Suicidal Ideation in Patients with Fibromyalgia: A Cross‐Sectional Study

Chronic pain, sleep disturbances, and depression, which are relevant symptoms of fibromyalgia syndrome, have been demonstrated to be associated with an increased likelihood of suicidal behaviors. Mortality from suicide has been shown to be greater among patients with fibromyalgia. This study aimed to assess the prevalence of suicidal ideation among a sample of patients with fibromyalgia and to evaluate its relationship with the clinical symptomatology of fibromyalgia. Baseline data from fibromyalgia patients willing to participate in different clinical studies were collected. Outcome measures included the Fibromyalgia Impact Questionnaire, the Beck Depression Inventory, the Pittsburgh Sleep Quality Index, the Brief Pain Inventory, and the SF‐12 Health Survey. The scores for these scales were compared between patients with and without suicidal ideation. The presence of suicidal ideation was assessed using the answer provided to item 9 of the Beck Depression Inventory. The results were adjusted by age, sex, total comorbidity, and time since diagnosis with multiple linear regression. The sample comprised 373 patients of whom one hundred and seventy‐nine (48%) reported suicidal ideation: 148 (39.7%) reported passive suicidal ideation and 31 (8.3%) active suicidal ideation. Suicidal ideation was markedly associated with depression, anxiety, sleep quality, and global mental health, whereas only weak relationships were observed between suicidal ideation and both pain and general physical health.     

Suicidal intent in patients with chronic pain

Suicidal ideation among individuals suffering from chronically painful conditions has not been widely studied, although rates of completed suicide are believed to be elevated in this population relative to the general population. The psychiatric literature on suicide documents the importance of controlling for the severity of depression when studying factors associated with suicidal ideation, attempts, or completion. The present study examined the relationships between suicidal ideation and the experience of pain, pain-related disability, and pain coping efforts among a sample of individuals experiencing chronically painful conditions. Of 200 patients evaluated on an inpatient rehabilitation unit in a psychiatric service, 13 individuals (6.5%) reported suicidal intent on a commonly used self-report measure of symptoms of depression, the Beck Depression Inventory. This group was compared to a matched (age, sex, pain duration) group of similarly depressed individuals (N=13) and a matched group of non-depressed individuals (N=13) on measures of pain, disability, pain beliefs, and pain coping strategies. A history of a suicide attempt was associated with suicidal intent. Family history of substance abuse was significantly more prevalent among the depressed groups, regardless of suicidal thinking. The depressed/suicidal group and depressed/non-suicidal groups reported higher levels of pain, higher levels of pain-related disability, lower use of active coping, and higher use of passive coping compared to the non-depressed group. The depressed groups did not differ from one another on any of the measures of pain experience. Depression, not suicidal status, consistently predicted level of functioning. The prevalence of suicidal intent was comparable to rates observed in other studies and relatively low. When individuals with chronic pain report suicidal intent, it is imperative that measures preventing self-harm be implemented immediately and the patient's depression be treated aggressively.     

Major depression and insomnia in chronic pain

OBJECTIVES: Insomnia and depression are common problems for people with chronic pain, and previous research has found that each is correlated with measures of pain and disability. The goal of this study was to examine the combined impact of major depression and insomnia on individuals with chronic pain. METHODS: The participants were patients with chronic musculoskeletal pain who underwent evaluation at an interdisciplinary treatment center. On the basis of semistructured interviews, participants were classified in three groups depending on whether they: (1) met criteria for major depression with insomnia (n = 38); (2) had insomnia without major depression (n = 58); or (3) had neither insomnia nor major depression (n = 47). The groups were then compared on self-report measures that included the McGill Pain Questionnaire, the Beck Depression Inventory, and the Multidimensional Pain Inventory. RESULTS: Participants with major depression and insomnia reported the most difficulty on measures of affective distress, life control, interference, and pain severity, although the insomniac patients without major depression also had elevated scores on some measures. In regression analyses, insomnia severity ratings did not contribute uniquely to the prediction of psychosocial problems when depression was controlled, but they did contribute to the prediction of pain severity. CONCLUSIONS: These results suggest that patients with chronic pain and concurrent major depression and insomnia report the highest levels of pain-related impairment, but insomnia in the absence of major depression is also associated with increased pain and distress.     

