Cosmetic surgery and associated chronic postsurgical pain: A cross-sectional study from Norway.

OBJECTIVES: Chronic postsurgical pain (CPSP) is a common postoperative sequela. Despite the increasing popularity of cosmetic surgeries, there is a notable lack of research on CPSP in this context, with existing studies focusing on breast surgeries only. To address existing gaps in knowledge, the objective of the present study was to investigate the self-reported prevalence of cosmetic surgery and associated CPSP among Norwegian adults. METHODS: An online questionnaire consisting of three questions inquiring prior cosmetic surgeries, associated CPSP, and whether participants had sought for pain management was constructed and distributed among adults residing in Norway. RESULTS: Between November 30, 2022 and December 16, 2022, 1,746 participants were recruited. 10% of respondents, 73.3% of which were female, affirmed to have undergone cosmetic surgery. About 1 in 4 of these was aged 18-29 years. The prevalence of CPSP was 12.6%. CPSP was five times more common among male, compared to female respondents. While about two thirds of participants indicating to have experienced CPSP were aged 18-29 years, CPSP was much less common among individuals of other ages. CONCLUSION: Consistent with international trends, there appears to be a young and growing population of cosmetic surgery consumers in Norway. According to our results, about 1 in 8 of these might be affected by CPSP, a condition that is notoriously hard to treat and weighting heavily on public healthcare and social welfare systems. Large-scale longitudinal studies further investigating the topic are thus urgently needed.

Epidemiology of classic psychedelic substances: results from a Norwegian internet convenience sample.

Objective: In recent years, there has been a renewed interest in investigating the use of classic psychedelics such as psilocybin and lysergic acid diethylamide (LSD) in the treatment of mental disorders and substance use disorders. However, knowledge about the epidemiology of classic psychedelics in the Nordic countries is limited. Methods: We recruited adult, Norwegian participants who have had a memorable experience after taking a classic psychedelic substance. They filled in an anonymous internet survey with 119 items covering matters related to recreational use of psychedelics using a secure, web-based application. Data are presented by using descriptive statistics (frequencies, means, and standard deviations). Results: We recruited 841 participants, 770 (72% male; 88% 45 years or younger) of which were included in the data analysis. The intentions behind taking the psychedelic substance were mainly recreational (46.1%) or therapeutic (42.3%). Most participants reported that their most memorable experience was with psilocybin. As in modern era clinical trials, most participants were well-prepared before, did processing during, and did integration work after the experience, whereas only a minority were supported by a therapist. Self-perceived symptoms of various mental disorders and substance use disorders were prevalent in the sample. Most subjects reported improvements in their condition. Although adverse reactions were usually mild and short-lived, 4.2% lasted for 1 year or more. Persisting flashbacks were present for a year or more among 2.9% of the participants. Conclusion: In this cross-sectional sample of Norwegian, self-selecting adults, we shed light on what characterizes the most memorable experience with a classic psychedelic substance, including short- and long-term risks and benefits. For the most part, the psychedelic experience led to improvements in self-perceived symptoms of mental disorders and substance use disorders. However, a small subset experienced persisting adverse reactions.

Chronic fatigue syndromes: real illnesses that people can recover from.

The 'Oslo Chronic Fatigue Consortium' consists of researchers and clinicians who question the current narrative that chronic fatigue syndromes, including post-covid conditions, are incurable diseases. Instead, we propose an alternative view, based on research, which offers more hope to patients. Whilst we regard the symptoms of these conditions as real, we propose that they are more likely to reflect the brain's response to a range of biological, psychological, and social factors, rather than a specific disease process. Possible causes include persistent activation of the neurobiological stress response, accompanied by associated changes in immunological, hormonal, cognitive and behavioural domains. We further propose that the symptoms are more likely to persist if they are perceived as threatening, and all activities that are perceived to worsen them are avoided. We also question the idea that the best way to cope with the illness is by prolonged rest, social isolation, and sensory deprivation.Instead, we propose that recovery is often possible if patients are helped to adopt a less threatening understanding of their symptoms and are supported in a gradual return to normal activities. Finally, we call for a much more open and constructive dialogue about these conditions. This dialogue should include a wider range of views, including those of patients who have recovered from them.

Can cognitive inflexibility reduce symptoms of anxiety and depression? Promoting the structural nested mean model in psychotherapy research.

