The relationship between response style and symptom reporting in cancer patients

PURPOSE

Patient-reported outcomes are considered the gold standard for documenting treatment-related toxicities and cancer-related symptoms in the management of oncology patients. Poor concordance between patients and health care professionals (HCPs) on patients' symptoms has been documented. The purpose of this study is to examine the association between social desirability, a response style, and symptom reporting in a colorectal cancer clinic.

METHODS

Patients being treated for colorectal cancer completed a social desirability measure and a symptom measure before their appointment in the oncology clinic. The HCP who saw the patient completed a symptom measure for the patient after the clinic visit.

RESULTS

One hundred sixty-nine patients consented to participate in the study. The majority of the patients had stage 4 disease. There was a statistically significant positive correlation between social desirability and overall reported symptom burden. There was a statistically significant negative correlation between social desirability and concordance between the patient and the HCP on the patient's symptoms. Social desirability scores were stable over the course of 1 year.

CONCLUSION

Sensitivity to social desirability effects seems to play an important role in patient self-report of symptoms. As social desirability is a stable quality, patients sensitive to it may be persistently at risk for undertreatment of symptoms due to limited symptom reporting.

Distress, depression, anxiety, and resilience in patients with cancer and caregivers

OBJECTIVE

Resilience is the ability to cope and function despite adversity, such as a cancer diagnosis, and has been conceptualized as the other end of a distress-resilience continuum. There are known associations among resilience, distress, depression, and anxiety-yet the nature of the associations is not well characterized. Less is known about the relationship among these variables for caregivers. We examined these associations in a convenience sample from a clinical setting with these hypotheses: (a) patients and nondyadic caregivers will report elevated, comparable levels of distress, depression, and anxiety, and (b) resilience will moderate the effect of distress on depression and anxiety.

METHOD

Participants were patients with a cancer diagnosis (n = 328) and nondyadic caregivers (n = 169). Participants completed a demographic/clinical questionnaire and self-report measures (National Comprehensive Cancer Network Distress Thermometer, Patient-Reported Outcomes Measurement Information System anxiety and depression measures, and Brief Resilience Scale). The statistical plan for this cross-sectional study included moderation analyses and various tests of association.

RESULTS

Patients and caregivers reported comparable levels of resilience and elevated distress; patients exhibited more severe depression and anxiety. There was no evidence for a moderating effect of resilience. For both groups, the model of distress predicting depression/anxiety exhibited improved fit when including resilience. Distress and resilience share variance in the prediction of depression/anxiety among patients.

CONCLUSIONS

Distress, depression, and anxiety are common in patients with cancer but also in cancer caregivers. Resilience appears to be an important variable to consider alongside distress and may enhance our understanding of the relationships among distress and depression/anxiety, especially for individuals with cancer. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Addressing distress management challenges: Recommendations from the consensus panel of the American Psychosocial Oncology Society and the Association of Oncology Social Work

Distress management (DM) (screening and response) is an essential component of cancer care across the treatment trajectory. Effective DM has many benefits, including improving patients' quality of life; reducing distress, anxiety, and depression; contributing to medical cost offsets; and reducing emergency department visits and hospitalizations. Unfortunately, many distressed patients do not receive needed services. There are several multilevel barriers that represent key challenges to DM and affect its implementation. The Consolidated Framework for Implementation Research was used as an organizational structure to outline the barriers and facilitators to implementation of DM, including: 1) individual characteristics (individual patient characteristics with a focus on groups who may face unique barriers to distress screening and linkage to services), 2) intervention (unique aspects of DM intervention, including specific challenges in screening and psychosocial intervention, with recommendations for resolving these challenges), 3) processes for implementation of DM (modality and timing of screening, the challenge of triage for urgent needs, and incorporation of patient-reported outcomes and quality measures), 4) organization-inner setting (the context of the clinic, hospital, or health care system); and 5) organization-outer setting (including reimbursement strategies and health-care policy). Specific recommendations for evidence-based strategies and interventions for each of the domains of the Consolidated Framework for Implementation Research are also included to address barriers and challenges.

