Baseline Pro-Inflammatory Cytokine Levels Moderate Psychological Inflexibility in Behavioral Treatment for Chronic Pain

Background: The medical and scientific communities struggle to understand chronic pain and find effective treatments. Multimodal approaches are encouraging but show significant individual differences. Methods: Seventy-eight persons (56 women) with chronic pain received Acceptance and Commitment Therapy and provided blood samples before and after treatment. The participants completed surveys with the blood sampling. Blood plasma was analyzed for IL-6 and TNF-α levels with the Olink Inflammation Panel (Olink Bioscience Uppsala, Sweden). The treatment effects and moderating effects of low-grade inflammation on changes in outcomes were analyzed using linear mixed models. Results: Pain interference (p < 0.001) and psychological inflexibility (p < 0.001) improved significantly during treatment, but pain intensity did not (p = 0.078). Cytokine levels did not change over the course of the treatment (IL-6/TNF-α p = 0.086/0.672). Mean baseline levels of IL-6 and TNF-α moderated improvement in psychological inflexibility during the course of treatment (p = 0.044), but cytokine levels did not moderate changes in pain interference (p = 0.205) or pain intensity (p = 0.536). Conclusions: Higher baseline inflammation levels were related to less improvement in psychological inflexibility. Low-grade inflammation may be one factor underlying the variability in behavioral treatment in chronic pain.publishedVersio

Exposure and acceptance in patients with chronic debilitating pain : A behavior therapy model to improve functioning and quality of life

A large number of patients suffer from reduced functioning and quality of life due to longstanding pain. The importance of psychological factors is undisputable and there is today substantial empirical support for treatments based on cognitive behavior therapy (CBT). Nevertheless, previous research also illustrates a clear need for improvements. For example, there is a lack of studies with children and adolescents that are severely disabled by longstanding pain other than headache. Also, the process by which CBT is effective is still rather unclear. Recently, developments within CBT, such as Acceptance and Commitment Therapy (ACT), suggest an approach that, in contrast to reduction or control of symptoms, promotes acceptance of negative private experiences like chronic pain and distress. This type of intervention is aimed at improving functioning and quality of life by increasing psychological flexibility, i.e. the ability to act in alignment with personal values also in the presence of e.g. pain, fear, and negative thoughts. Although studies exist, there is an urgent need for randomized controlled trials with chronic pain patients, especially children and adolescents. The presented studies were conducted within the development of a clinical model to improve functioning and quality of life in children, adolescents, and adults with chronic debilitating pain. The thesis had two general aims. One, to investigate the effectiveness of an intervention based on values-oriented exposure and acceptance (studies 1, 2, and 4 in the present thesis). Two, to develop and psychometrically evaluate a self-report instrument designed to assess psychological flexibility in people with chronic pain (studies 2 and 5). Initially, an uncontrolled pilot study (study 1) was conducted with adolescents suffering from chronic idiopathic pain (n=16). Following treatment, large and stable reductions were seen in e.g. functional disability, pain intensity, and catastrophizing, with generally large effect sizes. Study 3 included people with chronic pain and whiplash associated disorders (WAD) (n=22). Exposure and acceptance delivered in addition to treatment as usual (TAU) was compared with a control group receiving only TAU. Following the exposure and acceptance intervention, improvements were seen in all measures but pain intensity, and these effects were retained seven months following the end of treatment. Furthermore, significant differences following treatment, in favor of the exposure and acceptance group, were seen in e.g. pain disability, life satisfaction, fear of movement, and psychological inflexibility, with moderate to large effect sizes. In study 4, participants were children and adolescents with chronic idiopathic pain (n=32). The effectiveness of exposure and acceptance was evaluated by comparing it with a multidisciplinary treatment approach including amitriptyline (MDT). The exposure and acceptance group showed large and sustained improvements in all measures, including functioning, quality of life, and pain intensity, with mostly large effects sizes. The exposure and acceptance group performed significantly better than the MDT on e.g. perceived functional ability in relation to pain, kinesiophobia, pain intensity and pain related discomfort, with moderate to large effect sizes. Parallel to the treatment evaluations, two studies were conducted to develop and evaluate an instrument to assess central and discernible components of psychological flexibility, referred to as the Psychological Inflexibility in Pain Scale (PIPS). In the development study (study 2), data was collected from pain clinics and patient organizations (n=203). Based on an original set of 38 items, principal component analyses suggested a two-factor solution with 16 items, showing adequate internal consistency and concurrent criterion validity. In study 5, participants were recruited from a patient organization for people with WAD (n=611). Exploratory and confirmatory factor analyses resulted in a two-factor solution with 12 items, illustrating good reliability and validity. Only items that were retained in both studies 2 and 5 were included in the final version of the instrument. Furthermore, hierarchical regression analyses illustrated that PIPS explained a significant amount of variance in e.g. pain, work absence, life satisfaction, disability, depression, and kinesiophobia. In conclusion, despite some methodological limitations, the treatment evaluations indicate the effectiveness of the exposure and acceptance intervention, and suggest that it may be superior to TAU only, as well as to a multidisciplinary program including amitriptyline. Furthermore, data from two measurement development studies suggest that PIPS can be used as a reliable and valid measure to assess key components in psychological inflexibility in people with chronic pain. More studies are needed to confirm these findings; especially larger scale randomized controlled trials

