Self-discrepancy in chronic low back pain: relation to pain, depression, and psychological distress

1. Introduction 

Persistent pain is one of the most challenging stressors that a person can face. Persons suffering from prolonged pain frequently report that living with pain alters their views of themselves. In specialized pain treatment settings, in particular, patients often state that, because of changes brought on by pain, they are no longer able to live up to their own views of how they would like to be or how they feel they ought to be. There is growing recognition that a discrepancy between how one is and how one would like to be plays a role in the experience of pain-related suffering.1

Self-discrepancy theory2 provides a theoretical model that may be useful in understanding how patients adjust to persistent pain. This theory maintains that discrepancies between who people believe they are and who they would like to be or believe they ought to be are significant influences on people's emotional state. In self-discrepancy theory, the term actual self refers to how a person currently views him- or herself, ideal self refers to how a person would ideally like to be, and ought self refers to the attributes that a person believes he or she has an obligation to possess. This theory maintains that ideal self and ought self are self-guides that function as standards by which the actual self is evaluated and that discrepancies between actual self and ideal self or actual self and ought self may lead to increased psychological distress. Self-discrepancy theory also emphasizes the need to consider individuals' beliefs about how others view them, namely, the individual's perceptions of the kind of person others ideally would like them to be (ideal-other self) or believe they ought to be (ought-other self). According to self-discrepancy theory, discrepancies between actual self and ideal-other self and between actual self and ought-other self can also be quite important in influencing psychological functioning and adjustment.3., 4.

Researchers working in the area of self-discrepancy have developed a methodology for systematically assessing self-discrepancies, the Selves Questionnaire.5 This semi-structured measure is relatively brief and can be administered in paper-and-pencil or interview format. The Selves Questionnaire was developed to assess actual, ideal, and ought selves from the individual's own standpoint and from the standpoint of others (i.e., ideal-own self, ideal-other self).

Recent studies have used the Selves Questionnaire6 in normal populations and in populations suffering from depression and anxiety.7 These studies have revealed several important findings. First, persons who report experiencing a substantial discrepancy between actual self and ideal self are much more likely to feel depressed, sad, and discouraged than those reporting little or no actual-ideal discrepancy.8 Second, persons who report experiencing a large discrepancy between actual self and ought self have been found to be more likely to report feeling anxious, worried, and fearful than those who reported little or no actual-ought discrepancy. Third, the associations between actual-ideal discrepancy and depressive affect and between actual-ought discrepancy and anxious affect have been obtained even after statistically controlling for the other type of self-discrepancy and other type of emotion state.9 In the Strauman and Higgins9 study, these associations were obtained when ideal-own and ideal-other self-discrepancies were combined to form a composite ideal self-discrepancy measure. The researchers also combined ought-own and ought-other self-discrepancies to form a composite ought self-discrepancy measure. In the present study, “ideal” discrepancy was used to denote “ideal-own” discrepancy; “ought” discrepancy was used to denote “ought-own” discrepancy. Discrepancies based on beliefs about the opinions of significant others were labeled as “ideal-other” and “ought-other.” No composite measures were used because we wanted to examine each self-discrepancy type individually.

Although self-discrepancy measures have been applied in research with normal populations and depressed and anxious populations, to date they have not been used in patients suffering from chronic pain. Understanding self-discrepancies in persons having persistent pain is important for several reasons. First, it is possible that self-discrepancy may be associated with the intensity and unpleasantness of pain. Second, when pain persists, self-discrepancy may be related to higher levels of depression and psychological distress. Finally, newly developed interventions designed to reduce self-discrepancy (e.g., Self-System Therapy10) may be beneficial for persons suffering from chronic pain.

In order to understand the role of self-discrepancies in patients having persistent pain, however, a number of basic questions need to be addressed. First, can self-discrepancy be reliably assessed in persons having long-standing pain conditions such as chronic low back pain? Second, do each of the four types of self-discrepancies (actual self vs. ideal self, actual self vs. ought self, actual self vs. ideal-other self and actual self vs. ought-other self) measure a distinct type of self-discrepancy, or are they simply manifestations of a general type of self-discrepancy in patients suffering from chronic low back pain? Finally, how are self-discrepancies related to pain, depression, and psychological distress?

