Lachlan A. McWilliams

Mood and anxiety disorders associated with chronic pain: an examination in a nationally representative sample

&NA; Chronic pain and psychiatric disorders frequently co‐occur. However, estimates of the magnitude of these associations have been biased by the use of select clinical samples. The present study utilized the National Comorbidity Survey [Arch. Gen. Psychiatry 51 (1994) 8–19] Part II data set to investigate the associations between a chronic pain condition (i.e. arthritis) and common mood and anxiety disorders in a sample representative of the general US civilian population. Participants (N=5877) completed the Composite International Diagnostic Interview [World Health Organization (1990)], a structured interview for trained non‐clinician interviewers based on the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders [American Psychiatric Association (1987)], and provided self‐reports of pain and disability associated with a variety of medical conditions. Significant positive associations were found between chronic pain and individual 12‐month mood and anxiety disorders [odds ratios (OR) ranged from 1.92 to 4.27]. The strongest associations were observed with panic disorder (OR=4.27) and post‐traumatic stress disorder (OR=3.69). The presence of one psychiatric disorder was not significantly associated with pain‐related disability, but the presence of multiple psychiatric disorders was significantly associated with increased disability. The findings of the present study raise the possibility that improved efforts regarding the detection and treatment of anxiety disorders may be required in pain treatment settings.

Depression and anxiety associated with three pain conditions: results from a nationally representative sample

&NA; Investigations of the relationship between pain conditions and psychopathology have largely focused on depression and have been limited by the use of non‐representative samples (e.g. clinical samples). The present study utilized data from the Midlife Development in the United States Survey (MIDUS) to investigate associations between three pain conditions and three common psychiatric disorders in a large sample (N=3032) representative of adults aged 25–74 in the United States population. MIDUS participants provided reports regarding medical conditions experienced over the past year including arthritis, migraine, and back pain. Participants also completed several diagnostic‐specific measures from the Composite International Diagnostic Interview‐Short Form [Int. J. Methods Psychiatr. Res. 7 (1998) 171], which was based on the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders [American Psychiatric Association 1987]. The diagnoses included were depression, panic attacks, and generalized anxiety disorder. Logistic regression analyses revealed significant positive associations between each pain condition and the psychiatric disorders (Odds Ratios ranged from 1.48 to 3.86). The majority of these associations remained statistically significant after adjusting for demographic variables, the other pain conditions, and other medical conditions. Given the emphasis on depression in the pain literature, it was noteworthy that the associations between the pain conditions and the anxiety disorders were generally larger than those between the pain conditions and depression. These findings add to a growing body of evidence indicating that anxiety disorders warrant further attention in relation to pain. The clinical and research implications of these findings are discussed.

Neuroticism and self-criticism associated with posttraumatic stress disorder in a nationally representative sample

Broad and specific psychological traits may uniquely differentiate trauma victims with PTSD from trauma victims without PTSD, but there is a need for representative, population-based research. We investigated elevated neuroticism and self-criticism in association with the presence versus absence of PTSD in a nationally representative sample of adults who experienced a traumatic stressor. Respondents were from the National Comorbidity Survey Part II (N=5877) (). Individuals who experienced one or more traumatic events were selected (N=3238). In separate regression analyses, elevated levels of neuroticism and self-criticism were each significantly associated with PTSD among men and women who had experienced one or more traumatic events. After controlling for types of traumas experienced and other previously identified factors (Bromet, Sonnega, & Kessler, 1998. American Journal of Epidemiology, 147, 353-361), neuroticism remained significantly associated with PTSD in women and both neuroticism and self-criticism remained significant in men. Evidence from this nationally representative sample of adults who experienced traumatic events suggests that self-criticism and especially the broad personality domain of neuroticism may represent robust psychological dimensions associated with the presence of PTSD.

Impact of adult attachment styles on pain and disability associated with arthritis in a nationally representative sample.

OBJECTIVE The objective of this study was to evaluate Mikail et al.s hypothesis that adult attachment styles are associated with important pain-related variables such as pain and disability levels. DESIGN A cross-sectional design was used to examine the relation between measures of adult attachment styles and both pain and disability. SETTING The data used were obtained from the National Comorbidity Survey, a large and nationally representative sample of community-dwelling individuals aged 15 to 54 years. In the present study, individuals (n = 381) in the National Comorbidity Survey with arthritis or related conditions were included. OUTCOME MEASURES Ratings regarding three adult attachment styles (secure, anxious, and avoidant) were obtained by administering Hazan and Shavers attachment self-report in an interview format. Pain and disability were assessed in a similar manner using four-point rating scales. RESULTS Ratings of insecure attachment were positively and significantly correlated with both pain and disability. A multiple regression analysis revealed that pain severity and the rating of anxious attachment could account for 20.3% of the variance in disability. CONCLUSIONS The attachment theory holds promise for understanding reactions to pain conditions, and Mikail et al.s model warrants further investigation.

