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Miriam Kunz,1 Stefanie F Bunk,2 Anna J Karmann,3 Karl-Jürgen Bär,4 Stefan Lautenbacher3 1Department of Medical Psychology and Sociology, University of Augsburg, Augsburg, Germany; 2Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; 3Physiological Psychology, Otto-Friedrich University Bamberg, Bamberg, Germany; 4Department of Psychosomatic Medicine and Psychotherapy, University Hospital, Jena, GermanyCorrespondence: Miriam KunzDepartment of Medical Psychology and Sociology, University of Augsburg, Augsburg, GermanyTel +49 821 598-3720Fax +49 821 598-5116Email Miriam.kunz@med.uni-augsburg.dePurpose: Conditioned pain modulation (CPM) is most often assessed using self-report of pain. However, self-report of pain is not always available (eg in individuals with cognitive impairment) and is susceptible to report bias. In comparison, the facial expression of pain is more reflex-like and represents one of the most sensitive and specific non-verbal signals of pain. The aim of the present study was to investigate whether the facial expression of pain is sensitive enough to capture endogenous pain inhibition as elicited during CPM paradigms.Patients and Methods: In total, 26 female participants took part in this study. Facial and verbal responses to phasic heat pain were assessed once while participants immersed their hand in a hot water bath and once without additional stimulation. Facial responses were analyzed using the Facial Action Coding System (FACS). Verbal responses were assessed using a Numerical Rating Scale (NRS).Results: Pain-relevant facial responses as well as pain ratings to phasic heat pain were significantly reduced when participants simultaneously immersed their hand in a hot water bath compared to baseline. Thus, CPM effects could be demonstrated both on subjective as well as on facial responses. Moreover, CPM-induced changes in pain-relevant facial responses and in NRS ratings were significantly correlated.Conclusion: The present study shows that facial expressions of pain are sensitive enough to capture CPM effects. Given the proven clinical usefulness of assessing CPM, the parallel assessment of verbal and facial CPM effects might be a promising approach with wider scope of applications. Further research in other demographic healthy participant and clinical cohorts is warranted.Keywords: pain, CPM, conditioned pain modulation, facial expression, FACS

Cindy Stroemel-Scheder,1 Anna Julia Karmann,1 Elisabeth Ziegler,1 Michael Heesen,2 Katrin Knippenberg-Bigge,3 Philip M Lang,4 Stefan Lautenbacher1 1Physiological Psychology, University of Bamberg, Bamberg, Germany; 2Department of Anesthesiology and Pain Therapy, Kantonsspital Baden, Baden, Switzerland; 3Center for Pain Medicine, Regiomed Klinikum Lichtenfels, Lichtenfels, Germany; 4Department of Anesthesiology and Pain Therapy, Sozialstiftung Bamberg, Bamberg, GermanyCorrespondence: Cindy Stroemel-SchederDepartment of Physiological Psychology, University of Bamberg, Markusplatz 3, Bamberg 96045, GermanyTel +49 951 863 2056Email cindy.stroemel@uni-bamberg.dePurpose: Everyday variations in night sleep in healthy pain-free subjects are at most weakly associated with pain, whereas strong alterations (eg, sleep deprivation, insomnia) lead to hyperalgesic pain changes. Since it remains unclear how substantial sleep alterations need to be in order to affect the pain system and lead to a coupling of both functions, the present study aimed at providing sufficient variance for co-variance analyses by examining a sample consisting of both healthy subjects and chronic pain patients.Methods: A sample of 20 chronic musculoskeletal pain patients and 20 healthy controls was examined. This sample was assumed to show high inter-individual variability in sleep and pain, as pain patients frequently report sleep disturbances, whereas healthy subjects were required to be pain-free and normal sleepers. Sleep of two non-consecutive nights was measured using portable polysomnography and questionnaires. Experimental pain parameters (pressure pain thresholds (PPT), temporal summation of pain (TSP), conditioned pain modulation (CPM)) and situational pain catastrophizing (SCQ) were assessed in laboratory sessions before and after sleep. Pain patients’ clinical pain was assessed via questionnaire.Results: As expected, both groups differed in several sleep parameters (reduced total sleep time and sleep efficiency, more time awake after sleep onset, lower subjective sleep quality in the patients) and in a few pain parameters (lower PPTs in the patients). In contrast, no differences were found in TSP, CPM, and SCQ. Contrary to our expectations, regression analyses indicated no prediction of overnight pain changes by sleep parameters.Conclusion: Since sleep parameters were hardly apt to predict overnight pain changes, this leaves the association of both systems mainly unproven when using between-subject variance for verification.Keywords: sleep, chronic pain, experimental pain, clinical pain

