The West Haven-Yale Multidimensional Pain Inventory (WHYMPI)

The effects of perceived versus enacted social support on the discriminative cue function of spouses for pain behaviors

This study examined the effects of spouse social support on patient displays of pain behaviors. A standardized behavioral observation method was used to record pain behaviors in 110 chronic pain patients while the spouse was present and while the spouse was absent. Patients and their spouses also completed paper and pencil measures of spouse-provided social support as well as a demographic questionnaire. Results indicated that pain behaviors varied as a function of spouse presence and the type, or dimension, of support considered. Patients reporting higher levels of enacted support displayed a greater number of pain behaviors irrespective of spouse presence, consistent with the operant theory. When a measure of perceived support was used, the pain behaviors displayed differed, depending upon the level of support and spouse presence. Results are consistent with support-seeking and cognitive-behavioral models of the effects of social support on outcome. We discuss our findings within the context of a multidimensional model of support and pain and we caution against strict application of the operant model in treatment programs. Additional research is warranted to better understand the impact of support on the rehabilitation of patients with chronic pain.

Multidimensional Pain Inventory profile classifications and psychopathology

The Multidimensional Pain Inventory (MPI) and the MMPI have been used widely to assess chronic pain patients. This study examined the relationship between patient profile classifications generated by the MPI and psychopathology as measured by the MMPI. MPI Dysfunctional and Interpersonally Distressed means were significantly different than the MPI Adaptive Coper means on scales 4, 6, 7, and 8 of the MMPI. The Dysfunctional and Adapative Coper means were also significantly different on MMPI scale 2. MMPI profiles for 79% classified as Dysfunctional and 62% classified as Interpersonally Distressed displayed psychopathology as defined by significant two-point scale elevations. Only 23% of those classified as Adaptive Copers had significant two-point MMPI scale elevations.

Psychosocial functioning in the Ehlers-Danlos syndrome

Ehlers-Danlos Syndrome (EDS) is a group of related genetic disorders of connective tissue presenting with joint hypermobility, skin extensibility, and tissue fragility. Although the pathophysiology of EDS is increasingly understood, the psychosocial effects of having EDS have not been examined. We psychologically tested and interviewed 41 adults and 7 children with EDS. Anxiety, depression, anger, and interpersonal concerns were significantly elevated, varying from one-quarter to one-third of patients; over 70% had a history of some mental health care use. Psychological difficulties appear to result from chronic pain and disability, ostracism or avoidance of relationships and social activities, sexual difficulties and reproductive concerns, and frustration with the medical system. Specific types of EDS (e.g., EDS Type I) are associated with greater pain and psychological distress. Psychological intervention, prescribed with the recognition that psychiatric features are secondary to EDS, is recommended for some patients.

Depression in painful chronic disorders: the role of pain and conflict about pain

Chronic pain severity, the responses of the significant other to the patient's pain, and social network relationships were investigated for their contributions to depression among patients with myofascial pain disorders (N = 67) and arthritis (N = 83). Interview data were gathered using the Beck Depression Inventory, McGill Pain Inventory, Multidimensional Pain Inventory, and Interpersonal Relationships Inventory. Patients with myofascial pain disorders reported significantly more severe depression and pain, more conflict about their pain, and more network conflict than those with arthritis. They also reported less network social support. After controlling for the type of painful chronic disorder, multiple linear regression analyses indicated that more severe depression was significantly associated with more severe pain, conflict about pain, and less network social support. Conflict about pain may increase the risk of depression for patients with chronic painful disorders. Patients with myofascial pain disorders, however, may experience more conflict about their pain because of the absence of objective physical findings that corroborate the report of pain.

The Pain Disability Index: factor structure and normative data

The factor structure and normative data for the Pain Disability Index (PDI) were examined in a large (N = 1,059) sample of chronic pain patients. The results support a one-factor solution for the PDI. Analyses of normative data indicated very small effects associated with gender, age, and pain duration. Relatively larger effects were associated with compensation status, litigation status, and circumstances of pain onset. Working patients reported less disability than their nonworking counterparts, litigating patients reported more disability than nonlitigants, and patients injured at work reported higher levels of disability than those with pain origins unrelated to work. The results reflect the disability level of patients referred to a hospital-based pain management program and may be useful as a reference point when comparing disability levels of other patient groups or research samples.

Coping and marital support as correlates of tinnitus disability

Although there is increasing awareness that depression can add significantly to the disability associated with chronic medical illness, it is not clear whether all of the impact of psychosocial factors upon medical disability are mediated by or moderated by depression. It has not been determined whether treating depression alone is an adequate strategy for addressing psychosocial magnification of medical disability. We analyzed data collected at initiation of a treatment trial from 92 subjects with chronic severe tinnitus to assess the role of coping, and 49 subject-spouse pairs to assess the role of marital interaction in tinnitus-related role dysfunction. Three multiple regression models were developed. After accounting for gender, tinnitus loudness, and depressive severity among the 92 subjects, greater role dysfunction was associated appraisal of tinnitus as salient, and less role dysfunction with coping through avoidance or seeking social support. Marital interaction was assessed from patient and spouse perspectives. In the patient-rated set, less marital cohesion was associated with greater tinnitus-related role dysfunction. In the spouse-rated set, more punishing responses to subject illness behavior were associated with greater tinnitus-related role dysfunction. In each case the disabling effect was greater in the face of high levels of subject depression. This study provides evidence for the oft-stated analogy between chronic tinnitus and chronic pain, and provides justification for a similar multimodal treatment strategy. Reducing depression is an important means to reduce medical disability but should be supplemented by clinical attention to appraisal of the illness, modes of coping with the illness, and spousal response to the illness.

