Samantha D. Outcalt

Association between anxiety, health-related quality of life and functional impairment in primary care patients with chronic pain.

OBJECTIVE Anxiety and chronic pain are prevalent and frequently co-occur. Our purpose was to examine the association between anxiety, health-related quality of life (HRQL) and functional impairment in primary care patients with chronic musculoskeletal pain. METHODS Data were drawn from baseline interviews of the 250 primary care patients enrolled in the Stepped Care to Optimize Pain care Effectiveness trial. Validated measures were used to determine the proportion of patients screening positive for five common anxiety disorders: generalized anxiety, panic, social anxiety, posttraumatic stress and obsessive-compulsive disorder. Bivariate analyses examined associations between the type and number of anxiety disorders for which patients screened positive and representative pain, psychological and other HRQL outcomes. Multivariable models controlling for major depression and other covariates examined the association between the number of screen-positive anxiety conditions and functional impairment in psychological [SF-12 mental component summary (MCS) score], pain [Brief Pain Inventory (BPI) interference score] and work (disability days) domains. RESULTS One hundred fourteen (45%) patients screened positive for at least one anxiety disorder and, compared to the 136 screen-negative patients, had significantly worse scores across multiple pain, psychological and other HRQL domains. Substantial impairment was seen for each of the five screen-positive anxiety conditions and progressively worsened as the number of conditions increased from one (n=54) to two (n=26) to ≥3 (n=34). The number of screen-positive anxiety conditions was strongly associated (P<.0001) with worse BPI interference and MCS scores and more disability days in models adjusting for age, sex and medical comorbidity. After further adjusting for major depression, associations were attenuated but remained significant for BPI interference (P<.0001) and MCS (P=.018) and marginally significant for disability days (P=.062). CONCLUSION Nearly half of primary care patients with chronic pain screen positive for one or more anxiety disorders, which in turn are adversely associated with impairment across multiple domains of HRQL. Detecting and treating anxiety may be an important component of pain management.

Evaluation of Stepped Care for Chronic Pain (ESCAPE) in Veterans of the Iraq and Afghanistan Conflicts: A Randomized Clinical Trial

IMPORTANCE Despite the prevalence and the functional, psychological, and economic impact of chronic pain, few intervention studies of treatment of chronic pain in veterans have been performed. OBJECTIVE To determine whether a stepped-care intervention is more effective than usual care, as hypothesized, in reducing pain-related disability, pain interference, and pain severity. DESIGN, SETTING, AND PARTICIPANTS We performed a randomized clinical trial comparing stepped care with usual care for chronic pain. We enrolled 241 veterans from Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn with chronic (>3 months) and disabling (Roland Morris Disability Scale score, ≥7) musculoskeletal pain of the cervical or lumbar spine or extremities (shoulders, knees, and hips) in the Evaluation of Stepped Care for Chronic Pain (ESCAPE) trial from December 20, 2007, through June 30, 2011. The 9-month follow-up was completed by April 2012. Patients received treatment at a postdeployment clinic and 5 general medicine clinics at a Veterans Affairs medical center. INTERVENTIONS Step 1 included 12 weeks of analgesic treatment and optimization according to an algorithm coupled with pain self-management strategies; step 2, 12 weeks of cognitive behavioral therapy. All intervention aspects were delivered by nurse care managers. MAIN OUTCOMES AND MEASURES Pain-related disability (Roland Morris Disability Scale), pain interference (Brief Pain Inventory), and pain severity (Graded Chronic Pain Scale). RESULTS The primary analysis included 121 patients receiving the stepped-care intervention and 120 patients receiving usual care. At 9 months, the mean decrease from baseline in the Roland Morris Disability Scale score was 1.7 (95% CI, -2.6 to -0.9) points in the usual care group and 3.7 (95% CI, -4.5 to -2.8) points in the intervention group (between-group difference, -1.9 [95% CI, -3.2 to -0.7] points; P=.002). The mean decrease from baseline in the Pain Interference subscale score of the Brief Pain Inventory was 0.9 points in the usual care group and 1.7 points in the intervention group (between-group difference, -0.8 [95% CI, -1.3 to -0.3] points; P=.003). The Graded Chronic Pain Scale severity score was reduced by 4.5 points in the usual care group and 11.1 points in the intervention group (between-group difference, -6.6 [95% CI, -10.5 to -2.7] points; P=.001). CONCLUSIONS AND RELEVANCE A stepped-care intervention that combined analgesics, self-management strategies, and brief cognitive behavioral therapy resulted in statistically significant reductions in pain-related disability, pain interference, and pain severity in veterans with chronic musculoskeletal pain. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00386243.

