Paediatric headache trajectories - a reappraisal after nine years.

Background The long-term consequences of paediatric headache can involve functional disabilities and mental health problems in adulthood. Objective To analyse the predictive power of paediatric headache trajectory classes for headache and related outcomes in adulthood. Methods In a previous study, a population-based sample (N = 3227, 9-14 years of age at first assessment) was followed across four annual assessment points, and sex-specific headache trajectory classes were identified (girls: "no pain", "moderate pain", "increasing pain", "high pain"; boys: "no pain", "moderate pain"). These trajectory classes were used to predict headache frequency, functional disability, depression, quality of life and self-efficacy nine years later (N = 994). Negative binomial regression analyses and pairwise comparisons were computed. Results Women showing an elevated trajectory ("increasing pain" or "high pain") had a higher adult headache frequency and a poorer outcome on associated variables (functional disability, depression, quality of life, and self-efficacy) than women having a lower-level trajectory. Men of the "no pain" and "moderate pain" trajectory classes differed significantly from one another in their headache frequency and related variables. Conclusion Belonging to an elevated paediatric headache trajectory class involves a considerable risk for headache and headache-related problems in adulthood.

Examining differences in cognitive and affective theory of mind between persons with high and low extent of somatic symptoms: an experimental study.

BACKGROUND: Medically unexplained somatic symptoms are common, associated with disability and strongly related to depression and anxiety disorders. One interesting, but to date rarely tested, hypothesis is that deficits in both theory of mind (ToM) and emotional awareness may undergird the phenomenon of somatization. This study sought to investigate whether or not differences in ToM functioning and self-reported emotional awareness are associated with somatic symptoms in a sample from the general population. METHODS: The sample consisted of 50 healthy participants (37 females, 13 males) aged between 22 and 64 years (46.8 ± 11.7) of whom 29 reported a high extent of somatic symptoms (HSR), whereas 21 reported a low extent of somatic symptoms (LSR) based on the 30 highest and lowest percentiles of the Symptom List norms. The participants' affective and cognitive ToM were assessed with two experimental paradigms by experimenters who were blind to the participants' group membership. In addition, self-reports regarding emotional awareness, alexithymia, depressive and anxiety symptoms and current affect were collected. RESULTS: In the experimental tasks, HSR showed lower affective ToM than LSR but the groups did not differ in cognitive ToM. Although HSR reported lower emotional awareness than LSR in the self-report measure, this group difference vanished when we controlled for anxiety and depression. Depression, anxiety, emotional awareness and alexithymia were correlated positively. CONCLUSIONS: The data supported the hypothesis that deficits in affective ToM are related to somatic symptoms. Neither cognitive ToM nor self-reported emotional awareness were associated with somatic symptoms. Self-reported emotional awareness, alexithymia and symptoms of depression and anxiety shared a considerable amount of variance.

A multidisciplinary systematic review of the treatment for chronic idiopathic tinnitus.

The majority of tinnitus patients are affected by chronic idiopathic tinnitus, and almost 60 different treatment modalities have been reported. The present study is a multidisciplinary systematic analysis of the evidence for the different forms of treatment for chronic tinnitus. The results are used to form the basis of an S3 guideline. A systematic search was carried out in PubMed and the Cochrane Library. The basis for presenting the level of evidence was the evidence classification of the Oxford Centre of Evidence-based Medicine. Whenever available, randomised controlled trials were given preference for discussing therapeutic issues. All systematic reviews and meta-analyses were assessed for their methodological quality, and effect size was taken into account. As the need for patient counselling is self-evident, specific tinnitus counselling should be performed. Due to the high level of evidence, validated tinnitus-specific, cognitive behavioural therapy is strongly recommended. In addition, auditory therapeutic measures can be recommended for the treatment of concomitant hearing loss and comorbidities; those should also be treated with drugs whenever appropriate. In particular, depression should be treated, with pharmacological support if necessary. If needed, psychiatric treatment should also be given on a case-by-case basis. With simultaneous deafness or hearing loss bordering on deafness, a CI can also be indicated. For auditory therapeutic measures, transcranial magnetic or direct current stimulation and specific forms of acoustic stimulation (noiser/masker, retraining therapy, music, and coordinated reset) for the treatment of chronic tinnitus the currently available evidence is not yet sufficient for supporting their recommendation.

