Responding flexibly to the complex problem of chronic pelvic pain: Incorporating patient needs into program development.

BACKGROUND: Chronic pelvic pain (CPP) in women is both common and disabling, and access to interdisciplinary care is limited. Patient education programs may represent a pragmatic approach to delivering interdisciplinary care, but to date the specific educational needs of patients with CPP are unknown. METHOD: We surveyed 136 patients at a tertiary CPP treatment center to identify their educational needs and preferences; 71 (52%) completed surveys. Based on the results, we developed an interdisciplinary educational program, including expert presentations and an extensive participant handbook. We modified our program to a webinar format following the advent of COVID-19. Participants registered for the webinar only or for our study involving completion of three measures of pain-related functioning before and 2 months after the webinar. RESULTS: Our survey results indicated that CPP patients were most interested in learning about the diagnosis and treatment of CPP, coping with CPP, and diet and exercise in the context of CPP; patients also indicated a preference for brief, one-time programs. Of the 164 webinar participants, 64 (39%) enrolled in the study and completed baseline measures; 20 (31%) of those returned follow-up measures 2 months after the webinars. Participants who completed follow-up measures reported significant reduction in pain-related interference; no other significant differences were observed. Participants who completed feedback surveys were positive in their evaluation of the program. CONCLUSION: Patients with CPP desire more knowledge about their complex symptoms. Addressing their specific needs through educational supports may enhance their ability to manage their symptoms independently. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Chronic Pelvic Pain Profiles in Women Seeking Care in a Tertiary Pelvic Pain Clinic.

OBJECTIVE: Female chronic pelvic pain (CPP) has multiple pain generators and significant psychosocial sequalae. Biopsychosocial-based phenotyping could help identify clinical heterogeneity that may inform tailored patient treatment. This study sought to identify distinct CPP profiles based on routinely collected clinical information and evaluate the validity of the profiles through associations with social histories and subsequent health care utilization. METHODS: Women (18-77 years, n = 200) seeking care for CPP in a tertiary gynecological pelvic pain clinic between 2017 and 2020 were included. Baseline data of pain intensity, interference, catastrophizing, acceptance, overlapping pelvic pain syndromes, and co-occurring psychiatric disorders were subject to a partition around medoids clustering to identify patient profiles. Profiles were compared across social history and subsequent treatment modality, prescribed medications, and surgeries performed. RESULTS: Two profiles with equal proportion were identified. Profile 1 was vulvodynia and myofascial pelvic pain-dominant characterized by lower pain burden and better psychological functioning. Profile 2 was visceral pain-dominant featuring higher pain interference and catastrophizing, lower pain acceptance, and higher psychiatric comorbidity. Patients in Profile 2 had 2-4 times higher prevalence of childhood and adulthood abuse history (all P < .001), were more likely to subsequently receive behavioral therapy (46% vs 27%, P = .005) and hormonal treatments (34% vs 21%, P = .04), and were prescribed more classes of medications for pain management (P = .045) compared to patients in Profile 1. CONCLUSIONS: Treatment-seeking women with CPP could be separated into two groups distinguished by pain clusters, pain burden, pain distress and coping, and co-occurring mental health disorders.

Dysmenorrhea catastrophizing and functional impairment in female pelvic pain.

Background: Dysmenorrhea is suggested to increase the risk of chronic pain by enhancing central sensitization. However, little is known about whether emotional and cognitive responses induced by dysmenorrhea contribute to chronic pain interference. This study examined the association between catastrophizing specific to dysmenorrhea and both dysmenorrhea and chronic pelvic pain (CPP)-associated pain interference. Methods: Women (N = 104) receiving care for CPP through a tertiary gynecological pain clinic between 2017 and 2020 were recruited. They completed the Pain Catastrophizing Scale, the Brief Pain Inventory-pain interference, and a separate questionnaire regarding dysmenorrhea symptoms and treatment preceding the development of CPP. Dysmenorrhea catastrophizing and interference measures were developed and tested for internal consistency and construct validity. Multiple linear regression models examined dysmenorrhea catastrophizing in association with dysmenorrhea interference and CPP-associated pain interference. Results: Dysmenorrhea catastrophizing and interference measures demonstrated excellent internal consistency (Cronbach's Alpha = 0.93 and 0.92 respectively) and evidence of construct validity (correlated with dysmenorrhea severity and treatment, Ps < 0.01). Dysmenorrhea catastrophizing was moderately correlated with pain catastrophizing (ρ = 0.30, P = 0.003), and was associated with greater dysmenorrhea interference (P < 0.001) and CPP-associated pain interference (P = 0.032) accounting for general pain catastrophizing and other outcome-specific confounders. Dysmenorrhea intensity was most predictive of dysmenorrhea catastrophizing. Conclusion: Among our clinical sample of women with CPP, dysmenorrhea catastrophizing was associated with greater dysmenorrhea interference and subsequent CPP-associated pain interference. More research is needed to determine whether reduction in dysmenorrhea catastrophizing leads to reduced pain interference associated with female pelvic pain.

