Symptom structure of posttraumatic stress disorder in a nationally representative sample

Diagnostic criteria (e.g., Diagnostic and Statistical Manual of Mental Disorders, 4th ed.) for posttraumatic stress disorder (PTSD) posit three symptom clusters including reexperiencing, avoidance/numbing, and hyperarousal. Factor analytic studies have suggested several alternative models of PTSD symptomatology. It is uncertain whether these new models are widely generalizable as most studies have relied on relatively select treatment seeking samples (e.g., combat veterans). To address this limitation, confirmatory factor analysis was applied to symptom data from National Comorbidity Survey respondents with a lifetime history of PTSD (n = 429). Several models were tested. The model comprised of four intercorrelated factors (reexperiencing, avoidance, numbing, and hyperarousal) received the strongest support, but did not meet all the goodness-of-fit criteria. A follow-up principal-components analysis yielded a four-factor solution, with factors representing dysphoria, cued reexperiencing and avoidance, uncued reexperiencing and hyperarousal, and trauma-related rumination. The theoretical and clinical implications of these findings are discussed.

Do fundamental fears differentially contribute to pain-related fear and pain catastrophizing? An evaluation of the sensitivity index

Three fundamental fears - anxiety sensitivity (AS), injury/illness sensitivity (IS) and fear of negative evaluation (FNE) - have been proposed to underlie common fears and psychopathological conditions. In pain research, the relation between AS and (chronic) pain processes was the subject of several studies, whereas the possible role of IS has been ignored. The current research examines the role of IS with respect to various pain-related variables in two studies. In the first study, 192 healthy college students completed the Sensitivity Index (SI; a composite measure assessing the three fundamental fears) and various pain-related questionnaires. In a second study, 60 students out of the original sample took part in a pain induction procedure and completed the SI as well. We first examined the properties of the SI. Factor analysis on the SI replicated the proposed factor structure [Taylor S. The structure of fundamental fears, J Behav Ther Exp Psychiat 1993;24:289-99]. However, some items of the ASI did show problematic loadings and were therefore excluded in subsequent analyses. The main hypothesis of the current study states that IS is a stronger predictor than AS of pain catastrophizing and fear of pain as assessed by self-report measures, and of pain tolerance and anticipatory fear of pain as assessed in a pain induction study. This hypothesis could be confirmed for all variables, except for pain tolerance, which was not predicted by any of the three fundamental fears. The current study can be considered as an impetus for devoting attention to IS in future pain research.

Co-occurrence of posttraumatic stress disorder with positive psychotic symptoms in a nationally representative sample

The association between posttraumatic stress disorder (PTSD) and positive psychotic symptoms was examined in the National Comorbidity Survey (N = 5,877). The Composite International Diagnostic Interview (CIDI) was used to make DSM-III-R (Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised; American Psychiatric Association, 1987) diagnoses. Posttraumatic stress disorder was found to be associated with an increased likelihood of endorsing one or more psychotic symptoms after adjusting for sociodemographics, psychiatric and medical comorbidity (odds ratios (OR) = 1.83; 95% confidence interval (CI): 1.43-2.45; p < .001). The co-occurrence of PTSD with psychotic symptoms was marked by greater levels of severity (higher total number of PTSD symptoms, greater levels of comorbidity, and high distress) compared with PTSD alone. This is the first population-based study to investigate PTSD in relation to endorsement of positive psychotic symptoms, and a strong association was obtained.

Anxiety disorders associated with suicidal ideation and suicide attempts in the National Comorbidity Survey

This study examined the relationship between anxiety disorders and suicidal ideation or suicide attempts in a nationally representative sample (N = 5877; age, 15-54; response rate, 82.4%). A modified version of the Composite International Diagnostic Interview was used to make DSM-III-R mental disorder diagnoses. Two multivariate logistic regression analyses were performed with suicidal ideation (N = 754) and suicide attempts (N = 259) as dependent variables. In each regression, the independent variables entered were lifetime social phobia, panic disorder, agoraphobia, generalized anxiety disorder, simple phobia, and posttraumatic stress disorder (PTSD). Covariates in the analyses were sociodemographics, lifetime mood disorders, substance use disorders, nonaffective psychosis, antisocial personality disorder, and presence of three or more lifetime DSM-III-R diagnoses. PTSD was significantly associated with suicidal ideation (adjusted odds ratio = 2.79; p < 0.01) and suicide attempts (adjusted odds ratio = 2.67; p < 0.01). None of the other anxiety disorders were significantly associated with suicidal ideation or attempts. The robust association between PTSD and suicide attempts has important implications for psychiatric assessment of suicidal behavior. Future research is required to investigate the mechanisms underlying the relationship between PTSD and suicidal behavior.