Suicidal ideation, plans, and attempts in chronic pain patients: factors associated with increased risk

This study describes suicidal behavior in a cross-sectional sample of chronic pain patients and evaluates factors associated with increased risk for suicidal ideation. One hundred-fifty-three adults with nonmalignant pain (42% back pain) who were consecutively referred to a tertiary care pain center completed a Structured Clinical Interview for Suicide History, the McGill Pain Questionnaire, and the Beck Depression Inventory. Nineteen-percent reported current passive suicidal ideation (PSI), 13% had active thoughts of committing suicide (ASI), 5% had a current suicide plan, and 5% reported a previous suicide attempt. Drug overdose was the most commonly reported plan and method of attempt (75%). Thirteen-percent reported a family history of suicide attempt/completion. Pain-specific and traditional suicide risk factors were evaluated as predictors of current PSI and ASI. Logistic regression analyses revealed that a family history of suicide attempts/completions was associated with a 7.5 fold increase in risk of PSI (P=0.001) and a 6.6 fold increase in ASI (P=0.003), after adjusting for significant covariates. Having abdominal pain was associated with an adjusted 5.5 fold increase in PSI (P=0.05) and a 4.2 fold increase in ASI (P=0.10). Neuropathic pain significantly reduced risk for both PSI (P=0.002) and ASI (P=0.01). Demographics, pain severity, and depression severity were not associated with suicidal ideation in multivariate analyses. These findings highlight the need for routine evaluation and monitoring of suicidal behavior in chronic pain, especially for patients with family histories of suicide, those taking potentially lethal medications, and patients with abdominal pain.     

Pain-related catastrophizing as a risk factor for suicidal ideation in chronic pain

Living with chronic pain is associated with many deleterious outcomes, including a substantially increased risk of suicide. While many general risk factors for suicidal ideation and behavior have been identified, few studies have examined pain-related factors that confer increased or decreased risk for suicidality. The present study assessed individual differences in the use of pain-related coping strategies and pain-related catastrophizing as correlates of suicidal ideation in patients with chronic pain. A total of 1512 patients seeking treatment for chronic pain completed a variety of questionnaires assessing pain, coping, and psychosocial functioning. On written questionnaires, approximately 32% of this clinic sample reported some form of recent suicidal ideation. The two most consistent predictors of the presence and degree of suicidal ideation were the magnitude of depressive symptoms and the degree of pain-related catastrophizing, a maladaptive cognitive/emotional pain-coping strategy. Demographic and other pain-related variables such as pain severity and duration were not generally robust predictors of suicidal ideation in this sample of patients with chronic pain. These are the first findings to suggest a unique (e.g., independent of pain severity or depressive symptomatology) association between pain-coping strategies and suicide-related cognitions in the context of chronic pain. Further research in this area, including the addition of suicide prevention materials to pain-coping skills training programs, may benefit large numbers of individuals who are at elevated suicide risk as a consequence of chronic pain.     

Behavioral dimensions of adjustment in persons with chronic pain: pain-related anxiety and acceptance

Through empirical methods we now characterize patients with chronic pain as either dysfunctional, interpersonally distressed, or adaptive copers. Studying factors that differentiate these groups may reveal the behavioral processes that determine adjustment to pain. Subjects for this study were 190 patients referred for treatment of chronic pain. They were classified as dysfunctional (n = 41), interpersonally distressed (n = 28) or adaptive copers (n = 59) based on the Multidimensional Pain Inventory (Kerns, R.D., Turk, D.C. and Rudy, T.E., The West Haven-Yale Multidimensional Pain Inventory (WHYMPI), Pain, 23 (1985) 345-356) and compared on measures of pain-related anxiety and pain acceptance. Our analyses showed that the dysfunctional group reported greater pain-related anxiety and less acceptance of pain than the other groups. Additional analyses, statistically controlling for pain severity and depression, showed that the patient subtypes continued to differ on pain-related anxiety and acceptance. Discriminant function analyses including pain-related anxiety and acceptance correctly classified 72.5% of dysfunctional and 90.9% of adaptive copers. Again, anxiety and acceptance contributed uniquely to classification independent of depression and pain intensity. Pain-related anxiety and acceptance of pain appear to be unique behavioral dimensions of adjustment to chronic pain. Decreasing anxiety and increasing acceptance may 'move' patients with chronic pain from the dysfunctional to the adaptive coper category.     

