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Background: Pain affects most people approaching the end of life and can be severe for some. Opioid analgesia is effective, but evidence is needed about how best to support patients in managing these medicines., Objectives: To develop a self-management support toolkit (SMST) and delivery strategy and to test the feasibility of evaluating this intervention in a future definitive trial., Design: Phase I - evidence synthesis and qualitative interviews with patients and carers. Phase II - qualitative semistructured focus groups and interviews with patients, carers and specialist palliative care health professionals. Phase III - multicentre mixed-methods single-arm pre-post observational feasibility study., Participants: Phase I - six patients and carers. Phase II - 15 patients, four carers and 19 professionals. Phase III - 19 patients recruited to intervention that experienced pain, living at home and were treated with strong opioid analgesia. Process evaluation interviews with 13 patients, seven carers and 11 study nurses., Intervention: Self-Management of Analgesia and Related Treatments at the end of life (SMART) intervention comprising a SMST and a four-step educational delivery approach by clinical nurse specialists in palliative care over 6 weeks., Main Outcome Measures: Recruitment rate, treatment fidelity, treatment acceptability, patient-reported outcomes (such as scores on the Brief Pain Inventory, Self-Efficacy for Managing Chronic Disease Scale, Edmonton Symptom Assessment Scale, EuroQol-5 Dimensions, Satisfaction with Information about Medicines Scale, and feasibility of collecting data on health-care resource use for economic evaluation)., Results: Phase I - key themes on supported self-management were identified from evidence synthesis and qualitative interviews. Phase II - the SMST was developed and refined. The delivery approach was nested within a nurse-patient consultation. Phase III - intervention was delivered to 17 (89%) patients, follow-up data at 6 weeks were available on 15 patients. Overall, the intervention was viewed as acceptable and valued. Descriptive analysis of patient-reported outcomes suggested that interference from pain and self-efficacy were likely to be candidates for primary outcomes in a future trial. No adverse events related to the intervention were reported. The health economic analysis suggested that SMART could be cost-effective. We identified key limitations and considerations for a future trial: improve recruitment through widening eligibility criteria, refine the SMST resources content, enhance fidelity of intervention delivery, secure research nurse support at recruiting sites, refine trial procedures (including withdrawal process and data collection frequency), and consider a cluster randomised design with nurse as cluster unit., Limitations: (1) The recruitment rate was lower than anticipated. (2) The content of the intervention was focused on strong opioids only. (3) The fidelity of intervention delivery was limited by the need for ongoing training and support. (4) Recruitment sites where clinical research nurse support was not secured had lower recruitment rates. (5) The process for recording withdrawal was not sufficiently detailed. (6) The number of follow-up visits was considered burdensome for some participants. (7) The feasibility trial did not have a control arm or assess randomisation processes., Conclusions: A future randomised controlled trial is feasible and acceptable., Study and Trial Registration: This study is registered as PROSPERO CRD42014013572; Current Controlled Trials ISRCTN35327119; and National Institute for Health Research (NIHR) Portfolio registration 162114., Funding: The NIHR Health Technology Assessment programme.

Self-compassion is the ability to respond to one's failures, shortcomings, and difficulties with kindness and openness rather than criticism. This study, which might be regarded as a proof-of-concept study, aimed to establish whether self-compassion is associated with expected emotional responses and the likelihood of responding with problem solving, support seeking, distraction, avoidance, rumination, or catastrophizing to unpleasant self-relevant events occurring in 3 social contexts. Sixty chronic pain patients were presented with 6 vignettes describing scenes in which the principal actor transgressed a social contract with negative interpersonal consequences. Vignettes represented 2 dimensions: (1) whether pain or a nonpain factor interrupted the fulfillment of the contract and (2) variation in the social setting (work, peer, and family). The Self-Compassion Scale was the covariate in the analysis. Higher levels of self-compassion were associated with significantly lower negative affect and lower reported likelihood of avoidance, catastrophizing, and rumination. Self-compassion did not interact with pain vs nonpain factor. Work-related vignettes were rated as more emotional and more likely to be associated with avoidance, catastrophizing, and rumination and less likelihood of problem solving. The findings suggest that self-compassion warrants further investigation in the chronic pain population both regarding the extent of its influence as a trait and in terms of the potential to enhance chronic pain patients' ability to be self-compassionate, with a view to its therapeutic utility in enhancing psychological well-being and adjustment. Limitations regarding the possible criterion contamination and the generalizability of vignette studies are discussed.

