CAP Profiles

Bio

Bio

Beth Darnall, PhD, is Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine. She is a pain psychologist and scientist. Broadly, her research investigates how to best treat and prevent chronic pain. She is a principal investigator for $14M in federal and independent research awards.

She is principal investigator for a multi-site, 4-state pragmatic clinical trial that is investigating how to best help physicians and patients successfully reduce long term opioid use in chronic pain using patient-centered methods. The project is funded by the Patient Centered Outcomes Research Institute (PCORI) and will involve 1,300 patients taking long term opioids; the goal is to reduce patient health risks without increasing pain. This research involves a 3-arm RCT comparative effectiveness trial of two evidence-based behavioral treatments, cognitive behavioral therapy for pain and chronic pain self-management, within the context of voluntary, patient-centered opioid tapering. This research builds on her team's first report on "Patient-Centered Prescription Opioid Tapering in Community Outpatients with Chronic Pain" (Darnall et al, JAMA Int Med, 2018).

She is co-principal investigator for an NIH R01 project that is studying the mechanisms of pain catastrophizing treatment, including a novel single-session compressed pain psychology class she developed. She is also investigating an Internet-based pre-surgical pain psychology treatment she developed that aims to reduce distress and optimize post-surgical recovery, including pain and opioid cessation (tested in women undergoing surgery for breast cancer at Stanford). The goal of this research is to dismantle barriers to effective psychological treatment for pain.

Her primary interest is helping people with chronic pain to optimize their mind-body connection to reduce their own symptoms, improve health and function, and enhance response to medical treatments (placebo response). She is author of "Less Pain, Fewer Pills: Avoid the Dangers of Prescription Opioids and Gain Control Over Chronic Pain" © 2014, "The Opioid-Free Pain Relief Kit" © 2016, and the forthcoming book due in 2018 from the American Psychological Association Press entitled “Psychological Treatment for Chronic Pain: The Evidence-Based Basics”. Since 2016, she has been featured and published in the San Francisco Chronicle, Scientific American Mind, WebMD, BBC World Service Radio, The Washington Post, TIME Magazine, and Nature.

As a member of the Stanford Neurosciences Institute team, she spoke at the 2018 at the World Economic Forum in Davos, Switzerland on "The Psychology of Pain Relief".

www.bethdarnall.com
Twitter: @bethdarnall

Clinical Focus

  • Cognitive Behavioral Therapy for Pain
  • Pain Psychology
  • Psychology
  • opioid reduction
  • pain management

Academic Appointments

  • Clinical Professor, Anesthesiology, Perioperative and Pain Medicine
  • Clinical Professor (By courtesy), Psychiatry and Behavioral Sciences

Honors & Awards

  • 2015 Presidential Commendation, American Academy of Pain Medicine (2015)
  • Elected Member, Association of University Anesthesiologists (2016)

Boards, Advisory Committees, Professional Organizations

  • Opioid Advisory Committee, American Academy of Pain Medicine (2017 - Present)
  • Scientific Review and Guidelines Committee, American Academy of Pain Medicine (2017 - Present)
  • Annual conference planning committee, 2018 Kauai Pain Conference (2017 - 2018)
  • Consultant, Pain psychology treatment program development, Cedars-Sinai Health Care (2017 - 2017)
  • Education Initiatives Working Group, International Association for the Study of Pain (2016 - Present)
  • National Annual Conference Steering Committee, American Academy of Pain Medicine (2016 - Present)
  • Committee Member and Co-Author, ACOEM Chronic Pain National Guideline (2016 - 2017)
  • Medical Content Advisor, online pain education materials, Arthritis Foundation (2016 - 2016)
  • Co-Chair, Pain Psychology Shared Interest Group, American Academy of Pain Medicine (2015 - Present)
  • Scientific Advisory Board, Axial Healthcare (2015 - Present)
  • APS Clinical Resources and Guidelines Committee, American Pain Society (2015 - 2018)
  • Co-Chair, Pain Psychology Task Force, American Academy of Pain Medicine (2015 - 2017)
  • Co-Chair, 2016 Stanford Free Back Pain Education Day (2015 - 2016)
  • Content Advisor, American Society of Pain Educators (2015 - 2016)
  • Committee on the Principles of Analgesic Use in the Treatment of Chronic Pain and Cancer Pain, American Pain Society (2014 - 2016)
  • Co-Chair, Membership Task Force, American Academy of Pain Medicine (2014 - 2015)
  • Co-Chair, 2014 Pain Conference, Hosted by Stanford, Western Pain Society, American Academy of Pain Medicine (2014 - 2014)
  • Ethics Council, American Academy of Pain Medicine (2013 - Present)
  • Section Editor, Ethics Forum, Pain Medicine (2013 - Present)
  • Chair, APS Ethics Shared Interest Group, American Pain Society (2013 - 2016)
  • President, Pain Society of Oregon (2012 - 2012)
  • Scientific Program Committee, American Pain Society (2011 - 2014)
  • Conference Committee, "OHSU Pain Day: Scientific and Clinical Updates", Oregon Health & Science University (2011 - 2012)
  • APS Ethics Committee, American Pain Society (2010 - 2017)
  • Chair, Board of Directors, Pain Society of Oregon Portland Chapter (2010 - 2012)

Professional Education

  • PhD Training:University of Colorado at Boulder (2002) CO
  • Fellowship:The Johns Hopkins University (2004) MD
  • Internship:Southern Arizona VA Healthcare System (2002) AZ
  • MA, University of Colorado at Boulder, Clinical Psychology (1998)
  • PhD, University of Colorado at Boulder, Clinical Psychology (2002)
  • Post-Doc, The Johns Hopkins University School of Medicine, Rehabilitation Psychology (2004)