Brief Report: Factor Structure of the Childhood Illness Attitude Scales (CIAS)

OBJECTIVE

To examine the factor structure of the Childhood Illness Attitude Scales (CIAS). The CIAS is a 35-item self-report measure based on the Illness Attitudes Scales, designed for use with school-age children. The CIAS measures fears, beliefs, and attitudes associated with health anxiety and abnormal illness behavior in childhood.

METHODS

CIAS item responses for 201 school-age children were subjected to principal-components analysis with oblique rotation.

RESULTS

The CIAS was best conceptualized as comprising four factors: fears, help seeking, treatment experience, and symptom effects. Further factor analysis supported the notion that the CIAS can also be conceptualized as having a hierarchical structure, with four lower-order factors loading onto a single higher-order factor of health anxiety.

CONCLUSIONS

Results suggest that the CIAS possesses good psychometric properties, including factorial validity and internal consistency, and appears to be a psychometrically sound instrument for measuring children's health anxiety.

Dot-probe evaluation of selective attentional processing of pain cues in patients with chronic headaches

Evidence supporting the notion that patients with chronic pain are characterized by attentional biases for sensory and affect pain words, and that such biases are mediated by fear of pain, is mixed. The present investigation was an attempt to replicate and extend initial findings obtained with the dot-probe task. Thirty patients with chronic headache and 19 healthy controls were tested using a dot-probe task including affect pain, sensory pain, and neutral words. Individual difference variables, including fear of pain measures, were assessed and considered in analyses. Selective attention was denoted using the bias index, congruency index, and incongruency index. There were no significant between-group differences or interactions between group and word type observed for any of the indices of selective attention. Across groups there was evidence for a significant association between anxiety sensitivity and the bias index for sensory pain words, and between affective description of current pain and the incongruency index for affect pain words. These results do not provide convincing evidence that patients with chronic headache selectively attend to affect or sensory pain cues when compared to healthy controls. The significant cross-groups associations between anxiety sensitivity and current pain description and indices of selective attention are consistent with the notion that attentional biases may be influenced by fear propensity and current concerns. Implications of the findings and future research directions are discussed.

Are avoidance and numbing distinct PTSD symptom clusters?

We present the conceptual basis and empirical evidence for considering avoidance and numbing as distinct posttraumatic stress disorder (PTSD) symptom clusters. The majority of data from factor analytic studies supports the position that avoidance and numbing are distinct symptom clusters. As well, the available data suggest that (a) different treatment modalities have differential effects on reducing avoidance but not numbing, (b) patients with more severe pretreatment numbing have poorer treatment outcomes, (c) avoidance and numbing have different patterns of correlation with depression, and (d) they have different correlations with physiological indices of attention. We conclude that avoidance and numbing are distinct PTSD symptom clusters. This distinction has implications for revising current diagnostic criteria. The recognition of this distinction may lead to advances in understanding and treating PTSD.

Pain and PTSD symptoms in female veterans

BACKGROUND

There has been growing empirical examination of the co-occurrence of pain and post-traumatic stress disorder (PTSD) symptoms, and existing evidence suggests that the symptoms associated with each have a close association. To date, however, the association has only been examined within samples of mostly male participants.

AIM

In the present study, pain and PTSD symptoms were examined in a sample of 221 female veterans who utilised the VA Healthcare System between 1998 and 1999.

METHOD

Women who visited the clinic between 1998 and 1999 were mailed a self-report questionnaire package designed to elicit information regarding general health (including pain experiences), military and trauma history, childhood abuse and neglect, and PTSD symptoms. Analyses were conducted to identify differences in pain experience between those women classified as having PTSD, subsyndromal PTSD, and no PTSD. Analyses were also conducted to determine the degree to which pain-related (e.g., current pain, interference with activity) variables predicted PTSD symptom cluster scores.

RESULTS

The three groups differed significantly on a number of pain-related variables. Analyses suggested that pain-related variables were significant predictors of PTSD symptom cluster scores.

CONCLUSIONS

These results indicate that the association between pain and PTSD symptoms, previously observed in primarily male samples, is generalisable to females. Clinical implications and possible mechanisms of association are discussed.

