Egyptian Journal of Psychiatry

: 2019  |  Volume : 40  |  Issue : 2  |  Page : 104--113

The association between personality, coping, and depression in patients with chronic pain

Reem Deif, Kate Ellis 
 Department of Psychology, The American University in Cairo, New Cairo, Egypt

Correspondence Address:
Reem Deif
Department of Psychology, The American University in Cairo, AUC Avenue, P.O. Box 74, New Cairo 11835


Background As a rising concern in the medical and mental health fields, this study aims to examine predictors of depressive symptoms in a sample of Egyptian patients with chronic pain in terms of coping styles and personality traits. Patients with chronic pain are believed to experience different stressors, which include, but are not limited to, pain, disability, reduced productivity, and financial difficulties. Such factors, in addition to various psychosocial factors, constitute the disease burden of chronic pain. Objective This study examines the degree to which coping styles and personality traits can influence the disease outcome in terms of comorbid depressive symptoms. Patients and methods A total of 98 (50 patients with fibromyalgia and 48 patients with rheumatoid arthritis) patients were interviewed and were assessed in terms of their coping styles, personality profile, and severity of depressive symptoms. Results Findings show a high prevalence of depressive symptoms and suggest passive coping, high neuroticism, low extraversion, unmarried status, and more years of education to be moderate predictors of the severity of chronic pain. Conclusion Conclusion Findings of this study shed light on the significance of the psychological aspects of chronic pain conditions and may help in designing liaison interventions for the management of secondary and comorbid depressive symptoms.

How to cite this article:
Deif R, Ellis K. The association between personality, coping, and depression in patients with chronic pain.Egypt J Psychiatr 2019;40:104-113

How to cite this URL:
Deif R, Ellis K. The association between personality, coping, and depression in patients with chronic pain. Egypt J Psychiatr [serial online] 2019 [cited 2019 Dec 10 ];40:104-113
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Chronic pain

Chronic pain is characterized by the persistence of symptoms for at least 3 months as suggested by the International Association for the Study of Pain (Merskey, 1986). However, several studies acknowledge different biological and psychosocial factors in the processing and experiencing of pain (i.e. Goodman, 2000), and neuroimaging research suggests neurophysiological similarities between experiencing pain, social rejection, and observing it in others (Lumley et al., 2011). Pain may also have multidimensional physiological and psychological outcomes, which add to the disease burden (Brennan et al., 2007). On a similar note and according to McBeth and Silman (2001), the temporal relationship between depression and chronic pain can be explained in terms of one of three models: (a) depressive symptoms may result from chronic pain, (b) depressive symptoms may precede the onset of physical pain, and (c) both conditions may have a common pathophysiologic mechanism but are still etiologically independent from each other.

Rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic, progressive, and systematic inflammatory condition characterized by the migration of inflammatory cells from the bloodstream to different joints throughout the body (Pitzalis, 1999). Changes in levels of inflammation are also linked with irreversible structural deteriorations in the joint, which also result in more pain and higher risk of disability.

Chronic rheumatic conditions have been linked with depression to the extent that the concept of ‘the psychobiology of arthritis-related depressive disorder’ has been used in research (Zyrianova et al., 2006). Statistics suggest a high prevalence of depression in patients with RA, and one study demonstrated a 2.06 higher likelihood in RA than in controls (Wang et al., 2014). Historically, there have been many attempts to understand the psychological aspects of RA (Young, 1993) and to explain such statistical findings. For example, scholars following the psychoanalytic school of thought had been trying to demonstrate what they referred to as the ‘arthritic personality’.


