Ephrem Fernandez

Cognitive-Behavioral Therapy in the Treatment of Anger: A Meta-Analysis

Anger has come to be recognized as a significantsocial problem worthy of clinical attention andsystematic research. In the last two decades,cognitive-behavioral therapy (CBT) has emerged as themost common approach to anger management. Theoverall efficacy of this treatment has not beenascertained, and therefore, it was decided to conduct ameta-analysis of this literature. Based on 50 studiesincorporating 1,640 subjects, it was found that CBT produceda grand mean weighted effect size of .70, indicatingthat the average CBT recipient was better off than 76%of untreated subjects in terms of anger reduction. This effect was statistically significant,robust, and relatively homogeneous across studies. Thesefindings represent a quantitative integration of 20years of research into a coherent picture of theefficacy of CBT for anger management. The results alsoserve as an impetus for continued research on thetreatment of anger.

The utility of cognitive coping strategies for altering pain perception: a meta-analysis

The literature on the utility of cognitive coping strategies in pain control has been unclear because of 2 principal limitations: the lack of a validated classification system, and reliance on qualitative and quasi-statistical reviews. In this study, an empirically based multidimensional taxonomy was employed to categorize the variety of cognitive coping strategies into 6 major classes: external focus of attention, neutral imaginings, pleasant imaginings, dramatized coping, rhythmic cognitive activity and pain acknowledging. Meta-analytic techniques were introduced to evaluate the overall efficacy of cognitive strategies (in comparison to no-treatment controls), the relative efficacy of these strategies (how the different groups of strategies compare with one another), and the substantive efficacy of such strategies (how cognitive strategies fare against placebo/expectancy conditions). Results revealed that, in general, cognitive coping strategies are more effective in alleviating pain as compared to either no-treatment or expectancy controls. Each individual class of strategies significantly attenuates pain although the imagery methods are the most effective whereas pain acknowledging is the least effective. Positive expectancy is no better than no treatment. These findings stand in contrast with previous reviews that have not assigned prime importance to imagery or for that matter have not shown cognitive strategies to be particularly effective. Results are discussed with reference to attentional models and methodological issues.

The scope and significance of anger in the experience of chronic pain

This paper is divided into 3 sections. The first provides the conceptual framework by introducing definitions of anger and related constructs and highlighting pertinent aspects of the concept of pain. The second section examines the evidence for anger as a feature of chronic pain. The available research indicates that chronic pain patients experience anger but this may be underestimated because of denial. In fact, anger stands out as one of the most salient emotional correlates of pain, even though past research has been largely confined to the study of depression and anxiety. the third section explores the significance of anger in chronic pain, in terms of its compounding effects on pain, depression and psychosocial functioning, as well as its consequences for physical health and health habits. The impact of anger among chronic pain patients for treatment outcome is discussed. Finally, the information from these sections is integrated into a model depicting the antecedents and consequences of anger as specifically associated with the chronic pain experience.

Sensory and Affective Components of Pain: Separation and Synthesis

It has become increasingly accepted that pain is not simply a sensation generated by nociceptors, but a perceptual phenomenon with particular emotional qualities. The purpose of this article is to bring together vastly different streams of research on the divisibility of pain into sensory and affective components. Empirical evidence for this divisibility is drawn from recent studies using multivariate statistics, signal detection theory, and unidimensional scaling. An important conclusion is that separable though pain components may be, they are not necessarily independent. In critiquing previous research, new criteria are derived for partitioning pain into sensory and affective components. Finally, speculations are offered as to how these same components might be synthesized on the basis of theories of perceptual organization.

A classification system of cognitive coping strategies for pain

&NA; Cognitive strategies have received considerable interest in pain management, alongside the traditional approaches of physical intervention and behavior modification. However, the literature on these strategies is ridden with inconsistencies of terminology that present major difficulties in the conceptualization and evaluation of different strategies. A new classification scheme is hence proposed in which these strategies are grouped into 3 broad categories: imagery, self‐statements and attention‐diversion — which are further divided into a total of 10 subcategories. Examples are drawn from the literature to illustrate the use of each strategy. The new classification system offers a comprehensive nomenclature for the identification of cognitive coping strategies for pain and provides a basis for guiding research on the relative efficacy of different cognitive strategies in pain management.

Sensory and affective predictors of overall pain and emotions associated with affective pain

OBJECTIVE Psychological scaling techniques consistently produce separate ratings for sensory and affective components of pain. This study examines the relative contributions of these components to pain as a whole and the contributions of different emotions to the affective component of pain. DESIGN The design was correlational. Visual analogue scales were used to quantify overall pain, sensory pain, affective pain, and individual emotions. These data lent themselves to regression techniques for expressing pain as a function of sensation and affect as a function of emotion types. SETTING Data were collected at the Pain Clinic within the Department of Physical Medicine at the Ohio State University. PATIENTS Subjects were 40 chronic pain sufferers admitted to an inpatient pain management program. RESULTS AND CONCLUSIONS Ratings of overall pain were not a simple summation of sensory and affective ratings, but a linearly additive function of both component ratings each with a unique weighting. The affective component of pain was a function of three differentially weighted sets of emotions, anger, fear, and sadness being most salient. Implications arise for the broader assessment of chronic pain and the treatment of specific emotions that may be particularly associated with the pain.