Chronic illness of the temporomandibular joints as experienced by support-group members

PURPOSE

For temporomandibular disorders, the clinical situation is one of considerable etiologic, diagnostic, and therapeutic uncertainty. Using interview data, this report describes this condition and the search for care from the perspective of sufferers who are support-group members.

PARTICIPANTS AND METHODS

Thirty-two individuals participated; all were members of a support group for individuals with long-term problems attributed to the temporomandibular joints and/or the surrounding masticatory muscles. Using a structured, open-ended interview format, this study investigated how individuals understand and give meaning to their symptoms, their patterns of care seeking, and the consequences of the illness on their lives. The participants also completed several structured questionnaires.

RESULTS

For these support-group members, symptoms extended beyond the jaw and surrounding area, with extensive musculoskeletal involvement and resulting dysfunctions that have far-reaching consequences for the sufferers' lives. Primary care physicians are often consulted, especially early in the illness history. They also provide ongoing care and are asked for guidance when patients seek specialized treatment. A striking aspect of the findings from the interviews is the complex and costly pattern of health care seeking. This extended search for effective treatment is examined with reference to culturally based understanding, shared by patients and clinicians, about the nature of illness.

Assessment and measurement of pain

This paper provides an overview of issues relating to pain assessment and management. Areas to be covered include the problems involved in assessing pain as a subjective phenomenon, the constraints of assessment within the clinical field, factors that affect pain, and pain assessment tools and questionnaires. The aim of the reference list is to provide back-up reading to assist in exploring the options available when considering the possibility of compiling a pain assessment protocol for individual clinical areas.

Cognitive-behavioral classifications of chronic pain: replication and extension of empirically derived patient profiles

Many attempts have been made to classify patients with chronic pain in order to make sense of a very complex problem and to direct patients towards appropriate treatments for their condition. Unfortunately, these efforts have not been empirically based and have demonstrated limited clinical use. Predominant emphasis has been placed on either biomedical or psychopathological elements of the chronic pain experience with little integration of cognitive-behavioral factors. Turk and Rudy (1988) introduced an empirically derived pain patient taxonomy based on analyses of the Multidimensional Pain Inventory (MPI). The primary purpose of the present study was to replicate this classification system by using different measures for similar constructs in different groups of chronic pain patients. Items designed to measure 4 constructs (activity interference, emotional distress, pain intensity, and perceived support) were collected from 1594 pain patients evaluated at two separate pain treatment facilities. Confirmatory factor analytic results indicated high reliability of the items in measuring these 4 constructs. Replicated clustering techniques demonstrated the robustness of 3 patient profiles across the patient samples. The 3 clusters corresponded remarkably well to the groups initially labeled by Turk and Rudy (1988) as Dysfunctional, Interpersonally Distressed and Adaptive Copers. External validation of the classification system supported replication of the 3 groups and offered further interpretational clarity to the patient profiles. Strong evidence was found for a taxonomy of 3 chronic pain patient groups. Implication for predicting treatment outcome and for future research are discussed.

Chronic opioid therapy as alternative treatment for post-herpetic neuralgia

Neurosurgical procedures such as the dorsal root entry zone operation, ganglionectomy, and spinal-cord stimulation have been offered to patients with intractable post-herpetic neuralgia (PHN). Poor efficacy or high morbidity have limited the overall usefulness of these procedures. We recently conducted a preliminary open-label study with long-acting oral opioids. The mean pretreatment pain score, on a scale of 0 to 10 (0 = no pain) was 9.0 +/- 0.3 (mean +/- SEM, N = 20). At two months of treatment the average pain score was 4.0 +/- 0.4 (p < 0.001, paired t test), and at six months the average pain score was 3.8 +/- 0.2 (p < 0.001, N = 16). These observations warrant a controlled opioid trial for patients affected by PHN.

Pain and the use of health services among the elderly

This study examined pain management strategies and the relationship of pain to the use of health services in a sample of community-resident Canadian elderly. Analyses with the Andersen-Newman framework of need, enabling and predisposing variables revealed that pain did not make an incremental contribution to explaining service use. Traditional measures of need for services accounted for the majority of explained variance in health service use. The substantial number of participants who were found to be coping with chronic, frequent pain relied on themselves as much as formal health services for dealing with their pain. The most common coping style for these pain sufferers was a combination of analgesics and accepting mild pain as part of daily life. This combination of medical intervention and attitudinal factors appears to make the coping process very manageable.

Coping with long-term musculoskeletal pain and its consequences: is gender a factor?

We did a descriptive study of 121 patients (71 women and 50 men) to explore the role of gender in coping with long-term intractable pain of the neck, shoulder and back and to determine the consequences of pain. Questionnaires used to assess the dependent variables were the Coping Strategy Questionnaire (CSQ) and the Multidimensional Pain Inventory (MPI). Distinctions were found between men and women. In particular, the coping strategies used by women were those which in previous research had been found to be associated with dysfunction and poor outcome in terms of rehabilitation. Moreover, considering the consequences of pain on daily living, a more complex pattern of related factors was found in women rather than men. Given the high proportion of working women in Sweden with long-term musculoskeletal pain and considering recent observations in controlled studies showing that the benefits of cognitive behaviourally based treatments are confined to women, our findings suggest the need to tailor rehabilitative strategies differently for men and women and point to a research agenda which pays more attention to the distinctive challenges of women in the workplace when they are affected by chronic ailments.

