This document summarizes a study examining the relationships between pain, catastrophizing, pain behaviors, and their influence on patient-provider interactions. The study found that a patient's level of catastrophizing when entering a medical exam predicted the dynamics between the patient and provider during the exam and the patient's satisfaction afterwards. Patients with higher catastrophizing may express their pain perceptions through exaggerated pain behaviors, which can influence provider attitudes and behavior. Identifying factors that improve patient-provider communication may help advance chronic pain treatment and reduce associated costs.
Association of an Educational Program in Mindful Communication With Burnout, ...DAVID MALAM
This document summarizes a study that evaluated the effectiveness of an educational program in mindful communication for primary care physicians. The program included mindfulness meditation, narrative exercises, and appreciative inquiry techniques. It was associated with short-term and sustained improvements in physician well-being, burnout, empathy, mood, and personality factors related to patient-centered care. However, the before-and-after study design limits conclusions about the causal effects of the intervention. Randomized trials with larger and more diverse groups of physicians are needed to validate these preliminary findings.
The document discusses the goals and methods of counseling and psychotherapy. The main goals are to help clients adjust to change by resolving trauma, reconciling emotions, and challenging long-standing beliefs. Therapists do this by exploring the purpose and meaning of clients' problems, behaviors, and symptoms within relational contexts. They also continuously evaluate and refine treatment goals and plans to introduce new perspectives that disrupt rigid patterns and beliefs. The overall aim is to facilitate genuine human encounters that allow for personal and relational growth for both clients and therapists.
The document discusses the doctor-patient relationship and effective communication. Some key points include:
1. Establishing rapport and trust between the doctor and patient is essential to facilitate a therapeutic relationship and understanding. The biopsychosocial model also recognizes the influence of psychological, social, and cultural factors on a patient's health.
2. Effective communication involves both verbal and non-verbal elements like active listening, eye contact, and body language. It aims to understand the patient's perspective and provide information to involve them in treatment decisions.
3. Breaking bad news to a patient requires planning, honesty, empathy, and allowing time for questions. The patient's emotional response should be acknowledged and hope provided wherever possible
Indiana University Health University Hospital Palliative Care ServicesMike Aref
Introduction
In the past three years, Indiana University Health (IUH) University Hospital Palliative Care Services has expanded its size and scope. Our mission remains to treat the suffering of patients with chronic, progressive illnesses, their families, and their providers through symptom optimization and the search for meaning. While continuing to work with patients near the end-of-life and transitioning to hospice we have increasingly been involved with complex patients whose deaths are not imminent or even expected.
Our Team
The team has transitioned from a part-time to a full-time physician, a new full-time nurse practitioner, a new position in a nurse clinical coordinator, increased time for out part-time social worker, and continued part-time chaplain.
New Opportunities for Palliative Care
IUH University Hospital sees some of the sickest of the sick including advanced liver failure, advanced pulmonary disease, and transplant patients. Our service has become involved in alleviating suffering in pancreatic, liver, renal, and multivisceral transplant patients. Our expertise in opiates has placed us in a unique position to assist with patients having pain due to opioid-hyperalgesia and narcotic bowel syndrome. In addition we have started seeing more hepatology, oncology, hematology, and pulmonary patients earlier in their disease.
Out-Patient Services
We have expanded our service to now include out-patient, currently by embedding within other clinics at University Hospital including seeing patient in the multidisciplinary oncology clinic, hematology, digestive and liver disease clinic, and surgical out-patient clinic. In the near future we hope to have dedicated clinic space within the geriatrics clinic.
This document summarizes a study that examined the effects of distance healing as an adjunct treatment for patients with major depression. 40 patients receiving standard antidepressant medication and psychotherapy were randomly assigned to either receive daily distance healing for 6 weeks from trained healers (experimental group), or to only receive standard treatment (control group). Outcome measures including depression scores, general psychopathology, and functioning were assessed weekly for 6 weeks and biweekly for 6 more weeks. Results showed a nonsignificant trend for the experimental group to show greater improvement, and favorable outcomes in the experimental group were correlated with number of healing sessions and healers' ratings of session strength.
This document discusses caring for patients harmed by medical treatment. It notes that patients suffer physically and psychologically from their injuries as well as from poor handling of incidents. Injured patients need open disclosure, explanations, apologies and assurances to prevent future harm. However, disclosing errors is challenging for medical professionals due to fears of litigation and damage to reputation. The document recommends strategies like acknowledging the frequency of errors, providing peer and psychological support to staff, and training in disclosure and communication to help all parties cope after adverse events.
The document discusses therapeutic communication and the therapeutic nurse-patient relationship. It defines therapeutic communication as an interpersonal interaction between the nurse and patient that focuses on meeting the patient's specific needs. The principles of therapeutic communication include maintaining focus on the patient, using self-disclosure appropriately, and avoiding social relationships with patients. Effective therapeutic communication techniques include listening, clarification, reflection, and informing. The phases of developing a therapeutic relationship are the pre-interaction, orientation, working, and termination phases. Maintaining proper boundaries and addressing resistance, transference, and countertransference are important for overcoming therapeutic impasses.
This study investigated whether counselor familiarity with Twelve-Step Programs (TSPs) and time spent discussing TSPs during treatment sessions impacts counselor credibility from the client's perspective. The study found that:
1) Estimated percentage of in-session time spent discussing TSPs had a significant positive effect on counselor credibility.
2) Counselor familiarity with TSPs had a significant positive effect on credibility, especially for counselors in recovery themselves.
3) Counselor credibility is important for the therapeutic relationship and treatment outcomes, so these results suggest discussing TSPs can positively influence relationships between clients and counselors.
Association of an Educational Program in Mindful Communication With Burnout, ...DAVID MALAM
This document summarizes a study that evaluated the effectiveness of an educational program in mindful communication for primary care physicians. The program included mindfulness meditation, narrative exercises, and appreciative inquiry techniques. It was associated with short-term and sustained improvements in physician well-being, burnout, empathy, mood, and personality factors related to patient-centered care. However, the before-and-after study design limits conclusions about the causal effects of the intervention. Randomized trials with larger and more diverse groups of physicians are needed to validate these preliminary findings.
The document discusses the goals and methods of counseling and psychotherapy. The main goals are to help clients adjust to change by resolving trauma, reconciling emotions, and challenging long-standing beliefs. Therapists do this by exploring the purpose and meaning of clients' problems, behaviors, and symptoms within relational contexts. They also continuously evaluate and refine treatment goals and plans to introduce new perspectives that disrupt rigid patterns and beliefs. The overall aim is to facilitate genuine human encounters that allow for personal and relational growth for both clients and therapists.
The document discusses the doctor-patient relationship and effective communication. Some key points include:
1. Establishing rapport and trust between the doctor and patient is essential to facilitate a therapeutic relationship and understanding. The biopsychosocial model also recognizes the influence of psychological, social, and cultural factors on a patient's health.
2. Effective communication involves both verbal and non-verbal elements like active listening, eye contact, and body language. It aims to understand the patient's perspective and provide information to involve them in treatment decisions.
3. Breaking bad news to a patient requires planning, honesty, empathy, and allowing time for questions. The patient's emotional response should be acknowledged and hope provided wherever possible
Indiana University Health University Hospital Palliative Care ServicesMike Aref
Introduction
In the past three years, Indiana University Health (IUH) University Hospital Palliative Care Services has expanded its size and scope. Our mission remains to treat the suffering of patients with chronic, progressive illnesses, their families, and their providers through symptom optimization and the search for meaning. While continuing to work with patients near the end-of-life and transitioning to hospice we have increasingly been involved with complex patients whose deaths are not imminent or even expected.
Our Team
The team has transitioned from a part-time to a full-time physician, a new full-time nurse practitioner, a new position in a nurse clinical coordinator, increased time for out part-time social worker, and continued part-time chaplain.
New Opportunities for Palliative Care
IUH University Hospital sees some of the sickest of the sick including advanced liver failure, advanced pulmonary disease, and transplant patients. Our service has become involved in alleviating suffering in pancreatic, liver, renal, and multivisceral transplant patients. Our expertise in opiates has placed us in a unique position to assist with patients having pain due to opioid-hyperalgesia and narcotic bowel syndrome. In addition we have started seeing more hepatology, oncology, hematology, and pulmonary patients earlier in their disease.
Out-Patient Services
We have expanded our service to now include out-patient, currently by embedding within other clinics at University Hospital including seeing patient in the multidisciplinary oncology clinic, hematology, digestive and liver disease clinic, and surgical out-patient clinic. In the near future we hope to have dedicated clinic space within the geriatrics clinic.
This document summarizes a study that examined the effects of distance healing as an adjunct treatment for patients with major depression. 40 patients receiving standard antidepressant medication and psychotherapy were randomly assigned to either receive daily distance healing for 6 weeks from trained healers (experimental group), or to only receive standard treatment (control group). Outcome measures including depression scores, general psychopathology, and functioning were assessed weekly for 6 weeks and biweekly for 6 more weeks. Results showed a nonsignificant trend for the experimental group to show greater improvement, and favorable outcomes in the experimental group were correlated with number of healing sessions and healers' ratings of session strength.
This document discusses caring for patients harmed by medical treatment. It notes that patients suffer physically and psychologically from their injuries as well as from poor handling of incidents. Injured patients need open disclosure, explanations, apologies and assurances to prevent future harm. However, disclosing errors is challenging for medical professionals due to fears of litigation and damage to reputation. The document recommends strategies like acknowledging the frequency of errors, providing peer and psychological support to staff, and training in disclosure and communication to help all parties cope after adverse events.
The document discusses therapeutic communication and the therapeutic nurse-patient relationship. It defines therapeutic communication as an interpersonal interaction between the nurse and patient that focuses on meeting the patient's specific needs. The principles of therapeutic communication include maintaining focus on the patient, using self-disclosure appropriately, and avoiding social relationships with patients. Effective therapeutic communication techniques include listening, clarification, reflection, and informing. The phases of developing a therapeutic relationship are the pre-interaction, orientation, working, and termination phases. Maintaining proper boundaries and addressing resistance, transference, and countertransference are important for overcoming therapeutic impasses.
This study investigated whether counselor familiarity with Twelve-Step Programs (TSPs) and time spent discussing TSPs during treatment sessions impacts counselor credibility from the client's perspective. The study found that:
1) Estimated percentage of in-session time spent discussing TSPs had a significant positive effect on counselor credibility.
2) Counselor familiarity with TSPs had a significant positive effect on credibility, especially for counselors in recovery themselves.
3) Counselor credibility is important for the therapeutic relationship and treatment outcomes, so these results suggest discussing TSPs can positively influence relationships between clients and counselors.
Study and survey results indicate that digital can best be deployed by healthcare and life sciences/pharmaceuticals practitioners and companies to offer "warm" treatment that encourages and empowers patients in order to yield excellent health outcomes and operational efficiencies.
The document introduces a new measure called the Expectation and Preference Scales for Couple Therapy (EPSCT) which was developed to assess clients' expectations and preferences for couple therapy. It describes the development of the measure including creating items based on literature and expert feedback, and conducting four studies to evaluate the measure's psychometric properties. The key findings were that clients generally had positive outcome expectations but stronger role expectations for themselves than their partners. Clients also showed differentiated preferences for interventions from cognitive-behavioral, emotionally-focused, and family systems approaches. Expectations and preferences sometimes differed based on client characteristics and therapy experience. The authors discuss using the EPSCT in clinical practice and future research.
Vancouver Coastal Health Family Therapist, Rosalind Irving, outlines a CREST.BD pilot study which will explore new ways of working with people with BD through recovery-oriented care that incorporates patient narratives and storytelling.
Presented during a CREST.BD Public Engagement Event on February 23rd 2011 at UBC Robson Square.
Bronchial Asthma in Acute Exacerbation, Diabetes Mellitus-Type II, Hyperchole...Jack Frost
Bronchial Asthma in Acute Exacerbation, Diabetes Mellitus-Type II, Hypercholesterolemia , MANAGEMENT AND TREATMENT. This presentation contains real names of persons involve of this particular study. This names should not be copied or rewritten. Used the data of this study as basis only. All rights reserved 2009.
This study aims to examine the effects of a cognitive restructuring intervention and acceptance intervention on pain catastrophizing, perceived pain, and pain tolerance in female university students. Participants will be assigned to one of three conditions: cognitive restructuring, acceptance, or a control. Pain tolerance and perception will be measured before and after each intervention using cold pressor tasks and questionnaires. The researchers hypothesize that high catastrophizers will report more pain and lower tolerance than low catastrophizers, and that the cognitive restructuring and acceptance interventions will reduce pain levels and increase tolerance over the control condition.
The document discusses strategies for improving patient-centered care. It focuses on ensuring patients feel oriented, informed, and involved in their care. This includes introducing all medical staff, explaining plans in plain language, checking for understanding, keeping patients updated on delays, allowing them to explain concerns, and setting clear expectations for next steps. The goal is for patients to understand their care and feel their needs, preferences, and questions are being addressed.
Music Therapy in Consultation-Liaison PsychiatryJoana Novo
This document discusses the use of music therapy in consultation-liaison psychiatry at Hahnemann University Hospital. It describes how music therapy has been integrated into the consultation-liaison psychiatry service to provide intervention for medical and surgical patients with mental health issues. The music therapist plays an integral role in the consultation-liaison service by providing input during patient discussions and treatment planning. Music therapy sessions generally involve the use of various instruments and engaging patients in music experiences like improvisation, singing, and songwriting to support psychotherapy and facilitate expression of feelings. Examples provided illustrate how music therapy can help change patients' moods and increase involvement and coping during hospitalization.
Nursing diagnosis involves making a clinical judgment about a patient's health issues and developing a care plan accordingly. It has three main parts - the problem, likely cause, and defining characteristics. Common types of nursing diagnoses include actual, risk, and wellness diagnoses. Accurate nursing diagnoses are important for effective patient care, developing nursing autonomy, and ensuring accountability. However, errors can occur if the nurse lacks knowledge, misinterprets data, or chooses the wrong diagnostic label. To improve, nurses should seek guidance when unsure and state diagnoses specifically to guide interventions.
