Role of psychological aspects in both chronic pain and in daily functioning in CFS

[Dolphin]

I was going to wait till I had read this (don't have a copy) before starting this thread, but it was already mentioned in another thread so thought I'd start this thread.

Role of psychological aspects in both chronic pain and in daily functioning in chronic fatigue syndrome: a prospective longitudinal study.

Clin Rheumatol. 2012 Feb 16. [Epub ahead of print]

Meeus M, Nijs J, Van Mol E, Truijen S, De Meirleir K.

Division of Musculoskeletal Physiotherapy, Department of Health Sciences, Artesis University College Antwerp (AHA), Van Aertselaerstraat 31, Merksem, Antwerp, 2170, Belgium.

Abstract*

In addition to fatigue, many patients with chronic fatigue syndrome (CFS) experience chronic musculoskeletal pain.

We aimed at examining the role of catastrophizing, coping, kinesiophobia, and depression in the chronic pain complaints and in the daily functioning of CFS patients.

A consecutive sample of 103 CFS patients experiencing chronic widespread musculoskeletal pain completed a battery of questionnaires evaluating pain, daily functioning, and psychological characteristics (depression, kinesiophobia, pain coping, and catastrophizing).

Thirty-nine patients participated in the 6-12-month follow-up, consisting of questionnaires evaluating pain and pressure pain algometry.

Correlation and linear regression analyses were performed to identify predictors.

The strongest correlations with pain intensity were found for catastrophizing (r?=?-.462, p?<?.001) and depression (r?=?-.439, p?<?.001).

The stepwise multiple regression analysis revealed that catastrophizing was both the immediate main predictor for pain (20.2%) and the main predictor on the longer term (20.1%).

The degree of depression was responsible for 10% in the observed variance of the VAS pain after 6-12 months.

No significant correlation with pain thresholds could be revealed.

The strongest correlations with daily functioning at baseline were found for catastrophizing (r?=?.435, p?<?.001) and depression (r?=?.481, p?<?.001).

Depression was the main predictor for restrictions in daily functioning (23.1%) at baseline.

Pain catastrophizing and depression were immediate and long-term main predictors for pain in patients with CFS having chronic widespread musculoskeletal pain.

They were also correlated to daily functioning, with depression as the main predictor for restrictions in daily functioning at baseline.

PMID: 22349876

* I gave each sentence its own paragraph.

 

[biophile]

Just copying what I posted on another thread where I suggested this paper could be irresponsible:

Gives the impression that daily functioning and chronic pain in CFS just depend on psychological characteristics such as depression and "catastrophizing". Didn't even bother to evaluate whether ME/CFS symptoms correlate with daily functioning and catastrophizing, so phrases like "strongest correlations" and "main predictors" are essentially meaningless.

 

[charityfundraiser]

Hidden in the discussion is this sentence, "Based on the revealed correlations, the direction of the relation remains unclear." Correlation does not imply causation. However, the fact that the title is "Role of psychological aspects in both chronic pain and in daily function in CFS" rather than "Role of chronic pain and daily function in CFS in psychological aspects", and that they phrase it as catastrophising is a predictor of pain level rather than pain level is a predictor of catastrophising, sort of shows which direction they're trying to imply.

 

[Enid]

I cannot go beyond a heading here on the psychos Dolphin - good luck but even more bad luck !!!.

 

[justinreilly]

I wonder why Prof De Meirleir (whose daughter has ME i believe) did this paper. it doesn't look very good from reading the abstract.

 

[Dolphin]

I wonder why Prof De Meirleir (whose daughter has ME i believe) did this paper. it doesn't look very good from reading the abstract.

He has co-authored some similar stuff in the past e.g.

Exercise performance and chronic pain in chronic fatigue syndrome: the role of pain catastrophizing.
Nijs J, Van de Putte K, Louckx F, Truijen S, De Meirleir K.
Pain Med. 2008 Nov;9(8):1164-72. Epub 2007 Oct 3.

(there was one letter in reply: http://www.ncbi.nlm.nih.gov/pubmed/19744212.1
so doesn't mean there has been any particular change in his views recently.

 

[Dolphin]

Finished reading this last night.

It is generally about self-reported measures correlating with other self-reported measures so it's all a bit frustrating.

I think it's plausible that *some* people may overstate and other people may understate their pain levels due to their "state of mind"/similar making it difficult to make inferences and come to conclusions about management strategies.

 

[Dolphin]

Use of BDI-II to measure depression

The BDI-II was used to measure depression

Recently the following was published:

Factor Analysis of the Beck Depression Inventory-ii With Patients With Chronic Fatigue Syndrome.

J Health Psychol. 2011 Nov 21. [Epub ahead of print]

Brown M, Kaplan C, Jason L.

Source

DePaul University, Chicago, USA.

Abstract

This study examined the properties of the Beck Depression Inventory-II (BDI-II) in a sample of 111 patients with chronic fatigue syndrome (CFS).