Mental distress among adolescent and young adult (AYA) and adult cancer survivors

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Background: Mental distress is associated with poor treatment adherence and adverse psychosocial outcomes, and cancer survivors, especially adolescent and young adults (AYA), may experience greater distress than older adults and the general population. We tested this hypothesis by examining the association between AYA vs. adult cancer survivors vs. the general population without a history of cancer, and mental distress. Methods: Using the 2014-2017 National Health Interview Surveys, 2,516 AYA cancer survivors (aged 15 – 39 years) were identified. We then used propensity score matching (matched on sociodemographics, comorbidities, smoking status and visit to mental health professional in past year) to create 2,516 older cancer survivors (aged ≥ 40 years); and 2,516 adults without cancer (general population) as the comparison groups. Mental distress (outcome of interest) was measured using the validated Kessler nonspecific mental/psychological distress (K6) scale. The 6-item K6 scale examines how frequently within the past 30 days an individual felt nervous, hopeless, restless or fidgety, worthless, sad, and that everything was an effort. Responses were summed to yield a score ranging between 0 and 24 and classified as none/low (0≤K6 < 5), moderate (5≤K6 < 13), and severe (K6≥13) mental distress. Two separate weighted multinomial logistic regression models estimated the odds of mental distress in study population (AYA vs. adult cancer survivors; and AYA vs. general population), adjusting for known covariates. Results: Mental distress was more prevalent among AYAs than adult cancer survivors (moderate: 24.0% vs 18.3%; and severe: 5.7% vs 4.2% [ P= .0002]); and the general population (moderate: 24.3% vs 16.7%; and severe: 6.1% vs 5.3% [ P< .0001]). Similarly, prevalence was higher among adult cancer survivors than the general population (moderate: 16.8% vs 13.6%; and severe: 3.2% vs 2.7% [ P= .0002]). In the multivariable multinomial analyses, AYAs had greater odds of mental distress (aORmoderate = 1.44; 95% CI 1.09, 1.89; and aORsevere = 1.77; 95% CI 1.21, 2.58) vs. adult cancer survivors. AYAs also had greater odds of mental distress vs. the general population (aORmoderate = 1.39; 95% CI 1.08, 1.79), but no significant difference in severe distress. Conclusions: About 1-in-4 AYA cancer survivors report some mental distress, and distress is more prevalent among this younger age group than older adults with cancer and the general population. Psychosocial care may be especially needed in this younger population to mitigate adverse psychosocial outcomes.

Update on the Implementation of NCCN Guidelines for Distress Management by NCCN Member Institutions

The first NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Distress Management were published in 1999. Since then, a number of other organizations have advocated for distress screening. Previous surveys of distress screening showed modest progress in implementation of the NCCN Guidelines for Distress Management by NCCN Member Institutions (MIs); this review examined whether further progress has been made. Representatives appointed to the NCCN Distress Management Panel or their designee were asked to complete an online survey in the summer of 2018. The survey was developed based on similar surveys performed in 2005 and 2012 and a survey of psychosocial staffing conducted in NCCN MIs in 2012. New items solicited details about triaging, rescreening, formal screening protocols, and tracking of distressed patients. The survey was completed by representatives from 23 of 27 NCCN MIs (85%). Among the responding institutions, 20 (87%) currently conduct routine screening for distress and 3 are piloting routine screening. All respondents reported use of a self-report measure to screen for distress, with the Distress Thermometer most often used. A total of 70% of respondents rescreen patients for distress and 83% reported having a formal distress screening protocol in place. Once triaged, 65% of institutions who routinely screen for distress track clinical contacts and referrals; 70% track rates of adherence to screening protocols. Findings suggest wide acceptance and implementation of the NCCN Guidelines. Most respondents reported the existence of a formal distress screening protocol, with routine tracking of clinical contacts and referrals and rates of protocol adherence. Clinical experience and the American College of Surgeons Commission on Cancer accreditation standard for cancer centers appear to have resulted in greater adoption and implementation of the guidelines, but considerable opportunities for improvement remain.

