The role of stigma in health and functioning in chronic pain: Not just catastrophizing

BACKGROUND

People with chronic pain are frequently exposed to stigma, which is typically distressing and may lead to internal stigmatizing thoughts. The thought content associated with stigma has similarities to pain catastrophizing, although these concepts differ in that stigma is arguably more social in origin. Stigma can be measured by the Stigma Scale for Chronic Illness - 8-item version (SSCI-8). In this study, we first demonstrate the validity of this measure in Swedish. We then examine the role of stigma in the health and functioning of people with chronic pain, particularly beyond the role played by pain catastrophizing.

METHODS

Adult participants (N = 404) with chronic pain recruited online completed measures of pain, stigma, catastrophizing, pain interference, work and social adjustment and depression on two occasions.

RESULTS

A one-factor solution had an overall good model fit as long as residuals were allowed to covary, indicating some redundancy in the items. The SSCI-8 demonstrated good internal consistency and moderate temporal stability, and SSCI-8 scores demonstrated medium-to-large correlations with the measures of health and functioning. Furthermore, stigma was found to significantly contribute to explained variance in pain interference, work and social adjustment and depression, uniquely adding to the explained variance in these outcomes even after accounting for pain catastrophizing.

CONCLUSIONS

The SSCI-8 provides an adequate measure to capture stigma experiences. Stigma is uniquely associated with pain-related outcomes and should be further considered in pain research and clinical practice in the future.

SIGNIFICANCE

This study points to the importance of a social perspective on pain-related outcomes. We may need to more fully appreciate the way that people with chronic pain are treated by both health care providers and others can have an impact on their well-being. Potential negative impacts of stigmatizing responses to people with chronic pain are highlighted by the current results.

The role of psychological flexibility in relation to suicidal thinking in chronic pain

BACKGROUND

Suicidal thinking (ST) is common in people with chronic pain. It is relevant as it can be associated with suicidal attempts, and typically reflects significant suffering. While little is known about the psychological processes that contribute to ST, current psychological models, such as the Psychological Flexibility (PF) model, could help guide further investigation. This study investigates relations between ST and components of PF in chronic pain.

METHODS

Participants were 424 adults attending treatment for chronic pain in the UK. Included in measures administered before treatment were standardized measures of depression, pain, pain-related interference, and measures of PF, including acceptance, cognitive defusion, committed action, and self-as-context. An item from the measure of depression was used to reflect ST.

RESULTS

A large proportion of the sample reported ST, 45.7%. ST was uncorrelated with participant background characteristic, medications taken, or pain intensity. However, it was correlated with the presence of widespread pain, pain-related interference, and depression. Each component of PF was found to be significantly negatively associated with ST, as predicted. General acceptance correlated with ST at a level equal to that achieved by the depression score. In adjusted multivariate logistic regression general acceptance and committed action remained significantly uniquely associated with it.

CONCLUSION

This preliminary study suggests for the first time that components of PF are associated with part of a pattern of suicidal behaviour in people with chronic pain. They may be relevant for reducing avoidance in general and providing more positive behavioural options.

SIGNIFICANCE

This study provides evidence that components of psychological flexibility are associated with a reduced frequency of suicidal thinking in people with chronic pain. Treatments targeting psychological flexibility may help mitigate the impact of chronic pain on suicidal thinking.

Feasibility randomized-controlled trial of online Acceptance and Commitment Therapy for patients with complex chronic pain in the United Kingdom

BACKGROUND

Acceptance and Commitment Therapy (ACT) has growing support for chronic pain. However, more accessible treatment delivery is needed. This study evaluated the feasibility of online ACT for patients with complex chronic pain in the United Kingdom to determine whether a larger trial is justified.

METHODS

Participants with chronic pain and clinically meaningful disability and distress were randomly assigned to ACT online plus specialty medical pain management, or specialty medical management alone. Participants completed questionnaires at baseline, and 3- and 9-month post-randomization. Primary feasibility outcomes included recruitment, retention and treatment completion rates. Secondary outcomes were between-groups effects on treatment outcomes and psychological flexibility.

