The impact of perceived injustice on pain and psychological outcomes after traumatic injury: a longitudinal analysis.

ABSTRACT: Individuals' appraisals regarding the injustice of their pain or physical injury have emerged as a significant risk factor for worse physical and psychological outcomes. Injustice appraisals are defined by perceptions of external blame for pain or injury and viewing pain or injury as a source of irreparable loss. To date, research on the impact of injustice appraisal has been primarily cross sectional, and existing longitudinal studies have examined injustice appraisals at only 2 time points in the context of rehabilitation treatment. This study examined the trajectory of injustice appraisals in 171 patients admitted for traumatic injury at admission, as well as 3, 6, and 12 months after discharge and examined injustice appraisals as a potential moderator of recovery after injury. Findings can be summarized as follows: First, injustice perception was largely stable in the 12 months after hospital discharge. Second, elevated injustice perception was associated with decreased recovery in pain intensity and depressive symptomatology over the study period but did not moderate changes in pain catastrophizing or posttraumatic stress symptomatology over time. This study is the first naturalistic prospective analysis of injustice appraisal following trauma admission within the American healthcare system. Findings indicate that injustice appraisals do not naturally decrease in the aftermath of traumatic injury and may be a risk factor for poorer physical and psychological recovery. Future research should examine additional sociodemographic and psychosocial factors that may contribute to elevated injustice appraisal, as well as ways of addressing the potential deleterious impact of injustice appraisals in treatment settings.

Broadening the Scope of Resilience in Chronic Pain: Methods, Social Context, and Development.

PURPOSE OF REVIEW: A wellspring of new research has offered varying models of resilience in chronic pain populations; however, resilience is a multifaceted and occasionally nebulous construct. The current review explores definitional and methodological issues in existing observational and clinical studies and offers new directions for future studies of pain resilience. RECENT FINDINGS: Definitions of pain resilience have historically relied heavily upon self-report and from relatively narrow scientific domains (e.g., positive psychology) and in narrow demographic groups (i.e., Caucasian, affluent, or highly educated adults). Meta-analytic and systematic reviews have noted moderate overall quality of resilience-focused assessment and treatment in chronic pain, which may be attributable to these narrow definitions. Integration of research from affiliated fields (developmental models, neuroimaging, research on historically underrepresented groups, trauma psychology) has the potential to enrich current models of pain resilience and ultimately improve the empirical and clinical utility of resilience models in chronic pain.

Risk Factors for Chronic Prescription Opioid Use in Multiple Sclerosis.

OBJECTIVE: To characterize patterns of prescription opioid use among individuals with multiple sclerosis (MS) and identify risk factors associated with chronic use. DESIGN: Retrospective longitudinal cohort study examining US Department of Veterans Affairs electronic medical record data of Veterans with MS. The annual prevalence of prescription opioid use by type (any, acute, chronic, incident chronic) was calculated for each study year (2015-2017). Multivariable logistic regression was used to identify demographics and medical, mental health, and substance use comorbidities in 2015-2016 associated with chronic prescription opioid use in 2017. SETTING: US Department of Veterans Affairs, Veteran's Health Administration. PARTICIPANTS: National sample of Veterans with MS (N=14,974). MAIN OUTCOME MEASURE: Chronic prescription opioid use (≥90 days). RESULTS: All types of prescription opioid use declined across the 3 study years (chronic opioid use prevalence=14.6%, 14.0%, and 12.2%, respectively). In multivariable logistic regression, prior chronic opioid use, history of pain condition, paraplegia or hemiplegia, post-traumatic stress disorder, and rural residence were associated with greater risk of chronic prescription opioid use. History of dementia and psychotic disorder were both associated with lower risk of chronic prescription opioid use. CONCLUSION: Despite reductions over time, chronic prescription opioid use remains common among a substantial minority of Veterans with MS and is associated with multiple biopsychosocial factors that are important for understanding risk for long-term use.

Early Treatment Improvements in Depression Are Associated With Overall Improvements in Fatigue Impact and Pain Interference in Adults With Multiple Sclerosis.