How distinct is anxiety sensitivity from trait anxiety? A re-examination from a multidimensional perspective

Abstract Significant positive correlations between the Anxiety Sensitivity Index [ASI; Reiss, S., Peterson, R. A., Gursky, D. M. & McNally, R. J. (1986). Anxiety sensitivity, anxiety frequency and the prediction of fearfulness. Behaviour Research and Therapy, 24, 1–8.] and the Trait subscale of the State-Trait Anxiety Inventory [STAI-T; Spielberger, C. D., Gorsuch, R. L., Lushene, R. E., Vagg, P. R. & Jacobs, G. A. (1983). The state-trait anxiety inventory for adults manual. Palo Alto, CA: Mind Garden.] have been characterized as “moderate” and have been taken to indicate that Anxiety Sensitivity (AS) and Trait Anxiety (TA) are related but distinct constructs [e.g. McNally, R. J. (1999). Theoretical approaches to the fear of anxiety. In S. Taylor Anxiety sensitivity: theory, research, and treatment of the fear of anxiety (pp. 3–16). Mahwah, NJ: Erlbaum.]. The present study was designed to provide a more accurate assessment of the distinction between AS and TA by taking into account the multidimensional nature and the differing symptom focus of the ASI and the STAI-T. University students (n=317) completed both these measures and subscales representing the lower-order constructs of the STAI-T (i.e. Anxiety and Depression) and the ASI (i.e. Physical, Psychological, and Social Concerns) were created. Several comparisons were made regarding the correlations between these measures. Collectively, the results suggest that previous estimates regarding the distinction between AS and TA were reduced due to the use of a measure of TA that is best conceptualized as assessing cognitive symptoms associated with general negative affect and by the failure to consider the different content focus and multidimensional nature of the ASI. Additionally, disattenuated correlations, in which an adjustment is made for the reliability of the measures, were calculated to provide an assessment of the relationship between AS and TA rather than the measures used to operationalize them. These disattenuated correlations indicated the overlap between AS and TA is greater than previously thought. The implications of these findings are discussed.

Associations between pain conditions and borderline personality disorder symptoms: findings from the National Comorbidity Survey Replication.

Objectives:Associations between 4 forms of pain (ie, arthritis, severe/frequent headaches, chronic spinal pain, and other chronic pain) and borderline personality disorder (BPD) symptoms were investigated in the general population. Methods:Data from part II of the National Comorbidity Survey Replication (N=5692) were used. Pain conditions were assessed with self-reports. Arthritis was assessed on a lifetime basis. For the other pain conditions, variables were created to identify those with a remitted condition and those experiencing the condition in the past year. BPD symptoms were assessed with items from the International Personality Disorder Examination Screening Questionnaire. Axis I disorders were assessed with the Composite International Diagnostic Interview. Results:Multiple regression analyses adjusting for sociodemographic variables and past-year psychiatric disorders indicated that those with a history of each pain condition (either remitted or past-year) had higher levels of BPD symptoms relative to those with a lifetime absence of the condition. For each condition, follow-up analyses indicated that those experiencing the condition in the past year had higher levels of BPD symptoms than those reporting a remitted condition. After adjusting for axis I psychiatric disorders, only the difference between the remitted and past-year severe/frequent headache groups remained significant. Discussion:This is the first study to demonstrate that BPD symptoms are positively associated with chronic spinal pain, severe/frequent headaches, and other chronic pain conditions in a sample representative of the general population. The findings also suggest that relationships between remitted pain conditions and BPD symptoms warrant additional study.

Psychometric properties of an index of emotional distress in the U.S. National Comorbidity Survey

Abstract.Background: The National Comorbidity Survey (NCS; Kessler et al. 1994) was a nationwide household survey of the U.S. population designed to produce data on the prevalence and correlates of psychiatric disorders. The NCS dataset is now in public-use format and continues to be widely used for ongoing research efforts. The NCS dataset included a set of 14 items that have face validity as a measure of current emotional distress (depression and anxiety) and could serve as a potentially useful continuous measure of psychological distress. However, there have been no published studies on its psychometric properties and this measure has not yet been utilized by researchers using the NCS dataset. This paper provides an evaluation of the psychometric properties of the NCS Distress Index. Method: The NCS Part II public-use dataset (N = 5877) was used. Detailed diagnostic information was collected along with 14 items assessing current psychological distress and measures of Neuroticism and Openness to Experience. Results: The NCS Distress Index was found to be internally consistent (Alpha = 0.92) and a series of principal-components analyses demonstrated that the measure is most accurately conceptualized as a single-factor measure of general distress. The construct validity of the Distress Index was supported by its associations with the measures of Neuroticism and Openness to Experience. A series of comparisons between diagnostic groups also supported the construct validity of the measure. For example, those with disorders characterized by depressed mood and worry scored higher on the Distress Index than those with disorders characterized by fear and hyperarousal. Conclusions: The NCS Distress Index is a psychometrically sound measure of current emotional distress. Future studies utilizing the NCS public-use dataset could potentially benefit from the inclusion of this measure in addition to more commonly investigated categorical variables such as diagnosable disorders.