Fibromyalgia syndrome (FM; initially known as fibrositis syndrome) refers to a musculoskeletal chronic disorder characterized by a number of symptoms that have not received consensual recognition in the medical field yet. Looking into psychosocial risk factors, one prospective study was able to demonstrate the role of some risk factors in the onset of FM, including baseline self-reported depression which was the most significant predictor of FM diagnosis at a 5.5-year follow-up. Their results also suggested that women with depressive symptoms were at a six times higher risk of FM than women without depressive symptoms (Forseth et al., 1999). Another study supported the view of psychological risk factors and suggested that childhood abuse could predispose individuals for developing FM in adulthood (Eich et al., 2000). Similar to RA, FM is associated with significant harmful dysfunction in terms of psychological distress and reduced productivity. This is evident in the higher prevalence of symptoms of depression and anxiety than in the general population (Eich et al., 2000; White et al., 2002) and the positive correlation between psychological distress and pain severity (Wolfe et al., 1995). This has been confirmed in a study of Egyptian patients that showed the significant effect of the disease burden on the quality of life in addition to a strong association between severity of pain and severity of depression and anxiety (Helal et al., 2014).


Coping is conceptually defined as changing one’s cognitive and behavioral efforts to manage psychological stress. Speaking from an interactional model, coping is regarded as a dynamic process that involves continuous interactions between the individual, the stressor, and his/her environment. Looking at the functional role of coping when one is facing stressors, this has been articulated as ‘just as a competent immune system heals by altering bodily equilibrium, so do adaptive coping mechanisms reduce stress by influencing subjective perception of one’s condition’ (Zyrianova et al., 2011).

Different coping styles are broadly categorized as either active or passive. Active coping refers to strategies that involve taking initiative to manage one’s pain such as problem-solving and support-seeking behaviors. Passive, or emotion-focused, coping on the contrary refers to attempting to regulate negative emotions through withdrawing, wishful thinking, self-blame, catastrophizing, or cognitive disengagement (Smith et al., 2002). This kind of categorization is primarily based on the degree of internal or external control an individual exerts to manage stressors.


Personality can be generally defined as the distinctive differences between individuals in their patterns of feeling, thinking, and behaving (American Psychological Association, 2017). One systematic model of studying personality is the Big Five-Factor model, which identifies five major dimensions of personality: openness to experience, conscientiousness, extraversion, agreeableness, and neuroticism. Researchers attempted to study the personality profile of individuals with chronic pain and suggested it to be as follows: a vulnerable personality with high neuroticism, low extraversion, openness to experience and responsibility, and moderate agreeableness (Pastor et al., 2010).

The interaction between coping and personality

Costa et al. (1996) regarded coping behavior and personality as part of an adaptational continuum, suggesting structural and conceptual links between both (Watson and Hubbard, 1996). One study attempted to look beyond associations and correlations and demonstrated structural similarities between both constructs through joint factor analysis (Ferguson, 2001). The study showed that neuroticism loads positively with avoidance coping and that extroversion, on the contrary, was found to load with emotional and interactive coping. This is because extraversion is often associated with outgoingness and sociability, which favors the use of problem-focused and emotion-focused coping rather than escape and/or avoidance (Karimzade and Besharat, 2011). The research concluded that personality and coping cannot be functionally separated and also highlighted the need for future research on ‘coping trait complexes’.


The research suggests that depression affects up to more than 80% of individuals having chronic pain (Bair et al., 2003; Williams et al., 2003) and that those with comorbid depression are likely to have worse prognosis than those without comorbid depression (Fishbain et al., 1997). Previous research has attempted to explore the link between chronic pain and secondary depression through examining cognitive-behavioral mediators (Rudy et al., 1988; Elliott et al., 2003) and coping and adjustment (Rosenstiel and Keefe, 1983). However, a research gap exists in linking both coping and personality with depressive outcomes in individuals with chronic pain.


