The Perception of Being a Burden in Acute and Chronic Pain Patients Is Associated with Affirmation of Different Types of Suicidality.

OBJECTIVES: The perception of being a burden or self-perceived burden (SPB) is associated with suicide ideation in chronic pain patients (CPPs). The objective of this study was to determine if SPB is associated with five types of suicidality (wish to die, active suicide ideation, presence of suicide plan, history of suicide attempts, and preference for death over being disabled) in CPPs and acute pain patients (APPs). METHODS: Affirmation of SPB was statistically compared between community nonpatients without pain (CNPWP), APPs, and CPPs. APPs and CPPs who had affirmed any of the five types of suicidality were compared statistically for affirmation of SPB. Hierarchical regression analysis was utilized to determine the significance of SPB in predicting each of the five types of suicidality in APPs and CPPs controlling for age, gender, race, education status, and two types of measures of depression (current depression and vegetative depression). RESULTS: APPs and CPPs were statistically more likely to affirm SPB than CNPWPs and CPPs were more likely than APPs to do so. There were no differences between APPs and CPPs in affirming SPB in APPs and CPPs who had affirmed any of the five types of suicidality. In CPPs, SPB predicted each type of suicidality in a significant fashion utilizing both types of depression measures. For APPs, SPB predicted each type of suicidality in a significant fashion except for history of suicide attempt controlling for vegetative depression. CONCLUSIONS: SPB is associated with the vast majority of different types of suicidality in APPs and CPPs.

Do Acute and Chronic Pain Patients Differ on Affirmation of One Aspect of Pain Acceptance? Acknowledgement that a Cure Is Unlikely.

BACKGROUND: Many chronic pain patients (CPPs) cannot be cured of their pain, but can learn to manage it. This has led to research on pain "acceptance" which is defined as a behavior pattern with awareness of pain but not directed at changing pain. OBJECTIVE: CPPs who have accepted their pain generally acknowledge that a cure is unlikely. Time with pain may be necessary to reach such an acknowledgment. It was therefore hypothesized that fewer acute pain patients (APPs) than CPPs should affirm that a cure is unlikely and that other described aspects of acceptance such as denial of disability status should be associated with cure is unlikely in both APPs and CPPs. STUDY DESIGN: APPs and CPPs were compared for frequency of endorsement of 2 items/questions with face validity for cure is unlikely: little hope of getting better from pain (LH) and physical problem (pain) can't be cured (CBC). Demographic variables and variables reported associated with acceptance were utilized in logistic prediction models for the above items in APPs and CPPs. SETTING: Rehabilitation programs/offices. RESULTS: CPPs were statistically more likely than APPs to affirm both LH and CBC. In both APPs and CPPs, items reported associated with acceptance, e.g., denial of disability status, predicted LH and CBC. LIMITATIONS: Information gathered from CPP self-reports. CONCLUSIONS: APPs versus CPPs differ on their affirmation on acknowledgement that a cure is unlikely.

Prevalence comparisons of somatic and psychiatric symptoms between community nonpatients without pain, acute pain patients, and chronic pain patients.

OBJECTIVES: Somatic/psychiatric symptoms are frequently found in chronic pain patients (CPPs). The objectives of this study were to determine 1) which somatic/psychiatric symptoms are more commonly found in acute pain patients (APPs) and CPPs vs community nonpatients without pain (CNPWPs) and 2) if somatic/psychiatric symptom prevalence differs between APPs and CPPs. DESIGN: The above groups were compared statistically for endorsement of 15 symptoms: fatigue, numbness/tingling, dizziness, difficulty opening/closing mouth, muscle weakness, difficulty staying asleep, depression, muscle tightness, nervousness, irritability, memory, falling, nausea, concentration, and headaches. RESULTS: After controlling for age, gender, and level of pain, APPs and CPPs had a statistically significantly greater prevalence (at a P < 0.01 level) for 11 and 13 symptoms, respectively, vs CNPWPs. After controlling for age, gender, and level of pain, CPPs had a statistically significantly greater prevalence (at a P < 0.01 level) for eight symptoms vs APPs. Symptoms were highly correlated in both APPs and CPPs. CONCLUSIONS: CPPs are characterized to a significantly greater extent than comparison groups by somatic/psychiatric symptoms that are highly intercorrelated. This has implications for clinical practice and future research.

