Karen M. Gil

Conceptualizing and testing random indirect effects and moderated mediation in multilevel models: New procedures and recommendations.

The authors propose new procedures for evaluating direct, indirect, and total effects in multilevel models when all relevant variables are measured at Level 1 and all effects are random. Formulas are provided for the mean and variance of the indirect and total effects and for the sampling variances of the average indirect and total effects. Simulations show that the estimates are unbiased under most conditions. Confidence intervals based on a normal approximation or a simulated sampling distribution perform well when the random effects are normally distributed but less so when they are nonnormally distributed. These methods are further developed to address hypotheses of moderated mediation in the multilevel context. An example demonstrates the feasibility and usefulness of the proposed methods.

Pain coping skills training in the management of osteoarthritic knee pain: A comparative study

The purpose of this study was to determine whether a cognitive-behavioral intervention designed to improve pain coping skills could reduce pain, physical disability, psychological disability, and pain behavior in osteoarthritic knee pain patients. Patients in this study were older adults (mean age=64 years) having persistent pain (mean duration=12 years), who were diagnosed as having osteoarthritis of the knee on the basis of medical evaluation and x-rays. Patients were randomly assigned to one of three conditions: pain coping skills training, arthritis education, or a standard care control condition. Patients in the pain coping skills training condition (n=32) attended 10 weekly group sessions training them to recognize and reduce irrational cognitions and to use attention diversion and changes in activity patterns to control and decrease pain. Arthritis education subjects (n=36) attended 10 weekly group sessions providing them with detailed information on osteoarthritis. Standard care control subjects (n=31) continued with their routine care. Measures of coping strategies, pain, psychological disability, physical disability, medication use, and pain behavior were collected from all subjects before and after treatment. Results indicated that patients receiving pain coping skills training had significantly lower levels of pain and psychological disability post-treatment than patients receiving arthritis education or standard care. Correlational analyses revealed that patients in the pain coping skills training group who reported increases in the perceived effectiveness of their coping strategies were more likely to have lower levels of physical disability post-treatment. Taken together, these findings indicate that pain coping skills training can reduce pain and psychological disability in osteoarthritis patients. Future studies should examine whether behavioral rehearsal or spouse training can strengthen the effects of pain coping skills training in order to reduce physical disability and pain behavior as well as pain and psychological disability.

Sickle cell disease pain: relation of coping strategies to adjustment.

This study examines pain coping strategies in a relatively neglected pain population, sickle cell disease (SCD) patients. Seventy-nine patients diagnosed with SCD were given a structured interview to assess pain, activity level, and health care use during painful episodes. Patients also completed the SCL-90-R as an index of psychological distress and the Coping Strategies Questionnaire. Regression analyses controlled for age, sex, and disease severity measures. Results indicated that the coping strategies factors were important predictors of pain and adjustment. Individuals high on Negative Thinking and Passive Adherence had more severe pain, were less active and more distressed, and used more health care services. Individuals high on Coping Attempts were more active during painful episodes.

Role of child and maternal processes in the psychological adjustment of children with sickle cell disease

In this study, 64% of children aged 7-12 years with sickle cell disease were found to have a parent-reported behavior problem, and 50% met the criteria for a Diagnostic and Statistical Manual of Mental Disorders (3rd ed.) diagnosis based on a structural clinical interview of the child. Internalizing types of behavior problems and diagnoses were the most frequent. Support was provided for a transactional stress and coping model in delineating the processes associated with child adjustment. In particular, maternal anxiety accounted for 16%-33% of the variance in mother-reported internalizing and externalizing behavior problems, respectively, and child pain-coping strategies accounted for 21% of the variance in child-reported adjustment problems.

Osteoarthritic knee pain: a behavioral analysis.

&NA; This study used behavioral assessment techniques to analyze pain in osteoarthritis (OA) patients. Elghty‐seven OA patients having chronic knee pain served as subjects. Pain behavior was evaluated using a standard observation method and functional impairment was assessed using the Arthritis Impact Measurement Scales. Data analysis revealed that pain and limitations in physical activities were the most common functional impairments and that the most frequently observed pain behavior was guarded movement. Predictive analyses indicated that disability support status and scores on a Pain Control and Rational Thinking factor of the Coping Strategies Questionnaire (CSQ) were predictive of functional impairment. Patients receiving disability support payments were much more functionally limited than those not receiving this financial support. Patients scoring high on the Pain Control and Rational Thinking factor of the CSQ were much less functionally impaired, walked a 5 m course more rapidly and moved from a standing to a sitting or reclining position more quickly than patients scoring low on this factor. The implications of these results for behavioral treatment of OA knee pain are discussed.

