Gender moderates the association between depression and disability in chronic pain patients.

Pain-related anxiety and depression are important correlates of disability amongst chronic pain patients. Furthermore, women may differ in their experience of pain, anxiety and depression when compared to men. The aim of the current study was to determine the relative contribution of anxiety and depression on disability in male and female chronic pain patients. The sample consisted of 260 patients (101 males, 159 females) referred to the Pain Management Unit at the Royal National Hospital for Rheumatic Diseases in Bath, UK. As part of an initial assessment, all patients completed measures of depression, pain-related anxiety and disability. As predicted, both anxiety and depression were found to be significant positive predictors of pain, number of medications used and disability. Although gender did not significantly predict disability, it did moderate the relationship between depression and disability, in that when depression was high, women report greater disability than men. Gender was also found to moderate the relationship between depression and number of medications used, in that a positive association was found for men, but not women. However, gender did not significantly moderate the relationship between anxiety and disability. Together these results not only suggest that gender is an important moderator of the relationship between emotional responses and disability, but that such associations may be related more to depression than anxiety.     

Gender differences in treatment-seeking chronic headache sufferers

OBJECTIVE: To identify gender differences within a group of patients seeking treatment for chronic headache. Previous studies of the general population have reported differences in headache symptoms, frequency, disability, and psychological distress, with women affected with more severe and disabling symptoms than men. This study evaluated these features in a population seeking treatment. METHODS: Two hundred fifty-eight consecutive patients with headache attending a university headache clinic were evaluated with questionnaires about headache symptoms and psychological distress. Comparisons between men and women were made for headache symptoms, severity, frequency, trigger factors, comorbid depression and anxiety, and response to treatment. RESULTS: There were no gender differences in headache symptoms, frequency, severity, and duration. Headache triggers were gender-specific, with men more likely to endorse exercise and women more likely to endorse stress and exposure to odors. Psychological comorbidity was similar among men and women seeking treatment, with a mean Beck Depression Inventory score of 10 and a mean Spielberger trait anxiety score of 39 for both men and women. Disability was greater in men, with 46% reporting restrictions in activities more than 3 days per week because of headache compared with 29% of women. In addition, men were more likely to contribute headache control to external figures than women. CONCLUSIONS: Patients seeking treatment for chronic headache do not have the same gender-specific differences that have been reported in general population surveys. Men who seek treatment for headache are more likely to have significant disability, and are equally likely to have symptoms of depression and anxiety as women who seek treatment. Clinical and research investigations of headache triggers need to be gender-specific.     

Derivation of a clinical prediction rule to identify both chronic moderate/severe disability and full recovery following whiplash injury

Recovery following a whiplash injury is varied: approximately 50% of individuals fully recover, 25% develop persistent moderate/severe pain and disability, and 25% experience milder levels of disability. Identification of individuals likely to develop moderate/severe disability or to fully recover may help direct therapeutic resources and optimise treatment. A clinical prediction rule (CPR) is a research-generated tool used to predict outcomes such as likelihood of developing moderate/severe disability or experiencing full recovery from whiplash injury. The purpose of this study was to assess the plausibility of developing a CPR. Participants from 2 prospective, longitudinal studies that examined prognostic factors for poor functional recovery following whiplash injury were used to derive this tool. Eight factors, previously identified as predictor variables of poor recovery, were included in the analyses: initial neck disability index (NDI), initial neck pain (visual analogue scale), cold pain threshold, range of neck movement, age, gender, presence of headache, and posttraumatic stress symptoms (Posttraumatic Diagnostic Scale [PDS]). An increased probability of developing chronic moderate/severe disability was predicted in the presence of older age and initially higher levels of NDI and hyperarousal symptoms (PDS) (positive predictive value [PPV] = 71%). The probability of full recovery was increased in younger individuals with initially lower levels of neck disability (PPV = 71%). This study provides initial evidence for a CPR to predict both chronic moderate/severe disability and full recovery following a whiplash injury. Further research is needed to validate the tool, determine the acceptability of the proposed CPR by practitioners, and assess the impact of inclusion in practice.     

