Somatization disorder and stress in teachers: a comprehensive occupational health evaluation

Somatization disorder is a biopsychosocial‐based, stress‐induced disorder involving multiple physical ailments with no medical explanation. The teaching profession is characterized as very stressful, making teachers at risk of developing somatization disorder. This study examined somatization disorder in a K‐12 teacher population. A total of 2,988 teachers from 46 Texas districts responded to a comprehensive online occupational health survey. Somatization disorder was assessed using the Patient Health Questionnaire. Univariate analyses were conducted between teachers with and without somatization disorder to identify specific relationships with demographic variables, occupational variables, perceived stress, Axis I psychopathology, and physical health. A logistic regression was developed to identify the variables most strongly associated with the presence of somatization disorder in a teacher population. Analyses showed that female teachers are 3.3 times more likely to develop somatization disorder. Compared to Caucasians, African American teachers are 3.9 times and Hispanic teachers are 2.0 times more likely to develop somatization disorder. Moreover, higher levels of stress, poorer physical quality of life, major depression, panic and anxiety disorder were significantly related with somatization disorder (p  < .05). Higher levels of stress and poorer physical and mental health are among the psychosocial and demographic factors associated with somatization disorder in public school teachers.     

Utility of Pain Drawings Rated for Non‐Organic Pain in Chronic Low Back Pain Populations: A Qualitative Systematic Review

Pain drawings are useful for comprehensively assessing chronic pain. They are brief to administer and score, easy to use, and provide information about patient outcomes. In the present study, pain drawings evaluating non‐organic pain were examined for utility and effectiveness. A qualitative systematic review revealed that non‐organic pain drawings, although diverse in nature, are highly reliable and valid and relate to many constructs. Pain drawing ratings may be a general screener for psychosocial distress, as they relate to demographics, medication use, personality, cognition, quality of life, self‐reported disability, and work outcomes. Although utilization of non‐organic pain scales has become less frequent, the concept of non‐organic pain remains relevant, despite new terminology usage, such as somatization and central sensitization.     

Medical and psychiatric symptoms in women with childhood sexual abuse.

Although there is increasing awareness of the short-term psychological and social adaptations to childhood sexual abuse, little is known about the long-term effects of such abuse, particularly its effect on subsequent medical utilization and the experience and reporting of physical symptoms. We re-analyzed data from a previous study of 100 women scheduled for diagnostic laparoscopy (50 for chronic pain, 50 for tubal ligation or infertility evaluation) who received structured, physician-administered psychiatric and sexual abuse interviews. Women were regrouped by severity of childhood sexual abuse, and we compared the groups with respect to lifetime psychiatric diagnoses and medically unexplained symptom patterns. Unadjusted odds ratios showed that risk for lifetime diagnoses of major depression, panic disorder, phobia, somatization disorder and drug abuse, and current diagnoses of major depression and somatoform pain disorder were significantly higher in the severely abused group compared with women with no abuse or less severe abuse. Logistic regression analysis demonstrated that number of somatization symptoms, lifetime panic disorder and drug dependence were predictive of a prior history of severe childhood sexual abuse. Psychiatric disorders and medical symptoms, particularly chronic pelvic pain, are common in women with histories of severe childhood sexual abuse. Clinicians should inquire about childhood sexual and physical abuse experiences in patients with multiple medical and psychiatric symptoms, particularly patients with chronic pelvic pain.     

The differential effects of employment status on chronic pain and healthy comparison groups

We evaluated the differential effects of employment status on chronic pain and healthy comparison groups. Forty unemployed and 43 employed individuals with chronic pain, as well as 43 unemployed and 45 employed healthy comparison participants completed a series of measures assessing background information physical and psychological adjustment, and psychosocial features of employment status. In general, participants experiencing both chronic pain and unemployment reported poorer adjustment than the other groups and more financial strain, less structured and purposeful activity, fewer opportunities for skill use and task variety, and decreased social support than the employed chronic pain and healthy comparison groups. Groups did not differ, however, in work ethic values. Scores on measures of pain severity and features of employment status accurately predicted the group membership of more than 70% of respondents from four groups. The study suggests that there is utility in understanding experiences of chronic pain patients on the basis of features of their current employment status and points to a need for multidimensional measures that evaluate psychosocial facets of employment and unemployment specifically for chronic pain samples.     

