Suffering: the contributions of persistent pain

Testing the sequential model of pain processing in irritable bowel syndrome: a structural equation modeling analysis

Pain, the cardinal feature of irritable bowel syndrome (IBS), is a multidimensional phenomenon with sensory and affective dimensions. Price's pain processing model was used to delineate four a priori sequentially related stages (pain sensation intensity, immediate pain unpleasantness, long-term suffering, and pain-related behavior). Although prior research with both healthy individuals and somatic pain patients supports the model in general, its applicability to IBS is unclear. Our goal was to extend the scope of the sequential model and test its fundamental tenets using structural equation modeling (SEM) with data obtained from 168 Rome II diagnosed IBS patients (19% male, 81% female). A secondary goal was to assess the relationship between a set of contextual factors associated with IBS (age, gender, trait anxiety) and the four pain stages. Results were consistent with a successive order of pain processing such that the pain sensation directly impacts pain unpleasantness, which, in turn, leads to suffering and illness behaviors. However, contrary to a model with strictly successive stages, pain sensation had independent effects on illness behaviors over and above pain affect. The effect of anxiety on illness behavior was mediated by suffering, while psychopathology directly influenced pain sensation and pain unpleasantness but not later stages. Age was related to pain sensation and illness behaviors but not pain affect. Gender tended to be more strongly associated with more distal pain stages (e.g., pain affect) vis-a-vis its effects on pain sensation. These data are generally supportive of a four-stage pain processing model.

Pain management in ruminants

Based on the available literature, the most important tool available in modern veterinary medicine is preemptive analgesia. Veterinarians must capture "opportunities" to prevent the onset of pain, prevent noxious stimuli or their perception, and limit the pain-stress-distress cascade that results in altered behavior and deviation from physiologic norms. Rational treatment of pain requires an appreciation of its consequences, a fundamental understanding of the mechanisms that are responsible for its production,and a practical appreciation of the analgesic drugs that are available. The goal of pain treatment should be to restore normal (physiologic) pain responses and to eliminate pathologic pain processes. In this context, pain therapy should be directed at the multiple mechanisms (multimodal therapy)responsible for its production, and analgesic therapies should be instituted before (preemptive therapy) pain is initiated (eg, surgery) whenever possible.

Consequences of Inadequate Postoperative Pain Relief and Chronic Persistent Postoperative Pain

Inadequately controlled pain has undesirable physiologic and psychologic consequences such as increased postoperative morbidity, delayed recovery, a delayed return to normal daily living, and reduced patient satisfaction. Importantly, the lack of adequate postoperative pain treatment may lead to persistent pain after surgery, which is often overlooked. Overall, inadequate pain management increases the use of health care resources and health care costs. This article reviews the physiologic and psychologic consequences of inadequately treated pain, with an emphasis on chronic persistent postoperative pain.

Normalization of serum cortisol concentration with opioid treatment of severe chronic pain

Serum cortisol concentrations may be altered in severe, chronic pain due to excess stimulation of the hypothalamic-pituitary-adrenal axis. Among 40 consecutive patients with severe, chronic pain 26 (65.0%) demonstrated abnormal serum cortisol concentration. After 90 days of treatment, only 7 (17.5%; p<0.01) continued to show abnormal serum cortisol concentration indicating that serum cortisol and other serologic abnormalities may serve as biologic markers of severe, chronic pain.

Variation in reporting of pain and other subjective health complaints in a working population and limitations of single sample measurements

Measuring health complaints by administrating a single report is common. Our aim was to assess variation in pain and other subjective complaints over an extended period, whether a single-sample produces representative data, and determine associations between complaints. Health-complaint reports were collected from postal workers at monthly intervals over a period of 32-34 consecutive months (1997-2000). We computed six compound complaint-severity indices of 30 complaint-severity scores (intensity score x duration score, scale 0-9). In 67% of the scores, the complaints exhibited larger deviation from a reference (12 consecutive reports in the last 24 months of the study period) when using one report from the respective reference period compared with the mean of two consecutive reports. Four consecutive samples were needed to obtain agreement for 95% of the data when the criterion of accepted deviation from the reference was set to +/-1.0. Neither inspection of graphs nor statistical tests revealed any seasonal pattern or trend on either a group or individual level. The musculoskeletal and psychological complaint-severity indices correlated strongly (rs > 0.66). Correlations between the different somatic indices were generally weak or moderate (rs < 0.55). The initial report produced higher complaint ratings than subsequent reports did. Due to large intra-individual complaint variability and higher complaint-severity level exhibited on the initial report compared to those that followed, measuring subjective health with a single-sample approach does not produce data representativeness for average complaints over a period. More than two samples should be collected when the purpose is to reveal changes in health.

