Multilevel analysis of couple congruence on pain, interference, and disability

Incongruence in Perceptions of Pain: Associations with Mental Health in Couples Living with Fibromyalgia

Guided by the theory of dyadic illness management, this study examined the association between the within-couple incongruence regarding perceptions of pain experienced by adults with fibromyalgia (AwFM) and symptoms of depression and anxiety in AwFM and their partners. Participants included 204 couples. Three second-order dyadic variables were created from the couples' perceptions of pain interference experienced by AwFM: (1) absolute magnitude of incongruence in perception of pain, (2) average perception of pain, and (3) direction of incongruence (i.e., who perceives pain to be higher). Structural equational modeling was used to examine the association between the three dyadic variables and AwFM and partner symptoms of depression and anxiety, adjusting for covariates. These steps were repeated for pain severity. Higher average perception of pain interference within the couple was associated with greater symptoms of depression and anxiety in AwFM and partners. AwFM exhibited greater symptoms of depression when their perception of their pain interference was higher than their partner's. Incongruence variables were not significantly associated with AwFM or partners' anxiety symptoms. Near identical results were found for pain severity. A dyadic approach to mental health treatment, which includes enhanced communication skills, should be adopted to optimize the mental health of couples living with fibromyalgia.

Barriers to Pain Management: Incongruence in Black Cancer Caregiving Dyads

CONTEXT

To effectively manage cancer pain, there is a need to understand how caregiving dyads appraise symptoms. Dyadic appraisal of symptoms influences whether the dyad perceives the patient's pain is managed well and whether they are on the same page with their appraisal. Beliefs can act as barriers to the dyadic appraisal.

OBJECTIVES

This secondary data analysis examined incongruence within Black cancer caregiving dyads regarding beliefs about pain management and potential medication side effects using the Barriers Questionnaire-13. Associated factors were also examined.

METHODS

Guided by the Theory of Dyadic Illness Management, dyadic multilevel modeling was conducted with data from 60 Black cancer caregiving dyads to determine the dyadic appraisal of beliefs about pain management and potential medication side effects, which includes the average perception of barriers within the dyad (i.e., dyadic average) and the dyadic incongruence (i.e., gap between patient and caregiver).

RESULTS

On average, Black cancer caregiving dyads reported moderate barriers regarding pain management (2.262 (SE=0.102, P<0.001) and medication side effects (2.223 (SE=0.144, P<0.001). There was significant variability across dyads regarding barriers to pain management and medication side effects. Lower patient education and higher patient-reported pain interference were significantly associated with more perceived barriers to pain management and potential medication side effects. Incongruence within dyads regarding barriers to pain management and medication side effects were significantly associated with the caregiver's report of patient's pain interference.

CONCLUSION

Findings suggest the importance of appraisal that includes both members of Black cancer caregiving dyads regarding pain management.

Study protocol for the Exercising Together© trial: a randomized, controlled trial of partnered exercise for couples coping with cancer

BACKGROUND

Most cancer survivors are married, and cancer strains the physical and mental health of each partner and their intimate relationship. We created a partnered strength training program, Exercising Together©, where the survivor and his/her partner exercise as a team in order to improve physical and mental health of both members of the couple as well as the quality of their relationship. We have not yet determined if Exercising Together© is similarly effective in couples coping with different types of cancer nor if training as a team has unique and added benefits over those derived from supervised group training and/or shared behavior change. The purpose of this study is to determine the unique benefits of Exercising Together© on physical, mental, and relational health in couples coping with breast, prostate, or colorectal cancer.

METHODS

Survivors of prostate, breast and colorectal cancer (N = 294, 98 per cancer site) and their intimate, co-residing partners are recruited to participate in a single-blind, parallel group, randomized trial comparing three exercise groups that train twice per week for 6 months. Couples are randomized to one of three groups: (1) Exercising Together© where partners train as a team in a supervised group setting; (2) separate supervised group exercise classes for survivors or partners, respectively; (3) unsupervised home exercise program provided to each partner. The primary outcome is relationship quality (dyadic coping by the Dyadic Coping scale, emotional intimacy by the Dyadic Adjustment Scale, physical intimacy by the Physical Intimacy Behavior Scale, and symptom incongruence). Secondary outcomes are physical health (% body fat by DXA, serum fasting lipids (triglycerides, HDL, and LDL cholesterol), insulin resistance (HOMA-IR), resting blood pressure, C-reactive protein, TNF alpha, and physical functioning by the short Physical Performance Battery and SF-36) and mental health (depressive symptoms, anxiety, fear of recurrence) of each partner. Outcomes are collected at baseline, mid (3 months), post-intervention (6 months), and follow-up (12 months).

DISCUSSION

Exercising Together© could shift the paradigm of survivorship care toward novel couple-based approaches that could optimize outcomes for each partner because their health is interdependent on each other and their relationship.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03630354 . Registered August 14, 2018.

Pain interference may be an important link between pain severity, impairment, and self-reported disability in participants with wrist/hand pain

STUDY DESIGN

Cross-sectional.

INTRODUCTION

Pain severity, sensory and motor impairment, and psychological (distress and anxiety) and social factors have previously been related to self-reported disability in persons with wrist and hand pain.

PURPOSE OF THE STUDY

The purpose of this study to determine the relative contribution of pain severity, measures of impairment (sensory and motor function), psychosocial factors, and pain interference on self-reported disability experienced by persons with heterogeneous orthopedic injuries and conditions of the wrist and hand.

METHODS

Measures of disability and pain severity as well as measures of sensory (pressure pain thresholds, joint position sense), motor (grip strength, Purdue pegboard), and cognitive performance (Stroop test) and psychosocial variables related to pain and participation (West Haven-Yale Multidimensional Pain Inventory) were administered to 60 participants with wrist and hand pain. Pearson product correlations controlled for age and sex, and multiple linear regression was performed to determine the relationship between measures of impairment, pain severity, psychosocial variables, and pain interference with self-reported disability assessed with the Disability of Arm, Shoulder and Hand (DASH) questionnaire.

