Cognitive and somatic item response pattern of pain patients, psychiatric patients, and hospital employees

Standard psychological tests generally provide a single global score that reflects multidimensional constructs, such as depression and anxiety. This single score, however, integrates a range of item contents, including cognitive/affective, somatic, and behavioral characteristics of these multidimensional constructs. The present study was designed to compare the pattern of item endorsement among chronic pain patients (N = 50), psychiatric inpatients (N = 50), and hospital employees (N = 50) on the SCL-90-R (Derogatis, Rickels, & Rock, 1976). Pain patients reported the highest SCL-90 scale level of Somatization, while the psychiatric inpatients reported the highest level of Anxiety and Depression. Additionally, the within-scale pattern of item responses on the Anxiety and Depression scales differed among groups. Although psychiatric inpatients endorsed equivalent levels of somatic and cognitive items, the pain patients' reports of psychological distress were limited primarily to somatic signs of anxiety and depression. Thus, the interpretation of pain patients' psychological profiles and subsequent treatment recommendations may be inappropriate if based on normative data obtained from psychiatric and/or normal populations.     

Depressive symptoms and disability in acute and chronic back pain patients

Depression and level of disability are evaluated in acute and chronic low back pain (LBP) patients. To assess the possibility that some somatic symptoms are confounded with pain, the items of the Beck Depression Inventory arc divided into a cognitive-affective and somatic subscale. The sample consisted of 37 chronic LBP patients. 41 acute LBP patients, and 28 healthy participants. The level of disability was assessed by the Oswestry Low Back Pain Disability Questionnaire. Chronic LBP patients, but not acute LBP patients, have more depressive symptoms than controls. Additionally, chronic LBP patients report more somatic symptoms of depression (e.g.. emo ltional and self disturbance complaints) than cognitive-affective symptoms. Finally, correlation statistics reveal significant relations between the level of disability and depression scores. Whereas chronic patients show a significant correlation between the somatic subscale and level of disability, in acute patients the cognitive-affective subscale is significantly related to the level of disability. The findings suggest careful consideration of whether somatic symptoms of depression are related to pain when using self-report measurements of depression in pain patients. The separation of cognitive-affective and somatic symptoms of depression to evaluate pain problems seems appropriate.     

抑郁症躯体疼痛症状与述情障碍的研究

目的 研究抑郁症躯体疼痛症状与述情障碍之间的关系,进一步探讨影响躯体疼痛症状的因素.方法 将56例抑郁症患者分为无躯体症状组(单纯组),非疼痛躯体症状组(躯体症状组),疼痛躯体组(疼痛组),采用自编基本资料调查表、SCL-90症状自评量表、汉密尔顿抑郁量表(HAMD)、多伦多述情障碍量表(TAS-20)、疼痛等级评价量...     

Distinguishing affective and somatic dimensions of pain and depression: a confirmatory factor analytic study

In this study, we examined the overlap between pain and depression in a sample of 342 chronic pain patients treated at a specialty pain clinic. Confirmatory factor analysis was conducted to test the differentiation of pain and depression measured as latent factors derived from the subscales of the Short Form McGill Pain Questionnaire and the Center for Epidemiological Studies Depression Scale. The affective pain subscale did not load on latent depression and the somatic depression subscale loaded weakly on latent pain. Although pain and depression are linked, we found that affective pain is distinct from depression, and that somatic depression is distinct from pain. This finding justifies further examination of the casual relationship between pain and depression. © 2010 Wiley Periodicals, Inc. J Clin Psychol 66: 1–10, 2010.     