Chronic pelvic pain as a somatoform disorder

BACKGROUND: The purpose of this study was to determine whether psychiatric disturbances, particularly somatization, and an increased number of traumatic and critical life events, which have been found in women with idiopathic chronic pelvic pain (ICPP), can also be observed in women with chronic pelvic pain and abdominal adhesions (ACPP). METHODS: Forty women who underwent diagnostic laparoscopy were subdivided into three groups according to blind rated somatic pathologies: ICPP patients (n = 16), ACPP patients (n = 10), infertile controls without pain (n = 14). Besides the standardized assessment of DSM-III-R diagnosis, questionnaires and semistandardized interviews were used to estimate depression, somatization, pain, the prevalence of sexual and physical abuse, and the number of critical life events. RESULTS: Diagnostic criteria for somatoform pain disorder were fullfilled in 73.3% of the ICPP patients, 60% of the ACPP patients and none of the controls. With respect to the somatization symptom checklist the two pain groups scored significantly higher than the controls (p < 0.05). Referring to perceived pain, ACPP patients differed from the ICPP patients by one out of seven subscales (higher persistence of pain; p < 0.05). No correlation was found between the intensity of pain and the severity of classified adhesions. The two groups of pain patients significantly differed from controls by a higher prevalence of sexual abuse (p < 0.05). Depression was found neither in the pain groups nor in the controls. CONCLUSIONS: Because high somatization and high prevalence rates of abuse were not only found in patients suffering from ICPP but also in ACPP patients, it seems to be doubtful that the somatic pathology may fully explain the psychopathology in patients with ACPP.     

Somatization disorder in patients with chronic fatigue

One hundred adults with a chief complaint of chronic fatigue were evaluated in an outpatient setting to determine a possible association with somatization disorder. Somatization disorder was diagnosed in 15 patients. Eight functional somatic symptoms were reported more frequently by these patients: pain in extremities, joint paint, chest pain, other pain, shortness of breath, blurred vision, muscle weakness, and sexual indifference (p less than 0.001). Current mood disorders, anxiety disorders, and psychoactive substance use disorders were less common in patients with somatization disorders than in patients without this diagnosis (p less than 0.01).     

Self‐regulatory ability,fatigue, and the experience of pain: Mechanistic insights from pain‐free undergraduates

Self‐regulatory (SR) ability is an important resource for managing pain, but chronic pain patients experience chronic self‐regulatory fatigue even when they are not in pain. Pressure pain thresholds (PPT) and pain inhibition are two mechanisms that differentiate people with and without chronic pain. It was hypothesized that trait SR ability would be associated with higher PPT and better pain inhibition and that PPT and pain inhibition would be lower following high versus low SR fatigue. Three studies tested these hypotheses. Study 1 had 240 pain‐free undergraduates complete measures of trait SR ability and PPT; 122 also provided data on pain inhibition. Study 2 had 38 of Study 1’s participants return for two additional sessions in which they underwent PPT testing under conditions of high or low SR fatigue (within‐person, counterbalanced). Study 3 repeated these procedures with pain inhibition as the outcome (n = 39). Results revealed that individual differences in SR ability were not associated with PPT or pain inhibition (all ps > 0.05). Within people, neither PPT (F(1, 36) = 1.57, p = 0.22) nor pain inhibition (F(1, 37) = 1.79, p = 0.19) were significantly different under conditions of low versus high SR fatigue. Results do not support the hypotheses that PPT or pain inhibition associate with individual differences in trait SR ability or transient changes in state SR fatigue in the absence of pain. Instead, the SR deficits in chronic pain patients may arise from the experience of chronic pain.     

Somatization as a Predictor of Outcomes Following Functional Restoration of Chronic Disabling Occupational Musculoskeletal Pain Disorder Patients

Chronic disabling occupational musculoskeletal pain disorder (CDOMPD) patients often have high levels of somatization, a phenomenon in which somatic symptoms are medically unexplainable. Examination of 1,458 CDOMPD patients, who completed the patient health questionnaire (PHQ) somatization module from 2003 to 2010 and underwent functional restoration treatment, were divided into low, moderate, and high somatization at pretreatment. Somatization was highly responsive to treatment, and those with high somatization reported the highest depressive symptoms, disability, and pain intensity, and the lowest health‐related quality of life at pre‐ and post‐treatment. Somatization levels significantly predicted 1‐year socioeconomic outcomes of work return, work retention, and healthcare utilization. High somatization may act as a “red flag” for clinicians, indicating patients may be at risk for poor treatment outcomes.     

