Psychological processes underlying the development of a chronic pain problem: a prospective study of the relationship between profiles of psychological variables in the fear-avoidance model and disability

OBJECTIVES: Understanding the psychological processes that underlie the development of a chronic pain problem is important to improve prevention and treatment. The aim of this study was to test whether distinct profiles of variables within the fear-avoidance model could be identified and could be related to disability in a meaningful way. METHODS: In 81 persons with a musculoskeletal pain problem, cluster analysis was used to identify subgroups with similar patterns on fear and avoidance beliefs, catastrophizing, and depression. The clusters were examined cross-sectionally and prospectively on function, pain, health care usage, and sick leave. RESULTS: Five distinct profiles were found: pain-related fear, pain-related fear + depressed mood, medium pain-related fear, depressed mood, and low risk. These subgroups were clearly related to outcome. In contrast to the clusters "medium pain-related fear" and "low risk," the majority of those classified in the clusters "pain-related fear," "pain-related fear + depressed mood," and "depressed mood" reported long-term sick leave during follow-up. The subjects in the clusters with high scores on the depression measure reported the highest percentage of health care usage during follow-up (70% in the "pain-related fear + depressed mood" group and 42% in the "depressed mood" group reported >10 health care visits). CONCLUSIONS: Distinct profiles of psychological functioning could be extracted and meaningfully related to future disability. These profiles give support to the fear-avoidance model and underscore the need to address the psychological aspects of the pain experience early on.     

Symptom Trajectories Are Associated With Co-occurring Symptoms During Chemotherapy for Breast Cancer

Context

Symptoms are reported to co-occur during treatment for breast cancer. We previously identified three patterns of fatigue and two patterns of disturbed sleep, depressed mood, and anxiety in women undergoing chemotherapy for breast cancer using a Latent Growth Mixture Model.

Neuropsychological Functioning and Treatment Outcomes in Acceptance and Commitment Therapy for Chronic Pain

Neuropsychological (NP) performance has been associated with psychosocial treatment outcomes in nonpain conditions, but has never been investigated in chronic pain. We performed a secondary analysis on the association of baseline NP performance with treatment outcomes among veterans with chronic pain (N?=?117) undergoing an 8-week acceptance and commitment therapy (ACT) intervention. Participants completed measures of pain interference, pain severity, quality of life, activity levels, depression, and pain-related anxiety at baseline, midtreatment, and post-treatment. Executive functioning, working memory, processing speed, learning, and verbal memory were assessed at baseline. All study measures significantly improved from baseline to post-treatment. NP performance was related to changes in depression and pain-related anxiety during treatment. Specifically, relatively lower executive functioning and processing speed was associated with greater decreases in depressive symptoms, and relatively lower processing speed was associated with greater decreases in pain-related anxiety. Consistent with research in nonpain conditions, those with relatively lower NP functioning received greater benefit from psychosocial treatment, although most study outcomes did not differ as a function of NP performance. Our results suggest relatively lower NP functioning is not contraindicated for participation in psychosocial interventions like ACT but instead may be associated with greater relief.

Symptom clusters of pain, depressed mood, and fatigue in lung cancer: assessing the role of cytokine genes

Purpose

Symptom clusters, the multiple, co-occurring symptoms experienced by cancer patients, are debilitating and affects quality of life. We assessed if a panel of immune-response genes may underlie the co-occurrence of severe pain, depressed mood, and fatigue and help identify patients with severe versus non-severe symptom clusters.

Methods

Symptoms were assessed at presentation, prior to cancer treatment in 599 newly diagnosed lung cancer patients. We applied cluster analyses to determine the patients with severe versus non-severe symptom clusters of pain, depressed mood, and fatigue.