Exploring the Relationship of Three Medical Entitlement Beliefs and Psychiatric/Psychological Variables for Acute and Chronic Pain Patients.

OBJECTIVES: The belief in medical care entitlement has recently resulted in major changes in the medical system in the United States. The objectives of this study were the following: to compare endorsement of three medical entitlement beliefs (I deserve the best medical care no matter what the cost [BMC], I am entitled to all of the medical care I want at no charge [NC], I shouldn't have to wait to see my doctors [W]) in community nonpatients without pain (CNPWP), acute pain patients (APPs), and chronic pain patients (CPPs) and to develop predictor models for these beliefs in APPs and CPPs. DESIGN: CNPWP, APPs, and CPPs were compared statistically for frequency of endorsement of each belief. All available variables were utilized in logistic regression models to predict each belief in APPs and CPPs. Those affirming/nonaffirming each belief were compared by t-test for affirmation of narcissism, dependency, and antisocial practices on three scales from established inventories. RESULTS: CPPs were significantly more likely than APPs to endorse BMC. No other comparisons were significant. The logistic regression models identified variables that related to narcissism, anger, doctor dissatisfaction, depression, and anxiety, which entered the models for both APPs and CPPs for some beliefs. Those APPs and CPPs who affirmed the beliefs of NC and W were more likely than their counterparts to affirm antisocial practices, but not narcissism or dependency. CONCLUSIONS: Patient medical entitlement beliefs may be related to some psychiatric/psychological issues.

The Psychological Evaluation of Patients with Chronic Pain: a Review of BHI 2 Clinical and Forensic Interpretive Considerations.

Pain is the most common reason why patients see a physician. Within the USA, it has been estimated that at least 116 million US adults suffer from chronic pain, with an estimated annual national economic cost of $560-635 billion. While pain is in part a sensory process, like sight, touch, or smell, pain is also in part an emotional experience, like depression, anxiety, or anger. Thus, chronic pain is arguably the quintessential biopsychosocial condition. Due to the overwhelming evidence of the biopsychosocial nature of pain and the value of psychological assessments, the majority of chronic pain guidelines recommend a psychological evaluation as an integral part of the diagnostic workup. One biopsychosocial inventory designed for the assessment of patients with chronic pain is the Battery for Health Improvement 2 (BHI 2). The BHI 2 is a standardized psychometric measure, with three validity measures, 16 clinical scales, and a multidimensional assessment of pain. This article will review how the BHI 2 was developed, BHI 2 concepts, validation research, and an overview of the description and interpretation of its scales. Like all measures, the BHI 2 has strengths and weaknesses of which the forensic psychologist should be aware, and particular purposes for which it is best suited. Guided by that knowledge, the BHI 2 can play a useful role in the forensic psychologist's toolbox.

Examination of symptom clusters in acute and chronic pain patients.

BACKGROUND: Symptom clusters have not been previously explored in acute pain patients (APPs) and chronic pain patients (CPPs) with non-cancer pain. OBJECTIVES: The objectives of this study were to determine in CPPs and APPs which somatic and non-somatic symptoms cluster with each other, the number of clusters, and if cluster number and cluster symptom makeup differ by pain level. STUDY DESIGN: Study sample was 326 APPs and 341 CPPs who had completed a pool of questions that had included current symptom questions other than pain. Symptom cluster analyses were performed on 15 somatic and non-somatic symptoms for APPs and CPPs and for 2 CPP subgroups with moderate and severe pain. SETTING:   APPs and CPPs were from rehabilitation facilities located in 30 states in all geographical regions of the United States. RESULTS: APPs had 4 symptom clusters and CPPs had 5. For CPPs, the clusters represented memory, neurological, behavioral, somatic, and autonomic problems. CPPs with moderate and severe pain had 3 and 4 symptom clusters, respectively, and differed in cluster symptom constitution. LIMITATIONS: Patients selected themselves for study inclusion and were paid for their participation. This could have affected random selection. Lastly, we used the current time definitions of acute pain versus chronic pain (90 days) to separate our patients into these groups. Currently, no consensus exists regarding the optimal time duration to divide acute from chronic. CONCLUSIONS: APPs and CPPs are characterized by symptom comorbidities that form clusters. In CPPs, cluster number and cluster symptom makeup are affected by pain level. This has implications for clinical practice and future research.

