Niloofar Afari

A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain

Summary Acceptance and commitment therapy (ACT) and cognitive‐behavioral therapy are both effective for pain interference and mood in chronic pain patients; ACT may be more satisfactory. ABSTRACT Individuals reporting chronic, nonmalignant pain for at least 6 months (N = 114) were randomly assigned to 8 weekly group sessions of acceptance and commitment therapy (ACT) or cognitive‐behavioral therapy (CBT) after a 4–6 week pretreatment period and were assessed after treatment and at 6‐month follow‐up. The protocols were designed for use in a primary care rather than specialty pain clinic setting. All participants remained stable on other pain and mood treatments over the course of the intervention. ACT participants improved on pain interference, depression, and pain‐related anxiety; there were no significant differences in improvement between the treatment conditions on any outcome variables. Although there were no differences in attrition between the groups, ACT participants who completed treatment reported significantly higher levels of satisfaction than did CBT participants. These findings suggest that ACT is an effective and acceptable adjunct intervention for patients with chronic pain.

The association of posttraumatic stress disorder and metabolic syndrome: a study of increased health risk in veterans

BackgroundThere is accumulating evidence for a link between trauma exposure, posttraumatic stress disorder (PTSD) and diminished health status. To assess PTSD-related biological burden, we measured biological factors that comprise metabolic syndrome, an important established predictor of morbidity and mortality, as a correlate of long-term health risk in PTSD.MethodsWe analyzed clinical data from 253 male and female veterans, corresponding to five factors linked to metabolic syndrome (systolic and diastolic blood pressure, waist-to-hip ratio and fasting measures of high-density lipoprotein (HDL) cholesterol, serum triglycerides and plasma glucose concentration). Clinical cut-offs were defined for each biological parameter based on recommendations from the World Health Organization and the National Cholesterol Education Program. Controlling for relevant variables including sociodemographic variables, alcohol/substance/nicotine use and depression, we examined the impact of PTSD on metabolic syndrome using a logistic regression model.ResultsTwo-fifths (40%) of the sample met criteria for metabolic syndrome. Of those with PTSD (n = 139), 43% met criteria for metabolic syndrome. The model predicted metabolic syndrome well (-2 log likelihood = 316.650, chi-squared = 23.731, p = 0.005). Veterans with higher severity of PTSD were more likely to meet diagnostic criteria for metabolic syndrome (Wald = 4.76, p = 0.03).ConclusionThese findings provide preliminary evidence linking higher severity of PTSD with risk factors for diminished health and increased morbidity, as represented by metabolic syndrome.

Psychological Trauma and Functional Somatic Syndromes: A Systematic Review and Meta-analysis

Objective This meta-analysis systematically examined the association of reported psychological trauma and posttraumatic stress disorder (PTSD) with functional somatic syndromes including fibromyalgia, chronic widespread pain, chronic fatigue syndrome, temporomandibular disorder, and irritable bowel syndrome. Our goals were to determine the overall effect size of the association and to examine moderators of the relationship. Methods Literature searches identified 71 studies with a control or comparison group and examined the association of the syndromes with traumatic events including abuse of a psychological, emotional, sexual, or physical nature sustained during childhood or adulthood, combat exposure, or PTSD. A random-effects model was used to estimate the pooled odds ratio and 95% confidence interval. Planned subgroup analyses and meta-regression examined potential moderators. Results Individuals who reported exposure to trauma were 2.7 (95% confidence interval = 2.27–3.10) times more likely to have a functional somatic syndrome. This association was robust against both publication bias and the generally low quality of the literature. The magnitude of the association with PTSD was significantly larger than that with sexual or physical abuse. The association of reported trauma with chronic fatigue syndrome was larger than the association with either irritable bowel syndrome or fibromyalgia. Studies using nonvalidated questionnaires or self-report of trauma reported larger associations than did those using validated questionnaires. Conclusions Findings are consistent with the hypothesis that traumatic events are associated with an increased prevalence of functional somatic syndromes. The analyses also highlight limitations of the existing literature and emphasize the importance of prospective studies, examining the potential similarities and differences of these conditions, and pursuing hypothesis-driven studies of the mechanisms underlying the link between trauma, PTSD, and functional somatic syndromes.

