Gema T. Ruiz-Párraga

The contribution of posttraumatic stress symptoms to chronic pain adjustment.

OBJECTIVES To examine whether there are differences between non-trauma-exposed, trauma-exposed without posttraumatic stress symptoms (PSS), and trauma-exposed with PSS chronic musculoskeletal pain patients in vulnerability, protective, and pain-adjustment variables; to test the interactive relationship between PSS and the vulnerability and protective psychological variables across pain adjustment in the group of trauma-exposed-patients. METHOD Seven hundred and fourteen patients with chronic musculoskeletal pain were assessed. Of these, 346 patients (244 women and 102 men) completed the study (117 non-trauma-exposed, 119 trauma-exposed without PSS, and 110 trauma-exposed with PSS). The instruments used were the Stressful Life Event Screening Questionnaire Revised, Davidson Trauma Scale, Anxiety Sensitivity Index, Acceptance and Action Questionnaire, Pain Catastrophizing Scale, Fear-Avoidance Beliefs Questionnaire, Pain Anxiety Symptoms Scale, Pain Vigilance and Awareness Questionnaire, Resilience Scale, Chronic Pain Acceptance Questionnaire, Pain Numerical Rating Scale, Roland Morris Disability Questionnaire, and Hospital Anxiety and Depression Scale. RESULTS Eight ANCOVAs showed that there were statistically significant differences in vulnerability, protection, and pain adjustment variables between the trauma-exposed with PSS patients and the other 2 groups. The moderated multiple regression analyses showed that PSS added a significantly incremental variance to pain intensity, emotional distress, and disability when interacting with vulnerability and protection variables. CONCLUSION The current study supports the models of posttraumatic stress and chronic pain, such as the mutual maintenance and the shared vulnerability theories, providing an initial comprehensive framework for understanding the comorbidity of both disorders.

The role of experiential avoidance, resilience and pain acceptance in the adjustment of chronic back pain patients who have experienced a traumatic event: a path analysis.

BackgroundThe degree to which shared vulnerability and protective factors for chronic pain and trauma-related symptoms contribute to pain adjustment in chronic pain patients who have experienced a traumatic event remains unclear.PurposeThe purpose is to test a hypothetical model of the contribution of experiential avoidance, resilience and pain acceptance to pain adjustment in a sample of 229 chronic back pain patients who experienced a traumatic event before the onset of pain.MethodsStructural equation modelling was used to test the linear relationships between the variables.ResultsThe empirical model shows significant relationships between the variables: resilience on pain acceptance and trauma-related symptoms, experiential avoidance on trauma-related symptoms and experiential avoidance, pain acceptance and trauma-related symptoms on pain adjustment.ConclusionsThis study demonstrates the role of a vulnerability pathway (i.e. experiential avoidance) and a protective pathway (i.e. resilience and pain acceptance) in adaptation to pain after a traumatic event.

A confirmatory factor analysis of the Resilience Scale adapted to chronic pain (RS-18): new empirical evidence of the protective role of resilience on pain adjustment

PurposeRecent attention has focused on resilience as an important process in the experience and management of chronic pain. In this context, resilience is considered as a psychological factor that promotes adaptive responses to pain and pain-related life adversities. Current research suggests that it is a relevant variable in the prediction of pain adjustment among chronic pain patients. Recently, it was adapted the Resilience Scale to patients suffering chronic musculoskeletal pain (RS-18). The aims of this study were to confirm the internal structure of the RS-18 and to present new empirical evidence regarding its validity.MethodsA sample of 592 patients with chronic musculoskeletal back pain completed a battery of instruments to assess resilience, anxiety sensitivity, catastrophizing, fear-avoidance beliefs, hypervigilance, pain acceptance, and pain adjustment variables (pain intensity, emotional distress, functional impairment, and daily functioning).ResultsConfirmatory factor analysis supported the validity of the RS-18 and a single-factor solution. A series of moderated multiple regression analysis showed that resilience is a relevant psychological variable that not only independently predicts better pain adjustment, but also moderates the relationships between several psychological pain-related variables and pain adjustment variables.ConclusionsThese findings give empirical support to the consideration of resilience as a protective variable in chronic pain adjustment and highlight the consideration that improving resilient behaviour could be an important target for the treatment of pain patients.

