Validation of the Swedish version of the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM).

UNLABELLED: The purpose of this study was to perform an initial validation of a Swedish translation of the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM). The CORE-OM is a broad self-report instrument of psychological problems, designed as an outcome measure for evaluating the effects of psychological therapy. Participants included a non-clinical group of 229 university students and a clinical group of 619 persons from four primary care sites. The Swedish CORE-OM showed excellent acceptability, high internal consistency and test-retest reliability, as well as acceptable convergent validity. There was strong differentiation of the clinical and non-clinical samples, with the clinical group scoring significantly more psychological problems than the non-clinical group. Sensitivity to change was demonstrated in psychological treatments in primary care. Overall, the psychometric characteristics of the Swedish CORE-OM were very similar to the original UK data. Nevertheless, the validity of the Swedish version needs to be examined more in detail, in larger and more diverse samples. Our results so far, however, provide support for using the Swedish CORE-OM as a psychological problems measure. To our knowledge, there are few other relatively short measures in Swedish that are free to reprint that meet the demands for psychometric properties and utility in primary care settings in which patients typically present a broad range of psychological problems. KEY PRACTITIONER MESSAGE: The Swedish version of the CORE-OM is a valid questionnaire for assessing the severity of a broad range of psychological problems.

Early active rehabilitation after surgery for lumbar disc herniation: a prospective, randomized study of psychometric assessment in 50 patients.

In a randomized study, using psychometric assessment, we evaluated two training programs before and after surgical treatment of lumbar disc herniation. 26 patients were treated according to an early active training program (treatment group). 24 patients followed a traditional less active training program (control group). Before surgery, the patients filled in the following questionnaires 3 and 12 months after surgery: Multidimensional Pain Inventory (MPI), State and Trait Anxiety Inventory, and Beck Depression Inventory. Pain was assessed by the patient's pain drawing and a visual analog scale. Both groups improved as regards pain severity and state of anxiety. The MPI parameter, pain interference, improved more in the early active treatment group than in the control group. This suggests that the early active training program has a positive effect on the way patients cope with pain in their daily lives.

Depression, mood state, and back pain during microgravity simulated by bed rest.

OBJECTIVE: The objective of this study was to develop a ground-based model for spinal adaptation to microgravity and to study the effects of spinal adaptation on depression, mood state, and pain intensity. METHODS: We investigated back pain, mood state, and depression in six subjects, all of whom were exposed to microgravity, simulated by two forms of bed rest, for 3 days. One form consisted of bed rest with 6 degrees of head-down tilt and balanced traction, and the other consisted of horizontal bed rest. Subjects had a 2-week period of recovery between the studies. The effects of bed rest on pain intensity in the lower back, depression, and mood state were investigated. RESULTS: Subjects experienced significantly more intense lower back pain, lower hemisphere abdominal pain, headache, and leg pain during head-down tilt bed rest. They had higher scores on the Beck Depression Inventory (ie, were more depressed) and significantly lower scores on the activity scale of the Bond-Lader questionnaire. CONCLUSIONS: Bed rest with 6 degrees of head-down tilt may be a better experimental model than horizontal bed rest for inducing the pain and psychosomatic reactions experienced in microgravity. Head-down tilt with balanced traction may be a useful method to induce low back pain, mood changes, and altered self-rated activity level in bed rest studies.

Phobic avoidance and regular dental care in fearful dental patients: a comparative study.

The present investigation was a comparative study of 169 highly fearful dental patients, some of whom received regular dental care (n = 28) and some who never, or only when absolutely necessary, utilized dental care (n = 141). It was hypothesized that phobic avoidance is related to anticipatory stress and anxiety reactions, negative oral health effects, psychological distress, and negative social consequences. Background factors (sex, age, education, and dental attendance pattern), dental anxiety, general fears, general state and trait anxiety, mood states, depression, and quality of life effects were studied. Data were analyzed with descriptive statistics and with exploratory factor and multiple logistic regression analysis. It was shown that dental anxiety is significantly higher among the avoiders and this is in particular evident for anticipatory dental anxiety. Oral health differed between the groups, and it was shown that avoiders had significantly more missing teeth, whereas regular attenders had significantly more filled teeth. The avoiders reported a stronger negative impact on their daily life, whereas there were no significant differences between the groups with regard to general emotions. The logistic regression analysis showed that phobic avoidance was predicted only by anticipated dental anxiety and missing teeth. It was concluded that differences between high dental fear patients with regular dental care and phobic avoidance were mainly related to anticipated fear and anxiety, oral health effects, and concomitant negative life consequences. These results are discussed in terms of subjective stress, negative cognitions, social support, and coping-strategies.