The present study was designed to address these questions. Self-discrepancy was assessed in a sample of patients suffering from chronic low back pain, a common chronic pain condition.

2. Methods 

2.1. Participants 

Participants were 93 patients (55.9% women) suffering from chronic low back pain (CLBP) and receiving treatment in the Duke University Medical Center Pain and Palliative Care Clinic. The average disease duration for the participants was 8.64 years (±8.29 SD). The demographic information is presented in Table 1.

Table 1. Demographic Information of the Study Population

	Variable	%	n
	Agea (years)
	20–29	3.2	3
	30–39	7.5	7
	40–49	29.0	27
	50–59	30.1	28
	60–69	10.8	10
	70–79	10.8	10
	80–89	8.6	8
	Sexa
	Female	55.9	52
	Racea	23.7	22
	African American	23.7	22
	White	73.1	68
	Marital statusb
	Married	62.4	58
	Educationc
	< High school	16.1	15
	High school	23.7	22
	> High school	54.8	51

a Based on responses from 93 participants. b Based on responses from 90 participants. c Based on responses from 88 participants.

3. Results 

3.4. Descriptive analyses 

A series of analyses was performed to identify potential differences in self-discrepancy measures associated with sex, age, and pain duration. The results of t-tests found no statistically significant differences between women and men on self-reports of actual ideal, t(89)=1.51; actual ideal-other, t(88)=−0.21; actual ought, t(86)=0.58; and actual ought-other self-discrepancies, t(80)=0.58. Correlational analyses found no statistically significant associations between age and the self-discrepancy types(actual ideal, r=−0.002; actual ideal-other, r=−0.15; actual ought, r=−0.07; and actual ought-other, r=−0.06). Finally, the length of time since the onset of chronic low back pain was not significantly associated with actual ideal, actual ideal-other, actual ought, and actual ought-other self-discrepancies (r=−0.01, r=0.11, r=0.02, and r=0.08, respectively).

Table 2 presents descriptive information on the measures of actual ideal (n=91), actual ideal-other (n=90), actual ought (n=88), and actual ought-other (n=82) self-discrepancies and the outcome measures of pain (n=67), depression (n=70), and psychological distress (n=60). Negative numbers on the self-discrepancy measures denote fewer discrepancies between actual traits and ideal and ought traits. A test of within-subject effects found no significant differences in the magnitudes of the self-discrepancy types, F(3,78)=1.28.

Table 2. Descriptive Statistics for Self-Discrepancy and Outcome Measures

		n	Minimum	Maximum	Mean	SD
	Actual ideal	91	−6.00	6.00	−0.33	2.01
	Actual ideal-other	90	−5.00	2.00	−0.09	1.37
	Actual ought	88	−4.00	3.00	0.35	1.35
	Actual ought-other	82	−4.00	2.00	−0.32	1.24
	Present pain intensity	67	0	5	2.90	1.44
	Depression	70	1.00	47.00	16.17	11.24
	Psychological distress	60	0.08	2.73	0.92	0.70

Correlations between the four self-discrepancy types are presented in Table 3. All of the self-discrepancy types were significantly correlated with each other, with the magnitude of the correlations ranging from 0.24 to 0.54. However, the magnitudes of the correlations indicated some unique variance in the quantitative estimates of the measures and provided evidence of specific self-discrepancy types.

Table 3. Correlations Between Predictor and Outcome

		Actual Ideal-Other	Actual Ought	Actual Ought-Other	Present Pain-Intensity	Depression	Psychological Distress
	Actual ideal
	Pearson Correlation	0.538a	0.419a	0.457a	0.060	0.311a	0.289b
	Sig. (2-tailed)	0.000	0.000	0.000	0.631	0.009	0.025
	n	90	88	82	67	70	60
	Actual ideal-other
	Pearson Correlation		0.397a	0.244b	0.097	0.150	0.196
	Sig. (2-tailed)		0.000	0.028	0.434	0.215	0.134
	n		87	81	67	70	60
	Actual ought
	Pearson Correlation			0.532a	0.104	0.125	0.193
	Sig. (2-tailed)			0.000	0.405	0.307	0.144
	n			82	66	69	59
	Actual ought-other
	Pearson Correlation				0.263b	0.326a	0.457a
	Sig. (2-tailed)				0.042	0.009	0.000
	n				60	63	56
	Present pain intensity
	Pearson Correlation					0.227	0.346a
	Sig. (2-tailed)					0.065	0.007
	n					67	60
	Depression
	Pearson Correlation						0.755a
	Sig. (2-tailed)						0.000
	n						60

a Correlation is significant at the 0.01 level (2-tailed). b Correlation is significant at the 0.05 level (2-tailed).

