Mindfulness-based cognitive therapy for the treatment of headache pain: A mixed-methods analysis comparing treatment responders and treatment non-responders.

OBJECTIVES: Our recent pilot study demonstrated mindfulness-based cognitive therapy (MBCT) is a potentially efficacious headache pain treatment; however, it was not universally effective for all participants. This study sought to explore patient characteristics associated with MBCT treatment response and the potential processes of change that allowed treatment responders to improve and that were potentially lacking in the non-responders. DESIGN: We implemented a mixed-methods analysis of quantitative and qualitative data. The sample consisted of 21 participants, 14 of whom were classified as treatment responders (≥50% improvement in pain intensity and/or pain interference) and seven as non-responders (<50% improvement). SETTING: The study was conducted at the Kilgo Headache Clinic and the University of Alabama Psychology Clinic. INTERVENTION: Participants completed an 8-week MBCT treatment for headache pain management. MEASURES: Standardized measures of pain, psychosocial outcomes, and non-specific therapy factors were obtained; all participants completed a post-treatment semi-structured interview. RESULTS: Quantitative data indicated a large effect size difference between responders and non-responders for pre- to post-treatment change in standardized measures of pain acceptance and catastrophizing, and a small to medium effect size differences on treatment dose indicators. Both groups showed improved psychosocial outcomes. Qualitatively, change in cognitive processes was a more salient qualitative theme within treatment responders; both groups commented on the importance of non-specific therapeutic factors. Barriers to mindfulness meditation were also commented on by participants across groups. CONCLUSIONS: Results indicated that change in pain related cognitions during an MBCT intervention for headache pain is a key factor underlying treatment response.

Mindfulness-based cognitive therapy for the treatment of headache pain: a pilot study.

OBJECTIVE: This pilot study reports the findings of a randomized controlled trial (RCT) investigating the feasibility, tolerability, acceptability, and initial estimates of efficacy of mindfulness-based cognitive therapy (MBCT) compared to a delayed treatment (DT) control for headache pain. It was hypothesized that MBCT would be a viable treatment approach and that compared to DT, would elicit significant improvement in primary headache pain-related outcomes and secondary cognitive-related outcomes. MATERIALS AND METHODS: RCT methodology was employed and multivariate analysis of variance models were conducted on daily headache diary data and preassessment and postassessment data for the intent-to-treat sample (N=36), and on the completer sample (N=24). RESULTS: Patient flow data and standardized measures found MBCT for headache pain to be feasible, tolerable, and acceptable to participants. Intent-to-treat analyses showed that compared to DT, MBCT patients reported significantly greater improvement in self-efficacy (P=0.02, d=0.82) and pain acceptance (P=0.02, d=0.82). Results of the completer analyses produced a similar pattern of findings; additionally, compared to DT, MBCT completers reported significantly improved pain interference (P<0.01, d=-1.29) and pain catastrophizing (P=0.03, d=-0.94). Change in daily headache diary outcomes was not significantly different between groups (P's>0.05, d's≤-0.24). DISCUSSION: This study empirically examined MBCT for the treatment of headache pain. Results indicated that MBCT is a feasible, tolerable, acceptable, and potentially efficacious intervention for patients with headache pain. This study provides a research base for future RCTs comparing MBCT to attention control, and future comparative effectiveness studies of MBCT and cognitive-behavioral therapy.

The communal coping model of catastrophizing: patient-health provider interactions.

