Symptom clusters in women with relapsing-remitting multiple sclerosis

The purpose of this secondary analysis was to investigate the relationships among a set of symptoms (fatigue, depression, impaired cognitive function, sleep disturbance) with pain severity and demographic variables. The sample of 40 women with relapsing-remitting multiple sclerosis completed instruments of pain, fatigue, depression, sleep disturbance, and an objective cognitive measure. Analysis identified one symptom cluster of pain, fatigue, depression, sleep disturbance, and impaired cognitive function, whereas a relationship between that symptom cluster and employment status existed. Pain severity correlated with fatigue, sleep disturbance, depression, and impaired cognitive function. Preliminary findings support providing education on symptoms to women with relapsing-remitting multiple sclerosis to ultimately guide their care.     

Symptom cluster and physical activity in relapsing‐remitting multiple sclerosis

We compared the explanatory power of two symptom clusters that consisted of either three or five symptoms as correlates of physical activity in individuals with relapsing‐remitting multiple sclerosis (RRMS; N = 218). The data were primarily analyzed using covariance modeling in Mplus 3.0. A symptom cluster of fatigue, depression, and pain had a moderate, negative relationship with physical activity, and this relationship was comparable in magnitude with a symptom cluster of fatigue, depression, pain, perceived cognitive dysfunction, and poor sleep quality. The relationships were attenuated after controlling for exercise history and neurological impairment. Such findings further support the consideration of a narrowly defined cluster of three symptoms as an independent correlate of physical activity in persons with RRMS. © 2010 Wiley Periodicals, Inc. Res Nurs Health 33:398–412, 2010     

肺癌放疗患者病感症状群与炎性细胞因子的相关性研究

目的调查分析肺癌患者放疗期间病感症状群与炎性细胞因子的关系,从免疫学机制上明确病感症状群的内部症状。方法 2014年2月-2016年2月选择在我院接受放射治疗的肺癌患者作为研究对象。于放疗前、放疗后2周、放疗后4周及放疗结束时分别填写调查问卷,包括匹兹堡睡眠质量指数量表(PSQI)、焦虑自评量表(SAS)、抑郁自评量表(SDS)、疼痛及疲乏视觉模拟评分(VAS);于相同时期分别采集患者静脉血,检测细胞因子(IL-6、IL-1β)水平。结果随着放疗的进展,肺癌患者睡眠障碍、疼痛、疲乏程度呈逐渐上升的趋势,焦虑、抑郁程度呈先下降后上升的趋势(P0.05)。放疗结束时,肺癌患者睡眠障碍、焦虑、抑郁、疲乏均与IL-6水平呈正相关(P0.05)。结论肺癌患者放疗结束时病感症状群由睡眠障碍、焦虑、抑郁、疲乏组成。临床护理人员在放疗前、放疗中期有效评估肺癌患者病感症状群的阳性症状,及时发现、及早干预,可避免后期症状加重或叠加作用。     

The Role of Inflammation in the Pain,Fatigue, and Sleep Disturbance Symptom Cluster in Advanced Cancer

Context

Symptom researchers have proposed a model of inflammatory cytokine activity and dysregulation in cancer to explain co-occurring symptoms including pain, fatigue, and sleep disturbance.

Symptom clusters and physical function for patients receiving chemotherapy

OBJECTIVES: To examine the literature on symptom clusters and the impact of co-occurring symptoms on the physical function of patients with cancer during treatment. DATA SOURCES: Research and review articles. CONCLUSION: Unmanaged symptoms occur in what are often called symptom clusters. A focus on known and frequently present co-occurring symptoms, such as pain, fatigue, and sleep disturbance, might be the most efficient and effective way to manage specific symptoms and improve patient functioning. IMPLICATIONS FOR NURSING PRACTICE: Nurses should select assessments that identify multiple symptoms and define their co-occurrence.     