OBJECTIVE: To estimate the causal effect of executive functioning on the remission of depression and anxiety symptoms in an observational dataset from a vocational rehabilitation program. It is also an aim to promote a method from the causal inference literature and to illustrate its value in this setting. METHOD: With longitudinal (four-time points over 13 months) data from four independent sites, we compiled a dataset with 390 participants. At each time point, participants were tested on executive function and self-reported symptoms of anxiety and depression. We used g-estimation to evaluate whether objectively tested cognitive flexibility affected depressive/anxious symptoms and tested for moderation. Multiple imputations were used to handle missing data. RESULTS: The g-estimation showed a strong causal effect of cognitive inflexibility reducing depression and anxiety and modified by education level. In a counterfactual framework, a hypothetical intervention that could lower cognitive flexibility seemed to cause improvement in mental distress at the subsequent time-point (negative sign) for low education. The less flexibility, the larger improvement. For high education, the same but weaker effect was found, with a change in sign, negative during the intervention and positive during follow-up. DISCUSSION: An unexpected and strong effect was found from cognitive inflexibility on symptom improvement. This study demonstrates how to estimate causal psychological effects with standard software in an observational dataset with substantial missing and shows the value of such methods.

Stress specifically deteriorates working memory in peripheral neuropathic pain and fibromyalgia.

This study aimed to explore the influence of chronic stress, measured through hair cortisol, on executive functions in individuals with chronic pain. We expected that there would be significant differences in chronic stress and executive functioning between pain patients and healthy controls, as well as between primary and secondary pain classifications. We also hypothesized that hair cortisol concentration was predictive of worse performance on tests of executive functions, controlling for objective and subjective covariates. For this study, 122 participants provided a hair sample (n = 40 with fibromyalgia; n = 24 with peripheral neuropathic pain; n = 58 matched healthy controls). Eighty-four of these participants also completed highly detailed testing of executive functions (n = 40 with fibromyalgia; n = 24 with peripheral neuropathic pain; n = 20 healthy controls). To assess differences in stress levels and executive functions, t-tests were used to compare patients with controls as well as fibromyalgia with peripheral neuropathic pain. Then, univariate regressions were used to explore associations between stress and executive functioning in both chronic pain classifications. Any significant univariate associations were carried over to hierarchical multivariate regression models. We found that patients with chronic pain had significantly higher cortisol levels than healthy controls, but all groups showed similar executive functioning. Hierarchical multiple regression analyses disclosed that in a model controlling for age, sex and pain medication usage, hair cortisol levels explained 8% of the variance in spatial working memory strategy in individuals with chronic pain. The overall model explained 24% of the variance in spatial working memory. In a second model using imputed data, including both objective and subjectively reported covariates, hair cortisol levels explained 9% of the variance, and the full model 31% of the variance in spatial working memory performance. Higher levels of cortisol indicated worse performance. In this study, an applied measure of chronic stress, namely hair cortisol, explained a substantial part of the variance on a spatial working memory task. The current results have important implications for understanding and treating cognitive impairments in chronic pain.

A cross-sectional study of fear of surgery in female breast cancer patients: Prevalence, severity, and sources, as well as relevant differences among patients experiencing high, moderate, and low fear of surgery.

BACKGROUND: Fear of surgery has been associated with more postoperative pain, disability, and a lower quality of life among patients undergoing various surgical procedures. While qualitative studies indicate breast cancer patients to be afraid of surgery, detailed quantitative analyses are lacking. The present research aimed at investigating the prevalence, severity, and sources of fear of surgery in this patient group and to compare patients reporting different degrees of such fear. METHODS: This cross-sectional study included 204 breast cancer patients, 18-70 years old, and scheduled for surgery at Oslo University Hospital, Norway. Following their preoperative visit participants completed validated psychological questionnaires online. Among these, the primary outcome measure, the Surgical Fear Questionnaire (SFQ; scores: 0-10 per item, 0-80 overall). Patients were grouped based on SFQ-percentiles (<25th = little, 25th-75th = moderate and >75th percentile = high fear) and compared on psychological (anxiety, depression, experienced injustice, optimism and expected postsurgical pain), sociodemographic, and medical outcomes. RESULTS: 195 patients completed the SFQ. On average fear of surgery was low (M = 26.41, SD = 16.0, median = 26, min-max = 0-80), but omnipresent. Only 1.5% (n = 3) indicated no fear at all. Overall, patients feared surgery itself the most (M = 3.64, SD = 2.8). Groups differed significantly (p < .001) in their experience of anxiety, depression, and injustice, as well as their disposition to be optimistic, and expectance of postsurgical pain. Differences between groups concerning demographic and medical information were largely insignificant. DISCUSSION: This study was the first to demonstrate fear of surgery to be prevalent and relevant among female breast cancer patients. The higher a patients' fear group, the poorer their preoperative psychological constitution. This, largely irrespective of their current diagnoses or treatments, medical history, and demographics. Fear of surgery might thus cater as a prognostic marker and treatment target in this patient group. However, given the cross-sectional character of the present data, prognostic studies are needed to evaluate such claims.