Meta-analysis of dropout from cognitive behavioral therapy: Magnitude, timing, and moderators.

UNLABELLED In this era of insistence on evidence-based treatments, cognitive behavioral therapy (CBT) has emerged as a highly preferred choice for a spectrum of psychological disorders. Yet, it is by no means immune to some of the vagaries of client participation. Special concerns arise when clients drop out from treatment. OBJECTIVE The aim of this study was to answer questions about the rate and timing of dropout from CBT, with specific reference to pretreatment versus during treatment phases. Also explored were several moderators of dropout. METHOD A meta-analysis was performed on dropout data from 115 primary empirical studies involving 20,995 participants receiving CBT for a range of mental health disorders. RESULTS Average weighted dropout rate was 15.9% at pretreatment, and 26.2% during treatment. Dropout was significantly associated with (a) diagnosis, with depression having the highest attrition rate; (b) format of treatment delivery, with e-therapy having the highest rates; (c) treatment setting, with fewer inpatient than outpatient dropouts; and (d) number of sessions, with treatment starters showing significantly reduced dropout as number of sessions increased. Dropout was not significantly associated with client type (adults or adolescents), therapist licensure status, study design (randomized control trial [RCT] vs. non-RCT), or publication recency. CONCLUSIONS Findings are interpreted with reference to other reviews. Possible clinical applications include careful choice and supplementing of treatment setting/delivery according to the diagnosis, and use of preparatory strategies. Suggestions for future research include standardization of operational definitions of dropout, specification of timing of dropout, and exploration of additional moderator variables.

Male circumcision: pain, trauma, and psychosexual sequelae

Infant male circumcision continues despite growing questions about its medical justification. As usually performed without analgesia or anaesthetic, circumcision is observably painful. It is likely that genital cutting has physical, sexual and psychological consequences too. Some studies link involuntary male circumcision with a range of negative emotions and even post-traumatic stress disorder (PTSD). Some circumcised men have described their current feelings in the language of violation, torture, mutilation and sexual assault. In view of the acute as well as long-term risks from circumcision and the legal liabilities that might arise, it is timely for health professionals and scientists to re-examine the evidence on this issue and participate in the debate about the advisability of this surgical procedure on unconsenting minors.

Relative contributions of life events versus daily hassles to the frequency and intensity of headaches

This study investigated headache parameters (frequency and intensity) in relation to (the number and severity of) two types of psychosocial stress: major life events (as assessed by a revised Social Readjustment Rating Scale) and minor daily hassles (as assessed by a revised Hassles Scale). Subjects were 261 volunteers reporting headache. Results revealed that both headache frequency and intensity were significantly predicted by daily hassles, in particular, the average severity of these hassles, but there was a negligible relationship between headache parameters and any of the life event measures. Furthermore, a significant relationship emerged between life events and daily hassles themselves. This fits with recent findings that life events (while exerting little direct effect on headache) may trigger a succession of hassles which culminate in headaches. Also, it is not the number of hassles, but the perceived severity of these hassles that best predicts headache frequency and intensity. Finally, though significant as predictors, daily hassles explained a small portion of the variance in headache, thus pointing to the host of other possible biological and psychosocial contributions to headache.

Association of Anxiety and Depression with Reported Disease Severity in Patients Undergoing Evaluation for Chronic Rhinosinusitis

Objectives: We sought to determine the impact of psychiatric comorbidity on symptom density and resource utilization in chronic rhinosinusitis (CRS). Methods: A prospective cohort of patients who sought evaluation of CRS was studied with the Rhinosinusitis Symptom Inventory and the Hospital Anxiety and Depression Scale. Data concerning symptom scores, symptom domains, and psychiatric comorbidity were analyzed to determine the interactions among psychiatric comorbidity, symptom reporting, and resource utilization in CRS. Results: We studied 143 patients (mean age, 43.4 years). Low, moderate, and high levels of anxiety were reported by 48.3%, 25.9%, and 25.9% of patients, respectively. Low, moderate, and high levels of depression were reported by 76.2%, 9.1%, and 14.7%. For the combined psychopathology group, 43.3%, 25.9%, and 30% had low, moderate, and high levels. Patients with high anxiety levels reported significant elevations of oropharyngeal symptoms (p = .013) and total symptoms (p = .030) in comparison with the low group. Patients with high depression levels reported higher oropharyngeal (p = .003), systemic (p = .001), and total symptom (p = .003) scores than did the low group. High combined psychopathology scores were associated with elevated facial, oropharyngeal, and systemic scores (p < .05). Regarding medical utilization, high anxiety levels or high combined psychopathology scores were associated with more frequent physician visits (p < .05). A high level of depression was associated with increased antibiotic use, missed workdays, and physician visits (p < .05). Conclusions: High levels of anxiety and depression are common in patients who undergo evaluation for CRS. Psychiatric comorbidity is associated with increased symptoms in CRS and increased health-care utilization. Anxiety and depression should be identified in these patients to structure appropriate treatment.