RESULTS

Of 139 potential participants, 63 were eligible and randomized (45% recruitment rate). Retention rates were 76-78% for follow-up assessments. Sixty-one per cent of ACT online participants completed treatment. ACT online was less often completed by employed (44%) compared to unemployed (80%) participants. Fifty-six per cent of ACT online participants rated themselves as 'much improved' or better on a global impression of change rating, compared to only 20 per cent of control participants. Three-month effects favouring ACT online were small for functioning, medication and healthcare use, committed action and decentring, medium for mood, and large for acceptance. Small-to-medium effects were maintained for functioning, healthcare use and committed action at 9 months.

CONCLUSIONS

Online ACT for patients with chronic pain in the United Kingdom appears feasible to study in a larger efficacy trial. Some adjustments to treatment and trial procedures are warranted, particularly to enhance engagement among employed participants.

SIGNIFICANCE

This study supports the feasibility of online Acceptance and Commitment Therapy for chronic pain in the United Kingdom and a larger efficacy trial. Refinements to treatment delivery, particularly to better engage employed patients, may improve treatment completion and outcomes.

Beyond a physical symptom: the importance of psychosocial factors in multiple sclerosis pain

BACKGROUND AND PURPOSE

Pain affects around two-thirds of people with Multiple Sclerosis (pwMS). Biomedical treatments show limited efficacy. A recently developed cognitive-behavioural model of Multiple Sclerosis (MS) pain suggests several psychosocial factors may worsen pain and related disability. The current study investigated whether psychosocial factors drawn from this model explain significant amounts of the variance in pain severity and interference over and above measures of disease severity and pain subtype.

METHODS

Six hundred and twelve pwMS experiencing pain completed a U.K. wide cross-sectional survey including valid and reliable psychometric questionnaires. Hierarchical regressions determined the relative contribution of disease severity and psychosocial factors to predicting pain severity and interference.

RESULTS

All psychosocial factors including distress, negative beliefs about pain and its consequences, and avoidance of activity, were related to pain outcomes, explaining a further 24% and 30% of the variance in pain severity and interference after controlling for demographic and disease variables. Findings were similar for neuropathic and non-neuropathic pain subgroups.

CONCLUSIONS

All pwMS reported significant pain and associated disability even though over 90% were taking pain medication. Psychosocial factors identified as important in predicting pain severity and, to a greater extent, pain interference are potentially modifiable and may be important treatment targets for both pain subtypes.

Further development in the assessment of psychological flexibility: a shortened Committed Action Questionnaire (CAQ-8)

BACKGROUND

Committed action is a relatively understudied facet of the psychological flexibility model but a potentially important process of overt behaviour in relation to chronic pain. In this study, we take a previously developed measure of committed action, the Committed Action Questionnaire (CAQ), and validate a shorter version.

METHODS

A total of 664 adults seeking treatment for chronic pain participated in this study. They provided responses to the CAQ and also completed measures of acceptance and health-related daily functioning. Exploratory and confirmatory factor analyses as well as Mokken scaling analysis were used to explore the structure of the CAQ and produce an 8-item version (CAQ-8).

RESULTS

A two-factor scale emerged from the analyses that both meets criteria for reliability and validity and performs comparably to the longer original version. In validity correlation analyses, committed action as measured by the CAQ-8 was significantly associated with pain-related and general acceptance and with depression, physical and social functioning, mental health, vitality and general health.

CONCLUSIONS

The CAQ-8 appears equally adequate as the CAQ as a measure of committed action. Its development ought to facilitate further study of this process of engagement in activity and of the wider psychological flexibility model in relation to chronic pain.