Symptom experience during acute coronary syndrome and the development of posttraumatic stress symptoms

There is growing evidence for the development of posttraumatic stress symptoms as a consequence of acute cardiac events. Acute coronary syndrome (ACS) patients experience a range of acute cardiac symptoms, and these may cluster together in specific patterns. The objectives of this study were to establish distinct symptom clusters in ACS patients, and to investigate whether the experience of different types of symptom clusters are associated with posttraumatic symptom intensity at six months. ACS patients were interviewed in hospital within 48 h of admission, 294 patients provided information on symptoms before hospitalisation, and cluster analysis was used to identify patterns. Posttraumatic stress symptoms were assessed in 156 patients at six months. Three symptom clusters were identified; pain symptoms, diffuse symptoms and symptoms of dyspnea. In multiple regression analyses, adjusting for sociodemographic, clinical and psychological factors, the pain symptoms cluster (β = .153, P = .044) emerged as a significant predictor of posttraumatic symptom severity at six months. A marginally significant association was observed between symptoms of dyspnea and reduced intrusive symptoms at six months (β = -.156, P = .061). Findings suggest acute ACS symptoms occur in distinct clusters, which may have distinctive effects on intensity of subsequent posttraumatic symptoms. Since posttraumatic stress is associated with adverse outcomes, identifying patients at risk based on their symptom experience during ACS may be useful in targeting interventions.     

Depression in medical students: Cluster symptoms and management

Background

Rates of depression among medical students have been shown to be high and related to year of study and other factors. We report on cluster of symptoms related to depression and their association with other difficulties in specific domains.

Methods

481 (Response rate=79.8%) medical students completed a questionnaire about areas of difficulty in the medical school (studies, leisure, colleagues, professors, and patients), and Beck Depression Inventory (BDI). We studied correlation among areas of difficulty and clusters of BDI along with year in the course.

Results

Two areas which contributed most difficulty were studies and leisure. The significant associations for studies were seen between somatic cluster of depressive symptoms and the level of the course. Difficulties associated with leisure activities and with colleagues were correlated with the affective cluster of symptoms of depression. Activities related to clinical matters especially working with patients in the internship year were associated with somatic clusters. The different associations confirmed that rather than relying on scores emphasis should be placed on clusters of symptoms.

Limitations

Sample from a single medical school.

Conclusions

Although the clusters are associated with specific difficulties, it is important that educators and health professionals are aware of streesors the medical students face. The correlations if confirmed in future studies with qualitative factors could guide the development of more specific therapeutic or curriculum interventions.     

Patterns of depression in medical patients and their relationship with causal attributions for illness

The present study investigated the factor structure of the Beck Depression Inventory (BDI), and causal attributions for the development of illness in a sample of 102 inpatients of a thoracic surgery department, with the main objective of examining the power of causal attributions and functional support in predicting different factors derived from the BDI. The results revealed that the BDI clusters into affective/motivational, somatic/vegetative, self-blame and self-punitiveness dimensions. Causal attributions for the development of illness were represented by family conflicts, environmental adversity, finance/health problems, bad luck, and four self-related clusters. Examination of the predictors of the BDI dimensions showed that causal attributions to uncontrollable, unmodifiable variables were predictors for the affective/motivational dimension, whereas illness severity and greater age were related to the somatic/vegetative symptomatology. The results supported the recommendations for the exclusion of such symptoms in assessing depression severity among medical patients.     

Somatic items in the assessment of depressive symptoms in pediatric patients with diabetes

Depression inventories contain somatic items which may be related to disease rather than to depression in individuals with chronic illness. Adolescents with type 1 diabetes (n = 151) and medically well controls (n = 68) completed the Center for Epidemiological Studies-Depression Scale (CES-D) which includes somatic and cognitive/affective symptoms. Diabetes patients reported higher levels of all depressive symptoms than controls; the discrepancy was equivalent for somatic and cognitive/affective symptoms. For diabetes patients, somatic and cognitive/affective symptoms did not correlate with indices of disease control except for number of diabetes-related hospitalizations, where the correlations were equivalent. In participants with diabetes and in controls, somatic and cognitive/affective symptoms were strongly correlated with each other. These findings were not moderated by level of depressive symptoms. Our study suggests that the somatic items on the CES-D do not confound the measurement of depressive symptoms in young people with type 1 diabetes.     

