Into an 'overall' coping index. I have never done that in my own use of the scales. There is no such thing as an 'overall' score on this measure, and I recommend no particular way of generating a dominant coping style for a give person. Please do NOT write to me asking for instructions to for 'adaptive' and 'maladaptive' composites. The Coping with Anxiety Workbook contains assessments and guided self-exploration activities that can be used with a variety of populations to help participants cope more effectively with.
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Abstract
BACKGROUND:
Increasing attention is being devoted to cognitive-behavioural measures to improve interventions for chronic pain.
OBJECTIVE:
To develop an Italian version of the Coping Strategies Questionnaire – Revised (CSQ-R), and to validate it in a study involving 345 Italian subjects with chronic pain.
METHODS:
The questionnaire was developed following international recommendations. The psychometric analyses included confirmatory factor analysis; reliability, assessed by internal consistency (Cronbach’s alpha) and test-retest reliability (intraclass correlation coefficients); and construct validity, assessed by calculating the correlations between the subscales of the CSQ-R and measures of pain (numerical rating scale), disability (Sickness Impact Profile – Roland Scale), depression (Center for Epidemiological Studies – Depression Scale) and coping (Chronic Pain Coping Inventory) (Pearson’s correlation).
RESULTS:
Confirmatory factor analysis revealed that the CSQ-R model had an acceptable rules='groups'>Characteristicn (%)Marital status Unmarried156 (45.2) Married189 (54.8)Occupation Employee120 (34.8) Self-employed88 (25.5) Housewife47 (13.6) Pensioner90 (26.1)Education Primary school46 (13.3) Middle school102 (29.6) High school138 (40.0) University59 (17.1)Smoking Yes112 (32.5) No233 (67.5)Pain sites (principal) Cervical67 (19.4) Lumbar135 (39.1) Shoulder34 (9.9) Hip28 (8.1) Knee56 (16.2) Other25 (7.2)Drug use Antidepressants59 (17.1) Analgesics152 (44.1) Muscle relaxants37 (10.7) Nonsteroidal anti-inflammatory drugs97 (28.1)Comorbidities (principal) Hypertension111 (32.2) Non-insulin-dependant diabetes mellitus44 (12.8) Heart disease49 (14.2) Enteric disease38 (11.0) Liver disease33 (9.6) None70 (20.3)
The clinical and sociodemographic findings are largely consistent with those found by the original developers of the CSQ-Revised, being representative of subjects with chronic pain (,).
Translation and cross-cultural adaptation
The questionnaire was translated into Italian using a process of forward-backward translation involving four translators. It took two months to reach a culturally adapted version; all of the items were easily translated except two questions (“I try to feel distant from the pain almost as if the pain was in somebody else’s body” and “I try not to think of it as my body, but rather as something separate from me”), but these difficulties were overcome by means of careful wording. A further review by experts and the testing of the penultimate version confirmed the correctness of the process of translation/back-translation and the content of the items.
The adapted questionnaire is reproduced in Appendix 1.
Analytical scale properties
Acceptability:
All of the questions were well accepted. The CSQ-Revised was completed in 11.1±1.5 min, and there were no missing or multiple answers. There were no problems with regard to comprehension.
Factor analysis:
CFA met all of the fit criteria confirming the model on the present sample (Table 2) (). The item-scale correlations were satisfactory (Distraction, 0.751 to 0.913; Catastrophizing, 0.849 to 0.891; Ignoring pain sensations, 0.821 to 0.957; Distancing from pain, 0.925 to 0.932; Coping self-statements, 0.829 to 0.926; and Praying, 0.781 to 0.982).
TABLE 2
Results of confirmatory factor analysis of the factorial validity of the Coping Strategies Questionnaire – Revised
| Model | χ2/df | CFI | NFI | RMSEA | 90% CI of RMSEA |
|---|---|---|---|---|---|
| Robinson et al (7) | 2.97 | 0.936 | 0.908 | 0.078 | 0.072–0.083 |
χ2/df Ratio between χ2 and df; CFI Comparative fit index; NFI Normed-fit index; RMSEA Root-mean square error of approximation
Floor/ceiling effects:
No significant effects were found for any of the subscales (Table 3).
TABLE 3
Floor/ceiling effects and reliability of the Coping Strategies Questionnaire – Revised subscales
| Variables and subscales | Mean ± SD | Floor/ceiling effects, %/% | Internal consistency, α | Test-retest, ICC (95% CI) |
|---|---|---|---|---|
| Distraction (5 items) | 16.29±7.22 | 3.8/3.2 | 0.934 | 0.904 (0.853–0.939) |
| Catastrophizing (6 items) | 16.85±9.78 | 7.8/0.9 | 0.946 | 0.918 (0.873–0.947) |
| Ignoring pain sensations (5 items) | 14.21±8.37 | 6.7/5.8 | 0.957 | 0.899 (0.853–0.931) |
| Distancing from pain (4 items) | 9.38±6.36 | 7.0/2.6 | 0.961 | 0.911 (0.863–0.943) |
| Coping self-statements (4 items) | 16.22±5.51 | 3.2/11.0 | 0.928 | 0.850 (0.785–0.897) |
| Praying (3 items) | 11.78±4.89 | 6.4/12.8 | 0.914 | 0.851 (0.768–0.906) |
Reliability:
Cronbach’s alpha was acceptable for all of the subscales (α=0.914 to 0.961). Test-retest reliability was measured in all of the subjects, and the domains showed good/excellent intraclass correlation coefficients (0.850 to 0.918) (Table 3).