Prevalence of Psychoneurological Symptoms and Symptom Clusters in Women with Breast Cancer Undergoing Treatment: Influence on Quality of Life

ObjectivesTo identify subgroups of psychoneurological symptoms (PNS) and their relationship to different clinical variables in a sample of women with breast cáncer (BC) with different type of treatment, and the possible influence of these on quality of life (QoL), using a factorial principal components analysis.Data SourcesObservational, cross-sectional, non-probability study (2017–2021) at Badajoz University Hospital (Spain). A total of 239 women with BC receiving treatment were included.Results68% of women presented fatigue, 30% depressive symptoms, 37.5% anxiety, 45% insomnia, and 36% cognitive impairment. The average score obtained for pain was 28.9. All the symptoms were related between themselves, and within the cluster of PNS. The factorial analysis showed three subgroups of symptoms, which accounted for 73% of variance: state and trait anxiety (PNS-1), cognitive impairment, pain and fatigue (PNS-2), and sleep disorders (PNS-3). The depressive symptoms were explained equally by PNS-1 and PNS-2. Additionally, two dimensions of QoL were found (functional-physical and cognitive-emotional. These dimensions correlated with the three PNS subgroups found. A relationship was found between chemotherapy treatment and PNS-3, and its negative impact on QoL.ConclusionsA specific pattern of grouped symptoms in a psychoneurological cluster with different underlying dimensions has been identified which negatively influences QoL of survivors of BC.Implication for Nursing PracticeIt is important to raise awareness among professionals and patients about the existence of a cluster of PNS, the patient's profile, as well as the factors that exacerbate them. This will allow them to be treated more effectively and comprehensively.     

Symptom Cluster and Quality of Life in Multiple Sclerosis

ContextThere is abundant evidence that quality of life (QOL) is compromised in persons with multiple sclerosis (MS), but researchers have not yet examined the possible association between co-occurring symptoms and QOL in this population.ObjectivesThe objective of this study was to examine the symptom cluster of fatigue, pain, depression, and perceived cognitive complaints and its association with QOL in individuals with MS.MethodsThe sample included 133 individuals with a definite diagnosis of MS who completed a battery of self-report measures as part of a cross-sectional study of symptoms and physical activity. The battery included the Fatigue Severity Scale, the Center for Epidemiological Studies-Depression Scale, the short form of the McGill Pain Questionnaire, the Perceived Deficits Questionnaire, and the Multiple Sclerosis Impact Scale.ResultsResults indicated that 1) there were moderate bivariate correlations between fatigue, depression, pain, and perceived cognitive complaint scores; 2) the correlations between scores from the pairs of symptoms were attenuated when expressed as partial correlations controlling for the covariance of the remaining pair of symptoms; 3) exploratory and confirmatory factor analyses supported a single-factor model for the associations among fatigue, depression, pain, and perceived cognitive complaint scores; 4) cluster analysis identified three subgroups differing in experiences of fatigue, depression, pain, and perceived cognitive complaints; and 5) analysis of variance indicated a possible dose-response relationship between worsening symptoms and psychological and physical domains of QOL.ConclusionSuch findings provide emerging support for a dose-response relationship between worsening symptoms of fatigue, pain, depression, and perceived cognitive complaints and QOL in persons with MS.     

Mind-Body Treatments for the Pain-Fatigue-Sleep Disturbance Symptom Cluster in Persons with Cancer

ContextCo-occurring pain, fatigue, and sleep disturbance comprise a common symptom cluster in patients with cancer. Treatment approaches that target the cluster of symptoms rather than just a single symptom need to be identified and tested.ObjectivesTo synthesize evidence regarding mind-body interventions that have shown efficacy in treating two or more symptoms in the pain-fatigue-sleep disturbance cancer symptom cluster.MethodsA literature search was conducted using CINAHL, Medline, and PsychInfo databases through March 2009. Studies were categorized based on the type of mind-body intervention (relaxation, imagery/hypnosis, cognitive-behavioral therapy/coping skills training [CBT/CST], meditation, music, and virtual reality), and a preliminary review was conducted with respect to efficacy for pain, fatigue, and sleep disturbance. Mind-body interventions were selected for review if there was evidence of efficacy for at least two of the three symptoms. Forty-three studies addressing five types of mind-body interventions met criteria and are summarized in this review.ResultsImagery/hypnosis and CBT/CST interventions have produced improvement in all the three cancer-related symptoms individually: pain, fatigue, and sleep disturbance. Relaxation has resulted in improvements in pain and sleep disturbance. Meditation interventions have demonstrated beneficial effects on fatigue and sleep disturbance. Music interventions have demonstrated efficacy for pain and fatigue. No trials were found that tested the mind-body interventions specifically for the pain-fatigue-sleep disturbance symptom cluster.ConclusionEfficacy studies are needed to test the impact of relaxation, imagery/hypnosis, CBT/CST, meditation, and music interventions in persons with cancer experiencing concurrent pain, fatigue, and sleep disturbance. These mind-body interventions could help patients manage all the symptoms in the cluster with a single treatment strategy.     

