Application of a Clinical Approach to Diagnosing Primary Pain: Prevalence and Correlates of Primary Back and Neck Pain in a Community Physiatry Clinic

Chronic back or neck pain (CBNP) can be primary (nociplastic or neuroplastic; without clear peripheral etiology) or secondary (to nociceptive or neuropathic causes). Expanding on available models of nociplastic pain, we developed a clinic-ready approach to diagnose primary/nociplastic pain: first, a standard physical exam and review of imaging to rule out secondary pain; and second, a detailed history of symptom presentation to rule in primary pain. We trained a physician who evaluated 222 patients (73.9% female, age M = 59.6) with CBNP; patients separately completed pain and psychosocial questionnaires. We estimated the prevalence of primary CBNP and explored biomedical, imaging, and psychological correlates of primary CBNP. Although almost all patients (97.7%) had at least 1 spinal anomaly on imaging, the diagnostic approach estimated that 88.3% of patients had primary pain, 5.0% had secondary pain, and 6.8% had mixed pain. Patients with primary pain were more likely than the other 2 groups of patients (combined as "non-primary pain") to report certain functional conditions, central sensitization, and features such as sensitivity to light touch, spreading pain, and pain worsening with stress; however, no difference was detected in depression, anxiety, and pain catastrophizing between those with primary and nonprimary pain. These findings are consistent with prior estimates that 85 to 90% of CBNP is "nonspecific." Further research is needed to validate and perhaps refine this diagnostic approach, which holds the potential for better outcomes if patients are offered treatments targeted to primary pain, such as pain neuroscience education and several emerging psychological therapies. PERSPECTIVE: We developed an approach to diagnose chronic primary pain, which was applied in a physiatry clinic to 222 patients with CBNP. Most patients (88.3%) had primary pain, despite almost universal anomalies on spinal imaging. This diagnostic approach can guide educational and psychological treatments tailored for primary pain.

Emotion-Focused Psychodynamic Interview for People with Chronic Musculoskeletal Pain and Childhood Adversity: A Randomized Controlled Trial

Childhood adversity and emotional conflicts are associated with the presence and severity of chronic musculoskeletal pain (CMP), yet common treatments for CMP do not address such risk factors. We developed a single session, emotion-focused psychodynamic interview, based on Emotional Awareness and Expression Therapy and Intensive Short-term Psychodynamic Therapy, and we tested the interview's effects on pain-related outcomes and potential psychological mediators in a randomized, controlled trial. Adults (N = 91; ages 21-70, M = 44.64; 87.9% women) reporting CMP and at least 3 adverse childhood experiences completed measures at baseline and 6-week follow-up. Participants were randomized to immediate interview or waitlist control conditions. The 90-minute interview was conducted via videoconference, and the interviewer elicited disclosure of adversities and conflicts, linked these with pain, and encouraged the experience and expression of adaptive emotions. Analyses indicated that conditions did not differ significantly on change in pain severity; however, compared to control, the interview led to a significantly greater reduction in pain interference (P = .016, ηp2 = .05) and a similar trend for anxiety (P = .058, ηp2 = .04). The interview also significantly changed several potential mediators: pain-related anxiety (P = .008, ηp2 = .06), pain controllability (P = .016, ηp2 = .06), and psychological (P < .001, ηp2 = .15) and brain attributions (P = .022, ηp2 = .05) for pain. Participants viewed the interview as very valuable. We conclude that addressing childhood adversities and conflicts in a psychodynamic interview is beneficial for people with CMP. PERSPECTIVE: This study found that, compared to waitlist control, a 90-minute, remotely-administered, emotion-focused, psychodynamic interview improved pain interference, and anxiety among adults with chronic musculoskeletal pain and childhood adversity. Intensive emotional work can be done in a single session to the benefit of patients with chronic musculoskeletal pain.

Emotional Awareness and Expression Interview: Examining Interview Content and Patient Experiences in Two Medical Samples

A single session of Emotional Awareness and Expression Therapy (EAET)-the EAET Interview-was previously shown to lead to clinical benefits for patients with centralized somatic conditions in primary care (Ziadni et al. in Health Psychol 37(3):282-290, 2018) and tertiary care (Carty et al. in Pain Med 20(7):1321-1329, 2019) settings. There has yet to be an examination of patients' experiences of and reactions to the EAET Interview, which is crucial in evaluating possible clinical implementation of the interview. We conducted secondary analyses on 88 patients (M age = 41.32, 90.9% women) from the two prior trials (primary care N = 51; tertiary care N = 37). Analyses examined interview processes (stress disclosure themes, working alliance, and emotional processing) and patients' reactions to the interview (interview credibility and perceived value of the interview), comparing the two samples and examining correlations among these variables. All patients disclosed at least one stressful life experience, commonly interpersonal problems (89.2%) and childhood adversity (51.5%). Patients had moderately high levels of working alliance and emotional processing during the interview and reported high interview credibility and perceived value of the interview. More extensive emotional processing of stressors was associated with more positive patient reactions to the interview, including higher interview credibility (r = .23) and perceived value (r = .32). We conclude that the single-session EAET Interview was valued by most patients, and patients' emotional processing is particularly beneficial. Addressing the trauma and emotional conflicts of patients with centralized somatic conditions is both feasible and valuable in front-line medical settings.

"I don't have chronic back pain anymore": Patient Experiences in Pain Reprocessing Therapy for Chronic Back Pain

In a recently published randomized controlled trial, two-thirds of the patients receiving a novel psychological treatment, pain reprocessing therapy (PRT), reported elimination or near-elimination of chronic back pain. The mechanisms of PRT and related treatments remain poorly understood but are hypothesized to center on pain reappraisal, fear reduction, and exposure-potentiated extinction. Here, we investigated treatment mechanisms from the participants' perspective. A sample of 32 adults with chronic back pain who received PRT completed semi-structured posttreatment interviews about their treatment experiences. The interviews were analyzed with multiphase thematic analysis. The analyses identified 3 major themes reflecting participants' understanding of how PRT led to pain relief: 1) reappraisal to reduce fear of pain, which included guiding participants to relate to pain as a helpful indicator, overcoming pain-related fear and avoidance, and reconceptualizing pain as a "sensation;" 2) the link between pain, emotions, and, stress, which included gaining insight into these connections and resolving difficult emotions; and 3) social connections, which included patient-provider alliance, therapist belief in the treatment model, and peer models of recovery from chronic pain. Our findings support the hypothesized mechanisms of PRT centered on pain reappraisal and fear reduction, but also highlight additional processes from the participants' perspective, including a focus on emotions and relationships. This study underscores the value of qualitative research methods in illuminating the mechanisms of novel pain therapies. PERSPECTIVE: This article presents participants' perspectives on their experience engaging in a novel psychotherapy for chronic pain, PRT. Through pain reappraisal, linking pain, emotions, and stress, and connecting with their therapist and peers, many participants reported an elimination or near-elimination of their chronic back pain with therapy.

