Cognitive Therapy and Research, Vol. 21, No. 4, 1997, pp. 443-457
Self-Evaluation, Coping, and Depressive Affect in African American Adults with Sickle Cell Disease1 Jennifer J. Wilson,2,4 Karen M. Gil,2 and Lauren Raezer3
Selective evaluation theory suggests that when individuals are faced with a threat such as a chronic illness they may compare themselves to less fortunate others, worse times, or hypothetical worse worlds to help cope with the threat. Research testing this model has demonstrated that these downward comparisons are associated with better psychological functioning. Although the assumption that upward comparisons are associated with poorer psychological functioning is implicitly stated in the selective evaluation theory, systematic research has not been conducted to test this hypothesis. To examine this question and to extend the generalizability of the selective evaluation theory, patients with sickle cell disease were asked to rate the frequency of use of both downward and upward comparisons when they have sickle cell disease pain and to rate their level of depressive affect. The results demonstrated that self-evaluation style accounts for a significant amount of variance in patients' level of depressive affect over and above demographic, pain, and disease-related variables. Moreover, as predicted, upward comparison was associated with higher levels of depressive affect and downward comparison was associated with lower levels of depressive affect. 1This
work was supported by grant RO1 HL46953-04, by Project VI.B.2 in the Duke University—University of North Carolina Sickle Cell Center grant in P60HL2839-12, and by the University of North Carolina at Chapel Hill GCRC grant RR00046. The authors acknowledge the contribution of William F. Chaplin of the University of Alabama at Tuscaloosa for consultation in the beginning and ending of this project. We express appreciation to all of the staff of the Duke University—University of North Carolina Sickle Cell Center including Mary Abrams, Adrena Johnson-Telfair, Susan Jones, Daria Peace, Dell Strayhorn, Eugene Orringer, and Wendell Rosse. We also thank David Johndrow for help with data analyses. 2Department of Psychology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599. 3Department of Psychology, Duke University, Durham, North Carolina 27710. 4Address all correspondence to Jennifer J. Wilson, Ph.D., Department of Psychology, CB# 3270, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-3270. 443 0147-5916/97/0800-0443$12.50/0 O 1997 Plenum Publishing Corporation
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KEY WORDS: sickle cell disease; chronic pain; self-evaluation; coping.
When individuals lack objective criteria to evaluate their experience, they will compare their experience to that of others. Since Festinger (1954) observed this phenomenon, social psychologists have endeavored to understand the processes by which individuals evaluate their experiences. Wills (1987) hypothesized that individuals use comparison strategies for both selfevaluation and self-enhancement purposes. When faced with a threat such as a natural disaster or an illness, individuals will often use comparative strategies to make themselves feel more fortunate than others, thus cushioning their loss. That is, when threatened, individuals will use comparative strategies for self-enhancing purposes. In their selective evaluation model, Taylor, Wood, and Lichtman (1983) proposed that there are five comparative standards: (a) downward social comparisons—comparing oneself to a less fortunate other, (b) selective focus—focusing on specific attributes that make one appear at advantage, (c) creating hypothetical worse worlds—comparing one's present situation to a hypothetical worse world, (d) normative standard—believing that one is coping better than most would in a similar situation, and (e) construing benefit from the victimizing experience. The core feature of these comparative strategies is that a downward comparison is made to make the comparer feel more fortunate. Health psychologists have sought to use this theory to understand individuals' evaluation of and adjustment to chronic illness. Wood, Taylor, and Lichtman (1985) found that women with breast cancer were more likely to make downward comparisons than upward comparisons. This tendency to make downward comparisons has also been reported in patients with rheumatoid arthritis (Affleck, Tennen, Pfeiffer, Fifeld, & Rowe, 1987; DeVellis et al., 1991), mothers of high-risk infants (Affleck et al., 1987), elderly spinal-cord-injured persons (Schultz & Decker, 1985), and patients with chronic pain (Jensen & Karoly, 1992). A major premise of Taylor et al.'s (1983) theory is that use of downward comparison standards is associated with better psychological adjustment. Affleck et al. (1987) found that patients with rheumatoid arthritis who made spontaneous downward comparisons were rated by their health care providers as more positively adjusted regardless of the level of disease severity. However, the use of downward comparison standards was not related to ratings of mood. Jensen and Karoly (1992) found that patients with chronic pain who used downward comparison standards were less likely to be depressed. Others have found that the use of downward comparison standards was associated with both positive and negative mood