Subjective symptoms of acute asthma within a heterogeneous sample of asthmatics

A heterogeneous group of 175 severe asthma inpatients with perennial symptoms were asked to rate the frequency with which 77 symptoms occurred during their asthma attacks. The reported frequency of occurrence for individual symptoms and symptom categories of panic-fear, irritability, fatigue, hyperventilation-hypocapnia, and airway obstruction are presented. As expected, airway obstruction symptoms were the most frequently reported during acute asthmatic episodes. In decreasing order, the airway obstruction symptoms were followed by fatigue, panic-fear, irritability, and hyperventilation-hypocapnia. A separation of the patient sample into subgroups revealed no differences in reported occurrence of the symptom categories associated with age, age at onset, or length of illness. Females reported experiencing panic-fear and fatigue symptoms more frequently than males. Patients who subsequently had higher steroid regimens prescribed at discharge reported more frequent panic-fear symptoms. Those patients with an infectious component in their asthma reported symptoms of panic-fear, fatigue, and airway obstruction somewhat more frequently than those classified as having no infectious component in their asthma. The results suggest that subjective symptomatology may provide important clues concerning the nature of emotional factors in asthma and response to treatment.     

Delineating psychopathologic clusters within dysthymia: a study of 512 out-patients without major depression

BACKGROUND: The literature indicates that emotional-cognitive symptoms are much more characteristic of dysthymia than the vegetative and psychomotor symptoms of major depression, yet this is insufficiently emphasized in the official criteria listed in the criteria of the American Psychiatric Association. Furthermore, as previous studies have examined these symptoms more in relation to prevalence than to possible symptom aggregation, in the present analyses we address both aspects. METHODS: In two multicenter collaborative trials, 512 out-patients meeting the symptom criteria of DSM-III-R dysthymia but without major depression were recruited. In this respect they conformed to the conceptual framework of ICD-10 which tends to restrict dysthymia to a subthreshold depression without excursion into severe depressive episodes. The Montgomery Asberg Depression Rating Scale (MADRS) and the Hamilton Anxiety Rating Scale (HAM-A) were used to assess depressive and anxiety symptoms. RESULTS: Symptoms most frequently observed, besides depressed mood (100% by definition), were 'low energy or fatigue' (96%) and 'poor concentration or indecisiveness' (88%), followed by 'low self-esteem' (80%), 'insomnia or hypersomnia' (77%), 'poor appetite or overeating' (69%) and 'feeling of hopelessness' (42%). Interestingly, in the subjects with fewer than five symptoms, the most frequent were low energy or fatigue (93%), poor concentration or indecisiveness (79%) and low self-esteem (77%), the other symptoms being present in no more than half the sample. MADRS factor analysis identified two main factors: the first consisting of apparent and reported sadness, and the second concentration difficulties and lassitude. HAM-A factor analysis identified two factors clearly differentiating somatic and psychic symptoms. LIMITATIONS: Because suicidal patients were excluded on the ground of human subject concerns, our sample is representative of the milder range of symptomatology within the spectrum of dysthymia. This may in part explain the low prevalence of neurovegetative symptoms. CONCLUSION: Despite this, the present study involves the largest sample of pure dysthymia ever studied. Our results indicate that dysthymic disorder appears to primarily involve psychologic symptoms. The psychological symptoms themselves seem to cluster into sadness versus mental fatigue; as for anxiety symptoms, they appear divisible into somatic and psychic clusters, with the latter prevailing in dysthymia. Dysthymia proper, dominated by negative affectivity, might be distinguishable from a 'neurasthenic' subform dominated by low energy or 'deficit' symptoms at mental and physical levels.     