Chronic Pain Patients—Effects on Mental Health and Pain After a 57-Week Multidisciplinary Rehabilitation Program

Chronic musculoskeletal pain is a common health complaint in Norway and constitutes the largest proportion in terms of those who suffer long-term sickness and are in receipt of disability pensions. The aim of this study was to examine the relation between changes in pain and mental health among men and women with chronic musculoskeletal pain after a rehabilitation program. A total of 201 subjects (132 women and 63 men) with chronic pain (>6 months) and without any manifest organic diseases were referred to the 57-week multidisciplinary rehabilitation program. Measurements of pain (visual analog scale) and mental health (Hospital Anxiety and Depression Scale [HADS]), as well as sociodemographic data, were obtained before and after the rehabilitation period. At baseline, men showed higher HADS scores than women. Both women and men reported significant improvements in pain and mental health. The subjects scored higher on HADS both before and after the rehabilitation compared with a population-based study in the region. Older men and men with low education levels showed less improvement in HADS scores. In women, a significant association was found between change in pain and both change in anxiety and change in depression. The results support the hypothesis that there may be a strong association between change in chronic pain and psychologic factors, but there were gender differences.     

Differences between men and women in anxiety early after acute myocardial infarction.

BACKGROUND: Anxiety after acute myocardial infarction influences both short- and long-term recovery. Therefore, determining specific subgroups of patients who have relatively higher anxiety levels is important. Published findings about gender differences in anxiety after acute myocardial infarction are conflicting. OBJECTIVES: To determine whether gender differences in anxiety after acute myocardial infarction exist and whether any of the sociodemographic and clinical variables that often differ between men and women with acute myocardial infarction interact with gender to influence anxiety. METHODS: A total of 424 patients with confirmed acute myocardial infarction were enrolled in this multicenter prospective study. Patients' anxiety level was measured within 72 hours of their arrival at the hospital by using the State Anxiety Inventory and the Brief Symptom Inventory. RESULTS: Women had significantly higher anxiety than did men according to both the State Anxiety Inventory (42 +/- 12.9 vs 37.7 +/- 12.5; P = .001) and the Brief Symptom Inventory (0.83 +/- 0.97 vs 0.63 +/- 0.71; P = .02). Of the sociodemographic and clinical variables examined, only marital status and income significantly interacted with gender to influence anxiety. Married women had higher anxiety than did single and widowed women, and married men had lower anxiety than did single men. Women with lower income had higher anxiety than did women with higher income; income was not related to anxiety in men. CONCLUSION: Women report significantly greater anxiety early after acute myocardial infarction than men do. Women's greater anxiety may be partially explained by marital status and lower income at the time of the infarction.     

Predictive factors of chronic pain and disability in whiplash: A Delphi poll

The purpose of this study was to establish consensus on what factors might predict chronic pain and disability in whiplash injuries following motor vehicle collisions. A Delphi poll involving two rounds of data collection was used as a way to reach consensus among participating experts. Participating experts identified several physical, historical, psychological, and behavioral response factors that they believed were related to the development of chronic pain and related disability in people who have developed whiplash‐associated disorders. These included: (1) prior history: previous history of chronic pain; (2) physical factors: high severity of injury, presence of constant neck pain since the accident; (3) psychological factors: belief that pain mean danger and that he or she should avoid exercise, tendency to somatize, to have positive thoughts about pain, catastrophic thinking, low self‐efficacy expectancies, and to have symptoms of posttraumatic stress disorders; and (4) behavioral responses to symptoms: avoidance of activities that involve moving the neck through fear of experiencing more pain, and restriction in the use and movement of the neck. These findings may be used to help identify the specific domains that should be assessed in studies seeking to predict which individuals are at risk to develop chronic pain and disability following initial whiplash‐associated disorders sustained in crash. If these results are supported by future studies, then they could be used to help develop intervention programs that could prevent long‐term pain and disability in whiplash patients who are considered to be at risk to develop chronic disabling pain problems.     