RESULTS

The best-fitting regression model with DASH scores entered as the dependent variable (F_4,50 = 28.8, P < .01) included MPI Pain Interference (β = -0.54), Life Control (β = -0.16), Purdue pegboard scores (β = -0.32), and Stroop test times (β = 0.21). Pain Interference had the strongest correlation with self-reported disability (adjusted R² = 0.67, P < .01).

CONCLUSION

Pain interference appears to be an important factor explaining the link between impairment, pain severity, and self-reported disability. Addressing pain interference may be important to improve outcomes in this population.

Why do Patients Engage in Pain Behaviors? A Qualitative Study Examining the Perspective of Patients and Partners

OBJECTIVES

Patients' pain behavior plays an important role in the interaction between patients and their partners, as acknowledged in operant models of pain. However, despite the considerable research attention to pain behaviors, the underlying motives of such behaviors are still unclear. The current study explores the motives to engage in pain behaviors and the possible discrepancies between individuals experiencing pain and partners' perceptions of those motives.

METHODS

A qualitative study was performed, comprising semistructured interviews with 27 patients with chronic low back pain and their partners. They were recruited through purposive sampling at 2 pain clinics located in Tehran, Iran.

RESULTS

Patients and partners mentioned a variety of motives for pain behaviors, including protecting oneself against more pain, regulating negative emotions, informing others about the pain severity, seeking validation or intimacy, gaining advantages from pain, and expressing anger. Patients and partners revealed the most similarities in motives such as protecting oneself against more pain and informing others about the pain severity. However, partners rarely acknowledged patients' motives for seeking validation and they were more likely to mention negative motives (eg, expressing anger).

DISCUSSION

In conclusion, partners are more likely to attribute negative motives to the patient's pain behaviors, which may lead to their hostility toward patients. The findings of this study provide new insights into motives of pain behaviors from the perspective of patients and partners, which can inform couple-based interventions in terms of effective pain communication.

Depression, anxiety, fear of progression, and emotional arousal in couples after left ventricular assist device implantation

AIMS

Left ventricular assist device (LVAD) is a common treatment option for patients with heart failure waiting for a donor heart. Living with an LVAD is associated with many burdens and worries. Patients often depend on the support of their relatives, usually their spouses. This can also put a strain on the spouses and be associated with psychological stress for both. In couples, communication proves to be an important form of emotional support. Besides verbal aspects of communication, the extent of emotional arousal (f₀ ) that is vocally encoded plays an essential role as a non-verbal aspect of communication. This study aims to investigate the psychological impact of LVAD on couples in investigating to what extent depression, anxiety, and fear of progression (FoP) differ between patients and partners, the intrapersonal and interpersonal associations of anxiety, depression, and FoP, and differences in emotional arousal.

METHODS AND RESULTS

In this cross-sectional study, male LVAD patients and their female partners (N = 21 couples) responded to self-report questionnaires on depression, anxiety, and FoP. Emotional arousal (f₀ ) was evaluated during social support interactions between both spouses. Female partners experienced more anxiety than male patients (P = 0.016). No differences occurred in depression (P = 0.967) and FoP (P = 0.084). Regarding intrapersonal associations, for patients, correlations appeared between anxiety and depression (r = 0.859, P = 0.000), anxiety and FoP (r = 0.730, P = 0.000), and depression and FoP (r = 0.608, P = 0.004). For caregivers, correlations appeared between anxiety and depression (r = 0.906, P = 0.000), anxiety and FoP (r = 0.665, P = 0.001), and depression and FoP (r = 0.734, P = 0.000). Regarding interpersonal associations, correlations were found between patient's anxiety and caregiver's anxiety (r = 0.461, P = 0.041), caregiver's depression (r = 0.510, P = 0.018), and caregiver's FoP (r = 0.524, P = 0.015). Non-significant correlations were found for caregiver's anxiety and patient's FoP (r = 0.404, P = 0.078) and patient's depression (r = 0.286, P = 0.236). Patient's depression was associated with caregiver's FoP (r = 0.526, P = 0.017), but not with caregiver's depression (r = 0.337, P = 0.146). No significant correlations were found between caregiver's depression and patient's FoP (r = 0.386, P = 0.084) and patient's depression (r = 0.337, P = 0.146). Patient's and caregiver's FoP showed significant associations (r = 0.482, P = 0.027). Patient's and partner's f₀ were interrelated. Patient's f₀ was positively related with his own and his partner's psychological distress. Partner's f₀ showed associations to her own depression and FoP.

CONCLUSIONS

Findings indicate that women of LVAD patients are burdened similarly or even to a greater extent than men themselves. Women's psychological distress has an impact on patients' psychological distress and vice versa. Early interventions for both patient and partner represent a necessary intervention target.

Relationship Context Moderates Couple Congruence in Ratings of Sexual Arousal and Pain During Vaginal Sensations in the Laboratory

Genital pain is a social experience that needs to be studied as a dyadic interaction between partners. The present study relied on a sample of 42 heterosexual couples to examine the level of congruence between both partners' ratings of pain and sexual arousal in response to experimentally induced vaginal pressure that served as a simulation of vaginal sensations during penetration. We also inferred the men's ability to estimate their partner's level of pain and sexual arousal. Because the relationship has shown to influence pain estimations, we considered the moderating role of perceived partner responsiveness and relationship satisfaction. We found higher disagreement in pain ratings when vaginal pressure was induced in the context of a sexual film compared to a neutral film, with men overestimating the level of pain in women. Also sexual arousal ratings diverged between partners, with men underestimating their partners' level of sexual arousal during the induction of vaginal pressure, regardless of whether they were watching a sexual or neutral film. Importantly, the level of congruence between actual and estimated ratings of pain and sexual arousal depended on how relationally satisfied men and women were and how validated and supported women felt by their male partner. These results make an important contribution to the growing literature on the social determinants of sexual pain experiences.