Linking of Glycine Receptor Transmembrane Segments Three and Four Allows Assignment of Intrasubunit-Facing Residues

Glycine receptors (GlyRs) are pentameric ligand-gated ion channels that mediate inhibitory neurotransmission in the brain and spinal cord and are targets of alcohols and anesthetics. The transmembrane (TM) domain of GlyR subunits is composed of four α-helical segments (TM1-4), but there are conflicting data about the orientation of TM3 and TM4 and, therefore, also the proximity of residues (e.g., A288) that are important for alcohol and anesthetic effects. In the present study, we investigated the proximity of A288 in TM3 to residues in TM4 from M404 to K411. We generated eight double mutant GlyRs (A288C/M404C, A288C/F405C, A288C/Y406C, A288C/W407C, A288C/I408C, A288C/I409C, A288C/Y410C, and A288C/K411C), as well as the corresponding single mutants, and expressed them in Xenopus laevis oocytes. To measure glycine responses, we used two-electrode voltage clamp electrophysiology. We built homology models of the GlyR using structures of the nicotinic acetylcholine receptor (nAChR) and a prokaryotic ion channel (Gloeobacter violaceus, GLIC) as templates, and asked which model best fit our experimental data. Application of the cross-linking reagent HgCl(2) in the closed state produced a leftward shift in the glycine concentration-response curves of the A288C/W407C and A288C/Y410C mutants, suggesting they are able to form cross-links. In addition, when HgCl(2) was coapplied with glycine, responses were changed in the A288C/Y406C, A288C/I409C, and A288C/Y410C double mutants, suggesting that agonist-induced rotation of TM4 allows A288C/Y406C and A288C/I409C to cross-link. These results are consistent with a model of GlyR, based on nAChR, in which A288, Y406, W407, I409, and Y410 face into a four-helical bundle.

Multimethod assessment of treatment process in chronic low back pain: comparison of reported pain-related anxiety with directly measured physical capacity

Although cognitive behavioural treatments (CBT) have proven efficacy in improving symptom management, pain-related distress, physical performance and return to work. few studies have examined the relationship between changes in behavioural process variables during treatment and improvement in outcome variables following treatment. We designed a multimethod assessment strategy to test the relative contribution of changes in physical capacity and pain-related anxiety to treatment outcome variables. Low back pain patients (n = 59) were treated with an intensive programme of physical exercise and CBT. Comparisons from pre- to post-treatment showed significant improvement in pain severity, interference, affective distress, activity level, and depression. Improvements in pain-related anxiety were associated with improvements in all outcome variables except interference. Of three physical capacity composite scores, improvement in only one (lumbar extension and flexion capacity) was associated with improvements in all outcome variables except interference. Further analyses demonstrated that the relationship between changes in pain-related anxiety and treatment outcome were independent of changes in physical capacity performance. Changes during treatment in pain-related anxiety may be more important than changes during treatment in physical capacity when predicting the effect of treatment on behavioural outcome measures. These results are discussed in the context of how to improve assessment of the chronic pain patient and improve the effectiveness of multidisciplinary CBT.

Assessing depression in systemic lupus erythematosus: determining reliable change

Systemic lupus erythematosus (SLE) can follow an unpredictable course. Clinicians and researchers use various self-report inventories to track aspects of the patient's functioning during the course of the illness (e.g. health status, pain, fatigue, quality of life and psychological status). These self-report inventories are used to measure improvement or deterioration as a function of the natural history of the disease process, or as a function of response to treatment. Proper interpretation of scores derived from these inventories requires an understanding of their psychometric properties, in particular, their reliability. It is important to calculate reliable change difference scores for tests commonly used in rheumatology so clinicians can determine if a change score is a reliable indicator of improvement or deterioration in individual patients (i.e. the change score is not likely to be due to measurement error). The purpose of this article is to illustrate the use of the reliable change difference scores when assessing depression in patients with SLE using the Beck Depression Inventory (BDI).

Barriers to fecal occult blood testing and sigmoidoscopy among older Chinese-American women

PURPOSE

This study examined factors associated with fecal occult blood test (FOBT) and sigmoidoscopy screening use among Chinese-American women age 60 years and older.

DESCRIPTION OF STUDY

One hundred women were recruited from senior centers in two metropolitan areas on the east coast of the United States. Participants completed a questionnaire that included sections on demographics, health history, health insurance coverage, FOBT and sigmoidoscopy use, common and cultural barriers to colorectal cancer screening, and acculturation.

RESULTS

Logistic regression models found greater acculturation to be a significant predictor of having had a FOBT at least once, and found both greater acculturation and physician recommendation to be significant predictors of having had a sigmoidoscopy at least once. No significant predictors were found for regular adherence to colorectal screening guidelines, which include having undergone an FOBT in the past year and sigmoidoscopy in the past 5 years.

