Psychological flexibility as a mediator of improvement in Acceptance and Commitment Therapy for patients with chronic pain following whiplash

Cognitive behavior therapy (CBT) has made important contributions to chronic pain management, but the process by which it is effective is not clear. Recently, strong arguments have been raised concerning the need for theory driven research to e.g. identify mechanisms of change in CBT and enhance the effectiveness of this type of treatment. However, the number of studies addressing these issues is still relatively scarce. Furthermore, the arrival of varieties of CBT with seemingly different process targets increases the need for such information. The present study explored the processes of change in a previously reported successful randomized controlled trial evaluating the effectiveness of an exposure‐based form of behavioral and cognitive therapy, Acceptance and Commitment Therapy (ACT), on improvement in pain‐related disability and life satisfaction for patients suffering from whiplash‐associated disorder (WAD). Several process variables relevant to theories underlying traditional CBT were included: pain, distress, kinesiophobia, self‐efficacy, and the process primarily targeted by ACT: psychological inflexibility. Mediation analyses were performed using a non‐parametric cross‐product of the coefficients approach. Results illustrated that pain intensity, anxiety, depression, kinesiophobia, and self‐efficacy did not have significant mediating effects on the dependent variables. In contrast, significant indirect effects were seen for psychological inflexibility on pain‐related disability (pre‐ to post‐change scores) and life satisfaction (pre‐ to post; pre‐ to 4‐month follow‐up change scores). Although tentative, these results support the mediating role of psychological inflexibility in ACT‐oriented interventions aimed at improving functioning and life satisfaction in people with chronic pain.     

Assessing Psychological Flexibility and Inflexibility in Chronic Pain Using the Multidimensional Psychological Flexibility Inventory (MPFI)

Psychological flexibility (PF) is a model of well-being and daily functioning that is applied to chronic pain, and is the model behind Acceptance and Commitment Therapy (ACT). However, studies of PF in chronic pain are limited by the lack of a single measure capturing all facets. The Multidimensional Psychological Flexibility Inventory (MPFI) assesses all facets of PF and psychological inflexibility (PI) and could remedy this problem. The current study employs this measure. Adult participants with chronic pain (N = 404) were recruited online and completed the MPFI, other validated measures of PF/PI, and measures of pain, work and social adjustment, and depression, at two time points. The reliability, factor structure, and validity of the MPFI were assessed. Confirmatory factor analysis results demonstrated a good model fit for the proposed factor-and subscale structure. Correlations between MPFI and theoretically similar measures were moderate to strong, and correlations with pain intensity, pain interference, work-and social adjustment, and depression, were small to large. In this first examination of the potential utility of the MPFI within a chronic pain population, we found it to be valid and reliable. It should be noted that the MPFI was less predictive of outcomes compared with more established measures in most cases. Despite this, results from the wide range of variables available from the MPFI highlights the potential importance of aspects of PF and PI not previously emphasized, including the greater predictive utility of the inflexibility facets. Further use and study of the MPFI is recommended.ClinicalTrials.gov ID: NCT05050565PerspectiveThis article presents a comprehensive examination of a self-report measure assessing all facets of psychological flexibility and inflexibility, in a chronic pain sample. The results support the role of facets not previously emphasized. Comprehensive assessment of PF and PI appears possible and is recommended depending on research questions being asked.     

Psychosocial Predictors of Suicidal Ideation in Patients Diagnosed with Chronic Illnesses in Jordan