Empathic Accuracy in Chronic Pain: Exploring Patient and Informal Caregiver Differences and Their Personality Correlates

Background and objectives: Social factors have demonstrated to affect pain intensity and quality of life of pain patients, such as social support or the attitudes and responses of the main informal caregiver. Similarly, pain has negative consequences on the patient’s social environment. However, it is still rare to include social factors in pain research and treatment. This study compares patient and caregivers’ accuracy, as well as explores personality and health correlates of empathic accuracy in patients and caregivers. Materials and Methods: The study comprised 292 chronic pain patients from the Pain Clinic of the Vall d’Hebron Hospital in Spain (main age = 59.4 years; 66.8% females) and their main informal caregivers (main age = 53.5 years; 51.0% females; 68.5% couples). Results: Patients were relatively inaccurate at estimating the interference of pain on their counterparts (t = 2.16; p = 0.032), while informal caregivers estimated well the patient’s status (all differences p > 0.05). Empathic accuracy on patient and caregiver status did not differ across types of relationship (i.e., couple or other; all differences p > 0.05). Sex differences in estimation only occurred for disagreement in pain severity, with female caregivers showing higher overestimation (t = 2.18; p = 0.030). Patients’ health status and caregivers’ personality were significant correlates of empathic accuracy. Overall, estimation was poorer when patients presented higher physical functioning. Similarly, caregiver had more difficulties in estimating the patient’s pain interference as patient general and mental health increased (r = 0.16, p = 0.008, and r = 0.15, p = 0.009, respectively). Caregiver openness was linked to a more accurate estimation of a patient’s status (r = 0.20, p < 0.001), while caregiver agreeableness was related to a patient’s greater accuracy of their caregivers’ pain interference (r = 0.15, p = 0.009). Conclusions: Patients poorly estimate the impact of their illness compared to caregivers, regardless of their relationship. Some personality characteristics in the caregiver and health outcomes in the patient are associated with empathic inaccuracy, which should guide clinicians when selecting who requires more active training on empathy in pain settings.

Partners' Overestimation of Patients' Pain Severity: Relationships with Partners' Interpersonal Responses

Objectives

The present study examined whether concordance between patients' and their partners' reports of patient pain severity relates to partners' social support and behavioral responses in couples coping with chronic pain.

Methods

Fifty-two couples completed questionnaires about the patient's pain severity. Both dyad members also rated the partner's social support and negative, solicitous, and distracting responses toward the patient when in pain.

Results

Bivariate correlations showed moderate correspondence between patient and partner ratings of pain severity (r = 0.55) and negative (r = 0.46), solicitous (r = 0.47), and distracting responses (r = 0.53), but lower correspondence for social support (r = 0.28). Twenty-eight couples (54%) were concordant in their perceptions of patient pain; partners overestimated pain in 14 couples (27%), and partners underestimated pain in 10 couples (19%). Couple concordance in pain perceptions was not related to patients' reports; however, it significantly predicted partners' reports: Partners who overestimated pain reported giving more social support (β = 0.383, P = 0.016), fewer negative responses (β = -0.332, P = 0.029), and more solicitous responses (β = 0.438, P = 0.016) than partners who were in agreement or who underestimated pain.

Discussion

Partner overestimation of pain severity is associated with partner-reported but not with patient-reported support-related responses. This finding has important clinical implications for couple interventions in chronic pain.

Caregiver Reward and Burden: Differing Constructs in Family Members Providing Care for Medically Ill Homebound Older Adults

Objective: This study examined the relationship between caregiver burden and reward and how each relates to factors, such as depression, within the caregiving dyad. Method: A total of 101 older adults and their primary family caregivers were recruited upon enrolling in home health care services. Patients were assessed for sociodemographic information, depression, disability, pain, and caregiver support at baseline and at 8 weeks. Caregivers were assessed at baseline for sociodemographic information, depression, caregiver burden, caregiver reward, and caregiving tasks they provide. Results: Burden and reward were significantly inversely correlated, but differentially associated with distinct patient and caregiver variables. Patients whose caregivers reported higher baseline levels of caregiver reward were more likely to have lower depression scores at follow-up. Discussion: Given that different aspects of patients and caregivers influence reward and burden, assessing caregivers for both burden and reward may better target caregiver interventions at the individual and family levels, particularly for older adult depression.

Incongruent perceptions of the care values of hospitalized persons with dementia: a pilot study of patient-family caregiver dyads

OBJECTIVE

Many difficult decisions are made in the inpatient hospital setting regarding the daily care of persons with dementia (PWDs). Incongruent perceptions of the PWD's care values limit the family caregiver's ability to make surrogate decisions. The objectives of this pilot study were to describe and identify determinants of incongruent perceptions in the hospital setting.

METHODS

Using multilevel modeling (MLM), we examined cross-sectional data collected from 42 PWD-family caregiver dyads.

RESULTS

There was a significant amount of incongruence, on average, for all four subscales representing the PWD's care values: autonomy = -0.33 (p < .001); burden = -.49 (p < .001); safety/quality of care = -.26 (p < .001); and social interactions = -.21 (p = .004). Family caregivers (CG) rated the importance of care values to the PWD as lower than the PWD rated the importance. Determinants of greater incongruence included higher relationship strain and fewer positive dyadic interactions.

CONCLUSION

Our findings reveal significant levels of incongruence in perceptions of the PWD's values among dementia care dyads in the hospital setting. Our analysis suggests a potential impact of relationship variables on incongruence. Further research is needed around this overlooked interpersonal context for supporting the dementia care dyad in the hospital setting.

The Theory of Dyadic Illness Management

Despite the importance of both members of the adult patient-care partner dyad, a majority of research on illness management is focused on the patient or the care partner. The basic principle of the Theory of Dyadic Illness Management is that illness management is a dyadic phenomenon; the theory focuses extensively on the dyad as an interdependent team. The way dyads appraise illness as a unit influences the ways in which they engage in behaviors to manage illness together in a recursive fashion that influences dyadic health. Optimizing the health of both members of the dyad is a goal of the theory. In turn, the health of the dyad can feedback to influence how they appraise and manage illness together. Finally, dyadic illness management is an inherently variable process that is influenced by several contextual factors. Supportive evidence and implications for practice and future research are presented.