Biobehavioral pain profile: development and psychometric properties

Although a number of self-report indices that measure intensity and psychosocial components of the pain experience are available, these measures do not assess the range of cognitive, behavioral, and physiological reactions frequently associated with pain. This paper describes the initial determination of the psychometric properties of the Biobehavioral Pain Profile (BPP) developed to measure these reactions. The BPP is a 41-item self-report scale tested in a sample of 617 subjects with chronic recurrent pain, chronic non-malignant pain or chronic malignant pain. Kaiser's measure of sampling adequacy was 0.918. Factor analysis revealed 6 theoretically meaningful factors: Environmental Influences, Loss of Control, Health Care Avoidance, Past and Current Experience, Physiological Responsivity, and Thoughts of Disease Progression. Cronbach's alpha scores for the specific subscales ranged from r = 0.77 to r = 0.94. Test-retest reliability for the scales ranged from 0.57 to 0.73. Low correlations among the BPP and general indices of fear, depression, anxiety, body consciousness and social desirability are reported. The BPP appears to provide a unique composite assessment of self-report of behavioral, physiological, and cognitive reactions to pain experienced by individuals with a wide range of pain problems.

Anger expression and chronic pain

Intensity of angry feelings and styles of expressing anger were examined for their relationship to measures of the chronic pain experience. Subjects were 142 chronic pain patients. Multiple regression analyses revealed that a style of inhibiting the expression of angry feelings was the strongest predictor of reports of pain intensity and pain behavior among a group of variables including demographics, pain history, depression, anger intensity, and other styles of anger expression. In a similar manner anger intensity contributed significantly to predictions of perceived pain interference and activity level. More conservative hierarchical regression analyses supported these findings. Results are consistent with explanatory models of pain and disability that hypothesize an etiologic role of a pervasive inability to express intense negative emotions, particularly anger.

Prediction of pain rehabilitation outcomes by motivation measures

This study attempted to predict reduction in pain description, pain behaviour, and depression by measures of motivation and previous vocational development. Twenty-one patients randomly selected from an inpatient pain programme were given pre-admission the Goldberg Scale, a 2-h clinical interview synthesizing educational and vocational history, work values, interests, motivation to work, realistic assessment of pain disability and optimistic compared to pessimistic outlook towards the future. Repeated measures consisted of the McGill-Melzack Pain Questionnaire, the Pain Disability Index, and the Beck Depression Inventory, given at admission, discharge and follow-up. Pain was classified by the IASP categories. The Goldberg Scale predicted at p less than 0.05 level for reduction of subjective pain description on MMPQ and reduction of depressive symptoms on Beck, but failed to predict for reduction of pain behaviour at 0.05 level. A measure of motivation may be a useful adjunct to the broad array of measures to predict outcome in pain management programmes.

Detecting depression in chronic pain patients: adequacy of self-reports

Depression, a complex psychobiological syndrome, has been found to be prevalent among individuals with chronic pain problems. It has been repeatedly recommended that chronic pain patients be routinely screened for depression. Many self-report questionnaires have been used to screen for depression although few have addressed potential limitations of using a self-report questionnaire to identify depressed chronic pain patients. Among the most serious problems is an over-diagnosis since typical neurovegetative symptoms of depression often resemble patients' medical/physical conditions. Some have suggested that the physical items should be replaced and others have suggested that a higher cut-off criteria for diagnosing depression should be used. In this study, the validity of the Center for Epidemiological Studies-Depression (CES-D) scale was examined to determine (a) its sensitivity, specificity, and positive, and negative predictive value with chronic pain patients, (b) the biasing effect of somatic items, and (c) the optimal cut-off score for diagnosing depression. The results support the predictive validity of the CES-D and suggest that a cut-off score of 19 should be used for diagnosing depression in chronic pain patients rather than the standard cut-off point of 16. Interestingly, the removal of the somatic items did not enhance the effectiveness of the CES-D. The discriminatory ability of somatic items with the total assessment of depression is discussed.

The effects of a cognitive-behavioral pain management programme on the quality of work and employment status of severely impaired chronic pain patients

This study examined changes in employment status and quality of work in 109 chronic pain patients who underwent a cognitive-behavioural pain management course; 68% of patients were female, mean age was 45 years, mean pain chronicity 10.7 years, 70% had spinal pain, and mean impairment on the Sickness Impact Profile was 26%. Twenty-six per cent of patients were employed at pre-treatment; the remaining 74% had been unemployed for 4.3 years on average. Measures of work status and quality, mood, pain, self-efficacy and walking performance were taken before admission, and at 1-, 6-, and 12-month follow-ups. Among employed patients quality of work scores improved by 35% from pre- to post-treatment (p < 0.01). Thirty per cent of previously unemployed patients returned to work during the 1-year follow-up, although employment status fluctuated greatly during this period. Non-workers were generally more impaired than workers on most measures, but the same measures did not differentiate between those who successfully returned to work and those who remained unemployed.

