Tonny Elmose Andersen

The Prevalence of Four Types of Childhood Maltreatment in Denmark

Objectives: To estimate the prevalence of four types of childhood maltreatment in Denmark while taking into considerations how each of the types of maltreatment vary as a function of gender or child-protection status. Methods: Data were collected from a Danish national study conducted by The Danish National Centre for Social Research in 2008 and 2009. The study used a stratified random probability sample of young people aged 24 years. A sample of 4718 young adults were randomly selected by Statistics Denmark using the total birth cohort of all children born in 1984. The response rate was 63% leaving a total effective sample size of 2980. A structured residential or telephone interview enquired about a range of respondents maltreatment experiences. Results: Maltreatment is experienced by a significant proportion of Danish children. The reported prevalence rates were; physical neglect (3.0%), emotional abuse (5.2%), physical abuse (5.4%) and sexual abuse (3.4%). All trauma types were experienced by a greater percentage of females compared to males with the exception of physical abuse and all trauma types were experienced by a greater percentage of children given child-protection status. Conclusions: Female children and children who are given child protection status are those most at risk for experiencing maltreatment in Denmark. However, variability in prevalence rates of maltreatment across studies is problematic. Methodological variations and variation in abuse definitions may be partly attributable.

PTSD-8 – A short PTSD Inventory

Traumatic events pose great challenges on mental health services in scarcity of specialist trauma clinicians and services. Simple short screening instruments for detecting adverse psychological responses are needed. Several brief screening instruments have been developed. However, some are limited, especially in relation to reflecting the posttraumatic stress disorder (PTSD) diagnosis. Recently, several studies have challenged pre-existing ideas about PTSD’s latent structure. Factor analytic research currently supports two four factor models. One particular model contains a dysphoria factor which has been associated with depression and anxiety. The symptoms in this factor have been hailed as less specific to PTSD. The scope of this article is therefore to present a short screening instrument, based on this research; Posttraumatic Stress Disorder (PTSD) – 8 items. The PTSD-8 is shown to have good psychometric properties in three independent samples of whiplash patients (n=1710), rape victims (n=305), and disaster victims (n=516). Good test-rest reliability is also shown in a pilot study of young adults from families with alcohol problems (n=56).

The Relationship between Chronic Whiplash-Associated Disorder and Posttraumatic Stress - Attachment Anxiety may be a vulnerability Factor

Background: In more than 90% of whiplash accidents a good explanation regarding the association between trauma mechanism, organic pathology, and persistent symptoms has failed to be provided. Objective: We predicted that the severity of chronic whiplash-associated disorder (WAD), measured as number of whiplash symptoms, pain duration, pain-related disability, and degree of somatisation would be associated with the number of post-traumatic stress disorder symptoms (PTSD). Secondly, we expected attachment-anxiety to be a vulnerability factor in relation to both PTSD and WAD. Design: Data were collected from 1,349 women and 360 men suffering from WAD from the Danish Society for Polio, Traffic, and Accident Victims. The PTSD symptoms were measured by the Harvard Trauma Questionnaire. All three core PTSD clusters were included: re-experiencing, avoidance, and hyperarousal. Attachment security was measured along the two dimensions, attachment-anxiety and attachment-avoidance, by the Revised Adult Attachment Scale. Results: PTSD symptoms were significantly related to the severity of WAD. In particular, the PTSD clusters of avoidance and hyperarousal were associated with the number of whiplash symptoms, disability, and somatisation. Attachment-anxiety was significantly related to PTSD symptoms and somatisation but not to pain and disability. A co-morbidity of 38.8% was found between the PTSD diagnosis and WAD, and about 20% of the sample could be characterised as securely attached. Conclusions: The PTSD clusters of avoidance and hyperarousal were significantly associated with severity of WAD. The study emphasises the importance of assessing PTSD symptomatology after whiplash injury. Furthermore, it highlights that attachment theory may facilitate the understanding of why some people are more prone to develop PTSD and WAD than others. For abstract or full text in other languages, please see Supplementary files under Reading Tools online

Does attachment insecurity affect the outcomes of a multidisciplinary pain management program? The association between attachment insecurity, pain, disability, distress, and the use of opioids

Cognitive and behavioural treatments have been shown to be effective for the management of chronic pain. However, not all patients succeed at such a treatment. Attachment insecurity has recently been proposed as an individual vulnerability factor that may have a negative impact on pain, disability, psychological distress, and compliance with treatment, resulting in a poorer outcome. Furthermore, attachment avoidance has been associated with opioid abuse. We hypothesised that attachment anxiety would be associated with higher levels of pain intensity and disability, and that both attachment dimensions would be associated with anxiety and depression. Moreover, we hypothesised that attachment avoidance would be positively associated with the use of opioids. Finally, we predicted that patients with an insecure attachment orientation would profit less from a routine pain management program. Data were collected from 72 patients referred consecutively from December 2008 to August 2009 to a 13-week pain management program at a Danish multidisciplinary pain centre. Both attachment dimensions were positively associated with anxiety and depression. Moreover, the insecurely attached patients used significantly more opioids compared to the securely attached. None of the attachment dimensions was associated with pain and disability, and the pain management program was equally effective for both the secure and insecure groups. However, the level of anxiety and depression for insecurely attached patients did not decline below a clinical level post-treatment. The present study suggests that attachment insecurity plays an important role in the context of chronic pain management. With regards to the management of pain related anxiety, depression, and the use of opioids, the current results suggests that practitioners should keep attachment insecurity in mind.