Personal and professional pain experiences and pain management knowledge among Greek nurses

The purpose of this exploratory study was to describe Greek registered nurses' personal and professional pain experiences and to examine the relationship with their pain management knowledge. Forty-six Greek nurses provided written responses to open-ended questions about their personal and professional experiences with pain and beliefs about suffering. Reporting a personal pain experience was associated with describing a positive professional pain experience, Phi=0.44, p < 0.03. The nurses vividly described their personal and professional pain experiences. One nurse wrote " em leader I begged to lose consciousness, in order not to feel". These compelling accounts might motivate nurses to strengthen their understanding of pain management.

A qualitative study of head and neck cancer

The findings presented contribute to quality of life (QOL) research by highlighting the significance of factors affecting the communication by patients with primary-stage squamous cell carcinoma of the head and neck cancer (SCCHN) of their experiences of suffering after treatment to their clinicians. Qualitative research methodology based on open-ended interviews with 18 survivors of American Joint Committee on Cancer primary stage I and II SCCHN were used. The interviews were transcribed verbatim and thematically analyzed. Three important themes emerged: (1). a diminished self (2). fears of addiction, and (3). hopelessness and the loss of meaning in life after SCCHN. The findings indicate that SCCHN patients under-report their experiences mainly due to fear. As a consequence, and perhaps due to a failure on the part of clinicians and patients to adequately address such fears, SCCHN patients may experience greater psychological morbidity, becoming increasingly fatalistic about biomedicine's ability to restore them to health after cancer despite being "cured", or to relieve related symptoms. This qualitative study provides a perspective as to why such under-reporting occurs, thereby potentially enhancing clinician-patient communication and the QOL of SCCHN patients who present with curable disease.

Pathophysiology of pain

Pain is a major symptom of many different diseases. Modern pain research has uncovered important neuronal mechanisms that are underlying clinically relevant pain states, and research goes on to define different types of pains on the basis of their neuronal and molecular mechanisms. This review will briefly outline neuronal mechanisms of pathophysiological nociceptive pain resulting from inflammation and injury, and neuropathic pain resulting from nerve damage. Pain is the sensation that is specifically evoked by potential or actual noxious (i.e. tissue damaging) stimuli or by tissue injury. Pain research has not only explored the neuronal and molecular basis of the "pain system" of the healthy subject but has also provided insights into the function and plasticity of the "pain system" during clinically relevant pains such as post-injury pain, inflammatory pain, postoperative pain, cancer pain and neuropathic pain. This review will briefly describe the "pain system" and then address neuronal mechanisms that are involved in clinical pain states.

Existential pain--an entity, a provocation, or a challenge?

"Existential pain" is a widely used but ill-defined concept. Therefore the aim of this study was to let hospital chaplains (n=173), physicians in palliative care (n=115), and pain specialists (n=113) respond to the question: "How would you define the concept existential pain?" A combined qualitative and quantitative content analysis of the answers was conducted. In many cases, existential pain was described as suffering with no clear connection to physical pain. Chaplains stressed significantly more often the guilt issues, as well as various religious questions (P<0.001). Palliative physicians (actually seeing dying persons) stressed more often existential pain as being related to annihilation and impending separation (P<0.01), while pain specialists (seeing chronic patients) more often emphasized that "living is painful" (P<0.01). Thirty-two percent (32%) of the physicians stated that existential suffering can be expressed as physical pain and provided many case histories. Thus, "existential pain" is mostly used as a metaphor for suffering, but also is seen as a clinically important factor that may reinforce existing physical pain or even be the primary cause of pain, in good agreement with the current definition of pain disorder or somatization disorder.