Psychometrics in temporomandibular disorders. An overview

The purpose of this paper is to review the methods and results of psychometric testings in temporomandibular disorders (TMD) during the past decade. Assessments of psychologic and behavioral factors have been performed for various reasons. The results are often ambiguous and comparisons troublesome. No encompassing psychologic TMD profile has been identified, but small elevations in anxiety, depression, somatization, and stress are often reported; they may be cause or effect. Subcategorization of the patients into diagnostic subgroups suggests that psychologic differences exist but may be small; myogenic patients may have more psychologic difficulties than 'joint' patients. More distinct, robust psychologic subsets of patients, unrelated to the structural diagnosis, have been identified by means of clustering techniques. Irrespective of clinical signs, a certain proportion of the patients are psychologically distressed, whereas others easily adapt to the pain and dysfunction. No single variable has been identified that can predict outcome or compliance. Several psychometric instruments are described.

Effects of present pain level on recall of chronic pain and medication use

The present study experimentally manipulated pain intensity in chronic pain patients to evaluate whether the present pain level influenced the recall of past pain and medication use. For 1 week 30 chronic pain patients recorded every change in their pain levels and every use of medication on an electronic diary. At the end of the week, we evaluated recall of pain level and medication use for the previous day and week either before (control group, n = 15) or immediately after a physical therapy (PT) session (PT group, n = 15). As expected, the PT patients reported a significantly lower present pain level than did the control patients. More importantly, the PT patients recalled their usual and their highest levels of pain for the previous day and week to be less severe than did the control patients; furthermore, they significantly underestimated these levels as compared to their diary. In contrast, the control patients significantly overestimated their lowest and highest levels of pain for the previous day and their usual and lowest levels of pain for the previous week. In addition, PT patients recalled taking significantly less medication than they had recorded in their diaries, and less than the control patients. Our results demonstrate clearly that chronic pain patients recall their pain and medication use for the previous day and week in a way that is congruent with their present pain intensity.

An empirical evaluation of multidimensional clinical outcome in chronic low back pain patients

Individuals with persisting pain often present a constellation of symptoms that includes pain, health-related impairment and dysphoric mood. It is now widely accepted that comprehensive assessment must address each of these dimensions. Despite recognition of the value of multidimensional assessment, no empirical efforts have validated the construct of a multidimensional clinical outcome presentation based on the dimensions of pain, impairment and dysphoric mood. We employed cluster analytic procedures on standard measures of pain, impairment and depression in chronic low back pain (CLBP) patients (n = 96) attending a general orthopedic clinic in order to empirically characterize multidimensional clinical outcomes. Results indicated that 3 groups could be identified reliably: (1) 'Chronic Pain Syndrome' (n = 25; high levels of pain, impairment and depression), (2) 'Positive Adaptation to Pain' (n = 24; high levels of pain with low levels of impairment and depression) and (3) 'Good Pain Control' (n = 47; low levels of pain, impairment and depression). The reliability of this cluster solution was supported by several tests of internal consistency. Discriminability of the clusters was examined across both the outcome measures themselves and several additional independent variables. The cluster solution was then cross-validated in an independent sample of pain clinic CLBP patients (n = 180) to test its generalizability. Finally the stability of the cluster dimensions over time was tested by re-assessing 36 CLBP patients 6 months after they initially were characterized into 1 of the 3 outcome groups on the same measures. MANOVA results indicated that the outcome groups were differentiated statistically across assessments. The multiple outcome measures did not change significantly across time, nor did the outcome groups change differentially across time on these measures. We conclude that the outcome dimensions of pain, impairment and depression are relatively stable phenomena that differentially describe CLBP patients.

Effects of intraoral appliance and biofeedback/stress management alone and in combination in treating pain and depression in patients with temporomandibular disorders

To assess the differential efficacy of two commonly used treatments for temporomandibular disorders (TMD), intraoral appliances (IAs) and biofeedback (BF), separately and in combination, two studies were conducted. The first study directly compared IA treatment, a combination of biofeedback and stress management (BF/SM), and a waiting list control group in a sample of 80 TMD patients. Both treatments were determined to be equally credible to patients, ruling out this potential threat to the validity of the results obtained. The results demonstrated that the IA treatment was more effective than the BF/SM treatment in reducing pain after treatment, but at a 6-month follow-up the IA group significantly relapsed, especially in depression, whereas the BF/SM maintained improvements on both pain and depression and continued to improve. The second study examined the combination of IA and BF/SM in a sample of 30 TMD patients. The results of this study demonstrated that the combined treatment approach was more effective than either of the single treatments alone, particularly in pain reduction, at the 6-month follow-up. These results support the importance of using both dental and psychologic treatments to successfully treat TMD patients if treatment gains are to be maintained.

Chronic pain: intrusion and accommodation

Cognitive-behavioral and self-management perspectives on chronic pain emphasize the central role that patient's appraisals of their pain problems may have in determining aspects of the pain experience. This paper reports the development of a self-report instrument measuring two aspects of patients' appraisals of their pain and its impact on their lives. Two reliable and meaningful scales were derived via factor analysis, and a second sample was submitted to confirmatory factor analysis. Further analyses offered support for the internal consistency and stability of the scales. Pain Intrusion is related to greater depressive symptom severity and pain behaviors reflecting affective distress. Pain Accommodation is related to self-reports of greater self-control, viewing oneself as a problem-solver, fewer depressive symptoms, and fewer pain behaviors reflecting affective distress. This report introduces these constructs and the Chronic Pain Intrusion and Accommodation Scales that measure them, and discusses their theoretical and clinical relevance.