Acceptance and Commitment Therapy for Pediatric Chronic Pain: Theory and Application

Acceptance and Commitment Therapy (ACT) is a third wave behavior therapy approach which aims to increase engagement in activities that bring meaning, vitality, and value to the lives of individuals experiencing persistent pain, discomfort, or distress. This goal is particularly relevant when these aversive experiences cannot be effectively avoided or when avoidance efforts risk their exacerbation, all of which may be common experiences in children and adolescents with chronic pain conditions. The primary aim of the present paper is to review and summarize the extant literature on the application, utility, and evidence for using ACT with pediatric chronic pain populations by: (1) defining the theoretical assumptions of the ACT model; (2) summarizing research study findings and relevant measures from the published literature; and (3) critically discussing the strengths, limitations and areas in need of further development

When a crisis hits, send in the psychologists? A latent transition analysis of help-seeking behavior among Swedish healthcare workers during the Covid-19 pandemic

During a crisis there is limited time to plan support initiatives for healthcare workers and few resources available to secure that they engage with the initiatives. Within the context of the recent Covid-19 pandemic, this study aimed to investigate help-seeking behaviors among healthcare workers in relation to psychological support initiatives offered to them. Data from a Swedish longitudinal survey following healthcare workers from early (N = 681) to mid-pandemic (N = 396) were analyzed using latent class and transition analyses. We found three patterns of healthcare workers’ help-seeking behavior that applied to both time points: (1) engaging with different forms of group-based support, (2) not participating in any kind of offered support, and (3) only having been offered information-based support. The availability of support declined during mid-pandemic. Group support users were primarily nurses and frontline workers, with higher levels of burnout symptoms early pandemic. Our findings suggest that healthcare organizations should limit their implementation of psychological support during a crisis to a few key formats based on social support. Promoting participation from all staff groups may enhance inclusivity, effectiveness, and sustainability of the support

Psychological flexibility as a mediator of improvement in Acceptance and Commitment Therapy for patients with chronic pain following whiplash

Cognitive behavior therapy (CBT) has made important contributions to chronic pain management, but the process by which it is effective is not clear. Recently, strong arguments have been raised concerning the need for theory driven research to e. g. identify mechanisms of change in CBT and enhance the effectiveness of this type of treatment. However, the number of studies addressing these issues is still relatively scarce. Furthermore, the arrival of varieties of CBT with seemingly different process targets increases the need for such information. The present study explored the processes of change in a previously reported successful randomized controlled trial evaluating the effectiveness of an exposure-based form of behavioral and cognitive therapy, Acceptance and Commitment Therapy (ACT), on improvement in pain-related disability and life satisfaction for patients suffering from whiplash-associated disorder (WAD). Several process variables relevant to theories underlying traditional CBT were included: pain, distress, kinesiophobia, self-efficacy, and the process primarily targeted by ACT: psychological inflexibility. Mediation analyses were performed using a non-parametric cross-product of the coefficients approach. Results illustrated that pain intensity, anxiety, depression, kinesiophobia, and self-efficacy did not have significant mediating effects on the dependent variables. In contrast, significant indirect effects were seen for psychological inflexibility on pain-related disability (pre- to post-change scores) and life satisfaction (pre- to post; pre- to 4-month follow-up change scores). Although tentative, these results support the mediating role of psychological inflexibility in ACT-oriented interventions aimed at improving functioning and life satisfaction in people with chronic pain. (C) 2010 European Federation of International Association for the Study of Pain Chapters. Published by Elsevier Ltd. All rights reserved

