Exploring the associations shared by mood,pain-related attention and pain outcomes related to sleep disturbance in a chronic pain sample

Objective: Sleep disturbance in chronic pain is common, occurring in two-thirds of patients. There is a complex relationship between chronic pain and sleep; pain can disrupt sleep and poor sleep can exaggerate pain intensity. This may have an impact on both depressive symptoms and attention to pain. This study aims to evaluate the relationship between chronic pain and sleep, and the role of mood and attention.

Methods: Chronic pain patients, recruited from a secondary care outpatient clinic, completed self-report measures of pain, sleep, depressive symptoms and attention to pain. Hierarchical regression and structural equation modelling were used to explore the relationships between these measures. Participants (n = 221) were aged between 20 and 84 (mean = 52) years.

Results: The majority of participants were found to be ‘poor sleepers’ (86%) with increased pain severity, depressive symptoms and attention to pain. Both analytical approaches indicated that sleep disturbance is indirectly associated with increased pain severity Instead the relationship shared by sleep disturbance and pain severity was further associated with depressive symptoms and attention to pain.

Conclusions: Our results indicate that sleep disturbance may contribute to clinical pain severity indirectly though changes in mood and attention. Prospective studies exploring lagged associations between these constructs could have critical information relevant to the treatment of chronic pain.     

Anxiety sensitivity in the prediction of pain-related fear and anxiety in a heterogeneous chronic pain population

The present study evaluated anxiety sensitivity, along with depression and pain severity, as predictors of pain-related fear and anxiety in a heterogeneous chronic pain population (n=68). The results indicated that the global anxiety sensitivity factor, as indexed by the Anxiety Sensitivity Index (ASI: Reiss, Peterson, Gursky & McNally, 1986: Reiss, S., Peterson, R. A., Gursky, M. & McNally, R. J. (1986). Anxiety, sensitivity, anxiety frequency, and the prediction of fearfulness. Behaviour Research and Therapy, 24, 1-8) total score, was a better predictor of fear of and anxiety about pain relative to the other relevant variables. Additionally, the physical concerns subscale of the ASI was a better predictor of pain-related fear dimensions characterized by high degrees of physiological symptoms and behavioral activation on both the Fear of Pain Questionnaire-III (FPQ-III; McNeil & Rainwater, 1998: McNeil, D. W. & Rainwater, A. J. (1998). Development of the Fear of Pain Questionnaire-III. Journal of Behavioral Medicine.) and Pain Anxiety Symptoms Scale (PASS; McCracken, Zayfert & Gross, 1992: McCracken, L. M., Zayfert, C. & Gross, R. T. (1992). The Pain Anxiety Symptoms Scale: Development and validation of a scale to measure fear of pain. Pain, 50, 67-73). In a related way, the ASI psychological concerns subscale was a better predictor of pain-related anxiety dimensions characterized by cognitive symptoms of anxiety. Overall, these findings reiterate the importance of anxiety sensitivity in understanding pain-related fear and anxiety, and suggest anxious and fearful responding can be predicted more accurately with higher levels of correspondence between a particular anxiety sensitivity domain and events that closely match that fear.     

Prediction of experimental pain sensitivity by attention to pain-related stimuli in healthy individuals

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

The relationship of depression and somatic focus to experimental and clinical pain in chronic pain patients

Abstract

The present study examined Fields' proposal that depression increases the sensory experience of pain in part through greater somatic focus. Experimental and clinical pain measures were compared to self-report of depression and somatic focus in 60 chronic pain patients. Depression scores were unrelated to pain threshold or tolerance on the cold-pressor test. However, as hypothesized by Fields, path analytic models suggested that depression had a direct influence on the evaluative and affective aspects of pain, but the relationship between depression and sensory pain was mediated by somatic focus. These results provide partial support for Fields' neurobiological model of pain and depression.     

