Flumazenil potentiation of postoperative morphine analgesia.

OBJECTIVE: The goal of this study was to test the effect of concomitant administration of flumazenil (FL) and morphine (MO) on immediate postoperative analgesia and the MO requirement to control pain in human beings. DESIGN AND INTERVENTIONS: Thirty-six patients undergoing inguinal hernioplasty under lidocaine epidural anesthesia were enrolled in this double-blind, randomized, controlled study. On the first complaint of pain, either MO (2 mg) only or MO (2 mg) plus FL (0.2 mg) was administered. Additional doses of the same medications administered via a patient-controlled analgesia device with a 10-minute lockout period were available thereafter. The study continued for 2 hours after the loading doses of the medications were administered, with an additional 2-hour period of observation. RESULTS: Thirty-two patients completed the study. Both groups reached a similar satisfactory equianalgesic state (2 in a 0-10 visual analogue scale). The MO plus FL group consumed 9.5 +/- 1.1 mg of MO versus 14.1 +/- 1.1 mg of MO (p < 0.001) in the MO only group. The MO plus FL patients were subjectively (visual analogue scale) more comfortable and less sedated than the MO patients. "Fine" coordination (using an electronic maze) and "coarse" coordination (measured by transferring a pen from one hand to another as rapidly as possible with both arms placed inside an 80-cm metal frame) in the MO group were worse than in the MO plus FL group. End-tidal CO2 increased and blood pressure decreased in the MO group. There were few and insignificant side effects in the MO group. None of these patients required an MO antagonist, and recovery was prolonged in none. CONCLUSIONS: Flumazenil afforded lower MO consumption during the immediate postoperative period. Cognitive, hemodynamic, and respiratory functions were better after MO plus FL than after MO alone.

Cognitive aspects of pain and pain control.

The cognitive and cognitive-behavioral approaches have been shown to be very effective in controlling pain and its sequelae both in the laboratory and in the clinical setting. As used in most research and treatment, cognitive approaches are concerned with the way the person perceives, interprets, and relates to his or her pain rather than with the elimination of the pain per se. This article reviews some of the origins of cognitive theory and pain theory, as well as examples of the techniques used and the research support for the approach. Special emphasis is given to self-efficacy, perceived control, and stress inoculation therapy. There is also discussion of some of the limitations of the cognitive approach. The overall conclusion is that the cognitive approach is a powerful and effective one for pain control despite its limitations.

Supportive versus cognitive-behavioral intervention programs in achieving adjustment to home peritoneal kidney dialysis.

Two psychological interventions given for 8 weeks, supportive and cognitive-behavioral, were compared in achieving psychosocial adjustment to home peritoneal kidney dialysis. Participants were divided into 3 groups of patients and their spouses: a supportive group (18 couples), a cognitive-behavioral group (18 couples), and a no-intervention control group (24 couples). A group of 97 healthy participants served as a baseline control group. Self-report measurements were made before treatment (T1), halfway through (T2), and after treatment (T3). Results indicated that, without treatment, the no-intervention control group demonstrated a deterioration of psychosocial adjustment going from T1 to T3. Both interventions were effective in aiding patients and spouses in maintaining psychosocial adjustment in comparison with the no-intervention control group, with few differences between treatments. Most improvement was obtained in the emotional, cognitive, and interpersonal areas, with smaller gains made in the behavioral area.

Stress reactions of school-age children to the bombardment by Scud missiles: a 1-year follow-up.

Follow-up long-term stress effects to bombardment by scud missiles were restudied 1 year following the Persian Gulf war in a group of 326 6th, 8th, and 11th grade children from areas hit and not hit by the missiles. Postwar stress reactions were assessed by a continuous global symptom score (Frederick and Pynoos, 1988) and by a dichotomous PTSD index. Overall, a large drop in stress reactions was obtained with lapse of time. Residual long-term stress reactions were found to be associated with higher immediate (4-week) stress reactions, a greater degree of exposure, and younger age. Results were discussed in relation to residual and evaporation of stress reaction effect as well as in terms of childhood resilience.

Stress reaction of school-age children to the bombardment by SCUD missiles.