Anxiety sensitivity, fear, and avoidance behavior in headache pain

Recent research has implicated anxiety sensitivity (AS), the fear of anxiety-related sensations, as a mitigating factor involved in fear and avoidance in patients with chronic back pain [Understanding and treating fear of pain (2004) 3]. Given reported similarities between individuals experiencing chronic pain and those experiencing recurrent headaches, it is theoretically plausible that AS plays a role in influencing fear of pain and avoidance behavior in people with recurrent headache. This has not been studied to date. In the current study we used structural equation modeling to examine the role of AS in fear and avoidance behavior of patients experiencing recurrent headaches. Treatment seeking patients with recurrent headaches completed measures of AS, headache pain severity, pain-related fear, and pain-related escape and avoidance behavior. Structural equation modeling supported the prediction of a direct significant loading of AS on fear of pain. Headache severity also had a direct loading on fear of pain. Results also revealed that AS and headache severity had indirect relationships to pain-related escape and avoidance via their direct loadings on fear of pain. Headache severity also had a small direct loading on escape and avoidance behavior. These results provide compelling evidence that AS may play an important role in pain-related fear and escape and avoidance behavior in patients with recurrent headaches.

Psychological sequelae of remote exposure to the September 11th terrorist attacks in Canadians with and without panic

The purpose of the present investigation was to examine the psychological impact of remote exposure to the events and aftermath of the terrorist attacks in the USA on September 11th, 2001, and to assess what differences, if any, exist between individuals classified with probable panic disorder and those without. Telephone interviews were conducted with 122 residents of the capital city of the Canadian prairie province of Saskatchewan in spring 2002 in order to gather information regarding current mood, fears and avoidance behaviours as well as current post-traumatic stress disorder symptoms specific to September 11th. Consistent with previous findings and despite the remote nature of exposure, results indicated that the psychological well-being and behaviour of participants with probable panic disorder was more adversely affected by the events and aftermath of September 11th than those without panic disorder. These results suggest that remote viewing of traumatic events can have a significant and lingering impact on psychological well-being and behaviour and that these effects are more pronounced in those with panic disorder. Implications of the findings and future research directions are discussed.

Health Anxiety in Children: Development and Psychometric Properties of the Childhood Illness Attitude Scales

The course of severe anxiety surrounding health issues is unknown. The available literature suggests that adults who are overly anxious about health issues often interpret or misinterpret their bodily signs and symptoms to be indicative of a serious illness. The construct of health anxiety has not been examined in children and, to date, there has not been an instrument developed for this purpose. The Illness Attitude Scales is one of the most commonly used instruments for evaluating fears, beliefs, and attitudes that are associated with hypochondriasis and abnormal illness behaviour in adults. We sought to adapt the Illness Attitude Scales for use with children ages 8-15 years. The adapted Illness Attitude Scales was renamed the Childhood Illness Attitude Scales. Revisions to the adult version consisted of simplification of language, revision of Likert scale (i.e. 5-point to 3-point scale), and the addition of 7 questions to evaluate the role parents/guardians play in facilitating medical attention or treatment. Correlations between Childhood Illness Attitude Scales total scores and other self-report measures were supportive of the construct-related validity of the Childhood Illness Attitude Scales and suggested that it is a useful measure of health anxiety in school-age children. Practical and theoretical implications of the present results are discussed.

Exposure to traumatic events and experiences: aetiological relationships with personality function

Empirical research has shown that the odds of experiencing traumatic events are influenced by genetic factors and the heritability of trauma exposure varies with the type of trauma. Traumatic events per se are unlikely to be heritable; more likely to be inherited are factors such as personality that influence the person's risk for entering into, or creating, potentially hazardous situations. With data from 406 twin pairs (222 monozygotic and 184 dizygotic twin pairs) from the urban general population, the present study used multiple regression analysis to identify personality variables associated with exposure to trauma, and estimated the degree to which these relationships were mediated by genetic factors. The experience of violent assaultive traumatic events was predicted by antisocial personality traits, specifically juvenile antisocial behavior, self-harming behavior, Psychoticism (e.g. adult antisocial behavior and substance misuse), and being open to new ideas and experiences. Genetic factors were found to partially mediate these relationships as indexed by the genetic correlation coefficient. The values of the genetic correlations were statistically significant and ranged from 0.14 to 0.36, accounting for 5-11% of the observed correlation between personality and trauma exposure. These findings suggest that heritable personality characteristics explain part of the variance in the likelihood of exposure to some classes of traumatic events.

Factorial validity of the center for epidemiologic studies-depression (CES-D) scale in military peacekeepers

Despite widespread use of the Center for Epidemiologic Studies Depression Scale [CES-D], there are no investigations that examine its factor structure in a military sample. Separate confirmatory factor analyses were performed on responses to the CES-D obtained from 102 female and 102 male Canadian military peacekeepers in order to compare the fit of a four-factor intercorrelated (lower-order) model to a four-factor hierarchical (higher-order) model. The intercorrelated and hierarchical models fit the data well for both women and men, with hierarchical models fitting the data slightly better for women than men. These findings suggest that, for military women and men, the CES-D can be used to measure a set of distinct but interrelated depressive symptoms as well as a global construct of depression. Implications and future directions are discussed.