Background: Depression with comorbid pain is associated with a poor response to various treatments. The objective in this secondary analysis was to determine whether patients reporting pain have different depression and pain outcomes over time in response to acupuncture, counselling or usual care., Methods: Self-reported ratings of depression and pain from 755 patients in a pragmatic randomised controlled trial of acupuncture (302) or counselling (302) compared to usual care alone (151) are described and analysed using a series of regression models and analysis of covariance. Patient-reported outcomes of Patient Health Questionnaire (PHQ)-9 for depression, SF36 bodily pain and EQ-5D, all at baseline, 3, 6, 9 and 12 months., Results: At baseline, 755 patients reported EQ-5D pain categories; 384 (50.9%) reported moderate-to-extreme pain. Controlling for baseline depression, a linear regression model showed that the presence of pain at baseline was associated with poorer depression outcomes at 3 months mean difference=-1.16, (95% CI 0.12 to 2.2). Participants with moderate-to-extreme pain at baseline did better at 3 months if they received acupuncture (mean reduction in Patient Health Questionnaire 9 (PHQ-9) from baseline=6.0, 95% CI 5.0 to 7.1 and a mean reduction in SF-36 bodily pain=11.2, (95% CI 7.1 to 15.2) compared to improvements for those who received counselling (4.3, 95% CI 3.3 to 5.4; 7.6, 95% CI 3.6 to 11.6) or usual care (2.7, 95% CI 1.50 to 4.0: 7.2, 95% CI 2.3 to 12.1). In comparison, no notable differences were seen between treatment arms within the no pain comparator group., Conclusions: Patients with depression and pain at baseline recovered less well from treatment over 3 months than those with depression and no pain. Reductions in both depression and pain were most marked in the acupuncture group, followed by the counselling group and then the usual care group.

Research on the effectiveness of distraction as a method of pain control is inconclusive. One mechanism pertains to the motivational relevance of distraction tasks. In this study the motivation to engage in a distraction task during pain was experimentally manipulated. Undergraduate students (N=73) participated in a cold pressor test (CPT) and were randomly assigned to three groups: a distraction-only group performed a tone-detection task during the CPT, a motivated-distraction group performed the same task and received a monetary reward for good task performance, and a control group did not perform the tone-detection task. Results indicated that engagement in the distraction task was better in the motivated-distraction group in comparison with the distraction-only group. Participants in both distraction groups experienced less pain compared to the control group. There were no overall differences in pain intensity between the two distraction groups. The effect of distraction was influenced by the level of catastrophic thinking about pain. For low catastrophizers, both distraction groups reported less pain as compared to the non-distracted control group. This was not the case for high catastrophizers. For high catastrophizers it mattered whether the distraction task was motivationally relevant: high catastrophizers reported less intense pain in the motivated-distraction group, as compared to the non-distracted control group. We conclude that increasing the motivational relevance of the distraction task may increase the effects of distraction, especially for those who catastrophize about pain., (Copyright 2010 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.)