3.5. Relationships of self-discrepancy to pain, depression, and psychological distress 

A series of stepwise regression analyses was performed to evaluate the relative contributions of ideal, ideal-other, ought, and ought-other self-discrepancies to the prediction of pain, depression, and psychological distress. For each stepwise regression model, four self-discrepancy measures were entered in the following order: actual ideal, actual ideal-other, actual ought, actual ought-other. The rationale for this order is that historically the bulk of research on self-discrepancy and depression has focused on actual ideal discrepancies. Thus, it was important to enter the ideal discrepancies first and control for them prior to entering other self-discrepancy measures. Because actual ought and actual ought-other discrepancies have been more closely associated with heightened anxiety levels, we were interested in determining whether these discrepancies played a role in depression among CLBP patients. Table 4 provides a summary of the results of these analyses.

Table 4. Summary of Stepwise Regression Analyses

	Variable	Incremental R2	B	SE B	β	P
	Dependent variable: Present pain intensity (n=59)		3.020	0.189		<.001
	Constant: Actual ought-other	0.071	0.326	0.156	0.267	0.041
	Dependent variable: Depression (n=63)		16.798	1.261		<.001
	Constant: Actual ideal	0.143	2.662	0.834	0.378	0.002
	Dependent variable: Psychological distress (n=56)		1.005	0.083		<.001
	Constant: Actual ought-other	0.209	0.211	0.072	0.364	0.005
	Actual ideal	0.271	0.116	0.055	0.267	0.037

3.5.1. Self-discrepancy and psychological distress 

As can be seen in Table 4, ought-other and ideal self-discrepancies contributed significantly to the variance in psychological distress (n=56). Discrepancies between patients' actual traits and those traits they believed others felt they ought to possess accounted for 20.9% of the variance in psychological distress scores. Discrepancies between the traits actually possessed and the traits patients would ideally like to possess accounted for an additional 6.3% of the variance in psychological distress scores. An overall R2=0.271 indicated a large effect size.22

3.5.2. Self-discrepancy and depression 

As can be seen in Table 4, ideal discrepancy explained the most variance in depression (n=63). Discrepancies between actual traits and the traits patients wished they possessed accounted for 14% of the variance in self-reported depression scores, denoting a moderate effect size.22

3.5.3. Self-discrepancy and pain 

As can be seen in Table 4, ought-other was the discrepancy type that explained the most variance in present pain intensity ratings (n=59). Patients with greater discrepancies between how they perceived themselves to actually be and their beliefs about how others felt they ought to be reported greater present pain intensity. Ought-other discrepancies accounted for 7.1% of the variance in present pain intensity levels, indicating a small effect size.22

3.6. A posteriori analyses 

To further examine the relationship between self-discrepancy and depression, separate mean scores were calculated for the cognitive items (items 1–10) and somatic items (items 11–21) on the BDI. Separate stepwise regression analyses were performed to evaluate the relative contributions of actual ideal, actual ideal-other, actual ought, and actual ought-other self-discrepancies to the prediction of the cognitive and somatic items. As can be seen in Table 5, actual ideal discrepancy explained the most variance in the mean scores on the cognitive items and somatic items associated with depression (n=63).