Physical Health Consequences of Interpersonal Trauma: A Systematic Review of the Role of Psychological Variables:

Interpersonal forms of trauma are among the most commonly reported traumas. These types of traumas are more damaging to well-being than noninterpersonal forms. They have also been strongly associated with somatic symptoms and more general physical health problems. Nevertheless, the results of trauma studies are mixed and suggest that pathways may vary according to the stressors, mediators, and health outcomes investigated. This article presents a systematic qualitative review of published studies that have investigated interpersonal trauma, its association with physical health, and the potential role of intervening psychological variables. A systematic search was made of four psychology and health electronic databases. Of the 863 studies reviewed, 50 were preselected, 11 of which met the inclusion and methodological quality criteria. All but one study had a cross-sectional design. The findings showed that childhood trauma exposure was the most common category of interpersonal trauma addressed in the reviewed studies and that the physical health variables investigated were diverse. The psychological variables most frequently investigated in the studies were posttraumatic stress disorder, depression, dissociation, and substance abuse. Overall, the results suggest that interpersonal trauma exposure is associated with poorer physical health; however, the role of intervening psychological variables remains unclear. The limitations of the reviewed literature are discussed, and methodological recommendations are made for future research.

970 THE ROLE OF RESILIENCE AND ACCEPTANCE VERSUS CATASTROPHIZING AND PAIN-RELATED FEAR IN CHRONIC PAIN ADJUSTMENT

Background and Aims: Children endure an array of painful medical procedures starting at birth and continuing through adolescence. Most children can cope in these situations, but a few are distressed due to bad experiences and/or incapability of coping. The aims of this study were both to support children/adolescents that needed to undergo medical procedures and provide them with individual coping strategies easy to use in similar clinical circumstances. Methods: The criteria for inclusion were an established extreme fear of needles, that the patient was motivated to participate and that necessary medical procedures were impossible to carry out. An individual plan for treatment was created together with the patient. The treatment consisted of both education and training of coping strategies. E-mail communication made each child/adolescent involved in the decisions of the treatment. The purposes of the treatment sessions were to create a feeling of trust in the situation and to find individual coping strategies. A questionnaire evaluated the treatment. Results: Twenty-one children (4–18 years) were invited and 18 choose to participate. Two nurses were responsible for the treatment sessions and a play therapist was engaged in children younger than 6 years. Number of treatment sessions was median three and ranging between two and ten. Thirteen participants underwent the medical procedure by using positive coping strategies. Five participants were able to go through the procedures but were still lacking enough useful coping strategies. Conclusion: We have found a way to help children and adolescents cope with extreme fear of needles.

The Key Role of Pain Catastrophizing in the Disability of Patients with Acute Back Pain

PurposeThis study investigated the role of anxiety sensitivity, resilience, pain catastrophizing, depression, pain fear-avoidance beliefs, and pain intensity in patients with acute back pain-related disability.MethodTwo hundred and thirty-two patients with acute back pain completed questionnaires on anxiety sensitivity, resilience, pain catastrophizing, fear-avoidance beliefs, depression, pain intensity, and disability.ResultsA structural equation modelling analysis revealed that anxiety sensitivity was associated with pain catastrophizing, and resilience was associated with lower levels of depression. Pain catastrophizing was positively associated with fear-avoidance beliefs and pain intensity. Depression was associated with fear-avoidance beliefs, but was not associated with pain intensity. Finally, catastrophizing, fear-avoidance beliefs, and pain intensity were positively and significantly associated with acute back pain-related disability.ConclusionAlthough fear-avoidance beliefs and pain intensity were associated with disability, the results showed that pain catastrophizing was a central variable in the pain experience and had significant direct associations with disability when pain was acute. Anxiety sensitivity appeared to be an important antecedent of catastrophizing, whereas the influence of resilience on the acute back pain experience was limited to its relationship with depression.

Activity Pattern Profiles: Relationship With Affect, Daily Functioning, Impairment, and Variables Related to Life Goals

The aim of this cross-sectional study was to identify subgroups of patients on the basis of their activity patterns and to investigate their relationship with life goals, optimism, affect, and functioning. The sample was comprised of 276 patients with chronic musculoskeletal pain. Hierarchical cluster analysis was performed on the activity pattern variables and the resulting clusters were compared using 1-way analysis of variance. The 4-cluster was the optimal solution. The 4 clusters comprised: 1) avoiders: patients with high levels of avoidance and low levels of persistence, who use pacing to reduce pain, 2) doers: patients with high levels of persistence and low levels of pacing and avoidance, 3) extreme cyclers: patients with high levels of avoidance and persistence and low levels of pacing, and 4) medium cyclers: patients with moderately high levels of avoidance and persistence and high levels of pacing. Comparison of the clusters showed that doers had the most adaptive profile, whereas avoiders, followed by extreme cyclers, had unhealthy profiles. Doers showed a high level of optimism and a good balance between goal value, expectancy, and conflict. PERSPECTIVE It is useful to distinguish profiles on the basis of various activity patterns. In contrast to profiles characterized by avoidance, profiles characterized by high persistence and low avoidance were associated with adaptive results. Patients with this profile also showed a high level of optimism and a good balance between goal value, expectancy, and conflict.

