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Rau LM, Korwisi B, Barke A, Frosch M, Zernikow B, Wager J. 11th revision of the International Classification of Diseases chronic primary pain diagnoses in children and adolescents: representation of pediatric patients in the new classification system. Pain 2024:00006396-990000000-00701. [PMID: 39258738 DOI: 10.1097/j.pain.0000000000003386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 07/03/2024] [Indexed: 09/12/2024]
Abstract
ABSTRACT Chronic pain is common among children and adolescents; however, the diagnoses in the newly developed 11th revision of the International Classification of Diseases (ICD-11) chronic pain chapter are based on adult criteria, overlooking pediatric neurodevelopmental differences. The chronic pain diagnoses have demonstrated good clinical applicability in adults, but to date, no field study has examined these diagnoses to the most specific diagnostic level in a pediatric sample. The current study aimed to explore pediatric representation within the ICD-11, with focus on chronic primary pain. Healthcare professionals (HCPs) at a specialized pediatric pain center documented the symptoms of and assigned both ICD-10 and ICD-11 diagnoses to N = 402 patients. Using criteria-based computer algorithms, specific ICD-11 pain diagnoses were allocated for each documented pain location, with residual diagnoses (ie, "unspecified") assigned if criteria were not (fully) met. Within the ICD-11, the algorithms assigned specific pain diagnoses to most patients (73.6%). In ICD-10, HCPs could not specify a diagnosis for 5.2% of patients; the ICD-11 algorithm allocated a residual chronic primary pain diagnosis in 51.2%. Residual categories were especially prevalent among younger children, boys, patients with headaches, and those with lower pain severity. Overall, clinical utility of the ICD-11 was high, although less effective for chronic back pain and headache diagnoses. The latter also exhibited the lowest agreement between HCPs and algorithm. The current study underscores the need for evidence-based improvements to the ICD-11 diagnostic criteria in pediatrics. Developing pediatric coding notes could improve the visibility of patients internationally and improve the likelihood of receiving reimbursement for necessary treatments through accurate coding.
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Affiliation(s)
- Lisa-Marie Rau
- German Paediatric Pain Centre, Children's and Adolescents' Hospital Datteln, Datteln, Germany
- Department of Children's Pain Therapy and Paediatric Palliative Care, Witten/Herdecke University, Faculty of Health, School of Medicine, Witten, Germany
| | - Beatrice Korwisi
- Clinical Psychology and Psychological Interventions, Institute for Psychology, University of Duisburg-Essen, Essen, Germany
| | - Antonia Barke
- Clinical Psychology and Psychological Interventions, Institute for Psychology, University of Duisburg-Essen, Essen, Germany
| | - Michael Frosch
- German Paediatric Pain Centre, Children's and Adolescents' Hospital Datteln, Datteln, Germany
- Department of Children's Pain Therapy and Paediatric Palliative Care, Witten/Herdecke University, Faculty of Health, School of Medicine, Witten, Germany
| | - Boris Zernikow
- German Paediatric Pain Centre, Children's and Adolescents' Hospital Datteln, Datteln, Germany
- Department of Children's Pain Therapy and Paediatric Palliative Care, Witten/Herdecke University, Faculty of Health, School of Medicine, Witten, Germany
- PedScience Research Institute, Datteln, Germany
| | - Julia Wager
- German Paediatric Pain Centre, Children's and Adolescents' Hospital Datteln, Datteln, Germany
- Department of Children's Pain Therapy and Paediatric Palliative Care, Witten/Herdecke University, Faculty of Health, School of Medicine, Witten, Germany
- PedScience Research Institute, Datteln, Germany
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Sullivan MJL, Tripp DA. Pain Catastrophizing: Controversies, Misconceptions and Future Directions. THE JOURNAL OF PAIN 2024; 25:575-587. [PMID: 37442401 DOI: 10.1016/j.jpain.2023.07.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 07/05/2023] [Accepted: 07/06/2023] [Indexed: 07/15/2023]
Abstract
Recent reports have pointed to problems with the term "pain catastrophizing." Critiques of the term pain catastrophizing have come from several sources including individuals with chronic pain, advocates for individuals with chronic pain, and pain scholars. Reports indicate that the term has been used to dismiss the medical basis of pain complaints, to question the authenticity of pain complaints, and to blame individuals with pain for their pain condition. In this paper, we advance the position that the problems prompting calls to rename the construct of pain catastrophizing have little to do with the term, and as such, changing the term will do little to solve these problems. We argue that continued calls for changing or deleting the term pain catastrophizing will only divert attention away from some fundamental flaws in how individuals with pain conditions are assessed and treated. Some of these fundamental flaws have their roots in the inadequate training of health and allied health professionals in evidence-based models of pain, in the use of psychological assessment and intervention tools for the clinical management of pain, and in gender equity and antiracism. Critiques that pain scholars have leveled against the defining, operational, and conceptual bases of pain catastrophizing are also addressed. Arguments for reconceptualizing pain catastrophizing as a worry-related construct are discussed. Recommendations are made for remediation of the problems that have contributed to calls to rename the term pain catastrophizing. PERSPECTIVE: The issues prompting calls to rename the construct of pain catastrophizing have their roots in fundamental flaws in how individuals with pain are assessed and treated. Efforts to address these problems will require more than a simple change in terminology.
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Affiliation(s)
| | - Dean A Tripp
- Departments of Psychology, Anesthesiology and Urology, Queen's University, Kingston, Ontario, Canada
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Altermark N, Plesner Å. Austerity and identity formation: How welfare cutbacks condition narratives of sickness. SOCIOLOGY OF HEALTH & ILLNESS 2022; 44:1270-1286. [PMID: 36066495 PMCID: PMC9546179 DOI: 10.1111/1467-9566.13545] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 06/30/2022] [Indexed: 06/15/2023]
Abstract
In recent years, Swedish sick insurance has become more restrictive. In this article, we analyse how people not being granted payments, despite being seriously ill, are affected. Scholarship on identity formation and sickness stress the importance of constructing narratives in order to come to terms with one's situation. Our analysis of 30 qualitative interviews with people diagnosed with ME/CFS shows that workfare politics conditions such identity formation and often prevents it from taking place. Interviewees describe extreme stress as a result of their contacts with the Social Insurance Agency (SIA), which results in a perpetual crisis that is renewed with each new denied application. In particular, the sense of not having a future means that it is hard to construct narratives to make sense of one's situation. To escape the perpetual crisis, some people have politicised their situation, constructing a narrative about themselves as suffering from oppressive politics. Others have escaped by not applying for sick insurance or other social insurances. But generally speaking, the most common effect of being denied sick insurance is an ongoing crisis that leads to deteriorating health.
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Affiliation(s)
| | - Åsa Plesner
- Stockholm Business SchoolStockholm UniversityStockholmSweden
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What Is the Medication Iatrogenic Risk in Elderly Outpatients for Chronic Pain? Clin Neuropharmacol 2022; 45:65-71. [PMID: 35579486 DOI: 10.1097/wnf.0000000000000505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Medication iatrogeny is a major public health problem that increases as the population ages. Therapeutic escalation to control pain and associated disorders could increase polypharmacy and iatrogeny. This study aimed to characterize the medication iatrogenic risk of elderly outpatients with chronic pain. METHODS This was a prospective cohort study recruiting patients 65 years or older with chronic pain. A medication iatrogenic assessment was performed based on the best possible medication history to record risk of adverse drug events (Trivalle score), STOPP (Screening Tool of Older Person's Prescriptions)/START (Screening Tool to Alert doctors to Right Treatment) criteria, and potentially inappropriate medications. RESULTS We recruited 100 patients with an average age of 71 years. The median number of medications before pain consultation was 8 (interquartile range = [7;11]). Trivalle score showed that 43% of patients were at moderate or high medication iatrogenic risk. Before consultation, 79% and 75% of patients had at least 1 STOPP or START criterion on their orders, respectively. One-third of orders mentioned benzodiazepine prescribed for more than 4 weeks. At least 1 potentially inappropriate medication was prescribed for 54% of the patients, with a median of 1 per patient (interquartile range = [0;1]). A combination of several anticholinergics was prescribed in 23% of patients. CONCLUSION Elderly patients with chronic pain are at risk of medication iatrogeny. Preventive measures as multidisciplinary medication review could reduce the iatrogenic risk in these outpatients.This study is registered at clinicaltrials.gov as NCT04006444 on July 3, 2019.