This document is a 12,610 word research dissertation that examines the welfare of adult caregivers in domiciliary (home care) and residential services. It explores how caregiver susceptibility to anxiety and depressive symptomology compares between these populations and a non-caregiver control group. Additionally, it examines the extent to which psychological factors like locus of control, empathy, perceived organizational support, and self-esteem can predict anxiety and depression levels in caregivers. Through a cross-sectional questionnaire study comparing 51 domiciliary, 85 residential caregivers, and 67 non-caregivers, the dissertation aims to better understand the impact of poor organizational support practices on caregiver well-being.
The document discusses barriers to effective therapeutic relationships between community mental health practitioners and those with borderline personality disorder (BPD). It notes that BPD is often associated with negativity due to behaviors being misinterpreted and difficulties forming relationships. While therapeutic relationships are important for treatment, they can be challenging to achieve with BPD patients. The document examines the theory behind therapeutic relationships and potential barriers such as stigma, the nature of BPD symptoms, and feelings of practitioners. It recommends education and training for practitioners, reflection, and focusing on the individual beyond their diagnosis to strengthen empathetic and collaborative care.
The document discusses developing a therapeutic relationship between a nurse and client. It outlines the goals of such a relationship as helping the client develop social and coping skills, reduce anxiety, and take risks. Key characteristics for the nurse include empathy, warmth, genuineness, respect, concreteness, immediacy, and self-disclosure. The relationship progresses through phases including pre-interaction, orientation, working, and termination phases. During the working phase, the nurse helps the client gain insight, link thoughts and actions, set goals, and test new behaviors.
This document discusses compassion fatigue and burnout in nursing. It first defines compassion fatigue and burnout as occupational illnesses affecting nurses' health and leading to poorer patient outcomes and higher turnover. Several factors are identified as contributing to compassion fatigue and burnout, including lack of administrative support, ethical dilemmas, poor communication, and high patient ratios. The document then summarizes several research articles on compassion fatigue and burnout in more detail. It finds that personality traits, lack of support, stressful work environments, and constant exposure to patient suffering can increase risks of developing compassion fatigue or burnout. Early identification of risks and interventions are important to prevent nurses from leaving the profession.
The document discusses therapeutic communities and milieu therapy. It defines a therapeutic community as using a patient's social environment to provide therapeutic experiences and enable them to participate actively in their own care. Key aspects of therapeutic communities include daily community meetings, a patient government, and staff meetings. The document also defines milieu therapy and therapeutic milieu, noting they refer to using a patient's entire environment and interactions to facilitate treatment.
This document discusses therapeutic impasses in the nurse-patient relationship. It defines therapeutic impasses as blocks in the progress of the relationship that provoke intense feelings in both nurse and patient. It identifies several types of impasses that can occur, including resistance, transference, countertransference, boundary issues, and dual relationships. It also discusses impasses that can arise in different phases of the relationship, such as pre-interaction, orientation, working, and termination phases. Strategies are provided for overcoming each type of impasse, such as active listening, clarification, exploration, maintaining open communication, peer consultation, and involving supervisors.
Nurse-patient relationship is a supportive interaction that moves a patient toward wellness. It's based on trust, respect, interest, and empathy. Learn how to use these components to move patients through each phase of the relationship.
Introduction to clinical communication skills.pptx 2011Reina Ramesh
This document introduces clinical communication skills and their importance. It discusses how effective communication involves understanding the patient's perspective, sharing information with empathy and respect. Good doctors depend not only on medical knowledge but how they communicate with patients. The objectives are to explore what makes a good doctor and the importance of the medical interview from both the doctor and patient perspectives. Key aspects of a good doctor-patient relationship are establishing rapport, demonstrating interest and respect, and good communication skills like active listening and using appropriate language. The medical interview aims to obtain a factual account of the patient's illness and their perspective to help develop a management plan.
Incident opioid abuse and dependence sullivan 2014Paul Coelho, MD
This study investigated the association between prescription opioid exposure and risk of opioid use disorder (OUD) among individuals with chronic noncancer pain (CNCP). The study used claims data from 2000-2005 for over 500,000 individuals with a new CNCP diagnosis and no recent opioid use or OUD. The results showed significantly higher rates of OUD among those prescribed opioids compared to those not prescribed opioids. Risk increased with longer duration of therapy and higher daily doses. Chronic opioid therapy, even at low doses, was associated with substantially increased risk of OUD compared to acute therapy or no opioids. Duration of opioid therapy was more important than daily dose in determining OUD risk.
La Navidad es una festividad cristiana que celebra el nacimiento de Jesucristo. Se celebra el 25 de diciembre y es una ocasión para reunirse con la familia y los amigos, intercambiar regalos y mostrar afecto.
La Navidad es una festividad cristiana que celebra el nacimiento de Jesucristo. Se celebra el 25 de diciembre y es una ocasión para reunirse con la familia y los amigos, intercambiar regalos y disfrutar de la comida y las decoraciones.
Study and survey results indicate that digital can best be deployed by healthcare and life sciences/pharmaceuticals practitioners and companies to offer "warm" treatment that encourages and empowers patients in order to yield excellent health outcomes and operational efficiencies.
The document introduces a new measure called the Expectation and Preference Scales for Couple Therapy (EPSCT) which was developed to assess clients' expectations and preferences for couple therapy. It describes the development of the measure including creating items based on literature and expert feedback, and conducting four studies to evaluate the measure's psychometric properties. The key findings were that clients generally had positive outcome expectations but stronger role expectations for themselves than their partners. Clients also showed differentiated preferences for interventions from cognitive-behavioral, emotionally-focused, and family systems approaches. Expectations and preferences sometimes differed based on client characteristics and therapy experience. The authors discuss using the EPSCT in clinical practice and future research.
Vancouver Coastal Health Family Therapist, Rosalind Irving, outlines a CREST.BD pilot study which will explore new ways of working with people with BD through recovery-oriented care that incorporates patient narratives and storytelling.
Presented during a CREST.BD Public Engagement Event on February 23rd 2011 at UBC Robson Square.
Bronchial Asthma in Acute Exacerbation, Diabetes Mellitus-Type II, Hyperchole...Jack Frost
Bronchial Asthma in Acute Exacerbation, Diabetes Mellitus-Type II, Hypercholesterolemia , MANAGEMENT AND TREATMENT. This presentation contains real names of persons involve of this particular study. This names should not be copied or rewritten. Used the data of this study as basis only. All rights reserved 2009.
This study aims to examine the effects of a cognitive restructuring intervention and acceptance intervention on pain catastrophizing, perceived pain, and pain tolerance in female university students. Participants will be assigned to one of three conditions: cognitive restructuring, acceptance, or a control. Pain tolerance and perception will be measured before and after each intervention using cold pressor tasks and questionnaires. The researchers hypothesize that high catastrophizers will report more pain and lower tolerance than low catastrophizers, and that the cognitive restructuring and acceptance interventions will reduce pain levels and increase tolerance over the control condition.
The document discusses strategies for improving patient-centered care. It focuses on ensuring patients feel oriented, informed, and involved in their care. This includes introducing all medical staff, explaining plans in plain language, checking for understanding, keeping patients updated on delays, allowing them to explain concerns, and setting clear expectations for next steps. The goal is for patients to understand their care and feel their needs, preferences, and questions are being addressed.
Music Therapy in Consultation-Liaison PsychiatryJoana Novo
This document discusses the use of music therapy in consultation-liaison psychiatry at Hahnemann University Hospital. It describes how music therapy has been integrated into the consultation-liaison psychiatry service to provide intervention for medical and surgical patients with mental health issues. The music therapist plays an integral role in the consultation-liaison service by providing input during patient discussions and treatment planning. Music therapy sessions generally involve the use of various instruments and engaging patients in music experiences like improvisation, singing, and songwriting to support psychotherapy and facilitate expression of feelings. Examples provided illustrate how music therapy can help change patients' moods and increase involvement and coping during hospitalization.
Nursing diagnosis involves making a clinical judgment about a patient's health issues and developing a care plan accordingly. It has three main parts - the problem, likely cause, and defining characteristics. Common types of nursing diagnoses include actual, risk, and wellness diagnoses. Accurate nursing diagnoses are important for effective patient care, developing nursing autonomy, and ensuring accountability. However, errors can occur if the nurse lacks knowledge, misinterprets data, or chooses the wrong diagnostic label. To improve, nurses should seek guidance when unsure and state diagnoses specifically to guide interventions.
This document is a 12,610 word research dissertation that examines the welfare of adult caregivers in domiciliary (home care) and residential services. It explores how caregiver susceptibility to anxiety and depressive symptomology compares between these populations and a non-caregiver control group. Additionally, it examines the extent to which psychological factors like locus of control, empathy, perceived organizational support, and self-esteem can predict anxiety and depression levels in caregivers. Through a cross-sectional questionnaire study comparing 51 domiciliary, 85 residential caregivers, and 67 non-caregivers, the dissertation aims to better understand the impact of poor organizational support practices on caregiver well-being.
The document discusses barriers to effective therapeutic relationships between community mental health practitioners and those with borderline personality disorder (BPD). It notes that BPD is often associated with negativity due to behaviors being misinterpreted and difficulties forming relationships. While therapeutic relationships are important for treatment, they can be challenging to achieve with BPD patients. The document examines the theory behind therapeutic relationships and potential barriers such as stigma, the nature of BPD symptoms, and feelings of practitioners. It recommends education and training for practitioners, reflection, and focusing on the individual beyond their diagnosis to strengthen empathetic and collaborative care.
The document discusses developing a therapeutic relationship between a nurse and client. It outlines the goals of such a relationship as helping the client develop social and coping skills, reduce anxiety, and take risks. Key characteristics for the nurse include empathy, warmth, genuineness, respect, concreteness, immediacy, and self-disclosure. The relationship progresses through phases including pre-interaction, orientation, working, and termination phases. During the working phase, the nurse helps the client gain insight, link thoughts and actions, set goals, and test new behaviors.
This document discusses compassion fatigue and burnout in nursing. It first defines compassion fatigue and burnout as occupational illnesses affecting nurses' health and leading to poorer patient outcomes and higher turnover. Several factors are identified as contributing to compassion fatigue and burnout, including lack of administrative support, ethical dilemmas, poor communication, and high patient ratios. The document then summarizes several research articles on compassion fatigue and burnout in more detail. It finds that personality traits, lack of support, stressful work environments, and constant exposure to patient suffering can increase risks of developing compassion fatigue or burnout. Early identification of risks and interventions are important to prevent nurses from leaving the profession.
The document discusses therapeutic communities and milieu therapy. It defines a therapeutic community as using a patient's social environment to provide therapeutic experiences and enable them to participate actively in their own care. Key aspects of therapeutic communities include daily community meetings, a patient government, and staff meetings. The document also defines milieu therapy and therapeutic milieu, noting they refer to using a patient's entire environment and interactions to facilitate treatment.
This document discusses therapeutic impasses in the nurse-patient relationship. It defines therapeutic impasses as blocks in the progress of the relationship that provoke intense feelings in both nurse and patient. It identifies several types of impasses that can occur, including resistance, transference, countertransference, boundary issues, and dual relationships. It also discusses impasses that can arise in different phases of the relationship, such as pre-interaction, orientation, working, and termination phases. Strategies are provided for overcoming each type of impasse, such as active listening, clarification, exploration, maintaining open communication, peer consultation, and involving supervisors.
Nurse-patient relationship is a supportive interaction that moves a patient toward wellness. It's based on trust, respect, interest, and empathy. Learn how to use these components to move patients through each phase of the relationship.
Introduction to clinical communication skills.pptx 2011Reina Ramesh
This document introduces clinical communication skills and their importance. It discusses how effective communication involves understanding the patient's perspective, sharing information with empathy and respect. Good doctors depend not only on medical knowledge but how they communicate with patients. The objectives are to explore what makes a good doctor and the importance of the medical interview from both the doctor and patient perspectives. Key aspects of a good doctor-patient relationship are establishing rapport, demonstrating interest and respect, and good communication skills like active listening and using appropriate language. The medical interview aims to obtain a factual account of the patient's illness and their perspective to help develop a management plan.
Incident opioid abuse and dependence sullivan 2014Paul Coelho, MD
This study investigated the association between prescription opioid exposure and risk of opioid use disorder (OUD) among individuals with chronic noncancer pain (CNCP). The study used claims data from 2000-2005 for over 500,000 individuals with a new CNCP diagnosis and no recent opioid use or OUD. The results showed significantly higher rates of OUD among those prescribed opioids compared to those not prescribed opioids. Risk increased with longer duration of therapy and higher daily doses. Chronic opioid therapy, even at low doses, was associated with substantially increased risk of OUD compared to acute therapy or no opioids. Duration of opioid therapy was more important than daily dose in determining OUD risk.
La Navidad es una festividad cristiana que celebra el nacimiento de Jesucristo. Se celebra el 25 de diciembre y es una ocasión para reunirse con la familia y los amigos, intercambiar regalos y mostrar afecto.
La Navidad es una festividad cristiana que celebra el nacimiento de Jesucristo. Se celebra el 25 de diciembre y es una ocasión para reunirse con la familia y los amigos, intercambiar regalos y disfrutar de la comida y las decoraciones.
La Navidad es una festividad cristiana que celebra el nacimiento de Jesucristo. Se celebra el 25 de diciembre y es una ocasión para reunirse con la familia y los amigos, intercambiar regalos y disfrutar de la comida y las decoraciones.