Exploration of affirmation of childhood molestation (sexual abuse) in chronic pain patients, acute pain patients, community patients with pain and community nonpatients without pain.

OBJECTIVES: To further explore the controversy as to whether childhood molestation is associated with chronic pain in adulthood. DESIGN: Community nonpatients without pain (CNPWP), community patients with pain (CPWP), acute pain patients (APPs), and chronic pain patients (CPPs) were compared for endorsement of affirmation of childhood molestation by chi-square. Logistic regression was utilized to predict affirmation in male and female CPPs. RESULTS: A significantly higher percentage of male APPs affirmed molestation versus CNPWP and CPWP. No other comparisons were statistically significant for males. For females, no comparisons were significant. For male CPPs, the behavior health inventory-2 (BHI-2) survivor of violence scale and 1 item from this scale predicted affirmation. The following BHI-2 scales and items predicted affirmation for female CPPs: muscular bracing and survivor of violence scales; the item "I have been a victim of many sexual attacks"; and the item "My father was kind and loving to me when I was growing up" (scored opposite direction). CONCLUSIONS: In female PWCP, the prevalence of childhood molestation is not greater than in a number of unique comparison groups. Unique predictors of childhood molestation are yet to be identified.

The prevalence of smokers within chronic pain patients and highest pain levels versus comparison groups.

OBJECTIVES.: The objectives of this study were to (1) compare the prevalence of smoking within chronic pain patients (CPPs) to community non-patients without pain (CNPWP), community patients with pain (CPWP), and acute pain patients (APPs); and (2) compare smokers to nonsmokers within CPPs, APPs, and CPWP for highest pain level. DESIGN.: CNPWP, CPWP, APPs, and CPPs were compared to each other for smoking status (nonsmoker, less than one pack per day, one pack/day or more, any amount per day). Within CPWP, APPs, and CPPs, smokers were also compared to nonsmokers by t-test for highest reported pain level. For both analyses, sub-analyses were performed controlling for age or gender, or race or education. RESULTS.: Utilizing all available patients, the prevalence of smokers within CPPs was significantly greater vs each of the comparison groups (CNPWP, CPWP, APPs). In the sub-analyses, only CPPs who were 38 or younger or male or White, or had some college or above were at greater risk than CPWP for smoking one pack or greater per day. CPP smokers were not significantly more likely than nonsmokers to have higher pain, and this was confirmed in the sub-analyses. CONCLUSIONS.: The prevalence of smokers could be significantly greater within CPPs vs CPWP. CPPs who smoke do not have higher levels of pain than nonsmoking CPPs.

Biopsychosocial law, health care reform, and the control of medical inflation in Colorado.

PURPOSE: A noteworthy attempt at health care reform was the 1992 Colorado workers' compensation reform bill, which led to the creation of what has been called "biopsychosocial laws." These laws mandated the use of treatment guidelines for patients with injury or chronic pain, which advocated a biopsychosocial model of rehabilitation, and aspired to use a "best practice" approach to controlling costs. The purpose of this study was to examine the financial impact of this health care reform process, and to test the hypothesis that this approach can be an effective strategy to contain costs while providing good care. RESEARCH METHOD: This study utilized a dataset collected prospectively from 1992 to 2007 in 45 U.S. states for regulatory purposes. These data summarized the medical treatment and disability costs of 520,314 injured workers in Colorado, and an estimated 28.6 million injured workers nationally. As no other state passed a comparable bill, the Colorado worker compensation reform bill created a natural experiment, where a treatment group was created by legally enforceable medical treatment guidelines. RESULTS: In the 15 years following the implementation of the reform, the inflation of medical costs in Colorado workers' compensation was only one third that of the national average, saving an estimated $859 million on patients injured in 2007 alone. CONCLUSIONS: Although there were confounding variables, and causality could not be determined, these data are consistent with the hypothesis that Colorado's 1992 legislative efforts to reform workers compensation law using the biopsychosocial model worked as intended to provide good care while controlling costs.

