Treatment mechanism and outcome decoupling effects in cognitive therapy, mindfulness-based stress reduction, and behavior therapy for chronic pain.

ABSTRACT: Findings suggest that cognitive therapy (CT), mindfulness-based stress reduction (MBSR), and behavior therapy (BT) for chronic pain produce improvements through changes in putative mechanisms. Evidence supporting this notion is largely based on findings showing significant associations between treatment mechanism variables and outcomes. An alternative view is that treatments may work by reducing or decoupling the impact of changes in mechanism variables on changes in outcomes. We examined the degree to which relationships between previous changes in potential treatment mechanisms and subsequent changes in outcomes changed as treatment progressed and vice versa. Cognitive therapy, MBSR, BT, and treatment as usual (TAU) were compared in people with chronic low back pain (N = 521). Eight individual sessions were administered with weekly assessments of putative treatment mechanisms and outcomes. Lagged analyses revealed mechanism × session number interactions and outcome × session number interactions, such that associations between mechanism and outcome variables were strong and significant in the first third of treatment, but weakened over time and became nonsignificant by the last third of treatment. These effects were similar across treatment conditions but did not emerge among people undergoing TAU. Results suggest that during the course of CT, MBSR, and BT, the links between changes in treatment mechanism variables became decoupled from subsequent changes in outcomes and vice versa. Thus, starting by midtreatment and continuing into late treatment, participants may have learned through participation in the treatments that episodes of maladaptive pain-related thoughts and/or spikes in pain need not have detrimental consequences on their subsequent experience.

Understanding Intensive Care Unit Family Caregivers' Vulnerability to Post-Traumatic Stress Disorder: The Impact of Neurotic Personality Traits, Emotional Suppression, and Perceptions of Unexpected Death.

Rationale: Family members of patients who die in an intensive care unit (ICU) are at heightened risk of post-traumatic stress disorder (PTSD) symptoms. Not all surrogates develop these symptoms and heterogeneity exists in PTSD symptom clusters. Objectives: The study tested a personality model of PTSD symptoms in bereaved family caregivers of ICU patients. It was hypothesized that family members endorsing higher levels of neurotic personality traits would report higher levels of PTSD symptom clusters and that these associations would be explained by tendencies to view the patient's death as unexpected and to cope by suppressing their emotions. Methods: Participants were family members of ICU patients at an urban, academic medical center who either died or were discharged to an inpatient hospice unit. Participants were contacted for participation at least six months after the patient's death. Participants completed measures of personality, emotion regulation, and PTSD symptoms. Data were analyzed using path analysis. Results: Approximately one-third (35%) of the sample of 162 caregivers endorsed at-risk levels of PTSD. Individuals reporting higher levels of neurotic personality traits reported more PTSD symptoms (r = 0.53, p < 0.001). Perceptions that the patient death was unexpected partially explained the association of neuroticism with the intrusive re-experiencing PTSD symptoms (B = 0.45, p = 0.031). In contrast, emotional suppression partially explained the association of neuroticism with avoidance (B = 0.70, p = 0.010) and hyperarousal symptom clusters (B = 0.37, p = 0.041). Conclusions: Family vulnerability to PTSD after an ICU death can be conceptualized based on neurotic personality traits. Tendencies to view the patient's death as unexpected may contribute to intrusive thoughts and memories of the ICU experience. Individuals may avoid reminders and remain at heightened levels of arousal when they suppress their emotional experiences. Key Message: Family members who experience the death of a loved one following ICU treatment are vulnerable to PTSD symptoms. These reactions to ICU-related losses may be shaped by family members' personalities, expectations, and emotion regulation styles. Understanding these characteristics could inform family screening and intervention efforts in the ICU.

Written communication and the ICU team experience (WRITE): A pre-post intervention study.