Prospective Association between Dysmenorrhea and Chronic Pain Development in Community-Dwelling Women.

Despite emerging evidence of associations between dysmenorrhea, enhanced pain sensitivity, and functional neuroimaging patterns consistent with chronic pain, it is unknown whether dysmenorrhea is prospectively associated with chronic pain development. Gaining a better understanding of this relationship could inform efforts in prevention of chronic pain. Using data from the national Midlife in the United States cohort, we examined the prospective association between dysmenorrhea and chronic pain development during a 10-year follow-up (starting 10 years after dysmenorrhea was measured) among 874 community-dwelling women aged 25-74 at baseline (when dysmenorrhea was measured). We fit modified Poisson regression models adjusting for sociodemographic, lifestyle and psychosocial factors. Among women who were menstruating at baseline, self-reported dysmenorrhea was associated with a 41% greater (95% confidence interval [CI] = 6%-88%) risk of developing chronic pain. Women with dysmenorrhea also developed chronic pain in more body regions (≥3 regions vs 1-2 regions vs none, odds ratio [OR] = 1.77, 95% CI = 1.18-2.64) and experienced greater pain interference (high-interference vs low-interference vs none, OR = 1.73, 95% CI = 1.15-2.59). Among women who had stopped menstruation at baseline, we did not find evidence of an association between their history of dysmenorrhea and subsequent risk of chronic pain development. Results suggest dysmenorrhea may be a general risk factor for chronic pain development among menstruating women. PERSPECTIVE: This study supports the temporality of dysmenorrhea and chronic pain development in a national female sample. Dysmenorrhea was also associated with developing more widespread and disabling pain among women who were still menstruating. Early management of dysmenorrhea may reduce the development and severity of chronic pain in women, although further research is required to determine whether dysmenorrhea is a causal risk factor or a risk marker of chronic pain.

Association between dysmenorrhea and chronic pain: a systematic review and meta-analysis of population-based studies.

OBJECTIVE: The objective of the study was to synthesize the epidemiological findings for the associations between dysmenorrhea, including primary dysmenorrhea and endometriosis-associated dysmenorrhea and any chronic pain conditions, including chronic pelvic pain, and chronic nonpelvic pain. DATA SOURCES: The data sources included PubMed, Embase, and CINAHL from inception to December 2019. STUDY ELIGIBILITY CRITERIA: The study criteria included observational population-based studies in which the relationship between dysmenorrhea and the presence or severity of chronic pain was examined. STUDY APPRAISAL AND SYNTHESIS METHODS: Each study was double coded and evaluated for bias based on the modified Newcastle and Ottawa Scale. Random-effect meta-analyses were conducted to quantify the associations between dysmenorrhea and the presence of chronic pelvic and nonpelvic pain. RESULTS: Out of 9452 records, 32 studies were included, with 14 reporting associations between dysmenorrhea and chronic pelvic pain, and 20 for dysmenorrhea and chronic nonpelvic pain. Primary dysmenorrhea and endometriosis-associated dysmenorrhea were examined in 7 studies, respectively. More than 30% of the studies were categorized as poor quality, 56% as moderate, and 12.5% as high. Dysmenorrhea was positively associated with both the presence and severity of chronic pelvic and nonpelvic pain conditions. Based on 6689 women from 8 studies, those with chronic pelvic pain had 2.43 (95% confidence interval, 1.98-2.99, I2, 42%) times the odds of having dysmenorrhea compared with those without. Based on 3750 women from 11 studies, those with chronic nonpelvic pain had 2.62 (95% confidence interval, 1.84-3.72, I2, 72%) times the odds of having dysmenorrhea compared with those without. Overall, dysmenorrhea was associated with 2.50 (95% confidence interval, 2.02-3.10) times the odds of chronic pain, which did not differ by chronic pelvic vs chronic nonpelvic pain, community vs clinical populations, or different geographical regions. CONCLUSIONS: Dysmenorrhea may be a general risk factor for chronic pain, although whether primary dysmenorrhea increases the risk for chronic pain is unclear. Given that adolescence is a sensitive period for neurodevelopment, elucidating the role of primary dysmenorrhea in pain chronicity in future longitudinal studies is important for preventing both chronic pelvic and nonpelvic pain.