Exploration of the relationship between disability perception, preference for death over disability, and suicidality in patients with acute and chronic pain.

HYPOTHESIS: Passive, active, and historical suicidality are associated with preference for death over disability. DESIGN: Community nonpatients without pain, community patients with pain, and patients with acute and chronic pain were compared for endorsement of disability perception and preference for death over disability. Phi correlations and chi-square analyses were calculated between preference for death over disability and six suicidality items representing passive, active, and historical suicidality. Logistic regression was used to predict preference for death over disability in patients with acute and chronic pain. RESULTS: For patients with acute and chronic pain, endorsement of preference for death over disability correlated significantly with all six suicidality items. The logistic regression models identified the following variables as predictors for preference for death over disability in patients with acute pain: the Behavior Health Inventory (BHI 2) family dysfunction scale, history of wanting to die, and disability perception. For patients with chronic pain, predictors were the BHI 2 Borderline scale, history of wanting to die, treated fairly by family item, frequent suicide ideation, people I trust turn on me item, and disability perception. Preference for death over disability was a statistically significant predictor in patients with chronic pain for disability perception, recent suicide ideation, having a suicidal plan, and a history of wanting to die but was not a significant predictor for any suicide items in patients with acute pain. CONCLUSION: Preference for death over disability is associated with passive and active suicide ideation and historical suicidality in patients with chronic pain.

Exploration of anger constructs in acute and chronic pain patients vs. community patients.

OBJECTIVES: (1) Determine and compare prevalence of forms of anger (FOA; anger, hostility, aggression, anger-in, anger-out, chronic anger) in community nonpatients (n=478), community patients (n=158), acute pain patients (APPs; n=326), chronic pain patients (CPPs; n=341); and (2) develop FOA predictor models in APPs and CPPs. DESIGN: A large set of items containing the FOA items was administered to the above groups, who were compared statistically for FOA endorsement. APPs and CPPs affirming the anger and chronic anger items were compared with those not affirming on all available variables including the Battery for Health Improvement (BHI-2) with significant variables (P≤0.001) utilized in predictor models for anger and chronic anger in APPs and CPPs. Setting community plus rehabilitation facilities. RESULTS: FOA affirmation ranged from 8.28% for chronic anger in nonpatients to 37.54% for anger in CPPs. Only CPPs were more likely to affirm anger (P≤0.04) and chronic anger (P≤0.01) at a significantly higher rate than community patients. In both APPs and CPPs, all FOA items except anger management-in were significantly correlated with other FOA items. For anger and chronic anger for CPPs and APPs, hostility was the strongest predictor. All models predicted anger and chronic anger significantly better than the base rate prediction. CONCLUSION: According to the results of this study anger and chronic anger are more frequently found in CPPs vs. community patients supporting the clinical perception that many CPPs are angry. As such,clinicians should actively screen CPPs for the presence of anger in order to engage these CPPs in anger management treatment.

Predictors of homicide-suicide affirmation in acute and chronic pain patients.

OBJECTIVES: 1) Determine and compare prevalence for homicide-suicide (H-S) affirmation in community non-patients (N=478), community patients (N=158), acute pain patients (APPs; N=326), and chronic pain patients (CPPs; N=341); and 2) Develop H-S predictor models in APPs and CPPs. DESIGN: A large set of items containing the H-S item was administered to the above groups, who were compared statistically for H-S endorsement. APPs and CPPs affirming the H-S item were compared with those not affirming on all available variables including the Battery for Health Improvement (BHI 2) with significant variables (P≤ 0.001) utilized in predictor models for H-S in APPs and CPPs. SETTING: Community plus rehabilitation facilities. RESULTS: The above population groups affirmed the H-S item according to the following percentages: healthy community 1.88%, community patients 3.16%, rehabilitation patients without pain 3.64%, rehabilitation AAPs 3.99%, and rehabilitation CPPs 4.40%. For both APPs and CPPs, the H-S item was significantly correlated with some suicidality items and some homicide items. The model for APPs identified "having a suicide plan" as being predictive of H-S affirmation. For CPPs, the items of having thoughts of revenge killing, being motivated to seek revenge without any verbal warning, and the Doctor Dissatisfaction Scale of the BHI 2 predicted H-S affirmation. The APPs model classified 96% of the APPs correctly, while the CPPs model classified 97% of the CPPs correctly. These predictor rates, however, were no better than the base rate. CONCLUSION: The prevalence of H-S affirmation within APPs and CPPs is not insignificant. The APPs predictor model points to a close association between H-S affirmation and suicidality. The CPPs model indicates that there is a close association between H-S affirmation, and anger/hostility and anger directed at physicians. These results, however, should not lead to the belief that CPPs are at greater risk for actual H-S completion for the following reasons: 1) H-S is an extremely rare event; and 2) predictive validity of the H-S item for actual H-S completion has not been determined.