OBJECTIVE: The study sought to elucidate and refine the interpersonal, communicative dimension of the communal coping model (CCM) of catastrophizing. The primary aim was twofold. First, we examined the relations among pain intensity, catastrophizing, and pain behaviors as they function within the patient-health provider relationship. Second, we investigated the role of catastrophizing and pain behaviors in potentially influencing patient satisfaction with the provider, provider attitudes, and provider behavior. Mediation models were examined. DESIGN: The study was cross-sectional design with repeated measures. SETTING: This study was conducted at a university-based family medicine clinic and a private practice rheumatology clinic. Nineteen health providers and 49 chronic pain patients receiving treatment in a medical setting completed the study. OUTCOME MEASURES: Patient outcome measures included pain intensity, catastrophizing, pain behaviors, and patient satisfaction with the provider. Health provider outcome measures were an assessment of provider attitudes and length of medical exam. RESULTS: The patient's level of catastrophizing entering the medical exam significantly predicted the interactive dynamics between the patient and the health provider during the exam and patient satisfaction after the exam. The patient's perceptions of pain and catastrophic thought processes may be interpersonally expressed to health providers via exaggerated pain behaviors. CONCLUSIONS: Current findings indicate suggestions for refining the CCM. Results suggest that alleviation of catastrophic cognitions may facilitate more effective interpersonal communication within the patient-health provider relationship. Identification of those factors that improve patient-provider dynamics has important implications for the advancement of treatment for chronic pain and reducing the costs associated with persistent pain.

Clinical and translational studies of a phase II trial of the novel oral Akt inhibitor perifosine in relapsed or relapsed/refractory Waldenstrom's macroglobulinemia.

BACKGROUND: Waldenström's macroglobulinemia (WM) is a rare, low-grade lymphoproliferative disorder. Based on preclinical studies, we conducted a phase II clinical trial testing the efficacy and safety of the Akt inhibitor perifosine in patients with relapsed/refractory WM. PATIENTS AND METHODS: Thirty-seven patients were treated with oral perifosine (150 mg daily) for six cycles. Stable or responding patients were allowed to continue therapy until progression. RESULTS: The median age was 65 years (range, 44-82). The median number of prior therapy lines was two (range, one to five). Of the 37 patients, 4 achieved partial response (11%), 9 minimal response (24%), and 20 showed stable disease (54%). The median progression-free survival was 12.6 months. Additionally, beta2 microglobulin of >3.5 mg/dL was associated with poor event-free survival (P = 0.002). Perifosine was generally well tolerated; adverse events related to therapy were cytopenias (grade 3-4, 13%), gastrointestinal symptoms (grade 1-2, 81%), and arthritis flare (all grades, 11%). Translational studies using gene expression profiling and immunohistochemistry showed that perifosine inhibited pGSK activity downstream of Akt, and inhibited nuclear factor kappaB activity. CONCLUSION: Perifosine resulted in at least a minimal response in 35% of patients and a median progression-free survival of 12.6 months in patients with relapsed or relapsed/refractory WM, as well as in vivo inhibition of pGSK activity. The results of this study warrant further evaluation of perifosine in combination with rituximab or other active agents in patients with WM.

Association between renal disease and outcomes among HIV-infected women receiving or not receiving antiretroviral therapy.

BACKGROUND: The associations of proteinuria and an elevated creatinine level with progression to acquired immunodeficiency syndrome (AIDS) and death in the era of highly antiretroviral therapy (HAART) have not been fully described. METHODS: This analysis includes 2038 human immunodeficiency virus (HIV)-infected women from the Women's Interagency HIV Study. Time to the development of a new AIDS-defining illness (ADI) and death was modeled using proportional hazards regression before the widespread availability of HAART and after initiation of HAART. RESULTS: Of the 2038 subjects, the 14.1% of women with proteinuria had lower CD4 lymphocyte counts and higher viral loads (P<.0001 for all) at baseline and before initiation of HAART. Before the widespread availability of HAART, proteinuria was associated with an increased risk for development of ADI (hazard ratio [HR], 1.37; P=.005), and proteinuria and an elevated creatinine level were both associated with an increased risk of death (for proteinuria: HR, 1.35 [P=.04]; for creatinine: HR, 1.72 per decrease in the inverse unit [P=.02]). Among women initiating HAART, an elevated creatinine level remained associated with an increased risk of development of ADI (HR, 1.54 per decrease in the inverse unit; P=.03), and proteinuria and an elevated creatinine level were associated with an increased risk of death (for proteinuria: HR, 2.07 [P=.005]; for creatinine: HR, 1.96 per decrease in the inverse unit [P=.04]). CONCLUSIONS: Proteinuria and an elevated creatinine level were associated with an increased risk of death and development of ADI. These associations may reflect the direct role of the kidney in modulating HIV disease, or they may act as markers of greater comorbidity.