A Pain Severity–Hypothalamic–Pituitary–Adrenocortical Axis Interaction: The Effects on Pain Pathways1

Recent efforts have identified psychosocial and biological factors influencing the pathogenesis of chronic pain. The present study attempted to identify whether these two variables interact and, in turn, represent an underlying mechanism in the transition from acute to chronic pain. Salivary cortisol samples were collected upon waking up and 20 minutes later daily for 2 weeks from acute pain patients. Analyses revealed a direct relationship between pain severity and hypothalamic–pituitary–adrenocortical activity for temporomandibular disorder, and a negative relationship between these variables for low back pain populations. These results highlight the possible interaction between neuroendocrine and psychological factors to increase the risk for chronic pain.     

Health Care Utilization After Interdisciplinary Chronic Pain Treatment: Part II. Preliminary Examination of Mediating and Moderating Factors in the Use of Costly Health Care Procedures

Military chronic musculoskeletal pain accounts for over $1 billion in health care and disability costs annually. Recent advances in the tertiary treatment of chronic pain for military service members have demonstrated significant benefit for military pain sufferers who complete an interdisciplinary functional restoration program. Functional restoration patients demonstrate significant improvements in mood, pain‐related cognitions, physical functioning, self‐efficacy, and rates of retention on active duty. Examination of data from the military's Armed Forces Health Longitudinal Technology Application (AHLTA) for active duty service members with chronic pain who completed the functional restoration FORT (Functional and Occupational Rehabilitation Treatment) program revealed that FORT patients sought significantly lower levels of costly medical procedures for pain compared to those who received treatment as usual. FORT participants were significantly less likely to seek treatment through the Emergency Department for pain, undergo injections for pain relief, or receive radio frequency nerve ablations for pain. This study was undertaken to identify relevant factors that contribute to reliance on costly medical procedures for pain relief among military service members with chronic musculoskeletal pain. Numerous psychosocial, physical, and demographic variables assessed as part of the FORT study were analyzed with AHLTA procedure data. This preliminary analysis revealed that service members without children (55%) were significantly more likely to seek medical procedures for pain compared to those with children (16%). Those who sought medical procedures for pain demonstrated significantly higher levels of work‐related fear avoidance (x = 21.83) compared to non‐procedure patients (x = 11.79), and those who received procedures also demonstrated less lumbar flexion (x = 37.67 degrees) compared to non‐utilizers (x = 46.67 degrees). Lack of children, high work‐related fear avoidance, and low lumbar range of motion accounted for 36% of the variance in medical procedure use in this sample. Implications for future research are discussed.     

Coping in chest pain patients with and without psychiatric disorders

We first examined relations between psychiatric disorder and coronary heart disease (CHD) in 77 patients presenting with chest pain. The coping profiles of chest pain patients with and without psychiatric disorder and CHD were then compared. Psychiatric patients with no medical illness (n = 129) were also studied. On the basis of previous research we hypothesized specific coping differences across the groups. As expected, chest pain patients without psychiatric disorder scored significantly higher on a problem-focused coping scale than chest pain patients with psychiatric disorder, who in scored higher on this scale than psychiatric patients with no medical illness. The opposite pattern occurred for a measure of wishful thinking. Scores of chest pain patients with psychiatric disorder were higher on a measure of avoidance and lower on a measure of seeking of social supports than those without psychiatric disorder. Scores on a self-blame measure were not different across the groups. The results are discussed in the context of illness behavior and somatization.     

Abdominal pain in children and symptoms of somatization disorder

Children seen in a multispecialty medical clinic for abdominalpain were divided into three groups: 21 with confirmed organicfindings related to the abdominal pain, 14 with confirmed organicfindings unrelated to the pain, and 108 whose physical examinationswere negative (the functional pain group). For children withfunctional abdominal pain (but not for the others) the numberof symptoms of somatization disorder (Briquet's syndrome) wassignificantly related to the chronicity of the child's condition.Children with functional pain and no prior complaint had a meanof 1.95 symptoms; those with complaints of less than 1 year'sduration, 2.21 symptoms; those with complaints of more thana year since age 6, 4.04 symptoms; and those with complaintsfor more than a year with onset prior to age 6 years, 4.55 symptomsfrom the Somatization Disorder list. Findings were interpretedas preliminary evidence for a distinct, chronic, polysymptomatichysterical disorder beginning in childhood.     