OBJECTIVE: Families of critically ill patients may benefit from receiving a written update of patient care each day. Our objective was to develop a system to facilitate care provider creation of written updates and to determine the effect of implementing this process on the care provider experience. DESIGN: The experiences of ICU care providers (nurses, advanced practice providers, and physicians) were measured monthly during a 3-month pre-intervention and a 3-month intervention period. During the intervention period, written updates were sent to families each day and posted in the electronic medical record. Study investigators assisted by editing and distributing the written communication to families. SETTING: An urban academic medical center in the United States. MAIN OUTCOME MEASURES: Nurse-Physician Collaboration Scale (NPCS) and Maslach Burnout Inventory (MBI). RESULTS: Over the 3-month intervention period, care providers created written communication for families of 152 patients (average 5 ICU days per family). NPCS scores among the 65 participating care providers were significantly lower, indicating greater collaboration during the intervention vs. pre-intervention period: 49.9 (95 % CI 46.4-53.6) vs. 55.4 (95 % CI 51.5-59.3), p = 0.002. MBI scores were similar during the intervention vs. pre-intervention periods. A subset of care providers participated in individual interviews. Care providers reported that the process of creating written communication was acceptable and had clear benefits for both families and the medical team. CONCLUSIONS: Use of written communication as a supplement to verbal communication improves collaboration among ICU care providers without affecting symptoms of burnout. IMPLICATIONS FOR PRACTICE: We created a system to facilitate written communication with ICU families that was acceptable to care providers and improved aspects of their experience. In the future, use of written communication can be enhanced with refinements to the process that reduce the time spent creating written updates while highlighting the benefits to families and care providers.

Concurrent and lagged associations among pain medication use, pain, and negative affect: a daily diary study of people with chronic low back pain.

ABSTRACT: People with chronic pain often attempt to manage pain and concurrent emotional distress with analgesic substances. Habitual use of such substances-even when not opioid-based-can pose side effect risks. A negative reinforcement model has been proposed whereby relief of pain and emotional distress following medication consumption increases the likelihood that the experience of elevated pain and distress will spur further medication use. People with chronic low back pain (N = 105) completed electronic diary assessments 5 times/day for 14 consecutive days. Lagged and cross-lagged analyses focused on links between time 1 pain and negative affect (NA) and time 2 analgesic medication use and vice versa. Sex differences were also explored. Primary results were as follows: (1) participants on average reported taking analgesic medication during 41.3% of the 3-hour reporting epochs (29 times over 14 days); (2) time 1 within-person increases in pain and NA predicted time 2 increases in the likelihood of ingesting analgesic medications; (3) time 1 within-person increases in medication use predicted time 2 decreases in pain and NA; and (4) lagged associations between time 1 pain/NA and time 2 medication use were strongest among women. Findings suggest that the use of analgesic medications for many people with chronic pain occurs frequently throughout the day. Results support the validity of a negative reinforcement model where pain and distress lead to pain medication use, which in turn leads to relief from pain and distress.

Cognitive Therapy, Mindfulness-Based Stress Reduction, and Behavior Therapy for the Treatment of Chronic Pain: Predictors and Moderators of Treatment Response.

Psychosocial interventions for people with chronic pain produce significant improvements in outcomes, but these effects on average are modest with much variability in the benefits conferred on individuals. To enhance the magnitude of treatment effects, characteristics of people that might predict the degree to which they respond more or less well could be identified. People with chronic low back pain (N = 521) participated in a randomized controlled trial which compared cognitive therapy, mindfulness-based stress reduction, behavior therapy and treatment as usual. Hypotheses regarding predictors and/or moderators were based on the Limit, Activate, and Enhance model; developed to predict and explain moderators/predictors of psychosocial pain treatments. Results were: 1) low levels of cognitive/behavioral function at pre-treatment predicted favorable pre- to post-treatment outcomes; 2) favorable expectations of benefit from treatment and sound working alliances predicted favorable pre- to post-treatment outcomes; 3) women benefited more than men. These effects emerged without regard to treatment condition. Of note, high levels of cognitive/behavioral function at pre-treatment predicted favorable outcomes only for people in the treatment as usual condition. Analyses identified a set of psychosocial variables that may act as treatment predictors across cognitive therapy, mindfulness-based stress reduction and behavior therapy, as hypothesized by the Limit, Activate, and Enhance model if these 3 treatments operate via similar mechanisms. Findings point toward people who may and who may not benefit fully from the 3 psychosocial treatments studied here, and so may guide future research on matching people to these kinds of psychosocial approaches or to other (eg, forced-based interventions) non-psychosocial approaches. TRIAL REGISTRATION: The ClinicalTrials.gov Identifier is NCT02133976. PERSPECTIVE: This article examines potential predictors/moderators of response to psychosocial treatments for chronic pain. Results could guide efforts to match people to the most effective treatment type or kind.

