Perspectives of chronic pain: an evaluative comparison of restrictive and comprehensive models.

The authors compare theoretical perspectives of chronic pain using a restrictive comprehensive categorization. Four of the perspectives (mind-body dualism, psychological, radical operant--behavioral, and radical cognitive) are categorized as restrictive. The other 4 perspectives (International Association for the Study of Pain, gate control, nonradical operant--behavioral, and cognitive-behavioral) that incorporate multiple facets are categorized as comprehensive. On the basis of empirical support, practical application, and issues concerning potential research design problems, the restrictive perspectives could be rejected for not providing a model in which chronic pain can be thoroughly investigated. The comprehensive perspectives, however, demonstrate greater potential for serving that role. Nonetheless, the need for additional theory development by the comprehensive perspectives is noted.

Dispositional optimism, self-efficacy, and health beliefs as predictors of breast self-examination.

This cross-sectional study examined relationships among predictors of breast self-examination (BSE) derived from the Health Belief Model and behavioral self-regulation theory. Subjects were 427 gynecology outpatients. Although 64% indicated that they had practiced BSE at least once during the past year, only 27% indicated they practiced BSE monthly. The majority of the subjects knew about most of the recommended BSE steps. The most frequently endorsed reasons for completing BSE were early detection, recommendation from a doctor, and peace of mind. The most frequently endorsed barrier was forgetting/being too busy. Multivariate analysis showed that several psychological variables--including reasons for doing BSE, self-efficacy, and barriers to doing BSE--were related to frequency of BSE. Overall, the variables in this model accounted for about 37% of the variance in BSE frequency.

An assessment of the clinical skills of fourth-year students at four New England medical schools.

This paper describes a collaborative effort among five New England medical schools to assess important clinical skills of fourth-year medical students graduating in the class of 1988; results are presented from the four schools that provided sufficient data. Faculty from each school developed 36 patient cases representing a variety of common ambulatory-care problems. Over the course of a day, each student, on average, interacted with 16 different standardized patients, who were nonphysicians trained to accurately and consistently portray a patient in a simulated clinical setting. The students obtained focused histories, performed relevant physical examinations, and provided the patients with education and counseling. At each school, the performance of a small number of the students fell below standards set by the faculty. These deficiencies were not detected with the evaluation strategies currently being used. Although the use of standardized patients should not substitute for the process of faculty observing students as they interact with real patients, it appears that standardized patients can provide faculty with important information, not readily available from other sources, about students' performances of essential clinical activities and the levels of their clinical skills.

The Medical Education Evaluation Program of the state of Ohio.

In October 1988, seven foreign medical graduates participated in the first administration of the examination devised by the Medical Education Evaluation Program (MEEP) mandated by the State Medical Board of Ohio. The MEEP was established to provide an objective evaluation of an applicant's clinical competencies; passing the MEEP examination was intended to certify that the applicant's clinical skills were comparable to those of a medical student graduating from a school accredited by the Liaison Committee on Medical Education. An applicant who successfully passed the MEEP examination and fulfilled the other Ohio licensure requirements would be eligible to take the Federation Licensing Examination (FLEX) and apply for an unrestricted license to practice medicine in Ohio. The paper describes the origin and development of the MEEP examination and the testing modalities selected (multiple-choice examinations and the use of standardized patients). Four fundamental areas were tested; these are named and described, along with the method for calculating scores for each area and the criteria for passing the different components of the examination. Although the small sample size prohibited meaningful data analysis for the performance of the first group of MEEP candidates, the MEEP examination appears to meet psychometric standards of certifying and licensing examinations, based on data from comparable tests taken by beginning fourth-year medical students in New England and NBME Part III examination examinees. Some potential pitfalls of the MEEP examination are mentioned, as well as the fact that it presents a challenge to boards of medical examiners of other states to implement performance-based assessments of physicians who graduate from non-accredited medical schools.

Gender differences in the expression of depressive symptoms among chronic pain patients.

