Smärtpatienter – personlighet, upplevt sammanhang, kliniskt status, effekter av kognitiv terapi

Vad är det som påverkar en individs upplevelse av och förmåga att hantera stress och smärta? Trots att forskningen kring långvarig smärta, dess orsaker och konsekvenser länge har varit intensiv och numera ses ur ett biopsykosocialt perspektiv, kvarstår frågor om vilka faktorer som styr människors smärtupplevelse och ibland gör att smärtan blir långvarig och svårbehandlad. Denna artikel är en sammanställning av det examensarbete som författarna gjorde i samband med legitimationsgrundande utbildning i Kognitiv Psykoterapi vid Cognitivt Center i Kungälv 2005. I studien undersöktes sambandet mellan långvarig smärta och sårbarhetsfaktorer samt effekter av kognitiv terapi utifrån en kvantitativ och kvalitativ eftermätning avseende kliniskt status. The current study had 3 parts: 1a) A group of patients with stress related pain (assessed on a VAS-scale) was compared to a control group on personality profile (Scandinavian Universities Personality Scales), Sense of Coherence (SOC/KASAM), as well as clinical status: Relationship Styles (RSQ), depression (Beck Depression Inventory/BDI) and anxiety (Beck’s Anxiety Scale/BAI); 1b) the effects of cognitive psychotherapy on clinical status were assessed following treatment; and 2), interviews were conducted with a subgroup of the pain patients focusing on significant aspects of the therapy process. The Study 1a results indicated that patients with pain exhibited significantly more Somatic and Mental Stress propensity, Vulnerability to stress, Sensation seeking, Bitterness, and Distrust than the control group. In addition, they displayed significantly more “Preoccupied attachment”, less optimal Sense of Coherence, more depression and anxiety symptoms. Following treatment (Study 1b), pain patients showed a significant decrease in depression and pain, particularly among females. Study 2 interview data suggested a process going from chaos and powerlessness to an increased awareness, knowledge, and ability to look forward. Clinical implications are discussed. Keywords: Pain, psychopathology,attachment, sense of coherence(SOC), cognitive therap

Time to gain trust and change : - experiences of attachment and mindfulness-based cognitive therapy among patients with chronic pain and psychiatric co-morbidity

The treatment of patients with chronic pain disorders is complex. In the rehabilitation of these patients, coping with chronic pain is seen as important. The aim of this study was to explore the meaning of attachment and mindfulness-based cognitive therapy (CT) among patients with chronic pain and psychiatric co-morbidity. A phenomenological approach within a lifeworld perspective was used. In total, 10 patients were interviewed after completion of 7- to 13-month therapy. The findings reveal that the therapy and the process of interaction with the therapist were meaningful for the patients’ well-being and for a better management of pain. During the therapy, the patients were able to initiate a movement of change. Thus, CT with focus on attachment and mindfulness seems to be of value for these patients. The therapy used in this study was adjusted to the patients’ special needs, and a trained psychotherapist with a special knowledge of patients with chronic pain might be required

Response to vitamin B12 and folic acid in myalgic encephalomyelitis and fibromyalgia.

Patients with myalgic encephalomyelitis (ME, also called chronic fatigue syndrome) may respond most favorably to frequent vitamin B12 injections, in vital combination with oral folic acid. However, there is no established algorithm for individualized optimal dosages, and rate of improvement may differ considerably between responders.To evaluate clinical data from patients with ME, with or without fibromyalgia, who had been on B12 injections at least once a week for six months and up to several years.38 patients were included in a cross-sectional survey. Based on a validated observer's rating scale, they were divided into Good (n = 15) and Mild (n = 23) responders, and the two groups were compared from various clinical aspects.Good responders had used significantly more frequent injections (p<0.03) and higher doses of B12 (p<0.03) for a longer time (p<0.0005), higher daily amounts of oral folic acid (p<0.003) in good relation with the individual MTHFR genotype, more often thyroid hormones (p<0.02), and no strong analgesics at all, while 70% of Mild responders (p<0.0005) used analgesics such as opioids, duloxetine or pregabalin on a daily basis. In addition to ME, the higher number of patients with fibromyalgia among Mild responders was bordering on significance (p<0.09). Good responders rated themselves as "very much" or "much" improved, while Mild responders rated "much" or "minimally" improved.Dose-response relationship and long-lasting effects of B12/folic acid support a true positive response in the studied group of patients with ME/fibromyalgia. It's important to be alert on co-existing thyroid dysfunction, and we suspect a risk of counteracting interference between B12/folic acid and certain opioid analgesics and other drugs that have to be demethylated as part of their metabolism. These issues should be considered when controlled trials for ME and fibromyalgia are to be designed

Comparison of Good and Mild responders.

<p>Mean ± SD or frequency/percentage for a number of variables in Good (n = 15) or Mild responders (n = 23). P-value is calculated by Student’s t-test, or by Fischer’s exact two-tailed test in the categorical data. (n.s. = no significance)</p><p>Comparison of Good and Mild responders.</p

Prescribed Analgesics.

<p>Number of Good and Mild responders on daily use of prescribed analgesics. Tramadol, Codeine and Buprenorphine are opioids, while Duloxetine and Pregabalin are approved for the management of neuropathic pain. One patient was using Tramadol and Duloxetine at the same time.</p><p>Prescribed Analgesics.</p

Vitamin B12 and folate in monocarbon metabolism.

<p>Schematic view of where enzyme MTHFR is contributing to synthesis of methyl-folate, and the subsequent methyl group transition from folate to B12 to homocysteine, which transforms into methionine. Activated methionine (S-Adenosyl Methionine; SAM) is the most important methyl donor in cell metabolism.</p

Genotypes of MTHFR.

<p>Overview of prevalence (ref 6) and specific enzyme activity <i>in vitro</i> (ref 7) for various genotypes of MTHFR in healthy individuals, based on combinations of the polymorphisms C677T and A1298C.</p><p>Genotypes of MTHFR.</p