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Psychiatry Sleep-related myoclonus in rheumatic pain modulation disorder (fibrositis syndrome)and in excessive daytime somnolence
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intermittent tapping. Progressively increasing the stimulation frequency increased the rate of tapping and then evoked flutter and then vibration of gradually increasing intensity. Stimulation of type I slow adapting (SAI) fibers evoked a sensation of pressure which increased in force with increased stimulation frequency. Stimulation of type II SA fibers (SAII) did not evoke any recognizable sensation.
PSYCHIATRY Psychiatry and the cervical sprain syndrome, - H. Merskey (Dept. of Education and Research, London Psychiatric Hospital, P.O. Box 2532, Terminal A, London, Ont, N6A 4H1, Canada), Canad. med. Ass. J., 130 (1984) 1119-1121. This editorial discusses the relationship between injury, compensation, the whiplash (cervical sprain) syndrome and also the post-concussional syndrome. It is noted that expert evidence tends to favour the side which calls it. Nevertheless, follow-up studies have repeatedly shown that many patients fail to get better from compensable symptoms even after the legal proceedings are finished. An accumulation of other evidence is also listed to suggest that there is a significant organic basis both for the cervical sprain syndrome and the post-concussional syndrome after minor head injury. Psychiatric changes which develop are often secondary to pain and disability. The effects of dietary tryptophan on chronic maxillofacial pain and experimental pain tolerance. - S. Seltzer, D. Dewart, R.L. Pollack and E. Jackson (Ma~llofacial Pain Control Center, School of Dentistry, Temple University Hospital, 3223 N. Broad Street, Philadelphia, PA 19140, U.S.A.), J. psychiat. Res., 17 (1982/83) 181-186. This study investigated the effects of daily administration of 3 g of tryptophan in conjunction with a high carbohydrate, low fat, low protein diet on chronic maxillofacial pain, experimental pain thresholds, and anxiety and depression. In a double-blind study, 30 chronic pain patients were randomly assigned to a tryptophan or placebo group. At the initial appointment and 4 weeks later, the patients’ subjective ratings of their pain were recorded, electrical tooth pulp stimulation was used to measure pain thresholds, and psychological tests of depression and anxiety were administered. Over the 4 weeks of the study, there was a greater reduction in reported clinical pain and a greater increase in pain tolerance threshold in the tryptophan group than in the placebo group. The group did not differ in anxiety and depression - for all subjects there was lowered depression and anxiety over the 4 weeks of study. Sleepreiated myoclonus in rheumatic pain mutation disorder (fibrositis syndrome) and in excessive daytime somnolence. - H. Moldofsky, C. Tullis, F.A. Lue, G. Quance and J. Davidson (Edith Cave11 Wing, Toronto Western Hospital, 399 Bathurst Street, Toronto M5T 2S8, Canada), Psychosom. Med., 46 (1984) 145-151. A new syndrome, rheumatic pain modulation disorder (RPMD) (‘fibrositis syndrome’) with sleep-related myoclonus (involuntary periodic leg movements) is de-
203
scribed. Measures of sleepiness, fatigue and pain, before and after sleep, and aspects of sleep of 9 subjects (Ss) with RPMD and sleep-related myoclonus were compared to 9 subjects with excessive daytime somnolence and sleep-related myoclonus. In 8 of the RPMD with sleep-related myoclonus and 3 of those with daytime sleepiness, an alpha (7.5-11 Hz) EEG non-rapid eye movement sleep disorder was demonstrated. The RPMD with sleep-related myoclonus group contained a greater number of women, more pain, morning fatigue, and disturbances in sleep (more stage changes and alpha EEG sleep prior to leg myoclonus); but in comparison to the sleep-related myoclonus, daytime somnolent group, there were no differences in evening and morning sleepiness, number of limb movements, movement arousals, awakenings after sleep onset, sleep duration, and per cent sleep stages. Therapists’
aud chronic pain patients’ perceptions
of reagent
outcome.
-
M.
Daniel, C. Long, W. Murphy, R. Kores and W. Hutcherson (Department of Psychology, Memphis State University, Memphis, TN 38152, U.S.A.), J. nerv. ment. Dis., 171 (1983) 729-733. Pain is a complex phenomenon which is influenced by multiple factors; likewise, assessment of chronic pain patients’ response to treatment is influenced by many variables. A physician, psychologist, physical therapist and occupational therapist rated the extent of recovery of 40 chronic pain patients who had spent 4-6 weeks in an inpatient chronic pain treatment program. Each patient also rated his/her own degree of improvement. In addition, therapists and patients reported which factors were the primary determinants of their outcome ratings. Although therapists rated the patients as significantly more improved than the patients rated themselves, there was still a high degree of similarity between therapists’ and patients’ view of recovery. Therapists and patients were in high agreement concerning which patients were classified as treatment successes or failures. Furthermore, activity level and ability to cope with pain were frequently endorsed by therapists and patients as important determinants of recovery rating. Contrary to a previous report, the results of this study suggest that pain patients are not necessarily poor judges of (their own) treatment results. Perhaps more importantly, this study supports the use of a broad-based multidimensional approach to assessing treatment outcome for chronic pain patients.
PSYCHOLOGY Placebo in clinical drug trials: a multidisciplinary
review. - G. Haegerstam, B.S. Huitfeldt, B.S. Nilsson, J. Sjovall, E. Syv&l&htiand A. Wahlen, Meth. Find. exp. clin. Pharmacol., 4 (1982) 261-278. Placebo treatment has been a standard method for the control of psychological factors in clinical trials of analgesic agents. Scientifically, placebo trials offer a way of obtaining efficient and valid conclusions about therapeutic efficacy. However, the use of placebo medications in controlled clinical trials raises a number of difficult
intermittent tapping. Progressively increasing the stimulation frequency increased the rate of tapping and then evoked flutter and then vibration of gradually increasing intensity. Stimulation of type I slow adapting (SAI) fibers evoked a sensation of pressure which increased in force with increased stimulation frequency. Stimulation of type II SA fibers (SAII) did not evoke any recognizable sensation.