Psychophysiological reactions in dental phobic patients during video stimulation.

Electromyography (EMG) reflecting forehead muscle tension, heart rate (HR) and skin conductance (SC) were continuously recorded in dental phobic subjects (n = 126) and controls (n = 25) during exposure of dental and neutral video scenes in order to explore the relationship between dental fear and psychophysiological responses. This relationship is far from well established, and the present investigation was performed to contribute to the understanding of the psychophysiology of dental fear. Dental phobics had a mean anxiety level of 17.3 as measured by Corah's Dental Anxiety Scale (DAS) and refused conventional dental treatment. Control subjects reported regular dental treatment and a DAS score below population average (DAS < 8). Psychophysiological data was reduced to level (mean) and reactivity (means of intraindividual variations). Results showed that physiologic reactions to fear-relevant conditions measured by HR and EMG reflected degree of dental fear, and that neutral conditions, when presented for the second and third time, induced lower psychophysiologic reactions in phobics than in controls. Recordings of SC indicated that dental phobics may differ from individuals suffering from other types of specific phobia by showing weakened autonomic responsiveness to threat.

Structural relationships of dental anxiety, mood, and general anxiety.

The aim of this study was to explore the structural relationships between dental anxiety, mood, and general anxiety among 220 dentally anxious patients who participated in a clinical study. A structural equation modeling analysis (SEM) was applied by using the LISREL program on the hypothesized latent variables dental anxiety, mood, and general anxiety, which were measured by means of several psychometric tests. The final model showed that mood and general anxiety had positive factor loadings on dental anxiety. However, the impact of the general anxiety latent variable was not significant as compared with the mood factor. Another finding was that the residual variance for the latent variable dental anxiety was 0.68, indicating that a major portion of the variance is still unexplained by the tested variables. In conclusion, this study showed a relationship between dental anxiety, general anxiety, and mood among dentally anxious patients.

Relaxation vs. cognitively oriented therapies for dental fear.

Cognitive therapy has been reported for the treatment of dental phobia, but comparisons with other behavioral treatments are scarce. This study investigated the outcome of two modes of treatment for phobic dental fear. Relaxation and cognitively oriented therapy were compared in a sample of 112 adult fearful dental patients. The patient made questionnaire assessments of background and outcome variables, and the specialist dentist rated successful/non-successful outcome. It was shown that a higher number of patients who received cognitively oriented therapy completed the treatment program, while anxiety was more reduced among patients who received relaxation-oriented therapy. Dropout during the initial phobia therapy with a psychologist was related to lower motivation (willingness to engage in treatment), while failures during dental treatment after the completion of therapy were related to higher levels of general fear and anxiety. A multiple logistic regression model explaining 67% of the variance revealed that the risk of failure was only slightly increased by general fears, while patients with low (below median) motivation ran a 3.6-times-higher risk of dropping out. In conclusion, it was shown that the two treatment methods were both effective in reducing dental phobic reactions. However, while cognitively oriented therapy resulted in a higher number of patients completing therapy, relaxation-oriented treatment generally resulted in a more significant reduction in dental fear as well as in general anxiety and fear. Motivation was found to be a significant predictor of successful treatment outcome.

Perceived future in chronic pain: the relationship between outlook on future and empirically derived psychological patient profiles.

Perceived (subjective) future has been found to be a significant factor in explaining the relationship between pain and pain-related distress. The present study is based on the assumption that chronic pain patients with the three psychological profiles introduced by Turk and Rudy in 1988 could also be found in a sample of chronic pain patients and if so, these profiles have different perspectives on the future. The Multidimensional Pain Inventory (MPI) and The Future Scale were used to collect data from 569 patients with heterogeneous non-malignant chronic pain. A cluster analysis was conducted, where the resulting clusters closely resembled the profiles labelled by Turk and Rudy as 'dysfunctional', 'interpersonally distressed' and 'adaptive coper'. The results indicated that patients with adaptive coper profile have a more positive perception, while those with an interpersonally distressed profile have a more negative perception of the future. With an increased duration of pain, the proportion of the adaptive coper category decreased linearly, while an opposite trend was noted for the interpersonally distressed category. These results may better enable profiled psychological interventions in clinical pain treatment, e.g. by providing patients with therapies focused on positive future orientation, resulting in increased motivation for health-seeking behaviour and better abilities to cope with pain.

