Patients' Perceptions of Their Pain Condition Across a Multidisciplinary Pain Management Program

Treatment of last resort? Psychological therapy seeking in chronic pain patients

OBJECTIVE

Our goal was to assess how many chronic pain patients seek psychological treatment for their condition and what psychological and demographic characteristics are associated with that decision.

METHODS

The association between pain intensity, quality of life and psychological treatment seeking was tested in two hypothetical models which differed according to beliefs about either external or internal control over pain.

RESULTS

A minority of patients had experience with psychological treatment of chronic pain. Patients who had that experience were younger, suffered from more intense pain, and applied many more coping strategies than patients who never tried this kind of treatment. Intense pain and low quality of life motivated chronic pain patients to seek psychological treatment only if they believed that doctors could control their pain.

DISCUSSION

The study results stress the importance of diversifying the methods used to treat chronic pain and educating patients about the benefits of psychological treatment. Low numbers of chronic pain patients who take advantage of psychological treatment indicate that encouragement from medical professionals might be necessary.

Effectiveness of a Primary Care Multidisciplinary Treatment for Patients with Chronic Pain Compared with Treatment as Usual

To manage chronic pain, multidisciplinary interventions have been increasingly deployed, mostly in secondary or tertiary care settings. Evidence on the effectiveness of multidisciplinary intervention within primary care is scarce. This study examined the effectiveness of a primary care multidisciplinary treatment for chronic pain compared with treatment as usual (TAU). The intervention consisted of pain neuroscience education and treatment by a GP, psychologist, and physiotherapist. Both groups filled out patient-reported outcome measures at baseline, 6 months, and 12 months. The results indicated there were no statistically significant differences for the primary outcomes of pain intensity, number of pain sites, and health-related quality of life (HR-QoL). There was a statistically significant difference in the secondary outcome perceived health change in favor of the intervention group. None of the other differences were statistically significant. A post-hoc analysis showed that there were statistically significant effects on patients' illness perceptions in favor of the intervention group. Based on the results, the findings do not support effectiveness of a low intensity outpatient multidisciplinary primary care treatment to treat chronic pain compared with TAU. However, as a result of several study limitations, it is considered unwarranted to conclude that multidisciplinary treatment in primary care is not valuable at all.

The role of illness perceptions and exercise beliefs in exercise engagement during treatment for cancer

OBJECTIVES

This study examined whether exercise beliefs and illness perceptions were associated with changes in exercise behaviour following a cancer diagnosis.

DESIGN

This study uses a cross-sectional survey of 366 adults with a diagnosis of cancer, who were currently receiving treatment.

MAIN OUTCOME MEASURES

The main outcome measures are symptom severity, pre- and post-morbid exercise levels, exercise beliefs, and illness perceptions.

RESULTS

The majority of participants decreased their level of exercise after diagnosis (Decreasers; 58.1%). Approximately a third increased participation (Increasers; 30.4%) and a small group maintained (Maintainers; 9.2%) their pre-diagnosis exercise levels. After controlling for symptom severity and time since cancer diagnosis, Decreasers reported lower Self-Efficacy for exercise, higher levels of belief in the Negative Impact on Cancer of exercise, lower levels of Personal Control, and less Emotional Representation of their illness, than Increasers. Decreasers also reported lower levels of Self-Efficacy for exercise than Maintainers.

CONCLUSION

The results suggest that identifying unhelpful beliefs about the relationship between exercise and illness during cancer treatment and improving confidence and control of exercise through psycho-educational intervention could be an effective strategy for preventing cancer patients decreasing exercise following their diagnosis.

Prognostic Factors for Physical Functioning After Multidisciplinary Rehabilitation in Patients With Chronic Musculoskeletal Pain: A Systematic Review and Meta-Analysis

OBJECTIVES

This systematic review aimed to identify and evaluate prognostic factors for long-term (≥6 mo) physical functioning in patients with chronic musculoskeletal pain following multidisciplinary rehabilitation (MDR).

MATERIALS AND METHODS

Electronic searches conducted in MEDLINE, PsycINFO, EMBASE, CINAHL, Web of Science, and Cochrane CENTRAL revealed 25 original research reports, published 1983-2016, (n=9436). Potential prognostic factors relating to initial pain and physical and psychological functioning were synthesized qualitatively and quantitatively in random effects meta-analyses. The level of evidence (LoE) was evaluated with Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

Pain-related factors (intensity and chronicity) were not associated with function/disability at long-term follow-up, odds ratio (OR)=0.84; 95% confidence interval (CI), 0.65-1.07 and OR=0.97; 95% CI, 0.93-1.00, respectively (moderate LoE). A better function at follow-up was predicted by Physical factors; higher levels of initial self-reported functioning, OR=1.07; 95% CI, 1.02-1.13 (low LoE), and Psychological factors; low initial levels of emotional distress, OR=0.77; 95% CI, 0.65-0.92, low levels of cognitive and behavioral risk factors, OR=0.85; 95% CI, 0.77-0.93 and high levels of protective cognitive and behavioral factors, OR=1.49; 95% CI, 1.17-1.90 (moderate LoE).

DISCUSSION

While pain intensity and long-term chronicity did not predict physical functioning in chronic pain patients after MDR, poor pretreatment physical and psychological functioning influenced the prognosis negatively. Thus, treatment should further target and optimize these modifiable factors and an increased focus on positive, psychological protective factors may perhaps provide an opening for yet untapped clinical gains.

Cognitive Mediators of Change in Physical Functioning in Response to a Multifaceted Intervention for Managing Osteoarthritis

PURPOSE

Although non-pharmacological interventions have been shown to improve physical functioning in individuals with osteoarthritis (OA), the mechanisms by which this occurs are often unclear. This study assessed whether changes in arthritis self-efficacy, perceived pain control, and pain catastrophizing mediated changes in physical functioning following an osteoarthritis intervention involving weight management, physical activity, and cognitive-behavioral pain management.

METHOD

Three hundred Veteran patients of 30 primary care providers with knee and/or hip OA were cluster randomized to an OA intervention group or usual care. The OA intervention included a 12-month phone-based patient behavioral protocol (weight management, physical activity, and cognitive-behavioral pain management) plus patient-specific OA treatment recommendations delivered to primary care providers.

RESULTS

Using linear mixed models adjusted for provider clustering, we observed that baseline to 6-month changes in arthritis self-efficacy and pain control partially mediated baseline to 12-month physical functioning improvements for the intervention group; catastrophizing did not.