Communicating suffering in primary stage head and neck cancer*

The findings presented in this discussion seek to make a contribution to quality of life (QOL) research, by highlighting the import of factors affecting the communication of primary stage head and neck cancer patient's experiences of suffering after treatments by their clinicians. Qualitative research methodology based on open-ended interviews with 18 survivors of American Joint Committee on Cancer (AJCC) Stage I and Stage II, squamous cell carcinoma of the head and neck (SCCHN) were used. The interviews were transcribed verbatim and thematically analysed. In this preliminary analysis, three important themes emerged: (1) a self diminished by cancer; (2) the fear of addiction to pain medications; and (3) hopelessness and the loss of meaning in life after SCCHN. Our present findings indicate that SCCHN patients understand their experiences of cancer and under-report their experiences of suffering mainly because of fear. These include fears of: being further diminished by SCCHN, fears of addiction, and an inability to cope with the additional losses associated with SCCHN. As a consequence, and perhaps, because of a failure the part of clinicians and patients to adequately address these fears, SCCHN patients may also experience greater psychological morbidity, becoming fatalistic about biomedicine's ability to restore them to health after cancer, or related symptoms, including pain, despite being 'cured.' This study provides a perspective on why this under-reporting occurs, thereby potentially enhancing clinician-patient communication and the QOL of SCCHN patients who present with curable disease.

Blood pressure but not cortisol mediates stress effects on subsequent pain perception in healthy men and women

Research has demonstrated that exposure to acute stress may attenuate pain perception. Mechanisms of this effect in humans have not been determined. This study was conducted to determine the extent to which psychophysiological and adrenocortical responses to acute stress predict subsequent pain perception. One hundred and fifty-two healthy participants (80 women) were assigned to one of two conditions: rest followed by the cold pressor test (CPT; N=76) or stress followed by CPT (N=76). The stress protocol consisted of a public-speaking challenge. Participants rated their pain every 15 s during a 90-s hand CPT (0-4 degrees C), and they completed the short form of the McGill Pain Questionnaire. Salivary cortisol, mood, blood pressure (BP), and impedance cardiography measures were collected in both conditions. Women had lower BP and reported greater pain than men in both conditions (ps<0.01). Participants in the stress condition reported less pain during CPT than those in the rest condition (p=0.02). Regression analyses demonstrated that the stress effect on pain ratings was mediated by systolic BP level during stress; however, cortisol responses did not affect this relationship. Mood changes were independent predictors of pain. The study demonstrates that BP changes in response to stress mediate the stress-induced attenuation of pain perception.

Service users' and occupational therapists' beliefs about effective treatments for chronic pain: a meeting of the minds or the great divide?

PURPOSE

Research supports that beliefs about chronic pain and its treatment are individually constructed. It also suggests that lack of agreement between people with pain and treatment providers may contribute to negative treatment outcomes. The aim of this study is to identify patterns of congruence that exist between service users and occupational therapists in relation to beliefs about which treatments for chronic pain are important.

METHOD

These findings are extracted from a wider research study exploring congruence between service providers from a range of professional groups and service users regarding their endorsement of treatments for chronic pain. The survey findings reported here asked occupational therapists and service users their opinion about whether specific treatment components are important for people with chronic pain. The survey also included Skevington's Beliefs About Pain Control Questionnaire (BPCQ) which measured beliefs in the internal or personal control of pain, beliefs that powerful others (doctors) control pain and beliefs that pain is controlled by chance events.

RESULTS

There were few treatment components that 100% of the respondents agreed were important. Occupational therapists' and service users' responses demonstrated statistically significant differences in endorsement of treatments, BPCQ scores and the relationship between BPCQ scores and treatment endorsements.

CONCLUSIONS

Occupational Therapists and service users are distinctly heterogeneous groups in regards to what treatments they believe are important for chronic pain. It is possible that the therapeutic relationship and the outcome of available treatments are negatively affected as a consequence of disagreement about what treatments are important.

Intimacy and family relationships of women with chronic pain

This study explored family relationships and intimacy of women experiencing chronic pain from the perspective of the women and their family members. A narrative ethnographic qualitative research design was used. Narrative and field data were analyzed using the coding procedure outlined by Strauss aided by the QSR NUD*IST 4 qualitative computer software program. Twenty-five women self-identified as experiencing chronic pain, and 13 family members including 7 husbands, 1 father, 1 stepmother, and 4 children living in the home were interviewed. Three patterns of behavior emerged regarding family relationships: cycle of close involvement compensated with isolation, focus directed toward others, and loss of physical sexual intimacy. Findings of this study indicate that family members' perception is that chronic pain affects important basic relationships and both emotional and physical intimacy. A need exists to relieve some of the suffering that accompanies pain in these women and their families. Based on the study's findings, several treatment strategies are recommended.