Stress reactions of 5th-, 7th-, and 10th-grade children (N = 492) exposed to missile attacks during the Persian Gulf War were examined a month after the war by a questionnaire that assessed level of exposure to trauma and psychological symptoms. Higher stress responses were obtained in areas hit and were influenced by proximity to sites or individuals involved in actual damage. Gender, age, and region interacted such that 5th-grade boys reported the highest stress reactions regardless of region, whereas 5th-grade girls reported the highest stress responses only in regions hit. Gender, age, and objective and subjective stress correctly identified 75% of the children as potential clinical or nonclinical candidates. The possible mediating coping responses and applications for high-risk groups are discussed.

Coping of school-age children in the sealed room during scud missile bombardment and postwar stress reactions.

Children's coping behaviors in the sealed room (a shelter against chemical and biological weapons) during scud missile attacks in the Persian Gulf war were examined in relation to postwar stress reactions. Three weeks after the war, 5th, 7th, and 10th graders (N = 492) completed questionnaires assessing coping behaviors and emotional responses in the sealed room, as well as current stress reactions and posttraumatic stress disorder (PTSD). Despite an underlying feeling of tension, the dominant emotional stance in the sealed room was one of detached optimism. Common forms of coping involved information seeking, checking, and wishful thinking. Emotion-focused coping such as avoidance and distraction strategies was associated with less postwar stress reactions than persistence at direct problem-focused actions once the minimal actions available had been undertaken. Fifth graders were found to use less emotion-focused and more problem-focused coping strategies than were the 7th and 10th graders.

The case of a newspaper phobia in a 9-year-old child.

The case of E, a 9-year-old, male, with a newspaper phobia, is presented. The phobia developed over a 4-year period and gradually spread until it included many significant areas of E's life. Treatment took place over a 4-month period. It involved use of a token economy administered by E's parents. Cognitively, the treatment involved the concepts of the acquisition of perceived self-control as a consequence of the token economy agreement. This included volition, attention, and self-control by E as well as parental reinforcement.

Cultural and educational influences on pain of childbirth.

This study investigated the effects of sociocultural family of origin and educational level on the verbal ratings of pain and pain behavior during childbirth for 83 women. Coping style and extroversion were also measured. It was found that all women rated the pain of childbirth as high. Overall, women from a Middle-Eastern compared with a Western background gave higher ratings of pain and showed more pain behavior. This was found especially for Middle-Eastern women of a low educational background. Overall, low compared with high educational level resulted in higher ratings of pain and more pain behavior. No differences were obtained as a function of extroversion. Middle-Eastern and Western women did not differ in coping style. However, women who had higher monitoring scores rated the pain as less even through no differences were obtained for pain behavior. Sociocultural group of origin as well as other relevant reference groups, such as educational level, are important in determining pain perception and behavior. Combining this information with coping style could lead to an instructional intervention for preparing women for childbirth.

Posttraumatic stress disorder among frontline soldiers with combat stress reaction: the 1982 Israeli experience.

One year after the 1982 Lebanon War, the authors assessed the prevalence, type, and severity of posttraumatic stress disorder in a large representative sample of Israeli soldiers who had been treated for combat stress reactions. Comparisons were made with a group of soldiers who had fought in the same battles but had not been treated for this reaction. A dramatically higher percentage of soldiers with combat stress reaction (59%) than of soldiers without combat stress reaction (16%) developed posttraumatic stress disorder. Age was significantly associated with posttraumatic stress disorder. The authors discuss the differential quality of posttraumatic stress disorder among both groups as well as the factors facilitating recovery.

Pain: anxiety and attitudes in Black, white and Puerto Rican patients.

Reactions of black, white and Puerto Rican patients were studied in an outpatient dental emergency clinic. Measures used included the State-Trait Anxiety Inventory, palmar sweat prints, an interview to obtain patient characteristics and attitudes toward pain, Dental Anxiety Scale and a posttreatment dentist rating. No differences between ethnic and racial groups were obtained in amount of pain, number or type of symptoms patients had. Significant Trait Anxiety differences were obtained. Puerto Ricans had the highest level of Trait Anxiety, whites the lowest, with blacks in the middle. The Dental Anxiety Scale also yielded differences with Puerto Ricans scoring highest, blacks lowest and whites in between. Attitude differences reflected a relative willingness to deny, get rid of or avoid dealing with the pain. The Puerto Ricans scored highest, whites lowest, with blacks in between. No physiological differences were obtained with palmar sweat prints.