Psychosocial aspects of dental and general fears in dental phobic patients.

Phobic reactions can often be a significant health problem for fearful dental patients. This is true in particular for individuals with long-time avoidance and elevated general psychological distress. The aim of this study was to investigate the expression of dental fear among 67 dental phobic individuals with a low versus high degree of general fear. Reported etiologic background factors, avoidance time, general psychological distress and psychosocial manifestations and consequences of dental phobia were studied. No significant difference in dental anxiety level between individuals with low versus high general fear was found, and both groups reported high frequencies of negative dental experiences. The low-fear group reported a longer (though not statistically significant) average avoidance time than the high-fear group. However, patients with a high level of general fear showed a significantly higher degree of psychological distress, and also reported stronger negative social consequences from their dental anxiety. These results indicate that the character of dental fear might be different between different groups of fearful patients, which makes the condition psychologically handicapping. Such aspects should be assessed in the diagnostic analysis of patients with severe dental anxiety. In particular, assessments of signs of general psychological distress are warranted.

Changes in function and in pain-related and cognitive-behavioral variables after arthroscopy of temporomandibular joints.

The purpose was to prospectively evaluate changes in clinical, pain, and cognitive-behavioral variables in a structurally homogenous group of patients with painful temporomandibular joints (TMJ), who had undergone an identical intervention, arthroscopy. Twenty-six consecutive patients who had previously undergone unsuccessful conservative treatment participated. They were evaluated with the Craniomandibular Index (CMI), pain-related measures on visual analogue scales (VASs) for 1 wk, questionnaires, and the Multidimensional Pain Inventory (MPI). The mean CMI decreased significantly, from 0.28 to 0.18, 3 months after surgery. Pain measures also decreased significantly as rated on questionnaires, and "at worst" and "most of the time" on VASs. Intrapsychic variables related to pain also decreased significantly, while interpersonal and activity measures remained unchanged. An overall MPI dysfunctional variable correlated significantly with pain. Few further changes were observed at 12 months. Lysis and lavage of the upper TMJ compartment appears to effectively alleviate persisting functional and pain-related symptoms with low morbidity, in line with previous findings. Recoveries seem to be accompanied by changes in certain pain-related cognitive-behavioral variables within a limited sphere. Biological and intrapsychic features may interact with interpersonal factors in a complicated way in patients with orofacial pain.

Coping with fibromyalgia. A qualitative study.

This study aims to describe, from the perspective of patients with fibromyalgia themselves, their experiences of having to live with chronic pain and how they manage their situation. The sample consists of 22 female patients (22-60 years). Open-ended in-depth interviews were analysed by a method directed by the tradition of Grounded Theory. Three descriptive categories were grounded in the data, labelled subjective pain language, diversified pain coping, and pain communication. These descriptive categories formed the higher-order, or core, concept preoccupied with pain. Having to live with chronic pain seems to include that the sufferer becomes self-centred and preoccupied with the pain: the pain is mostly present and affects every aspect of life, leading to a continuous awareness of and coping with the pain. Pain tends to interrupt normal life, demands attention and is difficult to disengage from. Although coping should not be evaluated in terms of good and bad, passivity, escape behaviours, and resignation/catastrophizing, which dominated in the present study sample, might affect social and psychological functioning negatively. Patients with fibromyalgia might benefit from psychological support in coping with their pain and from reinforcement of healthy behaviours.

The predictive value of psychometric analysis in patients treated by extirpation of lumbar intervertebral disc herniation.