Role loss and emotional adjustment in chronic pain

Chronic pain interrupts behaviour, interferes with functioning, and may affect a person's identity: their sense of self. We tested whether loss of role and personal attributes and current and past self-concept differentiation, predicted adjustment as indexed by measures of depression. Chronic pain patients (n=80) completed measures of pain (MPQ), disability (PDI), depression and anxiety (BDI, HADS). Measures of role and attribute loss and self-concept differentiation were derived from a Role-Attribute Test in which participants identified four social roles in four domains (friendship, occupation, leisure, family) and nominated two personal attributes in each role prior to pain onset and current. Participants reported mean losses of 3.38 roles, and 6.97 attributes. Greater losses were observed in friendship, occupation and leisure domains compared with the family domain. Multiple regression analyses revealed that after controlling for demographic and clinical differences, role and attribute loss predicted depression scores. There was no evidence that depression was associated with past self-concept differentiation. The results are discussed with reference to the methodology used and the relevance of self-identity to understand adjustment to chronic pain.

Cognitive impairment in patients with chronic pain: the significance of stress

This review article examines the role of emotional distress and other aspects of suffering in the cognitive impairment that often is apparent in patients with chronic pain. Research suggests that pain-related negative emotions and stress potentially impact cognitive functioning independent of the effects of pain intensity. The anterior cingulate cortex is likely an integral component of the neural system that mediates the impact of pain-related distress on cognitive functions, such as the allocation of attentional resources. A maladaptive physiologic stress response is another plausible cause of cognitive impairment in patients with chronic pain, but a direct role for dysregulation of the hypothalamic-pituitary-adrenocortical axis has not been systematically investigated.

The amelioration of the suffering associated with spinal cord injury with subperception transcranial electrical stimulation

STUDY DESIGN

Double blind, partial crossover.

OBJECTIVES

To evaluate the analgesic activity of a novel cranial electrostimulus in people with spinal cord injury (SCI).

SETTING

Hereward College, a residential centre that provides educational facilities for students with disabilities.

METHODS

Subjects with SCI experiencing chronic pain were randomly assigned into two groups, one of which received sham and the other transcranial electrostimulation treatment (TCET) on two occasions daily for four successive days. After a 'wash-out' period of 8 weeks all subjects returned and received the identical stimulus that the treated cohort received on the first arm of the study.

RESULTS

Pain measurements applied before and after each session indicated that the pain decreased in the treated group to 51% of that reported at the commencement of treatment; reported pain intensity did not decrease significantly in the sham treated subjects. The same (sham) subject group reported experiencing 59% of the pain at the end of the second arm of the study (TCET) as on the first arm (sham). No significant differences were determined between the mood of all subjects estimated before and after each sham or TCET treatment session. The reported analgesic, and combined antidepressant and anxiolytic drug use in subjects receiving TCET on the second arm of the study, was 46% and 53% respectively of the average pre-study drug use. No similar decrease in the use of the drugs was noted in the same subjects after sham treatment on the first arm of the study. Salivary cortisol determinations made prior to and after each sham and treatment session implicated this corticoid in the pain-relieving mode of action of the treatment, but could not be associated with any changes in mood. Subjects receiving TCET had significantly higher urinary 3-methoxy-4-hydroxy-phenylglycol (MHPG) output after the TCET treatment period than sham stimulation, implicating increased central noradrenaline (NA) metabolism in the observed effects.

CONCLUSION

The subjects reported less pain during, and immediately after receiving this transcranial treatment, although they were using less medication than when receiving sham treatment.

