Akiko Okifuji

Prevalence and impact of posttraumatic stress disorder-like symptoms on patients with fibromyalgia syndrome.

OBJECTIVEnTraumatic events can result in a set of symptoms including nightmares, recurrent and intrusive recollections, avoidance of thoughts or activities associated with the traumatic event, and symptoms of increased arousal such as insomnia and hypervigilance. These posttraumatic stress disorder (PTSD)-like symptoms are frequently observed in persons with chronic pain syndromes. Little is known about how these two phenomena interact with one another. The present study evaluated PTSD-like symptoms in patients with fibromyalgia syndrome (FMS) and examined the relation between PTSD-like symptoms and problems associated with FMS.nnnDESIGNnNinety-three consecutive patients underwent a comprehensive FMS evaluation and completed self-report questionnaires measuring PTSD-like symptoms, disability, and psychosocial responses to their pain condition. Subjects were divided in two groups based on level of self-reported PTSD-like symptoms.nnnRESULTSnApproximately 56% of the sample reported clinically significant levels of PTSD-like symptoms (PTSD+). The PTSD+ patients reported significantly greater levels of pain (p < 0.01), emotional distress (p < 0.01), life interference (p < 0.01), and disability (p < 0.01) than did the patients without clinically significant levels of PTSD-like symptoms (PTSD-). Over 85% of the PTSD+ patients compared with 50% of the PTSD- patients demonstrated significant disability. Based on response to the Multidimensional Pain Inventory, a significantly smaller percentage of PTSD+ patients were classified as adaptive copers (15%) compared with the PTSD- group (48.2%).nnnCONCLUSIONSnResults suggest that PTSD-like symptoms are prevalent in FMS patients and may influence adaptation to this chronic illness. Clinicians should assess the presence of these symptoms, as the failure to attend to them in treatment may impede successful outcomes.

Assessment of patients' reporting of pain: an integrated perspective

A common assumption about pain is that it always results from the presence of underlying organic pathology. In the absence of objective pathology, an individuals report of pain may be ascribed to psychological causes. There is a wide variation in patients experience of pain and organic factors alone cannot explain individual differences in patients reports. Assessment of patients who report pain requires attention to psychosocial, behavioural, and organic factors. We describe a comprehensive approach to the assessment of psychological and behavioural variables that affect patients reports of pain. We counter the duality of the somatogenic versus psychogenic perspective and suggest a more integrated assessment that encompasses not only the severity of pain and related physical pathology but also the person who is reporting the presence of pain.

ANGER IN CHRONIC PAIN: INVESTIGATIONS OF ANGER TARGETS AND INTENSITY

The study was designed to assess the frequency and intensity of patients anger directed toward various potential targets and how intensity of anger toward different targets was related to the chronic pain experience. Ninety-six chronic pain patients who were referred for a comprehensive evaluation completed questionnaires to assess their levels of anger, pain, distress, and disability. Approximately 70% of the participants reported to have angry feelings. Most commonly, patients reported to be angry with themselves (74%) and health care professionals (62%). The relevance of anger to chronic pain experience seemed to vary across targets. Anger toward oneself was significantly associated with pain and depression, whereas only overall anger was significantly related to perceived disability. The results suggest that anger should be conceptualized as a multifactorial construct. In addition to presence, intensity, and expression of anger, targets of anger may be important to better understand psychological adaptation to chronic pain.

What factors affect physicians' decisions to prescribe opioids for chronic noncancer pain patients?

OBJECTIVEnTo evaluate the contribution of pain severity, physical pathology, demographic factors, initiators of symptoms, affective distress, behavioral expressions of pain, and functional activity levels in physicians decisions to prescribe opioid medication for chronic noncancer pain patients.nnnDESIGNnPatients were examined by a physician and physical therapist, interviewed by a psychologist, and asked to complete a medical history form and a set of self-report questionnaires. Patients who were prescribed opioids were compared with those who were not prescribed opioids on each of these. In addition, logistic regression analysis was performed to determine the best predictors of opioid prescriptions.nnnSUBJECTSnA total of 191 (96 female and 95 male) consecutive patients referred to a multidisciplinary pain treatment facility diagnosed with a variety of chronic pain syndromes.nnnRESULTSnNeither pain severity nor objective physical pathology influenced physicians prescribing of opioids medication. Similarly, duration of pain and demographic factors had minimal impact on prescribing of opioids. Patients behavioral manifestations of pain, distress, and suffering--pain behaviors--and reports of functional disability and distress did distinguish between patients prescribed opioid medications from those who did not. However, when all variables were entered into a logistic regression model, only observed pain behaviors showed a significant association with opioid prescriptions.nnnCONCLUSIONSnPhysicians practice in prescribing of opioids appears to be influenced most by patients nonverbal communications of pain, distress, and suffering. Some of the factors not directly evaluated in this study that may also contribute to the decision to prescribe opioids for chronic noncancer pain patients are discussed.