This study examined whether pain-related psychosocial factors predicted whether treatment gains were maintained following participation in a physical rehabilitation program for musculoskeletal injuries. The study assessed 310 individuals at admission to rehabilitation, discharge, and 1-year follow up. It found that individuals with high scores on measures of pain catastrophizing and fear of pain at discharge were more likely to experience a return of their pain symptoms and failure to maintain treatment gains at the 1-year follow up. The results suggest that treatment gains may not be sustained long-term if end-of-treatment scores on catastrophizing and fear of pain remain elevated.
Este documento resume que la Navidad es una de las festividades más importantes del cristianismo que conmemora el nacimiento de Jesucristo en Belén el 25 de diciembre en la mayoría de iglesias cristianas. Algunas iglesias ortodoxas lo celebran el 7 de enero debido a diferencias en el calendario. La Navidad busca celebrar el nacimiento de Jesús a través de diversas tradiciones en diferentes lenguas.
32 Ways a Digital Marketing Consultant Can Help Grow Your BusinessBarry Feldman
How can a digital marketing consultant help your business? In this resource we'll count the ways. 24 additional marketing resources are bundled for free.
The association between a history of lifetime traumatic events and pain sever...Paul Coelho, MD
This study examined the associations between a history of lifetime abuse and affective distress, fibromyalgia symptoms, pain severity, interference, and physical functioning in 3,081 chronic pain patients. The study found that those with a history of abuse had greater depression, anxiety, worse physical functioning, greater pain severity, worse pain interference, higher catastrophizing, and higher scores on the 2011 Fibromyalgia Survey criteria. Mediation models showed that fibromyalgia survey scores and affective distress independently mediated the relationship between abuse history and pain severity and physical functioning. The findings support a biopsychosocial model where affective distress and fibromyalgia symptoms interact to play roles in how abuse relates to increased pain morbidity.
Model of TreatmentEducation and its EvaluationProblem.docxhelzerpatrina
Model of Treatment/Education and its Evaluation
Problem(s)
Will Power +
Common Factors +
Any Specific Factor (any treatment model EBP or other) +
Feedback Informed Treatment + Deliberate Practice =
Effective Outcome
SPECIAL ARTICLE
How important are the common factors in
psychotherapy? An update
BRUCE E. WAMPOLD
Department of Counseling Psychology, University of Wisconsin, Madison, WI, USA; Modum Bad Psychiatric Center, Vikersund, Norway
The common factors have a long history in the field of psychotherapy theory, research and practice. To understand the evidence supporting
them as important therapeutic elements, the contextual model of psychotherapy is outlined. Then the evidence, primarily from meta-
analyses, is presented for particular common factors, including alliance, empathy, expectations, cultural adaptation, and therapist differ-
ences. Then the evidence for four factors related to specificity, including treatment differences, specific ingredients, adherence, and compe-
tence, is presented. The evidence supports the conclusion that the common factors are important for producing the benefits of psychotherapy.
Key words: Common factors, contextual model, psychotherapy, alliance, empathy, expectations, cultural adaptation, therapist differences,
specific ingredients
(World Psychiatry 2015;14:270–277)
The so-called common factors have a long history in psy-
chiatry, originating with a seminal article by S. Rosenzweig
in 1936 (1) and popularized by J. Frank in the various
editions of his book Persuasion and Healing (2-4). During
this period, the common factors have been both embraced
and dismissed, creating some tension (5-9). The purpose of
this paper is not to review or discuss the debate, but to pro-
vide an update, summarizing the evidence related to these
factors.
To understand the evidence for the common factors, it is
important to keep in mind that these factors are more than a
set of therapeutic elements that are common to all or most
psychotherapies. They collectively shape a theoretical mod-
el about the mechanisms of change in psychotherapy.
A particular common factor model, called the contextual
model, has been recently proposed (8,10). Although there
are other common factor models (e.g., 4,11), based on differ-
ent theoretical propositions, the predictions made about the
importance of various common factors are similar and the
choice of the model does not affect conclusions about the
impact of these factors. The contextual model is presented
below, followed by a review of the evidence for the common
factors imbedded in the model.
THE CONTEXTUAL MODEL
The contextual model posits that there are three path-
ways through which psychotherapy produces benefits. That
is, psychotherapy does not have a unitary influence on
patients, but rather works through various mechanisms.
The mechanisms underlying the three pathways entail
evolved characteristics of humans as the ultimate social spe-
cies; as such.
Model of TreatmentEducation and its EvaluationProblem.docxroushhsiu
This document discusses the importance of common factors in psychotherapy. It outlines the contextual model of psychotherapy, which posits that there are three pathways through which psychotherapy produces benefits: 1) the real relationship between therapist and patient, 2) the creation of expectations through providing an explanatory model of the patient's difficulties, and 3) the enactment of health-promoting actions. It then reviews evidence from meta-analyses supporting several important common factors, finding large effects for the therapeutic alliance, goal consensus/collaboration, and empathy. The evidence supports the conclusion that common factors, as conceptualized in the contextual model, are important for producing the benefits of psychotherapy.
Qual Health Res-2016-Krieger-1049732316645321Maddie Olhoeft
This document discusses distributed cognition in cancer treatment decision making. It begins by explaining how social networks influence health behaviors and decisions. It then discusses how previous research has focused on individual cognitive processes in decision making but more recently has considered distributed cognition, where schemas are shared between individuals. The document focuses on how family members provide decisional support, which is defined as reallocating decision making rights and responsibilities. It discusses four types of decision making styles based on patient autonomy and interdependence preferences. The implications for interventions to improve decision making quality are discussed.
Nursing Practice in Long Term Health Care Sample Paper.docx4934bk
The document analyzes two research articles on nursing practice in long-term health care. The first article examines fecal incontinence in nursing home patients using a new assessment tool. It found that patient comorbidities explained variations in fecal incontinence. The second article looked at the relationship between nurse attitudes about aging and their assessment of resident pain. It found that nurses with more positive attitudes toward older adults were more likely to properly assess pain. The document discusses how the findings can help guide the author's nursing practice, such as using assessment tools and addressing personal biases.
Physician-Patient Communication: A Dyadic Approach To C.C. Amd P.S.maxbury
This document proposes a study to examine the relationship between a physician's cultural competence, as perceived by patients, and patient satisfaction. It begins with an introduction discussing the importance of physician-patient communication and cultural competence in healthcare. It then reviews literature showing that patients are more satisfied when they share similarities like age, race or gender with their physician. The document proposes using a survey to collect data from 200 patients at a hospital to analyze whether a physician's cultural awareness, as perceived by patients, correlates with higher patient satisfaction. The goal is to address the research question of whether cultural competence impacts the physician-patient relationship and patient outcomes.
Interpersonal Communication Impact on Health OutcomesJack Davidson
This document summarizes and analyzes an article that examines how clinician-patient communication contributes to health outcomes. It discusses the article's exploration of indirect pathways from communication to outcomes, and introduces a model for mapping these pathways. The summary also analyzes challenges in past research and outlines conceptual and measurement issues to address.
The document discusses the importance of establishing a therapeutic relationship between health professionals like nurses and their patients. It argues that a therapeutic relationship, characterized by trust, collaboration and empowerment, is essential to achieving positive counseling outcomes. The qualities of empathy, congruence and acceptance have been shown to result in higher success rates for patients compared to those receiving less of these qualities. Examples from clinical practice demonstrate how therapeutic relationships can help patients feel supported and increase treatment effectiveness.
This document summarizes the results of moderator analyses from a large randomized controlled trial testing the effectiveness of cognitive behavioral therapy (CBT) for chronic pain from osteoarthritis. The trial compared 10 sessions of Pain Coping Skills Training (PCST), a form of CBT, delivered by nurse practitioners to a usual care control group. Several demographic and clinical variables were examined as potential moderators of treatment response. The analyses found that patients' pain coping style, expectations for treatment, disease severity, age, and education level significantly moderated outcomes, with some subgroups showing stronger responses to PCST. Sex, race, BMI, and depression did not impact treatment response. Specifically, patients with interpersonal pain coping problems did not benefit much from
This document outlines the key aspects of oncology and the role of clinical health psychologists in oncology settings. It begins with definitions of oncology and cancer. It then discusses primary prevention strategies and the relationship between social support and cancer patients' adjustment. Finally, it describes the clinical health psychologist's role in providing direct care, consultation, administration, research, and education to enhance patient care and communication within the oncology team.
Mechanisms Underlying Mindfulness-Based Addiction Treatment
versus Cognitive Behavioral Therapy and Usual Care for
Smoking Cessation
Claire Adams Spears1, Donald Hedeker2, Liang Li3, Cai Wu3, Natalie K. Anderson4, Sean C.
Houchins4, Christine Vinci5, Diana Stewart Hoover3, Jennifer Irvin Vidrine6, Paul M.
Cinciripini3, Andrew J. Waters7, and David W. Wetter8
1Georgia State University School of Public Health, Atlanta, GA
2The University of Chicago, Chicago, IL
3The University of Texas MD Anderson Cancer Center, Houston, TX
4The Catholic University of America, Washington, DC
5Rice University, Houston, TX
6Stephenson Cancer Center and The University of Oklahoma Health Sciences Center, Oklahoma
City, OK
7Uniformed Services University of the Health Sciences, Washington, DC
8University of Utah and the Huntsman Cancer Institute, Salt Lake City, UT
Abstract
Objective—To examine cognitive and affective mechanisms underlying Mindfulness-Based
Addiction Treatment (MBAT) versus Cognitive Behavioral Therapy (CBT) and Usual Care (UC)
for smoking cessation.
Method—Participants in the parent study from which data were drawn (N = 412; 54.9% female;
48.2% African-American, 41.5% non-Latino White, 5.4% Latino, 4.9% other; 57.6% annual
income < $30,000) were randomized to MBAT (n = 154), CBT (n = 155), or UC (n = 103). From
quit date through 26 weeks post-quit, participants completed measures of emotions, craving,
dependence, withdrawal, self-efficacy, and attentional bias. Biochemically-confirmed 7-day
smoking abstinence was assessed at 4 and 26 weeks post-quit. Although the parent study did not
find a significant treatment effect on abstinence, mixed-effects regression models were conducted
to examine treatment effects on hypothesized mechanisms, and indirect effects of treatments on
abstinence were tested.
Results—Participants receiving MBAT perceived greater volitional control over smoking and
evidenced lower volatility of anger than participants in both other treatments. However, there were
no other significant differences between MBAT and CBT. Compared to those receiving UC,
MBAT participants reported lower anxiety, concentration difficulties, craving, and dependence, as
Corresponding Author: Claire Adams Spears, Ph.D., Assistant Professor, Division of Health Promotion & Behavior, School of Public
Health, Georgia State University; [email protected]; Phone: 404.413.9335.
HHS Public Access
Author manuscript
J Consult Clin Psychol. Author manuscript; available in PMC 2018 November 01.
Published in final edited form as:
J Consult Clin Psychol. 2017 November ; 85(11): 1029–1040. doi:10.1037/ccp0000229.
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well as higher self-efficacy for managing negative affect without smoking. Indirect effects of
MBAT versus UC on abstinence occurred through each of these mechanisms.
Conclusions—Whereas se ...
1) The study examined the association between spousal or significant other solicitous responses and opioid dose in 466 patients with chronic pain. 2) It found that higher scores on a scale measuring solicitous responses, such as asking about pain symptoms, were associated with higher daily morphine equivalent doses. 3) This association remained even after adjusting for other factors like age, sex, depression and pain severity. The findings suggest solicitous responses may influence opioid dose among chronic pain patients.
1) The document discusses the concept of "shared mind" which refers to how new ideas and perspectives can emerge through the sharing of thoughts, feelings, and intentions between two or more people, especially in the context of making medical decisions during serious illness.
2) It uses the example of a patient named Richard Grayson who was struggling to choose between treatment options for pancreatic cancer, and describes how through discussions with his physician and partner, a decision emerged that incorporated input from all parties rather than being based solely on his preexisting preferences.
3) The document argues that autonomy is best conceptualized not just as an individual process but as one that can involve relationships and emerge through shared deliberation between patients, family, and
Effects of provider patient relationship on the rate of patient’s recovery am...Alexander Decker
This document discusses a study on the effects of provider-patient relationships on patient recovery and satisfaction rates among inpatients at Wa Regional Hospital in Ghana. The study found that patients had high levels of satisfaction with the care provided, which positively influenced their recovery rates. Satisfied patients were also more likely to comply with medical recommendations. The study aims to examine the psychological impact of provider-patient interactions on patient satisfaction. Effective communication between providers and patients is important for improving patient satisfaction and health outcomes. The theoretical framework is based on the Primary Provider Theory, which states that patient satisfaction is primarily linked to interactions with healthcare providers. Prior research also found relationships between patient satisfaction, treatment compliance, and health outcomes.
Importance of Effective CommunicationCommunication is the corner.docxcharisellington63520
Importance of Effective Communication
Communication is the cornerstone of healthcare. Effective communication is not only critical to meeting patient needs and providing safe, high-quality, and patient-centered care, it is necessary to how we manage healthcare delivery (James Merlino, 2017). It means that positive patient outcomes have effective communication between the patient and health care providers. Adverse results are likely to have ineffective communication that negatively impacts the process. It is in this regard that effective communication comes into perspective if quality service is to be realized. Understanding the patient's cultural and social construction is essential hence promoting cultural competence through effective communication. People have varying beliefs and attitudes regarding various issues at societal and personal levels (Markova & Broome, 2007), and healthcare providers cannot ignore these in a healthcare setting.
Promoting Cultural Competence
An individual's beliefs and attitudes determine how the person views illness and treatment. It means that for patient-centered care to be effectively achieved, a healthcare provider must understand the patient's cultural influences. For example, some illnesses such as mental health issues may be considered a curse, which means that medical intervention may not be seen as a viable treatment procedure. Awareness of such a belief would help a health care provider understand why a patient or family member may be hesitant to follow through with medical treatment. Nurses and physicians play a significant role in the patient-centered service. Patient concerns, attitudes, and biases could hinder the process if healthcare professionals concerned lack effective communication. Such communication dictates letting the patient understand the entire treatment process and expected outcomes.