Posttraumatic Stress Disorder and Co‐Occurring Substance Use Disorders: Advances in Assessment and Treatment

Posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) are prevalent and frequently co‐occur. Comorbid PTSD/SUD is associated with a more complex and costly clinical course when compared with either disorder alone, including increased chronic physical health problems, poorer social functioning, higher rates of suicide attempts, more legal problems, increased risk of violence, worse treatment adherence, and less improvement during treatment. In response, psychosocial treatment options have increased substantially over the past decade and integrated approaches—treatments that address symptoms of both PTSD and SUD concurrently—are fast becoming the preferred model for treatment. This article reviews the prevalence, etiology, and assessment practices as well as advances in the behavioral and pharmacologic treatment of comorbid PTSD and SUDs.     

Health-related quality of life using the SF-36 in patients with bipolar disorder compared with patients with chronic back pain and the general population

BACKGROUND: The purpose of this study was to assess and compare the health-related quality of life of patients with bipolar disorder and chronic back pain and, in turn, to compare these results with those previously generated for the general population. METHODS: Subjects were patients with bipolar disorder (n=44), a comparison group of chronic back pain patients (n=30), and a population-based control sample (n=2,474). Health-related quality of life was assessed using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), a self-administered questionnaire in which lower scores are indicative of greater impairment. RESULTS: Patients with bipolar disorder had lower mean scores than the general population on all scales except Physical Functioning. Bipolar patients had significantly higher scores than chronic back pain patients in the categories of Physical Functioning, Role Limitations--Physical, Bodily Pain, and Social Function. There were no significant differences between bipolar disorder and chronic back pain groups in the Mental Health and Role Limitations - Emotional categories. LIMITATIONS: The results of the study are limited by the relatively small sample sizes of the bipolar and back pain patient groups. CONCLUSIONS: Patients with bipolar disorder had substantial impairment in health-related quality of life in comparison with the general population. Bipolar patients were less compromised in areas of physical and social functioning than chronic back pain patients but had similar impairment in mental health.     

Selective processing of threat‐related cues in day surgery patients and prediction of post‐operative pain

Objective: To investigate the use of a measure of selective processing bias associated with anxiety as a predictor of post‐operative pain independently of self‐report measures of anxiety. Methods: Forty‐seven women admitted for minor gynaecological surgical procedures completed a selective processing task (modified Stroop) and the State‐Trait Anxiety Inventory immediately prior to surgery. Following surgery they completed the McGill Short‐Form Pain Questionnaire. Intraoperative analgesia consumption was also recorded. Results: Participants demonstrated significantly slower colour‐naming times for physical threat cues than control cues. This was not due to an emotionality effect, as colour‐naming times for neutral and positive cues were not significantly different. This bias was congruent with the participants’ current concerns, as colour‐naming times were significantly slower for physical threat words than for social threat words. This index of selective processing bias significantly predicted post‐operative pain independently of self‐reported state and trait anxiety. Conclusions: The advantages of measures of psychological constructs that are not reliant on self‐reporting are discussed.     

The Impact of Psychosocial Features of Employment Status on Emotional Distress in Chronic Pain and Healthy Comparison Samples

This study examined the extent to which measures of psychosocial features of employment status predict emotional distress in chronic pain (n = 83) and healthy comparison (n = 88) samples. Participants completed measures of emotional distress, pain severity, psychosocial features of employment status, and demographic data. After controlling for length of current unemployment, number of pain sites, and level of current pain severity, psychosocial measures (structured and purposeful time use, perceived financial security, skill use, social support from formal sources) were significant predictors of emotional distress in the chronic pain sample. Similar results were obtained for the healthy comparison sample. Structured and purposeful time use emerged as the most significant individual predictor of emotional distress for both samples. Findings are discussed in terms of their potential implications for treating chronic pain patients and the need to develop multidimensional measures that assess features of employment status within chronic pain samples.     