Results

Two homogenous clusters were identified. One hundred sixteen patients (19 %) comprised the severe symptom cluster, reporting high intensity of pain, depressed mood, and fatigue and 183 (30 %) patients reported low intensity of these symptoms. Using Bayesian model averaging methodology, we found that of the 55 single nucleotide polymorphisms assessed, an additive effect of mutant alleles in endothelial nitric oxide synthase (-1474 T/A) (posterior probability of inclusion (PPI)?=?0.78, odds ratio (OR)?=?0.54, 95 % credible interval (CI)?=?(0.31, 0.93)); IL1B T-31C (PPI?=?0.72, OR?=?0.55, 95 % CI?=?(0.31, 0.97)); TNFR2 Met¹⁹⁶Arg (PPI?=?0.70, OR?=?1.85, 95 % CI?=?(1.03, 3.36)); PTGS2 exon 10+837T?>?C (PPI?=?0.69, OR?=?0.54, 95 % CI?=?(0.28, 0.99)); and IL10RB Lys⁴⁷Glu (PPI?=?0.68; OR?=?1.74; 95 % CI?=?(1.04, 2.92)) were predictive for symptom clusters.

Conclusions

Genetic polymorphisms may facilitate identification of high-risk patients and development of individualized symptom therapies.     

Clinical overview of fibromyalgia

Fibromyalgia (FM) is a complex disorder that affects up to 5% of the general population worldwide, more frequently in women than in men. In addition to chronic widespread pain, patients with FM usually experience other characteristic symptoms, including fatigue, disturbed sleep, stiffness, reduced functioning, dyscognition, and depressed mood. Many patients also have comorbid conditions such as depression, irritable bowel syndrome, temporomandibular disorder, or migraine. Although the etiology of FM remains unclear, evidence suggests that biologic, genetic, and environmental factors are involved. The variability of symptoms and the frequency of comorbidities among patients with FM make this a difficult disorder to diagnose. Diagnosis may be further complicated by the stigmatization of this disorder among treatment providers, the health insurance industry, and the general population. Treating chronic pain disorders such as FM can be time consuming and costly, and other issues such as polypharmacy, treatment adherence, and access to treatment often need to be addressed. The aim of this article is to provide physicians with a general overview of FM, including a brief review of the pathophysiology that explains the biologic and genetic bases of this disorder. Also included is a synopsis of new diagnostic criteria and other useful diagnostic tools and a discussion of various treatment challenges and strategies.     

Experimentally Induced Mood Changes Preferentially Affect Pain Unpleasantness

Our group previously demonstrated that changes in mood induced by pleasant or unpleasant odors affect the perceived unpleasantness of painful heat stimuli, without significantly altering perceived pain intensity. In the present study, we examined whether changing mood by viewing emotionally laden visual stimuli also preferentially alters pain unpleasantness. Twelve female subjects immersed their right hand in hot water while observing a video showing a person experiencing the same type of pain (ie, model condition), unpleasant scenes not involving people (ie, disasters condition), or a cityscape video (ie, cityscape condition). Subjects were asked to rate pain intensity, pain unpleasantness, mood, anxiety/calmness, and video unpleasantness, and their skin conductance was measured throughout the experiment. Pain unpleasantness (but not intensity) ratings were higher during the disasters condition, which was associated with the worst mood, than during the cityscape condition; neither mood nor pain unpleasantness was altered in the model video compared with the cityscape video. Moreover, mood was significantly correlated with pain unpleasantness but not with pain intensity. Because these results are similar to those observed when odors were used to alter mood, we conclude that the effects of mood on the affective components of pain are independent of mood induction technique used.

Perspective

This article provides new evidence that changes in mood affect the pain experience by preferentially modulating pain unpleasantness. This finding could potentially help health professionals to treat pain symptoms in patients with altered mood, suggesting methods of pain management aimed at easing the affective, along with the sensory, components of pain.     

Behavioral Symptom Clusters,Inflammation, and Quality of Life in Chronic Low Back Pain