Anxiety, depression and sleep in male patients undergoing coronary artery bypass surgery

The aim of this study was to examine the prevalence of depression and anxiety following coronary artery bypass surgery (CABG) and to see how those patients with depression and anxiety differ in sleeping pattern. The individual reaction to sleep loss was tested as a predictor of certain emotional symptoms in the follow-up period. Thirty-eight males, between 45 and 68 years, were interviewed prior to, and 1 month after, surgery, and received a questionnaire at the 6-month follow-up. Eighty per cent scored moderate anxiety prior to surgery and six patients were depressed. An anxiety-prone individual reactivity persisted in the same patients in 38.9% (n = 14) following CABG, with significantly more sleep disturbances, firedness, energy deficits, immobility, and lower degree of quality of life (QoL). Sad/depressed mood or cognitive/behavioural fatigue symptoms as reactions to sleep loss were predictors of sleep problems and daytime sequelae, whereas a higher postoperative NYHA class was predicted by cognitive/behavioural fatigue and dysphoria reactions. Being less refreshed by sleep on final awakening prior to surgery related to 44.5% of the variance in QoL outcome 6 months following surgery. In conclusion, an anxiety-prone individual reactivity is significantly associated with sleep disturbances. Reactions to sleep loss prior to surgery are associated with emotional distress after surgery.     

Impact of Alzheimer disease patients' sleep disturbances on their caregivers

Sleep disturbance symptoms are common in persons living with Alzheimer disease (AD). However little is known about the impact of sleep disturbance symptoms in patients living with AD on caregiver burden and quality of life (QOL). The aims of this study were to determine the prevalence of symptoms of disturbed sleep in patients with AD, identify the care-recipient sleep disturbance symptoms that predict caregiver burden and QoL, and determine how care-recipient sleep disturbance symptoms compare to other caregiver and patient characteristics when predicting caregiver QoL. Caregiver burden was assessed using the Screen for Caregiver Burden. Sixty percent of the care-recipients had at least one sleep symptom. In 130 caregiver/patient dyads, nocturnal awakenings, nocturnal wandering, and snoring predicted caregiver burden. Multivariate modeling demonstrated that caregiver burden, caregiver physical and mental health, and caregiver depression were predictors of overall caregiver QoL. Treating disturbed sleep in care-recipients and caregiver mental health symptoms could have important public health impact by improving the lives of the caregiving dyad.     

Identification of Symptom Clusters in Patients With Chronic Venous Leg Ulcers

ContextPatients with venous leg ulcers experience multiple symptoms, including pain, depression, and discomfort from lower leg inflammation and wound exudate. Some of these symptoms impair wound healing and decrease quality of life (QOL). The presence of co-occurring symptoms may have a negative effect on these outcomes. The identification of symptom clusters could potentially lead to improvements in symptom management and QOL.ObjectivesTo identify the prevalence and severity of common symptoms and the occurrence of symptom clusters in patients with venous leg ulcers.MethodsFor this secondary analysis, data on sociodemographic characteristics, medical history, venous history, ulcer and lower limb clinical characteristics, symptoms, treatments, healing, and QOL were analyzed from a sample of 318 patients with venous leg ulcers who were recruited from hospital outpatient and community nursing clinics for leg ulcers. Exploratory factor analysis was used to identify symptom clusters.ResultsAlmost two-thirds (64%) of the patients experienced four or more concurrent symptoms. The most frequent symptoms were sleep disturbance (80%), pain (74%), and lower limb swelling (67%). Sixty percent of patients reported three or more symptoms at a moderate-to-severe level of intensity (e.g., 78% reported disturbed sleep frequently or always; the mean pain severity score was 49 of 100, SD 26.5). Exploratory factor analysis identified two symptom clusters: pain, depression, sleep disturbance, and fatigue; and swelling, inflammation, exudate, and fatigue.ConclusionTwo symptom clusters were identified in this sample of patients with venous leg ulcers. Further research is needed to verify these symptom clusters and to evaluate their effect on patient outcomes.     