Funding: This research was funded by the European Cooperation in Science and Technology; funding number: EU COST-Action TD1005. Facial expression is a key aspect in observational scales developed to improve pain assessment in individuals with cognitive impairments. Although these scales are used internationally in individuals with different types of cognitive impairments, it is not known whether observing facial expressions of pain might differ between regions or between different types of cognitive impairments. In a pilot study, facial responses to standardized experimental pressure pain were assessed among individuals with different types of cognitive impairments (dementia, mild cognitive impairment, Huntington's disease, and intellectual disability) from different countries (Denmark, Germany, Italy, Israel, and Spain) and were analyzed using facial descriptors from the PAIC scale (Pain Assessment in Impaired Cognition). We found high inter-rater reliability between observers from different countries. Moreover, facial responses to pain did not differ between individuals with dementia from different countries (Denmark, Germany, and Spain). However, the type of cognitive impairment had a significant impact; with individuals with intellectual disability (all being from Israel) showing the strongest facial responses. Our pilot data suggest that the country of origin does not strongly affect how pain is facially expressed or how facial responses are being scored. However, the type of cognitive impairment showed a clear effect in our pilot study, with elevated facial responses in individuals with intellectual disability.

Silvia Metzger, Bogomil Poliakov, Stefan LautenbacherDepartment of Physiological Psychology, University of Bamberg, Bamberg, GermanyBackground: Anxiety has been associated with both increased and decreased pain perception. Rhudy and Meagher (2000) showed that pain sensitivity is enhanced by anxiety (anticipation of shocks), but diminished by fear (confrontation with shocks). A problem of this approach is the confounding of emotional and attentional effects: Administered shocks (fear induction) divert attention away from pain, which might account for lower pain in this condition. Moreover, heterogeneous findings in the past might be due to inter-individual differences in the proneness to react to anxiety and fear such as ones anxiety sensitivity (AS) level.Objectives: Our aim was to clarify the association between anxiety, fear and pain. We used the NPU paradigm for inducing these emotions and recording pain sensitivity at once with one stimulus to prevent interference by distraction. We assumed that anxiety and fear affect pain differently. Moreover, we hypothesized that subjects with clinically relevant (high) AS (H-AS group) show enhanced pain perception in contrast to low AS subjects (L-AS group).Method: Forty healthy subjects (female: N=20; age M=23.53 years) participated and H-AS or L-AS status was determined by clinically discriminating cut-off scores of the Anxiety Sensitivity Index-3 (ASI-III). Emotions were induced by the application of unpredictable (anxiety) and predictable (fear) electric stimuli. Pain ratings of electric stimuli were compared between the conditions. Startle reflex and anxiety ratings were recorded.Results: Results showed no general effects of anxiety and fear on pain perception. However, anxiety enhanced pain sensitivity in H-AS subjects, whereas fear did not affect pain sensitivity. In L-AS subjects no effects on pain perception were found.Conclusion: Results revealed that anxiety, not fear, enhanced pain perception but only in subjects with clinically relevant AS levels. This indicates that subclinical AS levels are sufficient to increase pain sensitivity, in uncertain situations.Keywords: anxiety sensitivity index-3, enhanced pain sensitivity, attention effects, electric stimuli

Eva Susanne Capito,Stefan Lautenbacher,Claudia Horn-Hofmann Physiological Psychology, University of Bamberg, Bamberg, Germany Background: As known from everyday experience and experimental research, alcohol modulates emotions. Particularly regarding social interaction, the effects of alcohol on the facial expression of emotion might be of relevance. However, these effects have not been systematically studied. We performed a systematic review on acute alcohol effects on social drinkers’ facial expressions of induced positive and negative emotions. Materials and methods: With a predefined algorithm, we searched three electronic databases (PubMed, PsycInfo, and Web of Science) for studies conducted on social drinkers that used acute alcohol administration, emotion induction, and standardized methods to record facial expressions. We excluded those studies that failed common quality standards, and finally selected 13 investigations for this review. Results: Overall, alcohol exerted effects on facial expressions of emotions in social drinkers. These effects were not generally disinhibiting, but varied depending on the valence of emotion and on social interaction. Being consumed within social groups, alcohol mostly influenced facial expressions of emotions in a socially desirable way, thus underscoring the view of alcohol as social lubricant. However, methodical differences regarding alcohol administration between the studies complicated comparability. Conclusion: Our review highlighted the relevance of emotional valence and social-context factors for acute alcohol effects on social drinkers’ facial expressions of emotions. Future research should investigate how these alcohol effects influence the development of problematic drinking behavior in social drinkers. Keywords: alcohol, alcohol effects, emotion, encoding, social drinking context, facial action&nbsp