Suicide ideation (SI) is considered a major psychiatric emergency in patients diagnosed with chronic illnesses. Suicide ideation is a multifaceted issue that involves bio- psychosocial and cultural factors that interfere with patients’ abilities. The purpose of this study is to investigate the psychosocial predictors of SI among Jordanian patients with chronic illnesses. A cross-sectional design using self-administered questionnaires was used to collect data from 480 patients diagnosed with diabetes mellitus, cardiovascular diseases, and cancer. The mean score of suicide ideation was 4.07 (SD = 1.7) and almost 20% (n = 85) of the participants found to be suicidal, the majority were suffering from moderate to severe depressive symptoms and low levels of life satisfaction. Also, the analysis showed that the patients had a high level of optimism and moderate perception of social support from family, friends, and significant other. Type of illness has a significant relation to the ‘seriousness’ component of SI (p = 0.023). Depression (β = 0.345, p<0.001) was a significant risk factor for ‘thought’ component of SI, and optimism (β = –0.008, p<0.05) a significant protective factor against the thought component of SI. Patients with chronic illnesses suffer serious psychological disturbances and are in need of psychological care, and periodic psychological screening to maintain their psychological wellbeing.     

综合性医院住院患者自杀行为的心理干预

目的分析综合性医院住院患者的自杀问题,为维护患者安全提出心理干预防范措施。方法对2000年8月至2006年8月在综合性医院有自杀行为的9例患者进行回顾性调查分析和危机干预。结果6年间共发生跳楼自杀8例,割腕自杀1例;其中3例自杀未遂被及时解救。自杀行为发生时,44%的患者有心理障碍,88%的患者采取了高层坠楼自杀方式。结论自杀已成为综合性医院常见的意外死亡,提高综合性医院医务人员对患者自杀事件的认知水平,积极施行危机干预和心理疏导,对保障住院患者的住院安全具有重要意义。     

Suicidal thinking in multiple sclerosis

Purpose.?Studies demonstrate that suicidal ideation ((SI)) is greater in persons with multiple sclerosis ((MS)) than in the general population. SI may offer some MS patients a mechanism for feeling in control of their lives, in the face of a daunting, unpredictable disease. In this study, we determined what specific mental constructs or perceptual themes occur for MS patients experiencing SI, while also examining the construct of ‘control’ as a central theme.

Methods.?Individual interviews ((N == 16)) were audiotaped, transcribed and qualitatively analysed by two independent raters to test for key themes in MS patients reporting SI.

Results. In relation to SI, eight key themes were identified by both raters as having been expressed in interviews: perceived loss of control, increased family tension, loneliness, hopelessness and frustration, physical and psychological impact of MS, loss of perceived masculinity or femininity, regaining control and failure to achieve desired or expected role functioning. We created a model to explain the emergence of these themes as they contribute to SI among patients with MS. All participants indicated that perceived loss of control elicited thoughts of suicide.

Conclusion.?Perceived loss of control appears to be a major disease related burden associated with SI in MS patients.     

Aberrant reward processing in Parkinson's disease is associated with dopamine cell loss

Dopamine has been implicated in reward-related impulsivity, but the exact relationship between dopamine, reward and impulsivity in humans remains unknown. We address this question in Parkinson's disease (PD), which is characterized by severe dopamine depletion. PD is associated primarily with motor and cognitive inflexibility, but can also be accompanied by reward-related impulsivity. This paradoxical symptom of PD has often been attributed to dopaminergic overstimulation by antiparkinson medication, which is necessary to relieve the motor and cognitive inflexibility. However, factors other than medication may also contribute to aberrant impact of reward. Here we assess whether cognitive inflexibility and aberrant reward impact in PD are two sides of the same coin, namely dopamine cell loss. To measure dopamine cell loss, we employed ¹²³I-FP-CIT Single Photon Emission Computed Tomography (SPECT) in 32 PD patients (10 never-medicated patients and 22 patients after withdrawal of all medication for > 12 h) and related the values to behavior on a rewarded task-switching paradigm. Dopamine cell loss was associated not only with cognitive inflexibility (under low reward), but also with aberrant impact of reward. These effects could not be attributed to medication use. Relative to controls (n = 26), aberrant reward processing in PD was particularly expressed as reduced capacity to maintain (i.e., repeat) the current task-set under high reward. Our findings demonstrate that factors intrinsically related to PD may underlie the paradoxical symptoms of inflexibility and reward-related impulsivity in PD. The present results concur with observations that low baseline dopamine states predispose to drug and other addictions.     