The contribution of pain and depression to self-reported sleep disturbance in patients with rheumatoid arthritis

The objective of this article is to assess the contribution of disease activity, pain, and psychological factors to self-reported sleep disturbance in patients with rheumatoid arthritis (RA), and to evaluate whether depression mediates the effects of pain on sleep disturbance. The sample included 106 patients with confirmed RA who participated in an assessment of their disease activity, pain, psychological functioning, and sleep disturbance during a baseline evaluation prior to participating in a prospective study to help them manage their RA. Self-measures included the Rapid Assessment of Disease Activity in Rheumatology, the SF-36 Pain Scale, the Helplessness and Internality Subscales of the Arthritis Helplessness Index, the Active and Passive Pain Coping Scales of the Pain Management Inventory, the Center for Epidemiological Studies Depression Scale, and the Pittsburgh Sleep Quality Index. Hierarchical multiple regression analysis confirmed that higher income, pain, internality, and depression contributed independently to higher sleep disturbance. A mediational analysis demonstrated that depression acted as a significant mechanism through which pain contributed to sleep disturbance. Cross-sectional findings indicate that pain and depression play significant roles in self-reported sleep disturbance among patients with RA. The data suggest the importance of interventions that target pain and depression to improve sleep in this medical condition.     

Insomnia, sleep quality, pain, and somatic symptoms: sex differences and shared genetic components

This study investigated the sex differences, and the shared genetic and environmental factors underlying the associations of sleep disturbances (insomnia and sleep quality) with pain and somatic symptoms in both adolescents and middle-aged adults. We recruited 259 adolescents (69 with current insomnia) and their parents (256 middle-aged adults, 78 with current insomnia). Insomnia severity and sleep quality were measured by the Insomnia Severity Inventory (ISI) and Pittsburgh Sleep Quality Index (PSQI), respectively. Pain and somatic symptoms were measured by the Somatic Symptom Inventory and Visual Analogue Scale for overall pain. Subjects with insomnia scored higher on all measures of pain and somatic symptoms than non-insomnia patients, in both adolescents and adults (P<.001). Both pain and somatic measures were associated with ISI and PSQI scores after controlling for age, sex, depressive and anxiety symptoms. There was an interaction effect between insomnia and female sex on pain and somatic symptoms (P<.05), especially in adults. Pain and somatic symptoms ran in family with moderate heritability (range h(2)=0.15-0.42). The phenotypic associations of ISI and PSQI with pain and somatic measures were both contributed by genetic (range p(G)=0.41-0.96) and environmental (range p(E)=0.27-0.40) factors with a major genetic contribution. In summary, insomnia and poor sleep quality are closely associated with pain and somatic symptoms. Insomnia seems to modulate the sex differences in pain and somatic symptoms, especially in the adult population. A shared genetic predisposition might underlie the associations of insomnia and sleep quality with pain and somatic symptoms.     

Insomnia screening in postacute traumatic brain injury: utility and validity of the Pittsburgh Sleep Quality Index

OBJECTIVE: To assess insomnia in a rehabilitation population, the authors examined the utility and validity of the Pittsburgh Sleep Quality Index (PSQI). The assessment of insomnia is relevant to the treatment of traumatic brain injury at the postacute level and routine screening for insomnia may be enhanced by the availability of a standardized, conveniently used, self-report sleep questionnaire. DESIGN: The authors prospectively studied 91 consecutive patients with traumatic brain injury who were admitted to an outpatient neurorehabilitation program. Besides administering the PSQI, Beck Depression Inventory, Epworth Sleepiness Scale, and Multidimensional Pain Inventory, sleep diary and interview data were obtained and used to divide subjects into insomnia and noninsomnia groups according to the criteria established by the Diagnostic and Statistical Manual of Mental Disorders, ed 4. RESULTS: Sensitivity and specificity rates to the clinical diagnosis of insomnia were 93% and 100%, respectively, for a PSQI Global Score of >8, and 83% and 100% for a diagnosis of insomnia based exclusively on PSQI-derived sleep variable data. Sleep diary data provided concurrent validity for PSQI estimates of sleep-onset latency, sleep duration, and sleep efficiency. The Beck Depression Inventory, Epworth Sleepiness Scale, and Multidimensional Pain Inventory established concurrent validity for individual PSQI items pertaining to mood, hypersomnia, and pain disturbance. CONCLUSION: The PSQI was demonstrated to be a valid and useful screening tool for assessing insomnia among postacute patients with traumatic brain injury.     