This study follows the ‘consequence hypothesis,’ explaining the link between chronic pain and depression in terms of depression being a consequence following the development of chronic pain. In this regard, the following is hypothesized:Chronic pain is not the sole factor contributing to the development of depressive symptoms in the affected individuals, and different individual and background variables, coping styles, and personality traits contribute to the degree of depressive symptoms, or resilience, in individuals with chronic pain.The association between coping/personality and depressive symptoms will be more significant in individuals with longer duration of chronic pain. This is based on the background that higher chronicity allows coping and personality traits to become more manifest and influential.Passive coping will be more prevalent, given the hypothesized low perceived control over chronic pain and the cultural background which tends to adopt a more external locus of control, and this should predict high depressive symptoms. This is based on research showing an association between the type of coping and an individual’s locus of control, which is culturally influenced (Leandro and Castillo, 2010).

 Patients and methods


A total of 48 participants diagnosed with RA were recruited from the outpatient rheumatology clinics of two public hospitals, one private hospital, and one private rheumatology clinic in Cairo. Fifty patients with FM were reached and contacted through an FM support group for patients living in Cairo. Inclusion criteria included an age range of 21–60 years, the persistence of symptoms for at least 3 months, and the continuous occurrence of symptoms. Additionally, pain resulting from these symptoms should be nonpsychological in nature and can be clinically and primarily attributed to their medical condition. Both generalized pain and localized pain were included. Participants were excluded in case of being diagnosed with a comorbid nondepressive psychiatric disorder and/or being at a significant suicidal risk, which might influence the overall clinical profile. Other exclusion criteria included having a terminal illness, life-threatening medical disorders, use of illicit drugs and/or alcohol, and significant cognitive impairment that becomes evident by clinical observation of the participant’s orientation, registration, and language. An IRB approval was obtained from the American University in Cairo before data collection.

[Table 1] illustrates the descriptive statistics for the overall sample, the RA subsample, and the FM subsample. The vast majority of respondents were females, and as shown, the subsamples were matched for sex and marital status but not for age, educational attainment, and employment status.{Table 1}

Measures and methods of analysis

For cultural appropriateness and readability, scales assessing coping and personality were translated and then backtranslated between English and Arabic by two independent translators with graduate-level background knowledge in mental health.

Brief big five inventory

As an abbreviated version of the well-renowned big five inventory (BFI; John et al., 1991), the brief version of the big five inventory (BFI-10; Rammstedt and John, 2007) was used to assess different personality dimensions in terms of extraversion, agreeableness, conscientiousness, neuroticism, and openness to experience. It consists of 10 of the original 44 standardized BFI items with two items representing each dimension: one keyed/scored in the positive direction and one keyed/scored in the negative direction. Responses are scaled on a Likert-type scale ranging from 1 (fully disagree) to 5 (fully agree).

Pain coping inventory

For the assessment of coping styles, the pain coping inventory (PCI; Kraaimaat et al., 1997) was administered. The PCI is a 33-item scale that consists of six subscales covering different cognitive and behavioral coping strategies for individuals dealing with pain. Each item represents one means of coping and is rated in terms of frequency on a four-point Likert scale: 1 (hardly ever), 2 (sometimes), 3 (often), and 4 (very often). PCI items are classified into six factors based on the factor loadings and internal consistencies demonstrated by Kraaimaat and Evers (2003). These are pain transformation, distraction, reducing demand, retreating, worrying, and resting. The PCI items were further categorized into two factors based on the work of Perrot et al. (2008) which demonstrated the structural validity of the PCI and its application for differentiating between active and passive coping. Hence, items were reclassified again into those two categories: active (items of the pain transformation, distraction, and reducing demand subscales) and passive (items of the retreating, worrying, and resting subscales). The possible score ranges for the active and passive subscales are 12–48 and 21–84, respectively.

The Hamilton Depression Rating Scale

For the assessment of the severity of depressive symptoms, the Hamilton Depression Rating Scale (HDRS) was administered following a structured interview guide (Williams, 1996). The HDRS version used consists of 17 items targeting different symptoms of depression and inquiring about their severity over the past week. Nine items are scored on a five-point scale, ranging from 0 to 4, and eight items are scored on a three-point scale, ranging from 0 to 2. Scoring is based on the 17-item scale with a range of 0–52. An overall score between 0 and 7 is considered as being normal, 8–16 suggests mild depression, 17–23 suggests moderate depression, and scores over 24 are indicative of severe depression (Zimmerman et al., 2013).