Exploratory factor analysis identified two factors.

The mean score for the Somatic-Affective factor was significantly higher than the Cognitive factor.

Convergent and discriminant validity were assessed for BDI-II total score, the two factor scores, and the BDI for Primary Care (BDI-PC).

The BDI-PC and Cognitive factor demonstrated superior validity.

Results suggest patients endorse BDI-II somatic items that overlap with CFS symptoms at a high rate.

Factor scores should be evaluated separately, or the BDI-PC should be utilized with this population.

PMID: 22104663 [PubMed - as supplied by publisher]

The authors themselves acknowledge this. I find it slightly odd this is mentioned i.e. if you knew this, why did you use it (but possibly that is not what happened e.g. a reviewer suggested it). Anyway, good they mention it:

Another limitation in the present study is the use of the
BDI II to assess depressive symptoms. A number of items of
the BDI refer to somatic symptoms that are also part of CFS.
This could artificially inflate the correlation between depression
and pain/disability in CFS. For future research, it would
be better to use the BDI primary care version (which does
not use somatic symptoms) or the Hospital Anxiety and
Depression Scale for example in further studies. The latter
seems a valid screening tool for depression in patients with
CFS [41].

 

[Dolphin]

Typos - or am I missing something

I'm thinking of writing to the authors about the following. If anyone can see errors I've made, let me know. Thanks.

Catastrophizing, measured with the PCS, was significantly
correlated with the two pain measurements and with
the self-reported restrictions in activities and participation.
These were, in fact, the highest correlations with the pain
and functioning measurements (Table 2). Furthermore, the
PCS was the main predictor for the pain measurement but
could not predict daily functioning significantly (Table 3).

PCS predicts "activity limitations/participation restrictions" in Table 3.
However, perhaps there was another column "daily functioning" - see next comment.

The PCI subscales transforming pain, worrying, and reducing demands were positively associated with the activity limitations/participation restrictions, and retreating and resting were correlated with the amount of habitual daily activity (Table 2).

I can't see any row for "the amount of habitual daily activity". It looks like they are distinguishing it from activity limitations/participation restrictions. At first, I thought they might be referring to figures at 6-12 months but that is covered later in the results section.

Resting and transforming the pain were also responsible for about 14% of the variance on top of the main predictor BDI (Table 3).

Seems to be missing saying this is about "activity limitations/participation restrictions".

The mean VAS pain for women was 52.95 (23.746). For men, the mean VAS pain was 35.60 (20.406). Pain intensity was significantly different (p0.009).

Numbers don't match figures in Table 1

Also, habitual activity and restrictions in activities and participations are related to these factors.

Again, this makes me wonder whether there was a separate "daily functioning"/"habitual activity" measure.

Activity limitations and participation restrictions can be predicted by the four questionnaires for 41.7%. The main predictors are depression (23.1%), resting (8.9%), and transforming pain (4.9%).

Says PCS, not depression, in Table 3.

VAS pain 6 to 12 months later was mainly predicted by depression (12.7%), while pain assessed with the SF-36 was chiefly predicted by the catastrophizing subitem rumination (22.8%). These findings are slightly different from the result of the first phase, where the total score of the PCS was the main predictor for both pain assessments, and depression was not a significant predictor, although responsible for 23.1%.

I don't know what the 23.1% is supposed to refer to. I'm wondering did they mean to say depression wasn't a significant predictor of "activity limitations/participation restrictions" at 6-12 months but was for the baseline figure. This seems to be repeating the last error as it was PCS, not depression.

 

[Dolphin]

Their "big" theory

Their "big" theory:

Similar to the present findings, earlier investigations
pushed catastrophizing and depression forward as the most
important psychological predictors of pain in other chronic
pain patients, accounting for 7% to 31% of the variance in
pain ratings [6, 35]. In FM, the predictive value of pain
catastrophizing and depression for pain was reported by
Hassett et al. [6] (respectively 27% and 30%), and in female
CFS patients, catastrophizing accounted for 41% of the
observed variance in bodily pain, independent of depression
[36]. Petrie et al. [37] mentioned that CFS patients with
catastrophic thoughts experienced more fatigue and more
disabilities, but they did not study the interaction with
chronic pain in CFS.

This can be explained by the findings of Gracely et al.
[38]. They suggest that pain catastrophizing is significantly
associated with increased activity in brain areas related to
anticipation of pain (medial frontal cortex, cerebellum),
attention to pain (dorsal ACC, dorsolateral prefrontal cortex),
emotional aspects of pain (claustrum, closely
connected to the amygdala), and motor control. Catastrophizing
would influence pain perception through altering attention
and anticipation and heightening emotional
responses to pain, leading to avoidance, hypervigilance,
inactivity, and reduced pain tolerance.