Gaps in communication between cancer patients and healthcare providers: symptom distress and patients' intentions to disclose

PURPOSE

Good communication between patients and healthcare professionals (HCPs) is an important contributor to patient well-being. Few studies have focused on the gaps in communication between patients and HCPs about symptoms. This study examined patients' perspectives on symptom distress, intention to discuss symptoms, and actual symptom discussion in medical oncology visits.

METHODS

This was a cross-sectional descriptive study. Ninety-four patients provided demographic and clinical information and completed the Memorial Symptom Assessment Scale. Patients also answered questions about their plans for communication-and after the visit, their actual communication-with their medical team about their symptoms.

RESULTS

Patients reported many symptoms by questionnaire; however, they did not plan to discuss-nor actually discussed-most of their symptoms with their HCPs. For all symptoms, fewer than 42% of patients with the symptom intended to discuss it (except for lack of energy and pain) and less than 50% actually discussed the symptom. For bothersome symptoms, less than 42% of those with the symptom intended to discuss it (except for lack of energy) and less than 40% actually discussed the symptom. Psychological symptoms were endorsed by 24-41% of patients, depending on the symptom; however, of those endorsing a symptom, most did not discuss it with an HCP.

CONCLUSIONS

Results of this study support the perception of communication gaps between patients and HCPs about symptoms. Better understanding of these gaps is needed to ensure that patient-centered care is delivered and that patients' symptoms can be appropriately managed in oncology clinics.

Problem areas identified by cancer patients with a positive distress screen in the medical clinic

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Background: NCCN has been advocating for distress screening since the inaugural Distress Management Guidelines in 1999. ASCO’s Quality Oncology Practice Initiative incorporated an indicator of patients’ emotional well-being in 2009. The ACoS Commission on Cancer established mandatory distress screening as an accreditation requirement for cancer programs in January 2015. This latter requirement dramatically increased the number of cancer programs doing routine distress screening. We examined distress screening results at a comprehensive cancer center. Methods: Results of distress screening were reviewed in the following clinical areas: medical oncology, radiation oncology, gynecologic oncology, and otolaryngology. Distress screening was completed verbally as a part of the vitals assessment, using the NCCN Distress Thermometer and Problem List. Only patients with a positive screen ( < 6 on 0-10 rating scale) completed the Problem List, identifying relevant problem areas (Emotional, Family, Practical, Physical, Spiritual and Other). The MA or RN doing the distress screening entered the distress rating and the endorsed problem area(s) in the electronic medical record. Results: In the first 5 months of 2017, 11,155 screening results were entered into the medical record. The percent of positive screens ranged from 5.7 to 8.6%, with X = 6.6% of screens being positive for distress. The most common problem areas were Emotional, endorsed with X = 72.5% of positive screens (range = 33.5-96.6%); Physical, endorsed with X = 67.52% of positive screens (range = 42.8-86.4%); and Practical, endorsed with X = 43.1% of positive screens (range = 20.1-59.9%). Conclusions: While some cancer centers use a psychologically-focused screening method (e.g. PHQ-9, BDI), distress is a bio-psychosocial construct, which requires a screening method that includes multiple domains. Furthermore, the triage related to distress screening may best be accomplished by the cancer team at the clinic visit, so that physical problems can be further assessed and addressed during the visit. The medical team can also make referrals to social work or psychological services to address related problem areas, when identified by patients.

Lack of Patient-Clinician Concordance in Cancer Patients: Its Relation With Patient Variables

CONTEXT

Patients with cancer are bothered by its diagnosis, treatment, and associated uncertainty. Lack of concordance (LOC) of patients' reporting of their symptoms and quality of life (QOL) with that of their clinicians has been observed in cancer care. However, information regarding the reporting of patients' bother due to aspects of cancer experience and their clinicians' assessment is lacking.

OBJECTIVES

The objective was to describe cancer patients' bother due to aspects of their disease experience and explore the concordance (LOC) or a lack thereof between patients' and clinicians' reporting of patients' bother and factors associated with it.

