Update on structured pain assessment for the documentation of diagnosis-independent symptoms and signs associated with pain.

Concerning the diagnosis and therapy of pain syndromes, standardized descriptions similar to those used in the examination of psychopathological findings via the system produced by the AMDP ("Arbeitsgemeinschaft für Methodik und Dokumentation in der Psychiatrie", i. e., the working group establishing standardized methodology and documentation within psychiatry) are still lacking. Therefore, the authors of this article have founded a working group to establish standardized methodology and documentation for symptoms and signs associated with pain, although not at a diagnosis-specific level, in order to promote standardization in the documentation of pain and rating of the symptoms associated with a given set of medical results. This article presents a system for documenting the symptoms and signs associated with pain globally and independently of the diagnosis (Structured Pain Assessment System) with nomenclature that is inspired by the AMDP system. The objective of this working group is to develop documentation for a uniform multidimensional pain assessment (with defined terminology) that serves as a comparable and unified standard in the field.

Is 'anxiety sensitivity' predictive of postoperative nausea and vomiting?: A prospective observational study.

BACKGROUND: Postoperative nausea and vomiting (PONV) is an extremely distressing side effect for patients. Despite PONV prophylaxis guided by well established scoring systems, the incidence of PONV is still high. OBJECTIVE: The aim of the current study was to investigate the predictive value of anxiety sensitivity as an additional independent risk factor for PONV in patients with an increased risk of PONV. DESIGN: A noninterventional, observational study. SETTING: A tertiary care university hospital. PATIENTS: Patients with an increased risk of PONV (i.e. female, nonsmoking) undergoing elective surgery (general, gynaecological, urological, musculoskeletal or neurosurgical) under general anaesthesia. MAIN OUTCOME MEASURES: The number of patients with anxiety sensitivity assessed pre-operatively with the Anxiety Sensitivity Index-3 questionnaire, the number of patients experiencing PONV, predictive value of anxiety sensitivity compared with other established risk factors for PONV. RESULTS: Some 41.5% of the patients experienced PONV within the first 24 h after surgery. In these patients increased anxiety sensitivity (Anxiety Sensitivity Index-3 score higher than seven points) was associated with a five-fold increase in the odds ratio (OR) for PONV. From the regression model, the risk of PONV was increased by lack of PONV prophylaxis (OR, 3.68), the postoperative administration of opioids (OR, 3.60) and patient age (OR, 1.03), but laparoscopic surgery did not increase the risk. CONCLUSION: In addition to the well established risk factors, anxiety sensitivity can help to predict the risk of PONV. It seems justifiable to add psychological factors such as anxiety sensitivity to PONV risk-scores. PONV prophylaxis should be considered when anxiety sensitivity is high. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01875120.

Anxiety and its predictive value for pain and regular analgesic intake after lumbar disc surgery - a prospective observational longitudinal study.

BACKGROUND: Ongoing pain after surgery is a major problem and influences recovery and the quality of life of the patient. Associations between anxiety and their impact on postoperative pain after herniated disc surgery have been reported, but the results are inconsistent. The aim of the present longitudinal study was to evaluate the predictive value of preoperative anxiety for postoperative ongoing pain and prolonged analgesic intake after herniated disc surgery. METHODS: 106 patients with lumbar disc herniation were evaluated in the study. Anxiety was measured with the Generalized Anxiety Disorder 7-Item Scale (GAD-7) before surgery. Pain intensity was assessed on a numeric rating scale (NRS) at baseline, 6-weeks and 6-months after surgery. Regression analysis was performed to identify independent predictors of pain and regular utilization of analgesics up to 6 months after surgery while controlling for confounding variables. RESULTS: 42.5% of the patients were rated as anxiety cases (sum scores GAD-7 > 5), mean scores of anxiety showed mild to moderate symptom severity, and 43% suffered from chronic pain before surgery. Six months after surgery, 55.6% of the patients indicated pain levels of 4/10 (NRS) or higher and about 40% still took pain medication on a regular basis, regardless of their preoperative classification as anxiety-case (37.7% and 41.5%). The preoperative pain level was statistically significant for ongoing postsurgical pain in all four analyses (p < 0.001). With binary logistic regression analyses, preoperative pain intensity, but neither demographic factors nor preoperative anxiety, was identified as predictor for postoperative pain and need for analgesic medication up to 6 months after lumbar disc surgery. CONCLUSION: We found no evidence for the presence of anxiety before disc surgery being a prognostic factor for ongoing pain and regular postoperative intake of analgesics. Only preoperative pain intensity was predictive for increased pain and continued need for analgesic medication up to 6 months after lumbar disc surgery. TRIAL REGISTRATION: Clinicaltrials.gov NCT01488617 . Registered 6 December 2011.