Chronic pain and comorbid mental health conditions: independent associations of posttraumatic stress disorder and depression with pain, disability, and quality of life

Abstract Both posttraumatic stress disorder (PTSD) and depression are highly comorbid with chronic pain and have deleterious effects on pain and treatment outcomes, but the nature of the relationships among chronic pain, PTSD, and depression has not been fully elucidated. This study examined 250 Veterans Affairs primary care patients with moderate to severe chronic musculoskeletal pain who participated in a randomized controlled pain treatment trial. Baseline data were analyzed to examine the independent associations of PTSD and major depression with multiple domains of pain, psychological status, quality of life, and disability. PTSD was strongly associated with these variables and in multivariate models, PTSD and major depression each had strong independent associations with these domains. PTSD demonstrated similar relationships as major depression with psychological, quality of life, and disability outcomes and significant but somewhat smaller associations with pain. Because PTSD and major depression have independent negative associations with pain, psychological status, quality of life, and disability, it is important for clinicians to recognize and treat both mental disorders in patients with chronic pain.

Negative symptoms and poor insight as predictors of the similarity between client and therapist ratings of therapeutic alliance in cognitive behavior therapy for patients with schizophrenia.

Recent studies have found that clients with schizophrenia rate therapeutic alliance more highly than therapists. Unclear is whether there are clinical characteristics which predict the degree of difference in client and therapist ratings. To explore this, we correlated client and therapist ratings of therapeutic alliance with baseline assessments of positive negative, and disorganized symptoms and awareness of need for treatment. Participants were 40 adults with schizophrenia enrolled in a 6-month program of cognitive behavior therapy. Results indicated that clients produced higher ratings of therapeutic alliance than therapists and that therapist and client general ratings were more disparate when clients had fewer negative symptoms and better insight. Higher overall client ratings of therapeutic alliance were linked to lower levels of positive, negative, and disorganized symptoms and better awareness of need for treatment. Higher overall therapist ratings were linked only to lower levels of disorganized symptoms among clients.

Pain experience of Iraq and Afghanistan Veterans with comorbid chronic pain and posttraumatic stress

Chronic pain and posttraumatic stress disorder (PTSD) co-occur at high rates, and Veterans from recent wars in Iraq and Afghanistan may be particularly vulnerable to both conditions. The objective of this study was to identify key aspects of chronic pain, cognitions, and psychological distress associated with comorbid PTSD among this sample of Veterans. Baseline data were analyzed from a randomized controlled trial testing a stepped-care intervention for chronic musculoskeletal pain. Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) Veterans with chronic pain only (n = 173) were compared with those with chronic pain and clinically significant posttraumatic stress symptoms (n = 68). Group differences on pain characteristics, pain cognitions, and psychological distress were evaluated. Results demonstrated that OIF/OEF Veterans with comorbid chronic musculoskeletal pain and PTSD experienced higher pain severity, greater pain-related disability and increased pain interference, more maladaptive pain cognitions (e.g., catastrophizing, self-efficacy, pain centrality), and higher affective distress than those with chronic pain alone. Veterans of recent military conflicts in Iraq and Afghanistan may be particularly vulnerable to the compounded adverse effects of chronic pain and PTSD. These results highlight a more intense and disabling pain and psychological experience for those with chronic pain and PTSD than for those without PTSD.

Clinical and psychosocial significance of trauma history in schizophrenia spectrum disorders

Interest has arisen in the role stressors play in the development and outcome of schizophrenia. This article examines one such stressor – trauma experienced prior to the onset of illness. We discuss research on the incidence, types and correlates of trauma in schizophrenia, and review work suggesting trauma may increase risk for schizophrenia. Studies are further detailed that have examined links between trauma and heightened levels of positive symptoms and anxiety, and poorer social, vocational and treatment outcomes. Here, literature on approaches to addressing trauma among persons with schizophrenia is presented, along with a commentary that points to the need for research on how trauma might increase the risk for the development of schizophrenia and worsen the symptoms and treatment outcome of individuals in recovery from this illness.