BACKGROUND: Depression, fatigue, and pain commonly co-occur in multiple sclerosis (MS) and are positively associated with one another. However, it is unclear whether treatment-related improvement in one of these symptoms is associated with improvements in the other two symptoms. PURPOSE: This study examined whether early improvements in depressive symptoms, fatigue impact, and pain interference during a multisymptom intervention in persons with MS were associated with overall improvements in the other two symptoms. METHODS: Secondary analysis of a randomized controlled trial in which both treatments improved depressive symptoms, fatigue, and pain interference. Adults with MS experiencing chronic pain, chronic fatigue, and/or moderate depressive symptoms (N = 154, 86% women) participated in an 8-week, telephone-delivered intervention: self-management (n = 69) or education (n = 85); intervention groups were combined for the current study. Outcome measures were depressive symptoms (PHQ-9), fatigue impact (Modified Fatigue Impact Scale), and pain interference (Brief Pain Inventory). Path analysis examined associations between pre-to-mid intervention improvement in one symptom (i.e., depression, fatigue, pain interference) and pre-to-post (overall) improvement in the other two symptoms. RESULTS: Early reduction in depressive symptoms was associated with an overall reduction in pain interference and fatigue impact (p's < .01). Early reduction in fatigue impact was associated with an overall reduction in depressive symptom severity (p = .04) but not pain interference. Early reduction in pain interference was not associated with reductions in fatigue impact or depressive symptoms. CONCLUSIONS: These findings suggest the potential importance of reducing depressive symptoms to overall improvement in fatigue and pain interference in persons with MS. CLINICAL TRIAL REGISTRATIONS: NCT00944190.

Goal Pursuit, Goal Adjustment, and Pain in Middle-Aged Adults Aging With Physical Disability.

Objective: Aging with physical disability disrupts one's ability to achieve valued goals due to changes in symptoms and function. It is unclear how to cope optimally in this context. This study examined whether two possible strategies-tenacious goal pursuit (TGP) and flexible goal adjustment (FGA)-were associated with reduced pain interference and depressive symptoms and greater well-being, and protected against pain intensity, and FGA was more protective with increasing age and worse physical function. Method: Middle-aged adults with muscular dystrophy, multiple sclerosis, post-polio syndrome, or spinal cord injury (N = 874; MAGE = 58.3 years, range = 46-68; MDISEASEDURATION = 26.2 years, range = 2-67) completed two questionnaires, a year apart. Results: TGP and FGA use was associated with greater well-being. FGA use predicted decreased depressive symptoms. Concurrent use of both predicted decreased pain interference. Discussion: Adults with disability employ a variety of goal management strategies. Findings support TGP and FGA as potential intervention targets for healthy aging with disabilities.

Physical activity and depression in MS: The mediating role of behavioral activation.

BACKGROUND: Depression is a common comorbid condition among individuals with multiple sclerosis (MS) and is associated with greater overall disease burden and lower quality of life. Numerous clinical trials have supported physical activity interventions versus education, usual care, and attention control conditions for improving depressive symptoms in individuals with MS. However, little is known about the psychological mechanisms that may underlie physical activity-related improvements in depression. Behavioral activation posits that depression may stem from a reduction or loss of personally meaningful and rewarding activity. The process of behavioral activation involves re-engaging with these experiences. Behavioral activation might represent one mechanism by which physical activity interventions improve depression. OBJECTIVE: To examine behavioral activation as a mechanism mediating the effects of physical activity intervention on depressive symptom improvement in individuals with MS. METHODS: Mediational path analysis using data from a randomized controlled trial (N = 64) comparing telephone-based physical activity counseling (TC) to education (EC). RESULTS: Participation in TC resulted in greater improvements in behavioral activation from months 0-3. Improvements in behavioral activation were associated with fewer baseline-adjusted depressive symptoms at month 6. The corresponding indirect (mediational) pathway was significant. CONCLUSION: Behavioral activation may represent one mechanism by which physical activity improves depression in MS. Future physical activity trials should capitalize on this relationship and place additional emphasis on identifying and engaging in personally meaningful life activity. Future trials of therapies focused on behavioral activation might benefit from encouraging physical activity goals. TRIAL REGISTRATION: Trial Registration clinicaltrials.gov Identifier: NCT01198977.