However, effective communication between the patient and healthcare provider also requires understanding the patient's cultural, social, and family aspects. Such awareness makes the patient-centered process more effective and achievable, ultimately offering quality care with positive patient outcomes. For example, understanding the patient and family attitude towards chronic illness would help institute the best treatment strategy that brings both the patient and family on board. Traditional medicine use may thus be used alongside conventional treatment to alleviate suffering.
Globalization and subsequent immigration have resulted in people from various cultures interacting in multiple circles (Brown et al., 2016), and the healthcare setting is one of these circles. Thus, cultural competence includes language competence, hence the importance of diversity among healthcare providers to communicate with patients from different cultures effectively. A healthcare process can result in adverse outcomes when there are barriers in the communication process. For example, a patient can receive emergency treat.
Psychological correlates of acute post surgical pain.Paul Coelho, MD
This systematic review and meta-analysis examines relationships between presurgical psychological factors and acute postsurgical pain (APSP). Fifty-three studies were included. Pain catastrophizing, optimism, expectation of pain, neuroticism, anxiety, negative affect, and depression were found to be likely associated with APSP, while locus of control was unlikely associated. Meta-analyses showed pain catastrophizing had the strongest link to APSP. Patients reporting lower levels of pain catastrophizing and higher optimism/expectations tended to experience less APSP.
Collaboration between healthcare professionals is important for managing patients effectively. It increases awareness of each member's skills and improves decision making. As an AGACNP, responsibilities in outpatient settings include managing patients with life-threatening illnesses, treating symptoms, leading care discussions, and coordinating care. The role differs from inpatient settings by managing acute or chronic issues in any setting based on patient need. Christian perspectives can help meet patients' emotional, spiritual and physical needs by providing coping resources, pain management, and reducing health risks through spirituality and religiosity.
1) The study examined factors that influence oncology nurses' perceived quality of work life and risk of compassion fatigue. It explored the relationship between nurse characteristics and quality of work life, the impact of personal life stress on quality of work life, and nurses' beliefs about their risk of compassion fatigue.
2) Personal life stressors were found to impact 30% of nurses' well-being, theoretically placing them at risk for compassion fatigue. However, qualitative data did not support this and 55% of nurses described their work as life-affirming and rewarding.
3) Nurses reported multiple sources of work-related stress, including issues with communication, their work environment, and factors related to patient care. However,
Running head CONCEPT SYNTHESIS PAPER PERSONAL NURSING PHILOSOPHY.docxtodd271
Running head: CONCEPT SYNTHESIS PAPER: PERSONAL NURSING PHILOSOPHY 1
CONCEPT SYNTHESIS PAPER: PERSONAL NURSING PHILOSOPHY 10
Concept Synthesis Paper: Personal Nursing Philosophy
Yordanka Milanes
South University
Concept Synthesis Paper: Personal Nursing Philosophy
An understanding of nursing practice is made easier with a personal philosophy. Various theories have consequently been developed with the aim of defining practice concepts in this field. In specific, this paper focuses on Morse’s theory in nursing practice. The paper explores the author’s personal nursing autobiography in relation to Morse’s concepts of enduring and emotional suffering. In relation to Morse’s theory, the study discusses the four meta-paradigms namely person, health, nursing, and environment. Nurses who apply the identified concepts within the four meta-paradigms in personal philosophies attain positive outcomes.
Nursing Autobiography
My childhood desire was to serve and care for the needy people. Nursing was my target ambition, and now, I am in the profession. Throughout my role as a nurse practitioner, I have displayed acceptable standards of practices that achieve patient comfort and wellness. In reference to Morse’s concepts of enduring and emotional suffering, I serve with compassion and empathy with the aim of enhancing patient comfort and wellness. Having worked in the field of primary care, my zeal to exercise professionalism has consistently restored patient anguish and suffering. So as to achieve positive outcomes, I exhibit efficiency and effectiveness whenever dealing with patients. With frequent trainings that I undergo, I have developed a positive tendency of making influences on patients. More commonly, I try to advise them in line with Morse’s theory with the aim of facilitating their recovery and wellness.
It is paramount that I have advanced in my nursing philosophy. When handling patients, I specifically try to understand their needs, be it psychological, emotional, or even physical. In particular, this approach enables me to make personal contacts with affected patients in a bid to counter any associated enduring or emotional suffering. It is critical that my focus is based on paying special attention to suffering patients. It is essential that I employ nursing experience to address extreme cases. Against changing techniques in the healthcare setting, I have a philosophy of endeavoring to incorporate new ideas to enhance healing and comfort strategies. My aptitude to embrace diversity makes it easier for me to interact with all manner of patients irrespective of their backgrounds. In as much as I am proactively involved in nursing, I will always seek to equip myself with new knowledge to develop strategies for attaining emotional peace. My eagerness to integrate both preventive and curative measures is seen as fundamental in yielding positive patient outcomes.
Nursing Meta-paradigms in Morse’s Theory o.
Similar to Catastrophizing Predicts Patient Dissatisfaction (20)
This document contains summaries of several research papers on topics related to chronic pain, suicide risk, and bipolar disorder:
1) One study found that tapering opioid doses for chronic pain patients was associated with increased risks of overdose and mental health crisis compared to patients who did not taper. Higher tapering speeds were linked to even greater risks.
2) Another study observed chronic pain patients undergoing opioid tapering or transition to buprenorphine treatment. Higher initial opioid doses predicted needing buprenorphine, and benzodiazepine use predicted dropout. Pain levels varied after treatment.
3) Research on combat veterans found that those exposed to combat had higher rates of PTSD, suicide attempts, strokes and chronic pain
Labeling Woefulness: The Social Construction of FibromyalgiaPaul Coelho, MD
This document discusses the social construction of fibromyalgia and how it has been established as a legitimate disease label despite a lack of clear biological or clinical evidence. It argues that fibromyalgia serves social and economic purposes for various groups, including patients, doctors, pharmaceutical companies, and the media, but poses risks by medicalizing psychosocial problems. The document proposes that widespread pain is a normal human experience for some that is best addressed by exploring psychosocial factors rather than believing the solution lies in neurobiology. Examining fibromyalgia as a social construct may be more helpful for patients than continuing to medicalize their experiences.
Outcomes in Long-term Opioid Tapering and Buprenorphine Transition: A Retrosp...Paul Coelho, MD
This study analyzed outcomes for 240 patients with chronic pain who were prescribed long-term opioid therapy above 90 mg morphine-equivalent daily doses. Patients were offered an outpatient opioid taper or transition to buprenorphine if taper was not tolerated. 44.6% successfully tapered, 18.8% transitioned to buprenorphine, and 36.6% dropped out of treatment. Higher initial opioid doses predicted needing buprenorphine, and benzodiazepine/z-drug use predicted greater dropout. Pain intensity changes after treatment were mixed, with over half of tapered patients reporting increased pain and about half of transitioned patients reporting decreased pain.
This document appears to be a questionnaire assessing symptoms of widespread pain and calculating a WPI (Widespread Pain Index) score and SS (Symptom Severity) score. It asks the respondent to indicate areas of pain on a diagram and rate the severity of symptoms like fatigue, thinking difficulties, and unrefreshed sleep. It also inquires about additional symptoms like abdominal pain, depression, and headaches. The final section rates pain-related worry and fear on a scale. Additional questions determine if the respondent has a workers compensation or disability claim related to their pain complaint.
Fibromyalgia is a condition that causes chronic aches and pains all over the body, fatigue, and often a sleep disorder. The doctor diagnosed the patient with fibromyalgia based on a score of 13 or more on the fibromyalgia questionnaire from the American College of Rheumatology, which is consistent with the syndrome. By focusing on and managing the diagnosis of fibromyalgia, the patient's other pain symptoms can decrease.
This document contains two studies related to psychological treatments for chronic conditions:
1) A study of chronic fatigue syndrome patients found that poorer outcomes were predicted by membership in a self-help group, receiving sickness benefits, and symptoms of dysphoria. Severity and duration of symptoms did not predict response.
2) A randomized controlled trial of 125 fibromyalgia patients compared operant behavioral therapy, cognitive behavioral therapy, and attention placebo. Both behavioral therapies significantly reduced pain intensity while cognitive therapy improved cognitive and affective variables and operant therapy improved physical functioning and behaviors. The attention placebo resulted in no improvement or deterioration.
This document summarizes three studies on the risks and efficacy of opioids for chronic non-cancer pain (CNP). The first study finds that while opioids were associated with small improvements in pain and physical functioning compared to placebo, they also increased the risk of vomiting. Comparisons to other medications found similar benefits to pain and functioning. The second study finds no difference in pain-related function between opioid and non-opioid groups over 12 months, and higher rates of adverse effects and pain intensity in the opioid group. The third study finds limited effectiveness of opioids for CNP, as opioid users did not report improvements in outcomes after 2 years. Regarding risks, higher opioid doses are associated with increased overdose risk across several patient groups in
1) This randomized clinical trial compared opioid vs nonopioid medication therapy over 12 months for patients with chronic back, hip, or knee pain.
2) It found no significant difference in pain-related function between the two groups, but pain intensity was significantly better in the nonopioid group. Adverse effects were significantly more common in the opioid group.
3) The study concludes that opioid therapy was not superior to nonopioid medications for improving pain-related function over 12 months, and the results do not support initiating opioids for moderate to severe chronic musculoskeletal pain.
Mortality quadrupled among opioid-driven hospitalizations notably within lowe...Paul Coelho, MD
This study analyzed national hospitalization data from 1993-2014 to examine trends in mortality and characteristics of hospitalizations related to opioids compared to other drug and non-drug hospitalizations. The key findings were:
1) Mortality among opioid-related hospitalizations quadrupled from 0.43% before 2000 to 2.02% in 2014, increasing 0.12 percentage points per year relative to other drug hospitalizations.
2) While total opioid-related hospitalizations remained stable, diagnoses shifted from opioid dependence/abuse to opioid/heroin poisoning, which have higher mortality rates. Hospitalizations for poisoning grew by 0.01 per 1,000 people annually after 2000.
3) Patients hospitalized for opioid/
Prescriptions filled following an opioid-related hospitalization.Paul Coelho, MD
This study analyzed prescription drug fills within 30 days of discharge for 36,719 patients hospitalized for opioid misuse. Only 16.7% received medications approved for opioid dependence, while 40.3% filled antidepressant prescriptions and 22.4% filled opioid pain medication prescriptions. Concurrently, 13.9% filled benzodiazepine prescriptions and 7.4% filled both benzodiazepine and opioid prescriptions, indicating a need for improved education on risks. Overall, more effort is required to ensure patients receive recommended post-hospitalization treatment and support services.
This study examined the risk of psychiatric hospitalization in the offspring (second generation) of Finns who were evacuated to Sweden without parents during World War II (first generation), compared to offspring of Finns who were not evacuated. The study found that daughters of mothers who were evacuated during childhood had an elevated risk of psychiatric hospitalization, especially for mood disorders. However, there was no increased risk found for offspring of evacuated fathers or for male offspring of evacuated mothers. This suggests that early childhood adversity experienced by the first generation, such as war-related trauma, may be associated with mental health problems that persist into the second generation.
Correlation of opioid mortality with prescriptions and social determinants -a...Paul Coelho, MD
This study analyzed Medicare Part D data from 2013-2014 to examine the relationship between opioid prescription rates, socioeconomic factors, and opioid-related mortality rates at the county level in the United States. The results showed that higher county-level opioid prescription rates, especially those from emergency medicine, family medicine, internal medicine, and physician assistants, were associated with higher opioid-related mortality rates. Higher poverty levels and proportions of white populations in counties also correlated with increased mortality. Additionally, prescribers in the highest quartile of opioid prescription rates had a disproportionate impact on mortality compared to the remaining 75% of prescribers.
This report examines CMS's oversight of Medicare Part D beneficiaries who receive opioid prescriptions and providers who prescribe opioids to these beneficiaries. It finds that while CMS provides guidance to Part D plan sponsors on monitoring beneficiaries at high risk of opioid overuse, it lacks complete data on the full population of beneficiaries at risk. It also finds that CMS oversees prescribing through its contractor NBI MEDIC but does not specifically analyze opioid prescription data or require reporting on actions taken regarding inappropriate opioid prescribing. The report concludes that CMS needs more comprehensive oversight to reduce the risks of opioid misuse, overdose, and inappropriate prescribing among Medicare beneficiaries.
This study analyzed opioid prescription trends among medical specialties in the U.S. from 2007-2012 using a national prescription database. The key findings were:
- Primary care specialties (family practice, internal medicine, general practice) accounted for nearly half of all dispensed opioid prescriptions in 2012.
- Specialties treating pain conditions like pain medicine, surgery, and physical medicine had the highest rates of opioid prescribing.
- Overall opioid prescribing rates increased from 2007-2010 but stabilized from 2010-2012 as most specialties reduced rates.
- The greatest increase in opioid prescribing was among physical medicine specialists, while the largest decreases were in emergency medicine and dentistry.
The place-of-antipsychotics-in-the-therapy-of-anxiety-disorders-and-obsessive...Paul Coelho, MD
This document summarizes a research article about the use of antipsychotic drugs in the treatment of anxiety disorders and obsessive-compulsive disorders. The review finds evidence that certain second-generation antipsychotics (SGAPs), like quetiapine, risperidone, and aripiprazole, can be effective for generalized anxiety disorder (GAD) and obsessive-compulsive disorder (OCD). Quetiapine in particular receives a recommendation as a first-line treatment for GAD. However, the review finds insufficient evidence for SGAPs in the treatment of social anxiety disorder and panic disorder. First-generation antipsychotics are not recommended for any anxiety disorders based on their side effect profiles
Structured opioid refill clinic epic smartphrases Paul Coelho, MD
#*** I explained to the patient the risks of combining opioids and benzodiazepines based on medical literature. We agreed to slowly taper the patient off benzodiazepines and trial safer alternatives for sleep and anxiety issues.
