Howard Schubiner

Pain and emotion: a biopsychosocial review of recent research.

OBJECTIVE AND METHOD Research on emotion and pain has burgeoned. We review the last decades literature, focusing on links between emotional processes and persistent pain. RESULTS Neurobiological research documents the neural processes that distinguish affective from sensory pain dimensions, link emotion and pain, and generate central nervous system pain sensitization. Psychological research demonstrates that greater pain is related to emotional stress and limited emotional awareness, expression, and processing. Social research shows the potential importance of emotional communication, empathy, attachment, and rejection. CONCLUSIONS Emotions are integral to the conceptualization, assessment, and treatment of persistent pain. Research should clarify when to eliminate or attenuate negative emotions, and when to access, experience, and express them. Theory and practice should integrate emotion into cognitive-behavioral models of persistent pain.

Use of complementary/alternative therapies among children in primary care pediatrics

OBJECTIVES To determine the prevalence of and factors associated with use of complementary/alternative therapies (CAM) by pediatric patients seeking primary care. DESIGN AND SETTING A self-report questionnaire was administered to parents/caregivers in 6 general pediatric practices in urban and suburban Detroit from August 1999 to December 1999. RESULTS A total of 1013 questionnaires were completed; 67.5% of the patients were 5 years of age or younger. The overall use of CAM was 12%. Factors in families associated with use of CAM were maternal age greater than 31 years (P =.001), religious affiliation (P =.001), parent/caretaker born outside of the United States (P =.04), and use of CAM by the parent/caretaker or his/her spouse (P =.001). Significant factors associated with the children who used CAM were age greater than 5 years (P =.001), pediatric visit for an illness (P =.05), regular medication use (P =.001), and having an ongoing medical problem (P =.001). The most common types of CAM used were herbs (41%), prayer healing (37%), high-dose vitamin therapy and other nutritional supplements (34.5%), folk/home remedies (28%), massage therapy (19%), and chiropractic (18%). The majority of CAM users (66%) did not report the use of CAM to their primary care physician. A logistic regression analysis revealed that use of CAM by parents/caretakers was the single best predictor of CAM use in a child. CONCLUSION CAM use is significant among children who visit pediatric practices. Pediatricians should inquire about CAM use among patients, particularly those with ongoing medical problems and those with parents/caretakers who use CAM for themselves.

Exposure to violence among inner-city youth

Interpersonal violence is a major cause of morbidity and mortality among adolescents and young adults. In this study, 246 inner city, predominantly black youth (ages 14-23 years) were surveyed regarding their exposure to, and participation in, violent acts. An in-depth psychological interview was also completed. A total of 44% reported they could access a gun within one day, 42% have seen someone shot or knifed, and 22% have seen someone killed. In the preceding 3 months, 18% reported carrying a gun, and 32% had been in a physical fight; 34 subjects were rated by the psychologists as a high risk for involvement in violent acts. Those subjects were more likely to be of lower socioeconomic status (p < 0.01) and to have been physically abused (p < 0.001) but no more likely to be a witness to violent events. Inner-city youth are frequently exposed to violence. Those at risk for perpetration of violence were more likely to be at high risk for most other health-risk behaviors.

Substance Abuse in Patients with Attention-Deficit Hyperactivity Disorder

Attention-deficit hyperactivity disorder (ADHD) is a common disorder in children that frequently persists into adulthood. Studies have found that substance use disorders (SUD) are seen more commonly in those with ADHD than the general population. Although treatment with stimulant medications has been shown to be effective for individuals with ADHD, concern about the use of these agents in this population persists. This review article highlights the research in this area with a focus on the treatment of individuals who present with concomitant ADHD and SUD.Although stimulants can be abused, studies have shown that adolescents who are prescribed stimulants for ADHD have lower rates of SUD than those who are not treated with stimulants.It may be particularly difficult to evaluate adults for the diagnosis of ADHD when SUD is a co-morbid factor. Studies show that 20–30% of adults presenting with SUD have concomitant ADHD and approximately 20–40% of adults with ADHD have histories of SUD. Therefore, it is critical to perform careful diagnostic interviews to discern if patients have either or both of these disorders. Many clinical experts suggest that adults with ADHD and active SUD be treated for the SUD until a period of sobriety persists prior to initiation of specific treatment for ADHD. Since individuals with ADHD and active SUD are more likely to have more severe SUD and a worse prognosis, this approach may not serve many patients, as they relapse prior to obtaining ADHD treatment. Therefore, research has been directed towards determining if the treatment of ADHD with stimulant medications can be safe and effective for the individual with active SUD and concomitant ADHD. An initial trial of methylphenidate in a population of adults with active cocaine dependence and ADHD indicates that this is the case.Individuals with ADHD and SUD can present difficult diagnostic and therapeutic challenges. It appears that the most effective treatment option is to create a programme that uses the most effective treatment modalities available, including both behavioural and medical therapies, along with close supervision and monitoring. Newer medical treatment options of long-acting stimulants and non-stimulants (e.g. atomoxetine) offer effective treatment with a lower risk of abuse potential.