Depressive symptoms

[Table 2] summarizes the mean total Hamilton depression scores in the overall and the subsamples. [Figure 1] shows the distribution of scores in terms of the overall severity of depression.{Table 2}{Figure 1}

Looking into the relationship between duration of pain and the severity of depressive symptoms, the bivariate Pearson correlation test was conducted to test the relationship between duration of pain and different HDRS items; however, it yielded no significant results.

Personality traits

Scores on each of the BFI-10 subscales are summarized in [Table 3].{Table 3}

Pain coping

Mean scores on the PCI subscales are illustrated in [Table 4]. It is also important to note that all participants had been using pain medications during the data collection phase.{Table 4}

In terms of passive and active coping styles, and as shown in [Table 5], participants with FM scored significantly higher on passive coping than individuals in the RA subsample.{Table 5}

As shown in [Table 6], passive coping was negatively correlated with the score on the conscientiousness subscale. It was also negatively correlated with age and age of onset, however, only when diagnoses were not controlled for, given the statistically significant difference in age and age of onset between the RA and the FM subsamples. It was positively correlated with total score on the neuroticism subscale and the total HDRS score.{Table 6}

The overall model

[Table 7] shows the findings, which suggest some significant Pearson’s correlations between different variables.{Table 7}

Linear regression analysis

[Table 8] summarizes the three models examined using linear regression.{Table 8}

Based on previous literature supporting the mediational role of coping and cognitive appraisals in predicting health outcomes (i.e. Smith et al., 1990) and given that it had significant correlational relationships with each of the other variables, passive coping was tested as a mediator in the regression model. The reduced significance of neuroticism and extraversion when passive coping was added to the model explains its mediational effect. However, as it lacks a significant correlation with extraversion, passive coping appears to have a mediational effect only on neuroticism.

Taking this one step further, and given its significant role as a mediator in the model, passive coping was regressed as the outcome variable in another model testing independent variables that are hypothesized to be influential on the degree of passive coping. Below is a summary of the regression model ([Table 9]).{Table 9}


This study partially confirms the initial hypotheses in terms of the effect of coping and personality on the severity of depressive symptoms, and the higher prevalence of passive coping, rather than active coping, among chronic pain patients. Other interesting findings are discussed later with reference to the literature.

First of all, results are consistent with those from previous studies suggesting high prevalence of depressive symptoms in patients with chronic pain conditions. Looking at previous research examining depressive symptoms in patients with RA, one study showed a mean±SD HDRS score of 10.4±6.3 (Bagnato et al., 2015). Another study suggested a mean±SD HDRS score of 17.48±1.86 and demonstrated a positive correlation between disease duration and the total HDRS score (Isik et al., 2007). This study suggests a mean score that falls within this range, reflecting mild to moderate levels of depression in both subsamples. Findings also generally support the view that there are some psychological similarities between people with chronic pain regardless of the primary etiology (Hendler, 1982); however, some differences are still worth noting. For example, higher depressive symptoms were reported by patients with FM than patients with RA; this is in line with a previous study suggesting similar results (Hudson et al., 1985).

Similar to the hypothesized profile for individuals with chronic pain, the present study suggests neuroticism being the most dominant personality dimension and extraversion being the least. This study and previous research also demonstrated an association between neuroticism and passive forms of coping (Costa and McCrae, 1989; Endler and Parker, 1990). This is supported by Gray’s (1987) conceptualization of the behavioral inhibition system, which postulates that some neuropsychological processes mediate an individual’s response to anxiety-provoking stressors to produce avoidance behaviors. Predictions were significant and in the theorized direction in terms of the role of high neuroticism and low extraversion in predicting the severity of depressive symptoms. This link can be further illustrated in terms of the mediational role of coping behaviors and the role both personality dimensions play in determining the nature and effectiveness of how an individual copes with chronic pain as a stressor. In this regard, neuroticism is believed to predict mood pathologies (Clark et al., 1994; Vollrath and Torgersen, 2000) through the mediation of ineffective passive coping strategies (Bolger, 1990; Bolger and Zuckerman, 1995).