[The AMDS system for the documentation of symptoms and signs associated with pain]. / Das AMDS-System zur Dokumentation von Schmerzbefunden.

The authors present a system for nomenclature and documentation of symptoms and signs associated with pain. The system was compiled in a staged process by the study group for methods and documentation of pain-associated symptoms and signs (Arbeitsgemeinschaft für Methodik und Dokumentation von Schmerzbefunden [AMDS]). The suggested items were elaborated from terms used in current national and international guidelines and classifications and in part integrated into superordinate terms. The items that were built up by this approach aim to reflect the broad spectrum of pain diseases. The items for the description of pain-associated symptoms and signs are divided into the areas of algesiomotor, psychoalgesiological and somatoalgesiological findings. The aim is the documentation of a multidimensional algesiological description of findings with defined terminology, which can serve as a comparable and unified standard, particularly in the field of pain assessment. The AMDS system should enable a systematic description of pain, which is a reliable foundation for diagnostics, therapy planning and expert case evaluation.

Prevalence of pain 6 months after surgery: a prospective observational study.

BACKGROUND: Pain after surgery is a major issue for patient discomfort and often associated with delayed recovery. The aim of the present study was to evaluate the prevalence of pain and requirement for analgesics up to 6 months after elective surgery, independent if new pain symptoms occurred after surgery or if preoperative pain persisted in the postoperative period. METHODS: A prospective observational single center cohort study was conducted between January 2012 and August 2013. Eligible patients were scheduled to undergo elective surgical interventions including joint (hip, knee arthroplasty), back (nucleotomy, spondylodesis), or urological surgery (cystectomy, prostatectomy, nephrectomy). Pain was assessed on an 11-point numerical rating scale (NRS) before, on postoperative day 2 and 6 months after surgery. Clinical information was collected with structured questionnaires and by telephone interview. RESULTS: Six hundred and forty-four patients gave informed consent, including 54.4 % men (mean age 62.2, SD 14.3). Higher preoperative pain scores were found in patients undergoing joint (mean 7.6; 95 % confidence interval [CI]: 7.2-8.0) and back surgery (mean 7.1, CI: 6.8-7.5) than in patients prior to urological surgery (mean 2.3; CI: 1.8-2.8). After 6 months, about 50 % of patients after joint or back surgery indicated pain levels ≥3/10, compared to 15.9 % of patients after urological surgery (p < .001). 35.3 % of the patients after joint surgery and 41.3 % after back surgery still use pain medication 6 months postoperatively, in contrast to 7.3 % of patients after urological surgery. 13.6 % of patients who underwent back surgery indicated the regular intake of opioids. CONCLUSIONS: Our results reveal that a significant percentage of patients undergoing procedures in joint or back surgery still need pain medication up to 6 months postoperatively due to ongoing pain symptoms. Improved monitoring of pain management is warranted, especially after discharge from hospital, to improve long-term results. TRIAL REGISTRATION: Clinicaltrials.gov (Identifier: NCT01488617 ); date of registration December 6th 2011.

Assessing preoperative anxiety using a questionnaire and clinical rating: a prospective observational study.