Readability of Pediatric Patient Education Materials Current Perspectives on an Old Problem

Written patient education materials are an important part of ambulatory pediatric practices. We evaluated the readability of 33 representative pediatric education materials using three common formulas: Fog, Fry, and SMOG. The majority of pamphlets had readabilities of grade nine or above. The need to use multiple readability formulas was also demonstrated. Although the three readability formulas were highly correlated, they were significantly different from each other when using a repeated measures analysis of variance (ANOVA) design. In almost half, the readability estimates differed by at least two grade levels. In addition, a large intrapamphlet variability for some pamphlets suggests a need to focus more attention on the readability of multiple sections within a pamphlet, not only on the overall or average readability. We conclude that the readability levels of patient education materials continue to be too high.

The effects of a novel psychological attribution and emotional awareness and expression therapy for chronic musculoskeletal pain: A preliminary, uncontrolled trial

OBJECTIVE Current psychological and behavioral therapies for chronic musculoskeletal pain only modestly reduce pain, disability, and distress. These limited effects may be due to the failure of current therapies: a) to help patients learn that their pain is influenced primarily by central nervous system psychological processes; and b) to enhance awareness and expression of emotions related to psychological trauma or conflict. METHODS We developed and conducted a preliminary, uncontrolled test of a novel psychological attribution and emotional awareness and expression therapy that involves an initial individual consultation followed by 4 group sessions. A series of 72 patients with chronic musculoskeletal pain had the intervention and were assessed at baseline, post-treatment, and 6-month follow-up. RESULTS Participation and satisfaction were high and attrition was low. Intent-to-treat analyses found significant improvements in hypothesized change processes: psychological attributions for pain, emotional awareness, emotional approach coping, and alexithymia. Pain, interference, depression, and distress showed large effect size improvements at post-treatment, which were maintained or even enhanced at 6 months. Approximately two-thirds of the patients improved at least 30% in pain and other outcomes, and one-third of the patients improved 70%. Changes in attribution and emotional processes predicted outcomes. Higher baseline depressive symptoms predicted greater improvements, and outcomes were comparable for patients with widespread vs. localized pain. CONCLUSION This novel intervention may lead to greater benefits than available psychological interventions for patients with chronic musculoskeletal pain, but needs controlled testing.

Patterns of Inattentive and Hyperactive Symptomatology in Cocaine-Addicted and Non-Cocaine-Addicted Smokers Diagnosed with Adult Attention Deficit Hyperactivity Disorder

Abstract Despite a robust relationship between Attention Deficit Hyperactivity Disorder (ADHD) and cigarette smoking, as well as increased prevalence of other substance use disorders in these individuals, little is known about the particular patterns of ADHD symptomatology associated with different forms of drug abuse. The present study compared ADHD adults with and without cocaine dependence (COCDEP) on severity of ADHD symptomatology. Groups did not differ in smoking rate or degree of nicotine dependence. COCDEP ADHD smokers reported significantly more childhood and adult hyperactive/impulsive symptoms, and a higher number of symptoms overall, during adulthood, even after controlling for group differences in age and sex. Our finding of a more severe adult ADHD symptom profile among ADHD smokers with cocaine dependence, accounted for by elevated hyperactive/impulsive but not inattentive features, suggests that cocaine use in smokers with ADHD may be driven by excesses in hyperactivity. These findings have important implications for research, since similarities and differences in patterns and severity of ADHD symptomatology may shed light on drug-specific mechanisms. Our results may also point to improved approaches for treatment of substance abuse based on attention to patterns of ADHD symptomatology specific to different drugs.

