Chronic pain and cigarette smoking and nicotine dependence among a representative sample of adults

INTRODUCTION

Individuals with chronic pain problems are at an increased risk for certain types of substance abuse and dependence. Recent work suggests that there is a significant association between chronic pain and cigarette smoking; however, it is unclear as to whether pain-smoking effects are evident above and beyond sociodemographic factors and cooccurring substance use disorders. The present investigation examined the relation between lifetime and current (past year) chronic pain and cigarette smoking status and nicotine dependence.

METHODS

This investigation comprised a large representative sample of English-speaking adults (n = 9,282) residing in the United States. Data were collected primarily through face-to-face interviews conducted between February 2001 and April 2003.

RESULTS

After adjusting for sociodemographic variables and the presence of a lifetime substance use disorder, individuals with a lifetime history of chronic neck or back pain were significantly more likely to be current smokers and to be diagnosed with lifetime as well as current nicotine dependence. Although there was no significant incremental relation between current chronic neck and back pain and being a current smoker, there was a significant association with lifetime and current nicotine dependence. Similar relations were evident among those with and without medically unexplained chronic pain in regard to smoking status and lifetime and current nicotine dependence.

DISCUSSION

Findings are discussed in terms of better understanding the chronic pain-smoking association.

Human tonic immobility: measurement and correlates

BACKGROUND

Tonic immobility (TI) is a temporary state of motor inhibition believed to be a response to situations involving extreme fear. Limited attention has been directed to studying TI in humans; however, the phenomenon has been well documented in the animal literature. In humans, TI is believed to occur during sexual assault, and there have been reports of fear-induced freezing in the contexts of air, naval, and other disasters.

METHODS

This study had three main purposes: (1) to assess the factor structure of a new self-report measure--the Tonic Immobility Questionnaire--designed to assess human TI in a range of traumatic events; (2) to explore associations among discovered TIQ factors and a measure of posttraumatic symptoms in the context of trauma type; and (3) to determine whether TI is related to suspected and empirically supported predictors of posttraumatic stress disorder. Participants were a subset of undergraduate students (n=78) who reported a TI experience in the context of a traumatic event.

RESULTS

No differences were found in frequency or severity of TI reported across trauma types. Exploratory factor analysis of Tonic Immobility Questionnaire item responses resulted in a three-factor solution (i.e., physical immobility, fear, and dissociation). Significant positive correlations were found between the Tonic Immobility Questionnaire and measures of posttraumatic symptoms, dissociation, anxiety sensitivity, and absorption. Regression analysis revealed that peritraumatic dissociation scores alone accounted for 51% of the variance in TI scores.

CONCLUSIONS

TI may represent an extreme behavioral expression of trauma-induced peritraumatic dissociation. Implications and directions for future research are discussed.

Mental health correlates of intimate partner violence in marital relationships in a nationally representative sample of males and females

It is important to understand the epidemiology of intimate partner violence (IPV) experienced by both males and females. Data were drawn from the U.S. National Comorbidity Survey Replication. The relationships between physical IPV and child abuse, mental disorders, and suicidal ideation and attempts among males and females were examined. The results indicate that child sexual abuse was associated with IPV among males, whereas child physical and sexual abuse was associated with IPV among females. IPV was associated with poor mental health outcomes for males and females, although sex differences are noted. The sex differences indicate that females experience a wider range of poor mental health outcomes compared to males. Knowledge about correlates of IPV can be useful in identifying individuals exposed to violence. Further research is required to identify effective methods to reduce exposure to IPV and to adequately address the specific needs of male and female victims of IPV.

Pain-related anxiety and anxiety sensitivity across anxiety and depressive disorders

Fear-anxiety-avoidance models posit pain-related anxiety and anxiety sensitivity as important contributing variables in the development and maintenance of chronic musculoskeletal pain [Asmundson, G. J. G, Vlaeyen, J. W. S., & Crombez, G. (Eds.). (2004). Understanding and treating fear of pain. New York: Oxford University Press]. Emerging evidence also suggests that pain-related anxiety may be a diathesis for many other emotional disorders [Asmundson, G. J. G., & Carleton, R. N. (2005). Fear of pain is elevated in adults with co-occurring trauma-related stress and social anxiety symptoms. Cognitive Behaviour Therapy, 34, 248-255; Asmundson, G. J. G., & Carleton, R. N. (2008). Fear of pain. In: M. M. Antony & M. B. Stein (Eds.), Handbook of anxiety and the anxiety disorders (pp. 551-561). New York: Oxford University Press] and appears to share several elements in common with other fears (e.g., anxiety sensitivity, illness/injury sensitivity, fear of negative evaluation) as described by Reiss [Reiss, S. (1991). Expectancy model of fear, anxiety, and panic. Clinical Psychology Review, 11, 141-153] and Taylor [Taylor, S. (1993). The structure of fundamental fears. Journal of Behavior Therapy and Experimental Psychiatry, 24, 289-299]. The purpose of the present investigation was to assess self-reported levels of pain-related anxiety [Pain Anxiety Symptoms Scale-Short Form; PASS-20; McCracken, L. M., & Dhingra, L. (2002). A short version of the Pain Anxiety Symptoms Scale (PASS-20): preliminary development and validity. Pain Research and Management, 7, 45-50] across several anxiety and depressive disorders and to compare those levels to non-clinical and chronic pain samples. Participants consisted of a clinical sample (n=418; 63% women) with principal diagnoses of a depressive disorder (DD; n=22), panic disorder (PD; n=114), social anxiety disorder (SAD; n=136), obsessive-compulsive disorder (OCD; n=86), generalized anxiety disorder (GAD; n=46), or specific phobia (n=14). Secondary group comparisons were made with a community sample as well as with published data from a treatment-seeking chronic pain sample [McCracken, L. M., & Dhingra, L. (2002). A short version of the Pain Anxiety Symptoms Scale (PASS-20): preliminary development and validity. Pain Research and Management, 7, 45-50]. Results suggest that pain-related anxiety is generally comparable across anxiety and depressive disorders; however, pain-related anxiety was typically higher (p<.01) in individuals with anxiety and depressive disorders relative to a community sample, but comparable to or lower than a chronic pain sample. Results imply that pain-related anxiety may indeed be a construct independent of other fundamental fears, warranting subsequent hierarchical investigations and consideration for inclusion in treatments of anxiety disorders. Additional implications and directions for future research are discussed.

Structure of posttraumatic stress disorder symptoms in pain and pain-free patients scheduled for major surgery

Factor-analytic studies of the structure of posttraumatic stress disorder (PTSD) symptoms have yielded inconsistent results. One of the reasons for the inconsistency may be that PTSD is highly comorbid with other disorders; the observed factor structure might depend on the particular comorbid disorder. One such disorder is chronic pain. The goal of the present study was to investigate whether PTSD symptom structure differs between pain and pain-free patients scheduled to undergo major surgery. Four hundred and forty-seven patients who were approached 7 to 10 days prior to scheduled surgery completed the PTSD Checklist-Civilian (PCL-C) Version and the Current Pain and Pain History Questionnaire; the latter was used to divide patients into pain (N = 175) and pain-free (N = 272) groups. Results showed that in pain-free patients, PTSD symptoms were best expressed as 2 symptom clusters (re-experiencing/avoidance; emotional numbing/hyperarousal) accounting for 52.4% of the variance. In pain patients, PTSD symptoms were best expressed as a single symptom cluster accounting for 51.1% of the variance. These results suggest different interrelationships among PTSD symptoms in these 2 populations. Results reflect the need for (1) controlling for pain in studies looking at PTSD-symptom expression and (2) further research on PTSD-symptom expression in pain populations.