Health care utilization among veterans with pain and posttraumatic stress symptoms

OBJECTIVE To examine health care utilization among veterans with both chronic pain and posttraumatic stress symptoms. METHODS Retrospective cohort study of 40,716 veterans in a VA regional network from January 1, 2002 to January 1, 2007. Veterans were categorized into pain-only, posttraumatic stress disorder symptoms (PTSD)-only, and pain plus PTSD (pain+PTSD) comparison groups. Negative binomial models were used to compare adjusted rates of primary care, mental health, and specialty pain service use, as well as opioids, benzodiazepines, nonopioid analgesics, and antidepressant prescriptions. Rates of clinic visits were calculated by days per year, and rates of medication use were calculated by prescription months per year. Participants were followed for a mean duration of 47 months. RESULTS Participants were 94.7% men and had a mean age of 58.9 years. Nearly all used primary care (99.2%), 37.1% used pain-related specialty care, and 33.8% used mental health services. Nonopioid and opioid analgesics were the most commonly used medications (63.7% and 53.8%, respectively). Except for mental health visits, which did not differ between PTSD-only and pain+PTSD groups, the pain+PTSD group used significantly more of all categories of health care services than the pain-only and PTSD-only groups. For example, the pain+PTSD group had 7% more primary care visits (rate ratio [RR]=1.07; 95% confidence interval [CI]: 1.05, 1.09) than the pain-only group and 46% more primary care visits than the PTSD-only group (RR=1.46; 95% CI: 1.40, 1.52). Adjusted rates of opioid, benzodiazepine, nonopioid analgesic, and antidepressant prescriptions were higher for the pain+PTSD group than either of the comparison groups. CONCLUSIONS Our findings support our expectation that veterans with both pain and PTSD symptoms use more health care services than those with pain or PTSD symptoms alone. Research is needed to assess the health care costs associated with increases in health care utilization among these veterans.

The relationships between trauma history, trait anger, and stigma in persons diagnosed with schizophrenia spectrum disorders

The presence of a trauma history is linked to more recalcitrant psychosocial deficits for persons diagnosed with schizophrenia. Less clear are the psychological mechanisms by which trauma impedes function over time. To explore this, the current study examines two variables that could be affected by trauma and which may lead to disruption in quality of life: stigma and anger. Participants were 78 adults with a diagnosis of schizophrenia who completed concurrent assessments of trauma, self stigma and anger expression at baseline, and then repeated the assessments of stigma and anger five months later. Comparisons of groups with and without a history of sexual trauma revealed that those who had experienced trauma reported greater levels of discrimination experience, alienation, and social withdrawal due to stigma at baseline and five months later. The group without a history of sexual trauma also reported greater levels of trait anger and inward expression of anger than the group who did not report sexual trauma. Results may suggest that trauma history may lead to an increased vulnerability to stigmatizing beliefs as well as the experience of chronic anger which is inwardly directed.

Metastatic breast cancer patients’ expectations and priorities for symptom improvement

PurposeLittle research has examined cancer patients’ expectations, goals, and priorities for symptom improvement. Thus, we examined these outcomes in metastatic breast cancer patients to provide patients’ perspectives on clinically meaningful symptom improvement and priorities for symptom management.MethodsEighty women with metastatic breast cancer participated in a survey with measures of comorbidity, functional status, engagement in roles and activities, distress, quality of life, and the modified Patient-Centered Outcomes Questionnaire that focused on 10 common symptoms in cancer patients.ResultsOn average, patients reported low to moderate severity across the 10 symptoms and expected symptom treatment to be successful. Patients indicated that a 49% reduction in fatigue, 48% reduction in thinking problems, and 43% reduction in sleep problems would represent successful symptom treatment. Cluster analysis based on ratings of the importance of symptom improvement yielded three clusters of patients: (1) those who rated thinking problems, sleep problems, and fatigue as highly important, (2) those who rated pain as moderately important, and (3) those who rated all symptoms as highly important. The first patient cluster differed from other subgroups in severity of thinking problems and education.ConclusionsMetastatic breast cancer patients report differing symptom treatment priorities and criteria for treatment success across symptoms. Considering cancer patients’ perspectives on clinically meaningful symptom improvement and priorities for symptom management will ensure that treatment is consistent with their values and goals.

Symptom Experiences in Metastatic Breast Cancer Patients: Relationships to Activity Engagement, Value‐based Living, and Psychological Inflexibility

This study examined symptom‐based subgroups of metastatic breast cancer (MBC) patients and the extent to which they differed across key constructs of acceptance and commitment therapy (ACT).