BACKGROUND:Recognition of pain in people with dementia is challenging. Observational scales have been developed, but there is a need to harmonize and improve the assessment process. In EU initiative COST-Action TD1005, 36 promising items were selected from existing scales to be tested further. We aimed to study the observer agreement of each item, and to analyse the factor structure of the complete set. METHODS:One hundred and ninety older persons with dementia were recruited in four different countries (Italy, Serbia, Spain and The Netherlands) from different types of healthcare facilities. Patients represented a convenience sample, with no pre-selection on presence of (suspected) pain. The Pain Assessment in Impaired Cognition (PAIC, research version) item pool includes facial expressions of pain (15 items), body movements (10 items) and vocalizations (11 items). Participants were observed by health professionals in two situations, at rest and during movement. Intrarater and interrater reliability was analysed by percentage agreement. The factor structure was examined with principal component analysis with orthogonal rotation. RESULTS:Health professionals performed observations in 40-57 patients in each country. Intrarater and interrater agreement was generally high (≥70%). However, for some facial expression items, agreement was sometimes below 70%. Factor analyses showed a six-component solution, which were named as follows: Vocal pain expression, Face anatomical descriptors, Protective body movements, Vocal defence, Tension and Lack of affect. CONCLUSIONS:Observation of PAIC items can be done reliably in healthcare settings. Observer agreement is quite promising already without extensive training. SIGNIFICANCE:In this international project, promising items from existing observational pain scales were identified and evaluated regarding their reliability as an alternative to pain self-report in people with dementia. Analysis on factor structure helped to understand the character of the items. Health professionals from four countries using four different European languages were able to rate items reliably. The results contributed to an informed reduction of items for a clinical observer scale (Pain Assessment in Impaired Cognition scale with 15 items: PAIC15).

Metzger S, Poliakov B, Lautenbacher S. J Pain Res. 2019;12:1791–1801.On page 1791, in the abstract conclusion section the sentence “This indicates that subclinical AS levels are sufficientto increase pain sensitivity, in uncertain situations.” should read “This indicates that clinically relevant AS levels are sufficient to increase pain sensitivity, in uncertain situations.”Read the original article.

Oliver Dittmar,1 Corinna Baum,1,2 Raphaela Schneider,1 Stefan Lautenbacher1 1Physiological Psychology, University of Bamberg, Bamberg, 2Institute of Psychology, Technical University of Darmstadt, Darmstadt, Germany Background: Hypervigilance to pain is the automatic prioritization of pain-related compared with other stimuli. The processing of threat information is influenced by negative contexts. Therefore, we intended to explore such context effects on hypervigilance to pain-cues, taking individual differences in self-reported vigilance to pain into consideration. Methods: In all, 110 healthy subjects viewed task-irrelevant emotional facial expressions (anger, happy, neutral, and pain) overlaid in half of the trials with a fine grid. The instructed task was to indicate the presence/absence of this grid. A threatening context was established by applying electrical stimuli slightly below pain-threshold. Using scores of Pain Vigilance and Awareness Questionnaire, the sample was divided into high vs low pain vigilant subjects. Reaction times and event-related brain potentials were recorded. Results: No distinct attentional processing of pain faces (based on the event-related brain potentials) was observed as a function of high levels of self-reported vigilance to pain and contextual threat induction. High pain vigilant subjects showed generally enhanced processing of emotional and neutral faces as indicated by parameters of early (early posterior negativity) and late (late positive complex) processing stages. This enhancement was abolished when electro-stimuli were presented. Conclusion: Contextual threat does not enhance the attentional capture of pain-cues when they are presented concurrently with competing task demands. The study could, however, replicate a generally enhanced attentional processing of emotional cues in high pain vigilant subjects. This underpins that hypervigilance to pain is related to changes in emotional processing. Keywords: vigilance to pain, primary task paradigm, PVAQ, pain face, threat