Adaptation to metastatic cancer pain, regional/local cancer pain and non-cancer pain: role of psychological and behavioral factors

&NA; The present study compared the adaptation of cancer pain patients and chronic non‐cancer pain patients. Differences between samples of cancer pain patients with and without metastatic disease were also examined. Cancer pain patients reported comparable levels of pain severity to non‐cancer chronic pain patients; however, pain due to cancer was associated with higher levels of perceived disability (t(250)=2.97, P<0.004) and lower degree of activity (t(286)=2.45, P<0.04). The patients with cancer pain, particularly those with metastatic disease, reported significantly higher levels of support and solicitous behaviors from significant others, compared to non‐cancer chronic pain patients. The majority of the cancer patients, both with (81%) and without (84%) metastatic disease as well as non‐cancer chronic pain patients (85%), could be classified into one of three psychosocial subgroups that had been previously identified with non‐cancer chronic pain patients: ‘dysfunctional’ (high levels of pain, perceived interference, affective distress and low levels of perceived control and activity), ‘interpersonally distressed’ (high levels of affective distress, negative responses from significant others and low levels of perceived support) and ‘adaptive copers’ (low levels of interference and affective distress, high levels of perceived control and activity). The distribution of the profiles was significantly different across groups (&khgr;2(4)=12.79, P<0.02). However, within each profile, the response patterns were highly comparable across groups. Thus, contrary to the suggestions of some authors, cancer pain and non‐cancer chronic pain patients share many features in common. Furthermore, the heterogeneity of psychosocial adaptation to pain within each patient group suggests the importance of psychological assessment in determining the pain management plan.

Effects of type of symptom onset on psychological distress and disability in fibromyalgia syndrome patients

&NA; The purpose of the study was to investigate the differences between two types of onset (post‐traumatic versus idiopathic) in pain, disability, and psychological distress in patients with fibromyalgia syndrome (FS). Forty‐six FS patients with post‐traumatic onset and 46 FM patients with idiopathic onset, who were matched in age and pain duration, were included in the study. All participants completed self‐report inventories assessing their adaptation to the pain conditions, and during the medical examination, an examining physician completed an inventory (Medical Examination and Diagnostic Information Coding System; MEDICS) to indicate the degree of physical abnormality. The analysis revealed that the degrees of physical abnormality of the patients were comparable in the two groups. However, controlling for the involvement with financial compensation issues (e.g. disability, litigation), the post‐traumatic FS patients reported significantly higher degrees of pain, disability life interference, and affective distress as well as lower level of activity than did the idiopathic FS patients. Furthermore, evaluation of the treatment history in these patients revealed that a significantly larger number of the post‐traumatic FS patients were receiving opioid medications and had been treated with nerve block, physical therapy, and TENS. The results suggest that (1) post‐traumatic onset is associated with high level of difficulties in adaptation to chronic FS symptoms and (2) FS patients are a heterogeneous group of patients.

Does sex make a difference in the prescription of treatments and the adaptation to chronic pain by cancer and non-cancer patients?