METHODS

Data from a prospective study of cancer patients' symptoms were analyzed. LOC was defined as any discrepancy between patient-clinician pairs in reporting patients' bother due to disease, cancer treatment, comorbidity, and side effects of symptom management. The relation of LOC to patients' QOL and distress was also explored.

RESULTS

Of the 2597 patients analyzed, a perfect concordance was observed in 37%-42%. Clinicians underestimated the severity of bother in 62%-76% of discordant cases. LOC was significantly associated with patient-reported distress and poor QOL. Referral for symptom management was associated with the clinician's rating of patients' bother, and LOC was associated with likelihood of poor compliance with recommendations for symptom management.

CONCLUSION

Majority of clinicians tended to underestimate cancer patients' bother, and this was associated with poor QOL of cancer patients and their distress. Future studies should examine the LOC and its correlates to confirm the results of this study.

Comparing the symptom experience of cancer patients and non-cancer patients

PURPOSE

Symptom burden is an established concept in oncology encompassing the presence and severity of symptoms experienced by cancer patients. Few studies have examined differences in symptom burden between cancer patients and non-cancer patients. This study seeks to examine the differences in symptom burden between cancer patients (CP) and non-cancer patients (NCP) in order to better understand symptom burden in both populations.

METHODS

Two groups of patients completed the Memorial Symptom Assessment Scale: 301 patients from a general medical clinic and 558 cancer patients from a cancer tumor registry. Participants provided demographic information-age, race/ethnicity, and sex and completed the Memorial Symptom Assessment Scale. Medical comorbidity was also measured.

RESULTS

Most symptoms were more common in CP, except for pain, which was more prevalent in the NCP (45% of CP vs. 54% of NCP, p < .05). There was no difference in prevalence for the following symptoms: dry mouth, mouth sores, feeling nervous, worry, cough, and dizziness. The CP had greater mean MSAS Total scores (0.53 vs. 0.43, p < .01), number of symptoms (9.11 vs. 6.13, p < .01), and psychological subscale scores (0.77 vs. 0.64, p < .05). There was no difference by group in the physical nor the GDI subscale scores.

CONCLUSION

The results of this study support the perception that cancer patients have greater symptom burden. There were some unexpected results, particularly in terms of pain, which was more common in NCP and other symptoms that were experienced equally in both patient populations.

Cancer-related hair loss: a selective review of the alopecia research literature

OBJECTIVE

Alopecia is a common side effect of cancer treatment, affecting approximately 65% of patients. Healthcare providers and allied staff recognize that alopecia is distressing for people with cancer; however, they are often unaware of the extent of distress or the great efforts expended by patients to cope with hair loss. This study reviews the existing literature regarding the psychosocial impact of alopecia on cancer survivors and the coping strategies they use to manage hair loss.

METHODS

We searched for studies examining the psychosocial effects of alopecia on cancer survivors using PubMed and PsycInfo databases and Google Scholar.

RESULTS

A total of 36 peer-reviewed articles were deemed relevant to be included in this review. In this review, alopecia was consistently ranked as one of the most distressing side effects of cancer treatment. Survivors report that hair loss disrupts how they experience their bodies, interact with others, and conceptualize their body image beyond treatment. Although upsetting for both genders, the scarce literature that exists suggests that there may be some gender-specific aspects of experiencing cancer-related hair loss. Cancer survivors cope with alopecia in numerous ways and often rely on strategies such as concealment, social support, social avoidance, information seeking, and behavioral rehearsal.

CONCLUSIONS

Treatment-induced alopecia negatively affects millions of survivors each year in unique and nuanced ways. We hope that survivors' healthcare providers and loved ones may better appreciate the psychosocial challenges they experience related to hair loss, as well as the strategies they use to cope. Further research is much needed to better understand cancer-related alopecia. Copyright © 2015 John Wiley & Sons, Ltd.

Resilience in adults with cancer: development of a conceptual model

OBJECTIVE

Resilience is a construct addressed in the psycho-oncology literature and is especially relevant to cancer survivorship. The purpose of this paper is to propose a model for resilience that is specific to adults diagnosed with cancer.

