The role of self-criticism and self-compassion in the development of PTSD among midwives

OBJECTIVE

Healthcare providers might develop emotional distress following direct and indirect exposure to traumatic events. Evidence shows that midwives, who care for women in complicated situations, are often exposed to circumstances that have a potential to lead to a variety of psychological reactions, including symptoms identified with post-traumatic stress disorder (PTSD). Nevertheless, the positive-healthy context in which childbirth is mainly perceived raises questions regarding the protective role of personality traits, which are related to processing methods of stress and pain, in the development of PTSD among this unique population. This study aimed to explore the associations between traits such as self-compassion, self-criticism, resilience, cognitive thinking, and pain catastrophizing and PTSD symptoms among Israeli midwives.

SETTING

Using a quantitative cross-sectional study,123 midwives from ten hospitals in Israel anonymously reported their characteristics and severity of stress and/or PTSD symptoms by filling out the Psychopathy Checklist questionnaire. Analysis of personality traits was performed via the following questionnaires: Self-Compassion Scale - Short Form, Depressive Experiences Questionnaire - Self Criticism, and the Connor-Davidson Resilience Scale. Additionally, we measured the level of catastrophizing pain by employing the Pain Catastrophizing Scale questionnaire.

FINDINGS

Most of the midwives reported existing post-trauma symptoms, among them 11.38% had been diagnosed with PTSD. Severity of the PTSD correlated with their self-criticism and the pain catastrophizing rates. Additional examination of the involvement of personality traits showed that midwives with high self-criticism, low mental resilience, besides a high rate of pain catastrophizing, were more vulnerable to developing PTSD.

CONCLUSIONS

The findings can help to refine the understanding regarding the involvement of midwives' personality characteristics in the process of PTSD onset. Vulnerable midwives have been identified as those at risk to develop PTSD symptoms.

IMPLICATIONS FOR PRACTICE

The clinical significance of these insights is to promote the ability to identify midwives who are at risk to develop PTSD. Furthermore, this information might help to produce training programs and a support network to empower self-compassion and mental resilience, and to minimize self-criticism in order establish a support network, which would help to deal with the difficult experiences they face at work.

Dispositional and situational personal features and acute post-collision head and neck pain: Double mediation of pain catastrophizing and pain sensitivity

Pain variability can be partially attributed to psycho-cognitive features involved in its processing. However, accumulating research suggests that simple linear correlation between situational and dispositional factors may not be sufficiently explanatory, with some positing a role for mediating influences. In addition, acute pain processing studies generally focus on a post-operative model with less attention provided to post-traumatic injury. As such, this study aimed to investigate a more comprehensive pain processing model that included direct and indirect associations between acute pain intensity in the head and neck, pain catastrophizing (using pain catastrophizing scale (PCS)), and pain sensitivity (using the pain sensitivity questionnaire (PSQ)), among 239 patients with post-motor vehicle collision pain. The effect of personality traits (using Ten Items Personality Inventory (TIPI)) and emotional status (using Hospital Anxiety and Depression Scale (HADS) and Perceived Stress Scale (PSS)) on that model was examined as well. To this end, three Structural Equation Modeling (SEM) analyses were conducted. Overall, the data had good fit to all the models, with only PSQ found to have a direct correlation with acute pain intensity. The SEM analyses conversely revealed several mediations. Specifically, that: first, PSQ fully mediated the relationship between PCS and pain intensity; second, PCS and PSQ together fully mediated the relationship between conscientiousness (personality trait) and pain intensity; and finally, emotional status had direct and indirect links with PSQ and pain intensity. In conclusion, these models suggest that during the acute post-collision phase, pain sensitivity intermediates between emotional states and personality traits, partially via elevated pain catastrophizing thoughts.

Head- and neck-related symptoms post-motor vehicle collision (MVC): Separate entities or two-sides of the same coin?

BACKGROUND AND AIM

Although post-motor vehicle collision (MVC) pain and symptoms are largely convergent among those with mild traumatic brain injury (mTBI) and whiplash associated disorder (WAD), and patients oftentimes report initial neck and head complaints, the clinical picture of mTBI and WAD has been primarily studied as separate conditions which may result in an incomplete clinical picture. As such, this study was conducted to explore the role of pain and post-traumatic psychological features in explaining both head and neck-related symptom variability in a cohort of post-collision patients. This is with the goal of disentangling if contributory factors are uniquely related to each diagnosis, or are shared between the two.

METHODS

Patients recruited in the very early acute phase (<72 h) returned for clinical and psychological assessment at 6 months post-accident. In order to determine which factors were unique and which ones were overlapping the same potential contributors: mean head pain, mean neck pain, female gender, number of post-collision painful body areas, PTSD, and depression were included in the regression models for both neck disability index (NDI) and Rivermead post-concussion symptoms questionnaire (RPQ).

RESULTS

Of 223 recruited participants, 70 returned for a follow-up visit (age range 18-64, mean(SD) 37.6 (11.9), 29F). This cohort primarily met the criteria for mTBI, but also fulfilled the criteria for whiplash, reinforcing the duality of injury presentation. Correlations existed between the NDI and RPQ scores (Spearman's ρ=0.66, p<0.001), however overlap was only partial. Regression analysis showed that after the removal of area-of-injury pain neck related disability (r = 0.80, p <0.001) was explained solely by number of painful body areas (ß=0.52, p <0.001). In contrast, post-concussion syndrome symptoms (r = 0.86, p<0.001) are influenced by clinical pain, painful body areas (ß=0.31, p = 0.0026), female gender (ß=0.19, p = 0.0053), and psychological factors of depression (ß=0.31, p = 0.0028) and PTSD symptoms (ß=0.36, p = 0.0013).

CONCLUSIONS

It seems that while mechanisms of neck- and head-related symptoms in post-collision patients do share a common explanatory feature, of residual body pain, they are not entirely overlapping. In that psychological factors influence post-concussion syndrome symptoms, but not post-whiplash neck disability.

Enhanced Itch Intensity Is Associated with Less Efficient Descending Inhibition Processing for Itch But Not Pain Attenuation in Chronic Dermatology Patients

Objectives

The study aims were 1) to investigate the direction of mutual inhibitory pathways on itch intensity by utilizing conditioned pain modulation paradigms for pain and itch attenuation and 2) to explore whether itch severity is affected by the individual pain sensitivity profile, as well as pain scores reported during the tests and the past week.

Design

Cross-sectional.

Setting

Testing was conducted at the Department of Dermatology, Rambam Health Care Campus.

