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.

Using hypnotic suggestion in the rehabilitation of working memory capacity after acquired brain injury: study protocol for a randomized controlled trial.

OBJECTIVES: Establishment of effective evidence-based interventions in rehabilitation of working memory (WM) deficits after acquired brain injury (ABI) is sorely needed. Despite robust evidence for the efficiency of clinical hypnosis in a wide range of clinical conditions, and improved understanding of mechanisms underlying its effects, the potential of clinical hypnosis in cognitive rehabilitation is underexplored. A recent study has shown large effects of hypnotic suggestion on WM capacity following ABI. This randomized controlled trial aims to evaluate and explore the replicability of these findings and examine the generalization of treatment effects. The study will also explore possible mechanisms of change. METHODS: Ninety patients will be recruited from the Sunnaas Rehabilitation Hospital. Inclusion criteria are nonprogressive ABI, minimum 12-month post-injury, ongoing WM deficits, and age between 18 and 67 years. Patients will be randomized to either (a) an intervention group receiving four weekly 1-h sessions with induction and hypnosis, (b) an active control group receiving four weekly 1-h sessions of induction and mindfulness, or (c) a passive control group without intervention. The targeted procedure consists of suggestions about enhancing WM functions, for example through the instantiation of preinjury WM capacity in the present using age regression or through visualizations of brain plasticity. The non-targeted suggestions contain no explicit mention of ABI- or WM-related abilities. Each participant will be assessed at baseline, immediately after intervention, and 6 months after baseline. The primary outcome is the WM index from WAIS-IV and self- and informant-reported WM subscale from BRIEF-A, a questionnaire exploring executive functioning in everyday life. Secondary outcomes include a cognitive composite score derived from tests measuring processing speed, executive functions, learning capacity and memory, and self-reported measures of emotional distress, quality of life, and community integration. Exploratory measures include self-rated ABI and WM-related self-efficacy. DISCUSSION: Rehabilitation of impaired WM after ABI has hitherto yielded limited transfer effects beyond the training material, i.e., improvement effects on everyday WM capacity, and clinical trials of new interventions are thus warranted. Long-standing empirical evidence demonstrates that hypnosis is an effective therapeutic technique in a wide range of conditions, and recent exploratory research has suggested a high efficacy of hypnosis in improving WM capacity in patients with ABI. However, these extraordinary findings need replication in studies applying scientifically rigorous designs. If successful, our ambition is to provide recommendations and materials to implement hypnotic suggestion as an adjunct treatment following ABI. Study findings may inform future studies exploring the use of clinical hypnosis in other areas of rehabilitation, such as mild TBI, and in other neurological conditions where WM deficit is prominent. TRIAL REGISTRATION: ClinicalTrials.gov NCT05287542. Registered on March 2022 PROTOCOL VERSION: Protocol version 2.0, December 2023.

The effects of a structured communication tool in patients with medically unexplained physical symptoms: a cluster randomized trial.

Background: Medically Unexplained Physical Symptoms (MUPS) are prevalent among primary care patients and frequently lead to diminished quality of life, increased healthcare costs, and decreased work participation. We aimed to examine the effects of a work-focused structured communication tool based on cognitive-behavioral therapy in patients with MUPS. Methods: In a Norwegian two-arm cluster randomized trial, the effectiveness of the structured communication tool Individual Challenge Inventory Tool (ICIT) was compared to usual care for patients with MUPS using a two-arm cluster randomized design. Enrollment period was between March 7 and April 1, 2022. Ten groups (clusters) of 103 General Practitioners (GPs) were randomized to provide the ICIT or usual care for 11 weeks. Patients received two or more sessions with their GP, and outcomes were assessed individually. Primary outcome was patient-reported change in function, symptoms, and quality of life measured by the Patient Global Impression of Change (PGIC). Secondary outcomes included sick leave, work-related self-efficacy (RTW-SE), health-related quality of life (RAND-36), and patient experiences with consultants (PEQ). The trial was registered on ClinicalTrials.gov (NCT05128019). Findings: A total of 541 patients with MUPS were enrolled in the study. In the intervention group 76% (n = 223) showed a significant overall improvement in function, symptoms, and quality of life as measured by the PGIC, compared to 38% (n = 236) in the usual care group (mean difference -0.8 ([95% CI -1.0 to -0.6]; p < 0.0001). At 11 weeks, the intervention group had a 27-percentage point decrease in sick leave (from 52.0 to 25.2), compared to 4-percentage point decrease (from 49.7 to 45.7) in the usual care group. Furthermore, compared to usual care, the intervention group reported significant improvements in work-related self-efficacy, health-related quality of life, and greater satisfaction with the communication during the consultations. No adverse events were reported. Interpretation: The implementation of the structured communication tool ICIT in primary care significantly improved patient outcomes and reduced sick leave among patients with MUPS. Funding: The study was funded by The Norwegian Research Fund for General Practice.