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O'Connell N, Nicholson T, Blackman G, Tavener J, David AS. Medication prescriptions in 322 motor functional neurological disorder patients in a large UK mental health service: A case control study. Gen Hosp Psychiatry 2019; 58:94-102. [PMID: 31031213 DOI: 10.1016/j.genhosppsych.2019.04.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/01/2019] [Accepted: 04/02/2019] [Indexed: 01/26/2023]
Abstract
OBJECTIVE This study describes medication prescribing patterns in patients with motor functional neurological disorder (mFND) treated in South London and Maudsley NHS Foundation Trust (SLaM), comparing outcomes to a control group of psychiatric patients from the same hospital trust. METHOD This is a retrospective case-control study using a psychiatric case register. Cross-sectional data were obtained from 322 mFND patients and 644 psychiatry controls who had had contact with SLaM between 1st January 2006 and 31st December 2016. RESULTS A slightly lower proportion of mFND patients received medication compared to controls (76.6% v. 83.4%, OR: 0.59, CI: 0.39-0.89, p < 0.05). Of medication recipients, mFND patients were prescribed a higher number of agents (mean: 4.7 v 2.9, p = 0.001) and had higher prescription rates of antidepressants, anti-epileptics, analgesics, and certain non-psychotropic medications. Higher numbers of prescriptions were associated with co-morbid physical conditions, and previous psychiatric admissions. CONCLUSIONS This is the first study to describe medication prescriptions in a large cohort of mFND patients. Patients were prescribed a wide range of psychiatric and physical health medications, with higher rates of polypharmacy than controls. Psychotropic medication prescription is not necessarily the first line treatment for mFND, where physiotherapy and psychotherapy may be offered initially. There is limited, early-phase evidence for pharmacological therapies for mFND, and as such, the benefit-to-risk ratio of prescribing in this complex and poorly understood disorder should be carefully assessed.
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Affiliation(s)
- Nicola O'Connell
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 DeCrespigny Park, London SE5 8AF, United Kingdom. nicola.k.o'
| | - Timothy Nicholson
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 DeCrespigny Park, London SE5 8AF, United Kingdom.
| | - Graham Blackman
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 DeCrespigny Park, London SE5 8AF, United Kingdom.
| | - Jennifer Tavener
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 DeCrespigny Park, London SE5 8AF, United Kingdom.
| | - Anthony S David
- Institute of Mental Health, UCL Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London W1T 7BN, United Kingdom.
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Symptom management for medically unexplained symptoms in primary care: a qualitative study. Br J Gen Pract 2019; 69:e254-e261. [PMID: 30858336 DOI: 10.3399/bjgp19x701849] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 11/12/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND GPs have a central position in the care of patients with medically unexplained symptoms (MUS), but GPs find their care challenging. Currently, little is known about symptom management by GPs in daily practice for patients with MUS. AIM This study aimed to describe management strategies used by GPs when confronted with patients with MUS in daily practice. DESIGN AND SETTING Qualitative study in which videos and transcripts of 39 general practice consultations involving patients with MUS in the region of Nijmegen in the Netherlands in 2015 were analysed. METHOD A thematic analysis of management strategies for MUS used by GPs in real-life consultations was performed. RESULTS The study revealed 105 management strategies in 39 consultations. Nearly half concerned symptom management; the remainder included medication, referrals, additional tests, follow-up consultations, and watchful waiting. Six themes of symptom management strategies emerged from the data: cognitions and emotions, interaction with health professionals, body focus, symptom knowledge, activity level, and external conditions. Advice on symptom management was often non-specific in terms of content, and ambiguous in terms of communication. CONCLUSION Symptom management is a considerable part of the care of MUS in general practice. GPs might benefit from support in how to promote symptom management to patients with MUS in specific and unambiguous terms.
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Page LA, Wessely S. Medically Unexplained Symptoms: Exacerbating Factors in the Doctor-Patient Encounter. J R Soc Med 2017; 96:223-7. [PMID: 12724431 PMCID: PMC539474 DOI: 10.1177/014107680309600505] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- L A Page
- Department of Psychological Medicine, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK.
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Rossen CB, Buus N, Stenager E, Stenager E. Identity work and illness careers of patients with medically unexplained symptoms. Health (London) 2017; 23:551-567. [PMID: 29160105 DOI: 10.1177/1363459317739440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This article reports a case study of the illness career and identity work of patients who have had medically unexplained symptoms for many years with a particular emphasis on their interactions with a specialized and standardized health care system. Patients with medically unexplained symptoms often experience being met with mistrust and feel their identity threatened as a consequence of being illegitimately ill. There is a strong tendency in health care towards assessment thorough standardized so-called assessment packages. The study used a case study approach. Ethnographic fieldwork was carried out and several types of data were sampled through theoretical sampling, resulting in data from and about a sample of 13 patients, from which two patients were selected as cases. The study showed that a standardized health care system characterized by a tendency towards narrow diagnostic assessment with limited time can lead to a diagnostic limbo and that patients and health care professionals keep on searching for legitimate explanations for the patients' still unexplained symptoms. Consequently the patients were left in a constant identity negotiation.
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Affiliation(s)
- Camilla Blach Rossen
- Research Unit of Mental Health, Odense, Institute of Regional Health Services, University of Southern Denmark & Neurological Research Unit, Sønderborg, DenmarkElective Surgery Center, Silkeborg Regional Hospital, Denmark
| | - Niels Buus
- The University of Sydney, Australia; University of Southern Denmark, Denmark
| | - Elsebeth Stenager
- Institute of Regional Health Research, University of Southern Denmark, Denmark; Focused research Unit in Psychiatry, Åbenrå and Department of Psychiatry, Odense, Denmark
| | - Egon Stenager
- Institute of Regional Health Research, University of Southern Denmark, Denmark; MS-clinic of Southern Jutland and Focused research Unit in Neurology, Hospital of Southern Jutland, Sønderborg, Denmark
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Dwyer J, Taylor K, Boughey M. Survivorship of severe medically unexplained symptoms in palliative care. BMJ Support Palliat Care 2017; 7:281-285. [PMID: 28246082 DOI: 10.1136/bmjspcare-2016-001294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 02/15/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Patients who articulate their psychological distress primarily through physical symptoms (referred to as medically unexplained symptoms (MUS)) pose a challenge to the skills of most clinicians, including palliative care physicians. The philosophical underpinnings of palliative care with a stated focus on symptom management and care of the person in their psychosociospiritual context lend itself to the care of these patients. The aim of this study was to investigate the characteristics to improve identification of this patient group within palliative care. METHODS Here, we report a case series of 6 patients with severe MUS who were referred to palliative care. We use illustrative case vignettes, examine clinical and demographic characteristics and review the perspectives of the multidisciplinary team to identify the common threads. RESULTS This case series highlights the complexities and challenges that are inherent in providing assessment and care for patients with MUS that present to palliative care. Characteristics that were identified included the clustering of 'trigger' symptoms, backgrounds of multiple chronic illnesses and relationship dysfunction. Patient outcomes in this group were universally poor, including the death of 2 patients. CONCLUSIONS Knowledge of this patient group is vital given the likely increase in prevalence of MUS as palliative care broadens its focus earlier in the trajectory of illness. The strengths of palliative care, including psychosociospiritual assessment, multidisciplinary input and communication skills holds the potential to accurately identify patients with MUS and allow the opportunity for specialist psychiatric input with the hope of improving outcomes for patients and their families.
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Affiliation(s)
- Justin Dwyer
- Department of Psychosocial Cancer Care, St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Keryn Taylor
- Department of Psychosocial Cancer Care, St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Mark Boughey
- Vincent's Hospital, Fitzroy, Victoria, Australia
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A Cognitive-Behavioral Model of Persistent Postural-Perceptual Dizziness. COGNITIVE AND BEHAVIORAL PRACTICE 2017. [DOI: 10.1016/j.cbpra.2016.03.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Menon V, Shanmuganathan B, Babu Arun A, Thamizh JS, Selvakumar N, Sarkar S. A qualitative analysis of explanatory models in medically unexplained physical symptoms presenting to a tertiary health care psychiatric facility in South India. Int J Soc Psychiatry 2016; 62:608-615. [PMID: 27609766 DOI: 10.1177/0020764016662294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Knowledge about subjective perceptions and explanatory models has the potential to inform clinical evaluation and lead to development of patient-friendly treatment models in medically unexplained physical symptoms (MUPS). AIM To collect qualitative data about explanatory models in MUPS. METHODS A cross-sectional observational study was done among patients with MUPS presenting over a 2-year period to a specialty psychosomatic clinic. The Short Explanatory Model of Illness interview was used to gather qualitative data about explanatory models which were subsequently recoded using standard manuals. RESULTS A total of 123 subjects were evaluated. The nature of symptoms was most commonly reported as 'non-specific' ( n = 102, 82.9%) but of moderate to severe intensity ( n = 87, 73.8%). Getting cured or showing improvement was the most common expectation from treatment ( n = 58, 47.9%). Moderate to severe impact of symptoms was reported on work output ( n = 100, 84%), emotional life ( n = 85, 71.4%) and physical mobility ( n = 59, 49.1%). A considerable proportion was either dissatisfied ( n = 61, 50%) or frankly unhappy ( n = 38, 31.4%) with treatment received. CONCLUSION There is a need to re-calibrate the clinical approach to people with MUPS to enhance treatment satisfaction. Our findings could assist in evolving culturally sensitive conceptualizations of illness and in developing patient-centred models for therapy in MUPS patients.