Effect of cancer pain on performance status, mood states, and level of hope among Taiwanese cancer patients

The purposes of this study were: 1) to compare performance status, mood states, and level of hope between patients with cancer pain and patients without cancer pain; and 2) to determine the relationships of pain intensity and pain interference with daily life to performance status, mood states, and level of hope. A total of 233 Taiwanese cancer patients with pain and 251 without pain participated. The self report instruments consisted of the Chinese version of the Profile of Mood States (POMS) short form, the Chinese version of the Herth Hope Index, the Brief Pain Inventory-Chinese version (BPI-C), the Chinese version of the Karnorfsy Performance Scale (KPS), and a demographic questionnaire. The major findings of this study were that cancer patients with pain reported significantly lower levels of performance status and higher levels of total mood disturbance than did cancer patients who did not experience pain after controlling for sex, disease stage, and recruitment site. In addition, patients with cancer pain experienced significantly more anger, fatigue, depression, confusion, and lethargy than did patients without pain after controlling for sex, disease stage, and recruitment site. Among patients with pain, pain intensity was significantly correlated with performance status and mood state, but not with level of hope. Pain interference with daily life was significantly correlated both with performance status, mood state, and level of hope. Pain intensity and pain interference were significantly correlated with each mood state as well as with total mood disturbance. This study has demonstrated the effect of cancer pain on patients' physical, psychological, and spiritual life and has supported the multidimensional notion of the cancer pain experience in Taiwanese patients.

Tailored cognitive-behavioral therapy in early rheumatoid arthritis for patients at risk: a randomized controlled trial

Recent developments in chronic pain research suggest that effectiveness of cognitive-behavioral therapy (CBT) may be optimized when applying early, customized treatments to patients at risk. For this purpose, a randomized, controlled trial with tailor-made treatment modules was conducted among patients with relatively early rheumatoid arthritis (RA disease duration of <8 years), who had been screened for psychosocial risk profiles. All participants received standard medical care from a rheumatologist and rheumatology nurse consultant. Patients in the CBT condition additionally received an individual CBT treatment with two out of four possible treatment modules. Choice of treatment modules was determined on the basis of patient priorities, which resulted in most frequent application of the fatigue module, followed by the negative mood, social relationships and pain and functional disability modules. Analyses of completers and of intention-to-treat revealed beneficial effects of CBT on physical, psychological and social functioning. Specifically, fatigue and depression were significantly reduced at post-treatment and at the 6-month follow-up in the CBT condition in comparison to the control condition, while perceived support increased at follow-up assessment. In addition, helplessness decreased at post-treatment and follow-up assessment, active coping with stress increased at post-treatment, and compliance with medication increased at follow-up assessment in the CBT condition in comparison to the control condition. Results indicate the effectiveness of tailor-made CBT for patients at risk in relatively early RA, and supply preliminary support for the idea that customizing treatments to patient characteristics may be a way to optimize CBT effectiveness in RA patients.

Understanding pain in herpes zoster: an essential for optimizing treatment

After herpes zoster, immunocompetent persons frequently experience chronic pain and considerable suffering. Zoster-associated pain has a complex pathophysiology that begins with viral damage and increased sensitization of peripheral sensory neurons. The enhanced afferent barrage from these neurons sensitizes spinal neurons and leads to loss of synapses from descending inhibitory fibers, resulting in central neuropathic pain and allodynia. Antiviral therapy of acute zoster limits this sequence of pathophysiologic mechanisms. There is no clear consensus regarding the optimal means of determining the benefits of antiviral therapy in the management of pain of herpes zoster. A novel statistical approach utilizing rates of disappearance of pain of differing pathophysiologic mechanisms is proposed.

Unexplained severe chronic pain in general practice

The aim of this study was to estimate the prevalence of unexplained severe chronic pain (USCP) in general practice and to report medical as well as psychological descriptions of patients suffering from this condition.A total of 45 GPs in 35 different practices included patients throughout the year 1996. Patients were included according to the following criteria: between 18 and 75 years of age; pain which had lasted at least 6 months; pain is the most prominent aspect in the clinical presentation; pain is serious enough to justify clinical attention; pain has led to obvious discomfort and disability in daily life for at least for 1 month. Medical aspects were measured with the IASP taxonomy while psychological aspects were derived from the MPI. The overall prevalence of USCP was 7.91 per 1000 enlisted patients. Estimates ranged between 1.87 in the youngest age group and 13.50 in the 55-59 age category. The lower back and lower limbs were most frequently affected and 31% of the patients had pain in more than three major body sites. Pain was most frequently associated by the musculoskeletal system and most often (nearly) continuous. Mean severity of current pain was 3.7 on a scale from 0 (indicating no pain) to 6 (indicating a lot of pain). Mean rating of 'average pain in the last week' was 4.1. Regarding the psychosocial and behavioural aspects of pain, 27% of the patients could be described as perceiving severe pain while gaining social support for it. Fourteen per cent felt in the category 'pain combined with affective and relational distress' and 10% was classified as 'coping well with pain intensities lower than those of the other groups'. The other half of the patients were on average or not classifiable on these aspects. Unexplained severe chronic pain lasting more than 6 months had on overall prevalence of 7.91 per 1000 enlisted patients, ranging from 1.87 in the youngest to 13.50 in the oldest patients in these 35 general practices in The Netherlands. Our prevalence estimate of USCP is low compared to other studies on chronic pain. Probably for three reasons: Firstly, our study was confined to unexplained pain and not all chronic pain. Secondly, our inclusion criteria focused the attention of very severe chronic pain patients, and thirdly, we have defined 'chronic' as more than 6 months, while others have been using shorter time spans.