Community and International Work

  • Stanford Free Back Pain Education Day 2015, Stanford University

    Topic

    Community Outreach for people with back pain

    Partnering Organization(s)

    Stanford Hospitals and Clinics

    Populations Served

    Chronic Back Pain

    Location

    International

    Ongoing Project

    No

    Opportunities for Student Involvement

    No

  • Stanford 2014 Free Chronic Pain Education Day, Stanford University

    Topic

    Living Well with Chronic Pain

    Partnering Organization(s)

    Western Pain Society

    Populations Served

    Chronic Pain

    Location

    Bay Area

    Ongoing Project

    No

    Opportunities for Student Involvement

    No

  • Mirror therapy certification workshops for physicians, trauma, and healthcare providers in Vietnam, Can Tho, Dong Ha, and Hanoi, Vietnam

    Topic

    Self-delivered mirror therapy for phantom pain

    Partnering Organization(s)

    International Association for the Study of Pain; End the Pain Project; HealthSaaS

    Populations Served

    Vietnamese amputees

    Location

    International

    Ongoing Project

    No

    Opportunities for Student Involvement

    Yes

Contact

  • Jesmin Ram Administrative Associate
  • Stanford Pain Management Center 450 Broadway St Pavilion A 1st Fl MC 5340 Redwood City, CA 94063
    • Tel: (650) 723-6238
    Fax: (650) 721-3417

Links

Research & Scholarship

Current Research and Scholarly Interests

Current Research Awards:

PCORI (Patient Centered Outcomes Research Institute) 2017 - 2022

Principal Investigator (PI): “Comparative Effectiveness of Pain Cognitive Behavioral Therapy and Chronic Pain Self-Management Within the Context of Opioid Reduction.” Multisite pragmatic clinical trial conducted in 4 Western states in primary care and pain clinics. The goal is to help physicians and patients with chronic pain safely and effectively reduce opioid use. We will compare two evidence based group behavioral treatment classes (cognitive behavioral therapy and chronic pain self management) to facilitate opioid and pain reduction within the context of a patient-centered opioid tapering program (N=865).


NIH / NCCIH 09/01/2015 – 08/31/2020
R01AT008561
Title: Single Session Pain Catastrophizing Treatment: Comparative Efficacy & Mechanisms
Multi-PI: Darnall & Mackey

This project seeks to understand mechanisms of pain catastrophizing and optimize rapid delivery of targeted treatment. This comparative effectiveness trial studies the single-session 2-hour class I developed to treat pain catastrophizing (Darnall et al, J Pain Res, 2014; also see ‘treatment’ at en.wikipedia.org/wiki/Pain_Catastrophizing). I am now examining pre-surgical delivery of the class and testing post-op outcomes.

NIH / NICHD 09/01/2015 – 08/31/2020
R01
Title: Maternal Chronic Pain: Risk for Pain and Poor Outcomes in Children
(PI: Anna Wilson, PhD)
Darnall, Site PI for Stanford University

Stanford Faculty Innovation Program 12/18/14 - 12/17/15
Title: Pain Clinic Optimization of Patient Experience (Pain COPE): Leveraging Open Source Learning Health System for Prescriptive Analytics Approach to Patient Satisfaction
Multi-PI: Kao MC and Darnall



I developed a novel experimental model—a 10-minute pain catastrophizing induction—that allows us to study the immune responses (Darnall et al, Gender Med, 2010) and subsequent changes in sensory perception and neural functioning. These studies are designed to inform our understanding of the mechanisms by which pain catastrophizing shapes neural functioning, pain perception, and ultimately CNS structure in women with chronic pain.

I have a specific interest in developing low-cost, low-burden, easily accessible treatments that reduce suffering in patients. My work in this area includes the development of 6 patient products and treatment tools: two patient books (Less Pain, Fewer Pills, 2014; The Opioid-Free Pain Relief Kit (c) 2016); an enhanced pain management CD (2013), an evidence-based DVD (2010) (Darnall & Li, J Rehabil Med, 2010), and a standard pain management audiofile (2010). In 2013, I developed a single-session 2-hour class that is targeted treatment for pain catastrophizing (Darnall et al, J Pain Res, 2014; also see ‘treatment’ at en.wikipedia.org/wiki/Pain_Catastrophizing). The class is novel because pain catastrophizing is typically treated across 6-12 individual or group psychology sessions, and thus treatment imposes substantial burdens to patients in terms of time and costs. I adapted this class into an Internet-based treatment for pre-surgical patients ("My Surgical Success") and we are testing My Surgical Success in breast cancer surgery and orthopedic trauma surgery patients in the perioperative setting to improve time to pain resolution and opioid cessation, as well as in improving other post-surgical outcomes.

Finally, I develop pain psychology programs for large healthcare systems and facilitate the integration of psychological treatment for pain into primary care and pain care pathways.

Clinical Trials

  • Single Session Pain Catastrophizing Treatment: Comparative Efficacy & Mechanisms Recruiting

    This study aims to compare the efficacy of a single session psychological treatment, "From Catastrophizing to Recovery" (FCR), with the current standard of care, group Cognitive Behavioral Therapy (CBT) specifically on individuals with chronic low back pain suffering from Pain Catastrophizing (PC).

    View full details

  • Development and Validation of a Daily Pain Catastrophizing Scale Not Recruiting

    This study sought to develop and validate a brief, daily version of the Pain Catastrophizing Scale.

    Stanford is currently not accepting patients for this trial.