PERSPECTIVE

These results may have important implications for research on the comorbidity between PTSD and chronic pain, as well as for treatment of PTSD symptoms in patients presenting with pain problems.

Refining and validating the Social Interaction Anxiety Scale and the Social Phobia Scale

BACKGROUND

The Social Interaction Anxiety Scale and Social Phobia Scale are companion measures for assessing symptoms of social anxiety and social phobia. The scales have good reliability and validity across several samples, however, exploratory and confirmatory factor analyses have yielded solutions comprising substantially different item content and factor structures. These discrepancies are likely the result of analyzing items from each scale separately or simultaneously. The current investigation sets out to assess items from those scales, both simultaneously and separately, using exploratory and confirmatory factor analyses in an effort to resolve the factor structure.

METHODS

Participants consisted of a clinical sample (n 5353; 54% women) and an undergraduate sample (n 5317; 75% women) who completed the Social Interaction Anxiety Scale and Social Phobia Scale, along with additional fear-related measures to assess convergent and discriminant validity.

RESULTS

A three-factor solution with a reduced set of items was found to be most stable, irrespective of whether the items from each scale are assessed together or separately. Items from the Social Interaction Anxiety Scale represented one factor, whereas items from the Social Phobia Scale represented two other factors.

CONCLUSION

Initial support for scale and factor validity, along with implications and recommendations for future research, is provided.

Socially related fears following exposure to trauma: environmental and genetic influences

Few studies have examined why socially related fears and posttraumatic stress commonly, but not invariably, co-occur. It may be that only traumata of human agency (e.g., sexual assault), for which there is an interpersonal component, give rise to co-occurring socially related fears. These symptoms might also co-occur because of shared genetic factors. We investigated these issues using a sample of 882 monozygotic and dizygotic twins. No significant differences in socially related fear (i.e., fear of negative evaluation, fear of socially observable arousal symptoms) were found between participants reporting assaultive or nonassaultive trauma. However, significant differences in socially related fear were found when participants were grouped into probable PTSD and no PTSD groups. Participants with probable PTSD exhibited greater socially related fear (i.e., fear of negative evaluation) than those without PTSD. Using biometric structural equation modeling, trauma exposure was best explained by shared and nonshared environmental influences. The fear of socially observable arousal symptoms was influenced by genetic and nonshared environmental influences. Implications and directions for future research are discussed.

Waddell's symptoms as indicators of psychological distress, perceived disability, and treatment outcome

INTRODUCTION

Waddell's signs and symptoms have been described as patient presentations not within usual anatomic patterns of injury pathology. Waddell's signs were thought to indicate psychological distress and were termed "non-organic findings"; similarly, Waddell's symptoms were described as inappropriate and attributable to psychological features. Endorsement of more than two of Waddell's symptoms is thought to be associated with psychological distress, disability, and poor treatment outcomes; however, this has not been empirically assessed.

METHODS

The current study used a sample of patients (n = 108; 30% women) involved in a multi-disciplinary work hardening program provided by a third-party insurer. Patients who endorsed more than two of Waddell's symptoms were compared with those who did not on demographic variables as well as self-report measures of psychological distress, disability, and treatment outcome.

RESULTS

Patients who endorsed more than two of Waddell's symptoms reported higher levels of psychological distress, perceived disability, pain intensity, and pain durations. Moreover, consistent with previous research on Waddell's symptoms, patients endorsing more than two symptoms were also less likely to return to work.

CONCLUSIONS

Waddell's symptoms were associated with increased perceived disability and pervasive pain interference. Patients who endorsed more than two symptoms were significantly less likely to return to work than those who endorsed zero, one, or two symptoms. Patients who endorsed more than two symptoms may indeed be affected by factors beyond tissue pathology that nonetheless warrant clinical attention. Waddell's symptoms appear to have promise as a quick indicator of treatment complexity and outcome.

Relation between traumatic events and suicide attempts in Canadian military personnel

OBJECTIVE

To determine whether exposure to particular types of traumatic events was differentially associated with suicide attempts in a representative sample of active military personnel.

METHOD

Data came from the Canadian Community Health Survey: Mental Health and Well-Being Canadian Forces Supplement (CCHS-CFS), a cross-sectional survey that provided a comprehensive examination of mental disorders, health, and the well-being of currently active Canadian military personnel (n = 8441; aged 16 to 54 years; response rate 81.1%). Respondents were asked about exposure to 28 traumatic events that occurred during their lifetime. Suicide attempts were measured using a question about whether the person ever "attempted suicide or tried to take [his or her] own life."

RESULTS

The prevalence of lifetime suicide attempts for currently active Canadian military men and women was 2.2% and 5.6%, respectively. Sexual and other interpersonal traumas (for example, rape, sexual assault, spousal abuse, child abuse) were significantly associated with suicide attempts in both men (adjusted odds ratios [AORs] ranging from 2.31 to 4.43) and women (AORs ranging from 1.73 to 3.71), even after adjusting for sociodemographics and mental disorders. Additionally, the number of traumatic events experienced was positively associated with increased risk of suicide attempts, indicating a dose-response effect of exposure to trauma.

CONCLUSIONS

The current study is the first to demonstrate that sexual and other interpersonal traumatic events are associated with suicide attempts in a representative sample of active Canadian military men and women.

The symptom structure of posttraumatic stress disorder in the National Comorbidity Replication Survey

Previous research has provided mixed findings for the validity of various three- and four-factor models of posttraumatic stress disorder (PTSD) symptomatology. However, much of this research has been restricted to clinical samples rather than nationally representative community-based samples. The current study employed confirmatory factor analysis to evaluate the validity of three competing models of PTSD symptom structure using the DSM-IV-based National Comorbidity Replication Survey (part II of the NCS-R: N=5692). Individuals with a lifetime diagnosis of PTSD (N=588) were selected and symptom assessment was based on the World Health Organization Composite International Diagnostic Interview. Strong support was found for both the DSM-IV three-factor model and a four-factor model of PTSD symptoms by King et al. [King, D. W., Leskin, G. A., King, L. A., & Weathers, F. W. (1998). Confirmatory factor analysis of the clinician-administered PTSD scale: evidence for the dimensionality of posttraumatic stress disorder. Psychological Assessment,10, 90-96], a variation of the DSM-IV model in which avoidance and numbing are viewed as separate factors. There was some evidence, however, that the King et al. [King, D. W., Leskin, G. A., King, L. A., & Weathers, F. W. (1998). Confirmatory factor analysis of the clinician-administered PTSD scale: evidence for the dimensionality of posttraumatic stress disorder. Psychological Assessment,10, 90-96] model demonstrated a significantly superior fit over the DSM-IV three-factor model. Because this study provided support for both the DSM-IV three-factor model and the King et al., four-factor model of PTSD symptoms, further research is still necessary to provide more definitive conclusions in this area.

Canadian military personnel's population attributable fractions of mental disorders and mental health service use associated with combat and peacekeeping operations

OBJECTIVES

We investigated mental disorders, suicidal ideation, self-perceived need for treatment, and mental health service utilization attributable to exposure to peacekeeping and combat operations among Canadian military personnel.

METHODS

With data from the Canadian Community Health Survey Cycle 1.2 Canadian Forces Supplement, a cross-sectional population-based survey of active Canadian military personnel (N = 8441), we estimated population attributable fractions (PAFs) of adverse mental health outcomes.