Exploration of the illness uncertainty concept in acute and chronic pain patients vs community patients.

OBJECTIVE: Illness uncertainty (IU) theory proposes that patients with chronic illness may have difficulty adjusting to the illness if there is significant diagnostic or prognostic uncertainty. Two dimensions of IU theory are "lack of information about diagnoses or severity of the illness" (LIDSI) and "complexity regarding the health care system" (CRHCS). The primary objective of this study was then to compare the prevalence of IU in community nonpatients, community patients, and rehabilitation patients without pain/chronic pain patients (CPPs)/acute pain patients (APPs) as represented by two items with possible face validity for LIDSI ("doctors puzzled by my problems,""doctors missed something important") and three items with possible CRHCS face validity ("doctors don't believe me,""I need to prove my problem is real,""doctors think my problems are in my head"). The secondary objectives were to determine if the LIDSI items are associated with the CRHCS items and to develop predictor models for the LIDSI items in APPs and CPPs. DESIGN: The Battery for Health Improvement Research (BHI-R) version was administered to a healthy (pain-free) community sample (N = 1,478), community patient sample (N = 158), rehabilitation patients without pain (N = 110), rehabilitation APPs (N = 326), and rehabilitation CPPs (N = 341). The IU LIDSI and CRHCS items were contained within the BHI-R. These five patient groups were compared for the risk of endorsement of these items. Correlations were developed between the LIDSI and CRHCS items in APPs and CPPs. APPs and CPPs that affirmed IU items were compared with those not affirming the item on a wide range of demographic variables and Behavior Health Inventory (BHI 2) scales. Significant variables (P < or = 0.01) were then utilized as independent variables in predictor models for the LIDSI items. SETTING: Community patients and nonpatients, patients from physical therapy/work hardening/chronic pain/vocational rehabilitation programs, and physicians' offices. RESULTS: Affirmation for the LIDSI items ranged from 5.04% (community healthy) to 24.9% (CPPs) and for the CRHCS items, from 3.16% (community healthy) to 29.6% (CPPs). CPPs were significantly more likely than community patients to endorse one of the LIDSI items (doctors puzzled by my problem) plus all the CRHCS items. APPs, however, were no more likely than community patients to endorse any LIDSI IU items and two out of the three CRHCS items. LIDSI items were significantly correlated with the CRHCS items in both APPs and CPPs. The following items entered the final logistic regression models for LIDSI in APPs and CPPs: CRHCS items (APPs); items from the Doctor Dissatisfaction scale of the BHI 2 and the scale itself (APPs and CPPS); items related to faulty patient memory (APPs and CPPs); and various other items such as "hard muscles," etc. The models classified 87% (puzzling medical problem) and 91% (doctors missed something) of the APPs correctly. For CPPs, the models classified 79% (puzzling medical problem) and 88% (doctors missed something) of the patients correctly. None of these classifications, however, were better than the base rate. CONCLUSION: LIDSI and CRHCS IU is not unusual in nonpatient and patient groups. However, rehabilitation CPPs are at significantly greater risk than community patients for LIDSI and CRHCS IU. LIDSI IU is associated with CRHCS IU, and LIDSI IU is predicted by a large number of items, the most notable of these being perception of not being believed and dissatisfaction with the physician.

Breakthrough pain in community-dwelling patients with cancer pain and noncancer pain, part 2: impact on function, mood, and quality of life.