    View full details

  • Cognitive Behavioral Therapy and Chronic Pain Self-Management Within the Context of Opioid Reduction Not Recruiting

    The proposed study will fill several critical gaps in evidence that are preventing patients and physicians from making informed decisions about their pain care. This project will provide patients taking opioids and physicians with the specific evidence they need to choose the most effective route to pain control, reduced pain interference, opioid reduction, and improved role function, thereby improving patient care. The aims of this study are to (1) reduce or contain prescription opioid use while maintaining pain control and (2) compare the effectiveness of the Chronic Pain Self-Management Program (CPSMP), Cognitive Behavioral Therapy for chronic pain (pain-CBT), and no behavioral treatment within the context of patient-centered collaborative opioid tapering (Taper Only).

    Stanford is currently not accepting patients for this trial. For more information, please contact Eric A Dixon, B.A., (650) 725-1646.

    View full details

  • My Surgical Success: A Randomized Controlled Pilot Study of a Pre-surgical Psychological Intervention Not Recruiting

    The primary purpose of this study is to determine the feasibility and preliminary efficacy of a remote, Internet-based, pre-surgical psychoeducational intervention delivered to patients scheduled for breast cancer surgery (compared to an active control group that receives health education). Aim 1: Determine feasibility, satisfaction, and perceived utility of My Surgical Success. Hypothesis 1: For My Surgical Success, the investigators anticipate 50% engagement in the study (feasibility). Of those who complete My Surgical Success we expect 80% satisfaction ratings, and 80% perceived utility of the information learned. Aim 2: Determine group differences in within-subject pain catastrophizing scores (baseline - 0 to 48 hours before surgery). Hypothesis 2: My Surgical Success participants evidence greater reduction in pain catastrophizing (measured with the Pain Catastrophizing Scale; PCS) compared to the HE Control group. Aim 3: Determine group differences in time to post-surgical pain and opioid cessation. Hypothesis 3: My Surgical Success participants will evidence quicker time to post-surgical pain and opioid cessation compared to the HE Control Group. Aim 4: Determine group differences in post-surgical psychological correlates (PROMIS Depression, Anxiety, Function, Pain Interference, Sleep Disturbance, Sleep Related Impairment, Anger, Fatigue, Global, Distress, and Pain Intensity). Hypothesis 4: My Surgical Success participants will evidence greater post-surgical function and lower pain related interference compared to the HE Control Group. The goal of this research is to advance our understanding regarding the feasibility and effectiveness of remote psychoeducation interventions and impact on post-surgical outcomes.

    Stanford is currently not accepting patients for this trial.

    View full details

  • Stanford Center for Back Pain Recruiting

    The purpose of the Stanford Center for Back Pain is to investigate and characterize the mechanisms of four treatments for chronic low back pain. These interventions (research treatment) include real-time fMRI neurofeedback, mindfulness based stress reduction, cognitive behavioral therapy, and acupuncture treatment. The investigators plan to characterize both mechanisms of treatment effects and efficacy.

    View full details

  • Patient-Centered Opioid Tapering Study Not Recruiting

    This is an observational study of a voluntary opioid tapering protocol conducted in community outpatients taking long term prescription opioids for chronic pain. Patients who would otherwise continue with their existing opioid prescriptions were encouraged to participate in a voluntary opioid taper program. Interested patients were identified by their pain physician, Dr. Richard Stieg, and then completed an online informed consent document and baseline self-report assessments including types and doses of opioid medications as well as demographic and psychosocial measures, clinical and pain characteristics. Patients were either given or mailed a free copy of a patient book The Opioid-Free Pain Relief Kit, or Less Pain, Fewer Pills: Avoid the dangers of prescription opioids and gain control over chronic pain. Over the following weeks and up to 4 months, Dr. Stieg implemented a slow, individually tailored opioid taper in all patient participants. Follow-up online self-report surveys were completed at 4 months post enrollment. Opioid dose data were confirmed via medical chart review, and doses were converted to a standardized morphine equivalent daily dose (MEDD). Main outcome was change in opioid dose baseline to 4 months. Secondary outcome was change in pain intensity (numeric rating scale, 0-10) baseline to 4 months.

    Stanford is currently not accepting patients for this trial.

    View full details

Teaching

2017-18 Courses

Graduate and Fellowship Programs

  • Pain Management (Fellowship Program)

Publications

All Publications

  • Voluntary Opioid Tapering-Reply. JAMA internal medicine Darnall, B. D., Ziadni, M. S., Stieg, R. L. 2018; 178 (6): 875

    View details for DOI 10.1001/jamainternmed.2018.2112

    View details for PubMedID 29868754

  • Patient-Centered Prescription Opioid Tapering in Community Outpatients with Chronic Pain JAMA Internal Medicine Darnall, B., Ziadni, M., Stieg, R., Mackey, I., Kao, M., Flood, P. 2018; Feb 19

    View details for DOI 10.1001/jamainternmed.2017.8709

  • Comparative Efficacy and Mechanisms of a Single-Session Pain Psychology Class in Chronic Low Back Pain: Study Protocol for a Randomized Controlled Trial Trials Darnall, B., Siadni, M., Roy, A., Kao, M., Sturgeon, J., Cook, K., Lorig, K., Burns, J., Mackey, S. 2018: 165

    Abstract

    The Institute of Medicine (IOM) reported that chronic pain affects about 100 million U.S. adults, with chronic low back pain (CLBP) cited as the most prevalent type. Pain catastrophizing is a psychological construct shown to predict the development and trajectory of chronic pain and patient response to pain treatments. While effective treatment for pain catastrophizing typically includes eight-session groups of cognitive behavioral therapy (CBT), a single-session targeted treatment class yielded promising results which, if replicated and extended, could prove to efficiently and cost-effectively reduce pain catastrophizing. In this trial, we seek to determine the comparative efficacy of this novel single-session pain catastrophizing class to an eight-session course of pain CBT and a single-session back pain health education class. We will also explore the psychosocial mechanisms and outcomes of pain catastrophizing treatment.In this trial we will randomize 231 individuals with CLBP to one of three treatment arms: (1) pain-CBT (eight weekly 2-h group sessions with home exercises and readings); (2) a single 2-h pain catastrophizing class; or (3) a single 2-h back pain health education class (active control). For the primary outcome of pain catastrophizing, the trial is designed as a non-inferiority test between pain-CBT and the single-session pain catastrophizing class, and as a superiority test between the single-session pain catastrophizing class and the health education class. Team researchers masked to treatment assignment will assess outcomes up to six months post treatment.If the single-session targeted pain catastrophizing class is found to be an effective treatment for patients with CLBP, this low cost and low burden treatment could dismantle many of the current barriers and burdens of effective pain care. Further, elucidation of the mechanisms of pain catastrophizing treatments will facilitate future research on the topic as well as further development and refinement of treatments.ClinicalTrials.gov, NCT03167086 . Registered on 22 May 2017.