Evidence for Overlap Between Urological and Nonurological Unexplained Clinical Conditions

PURPOSE Unexplained clinical conditions share common features such as pain, fatigue, disability out of proportion to physical examination findings, inconsistent laboratory abnormalities, and an association with stress and psychosocial factors. We examined the extent of the overlap among urological and nonurological unexplained clinical conditions characterized by pain. We describe the limitations of previous research and suggest several possible explanatory models. MATERIALS AND METHODS Using hallmark symptoms and syndromes as search terms a search of 12 databases identified a total of 1,037 full-length published articles in 8 languages from 1966 to April 2008. The search focused on the overlap of chronic pelvic pain, interstitial cystitis, painful bladder syndrome, chronic prostatitis/chronic pelvic pain syndrome or vulvodynia with fibromyalgia, chronic fatigue syndrome, temporomandibular joint and muscle disorders or irritable bowel syndrome. We abstracted information on authorship, type of case and control groups, eligibility criteria, case definitions, study methods and major findings. RESULTS The literature suggests considerable comorbidity between urological and nonurological unexplained clinical conditions. The most robust evidence for overlap was for irritable bowel syndrome and urological unexplained syndromes with some estimates of up to 79% comorbidity between chronic pelvic pain and symptoms of irritable bowel syndrome. However, most studies were limited by methodological problems, such as varying case definitions and selection of controls. CONCLUSIONS The overlap between urological and selected nonurological unexplained clinical conditions is substantial. Future research should focus on using standardized definitions, and rigorously designed, well controlled studies to further assess comorbidity, clarify the magnitude of the association and examine common pathophysiological mechanisms.

Feeling Bad in More Ways than One: Comorbidity Patterns of Medically Unexplained and Psychiatric Conditions

BackgroundConsiderable overlap in symptoms and disease comorbidity has been noted among medically unexplained and psychiatric conditions seen in the primary care setting, such as chronic fatigue syndrome, low back pain, irritable bowel syndrome, chronic tension headache, fibromyalgia, temporomandibular joint disorder, major depression, panic attacks, and posttraumatic stress disorder.ObjectiveTo examine interrelationships among these 9 conditions.DesignUsing data from a cross-sectional survey, we described associations and used latent class analysis to investigate complex interrelationships.Participants3,982 twins from the University of Washington Twin Registry.MeasurementsTwins self-reported a doctor’s diagnosis of the conditions.ResultsComorbidity among these 9 conditions far exceeded chance expectations; 31 of 36 associations were significant. Latent class analysis yielded a 4-class solution. Class I (2% prevalence) had high frequencies of each of the 9 conditions. Class II (8% prevalence) had high proportions of multiple psychiatric diagnoses. Class III (17% prevalence) participants reported high proportions of depression, low back pain, and headache. Participants in class IV (73% prevalence) were generally healthy. Class I participants had the poorest markers of health status.ConclusionsThese results support theories suggesting that medically unexplained conditions share a common etiology. Understanding patterns of comorbidity can help clinicians care for challenging patients.

Post-traumatic stress disorder among patients with chronic pain and chronic fatigue

BACKGROUND Fibromyalgia (FM), a chronic pain condition of unknown aetiology often develops following a traumatic event. FM has been associated with post-traumatic stress disorder (PTSD) and major depression disorder (MDD). METHOD Patients seen in a referral clinic (N=571) were evaluated for FM and chronic fatigue syndrome (CFS) criteria. Patients completed questionnaires, and underwent a physical examination and a structured psychiatric evaluation. Critical components of the diagnostic criteria of FM (tender points and diffuse pain) and CFS (persistent debilitating fatigue and four of eight associated symptoms) were examined for their relationship with PTSD. RESULTS The prevalence of lifetime PTSD was 20% and lifetime MDD was 42%. Patients who had both tender points and diffuse pain had a higher prevalence of PTSD (OR=3.4, 95% CI 2.0-5.8) compared with those who had neither of these FM criteria. Stratification by MDD and adjustment for sociodemographic factors and chronic fatigue revealed that the association of PTSD with FM criteria was confined to those with MDD. Patients with MDD who met both components of the FM criteria had a three-fold increase in the prevalence of PTSD (95% CI 1.5-7.1); conversely, FM patients without MDD showed no increase in PTSD (OR=1.3, 95% CI 0.5-3.2). The components of the CFS criteria were not significantly associated with PTSD. CONCLUSION Optimal clinical care for patients with FM should include an assessment of trauma in general, and PTSD in particular. This study highlights the importance of considering co-morbid MDD as an effect modifier in analyses that explore PTSD in patients with FM.