Tinnitus- related distress: evidence from fMRI of an emotional stroop task.

BACKGROUND: Chronic tinnitus affects 5 % of the population, 17 % suffer under the condition. This distress seems mainly to be dependent on negative cognitive-emotional evaluation of the tinnitus and selective attention to the tinnitus. A well-established paradigm to examine selective attention and emotional processing is the Emotional Stroop Task (EST). Recent models of tinnitus distress propose limbic, frontal and parietal regions to be more active in highly distressed tinnitus patients. Only a few studies have compared high and low distressed tinnitus patients. Thus, this study aimed to explore neural correlates of tinnitus-related distress. METHODS: Highly distressed tinnitus patients (HDT, n = 16), low distressed tinnitus patients (LDT, n = 16) and healthy controls (HC, n = 16) underwent functional magnetic resonance imaging (fMRI) during an EST, that used tinnitus-related words and neutral words as stimuli. A random effects analysis of the fMRI data was conducted on the basis of the general linear model. Furthermore correlational analyses between the blood oxygen level dependent response and tinnitus distress, loudness, depression, anxiety, vocabulary and hypersensitivity to sound were performed. RESULTS: Contradictory to the hypothesis, highly distressed patients showed no Stroop effect in their reaction times. As hypothesized HDT and LDT differed in the activation of the right insula and the orbitofrontal cortex. There were no hypothesized differences between HDT and HC. Activation of the orbitofrontal cortex and the right insula were found to correlate with tinnitus distress. CONCLUSIONS: The results are partially supported by earlier resting-state studies and corroborate the role of the insula and the orbitofrontal cortex in tinnitus distress.

Developmental trajectories of paediatric headache - sex-specific analyses and predictors.

BACKGROUND: Headache is the most common pain disorder in children and adolescents and is associated with diverse dysfunctions and psychological symptoms. Several studies evidenced sex-specific differences in headache frequency. Until now no study exists that examined sex-specific patterns of change in paediatric headache across time and included pain-related somatic and (socio-)psychological predictors. METHOD: Latent Class Growth Analysis (LCGA) was used in order to identify different trajectory classes of headache across four annual time points in a population-based sample (n = 3 227; mean age 11.34 years; 51.2 % girls). In multinomial logistic regression analyses the influence of several predictors on the class membership was examined. RESULTS: For girls, a four-class model was identified as the best fitting model. While the majority of girls reported no (30.5 %) or moderate headache frequencies (32.5 %) across time, one class with a high level of headache days (20.8 %) and a class with an increasing headache frequency across time (16.2 %) were identified. For boys a two class model with a 'no headache class' (48.6 %) and 'moderate headache class' (51.4 %) showed the best model fit. Regarding logistic regression analyses, migraine and parental headache proved to be stable predictors across sexes. Depression/anxiety was a significant predictor for all pain classes in girls. Life events, dysfunctional stress coping and school burden were also able to differentiate at least between some classes in both sexes. CONCLUSIONS: The identified trajectories reflect sex-specific differences in paediatric headache, as seen in the number and type of classes extracted. The documented risk factors can deliver ideas for preventive actions and considerations for treatment programmes.

Developmental trajectories and predictors of externalizing behavior: a comparison of girls and boys.

