Assessing suffering in advanced cancer patients using Pictorial Representation of Illness and Self-Measure (PRISM), preliminary validation of the Spanish version in a Latin American population

The relationship between suffering, loneliness, social interaction, and perceived symptoms in advanced cancer patients

PURPOSE

Understanding how different factors contribute to suffering, particularly social ones, enables designing more comprehensive and evidence-based interventions. This study examined the relationship between suffering, loneliness, social interaction, and symptom distress in patients with advanced cancer.

METHODOLOGY

The authors conducted a quantitative, observational, analytical cross-sectional study. Patients with advanced cancer attending a pain and palliative care unit of an oncology institution participated. Assessment instruments included PRISM (suffering), the UCLA Loneliness Scale, the Edmonton Symptom Assessment Questionnaire, and Cohen's Social Network Index (SNI). Univariate, bivariate, and multiple regression analyses were performed.

RESULTS

One-hundred forty-four patients participated, mostly women (68.1%), with a median age of 62 years, and 48.6% lived with a partner. About 75% reported moderate to severe suffering, 33% had clinically significant loneliness, and half reported a large social network and frequent interactions. Fatigue as the most common problem and well-being had a median score of 5. Suffering was significantly correlated with loneliness, pain, fatigue, depression, and anxiety, but not with levels of social interaction. According to the Multiple Regression Analysis, only loneliness showed a positive and significant contribution to suffering.

CONCLUSIONS

A high percentage of patients show significant suffering, and almost a third show clinical levels of loneliness. This contrasts with a relatively large social network with frequent interactions and a generally low symptomatic burden. Our findings indicate that loneliness influences the experience of illness, contributing to suffering. Future studies should delve deeper into the relationship between suffering and loneliness.

The suffering measurement instruments in palliative care: A systematic review of psychometric properties

BACKGROUND

The relief of suffering is considered one of the main goals to reach at the end of life, and nurses play an essential role in the prevention and relief of suffering. Validated instruments for assessing suffering can be useful, and selection of the most appropriate measure is crucial. To date, no systematic review has been performed that contrasts the measurement properties of instruments assessing suffering in the palliative care population, according to the most up-to-date COnsensus-based Standards for the selection of health status Measurement INstruments methodology.

OBJECTIVES

The aim of this systematic review is twofold: (1) identify the measures assessing suffering in the palliative care population, and (2) assess the measurement properties of these measures.

DESIGN

A systematic review of the measurement properties of instruments assessing suffering in palliative care was carried out.

DATA SOURCES

The search strategy was conducted in Medline, CINAHL, PsycINFO, Web of Science, Cochrane Library, SciELO, Scopus, Cosmin database of systematic reviews and Open gray.

REVIEW METHODS

The following methodologies were applied: updated COnsensus-based Standards for the selection of health status Measurement INstruments, the Meta-Analysis of Observational Studies in Epidemiology, and the Assessing the Methodological Quality of Systematic Reviews tool. A protocol for this systematic review was registered in PROSPERO (Registration number: CRD42018106488). Eligible studies were those that satisfied the following criteria: a) validation studies of measures assessing suffering in the palliative care population, b) assessing at least one measurement property of a measure, c) published in English or Spanish and d) published between January 1980 and September 2019. The included studies were assessed for the methodological quality of the measurement properties and then compared in terms of both the measurement properties and the methodological quality of the processes used. The evidence for each measurement property was summarised and the quality of the evidence was graded using the Grading of Recommendations, Assessment, Development and Evaluation approach.

RESULTS

The search strategy yielded a total of nine studies and six instruments assessing suffering. The methodological quality of the studies was doubtful and the quality of the evidence was moderate for most of the measurement properties analysed. The Suffering Pictogram was the instrument with the best rating for methodological quality and quality of evidence, for most of the measurement properties evaluated.

CONCLUSIONS

Instruments assessing suffering in palliative care have been identified in this systematic review. The Suffering Pictogram seems to be the most useful instrument identified. Tweetable abstract: The relief of suffering is one of the main goals to reach at the end of life, and the selection of the most appropriate measure for assessing this construct is crucial.