The role of health anxiety among patients with chronic pain in determining response to therapy

Considerable research suggests that health anxiety (HA) influences the response of patients with chronic pain to pain and treatment. The present investigation extends the current understanding of HA and explores whether it affects how patients respond to a common therapeutic intervention, namely instructions to reduce pain behaviour. Sixty-five patients with chronic pain completed measures of pain, anxiety and cognition following an active occupational therapy session in which they were specifically instructed either to inhibit or reduce pain behaviour, or to carry out the session as they normally would. Regression analyses revealed that those with higher levels of HA experienced greater anxiety, somatic sensations and catastrophic cognitions during therapy than those with lower levels of HA. The regression analyses also revealed a consistent trend for an interaction between HA and instructional set; when those with higher HA reduced their pain behaviour, they subsequently reported greater anxiety, and more somatic sensations and catastrophic thoughts than when they carried out the session as they normally would. In contrast, only those with lower HA had a tendency to benefit from reducing pain behaviour, reporting lower state anxiety and fewer somatic sensations during the session than those who did not reduce their pain behaviour. The results suggest that HA should be taken into consideration during treatment.

PTSD and the experience of pain: research and clinical implications of shared vulnerability and mutual maintenance models

It is common for individuals with symptoms of posttraumatic stress disorder (PTSD) to present with co-occurring pain problems, and vice versa. However, the relation between these conditions often goes unrecognized in clinical settings. In this paper, we describe potential relations between PTSD and chronic pain and their implications for assessment and treatment. To accomplish this, we discuss phenomenological similarities of these conditions, the prevalence of chronic pain in patients with PTSD, and the prevalence of PTSD in patients with chronic pain. We also present several possible explanations for the co-occurrence of these disorders, based primarily on the notions of shared vulnerability and mutual maintenance. The paper concludes with an overview of future research directions, as well as practical recommendations for assessing and treating patients who present with co-occurring PTSD or chronic pain symptoms.

Posttraumatic stress disorder symptoms influence health status of deployed peacekeepers and nondeployed military personnel

Posttraumatic stress disorder (PTSD) is associated with depression and alcohol abuse. PTSD symptoms also contribute to poor health among military veterans. The aim of the present study was to test models pertaining to the direct and indirect influences of PTSD symptoms on the health status of deployed and sociodemographically comparable nondeployed military personnel. Participants were 1,187 deployed male peacekeepers and 669 nondeployed male military personnel who completed a battery of questionnaires, including measures of PTSD symptoms, depression, alcohol use, and general health status. Structural equation modeling was used to test predictions regarding the direct and indirect influences of PTSD symptoms on health status. Results indicate that PTSD symptoms have a direct influence on health, regardless of deployment status. PTSD symptoms also indirectly promote poorer health through influence on depression, but not alcohol use, in deployed and nondeployed peacekeepers. Increased alcohol use did not contribute to poorer health beyond the contribution of PTSD symptoms alone. Future research directions are discussed.

Using facial expressions to assess musculoskeletal pain in older persons

Past research examined measures of pain among seniors who were experiencing movement-related exacerbations of musculoskeletal pain and obtained clear support for the utility of the behavioural coding of pain-related body movements (e.g., bracing, guarding). Support for the utility of the Facial Action Coding System (FACS), which involves the objective coding of facial reactions, was not as strong. The findings concerning FACS could have been an artifact of the methodology that was used. Specifically, the duration of the facial reactions was not taken into account and the patients suffered from a variety of painful conditions. Thus, the physical activities involved in the study could have been painful for some patients but not for others. The present study corrected these methodological concerns by accounting for the duration of facial reactions and ensuring that all patients suffered from the same painful condition. Participants were 82 post-surgical (knee replacement) inpatients. Cognitive status was assessed using the Modified Mini Mental Status Examination. Under physiotherapist's supervision, the patients performed structured activities (i.e., reclining, standing, knee bends). Facial reactions were coded using FACS. Facial reactions varied as a function of the degree to which the various activities were strenuous. The results support the utility of FACS in the assessment of musculoskeletal pain among seniors undergoing rehabilitation following knee surgery.