OBJECTIVE: To investigate the extent to which gender differences in the expression of depressive symptomatology exist among chronic pain patients. SETTING: A multidisciplinary pain center affiliated with a state medical school in the southern United States. PATIENTS: A total general sample of 245 patients with heterogeneous chronic pain complaints randomly selected from a database of approximately 1,000 pretreatment evaluation patient files. A depressed subsample of 113 patients based on scores > or = 15 on the Beck Depression Inventory (BDI). MEASURE: The 21-item BDI. RESULTS AND CONCLUSIONS: Gender differences in total BDI scores were not revealed for the total general sample or depressed subsample, but gender differences in the expression of depressive symptoms (i.e., item level responses) were found via separate discriminant function analyses on the total general sample and depressed subsample. Consistent with previous studies performed on diverse samples, females' higher endorsement of body image distortion was noted in both of our samples. Females also endorsed significantly higher levels of fatigue in our total sample. Items that were not significant in our total sample include females' higher levels of loss of appetite and crying. In the depressed subsample, items probing pessimism and failure were not statistically significantly different to males' endorsing higher levels of each. Sensitivity to these gender differences is suggested in clinical practice. The likely consequences that these differences in the experience and expression of distress have on coping activities (e.g., help-seeking responses) and the reactions of others (e.g., health-care providers) are highlighted.

Brief neuropsychologic differentiation of demented versus depressed elderly inpatients.

Recent investigations have suggested the utility of brief, psychometric screening batteries in the early detection of abnormal mental decline. This study extended the investigation of one of these batteries, comprised of three tests (Controlled Oral Word Association, Visual Retention, Temporal Orientation), to the difficult issue of differentiating dementia from depression in a hospitalized sample composed of a group of depressed only patients (N = 50) vs an age-matched demented group (N = 50), some of whom presented mixed dementia/depression syndromes. Demented patients consistently performed more poorly as a group than depressed patients on each of the three measures. This was the case even when three-group (demented only, mixed demented/depressed, depressed only) comparisons were conducted. Impairment was more common on one or more tests with demented vs depressed patients. However, limitations for screening purposes and for the definitive detection of dementia were noted in view of only moderate predictive power of the tests with discriminant function analysis. Nevertheless, the potential clinical utility of the three tests in the general hospital and other primary care settings was apparent.

Family stress management following acute myocardial infarction: an educational and skills training intervention program.

Although the experience of acute myocardial infarction (AMI) is a family affair, little has been available to guide stress and distress reduction efforts focusing on all members of the family compared to the somewhat larger literature addressing stress management interventions with cardiac patients. This article provides a conceptual background for a specific behavioral therapy approach to family stress management in dealing with the sequelae of AMI for all family members with the goal of reducing morbidity for all family members as they cope with ongoing survivorship issues. The family intervention program is described and its pilot implementation discussed. Evaluation of the pilot suggests that an individually tailored focus for that subset of families at higher risk for elevated persistent distress may be the most cost-effective use of such a family intervention program.

Self-report differentiation of anxiety and depression in chronic pain.

The psychometric distinctiveness of self-reported anxiety and depression in patients with chronic pain was investigated. The item-level responses of 220 patients with heterogeneous pain conditions from the Beck Depression Inventory and State--Trait Anxiety Inventory State--Anxiety scale were submitted to common factor analysis. Three first-order factors were identified: depression, anxiety-absent, and anxiety-present. One second-order factor of negative affect was also identified. Correlations of first-order factor scores with other psychometric measures suggested only minor distinctiveness. The findings indicated that it is possible to distinguish anxiety and depression psychometrically in patients with chronic pain but suggested that negative affect may be the primary underlying construct of the affective experience of these patients.

Psychological characteristics of reflex sympathetic dystrophy versus myofascial pain syndromes.