    View details for DOI 10.1186/s13063-018-2537-3

    View details for PubMedCentralID PMC5838852

  • To treat pain, study people in all their complexity. Nature Darnall, B. 2018; 557 (7703): 7

    View details for DOI 10.1038/d41586-018-04994-5

    View details for PubMedID 29717254

  • Comparative Efficacy and Mechanisms of a Single-Session Pain Psychology: Protocol for a Randomized Controlled Trial in Chronic Low Back Pain Trials Darnall, B., Ziadni, M., Roy, A., Kao, M., Sturgeon, J., Cook, K., Lorig, K., Burns, J., Sean, M. 2018; 19 (165)
  • The impact of perceived injustice on pain-related outcomes: A combined model examining the mediating roles of pain acceptance and anger in a chronic pain sample Clin J Pain Carrier, J., Sturgeon, J., Yakabov, E., Kao, M., Mackey, S., Darnall, B. 2018

    View details for DOI 10.1097/AJP.0000000000000602

  • CARE Scale - 7: Development and preliminary validation of a measure assessing factors that impact self-care in chronic pain Clin J Pain Ziadni, M., You, S., Wilson, A., Darnall, B. 2018; March

    View details for DOI 10.1097/AJP.0000000000000606

  • Development and Validation of a Daily Pain Catastrophizing Scale. journal of pain Darnall, B. D., Sturgeon, J. A., Cook, K. F., Taub, C. J., Roy, A., Burns, J. W., Sullivan, M., Mackey, S. C. 2017

    Abstract

    To date, there is no validated measure for pain catastrophizing at the daily level. The Pain Catastrophizing Scale (PCS) is widely used to measure trait pain catastrophizing. We sought to develop and validate a brief, daily version of the PCS for use in daily diary studies to facilitate research on mechanisms of catastrophizing treatment, individual differences in self-regulation, and to reveal the nuanced relationships between catastrophizing, correlates, and pain outcomes. After adapting the PCS for daily use, we evaluated the resulting 14 items using 3 rounds of cognitive interviews with 30 adults with chronic pain. We refined and tested the final daily PCS in 3 independent, prospective, cross-sectional, observational validation studies conducted in a combined total of 519 adults with chronic pain who completed online measures daily for 14 consecutive days. For study 1 (N = 131), exploratory factor analysis revealed adequate fit and-unexpectedly-unidimensionality for item responses to the daily PCS. Study 2 (N = 177) correlations indicated adequate association with related constructs (anger, anxiety, pain intensity, depression). Similarly, results for study 3 (N = 211) revealed expected correlations for daily PCS and measures of daily constructs including physical activity, sleep, energy level, and positive affect. Results from complex/multilevel confirmatory factor analysis confirmed good fit to a unidimensional model. Scores on the daily PCS were statistically comparable with and more parsimonious than the full 14-item version. Next steps include evaluation of score validity in populations with medical diagnoses, greater demographic diversity, and in patients with acute pain.This article describes the development and validation of a daily PCS. This daily measure may facilitate research that aims to characterize pain mechanisms, individual differences in self-regulation, adaptation, and nuanced relationships between catastrophizing, correlates, and pain outcomes.

    View details for DOI 10.1016/j.jpain.2017.05.003

    View details for PubMedID 28528981

  • Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis BMJ-BRITISH MEDICAL JOURNAL Sun, E. C., Dixit, A., Humphreys, K., Darnall, B. D., Baker, L. C., Mackey, S. 2017; 356

    Abstract

    Objectives To identify trends in concurrent use of a benzodiazepine and an opioid and to identify the impact of these trends on admissions to hospital and emergency room visits for opioid overdose.Design Retrospective analysis of claims data, 2001-13.Setting Administrative health claims database.Participants 315 428 privately insured people aged 18-64 who were continuously enrolled in a health plan with medical and pharmacy benefits during the study period and who also filled at least one prescription for an opioid.Interventions Concurrent benzodiazepine/opioid use, defined as an overlap of at least one day in the time periods covered by prescriptions for each drug. Main outcome measures Annual percentage of opioid users with concurrent benzodiazepine use; annual incidence of visits to emergency room and inpatient admissions for opioid overdose.Results 9% of opioid users also used a benzodiazepine in 2001, increasing to 17% in 2013 (80% relative increase). This increase was driven mainly by increases among intermittent, as opposed to chronic, opioid users. Compared with opioid users who did not use benzodiazepines, concurrent use of both drugs was associated with an increased risk of an emergency room visit or inpatient admission for opioid overdose (adjusted odds ratio 2.14, 95% confidence interval 2.05 to 2.24; P<0.001) among all opioid users. The adjusted odds ratio for an emergency room visit or inpatient admission for opioid overdose was 1.42 (1.33 to 1.51; P<0.001) for intermittent opioid users and 1.81 (1.67 to 1.96; P<0.001) chronic opioid users. If this association is causal, elimination of concurrent benzodiazepine/opioid use could reduce the risk of emergency room visits related to opioid use and inpatient admissions for opioid overdose by an estimated 15% (95% confidence interval 14 to 16).Conclusions From 2001 to 2013, concurrent benzodiazepine/opioid use sharply increased in a large sample of privately insured patients in the US and significantly contributed to the overall population risk of opioid overdose.