Internet-based emotional awareness and expression therapy for somatic symptom disorder: A randomized controlled trial

OBJECTIVE

Somatic symptom disorder (SSD) is commonly encountered in health care settings. Cognitive-behavioural treatments have been most extensively studied, but they tend to have small effects of temporary duration. Emotional awareness and expression therapy (EAET) is a newly developed treatment for SSD, targeting emotional processing of trauma and conflict as a mechanism of symptom change. In an earlier uncontrolled study of self-guided, internet-administrated EAET (I-EAET), we found substantial reductions in somatic symptoms, prompting the need for a randomized controlled trial of I-EAET.

METHODS

We conducted a 2-arm RCT, comparing 10-week I-EAET (n = 37) to a waitlist control (WL; n = 37). Primary outcomes were reductions of somatic symptoms (PHQ-15) and pain intensity (BPI-4) at post-treatment, with a 4-month evaluation of effect duration. We also analysed emotional processing (EPS-25) and depression (PHQ-9) as possible mediators of I-EAET's effects.

RESULTS

Compared to controls, I-EAET significantly reduced somatic symptoms at both post-treatment and follow-up. I-EAET also reduced pain, depression, insomnia, and anxiety at post-treatment, but these effects were not retained at follow-up. As hypothesized, a facet of emotional processing partially mediated the treatment effect on somatic symptoms, even when controlling for depression.

CONCLUSIONS

Although treatment effects were smaller than in the previous uncontrolled trial, I-EAET is a promising treatment for SSD, with a minority of patients (around 20%) experiencing substantial clinical improvement. The benefits of I-EAET are partially mediated by improved emotional processing. Future research should identify and target patients who respond best to I-EAET and develop tailored treatment to enhance treatment effects. (Preregistered at clinicaltrials.gov: NCT04751825.).

Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial

IMPORTANCE

Chronic back pain (CBP) is a leading cause of disability, and treatment is often ineffective. Approximately 85% of cases are primary CBP, for which peripheral etiology cannot be identified, and maintenance factors include fear, avoidance, and beliefs that pain indicates injury.

OBJECTIVE

To test whether a psychological treatment (pain reprocessing therapy [PRT]) aiming to shift patients' beliefs about the causes and threat value of pain provides substantial and durable pain relief from primary CBP and to investigate treatment mechanisms.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial with longitudinal functional magnetic resonance imaging (fMRI) and 1-year follow-up assessment was conducted in a university research setting from November 2017 to August 2018, with 1-year follow-up completed by November 2019. Clinical and fMRI data were analyzed from January 2019 to August 2020. The study compared PRT with an open-label placebo treatment and with usual care in a community sample.

INTERVENTIONS

Participants randomized to PRT participated in 1 telehealth session with a physician and 8 psychological treatment sessions over 4 weeks. Treatment aimed to help patients reconceptualize their pain as due to nondangerous brain activity rather than peripheral tissue injury, using a combination of cognitive, somatic, and exposure-based techniques. Participants randomized to placebo received an open-label subcutaneous saline injection in the back; participants randomized to usual care continued their routine, ongoing care.

MAIN OUTCOMES AND MEASURES

One-week mean back pain intensity score (0 to 10) at posttreatment, pain beliefs, and fMRI measures of evoked pain and resting connectivity.

RESULTS

At baseline, 151 adults (54% female; mean [SD] age, 41.1 [15.6] years) reported mean (SD) pain of low to moderate severity (mean [SD] pain intensity, 4.10 [1.26] of 10; mean [SD] disability, 23.34 [10.12] of 100) and mean (SD) pain duration of 10.0 (8.9) years. Large group differences in pain were observed at posttreatment, with a mean (SD) pain score of 1.18 (1.24) in the PRT group, 2.84 (1.64) in the placebo group, and 3.13 (1.45) in the usual care group. Hedges g was -1.14 for PRT vs placebo and -1.74 for PRT vs usual care (P < .001). Of 151 total participants, 33 of 50 participants (66%) randomized to PRT were pain-free or nearly pain-free at posttreatment (reporting a pain intensity score of 0 or 1 of 10), compared with 10 of 51 participants (20%) randomized to placebo and 5 of 50 participants (10%) randomized to usual care. Treatment effects were maintained at 1-year follow-up, with a mean (SD) pain score of 1.51 (1.59) in the PRT group, 2.79 (1.78) in the placebo group, and 3.00 (1.77) in the usual care group. Hedges g was -0.70 for PRT vs placebo (P = .001) and -1.05 for PRT vs usual care (P < .001) at 1-year follow-up. Longitudinal fMRI showed (1) reduced responses to evoked back pain in the anterior midcingulate and the anterior prefrontal cortex for PRT vs placebo; (2) reduced responses in the anterior insula for PRT vs usual care; (3) increased resting connectivity from the anterior prefrontal cortex and the anterior insula to the primary somatosensory cortex for PRT vs both control groups; and (4) increased connectivity from the anterior midcingulate to the precuneus for PRT vs usual care.

CONCLUSIONS AND RELEVANCE

Psychological treatment centered on changing patients' beliefs about the causes and threat value of pain may provide substantial and durable pain relief for people with CBP.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03294148.

Emotional Processing and Its Association to Somatic Symptom Change in Emotional Awareness and Expression Therapy for Somatic Symptom Disorder: A Preliminary Mediation Investigation

Objective: The aim of this study was to investigate emotional processing as a potential mediator in therapist-guided, internet-based Emotional Awareness and Expression Therapy (I-EAET) for somatic symptom disorder, using data from a previously published pilot study.

Methods: Participants (N = 52) engaged in a 9-week I-EAET treatment. Before treatment and each week during treatment (i.e., 10 weekly measurements), emotional processing was assessed with the Emotional Processing Scale-25 (EPS-25), which contains five subscales, and somatic symptoms were assessed with the Patient Health Questionnaire-15 (PHQ-15).

Results: Mediation analyses using linear mixed models showed that two EPS-25 subscales—Signs of Unprocessed Emotions and Impoverished Emotional Experience—were uniquely associated with somatic symptom reduction. The proportion of the mediated effect was 0.49, indicating that about half of the total association of the PHQ-15 with symptoms was accounted for by the two EPS-25 subscales.

Conclusion: This preliminary mediation analysis suggests that improved emotional processing is associated with change in somatic symptoms in I-EAET. However, randomized controlled and comparison trials are needed to establish that I-EAET creates the change in emotional processing and that such changes are specific to I-EAET.

Short-Term Psychodynamic Psychotherapy for Functional Somatic Disorders: A Meta-Analysis of Randomized Controlled Trials

INTRODUCTION

Functionalsomatic disorders (FSD) are common and costly, thereby driving the need for the development of effective brief treatment options. Short-term psychodynamic psychotherapy (STPP) is one candidate treatment method.

OBJECTIVE

To review and meta-analyze, where possible, randomized controlled trials (RCTs) of STPP for FSD.