METHODS

To establish the proposed model, a brief review of the various definitions of resilience and of the resilience literature in oncology is provided.

RESULTS

The proposed model includes baseline attributes (personal and environmental) which impact how an individual responds to an adverse event, which in this paper is cancer-related. The survivor has an initial response that fits somewhere on the distress-resilience continuum; however, post-cancer experiences (and interventions) can modify the initial response through a process of recalibration.

CONCLUSIONS

The literature reviewed indicates that resilience is a common response to cancer diagnosis or treatment. The proposed model supports the view of resilience as both an outcome and a dynamic process. Given the process of recalibration, a discussion is provided of interventions that might facilitate resilience in adults with cancer.

Distress management

The integration of psychosocial care into the routine care of all patients with cancer is increasingly being recognized as the new standard of care. These NCCN Clinical Practice Guidelines in Oncology for Distress Management discuss the identification and treatment of psychosocial problems in patients with cancer. They are intended to assist oncology teams identify patients who require referral to psychosocial resources and to give oncology teams guidance on interventions for patients with mild distress to ensure that all patients with distress are recognized and treated.

A prospective longitudinal clinical trial evaluating quality of life after breast-conserving surgery and high-dose-rate interstitial brachytherapy for early-stage breast cancer

PURPOSE

To prospectively examine quality of life (QOL) of patients with early stage breast cancer treated with accelerated partial breast irradiation (APBI) using high-dose-rate (HDR) interstitial brachytherapy.

METHODS AND MATERIALS

Between March 2004 and December 2008, 151 patients with early stage breast cancer were enrolled in a phase 2 prospective clinical trial. Eligible patients included those with Tis-T2 tumors measuring ≤3 cm excised with negative surgical margins and with no nodal involvement. Patients received 3.4 Gy twice daily to a total dose of 34 Gy. QOL was measured using European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30, version 3.0, and QLQ-BR23 questionnaires. The QLQ-C30 and QLQ-BR23 questionnaires were evaluated during pretreatment and then at 6 to 8 weeks, 3 to 4 months, 6 to 8 months, and 1 and 2 years after treatment.

RESULTS

The median follow-up was 55 months. Breast symptom scores remained stable in the months after treatment, and they significantly improved 6 to 8 months after treatment. Scores for emotional functioning, social functioning, and future perspective showed significant improvement 2 years after treatment. Symptomatic fat necrosis was associated with several changes in QOL, including increased pain, breast symptoms, systemic treatment side effects, dyspnea, and fatigue, as well as decreased role functioning, emotional functioning, and social functioning.

CONCLUSIONS

HDR multicatheter interstitial brachytherapy was well tolerated, with no significant detrimental effect on measured QOL scales/items through 2 years of follow-up. Compared to pretreatment scores, there was improvement in breast symptoms, emotional functioning, social functioning, and future perspective 2 years after treatment.

Palliative care

These guidelines were developed and updated by an interdisciplinary group of experts based on clinical experience and available scientific evidence. The goal of these guidelines is to help patients with cancer experience the best quality of life possible throughout the illness trajectory by providing guidance for the primary oncology team for symptom screening, assessment, palliative care interventions, reassessment, and afterdeath care. Palliative care should be initiated by the primary oncology team and augmented by collaboration with an interdisciplinary team of palliative care experts.

IRB Member Judgments of Decisional Capacity, Coercion, and Risk in Medical and Psychiatric Studies

WHILE INDIVIDUALS WITH PSYCHIATRIC illnesses are widely considered a special class of research subjects regarding decisional capacity and coercion vulnerability, those with physical illnesses often are not. IRB members (N = 127) read vignettes that described clinical research targeting one of two levels of disease severity (high/low) for psychiatric or medical diagnoses. They then rated decisional capacity, coercion, and risks for hypothetical research subjects. IRB members viewed psychiatric subjects as having greater vulnerability to coercion and less decisional capacity than medical subjects, even when medical illness was of a severity likely to engender psychiatric comorbidities. These results suggest that IRB members may inflate the vulnerability and decisional incapacity of psychiatric subjects, while discounting vulnerability and incapacity in medical subjects.