RESULTS

Exposure to either combat or peacekeeping operations was associated with posttraumatic stress disorder (men: PAF = 46.6%; 95% confidence interval [CI] = 27.3, 62.7; women: PAF = 23.6%; 95% CI = 9.2, 40.1), 1 or more mental disorder assessed in the survey (men: PAF = 9.3%; 95% CI = 0.4, 18.1; women: PAF = 6.1%; 95% CI = 0.0, 13.4), and a perceived need for information (men: PAF = 12.3%; 95% CI = 4.1, 20.6; women: PAF = 7.9%; 95% CI = 1.3, 15.5).

CONCLUSIONS

A substantial proportion, but not the majority, of mental health-related outcomes were attributable to combat or peacekeeping deployment. Future studies should assess traumatic events and their association with physical injury during deployment, premilitary factors, and postdeployment psychosocial factors that may influence soldiers' mental health.

Prevalence and correlates of sleep paralysis in adults reporting childhood sexual abuse

Sleep paralysis (SP) occurs when rapid eye movement (REM) activity and concomitant paralysis of the skeletal muscles persist as an individual awakens and becomes conscious of his/her surroundings. SP is often accompanied by frightening hallucinations that some researchers suggest may be confounded with memories of childhood sexual abuse (CSA; [McNally, R. J., & Clancy, S. A. (2005). Sleep paralysis in adults reporting repressed, recovered, or continuous memories of childhood sexual abuse. Journal of Anxiety Disorders, 19, 595-602]). The purpose of this study was to evaluate relationships between CSA and SP. Based on self-report, participants (n=263) were categorized into three CSA groups: confirmed, unconfirmed, or no history of CSA. Relative to participants reporting no CSA history, those reporting CSA reported more frequent and more distressing episodes of SP. Post hoc analyses revealed that participants with clinically significant post-traumatic symptoms (irrespective of CSA history) also reported more frequent and more distressing episodes of SP. Significant correlations were found among SP indices and measures of post-traumatic symptoms, depression, dissociation, and absorption. Implications and future research directions are discussed.

Associations between dimensions of anxiety sensitivity and PTSD symptom clusters in active-duty police officers

Prior studies have shown that anxiety sensitivity (AS) plays an important role in posttraumatic stress disorder (PTSD) symptom severity. The purpose of this study was to evaluate associations between empirically supported PTSD symptom clusters (i.e. reexperiencing, avoidance, numbing, hyperarousal) and AS dimensions (i.e. psychological concerns, social concerns, somatic concerns). Participants were 138 active-duty police officers (70.7% female; mean age = 38.9 years; mean time policing = 173.8 months) who, as a part of a larger study, completed measures of trauma exposure, PTSD symptoms, AS, and depressive symptoms. All participants reported experiencing at least one event that they perceived as traumatic, and 44 (31.9%) screened positive for PTSD. Officers with probable PTSD scored significantly higher on AS total as well as the somatic and psychological concerns dimensional scores than did those without PTSD. As well, a higher percentage of officers with probable PTSD scored positively on the AS-derived Brief Screen for Panic Disorder (Apfeldorf et al., 1994) compared with those without PTSD. A series of regression analyses revealed that depressive symptoms, number of reported traumas, and AS somatic concerns were significant predictors of PTSD total symptom severity as well as severity of reexperiencing. Avoidance was predicted by depressive symptoms and AS somatic concerns. Only depressive symptoms were significantly predictive of numbing and hyperarousal cluster scores. These findings contribute to understanding the nature of association between AS and PTSD symptom clusters. Implications for the treatment of individuals having PTSD with and without panic-related symptomatology are discussed.

Media exposure and dimensions of anxiety sensitivity: differential associations with PTSD symptom clusters

The present investigation examined the impact of anxiety sensitivity (AS) and media exposure on posttraumatic stress disorder (PTSD) symptoms. Reactions from 143 undergraduate students in Hamilton, Ontario were assessed in the Fall of 2003 to gather information on anxiety, media coverage, and PTSD symptoms related to exposure to a remote traumatic event (September 11th). Regression analyses revealed that the Anxiety Sensitivity Index (ASI; [Peterson, R. A., & Reiss, S. (1992). Anxiety Sensitivity Index manual, 2nd ed. Worthington, Ohio: International Diagnostic Systems]) and State-Trait Anxiety Inventory trait form (STAI-T; [Spielberger, C. D., Gorsuch, R. L., & Lushene, R. E. (1970). State-trait anxiety inventory. Palo Alto, California: Consulting Psychologists Press]) total scores were significant predictors of PTSD symptoms in general. The ASI total score was also a significant predictor of hyperarousal and avoidance symptoms. Subsequent analyses further demonstrated differential relationships based on subscales and symptom clusters. Specifically, media exposure and trait anxiety predicted hyperarousal and re-experiencing symptoms, whereas the ASI fear of somatic sensations subscale significantly predicted avoidance and overall PTSD symptoms. Implications and directions for future research are discussed.

A Behavioral-Genetic Analysis of Health Anxiety: Implications for the Cognitive-Behavioral Model of Hypochondriasis

The leading contemporary cognitive-behavioral model of excessive health anxiety (HA) emphasizes the importance of environmental factors, such as learning experiences. The model has little to say about the role of genetic factors and, by ignoring these factors, seems to imply that they are unimportant. In contrast, results from the University of British Columbia Twin Study, using a sample of 88 monozygotic and 65 dizygotic twin pairs, indicated that various facets of HA, such as excessive disease fear, unrealistic beliefs that one has a serious disease, and HA-related interference in functioning, are moderately heritable. The present study extended the analyses of this data set by investigating the extent to which the various facets of HA are due to genetic or environmental factors that are common to all facets versus specific to each facet. Results indicated that all facets of HA are influenced by a common set of genes—there was very little evidence of facet-specific genetic influences. There was considerably stronger evidence for facet-specific environmental influences, where each facet is strongly influenced by environmental experiences that are specific to that facet. However, there was also evidence that particular environmental influences—especially those that shape disease conviction—also influence some of the other HA facets (fear and interference). The importance of environmental factors is consistent with the cognitive-behavioral model of HA, although the model needs to be refined to account for the role of genetic factors. Possibilities for refining the model are discussed, along with promising research directions to better understand the role of genes and the environment in HA.

A longitudinal investigation of fear of falling, fear of pain, and activity avoidance in community-dwelling older adults

OBJECTIVE

The primary purpose of this study was to examine the role of fear of falling, fear of pain, and associated activity avoidance in the prediction of pain and falls.

METHOD

A 6-month longitudinal study of older community-dwelling adults.

RESULTS

The authors found that fear of falling is a better predictor of falls than is activity avoidance. Moreover, fear of pain did not predict future pain-related avoidance or future pain in the sample of seniors.

DISCUSSION

The findings confirm the ability of fear of falling to predict falls but challenge preexisting models developed to account for the relationship between falls and fear. The findings also suggest limits on the generalizability of fear-avoidance models of pain. The authors conclude by suggesting mechanisms that could account for the relationship of fears with falls and pain. Unlike previous conceptualizations, these mechanisms do not rely on activity avoidance as an explanation.

Population attributable fractions of psychiatric disorders and suicide ideation and attempts associated with adverse childhood experiences

OBJECTIVES

We sought to determine the fractions of psychiatric disorders and suicide ideation and attempts in a general population sample attributable to childhood physical abuse, sexual abuse, and witnessing domestic violence.

METHODS

Data were obtained from the US National Comorbidity Survey Replication. Population attributable fractions were calculated to determine the proportion of psychiatric disorders and suicide ideation and attempts attributable to adverse childhood experiences. The analysis was stratified by gender.

