Subjective future as a mediating factor in the relation between pain, pain-related distress and depression

Web-based cognitive behavior therapy for chronic pain patients with aberrant drug-related behavior: How did it work and for whom?

This study explored mediating pathways, moderating factors, and moderated mediation effects of a web-based, cognitive behavioral therapy (CBT) intervention for chronic pain patients with aberrant drug-related behavior (ADRB). In a 2-arm RCT, patients with chronic pain who screened positive for ADRB received treatment-as-usual (TAU, n = 55) or TAU plus a 12-week, web-based CBT intervention (n = 55). Assessments were conducted at weeks 4, 8, and 12, and at 1- and 3-months post intervention. Web-CBT significantly reduced pain catastrophizing, which, in turn, reduced pain interference and pain severity via a pathway of pain catastrophizing. Web-CBT also significantly reduced ADRB both directly and indirectly by reducing pain catastrophizing. For pain interference and pain severity, web-CBT was more effective than TAU for younger patients (≤ age 50). For pain severity, web-CBT was more effective for both younger patients (≤ age 50), and those with a lifetime substance use disorder. Findings suggest that web-CBT's positive impact on pain outcomes and ADRB are mediated by its effect on pain catastrophizing, and its treatment effects may be most robust for younger patients and those with histories of substance dependence.

A multi-facet pain survey of psychosocial complaints among patients with long-standing non-malignant pain

Background and aims

Psychometric inventories and scales intended to measure cognitive, emotional and behavioural concomitants of pain are typically constructed by deducting items from theoretically derived concepts related to pain states, e.g. social support, perceived control, depressiveness, and catas- trophizing. The aim of this study was to design a clinically useful, generic pain distress inventory - The Multi-Facet Pain Survey (MFPS) - inductively derived from psychological and social complaints reported by a study group of individuals with severe chronic nonmalignant pain.

Methods

Extensive clinical interviews with hospitalized chronic pain patients were made by clinical psychologists. The purpose was to highlight the patients’ pain histories and their beliefs and feelings about the pain, and to determine factors possibly influencing their rehabilitation potential. The types of distress reported were sorted into categories with a procedure similar to content analysis. Distress reports were converted to statements, forming items in a questionnaire, the Multi-Facet Pain Survey.

Results

Our analyses supported a distress structure including 15 categories, or “facets”, comprising in all 190 types of psychosocial distress. Ten of the facets denote beliefs about the present condition and aspects of distress experienced in daily life (e.g. cognitive problems); three facets reflect the illness history, and two the patient’s views on future prospects. To improve the clinical utility, we shortened the scale into a 53 items inventory. A factor analysis of these 53 items revealed four clinically meaningful factors: (1) stress-related exhaustion; (2) impact of pain on daily life; (3) self-inefficacy in regard to future prospects; and (4) negative experiences of health care. While the second factor represents distress directly related to the pain, the first factor reflects long-term exhaustion effects of the pain condition similar to those seen in individuals exposed to long periods of stress. Items loading in the third factor reflect a pessimistic outlook on the future. The content validity of the scale was explored by predicting and testing correlations between the 15 MFPS facets, and the Symptom Checklist (SCL-90) and the West Haven Yale Multidimensional Pain Inventory (MPI). Some of the MFPS facets showed little or no agreement with any of the subscales of the comparison measures. The homogeneity was satisfactory both for facets and factors.

Conclusions

The Multi-Facet Pain Survey (MFPS) facets cover a broad array of experienced psychosocial distress in patients with severe, longstanding pain. Some facets of psychosocial impact of longstanding pain states shown in the qualitatively derived distress facets, or by the latent factors found in the factor analysis, may complement our understanding of the long-term impact of pain. Consequently, MFPS may improve the assessment of psychological and social complaints and complications in patients with chronic pain.

Implications

The MFPS will hopefully be an assessment tool supporting the psychological contribu-tion to a biopsychosocial evaluation of patients with severe, longstanding pain. By exposing a broadrange of suffering, MFPS may contribute to alternative treatment options and a better prognosis of future rehabilitation.