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.

Performance and acceptability of the Stressful Life Events Screening Questionnaire in a chronic pain population: a mixed-methods study.

Introduction: Pain-related fear, anxiety, and avoidance may play key roles in the chronification of pain and related disability. For practitioners, knowledge about the source or drivers of these fears, including patients' exposure to potentially traumatic events (PTEs) and related posttraumatic stress symptoms, could be particularly helpful in guiding their treatment approach. Objectives: We aimed to investigate whether the use of a brief screening for PTEs could help inform chronic pain treatment. Methods: The performance and acceptability of the Stressful Life Events Screening Questionnaire (SLESQ) was assessed among 567 adult patients (59% women, mean age 48.1 years) meeting at a hospital outpatient pain clinic. The sensitivity, specificity, and 20 months temporal stability of the SLESQ, assessing exposure to 14 specific trauma types followed by a 15th item capturing exposure to "other events," were assessed through digital administration and follow-up interviews with 55 participants. The qualitative responses of 158 participants reporting exposure to "other events" were reviewed and assessed based on fulfillment of the A Criterion for traumatic events in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. The acceptability of the SLESQ was assessed in clinical interviews with 12 participants. Results: The SLESQ demonstrated acceptable sensitivity (70.0%), high specificity (94.9%), and moderate temporal stability (κ = 0.66, P < 0.001). Participants' qualitative elaborations of "other events" were largely (76.3%) consistent with Criterion A events. The screening was well accepted and welcomed. Conclusion: The results indicate that the use of a brief screening for potential trauma may be helpful to guide clinical practice in chronic pain settings.

"It's all my fault": a qualitative study of how heterosexual couples experience living with vulvodynia.

INTRODUCTION: Vulvodynia, a chronic genital pain disorder with a high lifetime prevalence among women, has a significant negative impact on both women and their partners. Although there is a growing body of literature on the experiences of women with vulvodynia, there has been little research on the condition's implications for partners and romantic relationships. The aim of this study is to explore how heterosexual couples experience living with vulvodynia. MATERIAL AND METHODS: Eight Norwegian women diagnosed with vulvodynia by gynecologists were recruited with their partners (couples aged 19-32 years). Data was collected via individual semi-structured interviews and analyzed using inductive thematic analysis. RESULTS: Three main themes were identified in the analysis: Mysterious disorder, Social exclusion and Sexual expectations. The results show that the couples struggle with understanding the pain, as well as navigating their social and sexual lives. We discuss these findings in light of a new theoretical model: the fear-avoidance-endurance model of vulvodynia. CONCLUSIONS: Heterosexual couples living with vulvodynia experience communication difficulties with partners, health professionals, and their social network. This sustains avoidance and endurance behavior, increasing pain and dysfunction over time and giving rise to feelings of powerlessness and loneliness. Social expectations regarding male and female sexuality also promote guilt and shame for both parties in couples affected by vulvodynia. Our results suggest that heterosexual couples living with vulvodynia, as well as health professionals treating them, should be helped to communicate more effectively in order to break vicious circles of maladaptive avoidance and endurance behavior.

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.

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.

Validation of child-adapted short scales for measuring gastrointestinal-specific avoidance and anxiety.