Early detection measures and triage procedures for suicide ideation in chronic pain patients.

There is a dearth of writings about early detection of potential suicide patients in chronic pain centers. Early detection measures used at the Vanderbilt Pain Control Center include a Symptom Checklist-90, with questions about depressive symptomatology and "Thoughts of Ending Your Life"; medical and psychological interviews; monitoring of changes in emotional disturbance; and, if warranted, administration of the Scale of Suicidal Ideation. Three case studies are presented that indicate that the results of an assessment measure should be tempered with clinical judgment. Suicidal behavior, including suicidal ideation, is a medical emergency; therefore, there is great need for early detection and triage measures.     

Baseline Sleep Disturbances Modify Outcome Trajectories in Adolescents With Chronic Pain Receiving Internet-Delivered Psychological Treatment

Over 50% of adolescents with chronic pain report comorbid sleep disturbances (eg, difficulties with falling asleep), which is associated with increased pain-related disability and poorer quality of life. However, limited longitudinal data are available to understand how sleep disturbance may impact response to psychological treatment. Our primary hypothesis was that baseline sleep disturbances would significantly modify how adolescents responded to an internet-delivered psychological intervention for chronic pain in terms of outcome trajectories. The sample included 85 adolescents, 12 to 17 years, with chronic pain recruited from a multidisciplinary pain clinic and headache clinic who received access to an internet-delivered psychological intervention for chronic pain. Baseline sleep assessment included actigraphy monitoring for 7 days and survey measures. Outcomes were assessed at baseline, 8 weeks, and 3 months including core pain-related outcomes, executive functioning, fatigue, positive and negative affect. Results demonstrated that greater baseline insomnia and poorer sleep quality was associated with worse outcome trajectories for pain-related disability, depression, anxiety, fatigue, negative affect, and executive functioning. Findings extend the limited studies that examine how sleep disturbance may modify effectiveness of psychological treatments for adolescent chronic pain and emphasize the importance of treating comorbid sleep disturbance. This trial was registered at clinicaltrials.gov (NCT04043962).PerspectiveOur study suggests that sleep deficiency, in particular insomnia and poor sleep quality, may modify the effectiveness of psychological treatments for chronic pain, highlighting the urgent need to screen youth for sleep problems prior to initiating treatment, and to consider implementation of sleep-specific treatments such as cognitive-behavioral therapy for insomnia.     

The impact of chronic pain on depression, sleep, and the desire to withdraw from dialysis in hemodialysis patients

Pain is a multidimensional phenomenon with physical, psychological, and social components and is a significant problem for 50% of hemodialysis (HD) patients. Failure to treat pain adequately may lead to disruption in many aspects of life. This study examines the relationship between moderate to severe chronic pain and depression, insomnia, and the desire to withdraw from dialysis in HD patients. In a cross-sectional study of 205 Canadian HD patients, patients completed a questionnaire that included the Brief Pain Inventory, Beck Depression Inventory, and the Pittsburgh Sleep Quality Index. One hundred and three patients (50.2%) reported chronic pain and 85 (41.4%), moderate to severe pain. There was a higher prevalence of depression in patients with moderate or severe chronic pain compared to patients with mild or no pain (34.1% vs. 18.3%, odds ratio [OR]=2.31, P=0.01). Severe irritability, anxiousness, and inability to cope with stress were all more common in patients with pain compared to patients without pain (P<0.001). There was a higher prevalence of insomnia in patients with moderate or severe chronic pain compared to patients with mild or no pain (74.7% vs. 53.0%, OR=2.32, P=0.02). Although consideration of withdrawal from dialysis was significantly associated with moderate or severe pain compared to no or mild pain (46% vs. 16.7%, P<0.001), death due to withdrawal from dialysis was not. Chronic pain in HD patients is associated with depression and insomnia and may predispose patients to consider withdrawal of dialysis.     