Web-Delivered CBT Reduces Heavy Drinking in OEF-OIF Veterans in Primary Care With Symptomatic Substance Use and PTSD

Veterans from conflicts such as the wars in Iraq and Afghanistan commonly return with behavioral health problems, including posttraumatic stress disorder (PTSD) and hazardous or harmful substance use. Unfortunately, many veterans experience significant barriers to receiving evidence-based treatment, including poor treatment motivation, concerns about stigma, and lack of access to appropriate care. To address this need, the current study developed and evaluated a web-based self-management intervention based on cognitive behavioral therapy (CBT), targeting PTSD symptoms and hazardous substance use in a group of symptomatic combat veterans enrolled in VA primary care. Veterans with PTSD/subthreshold PTSD and hazardous substance use were randomized to primary care treatment as usual (TAU; n = 81) or to TAU plus a web-based CBT intervention called Thinking Forward (n = 81). Thinking Forward consisted of 24 sections (approximately 20 minutes each), accessible over 12 weeks. Participants completed baseline and 4-, 8-, 12-, 16-, and 24-week follow-up assessments. Three primary outcomes of PTSD, alcohol and other drug use, and quality of life were examined. Significant treatment effects were found for heavy drinking, but not for PTSD or quality of life. The effect of the intervention on heavy drinking was mediated by intervening increases in coping, social support, self-efficacy, and hope for the future. These results demonstrate the promise of a web-based, self-management intervention for difficult-to-engage OEF/OIF veterans with behavioral health and substance use concerns.

The pain experience and future expectations of chronic low back pain patients following spinal fusion

AIM

In a sample of patients who underwent instrumented spinal fusions for chronic low back pain (CLBP), the purposes of this study were: to determine the amount of pain patients experienced and to determine the impact of length of time since surgery, use of pain medication and their outlook on the future on these pain intensity scores.

BACKGROUND

An increasing number of people report CLBP and one of the treatments is instrumented fusion.

METHOD

The study used a cross-sectional design. Visual analogue scales were used to measure pain intensity in different locations and a single item measured patients' view of the future. Data were collected in November 2001.

RESULTS

The sample consisted of 101 patients (71% women) aged 26-59 years treated with instrumented fusion 1-8 years ago. As many as 87% reported pain 1-8 years after the surgery. Most patients reported pain of low-to-moderate intensity in the neck and shoulders, back and hips, feet and legs and in total pain. As many as 45% of the patients did not take pain medication and patients using more analgesics reported more pain than those using fewer analgesics (p < 0.05). Patients with a more positive outlook on the future reported significantly less pain in all of the locations that were evaluated (p < 0.01).

CONCLUSION

A high percentage of patients with CLBP continue to experience pain 1-8 years after spinal fusion. A positive outlook towards the future seems to be associated with less pain in these patients. Relevance to clinical practice. Patients who continue to experience pain and have a more negative outlook on the future may benefit from psychoeducational interventions that teach them how to better cope with their pain.

Living with low back pain-Stories of hope and despair

Previous qualitative research has illustrated a range of issues about the daily life of people living with low back pain (LBP). In this paper, we consider the struggle between hope and despair through consideration of six people's narratives about their experiences of chronic LBP. The six cases were selected from a larger qualitative study of 37 patients in the UK, sampled from a prospective cohort of people consulting their general practitioner. These six cases were selected for particular focus as they exemplify the fluctuating emotions of hope and despair. A number of linked themes emerged which influenced the extent to which people oscillate between hope and despair, the most salient of which were 'uncertainty', 'impact on self', 'social context of living with pain', and 'worry and fear of the future'. It is clear from the narrative accounts that it is not only just physical pain that the back pain sufferer must endure, but also that the psychosocial implications pose an added and often complicated challenge. Health care practitioners should consider these fluctuating emotions of hope and despair in order to facilitate more patient-centred strategies for treatment.