The traumatised chronic pain patient—Prevalence of posttraumatic stress disorder - PTSD and pain sensitisation in two Scandinavian samples referred for pain rehabilitation

Abstract Introduction Correctly identifying chronic pain patients with posttraumatic stress disorder (PTSD) is important because the comorbidity of a chronic pain condition and PTSD is found to compromise treatment success. In addition, the existence of PTSD is associated with pain sensitisation, elevated levels of pain, and disability. Furthermore, the diagnostic criteria for PTSD has changed dramatically in the last two decades which has had a profound impact on the reported prevalence rates of PTSD in chronic pain samples. To our knowledge, no study has employed the DSM-IV criteria for estimating the prevalence of PTSD in chronic pain patients referred consecutively for multidisciplinary pain rehabilitation. Aim The aim of the present study was to assess the prevalence of significant traumatic stressors and PTSD in chronic pain patients referred consecutively to multidisciplinary pain rehabilitation. We wanted to investigate whether specific pain diagnoses were more related to PTSD than others. Moreover, we investigated the possible association of altered sensory processing (hypersensitivity or hyposensitivity) and PTSD. Methods Data were collected from two Scandinavian multidisciplinary pain centres (Denmark and Finland). All patients referred consecutively were assessed for PTSD and sensitisation at admission. A total of 432 patients were assessed, of which 304 (DK, N =220, female n = 144; FIN, N=84, female n = 44) were admitted and consented to participate. All patients had to be diagnosed with a non-malign chronic pain condition lasting for at least 6 months (median = 6.0 years). The Harvard Trauma Questionnaire was employed to measure PTSD symptoms, using the DSM-IV criteria. To measure altered sensory processing, anaesthetists performed quantitative sensory testing on admission. Patients were asked to report if cold, brush, and pinprick mechanical stimulation resulted in decreased or increased sensation or pain. Results stimulation resulted in decreased or increased sensation or pain. Results: A high prevalence of PTSD was found in both consecutive samples. Using the DSM-IV criteria, 23% fulfilled the criteria for a possible PTSD diagnosis. There were no gender differences in PTSD. The three most reported traumatic events: traffic accidents, serious illness personally or in the family, and the actual loss of someone, were reported as the primary traumatic events by almost 50% of those with PTSD. No particular pain diagnosis was significantly related to PTSD. However, hypersensitivity to cold and hyposensitivity to brush were significantly associated with PTSD. Discussion The prevalence of PTSD in the present study was 23%. Earlier studies finding a lower prevalence rate of PTSD may reflect the use of older diagnostic criteria for PTSD or other estimates, for instance PTSD symptom cut-off scores. Conclusion The study emphasised the importance of screening all chronic pain patients for PTSD at admission for pain rehabilitation, using up to date diagnostic tools. Implications Untreated PTSD may exacerbate or maintain the pain condition and negatively affect outcome of pain rehabilitation.

Pain-catastrophizing and fear-avoidance beliefs as mediators between post-traumatic stress symptoms and pain following whiplash injury – A prospective cohort study

Knowledge about the course of recovery after whiplash injury is important. Most valuable is identification of prognostic factors that may be reversed by intervention. The mutual maintenance model outlines how post‐traumatic stress symptoms (PTSS) and pain may be mutually maintained by attention bias, fear, negative affect and avoidance behaviours. In a similar vein, the fear‐avoidance model describes how pain‐catastrophizing (PCS), fear‐avoidance beliefs (FA) and depression may result in persistent pain. These mechanisms still need to be investigated longitudinally in a whiplash cohort.

Chronic pain patients with possible co-morbid post-traumatic stress disorder admitted to multidisciplinary pain rehabilitation-a 1-year cohort study.