Acute and subacute postsurgical pain in women with breast cancer: incidence and associations with biopsychosocial predictors-a secondary analysis of a randomized controlled trial.

Introduction: Women who undergo breast cancer surgery risk suffering from postsurgical pain long after their surgery. Still, research on postsurgical pain in the subacute phase has been neglected. Objective: This study aims to investigate the incidence, intensity, unpleasantness, and presurgical predictors of acute and subacute postsurgical pain after breast cancer surgery. Methods: The study used an observational design through secondary analyses of the control group in a randomized controlled trial. Data from 102 women undergoing breast cancer surgery were included. Levels of acute and subacute pain intensity and unpleasantness were measured using 100 mm Visual Analogue Scales on the day of surgery and 4 weeks postsurgery. Linear regression analyses were performed to identify presurgical biopsychosocial predictors of acute and subacute postsurgical pain. Results: Average levels of postsurgical pain intensity and unpleasantness were as follows: 22.7 mm for acute pain intensity, 19.0 mm for acute pain unpleasantness, 10.3 mm for subacute pain intensity, and 11.7 mm for subacute pain unpleasantness. Pain expectancy predicted acute pain intensity (R2 = 0.04, p = 0.047) and acute unpleasantness (R2 = 0.06, p = 0.02). Perceived social support inversely predicted acute pain unpleasantness (R2 = 0.04, p = 0.014). Conclusion: Mild and moderate acute pain intensity and unpleasantness are common after breast cancer surgery, whereas levels of subacute pain intensity and unpleasantness are low. Pain expectancy predicts acute postsurgical pain intensity and unpleasantness, whereas expected social support inversely predicts acute postsurgical pain unpleasantness.

Meditative-based diaphragmatic breathing vs. vagus nerve stimulation in the treatment of fibromyalgia-A randomized controlled trial: Body vs. machine.

Importance: Vagus nerve innervation via electrical stimulation and meditative-based diaphragmatic breathing may be promising treatment avenues for fibromyalgia. Objective: Explore and compare the treatment effectiveness of active and sham transcutaneous vagus nerve stimulation (tVNS) and meditative-based diaphragmatic breathing (MDB) for fibromyalgia. Design: Participants enrolled from March 2019-October 2020 and randomly assigned to active tVNS (n = 28), sham tVNS (n = 29), active MDB (n = 29), or sham MDB (n = 30). Treatments were self-delivered at home for 15 min/morning and 15 min/evening for 14 days. Follow-up was at 2 weeks. Setting: Outpatient pain clinic in Oslo, Norway. Participants: 116 adults aged 18-65 years with severe fibromyalgia were consecutively enrolled and randomized. 86 participants (74%) had an 80% treatment adherence and 107 (92%) completed the study at 2 weeks; 1 participant dropped out due to adverse effects from active tVNS. Interventions: Active tVNS is placed on the cymba conchae of the left ear; sham tVNS is placed on the left earlobe. Active MDB trains users in nondirective meditation with deep breathing; sham MDB trains users in open-awareness meditation with paced breathing. Main outcomes and measures: Primary outcome was change from baseline in ultra short-term photoplethysmography-measured cardiac-vagal heart rate variability at 2 weeks. Prior to trial launch, we hypothesized that (1) those randomized to active MDB or active tVNS would display greater increases in heart rate variability compared to those randomized to sham MDB or sham tVNS after 2-weeks; (2) a change in heart rate variability would be correlated with a change in self-reported average pain intensity; and (3) active treatments would outperform sham treatments on all pain-related secondary outcome measures. Results: No significant across-group changes in heart rate variability were found. Furthermore, no significant correlations were found between changes in heart rate variability and average pain intensity during treatment. Significant across group differences were found for overall FM severity yet were not found for average pain intensity. Conclusions and relevance: These findings suggest that changes in cardiac-vagal heart rate variability when recorded with ultra short-term photoplethysmography in those with fibromyalgia may not be associated with treatment-specific changes in pain intensity. Further research should be conducted to evaluate potential changes in long-term cardiac-vagal heart rate variability in response to noninvasive vagus nerve innervation in those with fibromyalgia. Clinical trial registration: https://clinicaltrials.gov/ct2/show/NCT03180554, Identifier: NCT03180554.