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Affiliation(s)
- Vikas Menon
- 1 Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Balasubramanian Shanmuganathan
- 1 Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Anand Babu Arun
- 1 Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Jaiganesh Selvapandian Thamizh
- 1 Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Nivedhitha Selvakumar
- 1 Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Siddharth Sarkar
- 2 Department of Psychiatry, National Drug Dependence and Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
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Probability of Iatrogenesis in Gastroenterology. Dig Dis Sci 2016; 61:1775-7. [PMID: 26781257 DOI: 10.1007/s10620-015-4030-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 12/30/2015] [Indexed: 12/09/2022]
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Rosendal M, Carlsen AH, Rask MT. Symptoms as the main problem: a cross- sectional study of patient experience in primary care. BMC FAMILY PRACTICE 2016; 17:29. [PMID: 26965443 PMCID: PMC4785648 DOI: 10.1186/s12875-016-0429-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 03/04/2016] [Indexed: 12/02/2022]
Abstract
Background Symptoms are common in primary care. Besides providing thorough assessment of possible severe disease, the general practitioner (GP) must ensure good health care to all patients, irrespective of diagnoses. We aimed to explore patient satisfaction with the provided care and how well expectations in patients were met when no diagnosis was made during the consultation. Method Cross-sectional study based on a questionnaire survey conducted in 2008–2009 among 377 GPs and their patients in the Central Denmark Region. A total of 2286 patients completed a questionnaire after the consultation (response rate: 54 %). The questionnaire included four satisfaction items from the EUROPEP instrument and a question about unmet expectations. For each patient, the GP answered a one-page registration form including information about the main problem in the consultation, chronic disorders and assessment of prognosis. Statistical analyses were adjusted for patient characteristics and GP clustering. Results A higher proportion of patients reported illness worry (20 vs. 17 %, p-value: 0.005), unmet expectations (17 vs. 13 %, p-value: 0.019) and dissatisfaction with their GP after the consultation when no diagnosis was made. Dissatisfaction was primarily related to the medical examination (adjusted OR 1.30; 95 % CI: 1.06–1.60) and GP explanations (adjusted OR 1.40; 95 % CI: 1.14–1.71). Exploratory analyses revealed an association between dissatisfaction with examination and the GP assessment that symptoms were unrelated to biomedical disease. This association was found both in patients with ‘symptoms only’ and patients given a specific diagnosis. Conclusion GPs are challenged by patients presenting symptoms that do not fit the patterns of biomedical diagnoses. The current study demonstrates more illness worry, unmet expectations and dissatisfaction with the consultation in these patients compared to patients receiving a diagnosis. This trend is true for all patients assessed as having ‘symptoms only’ at the end of a consultation and not only for the minority group with ‘medically unexplained symptoms’. As primary care is the frontline of the health-care system, symptoms are managed as the main problem in almost one in three consultations. It is about time that we take the same professional approach to symptoms as we have done for years to biomedical disease. Electronic supplementary material The online version of this article (doi:10.1186/s12875-016-0429-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marianne Rosendal
- Department of Public Health, Research Unit for General Practice, Aarhus University, Bartholins Alle 2, DK-8000, Aarhus C, Denmark.
| | - Anders Helles Carlsen
- Department of Public Health, Research Unit for General Practice, Aarhus University, Bartholins Alle 2, DK-8000, Aarhus C, Denmark
| | - Mette Troellund Rask
- Department of Public Health, Research Unit for General Practice, Aarhus University, Bartholins Alle 2, DK-8000, Aarhus C, Denmark
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Weiland A, Blankenstein AH, Van Saase JLCM, Van der Molen HT, Jacobs ME, Abels DC, Köse N, Van Dulmen S, Vernhout RM, Arends LR. Training Medical Specialists to Communicate Better with Patients with Medically Unexplained Physical Symptoms (MUPS). A Randomized, Controlled Trial. PLoS One 2015; 10:e0138342. [PMID: 26381400 PMCID: PMC4575077 DOI: 10.1371/journal.pone.0138342] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 08/26/2015] [Indexed: 12/02/2022] Open
Abstract
Background Patients with medically unexplained physical symptoms (MUPS) are prevalent 25–50% in general and specialist care. Medical specialists and residents often find patients without underlying pathology difficult to deal with, whereas patients sometimes don’t feel understood. We developed an evidence-based communication training, aimed to improve specialists’ interviewing, information-giving and planning skills in MUPS consultations, and tested its effectiveness. Methods The intervention group in this multi-center randomized controlled trial received a 14-hour training program to which experiential learning and feedback were essential. Using techniques from Cognitive Behavioral Therapy, they were stimulated to seek interrelating factors (symptoms, cognitions, emotions, behavior, and social environment) that reinforced a patient’s symptoms. They were taught to explain MUPS understandably, reassure patients effectively and avoid unnecessary diagnostic testing. Before and after the intervention training, specialists videotaped a total of six consultations with different MUPS patients. These were evaluated to assess doctors’ MUPS-focused communicating skills using an adapted version of the Four Habit Coding Scheme on five-point Likert scales. Participants evaluated the training by self-report on three-point Likert scales. Doctors in the control group received training after completion of the study. Results 123 doctors (40% specialists, 60% residents) and 478 MUPS patients from 11 specialties were included; 98 doctors completed the study (80%) and 449 videotaped consultations were assessed. Trained doctors interviewed patients more effectively than untrained ones (p < 0.001), summarized information in a more patient-centered way (p = 0.001), and better explained MUPS and the role of perpetuating factors (p < 0.05). No effects on planning skills were found. On a 3-point scale the training was evaluated with 2.79. Conclusion MUPS-focused communication training increases the interviewing and information-giving skills of medical specialists. We recommend that the training is incorporated in postgraduate education for medical specialists and residents who frequently encounter patients with MUPS. Trial Registration Dutch Trial Registration NTR2612
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Affiliation(s)
- Anne Weiland
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Institute of Psychology, Faculty of Social Sciences, Erasmus University Rotterdam, Rotterdam, the Netherlands
- * E-mail:
| | - Annette H. Blankenstein
- Department of General Practice and Elderly Care Medicine, VU University Medical Centre Amsterdam, Amsterdam, the Netherlands
| | - Jan L. C. M. Van Saase
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Henk T. Van der Molen
- Institute of Psychology, Faculty of Social Sciences, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Mariël E. Jacobs
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of General Practice and Elderly Care Medicine, VU University Medical Centre Amsterdam, Amsterdam, the Netherlands
| | - Dineke C. Abels
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Faculty of Psychology, Open University, Heerlen, the Netherlands
| | - Nedim Köse
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Faculty of Psychology, Open University, Heerlen, the Netherlands
| | - Sandra Van Dulmen
- Department of Primary and Community Care, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
- NIVEL (Netherlands Institute for Health Services Research), Utrecht, the Netherlands
- Faculty of Health Science, Buskerud and Vestfold University College, Drammen, Norway
| | - René M. Vernhout
- Clinical Trial Center, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Lidia R. Arends
- Institute of Psychology, Faculty of Social Sciences, Erasmus University Rotterdam, Rotterdam, the Netherlands
- Department of Biostatistics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Institute of Pedagogical Sciences, Faculty of Social Sciences, Erasmus University Rotterdam, Rotterdam, the Netherlands
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Strachan E, Poeschla B, Dansie E, Succop A, Chopko L, Afari N. Clinical and evoked pain, personality traits, and emotional states: can familial confounding explain the associations? J Psychosom Res 2015; 78:58-63. [PMID: 25311873 PMCID: PMC4272603 DOI: 10.1016/j.jpsychores.2014.09.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 09/08/2014] [Accepted: 09/24/2014] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Pain is a complex phenomenon influenced by context and person-specific factors. Affective dimensions of pain involve both enduring personality traits and fleeting emotional states. We examined how personality traits and emotional states are linked with clinical and evoked pain in a twin sample. METHODS 99 female twin pairs were evaluated for clinical and evoked pain using the McGill Pain Questionnaire (MPQ) and dolorimetry, and completed the 120-item International Personality Item Pool (IPIP), the Positive and Negative Affect Scale (PANAS), and ratings of stress and mood. Using a co-twin control design we examined a) the relationship of personality traits and emotional states with clinical and evoked pain and b) whether genetics and common environment (i.e. familial factors) may account for the associations. RESULTS Neuroticism was associated with the sensory component of the MPQ; this relationship was not confounded by familial factors. None of the emotional state measures was associated with the MPQ. PANAS negative affect was associated with lower evoked pressure pain threshold and tolerance; these associations were confounded by familial factors. There were no associations between IPIP traits and evoked pain. CONCLUSIONS A relationship exists between neuroticism and clinical pain that is not confounded by familial factors. There is no similar relationship between negative emotional states and clinical pain. In contrast, the relationship between negative emotional states and evoked pain is strong while the relationship with enduring personality traits is weak. The relationship between negative emotional states and evoked pain appears to be non-causal and due to familial factors.