Suicidal ideation and the subjective aspects of depression

BackgroundSuicidal ideation is common in depression, but only moderately related to depression severity — in part because certain clusters of symptoms, such as those related to core mood disturbance, have a differential relationship to suicidal thinking.Methods400 medication free participants with current major depression were assessed with either or both the Hamilton Depression Rating Scale (HDRS, n = 396) and Beck Depression Inventory (BDI, n = 366), and the Scale for Suicide Ideation (SSI). Depression rating scales were decomposed into symptoms clusters previously reported (Grunebaum et al., 2005), in order to evaluate their association to suicidal thinking.ResultsCorrelations between overall depression severity ratings and the measure of suicidal ideation were modest, and reduced when specific items assessing suicidal thinking on these depression scales were removed. Symptom clusters assessing Psychic Depression (HDRS), Subjective Depression (BDI), and Self-Blame (BDI) were the strongest correlates of suicidal ideation; other somatic and vegetative symptoms had little or no association to suicidal ideation. Severity of these symptom clusters effectively discriminated those with (SSI > 0) and without (SSI = 0) ideation; severity of these symptom clusters was less strongly associated with the severity of ideation once ideation was present.LimitationsThis is a cross-sectional study, and the dynamic relationship between changes in the severity of various depressive symptoms and change in suicidal thinking remains to be explored.ConclusionsDepression severity is moderately associated with suicidal ideation, and accounted for primarily by core mood disturbance symptoms and self-punitive thinking. These associations may explain why suicide risk might remain high during treatment even though somatic and vegetative symptoms improve.     

Subgrouping of Peripheral Neuropathic Pain Patients According to Sensory Symptom Profile Using the Korean Version of the PainDETECT Questionnaire

BackgroundA culturally validated Korean version of the PainDETECT Questionnaire (PD-Q) was used to identify neuropathic pain components (NeP) in patients suffering from chronic pain. The purpose of this study was to determine if the Korean PD-Q can be used to subgroup patients with peripheral NeP according to sensory symptom profiles.MethodsThis study included 400 Korean patients with peripheral neuropathic pain diagnosed as probable or definite NeP. The total scores and subscores for each item in PD-Q were transformed into a Z-score for standardization. Hierarchical cluster analysis was performed to identify clusters of subjects by PD-Q scores.ResultsThe mean total PD-Q score of the study participants was 14.57 ± 6.46. A hierarchical cluster analysis identified 5 clusters with distinct pain characteristic profiles. Cluster 1 had relatively severe burning and tingling sensations. The mean total PD-Q score for cluster 2 was the lowest of the 5 clusters. Cluster 3 tended to be vulnerable to pain in response to cold/heat stimulation. Cluster 4 showed relatively severe pain induced by physical stimuli, such as light touch or slight pressure. Cluster 5 had high scores for all NeP symptoms.ConclusionThis study demonstrates the ability of patients to cluster by symptoms using the Korean PD-Q. Subgrouping of peripheral neuropathic pain by sensory symptom profile may be useful in making effective drug treatment decisions.     

Validation of a symptom provocation test for laboratory studies of abdominal pain and discomfort in children and adolescents

OBJECTIVE: Assessed the convergent and discriminant validity of a water load symptom provocation test (WL-SPT) in creating visceral sensations similar to the naturally occurring sensations experienced by children with functional abdominal pain. METHODS: Participants were pediatric patients with functional abdominal pain (N = 110) and healthy school children (N = 120) between the ages of 8 and 16 years. Pain patients completed questionnaires describing gastrointestinal (GI) and non-gastrointestinal (non-GI) symptoms associated with their typical abdominal pain episodes. Weeks later, the WL-SPT was administered to pain patients and well children. Before and immediately following the WL-SPT, children rated their symptoms. RESULTS: The WL-SPT produced (a) significant increases in children's GI symptoms that were reliably predicted by the children's naturally occurring GI symptoms, and (b) significantly greater increases in GI symptoms in pain patients than in well children. CONCLUSIONS: The WL-SPT produces clinically relevant symptoms for laboratory studies of children with functional abdominal pain.     