Longitudinal outcomes associated with significant other responses to chronic fatigue and pain

This study investigated significant others' behavior associated with fatigue, pain, and mental health outcomes among 68 individuals with chronic fatigue (43% also had fibromyalgia) over 18 months. More negative significant others' responses were associated with more pain, poorer physical and mental health, and more fatigue-related symptoms over time. More fibromyalgia tender points covaried with more solicitous significant others' responses over time. Better mental health covaried with more distracting significant others' responses over time. The results are discussed in terms of theoretical models of the role of perceived significant others' responses on patient outcomes and recommendations for future research.

Convergence in patient-therapist therapeutic alliance ratings and its relation to outcome in chronic depression treatment

OBJECTIVE

This study tested whether discrepancy between patients' and therapists' ratings of the therapeutic alliance, as well as convergence in their alliance ratings over time, predicted outcome in chronic depression treatment.

METHOD

Data derived from a controlled trial of partial or non-responders to open-label pharmacotherapy subsequently randomized to 12 weeks of algorithm-driven pharmacotherapy alone or pharmacotherapy plus psychotherapy. The current study focused on the psychotherapy conditions (N = 357). Dyadic multilevel modeling was used to assess alliance discrepancy and alliance convergence over time as predictors of two depression measures: one pharmacotherapist-rated (Quick Inventory of Depressive Symptoms-Clinician; QIDS-C), the other blind interviewer-rated (Hamilton Rating Scale for Depression; HAMD).

RESULTS

Patients' and therapists' alliance ratings became more similar, or convergent, over the course of psychotherapy. Higher alliance convergence was associated with greater reductions in QIDS-C depression across psychotherapy. Alliance convergence was not significantly associated with declines in HAMD depression; however, greater alliance convergence was related to lower HAMD scores at 3-month follow-up.

CONCLUSIONS

The results partially support the hypothesis that increasing patient-therapist consensus on alliance quality during psychotherapy may improve treatment and longer term outcomes.

Lovesick: How Couples' Relationships Influence Health

This review highlights recent advances in research addressing intimate partner relationships and health. Consideration of the strong mutual influences that the members of a couple have on each other's mental and physical health trajectories provides a new way to view the health implications of couples' convergence or interdependence; marital closeness can have a clear downside when one partner has mental or physical health problems. Couples' interconnectedness can also be leveraged to promote better treatment outcomes. Major themes include the pivotal role of depression and the importance of gender differences in the pathways from the marital relationship to physiological functioning and health. The health risks and benefits of support are weighed. Additionally, two prominent emerging paths from marital distress to poor health are emphasized: sleep problems and metabolic alterations that promote obesity and its comorbidities.

Lovesick: How Couples' Relationships Influence Health

This review highlights recent advances in research addressing intimate partner relationships and health. Consideration of the strong mutual influences that the members of a couple have on each other's mental and physical health trajectories provides a new way to view the health implications of couples' convergence or interdependence; marital closeness can have a clear downside when one partner has mental or physical health problems. Couples' interconnectedness can also be leveraged to promote better treatment outcomes. Major themes include the pivotal role of depression and the importance of gender differences in the pathways from the marital relationship to physiological functioning and health. The health risks and benefits of support are weighed. Additionally, two prominent emerging paths from marital distress to poor health are emphasized: sleep problems and metabolic alterations that promote obesity and its comorbidities.

Daily Spousal Responsiveness Predicts Longer-Term Trajectories of Patients' Physical Function

Everyday interpersonal experiences may underlie the well-established link between close relationships and physical health, but multiple-timescale designs necessary for strong conclusions about temporal sequence are rarely used. The current study of 145 patients with knee osteoarthritis and their spouses focused on a novel pattern in everyday interactions, daily spousal responsiveness-the degree to which spouses' responses are calibrated to changes in patients' everyday verbal expression of pain. Using couple-level slopes, multilevel latent-variable growth models tested associations between three types of daily spousal responsiveness (empathic, solicitous, and punishing responsiveness), as measured during a 3-week experience-sampling study, and change in patients' physical function across 18 months. As predicted, patients whose spouses were more empathically responsive to their pain expression showed better physical function over time compared with those whose spouses were less empathically responsive. This study points to daily responsiveness, a theoretically rooted operationalization of spousal sensitivity, as important for long-term changes in patients' objective physical function.

Pain Anxiety and Its Association With Pain Congruence Trajectories During the Cold Pressor Task

Incongruence of pain severity ratings among people experiencing pain and their observers has been linked to psychological distress. Previous studies have measured pain rating congruence through static self-report, involving a single rating of pain; however, this method does not capture changes in ratings over time. The present study examined the extent to which partners were congruent on multiple ratings of a participants' pain severity during the cold pressor task. Furthermore, 2 components of pain anxiety-pain catastrophizing and perceived threat-were examined as predictors of pain congruence. Undergraduate couples in a romantic relationship (N = 127 dyads) participated in this study. Both partners completed measures of pain catastrophizing and perceived threat before randomization to their cold pressor participant or observer roles. Participants and observers rated the participant's pain in writing several times over the course of the task. On average, observers rated participants' pain as less severe than participants' rated their own pain. In addition, congruence between partners increased over time because of observers' ratings becoming more similar to participant's ratings. Finally, pain catastrophizing and perceived threat independently and jointly influenced the degree to which partners similarly rated the participant's pain.

PERSPECTIVE

This article presents a novel application of the cold pressor task to show that pain rating congruence among romantic partners changes over time. These findings indicate that pain congruence is not static and is subject to pain anxiety in both partners.

The Roles of Dyadic Appraisal and Coping in Couples With Lung Cancer

Given the high symptom burden and low survivability of lung cancer, patients and their spouses have been found to experience poor mental health. The current study examined the roles of dyadic appraisal and dyadic coping on the mental health of 78 couples living with non-small cell lung cancer. Multilevel modeling revealed that spouses, on average, reported significantly worse mental health than patients. Dyadic appraisal and dyadic coping played important roles in predicting mental health, controlling for known developmental and contextual covariates. Dyadic appraisal of the patient's pain and fatigue was significantly associated with spouse mental health, albeit in opposite directions. Dyadic coping significantly predicted patient mental health. The study underlines the need to incorporate routine screening of both patient and spouse mental health, and highlights the complex role of appraisal within the couple in a life-threatening context. Viewing the couple as a unit, rather than separate individuals, raises important awareness about the role of disparate illness appraisals and coping strategies within the dyad on the health of both members. Nurses are particularly well situated to engage in a collaborative family-focused approach to the couple with cancer that promotes communication and health.