METHODS

Following a systematic search of the literature, we performed a meta-analysis of available RCT groups to determine the effects of STPP on a range of outcomes after treatment, and medium- and long-term follow-ups.

RESULTS

In meta-analyses of 17 RCTs, STPP significantly outperformed minimal treatment, treatment as usual, or waiting list controls on somatic symptom measures at all time frames, with small to large magnitude effect sizes. Descriptive reviews of 5 RCTs suggest that STPP performed at least as well as other bona fide psychological therapies. Limitations of this meta-analysis include small samples of studies and possible publication bias.

CONCLUSIONS

STPP is a valid treatment option for diverse FSD conditions resulting in somatic symptom reductions that persist over time. STPP should be included in FSD treatment guidelines.

Emotional awareness and other emotional processes: implications for the assessment and treatment of chronic pain

Emotional awareness (EA) is a key emotional process that is related to the presence and severity of chronic pain (CP). In this report, we describe primary and secondary emotions, discuss the distinction between emotional states and emotional regulation/processing, and summarize theory and research highlighting the significance of EA for CP. We describe ways to assess EA and diagnose centrally-mediated CP, for which emotional processes appear most relevant. We review several psychological interventions designed to enhance EA as well as several broader emotional processing treatments developed to address trauma and psychosocial conflicts underlying many patients' pain. We conclude by offering our perspective on how future integration of emotional processing into pain care could promote recovery from CP.

Internet-Administered Emotional Awareness and Expression Therapy for Somatic Symptom Disorder With Centralized Symptoms: A Preliminary Efficacy Trial

Background: There is growing evidence that trauma, psychosocial conflict, and difficulties with emotional processing contribute to centralized somatic symptoms. Emotional Awareness and Expression Therapy (EAET) was developed to address these factors and reduce symptoms, and EAET has shown efficacy in face-to-face formats. No trial of an internet-delivered EAET (I-EAET) exists, however, so we developed such an intervention and conducted an uncontrolled feasibility and potential efficacy trial of I-EAET for patients with Somatic Symptom Disorder (SSD) with centralized symptoms (SSD-CS). Method: After screening potential participants, a sample of 52 patients (50 women, two men; age M = 49.6, SD = 11.9) diagnosed with SSD-CS initiated treatment. I-EAET consisted of nine weekly modules focused on psychoeducation, emotional awareness and exposure, and anxiety regulation with self-compassion. Therapists communicated with each patient by email for about 20 min per week during treatment, answering questions and giving feedback on homework assignments. Patients completed measures of somatic symptoms, depression, anxiety, trauma-related symptoms, and functional disability before treatment and again at post-treatment and 4-month follow-up. Results: A large reduction in somatic symptoms (PHQ-15) occurred pre-to post-treatment (d = 1.13; 95% CI: 0.84-1.47) which was fully maintained at 4-month follow-up (d = 1.19; 95% CI: 0.88-1.56). Twenty-three percent of the patients at post-treatment and 27% at follow-up achieved a 50% or greater reduction in somatic symptoms, and about 70% achieved a minimally important clinical difference. In addition, at post-treatment, there were small to medium reductions (d's from 0.33 to 0.72) in anxiety (GAD-7), depression (PHQ-9), trauma-related symptoms (PCL-5), and functional disability (Sheehan Disability Scale). For all of these secondary outcomes, improvements were slightly to substantially larger at follow-up than at post-treatment (d's from 0.46 to 0.80). Conclusion: I-EAET appears to be a feasible treatment for adults with SSD and centralized symptoms, resulting in substantial and durable improvement not only in somatic symptoms but in other psychiatric symptoms and functioning. Controlled trials are needed determine the effects of I-EAET specifically and how this approach compares to face-to-face EAET and to other internet-delivered treatments, such as cognitive-behavioral interventions. Research should also identify treatment responders and mechanisms of change in EAET. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT04122846.

Effects of a Sexual Health Interview among Arab American Women: An Experimental Disclosure Study

Although sexuality is an important aspect of peoples' health and well-being, many people-professionals and patients alike-find sexuality uncomfortable to discuss. In Arab culture, certain sexual thoughts and behaviors are taboo, particularly for women, and it is not known whether an interview in which Arab American women disclose their sexuality to a health professional would be well-received and beneficial or upsetting and harmful. This experimental study tested whether engaging in a disclosure-oriented sexual health interview affects Arab American women's sexual and psychological health. A sample of 134 Arab American women, ages 18-35 years (M = 20.6), completed self-report measures of sexual health and attitudes and psychological symptoms, and then were randomized to an interview or control (waitlist) condition. The 60-min disclosure interview inquired about sexual attitudes, experiences, and conflicts. Five weeks later, all participants completed follow-up measures. Post-interview reports suggest that participants responded favorably to the interview and generally benefited from participation. Analyses of covariance (controlling for baseline levels of the outcome measure) indicated that the interview led to significantly greater sexual satisfaction and less discomfort with sexual self-disclosure at 5-week follow-up, compared to controls; the two conditions did not differ on follow-up sexual self-schema, sexual self-esteem, or psychological symptoms. Moderation analyses revealed that participation in the interview differentially improved the sexual self-schema of women with no past sexual experience, compared to women with sexual experience. These experimental findings suggest the value, rather than the risk, of clinicians encouraging Arab American women to openly disclose and discuss their sexual experiences and attitudes in a confidential, empathic setting.

The Effects of a Life Stress Emotional Awareness and Expression Interview for Women with Chronic Urogenital Pain: A Randomized Controlled Trial

OBJECTIVE

Women with chronic urogenital pain (CUP) conditions have elevated rates of lifetime trauma, relational stress, and emotional conflicts, but directly assessing and treating psychological stress is rarely done in women's health care settings. We developed and tested the effects on patients' somatic and psychological symptoms of a life stress interview that encourages disclosure about stressors and uses experiential techniques to increase awareness of links between stress, emotions, and symptoms.

METHODS

In this randomized trial, women with CUP recruited at a multidisciplinary women's urology center received either a single 90-minute life stress interview (N = 37) or no interview (treatment-as-usual control; N = 25). Self-report measures of pain severity (primary outcome), pain interference, pelvic floor symptoms, and psychological symptoms (anxiety and depression) were completed at baseline and six-week follow-up.

RESULTS

Differences between the life stress interview and control conditions at follow-up were tested with analyses of covariance, controlling for baseline level of the outcome and baseline depression. Compared with the control condition, the interview resulted in significantly lower pain severity and pelvic floor symptoms, but the interview had no effect on pain interference or psychological symptoms.

CONCLUSIONS

An intensive life stress emotional awareness expression interview improved physical but not psychological symptoms among women with CUP seen in a tertiary care clinic. This study suggests that targeting stress and avoided emotions and linking them to symptoms may be beneficial for this complex group of patients.

Psychological Therapy for Centralized Pain: An Integrative Assessment and Treatment Model

OBJECTIVE

Chronic pain is a significant health problem that is increasing in prevalence, and advances in treatment are needed.

