Justin M. Nash

Understanding psychological stress, its biological processes, and impact on primary headache.

Psychological stress is generally acknowledged to be a central contributor to primary headache. Stress results from any challenge or threat, either real or perceived, to normal functioning. The stress response is the bodys activation of physiological systems, namely the hypothalamic‐pituitary‐adrenal axis, to protect and restore functioning. Chronic activation of the stress response can lead to wear and tear that eventually can predispose an individual to disease. There are multiple ways that stress and headache are closely related. Stress can (a) be a predisposing factor that contributes to headache disorder onset, (b) accelerate the progression of the headache disorder into a chronic condition, and (c) precipitate and exacerbate individual headache episodes. How stress impacts headache is not often understood. However, stress is assumed to affect primary headache by directly impacting pain production and modulation processes at both the peripheral and central levels. Stress can also independently worsen headache‐related disability and quality of life. Finally, the headache experience itself can serve as a stressor that compromises an individuals health and well‐being. With the prominent role that stress plays in headache, there are implications for the evaluation of stress and the use of stress reduction strategies at the various stages of headache disorder onset and progression. Future directions can help to develop a better empirical understanding of the pattern of the stress and headache connections and the mechanisms that explain the connections. Further research can also examine the interactive effects of stress and other factors that impact headache disorder onset, course, and adjustment.

The Impact of Apathy and Depression on Quality of Life in Patients Infected with HIV

Apathy refers to decreased self-initiation and goal-directed behavior. Apathy is a relatively common neuropsychiatric symptom associated with HIV, yet the impact of apathy on health-related quality of life (QOL) has not been investigated. We examined the relationship between apathy, depression, and QOL among individuals infected with HIV. Apathy was quantified using the Marin Apathy scale and QOL was measured with the Medical Outcomes Study Short-Form 36 (SF-36). Results of the study revealed that both apathy and depression were more common among patients with HIV than healthy control subjects. Twenty-six percent of the patients with HIV reported clinically significant apathy while 80% of the patients reported clinically significant depression. Apathy did not relate to ratings of overall QOL, but it was modestly associated with ratings of mental health and role disruption secondary to mental health. By contrast, ratings of depression were strongly related to overall QOL and most indices of SF-36. Regression equations revealed that depression and apathy independently contributed to mental health and role disruption secondary to mental health. Importantly, ratings of depression accounted for the majority of variance for ratings of QOL. The findings indicate that while apathy is more common among individuals with HIV compared to healthy control subjects, the impact of apathy on QOL is less significant than depression. Clinicians should continue to focus on depression as an important neuropsychiatric symptom associated with HIV.

Transdisciplinary Training : Key Components and Prerequisites for Success

The training of transdisciplinary science is distinct in its intention to develop scientists who synthesize the theoretical and methodologic approaches of different disciplines. As a result, transdisciplinary scientists are better prepared to address the complexities of health problems. The most common form of transdisciplinary training is the multi-mentor apprenticeship model, with each mentor training from his or her own discipline. The transdisciplinary trainee is faced with many challenges, including learning the languages and cultures of different disciplines along with learning how to navigate within and between disciplines. The trainee also confronts unique career development risks. The climb up the academic ladder can be slower, rougher, and less linear than that of the trainees single-disciplinary-trained peers. A number of factors can help the trainee in overcoming the challenges: being able to develop a core set of values and behaviors that are essential for transdisciplinary scientists; having the commitment and support of training institutions, training directors, and mentors; and having training structures and processes in place to prevent the training and trainee from naturally regressing back to familiar single-disciplinary approaches. There is relatively little known empirically about transdisciplinary training. Future efforts can focus on developing a better understanding of the unique characteristics of transdisciplinary training, identifying the effective elements that relate to training outcomes, defining the critical outcome metrics at different time points during and following training, and creating toolkits to help with training processes.

A comparison of pharmacological (amitriptyline HCL) and nonpharmacological (cognitive-behavioral) therapies for chronic tension headaches

Forty-one recurrent tension headache sufferers were randomly assigned to either cognitive-behavioral therapy (administered in a primarily home-based treatment protocol) or to amitriptyline therapy (with dosage individualized at 25, 50, or 75 mg/day). Cognitive-behavioral therapy and amitriptyline each yielded clinically significant improvements in headache activity, both when improvement was assessed with patient daily recordings (56% and 27% reduction in headache index, respectively), and when improvement was assessed with neurologist ratings of clinical improvement (94% and 69% of patients rated at least moderately improved, respectively). In instances where differences in treatment effectiveness were observed (headache index, somatic complaints, perceptions of control of headache activity), cognitive-behavioral therapy yielded somewhat more positive outcomes than did amitriptyline. Neither treatment, however, eliminated headache problems.

Competencies for psychology practice in primary care.