CLINICAL IMPLICATIONS

This study found that older Chinese-American women underuse FOBT and sigmoidoscopy screening, as is recommended by the American Cancer Society colorectal cancer screening guidelines. These findings suggest that cultural factors may influence the initiation of colorectal cancer screening for Chinese-American women but are not predictive of adherence to screening over time. Outreach efforts to promote colorectal cancer screening in this population might target women who are less acculturated to facilitate an initial entry into the Western healthcare system to obtain screening.

A comparison of blacks and whites seeking treatment for chronic pain

OBJECTIVE

Most conceptualizations of chronic pain acknowledge the importance of culture and social circumstances. Cultural and social influences may differ for persons of different racial or ethnic groups, and this circumstance may lead them to experience and adjust differently to pain. The current study compared adjustment to chronic pain by blacks and whites seeking treatment for chronic pain.

SUBJECTS AND MEASURES

Fifty-seven black and 207 white patients completed measures of anxiety, depression, disability, pain, and physical symptoms during their initial visit to a university pain clinic.

RESULTS

Comparisons showed that the groups did not differ with regard to age, sex, education, chronicity of pain, pain location, work status, previous surgeries, medical diagnosis, medication, wage replacement, or involvement in litigation. However, the black group reported higher pain severity, more avoidance of activity, more fearful thinking, more physical symptoms, and greater physical and psychosocial disability. The groups remained significantly different with regard to avoidance, fearful thinking, and physical symptoms after pain severity was statistically controlled for; however, they did not remain different on disability.

CONCLUSIONS

These results show that blacks and whites with chronic pain experience pain differently. Several factors may underlie these differences, including family situation, health care experiences, or other unmeasured behavioral, environmental, or social influences. Other investigators should attempt to replicate these findings and more closely examine variables that may explain them.

Predicting complaints of impaired cognitive functioning in patients with chronic pain

Patients with chronic pain often complain of difficulties with cognitive functioning. Previous studies suggest that these occur with no history of head trauma or neurological disease. This study examined potential predictors of cognitive complaints in 275 consecutive patients referred to a university pain management center. Patients completed a brief set of self-report measures of problems with cognitive functioning, biographical information, pain severity, pain location, depression, anxiety, sleep quality, medication use, and litigation status during their first visit to the clinic. The most frequently reported cognitive complaints included forgetfulness (23.4%), minor accidents (23.1%), difficulty finishing tasks (20.5%), and difficulty with attention (18.7%). Fifty-four percent of patients reported at least one problem with cognitive functioning. Correlation analyses showed that using antidepressants, pain severity, pain-related anxiety, and depression were moderately associated with total cognitive complaints. Regression analyses showed that depression accounted for the largest unique proportion of variance in cognitive complaints (DeltaR2 = 29%). Given the high frequency of complaints of impaired cognitive functioning, this realm of functioning deserves routine assessment. When these complaints are encountered, a careful evaluation considering a range of neurological, social, and emotional influences is in order.

Cultural barriers to mammography, clinical breast exam, and breast self-exam among Chinese-American women 60 and older

BACKGROUND

This study examined screening utilization at least once and regular adherence to mammography, clinical breast exam, and breast self-exam among older Chinese-American women.

METHOD

One hundred women were recruited from senior centers in two metropolitan cities. Participants completed a questionnaire that included sections on demographics, health history, health insurance coverage, breast cancer screening, common and cultural barriers to screening, and acculturation.

RESULTS

Logistic regression models found insurance coverage for mammography and acculturation to be significant predictors of having had a mammogram at least once. Low perceived need/lack of physician recommendation and recency of physical examination were significant predictors of having had a mammogram in the past year. Acculturation and modesty were significant predictors of having had a clinical breast exam at least once, while recency of physical examination was a significant predictor of having had a clinical breast exam in the past year. Reliance on medial professionals for screening and forgetting were significant predictors of having performed breast self-exam at least once, and forgetting was a significant predictor of regular performance of breast self-exam.