METHODS

We briefly review the leading evidence-based psychological therapies for chronic pain-cognitive-behavioral and acceptance/mindfulness-based therapies-and examine several limitations and missing perspectives of these approaches. We review six lesser-known interventions that address these limitations, and we describe our integrative model for psychological assessment and treatment of centralized pain. We present a typical patient and describe how we apply this approach, along with challenges to its implementation and possible solutions to these challenges.

RESULTS

Greater pain treatment efficacy may be possible if clinicians: (a) distinguish patients with primarily centralized (i.e., somatoform or nociplastic) pain from those with primarily peripheral (nociceptive, inflammatory, or neuropathic) pain; (b) acknowledge the capacity of the brain not only to modulate pain but also generate as well as attenuate or eliminate centralized pain; (c) consider the powerful role that adverse life experiences and psychological conflicts play in centralized pain; and (d) integrate emotional processing and interpersonal changes into treatment. Our integrative treatment involves delivering a progression of interventions, as needed, to achieve pain reduction: tailored pain neuroscience education, cognitive and mindfulness skills to decrease the pain danger alarm mechanism, behavioral engagement in avoided painful and other feared activities, emotional awareness and expression to reverse emotional avoidance and overcome trauma or psychological conflict, and adaptive communication to decrease interpersonal stress.

CONCLUSIONS

This integrative assessment and treatment model has the potential to substantially reduce and sometimes eliminate centralized pain by changing the cognitive, behavioral, emotional, and interpersonal processes that trigger and maintain centralized pain.

Emotional Awareness and Expression Therapy for Chronic Pain: Rationale, Principles and Techniques, Evidence, and Critical Review

PURPOSE OF REVIEW

Patients with chronic pain, especially primary or centralized pain, have elevated rates of psychosocial trauma and intrapersonal or intrapsychic conflict. To address these risk factors and potentially reduce pain, the authors developed emotional awareness and expression therapy (EAET). This article presents the rationale for EAET, describes its principles and techniques, reviews its development and early testing as well as recent clinical trials, and critically analyzes the evidence base.

RECENT FINDINGS

Four initial trials (between 2006 and 2011) demonstrated the efficacy of earlier versions of EAET. Four recent randomized, controlled trials of different EAET durations (1 to 8 sessions) and formats (individual or group) in patients with fibromyalgia, irritable bowel syndrome, pelvic pain, or medically unexplained symptoms support the earlier findings. EAET reliably reduces pain and interference, although improvements in anxiety and depression are less reliably achieved and may be delayed. The largest and best conducted trial found superiority of EAET over cognitive-behavioral therapy for fibromyalgia. Patient retention in EAET is high, and adverse events are rare. EAET merits inclusion as a treatment option for primary pain conditions, and it may be the preferred treatment for some patients. Research is needed on EAET with other pain conditions and samples, using better controls and comparison conditions, and on additional ways to motivate and help patients engage in successful emotional processing.

Ambivalence over emotional expression and perceived social constraints as moderators of relaxation training and emotional awareness and expression training for irritable bowel syndrome

OBJECTIVE

Psychological treatments are generally beneficial for patients with irritable bowel syndrome (IBS), but patients' responses vary. A prior randomized controlled trial found that both relaxation training (RT) and emotional awareness and expression training (EAET) were superior to a waitlist control condition for IBS symptoms, quality of life, depression, and anxiety among IBS patients (Thakur et al., 2017).

METHOD

We conducted secondary analyses on these data to examine potential moderators of treatment outcomes. Baseline measures of patients' ambivalence over emotional expression and perceived social constraints, which have been hypothesized to influence some treatments, were tested as possible moderators of the effects of RT and EAET, compared to the control condition.

RESULTS

Results indicated that these variables moderated the effects of RT but not EAET. The benefits of RT occurred for patients who reported higher ambivalence over emotional expression or perceived social constraints, whereas the benefits of EAET were not influenced by these factors.

CONCLUSION

These findings suggest that RT might be particularly helpful for people who tend to avoid emotional disclosure and expression, supporting the possible benefit of targeting treatments to patient characteristics and preferences, whereas EAET might be helpful for a broader range of patients with IBS.

Emotional awareness and expression training improves irritable bowel syndrome: A randomized controlled trial

BACKGROUND

Current clinical guidelines identify several psychological treatments for irritable bowel syndrome (IBS). IBS patients, however, have elevated trauma, life stress, relationship conflicts, and emotional avoidance, which few therapies directly target. We tested the effects of emotional awareness and expression training (EAET) compared to an evidence-based comparison condition-relaxation training-and a waitlist control condition.

METHODS

Adults with IBS (N=106; 80% female, Mean age=36 years) were randomized to EAET, relaxation training, or waitlist control. Both EAET and relaxation training were administered in three, weekly, 50-minute, individual sessions. All patients completed the IBS Symptom Severity Scale (primary outcome), IBS Quality of Life, and Brief Symptom Inventory (anxiety, depressive, and hostility symptoms) at pretreatment and at 2 weeks posttreatment and 10 weeks follow-up (primary endpoint).

KEY RESULTS

Compared to waitlist controls, EAET, but not relaxation training, significantly reduced IBS symptom severity at 10-week follow-up. Both EAET and relaxation training improved quality of life at follow-up. Finally, EAET did not reduce psychological symptoms, whereas relaxation training reduced depressive symptoms at follow-up (and anxiety symptoms at posttreatment).

CONCLUSIONS & INFERENCES

Brief emotional awareness and expression training that targeted trauma and emotional conflicts reduced somatic symptoms and improved quality of life in patients with IBS. This emotion-focused approach may be considered an additional treatment option for IBS, although research should compare EAET to a full cognitive-behavioral protocol and determine which patients are best suited for each approach. Registered at clinicaltrials.gov (NCT01886027).

A life-stress, emotional awareness, and expression interview for primary care patients with medically unexplained symptoms: A randomized controlled trial

OBJECTIVE

Lifetime trauma, relationship adversities, and emotional conflicts are elevated in primary care patients with medically unexplained symptoms (MUS), and these risk factors likely trigger or exacerbate symptoms. Helping patients disclose stressors, increase awareness and expression of inhibited emotions, and link emotions to physical symptoms may improve health. We developed an emotional awareness and expression interview that targets stressful life experiences and conflicts and then tested its effects on primary care patients with MUS.

METHOD

Patients (N = 75) with MUS were recruited at a family medicine clinic and randomized to an interview condition or treatment-as-usual (TAU) control condition. In a single 90-min interview in the clinic, the interviewer elicited disclosure of the patient's stressors, linked them to the patient's symptom history, and encouraged emotional awareness and expression about unresolved relationship trauma or conflict. At baseline and 6-week follow-up, patients completed self-report measures of their physical and psychological health.

RESULTS

Analyses of covariance, controlling for baseline symptoms, compared patients in the interview condition with TAU at 6-week follow-up. Compared with TAU, the interview led to significantly lower pain severity, pain interference, sleep problems, and global psychological symptoms.