BACKGROUND: Prior studies of breakthrough pain (BTP) largely focus on patients with advanced cancer or those receiving inpatient care. Very few studies have evaluated BTP in populations with chronic noncancer pain. Data that illuminate the impact of BTP may not generalize to other, less selected patient populations. AIM: The aim of this study was to evaluate the impact of BTP in opioid-treated ambulatory patients with chronic cancer pain or noncancer pain treated in community practices. METHODS: Eligible patients--those with any diagnosis who reported chronic pain for at least 3 months, who were receiving long-term opioid therapy, and who met criteria for controlled baseline pain--were recruited for a cross-sectional observational study by primary care physicians or community-based oncologists at 17 sites in the United States. The patients responded to a structured interview for breakthrough pain and also completed the Brief Pain Inventory-Modified Short Form (BPI-SF) and the Brief Battery for Health Improvement 2 (BBHI 2). RESULTS: Of 355 patients screened, 191 were eligible and 177 (93 percent) provided data for analysis. Twenty-six of the 78 with cancer pain (33 percent) and 48 of the 99 with noncancer pain (48 percent) had BTP. Compared with those without BTP, both patients with cancer (p = 0.004) and patients without cancer (p = 0.019) with BTP had increased pain interference in function, as measured by the BPI-SF, and patients without cancer were more impaired than patients with cancer. On the BBHI 2, BTP was associated with increased somatic complaints (p = 0.036 cancer and p = 0.024 noncancer) and pain complaints (p = 0.037 cancer and p = 0.037 noncancer); among patients without cancer, BTP was also associated with increased difficulties with functioning (p = 0.023), depression (p = 0.039), and decreased quality of life (p = 0.003). CONCLUSIONS: These data extend published observations about the association between BTP and adverse effects on mood and function to populations undergoing routine treatment in the community setting and provide evidence that these associations are greater in those with noncancer pain. They suggest the need for additional studies to clarify causality and determine whether undertreatment of BTP is a factor contributing to adverse pain-related outcomes.

Breakthrough pain in community-dwelling patients with cancer pain and noncancer pain, part 1: prevalence and characteristics.

BACKGROUND: Most breakthrough pain (BTP) studies assess patients with advanced cancer or those receiving inpatient care. Studies in noncancer populations are limited to surveys of pain clinics and patients with other advanced diseases. To better understand BTP, data are needed from less selected populations. AIM: The aim of this study was to evaluate BTP in opioid-treated ambulatory patients with chronic cancer or noncancer pain treated in community practices. METHODS: Primary care physicians or community-based oncologists recruited a convenience sample for a cross-sectional study of BTP at 17 sites in the United States. Physicians could not be pain specialists. Patients were eligible if they had any type of pain for > or = 3 months and were receiving an opioid drug on a regular basis that controlled the pain. The patients responded to a structured interview comprising items that assessed the baseline pain and items that assessed BTP, if present. RESULTS: In total, 355 patients were screened, 191 were eligible and 177 (93 percent) provided data for analysis. Seventy-eight patients had cancer pain and 99 had noncancer pain. Patients with cancer were older (mean +/- SD age 61.3 +/- 11.2 years vs 51.4 +/- 13.6 years, p < 0.001), and patients without cancer had more neuropathic pain (21 vs 12 percent, p < 0.05) and a longer pain duration (median 3.5 vs 1 years, p < 0.001). BTP occurred in 33 percent with cancer and 48 percent with noncancer pain (p = 0.042). BTP did not vary by diagnosis, but neuropathic pain was more common in those with BTP (27 vs 10 percent, p < 0.001). In patients with and without cancer, the median daily number of episodes was 1, the median time to maximum pain was 1-2 minutes, and the median duration was 45-60 minutes. There were fewer BTP precipitants in the patients with cancer (46 vs 80 percent of pains, p < 0.05), and they had less predictable pain (p < 0.05). CONCLUSIONS: The prevalence of BTP among community-dwelling patients is lower than that found in prior studies of more selected populations. BTP is more prevalent among patients with noncancer pain than patients with cancer pain, and although there are many similarities, some differences may be relevant to treatment strategies.

Variables associated with self-prediction of psychopharmacological treatment adherence in acute and chronic pain patients.