Associations of Pain Intensity and Frequency With Loneliness, Hostility, and Social Functioning: Cross-Sectional, Longitudinal, and Within-Person Relationships.

BACKGROUND: The current studies investigated associations between pain intensity and pain frequency with loneliness, hostility, and social functioning using cross-sectional, longitudinal, and within-person data from community-dwelling adults with varying levels of pain. METHOD: Secondary analysis of preexisting data was conducted. Study 1 investigated cross-sectional (baseline data: n = 741) and longitudinal (follow-up data: n = 549, observed range between baseline and follow-up: 6-53 months) associations. Study 2 tested within-person associations using daily diaries across 30 days from a subset of the participants in Study 1 (n = 69). RESULTS: Cross-sectionally, pain intensity and frequency were associated with higher loneliness (ßintensity = 0.16, ßfrequency = 0.17) and worse social functioning (ßintensity = - 0.40, ßfrequency = - 0.34). Intensity was also associated with higher hostility (ß = 0.11). Longitudinally, pain intensity at baseline predicted hostility (ß = 0.19) and social functioning (ß = - 0.20) at follow-up, whereas pain frequency only predicted social functioning (ß = - 0.21). Within people, participants reported higher hostility (γ = 0.002) and worse social functioning (γ = - 0.013) on days with higher pain, and a significant average pain by daily pain interaction was found for loneliness. Pain intensity did not predict social well-being variables on the following day. CONCLUSION: Pain intensity and frequency were associated with social well-being, although the effects were dependent on the social well-being outcome and the time course being examined.

Sharing Positive Experiences Boosts Resilient Thinking: Everyday Benefits of Social Connection and Positive Emotion in a Community Sample.

The influence of shared enjoyment and positive affect (PA) on resilient thinking was examined in 191 middle-aged adults (40-65 years), participating in a study of resilience. Participants completed diaries assessing positive events, shared enjoyment, PA, and resilient cognitions (RC). Multilevel structural equation modeling was utilized to examine when and who engages in RC. Participants reported more RC on days they experienced more positive experiences. This relationship was explained by shared enjoyment and PA. Level-1 proportional reduction of variance (PRV) for shared enjoyment, PA, and RC was 9%, 10%, and 35%, respectively. Individuals reporting more positive experiences trended toward a more resilient mindset; PA accounted for this relationship. Shared enjoyment mediated the relationship between interpersonal events and PA. These findings suggest PA is integral to having a resilient mindset, and shared enjoyment is a potential mechanism that may influence PA. Level-2 PRV for shared enjoyment, PA, and RC was 22%, 21%, and 55%, respectively. RC were associated with less depression and anxiety; and greater well-being, vitality, and physical functioning at follow-up.

Positive factors, pain, and function in adults with multiple sclerosis.

OBJECTIVE: Much is known about the associations between negative factors and adjustment to chronic pain. However, less is known about how positive factors (e.g., positive affect [PA], resilience) function in relation to disability and mood in individuals with multiple sclerosis (MS). To better understand how positive factors contribute to function we sought to determine if (a) PA and/or trait resilience moderate the associations between pain intensity and function (pain interference, depressive symptoms), and (b) trait resilience concurrently mediates the association between PA and function in a sample of individuals with MS. METHOD: There were 455 adults with MS who provided data via an ongoing survey. RESULTS: Controlling for negative affect, demographic, and disease-related variables, cross-sectional path analysis revealed the following: PA and trait resilience did not moderate the associations between pain intensity and pain interference (ßPA = 0.01, p = .86; ßRESILIENCE = 0.04, p = .33), and pain intensity and depression (ßPA = 0.01, p = .79; ßRESILIENCE = -0.02, p = .60). However, trait resilience significantly mediated the associations between PA and both criterion variables (abINTERFERENCE = -0.03, p = .03; abDEPRESSION = -0.13, p < .001). CONCLUSIONS: The findings provide preliminary support for the conclusion that PA is indirectly related to pain interference and depression via resilience, rather than serves as a protective function. The findings are consistent with theoretical models suggesting that increases in PA build personal resources. Research examining the potential benefits of increasing PA and resilience to improve pain outcomes in individuals with MS is warranted. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Promoting resilience in individuals aging with multiple sclerosis: Results from a pilot randomized controlled trial.