    View details for DOI 10.1136/bmj.j760

    View details for Web of Science ID 000397014900002

    View details for PubMedID 28292769

  • The Effect of Pain Catastrophizing on Outcomes: A Developmental Perspective Across Children, Adolescents, and Young Adults With Chronic Pain. journal of pain Feinstein, A. B., Sturgeon, J. A., Darnall, B. D., Dunn, A. L., Rico, T., Kao, M. C., Bhandari, R. P. 2017; 18 (2): 144-154

    Abstract

    Pain catastrophizing is one of the most powerful predictors of poor outcomes in youth and adults with pain; however, little is known about differential effects of pain catastrophizing on outcomes as a function of age. The current study examined the predictive value of pain catastrophizing on pain interference and pain intensity across children, adolescents, and 2 age groups of young adults with chronic pain. Cross-sectional data are presented from the adult and pediatric Collaborative Health Outcomes Information Registry (CHOIR), including measures of pain catastrophizing, pain intensity, pain interference, and emotional distress from 1,028 individuals with chronic pain. Results revealed that age moderated the relation between pain catastrophizing and pain interference, with the strength of these effects declining with age. The effect of pain catastrophizing on pain interference was strongest in adolescents and relatively weak in all 3 other groups. Emotional distress was the strongest predictor of pain interference for children, whereas pain intensity was the strongest predictor for both adult groups. Pain catastrophizing was found to predict pain intensity and, although age was a significant moderator, statistical findings were weak. Developmental considerations and clinical implications regarding the utility of the construct of pain catastrophizing across age groups are discussed.This article explores differences in pain catastrophizing as predictors of pain interference and pain intensity across cohorts of children, adolescents, and 2 age groups of young adults. This work may stimulate further research on chronic pain from a developmental perceptive and inform developmentally tailored treatment interventions that target catastrophizing, emotional distress, and pain intensity.

    View details for DOI 10.1016/j.jpain.2016.10.009

    View details for PubMedID 27825857

  • Pain behavior mediates the relationship between perceived injustice and opioid prescription for chronic pain: a Collaborative Health Outcomes Information Registry study JOURNAL OF PAIN RESEARCH Carriere, J. S., Martel, M., Kao, M., Sullivan, M. J., Darnall, B. D. 2017; 10

    Abstract

    Perceived injustice has been defined as an appraisal regarding the severity and irreparability of loss associated with pain, blame and a sense of unfairness. Recent findings have identified perceived injustice as an important risk factor for pain-related outcomes. Studies suggest that perceived injustice is associated with opioid prescription in patients with pain conditions. However, the mechanisms by which perceived injustice is linked to opioid prescription are not well understood. The primary objective of this study was to examine the potential mediating roles of pain intensity, depressive symptoms and pain behavior in the association between perceived injustice and opioid prescription among patients with chronic pain.This cross-sectional study used a sample of 344 patients with chronic pain being treated at a tertiary pain treatment center. Participants completed measures of perceived injustice, pain intensity, depressive symptoms, pain behavior and opioid prescription. Bootstrapped multiple mediation analyses were used to examine the mediating role of patients' pain intensity, depressive symptoms and pain behavior in the association between perceived injustice and opioid prescription.Consistent with previous research, we found a significant association between perceived injustice and opioid prescription. Interestingly, results revealed that pain behavior was the only variable that mediated the association between perceived injustice and opioid prescription.This study was the first to examine the mechanisms by which perceived injustice is associated with opioid prescription in patients with chronic pain. We found that pain behavior, rather than pain intensity and depressive symptoms, mediated the association between perceived injustice and opioid prescription. Future research in this area should employ a longitudinal research design in order to arrive at clearer causal conclusions about the relationships between pain behavior, perceived injustice and opioid prescription.

    View details for DOI 10.2147/JPR.S128184

    View details for Web of Science ID 000396321100001

    View details for PubMedID 28331358

  • Pain catastrophizing moderates the relationship between pain intensity and opioid prescription: Non-linear gender differences revealed using a learning health system Anesthesiology Sharifzadeh, Y., Kao, M., Sturgeon, J., Mackey, S., Darnall, B. 2017: 136–46

    Abstract

    Pain catastrophizing is a maladaptive response to pain that amplifies chronic pain intensity and distress. Few studies have examined how pain catastrophizing relates to opioid prescription in outpatients with chronic pain.The authors conducted a retrospective observational study of the relationships between opioid prescription, pain intensity, and pain catastrophizing in 1,794 adults (1,129 women; 63%) presenting for new evaluation at a large tertiary care pain treatment center. Data were sourced primarily from an open-source, learning health system and pain registry and secondarily from manual review of electronic medical records. A binary opioid prescription variable (yes/no) constituted the dependent variable; independent variables were age, sex, pain intensity, pain catastrophizing, depression, and anxiety.Most patients were prescribed at least one opioid medication (57%; n = 1,020). A significant interaction and main effects of pain intensity and pain catastrophizing on opioid prescription were noted (P < 0.04). Additive modeling revealed sex differences in the relationship between pain catastrophizing, pain intensity, and opioid prescription, such that opioid prescription became more common at lower levels of pain catastrophizing for women than for men.Results supported the conclusion that pain catastrophizing and sex moderate the relationship between pain intensity and opioid prescription. Although men and women patients had similar Pain Catastrophizing Scale scores, historically "subthreshold" levels of pain catastrophizing were significantly associated with opioid prescription only for women patients. These findings suggest that pain intensity and catastrophizing contribute to different patterns of opioid prescription for men and women patients, highlighting a potential need for examination and intervention in future studies.

