Mobile assessment of experiential avoidance, mood, stress, and attendance in cardiopulmonary rehabilitation.

OBJECTIVES: This study utilized mobile ecological momentary assessment (EMA) to examine the dynamic relationships among experiential avoidance (EA), mood, and cardiopulmonary rehabilitation (CVPR) attendance. METHOD: Participants (n = 47; 40.4% female; 80.1% White; 85.1% Cardiac, 14.9% Pulmonary) were recruited from CVPR during their first 2 weeks of the program. They completed daily EMA prompts to assess momentary mood and EA for 2 weeks using a smartphone device. Multilevel modeling (MLM) was employed to investigate the impact of EA and mood on next-week attendance and the within-person within-prompt correlates, antecedents, and consequences of EA. RESULTS: Greater EA and negative mood significantly predicted worse next-week CVPR attendance rates. Within the same EMA prompt individuals with higher EA also reported greater negative affect and perceived stress, while individuals with lower EA reported greater positive mood. In addition, lagged analyses showed that EA was negatively related to next-day positive mood scores. CONCLUSIONS: EA appears to be an important targetable mechanism negatively related to CVPR program attendance and mood in CVPR patients. The present study builds upon previous research supporting EA as a dynamic and fluid emotion-regulation process, suggesting EA's impact on mood and behavior may be best understood through repeated real-time measurement methodology. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Post-Treatment Symptoms of Pain, Anxiety, Sleep Disturbance, and Fatigue in Breast Cancer Survivors.

BACKGROUND: In part because of improvements in early detection and treatment, the number of breast cancer survivors is increasing. After treatment, however, breast cancer survivors often experience distressing symptoms, including pain, sleep disturbance, anxiety, and fatigue; at the same time, they have less frequent contact with health care providers. Pain commonly co-occurs with other symptoms and the combination of symptoms contribute to the amount of distress experienced by survivors. Previous studies of post-treatment symptoms include primarily urban and white women. AIMS: The purpose of this study was to describe the post-treatment cluster of symptoms, to examine the correlations among these symptoms, and to examine the role pain intensity may play in understanding the variation in sleep disturbance, fatigue, and anxiety in a racially diverse sample of rural breast cancer survivors. DESIGN: The theoretical framework for this descriptive correlational study was the theory of unpleasant symptoms. SETTINGS: Outpatient university-affiliated cancer clinic. PARTICIPANTS/SUBJECTS: Forty women who were between 6 months and 5 years post breast cancer diagnosis. METHODS: Participants completed the following self-report instruments: Patient Reported Outcomes Measurement Information System of pain intensity, pain interference, anxiety, and sleep disturbance and the Piper Fatigue Short Form 12. RESULTS: The average age of participants was 58 years, and 57.5% were black. Most women reported sleep disturbance (78%), pain interference (68%), and pain intensity (63%) above the national average for an American adult. Black women reported higher pain intensity than whites. There were moderate to strong correlations among the symptoms (range r = 0.35-0.89). CONCLUSIONS: Nurses and health care providers in primary care settings need to screen for symptoms, and nursing interventions are needed to assist breast cancer survivors to manage distressing symptoms.

Educational Scholarship and Technology: Resources for a Changing Undergraduate Medical Education Curriculum.

Returning to the original emphasis of higher education, universities have increasingly recognized the value and scholarship of teaching, and medical schools have been part of this educational scholarship movement. At the same time, the preferred learning styles of a new generation of medical students and advancements in technology have driven a need to incorporate technology into psychiatry undergraduate medical education (UGME). Educators need to understand how to find, access, and utilize such educational technology. This article provides a brief historical context for the return to education as scholarship, along with a discussion of some of the advantages to this approach, as well as several recent examples. Next, the educational needs of the current generation of medical students, particularly their preference to have technology incorporated into their education, will be discussed. Following this, we briefly review the educational scholarship of two newer approaches to psychiatry UGME that incorporate technology. We also offer the reader some resources for accessing up-to-date educational scholarship for psychiatry UGME, many of which take advantage of technology themselves. We conclude by discussing the need for promotion of educational scholarship.