Evidence for indirect effects of pain catastrophizing on clinical pain among myofascial temporomandibular disorder participants: the mediating role of sleep disturbance

Sleep disturbance and pain catastrophizing are important mediators of the chronic pain experience. To date, these factors have not been considered concurrently despite compelling theoretical rationale to do so. In the present study, we examined whether pain catastrophizing not only has direct effects on clinical pain and pain-related interference, but also indirect effects through its association with sleep disturbance. We evaluated this hypothesis using a cohort (n=214) of myofascial temporomandibular disorder participants using a statistical bootstrapping technique recommended for tests of indirect effects. Results suggested that pain catastrophizing was associated with greater sleep disturbance, and that a significant portion of variance in clinical pain severity and pain-related interference attributable to pain catastrophizing was mediated by sleep disturbance. Supplementary analyses revealed that the rumination component of catastrophizing seemed to be indirectly related to clinical outcomes through sleep disturbance. No evidence for indirect effects was observed for helplessness and magnification components. These results suggest that rumination about pain may contribute to clinical pain indirectly through alterations in sleep. Prospective studies are needed to examine lagged associations between these constructs. These findings have important theoretical and clinical implications. Critically, interventions that reduce pain catastrophizing may concurrently improve sleep and clinical pain.     

Chronic Pain,TBI, and PTSD in Military Veterans: A Link to Suicidal Ideation and Violent Impulses?

The polytrauma clinical triad refers to the co-occurrence of chronic pain, traumatic brain injury (TBI), and posttraumatic stress disorder (PTSD). Despite research implicating dyadic relationships between these conditions and adverse outcomes, scant research has examined the polytrauma clinical triad's relation to suicide or violence. The present cross-sectional study was designed to examine whether this complex clinical presentation increases risk of suicidal ideation and violent impulses after accounting for other established risk factors. Veterans who served in the military since September 11, 2001 (N?=?667) who reported chronic pain completed an interview and self-report battery. Bivariate analyses showed that suicidal ideation and violent impulses both correlated with PTSD, TBI+PTSD, pain intensity and interference, drug abuse, and major depressive disorder (MDD). Multiple regression analyses showed that: 1) race, chronic pain with PTSD, alcohol abuse, and MDD significantly predicted suicidal ideation, 2) pain interference, chronic pain with TBI, chronic pain with PTSD, chronic pain with TBI+PTSD, drug abuse, and MDD significantly predicted violent impulses, and 3) pain interference was a more critical predictor of suicidal and violent ideation than pain intensity. Implications for risk assessment and treatment are discussed.

Multidimensional Pain Inventory derived classifications of chronic pain: evidence for maladaptive pain-related coping within the dysfunctional group

This study examines maladaptive pain-related fear-avoidance and endurance coping in subgroups of patients with chronic back pain. Hypotheses were derived from the avoidance-endurance model of pain [Hasenbring M. Attentional control of pain and the process of chronification. In: Sandkühler J, Bromm B, Gebhart GF, editors. Progress in pain research, vol. 129. New York: Elsevier; 2000. p. 525-34.], which assumes that endurance coping (cognitive, behavioral tendency to endure severe pain to finish current activities irrespective of pain increases) leads to overuse of muscles, joints, and discs with an increase of pain as long-term consequence. Participants were 120 patients referred for treatment of chronic pain to General Practices. They were classified as 'dysfunctional-DYS' (15.8%), 'interpersonally distressed-ID' (10.8%), and 'adaptive copers-AC' (61.7%) based on the Multidimensional Pain Inventory [Kerns RD, Turk DC, Rudy TE. The West Haven-Yale Multidimensional Pain Inventory (WHYMPI). Pain 1985;23:345-56.] and compared on measures of pain-related fear-avoidance coping (anxiety/depression; help-/hopelessness; catastrophizing; avoidance of social/physical activity) and endurance coping (positive mood; thought suppression; endurance behavior) using the Kiel Pain Inventory [Hasenbring M. The Kiel Pain Inventory-Manual. Three questionnaire scales for assessment of pain-related cognitions, emotions and copying strategies. Bern:Huber; 1994.]. Multivariate analysis of variance indicated that groups differed significantly for pain-related fear-avoidance and endurance coping, even after control for pain intensity and depression. Univariate effects revealed that patients classified as DYS reported more anxiety/depression, help-/hopelessness, and catastrophizing than did those classified as AC. Furthermore, the DYS group showed more thought suppression compared to AC; however, subgroups did not differ significantly with regard to avoidance of social and physical activity, and endurance behavior. Further, DYS as well as ID group showed more non-verbal pain behavior compared to AC, which refers to the special role of operant conditioning. Implications are considered for further investigation of endurance coping to provide a more comprehensive assessment and treatment for subgroups of chronic pain patients.     