    View details for DOI 10.1097/ALN.0000000000001656

    View details for PubMedCentralID PMC5478434

  • Pain catastrophizing, perceived injustice, and pain intensity impair life satisfaction through differential patterns of physical and psychological disruption Scand J Pain Sturgeon, J., Ziadni, M., Zina, T., Darnall, B., Mackey, S. 2017: 390–96

    Abstract

    Previous research has highlighted the importance of cognitive appraisal processes in determining the nature and effectiveness of coping with chronic pain. Two of the key variables implicated in appraisal of pain are catastrophizing and perceived injustice, which exacerbate the severity of pain-related distress and increase the risk of long-term disability through maladaptive behavioural responses. However, to date, the influences of these phenomena have not been examined concurrently, nor have they been related specifically to quality of life measures, such as life satisfaction.Using data from an online survey of 330 individuals with chronic pain, structural path modelling techniques were used to examine the independent effects of pain catastrophizing, perceived injustice, and average pain intensity on life satisfaction. Two potential mediators of these relationships were examined: depressive symptoms and pain-related interference.Results indicated that depressive symptoms fully mediated the relationship between pain catastrophizing and life satisfaction, and pain interference fully mediated the relationship between pain intensity and life satisfaction. Both depressive symptoms and pain interference were found to significantly mediate the relationship between perceived injustice and life satisfaction, but perceived injustice continued to demonstrate a significant and negative relationship with life satisfaction, above and beyond the other study variables.The current findings highlight the distinct affective and behavioural mediators of pain and maladaptive cognitive appraisal processes in chronic pain, and highlight their importance in both perceptions of pain-related interference and longer-term quality of life.

    View details for DOI 10.1016/j.sjpain.2017.09.020

    View details for PubMedCentralID PMC5726907

  • The relationship between negative metacognitive thoughts, pain catastrophizing, and adjustment to chronic pain Eur J Pain Ziadni, M., Sturgeon, J., Darnall, B. 2017

    View details for DOI 10.1002/ejp.1160

  • Effects of a Pain Catastrophizing Induction on Sensory Testing in Women with Chronic Low Back Pain: A Pilot Study PAIN RESEARCH & MANAGEMENT Taub, C. J., Sturgeon, J. A., Johnson, K. A., Mackey, S. C., Darnall, B. D. 2017

    Abstract

    Pain catastrophizing, a pattern of negative cognitive-emotional responses to actual or anticipated pain, maintains chronic pain and undermines response to treatments. Currently, precisely how pain catastrophizing influences pain processing is not well understood. In experimental settings, pain catastrophizing has been associated with amplified pain processing. This study sought to clarify pain processing mechanisms via experimental induction of pain catastrophizing. Forty women with chronic low back pain were assigned in blocks to an experimental condition, either a psychologist-led 10-minute pain catastrophizing induction or a control (10-minute rest period). All participants underwent a baseline round of several quantitative sensory testing (QST) tasks, followed by the pain catastrophizing induction or the rest period, and then a second round of the same QST tasks. The catastrophizing induction appeared to increase state pain catastrophizing levels. Changes in QST pain were detected for two of the QST tasks administered, weighted pin pain and mechanical allodynia. Although there is a need to replicate our preliminary results with a larger sample, study findings suggest a potential relationship between induced pain catastrophizing and central sensitization of pain. Clarification of the mechanisms through which catastrophizing affects pain modulatory systems may yield useful clinical insights into the treatment of chronic pain.

    View details for DOI 10.1155/2017/7892494

    View details for Web of Science ID 000395018300001

    View details for PubMedID 28348505

  • Perturbed connectivity of the amygdala and its subregions with the central executive and default mode networks in chronic pain. Pain Jiang, Y., Oathes, D., Hush, J., Darnall, B., Charvat, M., Mackey, S., Etkin, A. 2016; 157 (9): 1970-1978

    Abstract

    Maladaptive responses to pain-related distress, such as pain catastrophizing, amplify the impairments associated with chronic pain. Many of these aspects of chronic pain are similar to affective distress in clinical anxiety disorders. In light of the role of the amygdala in pain and affective distress, disruption of amygdalar functional connectivity in anxiety states, and its implication in the response to noxious stimuli, we investigated amygdala functional connectivity in 17 patients with chronic low back pain and 17 healthy comparison subjects, with respect to normal targets of amygdala subregions (basolateral vs centromedial nuclei), and connectivity to large-scale cognitive-emotional networks, including the default mode network, central executive network, and salience network. We found that patients with chronic pain had exaggerated and abnormal amygdala connectivity with central executive network, which was most exaggerated in patients with the greatest pain catastrophizing. We also found that the normally basolateral-predominant amygdala connectivity to the default mode network was blunted in patients with chronic pain. Our results therefore highlight the importance of the amygdala and its network-level interaction with large-scale cognitive/affective cortical networks in chronic pain, and help link the neurobiological mechanisms of cognitive theories for pain with other clinical states of affective distress.