Subjects

Forty patients suffering from chronic skin disorders associated with itch and treated in the Dermatology Clinic at Rambam Health Care Campus participated in the study.

Methods

Efficacy of descending inhibition was evaluated by two conditioned pain modulation (CPM) paradigms: by pruriception (CPMItch) induced by cold and heat as counterstimuli to inhibit itch intensity and by nociception (CPMPain). Severity and interference of clinical pain were assessed using the Brief Pain Inventory (BPI).

Results

Robust CPMItch responses were obtained following the various noxious stimulations. No associations were observed between CPMPain and CPMItch, itch severity, skin disease severity, and clinical pain symptoms. According to the linear regression model, itch severity was independently associated with less efficient CPMItch (B = –0.750, P &lt; 0.001) and more efficient CPMPain (B = 0.031, P = 0.016), which affects itch in opposing manners.

Conclusions

Findings indicate that the intrinsic capacity to inhibit pain and itch by exposure to exogenous noxious stimuli autonomously affects itch intensity in an opposing manner. These findings may shed new light on the mutual mechanistic similarity and dissimilarity between pain and itch and their hierarchy.

The role of itch and pain modulation in the prediction of phototherapy outcomes: a prospective cohort study

OBJECTIVES

Ability to predict which chronic itch patients will benefit from particular treatments is a challenge. Common features in itch and pain in respect to sensory elicitation, and mechanisms of processing including sensitization and inhibition at the peripheral and central levels, may serve to understand variability in treatment outcomes. As such this study aimed to explore whether phototherapy outcomes can be predicted by psychophysical parameters of pain and itch modulatory processing.

METHODS

Prospective cohort study on chronic-itch patients (n = 44) assessed before 20 treatments of NB UVB. Level of itch and pain reduction following painful stimulation (reflecting the 'pain inhibits pain' phenomenon) used to assess the top-down modulation response efficacy. Magnitude of Conditioned Pain Modulation (CPM) for itch (CPM-itch) and for pain (CPM-pain) (reflecting inhibition) and magnitude of temporal summation (TS) of pain (reflecting ascending facilitation pathways) assessed to predict treatment effect.

RESULTS

Higher improvement of itch symptoms following phototherapy was correlated with more efficient CPM-itch (r = 0.62, p < .001), but not magnitude of CPM-pain or level of temporal summation.

DISCUSSION

Findings emphasize the role of descending inhibition pathways in determining phototherapy efficacy in chronic itch patients. Such an evaluation-based approach may contribute to better patient selection for phototherapy improving patients' disease outcomes.

Matching actual treatment with patient administration-route-preference improves analgesic response among acute low back pain patients-a randomized prospective trial

Background

Accommodating a patient’s treatment preference has been reported to promote greater responsiveness and better clinical outcomes. The effect of administration route preference (ARP) on the individual analgesic response has not been extensively examined to date. This study aimed to investigate whether ARP-matched treatment, i.e., individualized intramuscular (IM) or oral (PO) analgesic administration according to patient choice, would increase the analgesic effect.

Methods

In this prospective randomized study, we collected 38 patients with acute low back pain (aLBP) presenting at the emergency room of the Galilee Medical Center (Naharia, Israel) and asked them to report their ARP for analgesics. Regardless of their reported preference, they received either PO or IM diclofenac according to the treating physician’s preference. Pain intensity was self-reported using the numeric pain score (NPS) before and during the first hour after drug administration.

Results

Both groups receiving PO or IM administration reported similar initial pain on admission, (NPS 8.63 ± 1.5 and 8.74 ± 1.6, respectively) and the same magnitude of pain reduction. However, patients who received the drug in their desired route (oral or injection) had a significantly greater reduction in pain levels (4.05 ± 2.8) as compared with patients who received the undesired route (2.08 ± 1.8), p < 0.05.

Conclusions

These findings support the hypothesis that individualized ARP-matched treatment in aLBP improves therapeutic outcomes, although further studies with larger cohorts are needed.

How Does Myofascial Physical Therapy Attenuate Pain in Chronic Pelvic Pain Syndrome?

Background

Chronic pelvic pain syndrome (CPPS) is a multifactorial disorder comprising structural and functional muscular abnormalities, a dysfunctional pain system, and psychological distress. Myofascial physical Therapy (MPT) that is targeted at improving pelvic muscle functioning is considered a first line nonpharmacological treatment for CPPS, although the precise mechanisms that lead to symptoms alleviation have not yet been elucidated.

Purpose

This longitudinal study aimed to examine the local and systemic effects of MPT intervention, including biopsychophysiological processes, among CPPS patients.

Methods

The study included 50 CPPS women. Morphologic assessment of the levator ani and quantitative sensory testing of the pain system were applied alongside with evaluation of pain-related psychological factors using designated questionnaires. All measures were evaluated both before and after MPT in 39 patients. The long-term effects of MPT were evaluated by clinical pain reports obtained at 3 and 9 months following MPT that were compared with a nontreated group of 11 untreated CPPS women.

Results

Along with an improvement in the clinical pain intensity (p = 0.001) and sensitivity to experimental pain tests (p = 0.001) following MPT, the results also indicate that MPT has anatomical, psychological, and social therapeutic effects (p = 0.04; p = 0.001; p = 0.01, respectively). Furthermore, clinical pain evaluation at 3 and 9 months after MPT revealed a significant improvement in women who received treatment (p = 0.001).

Conclusions

The findings of this pilot study suggest multisystemic (direct and indirect anatomical, neurophysiological, and psychological) effects of MPT on the multifactorial pain disorder of CPPS and therefore place MPT as a mechanism-based intervention.

"Death Lay Here on the Sofa": Reflections of Young Adults on Their Experience as Caregivers of Parents Who Died of Cancer at Home

The prevalence of terminally ill patients, who die at home, is increasing. The aim of this study was to address the meaning of being young adults, who were the caregivers of their dying parents. In-depth, semistructured interviews were conducted with 14 Israeli Jewish young adults, who had been the primary caregivers for parents who had cancer and eventually died at home. Three themes emerged: (a) "I was Chosen and was led into that situation": modes of taking on and performing the role of a caregiver, (b) "My life was on hold": the experience of performing the caregiving role, and (c) "I underwent . . . the real school of life": caring for the dying parent as an imprint on self-development. Participants integrated compassionate caring into their identity, reflecting an empowering encounter of young carers with their dying parents as a process of growth in the face of harsh, stressful experiences.