Prospective Longitudinal Evaluation of a Symptom Cluster in Breast Cancer

ContextSymptom cluster research expands cancer investigations beyond a focus on individual symptoms in isolation.ObjectivesWe conducted a prospective longitudinal study of sleep, fatigue, depression, anxiety, and perceived cognitive impairment in patients with breast cancer undergoing chemotherapy.MethodsPatient-reported outcome measures were administered prior to chemotherapy, at Cycle 4 Day 1, and six months after initiating chemotherapy. Participants were divided into four groups and assigned a symptom cluster index (SCI) score based on the number/severity of symptoms reported at enrollment.ResultsParticipants (N = 80) were mostly women (97.5%) with Stage II (69.0%) breast cancer, 29–71 years of age. Scores on all measures were moderately-highly correlated across all time points. There were time effects for all symptoms, except sleep quality (nonsignificant trend), with most symptoms worsening during chemotherapy, although anxiety improved. There were no significant group × time interactions; all four SCI groups showed a similar trajectory of symptoms over time. Worse performance status and quality of life were associated with higher SCI score over time.ConclusionWith the exception of anxiety, the coherence of the symptom cluster was supported by similar patterns of severity and change over time in these symptoms (trend for sleep quality). Participants with higher SCI scores prior to chemotherapy continued to experience greater symptom burden during and after chemotherapy. Early assessment and intervention addressing this symptom cluster (vs. individual symptoms) may have a greater impact on patient performance status and quality of life for patients with higher SCIs.     

Psychoeducational Intervention for Symptom Management of Fatigue,Pain, and Sleep Disturbance Cluster Among Cancer Patients: A Pilot Quasi-Experimental Study

Objectives

To assess the feasibility of conducting a trial of a psychoeducational intervention involving the provision of tailored information and coaching to improve management of a cancer-related symptom cluster (fatigue, pain, and sleep disturbance) and reduce symptom cluster impacts on patient health outcomes in the Vietnamese context and to undertake a preliminary evaluation of the intervention.

Symptom clusters and symptom interference of HCC patients undergoing TACE: a cross-sectional study in China

Objective

The aim of this study was to investigate the symptom and symptom clusters of patients with hepatocellular carcinoma (HCC) before and after transcatheter arterial chemoembolization (TACE), and to discuss the relationship between symptoms, symptom clusters, and symptom interference.

Materials and methods

Patients with HCC who received TACE were asked to rate their symptoms using the M. D. Anderson Symptom Inventory and the symptom checklist particularly for HCC. To determine the interrelationships among symptoms and identify the symptom clusters, a principal component analysis with varimax rotation was carried out on the symptom items. Spearman correlation analysis was done to assess the relationship between symptom clusters and symptom interference.

Results

A total of 155 patients finished the whole procedure between November 2010 and May 2011. Before TACE, the five most severe symptoms, ranked in order, were fatigue (3.40?±?2.26), distress (3.35?±?2.60), sadness (3.01?±?2.66), sleep disturbance (2.63?±?2.57), and lack of appetite (2.26?±?2.38). After TACE, fatigue (4.88?±?2.31) was the most serious symptom, followed by sleep disturbance (4.80?±?2.25), distress (4.59?±?2.32), sadness (4.45?±?2.16), lack of appetite (4.25?±?2.51). Two symptom clusters were found before TACE: psychological symptom cluster and sickness symptom cluster. Two new symptom clusters were found after TACE: upper gastrointestinal symptom cluster and liver function impairment symptom cluster, with the two original symptom clusters remained relatively stable. The highest symptom interference items pre- and post-TACE were work and enjoyment of life, followed by mood. The symptoms of distress, sadness, fatigue, sleep disturbance, and lack of appetite were all significantly associated with the total interference (r?=?0.443–0.615, p?<?0.01 or p?<?0.05). Symptom clusters were significantly correlated with the total symptom interference before and after TACE (r?=?0.176–0.638, p?<?0.01 or p?<?0.05).

Conclusion

Psychological symptom cluster and sickness symptom cluster are common for HCC patients before and after TACE. Liver function impairment and upper gastrointestinal symptom clusters are directly related to TACE treatment. Both the symptoms and symptom clusters have significant interference on the daily life of HCC patients undergoing TACE. However, more work is needed to further clarify the symptom clusters associated with TACE and to test the effectiveness of TACE in easing symptoms and improving quality of life of HCC patients.     