That being said, this study sheds light on passive coping as a factor that is significantly contributing to comorbid depression in chronic pain. Findings support the hypothesis that passive coping is more prevalent than active coping with an estimated ratio of 2 : 1. Looking into the building blocks of passive coping in terms of primary and secondary appraisals, it can be argued that individuals high in passive coping have negative cognitions about their pain experiences, their ability, and/or the availability or resources to manage pain and that, therefore, they perceive the stressor as a ‘threat’ rather than a ‘challenge’. From a cognitive model, this explains the association between passive coping, particularly worrying, and worse mental health outcomes (Smith et al., 1997; Skinner et al., 2003). Through its mediational effect, coping may also explain the link between the ‘big two of personality’ (extraversion and neuroticism) and the ‘big two of affect’ (positive and negative affect) as suggested by Watson and Hubbard (1996). Nonetheless, this finding can also be interpreted as suggesting that individuals with less depressive symptoms are more capable of using active coping than individuals with high depressive symptoms (Smith et al., 2002).Contrary to the notion that passive coping is associated with older age (LaChapelle and Hadjistavropoulos, 2005; Martin et al., 2008; Carver and Connor-Smith, 2010), findings suggest a negative correlation between age and passive coping. It has to be noted, however, that this finding does not necessarily mean a tendency toward active coping as both constructs are independent, at least as measured by the assessment tool used in this study. This finding may also support the assumption that individuals develop more advanced coping skills as they age and that this inverse link between age and passive coping is potentially mediated by lower levels of neuroticism.

Limitations of research

Despite its interesting findings, this study has a number of limitations. First, when looking at the functioning of an individual with chronic pain, it is important to examine his/her premorbid adjustment, which this study lacked owing to its limited design and timeframe. For example, employment history, family background, psychiatric history, high-risk behaviors, relationship history, financial conditions, sexual functioning, sleep, and weight should all be assessed to gain a good image of the individual’s functioning before and after the diagnosis (Hendler, 1982), and therefore, the study concluded that variations can be attributed to the disease burden. Similarly, the lack of follow-ups owing to time constraints should be considered in future research.

Future research

Future research should examine more specific mediators between chronic pain and depression, especially those that are believed to be culturally influenced. Other outcome variables also need to be examined to bridge the wide research gap in the field of chronic pain in Egypt. These may include, but are not limited to, pain intensity, sleep disorders, suicide risk, disability, and comorbid anxiety. Finally, as an area that remains to be vague, studies should also attempt to examine the dynamics of the relationship between psychiatric disorders and chronic pain and to demonstrate causal links, if any.


To our knowledge, this is the first study on coping styles and personality traits associated with chronic pain in Egypt. Although it provides some data on the dynamics between both variables and how they can predict depressive symptoms, it also highlights the research gap in this area. It confirms previous literature on the psychological burden of chronic pain; however, the findings of this study suggest some amendments to the initially hypothesized conceptual framework, and therefore, western literature should be dealt with cautiously given that cultural sensitivity of the studied topic. The final model draws to our attention the significance of unmarried status, more years of education, high neuroticism, low extraversion, and high passive coping in predicting the severity of depressive symptoms in patients with chronic pain. In this regard, it can be confidently argued that the disease burden is influenced by psychosocial factors that, either directly or indirectly, amplify the complications of chronic pain.[53]


The authors thank Dr Hassan Zaky for his kind assistance with the statistical analyses as well as Dr Sherine Ramzy and Dr Suher Zada who provided insight and expertise that greatly assisted the research.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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