CONCLUSIONS

This study provides preliminary evidence for the value of integrating a disclosure and emotional awareness and expression interview into the primary care setting for patients with MUS. (PsycINFO Database Record

The effects of a novel psychological attribution and emotional awareness and expression therapy for chronic musculoskeletal pain: A preliminary, uncontrolled trial

OBJECTIVE

Current psychological and behavioral therapies for chronic musculoskeletal pain only modestly reduce pain, disability, and distress. These limited effects may be due to the failure of current therapies: a) to help patients learn that their pain is influenced primarily by central nervous system psychological processes; and b) to enhance awareness and expression of emotions related to psychological trauma or conflict.

METHODS

We developed and conducted a preliminary, uncontrolled test of a novel psychological attribution and emotional awareness and expression therapy that involves an initial individual consultation followed by 4 group sessions. A series of 72 patients with chronic musculoskeletal pain had the intervention and were assessed at baseline, post-treatment, and 6-month follow-up.

RESULTS

Participation and satisfaction were high and attrition was low. Intent-to-treat analyses found significant improvements in hypothesized change processes: psychological attributions for pain, emotional awareness, emotional approach coping, and alexithymia. Pain, interference, depression, and distress showed large effect size improvements at post-treatment, which were maintained or even enhanced at 6 months. Approximately two-thirds of the patients improved at least 30% in pain and other outcomes, and one-third of the patients improved 70%. Changes in attribution and emotional processes predicted outcomes. Higher baseline depressive symptoms predicted greater improvements, and outcomes were comparable for patients with widespread vs. localized pain.

CONCLUSION

This novel intervention may lead to greater benefits than available psychological interventions for patients with chronic musculoskeletal pain, but needs controlled testing.

28B. Interdisciplinary Approach to Chronic Headaches

Focus Areas: Experiential Workshop, Alleviating Pain

Chronic headaches are a common complaint, affecting millions of people worldwide. Underlying causes are varied, and many individuals suffer from multiple types of head pain, including migraines, tension headaches, and temporomandibular joint dysfunction. Many factors can affect pain intensity and frequency including dietary components, physical activity, stress, medications, and emotional events. Because of the varied causes, a single therapeutic approach is unlikely to be successful in treating the majority of patients. Conventional therapies often rely heavily on oral medication, which may provide insufficient pain control or be poorly tolerated.

This presentation will bring together a variety of alternative treatment options for chronic headaches. The foundations of health will be reviewed in the context of headache care, including a focus on dietary factors. The evidence basis for treatment with supplements, botanicals, hormonal intervention, and energy therapies will be addressed. We will look at available manual techniques with a focus on massage therapy. We will explore the diagnosis of mind-body pain syndrome and its overlap with chronic headaches. Commonly prescribed oral pain medication often results in intolerable side effects. We will discuss the options for topical application of these same pain medications with a much more favorable side effect profile. Participants will gain an understanding of how different types of providers can work together to provide optimal care to treat this common problem.

27. Brief Office Interventions for Anxiety and Depression: Treating the Cause Rather than the Symptoms

Focus Areas: Integrative Approaches to Care, Mental Health

Anxiety and depression are among the most common disorders seen in medical practices. Physicians often have limited resources with which to help patients in a primary care setting. Pharmacologic treatments with selective serotonin reuptake inhibitors have not been shown to be more effective than placebos and have significant risk. Integrative treatments such as relaxation and mindfulness training can be effective but usually require referral to a program and tend to target the symptoms rather than the root cause.

Anxiety and depression are not primary processes but are symptoms caused by emotional reactions to stressful life events. Stressful life events frequently create emotional pathways of fear. In addition, other emotions, primarily anger, guilt, and grief, are typically held in to some degree and the combination of these suppressed emotions create the symptoms of anxiety and/or depression. It has been shown that experiencing, expressing, and releasing these emotions is very effective in reducing symptoms of anxiety and depression.

This workshop will offer a model for helping patients understand that the symptoms of anxiety and depression have been learned by their brains and bodies through a neuroplastic process. It provides a model to explain how their life events and emotional reactions to those events have led to neurologic sensitization that can be reversed by changing the emotional reactions to those events.

A method for quickly identifying the stressful events that have created anxiety and depression will be presented. Then a paradigm derived from a form of psychotherapy known as Intensive Short-Term Dynamic Psychotherapy will be presented. Video of this method will be shown and taught using a live demonstration. Trainees will be given an opportunity to practice this method during the workshop.

There will be ample time for questions and discussion of the topic, these methods, and issues presented by patients.

Pain and emotion: a biopsychosocial review of recent research

OBJECTIVE AND METHOD

Research on emotion and pain has burgeoned. We review the last decade's literature, focusing on links between emotional processes and persistent pain.

RESULTS

Neurobiological research documents the neural processes that distinguish affective from sensory pain dimensions, link emotion and pain, and generate central nervous system pain sensitization. Psychological research demonstrates that greater pain is related to emotional stress and limited emotional awareness, expression, and processing. Social research shows the potential importance of emotional communication, empathy, attachment, and rejection.

CONCLUSIONS

Emotions are integral to the conceptualization, assessment, and treatment of persistent pain. Research should clarify when to eliminate or attenuate negative emotions, and when to access, experience, and express them. Theory and practice should integrate emotion into cognitive-behavioral models of persistent pain.

Sustained pain reduction through affective self-awareness in fibromyalgia: a randomized controlled trial

BACKGROUND AND OBJECTIVE

Affect and how it is regulated plays a role in pain perception, maintenance of pain, and its resolution. This randomized, controlled trial evaluated an innovative affective self-awareness (ASA) intervention, which was designed to reduce pain and improve functioning in individuals with fibromyalgia.

PARTICIPANTS AND METHODS

Forty-five women with fibromyalgia were randomized to a manualized ASA intervention (n = 24) or wait-list control (n = 21). The intervention began with a one-time physician consultation, followed by 3 weekly, 2-h group sessions based upon a mind-body model of pain. Sessions focused on structured written emotional disclosure and emotional awareness exercises. Outcomes in both conditions were measured by a blinded assessor at baseline, post-intervention, and 6-month follow-up.

MEASURES

The primary outcome was pain severity (Brief Pain Inventory); secondary outcomes included tender-point threshold and physical function (SF-36 Physical Component Summary). Intent-to-treat analyses compared groups on outcomes using analysis of covariance and on the proportion of patients achieving ≥ 30% and ≥ 50% pain reduction at 6 months.

RESULTS

Adjusting for baseline scores, the intervention group had significantly lower pain severity (p < 0.001), higher self-reported physical function (p < 0.001), and higher tender-point threshold (p = 0.02) at 6 months compared to the control group. From baseline to 6 months, 45.8% of the ASA intervention group had ≥ 30% reduction in pain severity, compared to none of the controls (p < 0.001).