The purpose of this meta-analytic review was to quantify the effects of psychological therapies for the management of chronic pain in youth. Specifically, in this review we updated previous systematic reviews of randomized controlled trials by including new trials, and by adding disability and emotional functioning to pain as treatment outcomes. Electronic searches of the Cochrane Register of Randomised Controlled Trials, MEDLINE, PsycLIT, EMBASE, and the Social Sciences Citation Index were conducted from inception through August 2008. Methodological quality of the studies was assessed, and data extracted on the three primary outcomes of interest. Twenty-five trials including 1247 young people met inclusion criteria and were included in the meta-analysis. Meta-analytic findings demonstrated a large positive effect of psychological intervention on pain reduction at immediate post-treatment and follow-up in youth with headache, abdominal pain, and fibromyalgia. Small and non-significant effects were found for improvements in disability and emotional functioning, although there were limited data on these outcomes available in the included studies. Omnibus cognitive-behavioral therapy, relaxation therapy, and biofeedback all produced significant and positive effects on pain reduction. Studies directly comparing the effects of self-administered versus therapist-administered interventions found similar effects on pain reduction. Psychological therapies result in improvement in pain relief across several different pain conditions in children. Future trials are needed that incorporate non-pain outcome domains, that focus significant therapeutic content on reductions in disability, and that include extended follow-up to better understand maintenance of treatment effects.

Current theoretical models of pain catastrophizing have diverging predictions regarding the role of social context and perceived threat on pain expression. The communal coping model of catastrophizing predicts that high pain catastrophizers display more pain expression in the presence of another, regardless of the threat value of the pain, while a cognitive appraisal model predicts high pain catastrophizers to express more pain when pain has increased threat value, regardless of social context. A 2 x 2 factorial design was used to test the validity of both predictions. Healthy participants with varying levels of pain catastrophizing were exposed to a cold pressor task, consisting of a 60 s immersion and 60 s recovery period. Interestingly, the immersion results revealed that beyond and independent from the effects of pain catastrophizing, the effect of threat on verbal pain report and facial expression was dependent on social context and vice versa. In a threatening context, perceived threat of pain mediated the inhibitory effect of social presence on pain expression, suggesting that the observer acted as a safety signal. In the recovery period, social presence enhanced facial expression, but only when no threat was induced. The results are discussed in terms of the dynamic interaction between social context and threat appraisals.

The selection of outcome criteria for chronic pain, both the domain of measurement and the magnitude of change, in RCTs is largely determined by the investigators. The present study investigated patient-determined criteria for the magnitude of change necessary to achieve an 'acceptable outcome' (endpoint) on the brief pain inventory and two subscales of the multidimensional pain inventory. Seventy-eight patients attending a chronic pain out-patient clinic were asked to rate their current state on the measures and then complete the scales as they would if treatment were to result in an acceptable outcome. The differences between the two sets of scores are described in terms of raw change scores, percentage change and by comparing the judgments of acceptable outcomes to statistically defined criteria (reliable change index and clinically significant change). Participants indicated a lower level of pain severity, impact and interference and a higher level of activity as part of an acceptable outcome. The degree of acceptable changes indicated by participants was higher (median values=44-75%) than the 30-50% typically reported as the threshold for clinically significant change for measures of pain experience in other studies. We also conducted tests of two models of change judgment. Neither adequately fit the data. There were discrepancies between the patients' judgments of acceptable outcomes and the RCI and SCS criteria. Suggestions for future research and possible clinical implications are discussed.

Randomized controlled trials and meta-analyses provide evidence for the efficacy of cognitive-behaviourally informed treatment (CBT) programmes for chronic pain. The current study aims to provide practice-based evidence for the effectiveness of CBT in routine clinical settings. Over a 10-year period 1013 pain patients were accepted into a 4 week in-patient pain management programme. Data from more than 800 patients was available at pre-treatment and at one month post-treatment and for around 600 patients at pre-treatment and at 9 months follow-up. Measures reported in this analysis were pain experience and interference, psychological distress (depression and anxiety), self-efficacy, catastrophizing, and walking. Change from pre-treatment to post-treatment and follow-up was assessed with conventional statistical tests, the computation of effect sizes and by the reliable change index (RCI) and clinically significant change (CSC) methodology. These analyses provide evidence of statistical improvement at post-treatment and follow-up and the RCI/CSC methodology suggested that between 1 in 3 and 1 in 7 (depending on the outcome measure) achieved clinically significant gains. There was also evidence that a small percentage of patients (1-2%) reliably deteriorated during the period of treatment. The limitations in the inferences that can be drawn from this study and of the methodology are discussed. A case is made for the application of benchmarking methods using data from RCTs in order to more fully evaluate practice and to generate better quality practice based evidence.