Mediators of change in Acceptance and Commitment Therapy for pediatric chronic pain

Even though psychological interventions are well established in the treatment of pediatric chronic pain, there is a clear need for further development, especially with severely disabled patients. However, optimizing effectiveness in psychological treatments for pain requires clarification of the mechanisms of action. Studies addressing change processes are scarce, however, particularly in relation to pediatric chronic pain. Acceptance and Commitment Therapy (ACT), as an extension of traditional cognitive behavior therapy, is essentially aimed at improving functioning by increasing the ability to act effectively in the presence of pain and distress, that is, psychological flexibility. ACT has shown promising results for both adult and pediatric chronic pain. In the present study, the mediators of change in an ACT-oriented treatment for pediatric chronic pain were examined using a bootstrapped cross product of coefficients approach. Pain interference and depression were used as outcome variables. Six different variables relevant to theories underlying ACT and cognitive behavior therapy were included in the analyses as possible mediators of change: pain impairment beliefs, pain reactivity, self-efficacy, kinesiophobia, catastrophizing, and pain intensity. Results illustrated that pain impairment beliefs and pain reactivity were the only variables that significantly mediated the differential effects of treatment on outcomes at follow-up. Also, these 2 mediators were shown to independently predict effects in outcome variables at follow-up while controlling for earlier effects in outcome, but only for the ACT condition. Although tentative, the pattern of results suggests that variables consistent with psychological flexibility mediate the effects of ACT-based interventions to improve functioning in patients with chronic debilitating pain. (C) 2011 International Association for the Study of Pain. Published by Elsevier B. V. All rights reserved

Burnout among healthcare workers during a persistent crisis: A case-control study from the Covid-19 pandemic

Objectives: This study aimed to investigate if high levels of burnout symptoms during the first wave of the Covid-19 pandemic led to high burnout and depressive symptoms up to a year later, and if participation in psychological support initiatives was related to lower levels of burnout or depressive symptoms across the first year of the pandemic. Methods: A longitudinal case-control study followed 581 healthcare workers from two Swedish hospitals. Survey data were collected with a baseline in May 2020 and three follow-up assessments until September 2021. The case group were participants reporting high burnout symptoms at baseline. Logistic regression analyses were performed separately at three follow-ups with case/control group assignment as the main predictor and burnout and depression symptoms as outcomes, controlling for frontline work, changes in work tasks, and participation in psychological support. Results: One out of five healthcare workers reported high burnout symptoms at baseline. The case group was more likely to have high burnout and depression symptoms at all follow-ups. Participation in psychological support was not related to decreased burnout and depressive symptoms at any of the follow-ups. Conclusion: Burnout symptoms early in the pandemic predicted both high burnout and depressive symptoms later in the crisis. During a persistent crisis when job demands are high, healthcare organizations should be mindful of psychological reactions among staff and who they place in frontline work early in the crisis

Cognitive-behavioral therapy for insomnia in adolescents with comorbid psychiatric disorders : A clinical pilot study

Background: Insomnia is common in adolescents and often comorbid with psychiatric disorders. This study evaluated changes in insomnia, sleep, and comorbid symptoms following cognitive-behavioral therapy for insomnia (CBT-I) in adolescents with comorbid psychiatric disorders and chronic pain. Methods: In this non-controlled clinical pilot study, participants (n = 23, 78% female) were recruited from adolescent psychiatry and pediatric pain clinics. Assessments of self-reported insomnia, sleep onset latency, wake after sleep onset, total sleep time, sleep efficiency and depression, anxiety, functional disability, and pain intensity were completed at pre- and post-intervention and 3 months follow-up. Results: From pre- to post-intervention, statistically significant improvements were found for insomnia symptoms (p &lt; .001; d = 1.63), sleep onset latency (p &lt; .001; d = 1.04), wake after sleep onset (p &lt; .001; d = 0.38), total sleep time (p = .015; d = 0.22), sleep efficiency (p &lt; .001; d = 1.00), depression (p &lt; .001; d = 0.87), and anxiety (p = .001; d = 0.31). Only eight participants reported data at follow-up with maintained improvements for all measures. Conclusion: This study provides support that insomnia symptoms and sleep can improve following CBT-I delivered in a clinical setting and that co-occurring psychiatric symptoms can be reduced. The results should be interpreted with caution due to the uncontrolled conditions and limited sample size. Well-powered clinical trials are needed to validate the suggested effects