#*** I showed the patient their fibromyalgia screening questionnaire results, which were consistent with a fibromyalgia diagnosis. Fibromyalgia can amplify other painful conditions and is often the primary source of morbidity when present with other chronic pain diagnoses.
#*** We discussed the patient's high risk opioid regimen based on their dose exceeding CDC guidelines. While willing to work on a harm reduction plan, it will require a taper or switching to buprenorphine due to safety concerns.
Opioids for the Treatment of Chronic Pain: Mistakes Made, Lessons Learned, an...Paul Coelho, MD
This document summarizes the key issues regarding the use of opioids for chronic pain treatment:
1) An overreliance on opioids to treat chronic pain has contributed to the prescription opioid abuse epidemic in the US, as outpatient use allows for abuse and diversion of these addictive drugs.
2) While clinical trials show opioids effectively treat acute pain and are initially effective for chronic pain, real-world use reveals increased risks of abuse, addiction, and poor functional outcomes over the long-term.
3) The evidence supporting chronic opioid therapy was limited and observational in nature, yet convinced the medical community until larger population studies showed increased abuse rates contrary to initial assumptions.
The potential adverse influence of physicians’ words.Paul Coelho, MD
The physician's words can inadvertently amplify patients' symptoms and increase somatic distress if not carefully considered. Learning about potential side effects from medications, procedures, or test results can lead patients to experience and report those effects more frequently through psychological mechanisms like misattribution and increased attention to bodily sensations. Discussing concepts like nocebo and viscerosomatic amplification with patients can help provide reassuring explanations for symptoms and make them feel less intrusive. Physicians should thoughtfully consider their word choices and focus on benefits as well as side effects to minimize undue distress.
This document is an evidence report published by the Institute for Clinical and Economic Review (ICER) that evaluates the comparative clinical effectiveness and value of cognitive and mind-body therapies for chronic low back and neck pain. It was authored by Jeffrey Tice and others from ICER. The report assesses the clinical evidence on therapies such as cognitive behavioral therapy and mindfulness-based stress reduction and presents economic analyses of the long-term cost-effectiveness and potential budget impact of these therapies. It also incorporates input from clinical experts and stakeholders.
Solution manual for managerial accounting 18th edition by ray garrison eric n...rightmanforbloodline
Solution manual for managerial accounting 18th edition by ray garrison eric noreen and peter brewer_compressed
Solution manual for managerial accounting 18th edition by ray garrison eric noreen and peter brewer_compressed
English Drug and Alcohol Commissioners June 2024.pptxMatSouthwell1
Presentation made by Mat Southwell to the Harm Reduction Working Group of the English Drug and Alcohol Commissioners. Discuss stimulants, OAMT, NSP coverage and community-led approach to DCRs. Focussing on active drug user perspectives and interests
VEDANTA AIR AMBULANCE SERVICES IN REWA AT A COST-EFFECTIVE PRICE.pdfVedanta A
Air Ambulance Services In Rewa works in close coordination with ground-based emergency services, including local Emergency Medical Services, fire departments, and law enforcement agencies.
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Dr. Sherman Lai, MD — Guelph's Dedicated Medical ProfessionalSherman Lai Guelph
Guelph native Dr. Sherman Lai, MD, is a committed medical practitioner renowned for his thorough medical knowledge and caring patient care. Dr. Lai guarantees that every patient receives the best possible medical care and assistance that is customized to meet their specific needs. She has years of experience and is dedicated to providing individualized health solutions.
The Ultimate Guide in Setting Up Market Research System in Health-TechGokul Rangarajan
How to effectively start market research in the health tech industry by defining objectives, crafting problem statements, selecting methods, identifying data collection sources, and setting clear timelines. This guide covers all the preliminary steps needed to lay a strong foundation for your research.
"Market Research it too text-booky, I am in the market for a decade, I am living research book" this is what the founder I met on the event claimed, few of my colleagues rolled their eyes. Its true that one cannot over look the real life experience, but one cannot out beat structured gold mine of market research.
Many 0 to 1 startup founders often overlook market research, but this critical step can make or break a venture, especially in health tech.
But Why do they skip it?
Limited resources—time, money, and manpower—are common culprits.
"In fact, a survey by CB Insights found that 42% of startups fail due to no market need, which is like building a spaceship to Mars only to realise you forgot the fuel."
Sudharsan Srinivasan
Operational Partner Pitchworks VC Studio
Overconfidence in their product’s success leads founders to assume it will naturally find its market, especially in health tech where patient needs, entire system issues and regulatory requirements are as complex as trying to perform brain surgery with a butter knife. Additionally, the pressure to launch quickly and the belief in their own intuition further contribute to this oversight. Yet, thorough market research in health tech could be the key to transforming a startup's vision into a life-saving reality, instead of a medical mishap waiting to happen.
Example of Market Research working
Innovaccer, founded by Abhinav Shashank in 2014, focuses on improving healthcare delivery through data-driven insights and interoperability solutions. Before launching their platform, Innovaccer conducted extensive market research to understand the challenges faced by healthcare organizations and the potential for innovation in healthcare IT.
Identifying Pain Points: Innovaccer surveyed healthcare providers to understand their difficulties with data integration, care coordination, and patient engagement. They found widespread frustration with siloed systems and inefficient workflows.
Competitive Analysis: Analyzed competitors offering similar solutions in healthcare analytics and interoperability. Identified gaps in comprehensive data aggregation, real-time analytics, and actionable insights.
Regulatory Compliance: Ensured their platform complied with HIPAA and other healthcare data privacy regulations. This compliance was crucial to gaining trust from healthcare providers wary of data security issues.
Customer Validation: Conducted pilot programs with several healthcare organizations to validate the platform's effectiveness in improving care outcomes and operational efficiency. Gathered feedback to refine features and user interface.
Cyclothymia Test: Diagnosing, Symptoms, Treatment, and Impact | The Lifescien...The Lifesciences Magazine
The cyclothymia test is a pivotal tool in the diagnostic process. It helps clinicians assess the presence and severity of symptoms associated with cyclothymia.
As Mumbai's premier kidney transplant and donation center, L H Hiranandani Hospital Powai is not just a medical facility; it's a beacon of hope where cutting-edge science meets compassionate care, transforming lives and redefining the standards of kidney health in India.
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The Importance of Black Women Understanding the Chemicals in Their Personal C...bkling
Certain chemicals, such as phthalates and parabens, can disrupt the body's hormones and have significant effects on health. According to data, hormone-related health issues such as uterine fibroids, infertility, early puberty and more aggressive forms of breast and endometrial cancers disproportionately affect Black women. Our guest speaker, Jasmine A. McDonald, PhD, an Assistant Professor in the Department of Epidemiology at Columbia University in New York City, discusses the scientific reasons why Black women should pay attention to specific chemicals in their personal care products, like hair care, and ways to minimize their exposure.
2. PSYCHOLOGY, PSYCHIATRY & BRAIN
NEUROSCIENCE SECTION
Original Research Article
The Communal Coping Model of
Catastrophizing: Patient–Health
Provider Interactionspme_1288 66..79
Patricia Tsui, PhD,* Melissa Day, MA,†
Beverly Thorn, PhD,†
Nancy Rubin, PsyD,‡
Chelley Alexander, MD,§
and Richard Jones,
MD, PhD¶
*Stony Brook University Medical Center; Departments of
†
Psychology,
‡
Psychiatry and Behavioral Medicine,
§
Family Medicine, The University of Alabama;
¶
Clinic for Rheumatic Diseases/Biologic Therapy
Service, Tuscaloosa, Alabama, USA
Reprint requests to: Melissa A. Day, MA, Department of
Psychology, The University of Alabama, Box 870356,
Tuscaloosa, AL 35487-0348, USA.
Tel: 205-523-3831; E-mail: day014@crimson.ua.edu.
Disclosure: The authors have no conflicts of interest to
report.
Abstract
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 investi-
gated the role of catastrophizing and pain behaviors
in potentially influencing patient satisfaction with
the provider, provider attitudes, and provider behav-
ior. 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 behav-
iors, 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 sat-
isfaction 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 effec-
tive 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.
Key Words. Communal Coping Model (CCM); Cata-
strophizing; Patient–Provider Interactions; Chronic
Pain
Introduction
Cognitive factors, such as catastrophizing, are important
contributors in the behavioral expression of pain. Broadly
defined, pain-related catastrophizing is an “exaggerated
negative ‘mental set’ brought to bear during painful expe-
riences” [1]. Conceptually, catastrophizing represents a
maladaptive way of coping with stress in the face of real
or anticipated pain. Although initially conceptualized as a
dispositional variable, several studies have shown that
catastrophizing can be situational and state dependent
Pain Medicine 2012; 13: 66–79
Wiley Periodicals, Inc.
66
3. and can be assessed as such. Furthermore, compared
with measures of dispositional catastrophizing, situational
catastrophizing has been found to more accurately predict
current pain intensity [2–4]. Furthermore, although catas-
trophizing is traditionally viewed as an internal, personal
experience, the social context in which catastrophizing
occurs has received growing research interest.
The communal coping model (CCM) of catastrophizing is a
framework that theorizes how catastrophizing represents a
social-goal-oriented process and may be part of a broader
interpersonal orientation to coping with distress [1,5,6].
The CCM posits that catastrophic thoughts predicate
exaggerated displays of pain behaviors (i.e., grimacing,
sighs, and moans), and that these pain behaviors serve a
communicative function (i.e., express needs, garner atten-
tion, etc.) within the social context. Research on the inter-
personal domain of the CCM is currently limited; however,
there are some promising findings in the literature.
Experimental research by Sullivan and colleagues has
found that high catastrophizing individuals show more
sustained communicative pain behaviors and fewer pain
management behaviors (e.g., rubbing arm) when an
observer is present (compared with that when they are
alone) [5,7]. These findings suggest that individuals with a
propensity to catastrophize express more pain behaviors
in the social context, and that rather than serving a pallia-
tive function, these overt behaviors are mobilized to com-
municate information about perceived pain to others. This
supports the CCM premise that catastrophizing and
coping behaviors may be more associated with interper-
sonal goals rather than pain reduction per se. Survey
research has examined similar relations within clinical set-
tings and results indicated that among individuals with
chronic pain, catastrophizing is associated with self-
and other-reported pain behaviors, caregiver/partner
responses (i.e., perceived support, solicitousness, and
punishing behaviors), and relationship quality [8–11]. In
patients with chronic pain of relatively short duration, cata-
strophizing is significantly and positively related to patient-
perceived solicitous spousal responses. However, in
patients with pain of longer duration, no such relation is
observed; among these patients, catastrophizing is sig-
nificantly and positively related to patient-perceived pun-
ishing spouse responses [12].
Limited research on the patient–provider relationship indi-
cates that contextual variables such as situation (e.g., lack
of medical evidence, clinic setting), patient (e.g., severity
levels, behavior), and provider (e.g., training specialization,
attitude) variables are important factors and form the basis
for provider clinical decision making [13]. To the best of
our knowledge, no previous research has directly exam-
ined the relation between catastrophizing, pain behaviors,
and the support-seeking contextual components of the
CCM within the patient–health provider relationship. It is
plausible that catastrophic cognitions translate into exag-
gerated pain behaviors in the medical setting, and that
these behaviors represent a means by which patients
communicate needs to their health provider. Thus, cata-
strophic behaviors are potentially a cue to which health
providers respond when forming perceptions of their
patients; catastrophic behaviors may thereby influence
health provider attitudes and behavior.
The Current Study
The purpose of this study was to elucidate and refine the
interpersonal, communicative dimension of the CCM
within a clinical sample of chronic pain patients receiving
treatment in a medical setting. The primary specific aim
was twofold. Aim one was to examine the relations
between pain intensity, pain catastrophizing, and pain
behaviors as they function within the patient–health pro-
vider relationship. According to the CCM, individuals cata-
strophize in response to pain to serve interpersonal goals
and pain behaviors may be one way that catastrophizing is
manifested behaviorally. Thus, based on the hypothesized
relations within the CCM framework, we expected that
higher levels of reported pain intensity and catastrophizing
would be associated with increased pain behaviors, and
that catastrophizing would mediate the relation between
pain intensity and pain behaviors. Furthermore, given that
contextual factors have been shown to influence patient–
provider relationships, the effect of provider experience
and pain duration on the hypothesized aim one relations
was examined.
Our second aim was to investigate the role of catastroph-
izing and pain behaviors in potentially influencing patient
satisfaction with the provider, provider attitudes, and pro-
vider behavior (length of medical exam served as a proxy
for this outcome). Given that high pain catastrophizers
typically use more health care resources, it is likely that
providers generally have repeated, high exposure to such
patients [14]. Therefore, it is possible that providers
respond to patient pain behaviors reflective of catastroph-
izing in a manner similar to spouses of chronic pain
patients, i.e., in a punishing manner [12]. Within the
patient–provider context, this “punishing manner” may
manifest as the provider having a more negative attitude
toward the patient and a desire to spend less time with the
patient (i.e., shorter medical exam time). Concurrently, it is
logical that the complex interplay of these dynamics leave
the patient feeling less satisfied with their health care
provider. Hence, we hypothesized that increased catas-
trophizing and pain behaviors would be associated with
decreased patient satisfaction with the provider (i.e., the
extent to which the patient perceived the health provider
to meet their needs), more negative provider attitudes
toward patients, and decreased length of exam. The con-
textual factors controlled for in examination of aim one
were also included in aim two.
The CCM posits that patient-perceived solicitousness
may mediate the relation between catastrophizing and
pain behaviors. Thus, given this proposition, an explor-
atory aim was to examine the mediating role of patient
satisfaction with the provider on the hypothesized asso-
ciation between pain catastrophizing and provider atti-
tudes, and/or provider behavior.