BACKGROUND AND OBJECTIVES: Reflex sympathetic dystrophy (RSD) has sometimes been hypothesized to derive from a unique psychological predisposition because of its enigmatic features, as well as the profound behavioral and emotional characteristics manifested by some patients. This study compares the psychological characteristics of RSD and myofascial pain syndrome (MPS) patients to discern the extent of any aspects unique to RSD. METHODS: The patients included 58 with RSD and 214 with MPS, all of whom completed the Minnesota Multiphasic Personality Inventory (MMPI) as well as a pain questionnaire. Additional pertinent demographic and clinical characteristics were ascertained. RESULTS: The only significant demographic group differences revealed a higher proportion of RSD patients not working (P < .05) and a higher proportion of RSD patients receiving Workers' Compensation payments (P < .001). The RSD patients had shorter duration of pain (P < .01) and were taking fewer pain medications (P < .01) than the MPS group, but the two groups had comparable numbers of pain-related surgeries, pain intensity ratings, perceived ability to cope, and ongoing extent of involvement in social or recreational activities. A wide range of functioning was in evidence for both groups on the MMPI clinical scales, but with duration as a covariate, the RSD group had significantly (P < .05) lower scores on the hypochondriasis, depression, hysteria, and psychasthenia scales and higher scores on the hypomania scale. The duration covariate was significant (P < .05) only for the infrequency (rare responses) and depression scales. Duration and certain scale scores were inversely correlated. CONCLUSIONS: With only a few exceptions, RSD and MPS patients appear comparable with respect to a wide range of demographic, clinical, and psychological functioning indices. A specific psychological profile, uniquely neurotic or otherwise, has yet to be demonstrated in terms of any etiologic or maintenance factors in RSD.

MMPI short forms as predictors of response to conservative treatment for low back pain.

This study (N = 115) compared the abilities of the Faschingbauer Abbreviated Minnesota Multiphasic Personality Inventory (FAM), the Midi-Mult, and the standard MMPI to predict response to conservative medical treatment for low back pain, as assessed by patient ratings of pain intensity 6 to 12 months later. The results indicated that all three inventory formats yielded significant correlations between the Hypochondriasis, Depression, and Hysteria scales and follow-up pain ratings. Less consistent findings were obtained with other scales and indices. The results provide tentative support for the clinical and research utility of these abbreviated MMPIs in substituting for the standard MMPI in outcome studies with back pain patients.

Disinhibition in the gamma motoneuron circuitry: a neglected mechanism for understanding myofascial pain syndromes?

Dysregulation in the gamma motoneuron circuitry is proposed as one mechanism to explain the development of trigger point activity in myofascial pain syndrome. Dysregulation in this context is defined operationally as significantly (and functionally) different levels of electrical activity detected in the same muscle on the left and right sides of the body that is persistently present with movement of that muscle. Neurophysiological concepts as they pertain to muscles and motor control principles are reviewed. Research is integrated that ties together material from diverse fields of psychology and medicine. Dysregulation in the gamma motoneuron circuitry may lead to disinhibition of muscle that causes it to remain hyperactive after contraction, generate excessive electrical activity during movement, and/or inappropriately coactivate with other muscles during movement. Any or all of these phenomena may occur with dysregulation. Such dysregulation may be corrected by learning. Immediate clinical implications are discussed, including the addition of specifically targeted neuromuscular retraining procedures via surface electromyography, as well as some conceptual and research issues that require further clarification.

The mechanical activity of chick embryonic myocardial cell aggregates.