This article briefly reviews psychological aspects of pain, paying special attention to chronic pain. The review considers the interruptive and interference effects of pain and its impact on a person's identity. The importance of processes related to interruption, interference, and identity will vary across people and the duration of pain. Although brief phasic pain such as that presented in the laboratory will have marked interruptive effects, it is unlikely to produce interference or impact on a person's identity. Acute clinical pain will have both interruptive and interference effects, albeit of a temporary nature, but it is unlikely to have any impact on a person's identity. Chronic persistent pain or frequent recurrent episodic pain, such as headache, may have profound effects on a Person's life. Each of these themes is illustrated with examples drawn from the experimental and clinical literature.

Depression is a common feature of chronic pain, but there is only limited research into the content of depressed cognitions in pain patients. This study investigated the content of cognition in depressed pain patients, non-depressed pain patients, and two control groups, healthy controls, and osteopaths using a sentence completion task. Participants generated completed sentences to a set of predefined stems that included negative, positive and neutral self-reference, and past, future and world terms. Complete responses were coded by valence (negative, positive and neutral) and health/non-health related content. As predicted depressed pain patients produced more negative sentence completions to all stems than all other groups. Depressed pain patients produced more health related completions than either of the control groups. Pain patients who were not depressed did not differ from the osteopath control group in the number of health related completions. When negativity was considered depressed pain patients produced proportionately more negative health-related completions than all other groups. We suggest that the focus of depression in chronic pain patients is health related. Pain patients who are not depressed focus on health, but not necessarily in a negative way. The concept of themselves in the future might be a key aspect in depression in pain patients.

This paper reports the development of a scale for assessing the quality of reports of randomised controlled trials for psychological treatments. The Delphi method was used in which a panel of 15-12 experts generated statements relating to treatment and design components of trials. After three rounds, statements with high consensus agreement were reviewed by a second expert panel and rewritten as a scale. Evidence to support the reliability and validity of the scale is reported. Three expert and five novice raters assessed sets of 31 and 25 published trials to establish scale reliability (ICC ranges from 0.91 to 0.41 for experts and novices, respectively) and item reliability (Kappa and inter-rater agreement). The total scale score discriminated between trials globally judged as good and poor by experts, and trial quality was shown to be a function of year of publication. Uses for the scale are suggested.

The aim of this study was to test whether enmeshment of self and pain predicted adjustment (depression and acceptance) in a chronic pain population. 89 chronic pain patients completed standardized self-report measures of depression and acceptance and generated characteristics describing their current actual self, hoped-for self and feared-for self, and made judgments about the degree to which their future possible selves (hoped-for and feared-for) were dependent on the absence or presence of pain, i.e. enmeshed with pain. Hierarchical multiple regression analyses showed that after accounting for the influence of demographics (age, gender), pain characteristics and the degree of role interference attributable to pain, the proportion of hoped-for self characteristics that could be achieved even with the presence of pain predicted the magnitude of depression and acceptance scores. The findings are discussed with reference to the enmeshment hypothesis and theories of self-discrepancy, self-regulation and hopelessness.

Chronic pain interrupts behaviour, interferes with functioning, and may affect a person's identity: their sense of self. We tested whether loss of role and personal attributes and current and past self-concept differentiation, predicted adjustment as indexed by measures of depression. Chronic pain patients (n=80) completed measures of pain (MPQ), disability (PDI), depression and anxiety (BDI, HADS). Measures of role and attribute loss and self-concept differentiation were derived from a Role-Attribute Test in which participants identified four social roles in four domains (friendship, occupation, leisure, family) and nominated two personal attributes in each role prior to pain onset and current. Participants reported mean losses of 3.38 roles, and 6.97 attributes. Greater losses were observed in friendship, occupation and leisure domains compared with the family domain. Multiple regression analyses revealed that after controlling for demographic and clinical differences, role and attribute loss predicted depression scores. There was no evidence that depression was associated with past self-concept differentiation. The results are discussed with reference to the methodology used and the relevance of self-identity to understand adjustment to chronic pain.