67
Pain Catastrophizing and Pain Behaviors
4. Method
Design
The study was cross-sectional design with two repeated
measures; measurements of pain intensity and catastro-
phizing were obtained before and after provider interaction
with the patient. Pre-exam scores reflected baseline levels
of pain intensity and catastrophizing before seeing the
provider. Post-exam scores were collected after the
medical exam and participants were asked to reflect upon
pain intensity and catastrophizing thoughts experienced
during the medical exam. Based on previous research
suggesting that situational catastrophizing is distinct from
dispositional catastrophizing, we conceptualized catastro-
phizing as a situation-dependent variable in this study
[2–4]. During the medical exam, the provider asked the
patient to perform a set of physical tasks (i.e., walking,
sitting, standing, and lying down) while under the obser-
vation of a neutral third party who coded for total observed
pain behaviors. Details about presentation of additional
assessments will be described in the subsequent proce-
dure section.
Setting
This study was conducted at two clinics, a university-
based family medicine training clinic (clinic A) and a private
practice rheumatology clinic (clinic B). At clinic A, patients
were often being seen for acute care issues not related to
their chronic pain (e.g., infections, skin conditions, pelvic
exams, etc.). At clinic B, patients were being seen spe-
cifically for pain-related rheumatic issues. Prior to data
collection, Institutional Review Board permission was
obtained for both sites.
Participants
Patients
Participants were adult chronic pain patients who reported
having pain for longer than 3 months or were referred by
their health provider based on their diagnosis of a chronic
pain condition. Inclusion criteria were the following: 1)
history of chronic pain as indicated by patient self-report
or provider report; 2) at least 19 years of age; 3) were
under regular care of a health care provider at clinic A or
clinic B (at least two visits with a health care provider at the
facility for pain or other complaints); and 4) demonstrated
the ability to comprehend and complete questionnaires.
Primary pain diagnoses were obtained from patient report
and medical records.
Among the 206 patients approached for study participa-
tion, 77 (37.4%) met the inclusion criteria. At clinic A, a
large convenience sample was approached and it was not
known whether or not they had chronic pain, until patients
were asked. At clinic B, only physician referred patients
were approached. Of the eligible patients, 74 consented
to participate in the study, and 49 (27 from clinic A and 22
from clinic B) actually completed the study protocol. Even
though participants were encouraged to participate on the
same day, most patients completed the study on a sub-
sequent visit to the medical clinic. Subsequent visits with
the 25 other participants that initially consented to partici-
pate could not be coordinated. Reasons for nonparticipa-
tion included: not having available funds for additional
medical visits, wishing to speak with significant other
before agreeing and not having enough time to partici-
pate. Not all participants completed all the measures,
mostly due to personal time constraints, other scheduled
appointments, or follow-up tests, for example. Some par-
ticipants did not complete the pain behavior task as
administration of this assessment is contingent upon
provider involvement, and not all providers of patient
participants consented to be in the study.
Providers
Providers were eligible to participate if one of their patients
completed the study. Thus, even if a provider agreed to
participate, he or she may not have had participation
opportunity. In total, 30 health care providers consented to
participate in this study. Out of the 30 providers who
consented, 19 actually participated in the study. Fifteen
provider participants were located at clinic A, and four
providers were located at clinic B. Of the clinic A provider
participants, 12 were medical residents in their second or
third year of residency (specializing in family medicine),
one was a resident at the end of his first year of residency,
and the remaining two were attending physicians who
supervised residents. At clinic B, two physicians, one
nurse practitioner, and one occupational therapist (all of
whom had specialized training in rheumatic diseases and
working with people who have chronic pain) participated
in the study. The mean number of patient participants
seen by each provider was 2.2 (with a range of 1–8 patient
participants seen by a provider).
Patient Recruitment
Two methods for recruitment were used: 1) health care
provider referral and 2) research assistant (RA) recruitment
(i.e., approaching patients in the clinic waiting room). For
the first method, providers simply referred patients to the
study who met the inclusion criteria. Thereafter, the RA
approached the patient, typically in the exam room,
described the study, and obtained written informed
consent for study participation. In the second method,
RAs approached patients in the waiting room area, intro-
duced themselves as research assistants working with
investigators at the clinic, described the study, and
attempted to obtain consent for study participation.
Physician/Health Care Provider Recruitment
RAs typically approached providers during their scheduled
shifts and at group meetings. Two group emails were sent
to residents and attending physicians informing them
about the study and recruitment efforts. RAs made efforts
68
Tsui et al.
5. to not reveal the specific variables under investigation to
the providers to minimize reactivity during the pain behav-
ior task. Providers were told that their behaviors during the
pain behavior observation task were not being analyzed.
Providers were not told that the length of exam was being
recorded. Providers were also informed that patients
recruited for this study would be referred to resources,
such as free cognitive behavioral pain group treatment
and mental health services as necessary.
Procedure for Patient and Provider
See Figure 1 for a flowchart of the procedure. After obtain-
ing written informed consent, participants completed the
self-administered questionnaires. RAs accompanied the
patient to the exam room and assisted with completing
initial assessments. Pre-exam catastrophizing and pain
intensity scores were a reflection of pain experienced at
the present time of measurement. Subsequently, the RA
left the room during the medical exam and recorded the
length of time the provider remained in the exam room.
When the provider completed the exam, he or she
informed the RA that the patient was ready for behavior
observation. The provider read a script of commands for
the patient to perform (adapted from procedure used in
Feuerstein et al.) [15].
After the exam, the participants completed the remaining
assessments. For post-exam reports, participants were
asked to reflect upon their experience during the exam
while the provider was in the room. Thus, catastrophizing
and pain intensity scores taken after the exam were ret-
rospective reports on catastrophizing and pain intensity
during the medical exam. At the end of the study, partici-
pants were reimbursed $10 for their time and effort. Pro-
viders were asked to complete a brief questionnaire
assessing their attitudes toward their respective patients
within 24 hours.
Measures
Demographics
Brief demographic questionnaires were developed for use
in the current study. The following descriptive information
was obtained from patients: age, gender, race/ethnicity,
income, marital status, pain diagnosis or description of
pain, length of time with pain, and frequency of pain
episodes. Demographic variables for providers included:
age, gender, race/ethnicity, resident status (year in
program), length of time in practice, and specialty.
Pain Intensity
A visual analog scale (VAS) was used to assess pain
intensity. The VAS consists of a 10 cm line with two
anchors (“No pain” and “Worst possible pain”). Respon-
dents were asked to place a mark on the line that reflects
current pain intensity (pre-exam) and pain intensity expe-
rienced during the medical exam (post-exam). VAS scores
were measured in centimeters. Evidence supporting the
validity of the VAS has been demonstrated. VAS
responses have been positively correlated with other mea-
sures of self-reported pain intensity [16–18] and with
observed pain behavior [19,20]. The VAS was chosen for
its ease of administration and high number of response
categories. The VAS is potentially more sensitive to
changes in pain intensity than measures with limited
numbers of response categories [21].
Pain Catastrophizing
The pain-catastrophizing scale (PCS) was used to assess
the level of catastrophizing [22]. The 13-item measure
asks participants to rate, on a 5-point Likert scale ranging
from zero (“not at all”) to four (“all the time”), the degree to
which they have certain thoughts and feelings when expe-
riencing pain. Example items from the PCS included: “I
worry all the time about whether the pain will end;” “I feel
I can’t go on;” “It’s terrible and I think it’s never going to
get any better.” An overall PCS score is obtained by
summing the values of the 13 items with higher scores
indicating a greater degree of catastrophizing. The PCS
has exhibited strong internal consistency (a = 0.93), con-
current and discriminant validity, and high test–retest reli-
ability over a 6-week period (r = 0.78) [22–24]. For the
current study, instructions were modified to measure cata-
strophizing during two time points: pre-exam for pain
experienced at the present time and post-exam for pain
experienced during the exam. The full 13-item PCS was
Patient Informed Consent
|
Begin Questionnaires
|
Demographics, Pre-PCS, Pre-VAS
|
Medical Exam (RA records time)
|
Health Provider Read Script of Commands while RA codes
|
PBCL, PSQ-III, Post-PCS, Post-VAS
Health Provider Perception of Patient
Figure 1 Flowchart of procedures for patient
and provider. PBCL = pain behavior checklist;
Pre-PCS = pre-exam pain catastrophizing scale;
Post-PCS = post-exam pain catastrophizing scale;
PSQ-III = Patient Satisfaction Questionnaire III;
RA = research assistant; Pre-VAS = pre-exam visual
analog scale; Post-VAS = post-exam visual analog
scale.
69
Pain Catastrophizing and Pain Behaviors
6. used. Only the instructions were modified. For the pre-
exam catastrophizing assessment, the last sentence of
the instructions was modified as follows: “. . . Using the
following scale, please indicate the degree to which you
have these thoughts and feelings for your CURRENT
PAIN.” The question stem to the items was modified to
read: “When thinking about my pain now . . .” In the
current study adequate reliability was shown for the pre-
exam PCS measure (a = 0.95).
For the post-exam catastrophizing measure, the last
sentence of the instructions was modified as follows:
“. . . Using the following scale, please indicate the degree
to which you had these thoughts and feelings for your pain
DURING THE MEDICAL EXAM.” The question stem to the
items was modified to read: “When thinking about my pain
during the exam when my doctor was present . . .”
Adequate reliability of the post-exam PCS measure used
in the current study was shown (a = 0.95).
Observed Pain Behavior
The University of Alabama (UAB) Pain Behavior Scale was
used to quantify observed pain behaviors [25]. Patients
were observed while performing a set of physical activities
(e.g., walk, stand, and transition from sitting to standing)
and 10 target pain behaviors are scored on a 3-point
scale, where 0 = “None;” 0.5 = “Occasional (Less than
3¥);” and 1 = “Frequent (3¥ or more).” Coders rated how
frequent the participant displayed the following pain
behaviors: verbal complaints, nonverbal complaints (e.g.,
moans, gasps, and groans), facial grimaces, standing
posture, mobility, body language (clutching or rubbing
body part), the use of visible support equipment (e.g.,
braces, crutches, cane, and leaning on furniture), and
stationary movement (e.g., sitting still or how often there
was shifting positions) on a scale from none, occasional,
or frequent. The total process typically takes 5 minutes.
Self-report items of Down-time and Medication were
removed for this study; reliability and validity for the scale
without these items have been established in previous
research [15]. In the current study, a team of raters was
trained to administer the UAB Pain Behavior Scale. Initially,
two coders were in the room and practiced together until
reliability was consistently above 80%. After this was
achieved, only one coder could be present in the room.
Percentage agreement of over 80% among a team of
trained raters for the assessment of observed pain behav-
iors is usually considered acceptable reliability [26]; in the
current study, percentage agreement was 85%.
Self-Reported Pain Behaviors
The pain behavior checklist (PBCL) [27] is a self-report
assessment of pain behaviors and is based on Fordyce’s
categorization of pain behaviors [28]. The standard
instructions were given, which asked respondents to ref-
erence their experiences of chronic pain in general. Par-
ticipants rated how often they engaged in 25 behaviors on
a scale from 0 (“never”) to 6 (“very often”). Example items
include: “Walk with a limp or distorted gait;” “Move
extremely slowly;” “Walk in a protective fashion.” There is
evidence of criterion-related and discriminant validity for
patients with predominantly back and musculoskeletal
pain [27]. Reliability estimates for the subscales range
from 0.63 to 0.83 and the coefficient alpha for the total
PBCL is 0.85 [27]. The stability coefficient for the total
PBCL was 0.80, which indicates that the PBCL is stable
over time [27]. In the current study, adequate reliability of
the PBCL was shown (a = 0.90).
Patient Satisfaction with Provider
The Patient Satisfaction Questionnaire (PSQ-III) was used
to assess patient perception of treatment [29]. For the
purposes of this research, items related to financial
aspects of care, accessibility, availability, and convenience
of care were omitted as they were not directly measuring
perception of provider care. Items related to satisfaction
with provider were kept and statements were changed to
reflect attitudes pertaining to the most recent medical visit,
resulting in 22 items. Participants rated 22 items designed
to measure satisfaction with pain treatment on a 5-point
Likert scale ranging from strongly agree to strongly dis-
agree. Participants were instructed to make their rating on
the basis of the consultation with the health care profes-
sional included in this study. Sample items included: “The
doctor needs to be more thorough in treating and exam-
ining me;” “The doctor was good about explaining the
reason for medical tests;” “The doctor should have given
me more respect.” A total score was obtained by
summing scores. Several items were reverse coded so
that a higher total score would indicate greater patient
satisfaction with the provider. The PSQ has evidence of
predictive, content, convergent, and discriminant validity,
and reliability estimates ranged from 0.77 to 0.89 [30].
Adequate reliability of the 22-item version used in the
current study was shown (a = 0.85).
Provider Attitudes
Provider attitudes toward the patient were measured
using a scale used in previous research [31]. The original
scale was composed of 10 items and assessed provider
attitudes about patients with pain and confidence with
management of pain on a 5-point Likert scale ranging
from strongly agree to strongly disagree. Scale scores
were calculated by adding the numeric values of each
response and dividing by the number of items. Exploratory
and confirmatory factor analyses revealed two dimen-
sions, which were labeled confidence and attitude [31].
For this study, only the four items comprising the attitude
factor were included. Providers were asked to answer
questions about the degree of agreement with the follow-
ing statements: “The patient had unrealistic expectations
about what doctors can do for them;” “This patient will be
dissatisfied if I do not order additional lab tests;” “I often
have negative feelings about dealing with this patient;”
“This patient was probably very satisfied with my care.”
The overall response rate in this study was 75%.
70
Tsui et al.