Incidence of lipoatrophy and lipohypertrophy in the women's interagency HIV study.

OBJECTIVE: To estimate the incidence of lipoatrophy and lipohypertrophy among HIV-infected and HIV-uninfected women from the Women's Interagency HIV Study. DESIGN: Eight hundred fifteen women with semiannual data on self-report of bidirectional change in body fat, anthropometric measurements, weight, and bioelectric impedance analysis were included in a 30-month incidence analysis. METHODS: Lipoatrophy and lipohypertrophy in both peripheral (arms, legs, and buttocks) and central (waist, chest, and upper back) sites were defined by self-report of either a decrease or an increase in a body fat region over the previous 6 months that was confirmed by a corresponding change in anthropometric measurement. RESULTS: Weight and total body fat increased in HIV-uninfected women but remained stable in HIV-infected women over 30 months. Among HIV-infected women, the incidence of peripheral (relative hazard, 2.1; 95% confidence interval [CI], 1.4-3.3) and central (relative hazard, 1.9; 95% CI, 1.2-2.8) lipoatrophy was about double that among HIV-uninfected women, after adjustment for age and race. The incidence of peripheral lipohypertrophy appeared lower among HIV-infected women than among HIV-uninfected women (relative hazard, 0.8; 95% CI, 0.6-1.1), while the incidence of central lipohypertrophy did not differ by HIV status. Of HIV-infected women with 2 of 4 lipodystrophy outcomes, most (81%) had combined peripheral and central lipoatrophy or combined peripheral and central lipohypertrophy. Only 14% of these women had both peripheral lipoatrophy and central lipohypertrophy. CONCLUSIONS: These prospective data suggest that lipoatrophy, affecting both peripheral and central sites, predominates in HIV-infected women. The simultaneous occurrence of peripheral lipoatrophy and central lipohypertrophy was uncommon.

The effect of headache pain on attention (encoding) and memory (recognition).

Memory is a key cognitive variable in pain management. This study examined the effect of headaches on participants' encoding of words (attention) and later memory for words. The dependent measures were response time during encoding and recognition memory; headache pain was the independent measure. Eighty participants were randomized to one of four groups: two groups had the same condition (headache pain or no headache pain) for both the encoding and memory tasks and two groups had mixed conditions (i.e. pain during encoding/no pain during recognition; no pain during encoding/pain during recognition). Participants with pain during encoding judged words significantly slower (177.53ms) than participants without pain during encoding. Participants with pain during the memory task recognized significantly fewer words (5.4%) than participants without pain during the memory task, regardless of pain condition during encoding. Results from this and other pain and memory studies conducted in this laboratory suggest that pain, as it adversely affects memory, may operate at a threshold level rather than on a dose-response continuum.

Client-therapist intimacy: responses of psychotherapy clients to a consumer-oriented brochure.

Psychotherapy clients read two consumer-oriented brochures: a general brochure on psychology and a brochure on the topic of client-therapist intimacy. Half of the participants read the general brochure first and the brochure on client-therapist intimacy second, and half the participants did the reverse. Participants reported favorable reactions to the brochures, indicating they thought both should be made available to psychotherapy clients; that neither were too long, too sensitive, or too difficult to read; and that the brochures should be made available early during the therapeutic process. After reading the client-therapist intimacy brochure, participants also showed some changes in Likert-type scores measuring attitudes regarding intimate contact between clients and therapists. Although participants were more negative about issues of sexual misconduct after reading the client-therapist intimacy brochure, they did not indicate a decrease in trust of therapists, nor did they indicate a greater likelihood of filing a false complaint. We concluded that therapists' reservations about presenting clients with factual information regarding therapist sexual exploitation of clients are not empirically founded.