Sex Differences in Negative Emotional Responses to Chronic Pain

We proposed a sequential model of pain processing with pain intensity as stage 1, pain unpleasantness as stage 2, pain-related emotions (depression, anxiety, frustration, anger, fear) as stage 3, and overt behavioral expression of pain as stage 4. We tested hypotheses about relationships between sex and the first 3 stages of pain processing by conducting simultaneous regression analysis using LISREL-8 with data collected from 967 women and 680 men with chronic pain. We found the following results: (1) women reported higher pain-related frustration and fear; (2) frustration related most highly to pain intensity among women, as compared with anxiety and depression among men; (3) depression and frustration related most highly to usual and highest pain unpleasantness among women, as compared with frustration among men; and (4) contrary to expectations, pain-related emotions were more strongly related to pain for men. Consistent with the sequential model of pain processing, emotional response to pain was more closely related to pain unpleasantness than to pain intensity across sex. Anxiety and frustration were the emotions most highly related to pain. The current results highlight sex differences in the experience of chronic pain and the importance of assessing a range of emotions in patients with pain.     

Dispositional anxiety and the experience of pain: gender-specific effects.

AIM OF INVESTIGATION: Increased anxiety is believed to correlate with increased pain sensitivity in men and women. However, one laboratory-based study and one clinical-based study have offered evidence to suggest that the effect of anxiety in modulating pain sensitivity is specific to men only. The aim of the present study was to examine further whether anxiety differentially effects men and women's report of experimentally induced pain. METHODS: One hundred forty-four healthy university students (75 women, 69 men) were exposed to a contact heat pain procedure (ascending method of limits procedure, baseline temperature 30 degrees C, +/- 0.2 degrees C, rate of change 2.0 degrees C/s, cut-off limit 52 degrees C) and a cold pressor pain procedure (constant temperature +1 degrees C; +/-1 degrees C, cut-off limit 240 s). RESULTS: The results agreed with the previous two studies indicating a sex-specific effect of anxiety on pain report. Male participants scoring above the median on the Trait Anxiety Inventory reported significantly greater pain intensity, unpleasantness and showed lower pain tolerance compared to males scoring below the median on the cold pressor pain procedure, while no such differences in cold pressor pain report were found between high and low anxious women. No effect of anxiety was found on measures taken from the contact heat pain procedure, indicating that the sex-specific effect of anxiety on laboratory induced pain is dependent upon the method of stimulation used. CONCLUSION: Anxiety is an important factor when considering gender differences in pain perception and warrants further investigation.     

Adult attachment, anxiety, and pain self-efficacy as predictors of pain intensity and disability

Pain self-efficacy and anxiety have each been shown to contribute substantially to pain intensity and pain-related disability. Although adult attachment theory has been related separately to chronic pain, anxiety, and self-efficacy, it has not before been investigated with either pain self-efficacy or anxiety in the context of chronic pain. This study investigated the interrelations between these aspects of the chronic pain experience and their relative contributions towards pain intensity and disability. A clinical sample of 152 chronic pain patients participated in this study, completing self-report measures of attachment, self-efficacy, pain intensity, and disability, prior to attending a multidisciplinary pain clinic. Results revealed that fearful and preoccupied (anxious) attachment categories were associated with low pain self-efficacy, while high scores on the attachment dimension of comfort with closeness were linked with high pain self-efficacy, particularly for males. Insecure attachment (whether defined in terms of categories or dimensions) was related to higher levels of anxiety. Pain self-efficacy proved a stronger predictor of pain intensity than did anxiety and was a stronger predictor of disability than pain intensity or anxiety. In addition, comfort with closeness moderated the associations between pain self-efficacy and disability, pain self-efficacy and pain intensity, and anxiety and disability. Together, these findings support the value of adopting an attachment theoretical approach in the context of chronic pain. Treatment considerations and future research directions are considered.     

The Relation of Post-Traumatic Stress Symptoms to Depression and Pain in Patients With Accident-Related Chronic Pain

Symptoms of post-traumatic stress disorder (PTSD) are a common comorbidity in patients with a history of accident-related chronic pain and depression. However, little is known regarding the influence of PTSD in contributing to the affective distress, pain experience, and disability associated with chronic pain in this population. This study used structural equation modeling to examine 3 models that assess these relations in a sample of chronic pain patients with accident-related pain. Subjects were assessed for pain experience, depressive symptoms, anxiety, PTSD symptoms, pain disability, and relevant demographic variables. Pearson correlations indicated that symptoms of depression were significantly related to more severe pain, disability, and PTSD symptoms. PTSD symptoms were significantly associated with higher disability. The model of best fit indicated that after controlling for the influence of anxiety on the dependent measures, PTSD symptoms have a direct influence on severity of depressive symptoms, whereas depressive symptoms have a direct influence on pain intensity and an indirect impact on pain intensity by way of their effect on disability. These data point to the importance of unresolved PTSD symptoms in contributing to the level of depression, pain, and disability exhibited by chronic pain patients and highlight the need to consider directed and primary treatment of PTSD in pain rehabilitation programs.PerspectiveThis study highlights the impact of symptoms of PTSD on levels of depression, disability, and pain in patients with pain secondary to physical injury. Our results suggest that pain rehabilitation programs provide directed interventions for PTSD symptoms among this population to improve pain treatment outcomes.     