CONCLUSION

Findings of a mediating role of arthritis self-efficacy and pain control in intervention-related functional changes are consistent with hypotheses and align with theoretical assertions of the role of cognitions in cognitive and behavioral interventions for chronic pain. However, contrary to hypotheses, catastrophizing was not found to be a mediator of these changes.

Patient education and health literacy

INTRODUCTION

Patient education is a relatively new science within the field of health care. In the past it consisted mainly of the transfer of knowledge and mostly biomedically based advice. Research has shown this to not be effective and sometimes counterproductive. As health care has moved away from applying a traditional paternalistic approach of 'doctor knows best' to a patient-centred care approach, patient education must be tailored to meet persons' individual needs.

PURPOSE

The purpose of this master paper is to increase awareness of patients' health literacy levels. Health literacy is linked to literacy and entails people's knowledge, motivation and competences to access, understand, appraise and apply health information in order to make judgements and take decisions in everyday life concerning health care, disease prevention and health promotion to maintain or improve quality of life during the life course. Many patients have low health literacy skills, and have difficulty with reading, writing, numeracy, communication, and, increasingly, the use of electronic technology, which impede access to and understanding of health care information.

IMPLICATIONS

Multiple professional organizations recommend using universal health literacy precautions to provide understandable and accessible information to all patients, regardless of their literacy or education levels. This includes avoiding medical jargon, breaking down information or instructions into small concrete steps, limiting the focus of a visit to three key points or tasks, and assessing for comprehension by using the teach back cycle. Printed information should be written at or below sixth-grade reading level. Visual aids can enhance patient understanding.

The Association of Illness Perception and Prognosis for Pain and Physical Function in Patients With Noncancer Musculoskeletal Pain: A Systematic Literature Review

BACKGROUND

In the literature, illness perceptions have been reported to be important psychological factors associated with pain intensity and physical function in individuals with musculoskeletal pain.

OBJECTIVE

To assess the relationship of illness perceptions with pain intensity and physical function in individuals with noncancer musculoskeletal pain.

METHODS

In this systematic review, relevant literature databases, including PubMed, Embase, PsycINFO, CINAHL, and SPORTDiscus, were searched from inception through December 12, 2017. Two authors (E.D.R. and H.W.) independently performed the search procedures, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the A MeaSurement Tool to Assess systematic Reviews guidelines, and the risk-of-bias assessment, using the QUality In Prognosis Studies tool. A qualitative best-evidence synthesis was performed.

RESULTS

A total of 26 articles were included in the review. There were 11 cross-sectional studies concerning associations of illness perceptions with pain intensity and 11 cross-sectional studies of associations of illness perceptions with physical function. For the prognosis of pain intensity by illness perceptions, the authors found 4 longitudinal studies, and for the prognosis of physical function by illness perceptions, the authors found 12 longitudinal studies. All studies except 1 had high risk of bias. Across 15 cross-sectional studies on 9 different musculoskeletal conditions, the researchers found limited to moderate evidence for a consistent direction of the relationship of illness perceptions with pain intensity and physical function. Higher maladaptive illness perceptions imply stronger pain intensity and more limitation in physical function. Evidence in longitudinal studies is lacking, especially on pain.

CONCLUSION

There is limited to moderate evidence for the cross-sectional relationship between illness perceptions and various musculoskeletal conditions. The prognostic value, however, remains unclear. Future research is recommended to investigate the longitudinal relationship between illness perception domains and outcomes in greater detail. J Orthop Sports Phys Ther 2018;48(10):789-800. Epub 10 May 2018. doi:10.2519/jospt.2018.8072.

Prediction of persistent post-operative pain: Pain-specific psychological variables compared with acute post-operative pain and general psychological variables

BACKGROUND

Psychological variables and acute post-operative pain are of proven relevance for the prediction of persistent post-operative pain. We aimed at investigating whether pain-specific psychological variables like pain catastrophizing add to the predictive power of acute pain and more general psychological variables like depression.

METHODS

In all, 104 young male patients undergoing thoracic surgery for pectus excavatum correction were studied on the pre-operative day (T0) and 1 week (T1) and 3 months (T2) after surgery. They provided self-report ratings (pain-related: Pain Catastrophizing Scale, Pain Anxiety Symptoms Scale = PASS, Pain Vigilance and Awareness Questionnaire = PVAQ; general psychological: Screening for Somatoform Symptoms, State-Anxiety Inventory-X1, Center for Epidemiologic Studies Depression Scale = CES-D). Additional predictors (T1) as well as criterion variables (T2) were pain intensity (Numerical Rating Scale) and pain disability (Pain Disability Index).

RESULTS

Three months after surgery, 25% of the patients still reported clinically relevant pain (pain intensity ≥3) and over 50% still reported pain-related disability. Acute post-operative pain as well as general psychological variables did not allow for a significant prediction of persistent post-operative pain; in contrast, pain-related psychological variables did. The best single predictors were PASS for pain intensity and PVAQ for pain disability.

CONCLUSIONS

Pain-related psychological variables derived from the fear-avoidance model contributed significantly to the prediction of persistent post-operative pain. The best possible compilation of these measures requires further research. More general psychological variables may become relevant predictors later in the medical history.

SIGNIFICANCE

Our results suggest that pain-specific psychological variables such as pain anxiety and pain hypervigilance add significantly to the prediction of persistent post-operative pain and might even outperform established predictors such as acute pain and general psychological variables. Clinicians might benefit from the development of time-economic screening tools based on these variables.

Startle modulation by heat pain with varying threat levels in chronic pain patients and pain-free controls

Background

Empirical evidence suggests that affective responses to pain are changed in chronic pain. The investigation of startle responses to pain might contribute to clarifying whether such alterations also expand to motivational defensive reactions. We aimed at comparing startle responses to tonic heat pain with high threat (HT) or low threat (LT) in patients with chronic musculoskeletal pain and controls. As pain-related anxiety and catastrophizing are typically elevated in chronic pain, we expected to find stronger startle responses in patients specifically under experimental HT.

Methods

Patients with chronic musculoskeletal, preferentially, back pain (N = 19) and matched pain-free controls (N = 19) underwent two pain-related threat conditions (high and low) in balanced order. Only, in the HT condition, 50% of the trials were announced to include a short further noxious temperature increase at the end. Startle responses to loud tones were always assessed prior to a potential temperature increase in the phase of anticipation and were recorded by surface electromyogram.

Results

Surprisingly, we observed no differences in startle responses and ratings of emotional and pain responses between patients and controls despite significantly higher pain-related anxiety and catastrophizing in the patients. Overall, startle was potentiated in the HT condition, but only in participants who started with this condition.