This article reports on the outcome of a presidential initiative of 2012 American Psychological Association President Suzanne Bennett Johnson to delineate competencies for primary care (PC) psychology in six broad domains: science, systems, professionalism, relationships, application, and education. Essential knowledge, skills, and attitudes are described for each PC psychology competency. Two behavioral examples are provided to illustrate each competency. Clinical vignettes demonstrate the competencies in action. Delineation of these competencies is intended to inform education, practice, and research in PC psychology and efforts to further develop team-based competencies in PC.

Guidelines for Trials of Behavioral Treatments for Recurrent Headache, First Edition: American Headache Society Behavioral Clinical Trials Workgroup

Guidelines for design of clinical trials evaluating behavioral headache treatments were developed to facilitate production of quality research evaluating behavioral therapies for management of primary headache disorders. These guidelines were produced by a Workgroup of headache researchers under auspices of the American Headache Society. The guidelines are complementary to and modeled after guidelines for pharmacological trials published by the International Headache Society, but they address methodologic considerations unique to behavioral and other nonpharmacological treatments. Explicit guidelines for evaluating behavioral headache therapies are needed as the optimal methodology for behavioral (and other nonpharmacologic) trials necessarily differs from the preferred methodology for drug trials. In addition, trials comparing and integrating drug and behavioral therapies present methodological challenges not addressed by guidelines for pharmacologic research. These guidelines address patient selection, trial design for behavioral treatments and for comparisons across multiple treatment modalities (eg, behavioral vs pharmacologic), evaluation of results, and research ethics. Although developed specifically for behavioral therapies, the guidelines may apply to the design of clinical trials evaluating many forms of nonpharmacologic therapies for headache.

Quality of life and well‐being of patients with myasthenia gravis

The cardinal symptom of myasthenia gravis (MG) is weakness of voluntary muscles, a feature that may restrict full participation in life activities. In turn, such limitations may negatively affect quality of life (QOL) and well‐being among individuals with the disease. In the present study, we administered a measure of QOL to 27 patients with generalized MG. Results revealed that functional status was negatively impacted in the domains of physical functioning, energy, and general health. However, a clinically meaningful difference was evident only on perceived ability to accomplish physical tasks. The results suggest that although MG requires accommodations in physical activities, general QOL and well‐being does not differ markedly from the general population.

Migraine and obesity: epidemiology, possible mechanisms and the potential role of weight loss treatment.

Migraine and obesity are two public health problems of enormous scope that are responsible for significant quality of life impairment and financial cost. Recent research suggests that these disorders may be directly related with obesity exacerbating migraine in the form of greater headache frequency and severity, or possibly increasing the risk for having migraine. The relationship between migraine and obesity may be explained through a variety of physiological, psychological and behavioural mechanisms, many of which are affected by weight loss. Given that weight loss might be a viable approach for alleviating migraine in obese individuals, randomized controlled trials are needed to test the effect of weight loss interventions in obese migraineurs. Large‐scale weight loss trials have shown that behavioural interventions, in particular, can produce sustained weight losses and related cardiovascular improvements in patients who are diverse in body weight, age and ethnicity. Consequently, these interventions may provide a useful treatment model for showing whether weight loss reduces headache frequency and severity in obese migraineurs, and offering further insight into pathways through which weight loss might exert an effect.

Vulvodynia: an introduction and critical review of a chronic pain condition

&NA; Vulvodynia, or chronic vulvar discomfort, has become an increasingly recognized complaint in the medical literature. However, classification, assessment, and treatment for vulvodynia have not been universally established. There is a serious need for greater understanding of this disorder since evidence suggests, although not life‐threatening, vulvodynia appears to have a significant impact on quality of life. This article reviews the medical and psychological literature on vulvodynia published since 1983, the first year vulvodynia was recognized as a diagnosis in the medical literature. The purpose of this article is to provide a review of the literature on diagnostic issues, treatment options, and psychosocial sequelae with the aim of highlighting areas in need of future research. Finally, suggestions are made for considering vulvodynia from a multidimensional, chronic pain perspective.

Family physician self-efficacy with screening for inherited cancer risk.

BACKGROUND Recent evidence has shown low and inconsistent rates of family history screening among generalist physicians. Little has been done to investigate the physician factors likely to mediate this behavior. We investigated family physicians’ beliefs about screening their patients for inherited cancer risk, measuring their perceptions of self-efficacy and the importance of screening. METHODS We mailed a cross-sectional, 1-page questionnaire to all active members (691) of the Massachusetts Academy of Family Physicians, measuring their attitudes about predictive genetic cancer screening. RESULTS We received responses from 300 of the 691 members (43%). Although 87% believed screening to be important, less than two thirds believed they were effective in screening. CONCLUSIONS Many family physicians lack confidence in their ability to screen patients for a family history of cancer despite recognizing its importance to their practice.