Claudia Horn-Hofmann,1,2 Patricia Büscher,1 Stefan Lautenbacher,2 Jörg Wolstein1 1Pathosychology, University of Bamberg, Bamberg, Germany; 2Physiological Psychology, University of Bamberg, Bamberg, Germany Purpose: Alcohol is believed to have pain-dampening effects and is often used as self-medication by persons with pain problems; however, experimental evidence confirming this effect is scarce. We conducted a systematic review of experimental studies on the effects of nonrecurring alcohol administration on pain perception in healthy human subjects and the underlying mechanisms.Method: Three databases (PubMed, PsycINFO, and Web of Science) were searched for relevant studies using a predefined algorithm. In a next step, irrelevant articles were excluded by screening titles and abstracts. Finally, articles were checked regarding a set of methodological criteria; only publications meeting these criteria were selected for this review. A total of 14 experimental studies were identified.Results: Overall, most of the studies were able to show a pain-dampening effect of alcohol. However, many of them had methodological shortcomings (eg, lack of placebo control, insufficient blinding, or very small sample sizes). In addition, comparability is limited due to considerable variations in alcohol administration and pain measurement. More importantly, potential mechanisms of action and moderating variables have scarcely been investigated.Conclusion: Despite the frequent use of alcohol as self-medication by persons with pain problems, there are to date only a few experimental investigations of alcohol effects on pain perceptions. The results of these studies suggest that alcohol does in fact have pain-dampening effects. However, the mechanisms implicated in these effects are still unknown, and experimental research has been limited to pain-free subjects. Future research should provide more knowledge about alcohol effects on pain, especially in chronic pain patients.Keywords: pain, experimental pain, alcohol

C Horn-Hofmann,1 D Wolf,1 S Wolff,1 M Heesen,2 K Knippenberg-Bigge,3 P M Lang,3 S Lautenbacher1 1Department of Physiological Psychology, University of Bamberg, Germany; 2Department of Anesthesiology and Pain Therapy, Kantonsspital Baden, Switzerland; 3Department of Anesthesiology and Pain Therapy, Sozialstiftung Bamberg, Bamberg, Germany Background: Empirical evidence suggests that affective responses to pain are changed in chronic pain. The investigation of startle responses to pain might contribute to clarifying whether such alterations also expand to motivational defensive reactions. We aimed at comparing startle responses to tonic heat pain with high threat (HT) or low threat (LT) in patients with chronic musculoskeletal pain and controls. As pain-related anxiety and catastrophizing are typically elevated in chronic pain, we expected to find stronger startle responses in patients specifically under experimental HT. Methods: Patients with chronic musculoskeletal, preferentially, back pain (N = 19) and matched pain-free controls (N = 19) underwent two pain-related threat conditions (high and low) in balanced order. Only, in the HT condition, 50% of the trials were announced to include a short further noxious temperature increase at the end. Startle responses to loud tones were always assessed prior to a potential temperature increase in the phase of anticipation and were recorded by surface electromyogram. Results: Surprisingly, we observed no differences in startle responses and ratings of emotional and pain responses between patients and controls despite significantly higher pain-related anxiety and catastrophizing in the patients. Overall, startle was potentiated in the HT condition, but only in participants who started with this condition. Conclusion: Our results suggest that, in general, patients with pain are not more responsive emotionally to experimental threat manipulations despite elevated pain anxiety and catastrophizing. Instead, exaggerated responses in patients might be triggered only by individual concerns relating to pain, which are not sufficiently mirrored by our threat paradigm. Keywords: musculoskeletal pain, catastrophizing, anxiety, defensive motivation, experimental pain, startle reflex, threat induction