Cognitive therapy, mindfulness-based stress reduction, and behavior therapy for people with chronic low back pain: A comparative mechanisms study.

OBJECTIVE: Cognitive therapy (CT), mindfulness-based stress reduction (MBSR), and behavior therapy (BT) for chronic pain treatment produce outcome improvements. Evidence also suggests that changes in putative therapeutic mechanisms are associated with changes in outcomes. Nonetheless, methodological limitations preclude clear understanding of how psychosocial chronic pain treatments work. In this comparative mechanism study, we examined evidence for specific and shared mechanism effects across the three treatments. METHOD: CT, MBSR, BT, and treatment as usual (TAU) were compared in people with chronic low back pain (N = 521). Eight individual sessions were administered with weekly assessments of "specific" mechanisms (pain catastrophizing, mindfulness, behavior activation) and outcomes. RESULTS: CT, MBSR, and BT produced similar pre- to posttreatment effects on all mechanism variables, and all three active treatments produced greater improvements than TAU. Participant ratings of expectations of benefit and working alliance were similar across treatments. Lagged and cross-lagged analyses revealed that prior week changes in both mechanism and outcome factors predicted next week changes in their counterparts. Analyses of variance contributions suggested that changes in pain catastrophizing and pain self-efficacy were consistent unique predictors of subsequent outcome changes. CONCLUSIONS: Findings support the operation of shared mechanisms over specific ones. Given significant lagged and cross-lagged effects, unidirectional conceptualizations-mechanism to outcome-need to be expanded to include reciprocal effects. Thus, prior week changes in pain-related cognitions could predict next week changes in pain interference which in turn could predict next week changes in pain-related cognitions, in what may be an upward spiral of improvement. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Emotional distress predicts palliative cancer care attitudes: The unique role of anger.

OBJECTIVE: Although palliative care can mitigate emotional distress, distressed patients may be less likely to engage in timely palliative care. This study aims to investigate the role of emotional distress in palliative care avoidance by examining the associations of anger, anxiety, and depression with palliative care attitudes. METHODS: Patients (N = 454) with heterogeneous cancer diagnoses completed an online survey on emotional distress and palliative care attitudes. Emotional distress was measured using the Patient-Reported Outcomes Measurement Information System anger, anxiety, and depression scales. The Palliative Care Attitudes Scale was used to measure palliative care attitudes. Regression models tested the impact of a composite emotional distress score calculated from all three symptom measures, as well as individual anger, anxiety, and depression scores, on palliative care attitudes. All models controlled for relevant demographic and clinical covariates. RESULTS: Regression results revealed that patients who were more emotionally distressed had less favorable attitudes toward palliative care (p < 0.001). In particular, patients who were angrier had less favorable attitudes toward palliative care (p = 0.013) while accounting for depression, anxiety, and covariates. Across analyses, women had more favorable attitudes toward palliative care than men, especially with regard to beliefs about palliative care effectiveness. CONCLUSIONS: Anger is a key element of emotional distress and may lead patients to be more reluctant toward timely utilization of palliative care. Although psycho-oncology studies routinely assess depression or anxiety, more attention to anger is warranted. More research is needed on how best to address anger and increase timely utilization of palliative cancer care.