Pre- and post-operative psychological interventions to prevent pain and fatigue after breast cancer surgery (PREVENT): Protocol for a randomized controlled trial.

BACKGROUND: Breast cancer is the most common cancer type among women worldwide with over a million new cases each year. More than 40% of these women will struggle with chronic pain and fatigue after surgery, regardless of surgical procedure. These consequences are detrimental and result in distress and disability, including work disability. Few attempts have been made to prevent chronic pain and fatigue after surgery by applying a psychological approach, despite psychological risk factors being crucial in the development of both chronic pain and fatigue. In this study, we aim to develop and test an easily implementable strategy of preventing chronic pain and fatigue after breast cancer surgery. The intervention strategy involves a pre-operative hypnosis session and a web-based post-operative Acceptance and Commitment Therapy (ACT). The hypnosis has previously been found effective in alleviating acute post-operative pain and fatigue in breast cancer patients, while ACT is well suited to cancer populations as it offers a model of healthy adaptation to difficult circumstances. Together they form an intervention strategy with both a preventive and a rehabilitative focus. METHODS/DESIGN: This randomized controlled trial aims to estimate the effects of the pre- and post- operative interventions compared to attentional control and treatment as usual (TAU) and will also include a qualitative process evaluation. Participants will be randomized to receive either a pre-operative brief hypnosis session and a post-operative web-based psychological intervention (iACT) or a pre-operative one-session mindfulness through an audio file and post-operative TAU. Self-reported questionnaire data and biomarker data will be assessed pre-surgery, post-surgery and 3 and 12 months after surgery. In addition, we will assess registry data on sick leave and prescriptions until 2-year follow-up. In the qualitative process evaluation, data will be collected from participants from both study arms (through interviews and a diary) and two different analyses performed (socio-narrative and Grounded Theory) with the objective to describe the development of chronic post-surgical pain and fatigue and the potential influence of the interventions on these processes. The study is set-up to demonstrate a minimum difference in pain of 1 point on NRS (0-10) and 3 points on FACIT-F (0-52) between the groups at 3-months follow-up by including 200 breast cancer patients in total. DISCUSSION: This trial will be the first study to estimate the effect of a combined pre-operative hypnosis with a post-operative iACT to prevent pain and fatigue after breast cancer surgery. The results from our study might i) help the large group of women affected by chronic pain and fatigue after breast cancer surgery, ii) shed light on the mechanisms involved in chronic pain and fatigue development, and iii) serve as a model for other surgical procedures. TRIAL REGISTRATION: Clinicaltrials.gov, registration number NCT04518085. Registered on January 29th, 2020. https://clinicaltrials.gov/ct2/show/NCT04518085.

Coping expectancies and disability across the new ICD-11 chronic pain categories: A large-scale registry study.

BACKGROUND: Recently, a new classification system for chronic pain was included in the 11th edition of the International Classification of Diseases (ICD-11). This study aims to investigate how expectancies of coping, that is pain catastrophizing and general self-efficacy, are associated with ICD-11 chronic pain categories in a large pain clinic population. Furthermore, we investigate how coping expectancies are associated with pain-related disability, cross-sectionally and longitudinally across the novel pain classifications. METHODS: The sample was retrieved from the Oslo University Hospital Pain Registry and included baseline data from 2875 chronic pain patients and 12-month follow-up data for 920 patients. Demographic and clinical variables were compared across the ICD-11 chronic pain categories through ANOVA. Multiple regression models were carried out to investigate cross-sectional and longitudinal associations. RESULTS: With the exception of age, our data showed no significant differences across the ICD-11 chronic pain categories. Coping expectancies were associated with disability at baseline. At 12-month follow-up, coping expectancies did not predict pain-related disability when controlling for baseline levels of disability, pain intensity and pain duration. Pain classification (primary vs secondary) did not contribute significantly to the models. Helplessness had the strongest simple relationship to disability, compared with global pain catastrophizing and its additional subscales, both cross-sectionally and longitudinally. CONCLUSION: Coping expectancies, pain intensity and pain-related disability appear similar across the novel chronic pain classifications, indicating that all pain patients may benefit from targeting these variables. Consistent with recent developments in stress theory, helplessness and self-efficacy were cross-sectionally associated with negative pain outcomes. SIGNIFICANCE: Levels of coping expectancies, demographic characteristics, pain-related disability and pain intensity are similar across all ICD-11 chronic pain diagnostic categories. Thus, chronic primary pain is not stronger associated with psychosocial factors such as catastrophizing and self-efficacy than chronic secondary pain. Therefore, chronic pain patients, independent of diagnosis, may benefit from the assessment of these psychosocial factors and targeted interventions such as CBT should be considered.