CONCLUSIONS

These findings suggest that both common and cultural barriers play a role in breast cancer screening among older Chinese-American women, with cultural factors being more influential in the initiation of cancer screening behavior.

Cardiac exposure history as a determinant of symptoms and emergency department utilization in noncardiac chest pain patients

Although comparative studies differentiate noncardiac chest pain (NCCP), panic disorder, and coronary artery disease (CAD), little research has examined the defining features of NCCP, such as cardiac complaints, medical utilization, and learning history. We administered self-report measures to 80 Emergency Department (ED) patients with a primary complaint of chest pain who were subsequently found to not have CAD. Forty-eight percent of the ED utilization variance was accounted for by NCCP duration, age, cardiac distress symptoms, and prior exposure to both siblings' and friends' cardiac distress symptoms. In turn, 67% of the variance in cardiac distress symptoms was explained by education, age, NCCP duration, number of illnesses, noncardiac panic symptoms, prior exposure (friends), and prior observation of others' cardiac distress. No effects emerged for gender, ethnicity, avoidance, or depression. Results suggest that beyond the effects of age and distress intensity, prior exposure to other people's cardiac distress may influence NCCP.

Living forensics: a natural evolution in emergency care

'Throughout history, health care professionals have been called upon to assist the legal system in the prosecution of cases where patient care overlaps with the law and physiological realities collide' (Lynch 1995). Working for the last 21 years in the Accident & Emergency setting, the author is dedicated to increasing the awareness and assisting in the establishment of basic forensic evidence collection guidelines for the emergency care provider. Due to the nature of the clientele and setting, emergency personnel will inevitably care for 'victims of violence'. Domestic violence injuries, abuse and neglect in the elderly and young, the addictive client seeking emergency care, the sexual assault victim, and sufferers of occupational injuries, are but a few of the cases that would be classified in the forensic arena. Holistic care dictates looking after the patient as a whole. The nurse must meet the patient's physical and psychosocial needs. The forensic nurse ensures that the patient's civil and constitutional rights are also met. This forensic health care role can be achieved and strengthened by recognizing potential evidence and maintaining a 'chain of custody' of this evidence.

Assessing depressive symptoms in multiple sclerosis: is it necessary to omit items from the original Beck Depression Inventory?

Overlap between depression scale item content and medical symptoms may exaggerate depression estimates for patients with multiple sclerosis (MS). We reconsider Mohr and co-workers' (1997) recommendation to omit Beck Depression Inventory (BDI) items assessing work ability (item 15), fatigue (17), and health concerns (20) for MS patients. Subjects were medical patients with either MS (n = 105) or a medical disorder for which the BDI is empirically supported [diabetes mellitus (DM), n = 71; chronic pain (CP), n = 80], psychiatric patients with depressive disorder (MDD; n = 37), and healthy controls (HC; n = 80). Relative scores for the eight "somatic" BDI items were analyzed by multivariate analysis of variance with demographic variables and BDI total as covariates. The only significant difference was MS > HC (item 15). On raw scores, MS patients exceeded HCs on items 15 and 21 (sexual disinterest), but this was attributable to the low HC item endorsement. There were no other differences on somatic items or item-total correlations. Scale consistency was good across groups, regardless of item omission. Somatic items were unassociated with major MS parameters. We thus encourage continued application of the full BDI for assessing depressive symptoms in patients with MS.

Behavioral dimensions of adjustment in persons with chronic pain: pain-related anxiety and acceptance