Psychophysic-psychological dichotomy in very early acute mTBI pain: A prospective study

OBJECTIVE

To characterize the pain-related somatosensory and psychological presentation of very early acute patients with a mild traumatic brain injury (mTBI).

METHODS

Patients with an mTBI participated in a prospective observational study undergoing clinical, psychophysic, and psychological assessment within 72 hours after the accident. Healthy controls underwent similar protocol.

RESULTS

One hundred acute patients with an mTBI (age 36 ± 12.5 [SD] years, range 19-67 years, 42 women) and 80 healthy controls (age 43 ± 14.3 years, range 24-74 years, 40 women) participated. Patients with an mTBI demonstrated a pronociceptive psychophysic response in most tests such as less efficient pressure-pain threshold-conditioned pain modulation (0.19 ±0.19±.09 vs. 0.91±.10 kg, p < 0.001) and lower temperature needed to elicit a Pain50 response (44.72 ± 0.26°C vs 46.41 ± 0.30°C, p < 0.001). Their psychophysic findings correlated with clinical pain measures, e.g., Pain50 temperature and mean head (r = -0.21, p = 0.045) and neck (r = -0.26, p = 0.011) pain. The pain-catastrophizing magnification subscale was the only psychological variable to show a difference from the controls, while no significant correlations were found between any psychological measures and the clinical or psychophysic pain measures.

CONCLUSIONS

There appears to be a dichotomy between somatosensory and psychological findings in the very early acute post-mTBI stage; while the first is altered and is associated with the clinical picture, the second is unchanged. In the context of the ongoing debate on the pathophysiologic nature of the post-mTBI syndrome, our findings support its "physical" basis, free of mental influence, at least in the short time window after the injury.

The Effectiveness and Safety of High-Dose Colistin: Prospective Cohort Study

BACKGROUND

 Optimizing colistin dosing should translate to improved patient outcomes.

METHODS

 We used data from 2 prospective cohort studies performed between 2006 and 2009 and between 2012 and 2015. In the latter period, a new policy of high-dose colistin (9 million international units [MIU] loading dose followed by 9 MIU daily for normal renal function) was introduced in 2 participating hospitals. We included adult inpatients with invasive infections caused by carbapenem-resistant gram-negative bacteria treated with colistin. Our primary exposure variable was colistin dose, dichotomized to high-dose vs other regimens. The primary outcome was 28-day mortality. We generated a propensity score for high-dose colistin and conducted propensity-adjusted multivariable and matched-cohort analyses for mortality.

RESULTS

 Of 529 consecutive patients fulfilling inclusion criteria, 144 were treated with high-dose colistin and 385 with lower-dose colistin regimens. The median daily dose in the high-dose group was 9 MIU (interquartile range [IQR], 9-9) vs 4 MIU (IQR, 3-6) with other regimens. There were 50 of 144 (34.7%) deaths with high-dose colistin vs 165 of 385 (42.9%) with low-dose colistin (P = .1). The propensity-adjusted odds ratio (OR) for mortality was 1.07 (95% confidence interval [CI], .63-1.83) for high-dose colistin. Similar results were obtained when using the study period as the exposure variable, in the subgroup of bacteremic patients (n = 207) and in the propensity-matched cohort (OR, 1.11 [95% CI, .67-1.82]). Nephrotoxicity (RIFLE injury or higher; OR, 2.12 [95% CI, 1.29-3.48]; n = 396) and seizures were significantly more common with high-dose colistin.

CONCLUSIONS

 In a large cohort, we found no association between high colistin dosing and all-cause mortality. High dosing was associated with more nephrotoxicity.

A Brief Mindfulness Meditation Training Increases Pain Threshold and Accelerates Modulation of Response to Tonic Pain in an Experimental Study

OBJECTIVE

Research shows that mindfulness meditation (MM) affects pain perception; however, studies have yet to measure patterns of change over time. We examined effects of MM on perception of experimental heat pain using multiple psychophysical indices, including pattern of change in response to tonic painful stimuli. We also tested the potential moderating role of baseline mindfulness.

METHOD

Forty participants were randomly assigned to a brief MM training or control group. We assessed: a) heat pain threshold (HPT), b) temperature which induces pain at a fixed, target intensity level, and c) response pattern over time to tonic heat pain.

RESULTS

Compared to control group, the MM group showed increased HPT and more rapid attenuation of pain intensity for tonic pain stimuli. Moderation analyses indicated that baseline mindfulness moderated effects of MM on HPT.

CONCLUSIONS

A brief MM intervention appears to affect perception of experimental pain both by increasing pain threshold and accelerating modulation of response. Findings may help elucidate mechanisms of MM for chronic pain.

Relationship between Personality Traits and Endogenous Analgesia: The Role of Harm Avoidance

BACKGROUND

Whether psychological factors such as anxiety and pain catastrophizing levels influence the expression of endogenous analgesia in general and, more specifically, the conditioned pain modulation (CPM) response is still under debate. It may be assumed that other psychological characteristics also play a role in the CPM response. The neurotransmitters serotonin, dopamine, and norepinephrine are involved both in CPM, as well as personality traits such as harm avoidance (HA), novelty seeking (NS), and reward dependence (RD), which can be obtained by the Tridimensional Personality Questionnaire (TPQ). However, the associations between these traits (HA, NS, and RD) with endogenous analgesia revealed by CPM have not yet been explored.

METHODS

Healthy middle-age subjects (n = 28) completed the TPQ, Spielberger's State Anxiety Inventory, and the Pain Catastrophizing Scale and were assessed for CPM paradigms using thermal phasic temporal summation as the "test stimulus" and hand immersion into hot water bath (CPM water) or contact heat (CPM contact) for "conditioning stimulus."

RESULTS

Higher levels of HA were associated with less-efficient CPM responses obtained by both paradigms: CPM water (r = 0.418, P = 0.027) and CPM contact (r = 0.374, P = 0.050). However, NS and RD were not associated with the other measurements. No significant relationship was observed between state anxiety and pain catastrophizing levels and the CPM responses.

CONCLUSIONS

The relationship between the capacity of endogenous analgesia and the tendency to avoid aversive experience can be explained by mutual mechanisms involving similar neurotransmitters or brain areas. These findings illuminate the key role of harm avoidance obtained by the TPQ in determining the characteristics of pain modulation profile.