Wilco P Achterberg,1 Marjoleine JC Pieper,2 Annelore H van Dalen-Kok,1 Margot WM de Waal,1 Bettina S Husebo,3 Stefan Lautenbacher,4 Miriam Kunz,4 Erik JA Scherder,5 Anne Corbett6 1Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, 2Department of General Practice and Elderly Care Medicine, VU University Medical Center Amsterdam, Amsterdam, The Netherlands; 3Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway; 4Physiological Psychology, Otto Friedrich University Bamberg, Bamberg, Germany; 5Department of Clinical Neuropsychology, VU University Amsterdam, Amsterdam, The Netherlands; 6Wolfson Centre for Age-Related Diseases, King's College London, London, UK Abstract: There are an estimated 35 million people with dementia across the world, of whom 50% experience regular pain. Despite this, current assessment and treatment of pain in this patient group are inadequate. In addition to the discomfort and distress caused by pain, it is frequently the underlying cause of behavioral symptoms, which can lead to inappropriate treatment with antipsychotic medications. Pain also contributes to further complications in treatment and care. This review explores four key perspectives of pain management in dementia and makes recommendations for practice and research. The first perspective discussed is the considerable uncertainty within the literature on the impact of dementia neuropathology on pain perception and processing in Alzheimer's disease and other dementias, where white matter lesions and brain atrophy appear to influence the neurobiology of pain. The second perspective considers the assessment of pain in dementia. This is challenging, particularly because of the limited capacity of self-report by these individuals, which means that assessment relies in large part on observational methods. A number of tools are available but the psychometric quality and clinical utility of these are uncertain. The evidence for efficient treatment (the third perspective) with analgesics is also limited, with few statistically well-powered trials. The most promising evidence supports the use of stepped treatment approaches, and indicates the benefit of pain and behavioral interventions on both these important symptoms. The fourth perspective debates further difficulties in pain management due to the lack of sufficient training and education for health care professionals at all levels, where evidence-based guidance is urgently needed. To address the current inadequate management of pain in dementia, a comprehensive approach is needed. This would include an accurate, validated assessment tool that is sensitive to different types of pain and therapeutic effects, supported by better training and support for care staff across all settings. Keywords: pain assessment, Alzheimer's disease, cognitive impairment, behavior

Stefan Lautenbacher,1 Oliver Dittmar,1 Corinna Baum,1,2 Raphaela Schneider,1 Edmund Keogh,3 Miriam Kunz1 1Physiological Psychology, Otto-Friedrich University Bamberg, Bamberg, Germany; 2Institute of Medical Psychology, Justus-Liebig University Giessen, Giessen, Germany; 3Centre for Pain Research and Department of Psychology, University of Bath, Bath, UK Background: Pain-related stimuli are supposed to be automatically prioritized over other stimuli. This prioritization has often been tested using primary task paradigms in which pain information is irrelevant for completing the explicitly posed task. Task-irrelevant stimuli are only processed if they are very salient, and pain-related stimuli are assumed to be salient enough. Objective: We wanted to further investigate this assumption by assessing event-related brain potentials (ERPs) – a very sensitive method for studying attention and reaction times in response to pictures of people in pain and other emotional faces – using a primary task paradigm. In addition, we assumed that individuals describing themselves as vigilant to pain are especially responsive to pain cues. Methods: One hundred pain-free subjects were tested in a primary task paradigm using pictures of facial expressions of pain, anger, happiness, and neutral mood. ERPs were assessed at midline electrodes. Vigilance to pain was assessed by the pain vigilance and awareness questionnaire. Results: In contrast to previous studies (which have used pain words), effects of facial expressions of pain and other emotions on the ERPs and reaction times were surprisingly weak throughout and did not give evidence for a distinct processing of pain-related stimuli. However, hypervigilant subjects appeared to be strongly and cognitively absorbed by all emotional stimuli. Conclusion: Accordingly, it appears that pain-related stimuli are not always of outstanding salience, but that certain characteristics (eg, type of material, emotional richness) have to be present, for pain-related stimuli to be prioritized over stimuli of other emotional content. Hypervigilance to pain may generally predispose individuals to process emotional stimuli in greater depth. Keywords: hypervigilance for pain, ERP, LPC, pain face, primary task