Daily Mood and Stress Predict Pain, Health Care Use, and Work Activity in African American Adults with Sickle-Cell Disease

This study examined the extent to which daily mood and stress were associated with pain, health care use, and work activity in 41 adults (mean age=36 years) with sickle-cell disease. Multilevel model analyses of daily diaries (M=91 days) indicated that increases in stress and negative mood were associated with increases in same-day pain, health care use, and work absences. Lagged models suggested bidirectional relationships, with evidence that pain may be the more powerful initiating variable in pain-mood and pain-stress cycles. Of importance, positive mood was associated with lower same-day and subsequent day pain, as well as fewer health care contacts, suggesting that positive mood may serve to offset negative consequences of pain and other illness symptoms.

Preparing children for medical examinations: the importance of previous medical experience.

The relationship between past medical experience and childrens response to preparation for medical examinations was investigated in 79 pediatric outpatients aged 3 to 12 years. Children were randomly assigned to one of five preparation conditions prior to receiving a medical examination and a throat culture: sensory information about the exam, training in coping skills (deep breathing and positive self-talk), combined sensory information and coping skills training, attention control, and no-treatment control. The results indicated that children with previous negative medical experiences demonstrated more behavioral distress during a throat culture examination that did children with previous positive or neutral medical experiences. In addition, the attention control condition appeared to increase the distress of children with previous negative medical experiences. Amount of past exposure to the specific medical procedure was not related to observed distress. The implications of these findings for the preparation of children for medical procedures are discussed.

Triggers of uncertainty about recurrence and long-term treatment side effects in older African American and Caucasian breast cancer survivors.

PURPOSE/OBJECTIVES To examine the sources of uncertainty in older African American and Caucasian long-term breast cancer survivors by focusing on frequency of triggers of uncertainty about cancer recurrence and physical symptoms linked to long-term treatment side effects. DESIGN In the context of a larger randomized, controlled treatment-outcome study, data were gathered from 10 monthly follow-up telephone calls by nurses. SETTING Rural and urban regions of North Carolina. SAMPLE 244 older women (mean age = 64 years); 73 African American women and 171 Caucasian women who were five to nine years after breast cancer diagnosis. FINDINGS The most frequent triggers were hearing about someone elses cancer and new aches and pains. The most frequent symptoms were fatigue, joint stiffness, and pain. Although no ethnic differences occurred in the experience of symptoms, Caucasian women were more likely than African American women to report that their fears of recurrence were triggered by hearing about someone elses cancer, environmental triggers, and information or controversy about breast cancer discussed in the media. CONCLUSIONS Illness uncertainty persisted long after cancer diagnosis and treatment, with most women experiencing multiple triggers of uncertainty about recurrence and a range of symptoms and treatment side effects. IMPLICATIONS FOR NURSING Nurses can help cancer survivors to identify, monitor, and manage illness uncertainty and emotional distress.

Social support and pain behavior

&NA; Research has shown that social support is generally associated with better adaptation to chronic disease. However, the role that social support plays in adjustment to chronic pain syndromes has received less research attention. The present study was designed to examine the relation of high versus low levels of social support to pain behavior in chronic pain patients. Fifty‐one patients with chronic pain completed the Social Support Questionnaire (SSQ) and the McGill Pain Questionnaire. Patients were also observed using a standard observation system to assess pain behaviors. In order to compare pain behaviors displayed by subjects with high versus low levels of social support, a median split was performed on the 2 dimensions of the SSQ: (1) satisfaction with support and (2) availability of people for support. The results indicated that pain behavior varied as a function of level of satisfaction with social support. Individuals reporting high satisfaction with social support exhibited significantly higher levels of total pain behavior and higher levels of individual pain behaviors such as guarding, rubbing and bracing. There was no significant difference in total pain behaviors between those high versus low in terms of level of availability of support. There also were no differences between high versus low social support groups in total pain ratings as measured by the McGill Pain Questionnaire. The results are discussed in terms of an operant conditioning perspective on social support. Individuals who are satisfied with the quality of their social support may be satisfied because they receive positive reinforcement from the social environment when they engage in pain behavior.

Experimental induction of pain : utility in the study of clinical pain

Experimental pain methods have been used historically to examine sensory and perceptual mechanisms of pain report and response, generally in healthy populations. However, recent research points to the utility of these methods to investigate a variety of questions related to clinical pain. In this paper, experimental pain induction and measurement are briefly overviewed to provide readers with some background in these techniques. The utility of experimental pain induction techniques are overviewed with respect to three important emerging areas of clinical pain research: a) extending our understanding of the mechanisms of pain report and response, b) assessment and prediction of pain report and response, and c) the use of experimental pain as a vehicle to train pain coping skills and to evaluate their effectiveness in cognitive behavioral treatment. In addition, the unique contribution of each empirical paper in this special series is highlighted with respect to these three emerging areas.