The Role of Pain Catastrophizing in the Prediction of Acute and Chronic Postoperative Pain

Background and Objectives:

Despite the established association between greater pain catastrophizing and enhanced postoperative pain, it is still unclear: (i) what is the relative contribution of each of the pain catastrophizing scale (PCS) dimensions in the prediction of acute and chronic postoperative pain; and (ii) whether PCS scores mediate the association between acute and chronic postoperative pain intensity.

Methods:

The current prospective, observational study was conducted at Rambam Health Care Campus, Haifa, Israel. PCS was obtained in 48 pain-free patients a day before an elective thoracotomy in response to tonic heat pain. Acute postthoracotomy pain (APTP) was assessed during rest, including general pain (Restgeneral), and incision-related pain (Restincision), and in response to provoked physical activity, including hand elevation (Provokedhand) and cough (Provokedcough). Chronic postthoracotomy pain (CPTP) was assessed after 4.5±2.3 months.

Results:

Of the PCS subscales, only rumination: (i) was correlated with Restgeneral scores (r=0.337, P=0.027); and (ii) predicted chronic postthoracotomy pain in a regression analysis (P=0.001). General PCS and its subscales mediated the correlation between Restgeneral and chronic postthoracotomy pain intensity (Ps<0.006).

Conclusions:

Findings may elucidate the unique role of the rumination subscale in reflecting an individual's postopertive acute and chronic pain responsiveness. The transition from acute to chronic postoperative pain seems to be facilitated by enhanced pain catastrophizing.

Preoperative scar hyperalgesia is associated with post-operative pain in women undergoing a repeat Caesarean delivery

BACKGROUND

Over 1.4 million Caesarean deliveries are performed annually in the United States, out of which 30% are elective repeat procedures. Post-operative hyperalgesia is associated with an increased risk for persistent post-surgical pain; however, there are no data on whether residual scar hyperalgesia (SHA) from a previous Caesarean delivery (CD) persists until the next delivery. We hypothesized that residual SHA may be present in a substantial proportion of women and is associated with increased post-operative pain.

METHODS

One hundred and sixty-three women scheduled for a repeat CD under spinal anaesthesia were enrolled into the study. Mechanical temporal summation (mTS) and SHA index were measured preoperatively. SHA was considered present when the index was >0. Post-operative pain scores at 12, 24 and 48 h and wound hyperalgesia (WHA) at 48 h were recorded.

RESULTS

SHA was present in 67 women 41% with a median SHA index of 0.42 (Q (25)  = 0.25; Q (75)  = 1.1, range 0.03-4.25). Women with SHA had overall higher post-operative pain scores and SHA was correlated with preoperative mTS (r = 0.164, p < 0.05), post-operative pain severity (r = 0.25, p < 0.002) and WHA at 48 h (r = 0.608, p < 0.001). Severe pain (visual analogue pain scale-S48 ≥ 7, n = 20) was predicted with a sensitivity and specificity of 60% and 62%, respectively. Positive predictive value was 18% and negative predictive value was 92%.

CONCLUSIONS

Preoperative SHA is present in 41% of women scheduled for repeat CD and is associated with increased mTS and post-operative pain. Screening for preoperative SHA may predict women at risk for increased post-operative pain, and guide post-operative analgesia to include anti-hyperalgesic drugs.

Conditioned pain modulation predicts duloxetine efficacy in painful diabetic neuropathy

This study aims to individualize the selection of drugs for neuropathic pain by examining the potential coupling of a given drug's mechanism of action with the patient's pain modulation pattern. The latter is assessed by the conditioned pain modulation (CPM) and temporal summation (TS) protocols. We hypothesized that patients with a malfunctioning pain modulation pattern, such as less efficient CPM, would benefit more from drugs augmenting descending inhibitory pain control than would patients with a normal modulation pattern of efficient CPM. Thirty patients with painful diabetic neuropathy received 1 week of placebo, 1 week of 30 mg/d duloxetine, and 4 weeks of 60 mg/d duloxetine. Pain modulation was assessed psychophysically, both before and at the end of treatment. Patient assessment of drug efficacy, assessed weekly, was the study's primary outcome. Baseline CPM was found to be correlated with duloxetine efficacy (r=0.628, P<.001, efficient CPM is marked negative), such that less efficient CPM predicted efficacious use of duloxetine. Regression analysis (R(2)=0.673; P=.012) showed that drug efficacy was predicted only by CPM (P=.001) and not by pretreatment pain levels, neuropathy severity, depression level, or patient assessment of improvement by placebo. Furthermore, beyond its predictive value, the treatment-induced improvement in CPM was correlated with drug efficacy (r=-0.411, P=.033). However, this improvement occurred only in patients with less efficient CPM (16.8±16.0 to -1.1±15.5, P<.050). No predictive role was found for TS. In conclusion, the coupling of CPM and duloxetine efficacy highlights the importance of pain pathophysiology in the clinical decision-making process. This evaluative approach promotes personalized pain therapy.

Control: patients' aggression in psychiatric settings

Psychiatric patient assaults on staff are a serious problem, affecting staff, patients, and organizations. To understand the etiology of aggressive events, researchers have documented characteristics of aggressive patients, their victims, and to a lesser degree, the patient-provider interaction. Missing in the literature is how staff's different perceptions of aggressive incidents might impact their reactions. In this study, we conducted in-depth, semistructured interviews with 11 health care professionals working in a psychiatric ward in one Israeli psychiatric hospital. Through content analysis, we revealed two main themes: patients' and providers' controllability over patients' aggression. From the intersection of these two themes, four prototypes of the aggressive encounter emerged: the power struggle, the therapeutic encounter, inverse power relations, and victim-to-victim encounters, each distinctively characterized by different emotional, cognitive, and behavioral responses. We discuss our findings in light of attribution theory, which carries important theoretical and practical implications for handling aggression.

Cognitive manipulation targeted at decreasing the conditioning pain perception reduces the efficacy of conditioned pain modulation

Although painfulness of the conditioning stimulus (CS) is required for the activation of conditioned pain modulation (CPM), it is still unclear whether CPM expression depends on the objective physical intensity of the CS or the subjective perception of its pain. Accordingly, we cognitively manipulated the perceived CS pain, rendering the physical aspects of the CPM paradigm untouched. Baseline CPM was measured among 48 young healthy male subjects using the parallel paradigm with contact heat as test pain and hand immersion in hot water as CS. Subjects were then randomized into 4 groups, all of which were cognitively manipulated as to the CS-induced pain: group 1, placebo (CS less painful); group 2, nocebo (CS more painful); and groups 3 and 4, the informed control groups for groups 1 and 2, respectively. CPM was reassessed after the manipulation. Comparing the groups by MANCOVA (multivariate analysis of covariance) revealed that placebo exerted decreased CS pain and consequent attenuation of CPM magnitudes, while nocebo elicited increased CS pain, but without CPM elevation (P<.0001). Within the placebo group, the reduction in CS pain was associated with diminished CPM responses (r=0.767; P=.001); however, no such relationship characterized the nocebo group. Pain inhibition under CPM seems to depend on the perceived level of the CS pain rather than solely its physical intensity. Cognitively decreasing the perceived CS pain attenuates CPM magnitude, although a ceiling effect may limit CPM enhancement after cognitively increased CS pain. These findings emphasize the relevance of cognitive mechanisms in determining endogenous analgesia processes in humans.