A Global, Prospective, Observational Study Measuring Disease Burden and Suffering in Patients with Ulcerative Colitis Using the Pictorial Representation of Illness and Self-Measure Tool

BACKGROUND

The understanding the Impact of ulcerative COlitis aNd Its assoCiated disease burden on patients study [ICONIC] was a 2-year, global, prospective, observational study evaluating the cumulative burden of ulcerative colitis [UC] using the Pictorial Representation of Illness and Self-Measure [PRISM] tool that is validated to measure suffering, but not previously used in UC.

METHODS

ICONIC enrolled unselected outpatient clinic attenders with recent-onset UC. Patient- and physician-reported outcomes including PRISM, the Short Inflammatory Bowel Disease Questionnaire [SIBDQ], the Patient Health Questionnaire [PHQ-9], and the Simple Clinical Colitis Activity Indexes [patient: P-SCCAI; physician: SCCAI] were collected at baseline and follow-up visits every 6 months. Correlations between these measures were assessed using Spearman's rank correlation coefficient.

RESULTS

Overall, 1804 evaluable patients had ≥1 follow-up visit. Over 24 months, mean [SD] disease severity measured by P-SCCAI/SCCAI reduced significantly from 4.2 [3.6]/3.0 [3.0] to 2.4 [2.7]/1.3 [2.1] [p<0.0001]. Patient-/physician-assessed suffering, quantified by PRISM, reduced significantly over 24 months [p<0.0001]. SCCAI/P-SCCAI, and patient-/physician-assessed PRISM, showed strong pairwise correlations [rho ≥0.60, p<0.0001], although physicians consistently underestimated these disease severity and suffering measures compared with patients. Patient-assessed PRISM moderately correlated with other outcome measures, including SIBDQ, PHQ-9, P-SCCAI, and SCCAI (rho = ≤-0.38 [negative correlations] or ≥0.50 [positive correlations], p<0.0001).

CONCLUSION

Over 2 years, disease burden and suffering, quantified by PRISM, improved in patients with relatively early UC. Physicians underestimated burden and suffering compared with patients. PRISM correlated with other measures of illness perception in patients with UC, supporting its use as an endpoint reflecting patient suffering.

Recognising ethnocultural diversity in chronic pain assessment: validation of the Pictorial Representation of Illness and Self Measure (PRISM) for use with culturally diverse communities

BACKGROUND

A comprehensive and accurate assessment of pain is critical for successful pain management. However, there is a lack of reliable and valid assessment tools for exploring multidimensional aspects of the chronic pain experience in culturally and linguistically diverse communities. This study investigates the reliability and validity of the Pictorial Representation of Illness and Self Measure + (PRISM+) for evaluating pain-related suffering and the sociocultural context of chronic pain within culturally and linguistically diverse patient cohorts.

METHOD

Three prospective validation studies are reported for three culturally and linguistically diverse communities. Two hundred and fifty-one patients with chronic pain who self-identified as Assyrian (n = 85), Arabic (n = 83) or Vietnamese (n = 83) completed a PRISM+ assessment, alongside a battery of standardised pain assessments. To evaluate construct validity, the position of the 'pain' disk placement was correlated with the Brief Pain Inventory (BPI), Depression Anxiety and Stress Scale (DASS), and the Short-Form 36 Health Survey (SF-36). For content validity, thematic analysis of patient narratives accompanying each disk placement was conducted. Test-retest reliability of repeated 'pain' and five additional disks (PRISM+) values was analysed using intra-class correlation coefficients.

RESULTS

The PRISM pain assessment demonstrated moderate to good test-retest reliability for Arabic (ICC 0.76; 95% CI 0.65-0.84), Assyrian (ICC 0.65; 95% CI 0.50-0.76) and Vietnamese (ICC 0.82; 95% CI 0.73-0.88) patients. Moderate correlations between the PRISM 'pain' disk and sub-scores for the BPI, DASS and SF-36 were found (p < 0.001). Patient interpretations of the 'pain' disk aligned with accepted definitions of suffering, supporting content validity for PRISM. For the additional disks (PRISM+), moderate to good test-retest reliability (ICC 0.67-0.88) was observed and qualitative analysis highlighted each disk reflected social and cultural values.