The rational management of fibromyalgia patients

The exponential increase in pain research over the last 10 years has established fibromyalgia (FM) as a common chronic pain syndrome with similar neurophysiologic aberrations to other chronic pain states. As such, the pathogenesis is considered to involve an interaction of augmented sensory processing (central sensitization) and peripheral pain generators. The notion, that FM symptomatology results from an amplification of incoming sensory impulses, has revolutionized the contemporary understanding of this enigmatic problem and provided a more rational approach to treatment. To date, the management of FM has been mainly palliative, with the aims of reducing pain, improving sleep, maintaining function, treating psychologic distress and diminishing the impact of associated syndromes. The rapidly evolving neurophysiologic, psychophysiologic and molecular biologic basis for chronic pain states has already opened up new avenues for management which should be applicable to this difficult group of patients. Indeed, it is now possible to think about a "rational" approach to managing FM patients that was unthinkable just a few years ago.

The relationship of pain and depression to cognitive function in rheumatoid arthritis patients

The purpose of this study was to assess the hypothesis that pain and depression negatively impact the cognitive functioning of individuals with rheumatoid arthritis (RA). One hundred twenty-one community-dwelling RA patients (ages 34-84) completed a battery of cognitive tasks and multiple measures of pain and depression. Structural equation modeling techniques were used to assess the relative contributions of pain, depression, and age to cognitive performance. Individuals who performed poorly on cognitive tasks reported more pain and depression and were older than those individuals who performed well on cognitive tasks. Moreover, high levels of pain were associated with depression. Further analyses revealed that depression mediated the relationship between pain and cognition. That is, when depression was entered into the analyses, the previously significant effects of pain on cognition were no longer found. Interestingly, depression still mediated the pain-cognition relationship even after controlling for age. These findings suggest the importance of both pain and depression for understanding cognitive function in RA and may have important implications for treating this disease.

The development of national guidelines for pain control: synopsis and commentary

This synopsis outlines factors that prompted development of national clinical practice guidelines for the management of pain and presents the essential content of major pain control guidelines. Also described is the concurrent growth of the evidence-based pain management movement worldwide in the decade since initial US federal guidelines on acute and cancer pain were developed, and products of this global movement. The latter include systematic reviews and meta-analyses about treatments for pain, their assemblage in resources such as the Cochrane Collaboration, and (in the US) the embedding of pain assessment and management within quality assurance requirements for hospital accreditation. This survey will highlight recent research that evidence-based guidelines alone are insufficient to overcome established attitudes, practices and myths that hinder pain assessment and management. Hypotheses for the inadequacy of scientific evidence per se to overcome clinicians' attitudes and practices will be advanced, along with suggestions as to how those in the 'pain treatment community' may help to tip the balance.

Pain relief and wound care in a young woman with special needs

This article focuses on a teenage girl with cerebral palsy admitted for an orthopaedic procedure, and highlights the problems of pain and wound management discussed in this journal's Challenges in Wound Care study days.

Toward a praxis theory of suffering

This article revises and summarizes the major findings from a research program exploring the behavioral-experiential nature of suffering. Suffering is perceived as comprising two major behavioral states: enduring (in which emotions are suppressed; it is manifested as an emotionless state) and emotional suffering (an overt state of distress in which emotions are released). Individuals who are suffering move back and forth between these two states according to their own needs, their recognition/acknowledgment/acceptance of events, the context, and the needs and responses of others. Implications for the provision of comfort during suffering states are presented.