The Individual Placement and Support (IPS) in Pain Trial: A Randomized Controlled Trial of IPS for Patients with Chronic Pain Conditions.

OBJECTIVES: Although complex pain conditions require an interdisciplinary approach, employment services are rarely provided in pain centers. Individual Placement and Support (IPS) is an effective approach to increase work participation among patients with severe mental illness, and recent evidence suggests that this method can be successfully repurposed for new target groups. We aimed to investigate the effectiveness of IPS integrated with interdisciplinary treatment as usual (TAU) for patients with chronic pain in a tertiary pain center. METHODS: A randomized controlled trial comparing IPS integrated with TAU (n = 38) with TAU alone (n = 20) was conducted. Participants were patients with chronic pain who were 18-65 years of age and currently on long-term sick leave or disability benefits or unemployed. The primary outcome was employment within 12 months after enrollment, with additional long-term follow-up after 24 months. Secondary outcomes included health and quality of life, measured at baseline, 6 months, and 12 months. RESULTS: During 12-month follow-up, 52.8% in the IPS group and 38.9% in the TAU group had attained employment. The difference increased during 24-month follow-up but did not reach statistical significance. Findings on secondary outcomes were generally nonsignificant. CONCLUSIONS: The IPS in Pain trial is the first study to evaluate the effect of IPS for patients with chronic pain conditions. It shows that IPS can be integrated into the daily practice of interdisciplinary pain treatment, with employment rates exceeding 50% in 1 year and a clear trend in favor of the IPS group. Results did not, however, reach significance. Larger randomized controlled trials are needed to draw clear conclusions about effectiveness.

Perceived Injustice in Patients With Chronic Pain: Prevalence, Relevance, and Associations With Long-Term Recovery and Deterioration.

The Injustice Experience Questionnaire (IEQ) assesses the degree to which chronic pain sufferers perceive injustice in relation to their pain. The aim of the current study was to assess the prevalence and relevance of the IEQ and its association to perceived recovery and deterioration in a naturalistic pain clinic population. Data was obtained from the Oslo University Hospital's Pain Registry. Among 2,950 patients, the prevalence of low (<19), medium (19-29) and high (30+) IEQ was 39%, 32% and 29% respectively. High levels of injustice were positively associated with a wide range of adverse health outcomes. Differences between those with high vs low levels of IEQ were clinically significant for most health outcomes. A Venn diagram analysis showed considerable, but not complete, overlap between IEQ, pain catastrophizing, psychological distress and severe pain intensity. High IEQ was associated with reduced clinical recovery (OR 0.6, 95% CI 0.4-0.9) and deterioration (OR 3.6, 95% CI 2.1-6.2) at 12-months follow-up, however, not when controlling for pain-related disability and pain intensity. We conclude that perceived injustice is a prevalent and clinically relevant phenomenon in a chronic pain clinic population, and that more knowledge is needed regarding its role as indicator of poor prognosis and target for tailored treatment. PERSPECTIVE: This article shows that pain-related injustice is both prevalent and relevant in a large naturalistic pain clinic population. Higher levels of injustice were consistently associated with adverse pain outcomes. Injustice could as such be a viable target for treatment of chronic pain, with potential indirect effects on pain and disability.

Associations between workplace bullying and later benefit recipiency among workers with common mental disorders.