A Dyadic Approach to Managing Heart Failure With Confidence

BACKGROUND

The majority of heart failure (HF) self-care research remains focused on patients, despite the important involvement of family caregivers. Although self-care confidence has been found to play an important role in the effectiveness of HF self-care management on patient outcomes, no known research has examined self-care confidence within a dyadic context.

OBJECTIVE

The purpose of this study was to identify individual and dyadic determinants of self-care confidence in HF care dyads.

METHODS

Multilevel modeling, which controls for the interdependent nature of dyadic data, was used to examine 329 Italian HF dyads (caregivers were either spouses or adult children).

RESULTS

Both patients and caregivers reported lower-than-adequate levels of confidence, with caregivers reporting slightly higher confidence than patients. Patient and caregiver levels of confidence were significantly associated with greater patient-reported relationship quality and better caregiver mental health. Patient confidence in self-care was significantly associated with patient female gender, nonspousal care dyads, poor caregiver physical health, and low care strain. Caregiver confidence to contribute to self-care was significantly associated with poor emotional quality of life in patients and greater perceived social support by caregivers.

CONCLUSIONS

Findings are supportive of the need for a dyadic perspective of HF self-care in practice and research as well as the importance of addressing the needs of both members of the dyad to maximize optimal outcomes for both.

Caregivers' attentional bias to pain: does it affect caregiver accuracy in detecting patient pain behaviors?

Attentional bias to pain among family caregivers of patients with pain may enhance the detection of pain behaviors in patients. However, both relatively high and low levels of attentional bias may increase disagreement between patients and caregivers in reporting pain behaviors. This study aims to provide further evidence for the presence of attentional bias to pain among family caregivers, to examine the association between caregivers' attentional bias to pain and detecting pain behaviors, and test whether caregivers' attentional bias to pain is curvilinearly related to patient and caregiver disagreement in reporting pain behaviors. The sample consisted of 96 caregivers, 94 patients with chronic pain, and 42 control participants. Caregivers and controls completed a dot-probe task assessing attention to painful and happy stimuli. Both patients and caregivers completed a checklist assessing patients' pain behavior. Although caregivers did not respond faster to pain congruent than pain incongruent trials, caregiver responses were slower in pain incongruent trials compared with happy incongruent trials. Caregivers showed more bias toward pain faces than happy faces, whereas control participants showed more bias toward happy faces than pain faces. Importantly, caregivers' attentional bias to pain was significantly positively associated with reporting pain behaviors in patients above and beyond pain severity. It is reassuring that attentional bias to pain was not related to disagreement between patients and caregivers in reporting pain behaviors. In other words, attentional bias does not seem to cause overestimation of pain signals.

Self- and Carer-Rated Pain in People With Dementia: Influences of Pain in Carers

CONTEXT

Although pain is frequent in people with dementia (PwD), evidence on the prevalence and factors influencing ratings of pain in dementia is limited. Carer variables are often associated with bias in proxy ratings of pain, but few studies have examined the role of caregiver pain in influencing these ratings.

OBJECTIVES

This study explored the prevalence of pain in PwD in a large U.K.

SAMPLE

A secondary aim was to identify factors influencing ratings of pain in people with mild to moderate dementia and whether carer pain systematically influences proxy ratings.

METHODS

This was a cross-sectional study of 488 caregiving dyads living in the community. Self- and carer-rated pain was assessed as part of the EuroQoL-5D (EQ-5D). Depression and anxiety for the PwD were measured by the Cornell Scale for Depression in Dementia and the Rating of Anxiety in Dementia Scale. The Hospital Anxiety and Depression Scale was used to measure anxiety and depressive symptoms in carers. Using logistic regression modeling, we examined the relationship between self- and carer-rated (proxy) pain in PwD and psychological distress, functional ability, and health status. Carer variables included self-rated health, strain, anxiety, depression, and caregiver pain.

RESULTS

A total of 45% of PwD reported pain, whereas carer-rated pain was higher (59%). Self-rated pain was more frequent in those with lower self-rated health (adjusted odds ratio [AOR] 0.97; 95% CI 0.96-0.99, P ≤ 0.001) and higher anxiety (AOR 1.07; 95% CI 1.01-1.12, P = 0.013). Carer-rated (proxy) pain was additionally predicted by poor proxy-rated health in the PwD (AOR 0.98; 95% CI 0.96-0.99, P = 0.006) and carers' own experience of pain (AOR 0.36; 95% CI 0.21-0.63, P ≤ 0.001).

CONCLUSION

Our results indicate that pain is very frequently reported in PwD and that the presence of pain is associated with high levels of anxiety. Caregiver pain affects carers' perceptions of pain in PwD.

Incongruence between stroke survivor and spouse perceptions of survivor functioning and effects on spouse mental health: a mixed-methods pilot study

OBJECTIVES

This pilot study investigated stroke survivors' and caregiving spouses' individual perspectives on survivor cognitive and physical functioning and the extent to which incongruence between partners' perceptions affects spouse depressive symptoms and overall mental health.

METHOD

Mixed-methods, with quantitative survey data from 35 couples and qualitative interview data from a subsample of 13 couples being collected and analyzed using paired t-tests, multiple regression with survivor-spouse discrepancy scores as predictors of spouse depressive symptoms, and interpretive-description techniques.

RESULTS

Quantitative data indicated that spouses rated survivor cognitive functioning as significantly worse than survivors rated their own and that survivor-spouse discrepancy scores for physical functioning were significantly associated with spouse depressive symptoms. Qualitative data enhanced understanding about the nuances of partner incongruence and the ramifications of partner incongruence for spouse mental health.

CONCLUSION

Partner incongruence has an impact on spouse depressive symptoms and overall mental health. Interventions targeted at survivor-spouse dyads and focused on improving communication between partners about survivor abilities may be effective for improving the mental health of spousal caregivers.

Symptom incongruence trajectories in lung cancer dyads

CONTEXT

There is little known about the pattern of change in patient-family member symptom incongruence across the lung cancer trajectory.

