; 7: 381406. ENGEL GL. ‘Psychogenic pain’ and the pain-prone patient. Am J Med 1959; 26: 899-918. VERBRUGGE LM. Gender and health: an update on hypotheses and evidence. J Health Sot Behac 1985;
27.
1982; 44: 739-74
BIENVENUMJ. Measurement of marital communication. Fum Coordinator 1970; 1: 26-31. KINNUNEN 0, NIEMI P, J;~RVIKOSKIA. The Factors Influencing Marital Interaction. Research report from the Psychological Faculty in Turku University 17/1975: Turku, 1975. In Finnish. DEROGATISLR, MELISARATOSN. The brief symptom inventory: An introductory report. Psycho1 Med 1983; 13: 595405. ESTLANDERA-M, H.XRK~~P~KK. Presentation of a new attitude scale for patients with chronic pain. Psykologia 1985; 6: 428-432. In Finnish with an English summary. WALLSTON BS, WALLSTON KA, KAPLAN GD, MAIDES SA. Development and validation of the health locus of control scale. J Clin consult P,rychol 1976; 44: 580-585. KUORINKA 1, J~NS~QN B, KILBOM A, JONSSON B, KILBOM A, VINTERBERGERH, BIERING-SORENSENF, ANDERSSONG, JORGENSENK. Standardized Nordic questionnaires for the analysis of musculoskeletal symptoms. App Ergonomics 1987; 18: 233.-237. HUGHES AM, MEDLEY 1, TURNER G, BOND MR. Psychogenic pain. A study of marital adjustment.
26:
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HYYPP~CMT, ALARANTA H, HUKME M, NYKVIST F, LAH~ELA K. Gender differences in psychological and cortisol responses to distress. A five-year follow-up of patients and back pain. Srress Med 1988; 4: 117-121.
28.
SAARIJ;~RVIS, LAHTI T. LAHTI I. Time-limited patients. Fam Syst Med, 1990, in press.
structural
couple
therapy
with chronic
low back pain
CHRONIC
I, pp. 117-122, 1990.
0022-3999190 $3.00 + 00 7: 1990 Pergamon Press plc
LOW BACK PAIN PATIENT AND SPOUSE
S. SAARIJ~RVI,*M. T. HYYPP& V. LEHTINENand
E. ALANEN
(Receiced 3 May 1989; accepted in recited form 24 August 1989) Abstract-Marital adjustment, psychological distress, health attitudes and prevalence of musculoskeletal pain symptoms were studied and compared between 63 chronic low back pain (CLBP) patients and their spouses. The CLBP patients experienced somatization significantly more than their spouses, while other psychological distress scores did not reveal statistically significant differences between the couples. The CLBP patients experienced significantly more feelings of guilt at having pain than their spouses. The patients experienced significantly more internal control, while their spouses experienced more external locus control of health. The female spouses had had significantly more musculoskeletal pain symptoms in neck and shoulders during the past week than the male spouses. The prevalence of musculoskeletal pain symptoms in the CLBP patients did not differ significantly between sexes. The results of this study are compared to population studies where the same methods have been used.
INTRODUCTION
THEREis a growing interest in the relationship between the family and matital issues associated with chronic pain. It is assumed that family characteristics and behavior contribute to chronic pain and that they may influence the success of the outcome. Comprehensive reviews on this matter have recently been published [IA]. The earliest reports on the family life of chronic pain patients showed that they often had marital and sexual problems [5,6]. There are also reports which suggest that marital satisfaction in chronic pain patients and their spouses is high and correlates positively with pain, i.e. spouses who are satisfied with their marriage might be more likely to perpetuate the pain by reinforcing pain behavior [7-91. The emotional distress of the spouse, i.e. depression or anxiety, has been shown to relate to the emotional distress of the chronic pain patient [lo, 111. The high prevalence of pain symptoms has also been reported in the spouses of chronic pain patients [5,9]. Most of the above mentioned studies have been carried out on patients who have sought help at pain clinics. Patient selection may cause bias by focusing on the negative effects of chronic illness on the family. Recently it has been shown that persistent pain sufferers in a speciality pain clinic and in a family practice clinic are different on many pain behavior and emotional variables, and that persistent pain sufferers in the general population have a better prognosis than those who are referred to pain clinics [12]. As part of a large Finnish population study, Mini-Finland Health Survey, Joukamaa [13] compared 220 subjects reporting low back pain and their 101 controls. Sexual problems were more common among subjects with low back pain than among *Address for correspondence: Peltolantie 3, SF-20720 Turku,
The Rehabilitation Finland.