The literature suggests that the sex of patients is an important factor in understanding how they are treated by health care professionals and how they adapt to their symptoms. In two groups of patients with chronic pain (n = 428 non-cancer (Study 1) and n = 143 cancer-related (Study 2)), men and women were compared on medications prescribed, treatment history, and coping and adaptation. In Study 1 with the non-cancer pain patients, there were no significant differences between the sexes in past treatments, current analgesic use, pain, or disability. Women were significantly more depressed and were more likely to receive antidepressants than men. Subgrouping patients on the basis of pain-adaptation responses yielded groups with distinct psychosocial and behavioral characteristics. In Study 2 with the cancer pain patients, men and women did not show significant differences on any variables. Consistent with the results of Study 1, however, psychological subgroups differed significantly in pain severity, mood and disability regardless of sex. The results of both studies suggest that the role of patients sex in chronic pain may be less important than their psychosocial and behavioral responses. Thus, it appears that knowing the psychological characteristics of patients may be more important than their sex.

Evaluating the Role of Physical, Operant, Cognitive, and Affective Factors in the Pain Behaviors of Chronic Pain Patients

Behavioral manifestations of pain, distress, and suffering have been characterized as pain behaviors. Although acquisition and maintenance of pain behaviors have been considered to occur through reinforcement contingencies, empirical evidence suggests that pain behavior is better understood as a multidimensional entity. The present study was designed to evaluate the contributions of physical, operant, cognitive, and affective factors to individual differences in pain behaviors. A total of 63 chronic pain patients diagnosed with the disorder fibromyalgia underwent medical, physical, and psychological evaluations. Hierarchical regression analyses revealed that the physical, cognitive, and affective factors, but not operant factors, were significantly related to observed pain behaviors. The set of all factors accounted for 53% of the variance in observed pain behavior. The results in this study suggest that pain behaviors should be conceptualized as behavioral manifestation of pain based on a complex interaction of various psychological and physical factors.

Comparison of generalized and localized hyperalgesia in patients with recurrent headache and fibromyalgia

OBJECTIVESnResearch suggests that dysregulated pain modulation may play an important role in recurrent headaches and fibromyalgia syndrome (FMS). The primary objective of this study was to investigate algesic responses in localized cervical and pericranial regions (ie, headache-specific areas) and distal locations (ie, trochanter and gluteal) in patients with primary headaches (tension-type and migraine). The headache patients algesic responses were compared with those of a sample of patients with musculoskeletal pain who report generalized hyperalgesia, or FMS.nnnMETHODSnSeventy patients with mixed headache diagnoses and 66 patients with FMS underwent a standardized examination of generalized hyperalgesia based on American College of Rheumatology criteria.nnnRESULTSnTwenty-eight of the 70 headache patients reported the presence of widespread TP pain, suggesting generalized hyperalgesia. Headache diagnosis was unrelated to the presence or absence of generalized hyperalgesia. The subset of headache patients with generalized hyperalgesia did not differ from the FMS patients in pain sensitivity in the cervical and pericranial areas. Regression analyses revealed that pressure pain sensitivity was significantly related to self-reported pain only in the headache patients with generalized hyperalgesia.nnnCONCLUSIONSnThese results suggest that extensive dysregulation in pain modulation is important for a substantial minority of recurrent headache patients, who seem to be quite similar to FMS patients. Differential treatment planning targeting generalized hyperalgesia may be useful in treating headache patients exhibiting generalized hyperalgesia more effectively.

Nightly analyses of subjective and objective (actigraphy) measures of sleep in fibromyalgia syndrome: what accounts for the discrepancy?

ObjectivesTo evaluate the concordance between the subjective and objective methods of sleep assessment in patients with fibromyalgia syndrome (FMS) and to delineate factors associated with discrepancy between the 2 sleep assessment methods. MethodsSeventy-five patients with FMS completed a 7-day home assessment protocol. They wore an actigraphic device at all times. In the morning, they used the electronic diary to record the subjective report of sleep from the previous night and current severity of the FMS-related symptoms. ResultsOn average, the 2 assessment methods yielded a 73 absolute minute difference per night per patient. About half of the nights, sleep duration was underestimated. Approximately 20% of the nights had greater than 2-hour difference between the 2 methods. Factors related to this large discrepancy were (1) objective indicator of restless sleep, (2) subjective report of difficulty falling asleep, and (3) report of fatigue at the time of reporting. FMS-related symptoms were related to subjective report of poor sleep but not to objective sleep data. DiscussionMisestimation of sleep seems common in FMS patients, particularly when their sleep quality is poor. Careful considerations for evaluating the severity of patients sleep complaints are critical in adequate management of sleep disturbance that is commonly reported by FMS patients.