Comparing Postoperative Pain Experiences of the Adolescent and Adult Athlete After Anterior Cruciate Ligament Surgery

OBJECTIVE: To examine age-related differences in pain, catastrophizing, and affective distress (depression and anxiety) after athletic injury and knee surgery. DESIGN AND SETTING: Participants were assessed with measures of pain intensity, pain-related catastrophizing, depression, and anxiety symptoms at 24 hours after anterior cruciate ligament (ACL) surgery. SUBJECTS: Twenty patients (10 adolescents, 10 adults) with an acute complete tear of the ACL. MEASUREMENTS: Pain was assessed by Visual Analog Scale (VAS), catastrophizing with the Pain Catastrophizing Scale (PCS), depressive symptoms with the Beck Depression Inventory (BDI), and anxiety with the state form of the State-Trait Anxiety Inventory (STAI-S). RESULTS: At 24 hours postsurgery, adolescents reported greater pain, catastrophizing, and anxiety than adults. Ancillary analyses showed that helplessness and rumination were significant contributors to the differences in catastrophizing. Further, an analysis of covariance showed that controlling for the effects of catastrophizing, the adolescent and adult differences in pain scores were reduced to a null effect. CONCLUSIONS: After ACL surgery, athletic adolescents and adults differed significantly in pain, catastrophizing, and anxiety. Catastrophizing seemed to be a particularly strong factor in postoperative pain differences between adolescents and adults, with clinical-management implications. These data indicate the need for continued research into specific pain- and age-related factors during the acute postoperative period for athletes undergoing ACL surgery.     

Subtyping of psychiatric patients by cluster analysis of QEEG

We have previously reported successful classification of patients with a variety of psychiatric disorders, using multiple discriminant functions based upon selected neurometric QEEG variables. In independent replications, these functions accurately separate patients with different DSM-III-R diagnoses from one another and from normals. This capability demonstrates that distinctive and replicable patterns of neurometric abnormalities are correlated with the clinical symptom clusters upon which DSM-III-R diagnostic criteria are based. However, patients with the same clinical diagnoses often respond very differently to the same treatments. Similar symptoms may arise from different pathophysiology. This study explored the 'natural structure' of a population of psychiatric patients in 8 diagnostic categories, using uninformed cluster analysis based upon the same set of neurometric variables found useful in separating each of these categories from normal. This preliminary numerical taxonomic approach reveals that groups of patients in each of these DSM-III-R categories contain subtypes with markedly different pathophysiology; further, patients in different DSM-III-R categories were aggregated together within each cluster, displaying similar pathophysiological profiles. Objective classification based on such physiological measurements may add information useful to improve treatment outcomes.     

Somatization disorder in a US southern community: use of a new procedure for analysis of medical classification

The authors examine somatization disorder in a community population, using grade of membership analysis, a new multivariate analytical technique for the analysis of medical classification. The technique is used to examine whether somatic symptoms will cluster into a clinical syndrome resembling somatization disorder, as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), if no a priori assumptions are made about the interrelationship of somatic symptoms or their clustering into clinical syndromes. Grade of membership analysis is applied to all respondents in the US National Institute of Mental Health Epidemiological Catchment Area Project of the Piedmont region of North Carolina reporting three or more somatic symptoms from the somatization disorder section of the Diagnostic Interview Schedule. The analysis indicates that seven 'pure' types, roughly analogous to clusters in cluster analysis, best describe the interrelationship of the symptoms included in the analysis. One 'pure' type in the analysis is nearly identical to DSM-III somatization disorder and is associated with demographic characteristics consistently found among patients with DSM-III somatization disorder. The present results demonstrate that symptoms associated with this disorder do cluster in a highly predictable fashion and represent a strong validation of the natural occurrence of an entity resembling somatization disorder.     