Characteristics of attachment style in women with dyspareunia

In this study, the authors explored the relations among painful experience during sexual intercourse, attachment style, and somatization. The authors assessed these variables by self-report of dyspareunia (painful vaginal intercourse) and by completion of the Experience in Close Relationships Scale and the short version of the Brief Symptom Inventory. The sample included 110 women, 45 of whom reported painful intercourse and were defined as the dyspareunia group, and the remaining 65 were defined as the control group. The dyspareunia group showed greater incidence, compared with the control group, of insecure attachment styles defined by higher scores of anxiety and/or avoidance as well as higher somatization levels. Regression analyses revealed that increased level of somatization and higher level of avoidance predicted higher probability for dyspareunia. The authors' findings suggest that women with higher frequency of physical complaints in various body areas and insecure attachment style are more susceptible to report pain during intercourse.

An experimental paradigm for the prediction of Post-Operative Pain (PPOP)

Many women undergo cesarean delivery without problems, however some experience significant pain after cesarean section. Pain is associated with negative short-term and long-term effects on the mother. Prior to women undergoing surgery, can we predict who is at risk for developing significant postoperative pain and potentially prevent or minimize its negative consequences? These are the fundamental questions that a team from the University of Washington, Stanford University, the Catholic University in Brussels, Belgium, Santa Joana Women's Hospital in São Paulo, Brazil, and Rambam Medical Center in Israel is currently evaluating in an international research collaboration. The ultimate goal of this project is to provide optimal pain relief during and after cesarean section by offering individualized anesthetic care to women who appear to be more 'susceptible' to pain after surgery.

A significant number of women experience moderate or severe acute post-partum pain after vaginal and cesarean deliveries. ¹ Furthermore, 10-15% of women suffer chronic persistent pain after cesarean section. ² With constant increase in cesarean rates in the US ³ and the already high rate in Brazil, this is bound to create a significant public health problem. When questioning women's fears and expectations from cesarean section, pain during and after it is their greatest concern. ⁴ Individual variability in severity of pain after vaginal or operative delivery is influenced by multiple factors including sensitivity to pain, psychological factors, age, and genetics. The unique birth experience leads to unpredictable requirements for analgesics, from 'none at all' to 'very high' doses of pain medication. Pain after cesarean section is an excellent model to study post-operative pain because it is performed on otherwise young and healthy women. Therefore, it is recommended to attenuate the pain during the acute phase because this may lead to chronic pain disorders. The impact of developing persistent pain is immense, since it may impair not only the ability of women to care for their child in the immediate postpartum period, but also their own well being for a long period of time.

In a series of projects, an international research network is currently investigating the effect of pregnancy on pain modulation and ways to predict who will suffer acute severe pain and potentially chronic pain, by using simple pain tests and questionnaires in combination with genetic analysis. A relatively recent approach to investigate pain modulation is via the psychophysical measure of Diffuse Noxious Inhibitory Control (DNIC). This pain-modulating process is the neurophysiological basis for the well-known phenomenon of 'pain inhibits pain' from remote areas of the body. The DNIC paradigm has evolved recently into a clinical tool and simple test and has been shown to be a predictor of post-operative pain.⁵ Since pregnancy is associated with decreased pain sensitivity and/or enhanced processes of pain modulation, using tests that investigate pain modulation should provide a better understanding of the pathways involved with pregnancy-induced analgesia and may help predict pain outcomes during labor and delivery. For those women delivering by cesarean section, a DNIC test performed prior to surgery along with psychosocial questionnaires and genetic tests should enable one to identify women prone to suffer severe post-cesarean pain and persistent pain. These clinical tests should allow anesthesiologists to offer not only personalized medicine to women with the promise to improve well-being and satisfaction, but also a reduction in the overall cost of perioperative and long term care due to pain and suffering. On a larger scale, these tests that explore pain modulation may become bedside screening tests to predict the development of pain disorders following surgery.

Determinants of endogenous analgesia magnitude in a diffuse noxious inhibitory control (DNIC) paradigm: Do conditioning stimulus painfulness, gender and personality variables matter?

Descending modulation of pain can be demonstrated psychophysically by dual pain stimulation. This study evaluates in 31 healthy subjects the association between parameters of the conditioning stimulus, gender and personality, and the endogenous analgesia (EA) extent assessed by diffuse noxious inhibitory control (DNIC) paradigm. Contact heat pain was applied as the test stimulus to the non-dominant forearm, with stimulation temperature at a psychophysical intensity score of 60 on a 0-100 numerical pain scale. The conditioning stimulus was a 60s immersion of the dominant hand in cold (12, 15, 18 degrees C), hot (44 and 46.5 degrees C), or skin temperature (33 degrees C) water. The test stimulus was repeated on the non-dominant hand during the last 30s of the conditioning immersion. EA extent was calculated as the difference between pain scores of the two test stimuli. State and trait anxiety and pain catastrophizing scores were assessed prior to stimulation. EA was induced only for the pain-generating conditioning stimuli at 46.5 degrees C (p=0.011) and 12 degrees C (p=0.003). EA was independent of conditioning pain modality, or personality, but a significant gender effect was found, with greater EA response in males. Importantly, pain scores of the conditioning stimuli were not correlated with EA extent. The latter is based on both our study population, and on additional 82 patients, who participated in another study, in which EA was induced by immersion at 46.5 degrees C. DNIC testing, thus, seems to be relatively independent of the stimulation conditions, making it an easy to apply tool, suitable for wide range applications in pain psychophysics.

Clinical and experimental pain perception is attenuated in patients with painless myocardial infarction

BACKGROUND

The lack of pain alarm in painless myocardial infarction (MI) leads to increased morbidity and mortality, since patients do not seek medical treatment in a timely manner. We aimed to explore whether reduced systemic pain perception in response to experimental stimuli and pain related personality variables characterizes painless MI patients.