Sleep,fatigue, depression,and circadian activity rhythms in women with breast cancer before and after treatment: a 1-year longitudinal study

Purpose

Sleep disturbance, fatigue and depression are common complaints in patients with cancer, and often contribute to worse quality of life (QoL). Circadian activity rhythms (CARs) are often disrupted in cancer patients. These symptoms worsen during treatment, but less is known about their long-term trajectory.

Methods

Sixty-eight women with stage I-III breast cancer (BC) scheduled to receive ≥4 cycles of chemotherapy, and age-, ethnicity-, and education-matched normal, cancer-free controls (NC) participated. Sleep was measured with actigraphy (nocturnal total sleep time [nocturnal TST] and daytime total nap time [NAPTIME]) and with the Pittsburgh Sleep Quality Index (PSQI); fatigue with the Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF); depression with the Center of Epidemiological Studies-Depression (CES-D). CARs were derived from actigraphy. Several measures of QoL were administered. Data were collected at three time points: before (baseline), end of cycle 4 (cycle 4), and 1 year post-chemotherapy (1 year).

Results

Compared to NC, BC had longer NAPTIME, worse sleep quality, more fatigue, more depressive symptoms, more disrupted CARs, and worse QoL at baseline (all p values <0.05). At cycle 4, BC showed worse sleep, increased fatigue, more depressive symptoms, and more disrupted CARs compared to their own baseline levels and to NC (all p values <0.05). By 1 year, BC’s fatigue, depressive symptoms, and QoL returned to baseline levels but were still worse than those of NC, while NAPTIME and CARs did not differ from NC’s.

Conclusion

Additional research is needed to determine if beginning treatment of these symptoms before the start of chemotherapy will minimize symptom severity over time.     

Nausea still the poor relation in antiemetic therapy? The impact on cancer patients’ quality of life and psychological adjustment of nausea, vomiting and appetite loss, individually and concurrently as part of a symptom cluster

Purpose

Despite significant antiemetic advances, almost 50 % of treated cancer patients still experience nausea and vomiting (N&V). The goal of antiemetic therapy—complete prevention of treatment-induced nausea and/or vomiting (TIN+/?V)—remains elusive for several reasons. Potentially, N&V may be part of a symptom cluster where co-occurring symptoms negatively affect antiemetic management. Consequently, we examined TIN+/?V incidence and the impact of nausea, vomiting and symptom cluster(s) containing them, respectively, on patients’ quality of life (QoL) and psychological adjustment across treatment.

Methods

A longitudinal secondary analysis was performed on data from a prospective, observational QoL study involving 200 newly diagnosed cancer patients who underwent combined modality treatment. QoL, psychological adjustment and patient/clinical characteristics were examined at pretreatment, on-treatment (8 weeks) and post-treatment.

Results

Overall, 62 % of patients experienced TIN+/?V, with TIN (60 %) doubling TIV incidence (27 %). Exploratory factor analyses of QoL scores at each treatment time point identified a recurrent gastrointestinal symptom cluster comprising nausea, vomiting and appetite loss. Approximately two thirds of patients reported co-occurrence of all three symptoms, which exerted synergistic effects of multiplicative proportions on overall QoL. Patients who reported co-occurrence of these symptoms during treatment experienced significantly greater QoL impairment (physical, role and social functioning, fatigue, N&V, appetite loss, overall physical health, overall QOL) and psychological distress (cancer distress, premorbid neuroticism) than those unaffected (0.001?>?p?≤?0.05). Moreover, nausea was more pervasive than vomiting or appetite loss across treatment and had a greater impact on overall QoL. While antiemetic therapy was effective for vomiting and helped prevent/relieve associated appetite loss, the benefits for appetite loss were seemingly constrained by its failure to exert adequate control over nausea in many patients.

