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.

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.

Assessing older adults with generalized anxiety: a replication and extension.

Anxiety is a major health problem for older adults. The cornerstone for further work in this area is research that establishes the psychometric utility of standardized measurement strategies to characterize anxiety in older adults. The goals of the current study were to replicate and extend prior research addressing the psychometric properties of five self-report measures of anxiety in a sample of 57 older adults with generalized anxiety disorder (GAD). Data addressed the descriptive characteristics, internal consistency, test-retest reliability, interrelation of subscales, and convergent and divergent validity of the Penn state worry questionnaire (PSWQ), worry scale (WS), Spielberger state-trait anxiety inventory - Form Y (STAI), and two versions of the fear questionnaire (FQ). Descriptive data generally replicated prior findings, with some increased state and trait anxiety in the current sample. Measures were internally consistent, with evidence that a revised version of the FQ that focuses on severity of fear irrespective of associated avoidance demonstrated greater internal consistency than the original version. Measures of content-specific fears and worries (WS, FQ) were stable over time and demonstrated convergent validity. Evidence of convergent validity also was evident for measures of worry and general anxiety (WS, PSWQ, STAI-Trait), but two of these measures (PSWQ, STAI) were not reliable over time. Only the PSWQ showed evidence of divergent validity with respect to self-report measures of depression.

Percutaneous core biopsy of the breast: correlates of anxiety.

RATIONALE AND OBJECTIVES: The authors performed this study to investigate the level of patient anxiety immediately preceding breast biopsy and examined potential clinical and demographic correlates of anxiety. MATERIALS AND METHODS: The authors evaluated 102 women who were referred to a radiology breast clinic to undergo breast biopsy. The women were assessed with a self-report of demographic and medical items and the State Trait Anxiety Inventory (STAI) immediately before their biopsy. The STAI also was administered at 1 and 5 days after biopsy. RESULTS: The participants' mean state anxiety T score as measured with the State Trait Anxiety Inventory was 71.1 (standard deviation, 7.2). Multiple regression analysis was performed to determine the correlates of state anxiety. The variables that showed the strongest correlation with state anxiety were trait anxiety, being concerned about the results of biopsy, education (less education was associated with more anxiety), age (an older age was associated with more anxiety), and number of relatives with breast cancer. Given the expected overlap (r = 0.55) between state and trait anxiety, a second regression analysis was performed that controlled for trait anxiety. The results of this analysis also identified age, being concerned about the results of the biopsy. and number of relatives with breast cancer as relevant correlates of state anxiety. CONCLUSION: Overall, the results give some indication of the characteristics of women likely to be most anxious before biopsy. Future research should assess the effectiveness of different strategies for addressing situational anxiety.

Cognitive-behavior therapy for generalized anxiety in late life: an evaluative overview.

Of the pervasive anxiety disorders diagnosed in late life, generalized anxiety disorder (GAD) is the most prevalent. In this paper, the clinical features of GAD among older adults are described, with particular attention to differences in the nature of relevant symptoms among older and younger cohorts. Outcome studies addressing the efficacy of cognitive-behavior therapy (CBT) for younger and middle-aged adults with GAD then are reviewed briefly. Next, early literature investigating the potential usefulness of cognitive-behavioral treatments among older anxious community volunteers is then reviewed and critiqued in some detail. More recent work, some of which is currently in progress, has focused on the efficacy of CBT for older adults with well-diagnosed GAD. This research also is reviewed, and directions for future research in this area are provided.

Psychometric comparability of English- and Spanish-language measures of anxiety and related affective symptoms.

An array of measures of anxiety and related disorders (viz., Albany Panic and Phobia Questionnaire; Anxiety Sensitivity Index; Beck Anxiety Inventory; Beck Depression Inventory-II; Body Sensation Questionnaire; Fear Questionnaire; Padua Inventory; Penn State Worry Questionnaire; Post-Traumatic Stress Disorder Diagnostic Scale; Social Interaction Anxiety Inventory; and Worry Scale) was edited or translated from English into Spanish. Following an extensive edit and translation process, bilingual participants (n = 98) were assessed with the English and Spanish versions of these measures. Coefficient alphas were excellent and comparable across language versions. Means and standard deviations were also comparable across language versions. Evidence of convergent and discriminant validity was found for both language versions. The two language versions of each measure correlated highly with each other. This psychometric comparability adds confidence in using the newly edited or translated Spanish language measures in clinical practice and research.