BackgroundChronic low back pain is a prevalent condition, often involving an inflammatory process. Behavioral symptoms, including depressed mood, fatigue, and sleep disturbance, intensifies pain and reduces quality of life.AimsThe objectives of this pilot study were to identify behavioral symptom clusters (depressive mood, fatigue, poor sleep) in individuals with chronic low back pain, and to determine whether there are differences in pain, quality of life and inflammation (plasma IL-6) based on cluster membership.Design and SettingsA cross-sectional study was conducted in a pain clinic.Participants/ SubjectsParticipants between ages 21 to 70 years (N=69) were enrolled if they had chronic low back pain for at least six months.MethodsParticipants completed instruments measuring, pain, depressive mood, fatigue, sleep, and demographic form. Blood (10ml) was obtained. Latent class analysis was used to identify clusters.Results and ConclusionsFindings revealed a two-class model, with Class 1 characterized by more depressive mood, fatigue, and sleep disturbance compared to Class 2. Class 1 participants reported worse quality of life than those in Class 2. Pain severity and pain interference were not significantly different between the classes. Levels of IL-6 were significantly greater in Class 1 participants compared to Class 2 with higher levels of IL-6 correlating with greater pain severity and sleep disturbances. Logistic regression revealed higher levels of IL-6 predicted Class 1 membership. Behavioral symptoms cluster exist in chronic low back pain patients and impact quality of life. Inflammation may contribute to relationship between behavioral symptoms and pain severity.     

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.     

Unravelling Fibromyalgia—Steps Toward Individualized Management

The heterogeneity of the clinical presentation and the pathophysiologic mechanisms associated with fibromyalgia (FM), and the modest results on average for any therapy, call for a more individualized management strategy. Individualized treatment can be on the basis of subgrouping of patients according to associated conditions (mental health problems, chronic overlapping pain conditions, other somatic diseases) or on disease severity. Categorizing FM as mild, moderate, or severe can be on the basis of clinical assessment (eg, degree of daily functioning) or on questionnaires. Shared decision-making regarding treatment options can be directed according to patient preferences, comorbidities, and availability in various health care settings. The European League Against Rheumatism guidelines recommend a tailored approach directed by FM key symptoms (pain, sleep disorders, fatigue, depression, disability), whereas the German guidelines recommend management tailored to disease severity, with mild disease not requiring any specific treatment, and more severe disease requiring multicomponent therapy (combination of drug treatment with aerobic exercise and psychological treatments). When indicated, treatments should follow a stepwise approach beginning with easily available therapies such as aerobic exercise and amitriptyline. Successful application of a tailored treatment approach that is informed by individual patient characteristics should improve outcome of FM.

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

Objectives

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

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

Context

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

Number and Type of Post-Traumatic Stress Disorder Symptom Domains Are Associated With Patient-Reported Outcomes in Patients With Chronic Pain

Post-traumatic stress disorder (PTSD) commonly accompanies complex chronic pain, yet PTSD is often overlooked in chronic pain management. Using the 4-item Primary Care (PC)-PTSD screening tool, we evaluated the relationship between the number and type of PC-PTSD symptoms endorsed and a set of patient-reported outcomes, including: pain intensity and interference, function, mood, quality of life, and substance abuse risk in a consecutive sample of patients with chronic pain (n?=?4,402). Patients completed PainTracker, a Web-based patient-reported outcome tool that provides a multidimensional evaluation of chronic pain, as part of their intake evaluation at a specialty pain clinic in a community setting. Twenty-seven percent of the sample met PC-PTSD screening criteria for PTSD by endorsing 3 of the 4 symptom domains. Significant ordinal trends were observed between increasing number of PTSD symptoms and all outcomes evaluated. The occurrence of even 1 PTSD symptom was associated with overall poorer outcomes, suggesting that subsyndromal PTSD is clinically significant in the context of chronic pain. Among the 4 PTSD domains assessed, “numbness/detachment” was most strongly associated with negative pain outcomes in relative weight analysis. Results from this cross-sectional study suggest that a range of pain-related outcomes may be significantly related to comorbid PTSD.