Through empirical methods we now characterize patients with chronic pain as either dysfunctional, interpersonally distressed, or adaptive copers. Studying factors that differentiate these groups may reveal the behavioral processes that determine adjustment to pain. Subjects for this study were 190 patients referred for treatment of chronic pain. They were classified as dysfunctional (n = 41), interpersonally distressed (n = 28) or adaptive copers (n = 59) based on the Multidimensional Pain Inventory (Kerns, R.D., Turk, D.C. and Rudy, T.E., The West Haven-Yale Multidimensional Pain Inventory (WHYMPI), Pain, 23 (1985) 345-356) and compared on measures of pain-related anxiety and pain acceptance. Our analyses showed that the dysfunctional group reported greater pain-related anxiety and less acceptance of pain than the other groups. Additional analyses, statistically controlling for pain severity and depression, showed that the patient subtypes continued to differ on pain-related anxiety and acceptance. Discriminant function analyses including pain-related anxiety and acceptance correctly classified 72.5% of dysfunctional and 90.9% of adaptive copers. Again, anxiety and acceptance contributed uniquely to classification independent of depression and pain intensity. Pain-related anxiety and acceptance of pain appear to be unique behavioral dimensions of adjustment to chronic pain. Decreasing anxiety and increasing acceptance may 'move' patients with chronic pain from the dysfunctional to the adaptive coper category.

Pain-related anxiety predicts non-specific physical complaints in persons with chronic pain

Persons with chronic pain often report a range of physical symptoms beyond their primary pain complaint itself. We predicted that non-specific physical symptom complaints would correlate more strongly with pain-related distress than with general measures of distress, and that they would contribute directly to disability. Results from 210 adults with chronic pain showed that collateral physical complaints are common in persons with chronic pain. Correlational analyses showed that greater reporting of physical complaints was associated with reports of higher pain severity, higher levels of depression, more cognitive, escape/avoidance, fearful appraisal, and physiological symptoms of pain-related anxiety and more physical and psychosocial disability. Regression analyses showed that, with pain-related anxiety variables entered either before or after depression, physiological symptoms of pain-related anxiety significantly predicted physical complaints. In comparison with cognitive and somatic depression symptoms physiological symptoms of pain-related anxiety were the stronger predictor.

Coping with pain produced by physical activity in persons with chronic low back pain: immediate assessment following a specific pain event

Coping with chronic pain during exposure to pain produced by activity was examined in 30 patients with chronic low back pain referred to a university pain management center. Patients' range of motion, autonomic responses, and anticipatory anxiety ratings before exposure and ratings of pain and anxiety after exposure were assessed, and the number of repetitions of the activities that produced the pain was recorded. Analyses showed that using coping self-statement was associated with lower skin conductance during anticipation and greater range of motion. Praying, hoping, and catastrophizing were associated with greater anticipatory anxiety, greater anxiety during the painful activity, and less range of motion from the onset of increased pain to the point of pain tolerance. Praying and hoping were associated with higher pain ratings and fewer repetitions of the activity. Assessment of coping during an incident of pain and multiple methods to measure pain and distress provided convincing evidence that patients' self-management responses influence the consequences of pain exposure.

'Postconcussive' symptoms in persons with chronic pain

The purpose of this study was to examine the base rate of cognitive and neurobehavioural complaints in patients with chronic pain (N = 170) who had not sustained a head injury. The patients completed a packet of questionnaires that contained numerous questions regarding physical, cognitive, and psychological symptoms. The 'postconcussive-like' symptoms were selected and analysed. Specific symptom endorsement rates ranged from 5% to 76.5%. Disturbed sleep, fatigue, and irritability were reported by the majority of chronic pain patients. Cognitive complaints relating to forgetfulness (29%), difficulty maintaining attention (18%), and difficulty with concentration or thinking (16.5%) were endorsed by a significant minority of patients. Most patients (80.6%) endorsed three or more symptoms from Category C of the DSM-IV Postconcussional Disorder research criteria. This study further illustrates that postconcussive-like symptoms are not unique sequelae of mild head injury, and the presence of chronic pain should be considered when interpreting patients' physical, cognitive, and psychological complaints following closed head injury.

Assessment of satisfaction with treatment for chronic pain

The purpose of this study was to develop an instrument to assess satisfaction with treatment of chronic pain, evaluate the reliability and validity of this instrument, and then examine predictors and consequences of satisfaction. The Pain Service Satisfaction Test (PSST) is the result of this effort. Fifty adult patients receiving services for chronic pain in a university pain clinic completed the PSST as part of a survey mailed to their homes. Findings supporting the validity of the PSST included significant positive correlations with a general measure of treatment satisfaction, patient ratings of global treatment satisfaction and effects of treatment, and physician ratings of patient satisfaction with treatment. Regression analyses of predictors of satisfaction highlighted significant contributions of confidence and trust in the provider, pain reduction, and waiting in the clinic. These predictors together accounted for 60% of satisfaction with treatment. Treatment satisfaction was negatively correlated with depression, reported number of physicians consulted, and number of physician visits for pain in the past 12 months; and there was a trend toward a negative correlation with disability. Results of the present study support the importance of satisfaction with treatment as a predictor and possible determinant of later health, function, and service utilization.