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states (Blalock, Devellis, & Devellis, 1989; Buunk, Collins, Taylor, VanYperen, & Dakof, 1990; Major, Testa, & Bylsma, 1991). Further investigation of the relationships between downward comparison and adjustment and upward comparison and adjustment reveal even more complexity. Buunk et al. (1990) have proposed that making a downward comparison can lead to two pieces of information: (a) that you are not as bad off as others and/or (b) that you could be worse off. Similarly, comparing to someone who is better off than you provides you with two pieces of information: (a) that you are not as well off as others and/or (b) that you could be better off. Studies have demonstrated that it is not the direction of the comparison (i.e., upward vs. downward) that determines whether the comparison leads to self-enhancement; rather self-enhancement is determined by individual difference factors such as perceived control and self-esteem (Buunk et al., 1990; Jensen & Karoly, 1992). Buunk et al. found that individuals who reported more control over their symptoms and the future course of the illness were less likely to feel threatened by negative information in a downward comparison (i.e., "That could be me") or an upward comparison (i.e., "I am not there"). Consistently, Jensen and Karoly found that patients with chronic pain who reported having more control over their pain (i.e., felt less threatened) were more likely to use downward comparison information than patients who reported having less control. In light of the findings of Buunk et al., these results make sense. Individuals who feel more in control can more effectively use self-enhancing information. Clinical studies with pain populations have not found a relation between use of self-evaluation standards and pain intensity (Jensen & Karoly, 1992); however, studies examining the impact of self-evaluation standards on laboratory-analogue pain have demonstrated interesting results. For example, Litt (1988) found that undergraduates who were given downward comparison through experimental manipulation tolerated the cold pressor test longer than participants who were given no information or who were told they performed less well than others (upward comparison). Consistently, Wilson, Chaplin, and Thorn (1995) found that participants who were given an upward comparison version of a temporal standard (comparison to the participants' own less painful past experience) tolerated the cold pressor task for shorter periods of time and had higher pain ratings than participants who received no information or who were exposed to more painful experiences in a previous trial (downward comparison). These laboratory analogue studies are important because they demonstrate a direct influence of these standards on the experience of pain. Moreover, these studies examined explicitly the impact of upward comparison standards and found that it was associated with lower pain tolerance and higher pain ratings.
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Taken together, previous studies have demonstrated that individuals living with chronic illnesses generally make more downward comparisons than upward comparisons and that these downward comparisons are associated with better psychological adjustment. The impact of downward comparison may be influenced perceived control over the illness and individual difference factors such as self-esteem. In laboratory analogue pain situations, the use of upward comparison leads to shorter tolerance times and higher pain reports (Litt, 1988; Wilson et al., 1995); however, the relationship of upward comparison and psychological functioning in clinical populations has not been explicitly tested. Moreover, the relationship of these evaluation processes with other cognitive coping styles has not been systematically explored (Jensen & Karoly, 1992). The present study examined selective self-evaluations in a chronically ill population, individuals with sickle cell disease. It is particularly appropriate to study self-evaluation style, pain, coping, and depressive affect in patients with sickle cell disease for several reasons. The most common symptom of sickle cell disease is recurrent pain. Most patients experience recurrent and severe painful episodes for which there is no cure or adequate prevention (Platt et al., 1991; Shapiro, 1989). There is considerable variability in pain reports that is not adequately explained by physiological indicators (Weisman & Schechter, 1992). Depression occurs in 40% of adult patients with sickle cell disease (Thompson, Gil, Abrams, & Phillips, 1992). Research has demonstrated that the use of active coping strategies is associated with better psychological adjustment, and conversely, that cognitive distortions are associated with more depression and functional disability (Gil, Abrams, Phillips, & Keefe, 1989; Gil, Abrams, Phillips, & Williams, 1992). More recently, Gil et al. (1995) found that patients with sickle cell disease with more negative thoughts were more likely to report pain during noxious stimulation (i.e., during laboratory pain induction). Furthermore training in cognitive coping skills led to a decrease in negative thoughts, an increase in coping attempts, and a decrease in likelihood of reporting pain during noxious stimulation (Gil et al., 1996). Taken together, the results of these studies indicate that cognitive factors influence pain perception and psychological functioning—including level of depressive affect in patients with sickle cell disease. The use of selective self-evaluations has not been examined in this population. In this study, we examined the relationship between use of upward and downward comparison standards and one important aspect of psychological functioning in individuals with sickle cell disease, that is, level of depressive affect. While other studies have relied on unstructured interviews to assess use of both upward and downward comparison standards, this is one of the first studies to systematically assess the use of upward