Chronic Pain, Overweight, and Obesity: Findings from a Community-Based Twin Registry

UNLABELLED Chronic pain and obesity, and their associated impairments, are major health concerns. We estimated the association of overweight and obesity with 5 distinct pain conditions and 3 pain symptoms, and examined whether familial influences explained these relationships. We used data collected from 3,471 twins in the community-based University of Washington Twin Registry. Twins reported sociodemographic data, current height and weight, chronic pain diagnoses and symptoms, and lifetime depression. Overweight and obese were defined as body mass index of 25.0 to 29.9 kg/m(2) and >or= 30.0 kg/m(2), respectively. Generalized estimating equation regression models, adjusted for age, gender, depression, and familial/genetic factors, were used to examine the relationship between chronic pain, and overweight and obesity. Overall, overweight and obese twins were more likely to report low back pain, tension-type or migraine headache, fibromyalgia, abdominal pain, and chronic widespread pain than normal-weight twins after adjustment for age, gender, and depression. After further adjusting for familial influences, these associations were diminished. The mechanisms underlying these relationships are likely diverse and multifactorial, yet this study demonstrates that the associations can be partially explained by familial and sociodemographic factors, and depression. Future longitudinal research can help to determine causality and underlying mechanisms. PERSPECTIVE This article reports on the familial contribution and the role of psychological factors in the relationship between chronic pain, and overweight and obesity. These findings can increase our understanding of the mechanisms underlying these 2 commonly comorbid sets of conditions.

Acceptance and Commitment Therapy for Generalized Anxiety Disorder in Older Adults: A Preliminary Report

Some evidence suggests that acceptance-based approaches such as Acceptance and Commitment Therapy (ACT) may be well-suited to geriatric generalized anxiety disorder (GAD). The primary goal of this project was to determine whether ACT was feasible for this population. Seven older primary-care patients with GAD received 12 individual sessions of ACT; another 9 were treated with cognitive-behavioral therapy. No patients dropped out of ACT, and worry and depression improved. Findings suggest that ACT may warrant a large-scale investigation with anxious older adults.

PTSD, combat injury, and headache in Veterans Returning from Iraq/Afghanistan

Objective.— To examine the relationship between posttraumatic stress disorder, combat injury, and headache in Operation Iraqi Freedom and Operation Enduring Freedom veterans at the VA San Diego Healthcare System.

The MAPP research network: design, patient characterization and operations

BackgroundThe “Multidisciplinary Approach to the Study of Chronic Pelvic Pain” (MAPP) Research Network was established by the NIDDK to better understand the pathophysiology of urologic chronic pelvic pain syndromes (UCPPS), to inform future clinical trials and improve clinical care. The evolution, organization, and scientific scope of the MAPP Research Network, and the unique approach of the network’s central study and common data elements are described.MethodsThe primary scientific protocol for the Trans-MAPP Epidemiology/Phenotyping (EP) Study comprises a multi-site, longitudinal observational study, including bi-weekly internet-based symptom assessments, following a comprehensive in-clinic deep-phenotyping array of urological symptoms, non-urological symptoms and psychosocial factors to evaluate men and women with UCPPS. Healthy controls, matched on sex and age, as well as “positive” controls meeting the non-urologic associated syndromes (NUAS) criteria for one or more of the target conditions of Fibromyalgia (FM), Chronic Fatigue Syndrome (CFS) or Irritable Bowel Syndrome (IBS), were also evaluated. Additional, complementary studies addressing diverse hypotheses are integrated into the Trans-MAPP EP Study to provide a systemic characterization of study participants, including biomarker discovery studies of infectious agents, quantitative sensory testing, and structural and resting state neuroimaging and functional neurobiology studies. A highly novel effort to develop and assess clinically relevant animal models of UCPPS was also undertaken to allow improved translation between clinical and mechanistic studies. Recruitment into the central study occurred at six Discovery Sites in the United States, resulting in a total of 1,039 enrolled participants, exceeding the original targets. The biospecimen collection rate at baseline visits reached nearly 100%, and 279 participants underwent common neuroimaging through a standardized protocol. An extended follow-up study for 161 of the UCPPS participants is ongoing.DiscussionThe MAPP Research Network represents a novel, comprehensive approach to the study of UCPPS, as well as other concomitant NUAS. Findings are expected to provide significant advances in understanding UCPPS pathophysiology that will ultimately inform future clinical trials and lead to improvements in patient care. Furthermore, the structure and methodologies developed by the MAPP Network provide the foundation upon which future studies of other urologic or non-urologic disorders can be based.Trial registrationClinicalTrials.gov identifier: NCT01098279 “Chronic Pelvic Pain Study of Individuals with Diagnoses or Symptoms of Interstitial Cystitis and/or Chronic Prostatitis (MAPP-EP)”. http://clinicaltrials.gov/show/NCT01098279