The neuropsychology of antisocial personality disorder

Antisocial Personality Disorder (APD) is a psychological disorder most commonly associated with the legal and criminal justice systems, as many persons arrested for the commission of illegal acts meet the diagnostic criteria for this disorder, such as deception, manipulation, disregard for the rights of others, and a lack of remorse for their behavior. Most researchers agree that this disorder stems from brain abnormalities, including the theories of frontal lobe dysfunction and differences in the autonomic nervous systems in individuals diagnosed with APD. The Integrated Emotional Systems (IES) model, a third model of APD, is itself not a brain abnormality, but provides an understanding of antisocial characteristics based on dysfunctions in select parts of the brain. Based on research using neuropsychological assessments and other techniques, several cognitive characteristics appear to exist among these individuals. Examples include cognitive inflexibility, attention deficits, and inappropriate processing of contextual cues in the environment, sometimes leading to poor behavioral choices. Further research is needed to help identify the cause of this disorder so that the most appropriate treatments can be made available to these individuals.     

Cognitive Inflexibility Among Ruminators and Nonruminators

Dysphoric people who ruminate about their negative mood experience longer and more intense depressive episodes, yet often persist in ruminating. This study investigated whether a ruminative coping style would be related to a cognitive style marked by perseveration and inflexibility. We examined the performance of ruminators and nonruminators on the Wisconsin Card Sorting Test (WCST), a measure of cognitive flexibility, and tasks measuring related cognitive processes. Ruminators committed significantly more perseverative errors and failed to maintain set significantly more often than nonruminators on the WCST. On an advanced section of the WCST designed for this study, male ruminators exhibited significantly greater inflexibility than male nonruminators. These effects could not be attributed to differences in general intelligence or the presence of depressed mood. Results suggest that rumination may be characterized by, and perhaps prolonged by, an inflexible cognitive style.     

Moving cemeteries: a framework for facilitating curriculum revision

The process of revising a nursing curriculum can be accompanied by self-oriented faculty behaviors such as inflexibility, indifference, and territoriality. The authors, who served as members of a curriculum revision task force, suggest the need for planned, intentional, and goal-directed approaches when revising an academic program. Lancaster's six components of research by committee are used as a framework to offer insights for enhancing.     

Willing and Able: A Closer Look at Pain Willingness and Activity Engagement on the Chronic Pain Acceptance Questionnaire (CPAQ-8)

An 8-item version of the Chronic Pain Acceptance Questionnaire (CPAQ-8) has recently been proposed and validated. The aims of this study were to further investigate the reliability and validity of the CPAQ-8 in a new sample. Questionnaires were completed by 550 people with chronic pain (478 online survey, 72 paper survey). A demographic and pain history questionnaire was administered along with the CPAQ-8 and measures of pain self-efficacy, pain catastrophizing, psychological flexibility in pain, anxiety, and mood. In addition, 105 respondents completed the CPAQ-8 within 6 weeks to provide test-retest reliability data. The 2-factor structure of the CPAQ-8 (Activity Engagement [AE] and Pain Willingness [PW]) was confirmed and had reasonable-to-good scale score reliability and test-retest reliability. Pain acceptance as measured by the CPAQ-8 was associated with less depression, anxiety, pain interference, fear of reinjury, pain catastrophizing, and psychological inflexibility in pain, and higher levels of satisfaction with life, pain self-efficacy, and general acceptance. Furthermore, pain acceptance fully mediated the relationship between reported pain severity and emotional distress (anxiety and depression) and partially mediated the relationship between pain severity and pain interference in a structural equation model. The test-retest reliability after 4 to 6 weeks ranged from .68 for PW to .86 for AE; the overall score correlation was .81. We conclude that the CPAQ-8 is a reliable and valid measure of pain acceptance and that the 2 subscales of the measure each make an individual contribution to the prediction of adjustment in people with chronic pain.PerspectiveThe present study provides further evidence for the reliability and validity of the CPAQ-8. Support was found for the 2 related subscales, PW and AE, which appear to work in synergy to influence levels of pain interference and emotional distress in people living with chronic pain.     