RESULTS

The estimated attributable fractions for psychiatric disorders attributable to having experienced any adverse childhood event ranged from 22% to 32% among women and 20% to 24% among men. Having experienced any adverse event accounted for a substantial proportion of suicide ideation and attempts among women (16% and 50%, respectively) and men (21% and 33%, respectively). Substantial proportions of poor mental health outcomes were also attributable to increasing number of adverse events.

CONCLUSIONS

The estimated proportions of poor mental health outcomes attributed to childhood adversity were medium to large for men and women. Prevention efforts that reduce exposure to adverse childhood events could substantially reduce the prevalence of psychopathology and suicidal behavior in the general population.

The Fear of Pain Questionnaire – Short Form (FPQ-SF): Factorial validity and psychometric properties

McNeil and Rainwater's Fear of Pain Questionnaire III (FPQ-III, 1998) is an empirically derived self-report inventory that assesses fear of three broad categories of pain: Severe, Minor, and Medical Pain. Previous exploratory and confirmatory factor analyses suggest that the original 3-factor model of the FPQ-III has a poor fit [Osman A, Breitenstein JL, Barrios FX, Gutierrez PM, Kopper BA. The Fear of Pain Questionnaire-III: further reliability and validity with nonclinical samples. J Behav Med 2002;25:155-73; Albaret MC, Sastre MTM, Cottensin A, Mullet E. The Fear of Pain Questionnaire: factor structure in samples of young, middle-aged and elderly European people. Eur J Pain 2004;8:273-81; Roelofs J, Peters ML, Deutz J, Spijker C, Vlaeyen JWS. The Fear of Pain Questionnaire (FPQ): further psychometric examination in a non-clinical sample. Pain 2005;116:339-46.]. The goals of this study were to empirically evaluate the previously proposed 3-factor models of the FPQ-III, identify and remove items that contribute to the factor instability of the FPQ-III, and evaluate potential alternative models based on a reduced item pool. A sample of 589 participants from the University of Regina and the University of Manitoba communities was randomly divided into two subsamples of approximately equal size. FPQ-III data from these subsamples were subjected to confirmatory factor analysis and an iterative combination of exploratory and confirmatory factor analyses. The initial confirmatory factor analysis revealed that none of the previous models had acceptable fit to the data. Following iterative factor analyses and item reductions, a 4-factor model with good fit to the data and invariance across gender was identified. This model comprised 20-items distributed on factors representing Severe, Minor, Injection, and Dental Pain. The total scale and subscale scores based on the 4-factor model had good internal consistency, and preliminary support for construct validity was obtained. Use of this short version of the measure--the FPQ-Short Form--is discussed and directions for future research outlined.

An Exploration of the Psychometric Properties of the PASS-20 With a Nonclinical Sample

The Pain Anxiety Symptoms Scale-20 (PASS-20) assesses 4 factorially distinct components of pain-related anxiety (ie, cognitive, fear, escape/avoidance, physiological). The PASS-20 has good factor stability, reliability, and internal consistency in clinical samples. Psychometric data for nonclinical populations are not yet established. This study had 4 purposes: (1) To assess the factor structure of the PASS-20 with a nonclinical sample; (2) to assess concurrent validity of PASS-20 subscales with related self-report instruments; (3) to compare our results with findings of a similar study using a clinical pain sample; and (4) to suggest a preliminary cut-off score to identify individuals with significantly elevated pain-related anxiety. A sample of 155 undergraduates completed the PASS-20 as part of a larger study. Confirmatory factor analysis supported the existing 4-factor model, and internal consistencies for total and subscale scores were comparable with previous research. PASS-20 total and subscale scores were moderately correlated with other related measures, providing evidence of concurrent validity. On all PASS-20 subscales the nonclinical sample had significantly lower (P < .01) scores than those for a clinical pain sample. The majority of individuals classified as having high pain-related anxiety had PASS-20 total scores greater than 30. Implications and future research directions are discussed.

PERSPECTIVE

A nonclinical sample is used to explore the psychometric properties of the PASS-20. Confirmatory factor analysis, comparisons with a clinical pain sample, and preliminary cut-off scores indicative of high levels of pain-related anxiety are discussed. Pain-related anxiety is identified as a continuous construct, robust across both clinical and nonclinical samples.

Acceptance and mindfulness-based therapy: new wave or old hat?

Some contemporary theorists and clinicians champion acceptance and mindfulness-based interventions, such as Acceptance and Commitment Therapy (ACT), over cognitive-behavioral therapy (CBT) for the treatment of emotional disorders. The objective of this article is to juxtapose these two treatment approaches, synthesize, and clarify the differences between them. The two treatment modalities can be placed within a larger context of the emotion regulation literature. Accordingly, emotions can be regulated either by manipulating the evaluation of the external or internal emotion cues (antecedent-focused emotion regulation) or by manipulating the emotional responses (response-focused emotion regulation). CBT and ACT both encourage adaptive emotion regulation strategies but target different stages of the generative emotion process: CBT promotes adaptive antecedent-focused emotion regulation strategies, whereas acceptance strategies of ACT counteract maladaptive response-focused emotion regulation strategies, such as suppression. Although there are fundamental differences in the philosophical foundation, ACT techniques are fully compatible with CBT and may lead to improved interventions for some disorders. Areas of future treatment research are discussed.

Acute posttraumatic stress symptoms and depression after exposure to the 2005 Saskatchewan Centennial Air Show disaster: prevalence and predictors

OBJECTIVES

The purpose of this study was to determine the prevalence of acute distress-that is, clinically significant posttraumatic stress symptoms (PTSS) and depression-and to identify predictors of each in a sample of people who witnessed a fatal aircraft collision at the 2005 Saskatchewan Centennial Air Show.

DESIGN

Air Show attendees (N = 157) were recruited by advertisements in the local media and completed an Internet-administered battery of questionnaires.

RESULTS

Based on previously established cut-offs, 22 percent respondents had clinically significant PTSS and 24 percent had clinically significant depressive symptoms. Clinically significant symptoms were associated with posttrauma impairment in social and occupational functioning. Acute distress was associated with several variables, including aspects of Air Show trauma exposure, severity of prior trauma exposure, low posttrauma social support (ie, negative responses by others), indices of poor coping (eg, intolerance of uncertainty, rumination about the trauma), and elevated scores on anxiety sensitivity, the personality trait of absorption, and dissociative tendencies.

CONCLUSIONS

Results suggest that clinically significant acute distress is common in the aftermath of witnessed trauma. The statistical predictors (correlates) of acute distress were generally consistent with the results of studies of other forms of trauma. People with elevated scores on theoretical vulnerability factors (eg, elevated anxiety sensitivity) were particularly likely to develop acute distress.

Evaluating the efficacy of graded in vivo exposure for the treatment of fear in patients with chronic back pain: a randomized controlled clinical trial

Psychological treatments for chronic pain, particularly those based upon cognitive behavioural principles, have generally been shown to be efficacious. Recently, a treatment has been developed based upon the fear-avoidance model of chronic musculoskeletal pain, which suggests chronic pain can be relieved by exposing the individual to movements and tasks that have been avoided due to fear of (re)injury. This graded in vivo exposure treatment has been found to be beneficial in case studies. The present investigation utilized a randomized controlled trial method to assess the effectiveness of graded in vivo exposure relative to other conditions. Forty-four chronic low back pain patients were randomly assigned to graded in vivo exposure, graded activity, or a wait-list condition. While only trend differences were observed for pain-related disability, patients in the graded in vivo exposure condition demonstrated (a) significantly greater improvements on measures of fear of pain/movement, fear avoidance beliefs, pain-related anxiety, and pain self-efficacy when compared to those in the graded activity condition, and (b) significantly greater improvements on measures of fear-avoidance beliefs, fear of pain/movement, pain-related anxiety, pain catastrophising, pain experience, and anxiety and depression when compared to those in the wait-list control condition. Additionally, patients in the graded in vivo exposure condition maintained improvements in these areas at one month follow-up. Implications of these findings for the treatment of individuals with chronic low back and other pain conditions are discussed.