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comparison standards in a structured questionnaire format. We predicted that a downward comparison style (a tendency to make downward comparisons) would be associated with lower levels of depressive affect. Conversely, we predicted that an upward comparison style (a tendency to make upward comparisons) would be associated with higher levels of depressive affect. Because level of depressive affect is related to disease severity, painrelated, and demographic variables, we controlled for these variables when testing these hypotheses (Thompson et al., 1992). Consequently, we tested the unique contribution of self-evaluation style to level of depressive affect. Although we had no a priori predictions about which style would account for more variance in level of depressive affect, we conducted a follow-up comparison to assess the differential contribution of upward and downward comparison to level of depressive affect. Tb validate the self-evaluation style measure, we examined the relationship between upward and downward comparison style and measures of coping (Coping Strategy Questionnaire, Inventory of Negative Thoughts in Response to Pain). We expected to find that positive coping attempts would be associated with a downward comparison style and negative thinking would be associated with an upward comparison style. Taken together, there are three reasons why it is important to examine these hypotheses. First, these results may further elucidate the relation of depressive affect to downward and upward comparison styles, providing support for Taylor et al.'s (1983) selective evaluation theory and clarifying the role of upward comparison in depressive affect. Second, the results may support the validity of a brief structured self-report measure of upward and downward self-evaluation style. Third, our results may lead to intervention studies that test the benefit of systematically changing self-evaluation style to improve psychological adjustment. METHOD
Participants Participants were solicited by telephone from the sample of patients who participated in a larger treatment outcome study at the Duke University—University of North Carolina Comprehensive Sickle Cell Center (Gil et al., 1996). Of the 48 patients contacted, 47 agreed to participate. The sample consisted of 22 women and 25 men with a mean age of 34 years (SD = 9.45, range = 18 to 51). All subjects were African American. The mean educational level of the subjects was 13.2 years (SD = 1.96, range = 7 to 16). Thirty-two percent were married, 9% were divorced, and 58%
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were never married. Forty-three percent were working full or part time, 14% were students, and 42% were disabled or unemployed.
Procedures The primary measures of self-evaluation style, depressive affect, and pain were collected specifically for the purposes of this study during a telephone interview. For the purpose of assessing the validity of the self-evaluation scale, several measures of coping—the Coping Strategies Questionnaire and the Inventory of Negative Thoughts in Response to Pain—were utilized from the larger treatment study. Demographic information, such as age, and diseaserelated variables, such as type of sickle cell disease and number of acute and chronic events, were obtained from the medical records. Methods Self-Evaluation Style. The Self-Evaluation Style Scale consists of the four items developed by Jensen and Karoly (1992), and a fifth downward comparison item to assess temporal comparison, or comparison to past experiences. This item was added based on the results of the study by Wilson et al. (1995) that indicated that temporal comparison accounted for the most variance in participants' pain tolerance and pain intensity ratings compared to normative or hypothetical comparisons. In addition five upward comparison items were included. The upward comparison items were the inverse versions of the downward comparison items. Thus, there were a total of 10 items (see Table I). Participants were asked to rate the frequency with which they engaged in the 10 comparison standards when experiencing a sickle cell painful episode using a 7-point Likert scale (0 = never do that and 6 = always do that). Depressive Affect. The Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977) was used to assess depressive affect. The CES-D was developed for use with nonpsychiatric samples and thus contains few somatic symptoms which may make it more suitable for use with patients with chronic illness who may be experiencing somatic symptoms which are attributable to their illness rather than to their level depressive affect. The CES-D has good reliability and validity (Radloff, 1977). Pain and Perceived Control. Participants rated their pain intensity on the day we contacted them on a 0- to 100-point rating scale with 0 = no pain at all and 100 = pain as bad as it could be. Participants also rated perceived control over pain by rating the amount of control they felt they had over pain on that day using a 7-point Likert scale (Rosenstiel & Keefe, 1983).
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Self-Evaluation and Sickle Cell Disease Table I. Items on the Self-Evaluation Style Scale Item
Item name and number Downward comparison versions 1. Selectively focusing on the positive
When experiencing sickle cell pain, I remind myself about things that I have going for me that other people don't have, such as intelligence, good looks, and good friends.