The assessment of anxiety and fear in persons with chronic pain: a comparison of instruments

Instruments used to study anxiety and fear responses related to chronic pain vary along two dimensions. They differ in terms of the stimuli or situations that evoke anxiety responses and the types of anxiety responses included (i.e. cognitive, motoric, and physiological). This study examined relations of variables from the Pain Anxiety Symptoms Scale (PASS), the Fear-Avoidance Beliefs Questionnaire (FABQ), the Fear of Pain Questionnaire (FPQ), and the trait version of the Spielberger State-Trait Anxiety Inventory (STAI) with variables related to pain severity, perceived disability, and pain behavior. Subjects were 45 consecutive referrals to a university pain clinic who completed these measures during their evaluation. Results suggested that anxiety responses directly related to the patient's particular pain sensations are more relevant to the understanding of chronic pain than are more general tendencies to respond anxiously or fear more varied pain stimuli. Regression analyses showed that empirically selected subsets of the anxiety variables predict from 16 to 54% of the variance in pain severity, disability and pain behavior. Also, assessment of multiple anxiety response types appears useful for understanding pain behavior and disability. Further study of fear and anxiety responses of persons with pain is likely to benefit from careful selection of measures dependent on the stimulus and response dimensions assessed.

Research methods for investigating causal relations between SLE disease variables and psychiatric symptomatology

People with systemic lupus erythematosus (SLE) frequently experience psychiatric problems. Some researchers and clinicians presume that these psychiatric problems are a direct manifestation of the disease, while others suggest that psychosocial and environmental factors have greater etiological significance. The majority of the studies addressing these issues in patients with SLE are too methodologically limited to make confident conclusions regarding etiology. More methodologically sound research in this area is needed. This article describes some of the limitations in past research in the areas of sampling, measurement, research design, data analyses and data presentation. Suggestions for improved methodology in future research are offered.

Cross-sectional and longitudinal analyses of coping responses and health status in persons with systemic lupus erythematosus

The authors investigated the relations of coping with psychological adjustment and functional status in 46 adults with systemic lupus erythematosus (SLE). The participants completed questionnaires that measured coping with SLE, depression, and functional impairment. A subgroup (n = 22) completed the same questionnaires an average of 7.7 months later. Correlational and regression analyses revealed that, at Time 1, passive coping strategies (eg, avoidance, wishful thinking, blaming self) were significantly related to poorer psychological adjustment and functional status. Problem-focused coping was significantly associated with less depression. Longitudinal analyses showed that using wishful thinking and seeking social support at Time 1 were significant predictors of adjustment at Time 2. These findings are compared with findings from studies of other population groups with chronic illnesses.

Application of a forced-choice memory procedure designed to detect experimental malingering

The detection of dissimulated cognitive deficits is an important issue in many clinical assessment situations. Specific procedures designed to aid in this detection can be useful additions to standard assessment protocols. The present study investigates the potential utility of a modification of the forced-choice, symptom validity paradigm to the assessment of memory deficits. Previous research indicated that the procedure could discriminate between college students instructed to malinger memory impairment and college students instructed to perform at their best ability. The present study administered a forced-choice memory assessment instrument to 60 psychiatric patients, 60 normal community volunteers, and 60 neuropsychological patients. Thirty psychiatric patients and 30 community volunteers were given instructions to malinger. Discriminant function analyses yielded an overall correct group classification rate of 90.6%, with 5% of the nonmalingering subjects and 18.3% of the experimental malingerers incorrectly classified.