1. Simultaneous recordings of membrane potential and edge movement were obtained in spontaneously beating chick embryonic myocardial cell aggregates, which are known to behave as an isopotential syncytium.2. The time course of edge movement was similar in different aggregates, and in different regions of the same aggregate.3. Peak amplitude was increased by 10(-6)m-ouabain, and by rapid reduction of the external sodium concentration.4. Peak amplitude was decreased during single premature action potentials, but sustained rapid pacing produced an ascending staircase.5. Depolarizing current pulses increased both the amplitude and duration of the contraction, and caused potentiation of the next spontaneous beat. Edge displacement during a series of pulses was a monotonic function of membrane potential.6. Edge movement between action potentials (diastolic movement) was well fitted by an exponential with a mean time constant of 69 msec. Diastolic edge movement was due to a weak, slowly decaying contractile force, which was demonstrated in cells grown on a linear-elastic nylon bristle.7. The time course of diastolic edge movement remained constant, or nearly constant, during variations in peak amplitude that resulted from prematurity of the action potential, exposure to 10(-6)m-ouabain, spontaneous mechanical alternans, or prolongation of the action potential by current pulses.8. In contrast, reduction of the external sodium concentration produced marked, selective slowing of the diastolic edge movement. Similar slowing occurred during cooling and during staircase. Diastolic edge movement was selectively accelerated when the preceding interbeat interval was prolonged by a hyperpolarizing current pulse.9. The above observations are consistent with the hypothesis that edge displacement is a monotonic function of contractile force.10. The slow relaxation between action potentials probably reflects removal of intracellular calcium across the surface membrane in exchange for sodium. Changes in the rate of calcium removal may play a role in the regulation of contractility in this tissue.

Subtypes of psychosocial adjustment to breast cancer.

By means of cluster analytic techniques, four subtypes of psychosocial adjustment were identified in a sample of 122 breast cancer patients who completed the Psychosocial Adjustment to Illness Scale. Internal consistency and internal validity of the derived typology were suggested by the finding that two different hierarchical agglomerative clustering methods (average linkage between groups, Ward's) produced similar solutions. Three of the derived subtypes reported normal affect levels but different patterns of relative strengths and dysfunctions, while the fourth subtype appeared to be highly distressed and globally maladjusted. External validation was demonstrated by differentiating the subtypes on variables of negative affect, avoidance coping, and fighting spirit. The clinical and heuristic implications of these findings are discussed. The findings highlight the need for comprehensive assessment of psychosocial functioning of cancer patients. They demonstrate that even non-emotionally distressed patients can have very different profiles of adjustment and may benefit from correspondingly individually tailored psychosocial interventions.

Attitudes of cancer: psychometric properties of fighting spirit and denial.

Higher rates of recurrence-free survival at 5- and 10-year follow-up have been reported for breast cancer patients who initially responded to cancer with attitudes of "fighting spirit" or denial. We report here a factor analytic attempt, utilizing questionnaire data, to objectify these attitudes. A reliable factor structure replicated in breast and mixed cancer samples, yielding three factors: (1) Fighting Spirit or belief in the ability to fight back, conquer, and recover from cancer; (2) Information-Seeking behavior; and (3) Denial. Adequate 1-month test-retest correlations were obtained for Fighting Spirit and Information Seeking factor scores. A pattern of differential correlations with other measures (affect, coping, and optimism) distinguished Fighting Spirit and Information Seeking. The Denial factor appeared to be less stable and did not correlate significantly with other measures.

Treatment of fibromyalgia incorporating EEG-Driven stimulation: a clinical outcomes study.

Thirty patients from a private clinical practice who met the 1990 American College of Rheumatology criteria for fibromyalgia syndrome (FS) were followed prospectively through a brainwave-based intervention known as electroencephalograph (EEG)-driven stimulation or EDS. Patients were initially treated with EDS until they reported noticeable improvements in mental clarity, mood, and sleep. Self-reported pain, then, having changed from vaguely diffuse to more specifically localized, was treated with very modest amounts of physically oriented therapies. Pre- to posttreatment and extended follow-up comparisons of psychological and physical functioning indices, specific FS symptom ratings, and EEG activity revealed statistically significant improvements. EDS appeared to be the prime initiator of therapeutic efficacy. Future research is justified for controlled clinical trials and to better understand disease mechanisms.

Ethnic comparability of the MMPI in pain patients.