2. Hypothetical worse worlds
When experiencing sickle cell pain, I remind myself that things could be worse.
3. Downward social comparison
When experiencing sickle cell pain, I remind myself that there are people who are worse off than I am.
4. Normative standard
When experiencing sickle cell pain, I remind myself I am adjusting to my disease better than the average sickle cell patient.
5. Temporal standard
When experiencing sickle cell pain, I remind myself of times when I have experienced worse pain. Upward comparison versions
1. Selective focusing on the negative
When experiencing sickle cell pain, I remind myself about things that I do not have going for me that other people have, such as intelligence, good looks, and good friends.
2. Hypothetical better worlds
When experiencing sickle cell pain, I remind myself that things could be better.
3. Upward social comparison
When experiencing sickle cell pain, I remind myself that there are people who are better off than I am.
4. Normative standard
When experiencing sickle cell pain, I remind myself I am not adjusting to my disease better than the average sickle cell patient.
5. Temporal standard
When experiencing sickle cell pain, I remind myself of times when I have experienced less painful crises.
Measures of Coping. The Inventory of Negative Thoughts in Response to Pain (Gil, Williams, Keefe, & Beckman, 1990) is a 21-item scale composed of negative self-statements that a person might have during a painful episode. The respondent reads each thought and indicates how often he or she has each thought during a painful episode on a scale from 0 (never) to 4 (always). Two summary scores are calculated from the 21-item Inventory of Negative Thoughts in Response to Pain items: the total number of different thoughts endorsed (range from 0 to 21), and the average frequency of occurrence of negative thoughts calculated by summing the rat-
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ings of endorsed items and dividing by the number of items endorsed (possible range 0 to 4). The scale has adequate internal consistency and testretest reliability [r(24) = .72; Gil et al., 1995]. The second measure of coping is the Coping Strategy Questionnaire adapted for use with individuals with sickle cell disease (Gil et al., 1989; Rosenstiel & Keefe, 1983). This scale consisted of 13 subscales with six items each. Subjects rate each item on a 7-point Likert scale to indicate how often they used the strategy. The internal consistency of the Coping Strategy Questionnaire has been established in multiple previous studies (Gil et al., 1989; Rosenstiel & Keefe, 1983). Disease Severity and Demographics. In an effort to quantify disease severity, three measures were obtained from the medical records: (1) phenotype of sickle cell disease, (2) number of acute events, and (3) number of chronic events (Gil et al., 1989). Phenotype of sickle cell disease is likely to be related to pain severity. Sickle cell disease is a term used to refer to the entire group of hemoglobinopathies. Sickle cell disease results from the inheritance of two abnormal genes related to hemoglobin information. At least one of these genes is the sickle cell gene (S). Sickle cell anemia results from two S genes (SS), Two other phenotypes are hemoglobin SC, in which there is one gene for hemoglobin S and a second gene for another abnormal hemoglobin (C), and sickle beta thalassemia, in which the combination of hemoglobin S and thalassemia genes result in abnormal hemoglobin production. Although there is considerable variability, sickle cell anemia (SS) is usually considered to be the most severe of the clinical syndromes, followed by sickle beta thalassemia and hemoglobin SC disease, respectively (Rucknagel, 1974). Two other common measures of disease severity are the number of acute events (e.g., acute chest syndromes, seizures, strokes) and the number of chronic events (e.g., leg ulcers, renal complications, aseptic necrosis) that have occurred in the past year. The demographic information collected was age, gender, educational level, and employment status.