CONCLUSIONS

The affective self-awareness intervention improved pain, tenderness, and self-reported physical function for at least 6 months in women with fibromyalgia compared to wait-list control. This study suggests the value of interventions targeting emotional processes in fibromyalgia, although further studies should evaluate the efficacy of this intervention relative to active controls.

Overview of epidemiology, clinical features, genetics, neurobiology, and prognosis of adolescent attention-deficit/hyperactivity disorder

ADHD is a common neurobehavioral disorder that is highly heritable. Recent research has identified several genes that are associated with ADHD. In addition, there are several biological factors that are environmentally derived that appear to play a role in the etiology of ADHD. It is quite clear that ADHD begins in childhood, but persists into adolescence and adulthood for the majority of individuals. Since the criteria for the diagnosis of ADHD are most applicable to children, making the diagnosis in adolescents requires an understanding of how these symptoms are expressed in this age group. The prognosis of ADHD is variable and depends on several psychosocial factors, with approximately 20% of adolescents who perform well in social, emotional, and educational domains, another 20% who perform poorly in these domains, and the majority who perform somewhere in the middle.

ADHD in Children, Adolescents, and Adults

Attention-deficit-hyperactivity disorder (ADHD) is a commonly occurring, heritable neurobehavioral disorder distributed worldwide that does not typically resolve after childhood. The significant impact of ADHD on an individual's family, relationships, educational performance, and performance at work is now well established. Medical treatment of ADHD is effective, not only alleviating symptoms but also improving overall functioning. It is imperative that primary care physicians be well versed in this disorder and its clinical features across the age groups. The primary care physician should be able to screen, diagnose, educate, and initiate medication management in patients with uncomplicated ADHD.

Effects of oral cocaine on intravenous cocaine discrimination in humans

This study was designed to evaluate the drug discrimination paradigm as a model for assessing the ability of potential agonist medications to block the effects of intravenous cocaine. Previous research has demonstrated that oral cocaine attenuated the subjective and physiological effects of intravenous cocaine injections, and in the absence of a known efficacious medication for cocaine use disorders, a proof-of-concept approach was used in which cocaine was acutely administered orally to block intravenous cocaine's discriminative-stimulus effects. During training, 11 cocaine-dependent participants were able to discriminate between intravenous saline and 20 mg/70 kg iv cocaine, and 8 of these participants completed the study. After training, participants ingested capsules containing either placebo or 300 mg/70 kg cocaine 60 min prior to the intravenous injection of different doses of cocaine during test sessions with no contingencies in place. Each cocaine dose was administered twice, once under each oral pretreatment condition. Training sessions were interspersed among the test sessions. Physiological and subjective effects were measured throughout each session. Oral cocaine moderately increased some of the subjective and physiological effects of the lower doses of intravenous cocaine, whereas effects at the higher doses were unaltered. Similar changes were seen for the discrimination results. Thus, although oral cocaine given acutely likely is not a viable treatment medication for cocaine dependence, the usefulness of the drug discrimination model in the evaluation of agonist treatment medications remains unclear.

A controlled study of autonomic nervous system function in adults with attention-deficit/hyperactivity disorder treated with stimulant medications: results of a pilot study

OBJECTIVE

Despite the fact that autonomic nervous system (ANS) abnormalities are commonly found in adults and predict increased cardiovascular mortality, no studies have assessed ANS function in adults with attention-deficit/hyperactivity disorder (ADHD) taking stimulants.

METHOD

This pilot study evaluated ANS function in adults with ADHD in comparison with an age- and gender-matched control group.

RESULTS

The authors found that 4% of the control group had some abnormalities in the ANS in comparison with 24% of the ADHD group.

CONCLUSION

Because the control group had higher levels of exercise fitness, and the level of abnormalities in the ADHD group was comparable with that of the general population, the significance of these findings is unknown. In addition, we did not determine if ANS abnormalities were present in individuals with ADHD who were not on stimulant medications. Further research is warranted to determine if there is any association between ADHD and stimulant use and ANS abnormalities.

Intravenous cocaine discrimination in humans

Ten cocaine-dependent participants were trained to discriminate between intravenous saline and 20 mg/70 kg cocaine. During the first session, saline and cocaine injections were alternated twice, with each separated by 1 hr. The injections were identified by letter codes. During the next 3 sessions, 12 trials were conducted, with saline and cocaine administered 6 times each in pseudorandom order. Thirty minutes following each injection, participants were asked to identify the injection by letter code. Seven of the 10 learned the discrimination (at least 10 trials correct). To evaluate sensitivity, the investigators tested participants with different doses of cocaine in test sessions. In the next phase, methamphetamine (5 and 10 mg/70 kg) and pentobarbital (50 and 100 mg/70 kg) were given intravenously during test sessions to determine whether the discrimination exhibited pharmacological class selectivity. During the evaluation of sensitivity and selectivity, training sessions were interspersed. As dose of cocaine increased, the number of participants identifying the test dose as cocaine increased, demonstrating sensitivity. The higher doses of methamphetamine and pentobarbital substituted for cocaine. The physiological and subjective effects of cocaine and methamphetamine were stimulant-like and dose related. Pentobarbital produced no physiological changes but increased Visual Analog Scale ratings of Sedation, Good Drug Effect, and High. This failure to demonstrate pharmacological selectivity may be related to participants' learning a drug-vs.-no-drug discrimination, and thus it may be necessary to alter training procedures in future studies.

Substance abuse in patients with attention-deficit hyperactivity disorder : therapeutic implications

Attention-deficit hyperactivity disorder (ADHD) is a common disorder in children that frequently persists into adulthood. Studies have found that substance use disorders (SUD) are seen more commonly in those with ADHD than the general population. Although treatment with stimulant medications has been shown to be effective for individuals with ADHD, concern about the use of these agents in this population persists. This review article highlights the research in this area with a focus on the treatment of individuals who present with concomitant ADHD and SUD. Although stimulants can be abused, studies have shown that adolescents who are prescribed stimulants for ADHD have lower rates of SUD than those who are not treated with stimulants. It may be particularly difficult to evaluate adults for the diagnosis of ADHD when SUD is a co-morbid factor. Studies show that 20--30% of adults presenting with SUD have concomitant ADHD and approximately 20--40% of adults with ADHD have histories of SUD. Therefore, it is critical to perform careful diagnostic interviews to discern if patients have either or both of these disorders. Many clinical experts suggest that adults with ADHD and active SUD be treated for the SUD until a period of sobriety persists prior to initiation of specific treatment for ADHD. Since individuals with ADHD and active SUD are more likely to have more severe SUD and a worse prognosis, this approach may not serve many patients, as they relapse prior to obtaining ADHD treatment. Therefore, research has been directed towards determining if the treatment of ADHD with stimulant medications can be safe and effective for the individual with active SUD and concomitant ADHD. An initial trial of methylphenidate in a population of adults with active cocaine dependence and ADHD indicates that this is the case. Individuals with ADHD and SUD can present difficult diagnostic and therapeutic challenges. It appears that the most effective treatment option is to create a programme that uses the most effective treatment modalities available, including both behavioural and medical therapies, along with close supervision and monitoring. Newer medical treatment options of long-acting stimulants and non-stimulants (e.g. atomoxetine) offer effective treatment with a lower risk of abuse potential.