Table 5. Summary of A Posteriori Stepwise Regression Analyses

	Variable	Incremental R2	B	SE B	β	P
	Dependent variable: Depression: cognitive items (n=63)		7.730	0.766		<0.001
	Constant: Actual ideal	0.144	1.624	0.507	0.380	0.010
	Dependent variable: Depression: somatic items (n=63)		9.068	0.601		<0.001
	Constant: Actual ideal	0.101	1.039	0.397	0.317	0.011

4. Discussion 

This study had several major findings. First, the findings indicate that self-discrepancies can be reliably assessed in patients with persistent pain using the Selves Questionnaire. The level of inter-rater reliability obtained in this study of chronic low back pain patients, in fact, is quite similar to that reported in prior studies of self-discrepancy in normal and depressed populations. This finding is important because it suggests that the Selves Questionnaire may provide a reliable and standard method of assessing self-discrepancies in persons having persistent pain. Second, this study found that the magnitude of the correlations among the four different types of self-discrepancy were moderate but not so high as to suggest that we were gathering multiple measures of one self-discrepancy construct. As observed in previous studies, although related, each self-discrepancy type seems to measure a unique aspect of self-discrepancy. Third, variations in the level and type of self-discrepancy were significantly related to depression, and psychological distress, also consistent with previous findings.

One of the most interesting findings of this study was that self-discrepancy was related to psychological distress and depression in CLBP patients. We found support for the prediction of self-discrepancy theory that greater discrepancies between actual self and ideal self would be associated with increased levels of depression and that the association was evident for both the cognitive and somatic symptoms of depression. We also found an association between higher levels of actual ideal self-discrepancies and greater psychological distress. Actual ought-other self-discrepancies were also associated with greater psychological distress. Based on our findings, actual ideal self-discrepancies may contribute more to specific feelings of depression while actual ought-other self-discrepancies may contribute more to specific feelings of psychological distress.

One explanation for why psychological distress is high in patients who experience discrepancies between their actual self and the person they believe significant others think they ought to be may lie in how patients with persistent pain interpret the feedback that they get from significant others (e.g., responses in the form of gestures, words, and actions). The theory of symbolic interactionism maintains that feedback that significant others provide influences views of the self.23 According to this theory, individuals construct their self-concept, in part, by imagining and experiencing how significant others react to them and then internalizing this feedback into their own concept of their self. Thus, when patients having persistent pain perceive that the behaviors of significant others (e.g., being overly solicitous or overly criticizing) indicate that they are no longer able to be as independent and capable of fulfilling important responsibilities, these patients may adopt self-concepts that reflect this overly negative view. Symbolic interactionism would predict that, as this negative self-concept becomes entrenched, it tends to increase psychological distress.24

Another interesting finding was that discrepancies between actual self and ought-other self were related to pain intensity in CLBP patients. Patients who reported larger discrepancies between how they saw themselves (actual self) and how they believed others felt they ought to be (i.e., ought-other self-discrepancy) reported more intense pain. Two explanations for this association come to mind. First, perhaps greater experiences of pain result in a greater number of ought-other self-discrepancies. That is, increases in pain may make it difficult to maintain behaviors and engage in activities deemed important by family and other significant people in patients' lives, resulting in discrepancies between patients' perceptions of the traits they actually possess and the traits they believe others feel they ought to possess. Second, perhaps patients view their greater pain as a way of justifying the discrepancies they identify. Attributing the self-discrepancies to heightened pain levels may minimize individual responsibility and protect self-esteem,25 especially for CLBP patients who may be experiencing a lot of negative feedback from significant others. Although the underlying reason for the association between actual ought-other self-discrepancies and pain remains to be determined, this finding fits with a growing body of literature noting the importance of the social context in understanding the pain experience.26

This study found that two of the four types of self-discrepancy (i.e., actual self vs. ideal self, and actual self vs. ought-other self) were meaningfully related to measures of pain, depression, and psychological distress. We note that the same two self-discrepancies were the strongest predictors of distress in the original self-discrepancy research reported by Higgins and colleagues.6 These findings provide evidence that the self-discrepancy type constructs are functionally distinct and suggest that participants are able to distinguish between ideal and ought traits as viewed from their own standpoint and the standpoint of others. The findings also underscore the need for using caution when combining separate self-discrepancy types to form composite self-guides.

5. Conclusion 

To our knowledge, this study represents the first investigation to systematically examine self-discrepancy in a clinical population of patients suffering from a persistent pain condition. Taken together, these findings suggest that self-discrepancy is a useful concept in understanding pain, depression, and psychological distress in CLBP patients and support the need for future research in this area.