PURPOSE/OBJECTIVE: Starting in middle adulthood, individuals living with multiple sclerosis (MS) are confronted with the simultaneous challenge of coping with advancing MS alongside age-related changes. Psychological resilience is thought to play an important role in promoting healthy aging and thus may be important in the context of aging with MS. This study aimed to evaluate whether Everyday Matters, a novel positive psychology program, had a positive effect on resilience and other related outcomes in adults with MS relative to a wait-list control group. Research Method/Design: This was a single-center two-group pilot randomized (1:1) controlled trial comparing the Everyday Matters intervention to a waitlist control. Randomized participants were N = 31 adults with MS aged ≥ 45 years. The 6-week program, developed by the National MS Society, was delivered via group teleconference and supplemented with readings, videos, and online participation. Participants in both groups completed outcome assessments measuring resilience, satisfaction with social roles, mood, pain, fatigue, and sleep at baseline and posttreatment. RESULTS: Analyses on N = 27 participants who completed study assessments revealed a significant group effect for resilience and satisfaction with social roles, and trend differences for positive affect and well-being and depressive symptom severity. At posttreatment, participants in the intervention group reported the group to be very helpful, found the telephone-based delivery convenient, and felt the benefits of participating outweighed the effort. CONCLUSIONS/IMPLICATIONS: These results suggest that the Everyday Matters program shows promise for increasing resilience in adults with MS and that a full-scale randomized controlled trial is warranted. (PsycINFO Database Record

Cognitive and affective mechanisms of pain and fatigue in multiple sclerosis.

OBJECTIVE: To examine the extent to which pain catastrophizing, fatigue catastrophizing, positive affect, and negative affect simultaneously mediated the associations between common symptoms of multiple sclerosis (MS; i.e., pain, fatigue) and impact on daily life, depressive symptoms, and resilience. METHOD: Participants were community-dwelling adults with MS (N = 163) reporting chronic pain, fatigue, and/or moderate depressive symptoms. Multiple mediation path analysis was used to model potential mediators of pain and fatigue separately, using baseline data from a randomized controlled trial comparing two symptom self-management interventions. RESULTS: In the pain model, pain catastrophizing was a mediator of pain intensity with pain interference and depression. Negative affect was a mediator of pain intensity with depression and resilience. In the fatigue model, fatigue catastrophizing was a mediator of fatigue intensity with fatigue impact and depression. Positive affect was a mediator of fatigue intensity with depression and resilience. CONCLUSIONS: These findings provide preliminary support for the presence of differential effects of cognitive-affective mediators and suggest potential targets for psychological interventions based on an individual's clinical presentation. The differential mediating effects also support the inclusion of both positive and negative aspects of psychological health in models of pain and fatigue, which would not be otherwise apparent if negative constructs were examined in isolation. To our knowledge, this is the first study to utilize a multivariate path analysis approach to examine cognitive-affective mediators of pain and fatigue in MS, while also examining positive and negative constructs concurrently. (PsycINFO Database Record

Moderators of Treatment Outcomes After Telehealth Self-Management and Education in Adults With Multiple Sclerosis: A Secondary Analysis of a Randomized Controlled Trial.