The Beck Depression Inventory (BDI) is widely used to assess depression in chronic pain despite doubts about its structure and therefore its interpretation. This study used a large sample of 1947 patients entering chronic pain management to establish the structure of the BDI. The sample was randomly divided to conduct separate exploratory (EFA) and confirmatory factor analyses (CFA). EFA produced many satisfactory two-factor solutions. The series of CFA generated showed reasonable fit for ten of those solutions. All included a first factor identified as negative view of the self (items: failure, guilt, self-blame, self-dislike, punishment and body image change), and a second factor identified as somatic and physical function (items: work difficulty, loss of appetite, loss of libido, fatigability, insomnia and somatic preoccupation). The remaining items (suicidal ideation, social withdrawal, dissatisfaction, sadness, pessimism, crying, indecisiveness, weight loss, irritability) loaded infrequently or not at all in the CFA solutions. They did not form a coherent factor but comprised items associated with negative affect. When compared with published data from samples of depressed patients drawn from mental health settings the mean item scores for items reflecting the negative view of the self were consistently statistically lower that that observed in samples; there was no consistent difference between the samples on the items reflecting somatic and physical function; but the mean scores for the remaining affect items were significantly greater in the mental health samples. This version of depression is strikingly different from the psychiatric model of depression (e.g. DSM-IV or ICD-10), which is primarily defined by affective disturbance, and secondarily supported by cognitive and somatic symptoms. The finding is consistent with a reconsideration of what constitutes depression in the presence of chronic pain. It also has important clinical implications: it may provide a way to distinguish depressed patients with typical cognitive biases, who require specific treatment for depression alongside pain management., (Copyright 2002 International Association for the Study of Pain)

Do patients with chronic pain selectively process pain- and illness-related stimuli? The evidence with regard to attention, interpretation, and recall biases is critically reviewed. A model is proposed to account for the findings in which it is suggested that biases in information processing in chronic pain are the result of overlap between 3 schemas: pain, illness, and self. With frequent repeated or continued experience of pain, the pain schema becomes enmeshed with illness and self-schemas. The extent of the enmeshment and the salient content of the schema determine the bias. A fundamental assumption is that all patients with pain selectively process sensory-intensity information. A clinical implication of the results is that processing biases that extend beyond this healthy and adaptive process to enmesh the self-schema with pain and illness schemas could maintain and exacerbate distress and illness behavior in patients with chronic pain.

This study evaluated the multidimensional structure of affective verbal descriptors and investigated individual differences in the scaling of the descriptors. Patients with chronic low back pain, chronic headache and rheumatoid arthritis (25 per group) and 25 control subjects, matched for age and sex, made similarity judgements of a set of 12 verbal descriptors, e.g., awful, miserable. They also completed the Coping Strategies Questionnaire, the Hospital Anxiety and Depression Scale, McGill Pain Questionnaire Short Form, and a measure of verbal intelligence. The similarity data were subjected to individual differences multidimensional scaling (ALSCAL) and the resulting subject weights were related to group membership and the questionnaire data. The multidimensional nature of affective descriptors was confirmed. A 4-dimensional solution was identified: the first 3 dimensions were comparable with previous findings and labeled Tolerability, Focus of Attention and Minor Emotional Reaction. The 4th dimension was enigmatic and attributable to the back pain group. There were significant differences between the groups in their weighting of the dimensions and in their self-reported coping strategies. The results are discussed with reference to an earlier study and the degree of consistency across the studies is noted. Implications of the results for the conceptualisation and measurement of the affective domain of pain report are outlined.