OBJECTIVES

This study examined trajectories of patient-family member incongruence in perceptions of patient physical function, pain severity, fatigue, and dyspnea in lung cancer dyads and explored the association with family member grief after patient death.

METHODS

Lung cancer patients and their family members providing care (n = 109 dyads) rated patient symptoms and physical function five times over 12 months. Symptom incongruence trajectories were analyzed using multilevel modeling.

RESULTS

Patient-family member incongruence did not significantly change over time, on average, except in the case of patient physical function where incongruence significantly declined. There was significant variability around trajectories of incongruence for all symptoms except fatigue. Exploratory analysis on a subsample of 22 bereaved family members found that incongruence regarding patient fatigue was associated with family member grief two months after patient death.

CONCLUSION

Findings suggest the importance of modeling symptom incongruence over time and taking a dyadic approach to the illness context to identify interventions that promote adjustment and quality of life for both patient and family member.

Cross-cultural adaptation, evaluation and validation of the Spouse Response Inventory: a study protocol

INTRODUCTION

Since the response of spouses has been proven to be an important reinforcement of pain behaviour and disability it has been addressed in research and therapy. Fordyce suggested pain behaviour and well behaviour be considered in explaining suffering in chronic pain patients. Among existing instruments concerning spouse's responses the aspect of well behaviour has not been examined so far. The SRI (Spouse Response Inventory) tries to consider pain behaviour and well behaviour and appears to be acceptable because of its brevity and close proximity to daily language. The aim of the study is the translation into German, followed by evaluation and validation, of the SRI on a German sample of patients with chronic pain.

METHODS AND ANALYSES

The study is comprehensively designed: initially, the focus will lie on the translation of the instrument following the guidelines for cross-cultural translation and adaptation and evaluation of the German version according to the source study. Subsequently, a validation referring to predictive, incremental and construct validation will be conducted using instruments based on similar or close but different constructs. Evaluation of the resulting SRI-G (SRI-German) will be conducted on a sample of at least 30 patients with chronic pain attending a comprehensive pain centre. For validation at least 120 patients with chronic headache, back pain, cancer related pain and somatoform pain disorder shall be included, for a total of 480 patients. Separate analyses according to specific pain diagnoses will be performed to ensure psychometric property, interpretability and control of diagnosis of specific limitations. Analyses will include comprehensive investigation of psychometric property of the scale by hierarchical regression analyses, correlation analyses, multivariate analysis of variance and exploratory factor analyses (SPSS).

ETHICS

The study protocol was approved by the Ethics Committee of the University of Dresden (EK 335 122008) based on the Helsinki declaration.

Patterns and predictors of symptom incongruence in older couples coping with prostate cancer

PURPOSE

Prostate cancer survivors (PCSs) may experience persistent symptoms following treatment. If PCSs and spouses differ in their perceptions of symptoms, that incongruence may cause mismanagement of symptoms and reduced relationship quality. The purpose of this study was to examine symptom incongruence and identify the PCS and spouse characteristics associated with symptom incongruence in older couples coping with prostate cancer.

METHODS

Participants in the study were older PCSs (>60 years) and their spouses (N=59 couples). Symptom incongruence was determined by comparing patient and spouse independent ratings of the severity of his cancer-related symptoms. Predictor variables included PCS age, time since diagnosis, PCS comorbidity, PCS and spouse depressive symptoms, and spouse caregiving strain.

RESULTS

PCS and spouse ratings of his symptom severity and the amount of incongruence over his symptoms varied significantly across couples. Overall, couples rated a moderate level of PCS symptom severity, but PCSs and their spouses significantly differed in their perceptions of PCS symptom severity with spouses rating severity higher (t=-2.66, df=51, p<0.01). PCS younger age and high spouse caregiver strain accounted for 29 % of incongruence in perceptions of PCS symptom severity.

CONCLUSIONS

This study is among the first to show that PCSs and spouses may perceive cancer-related persistent symptoms differently. Among this older sample, younger PCS age and spouse caregiver strain were associated with incongruence in symptoms perceptions in couples. These and other factors may inform future interventions aimed at preserving relationship quality in older couples who have experienced prostate cancer.

Predictors of discrepancies between informants' ratings of preschool-aged children's behavior: An examination of ethnicity, child characteristics, and family functioning

The present study examined predictors of discrepancies between mothers', fathers', and teachers' ratings of 3-year-old children's hyperactivity, attention problems, and aggression. Participants were families of 196 3-year-old children who took part in child and family assessments. Ethnicity was one of the most consistent predictors of discrepancies. African American mothers and fathers were more likely to rate their children's hyperactivity, attention problems, and aggression lower than teachers. In contrast, Latina mothers were more likely to rate their children as more hyperactive and inattentive than teachers. ADHD/ODD diagnoses, parental depression, number of children, and children's pre-academic skills were also predictive of discrepancies for some measures for some informants. These findings provide insight into factors that may contribute to informant discrepancies in ratings of preschool children.

Correlates of spousal empathic accuracy for pain-related thoughts and feelings

OBJECTIVES

This study explored correlates of spousal ability to infer the thoughts and feelings of individuals with chronic pain (ICPs).

METHODS

Participant couples (N=57), who consisted of at least 1 couple member with chronic pain, engaged in a videotaped discussion about pain, after which they completed an empathic accuracy procedure where spouses of ICP were asked to infer thoughts/feelings of ICPs.

RESULTS

Overall levels of partner empathic accuracy were similar to other studies of couples. Several characteristics of the pain experience and the marital relationship correlated with empathic accuracy for thoughts and feelings. Specifically, partner catastrophizing about the ICP's pain was associated with less empathic accuracy for thoughts, whereas ICP pain severity was related to a greater empathic accuracy for feelings. Several significant interactions were also found, with marital satisfaction and partner's own pain experience acting as moderators.

DISCUSSION

These findings provide support for models of empathy that argue that characteristics of the pain condition and characteristics of the observer are important contributors to observers' understanding of pain. In addition, the findings support previous research that suggests there are different processes for understanding the emotional versus the cognitive experience of others.