RESULTS Examination of the Self-Evaluation Style Scale The first step of data analysis was to assess the internal consistency of the two conceptual factors—upward comparison style or downward comparison style. The simple correlations among items ranged from .00 to .53 for the five downward comparison items and from .20 to .74 for the five upward comparison items. The coefficient alpha for the five downward
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comparison items was .70 and for the five upward comparison items was .80. A composite score was calculated for each comparison style. The upward comparison composite score was calculated by summing of the five upward comparison items and the downward comparison composite score was calculated by summing of the five downward comparison items. Interestingly, the tendency to make upward comparisons was not significantly related to the tendency to make downward comparisons (r = .31). Self-Evaluation Style to Predict Depressive Affect A hierarchical regression analysis was conducted to assess the relation between patient self-evaluation style and depressive affect. In this analysis, the demographic variables of age and gender were entered in Step 1, disease-related variables of type of sickle cell disease and number of acute and chronic events were entered in Step 2, and pain-related variables of pain ratings and perceived control over pain were entered in Step 3. These control variables were entered first to control for their potential effects. The downward and upward comparison composite scores were entered in the fourth step. The CES-D served as the criterion variable. The results of this analysis are presented in Table II. None of the demographic variables, pain-related variables, or disease-related variables were significant predictors of variance in depressive affect. Self-evaluation
Table II. Results of Hierarchical Regression Analyses Predicting Depressive Affect; Criterion: Depressive Affect (CES-D)a Step and variable
Total R2
K2 change
F change
1: Demographic variables
.05
.05
.98
Age Gender 2. SCD-related variables SCD type Chronic events Acute events 3. Pain-related variables Pain intensity Perceived control 4. Self-evaluation style Upward comparison Downward comparison a
.07
.17 .44
.02
.10 .27
P
F
-0.14 6.24
0.31 1.90
-0.48 2.53 -0.15
0.00 0.52 0.01
1.30 0.29
3.19 0.03
1.66 -0.95
11.53* 4.63b
0.19
1.60 b
5.59
CES-D = Center for Epidemiologic Studies Depression Scale; SCD = sickle cell disease; df = 9, 24. p < .05.
b
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style was a significant predictor of level of depressive affect even after controlling for variance due to demographics, disease severity, and pain. An examination of the beta weights demonstrates that individuals who used more frequent downward comparisons reported lower levels of depressive affect, whereas individuals who reported more frequent use of upward comparisons reported higher levels of depressive affect. The total model accounted for 44% of the variance in depressive affect, with 27% of the variance accounted for by self-evaluation style. A follow-up comparison of the beta weights for upward and downward comparison styles revealed that these beta weights were significantly different from one another, F(1, 24) = 9.10, p < .006, with the upward comparison style contributing more to level of depressive affect than the downward comparison style.
Validity Analyses: Upward and Downward Comparison and Measures of Coping Pearson product-moment correlation coefficients were calculated to assess the relationship between upward and downward comparison styles and the coping attempts and negative thinking factors of the Coping Strategy Questionnaire, and the total number of negative thoughts and average frequency of negative thoughts as measured by the Inventory of Negative Thoughts in Response to Pain. Correlations were evaluated using Bonferroni's correction (see Table III). An upward comparison style was significantly related to a tendency to endorse more negative thoughts on the Coping Strategy Questionnaire and a greater average frequency of negative thoughts as measured by the Inventory of Negative Thoughts in Response to Pain.
Table III. Relationship of Self-Evaluation Style to Coping Measuresa Upward comparison Coping attempts— CSQ
-.05
Negative thinking— CSQ
.53b
Total number— INTRP
.26
Average frequency-INTRP
.62b
Downward comparison
.23 .21 -.17
.14
"CSQ = Coping Strategy Questionnaire; INTRP = Inventory of Negative Thoughts in Response to Pain. bp < .01.
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DISCUSSION Hierarchical regression analyses revealed that the self-evaluation style of patients with sickle cell disease predicted significant proportions of variance in their level of depressive affect beyond that accounted for by demographic, disease severity, and pain-related variables. Individuals with a downward comparison style report lower levels of depressive affect. Thus, individuals who compare their experience of sickle cell pain to less fortunate others, worse times, and hypothetical worse worlds have better psychological adjustment. This result is consistent with the predictions of the selective evaluation theory and consistent with the results of other studies that have demonstrated that use of downward comparisons is associated with better psychological adjustment (Affleck et al., 1987; Jensen & Karoly, 1992). By demonstrating the use of comparative standards in another chronically ill population, individuals with sickle cell disease, the generalizability of this phenomenon has been expanded. Furthermore, the present study evaluated the contribution of an upward comparison style to level of depressive affect and found that individuals who reported an upward comparison style reported higher levels of depressive affect. Thus, individuals who compared their experience of sickle cell disease pain to more fortunate others, better times, and hypothetical better worlds had higher levels of depressive affect. This finding is especially important because it is one of the first demonstrations that upward versions of Taylor et al.'s (1983) selective evaluations contribute to the level of depressive affect in a chronically ill population. Interestingly, a follow-up examination of the beta weights in the regression model revealed that the upward comparisons accounted for significantly more variance in subjects' levels of depressive affect than downward. In other words, an upward comparison style may be even more important than a downward comparison style in predicting depressive affect in sickle cell disease. The results are interesting in light of Wilson et al.'s (1995) findings that the upward comparison standard significantly reduced the subject's ability to tolerate pain but their downward comparison standard was not different from the neutral standard condition. This suggests that making downward comparisons has a neutral rather than positive effect. Although the dependent variable is ability to tolerate pain rather than psychological adjustment, the pattern was consistent in both studies. That is, the upward comparison standard appeared to account for more variance than the downward comparison standard. These findings are quite consistent with Kendall's (1992) observation of the "power of nonnegative thinking" (p. 3). That is, empirical studies have demonstrated that psychological