Combat and Peacekeeping Operations in Relation to Prevalence of Mental Disorders and Perceived Need for Mental Health Care

CONTEXT

Although military personnel are trained for combat and peacekeeping operations, accumulating evidence indicates that deployment-related exposure to traumatic events is associated with mental health problems and mental health service use.

OBJECTIVE

To examine the relationships between combat and peacekeeping operations and the prevalence of mental disorders, self-perceived need for mental health care, mental health service use, and suicidality.

DESIGN

Cross-sectional, population-based survey.

SETTING

Canadian military.

PARTICIPANTS

A total of 8441 currently active military personnel (aged 16-54 years).

MAIN OUTCOME MEASURES

The DSM-IV mental disorders (major depressive disorder, posttraumatic stress disorder, generalized anxiety disorder, panic disorder, social phobia, and alcohol dependence) were assessed using the World Mental Health version of the World Health Organization Composite International Diagnostic Interview, a fully structured lay-administered psychiatric interview. The survey included validated measures of self-perceived need for mental health treatment, mental health service use, and suicidal ideation. Lifetime exposure to peacekeeping and combat operations and witnessing atrocities or massacres (ie, mutilated bodies or mass killings) were assessed.

RESULTS

The prevalences of any past-year mental disorder assessed in the survey and self-perceived need for care were 14.9% and 23.2%, respectively. Most individuals meeting the criteria for a mental disorder diagnosis did not use any mental health services. Deployment to combat operations and witnessing atrocities were associated with increased prevalence of mental disorders and perceived need for care. After adjusting for the effects of exposure to combat and witnessing atrocities, deployment to peacekeeping operations was not associated with increased prevalence of mental disorders.

CONCLUSIONS

This is the first study to use a representative sample of active military personnel to examine the relationship between deployment-related experiences and mental health problems. It provides evidence of a positive association between combat exposure and witnessing atrocities and mental disorders and self-perceived need for treatment.

Anxiety sensitivity and intolerance of uncertainty: requisites of the fundamental fears?

Fears related to anxiety sensitivity (AS)-illness/injury sensitivity, fear of negative evaluation, and fear of pain-may have important theoretical associations with intolerance of uncertainty (IU). In separate investigations, AS and IU have been independently related to the same anxiety-related psychopathology. AS and IU seem to share a basis in fearing unknown, potentially harmful consequences; however, their inter-relationship remains uncertain. IU regarding a specific stimulus, a physical sensation for example, may result in a variety of interpretations and responses, including the catastrophic appraisals that characterize AS. The association between AS and IU was examined in a sample of 293 undergraduates. Results of confirmatory factor and correlation analyses suggest the two constructs are related, but nonetheless independent. It appears that IU may be a required component of catastrophic misappraisals while being an important construct related to fear and anxiety in its own right. Future research directions and potential applications are discussed.

Is the Latent Structure of Fear of Pain Continuous or Discontinuous Among Pain Patients? Taxometric Analysis of the Pain Anxiety Symptoms Scale

Elevated fear of pain is believed to denote a potential mechanism through which pain is maintained over time; however, our knowledge about fear of pain, its measurement, and its conceptualization is far from complete. It has been assumed that the latent structure of fear of pain is multidimensional and continuous. Although there is factor analytic evidence that it is multidimensional, there have been no empiric efforts to establish whether fear of pain is continuous or discontinuous (ie, taxonic or dichotomous latent class variable) in nature. Using taxometric methods in a sample of 650 patients seeking treatment for musculoskeletal or headache pain, we evaluated the latent structure of fear of pain as indexed by the Pain Anxiety Symptoms Scale. Results from analyses of simulated Monte Carlo data, MAXEIG-HITMAX, and MAMBAC and L-mode external consistency tests indicated that the latent structure of fear of pain was nontaxonic, characterized by latent continuity. Results are discussed in relation to the conceptual understanding of fear of pain, implications for treatment, and future directions for research on issues pertinent to pain-related fear.

PERSPECTIVE

This article presents an analysis designed to establish whether fear of pain is continuous or discontinuous in clinical samples. The findings, indicating that fear of pain is continuous, are important for understanding the nature of fear of pain and to designing appropriately targeted interventions.

Social anxiety and fear of negative evaluation: construct validity of the BFNE-II

The Brief Fear of Negative Evaluation Scale [BFNE; Leary, M. R. (1983). A brief version of the Fear of Negative Evaluation Scale. Personality and Social Psychology Bulletin, 9, 371-375] is a self-report measure designed to assess fear of negative evaluation, a characteristic feature of social anxiety disorders [Rapee, R. M., & Heimberg, R. G. (1997). A cognitive-behavioral model of anxiety in social phobia. Behaviour Research and Therapy, 35, 741-756]. Recent psychometric assessments have suggested that a 2-factor model is most appropriate, with the first factor comprising the straightforwardly worded items and the second factor comprising the reverse-worded items [Carleton, R. N., McCreary, D., Norton, P. J., & Asmundson, G. J. G. (in press-a). The Brief Fear of Negative Evaluation Scale, Revised. Depression & Anxiety; Rodebaugh, T. L., Woods, C. M., Thissen, D. M., Heimberg, R. G., Chambless, D. L., & Rapee, R. M. (2004). More information from fewer questions: the factor structure and item properties of the original and brief fear of negative evaluation scale. Psychological Assessment, 2, 169-181; Weeks, J. W., Heimberg, R. G., Fresco, D. M., Hart, T. A., Turk, C. L., Schneier, F. R., et al. (2005). Empirical validation and psychometric evaluation of the Brief Fear of Negative Evaluation Scale in patients with social anxiety disorder. Psychological Assessment, 17, 179-190]. Some researchers recommend the reverse-worded items be removed from scoring [e.g., Rodebaugh, T. L., Woods, C. M., Thissen, D. M., Heimberg, R. G., Chambless, D. L., & Rapee, R. M. (2004). More information from fewer questions: the factor structure and item properties of the original and brief fear of negative evaluation scale. Psychological Assessment, 2, 169-181; Weeks, J. W., Heimberg, R. G., Fresco, D. M., Hart, T. A., Turk, C. L., Schneier, F. R., et al. (2005). Empirical validation and psychometric evaluation of the Brief Fear of Negative Evaluation Scale in patients with social anxiety disorder. Psychological Assessment, 17, 179-190]; however [Carleton, R. N., McCreary, D., Norton, P. J., & Asmundson, G. J. G. (in press-a). The Brief Fear of Negative Evaluation Scale, Revised. Depression & Anxiety; Collins, K. A., Westra, H. A., Dozois, D. J. A., & Stewart, S. H. (2005). The validity of the brief version of the fear of negative evaluation scale. Journal of Anxiety Disorders, 19, 345-359] recommend that these items be reworded to maintain scale sensitivity. The present study examined the reliability and validity of the BFNE-II, a version of the BFNE evaluating revisions of the reverse-worded items in a community sample. A unitary model of the BFNE-II resulted in excellent confirmatory factor analysis fit indices. Moderate convergent and discriminant validity were found when BFNE-II items were correlated with additional independent measures of social anxiety [i.e., Social Interaction Anxiety & Social Phobia Scales; Mattick, R. P., & Clarke, J. C. (1998). Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Behaviour Research and Therapy, 36, 455-470], and fear [i.e., Anxiety Sensitivity Index; Reiss, S., & McNally, R. J. (1985). The expectancy model of fear. In S. Reiss, R. R. Bootzin (Eds.), Theoretical issues in behaviour therapy (pp. 107--121). New York: Academic Press. and the Illness/Injury Sensitivity Index; Carleton, R. N., Park, I., & Asmundson, G. J. G. (in press-b). The Illness/Injury Sensitivity Index: an examination of construct validity. Depression & Anxiety). These findings support the utility of the revised items and the validity of the BFNE-II as a measure of the fear of negative evaluation. Implications and future research directions are discussed.