Mental defeat in chronic pain: initial exploration of the concept

OBJECTIVES: "Mental defeat" has been found to be an important psychologic reaction to painful trauma. Chronic pain patients also report mental defeat in relation to their experience of pain episodes. A measure of mental defeat was devised and evaluated in terms of (1) psychometric properties and (2) specificity of scores in relation to disabling chronic pain. METHODS: A total of 304 participants completed the Pain Self Perception Scale, a questionnaire designed to measure mental defeat as a reaction to pain. Participants also completed the Short-Form McGill Pain Questionnaire and Hospital Anxiety and Depression Scale. Chronic pain patients from a tertiary hospital clinic (n=94) were compared with patients experiencing acute pain (n=38), pain-free controls (n=79), community volunteers suffering from chronic pain (n=32) or acute pain (n=30), and patients diagnosed with anxiety disorders (n=31). Test-retest reliability was assessed in subsamples of chronic pain patients and community volunteers. RESULTS: The mental defeat measure was both internally consistent and reliable. Chronic pain patients showed elevated levels of mental defeat relative to all other groups, including people with chronic pain of the same intensity of pain who were not seeking treatment. Pain-specific mental defeat may be linked to disability and the seeking of specialist treatment. CONCLUSIONS: Research on mental defeat may allow the development of new treatment strategies for chronic pain syndromes and a better understanding of the link between chronic pain, depression, and posttraumatic stress disorder.     

Depression,anxiety and acute pain: links and management challenges

Pain is a subjective experience that is influenced by genetics, gender, social, cultural and personal parameters. Opposed to chronic pain, which by definition has to last for at least 3 months, acute pain is mostly because of trauma, acute medical conditions or treatment. The link between mood disorders and acute pain has proven to be increasingly significant since the link is bi-directional, and both act as risk factors for each other. Depression and anxiety are associated with increased perception of pain severity, whereas prolonged duration of acute pain leads to increased mood dysregulation. Although both depression and anxiety have a proven association with acute pain, the link between depression and acute pain is more thoroughly studied. Pain can be the presenting or sole complaint in depressed patients who present to primary care practices and is often overlooked by clinicians. However, reports on the perception of experimentally-induced pain in depressed patients are mixed, showing both an increased and decreased pain threshold and pain tolerance across various studies. Although less data is published about anxiety and pain, the relationship is consistent across studies as increased anxiety leads to increased severity of pain perceived and decreased pain tolerance. Anxiety as well as fear, stress, and catastrophizing are also shown to be mediators in the causal pathway between pain and disability.     

Clinical signs in the jaw and neck region following whiplash trauma—A 2-year follow-up

Background

Pain in the orofacial region is often reported after whiplash trauma. However, prospective studies evaluating clinical signs related to orofacial pain and disability in whiplash populations are rare. The aim of the present study was to evaluate clinical signs related to pain and dysfunction in orofacial and neck regions after whiplash trauma, in a short- and long-term perspective.

Methods

In total, 84 cases (48 women) diagnosed with neck distortion after a car accident and 116 controls (68 women) were examined within 1 month, and 49 cases (27 women) and 71 controls (41 women) were re-examined 2 years later. Outcome measures were pain on palpation of jaw and neck muscles and maximal jaw opening. Analysis was performed using mixed-models.

Results

Cases and women were at higher risk for pain on palpation of jaw muscles (OR:7.7; p < 0.001 and OR:3.2; p = 0.010 respectively) and neck muscles (OR:12.7; p < 0.001 and OR:2.9; p = 0.020 respectively) but with no significant effect of time. Cases and women also had lower maximal jaw opening (−3.1; p = 0.001 and −3.3; p = 0.001 respectively). There was no significant time effect, but a significant interaction between cases and time (2.2; p = 0.004).