Assessing nicotine dependence: a comparison of the Fagerström Tolerance Questionnaire (FTQ) with the Fagerström Test for Nicotine Dependence (FTND) in a clinical sample

A recent effort to improve the psychometric properties of the Fagerström Tolerance Questionnaire (FTQ) resulted in the revised Fagerström Test for Nicotine Dependence (FTND). We endeavored to replicate and extend findings suggesting the superiority of the FTND by examining the psychometric properties of both instruments, as well as their relationship to self-report and biochemical variables associated with nicotine dependence in 110 smoking clinic participants. Results verified that the FTND represents a modest improvement over the FTQ, however, the need for continued development of self-report measures of nicotine dependence is noted.

Does anxiety affect coping with chronic pain?

OBJECTIVE

To evaluate whether symptoms of emotional distress related to pain affect patients' use of pain coping strategies. Relations between anxiety responses, as assessed by the Pain Anxiety Symptoms Scale, and coping strategies, as assessed by the Coping Strategies Questionnaire, were examined.

DESIGN

Cross-sectional, retrospective, correlational.

SETTING

A multidisciplinary pain management clinic in a university hospital.

PARTICIPANTS

One hundred sixty-five patients (49.7% female) with chronic pain complaints. The most frequent complaint was low back pain (73%). Average age was 45.3 years (SD = 13.8).

MAIN OUTCOME MEASURES

Pain coping strategy scores and ratings of ability to control and decrease pain.

RESULTS

Generally, cognitive anxiety was associated with less overall coping with pain, whereas physiological anxiety was associated with a greater coping with pain. Escape and avoidance anxiety responses were associated with greater use of overt pain behaviors for coping. Regression analyses indicated that anxiety symptoms combined across cognitive, motoric, and physiological response types accounted for significant variance in seven of eight coping strategy scores. These analyses also revealed significant unique relations of separate anxiety modalities with coping variables. Relations between anxiety scores and the Catastrophizing subscale of the CSQ were much greater than the relations of anxiety scores with other coping variables, suggesting that catastrophizing may be better conceptualized as a distress response rather than a coping strategy.

CONCLUSIONS

These results show that different types of anxiety symptoms have differing relations with pain coping responses. Cognitive anxiety symptoms may interfere with coping, whereas physiological anxiety symptoms may enhance coping. Possible mechanisms and implications are discussed.

Prediction of pain in patients with chronic low back pain: effects of inaccurate prediction and pain-related anxiety

This study investigated predictions of pain intensity, reports of pain and anxiety, frequency of pain-related anxiety symptoms, and range of motion, in 43 patients exposed to pain during a physical examination. All patients had primary complaints of low back pain. The pain stimuli used for this study included back and/or leg pain produced by repeatedly raising the extended leg of the patient to the point of pain tolerance. Generally, findings demonstrated that (a) predictions of pain were a function of discrepancies between previous predictions and experiences of pain, (b) patients reporting greater pain-related anxiety showed a tendency to overpredict new pain events, but corrected their predictions readily, (c) patients reporting less pain-related anxiety displayed a persistent tendency to underpredict pain, and (d) higher predictions of pain, independent of pain reports, related to less range of motion during a procedure that involved painful movement. Discussion focuses on differences between these results and those of previous studies and the implications of inaccurate prediction for continued pain and disability.

Treatment of paruresis with in vivo desensitization: a case report

In vivo desensitization was employed with a patient exhibiting chronic paruresis. Measures of urination delay, and subjective units of distress were obtained at pre-training, during training, at a generalization trial, and at a follow-up assessment. Urine volume was also measured at pre- and post-training. There was shorter delay in urination, greater urine output, and less subjective anxiety following treatment. These effects were also demonstrated during a generalization post-test in which the patient was exposed to an unknown observer. A follow-up trial involving exposure to a second unknown observer indicated that treatment effects were maintained at 7.5 months following treatment.

The detection of malingering in neuropsychological assessment

Although malingering, or the manipulation of data by the patient, is a problem commonly faced by neuropsychologists, there has been little systematic investigation of this problem. This paper reviews the literature on the detection of malingering in assessment instruments commonly used by clinical neuropsychologists. Criticism of previous research is discussed, and suggestions are made both for future research and for clinical practice.