The relationship between adolescent life stress events and delinquent conduct including conduct indicating a need for supervision.

Yeaworth, York, Hussey, Ingle, and Goodwin's (1980) Adolescent Life Change Event Scale was administered to 55 adolescents who were on probation or being held in detention for offenses ranging from a felony to conduct indicating a need for supervision (Texas Juvenile Probation Commission, 1983). The offenses committed during the previous 12 months were given weights, and weights obtained by Yeaworth (1980) were used for stress events experienced in the last 12 months. Pearson product moment correlation was computed to obtain a relationship between stress events and offenses. The results suggest that these adolescents are more stressed than nondelinquent adolescents when compared to the Yeaworth (1980) study. Nearly 82 percent of subjects in the present study had experienced the event of "failing one or more subjects in school." The correlation coefficient obtained relating stress events to offenses was -0.01727. The results were interpreted to mean that there is no relationship between total amount of stress experienced and total offenses committed. However, some patterns were found in runaway behavior and truancy that were related to several of the stress events; 87.5 percent of runaway subjects had experienced "hassling with parents," and 43.8 percent had experienced a "family member other than yourself having trouble with alcohol"; 94.1 percent of truancy subjects had experienced "failing one or more subjects in school," and 64.7 percent had experienced "getting into drugs or alcohol."

The association between patterns of family functioning and ego development of the juvenile offender.

The present study revealed an association between the family configurations of cohesion and adaptability and juvenile offenders' level of ego development. This association was explained by four post hoc comparisons which revealed that functional perspectives of family cohesion and adaptability by the juvenile offender and one or both parents were associated with higher levels of ego development. Lower levels of ego development were associated with (a) shared dysfunctional perspectives of the family dimensions by the juvenile offender and both parents, and (b) a functional perspective of the family dimensions by the juvenile offender which was not shared by either parent. These results were based on 61 nonchronic juvenile offenders and their parents who were assessed by the Family Adaptability and Cohesion Evaluation Scales II. The offenders' level of ego development was assessed by the Washington University Sentence Completion Test.

Psychometric properties of the Interpersonal Style Inventory.

This study investigated the reliabilities and conjectured factor structure of the subscales comprised by Lorr and DeJong's (1986) abbreviated form of the Interpersonal Style Inventory (ISI). The results suggest that internal consistency reliabilities of the subscales are presently inadequate for clinical or research purposes. The five-factor structure described by Lorr (1986) appeared to conform well to the empirical grouping in the data set. Only one scale, Approval Seeking, appeared incorrectly placed according to the a priori description. Another weakness in the a priori structure was that the Rule-Free subscale had only a minor role in identifying its conjectured factor. These results were based on ISI protocols from 268 adults. Overall's (1974) marker variable factor analysis was implemented to assess the adequacy of the a priori factor structure.

An investigation of the progressive sequence of ego development levels.

The progressive sequence of ego development levels as measured by the Washington University Sentence Completion Test was examined in relation to component scores on a construct identified from 12 objective measures related to ego development. The analysis was based on 229 adult subjects. The sequence of component scores for three groupings of ego development levels (Pre-Conformist, Conformist, and Post-Conformist) followed the predicted progression. Large standard deviations relative to the mean component scores for the groupings of ego development levels suggested overlap among the levels of ego development, which is consistent with the notion of décalage in developmental theory.

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.

Population recovery capabilities of 35 cluster analysis methods.

Comparative evaluation of population recovery capabilities of 35 cluster analysis methods defined by different combinations of 5 profile similarity measures and 7 agglomeration rules was undertaken using artificial data that represented duplicate mixture samples from 4 latent populations. The latent population mean profiles differed primarily in elevation or in pattern parameters. Latent population sampling variances were controlled to provide two different levels of realistic overlap. The within-population distributions were multivariate normal with diagonal covariance structure. Across all conditions examined, complete linkage and Ward's minimum variance methods, used with Euclidian or city block interprofile distance measures, performed best. Single linkage, median, and centroid methods were substantially inferior for clustering individuals in accordance with true population memberships.

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.

Self-reports and clinician-measured physical function among patients with low back pain: a comparison.