Recent studies have shown that the development of externalizing behavior in childhood and adolescence can be described through different developmental pathways. However, knowledge about differences between the sexes regarding the trajectories is limited. This study focused on potential differences by examining the trajectories of self-reported externalizing symptoms for girls and boys separately. In addition, the relationships of several familiar and child-specific variables with those developmental courses were assessed. The study was conducted on a large community sample of German youths (N = 3,893; mean age 11.38 years; 50 % girls) over 4 years. Using growth mixture modeling, three different classes of trajectories were found for both sexes. The classes differed with regard to the level and the course of symptoms ("low", "moderate", "high-decreasing"). Girls were overrepresented in the "low" class, whereas boys were predominant in the "moderate" and "high-decreasing" classes. The multiple group analysis revealed that the girls and boys differed significantly in their level and linear course of symptoms with regard to the "high-decreasing" class. In contrast, no sex differences were found in the growth factors of the "low" and "moderate" classes. The regression analyses showed that the children's depressive symptoms, dysfunctional parenting style, and negative family climate were associated significantly with the level and course of symptoms as well as the class membership of girls and boys. Life events predicted class membership only for boys, whereas maternal depressive symptoms and family conflict did not demonstrate any significant relationship. The sizes of the predictive associations with the growth factors were similar for both sexes. The results are discussed with regard to existing developmental models and their possible implications for prevention and future research.

Pediatric headache: associated psychosocial factors and psychological treatment.

All relevant databases (i.e., Pubmed, PsycINFO) were searched for studies published in 2011-2013 focusing on the association of behavioral, cognitive-emotional, and psychosocial factors with recurrent headache in children and adolescents. Only 3 studies were found dealing with psychological intervention for headache; only 2 of them presented empirical data but were not conducted as a RCT. Eleven studies (clinical and population) were concerned with the association of psychosocial factors, dysfunctional psychological traits, and symptoms and headache or examined certain pain features (triggers, course over time, disability). Most studies were interested in the association of cognitive-emotional symptoms (e.g., internalizing symptoms, anxiety) and their relation to headache, including a meta-analysis. In nearly all studies, a close bond between negative affectivity and headache, especially migraine, was revealed.

The role of catastrophizing in recent onset tinnitus: its nature and association with tinnitus distress and medical utilization.

OBJECTIVE: Persistent tinnitus affects 10 to 15% of adults. Little is understood about why only a small percentage of patients become severely affected. Catastrophic thinking has been suggested as one potentially relevant factor that might influence a patient's coping behavior, and thus tinnitus habituation. The current study investigates the concept of tinnitus catastrophizing and its relation with distress and medical utilization in recent onset tinnitus. DESIGN: Participants were administered a survey assessing catastrophizing, tinnitus distress, medical utilization, coping, and mood disturbance. Regression analyses investigated the nature of tinnitus catastrophizing and its contributions to distress and health care utilization. STUDY SAMPLE: 278 subjects with tinnitus for less than six months were recruited from Ear-Nose-Throat units, through the internet, and newspaper articles. RESULTS: Controlling for background variables, high subjective tinnitus loudness, low behavioral coping, and depressive symptoms were significantly associated with tinnitus catastrophizing. Furthermore, greater tinnitus catastrophizing was related to higher distress and more frequent medical visits. CONCLUSIONS: Tinnitus catastrophizing appears to be pivotal already at an early stage of tinnitus experience. Addressing catastrophizing by specific prevention and intervention programs might reduce the development of distress and medical utilization in the long term. Longitudinal studies are required to clarify cause-effect relations.

An internet-based cognitive-behavioural training for acute tinnitus: secondary analysis of acceptance in terms of satisfaction, trial attrition and non-usage attrition.