The clinical pattern of neuropathic pain, diagnosed using the quantitative sensory testing (QST) battery (German Research Network on Neuropathic Pain), could be partly mimicked in healthy volunteers after topical capsaicin application. However, similar to clinical neuropathic pain that develops in only a subgroup of patients who have a neurologic lesion, this attempt to mimick a neuropathic pain pattern succeeded only in a small fraction (18%) of healthy individuals. In the present assessment, we pursued the hypothesis that the inducible subgroup differed from the other healthy participants with respect to their psychological phenotype. Therefore, in an observational study, participants were assessed using a comprehensive set of psychological variables comprising general psychological and pain-related cognitive-emotional mechanisms. The sum scores of the questionnaires were significantly linearly correlated with each other. Principal component analysis indicated that a major source of variance (46%) could be attributed to dispositional optimism examined via the Life Orientation Test (LOT). The LOT score significantly differed between the groups of participants, either those in whom a neuropathy-like pattern of pain assessed via QST could be partly (50-60% of the 11 QST parameters) induced (n = 20) or not (n = 90; P = .0375). It emerged again as the main selection criterion in a classification and regression tree predicting a participant's group assignment (inducible neuropathy-like QST pattern versus noninducible neuropathy-like QST pattern) at a cross-validated accuracy of 95.5 ± 2.1%. Thus, the few participants in a random sample of healthy volunteers who, after topical capsaicin application, partly resemble (to a degree of about 60%) the clinical pattern of neuropathic pain in the QST test battery, are preselectable on the basis of psychological factors, with a particular emphasis on pessimistic life attitudes. Perspective In a small fraction of 18% of healthy volunteers, topical capsaicin application resulted in a neuropathy-like pattern in 50 to 60% of the components of a clinical test battery. These individuals displayed a more pessimistic life attitude as assessed by means of the LOT.

The acute response of plasma leptin levels to a hydrocortisone challenge was measured in 16 healthy volunteers. We additionally asessed insulin which is known to play a regulatory role in the leptin system. While plasma cortisol levels increased significantly after the administration of hydrocortisone, this rise was not associated with any change in leptin and insulin concentrations during the 3.5-hour experimental period. This result corroborates the assumption that glucocorticoid-induced increases in leptin levels, as described in the literature, occur delayed and are due rather to an activation of leptin synthesis than to a mere leptin release.

Pain is likely to be equally prevalent in people with dementia, however, only a small minority are prescribed regular analgesics. This is a key issue since untreated pain leads to reduced quality of life and increases the likelihood of emergence of behavioural and psychological symptoms such as agitation. Better assessment and treatment of pain in this fragile patient group are therefore mandatory. In this context, we reviewed the literature on pain and dementia and summarised the best available evidence regarding the frequency of pain and pain diagnosis. Unfortunately, hardly any randomized, controlled studies of pain treatment efficacy in patients with dementia are available, with the consequence that most pain treatment recommendations are not based on the highest level of evidence.

Background: Brain areas that are involved in cognition and mood also play a role in pain processing. Objective: The goal of the present study was to examine the relationship between chronic pain and cognition [executive functions (EF) and memory], while controlling for mood, in cognitively intact older persons and in patients with Alzheimer's disease (AD). Methods: Two groups of subjects participated: 20 older persons without dementia and 19 patients in an early stage of probable AD who suffered from arthrosis/arthritis. Pain intensity and pain affect were assessed by the Colored Analogue Scale for Pain Intensity and for Pain Affect, the Faces Pain Scale (FPS) and the Number of Words Chosen-Affective (NWC-A). Level of depression and anxiety were evaluated by questionnaires. EF and memory were assessed by neuropsychological tests. Results: The results show that significant correlations between specific cognitive functions, pain intensity and pain affect were lacking in the cognitively intact older persons. Cognition, in particular memory, appeared to be related to depressive symptoms. In contrast, a significant positive correlation was observed between EF, pain intensity and pain affect measured by the FPS in the AD group. Conclusions: Although older persons with depression were excluded, in studies on pain and cognition one should control for the presence of depressive symptoms in older persons with and without dementia. Copyright © 2008 S. Karger AG.