OBJECTIVE: To determine the relationships among self-reported activity limitation and clinician-measured functional performance tests. DESIGN: Case series survey. SETTING: A referral-based orthopedic spine clinic in Houston, TX. PATIENTS: Eighty-three patients (48 women, 35 men) with low back pain (LBP). INTERVENTIONS: The Roland-Morris Disability Questionnaire (RMDQ) and a physical performance test (PPT) battery. MAIN OUTCOME MEASURES: Self-reported activity limitation (eg, walking, bending, getting out of chair, putting on sock, doing heavy jobs) was assessed by the RMDQ. Clinician-measured functional performance was assessed with the PPT, a battery comprised 6 tests: lumbar flexion range of motion, a 50-foot walk at fastest speed, a 5-minute walk, 5 repetitions of sit-to-stand, 10 repetitions of trunk flexion, and loaded reach task (patients reached forward while holding a weight weighing 5% of their body weight). RESULTS: Pearson's product-moment correlations between total RMDQ score and each of the performance tests ranged from.29 to.41. Point biserial correlations between individual RMDQ items and their corresponding performance tests were slightly lower, ranging from.20 to.33. CONCLUSION: There were moderate correlations between self-reported activity limitation and corresponding clinician-measured performance tests. The unique perspective each method provides appears to be useful for a comprehensive understanding of physical function in patients with LBP.

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.

Effects of maximum performance instructions on the sentence completion test of ego development.

This modified replication of Jurich and Holt's (1987) test-retest study investigated the stability of scores on the Washington University Sentence Completion Test (SCT; Loevinger, 1985; Loevinger & Wessler, 1970; Loevinger, Wessler & Redmore, 1970) across alternate instructional formats. Initially, 90 adult participants completed the SCT using standardized instructions. After a 1-week interval participants were readministered the SCT based on random assignment to either a standardized instruction (control) group, a role-play instructional set, or a best-effort instructional set. A repeated measures multivariate analysis of variance yielded statistically significant differences in ego level scores across the 3 instructional sets. The differences in ego level scores were approximately one-half level higher for the role-play and best-effort instructional sets. Effect sizes for the experimental instructional sets ranged from .23 using item sum scores to .45 using total protocol ratings. Results are supportive of Jurich and Holt's (1987) findings, indicating that the standardized instruction SCT may be susceptible to the motivational set of the test-taker.

Measures of depression in older adults with generalized anxiety disorder: a psychometric evaluation.

Generalized anxiety disorder (GAD) is the most common of the pervasive anxiety disorders among older adults, with lifetime prevalence estimates of 6%. Because of this high prevalence rate, it is important to establish the utility of assessment tools with this population. Preliminary data exist with regard to the use of anxiety measures with older anxious adults; however, no similar information is available for self-report measures of depression in this population. This study examined the psychometric properties of the Beck Depression Inventory (BDI) and the Geriatric Depression Scale (GDS) with a sample of 54 older adults diagnosed with GAD, 22 of whom were diagnosed with a coexistent depressive disorder. Internal consistency, convergent and divergent validity, construct validity, and discriminative validity of the BDI and the GDS were examined. Overall, the results support the reliability and validity of these self-report measures of depressive symptoms in a sample of older anxious adults.

Physical performance: differences in men and women with and without low back pain.

OBJECTIVE: To determine the extent to which there may be major differences in scores on a battery of physical performance tasks among men with nonspecific, mechanical low back pain (LBP), women with LBP, healthy men, and healthy women. DESIGN: Case series survey. SETTING: A referral-based orthopedic clinic. PATIENTS: Thirty-three men and 46 women with LBP. Control Subjects: Twenty-one men and 25 women healthy controls. INTERVENTION: Completion of six clinician-assessed physical performance tasks and self-report inventories. MAIN OUTCOME MEASURE: Performance scores on distance walked in 5 minutes, 50-foot walk at fastest speed, repeated sit-to-stand, repeated trunk flexion, loaded forward reach, and the Sorensen fatigue tasks. RESULTS: Discriminant function analysis revealed that the four groups of subjects performed the physical tasks significantly different in two major ways: (1) healthy control subjects outperformed LBP patients, irrespective of gender, on tasks involving trunk control, coordination, and stability while withstanding heavy or quickly changing loads on the spine; (2) men outperformed women, irrespective of patient or nonpatient status, on tasks involving anthropometric features of limb length. The findings provide guidance on reasonable performance expectations for men and women patients with LBP. Future studies of treatment effectiveness also will be able to assess physical performance change in terms of the intersection between standards set by the men and women healthy control subjects and those of men and women patients. However, whether a return to nonpatient status is an appropriate treatment goal is left to future research.