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adjustment is related to the absence of negative thinking rather than the presence of positive thinking (Kendall, 1992). Taken together, the present results imply that there may be some clinical benefit in systematically assessing these comparison styles. Many clinicians who work with patients with chronic illnesses in group settings witness spontaneous comparisons by patients to more and less fortunate others, to better or worse times, or to worse or best hypothetical case scenarios. The results from this study suggest that self-evaluation style accounts for a significant amount of variance in level of depressive affect. Future studies might assess these styles in treatment outcome studies to determine whether self-evaluation style changes when improvements are observed in response to treatment. Intervention studies might evaluate the efficacy of trying to systematically decrease the frequency of upward comparisons and increase the frequency of downward comparisons. Additionally, assessment studies of this type should be conducted with children with sickle cell disease given that depression is a significant problem in this population (Thompson, Gil, Burbach, Keith, & Kinney, 1993). There are several issues related to internal consistency and validity that should be discussed. The self-evaluation style scale used in this study was based on Taylor et al.'s (1983) conceptual model that was expanded to include two dimensions—upward and downward comparison styles. Both the downward comparison factor and the upward comparison factor had adequate internal consistency. To explore the validity of the two self-evaluation styles, the present study examined the association between upward comparisons, downward comparisons, and coping measures. These analyses revealed interesting relations. An upward comparison style was associated with reporting more negative thoughts on both the Coping Strategies Questionnaire and the Inventory of Negative Thoughts in Response to Pain. No significant relations were found between a downward comparison style and the coping measures. Thus, the tendency to compare oneself to more fortunate situations and persons is associated with having negative thoughts about sickle cell disease pain. However, a tendency to compare oneself to less fortunate situations and persons is not significantly related to more effective coping. Furthermore, no relation was found between the upward comparison style and downward comparison style, providing preliminary evidence that these styles are independent of one another. These results provide further evidence that upward and downward comparisons are two separate phenomena associated with specific coping styles and levels of psychological adjustment. The present study has several limitations. First, the primary data were collected during a telephone interview, which may have promoted greater response bias than a pen and paper self-report measure. However, results from a previous study using a telephone interview (Jensen & Karoly, 1992)
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demonstrated a weak relationship between the CES-D and the MarloweCrown Social Desirability Scale thus, this seems unlikely. A second and related issue is whether we were actually measuring two different constructs of depressive affect and upward comparison style or a single construct of negative statements about self. Although this cannot be empirically addressed with these data, the consistency of our results with studies which empirically manipulated upward comparison information (e.g., Litt, 1988; Wilson et al., 1995) provides confidence that our results demonstrate the actual relationship of upward and downward comparison styles with depressive affect rather than reflect overlapping item content. Future research might address this concern by using a structured clinical interview for depression to minimize method variance. In addition, future research should include a self-report measure of self-evaluation as well as experimental methods to manipulate self-evaluation and then measure the impact on depressive affect. A third limitation of the present study is that the measures of self-evaluation style and coping were given on two separate occasions. Although the data indicate relations between comparison style and coping, these results must be considered preliminary in nature. However, the consistency across results is promising. Future research should include measures of coping and evaluation style on the same occasion and test hypotheses about the relationship between these variables using hierarchical regression analyses. A fourth limitation in the present study is that the data were correlational in nature and thus causal conclusions between self-evaluation and depressive affect cannot be made. Despite the limitations of this study, there are interesting clinical and research implications for these results. The self-evaluation style questionnaire used in this study is a useful measure of both the upward and downward comparison styles. The assessment of self-evaluation style may have clinical utility with patients with chronic illnesses because self-evaluation is predictive of depressive affect. Future studies might examine the relationship of self-evaluation to other aspects of adjustment such as health care use and work and social activities. Future research should also focus on testing whether self-evaluation style changes in response to treatment. The inclusion of strategies to modify self-evaluation style in the context of a psychological treatment protocol might yield clinical improvements, and this must be empirically tested.