Conclusion

Our results suggest that, in general, patients with pain are not more responsive emotionally to experimental threat manipulations despite elevated pain anxiety and catastrophizing. Instead, exaggerated responses in patients might be triggered only by individual concerns relating to pain, which are not sufficiently mirrored by our threat paradigm.

Illness beliefs among patients with chronic widespread pain - associations with self-reported health status, anxiety and depressive symptoms and impact of pain

Background

Chronic widespread pain (CWP) is a disabling condition associated with a decrease in health. Illness beliefs are individual and are acquired during life. Constraining beliefs may prevent patients from regaining health. Understanding these patients’ illness beliefs may be a way to improve the health care they are offered. The aim of this study was to describe illness beliefs among patients with CWP and associations with self-reported health, anxiety and depressive symptoms, and impact of pain.

Method

In this cross-sectional study, questionnaires were sent by mail to 330 patients including socio-demographic information, the Illness Perception Questionnaire (IPQ-R), the Short-Form General Health Survey (SF-36) and the Hospital Anxiety and Depression Scale (HADS). Data were analysed using descriptive statistics, non-parametric tests and linear regression analyses.

Results

Patients experienced and related a high number of symptoms to CWP (mean (SD) 9 (3)). The patients believed their illness to be long lasting, to affect their emotional well being, and to have negative consequences for their lives. Some 72% reported having severe or very severe pain, and impact of pain according to SF-36 was negatively correlated to several illness beliefs dimensions, anxiety- and depressive symptoms. In regression analyses, the Identity, Consequences and Personal control dimensions of IPQ-R and Anxiety- and Depressive symptoms explained 32.6–56.1% of the variance in the two component scores of SF-36.

Conclusion

Constraining illness beliefs in patients with CWP are related to worse health status, especially in cases of high number of physical or mental symptoms, beliefs of negative consequences or the illness affecting them emotionally. Identification and understanding of these beliefs may reduce patients’ suffering if they are taken into consideration in rehabilitation programs and in development of new evidence-based interventions aimed at increasing health in patients with CWP.

[Multimodal pain therapy. Current situation]

A multidisciplinary approach for the management of patients with chronic pain is now well-established in many countries, especially in situations involving a complex disease process in the sense of a biopsychosocial model. Both the efficacy and cost-effectiveness of multidisciplinary pain treatment programs and their superiority compared to unimodal therapy has been documented in a number of studies, reviews and meta-analyses, in particular for patients suffering from chronic low back pain. Nevertheless, there are still major shortcomings concerning the definition of multimodal and multidisciplinary treatment and the quality of structures and processes, compared for example to the standards defined by the German Pain Society (Deutsche Schmerzgesellschaft). Furthermore, there is still no consensus on specific therapeutic approaches, the differentiation between responders and non-responders as well as on the tools required for measurement. All these questions will have to be answered by concerted efforts in a multicenter setting.

Predictors of return to work following motor vehicle related orthopaedic trauma

Background

Work disability following motor vehicle related orthopaedic trauma is a significant contributor to the burden of injury and disease. Early identification of predictors for return to work (RTW) is essential for developing effective interventions to prevent work disability. The study aim was to determine the predictors (including compensation related factors) of time to RTW following motor vehicle related orthopaedic trauma.

Methods

Admitted patients were recruited prospectively from two trauma hospitals with upper and/or lower extremity fractures following a motor vehicle crash. Baseline and follow up data were collected by written questionnaire. For baseline, this occurred in person within 2 weeks of injury. For follow up, this occurred by mail at six, 12 and 24 months. Additional demographic and injury-related information was retrieved from hospital databases. Analysis involved: descriptive statistics; logrank test to detect survival distributions of categorical variables; and Cox proportional hazards regression models for risks of time to RTW using baseline characteristic and compensation related variables (at 6 months).

Results

Of 452 study participants 334 (74 %) were working pre-injury: results are based on this subset. Baseline characteristics were mean age 36 years (13.9 Standard Deviation [SD]), 80 % male; 72 % self-assessed very good-excellent pre-injury health, 83 % household income > AU$40,000 (Australian Dollar). Follow up data was available for 233 (70 %), 210 (63 %), and 182 (54 %) participants at six, 12 and 24 months respectively.

Significant risks of a longer time to RTW were greater injury severity, as measured by the New Injury Severity Score (NISS) (Hazards Rate Ratio [HRR] = 0.54, 95 % CI 0.35-0.82); and lower occupational skill levels (HRR = 0.53, 95 % CI 0.34-0.83). Significant risks of a shorter time to RTW were: recovery expectations for usual activities within 90 days (HRR = 2.10, 95 % CI 1.49-2.95); full-time pre-injury work hours (HRR = 1.99, 95 % CI 1.26-3.14); and very good self-assessed pre-injury health status (HRR = 1.41, 95 % CI 0.98-2.02). Legal representation (analysed at six months only) was not associated with time to RTW. At each time period, there were 146 (63 %), 149 (71 %), and 137 (76 %) working participants.

Conclusions

A longer time to RTW was associated with greater injury severity and lower occupational skill levels; while a shorter time to RTW was associated with recovery expectations for usual activities within 90 days, full-time pre-injury work hours, and very good self-assessed pre-injury health status. Our findings reinforce existing research. There is an opportunity to trial interventions that address potentially modifiable factors. The issues surrounding legal representation are complex and require further research.

Changes in illness perceptions mediated the effect of cognitive behavioural therapy in severe functional somatic syndromes

OBJECTIVE

Although there is substantial evidence that cognitive behavioural therapy alleviates symptoms in functional somatic syndromes, the mechanisms of change are less investigated. This study examined whether changes in illness perceptions mediated the effect of cognitive behavioural therapy.

METHODS

We analysed additional data from a randomised controlled trial comparing completers of cognitive behavioural group therapy (46 patients) to an enhanced usual care group (66 patients). Proposed mediators (illness perceptions) and primary (physical health) and secondary (somatic symptoms and illness worry) outcomes were assessed by means of questionnaires at referral, baseline, end of treatment, and 10 and 16 months after randomisation. Multiple mediation analysis determined whether (1) changes in specific illness perceptions during treatment mediated the effect of cognitive behavioural therapy (primary analysis), and (2) whether changes in illness perceptions during the whole trial period were associated with improved outcome (secondary analysis).