Symptoms of Anxiety, Depression, and Stress among Families of Critically Ill Patients with COVID-19: A Longitudinal Clinical Trial.

Rationale: Families of critically ill patients with coronavirus disease (COVID-19) may be at particularly high risk for anxiety, depression, and post-traumatic stress disorder after hospital discharge. Objectives: To assess symptoms of anxiety, depression, and stress among families of patients with COVID-19 during and after intensive care unit (ICU) admissions and to use qualitative methods to determine the sources of emotional distress. Methods: Families of patients with COVID-19 who participated in an ICU study were approached for participation in this post-hospital discharge study. Participants completed the Hospital Anxiety and Depression Scale (HADS) and the Impact of Events Scale-Revised (IES-R) at up to three points during the ICU stay and once after the ICU stay. Mixed-effects models were used to compare trajectories of HADS and IES-R scores over the ICU and post-ICU periods. Telephone interviews with participants were evaluated using thematic content analysis. Results: Among the 90 families that participated from September 2020 to April 2021, 47 respective patients were alive and 43 were deceased. Average HADS anxiety, HADS depression, and IES-R scores after hospital discharge were significantly higher (greater symptom burden) among families of deceased versus surviving patients: 9.2 (95% confidence interval [CI], 7.8-10.6) versus 6.3 (95% CI, 4.9-7.6) (P < 0.01), 7.1 (95% CI, 5.7-8.6) versus 3.2 (95% CI, 2.3-4.1) (P < 0.001), and 36.1 (95% CI, 31.0-41.2) versus 20.4 (95% CI, 16.1-24.8) (P < 0.001), respectively. HADS anxiety and HADS depression scores began to diverge during the ICU stay, whereas IES-R scores diverged after the stay for families of surviving versus deceased patients. Qualitative analysis confirmed a higher burden of psychological symptoms among families of deceased patients. Memories from the ICU stay became a focal point for participants who lost their loved ones, whereas families of surviving patients were able to look positively toward the future. In addition, families of deceased patients often viewed friends and family as sources of stress, whereas families of surviving patients typically viewed their community as a source of support. Conclusions: Patient death was associated with symptoms of anxiety, depression, and post-traumatic stress disorder among families of ICU patients with COVID-19. Psychological support interventions may be most beneficial for families of patients who died of COVID-19. Clinical trial registered with www.clinicaltrials.gov (NCT04501445).

Top Ten Tips Palliative Care Clinicians Should Know About Behavioral Pain Management for Persistent Pain.

Seriously ill patients often experience persistent pain. As a part of a comprehensive repertoire of pain interventions, palliative care clinicians can help by using behavioral pain management. Behavioral pain management refers to evidence-based psychosocial interventions to reduce pain intensity and enhance functional outcomes and quality of life. Conceptualized using the biopsychosocial model, techniques involve promoting helpful behaviors (e.g., activity pacing, stretching, and relaxation exercises) and modifying underlying patterns of thinking, feeling, and communicating that can exacerbate pain. The authors have expertise in pain management, clinical health psychology, geropsychology, behavioral science, and palliative medicine. The article reviews the current evidence for behavioral interventions for persistent pain and provides 10 recommendations for behavioral pain management.

Piloting Group-Based Behavioral Activation Therapy for Families of Deceased COVID-19 Patients.