Association of osteoporotic vertebral compression fractures with impaired functional status

PURPOSE

To determine if vertebral compression fractures in elderly women were associated with impairments in physical, functional, and psychosocial performance.

SUBJECTS AND METHODS

Ten white women with confirmed vertebral compression fractures were age- and race-matched with 10 control subjects without fractures in a case-control design. All subjects invited to participate in this study were patients of the Geriatrics Division of the Department of Medicine at Duke University Medical Center. All study participants lived either in the community or in the independent-living sections of local retirement communities in and around Durham, NC. Subjects with fractures (mean age = 81.9 years, SD = 5.9 years) had two or more vertebral compression fractures in their medical records, whereas control subjects (mean age = 79.6 years, SD = 6.5 years) had no history of vertebral fractures. Spinal radiographs of all women confirmed group assignment. Physical, functional, and psychosocial performances were evaluated. Physical performance was assessed by measurements of maximal trunk extension torque and thoracic and lumbar spinal motion in the sagittal plane, functional reach, mobility skills, 10-ft timed walk, and 6-minute walk test. Thoracic and lumbar spinal configurations were also determined. Functional performance was assessed using the Functional Status Index. Psychosocial performance was assessed with the following scales: Hopkins Symptom Checklist 90 Revised, Rosenberg Self-Esteem Scale, West Haven-Yale Pain Inventory, Beck Depression Inventory, and single-item health-belief questions.

RESULTS

Control subjects were not significantly different from patients with fractures in age, weight, number of current illnesses, number of prescribed medications, number of pain medications, ratings of lumbar spine degenerative disc disease, or lumbar spine facet joint arthritis. Activity levels and exercise participation were similar in both groups. Control subjects had no vertebral fractures, whereas fracture subjects had 4.2 +/- 2.6 fractures (range: 2 to 10). Thoracic kyphosis was increased and lumbar lordosis was reduced in fracture subjects. Fracture subjects had reduced maximal trunk extension torque, thoracic and lumbar spine sagittal plane motion, functional reach, mobility skills, and 6-minute walk test. The Functional Status Index showed reduced levels of functional performance in fracture subjects compared with controls with increased levels of assistance, pain with activity, and difficulty in activities. Psychosocial performance was limited in fracture subjects with increased psychiatric symptoms, increased pain, and greater perception of problems caused by health.

CONCLUSION

Vertebral compression fractures are associated with significant performance impairments in physical, functional, and psychosocial domains in older women.

Depressive symptoms and measures of disability: a prospective study

OBJECTIVE

The purpose of this study was to test the hypothesis that decreases in severity of depressive symptoms in patients with chronic tinnitus would correlate with reductions in measures of functional disability.

METHOD

This study describes the correlations between several measures of functional disability and Hamilton depression scores in two groups of patients with major depression and depressive symptoms (D-NOS) who were patients enrolled in a 12-week placebo-controlled, double-blind trial of nortriptyline. These patients had chronic severe tinnitus which was associated in most patients with high frequency hearing loss. The effect of whether affective symptoms improved and the patient's initial depression status (major depression versus depressive symptoms) are examined in order to increase understanding about the correlations between depressive symptoms and functional disability.

RESULTS

Most measures of functional disability decreased synchronously with Hamilton Depression Scale scores in both patients with major depression and those with subclinical depressive symptoms. Patients whose depression improved had a significantly greater change in each disability measure than patients whose depression did not improve. This significant decrease in functional disability was seen in 11 of 13 scales in the improved D-NOS group, versus only 3 of the 13 scales in the unimproved D-NOS group; 9 of 13 scales of functional disability significantly decreased in the improved major depression group, versus 3 of 13 scales in the unimproved major depression group.

CONCLUSIONS

The results suggest that there was a significant correlation between improvement in both major depression and depression-NOS symptoms, and decreases in measures of functional disability in an aging population with a chronic medical illness.

Relationship of sexual and physical abuse to pain and psychological assessment variables in chronic pelvic pain patients

This study examines the incidence of sexual and physical abuse and its relationship to selected pain description and psychological variables in a sample of 36 chronic pelvic pain patients. Abuse was measured on a 6-item reliable scale, and abused and non-abused respondents were compared on 4 categories of variables expected to be related to the effects of abuse (pain description, functional impact of pain, other's response to pain, and psychosocial impact of pain). Results indicated that 19 of 36 patients reported prior abuse. Physical abuse was reported less commonly than sexual abuse. No differences between the abused and non-abused groups were noted on demographic, pain description, or the functional interference variables. On the psychological variables, however, the abused group reported less perceived life control, greater punishing responses to pain, and higher levels of somatization and global distress than the non-abused group. These results indicate a high incidence of sexual abuse in patients with chronic pelvic pain and suggest that abused and non-abused patients differ on psychological but not pain description or self-reported functional interference variables.