Couple Interventions for Chronic Pain: A Systematic Review.

OBJECTIVE: Couple interventions for chronic pain have been shown to more effectively reduce pain intensity for individuals with chronic pain (ICPs) than individual behavioral interventions or usual care. This systematic review identified randomized controlled trials of couple interventions to highlight strategies that could be incorporated into psychotherapy with ICPs and their romantic partners. METHODS: The authors identified articles reporting randomized controlled trials of couple interventions for chronic pain. Three databases were searched (ie, PubMed, Embase, and PsycInfo), resulting in 18 studies and 22 articles. RESULTS: Couple interventions resulted in statistically significant improvements in pain intensity compared with other conditions in 8% to 40% of the studies depending on the comparator group (i.e., control, individual intervention, another couple intervention), and in statistically significant improvements on a pain-related outcome compared with other conditions in 31% to 50% of the studies depending on the comparator group (ie, control, individual intervention, another couple intervention). Educating couples about pain was the most common strategy (83%). Jointly administered relaxation or meditation skills were included in nearly half of the interventions (48%). Many interventions taught cognitive-behavioral skills jointly to couples (39%) or to the ICP with partner encouragement (30%). Teaching couples how to request and provide assistance (30%), and encouraging partners to avoid reinforcing pain behaviors (39%), occurred frequently. ICPs and their partners were often asked to set goals (30%). DISCUSSION: This review outlined strategies included in couple interventions for chronic pain that are derived from the cognitive-behavioral therapy, acceptance and commitment therapy, and operant behavioral traditions, but delivered relationally. Therapists working with ICPs and their partners may integrate these strategies into their practice to help couples who are managing chronic pain.

The relationship between cortisol, salivary alpha-amylase, and cognitive bias in young women.

Both animal and human studies suggest that cognitive bias toward negative information, such as that observed in major depression, may arise through the interaction of cortisol (CORT) and norepinephrine (NE) within the amygdala. To date, there is no published account of the relationship between endogenous NE and CORT levels and cognitive bias. The present study examined salivary CORT and salivary alpha-amylase (sAA), an indirect measure of NE, in relation to masked affective priming of words in young female participants. Women with higher salivary CORT showed increased priming to negative word pairs only when sAA was also high; when sAA was low, no effect of CORT on priming was observed. These results are in line with previous research indicating that increased CORT is linked to enhanced processing of negative information. However, our findings extend this literature in providing evidence that CORT predicts enhanced processing of negatively valenced information only in the presence of higher sAA.

Selective emotional processing deficits to social vignettes in schizophrenia: an ERP study.

Schizophrenia is associated with abnormalities in emotional processing and social cognition. However, it remains unclear whether patients show abnormal neurophysiological responses during fast, online appraisals of the emotional meaning of social information. To examine this question, event-related potentials (ERPs) were collected while 18 schizophrenia patients and 18 demographically matched controls evaluated 2-sentence vignettes describing negative, positive, or neutral social situations. ERPs were time locked to a critical word (CW) in the second sentence that conferred emotional valence. A late positivity effect to emotional (vs neutral) CWs was seen in both groups (in controls, to negative and positive CWs; in patients, to negative CWs only). However, the controls showed a greater late positivity effect to the negative and positive (vs neutral) CWs than the schizophrenia patients at mid-posterior (negative vs neutral) and at right posterior peripheral (positive vs neutral) sites. These between-group differences arose from reduced amplitudes of the late positivity to the negative and positive CWs in the patients relative to the controls; there was no difference between the 2 groups in the amplitude of the late positivity to the neutral CWs. These findings suggest that schizophrenia is associated with a specific neural deficit during the online evaluation of emotionally valent, socially relevant information.