METHODS

Level of chest pain intensity was assessed by numerical scale, range from 0 (no pain) to 100 (maximal pain). Heat pain threshold, magnitude estimation of supra-threshold phasic and tonic painful stimuli as well as anxiety and pain catastrophizing scores were assessed in 92 acute MI patients; 67 with and 25 without chest pain, respectively. All experimental stimuli were performed by Thermal Sensory Analysis (TSA) and applied to the right forearm.

RESULTS

Greater intensity of chest pain scores was inversely correlated with lower pain threshold (r=-0.417, p<0.001), and directly associated with higher pain scores in response to the heat pain (r=0.354, p=0.002). Patients with painful MI demonstrated lower pain threshold (41.9+/-3.6 degrees C vs. 44.9+/-3.8 degrees C, p=0.001) and higher catastrophizing level (10.6+/-12.0 vs. 5.4+/-8.8, p=0.032). Logistic regression analysis revealed that older age and lower pain scores in response to supra-threshold painful stimuli were associated with greater risk for painless MI. The demographic variables, history of ischemic heart, risk factors for coronary artery disease, ST-T segment changes on ECG and troponin levels were similar in both groups.

CONCLUSIONS

This study suggests that reduced systemic pain perception as well as cognitive personality variables play an important role in the etiology of painless MI.

Pain Catastrophizing, Response to Experimental Heat Stimuli, and Post–Cesarean Section Pain

This prospective study assessed the relation between pain catastrophizing, response to experimental pain stimuli, and pain perceived by women after elective cesarean sections. Forty-seven women who were scheduled for elective cesarean section were enrolled in the study. Magnitude estimation to suprathreshold phasic and tonic heat pain stimuli was assessed 1 or 2 days before surgery. Women completed the Pain Catastrophizing Scale after the heat stimuli and again on the first postoperative day. During the first and second postoperative days, perception of pain intensity was assessed by visual analog scale at each analgesia request. A multiple regression analysis revealed that pain on the first postoperative day was predicted by patient response to preoperative tonic heat stimuli (r(2) = .167, P = .008). Pain on the second postoperative day was predicted by preoperative pain catastrophizing (r(2) = .139, P = .021). No significant association was observed between preoperative response to heat stimuli or pain catastrophizing and the patient's analgesic consumption in the obstetrical ward. It is concluded that pain catastrophizing and response to experimental tonic heat pain correlate with post-cesarean section pain.

PERSPECTIVE

This article presents psychological and psychophysical measures that may be of help in the prediction of post-cesarean section pain. It may therefore contribute to the treatment of the sequelae of the most common major surgical procedure performed in women in their reproductive years.

Efficacy of suppository analgesia in postabortion pain reduction

PURPOSE

Termination of pregnancy is a painful procedure. Currently, there are no sufficient data regarding the best mode to reduce this pain. The aim of the study was to evaluate postabortion pain levels and to examine the analgesic effect of three different generic types of suppositories provided at the end of the surgical procedure prior to awakening from general anesthesia.

METHOD

Two hundred seventeen women were randomly assigned to four groups: indomethacin (100 mg), paracetamol (1000 mg), tramadol (100 mg), and control group with no suppository treatment. Pain levels were evaluated by VAS five times--15, 30, 60, 90 and 120 min after abortion. The number of doses of rescue analgesia with dipyrone (1 g po) was recorded.

RESULTS

There was a significant difference in pain levels between the four groups during the 2-h study (p<.05). Indomethacin always had the lowest VAS rank. Rescue analgesia was requested by 22/55 women in the control group, 10/55 in the tramadol group, 7/54 in the paracetamol group and 5/53 in the indomethacin group (chi(2)=19.0, p<.0001).

CONCLUSION

The application of a single suppository of an analgesic drug, especially indomethacin, is a simple, inexpensive and safe mode to reduce postabortion pain.

Domestic Violence Among Druze Women in Israel as Reflected by Health Status and Somatization Level

Women with a history of physical or emotional abuse demonstrate a higher incidence of medical disorders but may be reluctant to disclose the abuse to health care providers. The present study explored whether measures of health status may serve as an indication of violence against women. Sixty-two Druze women (18-50 years old) completed health status (SF-36 survey), somatization (Brief Symptom Inventory-BSI), and abuse (the Abuse Assessment Screen-AAS) questionnaires during a visit to the family physician in the community primary care clinic. Higher somatization symptoms and diminished health status were associated with severity of violence. Results attest to the value of these measures as an additional indirect device for screening victims of domestic violence in general and among traditional societies in particular.

Contact heat-evoked temporal summation: tonic versus repetitive-phasic stimulation

Temporal summation (TS) is usually evoked by repetitive mechanical or electrical stimuli, and less commonly by tonic heat pain. The present study aimed to examine the TS induction by repetitive-phasic versus tonic heat pain stimuli. Using 27 normal volunteers, we compared the extent of summation by three calculation methods: start-to-end pain rating difference, percent change, and double-logarithmic regression of successive ratings along the stimulation. Subjects were tested twice, and the reliability of each of the paradigms was obtained. In addition, personality factors related to pain catastrophizing and anxiety level were also correlated with the psychophysical results. Both paradigms induced significant TS, with similar increases for the repetitive-phasic and the tonic paradigms, as measured on 0-100 numerical pain scale (from 52.9+/-11.7 to 80.2+/-15.5, p<0.001; and from 38.5+/-13.3 to 75.8+/-18.3, p<0.001, respectively). The extent of summation was significantly correlated between the two paradigms, when calculated by absolute change (r=0.543, p=0.004) and by regression (r=0.438, p=0.025). Session-to-session variability was similar for both paradigms, relatively large, yet not biased. As with other psychophysical parameters, this poses some limitations on TS assessment in individual patients over time. The extent of TS induced by both paradigms was found to be associated with anxiety level and pain catastrophizing. Despite some dissimilarity between the repetitive-phasic and the tonic paradigms, the many similarities suggest that the two represent a similar physiological process, even if not precisely the same. Future clinical applications of these tests will determine the clinical relevance of the TS paradigms presented in this study.

The association between somatization and perceived ability: roles in dysmenorrhea among Israeli Arab adolescents

OBJECTIVE

The aim of this study was to investigate whether somatization and attitudes toward menstruation predict the incidence of pain intensity and dysmenorrhea among Israeli Arab adolescent females.