OBJECTIVE: In this study, we examined exposure to workplace bullying as a predictor of registry-based benefit recipiency among workers struggling with work participation due to common mental disorders. Further, we examined if the experience of receiving social support moderated the association between workplace bullying and benefit recipiency. DESIGN: Secondary analyses of a randomized controlled trial. PATIENTS: People struggling with work participation due to common mental disorders (CMD). METHODS: Study participants (n = 1193) were from a randomized controlled trial (The At Work and Coping trial (AWaC), trial registration http://www. CLINICALTRIALS: gov NCT01146730), and self-reported CMD as a main obstacle for work participation. Participants were at risk of sickness absence, currently on sickness absence or on long-term benefits. Benefit recipiency indicated sickness absence and/or long-term benefits (i.e., disability pension) at 6-month follow-up. RESULTS: Of the 1193 participants, 36% reported exposure to workplace bullying. Workplace bullying was significantly associated with benefit recipiency at 6-month follow-up (OR 1.41, CI 1.11-1.79). Social support did not moderate the association between bullying and benefit recipiency. CONCLUSIONS: The finding that workplace bullying increases the risk of later benefit recipiency suggest that bullying is a significant obstacle for work participation.

Translation and validation of the Norwegian version of the Injustice Experience Questionnaire.

OBJECTIVES: Perceived injustice is a theoretical construct comprising elements of loss, attribution of blame, and sense of unfairness. Patients with chronic pain often report high levels of perceived injustice, which can have negative impact on physiological and psychosocial aspects and treatment outcome. The Injustice Experience Questionnaire (IEQ) is a self-report 12-item questionnaire that shows good reliability and validity in patients with chronic pain. This study aimed to translate, validate, and expand the use of the Norwegian Injustice Experience Questionnaire (IEQ-N) to a chronic pain population. METHODS: A mixed-method approach was used to translate and validate the IEQ-N. It was forward-back translated, linguistically validated, and culturally adapted. Individual cognitive debriefing interviews (n=7) and a focus group interview (n=9) was used to explore the patients' experience with- and understanding of the questionnaire. Statistical descriptive, correlational, factor- and regression analyses were used to investigate the IEQ-N validity, reliability, and factorial structure in a large registry sample (n=3,068) of patients with chronic pain. RESULTS: Patients with chronic pain found the IEQ-N relevant. Registry analyses supported that the IEQ-N had a one-factor structure. The internal consistency was high (Chronbach's alpha=0.92). The construct validity was good, with moderate to strong significant univariate correlation (r=0.29-0.71) (p<0.05) between perceived injustice and related constructs of pain catastrophizing, pain severity, disability, psychological distress, and quality of life. Perceived injustice contributed with significant but small unique variance to pain-related factors (i.e., pain intensity, pain-related disability, psychological distress), but the additional contribution beyond pain catastrophizing was small (0.2-6.7%) (p<0.05). CONCLUSIONS: Patients in the study found the questionnaire relevant for their situation, and easy to understand. This study provides a reliable and valid Norwegian tool to assess perceived injustice in patients with chronic pain. ETHICAL COMMITTEE NUMBER: REK sør-øst, 2016/1942.

Clinical Hypnosis in Medical Care: A Mixed-Method Feasibility Study.

BACKGROUND: Preoperative hypnosis has shown promising effects in controlling side effects from breast cancer surgery, but the feasibility and effects are largely unknown outside the US. METHODS: A mixed-methods approach was applied involving a large-scale population survey and a small-scale pilot study. The survey assessed attitudes toward hypnosis in a representative sample from the general population (n = 1049), while the pilot study involved interviews with 5 women who received hypnosis prior to mastectomy/lumpectomy. RESULTS: In the survey, 8% reported to have previous experience with hypnosis, and 67% reported willingness to accept hypnosis in a medical setting. Increasing age was associated with more skepticism, while previous experience was associated with less skepticism. In the pilot study, 4 themes were identified: (1) caretaking, (2) experiences related to hypnosis, (3) thoughts and feelings related to diagnosis, and (4) surgery. All participants reported positive experiences related to hypnosis, and none described unpleasant side effects or postoperative pain (pain intensity > 3) after surgery. CONCLUSIONS: The results indicate that the general public is positive toward clinical hypnosis as a supplement to medical treatment and that preoperative hypnosis is feasible in Norwegian breast cancer patients. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04300283.

What Does CATS Have to Do With Cancer? The Cognitive Activation Theory of Stress (CATS) Forms the SURGE Model of Chronic Post-surgical Pain in Women With Breast Cancer.