OBJECTIVES: Recent studies on tinnitus have focused on the efficacy of Internet-based interventions. Other core features of the quality of service, e.g. acceptance and attrition, have often been overlooked. This study analyses Internet-based training regarding acceptance and attrition in a trial on minimal-contact interventions for acute tinnitus. Whenever possible, we give information on other forms of training for comparison. METHODS: In a randomised controlled trial with 337 participants, 87 persons took part in the Internet training. RESULTS: The participants were as satisfied with the Internet-based training as with a face-to-face group training. There was a 34.48% dropout from the Internet-based training (dropout attrition). The training attrition from the Internet-based training was even higher at 64.4%. CONCLUSIONS: Two out of three indicators for acceptance-satisfaction and dropout attrition-provide comparable results between the Internet-based training and a face-to-face group training. The third indicator, training attrition, shows a better result for the group training. Future research should focus on attrition in order to enhance the overall effectiveness of training.

A systematic review and meta-analysis on the efficacy of self-help interventions in tinnitus.

This study is a review and meta-analysis on the efficacy of cognitive-behavioural therapy (CBT) self-help interventions for tinnitus. Randomized controlled trials were identified by searching in databases (e.g. ISI Web of Knowledge, PubMed, Cochrane Library, and PSYNDEX) and by manual search. Ten studies with 1188 participants in total were included in the meta-analysis. Participants were 49.2 years old and had tinnitus for 5.2 years. Self-help interventions significantly reduced tinnitus distress (d = 0.48) and depressiveness (d = 0.25) when compared with a passive control (e.g. information only and discussion forums) at post-assessment. There was no difference to the face-to-face controls (group treatment). The presence of therapists and the methodological quality of the studies did not influence the results. Sensitivity analysis revealed that there might be a publication bias regarding the comparison to the face-to-face control. However, the results suggest that CBT self-help interventions are an effective treatment for tinnitus distress. Since few studies were identified, this conclusion must be supported by future meta-analyses.

The efficacy of minimal contact interventions for acute tinnitus: a randomised controlled study.

Acute tinnitus can lead to substantial distress and eventually result in long-lasting impairment. The aim of this study was to compare the efficacy of a cognitive-behavioural intervention (delivered as Internet self-management, bibliotherapy or group training) to the information-only control condition. Applicants suffered from subjective tinnitus for up to six months, were between 18 and 75 years old and received no other tinnitus-related psychological treatment. A total of 304 participants were randomly assigned to one of the four study arms. Tinnitus distress, depressive symptoms, psychosomatic discomfort and treatment satisfaction were assessed. At the post-assessment tinnitus distress was significantly lower in the Internet and the group training conditions compared to the control condition. Inter-group effect sizes were moderate to large. At follow-up, all active training conditions showed significantly reduced tinnitus distress compared to the control condition (intention-to-treat analysis). An additional completer analysis showed a significant reduction in tinnitus distress only for the group condition. All effect sizes were moderate. There were no differences regarding psychosomatic discomfort, but depressive symptoms were reduced in the group condition at the post-assessment (intention-to-treat analysis). Treatment satisfaction was significantly higher in the training conditions. The dropout rate was 39%. The present study shows that distress can be reduced as early as the acute stadium and that minimal-contact interventions are a promising way to do this. In particular, the Internet and group conditions led to a large, immediate decrease in distress, and the participants were highly satisfied with the training.

Different trajectories of depressive symptoms in children and adolescents: predictors and differences in girls and boys.

The development of depressive symptoms in childhood and adolescence can follow different pathways. This study examined heterogeneity in the development of self-reported depressive symptoms and the predictive influence of mothers' depressive symptoms, the number of life events, and loss events via growth mixture modeling over a four-year period in a large community sample of German children and adolescents (N = 3,902; mean age 11.39 years; 49.6% female). This procedure was conducted for the total sample as well as for separate samples of girls and boys. Four different classes of trajectories for the total and the girls' model were identified, but only three classes for the boys. Girls showed higher intercepts and stronger increases in symptoms over time, whereas boys displayed stronger decreases. In the total model, mothers' depressive symptoms and the number of life events significantly increased the level of depressive symptoms. In the gender models, only mothers' depressive symptoms showed significant influence on the level of symptoms in girls and boys, whereas for life events this was only true for boys. In every model, the significant predictors discriminated at least between some classes. Loss events showed no significant influence in any model. In sum, there are meaningful differences in the development of depressive symptoms in girls and boys. These results have several implications for prevention and future research.