Level of distress among workers undergoing work rehabilitation for musculoskeletal disorders

INTRODUCTION

Many studies have documented the high distress rates and their correlates among individuals experiencing persistent pain due to a musculoskeletal disorder (MSD). However, few have adopted a biopsychosocial perspective to understand this issue.

OBJECTIVE

The first objective of this study was to examine workers' distress levels before they start work rehabilitation and to compare it to those in a healthy population. The second objective was to assess the correlations between distress and biopsychosocial factors.

METHODS

The participants were 228 workers on sick leave due to persistent pain from an MSD and who were referred to an interdisciplinary work rehabilitation program.

RESULTS

The workers had very high distress levels compared to normative data. Also, the results of a multiple regression showed that duration of absence, high occupational stress, perception of disability, and fear of movement and (re)injury were significantly associated with distress.

CONCLUSIONS

These results highlight the importance of considering distress not only as a predictor of work disability, but as an independent outcome measure. This shift of paradigm could provide a more comprehensive approach in the understanding of workers' disability.

Living with a body separate from the self. The experience of the body in chronic benign low back pain: an interpretative phenomenological analysis

This paper presents an in-depth, idiographic study exploring the personal experience of chronic benign low back pain in relation to the participant's body and sense of self. Semi-structured interviews were conducted with patients and the resultant transcripts subjected to interpretative phenomenological analysis. One theme is presented in detail: 'Living with a body separate from the self', whereby when out of pain the body has little salience to the self yet when in pain it is consciously excluded from the self. The complex and paradoxical relationship between the body, chronic pain and the self is explored and evidence is provided to argue that the embodied unpleasantness of chronic pain involves an assault upon and a defence of a preferred or desirable self. The results are considered in relation to relevant themes in the extant literature.

Refractory chronic pain

Refractory chronic pain is a significant public health problem and frustrating to everyone affected by it. All physicians can participate in the care of these patients, but psychiatrists should take a leading role in their care. A comprehensive approach offers hope and increases the opportunities for successful treatment. Each perspective of an interdisciplinary formulation has a unique logic that defines specific methods for designing treatment for the patient with refractory chronic pain. The patient does not have to fit into one theoretic approach or model to receive and accept treatment. The patient's diagnoses are based on the formulation, which then directs treatment along rational directions. The linkages and interactions of a patient's diagnoses can then be investigated within a framework that includes the entire person and not just his or her biochemistry. If a patient's suffering persists, other factors must be considered that may have been overlooked before the treatment plan is abandoned or modified. Usually these factors are within one of the perspectives initially thought to be less important. A new combination of approaches is then required to treat the patient successfully. The perspectives appreciate not only that the patient is struggling through important life events but also that he is a person composed of vulnerabilities and strengths, having made many choices and afflicted by diseases.

Perceived future in chronic pain: the relationship between outlook on future and empirically derived psychological patient profiles

Perceived (subjective) future has been found to be a significant factor in explaining the relationship between pain and pain-related distress. The present study is based on the assumption that chronic pain patients with the three psychological profiles introduced by Turk and Rudy in 1988 could also be found in a sample of chronic pain patients and if so, these profiles have different perspectives on the future. The Multidimensional Pain Inventory (MPI) and The Future Scale were used to collect data from 569 patients with heterogeneous non-malignant chronic pain. A cluster analysis was conducted, where the resulting clusters closely resembled the profiles labelled by Turk and Rudy as 'dysfunctional', 'interpersonally distressed' and 'adaptive coper'. The results indicated that patients with adaptive coper profile have a more positive perception, while those with an interpersonally distressed profile have a more negative perception of the future. With an increased duration of pain, the proportion of the adaptive coper category decreased linearly, while an opposite trend was noted for the interpersonally distressed category. These results may better enable profiled psychological interventions in clinical pain treatment, e.g. by providing patients with therapies focused on positive future orientation, resulting in increased motivation for health-seeking behaviour and better abilities to cope with pain.