    View details for DOI 10.1097/j.pain.0000000000000606

    View details for PubMedID 27168362

  • Pediatric-Collaborative Health Outcomes Information Registry (Peds-CHOIR): a learning health system to guide pediatric pain research and treatment. Pain Bhandari, R. P., Feinstein, A. B., Huestis, S. E., Krane, E. J., Dunn, A. L., Cohen, L. L., Kao, M. C., Darnall, B. D., Mackey, S. C. 2016; 157 (9): 2033-2044

    Abstract

    The pediatric adaptation of the Collaborative Health Outcomes Information Registry (Peds-CHOIR) is a free, open-source, flexible learning health care system (LHS) that meets the call by the Institute of Medicine for the development of national registries to guide research and precision pain medicine. This report is a technical account of the first application of Peds-CHOIR with 3 aims: (1) to describe the design and implementation process of the LHS; (2) to highlight how the clinical system concurrently cultivates a research platform rich in breadth (eg, clinic characteristics) and depth (eg, unique patient- and caregiver-reporting patterns); and (3) to demonstrate the utility of capturing patient-caregiver dyad data in real time, with dynamic outcomes tracking that informs clinical decisions and delivery of treatments. Technical, financial, and systems-based considerations of Peds-CHOIR are discussed. Cross-sectional retrospective data from patients with chronic pain (N = 352; range, 8-17 years; mean, 13.9 years) and their caregivers are reported, including National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) domains (mobility, pain interference, fatigue, peer relations, anxiety, and depression) and the Pain Catastrophizing Scale. Consistent with the literature, analyses of initial visits revealed impairments across physical, psychological, and social domains. Patients and caregivers evidenced agreement in observable variables (mobility); however, caregivers consistently endorsed greater impairment regarding internal experiences (pain interference, fatigue, peer relations, anxiety, and depression) than patients' self-report. A platform like Peds-CHOIR highlights predictors of chronic pain outcomes on a group level and facilitates individually tailored treatment(s). Challenges of implementation and future directions are discussed.

    View details for DOI 10.1097/j.pain.0000000000000609

    View details for PubMedID 27280328

  • Incidence of and Risk Factors for Chronic Opioid Use Among Opioid-Naive Patients in the Postoperative Period. JAMA internal medicine Sun, E. C., Darnall, B. D., Baker, L. C., Mackey, S. 2016; 176 (9): 1286-1293

    Abstract

    Chronic opioid use imposes a substantial burden in terms of morbidity and economic costs. Whether opioid-naive patients undergoing surgery are at increased risk for chronic opioid use is unknown, as are the potential risk factors for chronic opioid use following surgery.To characterize the risk of chronic opioid use among opioid-naive patients following 1 of 11 surgical procedures compared with nonsurgical patients.Retrospective analysis of administrative health claims to determine the association between chronic opioid use and surgery among privately insured patients between January 1, 2001, and December 31, 2013. The data concluded 11 surgical procedures (total knee arthroplasty [TKA], total hip arthroplasty, laparoscopic cholecystectomy, open cholecystectomy, laparoscopic appendectomy, open appendectomy, cesarean delivery, functional endoscopic sinus surgery [FESS], cataract surgery, transurethral prostate resection [TURP], and simple mastectomy). Multivariable logistic regression analysis was performed to control for possible confounders, including sex, age, preoperative history of depression, psychosis, drug or alcohol abuse, and preoperatice use of benzodiazepines, antipsychotics, and antidepressants.One of the 11 study surgical procedures.Chronic opioid use, defined as having filled 10 or more prescriptions or more than 120 days' supply of an opioid in the first year after surgery, excluding the first 90 postoperative days. For nonsurgical patients, chronic opioid use was defined as having filled 10 or more prescriptions or more than 120 days' supply following a randomly assigned "surgery date."The study included 641 941 opioid-naive surgical patients (169 666 men; mean [SD] age, 44.0 [12.8] years), and 18 011 137 opioid-naive nonsurgical patients (8 849 107 men; mean [SD] age, 42.4 [12.6] years). Among the surgical patients, the incidence of chronic opioid in the first preoperative year ranged from 0.119% for Cesarean delivery (95% CI, 0.104%-0.134%) to 1.41% for TKA (95% CI, 1.29%-1.53%) The baseline incidence of chronic opioid use among the nonsurgical patients was 0.136% (95% CI, 0.134%-0.137%). Except for cataract surgery, laparoscopic appendectomy, FESS, and TURP, all of the surgical procedures were associated with an increased risk of chronic opioid use, with odds ratios ranging from 1.28 (95% CI, 1.12-1.46) for cesarean delivery to 5.10 (95% CI, 4.67-5.58) for TKA. Male sex, age older than 50 years, and preoperative history of drug abuse, alcohol abuse, depression, benzodiazepine use, or antidepressant use were associated with chronic opioid use among surgical patients.In opioid-naive patients, many surgical procedures are associated with an increased risk of chronic opioid use in the postoperative period. A certain subset of patients (eg, men, elderly patients) may be particularly vulnerable.

    View details for DOI 10.1001/jamainternmed.2016.3298

    View details for PubMedID 27400458

  • Pain Psychology and the Biopsychosocial Model of Pain Treatment: Ethical Imperatives and Social Responsibility. Pain medicine Darnall, B. D., Carr, D. B., Schatman, M. E. 2016

    View details for PubMedID 27425187

  • Social Disruption Mediates the Relationship Between Perceived Injustice and Anger in Chronic Pain: a Collaborative Health Outcomes Information Registry Study. Annals of behavioral medicine Sturgeon, J. A., Carriere, J. S., Kao, M. J., Rico, T., Darnall, B. D., Mackey, S. C. 2016: -?

    Abstract

    Perceptions of pain as unfair are a significant risk factor for poorer physical and psychological outcomes in acute injury and chronic pain. Chief among the negative emotions associated with perceived injustice is anger, arising through frustration of personal goals and unmet expectations regarding others' behavior. However, despite a theoretical connection with anger, the social mediators of perceived injustice have not been demonstrated in chronic pain.The current study examined two socially based variables and a broader measure of pain interference as mediators of the relationships between perceived injustice and both anger and pain intensity in a sample of 302 patients in a tertiary care pain clinic setting.Data from the Collaborative Health Outcomes Information Registry (CHOIR) were analyzed using cross-sectional path modeling analyses to examine social isolation, satisfaction with social roles and activities, and pain-related interference as potential mediators of the relationships between perceived injustice and both anger and pain intensity.When modeled simultaneously, ratings of social isolation mediated the relationship between perceived injustice and anger, while pain-related interference and social satisfaction did not. Neither social variable was found to mediate the relationship between perceived injustice and pain intensity, however.The current findings highlight the strongly interpersonal nature of perceived injustice and anger in chronic pain, though these effects do not appear to extend to the intensity of pain itself. Nevertheless, the results highlight the need for interventions that ameliorate both maladaptive cognitive appraisal of pain and pain-related disruptions in social relationships.

