Military veterans with and without post-traumatic stress disorder: results from a chronic pain management programme.

BACKGROUND AND AIMS: There is very little published evaluation of the treatment of military veterans with chronic pain, with or without post-traumatic stress disorder. Few clinical services offer integrated treatment for veterans with chronic pain and PTSD. Such veterans experience difficulty in accessing treatment for either condition: services may consider each condition as a contraindication to treatment of the other. Veterans are therefore often passed from one specialist service to another without adequate treatment. The veteran pain management programme (PMP) in the UK was established to meet the needs of veterans suffering from chronic pain with or without PTSD; this is the first evaluation. METHODS: The PMP was advertised online via veteran charities. Veterans self-referred with accompanying information from General Practitioners. Veterans were then invited for an inter-disciplinary assessment and if appropriate invited onto the next PMP. Exclusion criteria included; current severe PTSD, severe depression with active suicidal ideation, moderate to severe personality disorder, or who were unable to self-care in the accommodation available. Treatment was by a team of experienced pain management clinicians: clinical psychologist, physiotherapist, nurse, medical consultant and psychiatrist. The PMP was delivered over 10 days: five residential days then five single days over the subsequent 6 months. The PMP combines cognitive behavioural treatment, which has the strongest evidence base, with more recent developments from mindfulness-based CBT for pain and compassion-focused therapy. Standard pain management strategies were adapted to meet the specific needs of the population, recognising the tendency to use demanding activity to manage post-traumatic stress symptoms. Domains of outcome were pain, mood, function, confidence and changes in medication use. RESULTS: One hundred and sixty four military veterans started treatment in 19 programmes, and 158 completed. Results from those with high and low PTSD were compared; overall improvements in all domains were statistically significant: mood, self-efficacy and confidence, and those with PTSD showed a reduction (4.3/24 points on the IES-6). At the end of the programme the data showed that 17% reduced opioid medication and 25% stopped all opioid use. CONCLUSIONS: Veterans made clinically and statistically significant improvements, including those with co-existing PTSD, who also reduced their symptom level. This serves to demonstrate the feasibility of treating veterans with both chronic pain and PTSD using a PMP model of care. IMPLICATIONS: Military veterans experiencing both chronic pain and PTSD can be treated in a PMP adapted for their specific needs by an experienced clinical team.

How sickle cell disease patients experience, understand and explain their pain: An Interpretative Phenomenological Analysis study.

OBJECTIVES: Sickle cell disease (SCD) is the UK's most common blood disorder causing sickle shaped red blood cells to block small blood vessels inducing both acute and chronic pain. A crucial factor in determining quality of life for those with SCD is the severity, timing and number of painful sickling episodes. However, little research focuses on the nature of pain and so it is poorly understood. The aim of this study is to provide an in-depth and meaning led account of the experience of SCD pain. DESIGN: Qualitative research design. METHODS: Seven face-to-face semi-structured interviews were conducted. Interviews were transcribed and analysed using Interpretative Phenomenological Analysis. RESULTS: Participants described experiencing unimaginable, agonising, continuous, inescapable and limitless pain which was almost impossible to describe; participants resorted to using analogy and personification as a way to overcome this difficulty. Participants spoke about a process where, ultimately, they felt obliged to accept their illness as it would never be cured; but were able to appreciate life and recognize positive life lessons as a result of living with SCD. CONCLUSIONS: This research indicates that therapeutic work around analogy can help individuals understand and express their pain and that current attempts to measure pain are unhelpful for SCD populations. Further research is needed across a wider SCD population to forward the findings of this qualitative study. STATEMENT OF CONTRIBUTION: What is already known on this subject? Sickle cell disease (SCD) has an impact on all aspects of a person's life (Edwards et al., 2005, International Journal of Behavioral Medicine, 12, 171). Strickland , Jackson, Gilead, McGuire, and Quarles (2001, Journal of the National Black Nurses' Association, 12, 36) suggest that one of the crucial factors in determining quality of life for those with SCD is the severity, timing and number of painful sickling episodes. Exacerbations of pain are also cited as explanation for the majority of medical contacts for people with SCD (McClish et al., 2009, Pain, 145, 246). The majority of research focuses on the consequences of pain in terms of handicap, and its impact on emotional well-being, relationships and the need for medication/hospital treatment (Booker et al., 2006, Chronic Illness, 2, 39; Weisberg et al., 2013, Journal of Hospital Medicine, 8, 42) rather than how SCD patients experience and understand their pain. However, the actual nature of pain experience in SCD is poorly understood and sub-optimally managed (Booker et al., 2006; Taylor et al., 2010, Journal of Pain and Symptom Management, 40, 416). What does this study add? The experience of SCD pain is indescribable without the use of analogy, as it is unbearable, agonising, constant, inescapable and without limit. Difficulty describing pain creates a perception of being misunderstood or minimized by professionals. Personification of pain is often employed by patients to attempt to form a relationship with pain. Current pain measures used in clinical practice are inadequate at capturing the acute and chronic SCD pain experience.

The role of working memory and verbal fluency in autobiographical memory in early Alzheimer's disease and matched controls.

Retrieval of autobiographical memories (AMs) is important for "sense of self". Previous research and theoretical accounts suggest that working memory (WM) and semantic and phonemic fluency abilities facilitate the hierarchical search for, and reliving of past, personal events in the mind's eye. However, there remains a lack of consensus as to the nature of the relationships between these cognitive functions and the truly episodic aspects of AM. The present study therefore aimed to explore the associations between these variables in a sample with a wide range of cognitive abilities. The study incorporated a between-groups component, and a correlational component with multiple regression. Participants with Alzheimer's disease (n=10) and matched healthy controls (n=10) were assessed on measures of semantic and episodic AM search and retrieval, auditory and spatial WM, and semantic and phonemic fluency. The AD group produced less episodic AM content compared to controls. Semantic fluency predicted episodic AM retrieval independent of age effects but there were no significant relationships between measures of phonemic fluency, WM and episodic AM. The results suggest that the ability to maintain hierarchical search of the semantic knowledge-base is important for truly episodic reliving, and interventions for people with AM impairment might therefore benefit from incorporating structured, individualised external memory-aids to facilitate AM search and retrieval.