RESULTS

Improvements in illness perceptions during treatment partially mediated the effect of cognitive behavioural therapy on physical health one year after treatment (sum of indirect effects 1.556, BCa 95% CI (0.006; 3.620)). Improving perceived control was particularly important. Changes in illness perceptions from baseline to 16 months after randomisation were associated with clinically meaningful improvements in physical health, somatic symptoms and illness worry during the same period.

CONCLUSION

Our results suggest that changing patients' illness perceptions is an important process in cognitive behavioural therapy for functional somatic syndromes. Challenging patients' own understanding of their illness may hence be a key element of successful treatment.

The efficacy of a multidisciplinary group program for patients with refractory chronic pain

Comprehensive programs for chronic pain management provided at multidisciplinary clinics have been shown to be successful in Western countries. However, similar results have not yet been reported in Japan, and it is unclear whether these results are applicable to the Japanese culture. Accordingly, the authors report the results of the ‘Chronic Pain Class’, a program initiated at a multidisciplinary pain centre in Nagakute, Japan.

BACKGROUND:

Chronic pain is a major problem because it can result in not only a reduction in activities of daily living and quality of life but also requires initiation of social assistance. Seeking only to eliminate pain itself would appear to be too narrow an objective, in addition to often being unachievable; therefore, a multifaceted, comprehensive approach with multiple objectives is needed.

OBJECTIVE:

To describe the effects of a program (the ‘Chronic Pain Class’) offering cognitive behavioural therapy to small groups of individuals with refractory chronic pain in Japan. Exercise was an important feature of the program.

METHODS:

A total of 46 patients who were experiencing treatment difficulties and decreased activity participated in the program. The programs were conducted in groups of five to seven patients who met weekly for nine weeks. Weekly sessions, which were approximately 2 h in duration, combined lectures with exercise. Several measures related to pain and physical function were administered at the beginning and the conclusion of the program.

RESULTS:

Nine patients dropped out during the program. A number of measures (eg, pain intensity, disability, catastrophizing thoughts) showed significant improvements after intervention (P<0.002 after Bonferroni correction). Furthermore, most measures of physical function showed substantial improvement, especially seated forward bends, zig-zag walking, self-care and 6 min walk test (P<0.001).

CONCLUSION:

The results of the present study provide evidence that a combination of cognitive behavioural therapy and exercise should be recommended to patients with refractory chronic pain.

Illness perceptions of cancer patients: relationships with illness characteristics and coping

OBJECTIVE

Illness perceptions have proven to be predictive of coping and adjustment in many chronically ill patients. However, insights into illness perceptions of cancer patients are scarce. The purpose of the present study was to explore how a heterogeneous sample of cancer patients perceive their illness. We also examined the relationships between cancer patients' illness perceptions, their illness characteristics, and their coping strategies.

METHODS

Participants were 325 cancer patients of a generic nationwide longitudinal panel study among cancer patients in the Netherlands. They completed the revised Illness Perception Questionnaire (Winter 2011/2012) and the Mental Adjustment to Cancer Scale (Spring 2012). Analyses of variance and linear regression analyses were conducted.

RESULTS

Patients' views on the chronicity of cancer vary, but many believe their illness to be long-lasting. Furthermore, they strongly believe the cancer treatment to be effective. People with skin cancer experience relatively little negative consequences (p < 0.01). Recently treated patients experience more negative consequences (p < 0.001) and perceive their illness as more chronic (p < 0.01). Surprisingly, neither perceptions of treatment control nor perceptions of personal control are related to specific ways of coping. However, more passive ways of coping were more often found in patients who perceived their illness as long-lasting, more emotionally burdening, and having more negative consequences.

CONCLUSIONS

Our findings suggest that cancer patients might benefit more from support to alleviate the perceived severity and threat of their illness rather than from (further) strengthening their control beliefs.

Living with diabetes: a group-based self-management support programme for T2DM patients in the early phases of illness and their partners, study protocol of a randomised controlled trial

Background

The present article presents the protocol for a randomised controlled trial to test the effectiveness of a group-based self-management support programme for recently diagnosed type 2 diabetes mellitus (T2DM) patients (one to three years post-diagnosis) and their partners. The course aims to support T2DM patients and their partners in successfully integrating diabetes care into their daily lives and hereby enhance self-management and diabetes-specific health-related quality of life. The content of the course is based on the Common-Sense Model of Self-Regulation (CSM). Furthermore, principles from the Social Cognitive Theory (SCT) and social support theories are integrated.

Methods/Design

We aim to recruit 160 recently diagnosed T2DM patients and their partners from general practices in six different regions in the Netherlands. Patients need to be diagnosed with T2DM for one to three years and have to experience some degree of diabetes-related difficulties, as measured with a three-item screener. Participating patients and their partners are randomly allocated to the intervention or control condition. Participants in the intervention condition receive three monthly group sessions and a booster session three months later. Participants in the control condition receive a single information meeting. Data will be collected at baseline (T0), directly after the programme (T1) and six months post-programme (T2), including: self-management, diabetes-specific health-related quality of life, illness perceptions, attitudes, social support and empowerment. A three-level multilevel model will be used to compare change-scores between the conditions (intervention/control) on each outcome.

Discussion

Our study will be the first to determine whether a group-based support programme based on the CSM is effective in enhancing self-management and diabetes-specific health-related quality of life in recently diagnosed T2DM patients. The important role of patients’ partners in effective diabetes care is also acknowledged in the study.

Trial registration

Netherlands National Trial Register (NTR) NTR3302.

Rejection sensitivity and pain in bipolar versus unipolar depression

OBJECTIVES

Recent neuroimaging studies support the contention that depression, pain distress, and rejection distress share the same neurobiological circuits. In two recently published studies we confirmed the hypothesis that the perception of increased pain during both treatment-refractory depression (predominantly unipolar) and difficult-to-treat bipolar depression was related to increased state rejection sensitivity (i.e., rejection sensitivity when depressed). In the present study, we aimed to compare the correlates of pain and rejection sensitivity in individuals with bipolar versus unipolar depression and test the hypothesis that bipolar disorder may be distinguished from unipolar depression both by an increased perception of pain and heightened rejection sensitivity during depression.

METHODS

We analyzed data from 113 bipolar and 146 unipolar depressed patients presenting to the Black Dog Institute, Sydney, Australia. The patients all met DSM-IV criteria for bipolar disorder or unipolar depression (major depressive disorder).