Anxiety and Related Factors in Chronic Pain

Clinicians often encounter patients who present with both chronic pain and elevated levels of anxiety. In some cases, the source of the anxiety is vague and diffuse. For others, there is an identifiable precipitating object, event or situation. For example, some patients with chronic pain are able to attribute their anxiety to the possibility of not regaining lost functional abilities, financial difficulties, feelings of social inadequacy, or uncertainty about the meaning and consequences of pain. The association between chronic pain and anxiety may not be particularly surprising when one considers that, in the acute phase, both pain and target-oriented anxiety (or fear) motivate actions that serve to minimize the threat and maximize the likelihood of successful escape. As well, their neurobiology, while distinct, interacts in the reticular system (1). Evaluations of the association between chronic pain and fear-relevant constructs were initiated in the 1960s and 1970s (2,3). It has only been of late, however, that theorists and researchers have begun to focus their attention on delineating the precise nature of the relationship and its specific implications for the assessment and management of pain.

Validation of the Chronic Pain Coping Inventory

The Chronic Pain Coping Inventory (CPCI; Jensen, M.P., Turner, J.A., Romano, J.M. and Strom, S.E., The Chronic Pain Coping Inventory: development and preliminary validation, Pain, 60 (1995) 203-216) is a recently developed questionnaire comprising eight main subscales that measure coping strategies that are frequently targeted for change in interdisciplinary pain treatment programs. Preliminary research, carried out by the developers of the CPCI, supports the reliability and validity of the scale. The purpose of the present study was to further examine the validity of the CPCI independently. In the present study, 210 patients were administered the CPCI, along with the Coping Strategies Questionnaire (CSQ; Rosenstiel, A.K. and Keefe, F.J., The use of coping strategies in low back pain patients: relationship to patient characteristics and current adjustment, Pain, 17 (1983) 33-44; Riley III, J.L. and Robinson, M.E., CSQ: five factors or fiction? Clin. J. Pain, 13 (1997) 156-162), and the Multidimensional Pain Inventory (MPI; Kerns, R.D., Turk, D.C. and Rudy, T.E.. The West Haven-Yale Multidimensional Pain Inventory (WHYMPI), Pain, 23 (1985) 345-356) as part of a pre-admission screening. Principal components analysis with oblique rotation was performed on the 64 main CPCI scale items. An eight-factor solution was identified as most appropriate. The original subscales were generally supported, however, some modifications to scoring of subscales were suggested. As a second step in the study, the relationship between the modified CPCI subscales and the CSQ subscales were examined and their relative ability to predict concurrent adjustment to pain (MPI subscales) was assessed. Results indicated that CPCI subscales tap coping constructs that are conceptually different than the CSQ subscales. Several CPCI subscales were also found to be significantly and uniquely related to measures of concurrent adjustment, even after taking CSQ subscales and demographic and pain-related variables into account. These results suggest the CPCI is a valuable tool, above and beyond established coping measures, in the clinical assessment and research of pain. Directions for future research are discussed.

Growing pain: 10-year research trends in the study of chronic pain and headache

This study examined trends in chronic pain (including chronic headache) research from 1986 to 1995. Medical and psychological citation databases were accessed to identify chronic pain publications and yearly trends. Data from the PsycLIT (psychological) database indicated significant growth over the time frame analyzed in both raw number of chronic pain publications and the percentage of articles devoted to chronic pain. Conversely, the Medline (medical) database showed a significant decline in the percentage of chronic pain articles over the time frame analyzed. Analyses revealed increases on the PsycLIT and Medline databases in the number of studies on elderly people, and the Medline database showed increases in the number of studies of chronic pain in children. Remarkably, there were significant increases on PsycLIT in the number of drug-therapy studies for chronic pain, but a significant decrease was evident in the number of drug therapy articles abstracted on Medline. Factors that may be associated with these research trends are discussed, and future probable trends are anticipated.

Fear and avoidance in dysfunctional chronic back pain patients

Two studies that assess fear and avoidance in patients with chronic pain are presented. In the first study, 200 patients with chronic back pain were classified, using the Multidimensional Pain Inventory (Kerns et al., 1985) clustering procedure, as dysfunctional (n = 53), interpersonally distressed (n = 37), and adaptive copers (n = 62). Groups were compared on common measures of anxiety, fear and avoidance. Multivariate analysis of variance indicated that the groups differed significantly across measures. Univariate follow-up revealed that there were no differences between groups on agoraphobic, blood/injury, social fears, or anxiety sensitivity; however, patients classified as dysfunctional reported more pain-specific fear and avoidance than did those classified as interpersonally distressed or adaptive copers. In the second study, pain-specific fear and avoidance measures were used in a discriminant function analysis to predict the MPI classification of an independent sample of 55 patients with chronic pain. The measures correctly classified 76.5% of the dysfunctional group and 71.1% of a composite group of interpersonally distressed and adaptive copers. The implications of these findings are discussed.