Traumatic events and suicidal behavior: results from a national mental health survey

The current study examined whether exposure to different types of traumatic events was differentially associated with suicidal ideation and attempts after adjusting for sociodemographic factors and presence of mental and physical disorders. Data came from the US National Comorbidity Survey Part II (N = 5877, aged 15-54 years, response rate: 82.4%) public use dataset. Interpersonal traumas and exposure to three or more types of traumatic events were particularly associated with suicidal behaviors. Age of onset analyses revealed that the age of traumatic exposure was earlier than the age at which suicidal behaviors began in the majority of respondents. The results imply that exposure to traumatic events is associated with the incidence of suicidal behaviors above and beyond the effect of sociodemographics, mental disorders, and physical disorders assessed in the survey. Clinicians and researchers need to be aware of these findings to determine early intervention programs.

Physical and mental comorbidity, disability, and suicidal behavior associated with posttraumatic stress disorder in a large community sample

OBJECTIVE

To assess if posttraumatic stress disorder (PTSD), recognized as a common mental disorder in the general population and veteran samples, has a unique impact on comorbidity, disability, and suicidal behavior (after adjusting for other mental disorders, especially depression).

METHODS

Data came from the Canadian Community Health Survey Cycle 1.2 (n = 36,984; age > or = 15 years; response rate 77%). All respondents were asked if they had been given a diagnosis of PTSD by a healthcare professional. A select number of mental disorders were assessed by the Composite International Diagnostic Interview. Chronic physical health conditions, measures of quality of life, disability, and suicidal behavior were also assessed.

RESULTS

The prevalence of PTSD as diagnosed by health professionals was 1.0% (95% CI = 0.90-1.15). After adjusting for sociodemographic factors and other mental disorders, PTSD remained significantly associated with several physical health problems including cardiovascular diseases, respiratory diseases, chronic pain conditions, gastrointestinal illnesses, and cancer. After adjusting for sociodemographic factors, mental disorders, and severity of physical disorders, PTSD was associated with suicide attempts, poor quality of life, and short- and long-term disability.

CONCLUSIONS

PTSD was uniquely associated with several physical disorders, disability, and suicidal behavior. Increased early recognition and treatment of PTSD are warranted.

Brief fear of negative evaluation scale-revised

Rodebaugh et al. [2004: Psychol Assess 2:169-181] recently performed a confirmatory factor analysis (CFA) on the Brief Fear of Negative Evaluation scale (BFNE; Leary, 1983: Psychol Bull 9:371-375]. Their study resulted in the emergence of a two-factor solution comprising straightforwardly worded items and reverse-worded items. They concluded by recommending use of only the straightforwardly worded items in the BFNE. Our intent in this study was to evaluate this recommendation through replication and extension. Participants included 385 undergraduates from the Universities of Regina and Houston, who provided responses to a questionnaire battery including either the BFNE or a revision utilizing straightforwardly worded versions of the reverse-worded items (BFNE-II). A CFA of the BFNE, using the two-factor model proposed by Rodebaugh et al., supported their conclusion that the reverse-worded items comprise a separate, methodologically based factor. However, CFA of the BFNE-II resulted in an acceptable unitary model that conforms to the theoretical basis for the BFNE, without risking loss of sensitivity from item removal. Additional analyses suggest use of the BFNE-II rather than a shortened form.

Anxiety sensitivity and its impact on pain experiences and conditions: a state of the art

This paper serves as an introduction to the special issue of Cognitive Behaviour Therapy devoted to the topic of anxiety sensitivity (AS) and its impact on pain experiences and conditions. We provide a historical overview of relevant cognitive behavioural models of chronic pain, summarize recent models incorporating the AS construct, and introduce the papers in the special issue. These papers are organized into two sets--basic laboratory-based investigations and relatively more applied studies. We attempt to highlight some of the most important findings from each of these investigations and studies, in turn. Then, we consider several important conclusions derived from the set of special issue papers and the implications of these for the practice of cognitive-behavioural interventions with pain populations. Finally, we make several suggestions for directions for future investigations in this burgeoning area of cognitive behavioural research and practice.

Efficacy of Various Treatments for PTSD in Battered Women: Case Studies

Spousal abuse and other forms of domestic violence can lead to posttraumatic stress disorder (PTSD). Little is known about how to best treat this form of PTSD. The current case series, based on data collected as part of a larger clinical trial, was designed to evaluate the effectiveness of exposure therapy, Eye Movement Desensitization and Reprocessing (EMDR), or relaxation therapy. Three woman with battered-spouse-related PTSD were assigned to one of these treatments. The patient receiving exposure responded well to treatment and no longer met the criteria for PTSD at post-treatment or at 3-month follow-up. The battered women in the other two conditions continued to meet the criteria for PTSD at post-treatment and at follow-up. The patterns of treatment response were similar to those experienced by individuals with other forms of PTSD (N = 42) examined in the larger trial. The results of these case studies encourage further studies of exposure therapy for battered-spouse-related PTSD.

Is high fear of pain associated with attentional biases for pain-related or general threat? A categorical reanalysis

The purpose of this investigation was to clarify mixed findings reported in selective attention investigations. To accomplish this, recently published dot-probe data from 36 patients with chronic musculoskeletal pain and 29 healthy control participants were reanalyzed with consideration of fear of pain (FOP) as a categorical variable. FOP groups were identified by using a variety of strategies and represented differing conceptualizations of the FOP construct. Selective attention for sensory pain, affect pain, and health catastrophe words was assessed by using raw dot-probe detection latencies and the bias, congruency, and incongruency indices. Analysis of the raw detection latencies revealed no significant interactions that permit inferences regarding attentional shifts to or away from specific word types. Analyses of the attention indices revealed no evidence of pain-related selective attention as a function of FOP or the interaction between clinical status and FOP, regardless of the FOP categorization method used; however, for FOP groups derived by using the cluster method, participants with high FOP--all patients--exhibited hypervigilance for all word types on the dot-probe task when compared with those with low FOP. Implications for various categorical conceptualizations of FOP and future research directions are discussed.

PERSPECTIVE

Fear of pain can be used to categorize people into groups more or less vulnerable to disabling effects of pain. When fear of pain groups are derived by using measures of general and pain-specific fearfulness, people with high fear of pain are likely to selectively attend all potentially threatening stimuli in their environment.

The Illness/Injury Sensitivity Index: an examination of construct validity

The 11-item Illness/Injury Sensitivity Index [ISI; Taylor, 1993: J Behav Ther Exp Psychiatry 24:289-299] measures fears of injury and illness and has the potential to delineate some mechanisms underlying anxiety-associated chronic health conditions. In a principal components analysis in 2005, Carleton et al. [2005a: J Psychopathol Behav Assess 27:235-241] indicated that a two-factor solution (Fear of Injury and Fear of Illness) best explained the structure of the ISI. The primary purpose of this study was to examine the structural and construct validity of the ISI. Results supported a two-factor solution after removal of two overinclusive items. Although the measure demonstrated good factorial validity, convergent and discriminant validity require further evaluation. In addition, a substantial correlation with fear of pain suggests a shift in our perspective on what constitutes a fundamental fear. Future research implications are discussed.