The influence of chronic pain on the recall of autobiographical memories of pain and non-pain events was examined. Eleven chronic pain patients and 11 age- and sex-matched control subjects retrieved autobiographical memories to neutral and pain-related cue words. Patients and controls retrieved equal numbers of memories, but pain subjects retrieved more memories incorporating elements of physical pain. Analysis of the content of these memories revealed that patients and controls recalled equal numbers of memories of themselves and other people in acute pain and that the difference observed was attributable to the pain patients recalling memories of themselves in chronic pain. Memories of pain were recalled significantly faster than non-pain memories. The results are discussed with reference to the possible biasing effects of pain state on memory and the schematic processing of pain memories.

A 2-part study in which memory for everyday pains was investigated is reported. The first part compared ratings of vivid, 'flashbulb' memories of pain and non-pain events. Memories of pain events were rated as having been more surprising, having induced more negative emotional change, and having provoked greater change in ongoing activity than their non-pain event counterparts. In the second part of the study the relationship between remembering the pain event, experiencing the pain and re-experiencing the sensory qualities was examined. No subject reported sensory re-experiencing and 41% of subjects were unable to recall the sensory quality of the pain experience memory. Elements of pain experience (recalled intensity, distress and sensory quality) were differentially associated with components of pain event memory. Distress was associated with the reported frequency with which the pain event was rehearsed and with ratings of emotional and activity change induced by the pain event. In contrast, ratings of the intensity and sensory quality of the pain were associated with the reported vividness of the pain event memory. It is concluded that memories of painful events are readily retrievable and that the memory for a pain event, the sensory and affective qualities of pain experience and somatosensory component of pain are separated in their encoding and/or retrieval. The possible mechanisms whereby pain memories are encoded and retrieved are discussed. The clinical implications of the data concerning how judgements of past pain are made and the possible role of memory in coping are also noted.

Sixty patients having their wisdom teeth removed under general anaesthetic were tested immediately after surgery and 2 weeks later. Subjects completed versions of the McGill Pain Questionnaire (MPQ) and the UWIST Mood Adjective Checklist (UMACL). At the second test they were randomly assigned to 1 of 3 groups and either cued for their mood experience, cued for their pain experience or asked to recognise those words which they had chosen on the first occasion. Forty-nine patients completed the study. Accuracy of remembering was measured using Cohen's kappa (kappa) as a measure of agreement over the 2 tests. In general, accuracy of remembering was only 'fair' for both mood and pain (kappa = 0.5). Contrary to expectation cueing did not improve specific recognition, e.g., cueing for pain did not improve memory for pain words. However, there was evidence that memory of mood was more accurate when patients were cued to remember their pain. There was also evidence of a shift in the hedonic tone of the remembered mood; patients remembered their mood as being more negative than it actually was.

This paper reports a qualitative review of the literature on memory for pain. Most research has focused on the accuracy of memory for pain intensity. There is some evidence that recall is moderately accurate but this conclusion is tentative because of significant methodological problems. There is also some evidence that recall of acute pain is more accurate than recall of chronic pain and we make some suggestions as to why this difference might occur. We conclude that further research on memory for pain should be informed by reference to methodological practices developed in cognitive psychology and embedded within an appropriate theoretical framework.

In the first part of the study 20 subjects (11 headache, 9 normals) free-sorted descriptors from the intensity and affect scales of the Tursky pain perception profile (PPP) into groups on the basis of similar meaning. In part 2 they made similarity ratings of all pairs of words within the intensity and affect scales. In the third part of the study subjects completed a cross-modal matching task to scale the intensity and affect words. Data from the first 2 parts of the study were examined with multidimensional scaling (MDS) and hierarchical cluster analyses. Free-sorting the descriptors did not produce 2 groups corresponding to the intensity and affect descriptors described in the Tursky PPP. The descriptors were arranged in 6 groups described by subjects as reflecting increasing painfulness. An MDS analysis showed that the groups could be located in 2-dimensional space in which the dimensions of intensity and affective distress could be easily discerned. When the descriptors from the intensity and affect scales were rated within each scale, a second MDS analysis showed that, whereas the intensity descriptors could be fitted by a 1-dimensional representation, the affect descriptors required a 3-dimensional model. There was evidence that subjects with extensive pain experience placed greater weight on the second and third affective dimensions compared with relatively pain-free subjects.