Chronic post-surgical pain (CPSP) represents a highly prevalent and significant clinical problem. Both major and minor surgeries entail risks of developing CPSP, and cancer-related surgery is no exception. As an example, more than 40% of women undergoing breast cancer surgery struggle with CPSP years after surgery. While we do not fully understand the pathophysiology of CPSP, we know it is multifaceted with biological, social, and psychological factors contributing. The aim of this review is to advocate for the role of response outcome expectancies in the development of CPSP following breast cancer surgery. We propose the Cognitive Activation Theory of Stress (CATS) as an applicable theoretical framework detailing the potential role of cortisol regulation, inflammation, and inflammatory-induced sickness behavior in CPSP. Drawing on learning theory and activation theory, CATS offers psychobiological explanations for the relationship between stress and health, where acquired expectancies are crucial in determining the stress response and health outcomes. Based on existing knowledge about risk factors for CPSP, and in line with the CATS position, we propose the SURGEry outcome expectancy (SURGE) model of CPSP. According to SURGE, expectancies impact stress physiology, inflammation, and fear-based learning influencing the development and persistence of CPSP. SURGE further proposes that generalized response outcome expectancies drive adaptive or maladaptive stress responses in the time around surgery, where coping dampens the stress response, while helplessness and hopelessness sustains it. A sustained stress response may contribute to central sensitization, alterations in functional brain networks and excessive fear-based learning. This sets the stage for a prolonged state of inflammatory-induced sickness behavior - potentially driving and maintaining CPSP. Finally, as psychological factors are modifiable, robust and potent predictors of CPSP, we suggest hypnosis as an effective intervention strategy targeting response outcome expectancies. We here argue that presurgical clinical hypnosis has the potential of preventing CPSP in women with breast cancer.

Comparing objective cognitive impairments in patients with peripheral neuropathic pain or fibromyalgia.

Existing studies on cognitive impairments in chronic pain do not investigate peripheral neuropathic pain (PNP) or compare pain conditions in a satisfactory manner. Here we aimed to compare executive dysfunctions in PNP patients with fibromyalgia (FM) and healthy controls (HC). Patients who self-reported cognitive impairments were assessed according to criteria for PNP or FM. Seventy-three patients met criteria and completed testing on executive functioning and IQ measures. We also included twenty matched healthy controls. Regression models controlling for age, sex and IQ, tested associations between group category (PNP, FM or HC) and outcomes. If a substantial association was detected, we followed up with head-to-head comparisons between PNP and FM. Multivariate regression models then tested associations between executive functioning and pain type, controlling for significant confounders. Results from head-to-head comparison between pain conditions showed significant differences on years lived with pain (FM > PNP), the use of anticonvulsants (PNP > FM) and use of analgesics (PNP > FM). When controlled for all significant differences, PNP patients had significantly lower scores on an attention-demanding cued-recall task compared to FM. Poor performance on attention-demanding cued-recall task was associated with PNP, which translate into problems with retaining fast-pace or advanced information.

Motivational nondirective resonance breathing versus transcutaneous vagus nerve stimulation in the treatment of fibromyalgia: study protocol for a randomized controlled trial.

BACKGROUND: Chronic widespread pain (CWP), including fibromyalgia (FM), affects one in every ten adults and is one of the leading causes of sick leave and emotional distress. Due to an unclear etiology and a complex pathophysiology, FM is a condition with few, if any, effective and safe treatments. However, current research within the field of vagal nerve innervation suggests psychophysiological and electrical means by which FM may be treated. This study will investigate the efficacy of two different noninvasive vagal nerve stimulation techniques for the treatment of FM. METHODS: The study will use a randomized, single-blind, sham-controlled design to investigate the treatment efficacy of motivational nondirective resonance breathing (MNRB™) and transcutaneous vagus nerve stimulation (Nemos® tVNS) on patients diagnosed with FM. Consenting FM patients (N = 112) who are referred to the Department of Pain Management and Research at Oslo University Hospital, in Oslo, Norway, will be randomized into one of four independent groups. Half of these participants (N = 56) will be randomized to either an experimental tVNS group or a sham tVNS group. The other half (N = 56) will be randomized to either an experimental MNRB group or a sham MNRB group. Both active and sham treatment interventions will be delivered twice per day at home, 15 min/morning and 15 min/evening, for a total duration of 2 weeks (14 days). Participants are invited to the clinic twice, once for pre- and once for post-intervention data collection. The primary outcome is changes in photoplethysmography-measured heart rate variability. Secondary outcomes include self-reported pain intensity on a numeric rating scale, changes in pain detection threshold, pain tolerance threshold, and pressure pain limit determined by computerized pressure cuff algometry, blood pressure, and health-related quality of life. DISCUSSION: The described randomized controlled trial aims to compare the efficacy of two vagal nerve innervation interventions, MNRB and tVNS, on heart rate variability and pain intensity in patients suffering from FM. This project tests a new and potentially effective means of treating a major public and global health concern where prevalence is high, disability is severe, and treatment options are limited. TRIAL REGISTRATION: ClinicalTrials.gov NCT03180554 . Registered on August 06, 2017.