Conclusion

Individuals with a whiplash trauma present a higher risk for pain on palpation in jaw and neck muscles both in a short- and long-term perspective, but show normal jaw movements. No time effect suggests that cases do not spontaneously improve nor get worse. Investigating pain on palpation in the jaw and neck muscles after whiplash trauma can identify individuals at risk for developing long-term orofacial pain and dysfunction.

Significance

Orofacial pain is often reported after whiplash trauma but most previous studies concerning orofacial pain in whiplash populations have been questionnaire studies. Cases with a previous whiplash trauma and women, in general, had higher risk for pain on palpation in the jaw and neck region. Investigating pain on palpation after a whiplash trauma can help to identify individuals at risk of developing long-lasting pain in the orofacial region.     

Are there gender differences in pain perception?

Chronic pain conditions are increasingly prevalent. However, very little is known about the relationship between pain and gender. The purposes of this study were to determine gender differences in pain threshold and tolerance among Chinese adults in Hong Kong and to examine the role of anxiety in pain perception. One hundred seventy-eight healthy, pain-free adults (89 men and 89 women) were recruited from a local university by convenience sampling to participate in the study. All participants completed the State and Trait Anxiety Inventory and underwent a laboratory pain task to determine their pain threshold and tolerance levels. Pain was assessed by using the Pain Intensity Verbal Rating Scale-Chinese version. Compared to men, women had a lower threshold (p < .001) and tolerance (p < .001) for pressure pain, and women reported more pain (p < .01) at the pain tolerance level. Higher trait anxiety scores were associated with higher pain report in men only (r [89] = .22, p = .04). The study indicated that gender differences in pain perception exist among the Chinese population in Hong Kong. A better understanding of the factors that contribute to gender differences in pain perception could reduce gender bias in pain management.     

Social desirability response bias and self-report of psychological distress in pediatric chronic pain patients

The objective of this study was to investigate associations between social desirability response bias and self-report of pain, disability, and psychological distress (depression, anxiety, and somatic symptoms) in a sample of children presenting to a multidisciplinary pediatric chronic pain clinic. A retrospective review was conducted on 414 consecutive clinic patients, ages 12-17 years, with chronic pain complaints of at least 3 months' duration. As part of a clinical battery, children completed self-report psychological questionnaires including the Children's Depression Inventory, Children's Somatization Inventory, and Revised Children's Manifest Anxiety Scale including the Lie Scale, an indicator of social desirability influence. Children also provided self report of pain intensity, pain duration and functional disability. Clinician ratings of anxiety and depressive symptoms also were collected. Results show that children scoring high on the measure of social desirability reported fewer symptoms of depression and anxiety compared to children scoring low on the social desirability index. No differences arose between these groups on reports of somatic symptoms, pain duration, or pain-related disability. These findings suggest that social desirability response bias may have implications for the self-report of psychological distress among pediatric chronic pain patients. The limits of self-report of symptoms should be considered in the clinical and research contexts.     

Comparison of the relative benefits of 2 versus 10 days of soft collar cervical immobilization after acute whiplash injury

OBJECTIVE: To investigate the effects of 2-day and 10-day immobilization of the cervical spine on pain, range of motion (ROM), and disability of patients with Quebec Task Force (QTF) grade II whiplash injuries. DESIGN: Randomized controlled trial. SETTING: University hospital emergency department. PARTICIPANTS: Seventy patients with acute QTF grade II whiplash injuries. INTERVENTIONS: At the intake examination within 24 hours after the whiplash trauma, the patients were randomized to 2 therapy groups (2-d or 10-d immobilization with a soft cervical collar). All patients received pain drugs (nonsteroidal anti-inflammatory drugs) and after 7 days, all patients started a standardized physiotherapy program 2 to 3 times a week. MAIN OUTCOME MEASURES: Patients' pain and disability scores were assessed using visual analog scales and ROM was assessed using a goniometer. All parameters were measured within 24 hours after injury and after 2 and 6 months. RESULTS: After 2 months, the different periods of immobilization (2d or 10d) were associated with comparable improvements in pain symptoms (median, 4.60 vs 4.65), ROM (median, 100.0 degrees vs 117.5 degrees ), and disability score (median, 4.90 vs 5.15). No statistically significant differences could be identified between the 2 treatment groups. After 6 months, persistent pain was reported by 4 patients in each group (12.5%). CONCLUSIONS: In patients with QTF grade II whiplash injuries, there is no short- or long-term difference between 2-day and 10-day immobilization with a cervical collar in terms of pain, ROM, or disability.     