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Affiliation(s)
- Eric Strachan
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA
- University of Washington Twin Registry, University of Washington, Seattle, WA
| | - Brian Poeschla
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA
| | - Elizabeth Dansie
- Department of Anesthesiology, University of Washington, Seattle, WA
| | - Annemarie Succop
- University of Washington Twin Registry, University of Washington, Seattle, WA
- Department of Medicine, University of Washington, Seattle, WA
| | - Laura Chopko
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA
- University of Washington Twin Registry, University of Washington, Seattle, WA
| | - Niloofar Afari
- University of Washington Twin Registry, University of Washington, Seattle, WA
- VA Center of Excellence for Stress and Mental Health, VA San Diego He althcare System, and Department of Psychiatry, University of California, San Diego, CA
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Twigg OC, Byrne DG. The influence of contextual variables on judgments about patients and their pain. PAIN MEDICINE 2014; 16:88-98. [PMID: 25280115 DOI: 10.1111/pme.12587] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Professional judgments about persistent pain are influenced by contextual variables, which are features relating to the patient, the assessor, or the broader situation. Such judgments directly inform assessment and treatment and therefore represent an important area of research. While current formulations of persistent pain adopt a biopsychosocial framework, contextual variables relating to psychosocial information have not been well examined in the literature. DESIGN We employed a within-subjects experimental vignette paradigm to investigate the influence of four contextual variables, 2 (medical evidence: present vs absent) × 2 (pain behavior: present vs absent) × 2 (referral to a psychologist: yes vs no) × 2 (responsibility: onset controllable vs onset uncontrollable), on perceptions of pain. Judgments about patients with chronic low back pain were made across several dimensions. SUBJECTS One hundred sixteen medical and nursing students. RESULTS Main findings revealed that identifiable pain pathology led to increased ratings of pain intensity and emotional distress, and decreased perceived likelihood of malingering. Pain behavior and referral to a psychologist were also found to increase ratings of pain intensity and emotional distress. Encouragingly, psychological referral was not found to increase the perceived likelihood of malingering. Responsibility for the initial injury was found to influence judgments, but this occurred in interaction with medical evidence as well as pain behavior. CONCLUSIONS These findings suggest that contextual variables have an important influence on medical and nursing students' perceptions of patients and their pain. Theoretical and practical implications for provider training and community education are discussed.
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Affiliation(s)
- Olivia Charlotte Twigg
- Research School of Psychology, Australian National University, Canberra, Australian Capital Territory, Australia
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Nichtspezifische, funktionelle und somatoforme Körperbeschwerden. PSYCHOTHERAPEUT 2014. [DOI: 10.1007/s00278-014-1030-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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de Siqueira SRDT, Nóbrega JCM, Teixeira MJ, de Siqueira JTT. SUNCT Syndrome Associated with Temporomandibular Disorders: A Case Report. Cranio 2014; 24:300-2. [PMID: 17086860 DOI: 10.1179/crn.2006.046] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
This case report relates the association between a rare neuralgiform syndrome (SUNCT) and masticatory myofascial pain (TMD); two different diseases with different diagnosis criteria and treatments. SUNCT syndrome was treated with a balloon microcompression procedure of the trigeminal ganglion, and the myofascial pain with injections and physical therapy. The patient was without pain at a twelve-month follow-up evaluation.
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Is physical disease missed in patients with medically unexplained symptoms? A long-term follow-up of 120 patients diagnosed with bodily distress syndrome. Gen Hosp Psychiatry 2014; 36:38-45. [PMID: 24157056 DOI: 10.1016/j.genhosppsych.2013.09.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Revised: 08/22/2013] [Accepted: 09/17/2013] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Bodily distress syndrome (BDS) was recently introduced as an empirically based, unifying diagnosis for so-called medically unexplained symptoms and syndromes. BDS relies on a specific symptom pattern rather than on a lack of objective findings, which may increase the risk of overlooking physical disease. We investigated whether physical disease was missed in the first patients diagnosed with BDS. METHOD The study was a register-based follow-up study of 120 patients diagnosed with BDS at a University Clinic from 2005 to 2007. Median follow-up time was 3.7 years. We used data containing all diagnoses from inpatient, outpatient and emergency admissions supplied by systematic review of hospital records. Medical specialists evaluated all cases of suspected overlooked physical disease. RESULTS According to registered diagnoses, none of the 120 patients had been misdiagnosed with BDS. In five cases [4.2% (95% confidence interval: 1.4-9.5)] though, we found comorbid medical problems that had not been taken properly care of alongside BDS management. These were disc protrusion, degeneration and prolapsus, hip osteoarthritis, anemia and calcific tendinitis. CONCLUSION The BDS symptom pattern reliably identified patients with multiple medically unexplained symptoms referred to tertiary care. Nevertheless, differential diagnostics remains important in order to identify comorbid medical problems that require additional treatment.
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Pike AJ. Body-mindfulness in physiotherapy for the management of long-term chronic pain. PHYSICAL THERAPY REVIEWS 2013. [DOI: 10.1179/174328808x251957] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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21
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Schaefert R, Hausteiner-Wiehle C, Häuser W, Ronel J, Herrmann M, Henningsen P. Non-specific, functional, and somatoform bodily complaints. DEUTSCHES ARZTEBLATT INTERNATIONAL 2012; 109:803-13. [PMID: 23248710 PMCID: PMC3521192 DOI: 10.3238/arztebl.2012.0803] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Accepted: 09/19/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND 4-10% of the general population and 20% of primary care patients have what are called "non-specific, functional, and somatoform bodily complaints." These often take a chronic course, markedly impair the sufferers' quality of life, and give rise to high costs. They can be made worse by inappropriate behavior on the physician's part. METHODS The new S3 guideline was formulated by representatives of 29 medical and psychological specialty societies and one patient representative. They analyzed more than 4000 publications retrieved by a systematic literature search and held two online Delphi rounds and three consensus conferences. RESULTS Because of the breadth of the topic, the available evidence varied in quality depending on the particular subject addressed and was often only of moderate quality. A strong consensus was reached on most subjects. In the new guideline, it is recommended that physicians should establish a therapeutic alliance with the patient, adopt a symptom/coping-oriented attitude, and avoid stigmatizing comments. A biopsychosocial diagnostic evaluation, combined with sensitive discussion of signs of psychosocial stress, enables the early recognition of problems of this type, as well as of comorbid conditions, while lowering the risk of iatrogenic somatization. For mild, uncomplicated courses, the establishment of a biopsychosocial explanatory model and physical/social activation are recommended. More severe, complicated courses call for collaborative, coordinated management, including regular appointments (as opposed to ad-hoc appointments whenever the patient feels worse), graded activation, and psychotherapy; the latter may involve cognitive behavioral therapy or a psychodynamic-interpersonal or hypnotherapeutic/imaginative approach. The comprehensive treatment plan may be multimodal, potentially including body-oriented/non-verbal therapies, relaxation training, and time-limited pharmacotherapy. CONCLUSION A thorough, simultaneous biopsychosocial diagnostic assessment enables the early recognition of non-specific, functional, and somatoform bodily complaints. The appropriate treatment depends on the severity of the condition. Effective treatment requires the patient's active cooperation and the collaboration of all treating health professionals under the overall management of the patient's primary-care physician.
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Affiliation(s)
- Rainer Schaefert
- Department of General Internal Medicine and Psychosomatics, Heidelberg University Hospital, Thibautstrasse 2, Heidelberg, Germany.
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Morriss R, Lindson N, Coupland C, Dex G, Avery A. Estimating the prevalence of medically unexplained symptoms from primary care records. Public Health 2012; 126:846-54. [PMID: 22922044 DOI: 10.1016/j.puhe.2012.05.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 03/08/2012] [Accepted: 05/21/2012] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To develop models to estimate the likely prevalence of medically unexplained symptoms (MUS) and severe MUS in a primary care practice from existing patient electronic records collected in the previous 2 years for secondary prevention and commissioning of psychological treatment. STUDY DESIGN Cross-sectional survey comparing general practitioners' (GPs) assessment of the presence or absence of MUS and severe MUS with clinical, demographic and service use variables associated with MUS or functional somatic syndromes from previous research in the patient's routine electronic record over the previous 2 years. METHODS Seventeen GPs from eight practices identified cases of MUS and severe MUS in 828 consecutive consulters in primary care. Models of variables associated with MUS and severe MUS were constructed using multivariate multilevel logistic regression. The predictive validity of the final models was tested, comparing predicted with observed data and expected prevalence rates from the literature. RESULTS Models to predict MUS and severe MUS had areas under the receiver operating characteristic curve of 0.70 [95% confidence interval (CI) 0.65-0.74] and 0.76 (95% CI 0.70-0.82), respectively. Both models showed adequate goodness of fit with observed data, and had good predictive validity compared with the expected prevalence of MUS, severe MUS, and anxiety or depression. CONCLUSION Models to predict the prevalence of MUS and severe MUS from routine practice records for commissioning purposes were successfully developed, but they require independent validation before general use. The sensitivity of these models was too low for use in clinical screening.
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Affiliation(s)
- R Morriss
- Department of Psychiatry, Institute of Mental Health, University of Nottingham, Innovation Park, Triumph Road, Nottingham NG7 2TU, UK.