RESULTS

Bipolar disorder predicted a major increase in state rejection sensitivity when depressed (p = 0.001), whereas trait rejection sensitivity (i.e., a long-standing pattern of rejection sensitivity) was not predicted by polarity. A major increase in the experience of headaches (p = 0.007), chest pain (p < 0.001), and body aches and pains (p = 0.02) during depression was predicted by a major increase in state rejection sensitivity for both bipolar and unipolar depression.

CONCLUSIONS

State, but not trait, rejection sensitivity is significantly predicted by bipolar depression, suggesting that this might be considered as a state marker for bipolar depression and taken into account in the clinical differentiation of bipolar and unipolar depression.

Tailored support for type 2 diabetes patients with an acute coronary event after discharge from hospital - design and development of a randomised controlled trial

BACKGROUND

Type 2 diabetes mellitus patients with an acute coronary event (ACE) experience decreased quality of life and increased distress. According to the American Diabetes Association, discharge from the hospital is a time of increased distress for all patients. Tailored support specific to diabetes is scarce in that period. We developed an intervention based on Bandura's Social Cognitive Theory, Leventhal's Common Sense Model, and results of focus groups. The aim of this study is to evaluate the effectiveness of the intervention to reduce distress in type 2 diabetes patients who experienced a first ACE.

METHODS

Randomised controlled trial. Two hundred patients are recruited in thirteen hospitals. A diabetes nurse visits the patients in the intervention group (n = 100) at home within three weeks after discharge from hospital, and again after two weeks and two months. The control group (n = 100) receives a consultation by telephone. The primary outcome is diabetes-related distress, measured with the Problem Areas in Diabetes (PAID) questionnaire. Secondary outcomes are well-being, health status, anxiety, depression, HbA1c, blood pressure and lipids. Mediating variables are self-management, self-efficacy and illness representations. Outcomes are measured with questionnaires directly after discharge from hospital and five months later. Biomedical variables are obtained from the records from the primary care physician and the hospital. Differences between groups in change over time are analysed according to the intention-to-treat principle. The Holm-Bonferroni correction is used to adjust for multiplicity.

DISCUSSION

Type 2 diabetes patients who experience a first ACE need tailored support after discharge from the hospital. This trial will provide evidence on the effectiveness of a supportive intervention in reducing distress in these patients.

TRIAL REGISTRATION

NCT01801631.

Pain, perceptions, and perceived conflicts: improving the patient's experience

Pain is the number 1 reason patients seek care in an emergency department (ED). A limiting factor for effective pain management may be clinical staff attitudes about pain and pain management. Analysis of data from an investigation into pain, perceptions, and perceived conflicts of ED staff pain management revealed a need for change. Operation Pain and ED pain champions created an environment that promoted enhanced pain management resulting in measurable outcomes. Emergency nurses participating in Operation Pain placed a higher priority on pain management for their patients.

Risk factors for moderate and severe persistent pain in patients undergoing total knee and hip arthroplasty: a prospective predictive study

Persistent post-surgical pain (PPSP) is a major clinical problem with significant individual, social and health care costs. The aim of this study was to examine the joint role of demographic, clinical and psychological risk factors in the development of moderate and severe PPSP after Total Knee and Hip Arthroplasty (TKA and THA, respectively). This was a prospective study wherein a consecutive sample of 92 patients were assessed 24 hours before (T1), 48 hours after (T2) and 4–6 months (T3) after surgery. Hierarchical logistic regression analyses were performed to identify predictors of moderate and severe levels of PPSP. Four to six months after TKA and THA, 54 patients (58.7%) reported none or mild pain (Numerical Rating Scale: NRS ≤3), whereas 38 (41.3%) reported moderate to severe pain (NRS >3). In the final multivariate hierarchical logistic regression analyses, illness representations concerning the condition leading to surgery (osteoarthritis), such as a chronic timeline perception of the disease, emerged as a significant predictor of PPSP. Additionally, post-surgical anxiety also showed a predictive role in the development of PPSP. Pre-surgical pain was the most significant clinical predictive factor and, as expected, undergoing TKA was associated with greater odds of PPSP development than THA. The findings on PPSP predictors after major joint arthroplasties can guide clinical practice in terms of considering cognitive and emotional factors, together with clinical factors, in planning acute pain management before and after surgery.

Does severe acute pain provoke lasting changes in attentional and emotional mechanisms of pain-related processing? A longitudinal study

Pain experiences, learning, and genetic factors have been proposed to shape attentional and emotional processes related to pain. We aimed at investigating whether a singular major pain experience also changes cognitive-emotional processing. The influence of acute postoperative pain after cosmetic surgery of the thorax was tested in 80 preoperatively pain-free male individuals. Acute pain was measured as independent variable during the first week postsurgery by pain intensity ratings and the requested analgesic boluses (Patient-Controlled Epidural Analgesia (PCEA)). Pain catastrophizing (Pain Catastrophizing Scale (PCS)), pain anxiety (Pain Anxiety and Symptom Scale (PASS)), pain hypervigilance (Pain Vigilance and Awareness Questionnaire (PVAQ)), and attentional biases to emotionally loaded stimuli (including pain) in a dot-probe task were assessed 1 week, 3 months, and 6 months postsurgery as dependent variables. Hierarchical regression analyses were performed to test whether the 2 acute pain parameters can predict these cognitive-emotional variables. As a rigorous test, significant prediction was required in addition to the prediction of the dependent variables by themselves with lag-1. Acute pain (mainly the pain ratings) appeared to be a significant predictor for PCS, PASS, and PVAQ 1 week after surgery (deltaR(2) = [8.7% to 11.3%]). In contrast, the attentional biases in the dot-probe task could not be predicted by the pain ratings. The levels of pain catastrophizing and pain hypervigilance increased in the acute phase after surgery when influenced by acute pain and declined, along with pain anxiety, during the next 3 months. In conclusion, a one-time intense pain experience, such as acute postoperative pain, appeared to produce at least short-lived changes in the attentional and emotional processing of pain.

Psychological therapies for the management of chronic pain (excluding headache) in adults

BACKGROUND

Psychological treatments are designed to treat pain, distress and disability, and are in common practice. This review updates and extends the 2009 version of this systematic review.

OBJECTIVES

To evaluate the effectiveness of psychological therapies for chronic pain (excluding headache) in adults, compared with treatment as usual, waiting list control, or placebo control, for pain, disability, mood and catastrophic thinking.

SEARCH METHODS

We identified randomised controlled trials (RCTs) of psychological therapy by searching CENTRAL, MEDLINE, EMBASE and Psychlit from the beginning of each abstracting service until September 2011. We identified additional studies from the reference lists of retrieved papers and from discussion with investigators.