OBJECTIVES: The objectives of this article were the following: (1) determine risk for self-predicted future psychopharmacological nonadherence in rehabilitation acute pain patients (APPs) and rehabilitation chronic pain patients (CPPs) vs. pain-free community controls and community patients, and (2) determine which variables predict nonadherence. DESIGN: The Battery for Health Improvement 2 was developed utilizing a healthy (pain-free) community sample (N = 1,478), a community patient sample (N = 158), and a rehabilitation patient sample (N = 777) of which 326 were APPs, 341 were CPPs, and 110 were patients without pain. These groups predicted their future psychopharmacological treatment adherence. Risk for nonadherence was calculated for each group utilizing the healthy community sample as the reference group. Nonadherent and adherent APPs and CPPs were compared statistically on variables of interest. Significant variables (P ≤ 0.01) were utilized in APPs' and CPPs' logistic regression models to predict nonadherence. SETTING: The participants in this article were from a variety of settings. RESULTS: Of APPs and CPPs, 10.74% and 10.85%, respectively, predicted that they would be nonadherent. Risk for nonadherence was greater in both groups vs. healthy nonpain community subjects and nonhealthy community patients. The predictors for APPs' nonadherence were general resistance to using medications and a tendency to forget physicians' suggestions. For CPPs, the predictors were general resistance to using medications, fear of dependence on prescription medications, and fighting with loved ones. The models classified 90% and 89% of APPs and CPPs (respectively) correctly. However, these were no better than the base rate. CONCLUSIONS: APPs and CPPs are at greater risk for self-predicted psychopharmacological nonadherence than healthy community subjects and community patients. We cannot as yet predict self-predicted psychopharmacological nonadherence at greater than the base rate. However, the identified variables could be clinically useful.

Borderline personality disorder features and pain: the mediating role of negative affect in a pain patient sample.

OBJECTIVES: There is considerable evidence that personality disorders, including borderline personality disorder (BPD), tend to co-occur with chronic pain. There is also evidence that mood disorders co-occur with chronic pain conditions. Given the central role of affective instability and negative mood states in BPD, we proposed that affective features of depression, anxiety, and hostility may account for the association between BPD features and the severity of pain reported in a patient sample. METHODS: Seven hundred seventy-seven patient participants completed the Battery for Health Improvement. This included measures of DSM-IV BPD features, affect scales (depression, anxiety, hostility), and pain items assessing the severity of pain and somatic symptoms. RESULTS: As predicted, individuals with higher levels of BPD features reported greater severity of pain and somatic complaints, including higher levels of maximum and minimum pain levels in the past month. In addition as predicted, this association was no longer significant after controlling for affect scales. In particular, depression was strongest in accounting for this association. DISCUSSION: These results indicate that the association between BPD features and pain is accounted for by negative affect, primarily in the form of depression. This is consistent with current theoretical perspectives on BPD. This also suggests that clinicians observing or detecting BPD features among pain patients should consider negative affect, especially depression, in addressing these issues.

What variables are associated with an expressed wish to kill a doctor in community and injured patient samples?

Working in a health care setting has been identified as a primary risk factor for violent assault, which is often perpetrated by patients. Patient dangerousness is a multidimensional phenomenon, which may include violent ideation, homicidal planning, a history of violent acts, or overt threatening behavior. Although the verbal report of thoughts of killing a doctor is only one of many risk factors for patient dangerousness, reports of homicidal ideation are widely regarded as being sufficient to warrant concern, and to indicate a need for further assessment of the patient. In this study, 2264 subjects (1329 healthy community subjects, 158 non-healthy community subjects, and 777 rehabilitation patients) were asked if they had a desire to kill a doctor that they had seen. Subjects responding positively to this item were compared to subjects responding negatively to the item using all available demographic variables and BHI 2 scales using chi-square or t-test. Significant variables (p<.01) were then utilized in a logistic regression to generate a model for this wish. Three variables significantly predicted this wish: the Doctor Dissatisfaction (p<.001) and Borderline (p<.001) scales of the BHI 2, and injury-related litigation status (p=.002). The presence of one of these variables, especially Doctor Dissatisfaction, should prompt a more thorough assessment of potential danger to healthcare workers.