Graded exposure in vivo in the treatment of pain-related fear: a replicated single-case experimental design in four patients with chronic low back pain

The aim of this investigation was to examine the effectiveness of a graded exposure in vivo treatment with behavioural experiments as compared to usual graded activity in reducing pain-related fears, catastrophising and pain disability in chronic low back pain patients reporting substantial fear of movement/(re)injury. Included in the study were four consecutive CLBP patients who were referred for outpatient behavioural rehabilitation, and who reported substantial fear of movement/(re)injury (Tampa Scale for Kinesiophobia score>40). A replicated single-case cross-over design was used. After a no-treatment baseline measurement period, the patients were randomly assigned to one of two interventions. In intervention A, patients received the exposure first, followed by graded activity. In intervention B, the sequence of treatment modules was reversed. Sixty-three daily measures of pain-related cognitions and fears were recorded with visual analogue scales. Before and after the treatment, the following measures were taken: pain-related fear, pain catastrophising, pain control and pain disability. Using time series analysis on the daily measures of pain-related cognitions and fears, we found that improvements only occurred during the graded exposure in vivo, and not during the graded activity, irrespective of the treatment order. Analysis of the pre-post treatment differences also revealed that decreases in pain-related fear concurred with decreases in pain catastrophising and pain disability, and in half of the cases an increase in pain control. This study shows that the external validity of exposure in vivo also extends to the subgroup of chronic low back pain patients who report substantial fear of movement/(re)injury.     

Distress in spouses of chronic pain patients

This paper critiques the research on distress in spouses of chronic pain patients and includes a review of two studies of spouses conducted at the Miriam Hospital Chronic Pain Research Unit. The clinical implications of this research are discussed and case material is presented to illustrate the role of spouse distress in the treatment of patients with chronic pain. Future directions for research in this area are recommended.The research conducted at the Miriam Hospital Chronic Pain Research Unit was supported by the Alcohol, Drug and Mental Health Administration of the National Institute of Mental Health, Small Grants Program, Grant No. 1 R03 MH39257001A1.     

Alexithymia and Early Maladaptive Schemas in chronic pain patients

Psychological factors have an impact on subjective pain experience. The aim of this study was to explore the occurrence of alexithymia and Early Maladaptive Schemas in a sample of 271 first visit chronic pain patients of six pain clinics. The patients completed the study questionnaire consisting of the Toronto Alexithymia Scale‐20, the Finnish version of the Young Schema Questionnaire short form‐extended, the Beck Depression Inventory‐II, and pain variables. Alexithymic patients scored higher on Early Maladaptive Schemas and had more pain intensity, pain disability and depression than nonalexithymic patients. Both alexithymia and depression correlated significantly with most Early Maladaptive Schemas. The co‐occurrence of alexithymia, Early Maladaptive Schemas and depression seems to worsen the pain experience. Screening of alexithymia, depression and Early Maladaptive Schemas may help to plan psychological treatment interventions for chronic pain patients.     

Relation between catastrophizing and depression in chronic pain patients

The relation between catastrophizing, depression, and pain was examined in 125 chronic pain patients. The Coping Strategies Questionnaire (CSQ; Rosenstiel & Keefe, 1983) assessed patients' use of cognitive and behavioral strategies to cope with chronic pain. A significant association between catastrophizing and depression was found. In order to address questions of measurement redundancy, 6 clinical psychologists rated the degree to which items on the CSQ reflected depressive symptomatology. All items contained in the Catastrophizing subscale were rated by all psychologists as being reflective of symptoms of depression and were removed from the CSQ. When this subscale was excluded, none of the remaining CSQ subscales were significantly related to depression. The discussion addresses the interpretive difficulties that arise from hypothesizing mediating relations between variables that are conceptually and operationally confounded.     

The contribution of recollection and familiarity to recognition memory performance in chronic pain patients

This study examines the selective impact of chronic pain on memory functioning in a recognition task. Thirty chronic pain patients and 30 healthy control subjects performed a yes-no word recognition test. The contribution of recollection and familiarity to both groups' performance was compared by means of the Remember/Know (R/K) procedure, which distinguishes recognition based on the recollection of the encoding episode (R responses) and recognition accompanied by a feeling of familiarity (K responses). Chronic pain patients showed a decrease in recollection together with an increase in familiarity: indeed, they reported less R and more K responses than control subjects. This pattern of performance was not related to the overall recognition ability. These findings are consistent with the hypothesis of the attentional cost of chronic pain, suggesting a selective impact of chronic pain on the most attention-demanding cognitive processes, such as recollection. This study emphasises the relevance of specific procedures distinguishing the underlying components of memory functioning rather than solely global indicators.     