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Abstract
The use of opioids has long been accepted as the standard of care in patients with cancer and acute pain. Opioids can further be used effectively in specific subgroups of patients with chronic nonmalignant pain states. While the development of tolerance and physical dependence are known effects of opioids in cancer and noncancer pain populations, these patients can not be regarded as addicted. However, long-term therapy with short-acting opioids predisposes to tolerance and addiction. Recent research has confirmed the important role of psychopathologic and psychosocial conditions as predictors of failed opioid effectiveness in a significant number of noncancer pain subgroups. The clinical picture of failed therapy may be complicated by noncompliance, concealed consumption of psychotropic substances, and diversion of prescribed opioids for various purposes as, e.g., selling for profit, or sharing excess opioids with others. This article discusses the effects of opioid therapy, including tolerance, physical dependence, drug-aberrant behavior, drug history, psychopathology, and somatization.
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Affiliation(s)
- Jürgen Jage
- Department of Anaesthesiology, University Hospital, Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany.
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Ciaramella A, Grosso S, Poli P, Gioia A, Inghirami S, Massimetti G, Conti L. When pain is not fully explained by organic lesion: a psychiatric perspective on chronic pain patients. Eur J Pain 2012; 8:13-22. [PMID: 14690670 DOI: 10.1016/s1090-3801(03)00062-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Recent literature demonstrates the relationship between psychopathology and medically unexplained pain, even if the results of several studies show a high degree of variability. The present study was planned with the aim of analysing both the possible relationship between the level (low/high) of organicity and the presence of psychopathology, and the degree to which these differences are related to methodological problems. Between 1998 and 2000, four hundred and thirty six consecutive patients seen at the Pisa Pain Therapy and Palliative Care Unit were requested to fill in a questionnaire, the GHQ-12, to screen the subjects probably with (GHQ-12>3) or without (GHQ-12</=3) psychopathology. All the patients scoring above the GHQ-12 threshold (score of 3), and a randomised sample of those scoring below the GHQ-12 threshold, were included in the study. These patients were then interviewed using three different instruments: the Mini International Neuropsychiatric Interview (MINI) for a standardised psychiatric diagnosis, the Semistructured Interview for Depression (SID) for the characterisation of temperament, and the Italian Pain Questionnaire (IPQ) for the evaluation of pain. Our results suggest that Somatisation Disorders are more frequent in the medically unexplained pain group than in the medically explained pain group, whereas the other psychiatric disorders have a similar prevalence in the two pain groups. Mood and anxiety disorders are correlated with high scores on GHQ-12 and medically explained pain has a higher prevalence of GHQ-12>3 than the medically unexplained pain group. These results confirm that methodology is an important factor that could modify results in psychiatric research. Both medically unexplained pain and the presence of psychopathology are significantly correlated with sex, and age: females and young patients have a higher prevalence of psychopathology and of medically unexplained pain. Our results suggest that in the correlation between the low organicity of pain and psychopathology, the age and sex play a relevant role.
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Affiliation(s)
- A Ciaramella
- Pain Therapy and Palliative Care Unit, Azienda Ospedaliera Pisana, Via Roma 67, Pisa, 56100, Italy.
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Mehta S, MacDermid J, Tremblay M. The implications of chronic pain models for rehabilitation of distal radius fracture. HAND THERAPY 2010. [DOI: 10.1258/ht.2010.010022] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Distal radius fracture (DRF) is the most common fracture and usually occurs as a result of a fall. Most patients recover following DRF with minimal residual pain or disability; however, a small subset of patients continue to experience pain and disability even one year after the injury. Currently, there are no practice guidelines for early identification and treatment of patients who are potentially at greater risk of developing these adverse outcomes. As a result, hand therapy management of patients following DRF does not incorporate screening of these at-risk patients. The objective of this paper is to apply constructs from learned helplessness and cognitive-behavioural models of chronic pain in assessing the psychosocial risk profile of patients following DRF. We have also integrated key findings derived from studies addressing personal and life-style factors in assessing this risk profile. This framework is proposed as a basis to categorize patients as higher or lower psychosocial risk for developing chronic pain and disability following DRF. We outline a model depicting the RACE approach (Reducing pain, Activating, Cognitive reshaping, Empowering) towards the management of patients following DRF. The model suggests that patients with minimal psychosocial risk factors are managed based on their injury profile and those with higher psychosocial risk are treated with the risk-based RACE approach. Using a biopsychosocial RACE approach to prognosis and treatment, hand therapy intervention can be customized for patients recovering from DRF. In future, researchers can conduct clinical trials to compare the RACE-based treatment approach to routine hand therapy in mitigating the risk of chronic pain and disability in patients with elevated risk profile for adverse outcomes following DRF.
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Affiliation(s)
- Saurabh Mehta
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Joy MacDermid
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
- Hand and Upper Limb Centre Clinical Research Laboratory, St Joseph's Health Centre, London, Ontario, Canada
| | - Mary Tremblay
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
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Schaefert R, Laux G, Kaufmann C, Schellberg D, Bölter R, Szecsenyi J, Sauer N, Herzog W, Kuehlein T. Diagnosing somatisation disorder (P75) in routine general practice using the International Classification of Primary Care. J Psychosom Res 2010; 69:267-77. [PMID: 20708449 DOI: 10.1016/j.jpsychores.2010.05.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2009] [Revised: 05/04/2010] [Accepted: 05/04/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE (i) To analyze general practitioners' diagnosis of somatisation disorder (P75) using the International Classification of Primary Care (ICPC)-2-E in routine general practice. (ii) To validate the distinctiveness of the ICD-10 to ICPC-2 conversion rule which maps ICD-10 dissociative/conversion disorder (F44) as well as half of the somatoform categories (F45.0-2) to P75 and codes the other half of these disorders (F45.3-9), including autonomic organ dysfunctions and pain syndromes, as symptom diagnoses plus a psychosocial code in a multiaxial manner. METHODS Cross-sectional analysis of routine data from a German research database comprising the electronic patient records of 32 general practitioners from 22 practices. For each P75 patient, control subjects matched for age, gender, and practice were selected from the 2007 yearly contact group (YCG) without a P75 diagnosis using a propensity-score algorithm that resulted in eight controls per P75 patient. RESULTS Of the 49,423 patients in the YCG, P75 was diagnosed in 0.6% (302) and F45.3-9 in 1.8% (883) of cases; overall, somatisation syndromes were diagnosed in 2.4% of patients. The P75 coding pattern coincided with typical characteristics of severe, persistent medically unexplained symptoms (MUS). F45.3-9 was found to indicate moderate MUS that otherwise showed little clinical difference from P75. Pain syndromes exhibited an unspecific coding pattern. Mild and moderate MUS were predominantly recorded as symptom diagnoses. Psychosocial codes were rarely documented. CONCLUSIONS ICPC-2 P75 was mainly diagnosed in cases of severe MUS. Multiaxial coding appears to be too complicated for routine primary care. Instead of splitting P75 and F45.3-9 diagnoses, it is proposed that the whole MUS spectrum should be conceptualized as a continuum model comprising categorizations of uncomplicated (mild) and complicated (moderate and severe) courses. Psychosocial factors require more attention.
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Affiliation(s)
- Rainer Schaefert
- Department of General Internal Medicine and Psychosomatics, University of Heidelberg, Thibautstrasse 2, Heidelberg, Germany.
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Burbaum C, Stresing AM, Fritzsche K, Auer P, Wirsching M, Lucius-Hoene G. Medically unexplained symptoms as a threat to patients' identity? A conversation analysis of patients' reactions to psychosomatic attributions. PATIENT EDUCATION AND COUNSELING 2010; 79:207-217. [PMID: 19914023 DOI: 10.1016/j.pec.2009.09.043] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2009] [Revised: 09/18/2009] [Accepted: 09/18/2009] [Indexed: 05/28/2023]
Abstract
OBJECTIVE Interactions between patients suffering from medically unexplained symptoms (MUS) and their physicians are usually perceived as difficult and unsatisfactory by both parties. In this qualitative study, patients' reactions to psychosomatic attributions were analyzed on a micro-level. METHODS 144 consultations between consultation-and-liaison (CL) psychotherapists and inpatients with MUS, who were treated according to a modified reattribution model, were recorded. Linguists and psychologists evaluated these consultations by applying conversation and positioning analysis. RESULTS When introducing a psychosomatic attribution, therapists use discursive strategies to exert interactional pressure on the patient; while simultaneously using careful and implicit formulations. Three linguistic patterns could be found in which patients subtly refute, drop or undermine the psychosomatic attribution in their reply. Moreover, in this context patients position themselves as somatically ill or justify their own life situation. CONCLUSION The results suggest that patients interpret psychosomatic attributions and even subtle suggestions from the psychotherapists as face-threatening 'other-positionings'. PRACTICE IMPLICATIONS When implementing the reattribution model, it should be taken into account that interactional resistance might be a necessary step in the process of the patient's understanding. Nevertheless therapists should introduce reattribution in a patient-centered rather than persuasive way and they should openly address patients' fears of being stigmatized.