SELECTION CRITERIA

Full publications of RCTs of psychological treatments compared with an active treatment, waiting list or treatment as usual. We excluded studies if the pain was primarily headache, or was associated with a malignant disease. We also excluded studies if the number of patients in any treatment arm was less than 20.

DATA COLLECTION AND ANALYSIS

Forty-two studies met our criteria and 35 (4788 participants) provided data. Two authors rated all studies. We coded risk of bias as well as both the quality of the treatments and the methods using a scale designed for the purpose. We compared two main classes of treatment (cognitive behavioural therapy(CBT) and behaviour therapy) with two control conditions (treatment as usual; active control) at two assessment points (immediately following treatment and six months or more following treatment), giving eight comparisons. For each comparison, we assessed treatment effectiveness on four outcomes: pain, disability, mood and catastrophic thinking, giving a total of 32 possible analyses, of which there were data for 25.

MAIN RESULTS

Overall there is an absence of evidence for behaviour therapy, except a small improvement in mood immediately following treatment when compared with an active control. CBT has small positive effects on disability and catastrophising, but not on pain or mood, when compared with active controls. CBT has small to moderate effects on pain, disability, mood and catastrophising immediately post-treatment when compared with treatment as usual/waiting list, but all except a small effect on mood had disappeared at follow-up. At present there are insufficient data on the quality or content of treatment to investigate their influence on outcome. The quality of the trial design has improved over time but the quality of treatments has not.

AUTHORS' CONCLUSIONS

Benefits of CBT emerged almost entirely from comparisons with treatment as usual/waiting list, not with active controls. CBT but not behaviour therapy has weak effects in improving pain, but only immediately post-treatment and when compared with treatment as usual/waiting list. CBT but not behaviour therapy has small effects on disability associated with chronic pain, with some maintenance at six months. CBT is effective in altering mood and catastrophising outcomes, when compared with treatment as usual/waiting list, with some evidence that this is maintained at six months. Behaviour therapy has no effects on mood, but showed an effect on catastrophising immediately post-treatment. CBT is a useful approach to the management of chronic pain. There is no need for more general RCTs reporting group means: rather, different types of studies and analyses are needed to identify which components of CBT work for which type of patient on which outcome/s, and to try to understand why.

Risk factors for persistent postsurgical pain in women undergoing hysterectomy due to benign causes: a prospective predictive study

Persistent postsurgical pain (PPSP) is a major clinical problem with significant individual, social, and healthcare costs. The aim of this study was to examine the role of demographic, clinical, and psychological risk factors in the development of PPSP after hysterectomy due to benign disorders. In a prospective study, a consecutive sample of 186 women was assessed 24 hours before surgery (T1), 48 hours after surgery (T2), and 4 months after surgery (T3). Regression analyses were performed to identify predictors of PPSP. Four months after hysterectomy, 93 (50%) participants reported experiencing pain (numerical rating scale >0). Age, pain due to other causes, and type of hysterectomy emerged as significant predictive factors. Baseline presurgical psychological predictors identified were anxiety, emotional illness representation of the condition leading to surgery, and pain catastrophizing. Among the identified psychological predictors, emotional illness representation emerged as the strongest. Acute postsurgical pain frequency and postsurgical anxiety also revealed a predictive role in PPSP development. These results increase the knowledge on PPSP predictors and point healthcare professionals toward specific intervention targets such as anxiety (presurgical and postsurgical), pain catastrophizing, emotional illness representations, and acute pain control after surgery.

PERSPECTIVE

This study found that presurgical anxiety, emotional illness representations, and pain catastrophizing are risk factors for PPSP 4 months after hysterectomy, over and above age and clinical variables. These findings improve knowledge on PPSP and highlight potential intervention targets for healthcare professionals.

Multidisciplinary pain treatment - Which patients do benefit?

Background The prevalence of chronic non-malignant pain in developed countries is high, ranging from 14% to 50%. Patients with chronic pain are active users of health-care services and they report impaired health-related quality of life (HRQoL) when compared with the general population. Psychological distress has been identified as one of the risk factors for pain chronicity. Depression, anxiety and negative beliefs are associated with pain interference and perceived disability. Multidisciplinary pain management (MPM) aims to rehabilitating chronic pain patients by addressing both physical, psychological, social and occupational factors related to the pain problem. MPM programmes have been shown to be effective in reducing pain and improving function in patients with diverse chronic pain states. However, MPM programmes are often heterogeneous and predicting MPM treatment results in different patients groups may be difficult. Methods The present study examined changes in HRQoL after MPM in 439 patients treated at a multidisciplinary pain clinic using the 15D HRQoL questionnaire. The characteristics of the 100 patients with the greatest improvement and the 100 patients with the largest decrease in HRQoL were examined more closely (demographics, characteristics of pain, pain interference, psychiatric comorbidity, employment status, details of MPM) after answering a follow-up 15D questionnaire at three years after their MPM had ended. Result During MPM, HRQoL was significantly improved in 45.6% of the 439 patients, decreased in 30.7% of the patients and did not change in 23.7% of the patients. Patient-related factors that predicted a better HRQoL among the 100 patients with good MPM outcome compared with the 100 patients with poor MPM outcome were higher education and better employment status. Age, gender, marital status, duration of pain, number of pain sites, pain intensity or pain interference at baseline did not differ between the patient groups. Patient expectations regarding MPM were similar. A tendency towards more psychiatric comorbidity in the non-responder group was seen. The duration of MPM in the two patient groups was similar, as well as the number of medications started, the variety of specialists seen and psychiatric counselling with supportive therapy included. More non-responder than responder patients had died during the three-year follow-up period, some of the deaths were related to substance abuse. Conclusions and Implications HRQoL in chronic pain patients was significantly improved during MPM compared with the baseline. Pain duration of several years, multiple pain sites and neuropathic pain were not discerning factors between the responders and non-responders of the present study, implying that a positive change in HRQoL may be achieved by MPM even in these pain patients. In agreement with previous studies, factors predicting poor treatment outcome in the non-responder group of chronic pain patients were not treatment related. To further improve MPM outcome even in pain patients with risk factors for less benefit of treatment such as low education and poor general health, more individualized MPM approaches with emphasis on analysis and treatment of psychological symptoms and patient beliefs is essential.

Quality of life and academic functioning 6 years after paediatric referral for chronic pain

AIM

To assess health-related quality of life (HR-QoL) and academic functioning in adolescents and young adults 6 years after paediatric referral for chronic pain.