Documenting the symptom experience of cancer patients

BACKGROUND

Cancer patients experience symptoms associated with their disease, treatment, and comorbidities. Symptom experience is complicated, reflecting symptom prevalence, frequency, and severity. Symptom burden is associated with treatment tolerance as well as patients' quality of life (QOL).

OBJECTIVES

The purpose of this study was to document the symptom experience and QOL of patients with commonly diagnosed cancers. The relationship between symptoms and QOL was also explored.

METHODS

A convenience sample of patients with the five most common cancers at a comprehensive cancer center completed surveys assessing symptom experience (Memorial Symptom Assessment Survey) and QOL (Functional Assessment of Cancer Therapy). Patients completed surveys at baseline and at 3, 6, 9, and 12 months thereafter. This article describes the study's baseline findings.

RESULTS

Surveys were completed by 558 cancer patients with breast, colorectal, gynecologic, lung, or prostate cancer. Patients reported an average of 9.1 symptoms, with symptom experience varying by cancer type. The mean overall QOL for the total sample was 85.1, with results differing by cancer type. Prostate cancer patients reported the lowest symptom burden and the highest QOL.

LIMITATIONS

The sample was limited in terms of racial diversity. Because of the method of recruitment, baseline data were collected 6-8 months after diagnosis, meaning that participants were at various stages of treatment.

CONCLUSIONS

The symptom experience of cancer patients varies widely depending on cancer type. Nevertheless, most patients report symptoms, regardless of whether or not they are currently receiving treatment. Patients' QOL is inversely related to their symptom burden.

Assessment of consent capability in psychiatric and medical studies

In order to evaluate psychiatric factors that potentially influence assessment of consent capacity, 195 IRB members read summaries of hypothetical medical (cancer vs. neuropathic pain) and psychiatric trials. They then rated research participants' capacity for consent (capable or not capable), autonomy, and decisional abilities, as well as the legal risk to the institution of the study. Levels of depression information varied across the medical disorders. Significantly fewer IRB members judged participants in the depression trial to possess adequate capacity for consent relative to 4 of 6 medical conditions; legal risk to the institution also was rated higher in the psychiatric study. While IRB members judged participants in depression trials to have less capacity for consent and to pose higher levels of institutional risk than medical trial participants, the addition of increasing information regarding depressive co-morbidities had little or no effect on judgments of medical studies. Implications are discussed relative to the apparent overprotection of participants in psychiatric trials and underprotection of those in medical trials.

Psychological Status at Time of Diagnosis and Patients' Ratings of Cosmesis Following Radiation Therapy for Breast Cancer

This retrospective pilot study examined the relationship between psychological status at the time of breast cancer diagnosis and ratings of cosmetic outcome later. Sixty-three patients completed measures of depression, anxiety, and quality of life at the time of diagnosis. Following lumpectomy and radiation therapy, these patients and their radiation oncologists completed ratings of the quality of the cosmetic outcome (Cosmesis). The results indicated that both psychological distress and quality of life were related to patients' ratings of Cosmesis, while only patients' quality of life was related to physicians' ratings of Cosmesis. We conclude that Cosmesis is a multifaceted construct that incorporates both physical and psychological factors.

Psychological and cognitive status before and after heart transplantation

Advances in the technical aspects of heart transplantation and the medical management of rejection have allowed a shift toward research evaluating psychological factors affecting heart transplant candidates and psychosocial sequelae following transplantation. This study examined the psychological and cognitive status of patients presenting for heart transplant evaluation. The findings indicated that this patient group was characterized by impaired verbal memory and a tendency toward depression and anxiety. The second part of the study examined changes in psychological and cognitive status from the initial evaluation to a follow-up assessment 1 year after transplantation. The results indicated that psychological distress (depression, anxiety) and several indices of cognitive function improved after transplantation. Finally, correlations were determined to evaluate the association between the psychological and cognitive measures and episodes of rejection in the first 6 months after transplantation. Anxiety, depression, and a nonverbal measure of intelligence were found to be associated with the number of episodes of rejection. The implications of these findings are discussed.