Strategic and Automatic Threat Processing in Chronic Musculoskeletal Pain: A Startle Probe Investigation

Attentional bias research with chronic pain samples has yielded conflicting results. In the present investigation the startle paradigm was used to test the postulate that fear-based mechanisms play an important role in attentional biases for pain-related threat in chronic pain. Participants, including 31 individuals with chronic musculoskeletal pain and 20 healthy controls, completed a startle task designed to measure attention to different types of words (neutral vs sensory pain vs affective pain vs health catastrophe) presented at different levels of cognitive processing (strategic vs automatic). Measures of fear-based individual difference variables, including anxiety sensitivity and fear of pain, were also completed. Startle amplitudes and latencies to acoustic startle probes that followed word presentations were recorded. Data were analyzed with repeated measures ANOVAs and correlational analysis. Significant between-group differences were found indicating that, relative to chronic pain participants, healthy controls had higher startle amplitude index scores for health catastrophe words. There was also a trend among patients with chronic pain for greater startle amplitude index scores for strategic presentations of sensory pain words. In the automatic condition, all participants demonstrated a lower startle latency index for sensory words relative to both affect and health catastrophe words, suggesting participants had more difficulty disengaging from affect and health catastrophe words or were more avoidant of sensory words. Correlational analyses indicated that startle response indices for words related to health catastrophe became more pronounced for chronic pain patients as anxiety sensitivity and fear of pain increased. Implications and directions for future research are discussed.

Simple versus complex PTSD: a cluster analytic investigation

A cluster analytic investigation was conducted on measures of PTSD associated features (e.g., personality pathology, dissociative tendencies) to investigate whether empirically-defined clusters correspond to Herman's [1992, Complex PTSD: a syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress, 5, 377-391; 1997, Trauma and recovery (Rev. ed.). New York: Basic Books] distinction between simple and complex PTSD. Results from a sample of 60 PTSD patients were broadly consistent with this distinction, although some inconsistencies were observed. Treatment outcome generally did not differ between the two clusters. Implications for classifying and treating PTSD are discussed.

The relationship of adult attachment dimensions to pain-related fear, hypervigilance, and catastrophizing

Despite the prominence of fear-avoidance models of chronic pain, there is a paucity of research regarding the origins of pain-related fear. Based on the premise that insecure attachment could be a developmentally based origin of elevated fear of pain, associations between adult attachment dimensions and constructs included in fear-avoidance models of chronic pain were investigated. Consistent with Bartholomew and Horowitz's [Bartholomew K, Horowitz LM. Attachment styles among young adults: a test of a four-category model. J Pers Soc Psychol 1991;61:226-44.] model, attachment was conceptualized as being comprised of a model of self dimension (i.e., degree of anxiety regarding rejection based on beliefs of personal unworthiness) and a model of others dimension (i.e., degree of interpersonal mistrust and discomfort with interpersonal closeness). A large university student sample free of chronic pain (N=278) completed a measure of adult romantic attachment (i.e., Experiences in Close Relationships Questionnaire; [Brennan KA, Clark CL, Shaver PR. Self-report measurement of adult attachment: an integrative overview. In: Simpson JA, Rholes WS, editors. Attachment theory and close relationships. New York: The Guilford Press, 1998. p. 46-76.]), the Fear of Pain Questionnaire-III [McNeil DW, Rainwater AJ. Development of the fear of pain questionnaire - III. J Behav Med 1998;21:389-410.], the Pain Vigilance and Awareness Questionnaire [McCracken LM. Attention to pain in persons with chronic pain: a behavioural approach. Behav Ther 1997;28:271-84.], and the Pain Catastrophizing Scale [Sullivan MJ, Bishop SR, Pivik J. The pain catastrophizing scale: development and validation. Psychol Assess 1995;7:24-532.]. It was hypothesized that insecure attachment would be positively associated with reports of pain-related fear, hypervigilance, and catastrophizing and that the model of self dimension would be the attachment variable most strongly associated with these variables. Correlation and multiple regression analyses supported these hypotheses. The model of self dimension had significant positive associations with each of the fear-avoidance constructs. The model of others dimension had a significant positive association with pain catastrophizing, but was not significantly associated with fear of pain and pain hypervigilance. Future research directions and potential clinical implications are discussed.

A controlled trial of cognitive-behavior therapy combined with vestibular rehabilitation in the treatment of dizziness

Dizziness is a common and often untreated symptom in the general population. The aim of this study was to investigate the effects of a combined cognitive-behavioral/vestibular rehabilitation (VR) program, using a randomized control design. A total of 29 participants were randomized to treatment consisting of psychoeducation, vestibular exercises, relaxation and cognitive interventions, or to serve as waiting list controls. Measures of dizziness-related handicap, dizziness-provoking movements, and daily diary registrations of dizziness symptoms at pre- and post-treatment showed statistically significant improvements in many domains, which translated to moderate effect sizes. These findings provide preliminary support for the combination of Cognitive-behavioral therapy (CBT) and VR methods in the treatment of dizziness.

Health care utilization by United Nations peacekeeping veterans with co-occurring, self-reported, post-traumatic stress disorder and depression symptoms versus those without

It remains to be determined whether patients with comorbid post-traumatic stress disorder (PTSD) and depression use more health care resources than do those without. United Nations peacekeeping veterans from Canada were divided into four groups, i.e., PTSD alone (n = 23), depression alone (n = 167), comorbid PTSD and depression (n = 119), and neither (n = 164), and compared with respect to total number of visits to any health care professional in the past year. Analysis of variance revealed that the groups significantly differed in total visits. Post hoc analyses indicated that veterans with co-occurring PTSD and depression symptoms had more visits than did those in the other groups and that veterans with PTSD symptoms alone and depression symptoms alone had more visits than did those with neither PTSD nor depression. Additional analyses revealed that veterans with co-occurring PTSD and depression symptoms made more visits to general practitioners, specialists, pharmacists, and mental health professionals than did the others. Future research directions and implications for treatment planning are discussed.

Post-traumatic stress disorder symptoms in United Nations peacekeepers: an examination of factor structure in peacekeepers with and without chronic pain

Recent factor analytic investigations of post-traumatic stress disorder in military veterans suggest that symptoms are best described by either a hierarchical 2-factor model or a 4-factor inter-correlated model. Other recent evidence suggests that post-traumatic stress disorder and chronic pain are intricately related; however, the nature of this relationship is not well understood. Factor analysis provides one method for clarifying this relationship. In study 1, we compared competing models of post-traumatic stress disorder symptom structure in a sample of 400 male United Nations peacekeepers using confirmatory factor analysis. Results indicated that both the hierarchical 2-factor and the 4-factor inter-correlated models provided good fit to the data. In study 2, the reliability of these models was assessed in 427 male United Nations peacekeepers with chronic back pain and 341 without. Group comparisons of the confirmatory factor analysis results revealed that the structure of the hierarchical 2-factor and 4-factor inter-correlated models both provided good fit to the data in both the chronic back pain and the group without. However, the structure of the models for the group with chronic back pain group differed in significant ways from that of the group without chronic back pain. Post-traumatic stress disorder symptoms in military veterans can be adequately conceptualized using either a hierarchical 2-factor or 4-factor inter-correlated model. Chronic pain has a minimal influence on overall factor structure. The hierarchical 2-factor model, while parsimonious, does not provide the degree of symptom detail provided by the 4-factor inter-correlated model. Implications for conceptualization of post-traumatic stress disorder symptoms for patients with chronic back pain and significant post-traumatic stress disorder symptomatology are discussed.