Content validity:
The percentage of affirmative answers was >90% and, thus, the content of the items was considered to be adequate, appropriate for the target population, comprehensive and relevant for investigating coping strategies in this population.
Construct validity:
Most of the a priori hypotheses were confirmed. As expected, Catastrophizing (from r=0.27 to r=0.49) and Praying (from r=0.14 to r=0.23) were statistically significantly and positively related to other similar constructs. Catastrophizing was moderately correlated with Depression (r=0.49; P<0.01) (Table 4).
Coping Skills Assessment Pdf Template
TABLE 4
Correlations between the Coping Strategies Questionnaire – Revised (CSQ-R) subscales and pain, disability and depression
| Variables and subscales | Pain (NRS) | Disability (SIP-Roland) | Depression (CES-D) |
| CSQ-R | |||
| Distraction (5 items) | −0.06 | 0.08 | −0.18* |
| Catastrophising (6 items) | 0.27** | 0.36** | 0.49** |
| Ignoring pain sensations (5 items) | 0.07 | −0.12 | −0.19** |
| Distancing from pain (4 items) | 0.11 | 0.11 | −0.18** |
| Coping self-statements (4 items) | 0.01 | −0.08 | −0.33** |
| Praying (3 items) | 0.14* | 0.23** | 0.15* |
CES-D Center for Epidemiological Studies – Depression Scale; NRS Numerical rating scale; SIP-Roland Sickness Impact Profile –Roland Scale
When the coping questionnaires were compared, Catastrophizing and Praying were statistically significantly and positively related to CPCI maladaptive strategies (from r=0.11 to r=0.26, and from r=0.17 to r=0.29); weaker correlations were found in the case of adaptive strategies, except when CPCI Seeking social support was compared with Catastrophizing (r=0.14) and Praying (r=0.26). Likewise, Distraction, Distancing from pain and Coping self-statements were statistically significantly and positively related to CPCI adaptive strategies (from r=0.25 to r=0.50, from r=0.23 to r=0.43, and from r=0.13 to r=0.54) (Table 5).
TABLE 5
Correlations between the Coping Strategies Questionnaire – Revised and Chronic Pain Coping Inventory (CPCI) subscales
| CPCI subscales | Coping Strategies Questionnaire – Revised subscales | |||||
|---|---|---|---|---|---|---|
| Distraction | Catastrophizing | Ignoring pain sensations | Distancing from pain | Coping self-statements | Praying | |
| Guarding | 0.21** | 0.18** | −0.22** | 0.02 | −0.05 | 0.29** |
| Resting | 0.11 | 0.11 | −0.14* | −0.09 | −0.04 | 0.17** |
| Asking for assistance | 0.09 | 0.26** | −0.21** | −0.06 | −0.09 | 0.28** |
| Relaxation | 0.50** | 0.03 | 0.06 | 0.43** | 0.35** | 0.05 |
| Task persistence | 0.26** | −0.20** | 0.55** | 0.43** | 0.46** | −0.25** |
| Exercise/stretch | 0.25** | 0.01 | 0.09 | 0.23** | 0.13* | 0.05 |
| Seeking social support | 0.35** | 0.14* | 0.06 | 0.23** | 0.30** | 0.26** |
| Coping self-statements | 0.48** | −0.10 | 0.23** | 0.33** | 0.54** | 0.07 |
DISCUSSION
The present study reports the adaptation of the CSQ-Revised and its validation in a sample of previously uninvestigated Italian patients with chronic pain. Analyzing the psychometric properties of an outcome measure is a continuous process that is strongly recommended to strengthen its properties and expand its applicability to specific populations and contexts (24). Our findings provide further evidence regarding the relationships between CSQ-Revised and CPCI, two widely used questionnaires that assess coping strategies in individuals with chronic pain.
The meaning of the original items was adequately captured by the idiomatic translation of the CSQ-Revised. The difficulties encountered by the translators were overcome by means of careful wording. The questionnaire was acceptable and easily understood, and could be self-administered in approximately 10 min. It responded satisfactorily to the requirements of relevance and completeness, and appeared to be fully applicable to everyday clinical practice. No significant floor/ ceiling effects were found, which suggests the scale correctly assesses its construct.
The factorial structure of the CSQ-Revised was confirmed, and the satisfactory item-scale correlations enabled us to include all of the 27 items, as originally proposed (). This model adequately fits the data obtained from our sample, which suggests that coping strategies can be thoroughly described as a process with six components. French researchers have also performed a CFA using the CSQ-Revised, and achieved satisfactory results consistent with our findings and those of Riley and Robinson (,).