Patterns of inattentive and hyperactive symptomatology in cocaine-addicted and non-cocaine-addicted smokers diagnosed with adult attention deficit hyperactivity disorder

Despite a robust relationship between Attention Deficit Hyperactivity Disorder (ADHD) and cigarette smoking, as well as increased prevalence of other substance use disorders in these individuals, little is known about the particular patterns of ADHD symptomatology associated with different forms of drug abuse. The present study com- pared ADHD adults with and without cocaine dependence (COCDEP) on severity of ADHD symptomatology. Groups did not differ in smoking rate or degree of nicotine dependence. COCDEP ADHD smokers reported significantly more childhood and adult hyperactive/impulsive symptoms, and a higher number of symptoms overall, during adulthood, even after controlling for group differences in age and sex. Our finding of a more severe adult ADHD symptom profile among ADHD smokers with cocaine dependence, accounted for by elevated hyperactive/impulsive but not inattentive features, suggests that cocaine use in smokers with ADHD may be driven by excesses in hyperactivity. These findings have important implications for research, since similarities and differences in patterns and severity of ADHD symptomatology may shed light on drug-specific mechanisms. Our results may also point to improved approaches for treatment of substance abuse based on attention to patterns of ADHD symptomatology specific to different drugs.

Double-blind placebo-controlled trial of methylphenidate in the treatment of adult ADHD patients with comorbid cocaine dependence

In this 12-week double-blind placebo-controlled trial of methylphenidate (MTP) versus placebo in 48 cocaine-dependent attention-deficit/hyperactivity disorder (ADHD) adults, the authors sought to determine whether MTP would be safe, control ADHD symptoms, and affect cocaine use. Efficacy indexes revealed significantly greater ADHD symptom relief in the MTP group. There were no group differences in self-reported cocaine use, urinalysis results, or cocaine craving. Because of the relatively small sample size, the results are preliminary. However, we found that MTP improved subjective reports of ADHD symptoms and did not worsen cocaine use while participants were in treatment.

Double-blind placebo-controlled trial of methylphenidate in the treatment of adult ADHD patients with comorbid cocaine dependence

In this 12-week double-blind placebo-controlled trial of methylphenidate (MTP) versus placebo in 48 cocaine-dependent attention-deficit/hyperactivity disorder (ADHD) adults, the authors sought to determine whether MTP would be safe, control ADHD symptoms, and affect cocaine use. Efficacy indexes revealed significantly greater ADHD symptom relief in the MTP group. There were no group differences in self-reported cocaine use, urinalysis results, or cocaine craving. Because of the relatively small sample size, the results are preliminary. However, we found that MTP improved subjective reports of ADHD symptoms and did not worsen cocaine use while participants were in treatment.

Use of complementary/alternative therapies among children in primary care pediatrics

OBJECTIVES

To determine the prevalence of and factors associated with use of complementary/alternative therapies (CAM) by pediatric patients seeking primary care.

DESIGN AND SETTING

A self-report questionnaire was administered to parents/caregivers in 6 general pediatric practices in urban and suburban Detroit from August 1999 to December 1999.

RESULTS

A total of 1013 questionnaires were completed; 67.5% of the patients were 5 years of age or younger. The overall use of CAM was 12%. Factors in families associated with use of CAM were maternal age greater than 31 years (P =.001), religious affiliation (P =.001), parent/caretaker born outside of the United States (P =.04), and use of CAM by the parent/caretaker or his/her spouse (P =.001). Significant factors associated with the children who used CAM were age greater than 5 years (P =.001), pediatric visit for an illness (P =.05), regular medication use (P =.001), and having an ongoing medical problem (P =.001). The most common types of CAM used were herbs (41%), prayer healing (37%), high-dose vitamin therapy and other nutritional supplements (34.5%), folk/home remedies (28%), massage therapy (19%), and chiropractic (18%). The majority of CAM users (66%) did not report the use of CAM to their primary care physician. A logistic regression analysis revealed that use of CAM by parents/caretakers was the single best predictor of CAM use in a child.

CONCLUSION

CAM use is significant among children who visit pediatric practices. Pediatricians should inquire about CAM use among patients, particularly those with ongoing medical problems and those with parents/caretakers who use CAM for themselves.

A time-motion study of the activities of attending physicians in an internal medicine and internal medicine-pediatrics resident continuity clinic

PURPOSE

To describe the activities of attending physicians in a residency-based continuity clinic and to examine factors that affect their teaching of, supervision of, and interaction with residents.

METHOD

Six full-time board-certified faculty members (three internal medicine, three internal medicine-pediatrics) in an urban residency program participated in a descriptive observational time-motion study. The attending faculty were directly observed by "shadow" technique for 30 half-day sessions from April 1994 through September 1994. Each activity was measured by a trained research assistant using a digital stopwatch. The observed activities were assigned to one of 16 subcategories.

RESULTS

6,389 minutes of activities were observed. Activities were distributed among four general categories: direct contact with residents (43.1%), clinic operations (33.7%), personal and/or professional activities (18.0%), and miscellaneous time (5.2%). Attending physicians spent the most time in direct contact with residents when the patient-to-attending ratio was 10-14:1.

DISCUSSION

The activities of the clinic's attending physicians were quite varied. Less than half of their time in the clinic was spent in contact with residents. This contact time may be significantly increased by changes to clinic policies, such as optimizing the patient-to-faculty ratio and increasing administrative support for the clinic. These findings can be used as a reference point for studies of attending physicians' activities since the federally mandated rules changes regarding their responsibilities for supervising residents.

Discrimination of intranasal cocaine

In the development of medications for the treatment of cocaine abuse, the drug discrimination paradigm can be used to identify medications that can attenuate the discriminative stimulus effects of cocaine. To ascertain that participants are basing the discrimination on the drug's central effects, this paradigm requires that the drug and placebo administrations do not produce any peripheral effects on which the discrimination can be based. This study examined whether intranasal cocaine (50 mg) can be discriminated from placebo (46 mg lactose + 4 mg cocaine), how quickly this discrimination can be made, and whether pretreatment with intranasal benzocaine can affect this discrimination. Results showed that subjects were generally able to discriminate the drug conditions correctly 15 s after administration, and this was unaffected by benzocaine. These results suggest that subjects base the discrimination on peripheral drug effects (e.g. taste) that are not affected by anaesthesia of the nasal passage, and that the intranasal route of cocaine administration is unlikely to be feasible with a drug discrimination paradigm.

Prevalence of attention-deficit/hyperactivity disorder and conduct disorder among substance abusers

BACKGROUND

This cross-sectional study sought to determine the prevalence of attention-deficit/hyperactivity disorder (ADHD) and conduct disorder among adults admitted to 2 chemical dependency treatment centers. It was hypothesized that ADHD alone or in combination with conduct disorder would be overrepresented in a population of patients with psychoactive substance use disorders.