Race, age, and gender influences among clusters of African American and white patients with chronic pain.

Racial and ethnic minorities, older people, and women are differentially affected by chronic pain. This study aimed to identify the experiences of adult African Americans and whites with chronic pain while identifying patient clusters on the basis of clinical characteristics as well as race, age, and gender influences within and between clusters. Three clusters of patients with chronic pain were identified within race, age, and gender categories: chronic pain syndrome, good pain control, and disability with mild syndrome. African American and younger patients experiencing chronic pain were more likely to present with chronic pain syndrome. African American patients presenting with chronic pain syndrome or disability with mild pain syndrome reported a higher disability than their counterparts. Older patients and women within the good pain control cluster reported a lower level of (1) pain and depression and (2) depression, respectively. Older patients presenting with a disability with mild syndrome also reported lower pain and depression. Despite similar physical, emotional, and pain characteristics, this study confirmed that the chronic pain experience differs across racial and age groups. Further study is necessary to evaluate how these factors influence pain services among an ethnically diverse population across the age continuum. PERSPECTIVE: This study found important racial and age-related variability in the symptom severity of patients with chronic pain presenting with similar physical, emotional, and pain characteristics to a tertiary care pain center. These findings have important clinical implications on chronic pain assessment and management.     

Pain tolerance as a predictor of outcome following multidisciplinary treatment for chronic pain: differential effects as a function of sex

Sex-related differences in the experience of clinical and experimental pain have been widely reported. Females are at elevated risk for developing several chronic pain conditions and women demonstrate greater sensitivity to noxious stimulation in the laboratory. However, relationships between responses to experimental noxious stimuli and the experience of clinical pain have not been well characterized. One previous study of healthy adults indicated that pain threshold and tolerance were associated with clinical pain among women but not men (i.e. females with lower pain threshold and tolerance reported more clinical pain). In the present investigation, relationships between pain tolerance and outcomes of treatment for chronic pain were evaluated in a sex-dependent manner. Ischemic pain tolerance was assessed prior to treatment in 171 chronic pain patients completing a pain management program. Outcomes were measured as changes in pain severity, affect, and pain-related disability. Over the course of treatment, women demonstrated greater improvement in pain-related disability while men showed more reduction in pain. Ischemic pain tolerance was related to outcome in a sex-specific fashion. Women with higher pain tolerances showed greater improvement in pain, more reduction in pain-related interference, and more increases in activity level than women with lower pain tolerances. In contrast, pain tolerance was not associated with positive treatment outcomes among men. These results indicate that experimental pain responses may be most clinically relevant for women, and that sex differences may exist in the determinants of pain-treatment outcomes.     

Sex-specific effects of pain-related anxiety on adjustment to chronic pain

OBJECTIVE: Considerable research indicates that both high levels of anxiety and female sex are associated with increased sensitivity to experimental pain and greater experience of clinical pain. In general, however, previous research has not investigated the joint effects of sex and anxiety on pain responses. A single previous laboratory-based study indicated that anxiety was inversely related to pain thresholds among men but not among women. The present study examined the relation between pain-related anxiety and adjustment to chronic pain in a sex-dependent manner. DESIGN AND SETTING: A total of 215 (114 women, 101 men) chronic pain patients referred to a multidisciplinary treatment center completed questionnaires assessing anxiety and adjustment to chronic pain. RESULTS: Results generally supported the previous laboratory-based finding indicating that an inverse relation between anxiety and adjustment to chronic pain was present only among male patients. Although male patients with high pain-related anxiety reported greater pain severity, greater interference of pain, and lower levels of daily activity than male patients with low anxiety, this effect was not present among female patients. Moreover, the effects of pain-related anxiety on adjustment to chronic pain were not attributable to either hypervigilance or use of passive coping strategies. Potential explanations and implications for the present findings are discussed.