What can Event-related Potentials tell us about language, and perhaps even thought, in schizophrenia?

Disturbances of thought and language are fundamental to schizophrenia. Cognitive behavioral and electrophysiological research has implicated problems in two different neurocognitive mechanisms: abnormalities in the structure and function of semantic memory, and abnormalities in combining and integrating words together to build up sentence and discourse context. This review discusses recent electrophysiological evidence suggesting that these two deficits are not completely distinct, but rather that language impairment in schizophrenia results from a dysfunctional interaction between these systems in an effort to build up higher-order meaning. Moreover, although language abnormalities are more pronounced in patients with positive thought disorder, they manifest themselves in all patients when increased demands are placed on the comprehension system. Further investigation of language dysfunction may also provide insights into other aspects of psychotic thought.

Why all the confusion? Experimental task explains discrepant semantic priming effects in schizophrenia under "automatic" conditions: evidence from Event-Related Potentials.

The schizophrenia research literature contains many differing accounts of semantic memory function in schizophrenia as assessed through the semantic priming paradigm. Most recently, Event-Related Potentials (ERPs) have been used to demonstrate both increased and decreased semantic priming at a neural level in schizophrenia patients, relative to healthy controls. The present study used ERPs to investigate the role of behavioral task in determining neural semantic priming effects in schizophrenia. The same schizophrenia patients and healthy controls completed two experiments in which word stimuli were identical, and the time between the onset of prime and target remained constant at 350 ms: in the first, participants monitored for words within a particular semantic category that appeared only in filler items (implicit task); in the second, participants explicitly rated the relatedness of word-pairs (explicit task). In the explicit task, schizophrenia patients showed reduced direct and indirect semantic priming in comparison with healthy controls. In contrast, in the implicit task, schizophrenia patients showed normal or, in positively thought-disordered patients, increased direct and indirect N400 priming effects compared with healthy controls. These data confirm that, although schizophrenia patients with positive thought disorder may show an abnormally increased automatic spreading activation, the introduction of semantic decision-making can result in abnormally reduced semantic priming in schizophrenia, even when other experimental conditions bias toward automatic processing.

Neural evidence for faster and further automatic spreading activation in schizophrenic thought disorder.

It has been proposed that the loose associations characteristic of thought disorder in schizophrenia result from an abnormal increase in the automatic spread of activation through semantic memory. We tested this hypothesis by examining the time course of neural semantic priming using event-related potentials (ERPs). ERPs were recorded to target words that were directly related, indirectly related, and unrelated to their preceding primes, while thought-disordered (TD) and non-TD schizophrenia patients and healthy controls performed an implicit semantic categorization task under experimental conditions that encouraged automatic processing. By 300-400 milliseconds after target word onset, TD patients showed increased indirect semantic priming relative to non-TD patients and healthy controls, while the degree of direct semantic priming was increased in only the most severely TD patients. By 400-500 milliseconds after target word onset, both direct and indirect semantic priming were generally equivalent across the 3 groups. These findings demonstrate for the first time at a neural level that, under automatic conditions, activation across the semantic network spreads further within a shorter period of time in specific association with positive thought disorder in schizophrenia.

The role of animacy and thematic relationships in processing active English sentences: evidence from event-related potentials.