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Blalock, S. J., DeVellis, B. M., & DeVellis, R. F. (1989). Social comparison among individuals with rheumatoid arthritis. Journal of Applied Social Psychology, 19, 665-680. Buunk, B. P., Collins, R. L., Taylor, S. E., VanYperen, N. W., & Dakof, O. A. (1990). The affective consequences of social comparison: Either direction has its ups and downs. Journal of Personality and Social Psychology, 59, 1238-1249. DeVellis, R. F., Blalock, S. J., Holt, K., Renner, B. R., Blanchard, L. W., & Klotz, M. L. (1991). Arthritis patients' reactions to unavoidable social comparisons. Personality and Social Psychology Bulletin, 17, 392-399. Festinger, L. A. (1954). (1954). A theory of social comparison processes. Human Relations, 7, 117-140. Gil, K. M., Abrams, M. R., Phillips, G., & Keefe, F. J. (1989). Sickle cell disease pain: Relation of coping strategies to adjustment. Journal of Consulting and Clinical Psychology, 57, 725-731. Gil, K. M., Abrams, M. R., Phillips, G., & Williams, D. A. (1992). Sickle cell disease pain: II. Predicting health care use and activity level at nine-months follow-up. Journal of Consulting and Clinical Psychology, 60, 267-273. Gil, K. M., Phillips, G., Webster, D. A., Martin, N. J., Abrams, M., Grant, M., Clark, W. C., & Janal, M. N. (1995). The relationship of negative thoughts to pain sensitivity in adults with sickle cell disease. Behavior Therapy, 26, 273-293. Gil, K. M., Williams, D. A., Keefe, F. J., & Beckham, J. C. (1990). The relationship of negative thoughts to pain and psychological distress. Behavior Therapy, 21, 349-362. Gil, K. M., Wilson, J. J., Edens, J. L., Webster, D. A., Abrams, M. A., Orringer, E., Grant, M. M., Clark, W. C, & Janal, M. N. (1996). The effects of cognitive coping skills training on coping strategies and experimental pain sensitivity in African American adults with sickle cell disease. Health Psychology, 15, 3-10. Jensen, M. P., & Karoly, P. (1992). Comparative self-evaluation and depressive affect among chronic pain patients: An examination of selective evaluation theory. Cognitive Therapy and Research, 16, 297-308. Kendall, P. C. (1992). Healthy thinking. Behavior Therapy, 23, 1-11. Litt, M. D. (1988). Self-efficacy and perceived control: Cognitive mediators of pain tolerance. Journal of Personality and Social Psychology, 54, 149-160. Major, B., Testa, M., & Bylsma, W. H. (1991). Responses to upward and downward social comparisons: The impact of esteem-relevance and perceived control. In J. Suls & T. A. Wills (Eds.), Social comparison: Contemporary theory and research (pp. 237-260). Hillsdale, NJ: Erlbaum. Platt, O. S., Thornington, B. D., Brambilla, D. J., Milner, P. F., Rosse, W. F., Vichinisky, E., & Kinney, T. R. (1991). Pain in sickle cell disease. The New England Journal of Medicine, 325, 11-16. Radloff, L. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385-401. Rosensteil, A. K., & Keefe, F. J. (1983). The use of coping strategies in chronic low back pain patients: Relationship to patient characteristics and current adjustment. Pain, 17, 33-44. Rucknagel, D. L. (1974). The genetics of sickle cell anemia and related syndromes. Archives of Internal Medicine, 133, 595-606. Schulz, R., & Decker, S. (1985). Long-term adjustment to physical disability: The role of social support, perceived control, and self-blame. Journal of Personality and Social Psychology, 48, 1162-1172. Shapiro, B. S. (1989). The management of pain in sickle cell diseases. Pediatric Clinics of North America, 36, 1029-1045. Taylor, S. E., Wood, J. V., & Lichtman, R. R. (1983). It could be worse: Selective evaluation as a response to victimization. Journal of Social Issues, 39, 19-40. Thompson, R. J., Gil, K. M., Abrams, M. R., & Phillips, G. (1992). Stress, coping, and psychological adjustment of adults with sickle cell disease. Journal of Consulting and Clinical Psychology, 60, 433-440.
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