Couple perceptions of fibromyalgia symptoms: the role of communication

The objectives of the current study were to describe fibromyalgia patient-spouse incongruence regarding patient pain, fatigue, and physical function; and to examine the associations of individual and interpersonal factors with patient-spouse incongruence. Two hundred four fibromyalgia patients and their coresiding partners rated the patient's symptoms and function. Multilevel modeling revealed that spouses, on average, rated patient fatigue significantly lower than patients. Couple incongruence was not significantly different from zero, on average, for pain severity, interference, or physical function. However, there was significant variability across couples in how they rated the severity of symptoms and function, and how much incongruence existed within couples. Controlling for individual factors, patient and spouse reports of communication problems were significantly associated with levels of couple incongruence regarding patient fatigue and physical function, albeit in opposing directions. Across couples, incongruence was high when patients rated communication problems as high; incongruence was low when spouses rated communication problems as high. An important within-couple interaction was found for pain interference, suggesting that couples who are similar on level of communication problems experience low incongruence; those with disparate ratings of communication problems experience high incongruence. Findings suggest the important roles of spouse response and the patient's perception of how well the couple is communicating. Couple-level interventions targeting communication or other interpersonal factors may help to decrease incongruence and lead to better patient outcomes.

Chronic pain and the family: the experience of the partners of people living with chronic pain

AIMS AND OBJECTIVES

The purpose of this study was to explore the impact of chronic pain on the partner and family of a person with chronic pain.

BACKGROUND

Chronic pain impacts not only on the individual but also their partner and/or other family members. Families of people with chronic pain have reported feeling powerless, alienated, emotionally distressed, and isolated. These impacts have affected their relationship with the person with chronic pain.

DESIGN

An interpretive qualitative design using in-depth interviews and thematic analysis was undertaken.

METHODS

Purposive sampling and in-depth interviewing were undertaken to develop a rich description of the experience.

RESULTS

Findings indicate the impact of chronic pain on the family is extensive, resulting in physical, social, and emotional changes. Four themes were revealed: (1) Family loss, (2) Life changes, (3) Emotional impact of pain, and (4) Future plans.

CONCLUSION

This study reinforces and expands current knowledge regarding the impact of chronic pain on partners and families. Understanding this phenomenon opens opportunities for nurses and other health workers to develop and implement strategies to better support partners/families in the future.

RELEVANCE TO CLINICAL PRACTICE

Nurses can help reduce the negative impact of pain by including families in assessment, education, referral and treatment processes, and by offering support and education to partners/families.

Longitudinal linkages among parent-child acculturation discrepancy, parenting, parent-child sense of alienation, and adolescent adjustment in Chinese immigrant families

Parent-child acculturation discrepancy is a risk factor in the development of children in immigrant families. Using a longitudinal sample of Chinese immigrant families, the authors of the current study examined how unsupportive parenting and parent-child sense of alienation sequentially mediate the relationship between parent-child acculturation discrepancy and child adjustment during early and middle adolescence. Acculturation discrepancy scores were created using multilevel modeling to take into account the interdependence among family members. Structural equation models showed that during early adolescence, parent-child American orientation discrepancy is related to parents' use of unsupportive parenting practices; parents' use of unsupportive parenting is related to increased sense of alienation between parents and children, which in turn is related to more depressive symptoms and lower academic performance in Chinese American adolescents. These patterns of negative adjustment established in early adolescence persist into middle adolescence. This mediating effect is more apparent among father-adolescent dyads than among mother-adolescent dyads. In contrast, parent-child Chinese orientation discrepancy does not demonstrate a significant direct or indirect effect on adolescent adjustment, either concurrently or longitudinally. The current findings suggest that during early adolescence, children are more susceptible to the negative effects of parent-child acculturation discrepancy; they also underscore the importance of fathering in Chinese immigrant families.

Self-reported spousal support modifies the negative impact of pain on disability in men with chronic prostatitis/chronic pelvic pain syndrome

OBJECTIVES

To examine changes in the association between pain and patient quality of life (QoL), depressive symptoms, and disability in men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) at varying levels of spouse responses to pain.

MATERIAL AND METHODS

One-hundred eighty-eight men with CP/CPPS completed a questionnaire, including demographic information. The outcome variables were mental QoL (SF-12 MCS), physical QoL (SF-12 PCS), depressive symptoms (Center for Epidemiological Studies Depression Scale), and disability (Pain Disability Index). Patients also reported on the types of responses they had from their spouses (Multidimensional Pain Inventory), and pain (Short-Form McGill Pain Questionnaire).

RESULTS

The association between pain and disability was stronger at higher levels of solicitous responses (eg, "Does some of my chores") (β = 0.66, P <.05) than it was at moderate (β = 0.44, P <.05) and lower (β = 0.23, ns) levels. In contrast, the association between pain and disability was stronger at lower levels (β = 0.64, P <.05) of distracting responses (eg, "Tries to get me involved in some activity") than it was at moderate (β = 0.44, P <.05) and higher (β = 0.25, P <.05) levels.

CONCLUSIONS

Solicitous responses to pain increased the negative impact of pain on disability, whereas distracting responses to pain decreased the negative impact of pain on disability in men with CP/CPPS. Solicitous responses may be a reaction to patient pain and associated disability, or may help create or maintain the patient's pain and disability. In either case, distracting rather than solicitous responses to patient pain are to be encouraged in symptom management.

Associations between depression, pain behaviors, and partner responses to pain in metastatic breast cancer

Women with metastatic breast cancer (MBC) rely on their partners for emotional and practical support. They also experience significant pain and depression, which can trigger maladaptive pain behaviors (eg, distorted ambulation). The biopsychosocial model of pain posits that partner solicitous responses can reinforce pain behaviors, whereas punishing or distracting responses can minimize their occurrence. This study explored how psychosocial variables (ie, depression and partner responses) influence patient pain behaviors and partner responses in 191 couples coping with MBC. Because few studies have examined the biopsychosocial model in cancer, it also examined associations between partner responses and patient pain behaviors. Multilevel models showed that depression partially mediated: (1) associations between patients' and partners' reports of patient pain (MPI) and their ratings of patient pain behaviors (PBCL), accounting for 41% to 71% of the variance; and (2) associations between both partners' reports of patient pain and the partner's distracting and punishing responses (MPI), accounting for 66% to 75% of the variance. Partner punishing responses moderated associations between patient pain severity and pain behaviors. Specifically, punishing responses were associated with more pain behaviors for patients with low levels of pain and fewer pain behaviors for patients with higher levels of pain (effect size r=.18). These findings provide partial support for the biopsychosocial model of pain but also clarify and extend it in the cancer context. Future pain management programs in MBC may benefit from addressing both partners' depression levels and teaching partners to engage in fewer punishing responses when the patient is experiencing low levels of pain.