Diagnostic accuracy of eye movements in assessing pedophilia.

INTRODUCTION: Given that recurrent sexual interest in prepubescent children is one of the strongest single predictors for pedosexual offense recidivism, valid and reliable diagnosis of pedophilia is of particular importance. Nevertheless, current assessment methods still fail to fulfill psychometric quality criteria. AIMS: The aim of the study was to evaluate the diagnostic accuracy of eye-movement parameters in regard to pedophilic sexual preferences. METHOD: Eye movements were measured while 22 pedophiles (according to ICD-10 F65.4 diagnosis), 8 non-pedophilic forensic controls, and 52 healthy controls simultaneously viewed the picture of a child and the picture of an adult. Fixation latency was assessed as a parameter for automatic attentional processes and relative fixation time to account for controlled attentional processes. MAIN OUTCOME MEASURES: Receiver operating characteristic (ROC) analyses, which are based on calculated age-preference indices, were carried out to determine the classifier performance. Cross-validation using the leave-one-out method was used to test the validity of classifiers. RESULTS: Pedophiles showed significantly shorter fixation latencies and significantly longer relative fixation times for child stimuli than either of the control groups. Classifier performance analysis revealed an area under the curve (AUC) = 0.902 for fixation latency and an AUC = 0.828 for relative fixation time. The eye-tracking method based on fixation latency discriminated between pedophiles and non-pedophiles with a sensitivity of 86.4% and a specificity of 90.0%. Cross-validation demonstrated good validity of eye-movement parameters. CONCLUSIONS: Despite some methodological limitations, measuring eye movements seems to be a promising approach to assess deviant pedophilic interests. Eye movements, which represent automatic attentional processes, demonstrated high diagnostic accuracy.

Headache disorders in children and adolescents: their association with psychological, behavioral, and socio-environmental factors.

OBJECTIVE: This cross-sectional study on a randomly drawn population sample of children and adolescents (n = 3399; aged 9 to 15) aimed at the assessment of patterns of associations between psychosocial variables and primary headache disorders like migraine (MIG) or tension-type headache. A headache-free group served as a control. METHODS: Data on headache and psychological trait variables (eg, internalizing symptoms), behavioral factors (eg, physical activities), and socio-environmental factors (eg, life events) were gathered by questionnaire. Logistic regression analyses were conducted with headache types (MIG, tension-type, and non-classifiable headache) as dependent variables. RESULTS: The pattern of correlations was largely congruent between the headache disorders. Associations were closest regarding maladaptive psychological traits (in particular internalizing symptoms with an odds ratio > 4 regarding MIG) compared with socio-environmental factors and particularly the behavioral factors. Unfavorable psychological traits and socio-environmental strains demonstrated distinctly stronger associations with MIG than tension-type headache and explained more variance in the occurrence of pediatric headache disorders than parental headache. Sex-specific analyses showed similarities as well as differences regarding the correlations, and in general, the associations were stronger in girls than boys. CONCLUSIONS: A common path model as posited by several researchers in the field may explain the parallelism in biopsychosocial vulnerability regarding the different headache disorders.

Children in pain: recurrent back pain, abdominal pain, and headache in children and adolescents in a four-year-period.

OBJECTIVE: To analyze the development of recurrent pain in 3 body locations in children and adolescents (baseline age, 9 to 14 years) in a 4-year period. STUDY DESIGN: In a large population-based longitudinal epidemiological study data was collected through annual postal questionnaires (longitudinal, n = 2025). Descriptive statistics and generalized estimating equations were used. RESULTS: Girls were more likely to report recurrent pain, demonstrated a steeper development during the 4-year period, and reported multiple pain more often than boys. Younger children reported less recurrent pain, but displayed a steeper trend of increasing prevalence rates as they grew older. Older children illustrated a more stable development of recurrent pain and reported multiple pain more often. Disability experienced because of recurrent pain was related strongest to pain intensity. Stable patterns of pain were related to higher intensity and disability reports. The children experienced headache as the most disabling of the 3 pains. CONCLUSION: The results show that boys and girls report recurrent pain in different patterns in the years. To identify risk factors, analysis should be performed separately for boys and girls. Furthermore, it is recommended to include children before the age of 9 years in a prevention study.