Background Although post-traumatic stress disorder (PTSD) is a common co-morbidity in chronic pain, little is known about the association between PTSD and pain in the context of chronic pain rehabilitation. Objective The aim of the present study was two-fold: (1) to investigate the association of a possible PTSD diagnosis with symptoms of pain, physical and mental functioning, as well as the use of opioids, and (2) to compare the outcome of multidisciplinary chronic pain rehabilitation for patients with a possible PTSD diagnosis at admission with patients without PTSD at admission. Method A consecutively referred cohort of 194 patients completed a baseline questionnaire at admission covering post-traumatic stress, pain symptoms, physical and mental functioning, as well as self-reported sleep quality and cognitive difficulties. Medication use was calculated from their medical records. A total of 95 were admitted to further multidisciplinary treatment and included in the outcome study. Results A high prevalence of possible PTSD was found (26.3%). Patients with possible co-morbid PTSD experienced significantly poorer general and mental health, poorer sleep quality, and more cognitive problems as well as inferior social functioning compared to patients without PTSD. Possible co-morbid PTSD did not result in higher use of opioids or sedatives. Surprisingly, possible co-morbid PTSD at admission was not associated with lower levels of symptom reduction from pre- to post-treatment. Conclusions Possible co-morbid PTSD in chronic pain is a major problem associated with significantly poorer functioning on several domains. Nevertheless, our results indicate that pain-related symptoms could be treated with success despite possible co-morbid PTSD. However, since PTSD was only measured at admission it is not known whether rehabilitation actually reduced PTSD.

PTSD Symptoms Mediate the Effect of Attachment on Pain and Somatisation after Whiplash Injury

Introduction: The development of persistent pain post-whiplash injury is still an unresolved mystery despite the fact that approximately 50% of individuals reporting whiplash develop persistent pain. There is agreement that high initial pain and PTSD symptoms are indicators of a poor prognosis after whiplash injury. Recently attachment insecurity has been proposed as a vulnerability factor for both pain and PTSD. In order to guide treatment it is important to examine possible mechanisms which may cause persistent pain and medically unexplained symptoms after a whiplash injury. Aim: The present study examines attachment insecurity and PTSD symptoms as possible vulnerability factors in relation to high levels of pain and somatisation after sub-acute whiplash injury. Methods: Data were collected from 327 patients (women = 204) referred consecutively to the emergency unit after acute whiplash injury. Within 1-month post injury, patients answered a questionnaire regarding attachment insecurity, pain, somatisation, and PTSD symptoms. Multiple mediation analyses were performed to assess whether the PTSD symptom clusters mediated the association between attachment insecurity, pain, and somatisation. Results: A total of 15% fulfilled the DSM-IV symptom cluster criteria for a possible PTSD diagnosis and 11.6% fulfilled the criteria for somatisation. PTSD increased the likelihood of belonging to the moderate-severe pain group three-fold. In relation to somatisation the likelihood of belonging to the group was almost increased four-fold. The PTSD symptom clusters of avoidance and hyperarousal mediated the association between the attachment dimensions, pain, and somatisation. Conclusion: Acknowledging that PTSD is part of the aetiology involved in explaining persistent symptoms after whiplash, may help sufferers to gain early and more suited treatment, which in turn may prevent the condition from becoming chronic.

Motives for sports participation as predictions of self-reported outcomes after anterior cruciate ligament injury of the knee.

Aim of the study was to access how individuals motives for participation in sports impact on self‐reported outcomes 2 years after an anterior cruciate ligament injury. Based on a longitudinal cohort study, this secondary analysis present data from the Knee Anterior Cruciate Ligament, Nonsurgical versus Surgical Treatment (KANON) study, a randomized controlled trial. At baseline, 121 patients recorded in an initial questionnaire that their motives for sports participation fell into four categories: achievement, health, social integration, or fun and well‐being. These four categories were used as variables in the analyses. All 121 subjects completed the 2‐year follow‐up. The largest improvement was seen in the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscale sports and recreation function, with an effect size of 2.43. KOOS sports and recreation function was also the subscale score best predicted by the motives for sports participation. Baseline motives achievement and fun and well‐being predicted worse levels of pain and function 2 years after the injury, even after adjusting for age, gender, treatment and baseline scores. Psychological aspects, such as motives for participation in sport, can be factors in predicting of patient‐reported outcomes 2 years after injury. Evaluating motives for sports participation may help predict the outcome 2 years after ACL injury.

Attachment and Posttraumatic Stress Disorder in Multiple Trauma Samples

Introduction: Attachment orientations are associated with the severity of posttraumatic stress disorder (PTSD). However, the mediator role of trauma type in the association between attachment orientation and PTSD remains unknown. Method: The relationship between trauma type, attachment, and PTSD was investigated in a large multiple trauma sample (n=3735). All participants were assessed for PTSD using the Harvard Trauma Questionnaire (HTQ) and for attachment orientations utilizing the Revised Adult Attachment Scale (RAAS). Results: Overall, a secure attachment style was related to lower PTSD severity, while insecure attachment styles were related to higher PTSD severity. Although both attachment dimensions were related to PTSD severity, attachment anxiety had greater contribution in predicting PTSD. PTSD symptom clusters were not found to depend on attachment dimensions. Finally, type of traumatic event moderated the association between attachment dimensions and PTSD severity. While among trauma survivors of family illness, the securely attached group showed the lowest PTSD severity, among trauma survivors of disease and physical health, the dismissively attached individuals showed the lowest level of PTSD severity, compared to other attachment groups. Conclusion: The results underscore the importance of taking into account the nature of the traumatic event while assessing the effects of attachment in posttraumatic reactions. Moreover, dismissing attachment style might be adaptive when facing the trauma of disease.