Recent event-related potential studies report a P600 effect to incongruous verbs preceded by semantically associated inanimate noun-phrase (NP) arguments, e.g., "eat" in "At breakfast the eggs would eat...". This P600 effect may reflect the processing cost incurred when semantic-thematic relationships between critical verbs and their preceding NP argument(s) bias towards different interpretations to those dictated by their sentences' syntactic structures. We have termed such violations of alternative thematic roles, 'thematic role violations.' Semantic-thematic relationships are influenced both by semantic associations and by more basic semantic features, such as a noun's animacy. This study determined whether a P600 effect can be evoked by verbs whose thematic structures are violated by their preceding inanimate NP arguments, even in the absence of close semantic-associative relationships with these arguments or their preceding contexts. ERPs were measured to verbs under four conditions: (1) non-violated ("At breakfast the boys would eat..."); (2) preceded by introductory clauses and animate NPs that violated their pragmatic expectations but not their thematic structures ("At breakfast the boys would plant..."); (3) preceded by semantically related contexts but inanimate NPs that violated their thematic structures ("At breakfast the eggs would eat..."); (4) preceded by semantically unrelated contexts and inanimate NPs that also violated their thematic structures ("At breakfast the eggs would plant..."). Pragmatically non-thematic role violated verbs preceded by unrelated contexts and animate NPs evoked robust N400 effects and small P600 effects. Thematically violated verbs preceded by inanimate argument NPs evoked robust P600 effects but no N400 effects, regardless of whether these inanimate arguments or their preceding contexts were semantically related or unrelated to these verbs. These findings suggest that semantic-thematic relations, related to animacy constraints on verbs' arguments, are computed online and can immediately impact verb processing within active, English sentences.

An electrophysiological investigation of indirect semantic priming.

In two experiments, direct and indirect semantic priming were measured using event-related potentials. In Experiment 1, participants rated the relatedness between prime and target on a seven-point scale. In Experiment 2, participants simply read the primes and targets as they monitored for a semantic category in probe filler items. Significant direct and indirect N400 priming effects were observed in both experiments. In Experiment 1, the indirect N400 priming effect remained significant when indirectly related and unrelated word pairs were matched for participants' explicit relatedness judgments. In both experiments, the indirect N400 priming effects were preserved when indirectly related and unrelated word pairs were matched on more global and objective measures of semantic similarity. These findings are discussed in the context of current theoretical models of semantic memory and semantic priming.

Building up linguistic context in schizophrenia: evidence from self-paced reading.

An impairment in the build-up and use of context has been proposed as a core feature of schizophrenia. The current study tested the hypothesis that schizophrenia patients show impairments in building up context within sentences because of abnormalities in combining semantic with syntactic information. Schizophrenia patients and healthy controls read and made acceptability judgments about sentences containing verbs that were semantically associated with individual preceding words but that violated either the meaning (animacy/semantic constraints) or the syntactic structure (morphosyntactic constraints) of their preceding contexts. To override these semantic associations and determine that such sentences are unacceptable, participants must integrate semantic with syntactic information. These sentences were compared with congruous and pragmatically/semantically violated sentences that imposed fewer semantic-syntactic integration demands. At sentence-final words and decisions, patients showed smaller reaction time differences than controls to animacy/semantically violated or morphosyntactically violated sentences relative to pragmatically/semantically violated or nonviolated sentences. The relative insensitivity to these violations in patients with schizophrenia may arise from impairments in combining semantic and syntactic information to build up sentence context.

Low-level lead exposure, executive functioning, and learning in early childhood.

The current paper presents evidence relating low-level lead exposure to impaired executive functioning in young children. Using the Shape School task, we assessed focused attention, attention switching, working memory, and the ability to inhibit automatic responses in a cohort of 170 children. Participants performed the Shape School task at both 48 and 54 months of age; the mean blood lead level was 6.49 microg/dl at 48 months. After controlling for a wide range of sociodemographic, prenatal, and perinatal variables, blood lead level was negatively associated with children's focused attention while performing the tasks, efficiency at naming colors, and inhibition of automatic responding. In addition, children with higher blood lead levels completed fewer phases of the task and knew fewer color and shape names. There was no association between blood lead and performance on the most difficult tasks, those requiring attention switching or the combination of inhibition and switching. Children's IQ scores were strongly associated with blood lead and Shape School performance, and when entered as a covariate, only color knowledge and the number of tasks completed remained significant. Results provide only weak support for impaired executive functioning, but the deficits in color knowledge may indicate a primary sensory deficit or difficulty with forming conditional associations, both implicating disruptions in dopamine system function.