Short-term outcome of arthroscopic surgery of temporomandibular joint osteoarthrosis and internal derangement: a randomized controlled clinical trial

Various types of treatment have been proposed for patients with temporomandibular joint (TMJ) osteoarthrosis and internal derangement. We examined the suitability of several assessment instruments developed in previous investigations for treatment-evaluation in a clinical trial comparing arthroscopic surgery with non-surgical treatment for a specific subgroup of TMJ osteoarthrosis and internal derangement, characterized by joint pain and restricted mobility. Twenty-one patients appeared to obey strict criteria for participation, and were randomly assigned to receive arthroscopic surgery followed by post-operative physical therapy (n = 9), or non-surgical treatment (n = 12). Individual outcome was assessed immediately following treatment and after 6 months based on a priori defined criteria. Patients treated with arthroscopic surgery reported more pain relief and more improvement of mobility than patients treated non-surgically, although clinical assessment results were comparable between the two groups. No major changes were observed regarding general well-being and interference with daily activities. The results of this pilot study indicate that the assessment methods are sufficiently sensitive for changes in pain, mobility, and functional ability. Despite the higher degree of subjective pain relief and appreciation of improvement of mobility in the arthroscopic surgery group, with these more formal assessment instruments this difference could not be confirmed. It is concluded that the preliminary results should be verified in a larger trial with a slightly adjusted design.

Assessment of pain-related cognitions in chronic pain patients

The construction of the Pain-Related Self Statements Scale (PRSS) and the Pain-Related Control Scale (PRCS) is described. The PRSS assesses situation-specific aspects of patients' cognitive coping with pain, while the PRCS measures general attitudes towards pain. The reliability and validity of these scales were determined in a sample of 120 chronic pain patients suffering from various rheumatic disorders, 213 patients who suffered from chronic back pain, 44 patients with temporomandibular pain and dysfunction and 38 healthy controls. The analysis of the PRSS yielded two scales termed 'Catastrophizing' and 'Coping'; the PRSC consists of the subscales 'Helplessness' and 'Resourcefulness'. All four subscales were demonstrated to be valid and sensitive to change, and they are closely related to pain intensity and interference from pain experiences.

Pain profiles of patients with nonorganic chest pain: a preliminary report of the Multidimensional Pain Inventory

The primary purpose of this report is to extend the range of the Multidimensional Pain Inventory (MPI) to include patients with nonorganic chest pain. Previous research with the MPI has not included this patient population, although this instrument has been used to derive an empirically based taxonomy of patient responses to chronic pain. Scale scores are provided for a sample of 43 chest pain patients and compared with normative scores from samples of chronic lower back pain patients and patients suffering from temporomandibular disorder. The MPI taxonomy was applicable for only 34.8% (N = 15) of this sample. Scale intercorrelations are examined and compared with those derived during development of the MPI, to explore reasons for this low classification rate. The results are discussed in light of cognitive-behavioral factors present in persistent chest pain, with implications for scale development and use of the MPI.

The relationship between spouse solicitousness and pain behavior: searching for more experimental evidence

In this study 42 chronic back pain patients participated twice in a treadmill test. During 1 of these 2 sessions, the partner was present. Walking time, pain intensity ratings, and heart rate were measured before and after the tests. From the results of previous studies it was expected that, in the presence of a relatively solicitous spouse, patients would report more pain, would have a shorter walking time, and would exert themselves less physically. Spouse solicitousness was measured in 2 ways: from the patient's perspective as well as from that of the spouse. Results based on the patient's interpretation of his/her partner's responses are not in accordance with previous findings. Results based on the spouse's view demonstrate, however, that patients with solicitous spouses do, in fact, report more pain and walk for a shorter duration in the presence of the spouse than patients with relatively non-solicitous spouses. Theoretical and practical implications are discussed.

Chronic Pain and Depression

Because of the increased incidence of chronic disease and other health problems associated with aging, chronic pain is a common companion for the elderly. Pain is of great clinical importance, often associated with disability, loss of independence, and reduced quality of life. A fact that is of interest to psychiatric nurses is that many elderly with complaints of chronic pain also exhibit signs and symptoms of depressive disorders. Treating chronic pain conditions is complex and difficult, and health-care professionals are increasingly recognizing that psychological factors are often involved in the development and continuation of chronic pain problems. Depression is one of these influential variables. Increased understanding of the role of depression in the etiology and maintenance of chronic pain can improve assessment and intervention for the elderly with chronic pain complaints.

Pain-elicited responses and their role in predicting future pain duration and severity

The first objective of this study was to carry out a prospective investigation of the behavioral and affective responses to headache pain over a 72 hr period. A sample of 74 headache sufferers provided self-reported ratings of affective and behavioral responses as measured by a composite of standardized questionnaires. Highly significant and clinically meaningful levels of both types of responses were found on the headache day. Interestingly, significant levels of behavioral and affective disturbances were also reported 24 hr after pain termination, indicating that responses to pain actually outlasted pain perception by at least 1 day. The second goal of this study was to investigate whether affective or behavioral responses were predictors of future pain intensity, duration or severity. A smaller sample of 25 subjects provided ratings on two sequential headaches. A series of time-lag analyses indicated that, unlike behavioral responses, strong affective responses during a given episode were associated with subsequently longer and more severe headaches. These results suggest that affective pain-elicited responses may be a risk factor for suffering a worse headache during the episode that follows.