Training Psychiatry Residents in Psychotherapy: The Role of Manualized Treatments.

Evidence-based treatment and manualized psychotherapy have a recent but rich history. As interest and research have progressed, defining the role of treatment manuals in resident training and clinical practice has become more important. Although there is not a universal definition of treatment manual, most clinicians and researchers agree that treatment manuals are an essential piece of evidence-based therapy, and that despite several limitations, they offer advantages in training residents in psychotherapy. Requirements for resident training in psychotherapy have changed over the years, and treatment manuals offer a simple and straightforward way to meet training requirements. In a search limited to only depression, two treatment manuals emerged with the support of research regarding both clinical practice and resident training. In looking toward the future, it will be important for clinicians to remain updated on further advances in evidence based manualized treatment as a tool for training residents in psychotherapy, including recent developments in online and smartphone based treatments.

Advancements in Undergraduate Medical Education: Meeting the Challenges of an Evolving World of Education, Healthcare, and Technology.

Restructuring of undergraduate medical education (UGME) has occurred from time to time over the past century. Many influences, including the persuasive report of Abraham Flexner in 1910, acted to reorganize medical education in the early twentieth century [1, 2]. In his report, Flexner called on American medical schools to enact higher graduation standards and to stringently adhere to the protocols of mainstream science in their teaching. Prior to this report, UGME had changed little over the previous century but over the last several decades, reform within medical education has become routine. This increasing rate of change has been challenging for those within the realm of undergraduate medical education and can be frustrating to those outside this sphere. Today, the Association of American Medical Colleges (AAMC) and Liaison Committee on Medical Education (LCME) are typically the driving forces behind such changes, along with acceleration of advances in medical care and technology. The number of changes in the last decade is significant and warrants review by those interested or involved in education of medical students. This article aims to provide a summary of recent changes within UGME. Within the article, changes in both the pre-clerkship (1st and 2nd years) and clinical years (3rd and 4th) will be discussed. Finally, this review will attempt to clarify new terminology and concepts such as the recently released Core Entrustable Professional Activities (EPAs). The goal of these UGME changes, as with Flexner's reform, is to ensure future physicians are better prepared for patient care.

Comparison of pain, functioning, coping, and psychological distress in patients with chronic low back pain evaluated for spinal cord stimulator implant or behavioral pain management.

OBJECTIVE: Subgroups of patients with chronic low back pain may exhibit differences in self-reported measures of pain, functioning, coping, and psychological distress. The present study compared subgroups of patients with chronic low back pain referred either for pre-spinal cord stimulator (SCS) psychological evaluations or for behavioral pain management (BPM). DESIGN: Measures from comprehensive pain, functioning, and psychological assessments were compared using multivariate ancova. SETTING: Tertiary care medical outpatient pain management center. SUBJECTS: One hundred and two patients (64% female, mean age = 53.7, standard deviation = 14.3) with chronic low back pain diagnoses were evaluated either as possible candidates for SCS (N = 73) or as part of treatment planning for BPM (N = 29). METHODS: These groups were compared on measures of pain, interference, disability, pain-related anxiety, pain coping, pain catastrophizing, depression, post-traumatic stress symptoms, affective distress, and interpersonal distress assessed using standardized scales. It was hypothesized that the two groups would report similar levels of pain, functioning, and coping, but pre-SCS patients would report fewer psychological symptoms of psychological distress compared with BPM patients in order to gain approval for SCS. RESULTS: Consistent with hypotheses, BPM and pre-SCS patients reported similar pain, functioning, and coping, but pre-SCS patients reported fewer psychological symptoms. CONCLUSIONS: Pre-SCS patients possibly underreport psychological symptoms perhaps to gain SCS approval for SCS. Separate norms and cutoffs for pre-SCS psychological evaluations may be needed to better identify risks of unsuccessful outcomes. Validity scales for measures of psychological distress also could be developed to detect biased reporting. Alternatively, referring clinicians may have referred patients for BPM who were more psychologically distressed and perceived as more in need of psychosocial intervention than those referred for pre-SCS evaluations. Further investigation of clinical referral decisions and assessment bias is warranted to clarify the meaning of these differences and how they apply to patient outcomes.