AIM: To validate child-adapted shortened versions of the Irritable Bowel Syndrome-Behavioural Responses Questionnaire (IBS-BRQ; short scale denoted BRQ-C) and the Visceral Sensitivity Index (VSI; short scale denoted VSI-C) for children with functional abdominal pain disorders (FAPDs). METHODS: A child psychologist supervised by a child gastroenterologist was responsible for shortening the scales (BRQ-C, 11 items; and VSI-C, 7 items). Then, a sample of 89 children aged 8-12 years with FAPDs was used in the validation. Construct validity was assessed with correlations. Measures included gastrointestinal symptoms, quality of life, pain intensity and anxiety. Also, internal consistency, test-retest reliability, administration time and factor structure were assessed. RESULTS: Internal consistency for the BRQ-C and the VSI-C was α = 0.84 and α = 0.80, respectively. Correlations with related scales were similar between child-adapted scales and original scales, indicating construct validity equivalence. Correlations between short scales and original scales were high. Mean administration time was reduced by 47% (BRQ-C) and 42% (VSI-C), compared with original scales. Test-retest reliability was r = 0.72 for BRQ-C and r = 0.83 for VSI-C. BRQ-C had two factors (Avoidance and Bowel control). VSI-C had a unifactorial structure. CONCLUSION: The BRQ-C and the VSI-C were found to be time-saving, reliable and valid for children with FAPDs.

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.

Development of the workplace inclusion questionnaire (WIQ).

AIMS: To develop a questionnaire to examine attitudes among employees and managers to include people with various health problems into their work group, and to test the questionnaire in one relevant population within the labour market. METHODS: A questionnaire was developed through a process involving discussions in a scientific forum and pilot testing with group discussions. The final questionnaire, which was tested in a survey study of managers and employees in 33 Norwegian kindergartens (N=485), contained 10 short case stories followed by questions concerning workplace inclusion. The case stories described individuals with musculoskeletal and mental disorders, as well as individuals with potentially stigmatising behavioural history and lifestyle, and control cases. Risk ratios with 95% confidence intervals (CIs) were used to compare the case stories. Cases with high risk ratios had an increased risk of not being included compared to a control case. RESULTS: Attitudes for workplace inclusion varied between the different case stories. Cases portraying mental illness had the highest risk ratios, indicating that employees and managers are less likely to include people with mental illness than people with musculoskeletal illness. Furthermore, unspecific or chronic illness had higher risk ratios than specific and acute illness. The most important barriers also varied between case stories. CONCLUSIONS: The workplace inclusion questionnaire fulfills the need for a quantitative measure of attitudes to include individuals with various health problems into the workplace. Comparison of risk ratios showed clear differences between case stories, indicating that the workplace inclusion questionnaire is a valuable tool to measure the variance in workplace inclusion.

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.

Metacognitive therapy and work-focused interventions for patients on sick leave due to anxiety and depression: study protocol for a randomised controlled wait-list trial.

BACKGROUND: Common mental disorders such as depression and anxiety are major contributors to the global burden of disease. Affected individuals suffer reduced quality of life, impaired functioning and reduced capacity to work. Maintaining employment is an important determinant for health and wellbeing, and the economic impact of depression and anxiety is a significant societal expense. Treatments providing effective symptom reduction and helping patients return to work (RTW) would thus have substantial public health benefits. The present study will explore the effectiveness of metacognitive therapy (MCT) and work-focused interventions on reducing symptoms and increasing RTW rates for patients on sick leave due to depression and anxiety. METHODS: The study is a randomised controlled wait-list trial (RCT; N = 240). The intervention group will receive protocol-based MCT and work-focused interventions immediately after inclusion. The control condition is a wait-list control group. All patients will receive up to 12 weekly sessions. The study context is a Norwegian outpatient clinic part of a national programme aimed at reducing sick leave. The co-primary outcomes are change in RTW and symptoms of depression and anxiety at the end of treatment. In addition to self-report, sick leave will also be collected from national registries from 2 years prior to intervention to 4 years after intervention. Symptoms of scores will be collected by self-report at pre- and post-treatment and at 6 and 12 months follow-up after treatment. A cost-effectiveness analysis will use total cost and quality-adjusted life-years as the secondary outcomes. DISCUSSION: There is broad consensus on the importance of identifying treatment that effectively reduces depression and anxiety symptoms and aids RTW. This study is an important contribution to the field as it is the first RCT on MCT and work-focused interventions for patients on sick leave due to anxiety and depression. TRIAL REGISTRATION: ClinicalTrials.gov NCT03301922 . Registered on October 4, 2017.

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.