Research
117
Centre
of the Social Insurance
Institution,
118
S. SAARIJ~RVIet al.
their controls. However, in terms of overall marital adjustment no differences were noted. One-fifth of both groups reported marital conflict and dissatisfaction. Independently of research strategies the common conclusion has been that family factors play a crucial role in the maintenance and perpetuation of pain behavior, and that participation of the spouse in rehabilitation programs might be useful [l-4]. The purpose of the present study was to clarify how satisfied CLBP patients, who present themselves in primary health care, and their spouses are in their relationships? How much strain do they experience? What kind of health locus of control and attitudes to pain and health issues do they have? The objective of this study is to compare CLBP patients with their own spouses. METHODS Suhiects The CLBP patients were recruited from the communal ptimary health care centers in the city of Turku. They had been selected by general practitioners in health care centres and they had already participated in another study, in which the effectiveness of educational physiotherapy had been examined. This present study was carried out in combination with the one year follow-up of the earlier study. The CLBP patients came to the Rehabilitation Research Centre (RRC) of the Social Insurance Institution in Turku. A physiatrist examined the functional status of the patients, and they were asked to participate in the present study. The patients were fully informed about the nature of the study protocol which had been approved by the Ethical Committees of the Turku University Central Hospital and the RRC. The etiology of CLBP did not influence patient selection. The inclusion criteria of the study were the following: (1) the patient was married and/or was cohabiting together with his/her spouse; and (2) the CLBP was still a problem causing difficulties in the activities of daily living; (3) if the patient had been operated on for a herniated disc, over 3 months should have elapsed since the operation; (4) the patient or the spouse should not have a disease causing more handicap or disability than the CLBP. One hundred and seventy-five CLBP patients attended the RRC. and 98 of them met the above inclusion criteria (20 cases were excluded due to the 4th criterium). In 63 cases both spouses were willing to participate in this study. Among the compliant CLBP patients 31 were men and 32 women. The age of the patients ranged from 23 to 64 yr, the mean was 46.9 and the SD was 8.8 yr. The age of the spouses ranged from 22 to 68 yr, the mean was 47.1 and the so was 9.6 yr. The duration of CLBP varied from 13 to 108 months, the mean was 22 and the so was 20.4 months, The duration of their relationship varied from 1 to 36 yr, the mean was 18.7 and the SD was 1 I .6 yr. 35 pairs refused to parttcipate in the study. Among them 25 index persons were women and IO were men. The age of them varied from 29 to 59 yr. the mean was 44.0 yr, and the SD was 8.6 yr. The duration of low back pain varied from 13 to 108 months, the mean was 21.5 months and the SD was 24.4 months.
Both spouses came to the RRC together and filled out the questionnaires for the study, independently but with the aid of a nurse. (1) The Marital Questionnaire, which consisted of (a) fourteen items from Dyadic Adjustment Scale (DAS). The reliability for the entire 32-item scale has shown to be high (0.96). The correlation with the LockeeWallace Marital Adjustment Test scale was 0.86 among married respondents [14]. It has been shown that while the DAS measures dyadic adjustment reliably the majority of 32 items are unnecessary and it has been suggested that fewer items are enough to get reliable information of adjustment [15]. The inter-item correlations varied between 0.574.77 in our sample. (b) Six items were derived from the Marital Communication Inventory (MCI). The reliability of the MCI has shown to be high (0.93) [16]. In a Finnish validity study those items distinguished well between good and poor communication between spouses [I 71. The inter-item correlations varied between 0.634.81 in our sample. (c) One direct question on overall marital happiness was also included. The alternatives were very happy, happy. neither happy nor unhappy. unhappy, or very unhappy. (2) The Brief Symptom Inventory (BSI); a shortened version of SCL-90-R [18], covers psychological distress symptoms. i.e. somatization. depression, anxiety, phobic anxiety, hostility and obsessivrecompulsive traits. Both test retest and internal consistency reliabilities of the BSI have shown to be very good [IX].
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yipqi
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120
TABLE L-PSYCHOLOGICAL
al.