Change in Suicidal Ideation After Interdisciplinary Treatment of Chronic Pain

Objectives:To examine suicidal ideation (SI) in individuals with chronic pain, especially change in suicidal thinking after interdisciplinary treatment. Materials and Methods:Consecutive patients (n=250) admitted to a 4-week, group-based chronic pain management program completed measures of pain intensity, functional limitations, depressive symptoms, overall distress, pain catastrophizing, self-perceived burden, and SI at pretreatment and posttreatment. Results:Before treatment, 30 (12.0%) participants were classified as having a high level of SI, 56 (22.4%) had a low level of SI, and 164 (65.6%) reported none. After treatment, there was a significant reduction in SI and improvements in all other outcomes, but there were still some individuals with high (n=22, 8.8%) or low (n=28, 11.2%) levels at discharge. Patients with high SI at baseline differed from those with no suicidal thinking on pretreatment and posttreatment measures of depression, distress, catastrophizing, and self-perceived burden, but not on pain intensity or functional limitations. Patients high in SI endorsed greater pain catastrophizing and self-perceived burden than those low in suicidal thinking. Sustained SI after treatment was associated with higher baseline levels of suicidal thinking and self-perceived burden to others, as well as a more limited overall response to treatment. Discussion:SI was common in individuals with chronic pain, although mostly at a low level. Interdisciplinary treatment may result in reduced suicidal thinking; however, some patients continue to express thoughts of self-harm. Future studies could examine processes of change and interventions for treatment-resistant suicidal concerns.

Testing the Interpersonal Theory of Suicide in Chronic Pain

Objective: The interpersonal theory of suicide offers a conceptual framework for understanding suicidal ideation (SI) that may be applicable to individuals with chronic pain. The theory emphasizes the importance of 2 interpersonal constructs as precursors to SI: perceived burdensomeness (the belief that one has become a burden to others) and thwarted belongingness (a lack of social integration or connection). Our objective was to test the interpersonal theory of suicide in people with chronic pain. Methods: Hierarchical regression analysis was used in a cross-sectional study of 282 patients of an interdisciplinary pain clinic. The Beck Scale for Suicide Ideation was the criterion measure of SI, and independent variables included both general and pain-specific predictors. Results: After adjusting for other known or putative risk factors related to pain and mental health, perceived burdensomeness significantly predicted SI, whereas thwarted belongingness did not. As expected according to theory, the interaction between perceived burdensomeness and thwarted belongingness was also significant; perceived burdensomeness was a strong predictor of SI at high levels of thwarted belongingness, but only marginally at low levels. Other independent predictors were male sex, number of prior suicide attempts, and hopelessness. Discussion: These findings are in line with some, but not all, of the major predictions of the interpersonal theory of suicide. In general, however, they support the relevance of the theory for individuals with chronic pain.

A longitudinal investigation of pain-related social support preferences in a chronic pain treatment sample.

Objectives:Chronic pain patients’ pain-related social support preferences have received little clinical or research attention. However, recent research utilizing the Pain Response Preference Questionnaire (PRPQ) has indicated that such preferences are related to pain-related disability. This study investigated whether pain-related social support preferences: (1) were related to disability levels, (2) predicted changes in pain and disability following a group-based treatment program, and (3) changed from pretreatment to posttreatment. Methods:At pretreatment and posttreatment, chronic pain patients (N=45) participating in a self-management psychoeducation program completed the PRPQ and measures of pain severity and disability. Results:A multiple regression analysis indicated that at pretreatment the Solicitude scale of the PRPQ was positively associated with disability, and that this association was moderated by the other 2 PRPQ scales (Activity Direction and Suppression). The PRPQ scales did not predict changes in pain or disability and there were no significant changes in the PRPQ scale scores. However, participants did not respond to the Solicitude scale in a consistent manner from pretreatment to posttreatment (51.1% decreased, 35.5% increased, and 13.3% remained the same). These changes were unrelated to changes in pain or disability. Discussion:Additional research aimed at identifying the processes underlying the association between pain-related support preferences and disability is warranted. Given the potentially important role that a desire for solicitous support may play in shaping the social context of pain, understanding the unexpected changes in Solicitude scale scores found in the present study may be particularly important for improving self-management treatments for chronic pain.