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Affiliation(s)
- Christina Burbaum
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Freiburg, Freiburg, Germany.
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Psychological correlates of medical comorbidities in patients with temporomandibular disorders. J Am Dent Assoc 2010; 141:22-31. [DOI: 10.14219/jada.archive.2010.0017] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Furness P, Glazebrook C, Tay J, Abbas K, Slaveska-Hollis K. Medically unexplained physical symptoms in children: exploring hospital staff perceptions. Clin Child Psychol Psychiatry 2009; 14:575-87. [PMID: 19759075 DOI: 10.1177/1359104509338437] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Many children present at GP surgeries with debilitating symptoms with no obvious physical cause and are then referred to acute settings for investigation. Research with GPs suggests caring for this group of patients presents a significant challenge, however, the impact upon the range of hospital staff with whom they have contact has been little studied. This study aimed to explore perceptions and experiences of caring for children with medically unexplained physical symptoms (MUPS) and their families among the paediatric staff at one large UK hospital Trust. Data demonstrated staff awareness that children affected by MUPS have complex needs and the perception that those needs resulted in extra demands and anxieties, especially regarding time management, care protocols and communication. There was a clear desire by general paediatric staff for more information and training from psychiatric services to help them care for this group. Results also revealed staff perceptions of the quality of current MUPS care and suggestions as to how this could be improved.
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Affiliation(s)
- Penny Furness
- Sheffield Hallam University, 30 Collegiate Crescent, Sheffield S10 2BP, UK.
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Abstract
There are concerns about the effectiveness of health professionals when they are working with people who have pain.Health professionals have reported a lack of confidence when working with people with complex pain conditions.Review of pain education in health professional training may improve clinical practice.The International Association for the Study of Pain curricula can be useful in developing pain education initiatives.The up-dated IASP core curriculum appears to be a useful resource for curriculum designers of pre-registration physiotherapy programmes, while the IASP discipline-specific curriculum is in need of revision.
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Affiliation(s)
- Lester Jones
- Lecturer, Faculty of Health Sciences, La Trobe University, Melbourne, Australia
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Fabri GMC, Siqueira SR, Simione C, Nasri C, Teixeira MJ, Siqueira JTT. Refractory craniofacial pain: is there a role of periodontal disease as a comorbidity? ARQUIVOS DE NEURO-PSIQUIATRIA 2009; 67:474-9. [DOI: 10.1590/s0004-282x2009000300018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2008] [Accepted: 05/02/2009] [Indexed: 11/21/2022]
Abstract
OBJETIVE: To evaluate the influence of the periodontal disease (PD), a chronic infection, in patients with chronic craniofacial pain complaints. METHOD: Twenty patients with chronic craniofacial pain and PD (CFP group) and 20 patients with PD (PD group) were assessed before and after periodontal treatment (baseline, 30 and 180 days after treatment). The paramenters evaluated were: plaque index, bleeding index, clinical probe insertion, Visual Analogic Scale (VAS) for pain intensity and Numerical Rating Scale (NRS) and Verbal Rating Scale (VRS) for the "chief complaint". RESULTS: After 180 days PD was controlled in both groups (p<0.001); the VAS decreased in CFP group (p<0.001); "chief complaint" improved (p=0.005 and p=0.027, respectively in CFP and PD group). VRS showed improvement between the groups in 30 (p=0.004) and 180 days (p=0.001). CONCLUSION: These results suggest a possible influence of periodontal disease, as a comorbidity, in refractory craniofacial pain patients and in their pain levels.
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Patienten mit vorbestehender Schmerzchronifizierung und/oder psychischen Auffälligkeiten. DER ORTHOPADE 2008; 37:990, 992-6. [DOI: 10.1007/s00132-008-1335-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Dowrick C, Gask L, Hughes JG, Charles-Jones H, Hogg JA, Peters S, Salmon P, Rogers AR, Morriss RK. General practitioners' views on reattribution for patients with medically unexplained symptoms: a questionnaire and qualitative study. BMC FAMILY PRACTICE 2008; 9:46. [PMID: 18713473 PMCID: PMC2533666 DOI: 10.1186/1471-2296-9-46] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Accepted: 08/19/2008] [Indexed: 01/28/2023]
Abstract
Background The successful introduction of new methods for managing medically unexplained symptoms in primary care is dependent to a large degree on the attitudes, experiences and expectations of practitioners. As part of an exploratory randomised controlled trial of reattribution training, we sought the views of participating practitioners on patients with medically unexplained symptoms, and on the value of and barriers to the implementation of reattribution in practice. Methods A nested attitudinal survey and qualitative study in sixteen primary care teams in north-west England. All practitioners participating in the trial (n = 74) were invited to complete a structured survey. Semi-structured interviews were undertaken with a purposive sub-sample of survey respondents, using a structured topic guide. Interview transcripts were used to identify key issues, concepts and themes, which were grouped to construct a conceptual framework: this framework was applied systematically to the data. Results Seventy (95%) of study participants responded to the survey. Survey respondents often found it stressful to work with patients with medically unexplained symptoms, though those who had received reattribution training were more optimistic about their ability to help them. Interview participants trained in reattribution (n = 12) reported that reattribution increased their confidence to practice in a difficult area, with heightened awareness, altered perceptions of these patients, improved opportunities for team-building and transferable skills. However general practitioners also reported potential barriers to the implementation of reattribution in routine clinical practice, at the level of the patient, the doctor, the consultation, diagnosis and the healthcare context. Conclusion Reattribution training increases practitioners' sense of competence in managing patients with medically unexplained symptoms. However, barriers to its implementation are considerable, and frequently lie outside the control of a group of practitioners generally sympathetic to patients with medically unexplained symptoms and the purpose of reattribution. These findings add further to the evidence of the difficulty of implementing reattribution in routine general practice.
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Affiliation(s)
- Christopher Dowrick
- Division of Primary Care, School of Population, Community and Behavioural Sciences, University of Liverpool, Liverpool L69 3GB, UK.
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Nóbrega JCM, Siqueira SRDTD, Siqueira JTTD, Teixeira MJ. Diferential diagnosis in atypical facial pain: a clinical study. ARQUIVOS DE NEURO-PSIQUIATRIA 2008; 65:256-61. [PMID: 17607424 DOI: 10.1590/s0004-282x2007000200013] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2006] [Accepted: 12/07/2006] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate a sample of patients with atypical facial pain (AFP) in comparison to patients with symptomatic facial pain (SFP). METHOD 41 patients with previous diagnostic of AFP were submitted to a standardized evaluation protocol, by a multidisciplinary pain team. RESULTS 21 (51.2%) were considered AFP and 20 (48.8%) (SFP) received the following diagnosis: 8 (40.0%) had temporomandibular disorders (TMD); 3 (15.0%) had TMD associated to systemic disease (fibromyalgia, systemic erythematosus lupus); 4 (20.0%) had neuropathy after ear, nose and throat (ENT) surgery for petroclival tumor; 2 (10.0%) had Wallenberg syndrome; 1 (5.0%) had intracranial tumor; 1 (5.0%) had oral cancer (epidermoid carcinoma), and 1 (5.0%) had burning mouth syndrome (BMS) associated to fibromyalgia. Spontaneous descriptors of pain were not different between AFP and SFP groups (p=0.82). Allodynia was frequent in SFP (p=0.05) and emotion was the triggering factor most prevalent in AFP (p=0.06). AFP patients had more traumatic events previously to pain (p=0.001). CONCLUSION AFP patients had more: a) traumatic events previously to pain onset, and b) emotions as a triggering factor for pain. These data support the need of trained health professionals in multidisciplinary groups for the accurate diagnosis and treatment of these patients.
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Dickson A, Knussen C, Flowers P. Stigma and the delegitimation experience: An interpretative phenomenological analysis of people living with chronic fatigue syndrome. Psychol Health 2007. [DOI: 10.1080/14768320600976224] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Marazziti D, Mungai F, Vivarelli L, Presta S, Dell'Osso B. Pain and psychiatry: a critical analysis and pharmacological review. Clin Pract Epidemiol Ment Health 2006; 2:31. [PMID: 17087832 PMCID: PMC1660535 DOI: 10.1186/1745-0179-2-31] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2006] [Accepted: 11/06/2006] [Indexed: 11/10/2022]
Abstract
Pain is one of the most difficult medical problems to diagnose and treat and can be a common symptom of several psychiatric disorders. Pain-related issues are heterogeneous and often underestimated or misinterpreted, with the result that psychiatric interventions, which might have been beneficial from the outset, are often delayed or requested only as a last measure. Several problems arise from the definition, classification and assessment of pain, when documented according to the different scales which are commonly used, since these attempt to cover a multitude of analytical requirements, without really succeeding. An area of constant debate regards the connection between pain and various psychiatric disorders, and the difficulty in the classification of pain disorders within the currently existing framework. The pharmacological treatment of pain is complex and implies a variety of different compounds, from opioids to psychotropic medications like antidepressants and anticonvulsivants. This paper explores the mutual and reciprocal influence between pain and psychiatric disorders reviewing the latest developments in the definition, assessment and treatment of pain, with special emphasis on the impact of pain on psychiatric disorders (and vice versa), and on the use of psychotropic drugs in the treatment of pain syndromes.