Pain and emotion: a biopsychosocial review of recent research

OBJECTIVE AND METHOD

Research on emotion and pain has burgeoned. We review the last decade's literature, focusing on links between emotional processes and persistent pain.

RESULTS

Neurobiological research documents the neural processes that distinguish affective from sensory pain dimensions, link emotion and pain, and generate central nervous system pain sensitization. Psychological research demonstrates that greater pain is related to emotional stress and limited emotional awareness, expression, and processing. Social research shows the potential importance of emotional communication, empathy, attachment, and rejection.

CONCLUSIONS

Emotions are integral to the conceptualization, assessment, and treatment of persistent pain. Research should clarify when to eliminate or attenuate negative emotions, and when to access, experience, and express them. Theory and practice should integrate emotion into cognitive-behavioral models of persistent pain.

Agreement on perceptions of quality of life in couples dealing with infertility

OBJECTIVE

To examine the extent to which men and women seeking treatment for infertility were able to accurately perceive their partners' ratings of their quality of life (QOL).

DESIGN

Cross-sectional prospective study. Quality of life was measured as a multidimensional construct.

SETTING

Assisted reproduction clinic of a university hospital.

PARTICIPANTS

One hundred and sixty-two couples participated. The men's and women's mean ages were 36.1 and 32.1 years, respectively. Most participants had no children, and no previous assisted reproduction attempts.

METHODS

Men and women completed the World Health Organization-Quality of Life-Brief (WHOQOL-Brief) and the Beck Depression Inventory independently. Paired t tests were used to explore men's perceptions of their wives' QOL ratings and wives' perceptions of their husbands' ratings. Multiple regression and repeated-measures ANCOVA were used to examine the role of depression.

RESULTS

Proxy assessments were consistently lower than self-reports on the domains of QOL. The influence of depression on agreement was minimal, and no gender effect was observed.

CONCLUSION

Findings indicated little agreement in perceptions of the partner's QOL, with each partner tending to underrate the other's view. Practitioners need to consider the differences between partners to enable partners to better understand and support each other.

Disability assessment in temporomandibular disorders and masticatory system rehabilitation

The consequences of a disease or condition such as temporomandibular disorders (TMD) include functional limitation and psychosocial disability. These two concepts refer to the individual's experience of limitations in function associated with the affected part of the body and to disarray in one's life, respectively. Models of disability emphasize the individual's self-report in describing these states and the centrality of these concepts as part of the disease and illness process. However, assessment approaches typically used in medicine and especially in dentistry do not yet routinely include these domains. TMD, as a musculoskeletal pain condition, can clearly lead to both limitation and disability, and the available evidence suggests that dentofacial disorders can also lead to both consequences. The relatively low contribution of disease impairment (measured changes in function through objective tests), however, to the reported limitation or disability in either TMD or dentofacial disorders remains complex and poorly understood. This article reviews the overall model of disablement, the necessary properties of measures to assess disablement, the present state of knowledge about these concepts, and what measures should be considered as part of routine assessment.

Executive functions, self-regulation, and chronic pain: a review

BACKGROUND

Chronic pain conditions are complicated and challenging to live with. Capacity to adjust to such conditions may depend on the ability to self-regulate, that is, the ability to alter thoughts, feelings, and behaviors. Self-regulation appears to rely on executive cognitive functions, and the current review, therefore, sought to draw attention to the impact of self-regulatory capacity and executive functions on chronic pain.

DISCUSSION

Chronic pain conditions present with complex interactions of cognitive, emotional, behavioral, and physiological components for which self-regulatory ability is crucial. The ability to self-regulate varies, and self-regulatory strength appears to be a limited resource that can be fatigued. The many challenges of chronic pain conditions could, therefore, tax self-regulatory strength, leading to self-regulatory deficits.

CONCLUSION

The current review proposes a relationship among pain, self-regulatory capacity, self-regulatory demands, executive functions, and self-regulatory fatigue, suggesting that executive functions and self-regulatory deficits are indeed part of the etiology and maintenance of chronic pain conditions.

Individual and relational correlates of pain-related empathic accuracy in spouses of chronic pain patients

OBJECTIVE

This study aims to investigate correlates of pain-related empathic accuracy in spouses of chronic pain patients. Specifically, analyses addressed: (1) the correlates of pain-related empathic accuracy, (2) the relation between pain-related empathic accuracy, and patient and spouse adaptational outcomes, and (3) the relation between pain-related empathic accuracy and relational outcomes.

METHODS

Fifty-eight chronic pain patients (28 women and 30 men) were filmed while participating in a simulated occupational lifting task. Patients were asked to report their level of pain while lifting canisters partially filled with sand. Spouses were later asked to view the video record of their partner's performance and to estimate their partner's level of pain. Empathic accuracy was defined in terms of the overall discrepancy between patients' pain ratings and spouses' pain estimates, and by the degree of covariation between patients' pain ratings and spouses' pain estimates across trials.

RESULTS

Analysis revealed that patients' pain severity, catastrophizing, fear of pain, and level of disability were significant correlates of empathic accuracy. Higher levels of pain-related empathic accuracy were associated to negative adaptational outcomes for chronic pain patients. With regard to the spouse, empathic accuracy was associated with the spouses' perceiving that they express less punitive responses when the patient is in pain. Empathic accuracy was not significantly related to relational outcomes.

DISCUSSION

The results of this study suggest that empathic accuracy is associated with negative outcomes for the patient, and might not be an important correlate of marital satisfaction in couples in which one of the partners is suffering from chronic pain.