Our internal consistency was satisfactory, thus confirming the extent to which the items assessed the same construct. Our estimates were higher than that of the developers of the CSQ-Revised (α=0.72 to 0.86) and the French adaptation (α=0.57 to 0.83) (,).
The CSQ-Revised also showed satisfactory test-retest reliability in the investigated population and context; however, this psychometric property was not tested in the original and other adapted versions of the CSQ-Revised and, thus, no comparisons are possible.
Consistent with the English findings (), our estimates of construct validity highlighted the adaptive (ie, Distraction, Ignoring pain sensations, Distancing from pain and Coping self-statements) and maladaptive properties (Catastrophizing and Praying) of most of the subscales (,).
The correlations between the CSQ-Revised and the CPCI contributed further evidence of the adaptive and maladaptive strategies investigated by both measures. Our findings also suggest that the CSQ-Revised and CPCI have different constructs, thus highlighting their distinctive contribution to multidisciplinary pain programs and confirming the intent of the original developers of the CPCI to create a questionnaire that investigated previously ignored coping strategies (). As observed in previous studies (), exceptions were the correlations between CPCI-Task persistence and CSQ-Ignoring pain sensations, CSQ-Distancing from pain and CSQ-Coping self-statements; between CPCI-Relaxation and CSQ-Distraction and CSQ-Distancing from pain; and between CPCI-Coping self-statements and CSQ-Distraction and CSQ-Coping self-statements, which suggests that these constructs likely overlap in scale content and require further investigations.
There were several limitations to the present study. First, its cross-sectional design means that significant correlations should not be confused with causal effects. Second, the relationships between self-reported beliefs and objective measures of coping, such as behavioural observations or reports of cognitive coping during structured or standardized situations, were not considered because only self-administered measures were used. Third, additional studies of the properties of CSQ-Revised using modern test theory methods, such as Rasch measurement theory or item response theory, are recommended because only classical test theory psychometric properties were evaluated.
CONCLUSION
The Italian version of the CSQ-Revised confirmed the factor structure of the original English version and showed good psychometric properties. It can be recommended for use in chronic pain research and multidisciplinary pain assessments.
Acknowledgments
The authors thank Kevin Smart for his help in preparing the English version of the manuscript.
APPENDIX 1
CSQ-R-I, Coping Strategies Questionnaire – Revised: Italian Version
Le persone sviluppano strategie per fronteggiare e gestire il dolore che sentono. Queste strategie includono dire cose a noi stessi quando si prova dolore o quando si svolgono le attività quotidiane. Di seguito è riportato un elenco di cose che le persone hanno raccontato di fare quando provano dolore. Per cortesia, per ogni attività descritta indichi utilizzando la scala sotto riportata in che misura si sente coinvolto/a quando prova dolore.
| 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| non lo | ogni tanto | lo faccio | ||||
| faccio mai | lo faccio | sempre |
Strategie di coping
Distrarsi (,5): …./30
Catastrofismo (,21,): …./36
Ignorare le sensazioni dolorose: (,10,): …./30
Prendere le distanze dal dolore (,14,15,): …./24
Strategie di auto-affermazione (8,9,26,27): …./24
Pregare (,24,): …/18
| Domande | Punteggi |
|---|---|
| 1) Immagino cose che mi fanno piacere | |
| 2) Immagino persone con cui amo divertirmi | |
| 3) Ripenso a piacevoli esperienze trascorse | |
| 4) Faccio cose che mi gratificano come guardare la televisione o ascoltare la musica | |
| 5) Cerco di pensare a qualcosa di piacevole | |
| 6) Cerco di andare avanti come se niente fosse | |
| 7) Non presto attenzione al dolore | |
| 8) Dico a me stesso che il dolore non deve interferire con ciò che faccio | |
| 9) Anche se provo dolore cerco di andare avanti | |
| 10) Non penso al dolore | |
| 11) Ignoro il dolore | |
| 12) Fingo che il dolore non ci sia | |
| 13) Immagino che il dolore sia estraneo al mio corpo | |
| 14) Fingo che il dolore non mi appartenga | |
| 15) Cerco di estraniarmi dal dolore, come se appartenesse a qualcun altro | |
| 16) Cerco di pensare che il dolore non appartenga al mio corpo ma che sia qualcosa di estraneo | |
| 17) Ho la sensazione di non poter più sopportare il dolore | |
| 18) Ho la sensazione di non riuscire ad andare avanti | |
| 19) Sono preoccupato riguardo a quando finirà il dolore | |
| 20) Ho la sensazione che non valga la pena vivere | |
| 21) Il dolore è terribile e ho la sensazione che mi travolga | |
| 22) Il dolore è terribile e ho la sensazione che non migliorerà mai | |
| 23) Prego Dio che il dolore non duri a lungo | |
| 24) Supplico che il dolore finisca | |
| 25) Confido nella fede in Dio | |
| 26) Dico a me stesso che posso superare il dolore | |
| 27) Dico a me stesso di avere coraggio e di andare avanti nonostante il dolore |
Footnotes
DISCLOSURES: The authors have no conflicts of interest to declare.
IRB APPROVAL: The authors’ Institutional Review Board approved the study, which was conducted in accordance with ethical and humane principles of research.