METHODS

Participants were 160 Israeli Arab adolescents, including 50 Muslims, 50 Christians, and 60 Druze. A 20-item questionnaire was used to assess attitudes regarding menstruation. The short version of the Brief Symptom Inventory was used to measure the level of somatization.

RESULTS

Factor analysis of the Attitudes Toward Menstruation Instrument revealed two significant composites: perceived ability and impurity during menstruation. High levels of somatization predicted pain intensity and low levels of perceived ability predicted the prevalence of dysmenorrhea. Although the Israeli Muslim adolescents revealed higher levels of somatization as compared with their Christian and Druze counterparts and the Druze revealed the lowest levels of perceived ability compared with the other subgroups, no significant role for ethnicity and impurity was found. No differences were found between groups in scores of menstrual pain and prevalence of dysmenorrhea. Higher levels of somatization and lower levels of perceived ability, as well as a greater portion of Muslim and Druze and higher levels of religiosity, were found among rural residents.

CONCLUSIONS

The role of cultural variables and personality traits in the complexity of dysmenorrhea as a socio-bio-psychological phenomenon is proposed in light of contemporary interactive models. It is suggested that within the Israeli Arab minorities the impact of cultural background on health affects more the perceptual and cognitive levels and are not generalized to overt behavior and morbidity such as dysmenorrhea.

Association between regional idiopathic neuropathy and salivary involvement as the possible mechanism for oral sensory complaints

The idiopathic sensorial disturbances of burning mouth syndrome (BMS), taste disturbances (dysgeusia), and dry mouth (xerostomia) have recently been recognized as one entity and given the generic name of oral sensorial complaints (OSC). However, not all patients with OSC complain of all three disturbances, and the underlying mechanism of OSC has not yet been elucidated. This study sought to determine whether OSC was associated with the alteration of oral sensory perception, salivary profile and/or personality traits. It examined 35 patients with OSC and 19 controls. Sensory perception was assessed by Quantitative Sensory Testing (QST) applied to the tongue, including thresholds for thermal sensations and pain, and the magnitude estimation of tonic suprathreshold heat pain stimuli. The salivary profile included flow rate and compositional analysis. Personality traits were examined by both state and trait anxiety and somatization scoring. Results showed significantly elevated thermal sensory thresholds and decreased pain scores for tonic heat pain. In addition, there was an increased level of somatization in the OSC group as compared to the control group (15.1 +/- 1.5 vs. 6.6 +/- 2.1, respectively; P = .003). Concomitantly, altered salivary composition (elevated Na, K, Cl, Ca, IgA, and amylase concentrations)-but not salivary flow rate reduction-was observed in those patients despite their complaints of oral dryness. All parameters were similar among the patients with OSC regardless of their type of complaint. Linear regression analysis revealed that an elevated warm sensory threshold was associated with higher levels of salivary K and Cl concentrations in the patients with OSC. These findings may be attributed to a regional small fiber idiopathic neuropathy affecting oral sensation and salivary secretion in OSC. Alternatively, a primary idiopathic salivary dysfunction might cause sensory neural dysfunction at the receptor level by changing the oral cavity milieu.

PERSPECTIVE

Based on the salivary, psychophysical, and personality traits analysis currently presented, as well as on the available literature, we hypothesize that a comprehensive mechanism for OSC is based on a regional neuropathy, which is expressed by complaints of BMS, taste disturbances, and/or xerostomia. All are clearly distinguishable from similar conditions with established organic/therapeutic-related etiologies.

The roles of pain catastrophizing and anxiety in the prediction of postoperative pain intensity: a prospective study

OBJECTIVES

This study was a prospective investigation of the extent to which psychologic variables could be predictive of postoperative pain. Study aims were: 1) to evaluate whether an assessment of pre-operative distress factors could predict the intensity of postoperative pain; and 2) to characterize the unique pattern in which anxiety and pain catastrophizing scores relate to postoperative pain.

METHODS

The Pain Catastrophizing Scale and the State-Trait Anxiety Inventory were administered to 38 patients scheduled for elective abdominal surgery. The questionnaires were completed on the day of admission, a day before the operation. On day 1 and day 2 following the operation, perception of pain intensity at the surgical wound was assessed by visual analog scale.

RESULTS

The Pain Catastrophizing Scale and State-Trait Anxiety Inventory scores were significantly correlated with the postoperative pain scores. A linear regression analysis showed that Pain Catastrophizing Scale predicted the level of postoperative pain intensity even after controlling for state anxiety and that trait anxiety was not a significant predictor. In addition, analysis of the unique pattern of each predictor related to postoperative pain intensity indicated a linear curve for the Pain Catastrophizing Scale and curvilinear curve for the state anxiety.

DISCUSSION

The results are discussed in light of appraisal and coping theories. It is suggested that a simple assessment of preoperative catastrophizing tendency and anxiety scores may assist medical teams in postoperative pain management.

Psychological factors associated with perception of experimental pain in vulvar vestibulitis syndrome

This study assessed the association between pain perception and psychological variables in women with vulvar vestibulitis syndrome (VVS) by comparing 28 VVS women with 50 healthy women. We assessed non genital systemic pain perception with quantitative sensory testing by administering experimental pain stimuli to the forearm. The VVS women demonstrated a lower pain threshold and a higher magnitude estimation of pain, combined with a higher trait anxiety, increased somatization, and a lower body image. Among the VVS women, nonvaginal pain catastrophizing was significantly related to reported pain during coitus. A cluster analysis revealed four subtypes of VVS women, as characterized by levels of pain and personality variables. I suggest implications for the assessment and treatment of women suffering from painful coitus.

Personality traits associated with perception of noxious stimuli in women with vulvar vestibulitis syndrome

Vulvar vestibulitis syndrome (VVS) is associated with enhanced pain sensitivity. The present study explores the role of personality on the perception of noxious stimuli among women with VVS. More specifically, the aim of the study was to explore whether the personality traits assessed by Cloninger's Tridimensional Personality Questionnaire (TPQ) (harm avoidance [HA], novelty seeking [NS], and reward dependence [RD]) are associated with the augmented pain perception in women with VVS. Quantitative sensory tests were applied to the forearm of 98 women with VVS and 135 control subjects, all of whom completed the TPQ. The women with VVS scored higher than the control subjects on HA and RD with no significant differences in NS. Linear regression analyses revealed that in the VVS group, lower pain thresholds and higher magnitude estimations of suprathreshold pain stimuli were associated with higher HA and RD scores. The enhanced pain perception among women with VVS might reflect their tendency to respond intensely to signals of reward and to elevate the perceived risk. This might lead them to avoid hazards by overestimating the level of potential harm, as represented by greater pain sensitivity. The association between personality traits assessed by Cloninger's Tridimensional Personality Questionnaire, ie, harm avoidance, novelty seeking, and reward dependence, and the enhanced perception of noxious stimuli in vulvar vestibulitis syndrome might suggest neurochemical mechanisms of pain experience affected by personality, with possible application for future treatment approaches toward pain disorders.