Surrogate decision-making is a stressful process for many family members of critically ill patients. The COVID-19 pandemic may have amplified the risk for anxiety, depression, and posttraumatic stress disorder (PTSD) symptoms in ICU surrogates. OBJECTIVES: This study piloted an online group-based behavioral intervention with family members of deceased COVID-19 patients. Participant engagement, perceptions, and responses related to the intervention were assessed. DESIGN: A single-arm pilot study was conducted with bereaved families. Quantitative analysis of measures of anxiety, depression, and PTSD symptoms was conducted with mixed models. Qualitative data were analyzed to identify themes in surrogates' experiences with the intervention. SETTING: Participants were recruited from ICUs at a tertiary academic medical center. Participants completed the intervention, measures, and interviews online. SUBJECTS: Participants were family members of patients who died from COVID-19. INTERVENTIONS: The intervention involved six online group-based behavioral activation sessions. Sessions covered topics pertinent to grieving and engagement in personally meaningful activities. MEASUREMENTS AND MAIN RESULTS: Semi-structured interviews explored participants' experiences with the intervention. Surrogates also completed measures of anxiety, depression, and PTSD symptoms before and after the intervention. Nineteen of 26 participants (73.1%) completed the study. Thematic analysis suggested that surrogates found the group helpful for overcoming perceived isolation, receiving validation, and developing coping skills. Significant pre-to-post reductions were observed in symptoms of Hospital and Anxiety Disorder Scale (HADS) anxiety (pre-mean = 9.27, sd = 5.30 vs post-mean = 6.80, sd = 4.16; p = 0.0271), HADS depression (pre-mean =6 .65, sd = 4.58 vs post- mean = 4.89, sd = 3.40; p = 0.0436), and Impact of Events Scale-Revised PTSD (pre-mean = 36.86, sd = 16.97 vs post-mean = 24.14, sd = 13.49; p = 0.0008). LIMITATIONS: This was a preliminary study based on qualitative and self-report measures. Future studies should include a control group. CONCLUSIONS: Online group-based behavioral activation therapy appears to be a potentially useful intervention for family members of ICU patients who died from COVID-19.

Application of Terror Management Theory to End-Of-Life Care Decision-Making: A Narrative Literature Review.

Patients with serious illnesses often do not engage in discussions about end-of-life care decision-making, or do so reluctantly. These discussions can be useful in facilitating advance care planning and connecting patients to services such as palliative care that improve quality of life. Terror Management Theory, a social psychology theory stating that humans are motivated to resolve the discomfort surrounding their inevitable death, has been discussed in the psychology literature as an underlying basis of human decision-making and behavior. This paper explores how Terror Management Theory could be extended to seriously ill populations and applied to their healthcare decision-making processes and quality of care received.

Emotion Dysregulation and Workplace Satisfaction in Direct Care Worker Burnout and Abuse Risk.

BACKGROUND/OBJECTIVES: Direct care workers frequently encounter difficult interactions with the patients they serve and experience frustration and burnout. The current study tested a hypothesized model in which predictors of caregiver abuse risk (emotional dysregulation, difficulty managing patient behavior, and workplace satisfaction) were mediated by symptoms of burnout. DESIGN: The study used an online cross-sectional survey design. SETTING AND PARTICIPANTS: The study was implemented online via Qualtrics. Participants were 206 direct care workers (eg, certified nursing assistants, patient care technicians, home health aides, and medical assistants). MEASUREMENTS: All respondents completed the Caregiver Abuse Screen (CASE), Difficulty with Emotional Regulation Scale (DERS-SF), and the Abbreviated Maslach Burnout Inventory. Demographic data and employment history were also collected. Correlational methods, including path analysis, were used to assess associations between study variables. RESULTS: More than half of this heterogenous sample endorsed significant risk for engaging in patient abuse. Path analysis suggested emotional dysregulation and low workplace satisfaction were associated with greater risk of patient abuse, and these associations were partially and simultaneously mediated by burnout facets of depersonalization and emotional exhaustion. CONCLUSIONS AND IMPLICATIONS: This study provided preliminary support for a model of caregiver abuse in which underlying difficulties regulating emotions convey risk for caregiver abuse via burnout facets including emotional exhaustion and depersonalization. Enhancing basic emotion regulation skills and reducing burnout in direct care staff may reduce the risk of abuse for older adults. Thus, providing training necessary to help direct care workers manage their own emotions in order to better recognize, understand, and respond effectively to the needs of older adults may reduce staff burnout and, consequently, lower the risk of abuse for older adults.