METHODS

In 99 children and adolescents with chronic pain (aged 8-17) referred to a paediatric outpatient clinic, pain and psychiatric disorders were assessed between 2000 and 2002. Participants were reassessed after minimal 5 years (aged 13-24). HR-QoL [Medical Outcomes Study 36-item Short-Form (SF-36)] was compared with Dutch population norms. Academic functioning (structured questionnaire) was compared with baseline.

RESULTS

Participant's ratings in most HR-QoL dimensions did not differ from population norms. Outcome was significantly decreased in Bodily Pain (p = 0.001 males, p < 0.000 females) and female General Health (p = 0.001). Poor general health perceptions (p = 0.002), poor global general health (p = 0.003) and a high somatic symptom level (p = 0.004) at baseline predicted poor HR-QoL outcome. School/work attendance was significantly better than at baseline (p = 0.002).

CONCLUSION

Six years after paediatric referral for chronic pain, HR-QoL was mostly comparable to that of peers, and academic functioning improved. Self-evaluated global health at referral may be an important predictor of HR-QoL outcome of children with chronic pain, rather than psychiatric comorbidity.

Development and validation of an instrument to predict functional recovery in tibial fracture patients: the Somatic Pre-Occupation and Coping (SPOC) questionnaire

OBJECTIVE

To explore the role of patients' beliefs in their likelihood of recovery from severe physical trauma.

METHODS

We developed and validated an instrument designed to capture the impact of patients' beliefs on functional recovery from injury: the Somatic Pre-Occupation and Coping (SPOC) questionnaire. At 6-weeks postsurgical fixation, we administered the SPOC questionnaire to 359 consecutive patients with operatively managed tibial shaft fractures. We constructed multivariable regression models to explore the association between SPOC scores and functional outcome at 1 year as measured by return to work and Short Form-36 (SF-36) physical component summary and mental component summary scores.

RESULTS

In our adjusted multivariable regression models that included preinjury SF-36 scores, SPOC scores at 6 weeks postsurgery accounted for 18% of the variation in SF-36 physical component summary scores and 18% of SF-36 mental component summary scores at 1 year. In both models, 6-week SPOC scores were a far more powerful predictor of functional recovery than age, gender, fracture type, smoking status, or the presence of multitrauma. Our adjusted analysis found that for each 14-point increment in SPOC score at 6 weeks (14 chosen on the basis of half a standard deviation of the mean SPOC score), the odds of returning to work at 1 year decreased by 40% (odds ratio, 0.60; 95% confidence interval, 0.50-0.73).

CONCLUSION

The SPOC questionnaire is a valid measurement of illness beliefs in patients with tibial fracture and is highly predictive of their long-term functional recovery. Future research should explore if these results extend to other trauma populations and if modification of unhelpful illness beliefs is feasible and would result in improved functional outcomes.

Prediction of Experimental Pain Sensitivity by Attention to Pain-Related Stimuli in Healthy Individuals

The aim of the present study was to assess the predictive power of the processing of pain-related information, comprising concepts of hypervigilance to pain, pain catastrophizing, and pain-related anxiety (questionnaires) as well as attentional processes related to pain-related stimuli (dot-probe task) in explaining individual differences in experimental pain sensitivity (pressure/thermal pain threshold). In 160 healthy participants (ages 13–61; 80 females), results of hierarchical multiple regression analyses showed that self-reported hypervigilance contributed significantly to the prediction of pain sensitivity, whereas pain catastrophizing and anxiety did not. However, inconsistent with prediction, the effect was in the opposite direction, indicating that vigilance to pain sensations or stimuli is associated with lower pain sensitivity in healthy individuals. Entering the attentional bias indices from the dot-probe task showed that an increased bias to pain words is related to higher experimental pain sensitivity, which confirms the hypothesis.

Chronic pain in the Republic of Ireland--community prevalence, psychosocial profile and predictors of pain-related disability: results from the Prevalence, Impact and Cost of Chronic Pain (PRIME) study, part 1

The aims of the PRIME study (Prevalence, Impact and Cost of Chronic Pain) were 3-fold: (1) to determine the point prevalence of chronic pain in Ireland; (2) to compare the psychological and physical health profiles of those with and without chronic pain; and (3) to explore a predictive model of pain-related disability. A postal survey of 3136 people was conducted with a representative community-based sample of adults. Measures were obtained for sociodemographic variables, physical and psychological well-being, depressive symptoms, presence of pain, pain severity, pain-related disability, and illness perceptions. Responses were received from 1204 people. The prevalence of chronic pain was 35.5% (95% CI=32.8-38.2) (n=428). No gender difference in prevalence was found. Prevalence of pain increased with age and was associated with manual employment. The most commonly reported site of pain was the lower back (47.6%); however, multiple pain sites was the norm, with more than 80% of participants reporting more than 1 pain site. Approximately 12% of participants were unable to work or were on reduced work hours because of pain. Of those with chronic pain, 15% met the criteria for clinically relevant depression compared with 2.8% of those without pain. A multiple regression analysis, predicting 67% of variance, showed that pain intensity was the strongest predictor of pain-related disability. Depression and illness perceptions were also predictive of pain-related disability, after controlling for the effects of pain intensity. Chronic pain is a prevalent health problem in Ireland and is associated with significant psychological and functional disability. Psychological factors appear to influence the level of pain-related disability.

Pain and rejection sensitivity in bipolar depression

OBJECTIVES

Little is known regarding the correlates of pain in bipolar disorder. Recent neuroimaging studies support the contention that depression, as well as pain distress and rejection distress, share the same neurobiological circuits. In a recently published study, we confirmed the hypothesis that perception of increased pain during treatment-refractory depression, predominantly unipolar, was related to increased rejection sensitivity. In the present study, we aimed to test this same hypothesis for bipolar depression.

METHODS

The present study analysed data from 67 patients presenting to the Black Dog Institute Bipolar Disorders Clinic in Sydney, Australia. The patients all met DSM-IV criteria for bipolar disorder and had completed a self-report questionnaire regarding perceived pain and rejection sensitivity during depression.

RESULTS

A significant increase in the experience of headaches (p=0.003) as well as chest pain (p=0.004) during bipolar depression was predicted by a major increase in rejection sensitivity when depressed, i.e., state rejection sensitivity. Being rejection sensitive in general, i.e., trait rejection sensitivity, did not predict pain during depression.

CONCLUSIONS

The experience of increased headaches and chest pain during bipolar depression is related to increased rejection sensitivity during depression. Research to further elucidate this relationship is required.