Grading the severity of chronic pain

This research develops and evaluates a simple method of grading the severity of chronic pain for use in general population surveys and studies of primary care pain patients. Measures of pain intensity, disability, persistence and recency of onset were tested for their ability to grade chronic pain severity in a longitudinal study of primary care back pain (n = 1213), headache (n = 779) and temporomandibular disorder pain (n = 397) patients. A Guttman scale analysis showed that pain intensity and disability measures formed a reliable hierarchical scale. Pain intensity measures appeared to scale the lower range of global severity while disability measures appeared to scale the upper range of global severity. Recency of onset and days in pain in the prior 6 months did not scale with pain intensity or disability. Using simple scoring rules, pain severity was graded into 4 hierarchical classes: Grade I, low disability--low intensity; Grade II, low disability--high intensity; Grade III, high disability--moderately limiting; and Grade IV, high disability--severely limiting. For each pain site, Chronic Pain Grade measured at baseline showed a highly statistically significant and monotonically increasing relationship with unemployment rate, pain-related functional limitations, depression, fair to poor self-rated health, frequent use of opioid analgesics, and frequent pain-related doctor visits both at baseline and at 1-year follow-up. Days in Pain was related to these variables, but not as strongly as Chronic Pain Grade. Recent onset cases (first onset within the prior 3 months) did not show differences in psychological and behavioral dysfunction when compared to persons with less recent onset. Using longitudinal data from a population-based study (n = 803), Chronic Pain Grade at baseline predicted the presence of pain in the prior 2 weeks. Chronic Pain Grade and pain-related functional limitations at 3-year follow-up. Grading chronic pain as a function of pain intensity and pain-related disability may be useful when a brief ordinal measure of global pain severity is required. Pain persistence, measured by days in pain in a fixed time period, provides useful additional information.

Symptom-specific psychophysiological responses in chronic pain patients

Symptom-specific psychophysiological responding was assessed in 20 chronic back pain patients, 20 patients suffering from temporomandibular pain and dysfunction, and 20 matched healthy controls. Surface EMG from the lower and upper back, the masseter, and the biceps muscles, and heart rate and skin conductance level were continuously recorded during adaptation, resting baseline, and stressful and neutral imagery phases. Univariate and multivariate analyses of variance were performed on raw data as well as data corrected for autocorrelation. The results showed significantly higher EMG reactivity which was lateralized to the left side at the patients' site of pain but not distal sites. This hyperreactivity was observed only during stressful imagery. The healthy controls displayed a significantly higher response in heart rate, but skin conductance level was not significantly different. The results are interpreted as indicative of idiosyncratic muscular response patterns to personally relevant situations at the site of pain in patients suffering from chronic muscular pain.

The Pain Anxiety Symptoms Scale: development and validation of a scale to measure fear of pain

Fear of pain has been implicated in the development and maintenance of chronic pain behavior. Consistent with conceptualizations of anxiety as occurring within three response modes, this paper introduces an instrument to measure fear of pain across cognitive, overt behavioral, and physiological domains. The Pain Anxiety Symptoms Scale (PASS) was administered to 104 consecutive referrals to a multidisciplinary pain clinic. The alpha coefficients were 0.94 for the total scale and ranged from 0.81 to 0.89 for the subscales. Validity was supported by significant correlations with measures of anxiety and disability. Regression analyses controlling for measures of emotional distress and pain showed that the PASS made a significant and unique contribution to the prediction of disability and interference due to pain. Evidence presented here supports the potential utility of the PASS in the continued study of fear of pain and its contribution to the development and maintenance of pain behaviors. Factor analysis and behavioral validation studies are in progress.

Psychiatric assessment of chronic pain

The subject of pain used to be considered the province of the physiologist, physician, and surgeon. In a prominent medical textbook written over 20 years ago, pain was simply defined as “that sensory experience evoked by stimuli that injure” (Mountcastle, 1968). This explanation of tissue damage that generates nervous impulses along recognised pain pathways is appropriate for acute pains. But if pain persists beyond the normal time of healing, which is normally less than three months but can be as long as six months, the correspondence between extent of injury and pain sensation is much less precise.

The effectiveness of psychological interventions for the rehabilitation of low back pain: a randomized controlled trial evaluation

Forty-five low back pain patients were randomly assigned to either a standard inpatient rehabilitation program or the standard program with additional psychological components. The standard program emphasized education, support, and physical reconditioning through exercise. Patients receiving the psychological program were given additional training in relaxation and other coping skills and received contingent reinforcement for exercise. Both programs included reduction of medication intake and an emphasis on family involvement after discharge. Measures of functional status were taken prior to the program, at discharge from the 3-week inpatient program, and at a 6-month follow-up appointment. These data revealed that patients improved their overall functioning at discharge and maintained these gains at the follow-up assessment. A similar pattern of findings was obtained for self-reported pain and interference. Furthermore, 81% of the patients had returned to work or were engaged in active job retraining by the follow-up. Using a conservative measure of full-time return to the same or an equivalent job, 57% were employed by the follow-up. Patient improvement, however, was not differentially affected by treatment group assignment, suggesting that the psychological treatment failed to add to the effectiveness obtained by the standard rehabilitation program. Results are discussed in the context of improving patient outcomes from rehabilitation for low back pain.