MMPI-2 profiles of patients with intractable epilepsy.

MMPI-2 profiles of 93 presurgical intractable epilepsy patients were examined using Ward's method of cluster analysis. Three clusters were identified. The means of each cluster suggest that 45% of the sample had minimal psychological complaints, 30% presented with generalized clinical elevations, and 25% of the patients had profiles of intermediate elevations with a tendency to emphasize somatic complaints and/or depression. Gender, age of seizure onset, and seizure laterality were not found to be uniquely associated with the cluster profiles. Further examination of correlates of group membership is warranted to provide information for treatment planning.     

Medication usage, emotional disturbance, and pain behavior in chronic low back pain patients

Examined chronic low back pain outpatients (N = 126) at a university hospital outpatient back clinic. Prior to their orthopedic examination, patients were given the MMPI, the Pain Experience Questionnaire (a modified form of the McGill Pain Questionnaire), and a medical history form that indicated onset of injury, number of surgeries, functional limitations, and use of medications. Four patterns of drug usage emerged with sufficient number to permit statistical analysis: (1) none; (2) aspirin-type medications; (3) single narcotics alone; and (4) narcotics combined with other medications. Group 4 patients scored significantly higher on the Hypochondriasis and Hysteria scales than the others, whereas Group 3 patients scored higher on the PD (acting out) scale. Group 4 patients reported more intense pain and chose more affective terms (punishing/terrorizing/sickening) in describing their pain than the other three groups. Group 1 patients reported significantly less limitation in walking, running, and climbing.     

Somatic symptoms for diagnosing major depression in cancer patients

Diagnosing depression in cancer patients has been challenging because the diagnostic criteria include somatic symptoms frequently attributed to the cancer itself or its treatment. However, few studies have explored how to appropriately deal with individual somatic symptoms. The authors used data from 220 cancer patients with major depression to examine the intercorrelations among the DSM-IV somatic and nonsomatic symptom criteria as well as whether the presence of an individual somatic symptom could discriminate the severity of major depression. Appetite changes and a diminished ability to think were positively associated with anhedonia. Sleep disturbance and fatigue were not significantly associated with nonsomatic symptoms. These associations were consistent after adjusting for physical functioning and pain. Only patients with appetite changes showed a higher severity of depression. These results suggest that individual somatic symptoms differ in nature and that appetite-related symptoms and a diminished ability to think may be useful for diagnosing depression in cancer patients, whereas sleep disturbances and fatigue may not be as useful.     

Psychological effects of chemical weapons: a follow-up study of First World War veterans

BACKGROUND: Chemical weapons exercise an enduring and often powerful psychological effect. This had been recognized during the First World War when it was shown that the symptoms of stress mimicked those of mild exposure to gas. Debate about long-term effects followed the suggestion that gassing triggered latent tuberculosis.MethodA random sample of 103 First World War servicemen awarded a war pension for the effects of gas, but without evidence of chronic respiratory pathology, were subjected to cluster analysis using 25 common symptoms. The consistency of symptom reporting was also investigated across repeated follow-ups. RESULTS: Cluster analysis identified four groups: one (n=56) with a range of somatic symptoms, a second (n=30) with a focus on the respiratory system, a third (n=12) with a predominance of neuropsychiatric symptoms, and a fourth (n=5) with a narrow band of symptoms related to the throat and breathing difficulties. Veterans from the neuropsychiatric cluster had multiple diagnoses including neurasthenia and disordered action of the heart, and reported many more symptoms than those in the three somatic clusters. CONCLUSIONS: Mild or intermittent respiratory disorders in the post-war period supported beliefs about the damaging effects of gas in the three somatic clusters. By contrast, the neuropsychiatric group did not report new respiratory illnesses. For this cluster, the experience of gassing in a context of extreme danger may have been responsible for the intensity of their symptoms, which showed no sign of diminution over the 12-year follow-up.