The Moderating Role of Motivation in the Real-Time Associations of Fatigue,Cognitive Complaints,and Pain With Depressed Mood Among Stroke Survivors: An Ecological Momentary Assessment Study

ObjectiveStroke symptoms fluctuate during the day as stroke survivors participate in daily activities. Understanding the real-time associations among stroke symptoms and depressed mood, as well as the role of motivation for daily activities, informs, and post-stroke symptom management in the context of everyday living. This study aimed to (1) investigate the real-time associations of fatigue, cognitive complaints, and pain with depressed mood and (2) examine the role of motivation for daily activity participation as a potential moderator of these associations in stroke survivors.DesignA prospective cohort study involving 7 days of ecological momentary assessment (EMA), during which participants completed 8 EMA surveys per day. Multilevel modeling was used to analyze data.SettingCommunity.ParticipantsForty community-dwelling stroke survivors (N=40).InterventionsNot applicable.Main Outcome MeasuresEMA measures of depressed mood, stroke symptoms (physical and mental fatigue, cognitive complaints, and pain), and motivation (autonomous motivation, controlled motivation).ResultsHigher levels of within- and between-person physical fatigue, mental fatigue, cognitive complaints, and pain were momentarily associated with greater depressed mood (Ps<.001). Within-person autonomous motivation significantly buffered the momentary associations of physical fatigue (B=-0.06, P<.001), mental fatigue (B=-0.04, P=.032), and pain (B=-0.21, P<.001) with depressed mood.ConclusionsFindings indicate the momentary associations of fatigue, cognitive complaints, and pain with depressed mood in stroke survivors. Autonomous motivation underpinning daily activity participation was found to buffer the associations of fatigue and pain with depressed mood. Promoting autonomous motivation for daily activity participation may be viable for preventing and mitigating poststroke depression.     

Women, but not men, report increasingly more pain during repeated (un)predictable painful electrocutaneous stimulation: Evidence for mediation by fear of pain

An abundance of animal research suggests that fear inhibits pain whereas anxiety increases it. Human studies on this topic are more scarce, and the existing evidence seems rather inconsistent. Therefore, we aimed to investigate the divergent effects of both negative emotional states-that is, pain-related fear and anxiety on pain sensitivity and unpleasantness. Possible sex-related differences were also under investigation, as well as the potential mediational role of fear of movement-related pain on the differences in pain intensity and unpleasantness between both sexes. We employed a voluntary joystick movement paradigm using movements as conditioned stimuli (CSs) and a painful electrocutaneous stimulus as the unconditioned stimulus. Healthy participants received predictable shocks in one condition and unpredictable shocks in another condition. The former procedure is known to induce fear of movement-related pain to the CS+ movement (movement consistently followed by pain), whereas the latter procedure induces (contextual) pain-related anxiety. Results showed that fear of movement-related pain indeed resulted in decreased pain intensity/unpleasantness ratings, while pain-related anxiety led to increased pain intensity/unpleasantness reports. Further, the anticipated sex difference was modulated by time. That is, women gradually reported more pain/unpleasantness, whereas men do not show such a sensitization effect. Moreover, this sex-specific sensitization is partially mediated by (conditioned) fear of movement-related pain. Women also report increasingly more fear of pain over conditioning blocks, while men do not. These results might be interesting in the light of the overrepresentation of women in a number of clinical pain conditions as well as anxiety disorders.     

Differences in unpleasantness induced by experimental pressure pain between patients with fibromyalgia and healthy controls.

Pain possesses both sensory and affective dimensions, which are highly correlated yet distinct. Comparison of these dimensions within experimental pain settings has resulted in the construct of relative unpleasantness. Relative unpleasantness is defined as the amount of affective unpleasantness elicited for a given sensory magnitude. The aim of this study was to determine the relationship between affective and sensory components of evoked pain in subjects with fibromyalgia (FM) and healthy controls. Here we show that patients with FM unexpectedly display less relative unpleasantness than healthy controls in response to random noxious pressure stimuli. Relative unpleasantness was not correlated with distress, anxiety, or depression, which were pronounced in the FM group. Clinical pain in patients with FM was perceived to be more unpleasant than the evoked pain stimuli. These results are consistent with the concept that chronic pain may reduce the relative unpleasantness of evoked pain sensations.     

Nonmalignant Pain Symptom Subgroups in Nursing Home Residents

Context

Despite many nursing home residents experiencing pain, research about the multidimensional nature of nonmalignant pain in these residents is scant.

Breakthrough pain: characteristics and impact in patients with cancer pain.