Psychosocial and psychophysical assessments of patients with unexplained chest pain

It is imperative to assess the psychosocial factors that may influence the subjective experiences and pain behavior of persons with chronic unexplained chest pain. Both psychologists and physicians tend to rely on self-report measures of psychological distress, which provide little unique information about patients with chronic chest pain to differentiate them from patients with other painful disorders such as irritable bowel syndrome, gastroesophageal reflux disease, or coronary artery disease. However, assessment of pain-coping strategies, spouse responses to the patient's pain behaviors, and pain thresholds for esophageal balloon distention do differentiate patients with chronic chest pain from healthy controls and patients with various other chronic pain disorders. Specifically, chronic chest pain patients tend to use relatively passive pain-coping strategies such as praying and hoping, and to report relatively high levels of spouse reinforcement of pain behaviors. Finally, in response to esophageal balloon distention, chronic chest pain patients display low pain thresholds that do not generalize to stimulation by mechanical finger pressure. Preliminary evidence suggests these low thresholds are due primarily to a tendency to set low standards for making pain judgments regarding esophageal stimuli of moderate-to-high intensity levels.

Respiratory function, cognitions, and panic in chronic obstructive pulmonary patients

The present study investigated the relationship between respiratory function, catastrophic thoughts about anxiety, and panic in 48 Chronic Obstructive Pulmonary Disease (COPD) patients. During a routine office visit which included respiratory function tests (Forced Vital Capacity, FVC; Forced Expiratory Volume--first second, FEV1) patients completed a battery of questionnaires which assessed history of panic, days with shortness of breath, general activity level, agoraphobic cognitions, perception of bodily sensations, anxiety and depression. Thirty-seven percent of the sample reported experiencing a panic attack. Subjects showed a significant impairment in respiratory functioning. Patients with a history of panic did not differ from those who had not experienced panic on demographic, physiologic, or activity variables. Patients who experienced panic reported significantly more agoraphobic cognitions and greater concern with bodily sensations than did patients who did not experience panic.

A critical review of questionnaires for assessing pain-related disability

Standardized questionnaires offer a practical and cost-effective means for measuring moderate disability. Fourteen questionnaires that can be used for assessing pain-related disability are reviewed in this article. Their comparative attributes are summarized. Most of the questionnaires obtain information about specific activities of daily living. They vary in terms of structure, content, and intended applications. Psychometric theory provides the optimal method for evaluating these questionnaires, highlighting the importance of reliability and validity. Being mindful of psychometric qualities will help the evaluator to select an appropriate questionnaire. The present array of existing instruments points toward a need for comparison studies that may eventually result in more uniform methods for evaluating pain-related disability.

Pain measurement from the neurosurgical standpoint

A selective review of the current methods of pain measurement and validation (psychophysical methods, verbal and analogical scales, psychological tests) is presented with emphasis on patient selection for surgical pain relief, and analysis of outcome. The identification of homogeneous groups of patients with clinical and research objectives is prevented by the lack of a reliable pain scale, based on the assessment of objective and comprehensive parameters. This obstacle seems to be inherent to the complex nature of human pain experience. Psychiatric examination has proved important to elucidate the operative indications, particularly in cases of non-malignant obscure neuralgias. The importance of separate validation of the pain compliant and the psychiatric assessment is stressed. A critical comment is made on Hitchcock's pain scale and Lindqvist's psychiatric classification of candidates for surgery.

Psychosocial factors in chronic spinal cord injury pain

Chronic pain is a problem among patients with spinal cord injuries, but the psychosocial factors associated with spinal cord injury (SCI) pain are not well understood. To understand SCI pain further, 54 patients (19 with quadriplegia and 35 with paraplegia) completed the Beck Depression Inventory, State-Trait Anxiety Inventory, Profile of Mood States, Acceptance of Disability Scale and SCI Interference Scale. Forty-two patients stated they had SCI pain and completed the Multidimensional Pain Inventory and the Pain Experience Scale. Results revealed that anger and negative cognitions were associated with greater pain severity. Patients who reported pain in response to a general prompt experienced more severe pain than patients who reported pain only when directly questioned about the presence of pain, but these different reporting groups did not differ on emotional variables. Those who were less accepting of their disability reported greater pain severity. Additionally, patients who perceived a significant other expressing punishing responses (e.g., expressing anger at the patients or ignoring the patients) to their pain behaviors reported more severe pain. Level of lesion, completeness of injury, surgical fusion and/or instrumentation and veteran status were not associated with pain severity. Finally, pain was associated with emotional distress over and above the distress associated with the SCI itself. Overall, psychosocial factors, not physiological factors, were most closely associated with the experience of pain. Multidimensional aspects of pain are used to explain these findings and suggest that treatment should be directed at the emotional and cognitive sequelae of chronic SCI pain.

Recent advances in temporomandibular disorders and orofacial pain

Consistent with chronic pain disorders in other areas of the body, there has been growing attention given to patients with temporomandibular disorders and orofacial pain among health care professionals and the general public. As a result of increased clinical and research activities, significant progress has been made in improving care.

Pain disability index: construct and discriminant validity

The Pain Disability Index (PDI) was developed as a self-report measure of general and domain-specific, pain-related disability. This study's purpose was twofold: (1) to assess construct validity of the scale relative to other measures of pain-related disability and psychologic distress and (2) to assess the strength of the PDI, independent of pain intensity, in accounting for behavioral and psychologic aspects of disability. Results indicated stronger correlations for PDI factor 1 (discretionary activities) than factor 2 (obligatory activities), with factor scores significantly related to both psychologic distress and behavioral measures of disability. Partial correlation controlling for pain intensity demonstrated PDI factor 1 was significantly related to depression, employment status, and medication usage. The finding supports the usefulness of the PDI in providing important information on functional disability beyond what is provided by a simple measure of pain intensity.