CONCLUSION

The PRISM demonstrates acceptable psychometric properties for measuring pain-related suffering for participants with chronic pain across three culturally and linguistically diverse communities. The use of additional disks (PRISM+) presents a reliable and valid option for exploring social and cultural dimensions of chronic pain in clinical encounters.

Pictorial Representation of Illness and Self Measure-Revised 2 (PRISM-R2): an effective tool to assess perceived burden of thyroid cancer in mainland China

PURPOSE

Thyroid cancer, especially differentiated thyroid cancer (DTC), is a highly prevalent chronic disease that is known to cause considerable distress, related both to the high recurrence and treatment of the disease. The Pictorial Representation of Illness and Self Measure-Revised 2 (PRISM-R2) has been developed as a visual measure to assess suffering. The aim of this study was to evaluate the ability of the instrument to identify patients with DTC with different levels of suffering who may need additional support care.

METHODS

Participants were 338 adult inpatients with DTC who were accepting the radioiodine for remnant ablation in the nuclear medicine department. The assessment tools included the following: (1) the PRISM-R2, yielding Self-Illness Separation (SIS) and Illness Perception Measure (IPM); (2) distress thermometer (DT), a measure of thyroid cancer-related distress; (3) posttraumatic growth inventory (PTGI); (4) 12-item Short-Form health survey (SF-12); and (5) the Supportive Care Needs Survey Short Form (SCNS-SF34). In addition, the content validity of PRISM-R2 was tested using the patients' comments.

RESULTS

SIS and IPM showed medium intercorrelation (r = -.482; p < 0.01), and both of them showed strongly significant associations with DT. SIS also showed significant correlations with one factor of PTGI (personal strength), four factors of SF-12 (general health, role-emotional, mental health, and vitality), and one factor of SCNS-SF34 (psychological needs). IPM showed significant correlations with five factors of SF-12 and all the factors of SCNS-SF34. No correlation was found between IPM and PTGI.

CONCLUSIONS

PRISM-R2 is a well-accepted and understandable tool to assess the psychological burden of patients with thyroid cancer in Chinese settings. It may be useful to guide or evaluate the interventions for the patients.

Assessing Suffering in Experimental Pain Models

Abstract. Although suffering is a central issue in pain, there is only little research on this topic. The aim of this study was to assess suffering in an experimental context using various stimulation methods and durations, and to examine which psychological or psychophysiological measures covary with pain-related suffering. Twenty-one healthy volunteers participated in two experiments in which we used tonic thermal and phasic electric stimuli with short and long stimulus durations. The participants rated pain intensity, unpleasantness, and pain-related suffering on separate visual analog scales (VAS) and completed the Pictorial Representation of Illness and Self Measure (PRISM), originally developed to assess suffering in chronic illness. We measured heart rate, skin conductance responses (SCRs), and the electromyogram (EMG) of the musculus corrugator supercilii. For both heat and electric pain, we obtained high ratings on the suffering scale confirming that suffering can be evoked in experimental pain conditions. Whereas pain intensity and unpleasantness were highly correlated, both scales were less highly related to suffering, indicating that suffering is distinct from pain intensity and unpleasantness. Higher suffering ratings were associated with more pronounced fear of pain and increased private self-consciousness. Pain-related suffering was also related to high resting heart rate, increased SCR, and decreased EMG during painful stimulation. These results offer an approach to the assessment of suffering in an experimental setting using thermal and electric pain stimulation and shed light on its psychological and psychophysiological correlates.

PRISM, a Novel Visual Metaphor Measuring Personally Salient Appraisals, Attitudes and Decision-Making: Qualitative Evidence Synthesis

Background

PRISM (the Pictorial Representation of Illness and Self Measure) is a novel, simple visual instrument. Its utility was initially discovered serendipitously, but has been validated as a quantitative measure of suffering. Recently, new applications for different purposes, even in non-health settings, have encouraged further exploration of how PRISM works, and how it might be applied. This review will summarise the results to date from applications of PRISM and propose a generic conceptualisation of how PRISM works which is consistent with all these applications.

Methods

A systematic review, in the form of a qualitative evidence synthesis, was carried out of all available published data on PRISM.