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Affiliation(s)
- Donatella Marazziti
- Dipartimento di Psichiatria, Neurobiologia, Farmacologia e Biotecnologie, University of Pisa, Italy
| | - Francesco Mungai
- Dipartimento di Psichiatria, Neurobiologia, Farmacologia e Biotecnologie, University of Pisa, Italy
| | - Laura Vivarelli
- Dipartimento di Psichiatria, Neurobiologia, Farmacologia e Biotecnologie, University of Pisa, Italy
| | - Silvio Presta
- Dipartimento di Psichiatria, Neurobiologia, Farmacologia e Biotecnologie, University of Pisa, Italy
| | - Bernardo Dell'Osso
- Compulsive, Impulsive and Anxiety Disorders Program, Department of Psychiatry, Mount Sinai School of Medicine, New York, NY, USA
- Department of Psychiatry, Institute of Biomedical Sciences, Hospital "L. Sacco", University of Milan, Via G.B. Grassi 74, 20157, Milan, Italy
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Eriksen J, Sjøgren P, Bruera E, Ekholm O, Rasmussen NK. Critical issues on opioids in chronic non-cancer pain:. Pain 2006; 125:172-9. [PMID: 16842922 DOI: 10.1016/j.pain.2006.06.009] [Citation(s) in RCA: 358] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2005] [Revised: 06/07/2006] [Accepted: 06/08/2006] [Indexed: 11/22/2022]
Abstract
The aim of the study was epidemiologically to evaluate the long-term effects of opioids on pain relief, quality of life and functional capacity in long-term/chronic non-cancer pain. The study was based on data from the 2000 Danish Health and Morbidity Survey. As part of a representative National random sample of 16,684 individuals (>16 years of age), 10,066 took part in an interview and completed a self-administered questionnaire. Cancer patients were excluded. The interview and the self-administered questionnaire included questions on chronic/long-lasting pain (>6 months), health-related quality of life (SF-36), use of the health care system, functional capabilities, satisfaction with medical pain treatment and regular or continuous use of medications. Participants reporting pain were divided into opioid and non-opioid users. The analyses were adjusted for age, gender, concomitant use of anxiolytics and antidepressants and pain intensity. Pain relief, quality of life and functional capacity among opioid users were compared with non-opioid users. Opioid usage was significantly associated with reporting of moderate/severe or very severe pain, poor self-rated health, not being engaged in employment, higher use of the health care system, and a negative influence on quality of life as registered in all items in SF-36. Because of the cross-sectional nature causative relationships cannot be ascertained. However, it is remarkable that opioid treatment of long-term/chronic non-cancer pain does not seem to fulfil any of the key outcome opioid treatment goals: pain relief, improved quality of life and improved functional capacity.
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Affiliation(s)
- Jørgen Eriksen
- Multidisciplinary Pain Centre, H:S Rigshospitalet, Copenhagen, Denmark
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Richardson C, Adams N, Poole H. Psychological approaches for the nursing management of chronic pain: part 2. J Clin Nurs 2006; 15:1196-202. [PMID: 16911061 DOI: 10.1111/j.1365-2702.2006.01456.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
AIMS AND OBJECTIVES The aim of this article was to present the ways that nurses can integrate psychological approaches into their management of chronic pain conditions using a biopsychosocial framework. Communication, the importance of the patient-practitioner interaction, the role of education and provision of information, reassurance and reduction of anxiety and the use of coping strategies training in the management of chronic pain are reviewed alongside the key skills of nursing. BACKGROUND This is the second part of a two-part article. Part 1 was a discussion of psychosocial factors associated with chronic pain conditions and the psychological approaches used in the management of these conditions. CONCLUSIONS It is identified that key nursing skills often equate to the requirements of the psychological approaches, therefore specific techniques from a cognitive-behavioural framework can be readily applied, integrated and used by nurses in the management of chronic pain conditions. RELEVANCE TO CLINICAL PRACTICE Commonly utilized nursing skills are similar to those required for cognitive-behavioural therapy. It is reasonable to assume therefore that nurses can and should be involved in effectively managing the psychological aspects associated with chronic pain conditions.
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Affiliation(s)
- Clifford Richardson
- School of Nursing, Midwifery and Social work, University of Manchester, South Piccadilly, Manchester, UK
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Engel CC, Hyams KC, Scott K. Managing future Gulf War Syndromes: international lessons and new models of care. Philos Trans R Soc Lond B Biol Sci 2006; 361:707-20. [PMID: 16687273 PMCID: PMC1569617 DOI: 10.1098/rstb.2006.1829] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
After the 1991 Gulf War, veterans of the conflict from the United States, United Kingdom, Canada, Australia and other nations described chronic idiopathic symptoms that became popularly known as 'Gulf War Syndrome'. Nearly 15 years later, some 250 million dollars in United States medical research has failed to confirm a novel war-related syndrome and controversy over the existence and causes of idiopathic physical symptoms has persisted. Wartime exposures implicated as possible causes of subsequent symptoms include oil well fire smoke, infectious diseases, vaccines, chemical and biological warfare agents, depleted uranium munitions and post-traumatic stress disorder. Recent historical analyses have identified controversial idiopathic symptom syndromes associated with nearly every modern war, suggesting that war typically sets into motion interrelated physical, emotional and fiscal consequences for veterans and for society. We anticipate future controversial war syndromes and maintain that a population-based approach to care can mitigate their impact. This paper delineates essential features of the model, describes its public health and scientific underpinnings and details how several countries are trying to implement it. With troops returning from combat in Afghanistan, Iraq and elsewhere, the model is already getting put to the test.
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Affiliation(s)
- Charles C Engel
- Department of Veterans Affairs, VA Central Office (13A) Office of Public Health and Environmental Hazards, Washington, DC 20420, USA.
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Adams EH, Breiner S, Cicero TJ, Geller A, Inciardi JA, Schnoll SH, Senay EC, Woody GE. A comparison of the abuse liability of tramadol, NSAIDs, and hydrocodone in patients with chronic pain. J Pain Symptom Manage 2006; 31:465-76. [PMID: 16716877 DOI: 10.1016/j.jpainsymman.2005.10.006] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/10/2005] [Indexed: 11/16/2022]
Abstract
Concern about abuse/dependence in chronic pain patients taking opioid analgesics may lead to undertreatment of pain, yet little is known about the prevalence of abuse/dependence in these patients and how it differs among analgesic agents. The objective of this study was to assess the prevalence of tramadol abuse compared to nonsteroidal anti-inflammatory drugs (NSAIDs) and hydrocodone-containing analgesics in patients with chronic noncancer pain (CNP). The study had three arms. The first arm consisted of subjects prescribed tramadol alone; the second of subjects randomized to either NSAIDs or tramadol; and the third of subjects randomized to hydrocodone or tramadol. Each investigator received two boxes of prescriptions randomized so that one in every four prescriptions was for tramadol. Upon deciding on the therapeutically appropriate arm, the physician selected the appropriate box, opened the next envelope and completed the enclosed prescription. After the initial randomization, physicians could prescribe whatever medication was therapeutically appropriate. A total of 11,352 subjects were enrolled. Up to nine interviews using a structured questionnaire were conducted over a 12-month period. An algorithm called the "Abuse Index" was developed to identify subjects who were abusing the drug. The primary components of the index were increasing dose without physician approval, use for purposes other than intended, inability to stop its use, and withdrawal. The percent of subjects who scored positive for abuse at least once during the 12-month follow-up were 2.5% for NSAIDs, 2.7% for tramadol, and 4.9% for hydrocodone. When more than one hit on the algorithm was used as a measure of persistence, abuse rates were 0.5% for NSAIDs, 0.7% for tramadol, and 1.2% for hydrocodone. Thus, the results of this study suggest that the prevalence of abuse/dependence over a 12-month period in a CNP population that was primarily female was equivalent for tramadol and NSAIDs, with both significantly less than the rate for hydrocodone.
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Affiliation(s)
- Edgar H Adams
- Edgar Adams Consulting, Covance, Princeton, New Jersey 08540, USA.
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Abstract
Perceived poisoning may manifest in numerous ways; however, all cases share certain characteristics. All are fostered by the wide availability of unreliable information about chemical safety, poor understanding of scientific principles, and ineffective risk communication. Although this problem is still incompletely understood, some approaches have been demonstrated to be useful, such as education about risk, appropriate reassurance, and empathy on the part of the practitioner. Successful management may curtail the spread or exacerbation of symptoms, whereas unsuccessful treatment may cause the problems to escalate, with detrimental effects on both society and patient.
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Affiliation(s)
- Kristine A Nañagas
- Division of Medical Toxicology, Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN 46206-1367, USA.