PSYCHIATRY Psychiatry and the cervical sprain syndrome, - H. Merskey (Dept. of Education and Research, London Psychiatric Hospital, P.O. Box 2532, Terminal A, London, Ont, N6A 4H1, Canada), Canad. med. Ass. J., 130 (1984) 1119-1121. This editorial discusses the relationship between injury, compensation, the whiplash (cervical sprain) syndrome and also the post-concussional syndrome. It is noted that expert evidence tends to favour the side which calls it. Nevertheless, follow-up studies have repeatedly shown that many patients fail to get better from compensable symptoms even after the legal proceedings are finished. An accumulation of other evidence is also listed to suggest that there is a significant organic basis both for the cervical sprain syndrome and the post-concussional syndrome after minor head injury. Psychiatric changes which develop are often secondary to pain and disability. The effects of dietary tryptophan on chronic maxillofacial pain and experimental pain tolerance. - S. Seltzer, D. Dewart, R.L. Pollack and E. Jackson (Ma~llofacial Pain Control Center, School of Dentistry, Temple University Hospital, 3223 N. Broad Street, Philadelphia, PA 19140, U.S.A.), J. psychiat. Res., 17 (1982/83) 181-186. This study investigated the effects of daily administration of 3 g of tryptophan in conjunction with a high carbohydrate, low fat, low protein diet on chronic maxillofacial pain, experimental pain thresholds, and anxiety and depression. In a double-blind study, 30 chronic pain patients were randomly assigned to a tryptophan or placebo group. At the initial appointment and 4 weeks later, the patients’ subjective ratings of their pain were recorded, electrical tooth pulp stimulation was used to measure pain thresholds, and psychological tests of depression and anxiety were administered. Over the 4 weeks of the study, there was a greater reduction in reported clinical pain and a greater increase in pain tolerance threshold in the tryptophan group than in the placebo group. The group did not differ in anxiety and depression - for all subjects there was lowered depression and anxiety over the 4 weeks of study. Sleepreiated myoclonus in rheumatic pain mutation disorder (fibrositis syndrome) and in excessive daytime somnolence. - H. Moldofsky, C. Tullis, F.A. Lue, G. Quance and J. Davidson (Edith Cave11 Wing, Toronto Western Hospital, 399 Bathurst Street, Toronto M5T 2S8, Canada), Psychosom. Med., 46 (1984) 145-151. A new syndrome, rheumatic pain modulation disorder (RPMD) (‘fibrositis syndrome’) with sleep-related myoclonus (involuntary periodic leg movements) is de-
203
scribed. Measures of sleepiness, fatigue and pain, before and after sleep, and aspects of sleep of 9 subjects (Ss) with RPMD and sleep-related myoclonus were compared to 9 subjects with excessive daytime somnolence and sleep-related myoclonus. In 8 of the RPMD with sleep-related myoclonus and 3 of those with daytime sleepiness, an alpha (7.5-11 Hz) EEG non-rapid eye movement sleep disorder was demonstrated. The RPMD with sleep-related myoclonus group contained a greater number of women, more pain, morning fatigue, and disturbances in sleep (more stage changes and alpha EEG sleep prior to leg myoclonus); but in comparison to the sleep-related myoclonus, daytime somnolent group, there were no differences in evening and morning sleepiness, number of limb movements, movement arousals, awakenings after sleep onset, sleep duration, and per cent sleep stages. Therapists’
aud chronic pain patients’ perceptions
of reagent
outcome.
-
M.
Daniel, C. Long, W. Murphy, R. Kores and W. Hutcherson (Department of Psychology, Memphis State University, Memphis, TN 38152, U.S.A.), J. nerv. ment. Dis., 171 (1983) 729-733. Pain is a complex phenomenon which is influenced by multiple factors; likewise, assessment of chronic pain patients’ response to treatment is influenced by many variables. A physician, psychologist, physical therapist and occupational therapist rated the extent of recovery of 40 chronic pain patients who had spent 4-6 weeks in an inpatient chronic pain treatment program. Each patient also rated his/her own degree of improvement. In addition, therapists and patients reported which factors were the primary determinants of their outcome ratings. Although therapists rated the patients as significantly more improved than the patients rated themselves, there was still a high degree of similarity between therapists’ and patients’ view of recovery. Therapists and patients were in high agreement concerning which patients were classified as treatment successes or failures. Furthermore, activity level and ability to cope with pain were frequently endorsed by therapists and patients as important determinants of recovery rating. Contrary to a previous report, the results of this study suggest that pain patients are not necessarily poor judges of (their own) treatment results. Perhaps more importantly, this study supports the use of a broad-based multidimensional approach to assessing treatment outcome for chronic pain patients.
PSYCHOLOGY Placebo in clinical drug trials: a multidisciplinary
review. - G. Haegerstam, B.S. Huitfeldt, B.S. Nilsson, J. Sjovall, E. Syv&l&htiand A. Wahlen, Meth. Find. exp. clin. Pharmacol., 4 (1982) 261-278. Placebo treatment has been a standard method for the control of psychological factors in clinical trials of analgesic agents. Scientifically, placebo trials offer a way of obtaining efficient and valid conclusions about therapeutic efficacy. However, the use of placebo medications in controlled clinical trials raises a number of difficult