Bei 46 Typ-I-Diabetikern im Alter zwischen 15 und 44 Jahren wurden die Auswirkungen der viszeralen Deafferentierung bei autonomer Diabetesneuropathie auf körperliche Befindlichkeit und Emotionalität untersucht. Die Erfassung des Ausprägungsgrad der autonomen Neuropathie erfolgte mit vegetativen Funktionstest. Diabetiker ohne Neuropathie (N = 14), mit leichter Neuropathie (N = 23) und mit schwerer Neuropathie (N = 9) wurden miteinander verglichen. Gering ausgeprägte autonome Neuropathie führt zu vegetativen Funktionsstörungen, ist aber gleichzeitig mit einer verminderten Wahrnehmung körperlicher Beschwerden - erfaßt mit der Freiburger Beschwerdenliste - verbunden. Im Streß- und Copingverhalten (SCOPE) und in bestimmten Persönlichkeitsdimensionen (FPI) finden sich dabei Hinweise auf eine verminderte emotionale Reaktivität. Patienten mit fortgeschrittener autonomer Neuropathie haben zumeist ausgeprägte diabetische Folgekrankheiten (diabetische Retinopathie, Makro- und Mikroangiopathie etc.), scheinen aber die damit verbundenen körperlichen Beeinträchtigungen und emotionalen Belastungen nicht stärker als Diabetiker ohne Neuropathie wahrzunehmen. Die autonome Deafferentierung bei Diabetikern scheint somit sowohl zu einer gestörten Wahrnehmung körperlicher Beschwerden wie auch zu einer beeinträchtigten emotionalen Reaktionsfähigkeit zu führen., Bei 46 Typ-I-Diabetikern im Alter zwischen 15 und 44 Jahren wurden die Auswirkungen der viszeralen Deafferentierung bei autonomer Diabetesneuropathie auf körperliche Befindlichkeit und Emotionalität untersucht. Die Erfassung des Ausprägungsgrad der autonomen Neuropathie erfolgte mit vegetativen Funktionstest. Diabetiker ohne Neuropathie (N = 14), mit leichter Neuropathie (N = 23) und mit schwerer Neuropathie (N = 9) wurden miteinander verglichen. Gering ausgeprägte autonome Neuropathie führt zu vegetativen Funktionsstörungen, ist aber gleichzeitig mit einer verminderten Wahrnehmung körperlicher Beschwerden - erfaßt mit der Freiburger Beschwerdenliste - verbunden. Im Streß- und Copingverhalten (SCOPE) und in bestimmten Persönlichkeitsdimensionen (FPI) finden sich dabei Hinweise auf eine verminderte emotionale Reaktivität. Patienten mit fortgeschrittener autonomer The perception of visceral activity is impaired in diabetics with autonomie neuropathy. This should affect the perception of somatic complaints and the emotional state of these patients. The degree of auronomic neuropathy was examined with three physiological tests for autonomie functions. Differences were evaluated between diabetics without neuropathy (N = 14), with mild neuropathy (N = 23) and with severe neuropathy (N = 9). It was found that mild autonomie neuropathy is related to a small increase in somatic problems (resulting from diabetes). In spite of this, autonomie deafferentation leads to a de~rease in somatic complaints (Freiburger Beschwerden Liste (FBL» and to a reduction in emotionality (assessed with personality questionaires (SCOPE and FPI». Patients with severe autonomie neuropathy exhibit frequent somatic problems. The somatic complaints and the emotionality of these patients are comparable with diabetics without neuropathy. The results show that autonomie deafferentation in diabetics is related to a reduced perception of somatic complaints and a decrease in the emotionality of these patients.

This article introduces the ifo Business Uncertainty, a measure of how difficult it is for managers to predict the future business development of their firm. The indicator is based on a new monthly question in a representative survey of the German economy, the ifo Business Survey. It captures the perceived uncertainty of managers, because it could affect their investment and hiring decisions, and thus the business cycle. We show that our new measure of perceived un-certainty increased sharply at the beginning of the Covid-19 crisis. Since then, it has decreased somewhat, but it remains at an elevated level. Moreover, we compare the ifo Business Uncertainty to a second indicator of firms’ subjective uncertainty and find that they are almost perfectly aligned. Last, we show that the relationship of the ifo Business Uncertainty with the ifo Business Climate Index is strongly negative.