The MMPI basic validity and clinical scales' patterns of 295 White-, African- and Latino-American pain patients were compared. Mean group differences across ethnic groups on scales L, F, K, Mf, and Si were revealed in multivariate analysis of covariance for females, while differences across ethnic groups on scales F, K, Mf, Sc, Ma, and Si were revealed for males. In the univariate follow-up analyses of covariance, significant main effects were obtained for ethnicity along with education and (occasionally for males) duration of pain. Various high-point, two-point, and other profile patterns were examined and notable gender/ethnic group differences were found. The pattern of intercorrelations of the MMPI scales mean T scores with various demographic and clinical characteristics suggested some notable divergence across subgroups on certain correlates of the pain experience.

The Washington University Sentence Complete Test: are the two halves alternate forms? Are the female and male forms comparable?

Evidence from 85 adult medical outpatients supported psychometric comparability of the 2 halves of the Washington University Sentence Completion Test (SCT) Form 81 and of the female and male forms of the SCT. There was slightly stronger internal consistency for the first versus the second half of the SCT. Each half correlated highly with the ogive total protocol rating and 36-item-sum rating. Intercorrelations of the 2 halves with external measures also suggested essentially equivalent relations. For the 30 identical items across gender, the median correlation between individual item ratings with the item-sum ratings was nearly equal for women and men. When the 6 nonidentical items were considered with the identical items, the median item-total correlation was slightly higher for men (45) than women (41). This difference was accounted for by the slightly larger variability in the mate subsample. Practically speaking, the 2 halves and the female and male forms may be used with minimal concern regarding psychometric comparability in similar medical outpatient settings.

Coping with chronic pain: sources of intrinsic and contextual variability.

Univariate and multivariate analyses were used to investigate intrinsic and contextual sources of coping variability among 90 patients with chronic pain. Pain coping strategies were assessed by the subscales of the Coping Strategies Questionnaire. Intrinsic variables included demographic characteristics and dispositional optimism. Contextual variables included pain-related variables and pain control appraisals. In univariate analyses, ethnicity was a statistically significant intrinsic source of variability for the praying and hoping coping subscale; however, comparisons between pairs of ethnic groups were not statistically significant. A multivariate perspective of the data found three independent and salient patterns of correlation between the intrinsic and contextual variables and coping subscales. These patterns of correlation accounted for 96% of the total variance and were conceptualized as optimistic active coping, educated rational coping, and optimistic restricted coping. The findings raise the prospect that there are intrinsic and contextual explanations of coping variability for patients with chronic pain.

Potential contributions of neck muscle dysfunctions to initiation and maintenance of carpal tunnel syndrome.

A biomechanical perspective of the carpal tunnel (CT) is reviewed that lends itself to an understanding of carpal tunnel syndrome (CTS) from a broader pathophysiological perspective than focusing narrowly or solely on nerve disturbance in the extremity. A wider integration of physiological systems in the etiology and maintenance of CTS is proposed that links muscular dysfunction in the neck and possibly elsewhere to dysfunction at the CT. A significant subset of individuals who develop CTS have a primary contribution from muscular dysfunctions rather distal to the CT itself. Neurophysiological dysregulation of normal inhibitory feedback at the level of the motoneuron pool specifically involving gamma motoneuron impulses may be a primary contributing mechanism. Empirical demonstration of amelioration of CTS symptoms by means of surface electromyography (sEMG) retraining of dysfunctional neck muscle patterns is reviewed as support for the hypothesized link. The specific retraining techniques are described. Future conceptual and research directions are noted.

Women with breast cancer: perception of family functioning and adjustment to illness.

Fifty-seven women with breast cancer completed measures of family adaptability and cohesion, marital adjustment, and psychosocial adjustment to illness. Using a circumplex model of family systems, we examined whether subjects who perceived their families at moderate levels of cohesion and adaptability reported better psychosocial adjustment than subjects from families with extreme levels of cohesion and adaptability. The results indicated that the patients who reported the best adjustment to breast cancer and in their marriages, also reported the highest levels of family cohesion. There was not a significant relationship between adjustment to illness and adaptability. The implications for the treatment of women with breast cancer and for the families of these patients were discussed.