Genetic and environmental origins of health anxiety: a twin study

Excessive health anxiety - which is anxiety about one's health that is disproportionate to the person's medical status - is a common and often debilitating problem. Little is known about its etiology. The present study investigated the role of genetic and environmental factors using a classic twin study method. Results indicated that, after controlling for medical morbidity, environmental influences accounted for most of individual differences in health anxiety. These findings underscore the importance of psychosocial interventions, which have been shown to be among the most effective interventions for excessive health anxiety.

Effects of three PTSD treatments on anger and guilt: exposure therapy, eye movement desensitization and reprocessing, and relaxation training

This study sought to investigate the efficacy of prolonged exposure, eye movement desensitization and reprocessing, and relaxation training on trait anger and guilt and on trauma-related anger and guilt within the context of posttraumatic stress disorder (PTSD) treatment. Fifteen PTSD patients completed each treatment and were assessed at posttreatment and at 3-month follow-up. All three treatments were associated with significant reductions in all measures of anger and guilt, with gains maintained at follow-up. There were no significant treatment differences in efficacy or in the proportion of patients who worsened on anger or guilt measures over the course of treatment. Between-treatment effect sizes were generally very small. Results suggest that all three treatments are associated with reductions in anger and guilt, even for patients who initially have high levels of these emotions. However, these PTSD therapies may not be sufficient for treating anger and guilt; additional interventions may be required.

The relationship between anxiety disorders and physical disorders in the U.S. National Comorbidity Survey

Although depression has clearly been shown to be associated with physical disorders, few studies have examined whether anxiety disorders are independently associated with medical conditions after adjusting for comorbid mental disorders. We examined the relationship between anxiety disorders and a wide range of physical disorders in a nationally representative sample. Data came from the National Comorbidity Survey (N=5,877, range=age 15-54 years, response rate=82.4%). The Composite International Diagnostic Interview [Kessler et al., 1998] was used to make DSM-III-R [American Psychiatric Association, 1987] mental disorder diagnoses. Physical disorders were assessed based on a list of several conditions shown to respondents. All analyses utilized multiple logistic regression to examine the relationship between past-year anxiety disorder diagnosis and past-year chronic physical disorder. Anxiety disorders were positively associated with physical disorders even after adjusting for mood disorders, substance-use disorders, and sociodemographics. Among respondents with one or more physical disorders, a comorbid anxiety disorder diagnosis was associated with an increased likelihood of disability even after adjusting for severity of pain, comorbid mood, and substance use disorders. Among specific anxiety disorders, posttraumatic stress disorder, panic attacks, and agoraphobia were more likely to be associated with specific physical disorders than generalized anxiety disorder, social phobia, or simple phobia. There is a strong and unique association between anxiety disorders and physical disorders. Clinically, the presence of an anxiety disorder among patients with physical disorders may confer a greater level of disability.

Fear of Pain is Elevated in Adults with Co‐Occurring Trauma‐Related Stress and Social Anxiety Symptoms

The aim of this study was to determine whether fear of pain and related fear constructs are elevated in people with co-occurring trauma-related stress and social anxiety symptoms relative to people with 1 or neither of these conditions. Eighty students were selected from a larger sample and divided into 4 equal groups comprising those with both high trauma-related stress and social anxiety symptom scores (TRS/SAS), only high trauma-related stress symptom scores (TRS), only high social anxiety symptom scores (SAS), or neither (N). Results indicated that the TRS/SAS group had significantly higher scores on all fear of pain measures, anxiety sensitivity, and illness/injury sensitivity than any other group, even when level of current pain was included as a covariate. These findings suggest that people with co-occurring trauma-related and social anxiety symptoms are most likely to be fearful of pain and to thereby be at increased risk of developing chronic and disabling pain. Implications for future research and treatment are discussed.

Hypervigilance and attentional fixedness in chronic musculoskeletal pain: consistency of findings across modified stroop and dot-probe tasks

Results from modified Stroop and dot-probe tasks have provided mixed evidence regarding attentional biases for sensory and affect pain stimuli in chronic pain patients. No studies have compared the same groups of chronic pain and healthy control participants on both tasks. We tested 36 patients with chronic musculoskeletal pain and 29 healthy control subjects on the modified Stroop and dot-probe tasks. Stimuli comprised affect pain, sensory pain, physical catastrophe, and neutral words. There was no evidence to suggest differential processing of threat cues by patients and control subjects on the modified Stroop task. All participants did, however, show differential processing of affect pain words. This was evident on both masked and unmasked presentation formats. There were no significant interactions between clinical status and threat word type observed for any of the indices of selective attention derived from the dot-probe task, but all participants had difficulty disengaging attention from affective pain and health catastrophe words. Findings were not influenced by individual differences in mood, anxiety, or fear of pain. Correlational analyses of the standard (unmasked) Stroop interference index and dot-probe indices of selective attention revealed a consistent lack of significant association, suggesting that the 2 tasks might be measuring different phenomena. Taken together, these findings provide evidence that chronic pain patients and healthy control participants do not differ in the way they attend to threatening linguistic stimuli.

PERSPECTIVE

Some patients with chronic pain might have trouble paying attention to anything other than the affective components of pain and associated catastrophic health consequences. Interventions that specifically target this attentional fixedness might facilitate shifting attention to other targets and thereby reduce pain-specific anxiety and fear.

Anxiety disorders and risk for suicidal ideation and suicide attempts: a population-based longitudinal study of adults

CONTEXT

Controversy exists whether anxiety disorders are independently associated (ie, after adjusting for comorbid mental disorders) with suicidal ideation and suicide attempts.

OBJECTIVE

To examine whether anxiety disorders are risk factors for suicidal ideation and suicide attempts in a large population-based longitudinal study.

METHODS

Data come from the Netherlands Mental Health Survey and Incidence Study, a prospective population-based survey with a baseline and 2 follow-up assessments over a 3-year period. The Composite International Diagnostic Interview was used to assess DSM-III-R mental disorders. Lifetime diagnoses of anxiety disorders (social phobia, simple phobia, generalized anxiety disorder, panic disorder, agoraphobia, obsessive-compulsive disorder) were assessed at baseline. Multiple logistic regression analyses were used to examine whether anxiety disorders were associated with suicidal ideation and attempts at baseline (n = 7076) and whether anxiety disorders were risk factors for subsequent onset of suicidal ideation and attempts (n = 4796).

RESULTS

After adjusting for sociodemographic factors and all other mental disorders assessed in the survey, baseline presence of any anxiety disorder was significantly associated with suicidal ideation and suicide attempts in both the cross-sectional analysis (adjusted odds ratio for suicidal ideation, 2.29; 95% confidence interval, 1.85-2.82; adjusted odds ratio for suicidal attempts, 2.48; 95% confidence interval, 1.70-3.62) and longitudinal analysis (adjusted odds ratio for suicidal ideation, 2.32; 95% confidence interval, 1.31-4.11; adjusted odds ratio for suicide attempts, 3.64; 95% confidence interval, 1.70-7.83). Further analyses demonstrated that the presence of any anxiety disorder in combination with a mood disorder was associated with a higher likelihood of suicide attempts in comparison with a mood disorder alone.

CONCLUSIONS

This is the first study to demonstrate that a preexisting anxiety disorder is an independent risk factor for subsequent onset of suicidal ideation and attempts. Moreover, the data clearly demonstrate that comorbid anxiety disorders amplify the risk of suicide attempts in persons with mood disorders. Clinicians and policymakers need to be aware of these findings, and further research is required to delineate whether treatment of anxiety disorders reduces the risk of subsequent suicidal behavior.