Personality, cognitive appraisal and adjustment in chronic pain patients

This study investigated the relationship between clinical personality patterns and cognitive appraisal as well as their repercussions on adjustment to chronic pain in a sample of 91 patients. It was predicted that clinical personality patterns would be related to adjustment and cognitive appraisal processes, whereas cognitive appraisals would be related to anxiety, depression and levels of perceived pain. The instruments used were as follows: the Millon Clinical Multiaxial Inventory, the Cognitive Appraisal Questionnaire, the Hospital Anxiety and Depression Scale, and the McGill Pain Questionnaire. Multiple regression analyses, the Kruskal-Wallis test, and the Mann Whitney U-test were used to analyse the data obtained. The results show that certain clinical personality patterns were associated with poor adjustment to chronic pain. The use of cognitive appraisal of harm predicted higher anxiety levels and greater perceived pain in chronic pain patients. The use of cognitive appraisals of challenge predicted lower depression levels.     

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

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

Relationships among pain intensity,pain-related distress,and psychological distress in pre-surgical total knee arthroplasty patients: a secondary analysis

The current study aimed to examine the relationships between movement and resting pain intensity, pain-related distress, and psychological distress in participants scheduled for total knee arthroplasty (TKA). This study examined the impact of anxiety, depression, and pain catastrophizing on the relationship between pain intensity and pain-related distress. Data analyzed for the current study (N = 346) were collected at baseline as part of a larger Randomized Controlled Trial investigating the efficacy of TENS for TKA (TANK Study). Participants provided demographic information, pain intensity and pain-related distress, and completed validated measures of depression, anxiety, and pain catastrophizing. Only 58% of the sample reported resting pain >0 while 92% of the sample reported movement pain >0. Both movement and resting pain intensity correlated significantly with distress (r_s = .86, p < .01 and .79, p < .01, respectively). About three quarters to two thirds of the sample (78% for resting pain and 65% for movement pain) reported different pain intensity and pain-related distress. Both pain intensity and pain-related distress demonstrated significant relationships with anxiety, depression, and catastrophizing. Of participants reporting pain, those reporting higher anxiety reported higher levels of distress compared to pain intensity. These findings suggest that anxious patients may be particularly distressed by movement pain preceding TKA. Future research is needed to investigate the utility of brief psychological interventions for pre-surgical TKA patients.     

The role of optimism and pessimism in chronic pain patients adjustment

This study analyses the relationships between patients' dispositional optimism and pessimism and the coping strategies they use. In addition, the coping strategies repercussions on adjustment to chronic pain were studied. Ninety-eight patients with heterogeneous chronic pain participated. The assessment tools were as follows: Life Orientation Test (LOT), the Vanderbilt Pain Management Inventory (VPMI), the McGill Pain Questionnaire (MPQ), Hospital Anxiety and Depression Scale (HADS), and the Impairment and Functioning Inventory for Chronic Pain Patients (IFI). The hypothetical model establishes positive relationships between optimism and the use of active coping strategies, whereas pessimism is related to the use of passive coping. Active coping is associated with low levels of pain, anxiety, depression and impairment and high levels of functioning. However, passive coping is related to high levels of pain, anxiety, depression and impairment and low levels of functioning. The hypothetical model was empirically tested using the LISREL 8.20 software package and the unweighted least squares method. The results support the hypotheses formulated regarding the relations among optimism, pessimism, coping and adjust of chronic pain patients. By analysing optimism among chronic pain patients, clinicians could make better predictions regarding coping and adjustment.     