Autonomic arousal and experimentally induced pain: a critical review of the literature.

BACKGROUND: Autonomic arousal frequently is assumed to be a component of the pain response, perhaps because physiological mechanisms connecting pain and autonomic reactivity can be easily conceptualized. The evidence clarifying autonomic responses specific to painful stimulation, however, has been rather sporadic and lacks coherence; thus, a summary and critical review is needed in this area. OBJECTIVES: To summarize and integrate findings from 39 experimental investigations from 1970 to 2012 of pain-induced autonomic arousal in humans. METHODS: Medline and PsycINFO databases were searched for relevant articles. References from these articles were also considered for review. RESULTS: Painful stimuli increase respiration rate, induce muscle tension, intensify electrodermal activity and dilate the pupils. Cardiovascular activity also increases, but the pattern displayed in response to pain is complex; peripheral vasoconstriction and sympathetically mediated cardiac responses are most typical. Additionally, autonomic expression of pain shows inconsistent relations with verbal and overt motor responses. CONCLUSIONS: Autonomic arousal can be legitimately measured and modified as one facet of the pain response. Future research should particularly focus on increasing sample size and broadening the diversity of participants. To improve the ability to compare and contrast findings across studies, as well as to increase the applicability of laboratory findings to naturalistic pain, investigators also must enhance experimental design by increasing uniformity or accounting for differences in methodology. Finally, further work remains to utilize more specific assessments of autonomic response and to assess relationships of autonomic reactivity with other cognitive (e.g., attention) and affective (e.g., anxiety) variables.

Effects of conscious sedation on patient recall of anxiety and pain after oral surgery.

OBJECTIVE: This study examined the effect of conscious ("moderate") sedation with amnestic effects and local anesthetic, versus local anesthetic alone, on recall of pain and anxiety related to surgical tooth extraction. Greater anxiety and pain were hypothesized in the local anesthesia-alone group. STUDY DESIGN: Patients undergoing tooth extraction, receiving moderate sedation plus local anesthetic (n = 27) or local anesthetic alone (n = 27), were assessed on trait dental anxiety, preextraction state pain and anxiety, anticipated pain and anxiety, and 1-month recall of pain and anxiety. RESULTS: Patients with moderate sedation, compared with those administered only local anesthetic, recalled less procedural pain and anxiety after 1 month. The local anesthetic-alone group reported more preextraction pain and anticipated more procedural anxiety. CONCLUSIONS: Moderate sedation had the desired effect of lower recalled pain and anxiety associated with extraction, even 1 month later. Anticipating moderate sedation also prompts expectation of less anxiety during the procedure.

Interaction of intensity and order regarding painful events.

While stimulus intensity obviously affects degree of pain responding, presentation order effects of stimuli of different intensities on acute pain responses are under-researched. The present study examined the effects of manipulating presentation order of lower and higher pain stimulus intensity. Using 96 undergraduates, this investigation employed a 2 x 2 mixed research design, with pain stimulus sequence as a between-subjects variable and pain stimulus trial as a repeated measure. When the greater pain stimulus intensity was presented last, verbal report of pain was higher. Also, performance of a cognitive task was interrupted the least when the lower stimulus intensity was presented last. Heart rate, however, was highest when the greater stimulus intensity was presented first, and pain tolerance was greatest when the lower stimulus intensity was presented first. Results are discussed in relation to adaptation-level effects, and implications for pain experienced in clinical settings are suggested.