Attentional and emotional mechanisms of pain processing and their related factors: a structural equations approach

BACKGROUND/OBJECTIVE

It is known that maladaptive attentional and emotional mechanisms of pain processing - as indicated by constructs such as pain hypervigilance, pain-related anxiety and pain catastrophizing - play an important role in the development and maintenance of chronic pain conditions. However, little is known to date about the potential risk factors for these forms of maladaptive processing. The aim of the present study was to shed more light on this issue. A very comprehensive set of predictor variables was examined in healthy pain-free subjects.

METHOD

Participants were 92 young and healthy subjects (mean [+/- SD] age 26.99+/-6.90 years; 47 men, 45 women). Maladaptive attentional and emotional mechanisms of pain processing were assessed by self-report measures of pain hypervigilance, pain-related anxiety and pain catastrophizing, as well as by a dot-probe task. The comprehensive set of predictor variables included measures of affective and bodily distress (depression, anxiety and somatization), experimental pain sensitivity, and cortisol reactivity. Directed relationships were estimated by using structural equation modelling.

RESULTS

Structural equation modelling revealed a significant path from affective and bodily distress to self-reported maladaptive attentional and emotional pain processing. In contrast, the paths from pain sensitivity and cortisol reactivity did not reach the level of significance.

CONCLUSION

These results support the position that anxiety and depression, as well as somatization, contribute to the aberrance of attentional and emotional mechanisms of pain processing. Surprisingly, the assumption of a close relationship between these maladaptive mechanisms of pain processing and pain sensitivity could not be confirmed.

The Development of and First Experiences with a Behavioural Self-regulation Intervention for End-stage Renal Disease Patients and Their Partners

This article describes the development of an intervention programme for patients with end-stage renal disease (ESRD) and their partners. The programme is based on theories of self-regulation, social learning, and self-determination aimed at maintaining and increasing patients’ activities, including paid work, and sense of autonomy. The intervention was evaluated on its feasibility and first experiences among a group of 12 patients and partners. Results show that the intervention is feasible. The outcomes observed by the patients themselves are encouraging. The findings show that an approach in which cognitive, emotional, behavioural, and contextual aspects are integrated is promising. Areas of attention for developing and implementing interventions are discussed.

Patient and physician perceptions of treatment of moderate-to-severe chronic pain with oral opioids

OBJECTIVE

To study physician and patient perceptions of moderate-to-severe chronic pain and its management with oral opioids.

METHODS

Two separate surveys were developed and administered to one of two respective study groups: patients and physicians. All study participants recruited from a pool of individuals who had previously agreed to participate in market research. Survey questions addressed the impact of various factors (e.g., quality of life indicators, potential for opioid addiction, side-effects) on pain management decision making, patient satisfaction and compliance. Responses for the first 500 patients and 275 physicians to respond were assessed using descriptive statistics.

RESULTS

On average, patients were 53 years of age, white (89%), and female (71%). The majority of patients (80%) had been taking oral opioids longer than 6 months. Physicians reported that 45% of their patients received schedule II opioids, with 27% having severe chronic pain. Patients indicated the most common activities interfered with by chronic pain were exercising (76% of patients), working outside the home (67%), and job responsibilities (60%). When developing a treatment approach physicians considered patients' sleeping (91%), walking (86%), maintaining an independent lifestyle (84%), and job responsibilities (83%). Patients and physicians both rated the ability to relieve pain and the duration of relief as the most important factors when considering opioid therapy. The majority (63%) of patients reported experiencing opioid side effects. When physicians discontinued opioids due to side effects, the most frequent reason was nausea (78%) for immediate-release opioids, and constipation (64%) for extended-release formulations.

CONCLUSION

The ability to relieve pain and the duration of that pain relief are the most important factors for both patients and physicians when selecting an opioid. A high percentage of patients surveyed experienced side effects related to their treatment, which may impact adherence and overall treatment effectiveness. Study results should be assessed within study limitations including responder and selection biases, physicians responded about their patients, who were not the same patients surveyed, and the fact that the survey instruments were not formally validated. Further research is warranted to address these limitations.

Pain catastrophizing in patients with noncardiac chest pain: relationships with pain, anxiety, and disability

OBJECTIVE

To examine the contributions of chest pain, anxiety, and pain catastrophizing to disability in 97 patients with noncardiac chest pain (NCCP) and to test whether chest pain and anxiety were related indirectly to greater disability via pain catastrophizing.

METHODS

Participants completed daily diaries measuring chest pain for 7 days before completing measures of pain catastrophizing, trait anxiety, and disability. Linear path model analyses examined the contributions of chest pain, trait anxiety, and catastrophizing to physical disability, psychosocial disability, and disability in work, home, and recreational activities.

RESULTS

Path models accounted for a significant amount of the variability in disability scales (R(2) = 0.35 to 0.52). Chest pain and anxiety accounted for 46% of the variance in pain catastrophizing. Both chest pain (beta = 0.18, Sobel test Z = 2.58, p < .01) and trait anxiety (beta = 0.14, Sobel test Z = 2.11, p < .05) demonstrated significant indirect relationships with physical disability via pain catastrophizing. Chest pain demonstrated a significant indirect relationship with psychosocial disability via pain catastrophizing (beta = 0.12, Sobel test Z = 1.96, p = .05). After controlling for the effects of chest pain and anxiety, pain catastrophizing was no longer related to disability in work, home, and recreational activities.

CONCLUSIONS

Chest pain and anxiety were directly related to greater disability and indirectly related to physical and psychosocial disability via pain catastrophizing. Efforts to improve functioning in patients with NCCP should consider addressing pain catastrophizing.

Pain during depression and relationship to rejection sensitivity

OBJECTIVE

Approximately 50% of patients with depression report symptoms of pain, yet the clinical and biological mechanisms underlying this association remain unclear. Recent neuroimaging studies, however, support the contention that depression, as well as pain distress and rejection distress, share the same neurobiological circuits. In this study, we aimed to examine the hypothesis that perception of increased pain during depression is related to increased rejection sensitivity.

METHOD

The present study analysed data from a study of 186 treatment-resistant depressed patients who met DSM-IV criteria for depression and had completed a self-report questionnaire regarding currently perceived pain and rejection sensitivity.

RESULTS

A major increase in the experience of pain during depression was predicted by a major increase in rejection sensitivity during depression.

CONCLUSION

The experience of increased pain during depression is related to increased rejection sensitivity. Research to further elucidate this relationship is required.