BACKGROUND: Preoperative anxiety and need for information can be detected during preoperative consultation via structured and standardised screening by the Amsterdam Preoperative Anxiety and Information Scale (APAIS) questionnaire. OBJECTIVE: To identify the prevalence of preoperative anxiety and need for information, with regard to influencing factors such as age, sex, previous operation and grade of surgery, and to examine the level of agreement between patients' self-rating and physicians' ratings. DESIGN: Prospective observational study. SETTING: Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg University Mainz, Germany. PATIENTS: Two hundred seventeen patients scheduled for elective surgery. INTERVENTIONS: The patients completed questionnaires prior to the interaction with the anaesthesiologist. Physicians were blinded to the patients' ratings and provided their subjective ratings about patients' anxiety and need for information immediately after seeing the patient. MAIN OUTCOME MEASURE: Degree of anxiety and need for information, agreement of patients' self-reports and physician's rating. RESULTS: 18.9% of patients were classified as 'anxiety cases' (31.8% in women and 10.6% in men). The grade of the intended surgery but no other investigated factor was related to patients' anxiety. Age (older patients) was correlated with information requirement (r = 0.21, P = 0.002). Analysis of agreement showed only weak correlations between patients' self-reports and physicians' ratings, demonstrated in low weighted Kappa-coefficients (0.12 to 0.32). CONCLUSION: The APAIS is a useful instrument to assess the level of patients' preoperative anxiety and the need for information. Given the relationship between preoperative anxiety and postoperative outcome, it seems justified to incorporate this approach into the preoperative consultation. TRIAL REGISTRATION: German Clinical Trials Register DRKS00003084.

[Emotional childhood parentification and mental disorders in adulthood]. / Parentifizierung in der Kindheit und psychische Störungen im Erwachsenenalter.

BACKGROUND: Emotional parentification is considered harmful to a child's development. METHOD: A total of about 975 patients were examined at a Department of Psychosomatic Medicine and in the practices of general practitioners with regard to childhood adversities. RESULTS: Emotional parentification is a risk factor for 2 symptom groups: the patients with depression and the patients with somatoform pain. While the occurrence of depression is mainly predicted by maternal emotional parentification, paternal influences are also relevant in regard to the development of somatoform pain. CONCLUSION: Emotional parentification is an important risk factor for the occurrence of psychological and somatoform complaints in adulthood. This is especially apparent in combination with further risk factors, such as low reported values for love, sexual abuse, or being raised without a father.

A short screening instrument for mental health problems: the symptom checklist-27 (SCL-27) in Poland and Germany.

OBJECTIVE: The symptom checklist SCL-27 is a short, multidimensional screening instrument for mental health problems. It contains six scales: depressive, dysthymic, vegetative, agoraphobic and sociophobic symptoms; symptoms of mistrust; and a global severity index (GSI-27). METHODS: A survey of two student samples from Poland and Germany (n ∼ 400) is presented. RESULTS: Most scales of the SCL-27 showed good to satisfactory reliability (i.e. Cronbach's α > 0.70). Some items displayed different characteristics in students than in non-student samples. These discrepancies can be explained partly by the particular situation students face and partly by some country-specific or language-specific aspects of the measuring instrument. Differences between Polish and German students were marginal at best; in general, the Polish students tended to assent more easily to the items of the SCL-27 than did the German students. CONCLUSIONS: The SCL-27 is suitable for international comparisons. In both, Germany and Poland, students display a characteristic response pattern that differs from those of other samples. It can be applied as a separate instrument or for reanalysis of data collected with the SCL-90_R.

[Determinants of quality of life in patients with somatoform disorders with pain as main symptom - the case for differentiating subgroups]. / Determinanten der Lebensqualität bei somatoformen Störungen mit Leitsymptom Schmerz - Plädoyer für eine Subgruppen-Differenzierung im ICD-11.

OBJECTIVES: What impact do the degree of somatization and the presence of a comorbid psychological disorder have on health-related quality of life in patients with pain-dominated somatoform disorders? METHODS: 282 consecutive patients (57.6 %) from a total population of N=490 patients fulfilling the criteria of somatoform pain disorders were included in the study following a thorough interdisciplinary diagnostic process at a German university hospital. Structured interviews (SKIDI and SKID-II) to assess comorbid psychological disorders as well as a structured biographical interview to assess chronification factors were conducted. We employed the Screening for Somatoform Disorders form (SOMS) to discover the extent and distribution of somatic symptoms and the SF-36 to determine the health-related quality of life. RESULTS: The patients exhibited a multiplicity of further somatic complaints apart from pain. 69 % had a comorbid psychological disorder. The health-related physical and psychological quality of life was clearly impaired in patients with "small", "substantial" and "pronounced" somatization. Regression analysis explained 48 % of the variance of the body-related and 35 % of the variance of the psychological quality of life: Besides the extent of somatization, older age, duration of pain-associated hospitalizations and the subjective amount of occupational impairment proved to be important. With regard to the psychological (but not the somatic) health-related quality of life, the presence of a current comorbid psychological disorder was also relevant. CONCLUSION: Patients with pain-dominated somatoform disorders are substantially impaired in their quality of life. Because 31 % of the patients with such disorders have no additional comorbid psychic disorder and the existence of a comorbid psychic disorder impacts only the psychological domain of their health-related quality of life, the results appear to strongly support maintaining the diagnostic category of somatoform disorders in ICD-11 and DSM-V. They also support the grading of the severity of the somatization similar to the grading of depressive disorders.