The authors studied the predictive value of a psychometric evaluation of 50 patients (14 women, 36 men) with a mean age of 40 years who were treated by extirpation of a lumbar disc herniation. Patient satisfaction was evaluated by an unbiased observer. The Beck Depression Inventory (BDI), the State-Trait Anxiety Inventory (STAI), and a Pain Visual Analogue Scale (PVAS) were used to assess pain and psychological distress before surgery and 3 and 12 months after surgery. Two years after surgery, 37 patients were contented with the surgical outcome and 10 patients were not. Three patients did not return the questionnaire. Before surgery, the patients who later became discontented were more depressed, more anxious, and experienced more pain. In a discriminant analysis, a combination of BDI, STAI, and PVAS scores correctly classified 78% of the discontented and 76% of the contented patients. The study shows psychometric analysis is a valuable tool for predicting the outcome of surgical treatment for lumbar disc herniation.

Psychosocial vulnerability and maintaining forces related to fibromyalgia. In-depth interviews with twenty-two female patients.

The aim of this qualitative study was to describe, from the perspective of 22 women (aged 22-60 years) with fibromyalgia, their experiences and beliefs of the pain and its origin and how the pain affects family and social life. Open-ended interviews were analysed via a method influenced by grounded theory. Seven descriptive categories were grounded in the data, forming two higher-order concepts: psychosocial vulnerability and maintaining forces. The first of these core concepts, psychosocial vulnerability, comprises the categories: traumatic life history, over-compensatory perseverance, pessimistic life view, and unsatisfying work situation. In the interviews, there are abundant examples of early loss, high degree of responsibility early in life, and social problems with feelings of helplessness and hoplessness later in life. The second core concept, maintaining forces, consists of the categories professional care, pain benefits and family support, which seem to contribute to the persistence of pain. Our results indicate intrapsychic and psychosocial dimensions, which support the hypothesis that individuals with insecure attachment styles are overrepresented among patients with chronic pain.

Relations between self-rated musculoskeletal symptoms and signs and psychological distress in chronic neck and shoulder pain.

The purposes of the present study were to describe physical and psychological characteristics of 55 chronic pain patients with predominantly nociceptive neck and shoulder complaints, and to explore relationships between physical assessment methods, self-reported pain and psychological distress. The physical measures included cervical and shoulder mobility and muscle tenderness. The Pain Severity and Interference subscales from the Multidimensional Pain Inventory (MPI), Becks Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI-Y), and a pain drawing assessed self-reports of pain and psychological distress. The number of tender points (TP score) correlated significantly with pain severity, (p < 0.01) Interference (p < 0.05), pain drawing score (p < 0.05), BDI (p < 0.05) and state anxiety (p < 0.05). No significant correlation was seen between TP score and age, pain duration or trait anxiety. The results suggest that there are relationships between observers' ratings of muscle tenderness (TP score) and self-reports of pain severity, interference of pain and psychological distress in patients with chronic cervico-brachial pain.

Cognitive-behavioral profiles among different categories of orofacial pain patients: diagnostic and treatment implications.

Psychological homogeneity in temporomandibular disorders (TMD) is not conclusive. The multidimensional pain inventory (MPI) has previously identified 3 cognitive-behavioral profiles in TMD and chronic pain patients. Our aims were to replicate these findings in another cultural setting and relate the profiles to the diagnosis and to the treatment demand and outcome. The MPI was administered to 112 referrals comprising 6 categories of patients diagnosed with TMD or intractable orofacial pain. Dysfunctional profiles (high in pain and distress) were most common in patients with orofacial pain of obscure origin and more common in myofascial pain patients than in patients with other TMD diagnoses. Interpersonally-distressed profiles were found in all categories. Among patients with disk displacement, the 3rd profile (adaptive copers with low pain and distress and high control and activity) was most common in earlier successfully diskectomized patients and least common in those about to undergo invasive interventions. A dysfunctional profile was associated with treatment failure, conservative or surgical, and with the demand for radical therapy. Some support for a cyclical causality between pain and psychological factors was found. It is concluded that the robustness of the MPI as a relevant assessment instrument was further strengthened.

Assessment of patients with phobic dental anxiety.