The influence of pain-related comorbidities on pain intensity and pain-related psychological distress in patients presenting with musculoskeletal pain

BackgroundMusculoskeletal pain (MSP) is the largest contributor to chronic pain and frequently occurs alongside other medical comorbidities.ObjectiveExplore the relationships between the presence of pain-related comorbidities, pain intensity, and pain-related psychological distress in patients with MSP.MethodsA longitudinal assessment of individuals 18–90 years old in the Midwestern United States beginning a new episode of physical therapy for MSP. Electronic medical records were assessed the full year prior for care-seeking of diagnoses for pain-related comorbidities (anxiety, metabolic disorder, chronic pain, depression, nicotine dependence, post-traumatic stress disorder, sleep apnea, and sleep insomnia). Pain intensity and pain-related psychological distress (Optimal Screening for Prediction of Referral and Outcome - Yellow Flags tool) were captured during the physical therapy evaluation. Generalized linear models were used to assess the association between pain intensity, psychological distress, and pain-related co-morbidities. Models were adjusted for variables shown in the literature to influence pain.Results532 participants were included in the cohort (56.4% female; median age of 59 years, Interquartile Range [IQR]:47, 69). Comorbid depression (beta coefficient (β) = 0.7; 95%CI: 0.2, 1.2), spine versus lower extremity pain ((β = 0.6; 95%CI: 0.1, 1.1), and prior surgery (β = 0.8, 95%CI: 0.3, 1.4) were associated with higher pain intensity scores. No pain-related comorbidities were associated with pain-related psychological distress (yellow flag count or number of domains). Female sex was associated with less pain-related psychological distress (β = −0.2, 95%CI: −0.3, −0.02).ConclusionsDepression was associated with greater pain intensity. No comorbidities were able to account for the extent of pain-related psychological distress.     

A confirmatory factor analysis of the Beck Depression Inventory in chronic pain

The Beck Depression Inventory (BDI) is widely used to assess depression in chronic pain despite doubts about its structure and therefore its interpretation. This study used a large sample of 1947 patients entering chronic pain management to establish the structure of the BDI. The sample was randomly divided to conduct separate exploratory (EFA) and confirmatory factor analyses (CFA). EFA produced many satisfactory two-factor solutions. The series of CFA generated showed reasonable fit for ten of those solutions. All included a first factor identified as negative view of the self (items: failure, guilt, self-blame, self-dislike, punishment and body image change), and a second factor identified as somatic and physical function (items: work difficulty, loss of appetite, loss of libido, fatigability, insomnia and somatic preoccupation). The remaining items (suicidal ideation, social withdrawal, dissatisfaction, sadness, pessimism, crying, indecisiveness, weight loss, irritability) loaded infrequently or not at all in the CFA solutions. They did not form a coherent factor but comprised items associated with negative affect. When compared with published data from samples of depressed patients drawn from mental health settings the mean item scores for items reflecting the negative view of the self were consistently statistically lower that that observed in samples; there was no consistent difference between the samples on the items reflecting somatic and physical function; but the mean scores for the remaining affect items were significantly greater in the mental health samples. This version of depression is strikingly different from the psychiatric model of depression (e.g. DSM-IV or ICD-10), which is primarily defined by affective disturbance, and secondarily supported by cognitive and somatic symptoms. The finding is consistent with a reconsideration of what constitutes depression in the presence of chronic pain. It also has important clinical implications: it may provide a way to distinguish depressed patients with typical cognitive biases, who require specific treatment for depression alongside pain management.     