METHOD

Two hundred one participants were selected randomly from 2 chemical dependency treatment centers. Standardized clinical interviews were conducted using the Structured Clinical Interview for DSM-IV, the Addiction Severity Index, and DSM-IV criteria for ADHD. Reliabilities for the diagnostic categories were established using the Cohen kappa, and the subgroups of individuals with and without ADHD and conduct disorder were compared.

RESULTS

Forty-eight (24%) of the participants were found to meet DSM-IV criteria for ADHD. The prevalence of ADHD was 28% in men (30/106) and 19% in women (18/95; NS). Seventy-nine participants (39%) met criteria for conduct disorder, and 34 of these individuals also had ADHD. Overall, individuals with ADHD (compared with those without ADHD) were more likely to have had more motor vehicle accidents. Women with ADHD (in comparison with women without ADHD) had a higher number of treatments for alcohol abuse. Individuals with conduct disorder (in comparison with those without conduct disorder) were younger, had a greater number of jobs as adults, and were more likely to repeat a grade in school, have a learning disability, be suspended or expelled from school, have an earlier age at onset of alcohol dependence, and have had a greater number of treatments for drug abuse. They were more likely to have a lifetime history of abuse of and/or dependence on cocaine, stimulants, hallucinogens, and/or cannabis.

CONCLUSION

A significant overrepresentation of ADHD exists among inpatients with psychoactive substance use disorders. Over two thirds of those with ADHD in this sample also met criteria for conduct disorder. Our sample had a very large overlap between ADHD and conduct disorder, and the major comorbidities identified here were attributable largely to the presence of conduct disorder. Individuals who manifest conduct disorder and/or ADHD represent a significant proportion of those seeking treatment for psychoactive substance use disorders. They appear to have greater comorbidity and may benefit from a treatment approach that addresses these comorbidities specifically through medical and behavioral therapies.

Tobacco cessation and youth: the feasibility of brief office interventions for adolescents

BACKGROUND

The prevalence of tobacco use among adolescents remains high and the great majority of adult smokers begin smoking prior to the age of 18. While there have been a number of primary prevention projects in communities and schools, less attention has been given to smoking cessation for adolescents. This paper reviews the literature on the theory and practice of cessation as applicable to adolescents.

METHODS

The relevant literature was culled from a MEDLINE search and supplemented with secondary searches from those articles.

RESULTS

There have been few studies on brief interventions for adolescent smoking cessation in health care settings. However, there are several models for smoking cessation that are either applicable to or designed for adolescents. Pharmacologic treatments are also beginning to be used.

CONCLUSIONS

There is a great need for the development and evaluation of models for adolescent smoking cessation in health care settings. Recent developments, however, give cause for optimism in helping adolescent smokers in tobacco cessation.

Parent and adolescent perceived need for parental consent involving research with minors

OBJECTIVE

To assess parents' and adolescents' perceived need for parental consent for minor adolescents to participate in minimal risk research studies based on procedural invasiveness (anonymous surveys, interviews, and blood or urine testing) and sensitivity of the topics (sexuality, drug and alcohol use, and sexually transmitted diseases and human immunodeficiency virus [HIV]).

METHODS

An anonymous self-report questionnaire was administered to 100 adolescent-parent pairs at 2 clinical sites (urban and suburban) of Children's Hospital of Michigan in Detroit.

RESULTS

By invasiveness of the research procedure, the proportions of parents and adolescents who perceived a need for parental consent were as follows: face-to-face interviews, 62% vs 48%; telephone interviews, 72% vs 46%; blood or urine testing, 77% vs 62%; and blood testing for HIV status, 78% vs 59%. These differences were only significant for telephone interviews and HIV blood testing. For anonymous surveys, a minority of parents (33%) and adolescents (26%) reported that parental consent was needed. Based on sensitivity of the research topics, the proportions of parents and adolescents who perceived a need for parental consent were as follows: sexuality, 60% vs 34%; drug and alcohol use, 56% vs 44%; contraception, 62% vs 46%; and sexually transmitted diseases and HIV testing, 56% vs 52%. These differences were only significant for sexuality. Parents with higher education believed that teens could give their own consent (P < .05). Fifty-seven percent of parents and their teens agreed that parental consent for anonymous surveys was not necessary. For more invasive procedures and more sensitive topics, the percentage of disagreement ranged from 28% to 55.5%.

CONCLUSIONS

There is a greater perceived need for parental consent to adolescent participation in research studies among parents than among teens for more invasive procedures and more sensitive topics. These results suggest the need for sensitivity to differing adolescent and parental perceived need for parental consent for a minor adolescent to participate in such studies. Further studies with larger samples are needed to determine what factors influence diverse parent and adolescent opinions.

Current positions of graduates of internal medicine-pediatrics training programs

OBJECTIVE

To determine what positions graduates of internal medicine-pediatrics programs currently hold.

DESIGN

A survey of the program directors of residencies in internal medicine-pediatrics.

PARTICIPANTS

Program directors of the 85 internal medicine-pediatrics training programs listed in the 1993-1994 Graduate Medical Education Directory.

MAIN OUTCOME MEASURES

A 1-page survey that described the current positions of trainees graduating between 1987 and 1993.

RESULTS

Seventy-four (87%) of the 85 program directors completed the survey. Of the 708 graduates reported on, 68% were practicing as generalists. The generalists of this cohort (n = 480) were primarily in private practice settings (n = 390, 81%) and most were practicing internal medicine-pediatrics (n = 416, 85%). Only 12% of the generalists had chosen to practice either pediatrics or internal medicine. Twenty-one percent of the total graduates had entered subspecialty training.

CONCLUSIONS

To our knowledge, the sample of 708 graduates is the largest survey of graduates of internal medicine-pediatrics programs to date and shows that 68% of graduates are practicing in primary care fields. Graduates of internal medicine-pediatrics programs should be considered as an important source of primary care physicians.

Fifteen years of a videotape review program for internal medicine and medicine-pediatrics residents

The medical interview remains the most valuable component in patient evaluation. In addition to its diagnostic usefulness, it is the foundation upon which the doctor-patient relationship is built. It is essential, therefore, that health care providers be well trained in interviewing. Evidence suggests that having residents conduct videotaped interviews with patients and review the videotapes with faculty is an excellent way to teach interviewing skills. Videotape review has been part of the residency programs in primary care internal medicine and medicine-pediatrics at Wayne State University School of Medicine for 15 years. Throughout the history of the videotape program, the authors have endeavored to make the review process less stressful for residents by ensuring that the reviews are nonthreatening, nonjudgmental, and learner-centered. In this paper, the authors discuss (1) the structure and process of the videotape review program; (2) recurrent themes of the review sessions; (3) residents' perspectives on the process; and (4) potential barriers to a successful videotape review program and suggestions for how to avoid or overcome them.