Anxiety at 13 and its effect on pain,pain-related anxiety,and pain-related disability at 17: An ALSPAC cohort longitudinal analysis

The aim of the present study was to investigate the influence of anxiety at 13 years of age on the presence of chronic pain, pain-related anxiety, and pain-related disability at 17 years of age in a large longitudinal cohort. We hypothesized that mother-reported anxiety at 13 would be associated with the presence of chronic pain at 17 and an increase in pain-related anxiety using all available data from the longitudinal cohort. Further, we hypothesized that anxiety at 13 would predict pain-related disability in adolescents who reported chronic pain at 17 years of age. Participants were recruited from the Avon Longitudinal Study of Parents and Children based in the UK who attended a university research clinic at 17. Child anxiety (reported by the mother) was extracted at child age 13, and self-report of the presence of chronic pain, pain-related anxiety, and pain-related disability at 17. Analyses revealed that child anxiety at 13 was not significantly associated with the presence of chronic pain at 17 (n = 842). However, anxiety at 13 was significantly associated with pain-related anxiety at 17 (n = 1831). For the subsample of adolescents who reported chronic pain, anxiety at 13 was associated with pain-related disability at 17 (n = 393). Further analyses revealed that pain-related anxiety at 17 mediated the association between anxiety at 13 and pain-related disability at 17, suggesting that pain-related anxiety should be a target for treatment in adolescents with chronic pain, to reduce the impact of pain in later adolescence. General anxiety at 13 was unrelated to the presence of chronic pain at 17, but should be considered a risk factor for later pain-related anxiety and disability in a subset of adolescents who develop chronic pain.     

Suppressing and focusing on a negative memory in social anxiety: effects on unwanted thoughts and mood

Researchers have hypothesized that thought suppression contributes to the large volume of unwanted thoughts in anxiety disorders. However, comparisons to both non-suppression and non-anxious groups are necessary for studies on thought suppression in high anxiety. Participants completed a series of thought verbalization periods and a social interaction. During one period, participants were randomly assigned to focus upon a negative social memory, suppress it, or think freely while monitoring the memory. Results indicated that thought suppression and focusing caused a greater rise and subsequent decline in unwanted thoughts than monitoring instructions for both high and low social anxiety groups. Importantly, highly socially anxious participants had more unwanted thoughts overall, but did not respond significantly differently to thinking instructions when compared to the less anxious group. Interestingly, highly socially anxious participants did report more thought suppression attempts in their everyday life. They also appeared to benefit by experiencing less shyness after suppression when compared to focusing, a pattern not evident for the low social anxiety group.     

A prospective analysis of acceptance of pain and values-based action in patients with chronic pain.

OBJECTIVE: Acceptance of pain and values-based action appear important in the emotional, physical, and social functioning of individuals with chronic pain. The purpose of the current study was to prospectively investigate these combined processes. METHOD: 115 patients attending an assessment and treatment course for chronic pain in the U.K. completed a standard set of measures on two occasions separated by an average of 18.5 weeks. RESULTS: Correlation analyses showed that acceptance of pain and values-based action measured at Time 1 were significantly correlated with pain, pain-related distress, pain-related anxiety and avoidance, depression, depression-related interference with functioning, and physical and psychosocial disability measured at Time 2. Multiple regression analyses, in which pain and relevant patient background variables were controlled, showed that the combined acceptance and values measures accounted for between 6.5% and 27.0% of variance in six key measures of patient functioning later in time. CONCLUSION: These results support the importance of acceptance and values-related processes in relation to chronic pain. These results also encourage continued applications of a functional contextual model of psychopathology, the model underlying Acceptance and Commitment Therapy and related approaches such as Contextual Cognitive-Behavioral Therapy.     

Nature of marital relations among chronic pain patients

Fifty-two chronic pain patients and their spouses were evaluated for their marital relations utilizing the FACES III. In most areas of family functioning the couples provided evidence of difficulties and demonstrated a significant level of agreement about the nature of the problems. On the circumplex model the couples were functioning at the mid-to extreme-range. This study suggests that marital difficulties among chronic pain sufferers may indeed be pervasive.