Conclusions

TIN+/?V still represents a very major concern for patients. Uncontrolled TIN+/?V often results in significant appetite and weight loss, leading to increased risk for malnutrition. Malnutrition and weight loss, in turn, are associated with poorer prognosis, treatment tolerance and response, performance status, QoL and survival. Consequently, a multiple symptom intervention approach focusing on N&V as core symptoms is recommended. Clinicians should genuinely consider combining essential antiemetic therapies with other evidence-based pharmacological (e.g. nausea: psychotropics, such as olanzapine) and non-pharmacological approaches (e.g. N&V: relaxation) in attempts to not only improve prevention and control of N&V for their patients, but also reduce the synergistic impact of cluster symptoms (e.g. N&V, appetite loss) as a whole and resultant QoL impairment likewise. Where associated symptoms are not adequately controlled by these antiemetic-based interventions, targeted evidence-based strategies should be supplemented.     

The identification of multiple symptom clusters and their effects on functional performance in cancer patients

Aims and objectives. To identify cancer-related symptom clusters, to explore their inter-relationships and to examine the effects of single symptoms and the synergistic effects of symptom clusters on functional performance using path analysis by structural equation modelling in patients with various types of cancer. Background. Recent studies suggest that cancer patients frequently experience three or more concurrent related symptoms and that this clustering of symptoms is likely to have negative synergistic impacts on outcomes, because of the complicated dynamics of clusters. Design. A cross-sectional design. Methods. One hundred and ten patients with various types of cancer were recruited as in- and out-patients at a University Hospital in Incheon, South Korea. Data collection was performed using a questionnaire and by direct interview. Pain, insomnia, fatigue, depression and functional performance were measured. Results. The developed model was composed of antecedents, symptom clusters and outcomes. Of the symptoms often encountered as clusters in cancer patients, insomnia, depression and fatigue were found to have significant single (direct) effects on functional performance. Seven symptom clusters were identified between pain and functional performance, three between insomnia and functional performance and one between depression and functional performance. These single symptoms and symptom clusters were found to have significant synergistic effects on functional performance and to explain 24% of functional performance variance. Conclusions. Multiple cancer-related symptom clusters may occur and the dynamics within symptom clusters is complicated. Our findings provide sound evidence regarding the importance of assessing and managing clusters of symptoms simultaneously rather than focusing on single symptoms. Relevance to clinical practice. A comprehensive understanding of symptom clusters in cancer patients would help establish valid diagnostic symptom cluster entities and aid the development of subjective/objective phenotypic criteria for symptom cluster based diagnoses and of nursing care protocols for managing symptom clusters.     

Cognitive complaints are associated with depression, fatigue, female sex, and pain catastrophizing in patients with chronic pain

OBJECTIVE: To examine the relation between demographic, pain-related, psychosocial, affective, and treatment factors and complaints of cognitive dysfunction among patients with chronic pain. DESIGN: Cross-sectional survey. SETTING: A university hospital outpatient multidisciplinary chronic pain program. PARTICIPANTS: Chronic pain patients (N=222; 135 women, 87 men) completed a battery of psychometric questionnaires as part of an initial evaluation on referral to the program. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Cognitive impairment was assessed with items from the Brief Symptom Inventory; measures of depressive symptoms, pain intensity, posttraumatic stress disorder (PTSD), and pain catastrophizing were obtained from the Beck Depression Inventory (negative affect, negative self, somatic/physical function), McGill Pain Questionnaire, Modified Posttraumatic Chronic Pain Test, and Coping Strategies Questionnaire, respectively; and measures of subjective sleep disturbance, fatigue, opiate use, compensation/litigation status, pain location, and relevant demographic data were obtained from an open-ended questionnaire. RESULTS: Correlational analysis indicated that female sex, pain intensity, PTSD symptoms, depressive symptoms, catastrophizing, pain location (neck), and fatigue were all positively related to cognitive complaints. Simultaneous regression analysis showed that all factors combined accounted for 52% of the variance in self-report of cognitive difficulties and that 6 variables had a significant unique contribution to the report of cognitive complaints in the following order of importance: depression-negative affect (beta=.28, P <.05), fatigue (beta=.17, P <.05), depression-somatic/physical function (beta=.16, P <.05), depression-negative self (beta=.14, P =.05), pain catastrophizing (beta=.12, P =.08), and female sex (beta=.12, P <.05). CONCLUSIONS: Complaints of cognitive impairment among chronic pain patients appear to be associated with multiple factors, with particular attention to depressive symptoms, fatigue, and catastrophizing. Our results also suggest that women with chronic pain are particularly vulnerable to cognitive dysfunction.