This study investigated a screening procedure for psychologic distress in adult patients with dental phobia before treatment of dental fear. The screening procedure was performed among 191 individuals in consecutive steps and included a medical/dental history, psychologic interviewing, and testing. Data collected during this process were analyzed and compared with SCL-90(R) data. The screening process was successful in selecting individuals without major psychologic distress problems. Among the excluded patients 91% had general symptoms scores on the SCL-90(R) exceeding a normative population mean, and 95% of included patients had a mean lower than an average for psychiatric outpatients. There were statistically significant differences between included and excluded patients on all subdimensions of the SCL-90. Thus, excluded patients had higher levels of psychologic distress, poorer psychosocial background, and more psychosomatic symptoms. This was accompanied by higher levels of negative attitudes toward dentists and their performance of dentistry, whereas no significant differences were found among the dental fear measures used.

Assessment of patients with direct conditioned and indirect cognitive reported origin of dental fear.

This study investigated the reported conditioned or cognitive origin of dental phobia in 100 adult patients at a specialized dental phobia clinic. It was shown that a majority of patients reported a conditioned background to their dental fear. Patients' avoidance time and level of dental anxiety corresponded to previously reported data for fearful groups. Individuals with an arousal conditioning etiology of dental fear reported significantly longer avoidance time as compared to individuals with a cognitively learned reaction. With the exception of an elevated level of general fears, most psychometrically assessed emotional reactions were well within normal ranges. However, patients with a non-conditioned, cognitive etiology reported significantly higher levels of trait anxiety and fear of embarrassment. In addition, a separate analysis among women revealed a greater fear of physical injuries among patients with cognitive etiology.

Busy with pain: disorganization in subjective time in experimental pain.

The cold pressor test was used to investigate perception of time and change of mood in subjects experiencing pain. Using a within-group design, 15 subjects were tested in a pain vs no-pain condition. Subjects were requested to fill in the mood adjective checklist (MACL) concerning the mood factors of activity, calmness and pleasantness, and were interviewed about their perceptions before and immediately after each condition. The results indicated that subjects in the pain condition estimated retrospective time passage as significantly shorter, indicating a disorganization of temporal orientation (the relative dominance of past, present and future in a person's thought). In addition, results indicated that many of the subjects in the pain condition, although underestimating time, experienced time as long-lasting. The main finding concerning mood was that the activity level was increased, and calmness and pleasantness were significantly reduced in the pain condition. The main conclusion is that pain per se changes the perception of duration of time intervals and temporal orientation within the same individual.

Repeated measurements of mood during psychologic treatment of dental fear.

The aims of the present study were to analyze mood changes during psychologic treatment of dental fear by assessing the rate of improvement. Twenty-one patients who refused conventional dental treatment and reported extreme dental anxiety participated in the study. Levels of dental anxiety and mood were measured with the Dental Anxiety Scale (DAS) and a Mood Adjective Checklist (MACL). MACL included two dimensions, degree of relaxation (r) and pleasantness (h) as experienced in a dental situation. Mood was monitored at each treatment session from base line to termination of the therapy (eight measurements). Two different treatment modalities were used, one with a more cognitive approach (n = 9) and one emphasizing the relaxation component (n = 12). A hierarchical linear models approach was applied to analyze individual change with repeated measurements. The results showed that positive mood changes over time were statistically significant. The mean improvement in mood scores per week and session was estimated for MACL(r) and MACL(h) to be 0.14/week and 0.09/week, respectively. The growth was not affected by DAS levels or treatment mode. This study also illustrated a powerful method for analyzing a longitudinal clinical trial design with repeated measurements.

Effects of repeated sensory stimulation sessions (electro-acupuncture) on skin temperature in chronic pain patients.

Changes in skin temperature and haemodynamics were studied during experimentally administered electro-acupuncture before and after a 4-week period of electro-acupuncture (EA) treatments. Subjective pain intensity was evaluated using a pain questionnaire. Twelve patients with long-lasting nociceptive pain were included. Before clinical treatment, skin temperature tended to decrease after 30 minutes' stimulation. In contrast, a significant increase was seen after the clinical treatment. No significant changes were seen for blood pressure, heart rate or pain intensity before and after the clinical treatment. The data indicate that an increased skin vasoconstrictor sympathetic activity may be responsible for the decreased skin temperature during the electro-acupuncture in the initial test sessions, whereas an inhibition of skin sympathetic activity and/or a release of vasodilatory substances may be responsible for the increase in temperature after completed clinical treatment. Despite a small number of subjects and correction for multiple inference, the difference in temperature effects before and up to 3 months after acupuncture treatment was significant.