Multiple pains in children and adolescents: a risk factor analysis in a longitudinal study.

OBJECTIVE: The aim of the study was to ascertain the prevalence of multiple pains (MPs) and detect psychosocial risk factors assessed 1 year previously. METHOD: MPs were defined by the number of sites where pain was reported to occur at least "sometimes" in a general population sample of 2,219 German youths. RESULTS: Two or more sites of recurrent pain were reported by 54% of the participants, whereas 27% reported no pains. Girls were much more prone to MPs than boys. Stability of MP was high in the two waves. Regression analysis revealed that prior MP, age, sex, internalizing/externalizing symptoms, and time spent with visual media explained 25% of the variance: the contribution of the psychosocial factors to the model was small. Separate analyses for boys and girls displayed different risk-factor profiles and a higher degree of predictability in girls. CONCLUSION: A supposedly biological disposition, namely pain vulnerability, being particularly high in girls, is assumed to build the basis of pains felt in various sites of the body. Further research is needed to corroborate and specify these assumptions.

The cross-sectional GRAS sample: a comprehensive phenotypical data collection of schizophrenic patients.

BACKGROUND: Schizophrenia is the collective term for an exclusively clinically diagnosed, heterogeneous group of mental disorders with still obscure biological roots. Based on the assumption that valuable information about relevant genetic and environmental disease mechanisms can be obtained by association studies on patient cohorts of ≥ 1000 patients, if performed on detailed clinical datasets and quantifiable biological readouts, we generated a new schizophrenia data base, the GRAS (Göttingen Research Association for Schizophrenia) data collection. GRAS is the necessary ground to study genetic causes of the schizophrenic phenotype in a 'phenotype-based genetic association study' (PGAS). This approach is different from and complementary to the genome-wide association studies (GWAS) on schizophrenia. METHODS: For this purpose, 1085 patients were recruited between 2005 and 2010 by an invariable team of traveling investigators in a cross-sectional field study that comprised 23 German psychiatric hospitals. Additionally, chart records and discharge letters of all patients were collected. RESULTS: The corresponding dataset extracted and presented in form of an overview here, comprises biographic information, disease history, medication including side effects, and results of comprehensive cross-sectional psychopathological, neuropsychological, and neurological examinations. With >3000 data points per schizophrenic subject, this data base of living patients, who are also accessible for follow-up studies, provides a wide-ranging and standardized phenotype characterization of as yet unprecedented detail. CONCLUSIONS: The GRAS data base will serve as prerequisite for PGAS, a novel approach to better understanding 'the schizophrenias' through exploring the contribution of genetic variation to the schizophrenic phenotypes.

Hypersensitivity to sound in tinnitus patients: an analysis of a construct based on questionnaire and audiological data.

The purpose of this study was to analyse the Questionnaire on Hypersensitivity to Sound (GUF; Nelting & Finlayson, 2004 ) and to improve its validity based on the analysis of intercorrelations (single item level) with other methods of assessing hyperacusis (uncomfortable loudness level, individual loudness function, self-rated severity of hyperacusis). Subjects consisted of 91 inpatients with tinnitus and hyperacusis. The GUF showed a good reliability (alpha = .92). The factorial structure of the questionnaire reported by Nelting et al (2002) was not completely supported by the evidence in this study. The total score and the single items showed small to moderate correlations with the other modes of measuring hyperacusis. Evidence for convergent and discriminant validity were found, but overall the results corroborate the conceptual heterogeneity of the construct hyperacusis and its dependency on the assessment method. Four items of the GUF with particularly low correlations were excluded from the questionnaire. The revised GUF total score showed slightly but not statistically significant higher convergent and discriminant validity.