Few surveys have been performed to define the characteristics and impact of breakthrough pain in the cancer population. In this cross-sectional survey of inpatients with cancer, patients responded to a structured interview (the Breakthrough Pain Questionnaire) designed to characterize breakthrough pain, and also completed measures of pain and mood (Memorial Pain Assessment Card (MPAC)), pain-related interference in function (Brief Pain Inventory (BPI)), depressed mood (Beck Depression Inventory (BDI)), and anxiety (Beck Anxiety Inventory (BAI)). Of 178 eligible patients, 164 (92.2%) met the criteria for controlled background pain. The median age was 50.6 years (range 26 to 77 years), 52% were men, and 80.6% were Caucasian. Tumor diagnoses were mixed, 75% had metastatic disease, 65% had pain caused directly by the neoplasm, and a majority had mixed nociceptive-neuropathic pain. The median Karnofsky Performance Status score was 60 (range 40 to 90). Eighty-four (51.2%) patients had experienced breakthrough pain during the previous day. The median number of episodes was six (range 1 to 60) and the median interval from onset to peak was 3 min (range 1 s to 30 min). Although almost two-thirds (61.7%) could identify precipitants (movement 20.4%; end-of-dose failure 13.2%), pain was unpredictable in a large majority (78.2%). Patients with breakthrough pain had more intense (P < 0.001) and more frequent (P < 0.01) background pain than patients without breakthrough pain. Breakthrough pain was also associated with greater pain-related functional impairment (difference in mean BPI. P < 0.001), worse mood (mood VAS, P < 0.05; BDI, P < 0.001), and more anxiety (BAI, P < 0.001). Multivariate analysis confirmed that breakthrough pain independently contributed to impaired functioning and psychological distress. These data confirm that cancer-related breakthrough pain is a prevalent and heterogeneous phenomenon. The presence of breakthrough pain is a marker of a generally more severe pain syndrome, and is associated with both pain-related functional impairment and psychological distress. The findings suggest the need for further studies of breakthrough pain and more effective therapeutic strategies.     

Are anxiety and depressed mood related to physical symptom burden? A study in hospitalized advanced cancer patients

BACKGROUND: Anxiety and depressed mood are common symptoms in hospitalized advanced cancer patients. It is often presumed that anxiety and depression affect the occurrence and experience of physical symptoms. PURPOSE: To analyse the relation between anxiety, depressed mood and the presence and intensity of physical symptoms. PATIENTS AND METHODS: Anxiety and depressed mood were assessed in a hospitalized advanced cancer population (n = 79) primarily by the Hospital Anxiety and Depression Scale (HADS), and also by a single-item question ;Are you anxious and/or depressed?' and by the Edmonton Symptom Assessment System (ESAS). Physical symptoms were assessed by a semi-structured interview and by the ESAS. RESULTS: Thirty-four percent of the patients reported anxiety, 56% depressed mood and 29% both, as assessed by the HADS. The correlations between HADS, the single-item question and the ESAS were low. No association was found between anxiety or depressed mood and the presence of physical symptoms. Patients who were anxious or depressed had higher ESAS scores for insomnia and drowsiness; scores for pain, anorexia, asthenia, nausea and dyspnea were independent of anxiety and/or depressed mood. CONCLUSION: The relationship between anxiety, depressed mood and the presence and intensity of physical symptoms in hospitalized advanced cancer patients is very limited.     

Caring for the patient with fibromyalgia: the rehabilitation nurse's role.

Fibromyalgia (FM) is a chronic, potentially disabling, cluster of symptoms that manifests as pain for 3 months or more and pain with pressure on 11 of 18 tender points throughout the body. Because there is no known cause, and therefore, no cure, treatment focuses on the control or relief of symptoms. Many patients are referred to rehabilitation settings for physical or exercise therapy. While exercise is helpful in the control of the pain, stiffness, fatigue, sleep disorders, and mood changes, a holistic approach to treatment is more effective. Rehabilitation nurses provide major support for patients with FM. Validation of the patients' experiences is essential for achieving quality of life. Many patients have a history of being undertreated because of a lack of credibility and invisibility of the illness. This article provides background information about FM, summarizes the FM trajectory, reviews approaches to management, and discusses the role of rehabilitation nurses in a holistic approach to care of clients with FM.