7. Statistical Analyses
All analyses were conducted using SPSS version 16.0
(SPSS Inc., Chicago, IL, USA). For any missing item data,
the mean of the completed items within the questionnaire
was substituted provided that the number of missing
items did not exceed 10% for any individual’s responses
to a questionnaire. Questionnaire data were considered
missing if the individual completed less than 10% of the
items. Any case with missing questionnaire data was not
included in the analysis for that questionnaire. Pearson
product-moment correlations were used to determine
bivariate relations. Frequency statistics were obtained,
and reliability and validity of pain behavior coding were
examined. Exploratory independent samples t-test analy-
ses were conducted to examine potential clinic differences
in terms of the following patient population characteristics:
1) duration of pain; 2) pain intensity; 3) pain catastrophiz-
ing; 4) pain behaviors (both observed and self-reported);
and 5) length of medical exam. Mean changes in pain
intensity and catastrophizing from pre- to post-exam were
analyzed using paired-samples t-tests.
Separate hierarchical regression analyses were con-
ducted in accordance with the aims of the study. The
hierarchical models conducted for aim one examined the
associations between the independent variables of
pre- and post-exam pain intensity and pre- and post-
exam pain catastrophizing on the dependent variables:
observed pain behaviors and self-reported pain behaviors.
For aim two, the hierarchical models examined the rela-
tions between the independent variables of pre- and post-
exam pain catastrophizing, observed pain behaviors and
self-reported pain behaviors on the dependent variables:
patient satisfaction, provider attitudes, and length of exam
time. Duration of pain and clinic site were included as
covariates in all hierarchical models. Nonsignificant cova-
riates were removed from the final models.
For each regression analysis, parametric assumptions of
normality, equality of variances and independence were
examined to ensure appropriateness of selected statistics.
Omnibus tests for the regression models predicting
each of the criterion variables were measured using the
F statistic.
To examine the hypothesized and exploratory mediation
models, the bootstrapping technique (with N = 5,000
bootstrap re-samples) was implemented [32]. Bootstrap-
ping is a nonparametric re-sampling procedure that
makes no assumptions about the shape of the distribu-
tions of the variables or the sampling distribution of the
statistic. The bootstrapping sampling distributions are
empirically generated and the indirect effects are calcu-
lated in the re-samples. This way, point estimates and
confidence intervals are estimated for the indirect effects.
As a stringent test of the hypotheses, point estimates
of indirect effects are significant in the case zero is not
contained within the confidence interval. If zero is con-
tained within the confidence interval, then it cannot be
determined that the result is significantly different from
zero. The 99% confidence interval was used to determine
significance of the bootstrap mediation analyses.
Referencing the paths depicted in Figure 2, it was deter-
mined that: 1) the independent variable was significantly
related to the dependent variable (direct path c1); 2) the
independent variable was significantly related to the pro-
posed mediator (path a1); and 3) the proposed mediator
was significantly related to the dependent variable (path
b1) while controlling for the effects of the independent
variable. The indirect effect is represented by the product
of the coefficients (e.g., a1 b1 in Figure 2).
Results
Preliminary Analyses
Summary data from the 49 patient participants and 19
health provider participants are presented in Tables 1 and
2. Table 3 presents means and standard deviations for
the two independent variables and five dependent vari-
ables analyzed in this research. Table 4 shows Pearson
product-moment correlations among these measures.
Pre- and Post-Exam Scores
Participants at clinic B (M = 13.84, standard deviation
[SD] = 9.53) reported experiencing pain for a significantly
longer duration of time (in years) than participants at clinic
A (M = 8.45, SD = 8.19; t[45] = -2.09, P = 0.04). Effect
size was medium (d = 0.61) [33]. There were no significant
mean differences between the clinics in the following vari-
ables: pre-exam pain intensity (t[42] = -1.18, P = 0.25),
post-exam pain intensity (t[43] = -1.55, P = 0.13), pre-
exam catastrophizing (t[42] = 0.53, P = 0.60), post-exam
catastrophizing (t[43] = 1.24, P = 0.22), self-reported pain
behaviors (t[44] = -0.06, P = 0.95), observed pain behav-
iors (t[40] = -0.54, P = 0.59), and length of medical exam
Figure 2 Paths tested to examine the mediating role of pain catastrophizing and depression.
71
Pain Catastrophizing and Pain Behaviors
8. (t[38] = -1.00, P = 0.32). Therefore, pre- to post-exam
changes in pain intensity and catastrophizing were ana-
lyzed for the total sample only. It was found that pain
intensity scores did not change significantly from pre- to
post-exam (t[42] = -0.56, P = 0.58). Pain catastrophizing
scores were significantly lower on post-exam than pre-
exam (t[39] = 2.71, P = 0.01). Effect size was small
(d = 0.16) [33].
Hierarchical Regression Models
Parametric assumptions were met for all hierarchical
regression models. The order of entry of all predictor vari-
ables was determined on the basis of relative causal pri-
ority and relevant past research. See Table 5 for results of
the hierarchical regression models examining the relations
among pain intensity, pain catastrophizing, and pain
behaviors as they function within the patient–health pro-
vider relationship (aim one). In all aim one models, both
duration of pain and clinic site were nonsignificant cova-
riates, thus they were removed from the models for final
analyses. In the final aim one models, pain intensity was
entered in step one and pain catastrophizing in step two.
The observed pain behaviors regression models indicated
that only post-exam pain intensity contributed significantly.
Tests of the parameter estimates determined that as post-
exam pain intensity increased, so did the observed
pain behaviors (b = 0.349, t[1] = 2.235, P = 0.032,
R2
D = 12.2%). In the self-reported pain behavior models,
pre- and post-exam pain intensity and pre- and post-
exam pain catastrophizing accounted for a significant pro-
portion of the variance. Parameter estimates indicated
that self-reported pain behaviors increased as pre-
and post-exam pain intensity increased (b = 0.615,
t[1] = 4.805, P < 0.001, R2
D = 37.8%, and b = 0.603,
t[1] = 4.719, P < 0.001, R2
D = 36.3%, respectively).
Increased pre- and post-exam pain catastrophizing was
also uniquely associated with increased self-reported pain
behaviors while controlling for pain intensity (b = 0.425,
Table 1 Patient demographic data for the total sample and broken down for clinic A (university-based
family medicine training clinic) and clinic B (private practice rheumatology clinic)
Total sample (N = 49) Clinic A (N = 27) Clinic B (N = 22)
Age
Mean (SD) 54.122 (13.092) 54.667 (14.027) 53.455 (12.137)
Sex (%)
Male 12.2 22.2 0.0
Female 87.8 77.8 100.0
Marital status (%)
Married 53.2 53.8 52.4
Not married 46.8 46.2 47.6
Race or ethnicity (%)
Non-Hispanic white 57.1 63.0 50.0
African American 20.4 22.2 18.2
Hispanic/Latino 6.1 0.0 13.6
Native Americans 10.2 11.1 9.1
Asian 2.0 0.0 4.5
Other 4.1 3.7 4.5
Yearly income (%)
0–24,999 52.2 62.5 40.9
25,000–49,999 28.3 16.7 40.9
50,000–74,999 8.7 12.5 4.5
75,000–99,999 6.5 4.2 9.1
100,000+ 4.3 4.2 4.5
Pain diagnosis (%)
Arthritis 18.4 22.2 13.6
Back pain 6.1 11.1 0
Fibromyalgia 8.2 7.4 9.1
Neuropathic pain 2.0 3.7 0
Abdominal 2.0 3.7 0
Multiple pain sites 42.9 33.3 54.5
Other 20.4 18.5 22.7
Pain duration (years)
Mean (SD) 10.86 (9.12) 8.45 (8.19) 13.84 (9.53)
SD = standard deviation.
72
Tsui et al.
9. t[2] = 2.772, P = 0.009, R2
D = 10.7%, and b = 0.345,
t[2] = 2.157, P = 0.037, R2
D = 6.9%, respectively).
See Table 6 for the results of the hierarchical regression
models conducted to examine the role of catastrophizing
and pain behaviors in potentially influencing patient satis-
faction with the provider, provider attitudes, and provider
behavior (aim two). For the outcomes of patient satisfac-
tion and provider attitudes, both duration of pain and clinic
site were nonsignificant covariates, thus they were
removed from these models for final analyses. In the
patient satisfaction and provider attitudes models, pain
catastrophizing was entered in step one, and pain behav-
iors were entered in step two. In the model examining
variance in provider behavior (length of medical exam),
pain duration was a significant covariate and was there-
fore entered in step one and was statistically controlled.
Clinic site was a nonsignificant covariate, thus was
removed from the model for final analyses. Thus, in
the provider behavior model, pain catastrophizing was
entered in step two, and pain behaviors were entered in
step three. The patient satisfaction regression models indi-
cated that pre- and post-exam pain catastrophizing
accounted for a significant proportion of the variance.
When observed and self-reported pain behaviors were
Table 2 Provider demographic data
Total sample
(N = 19)
Medical clinic (%)
Clinic A 60.9
Clinic B 39.1
Sex (%)
Male 62.5
Female 37.5
Race or ethnicity (%)
Non-Hispanic white 70.8
African American 0.0
Hispanic/Latino 0.0
Native Americans 12.5
Asian 16.7
Other 4.1
Year of residency (%)
1 12.5
2 31.2
3 56.2
Specialty (%)
Family medicine 79.2
Rheumatology 8.3
Table 3 Summary of means and standard deviations
Total sample
mean (SD)
Clinic A
mean (SD)
Clinic B
mean (SD)
Pre-exam pain intensity 5.682 (2.417) 5.255 (2.088) 6.109 (2.688)
Post-exam pain intensity 5.727 (2.748) 5.112 (2.384) 6.364 (3.006)
Pre-exam catastrophizing 24.909 (14.837) 26.044 (13.660) 23.667 (16.277)
Post-exam catastrophizing 22.533 (14.075) 24.958 (13.547) 19.762 (14.481)
Total self-reported pain behavior 52.370 (21.848) 52.192 (22.466) 52.600 (21.595)
Total observed pain behavior 3.226 (1.665) 3.104 (1.622) 3.389 (1.754)
Patient satisfaction 95.341 (12.706) 93.167 (13.249) 97.950 (11.821)
Provider attitudes 15.541 (3.540) 15.842 (4.537) 15.222 (2.130)
Length of medical exam (minutes) 19.48 (12.96) 17.524 (9.136) 21.632 (16.184)
SD = standard deviation.
Table 4 Pearson product-moment correlation matrix (N = 49)
Measure 1 2 3 4 5 6 7 8 9
1. Observed pain behavior — 0.489** 0.227 0.179 0.322* 0.374* 0.083 -0.209 -0.060
2. PBCL — 0.654** 0.585** 0.609** 0.617** -0.247 -0.026 0.009
3. Pre-exam PCS — 0.895** 0.658** 0.719** -0.376* -0.054 -0.133
4. Post-exam PCS — 0.555** 0.658** -0.406* -0.162 -0.046
5. Pre-exam VAS — 0.853** -0.108 -0.159 -0.119
6. Post-exam VAS — -0.112 -0.231 -0.046
7. PSQ-III — 0.141 0.067
8. Provider attitudes — 0.147
9. Length of medical exam —
* P < 0.05; ** P < 0.01.
PBCL = pain behavior checklist; PCS = pain catastrophizing scale; PSQ-III = Patient Satisfaction Questionnaire III; VAS = visual
analog scale.
73
Pain Catastrophizing and Pain Behaviors
10. included in the regression models, higher pre-exam pain
catastrophizing was uniquely associated with less patient
satisfaction with the provider (b = -0.387, t[1] = -2.408,
P = 0.022, R2
D = 14.9%, and b = -0.344, t[1] = -2.261,
P = 0.030, R2
D = 11.9%, respectively). Higher post-exam
pain catastrophizing was associated with less satisfaction
with the provider in models including both observed and
self-reported pain behaviors (b = -0.407, t[1] = -2.562,
P = 0.015, R2
D = 16.6%, and b = -0.385, t[1] = -2.575,
P = 0.014, R2
D = 14.9%, respectively). In the models
examining variance in provider attitudes, no independent
variables accounted for a significant proportion of the
variance. The provider behavior regression models indi-
cated that the only significant variable accounting for vari-
ance was the covariate, pain duration, such that higher
duration was associated with longer exam time (see
Table 6).
Mediation Models
Mediation was tested to explore the hypothesis that pain
catastrophizing would mediate the relationship between
pain intensity and pain behaviors (included as part of aim
one; see Table 7). Baron and Kenny’s assumptions were
met for examination of mediation in reference to self-
reported pain behaviors, but not observed pain behaviors
[34]. In the first model (see Table 7), pre-exam catastro-
phizing was examined as a mediator of the relation
between pre-exam pain intensity and self-reported pain
behaviors. After controlling for pre-exam catastrophizing,
the effect of pain intensity on pain behaviors was reduced
but remained significant. Examination of the 99% confi-
dence interval generated by the bootstrapping procedure
indicated that pre-exam pain catastrophizing partially
mediated the relation between pre-exam pain intensity
and pain behaviors.
In the second mediation model (see Table 7), post-exam
catastrophizing was examined as a mediator of the post-
exam intensity to self-reported pain behaviors relation.
After controlling for post-exam catastrophizing score, the
effect of intensity on pain behaviors was reduced but
remained significant. Examination of the 99% confidence
interval indicated that post-exam catastrophizing did not
mediate the post-exam pain intensity to pain behaviors
relation.
Mediation was tested to examine the exploratory models
investigating the mediating role of patient satisfaction with
the provider on the hypothesized association between
pain catastrophizing and provider attitudes, and/or pro-
vider behavior. Given that catastrophizing did not predict
provider attitudes or behavior in the regression models,
the mediating role of these variables was not further exam-
ined. The ability of patient satisfaction to mediate the pain
catastrophizing to pain behaviors relation was explored
(see Table 7); however, patient satisfaction did not signifi-
cantly predict variance in self-reported pain behaviors
(path b). Thus, Baron and Kenny’s criteria for mediation
were not met, indicating further investigation of this pro-
posed exploratory model is not warranted in the present
data [34].