Pain and sleep quality in children with non‐vascular Ehlers–Danlos syndromes

The objective of this study was to explore the factors contributing to quality of life in pediatric patients with non‐vascular Ehlers–Danlos syndromes (EDS). Data were analyzed on 41 children with a diagnosis of non‐vascular EDS from the de‐identified data available from the National Institute on Aging (NIA) study of heritable disorders of connective tissue. Children under age 19 years were seen as part of a long‐term evaluation project from 2003 to 2013 on a larger natural history of patients with heritable disorders of connective tissue. Data collected included medical history, physical examination findings, diagnostic study results, and responses on validated questionnaires. We reviewed a sub‐cohort of children with a diagnosis of non‐vascular EDS and explored pain severity and interference via the Brief Pain Inventory, and sleep quality via the Pittsburgh Sleep Quality Index. Pain severity had a strong correlation with pain interference, and both were similar to other disorders that include chronic pain reported in the literature. Sleep quality did not correlate with pain severity or interference, but all patients had poor sleep quality in comparison to historical controls. We conclude that pain and sleep are significant issues in the pediatric non‐vascular EDS population, and future research may be directed toward these issues.     

Comparing physical and behavior therapy for chronic low back pain on physical abilities,psychological distress,and patients' perceptions

A treatment-outcome study was conducted to study the impact of behavior and physical therapy on components of the chronic low back pain syndrome. Eighteen patients received behavior therapy and 15 patients received physical therapy. All patients had at least a 6-month history of seeking treatment for chronic low back pain. Prior to treatment patients were assessed in four principal areas of functioning: (1) physical abilities; (2) current physical functioning; (3) psychological and psychosocial functioning; and (4) pain intensity and pain perception. Treatments were conducted in a group (five to eight patients) outpatient setting. Both behavior therapy and physical therapy groups met for 10-weekly sessions, each lasting 2 hr. Behavior therapy was designed to address the environmental, social, and emotional components of the low back pain syndrome as well as the depression and decreased activity that result from chronic low back pain. Physical therapy was based upon traditional rehabilitation theory and was designed to improve low back function. Patients were reevaluated at posttreatment, 6 months, and 1 year. The results showed a general improvement for patients in both groups and a few treatment-specific differences in outcome measures.This research was supported by the Veterans Administration Medical Research Program. Portions of this paper were read at the Annual Meeting of the American Pain Society, New York, September 1980.     

Colorectal adenocarcinoma with mucinous component: relation of MMP‐13, EGFR,and E‐cadherin expressions to clinicopathological features and prognosis

The aim of this study was to compare colorectal adenocarcinoma with mucinous component, ordinary adenocarcinoma (OA) and mucinous adenocarcinoma (MA) regarding clinicopathological parameters, survival, EGFR, MMP‐13, and E‐cadherin. We studied tumor tissue specimens from 28 patients with adenocarcinoma with mucinous component, 47 with OA, and 56 with MA, who underwent radical surgery from January 2007 to January 2012 at the Gastroenterology Centre, Mansoura University, Egypt. High density manual tissue microarrays were constructed and immunohistochemistry for EGFR, MMP‐13, and E‐cadherin was done. Colorectal adenocarcinoma with mucinous component (AWMC) was significantly associated with more perineural invasion, lower EGFR, and MMP‐13 expressions than OA, with no difference in E‐cadherin expression. Conversely, only microscopic abscess formation was significantly more with colorectal AWMC than MC with no difference in EGFR, MMP‐13 and E‐cadherin expression between both groups. Colorectal AWMC showed a better survival than MA with no difference with OA. In a univariate analysis, EGFR, MMP‐13, and E‐cadherin expressions did not show a significant impact on disease‐free or overall survival in patients with colorectal AWMC. Colorectal AWMC remains a vague entity that resembles OA in some clinicopathological and molecular respects as well as MA.     

Cross‐sectional assessment of pain and physical function in skeletal dysplasia patients

Short stature skeletal dysplasia (SD) patients have orthopedic and neurologic complications causing significant pain and physical disability. We conducted a large cross‐sectional online survey in 361 people with short stature SD (>10 years) to describe pain prevalence, characteristics, and the relationship between pain and function. Chronic pain prevalence per Brief Pain Inventory (BPI) was 70.3%. Women reported more pain than men (73% vs 63% p = 0.04). Pain Severity Score (average of current, worst, least and average pain) averaged 3.3 ± 2, while the Pain Interference Score (with daily activities) averaged 3.4 ± 2.7 on a 10‐point scale. Per Bleck scale, 20.5% had little or no functional capacity. Increasing age and decreased ambulation independently predicted chronic pain. Chronic pain is prevalent in short stature SD patients and associated with poor physical function. Further study is required to clarify the temporal relationship among pain, function and treatments.