Pain psychology in the 21st century: lessons learned and moving forward.

Background and aims In the spring of 2019, Professor Steven J. Linton, the founder of the Center for Health and Medical Psychology (CHAMP) at Örebro University, Sweden, formally retired. As a tribute to his scholarly work covering decades of influence and inspiration to the field of pain psychology, the research center organized a topical conference titled "Pain in the 21st century: Where do we come from and where are we going?", which resulted in this state-of the-art synthesis. The aim of this declaration is to highlight lessons learned but not in the least is meant to inspire and guide our continued journey forward, developing pain psychology into the 21st century. Methods Several collaborators of Professor Linton have summarized and reflected on the current state-of-the-art of pain psychology from the perspective of his input to the field, as well as on developments from the last years of advancements in pain psychology. Results The topics have been divided into six themed sections covering the fear avoidance model, transdiagnostics, secondary prevention, risk- and protective factors, communication and contextual factors. The sections cover a broad spectrum, from basic experimental studies, integrating emotion and motivational theories into current theoretical models, to applied research on the effect of early interventions as well as sophisticated emotion-focused treatment models for pain patients with concurrent emotional ill-health. Conclusions There have been major advancements within pain psychology research during the last decades, moving the field towards a more comprehensive picture, taking emotional and motivational aspects into account to understand pain sufferers. Although psychologically informed interventions in general mainly focus on the individual, it has been put forward that pain management is highly influenced by the surrounding environment, including communication with health care providers, and the occupational and social context. Implications Professor Steven J. Linton has been at the forefront of pain psychology research during the last decades, and inspired by his work this journey will continue into the 21st century, with the ultimate goal of enhancing the understanding and treatment for all people suffering from persistent and disabling pain.

Interpersonal problems as a predictor of pain catastrophizing in patients with chronic pain.

Background and aims Pain catastrophizing has consistently been related to a variety of negative outcomes within chronic pain conditions, but competing models exist explaining the role of catastrophizing. According to the fear-avoidance model (FAM), catastrophizing is primarily related to the appraisal of pain (i.e. "intrapersonal"), whereas the communal coping model (CCM) suggests that catastrophizing is a strategy to elicit support (i.e. "interpersonal"). In order to examine the interpersonal nature of catastrophizing, this cross-sectional study examined interpersonal problems as a predictor of pain catastrophizing in a sample of patients (n = 97) with chronic pain. Methods Self-report data was taken from patients entering a multidisciplinary, inpatient rehabilitation program. The four quadrants of the Inventory of Interpersonal Problems circumplex model (Hostile-Dominant, Hostile-Submissive, Friendly-Submissive, Friendly-Dominant) were used as predictors of pain catastrophizing in a series of separate, hierarchical regression analyses. Results After controlling for relevant confounding variables such as demographics (gender, age), pain severity, psychiatric symptoms (anxiety/depression, fatigue, insomnia), adverse life experiences and perceived social support, higher levels of Hostile-Dominant interpersonal problems predicted higher levels of pain catastrophizing (p ≤ 0.01, d = 0.56). Conclusions The results add support to the notion that pain catastrophizing may serve a communicative functioning, as predicted by the CCM, with cold, dominant and controlling behaviors as a maladaptive interpersonal strategy to elicit support. It may thus be useful to consider the broader interpersonal context of the individual, and not only the patient's appraisal of pain, when conceptualizing the role of pain catastrophizing in patients with chronic pain. Implications Future psychosocial research and treatment of chronic pain could be informed by including interpersonal theory as a useful theoretical framework, which may help shed more light on how interpersonal problems relates to pain catastrophizing.