Results

Fifty-two publications were identified, with a total of 8254 participants. Facilitated by simple instructions, PRISM has been used with patient groups in a variety of settings and cultures. As a measure of suffering, PRISM has, with few exceptions, behaved as expected according to Eric Cassell’s seminal conceptualisation of suffering. PRISM has also been used to assess beliefs about or attitudes to stressful working conditions, interpersonal relations, alcohol consumption, and suicide, amongst others.

Discussion

This review supports PRISM behaving as a visual metaphor of the relationship of objects (eg ‘my illness’) to a subject (eg ‘myself’) in a defined context (eg ‘my life at the moment’). As a visual metaphor, it is quick to complete and yields personally salient information. PRISM is likely to have wide applications in assessing beliefs, attitudes, and decision-making, because of its properties, and because it yields both quantitative and qualitative data. In medicine, it can serve as a generic patient-reported outcome measure. It can serve as a tool for representational guidance, can be applied to developing strategies visually, and is likely to have applications in coaching, psychological assessment and therapeutic interventions.

Invasive treatment of pain associated with pancreatic cancer on different levels of WHO analgesic ladder

Background

Pancreatic cancer is a malignant neoplasm with a high mortality rate, often associated with a delayed diagnosis, the early occurrence of metastasis and an overall, poor response to chemotherapy and radiotherapy. Pain management in pancreatic cancer consists mainly of pharmacological treatment according to the WHO analgesic ladder. Surgical treatment for pain relief, such as splanchnicectomy, is considered amongst the final step of pain management. It has been proven that splanchnicectomy is a safe procedure with a small percentage of complications, nevertheless, it is often used as a last resort, which can significantly decrease its effectiveness. Performance of thoracoscopic splanchnicectomy along the first step of the analgesic ladder may lead to long-lasting protection against the presence and severity of pain.

Methods/Design

A prospective, open label, 1:1 randomized, controlled trial, conducted at a single institution to determine the effectiveness of invasive treatment of pain via splanchnicectomy, in patients with advanced pancreatic cancer. The size of tested group will consist of 26 participants in each arm of the trial, to evaluate the level of pain relief and its impact on quality of life. To evaluate the influence on patients’ rate of overall survival, a sample size of 105 patients is necessary, in each trial arm. Assessments will not only include the usage of analgesic pharmacotherapy throughout the course of disease, and overall patient survival, but also subjective pain perception at rest, in movement, and after meals (measured by NRS score questionnaire), the patient’s quality of life (measured using the QLQ-C30 and FACIT questionnaires), and any pain-related suffering (measured with the PRISM projection test). The primary endpoint will consist of pain intensity. Questionnaires will be obtained upon the initial visit, the day of surgery, the day after surgery, as well as during long-term follow-up visits, held every two weeks thereafter.

Discussion

Earlier implementation of invasive treatment, such as thoracoscopic splanchnicectomy, can provide a higher efficacy of pain management, prevent deterioration in the patient’s quality of life, and lengthen their overall survival.

Trial registration

ClinicalTrials.gov identifier: NCT02424279. Date of registration January 2, 2015.

Disentangling tinnitus distress and tinnitus presence by means of EEG power analysis

The present study investigated 24 individuals suffering from chronic tinnitus (TI) and 24 nonaffected controls (CO). We recorded resting-state EEG and collected psychometric data to obtain information about how chronic tinnitus experience affects the cognitive and emotional state of TI. The study was meant to disentangle TI with high distress from those who suffer less from persistent tinnitus based on both neurophysiological and behavioral data. A principal component analysis of psychometric data uncovers two distinct independent dimensions characterizing the individual tinnitus experience. These independent states are distress and presence, the latter is described as the perceived intensity of sound experience that increases with tinnitus duration devoid of any considerable emotional burden. Neuroplastic changes correlate with the two independent components. TI with high distress display increased EEG activity in the oscillatory range around 25 Hz (upper β-band) that agglomerates over frontal recording sites. TI with high presence show enhanced EEG signal strength in the δ-, α-, and lower γ-bands (30-40 Hz) over bilateral temporal and left perisylvian electrodes. Based on these differential patterns we suggest that the two dimensions, namely, distress and presence, should be considered as independent dimensions of chronic subjective tinnitus.