OBJECTIVE: To examine moderators of treatment effects in a randomized controlled trial comparing a telehealth self-management intervention with a telehealth multiple sclerosis (MS) education intervention for fatigue, pain, and mood in adults with MS. DESIGN: Secondary analysis of a single-blind randomized controlled trial. SETTING: Community. PARTICIPANTS: Adults with MS and chronic fatigue, chronic pain, and/or moderate depressive symptoms (N=163) recruited from across the United States. INTERVENTIONS: Two 8-week, telephone-delivered symptom interventions delivered 1:1: a self-management intervention (n=75) and an MS education intervention (n=88). MAIN OUTCOME MEASURES: Outcome measures were fatigue impact pain interference, and depressive symptom severity assessed at baseline and posttreatment. Potential moderators of treatment effects assessed at baseline were demographics (age, sex, and education), clinical characteristics (disease duration and disability severity), symptoms (perceived cognitive impairment and pain intensity), baseline levels of the treatment outcomes (pain interference, fatigue impact and depressive symptom severity), and cognitive behavioral factors (pain catastrophizing, fatigue catastrophizing, self-efficacy, and patient activation). RESULTS: Moderation analyses found significant moderation for fatigue impact but not for pain intensity or depressive symptom severity. Baseline patient activation interacted with treatment group to predict fatigue impact at posttreatment (P=.049). Among participants with high baseline patient activation, the self-management group reported significantly less fatigue at posttreatment than the education group. No other variables moderated the study outcomes. CONCLUSIONS: At the group level, participants responded to both interventions, regardless of disease characteristics, demographics, symptom levels, and cognitive behavioral factors. Self-management and education are both potentially beneficial symptom treatments that may be recommended to individuals with MS and chronic pain, fatigue, and/or depressive symptoms.

The Psychosocial Context of Financial Stress: Implications for Inflammation and Psychological Health.

OBJECTIVE: Psychological distress may contribute to chronic activation of acute-phase inflammation. The current study investigated how financial stressors influence psychosocial functioning and inflammation. This study examined a) the direct relations between financial stress and inflammation; b) whether the relationships between financial stress and inflammation are mediated in part by negative interpersonal events, psychological distress, and psychological well-being; and c) whether social standing in one's community moderates the relations between financial stress and psychological distress, psychological well-being, and markers of inflammation (interleukin-6 [IL-6] and C-reactive protein). METHODS: Stressful financial and interpersonal events over the previous year, perceived social status, indices of psychological well-being and distress, and levels of IL-6 and C-reactive protein were assessed in a community sample of 680 middle-aged adults (ages 40-65 years). RESULTS: Structural equation modeling analyses revealed significant relations among financial stress, interpersonal stress, and psychological distress and well-being, and complex relationships between these variables and inflammatory markers. Psychological well-being mediated the association between financial stress and IL-6 ([mediation] ab = 0.012, standard error [SE] = 0.006, p = .048). Furthermore, individuals with higher perceived social standing within their communities exhibited a stronger relation between negative financial events and both interpersonal stressors (interaction B = 0.067, SE = 0.017, p < .001) and C-reactive protein (interaction B = 0.051, SE = 0.026, p = .050). CONCLUSIONS: Financial stress demonstrates complex relations with inflammation, due partly to psychological well-being and social perceptions. Findings are discussed with regard to the social context of stress and physiological factors pertinent to stress adaptation and inflammation.

A multilevel structural equation modeling analysis of vulnerabilities and resilience resources influencing affective adaptation to chronic pain.

The processes of individual adaptation to chronic pain are complex and occur across multiple domains. We examined the social, cognitive, and affective context of daily pain adaptation in individuals with fibromyalgia and osteoarthritis. By using a sample of 260 women with fibromyalgia or osteoarthritis, we examined the contributions of pain catastrophizing, negative interpersonal events, and positive interpersonal events to daily negative and positive affect across 30days of daily diary data. Individual differences and daily fluctuations in predictor variables were estimated simultaneously by utilizing multilevel structural equation modeling techniques. The relationships between pain and negative and positive affect were mediated by stable and day-to-day levels of pain catastrophizing as well as day-to-day positive interpersonal events, but not negative interpersonal events. There were significant and independent contributions of pain catastrophizing and positive interpersonal events to adaptation to pain and pain-related affective dysregulation. These effects occur both between persons and within a person's everyday life.