DISTRESSOF THE CLBP THEIRspousFs
PATIENTS AND
CLBP
patients Somatization Depression Anxiety Phobic anxiety Hostility Obsessive-Compulsive
(n = 63)
Spouses (n = 63)
1.2 0.8 0.8 0.3 0.8 1.1
0.9 0.7 0.8 0.3 0.8 1.2
(0.7) (0.7) (0.6) (0.5) (0.6) (0.8)
pain is dependent on chance (p = 0.03). In the spouses in health attitudes were noted. Musculoskeletal
symptoms
during
p
(0.7) (0.5) (0.6) (0.4) (OS) (0.7)
0.01 0.42 0.95 0.91 0.82 0.42
no significant
sex differences
the past week
The female spouses had experienced significantly more often pain symptoms during the past week in neck (53%) than the male spouses (16%) (p = 0.002), and in shoulders (66% vs 38%) (p = 0.02). In the prevalence of pain symptoms in upper or lower back no significant sex differences were noted. In the CLBP patients no significant sex differences in the occurrence of pain symptoms in different sites were found. DISCUSSION
Both the CLBP patients and their spouses expressed high marital satisfaction. The finding of marital congruency is in accordance with recent reports [8,22]. In a Finnish population sample in which marital happiness was assessed with the same overall assessment question as in this study, 58% of men, and 59% of women regarded their marriage as happy or very happy [23]. The assessments of marital happiness were higher in the study sample. In this respect, it must be noted that the willingness of the couples to participate in the present study alredy speaks for their positive marital relationship. It is possible that those CLBP patients (n = 35) who fulfilled the inclusion criteria but refused to participate may have had more conflicts in their marriages. This is the major limitation of our study because we assume that marital satisfaction is associated with psychological distress and with health attitudes of CLBP patients. But we thought that the only reliable way to assess marital TABLE [I.-HEALTH
ATTITUDESOF THE CLBP
PATIENTSA&D THEIKSPOUSES CLBP
Faith in the future Punishment and guilt Confidence in health care authorities Contentment with information concerning the health problem Acceptance of psychological factors influencing the pain problem External control Internal control Chance
patient (n = 63)
Spouse (n = 63)
2.6 1.5 3.2 3.4 2.2 I.9 2.5 I.9
2.6 1.1 3.1 3.5 2.1 2.3 2.1 1.7
(0.6) (0.5) (0.5) (0.6) (0.6) (0.4) (0.5) (0.5)
(0.5) (0.2) (0.5) (0.5) (0.6) (0.5) (0.5) (0.5)
” 0.94 0.0001 0.20 0.28 0.27 0.0001 0.0001 0.10
Chronic
low back pain patient
121
and spouse
adjustment was that both spouses together came to the RRC and an independent answering to the questionnaires was guaranteed. In the present study somatization was the only statistically significant indicator of psychological distress which distinguished the CLBP patients from their spouses, i.e. the CLBP patients experienced more somatization than their spouses. There were no significant sex differences in somatization in the CLBP patients, while in the spouses women somatized more than men. Psychological distress scores in the BSI of the CLBP patients and their spouses, especially somatization, depression, anxiety and hostility seemed to be somewhat higher than in a Finnish population sample of people with same civil status and at the same age group (Kronholm E., pers. commun.). As compared with the community norms, the scores of the Health Locus of Control in the CLBP patients were at the same level as in a Finnish population sample of people with same civil status and at the same age group (Mattlar C.-E., Helenius H., pers. commun.). The spouses expressed more external and less internal control than in the population sample. This discrepancy may reflect the caretaking attitudes of the spouses. The CLBP patients, and especially men experienced guilt at having pain. This observation gives some support to the concept of ‘pain-proneness’ [24,25], according to which either conscious or unconscious guilt is essential for the psychodynamics of pain patients, and that pain may represent self punishment. The observed sex difference may be due to the cultural expectancies and gender-related coping strategies [26], i.e. for men especially it seems to be difficult to accept the limitations of their functional capacity and to cope with the negative feelings associated with pain [27]. The spouses, and especially women had often experienced musculoskeletal pain symptoms during the past week. This finding is consistent with earlier reports in which frequent pain complaints in the spouses of chronic pain patients have been observed [5,9]. In a Finnish community sample of people with same civil status and at the same age group women had significantly more pain symptoms in neck and shoulders than men and this kind of sex difference was not found in pain symptoms in upper and lower back (Jarvisalo J., Knuts L.-R., pers. commun.). However, in the CLBP patients no significant sex differences in pain symptoms in different pain sites were observed. It may be that the CLBP patients are more sensitive to experiencing pain in other sites too. Because CLBP seems to affect both spouses, e.g. in the form of increased psychological distress, it could be helpful in the rehabilitation of CLBP patient to meet the couple in conjoint sessions. The aim of these discussions should be in helping the couple to cope better with their life situation, and, thereby also coping with chronic pain and its affective covariates in a more effective way [28]. Acknowled~rmenrs-This
study was supported
by a grant from the Social Insurance
Institution,
Finland.
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structural
couple
therapy
with chronic
low back pain