Sleep onset insomnia symptoms during hospitalization for major burn injury predict chronic pain

Both cross-sectional studies of chronic pain and sleep deprivation experiments suggest a bi-directional relationship between sleep and pain. Few longitudinal studies, however, have assessed whether acute insomnia following traumatic injury predicts the development of persistent pain. We sought to evaluate (1) whether in-hospital insomnia independently predicts long-term pain after burn injury and (2) whether in-hospital pain predicts future insomnia symptoms. We analyzed data on 333 subjects hospitalized for major burn injury (72.7% male; mean age=41.1+/-14.5years) who were participating in the multi-site, Burn Model System project. Subjects completed measures of health, function (SF-36), and psychological distress (Brief Symptom Inventory) while in hospital, at 6, 12, and 24months after discharge. Participants were categorized as either having or not having sleep onset insomnia at discharge. Linear mixed effects analyses revealed that persons reporting insomnia at discharge (40.5%) had significantly decreased improvement in pain and increased pain severity during long-term follow-up (p<0.001). More severe pain during the week preceding hospital discharge, time from injury, lack of college education and older age also contributed independent effects on chronic pain (p<0.05). In a reciprocal model (N=299), more severe pain during the week preceding discharge predicted increased rates of long-term sleep onset insomnia. In-hospital insomnia and pre-burn mental health symptoms were also highly significant predictors of insomnia. This study provides support for a long-term, prospective and reciprocal interaction between insomnia and pain. Future work should ascertain whether treatment of insomnia and pain during acute injury can prevent or minimize chronic pain.     

Partner responses to pain behaviors are associated with depression and activity interference among persons with chronic pain and spinal cord injury.

This study investigated the extent to which psychosocial factors (partner responses to pain behaviors, social support) are associated with pain-related activity interference and depressive symptom severity among individuals with spinal cord injury (SCI) and chronic pain. Seventy adults (45 men, 25 women) with SCI and pain and 68 partners completed Part II of the West Haven-Yale Multidimensional Pain Inventory, a measure of partner responses to pain behaviors. Individuals with SCI and pain also completed the Social Support Questionnaire-6, a modified Brief Pain Inventory Pain Interference Scale, and the Center for Epidemiological Studies-Depression scale. SCI subject ratings of partner responses to pain behaviors, but not partner ratings, were associated significantly with pain-related activity interference and depressive symptom severity. Negative partner response to pain behaviors explained the most variance in these 2 outcome measures. The results provide preliminary support for the importance of partner responses to pain behaviors in outcomes of individuals with chronic pain and SCI. PERSPECTIVE: Chronic pain is a significant problem for many persons with spinal cord injury. In this sample of individuals with spinal cord injury and pain, perceived partner negative responses to pain behaviors were associated positively with activity interference and depression. Decreasing negative partner responses to pain behaviors might be a potentially important clinical intervention in this population.     

The impact of chronic pain in children and adolescents: Development and initial validation of a child and parent version of the Pain Experience Questionnaire

Psychosocial factors are crucial for understanding and treating chronic pain in adults, but also in children. For children, very few questionnaires for a multidimensional pain assessment exist. In adults, the Multidimensional Pain Inventory (MPI; [Kerns RD, Turk DC, Rudy TE. The West Haven-Yale Multidimensional Pain Inventory (WHYMPI). Pain 1985;23:345-56]) has been widely used to determine patients' adjustment to chronic pain. Using one section of the MPI as a model, we developed and evaluated the Pain Experience Questionnaire (PEQ) - child and parent version - that assesses the psychosocial impact of chronic pain in children and adolescents. As substantiated by confirmatory factor analysis in a sample of 111 children and adolescents (7-18 years) with chronic pain, the child PEQ entails the subscales pain severity, pain-related interference, affective distress and perceived social support. The parent version contains the subscales severity of the child's pain, interference and parental affective distress. Child and parent PEQ subscales were internally consistent. Age was unrelated to PEQ subscale scores. Girls and their mothers endorsed significantly greater pain severity, interference and affective distress. Validity analyses yielded a pattern of correlations with measures of depression, trait anxiety, pain activity, child behaviors, pain-related cognitions, and parenting behavior that is consistent with psychometric data of the adult MPI and previous findings on psychosocial aspects of chronic pediatric pain. Significant differences between children depending on patient status (participants in experimental or treatment studies, outpatients, inpatients) suggest external validity of the PEQ. Despite the preliminary nature of the psychometric evaluation, the child and parent PEQ seem promising for a comprehensive assessment of pediatric pain.