Shame in Response to Affective Expression and Its Relation to Social Anhedonia and Schizotypy Traits.

ABSTRACT: Schizotypy is marked by negative symptoms including blunted affect, social isolation, and social anhedonia. Contemporary personality theory suggests that maladaptive shame regulation may disrupt interpersonal function across personality disorders. We hypothesized that "affect shame"-a conditioned response of shame evoked by openly expressing emotions would co-occur with interpersonal deficits in schizotypy. As hypothesized, affect shame was associated with interpersonal deficits (r = 0.17, p < 0.001), physical anhedonia (r = 0.13, p = 0.001), and social anhedonia (r = 0.17, p = 0.001). The observed findings were upheld in analyses controlling for demographic characteristics, depression symptom severity, and neuroticism and were maintained consistently across sensitivity analyses. Findings suggest that shame related to emotional expression is related to interpersonal deficits in schizotypy and have implications for our understanding of the etiology and treatment of this disorder.

Experiential Avoidance and Post-traumatic Stress Symptoms Among Child Abuse Counselors and Service Workers: A Brief Report.

Professionals who counsel and serve survivors of childhood abuse may be at risk of experiencing symptoms of post-traumatic stress disorder (PTSD), which can be exacerbated by cognitive and emotional processes. It is hypothesized that (1) a significant proportion of professionals who primarily serve child abuse survivors experience elevated levels of PTSD symptoms and (2) elevated PTSD symptoms are associated with psychological inflexibility processes, specifically increased experiential avoidance, cognitive fusion, and emotion regulation difficulties. Child abuse counselors and service workers (N = 31) in a major metropolitan area were recruited for a small pilot study. Participants completed self-report measures of PTSD symptoms and levels of psychological flexibility processes. A significant proportion of counselors endorsed clinically significant PTSD symptoms (n = 13, 41.9%). PTSD symptoms were significantly associated with experiential avoidance (r = .54, p < .01) and emotion regulation difficulties (r = .51, p < .01). These associations remained significant after controlling for the personality trait of emotional stability/neuroticism. These findings suggest that PTSD symptoms may be common among child abuse counselors and service workers, and these symptoms tend to be of greater intensity when responded to in avoidant and inflexible ways.

Surrogate and Physician Decision Making for Mechanically Ventilated Patients According to Expected Patient Outcome.

Background: Surrogates and physicians may differ in their priorities and perspectives when making decisions for incapacitated, critically ill patients. Objectives: To determine the extent to which surrogate and physician decisions to sustain life support are associated with their expectations for patient outcomes. Setting/Subjects: Surrogates and physicians of 100 mechanically ventilated patients at an academic, tertiary care medical center in the United States were surveyed. Measurements: Linear regression was used to determine if participant expectations for patient survival, good quality of life, and confidence in these expectations were associated with their agreement that mechanical ventilation should be continued if required for patient survival. Results: Surrogates were more likely than physicians to expect that patients would be alive in three months (91% interquartile range [IQR 70-95%] vs. 65% [IQR 43-77%], p < 0.001) and have good quality of life in three months (71% [IQR 50-90%] vs. 40% [IQR 19-50%], p < 0.001). Surrogates who were most confident in their prognostic abilities were also the most optimistic for good patient outcomes. As such, expectations for patient survival and good quality of life were not associated with level agreement that mechanical ventilation should be continued among confident surrogates, (R2 = 0.03, p = 0.13) and (R2 = 0.01, p = 0.53), respectively. In contrast, among physicians, confidence was not synonymous with optimism. Instead, the significant associations between expectations for patient survival and good quality of life with the agreement that mechanical ventilation should be continued were strengthened when physicians were confident, (R2 = 0.34, p < 0.01) and (R2 = 0.47, p < 0.001), respectively. Conclusion: Surrogates and physicians have different approaches to incorporating their expectations for patient prognosis and their confidence in these expectations when they are making decisions for incapacitated critically ill patients.