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Jage J, Willweber-Strumpf A, Maier C. Risikofaktoren für Missbrauch und Abhängigkeit bei der Opioidtherapie chronischer nicht-tumorbedingter Schmerzen. Schmerz 2005; 19:434-6, 437-40. [PMID: 16133301 DOI: 10.1007/s00482-005-0426-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Opioids are valuable analgesics, capable of providing pain relief and functional improvement not only in patients with cancer-related pain, but also in chronic noncancer-related pain patients. However, recent data have shown that the increasing prescription of opioids is associated with a rise in aberrant drug-related behaviour. The causes of this behaviour are multifactorial. Some pharmacotherapeutic, but in particular psychosocial risk and etiologic pain factors have been identified. The indication for the prescription of opioids must be very carefully weighed in the presence of any risk factors. In these cases the integration into a multimodal, interdisciplinary therapy programme is mandatory. A contractual agreement on the opioid therapy including goals, side effects, controls including urine drug testing and criteria to finish the opioid therapy are advisable. Assessment of the progress of therapy is based on the following factors: analgesic efficacy, adverse side effects, functional status and aberrant drug-related behaviour. In the absence of a successful opioid therapy, the treatment must be discontinued to avoid iatrogenic damage, substance abuse and illegal diversion. After discontinuation of the therapy, a comprehensive interdisciplinary re-evaluation is required.
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Affiliation(s)
- J Jage
- Klinik für Anästhesiologie, Klinikum der Johannes-Gutenberg-Universität, Mainz.
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Silberstein SD, Olesen J, Bousser MG, Diener HC, Dodick D, First M, Goadsby PJ, Göbel H, Lainez MJA, Lance JW, Lipton RB, Nappi G, Sakai F, Schoenen J, Steiner TJ. The International Classification of Headache Disorders, 2nd Edition (ICHD-II)--revision of criteria for 8.2 Medication-overuse headache. Cephalalgia 2005; 25:460-5. [PMID: 15910572 DOI: 10.1111/j.1468-2982.2005.00878.x] [Citation(s) in RCA: 286] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Townsend CO, Sletten CD, Bruce BK, Rome JD, Luedtke CA, Hodgson JE. Physical and emotional functioning of adult patients with chronic abdominal pain: Comparison with patients with chronic back pain. THE JOURNAL OF PAIN 2005; 6:75-83. [PMID: 15694873 DOI: 10.1016/j.jpain.2004.10.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2004] [Revised: 10/02/2004] [Accepted: 10/20/2004] [Indexed: 01/01/2023]
Abstract
UNLABELLED Adults with chronic abdominal pain remain a poorly defined population, despite the debilitation and depression associated with this therapeutically challenging condition. This study compared patients with chronic abdominal pain with an empirically well-known group of patients with chronic pain (back pain) to investigate similarities and differences in their physical and mental functioning. This retrospective, cross-sectional study included 136 patients with abdominal pain and 364 patients with back pain seen in a comprehensive pain rehabilitation center. Patients' functioning was assessed with the Short Form-36 Health Survey, Multidimensional Pain Inventory, Center for Epidemiological Studies-Depression scale, and Coping Strategies Questionnaire-Catastrophizing subscale. Both the abdominal and back pain patients reported long-standing and severe pain, numerous surgery procedures, poor functioning, and high prevalence of depression. When age, education, and marital status were controlled for, analyses showed that although patients with abdominal pain reported significantly better physical functioning than patients with back pain (P < .001), their overall health perception was significantly poorer (P < .001). Although less prevalent, it is clear that patients with chronic abdominal pain exhibit poor functioning and prevalence of depression that are comparable to patients with chronic back pain. This study also suggests distinct characteristics that are vital to consider for effective treatment of this chronic pain population. PERSPECTIVE As a result of being an overlooked and poorly defined population, adults with chronic abdominal pain might not receive adequate pain management treatment. Learning more about the physical and emotional functioning of patients with long-standing abdominal pain can increase recognition of the needs of and improve treatment for this population.
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Affiliation(s)
- Cynthia O Townsend
- Department of Psychiatry and Psychology, Pain Rehabilitation Center, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Siqueira JTTD, Lin HC, Nasri C, Siqueira SRDTD, Teixeira MJ, Heir G, Valle LBS. Clinical study of patients with persistent orofacial pain. ARQUIVOS DE NEURO-PSIQUIATRIA 2004; 62:988-96. [PMID: 15608957 DOI: 10.1590/s0004-282x2004000600011] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJETIVE: To evaluate a sample of patients with persistent facial pain unresponsive to prior treatments. METHODS: Hospital records of 26 patients with persistent facial pain were reviewed (20 female and 6 male). RESULTS: Patients were classified into three groups according to their presenting symptoms: a)Group I, eight patients (30.7%) with severe, diffuse pain at the face, teeth or head; b)Group II, eight patients (30.7%) with chronic non-myofascial pain and; c)Group III, ten patients with chronic myofascial pain (38.4%). We find 11 different diagnoses among the 26 patients: pulpitis(7), leukemia(1), oropharyngeal tumor(1), atypical odontalgia(1), Eagle's syndrome(1), trigeminal neuralgia(4), continuous neuralgia(1), temporomandibular disorders (9), fibromyalgia (2), tension-type headache(1), conversion hysteria(2). After the treatment program all patients had a six-month follow-up period with pain relief, except the patient with tumor. CONCLUSION: The wide variability of orofacial pain diagnosis (benign to life-threatening diseases) indicates the necessity to reevaluate patients presenting recurrent pain that is refractory to the usual treatments.
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Brown RJ. Psychological mechanisms of medically unexplained symptoms: an integrative conceptual model. Psychol Bull 2004; 130:793-812. [PMID: 15367081 DOI: 10.1037/0033-2909.130.5.793] [Citation(s) in RCA: 287] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Theories of medically unexplained illness based on the concepts of dissociation, conversion, and somatization are summarized. Evidence cited in support of these theories is described and the conceptual strengths and shortcomings of each approach are considered. It is argued that each of these approaches adds to the understanding of unexplained illness but that none is able to provide a comprehensive explanation of the phenomenon. An integrative conceptual model of unexplained illness based on cognitive psychological principles is then presented. This model attempts to combine existing theoretical approaches within a single explanatory framework, extending previous theory by explaining how compelling symptoms can exist in the absence of organic pathology. The clinical and empirical implications of the model are then considered.
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Affiliation(s)
- Richard J Brown
- Academic Division of Clinical Psychology, University of Manchester, Manchester, United Kingdom.
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48
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49
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Henningsen P. [The psychosomatics of chronic back pain. Classification, aetiology and therapy]. DER ORTHOPADE 2004; 33:558-67. [PMID: 15138684 DOI: 10.1007/s00132-003-0615-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
An overview is given on the current classification, description and treatment of chronic pain with causally relevant psychological factors. It is based on the "practice guidelines on somatoform disorders" and on a thematically related meta-analysis. The classificatory problems, especially of the demarcation of somatoform and other chronic pain, are presented. Additional descriptive dimensions of the relevant psychosocial factors are: pain description, other organically unexplained pain- and non-pain-symptoms, anxiety and depression, disease conviction and illness behaviour, personality and childhood abuse. A modified psychotherapy for (somatoform) chronic pain is outlined. Finally, this aetiologically oriented psychosomatic-psychiatric approach is compared to psychological coping models for chronic pain.
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Affiliation(s)
- P Henningsen
- Psychosomatische Klinik der Universität Heidelberg.
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50
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Ring A, Dowrick C, Humphris G, Salmon P. Do patients with unexplained physical symptoms pressurise general practitioners for somatic treatment? A qualitative study. BMJ 2004; 328:1057. [PMID: 15056592 PMCID: PMC403850 DOI: 10.1136/bmj.38057.622639.ee] [Citation(s) in RCA: 129] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To identify the ways in which patients with medically unexplained symptoms present their problems and needs to general practitioners and to identify the forms of presentation that might lead general practitioners to feel pressurised to deliver somatic interventions. DESIGN Qualitative analysis of audiorecorded consultations between patients and general practitioners. SETTING 7 general practices in Merseyside, England. PARTICIPANTS 36 patients selected consecutively from 21 general practices, in whom doctors considered that patients' symptoms were medically unexplained. MAIN OUTCOME MEASURES Inductive qualitative analysis of ways in which patients presented their symptoms to general practitioners. RESULTS Although 34 patients received somatic interventions (27 received drug prescriptions, 12 underwent investigations, and four were referred), only 10 requested them. However, patients presented in other ways that had the potential to pressurise general practitioners, including: graphic and emotional language; complex patterns of symptoms that resisted explanation; description of emotional and social effects of symptoms; reference to other individuals as authority for the severity of symptoms; and biomedical explanations. CONCLUSIONS Most patients with unexplained symptoms received somatic interventions from their general practitioners but had not requested them. Though such patients apparently seek to engage the general practitioner by conveying the reality of their suffering, general practitioners respond symptomatically.
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Affiliation(s)
- Adele Ring
- Department of Clinical Psychology, University of Liverpool, Whelan Building, Brownlow Hill, Liverpool L69 3GB
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