101 subjects engaged in a self-administered cross-modal matching task to scale descriptors of pain intensity and unpleasantness. The correlation between the two responses was used to determine reliability (internal consistency). When r greater than or equal to 0.90 was set as a criterion about 3% of the subjects were unable to calibrate standard stimuli reliability, 6% were unable to calibrate intensity descriptors and 60% were unable to calibrate unpleasantness descriptors reliably. When the criterion reliability was set at r greater than or equal to 0.85 all subjects successfully scaled the intensity descriptors. Further relaxation of the criterion to r greater than or equal to 0.80 reduced the 'failure' rate for unpleasantness descriptors to 24%. These data compare favourably with other published results from non-chronic and chronic pain patients. The provision of a fixed reference value produced range effects in the resulting scale but do not severely attenuate the range of the scale as has been previously suggested. It is concluded that a self-administered version of the task is feasible. Reasons for the poor performance with the unpleasantness descriptors are discussed.

Twenty chronic pain patients carried out a self-administered cross-modal matching task to scale pain intensity and unpleasantness descriptors on 2 occasions separated by 2-3 weeks. Measures of psychological distress (HAD and GHQ) and verbal intelligence (Mill Hill Synonym Test) were also taken. On the 2 occasions 65% and 70% of patients were able to scale intensity words with an internal consistency of r greater than or equal to 0.90. Eleven (55%) patients met this criterion on both occasions. The percentage of patients meeting the internal consistency criterion for unpleasantness descriptors was much lower, 25% and 40% on the 2 occasions. For patients who met the internal consistency criterion for intensity words there was very high test-retest stability for the group scale values of the intensity words. There was no evidence that the level of psychological distress was associated with ability to scale unpleasantness words. Intelligence was positively related to the ability to scale intensity descriptors.

Psychological interventions are a mainstay of modern pain management practice and a recommended feature of a modern pain treatment service. Systematic reviews for the evidence of psychological interventions are reviewed in this article. The evidence for effectiveness is strongest for cognitive behavioural therapy with a focus on cognitive coping strategies and behavioural rehearsal. Most evidence is available for treatments of adult pain, although adolescent chronic pain treatments are also reviewed. It is clear that treatment benefit can be achieved with cognitive behavioural methods. It is possible to effect change in pain, mood, and disability, changes not achieved by chance or by exposure to any other treatment. However, the overall effect sizes of treatments for adults, across all trials, are modest. Reasons for the relatively modest treatment effects are discussed within the context of all treatments for chronic pain being disappointing when measured by the average. Suggestions for improving both trials and evidence summaries are made. Finally, consideration is given to what can be achieved by the pain specialist without access to specialist psychology resource. [ABSTRACT FROM PUBLISHER]

Avulsion of nerve roodets from the spinal cord following traction injuries to the brachial plexus frequently produces a highly characteristic pain syndrome. Constant spontaneous crushing and burning pain is felt in the distal part of the anaesthetic limb, frequently accompanied by shooting pain. It is not uncommon for the pain to persist for many years. The consistency of description between subjects coupled with the anatomical precision of the diagnosis provides a remarkable human model of central neuropathic pain. Opioids, anticonvulsants and tricyclic antidepressants are all used in the empirical management of this condition. They are partially effective at best and there is only anecdotal evidence to support their use. Many of our patients have given us spontaneous reports of the efficacy of 'street' cannabis. This has led us to test two cannabis-based whole plant medicinal extracts administered via oromucosal spray to patients with this condition. [ABSTRACT FROM AUTHOR]