Discussion
This is the first study to examine the CCM of catastroph-
izing within the patient–physician relationship. Results
indicated that within a clinical sample of chronic pain
patients, internal perceptions of pain and catastrophic
thought processes related to pain may externally manifest
and be expressed to health providers via exaggerated
pain behaviors. Furthermore, the contextual social deter-
minants within the patient–health provider relationship
have the potential to elicit and reinforce catastrophic
thought processes and their potential behavioral concomi-
tants. The current findings indicate suggestions for refining
the interpersonal, communicative dimension of the CCM.
Consistent with previous research [1,22,35], and the
CCM’s premise that people with higher pain intensities
may catastrophize more to achieve interpersonal goals,
pain intensity was significantly associated with pain cata-
strophizing in the current study. Furthermore, pain inten-
sity accounted for a significant proportion of the variance
in both observed and self-reported pain behaviors. Cata-
strophic thoughts were found to translate into communi-
cative pain behaviors; however, the nature of this relation
varied as a function of assessment methodology (i.e.,
observed vs self-reported). Within the current sample,
pre- and post-exam catastrophizing were significantly
related to self-reported pain behaviors, but not observed
pain behaviors. Although inter-rater reliability of observed
pain behaviors could not be calculated in the current
study, it should be noted that the UAB Pain Behavior Scale
was designed for clinical application, and thus the stan-
dard method of administration is with one single coder.
While an alternative explanation for the finding that cata-
strophizing was unrelated to observed pain behaviors
Table 5 Examination of the relations between
pain intensity and pain catastrophizing on both
observed and self-reported pain behaviors
Model IV F B (SE) R2
1†
Pre-VAS 3.911 0.218 (0.110) 0.103
Pre-PCS 1.899 -0.001 (0.025) 0.000
2†
Post-VAS 4.997 0.225 (0.101) 0.122*
Post-PCS 2.512 -0.010 (0.025) 0.004
1‡
Pre-VAS 23.092 5.829 (1.213) 0.378***
Pre-PCS 17.418 0.659 (0.238) 0.485**
2‡
Post-VAS 22.270 5.061 (1.072) 0.347***
Post-PCS 14.505 0.552 (0.256) 0.403*
* Significant at the P < 0.05 level.
** Significant at the P < 0.01 level.
*** Significant at the P < 0.001 level.
†
Dependent variable: Observed pain behaviors.
‡
Dependent variable: Pain behavior checklist (self-reported
pain behaviors).
IV = independent variable; PCS = pain catastrophizing scale;
SE = standard error; VAS = visual analog scale.
74
Tsui et al.
11. might be low potential reliability of coded pain behaviors,
we think this is unlikely based on the initial reliability values
that we obtained (i.e., initial percentage agreement among
raters of 85%).
Based on the above noted findings, both time-point mea-
sures of catastrophizing were examined as potential
mediators of the pain intensity to self-reported pain behav-
iors relation. Results showed that pre-exam catastrophiz-
ing was a significant partial mediator of this relation,
supporting the idea that one’s cognitive appraisal of pain
influences perceptions of pain intensity and expression of
pain behaviors. Thus, given that perceptions of pain inten-
sity were found to be significantly and uniquely associated
with pain behaviors, a possible refinement to the CCM is
the inclusion of a direct path from perceived pain intensity
to greater pain behaviors.
Thorn and colleagues hypothesized that there is a distinc-
tion between catastrophic thinking and exaggerated,
catastrophic behaviors in chronic pain patients [6]. The
aforementioned mediation findings suggest that the
nature of the relation is such that catastrophizing is pos-
sibly an antecedent to subsequent pain behaviors rather
than a co-occurring phenomenon. Preliminary support for
this hypothesized time sequential relation was demon-
strated in the present results; while pre-exam catastroph-
izing was a significant partial mediator of the pain intensity
to pain behaviors relation, catastrophizing during the
medical exam was not.
Results also indicated that the mean pain catastrophiz-
ing score was significantly lower during the medical
exam than before the exam; however, pain intensity
was not significantly different at these time points. This is
Table 6 Examination of the relations between pain catastrophizing, observed pain behaviors, and
self-reported pain behaviors on patient satisfaction, provider attitudes, and provider behavior
Model IV F B (SE) R2
1†
Pre-PCS 5.798 -0.342 (0.142) 0.149*
Obs. PB 4.262 2.216 (1.411) 0.210
2†
Post-PCS 6.564 -0.350 (0.137) 0.166*
Obs. PB 4.341 1.877 (1.351) 0.213
3†
Pre-PCS 5.111 -0.308 (0.136) 0.119*
PBCL 2.488 0.000 (0.118) 0.119
4†
Post-PCS 6.630 -0.335 (0.130) 0.149*
PBCL 3.237 -0.013 (0.104) 0.149
1‡
Pre-PCS 0.062 -0.012 (0.047) 0.002
Obs. PB 0.408 -0.360 (0.414) 0.028
2‡
Post-PCS 0.576 -0.035 (0.045) 0.019
Obs. PB 0.632 -0.344 (0.412) 0.042
3‡
Pre-PCS 0.046 -0.011 (0.049) 0.002
PBCL 0.095 0.015 (0.038) 0.007
4‡
Post-PCS 0.741 -0.040 (0.046) 0.023
PBCL 0.519 0.020 (0.036) 0.033
1§
Pain duration 7.720 0.620 (0.223) 0.210**
Pre-PCS 3.886 -0.078 (0.155) 0.217
Obs. PB 2.535 -0.382 (1.303) 0.220
2§
Pain duration 5.426 0.489 (0.214) 0.153*
Post-PCS 2.718 -0.063 (0.157) 0.158
Obs. PB 1.768 -0.280 (1.315) 0.159
3§
Pain duration 4.580 0.530 (0.248) 0.125*
Pre-PCS 3.470 -0.245 (0.165) 0.183
PBCL 2.494 -0.113 (0.143) 0.200
4§
Pain duration 3.275 0.430 (0.238) 0.090
Post-PCS 2.885 -0.250 (0.163) 0.153
PBCL 2.088 -0.100 (0.133) 0.168
* Significant at the P < 0.05 level.
** Significant at the P < 0.01 level.
†
Dependent variable: Patient Satisfaction Questionnaire III.
‡
Dependent variable: Provider attitudes.
§
Dependent variable: Provider behavior (length of medical exam, minutes).
IV = independent variable; Obs. PB = observed pain behaviors; PBCL = pain behavior checklist; PCS = pain catastrophizing scale;
SE = standard error.
75
Pain Catastrophizing and Pain Behaviors
12. consistent with research demonstrating that catastrophiz-
ing may be conceptualized as a fluid, situational/state-
dependent construct, rather than a stable, trait-like
variable [2–4]. These findings suggest that even though
pain per se was not reduced after seeing the provider in
the current study, the presence of the health provider and
the subsequent patient–health provider interaction func-
tioned to alleviate distress associated with pain. More
importantly, previous research has found that reducing
anxiety and catastrophic thoughts during the medical
exam decreases future health care usage [14].
The finding that catastrophizing (both pre- and post-exam)
was not significantly associated with observed pain
behaviors, yet accounted for a significant proportion of the
variance in self-reported pain behaviors was contrary to
what has been found in previous studies [5,36–38]. The
nature of this conditional relationship found in the present
results suggests there may be important differences
between how patients perceive their own behavioral
expressions of pain, and how these behaviors are quan-
tified by trained observers. High catastrophizing patients
may believe they are outwardly expressing more pain
behaviors than what is actually observable, and subse-
quently responded to by others, including health provid-
ers. Unless the health provider routinely addresses
catastrophic thoughts during the exam, the lack of health
provider response to the patients’ perceived behavior may
subsequently influence patient satisfaction with their
health provider. This may then lead to further catastrophic
thinking and heightened, exaggerated displays of pain
behaviors in future medical visits.
In partial support for this conjecture was the finding that
higher levels of catastrophizing (both pre- and post-exam)
were associated with decreased patient satisfaction.
These concurrent findings indicate an interconnection
between internal thought processes, communicative
behaviors, and social perceptions, as proposed within the
CCM framework. The present data precluded the ability to
fully elucidate the causal connections between catastro-
phizing, patient satisfaction, and pain behaviors due to
Baron and Kenny’s criteria not being met in the third
mediation model [34]. However, the results provide pre-
liminary evidence to suggest that catastrophizing may lead
to increased displays of exaggerated, observable pain
behaviors, and this may predominantly occur within the
context in which the patient both expects and then per-
ceives the health provider to not meet their needs (and
vice versa).
Results indicated that outcome variables, specifically
measuring health provider attitudes and behaviors, were
not significantly related to any of the patient outcome
variables. This finding is somewhat inconsistent with pre-
vious research, comparing solicitous partner responses in
the context of short vs long duration pain [12]. Given it is
probable that health providers frequently interact with high
catastrophizing patients (due to their increased usage of
health care resources) [14], we had initially expected that
health providers would respond to such patients in a
Table7Summaryofmediationresultsforpre-andpost-exampaincatastrophizingandpatientsatisfaction(5,000bootstrapsamples)
Independent
Variable(IV)
Mediating
Variable(M)
Dependent
Variable(DV)
EffectofIV
onM(a)
EffectofM
onDV(b)
Total
Effects(c)
Direct
Effects(c′)
Indirect
Effect(a¥b)
Confidence
Interval‡
1.Pre-VASPre-PCSPBCL3.890.655.823.312.51†
0.15–6.65
2.Post-VASPost-PCSPBCL3.380.555.063.201.87†
-0.22–5.96
3.Pre-PCSPSQ-IIIPBCL-0.32-0.010.980.980.004-0.29–0.25
†
Significantpointestimate(P<0.01).
‡
Bias-correctedandacceleratedconfidenceinterval.
PBCL=painbehaviorchecklist;PCS=paincatastrophizingscale;PSQ-III=PatientSatisfactionQuestionnaireIII;VAS=visualanalogscale.
76
Tsui et al.
13. similar manner as spouses do in response to long duration
pain (i.e., with more frequent punishing behaviors in the
form of poorer provider attitudes and reduced exam time
length). It may be that the lack of support we found for this
hypothesis is a function of the different contextual factors
within the medical setting in comparison to other social
environments. It is also possible that our assessment of
health provider behaviors was not sensitive enough to
detect such relational nuances. Future studies should
include more objective assessments of solicitous vs pun-
ishing health provider responses, such as direct, third-
person observation and/or coding of digitally recorded
health providers’ behaviors during the medical exam.
Additionally, it would be interesting to investigate how
such an objective assessment of health provider behavior
during the exam corresponded with indicators of treat-
ment (e.g., diagnosis, referral pattern, and prescribed
treatment).
Limitations
A potential limitation of the current research is the lack of
an assessment of depression and the affective concomi-
tants of pain, which are included as peripheral compo-
nents within the CCM. While the purpose of this study was
to specifically examine and refine the interpersonal, com-
municative dimension of the CCM, future studies should
include assessment of these components to facilitate
comprehensive examination of the model as a whole.
Another potential limitation in this study was that the type
of chronic pain reported by patients in this sample was
quite diverse. It is possible that patient–provider interac-
tions vary as a function of pain type; future studies should
investigate this possibility. Furthermore, it is also likely the
entire visit was not spent discussing issues directly related
to chronic pain, particularly at the family medicine clinics.
Objective recordings (as suggested above) would help
determine if discussion of numerous issues other than
chronic pain influences patient–provider interactions and
overall treatment outcome. An additional consideration
was that provider experience in the current study was also
diverse, and, in some cases, paramedical professionals
were included, which may influence patient–provider inter-
active dynamics. A further limitation was that the sample
size was relatively small, which was further compounded
by participants failing to complete each measure included
within the study design. While this is an inherent concern
when working with a clinical population, the effects of
missing data become less influential when sample size is
large. However, this is the first study to examine the tenets
of the CCM within a medical setting and despite the
restricted statistical power stemming from the aforemen-
tioned issues, significant findings were obtained that add
incrementally to the literature on this topic.
Conclusions
Individuals with chronic pain often seek help from
specialized pain providers to decrease pain and increase
the number of pain-free periods [39]. Health care
maintenance organizations have put provider time at a
premium; however, chronic pain still annually costs
upward of $100 billion due to lost work days, medical
expenses, and other benefit costs [40]. While past clinical
literature investigating the CCM has examined only the
applicability of this model within spousal relationships, this
study extends the application of the CCM to other impor-
tant interpersonal contexts within the realm of chronic
pain. Results indicate that the CCM of catastrophizing
provides a heuristic framework for understanding patient
behaviors within the health care context. The current study
found that the internal, cognitive framework of the patient
entering the medical exam is strongly determinative of the
interactive dynamics between the patient and the health
provider during the exam and patient satisfaction after the
exam. More importantly, health providers have the capac-
ity to positively influence patient cognitions and subse-
quent behaviors, which may help prevent excessive health
care usage. Identifying the specific factors within the
patient–health provider relationship, which facilitate or
enhance adaptive ways of thinking about pain, accep-
tance of pain, and self-management behaviors, has the
potential to inform interventions to improve treatment
for chronic pain and reduce the astronomical expenses
associated with persistent painful conditions.
Acknowledgments
The authors would like to acknowledge the health care
staff at UMC and CRD for giving us the opportunity to
conduct this study and for helping facilitate collection of
the data. The authors also express appreciation for the
resident and attending physicians at UMC and health care
providers at CRD who made time to participate in this
research. We also thank Chalanda Cabbil, Mallory
Bennett, Amber Davis, and Ty Patterson for their valuable
contributions in helping collect the data reported in the
current paper. Finally, the authors acknowledge Francis
Keefe and Laura Pence for their assistance throughout the
process of coding the pain behaviors analyzed in this
research.
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