Background: Over the last decades, a considerable number of observational scales have been developed to assess pain in persons with dementia. The time seems ripe now to build on the knowledge and expertize implemented in these scales to form an improved, “best‐of” meta‐tool. The EU‐COST initiative “Pain in impaired cognition, | KUNZ et al. 193 1 | INTRODUCTION The need for better pain assessment in cognitively impaired individuals who are not able to verbally communicate their pain, including people with dementia, has been widely acknowledged (Achterberg et al., 2013; Hadjistavropoulos et al., 2014). Standard pain assessment methods that rely heavily on self‐report lead to a dramatic under‐detection and under‐treatment of pain in these patient groups (Gibson & Lautenbacher, 2017; Hadjistavropoulos et al., 2014). To improve this situation, a considerable number of diverse observational scales has been developed, which aim to assess pain by observing behavioural responses, mainly including facial expressions, body movements and vocalizations (see Herr, Zwakhalen, & Swafford, 2017; Zwakhalen, Hamers, Abu‐ Saad, & Berger, 2006; Zwakhalen, Herr, & Swafford, 2017 for reviews). Most of these tools have undergone initial psychometric testing; however, many were not developed using evidence‐based methods and they lack comprehensive psychometric data from larger samples of patients. Few define the specific situation in which assessment should take place (e.g. rest vs. activity of daily living), most were not developed for ease of use in clinical settings. Moreover, given the considerable number of scales, it is difficult to gather comparable data. As a result, no widely accepted and internationally agreed‐upon tool for detecting pain in individuals with cognitive impairment exists and national guidelines vary in recommendations. To change this, we initiated a collaboration and combined clinical, research and methodological expertize from different European countries and disciplines, with the aim to develop an internationally agreed‐upon tool to assess pain in individuals with cognitive impairment, especially dementia (Corbett et al., 2014). After reviewing and discussing the many existing scales, we came to the conclusion that all relevant pain‐related observational items had been identified. However, existing scales include pain‐ irrelevant items or items of poor psychometric quality. Therefore, the main task was to reduce and refine the number of items. Thus, rather than starting from scratch, we Funding information The initiative was funded by the EU‐COST (action TD 1005). especially dementia” aimed to do this by selecting items out of existing observational scales and critically re‐assessing their suitability to detect pain in dementia. This paper reports on the final phase of this collaborative task. Methods: Items from existing observational pain scales were tested for “frequency of occurrence (item difficulty),” “reliability” and “validity.” This psychometric testing was carried out in eight countries, in different healthcare settings, and included clinical as well as experimental pain conditions. Results: Across all studies, 587 persons with dementia, 27 individuals with intellectual disability, 12 Huntington's disease patients and 59 cognitively healthy controls were observed during rest and movement situations or while receiving experimental pressure pain, respectively. The psychometric outcomes for each item across the different studies were evaluated within an international and multidisciplinary team of experts and led a final selection of 15 items (5x facial expressions, 5x body movements, 5x vocalizations). Conclusions: The final list of 15 observational items have demonstrated psychometric quality and clinical usefulness both in their former scales and in the present international evaluation; accordingly, they qualified twice to form a new internationally agreed‐on meta‐tool for Pain Assessment in Impaired Cognition, the PAIC‐15 scale. Significance: Using a meta‐tool approach by building on previous observational pain assessment scales and putting the items of these scales through rigorous empirical testing (using experimental as well as clinical pain studies in several European countries), we were able to identify the best items for pain assessment in individuals with impaired cognition. These selected items form the novel PAIC15 scale (pain assessment in impaired cognition, 15 items).

Pains from the musculoskeletal system represent a major proportion of complaints among patients seeking health services. Moreover, the efficacy of treatment of many musculoskeletal pain conditions by currently available pharmacologic and nonpharmacologic interventions is often less than optimal (Curatolo and Bogduk, 2001). Thus, it is generally accepted that pain from deep tissues constitutes a special diagnostic and therapeutic challenge, and further insights into the peripheral and central neurobiological mechanisms are necessary to improve diagnosis and management strategies. This chapter will mainly focus on the so-called myofascial pain syndrome (MPS). An unrefined search in PubMed reveals more than 4000 publications with the keyword “myofascial pain syndrome” and several extensive reviews and books are available on this topic (Fricton and Awad, 1990; Vaeroy and Merskey, 1993; Simons et al., 1999; Mense and Simons, 2001; Rivner, 2001; Borg-Stein and Simons, 2002). However, this chapter will attempt to critically review some of the proposed pain mechanisms and most prominent clinical presentations of MPS. In addition, the utility of quantitative sensory testing in assessment of muscle pain conditions will be discussed (Arendt-Nielsen 1997).

It has always been the dream of clinicians working with pain patients to have an objective measure of their pain—this is not possible and will most likely never be possible. However today we have ways to assess quantitatively some aspects of the complex sensory experience of pain. By measuring different aspects and then combining them, we may learn something about which pathways are impaired and which are functioning normally.