Strategies for health education for adolescent patients: A preliminary investigation

OBJECTIVE To determine the effect of unidirectional and bidirectional health education strategies on the amount of patient participation in the discourse between adolescent patients and physicians. METHODS Videotapes of medical interviews between physician and adolescent patients that had been made in an earlier study of the efficacy of a self-report questionnaire were reviewed. An inductive method of content analysis from a small sample of videotapes was used to develop mutually exclusive categories of health education communication strategies from the variety of strategies employed by physicians. Seven different strategies were identified and grouped into two categories, unidirectional and bidirectional. Thirty videotapes were randomly selected (from the 79 available videotapes) and health education segments were identified, categorized, and coded for the amount of time the patient and physician spent talking. Paired students t-tests were used to compare the time spent talking by patients and physicians in the two health education strategy categories. RESULTS The patients consisted of 17 females and 13 males (mean age = 19.3). Two hundred thirty five individual health education strategies were identified, of which 183 (78%) were unidirectional and 52 (22%) were bidirectional. Physicians spent an average of 44.4 seconds talking in the unidirectional strategies, and 11.4 seconds in the bidirectional strategies (p = 0.0001). Patients spent 10.9 seconds and 26.1 seconds talking, respectively, in response to these strategies, (p = 0.07). The ratio of the time spent talking by patients to physicians was 0.14 for the unidirectional strategies and 1.06 for the bidirectional strategies (p = 0.004). CONCLUSIONS Bidirectional health education communication strategies increase the amount of participation of adolescent patients in physician-patient discourse when compared to unidirectional strategies. The implications of these data for health education with adolescent patients are discussed.

Evaluation of two rapid tests for the diagnosis ofChlamydia trachomatis genital infections

The performance of two new enzyme immunoassays (EIA) for the detection ofChlamydia trachomatis in a practice setting was compared. A consecutive series of 207 female patients seen at an inner-city sexually transmitted disease clinic were tested by cell culture, the Kodak SureCell (SC) and Abbott TestPack Chlamydia (TP) EIAs. In addition 210 male patients, selected by physicians on the basis of the fact that multiple urethral samples could be obtained, were tested by cell culture and SC. The prevalence of infection was 19 % in the females and 12.5 % in males. The sensitivity, specificity, positive predictive value and negative predictive value for the SC and TP were 88 %, 95 %, 81 %, 97 % and 59 %, 99 %, 95 %, 91 %, respectively, in the female population. The sensitivity of the SC was significantly greater than that of the TP (p ≤ 0.002). The performance values of the SC in men (in the same order) were 64 %, 96 %, 71 % and 95 %, respectively. The SC in male patients and the TP in female patients had low sensitivity. The sensitivity of the SC in female patients was significantly higher than that of the TP. However, the SC yielded more false positive results. To determine the utility of these tests in a practice setting further studies are required.

Emotional awareness and expression therapy, cognitive behavioral therapy, and education for fibromyalgia: a cluster-randomized controlled trial

Abstract Patients with fibromyalgia (FM) experience increased lifetime levels of psychosocial adversity, trauma, and emotional conflict. To address these risk factors, we developed emotion awareness and expression therapy (EAET) and tested its benefits against an active control condition, FM education, and the fields gold standard intervention for FM, cognitive behavioral therapy (CBT) for symptom management. Adults with FM (N = 230) formed 40 treatment groups, which were randomized to EAET, CBT, or education and given 8, 90-minute sessions. Patient-reported outcomes were assessed at baseline, posttreatment, and 6-month follow-up (primary end point). Retention of patients to follow-up was excellent (90.4%). Intent-to-treat analyses indicated that although EAET did not differ from FM education on pain severity (primary outcome), EAET had significantly better outcomes than FM education on overall symptoms, widespread pain, physical functioning, cognitive dysfunction, anxiety, depression, positive affect, and life satisfaction (between-condition ds ranging from 0.29-0.45 SD) and the percentage of patients reporting being “very much/much” improved (34.8% vs 15.4%). Emotional awareness and expression therapy did not differ from CBT on the primary or most secondary outcomes, but compared to CBT, EAET led to significantly lower FM symptoms (d = 0.35) and widespread pain (d = 0.37) and a higher percentage of patients achieving 50% pain reduction (22.5% vs 8.3%). In summary, an intervention targeting emotional awareness and expression related to psychosocial adversity and conflict was well received, more effective than a basic educational intervention, and had some advantages over CBT on pain. We conclude that EAET should be considered as an additional treatment option for FM.