Cognitive-processing bias in chronic pain: a review and integration

Do patients with chronic pain selectively process pain- and illness-related stimuli? The evidence with regard to attention, interpretation, and recall biases is critically reviewed. A model is proposed to account for the findings in which it is suggested that biases in information processing in chronic pain are the result of overlap between 3 schemas: pain, illness, and self. With frequent repeated or continued experience of pain, the pain schema becomes enmeshed with illness and self-schemas. The extent of the enmeshment and the salient content of the schema determine the bias. A fundamental assumption is that all patients with pain selectively process sensory-intensity information. A clinical implication of the results is that processing biases that extend beyond this healthy and adaptive process to enmesh the self-schema with pain and illness schemas could maintain and exacerbate distress and illness behavior in patients with chronic pain.

Psychosocial and health status variables independently predict health care seeking in fibromyalgia

OBJECTIVE

To determine whether variables derived from the self-regulatory model of health and illness behavior accurately predict status as a patient or nonpatient with fibromyalgia (FM).

METHODS

Subjects were 79 patients who met American College of Rheumatology (ACR) criteria for FM and 39 community residents who met ACR criteria for FM but had not sought medical care for their symptoms (nonpatients). Subjects were administered 14 measures that produced 6 domains of variables: background demographics and pain duration; psychiatric morbidity; and personality, environmental, cognitive, and health status factors. These domains were entered in 4 different hierarchical logistic regression analyses to predict status as patient or nonpatient.

RESULTS

The full regression model was statistically significant (P < 0.0001) and correctly identified 90.7% of the subjects with a sensitivity of 92.4% and a specificity of 87.2%. The best individual predictors of group status were self-reports of self-efficacy, negative affect, recent stressful events, and perceived pain. Relative to nonpatients, patients reported higher levels of negative affect and perceived pain and a greater number of recent stressful experiences, as well as lower levels of self-efficacy.

CONCLUSION

Consistent with the self-regulatory model of health and illness behavior, psychosocial and health status variables predict health care-seeking behavior in persons with FM independently of background demographics and psychiatric morbidity. These variables may influence the severity of symptoms experienced by persons with this disorder as well as their health care-seeking behavior, but they are not necessary to produce abnormal pain sensitivity in FM.

Psychological determinants of fibromyalgia and related syndromes

Fibromyalgia and other chronic pain and fatigue syndromes constitute an increasingly greater societal burden that currently is not being approached effectively by traditional Western medicine. Although the hallmarks of fibromyalgia--chronic widespread pain, fatigue, and multiple other somatic symptoms--have neurophysiologic and endocrinologic underpinnings, these biological aspects derive primarily from psychological variables. Female gender, adverse experiences during childhood, psychological vulnerability to stress, and a stressful, often frightening environment and culture are important antecedents of fibromyalgia. To understand fibromyalgia and related syndromes and to provide optimum care requires a biopsychosocial, not a biomedical, viewpoint.

A passion of the soul: an introduction to pain for consciousness researchers

Pain is an important focus for consciousness research because it is an avenue for exploring somatic awareness, emotion, and the genesis of subjectivity. In principle, pain is awareness of tissue trauma, but pain can occur in the absence of identifiable injury, and sometimes substantive tissue injury produces no pain. The purpose of this paper is to help bridge pain research and consciousness studies. It reviews the basic sensory neurophysiology associated with tissue injury, including transduction, transmission, modulation, and central representation. In addition, it highlights the central mechanisms for the emotional aspects of pain, demonstrating the physiological link between tissue trauma and mechanisms of emotional arousal. Finally, we discuss several current issues in the field of pain research that bear on central issues in consciousness studies, such as sickness and sense of self.

Assessment of patients' reporting of pain: an integrated perspective

A common assumption about pain is that it always results from the presence of underlying organic pathology. In the absence of objective pathology, an individual's report of pain may be ascribed to psychological causes. There is a wide variation in patient's experience of pain and organic factors alone cannot explain individual differences in patients' reports. Assessment of patients who report pain requires attention to psychosocial, behavioural, and organic factors. We describe a comprehensive approach to the assessment of psychological and behavioural variables that affect patients' reports of pain. We counter the duality of the somatogenic versus psychogenic perspective and suggest a more integrated assessment that encompasses not only the severity of pain and related physical pathology but also the person who is reporting the presence of pain.