Spanish Version of the Avoidance-Endurance Questionnaire: Factor Structure and Psychometric Properties

To analyze the factorial structure and psychometric properties of the Spanish adaptation of the AEQ, and to validate it by reporting relevant pain-related variables, which were not investigated in the original study. One hundred and fifty Spanish patients diagnosed with chronic back and neck pain were referred by physicians from different pain clinics in Spain; all the patients filled out the questionnaires at their clinic. A series of principal components analyses (PCA) was performed to develop the Spanish version of the AEQ. Reliability and validity were also calculated. The PCAs revealed five fear-avoidance scales (Kaiser-Meyer-Olkin measures were between .60 and .88, and Bartletts tests were significant, p .73) and suitable validity (p < .05). New results associated with pain-related cognitive/affective and behavioural responses are discussed. This instrument will probably help clinicians to identify Spanish patients at a high risk of chronicity and to develop treatments tailored to the different profiles in order to improve secondary and tertiary prevention in back and neck pain.

Optimism, positive and negative affect, and goal adjustment strategies: their relationship to activity patterns in patients with chronic musculoskeletal pain

Objective Activity patterns are the product of pain and of the self-regulation of current goals in the context of pain. The aim of this study was to investigate the association between goal management strategies and activity patterns while taking into account the role of optimism/pessimism and positive/negative affect. Methods Two hundred and thirty-seven patients with chronic musculoskeletal pain filled out questionnaires on optimism, positive and negative affect, pain intensity, and the activity patterns they employed in dealing with their pain. Questionnaires were also administered to assess their general goal management strategies: goal persistence, flexible goal adjustment, and disengagement and reengagement with goals. Results Structural equation modelling showed that higher levels of optimism were related to persistence, flexible goal management, and commitment to new goals. These strategies were associated with higher positive affect, persistence in finishing tasks despite pain, and infrequent avoidance behaviour in the presence or anticipation of pain. Conclusions The strategies used by the patients with chronic musculoskeletal pain to manage their life goals are related to their activity patterns.

Behavioral Inhibition and Activation Systems, and Emotional Regulation in Individuals With Chronic Musculoskeletal Pain

Grays Reinforcement Sensitivity Theory postulates two distinct neurophysiological systems that underlie thoughts, emotions, and behavior: the Behavioral Inhibition System (BIS) and the Behavioral Approach System (BAS). Preliminary research suggests that both systems may play relevant roles in the adjustment of individuals with chronic pain. However, there is a lack of research on the extent to which emotional regulation (i.e., cognitive reappraisal and expressive suppression) mediates the associations between BIS and BAS activation and emotional responses in individuals with chronic pain. The aim of this study was to test a model of the associations between the BIS and BAS, cognitive reappraisal and expressive suppression, and positive and negative affect in individuals with chronic musculoskeletal pain. In total, 516 participants were interviewed. Structural Equation Modeling was used to estimate the associations between variables. The empirical model showed a good fit to the data (χ2/df = 1.95; RMSEA = 0.04; GFI = 0.99; AGFI = 0.98; CFI = 0.99). The hypothesized model received partial support. The BIS was associated with cognitive reappraisal and expressive suppression; cognitive reappraisal was associated with negative and positive affect; expressive suppression was positively associated with affect; and the BAS was not associated with the emotional regulation strategies assessed. However, the BIS and BAS were both directly associated with negative and positive affect. The results suggest that individuals with chronic pain with higher BIS activation appear to use greater expressive suppression. Cognitive reappraisal strongly mediated the BIS-negative affect association. The results also suggest that BAS activation may have a weak or inconsistent association with emotional regulation approaches in individuals with chronic pain. These data provide new and relevant information on the potential role of the BIS and BAS as predictors of psychological functioning in individuals with chronic pain. They suggest that the BIS-BAS model of chronic pain may need to be modified to take into account the potential negative effects of BAS activation. The findings suggest that treatments for emotional regulation could potentially reduce the negative impact of chronic pain via BIS.