Catastrophizing labor pain compromises later maternity adjustments

OBJECTIVE

The purpose of this study was to evaluate the impact of labor pain intensity and labor pain catastrophizing on maternity blues and postpartum social functioning.

STUDY DESIGN

Pain intensity and pain catastrophizing were assessed in 89 women in active labor before the administration of analgesia. Both these measures were assessed again retrospectively 2 days after delivery in 82 women who had a spontaneous vaginal delivery. Women also filled out the Edinburgh Postnatal Depression Scale. Six weeks later women completed the social functioning domain of the short form SF36 health survey.

RESULTS

Pain catastrophizing during labor significantly predicted both maternity blues (P = .001) and postpartum social functioning (P = .001) when being controlled for maternal age and education, parity, type of analgesia, and labor pain intensity. Low level of education and younger age also contributed to the prediction of maternity blues and social functioning.

CONCLUSION

Labor pain catastrophizing rather than labor pain intensity predicts postpartum maternal adjustments.

Perceptions of Breast Cancer Among Arab Israeli Women

The incidence of breast cancer is increasing among Arab Israeli women, yet few Arab women over the age 50 take advantage of free mammography available to them. In this study we attempted to identify social and cultural aspects of the Arab Israeli woman's life that may reduce screening attendance for early detection of breast cancer. This qualitative study consisted of 6 focus groups. The fundamental theme identified as a barrier to prevention behavior was the role of the Arab woman in society expressed as marrying, having children and being totally committed to her family. In this model, without these roles her life is purposeless and her place in society is lost. The women perceived the chain of events that begins with screening for breast cancer as possibly resulting in cancer diagnosis and having breast cancer will lead to an inability to fulfill female roles. This feedback mechanism inherent in the chain of events may be the cause of the low rates of compliance in performing early detection and mammography. Interventions aimed at increasing the rate of Arab women's performance of mammography should take these issues into consideration.

Primary and secondary vulvar vestibulitis syndrome: systemic pain perception and psychophysical characteristics

OBJECTIVE

Women with primary and secondary vulvar vestibulitis syndrome (VVS) report similar vulvar pain symptoms; however, it is not clear whether these subsets have similar pain and psychophysical characteristics. This study evaluated systemic pain perception, cardiovascular measures, and anxiety level in women with primary and secondary VVS.

STUDY DESIGN

Eighty-nine women were enrolled in the study: 44 had primary vulvar vestibulitis, 45 had secondary vulvar vestibulitis. Their anxiety level was first assessed. Then, heat pain stimuli were applied to the forearm, and pain threshold and pain scores for suprathreshold phasic (44 degrees C-48 degrees C) and tonic (46 degrees C) stimuli were assessed by visual analog scale. Finally, blood pressure was recorded using a volume clamp method before, during, and after a tonic stimulus of 1 minute at 46 degrees C.

RESULTS

Women with primary vulvar vestibulitis had higher visual analog scale scores for pain perception at 46 degrees C to 48 degrees C, a higher level of trait anxiety 43.3 +/- 1.5 versus 37.8 +/- 1.5 (P=.010), an increased incidence of dysmenorrhea (chi(2) 8.9, P=.003), and lower resting blood pressure: systolic (108.6 +/- 2.1 vs 118.9 +/- 2.0 mm Hg) (P>.001) and diastolic (59.3 +/- 1.6 vs 64.2 +/- 1.5 mm Hg) (P=.038). Logistic regression revealed that dysmenorrhea and lower systolic blood pressure are associated with primary VVS.

CONCLUSION

Women with primary and secondary VVS differ in their systemic pain perception and psychophysical characteristics. The impact of these findings on treatment modalities should be further evaluated.

Association between quantitative sensory testing, treatment choice, and subsequent pain reduction in vulvar vestibulitis syndrome

The chronic pain syndrome of vulvar vestibulitis is a major cause of sexual dysfunction, and complete cure is not always achieved. The aim of the study was to determine whether the psychophysical characteristics of systemic pain perception predict treatment choice and outcome. Ninety women with vulvar vestibulitis syndrome were evaluated by using quantitative sensory testing with heat pain threshold measurements and pain scores for suprathreshold stimuli applied to the forearm, blood pressure measurements, and an assessment of the number of other pain disorders. Women were free to choose a surgical procedure (ie, vestibulectomy), one of the possible nonsurgical treatments (eg, biofeedback, cognitive-behavioral therapy, or hypoallergic agents), or to avoid treatment entirely. Eight months later, women reported the success of the treatment on the basis of reduction in the level of vulvar pain. Vestibulectomy demonstrated the best therapeutic effectiveness (chi2, 26.4; P <.0001). Women who chose this type of treatment had lower pain scores (P =.038) and fewer pain syndromes other than the vulvar pain (P =.025). Logistic regression analysis, controlling for the effect of vestibulectomy, indicated that lower experimental pain scores (P =.044), fewer pain disorders (P =.023), and higher systolic blood pressure (P =.039) are predictive variables for reduction of vulvar pain. An assessment of systemic pain perception might be helpful in choosing the optimal treatment and in predicting its success.

PERSPECTIVE

The present study suggests that pain perception variables might be of value in the prediction of treatment choice and outcome among women with vulvar vestibulitis.

Gender differences in the perception of chest pain

This study investigated gender differences in pain perception as characterized by pain symptoms in patients diagnosed with unstable angina pectoris. Twenty-nine women and 32 men were asked to characterize their chest pain using a semi-open questionnaire assessing pain intensity (by numerical rating), pain location, pain characteristics, complaints following chest pain, factors that evoked or reduced chest pain, and whether the chest pain was related to heart disease. Significant gender differences were found. Women scored the intensity of their chest pain significantly higher than men (Chi-square 14.8, P < 0.0001), and related their chest pain less to heart disease (Chi-square 24.6, P < 0.0001). The women described an atypical clinical picture of chest pain that was significantly different from men's. The results are discussed in light of pschological theories regarding gender differences in pain perception. These findings imply the need for special attention to the unique clinical pictures that appear for women and men.