 

[Dolphin]

Thought this was "mildly" interesting:

To obtain a more accurate estimation of the predictive
value of catastrophizing and depression for pain after 6
12 months, we reanalyzed the determination of VAS pain
and SF-36 pain reported during the follow-up moment by
correcting for the relationship with baseline pain. This was
done by the use of blocks in a hierarchical multiple regression
analysis. The baseline variables were entered as a
covariate in a second block. In the case of the VAS pain,
this leads to an R square change of .065 (p0.141), but in the
case of the SF-36, pain was significant (p0.001) with an R
square change of .289. So this means that the pain measured
with the SF-36 was more predicted by the baseline SF-36
pain than by the psychological variables! The differences
between the two pain measurements may be due to the fact
that the VAS pain measures pain intensity during the last
24 h, while the SF-36 evaluated the last 2 weeks, which is
more an average score. This inconsistent finding requires
further research.

I think they are probably right on the variability of the VAS measure - probably doing a test-retest assessment would show this.

 

[Dolphin]

"resting" described as a "passive or maladaptive coping style"

"resting" described as a "passive or maladaptive coping style"

The relation between the coping styles resting and worrying and pain and daily functioning was also expected, given the fact that these passive or maladaptive coping styles [10] have been found to be associated with worse outcomes in CFS patients [12, 13]. Coping styles were even found to be major predictors of long-term outcome in CFS patients [40]. Furthermore, taking rest is obviously related to a restriction in physical activities. The present study, however, was the first to study kinesiophobia and coping strategies in relation to pain and daily functioning in CFS patients having chronic widespread pain, rather than patients with CFS in general.

10. Kraaimaat FW, Bakker A, Evers AWM (1997) Pijncopingstrategien
bij chronische pijnpatinten: de ontwikkeling van de
Pijn Coping Inventarisatielijst (PCI). Gedragstherapie 30:185201
12. Ray C, Jefferies S, Weir WR (1995) Coping with chronic fatigue
syndrome: illness responses and their relationship with fatigue,
functional impairment and emotional status. Psychol Med
25:937945
13. Heijmans MJ (1998) Coping and adaptive outcome in chronic
fatigue syndrome: importance of illness cognitions. J Psychosom
Res 45:3951
40. Wilson A, Hickie I, Lloyd A et al (1994) Longitudinal study of
outcome of chronic fatigue syndrome. BMJ 308:756759

Earlier they had said in the introduction:

Active pain coping strategies such as persisting in tasks despite pain, exercising, and diverting attention from pain have been reported to be negatively associated with functional disabilities in patients with CFS [12].

12. Ray C, Jefferies S, Weir WR (1995) Coping with chronic fatigue
syndrome: illness responses and their relationship with fatigue,
functional impairment and emotional status. Psychol Med
25:937945

I read that those were not good pain coping strategies. But perhaps they meant "negatively" in the correlation sense (slope of line less than 0) and in this case they should be read as being associated with higher functioning?

 

[Dolphin]

Reduced pain after CBT wasn't due to increased activity (on another study)

Reduced pain after CBT wasn't due to increased activity.
We knew this with regard to fatigue (Wiborg et al, 2010). Not sure it was well-known with regard to pain?

On the other hand, it seems that cognitive behavior therapy (CBT) aimed at fatigue in CFS also leads to a reduction of pain. Surprisingly, changes in physical activity, in negative affectivity, or in body consciousness could not explain the decrease in pain severity after cognitive behavior therapy. Only a relationship between the decrease in fatigue and the decrease in pain was found. This implies that pain in CFS is part of the syndrome and is directly related to chronic fatigue [47]. Unfortunately, the role of catastrophizing was not studied in the latter study, since CBT also seems to reduce pain catastrophizing in patients with fibromyalgia [48]. Therefore, it would be interesting to study whether the reduced pain after CBT may be mediated by reduced catastrophizing.

47. Knoop H, Stulemeijer M, Prins JB et al (2007) Is cognitive behaviour therapy for chronic fatigue syndrome also effective for pain symptoms? Behav Res Ther 45:20342043

"Improvement" may simply be a reporting bias after CBT?

 

[Bob]

I've only read the abstract, but it seems like one of those annoying studies that confuses cause and effect, and does not actually carry out any research to shed any light on which is which.

This is an extract from the abstract:

"Pain catastrophizing and depression were immediate and long-term main predictors for pain in patients with CFS having chronic widespread musculoskeletal pain. Pain was also correlated to daily functioning, with depression as the main predictor for restrictions in daily functioning at baseline."

It seems to me that the above extract could be written just as factually as follows, but with very different connotations in terms of the potential conclusions that can be drawn:

"Pain was an immediate and long-term main predictors for pain catastrophizing and depression in patients with CFS having chronic widespread musculoskeletal pain. They were also correlated to daily functioning, with pain as the main predictor for restrictions in daily functioning at baseline."

Spot the difference? I've swapped the word 'pain' with 'depression' and/or 'catastrophizing'. And it seems to make much more sense now!

I haven't read the full paper so I might be missing some important info, but it seems like I've rewritten it in a way that could be equally factual.