Menarche in girls and headache--a longitudinal analysis.

BACKGROUND: Puberty is assumed to influence the occurrence of headache, increasing the risk for recurrent episodes, especially in girls. The increase of headache, in particular recurrent headache, in girls from around the age of 12 on, is often ascribed to the occurrence of menarche as the most stringent indicator of completed puberty. OBJECTIVES: We examined the hypothesis that the occurrence of menarche in girls is predictive of recurrent headache in reference to no or rare headache in the past 6 months. Furthermore, the assumption was tested that headache episodes increase after onset of menarche but remain unchanged in girls not having experienced their first menstruation. We also expected a higher probability of migraine type of headache after menarche. In a further analysis girls with and without menarche were compared with boys, and a difference between gender only for girls with menarche was predicted. METHODS: In an epidemiological study recruiting 8800 families with children 7-14 years in Southern Lower Saxony (Germany), we conducted 3 yearly panels based on postal questionnaires. Headache data are based on self-report of children from 9 years on. Parents were asked for information regarding the onset of menarche. Approximately 1100 girls and about the same number of boys constitute the sample for our analyses. RESULTS: The results of a logistic regression analysis demonstrate that in 11- to 16-year-old girls having experienced menarche in either the year of the assessment of headache or 2 years before that, the risk for recurrent headache is increased when compared with girls without menarche. Intraindividual longitudinal analyses, however, do not support our hypotheses that after the onset of menarche headaches become more frequent. The expected differences in headache between girls with menarche and boys were found. The risk for migraine-like headaches is not significantly higher after onset of menarche than before. CONCLUSIONS: Thus, results do not consistently support the hypothesis that puberty is a moderator of headache frequency. Even in cases where the outcome of regression analyses is supportive of our expectations, explained variance is diminutive (maximum 2.2%). Thus, the influence of menarche on headache seems to be only marginal.

How does reduction in pain lead to reduction in disability in patients with musculoskeletal pain?

PURPOSE: Reduction in pain following multidisciplinary treatment is most often associated with a reduction in disability. To further elaborate the relationship between pain intensity and disability, the present study investigated three main questions: first, whether multidisciplinary treatment leads to a significant improvement in pain, disability and psychological variables (depression, pain acceptance and catastrophizing). Second, it was examined whether pain reduction may account for significant changes in the psychological variables (pre- to follow-up change scores). Finally, it was analyzed whether the psychological changes mediate the association between reduction in pain and in disability after controlling for age, sex and pain history. PATIENTS AND METHODS: Patients suffering from chronic musculoskeletal pain (n=279) attended a German inpatient multidisciplinary program lasting 15 consecutive days on average, with self-report data collected at pretreatment, posttreatment and three-month follow-up. RESULTS: Repeated measures ANOVAs showed a significant improvement in pain intensity, disability, pain acceptance, catastrophizing and depression at posttreatment and follow-up. Univariate regression analyses revealed that changes in pain intensity accounted for significant changes in depression, pain catastrophizing and pain acceptance (pre- to follow-up change scores). The results of Multiple Mediation Procedure showed that pain reduction did affect reduction in disability through improvement of depression, catastrophizing and acceptance. CONCLUSION: Our findings support a cognitive-behavioral model of pain that posits an important role for pain-related cognitive and emotional processes in long-term outcomes following multidisciplinary pain treatment, in particular for the modulation of disability due to pain. The results add evidence to the notion that pain-related cognitions are dynamic features varying over time dependent on the internal situation. PERSPECTIVE: The current findings are relevant to the management of patients with musculoskeletal pain. The results support the notion that, in contrast with the view of enduring personality traits, pain-related cognitions and emotions reflect a situational response that varies over time.