Determinants of health-related quality of life in patients with persistent somatoform pain disorder.

BACKGROUND: Health-related quality of life (HRQOL) has been investigated widely in patients with chronic pain, but no study has focused particularly on the situation of patients with persistent somatoform pain disorder. AIMS: To survey the impairments of patients with somatoform pain disorder (ICD-10: F45.4) and to predict pain-related impairments and HRQOL on the basis of coping styles. METHODS: A consecutively recruited sample of 100 patients (65% female) was examined in a cross-sectional study. Questionnaires were administered to assess pain intensity (visual analogue scale), pain-related disabilities (Pain Disability Index), quality of life (Short-Form Health Survey-36), and ways of coping with pain (Coping Strategies Questionnaire). To predict pain-related impairments and HRQOL, a multiple linear regression analysis was carried out. RESULTS: HRQOL of patients with somatoform pain is strongly and significantly reduced compared with the general population. Among the coping measures, Increasing Pain Behaviors and Catastrophizing have a negative influence on patients' pain-related impairments and the physical components of HRQOL. The mental component of HRQOL was predicted solely by Catastrophizing. No positive effect of active coping styles on health-related outcome variables could be observed. CONCLUSION: Patients with persistent somatoform pain disorder feel severely impaired. A clear pattern emerges for negative effects of the coping styles Increasing Pain Behaviors and Catastrophizing, while the identification of beneficial coping failed.

[Long-term effects of adverse childhood experiences - Actual evidence and needs for research1/2]. / Früher Stress und Langzeitfolgen für die Gesundheit - Wissenschaftlicher Erkenntnisstand und Forschungsdesiderate1/2.

There is evidence from some prospective and several retrospective studies that early biological and psychosocial stress in childhood is associated with long-term vulnerability to various mental and physical diseases. In the last few years research findings have accumulated on those emotional, behavioural and psychobiological factors which are responsible for the mediation of these lifelong consequences. They are the cause of an increased risk of somatization and other mental disorders. Particularly anxiety, depression and personality disorders often result in high-risk behaviour that itself is associated with physical disease (cardiovascular disorders, stroke, viral hepatitis, type 2 diabetes, chronic lung diseases) as well as with aggressive behaviour. A survey on the current knowledge of how these various factors interact is presented and a bio-psychopathological model of vulnerability is educed. Implications for future research are outlined and contrasted to actual political trends in Germany.

[Symptom Checklist SCL-27]. / Die Symptom-Checkliste SCL-27 - Ergebnisse einer deutschen Repräsentativbefragung.

The Symptom-Checklist-27 (SCL-27) forms a modification of the widely used Symptom-Checklist-90-R, with the latter demonstrating considerable shortcomings in psychometric properties. The SCL-27 is designed to screen for psychiatric symptoms in patients presenting somatic complaints. It contains the six subscales depressive, dysthymic, vegetative, agoraphobic, sociophobic symptoms and symptoms of mistrust. Additionally, a global severity index (GSI-27), similar to the GSI in the SCL-90-R is available. The subscales are short, the number of items varies between four and six. Psychometric properties and reference values based on a representative German sample of more than 2000 subjects are presented for the various subscales. All subscales show sufficient internal consistency with Cronbach's alpha > or = 0.70 and for the GSI-27 alpha is = 0.93. The correlation between GSI-27 and GSI is r = 0.93. Sex-specific cut-offs are presented to identify those patients, who need further examination.