Relationship between social desirability and self-report in chronic pain patients

OBJECTIVE

To examine the relationship between social desirability and self-report in data collected from chronic pain patients.

SETTING

A multidisciplinary pain management center located in a major university medical center.

PATIENTS

Two hundred persons presenting with chronic pain, including low back, head/neck, and extremity pain.

MEASURES

Marlowe-Crowne Social Desirability Scale, Beck Depression Inventory--Short Form, Spielberger Trait Anxiety Inventory, Psychosomatic Symptom Checklist, McGill Pain Questionnaire, Pain Disability Index, Quality of Life Scale, Pain Drawing.

RESULTS AND CONCLUSIONS

Correlations showed that patients with greater social desirability response bias reported less depression and anxiety but higher levels of pain severity. When depression effects were controlled in a regression analysis, social desirability correlated positively with self-reported disability. These results show systematic response patterns associated with social desirability, suggesting that social desirability response biases should be considered in both research and clinical assessments of chronic pain patients.

Prevalence of temporomandibular symptoms in a large United States metropolitan area

The prevalence of five symptoms of temporomandibular disorder and associated symptoms of pain, headache, and stress was estimated in a random telephone survey of a large United States metropolitan area. The prevalences for nocturnal bruxing, joint noise with use, soreness on waking, soreness with use, and diurnal clenching were roughly equivalent (ranging from 8% to 12%) and were within the range of prevalences reported in previous studies. Overall, 149 of the 500 respondents reported one or more of the five symptoms. Symptoms were not more prevalent among women than men, but were more prevalent among younger respondents. Soreness on waking and daytime clenching were the only symptoms significantly associated with report of pain. Pain was more commonly reported by respondents with multiple (four or five) symptoms. The results are compared with those of previous random surveys, and limitations to generalization of the present findings are discussed.

Stable factors in chronic pain

In an effort to identify components of the chronic pain experience, a sample of 444 chronic pain patients who had completed a battery of self-report measures was divided into two groups. The data from each group were analyzed using principal components analysis. Four factors emerged for one group of patients, which accounted for 57.6% of the variance and represented the dimensions of psychological distress, pain-related disability, pain description, and pain history. In the other group, five factors emerged that accounted for 64.2% of the variance. These factors represented psychological distress, disability, pain intensity, pain sensation, and pain history. The similarity of these factors across groups suggests that they represent stable dimensions of the patient's pain experience. Research implications and methodological considerations are discussed.

The experience of anger in chronic illness: a preliminary investigation

The experience of anger was investigated in relation to essential hypertension, in particular, and chronic disease states, in general. A hypertensive patient group was compared to a chronic disease control group (diabetics) and a nonpatient normotensive control group on measures of anger expression, assertiveness, and perceptions of health status. The chronic patient groups differed significantly from the nonpatient controls in reporting more anger in general, greater frequency of anger experiences, and a tendency to express anger more outwardly. The chronic patient groups also reported greater severity of health problems. Comparisons between the hypertensives and diabetics revealed a greater level of current anger among diabetics. The findings are discussed in terms of their implications for anger and chronic illness. Suggestions for future research regarding anger and hypertension also are made.

Trimethyltin-induced changes in gross morphology of the hippocampus

Acute exposure to trimethyltin (TMT) produces alterations in hippocampal morphology. The purpose of this study was to arrive at a simple method for quantitative assessment of the gross changes in morphology which could then be used as a correlate in studies of TMT toxicity. Adult Long-Evans male hooded rats were treated with a single dose of TMT chloride and sacrificed either (a) within 11 days; (b) following 30 days; or (c) 105 days following treatment. Among a variety of morphological measures explored, the easiest and most clearly dosage-related was length of the line of pyramidal cells, from CA1 through CA3c. TMT shortened this line in a dosage- and time-dependent manner. Loss of cells appeared to begin in CA3c and progress through CA3b and CA3a as a dosage and time since treatment increased. It was concluded that this measurement may provide a useful morphological correlate for physiological and behavioral studies of TMT toxicity.