The role of a research nurse in translating evidence into practice

This article describes the role and experiences of a research nurse working with a nursing team to implement best practice guidelines. The structure of the research project and resources were found to support the change, resulting in better patient care. Challenges promoting change as part of a research project included inflexibility of research paperwork and competing local trust priorities. The research nurse was able to support the clinical team to implement change through education and regular visits to the ward to monitor progress and feedback good practice.     

Suicidal ingestion of potassium permanganate

BACKGROUND:

Potassium permanganate is used clinically as an antiseptic and antifungal agent. Ingestion of potassium permanganate may result in damage to the upper gastrointestinal tract. Burns and ulceration of the mouth, esophagus and stomach occur due to its action. Emergency endoscopy is useful to assess the severity of damage and also to guide management.

METHODS:

We reported a patient presenting to the emergency department after suicidal ingestion of potassium permanganate.

RESULTS:

After treatment, the patient was discharged home on the 7th day after admission.

CONCLUSION:

Early emergency endoscopy should be considered to determine the extent of upper gastrointestinal damage in the emergency department.KEY WORDS: Emergency endoscopy, Gastric damage, Suicide, Potassium permanganate     

Suicidal ideation in multiple sclerosis

OBJECTIVE: To examine risk factors for suicidal ideation among people with multiple sclerosis (MS). DESIGN: Cohort study linking computerized medical records with a mailed self-report survey. SETTING: Veteran's Health Administration (VHA) region covering the northwestern United States. PARTICIPANTS: VHA patients with MS (N=445) who returned mailed surveys. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Suicidal ideation is assessed by the Patient Health Questionnaire (PHQ) suicide item with suicidal ideation more than half the days considered persistent. RESULTS: One hundred thirty-one (29.4%) of 445 respondents (95% confidence interval [CI], 25.4%-33.9%) endorsed suicidal ideation, and 35 (7.9%; 95% CI, 5.7%-10.8%) endorsed persistent suicidal ideation over the last 2 weeks. In bivariate analyses, suicidal ideation was associated with younger age, earlier disease course, progressive disease subtype, lower income, not being married, lower social support, not driving, higher levels of physical disability (mobility, bowel, bladder), and depression. Analyses on persistent suicidal ideation yielded similar results. In fully adjusted multivariate logistic regression, only depression severity and bowel disability were independently associated with suicidal ideation. Only depression severity was independently associated with persistent suicidal ideation. By using the 2-question depression screen (U.S. Preventive Services Task Force) consisting of the depression and anhedonia items from the PHQ-9, sensitivity and specificity were marginal for suicidal ideation (65.6% and 79.9%) but acceptable for persistent suicidal ideation (88.6% and 71.2%). CONCLUSIONS: Suicidal ideation is common among VHA patients with MS, and depression severity is the best risk marker. Brief screening for depression in MS should include the assessment of suicidal ideation.     

Hypnotherapy and the Suicidal Patient

Three cases are presented in which a family physician treats a suicidal patient by the hypnotherapeutic method described. It is postulated that such a method may be quick, effective, and relatively safe method for a diagnostic and therapeutic approach in family practice. In the hypnotic state, the patient is hypersuggestible and can accept suggestions which meet her unconscious needs to be loved as an individual within the milieu of the ego state at the time her psychopathology occurred.     

Clinical Assessment of Suicidal Risk

Success in preventing suicide is hard to prove, but there are some guidelines that can help to identify high risk. Assessment of suicidal risk depends on recognition of a depressive state as well as evaluation of chronic risk factors and acute signs of suicidal behavior.