    View details for PubMedID 27325314

  • (321) Enhanced secondary hyperalgesia following a pain catastrophizing induction in women with chronic low back pain. journal of pain Taub, C., Darnall, B., Johnson, K., Mackey, S. 2016; 17 (4S): S56-?

    View details for DOI 10.1016/j.jpain.2016.01.228

    View details for PubMedID 28162559

  • (418) A novel glial cell inhibitor, low dose naltrexone, reduces pain and depression, and improves function in chronic pain: A CHOIR study. journal of pain Noon, K., Sturgeon, J., Kao, M., Darnall, B., Mackey, S. 2016; 17 (4S): S79-?

    View details for DOI 10.1016/j.jpain.2016.01.395

    View details for PubMedID 28162662

  • (527) An internet-based perioperative pain psychology treatment program: results of a randomized controlled trial in breast oncology surgery patients. journal of pain Darnall, B., Wheeler, A., Taub, C., MACKEY, I., Wapnir, I., Schultz, C., RICO, T., Flood, P. 2016; 17 (4S): S106-?

    View details for DOI 10.1016/j.jpain.2016.01.334

    View details for PubMedID 28162332

  • (489) An examination of the roles of perceived injustice and pain acceptance on pain interference and pain intensity in patients with chronic pain: A Collaborative Health Outcomes Information Registry (CHOIR) Study. journal of pain Carriere, J., Darnall, B., Kao, M., Mackey, S. 2016; 17 (4S): S97-?

    View details for DOI 10.1016/j.jpain.2016.01.296

    View details for PubMedID 28162741

  • (162) Social disruption, but not pain interference, mediates the relationship between perceived injustice and anger in chronic pain: A Collaborative Health Outcomes Information Registry (CHOIR) study. journal of pain Sturgeon, J., Carriere, J., Darnall, B., Mackey, S. 2016; 17 (4S): S16-?

    View details for DOI 10.1016/j.jpain.2016.01.065

    View details for PubMedID 28162384

  • (448) Perceived injustice, pain behavior and opioid prescriptions: a vicious circle? A Collaborative Health Outcomes Information Registry (CHOIR) Study. journal of pain Carriere, J., Darnall, B., Sullivan, M., Kao, M., Mackey, S. 2016; 17 (4S): S86-?

    View details for DOI 10.1016/j.jpain.2016.01.425

    View details for PubMedID 28162695

  • (180) Development and validation of a Daily Pain Catastrophizing Scale (Daily PCS) measure. journal of pain Darnall, B., Sturgeon, J., Cook, K., Taub, C., Kao, M., RICO, T., Mackey, S. 2016; 17 (4S): S20-S21

    View details for DOI 10.1016/j.jpain.2016.01.083

    View details for PubMedID 28162404

  • (163) Pain catastrophizing, perceived injustice, and pain intensity impair life satisfaction through differential patterns of physical and psychological disruption. journal of pain Sturgeon, J., Dixon, E., Darnall, B., Mackey, S. 2016; 17 (4S): S16-?

    View details for DOI 10.1016/j.jpain.2016.01.066

    View details for PubMedID 28162385

  • Pain Psychology and Pain Catastrophizing in the Perioperative Setting: A Review of Impacts, Interventions, and Unmet Needs. Hand clinics Darnall, B. D. 2016; 32 (1): 33-39

    Abstract

    This article provides a brief overview of the literature on perioperative pain psychology in terms of relevant factors and treatments. Where possible, the content emphasizes hand surgery or hand trauma populations, although this literature is notably limited, as well as the relevant musculoskeletal surgery literature. In addition, gaps in understanding and patient care are identified and discussed.

    View details for DOI 10.1016/j.hcl.2015.08.005

    View details for PubMedID 26611387

  • Pain Psychology and Pain Catastrophizing in the Perioperative Setting: A Review of Impacts, Interventions, and Unmet Needs. Hand clinics Darnall, B. D. 2016; 32 (1): 33-39

    View details for DOI 10.1016/j.hcl.2015.08.005

    View details for PubMedID 26611387

  • Pain Psychology: A Global Needs Assessment and National Call to Action PAIN MEDICINE Darnall, B. D., Scheman, J., Davin, S., Burns, J. W., Murphy, J. L., Wilson, A. C., Kerns, R. D., Mackey, S. C. 2016; 17 (2): 250-263

    Abstract

    The Institute of Medicine and the draft National Pain Strategy recently called for better training for health care clinicians. This was the first high-level needs assessment for pain psychology services and resources in the United States.Prospective, observational, cross-sectional.Brief surveys were administered online to six stakeholder groups (psychologists/therapists, individuals with chronic pain, pain physicians, primary care physicians/physician assistants, nurse practitioners, and the directors of graduate and postgraduate psychology training programs).1,991 responses were received. Results revealed low confidence and low perceived competency to address physical pain among psychologists/therapists, and high levels of interest and need for pain education. We found broad support for pain psychology across stakeholder groups, and global support for a national initiative to increase pain training and competency in U.S. therapists. Among directors of graduate and postgraduate psychology training programs, we found unanimous interest for a no-cost pain psychology curriculum that could be integrated into existing programs. Primary barriers to pain psychology include lack of a system to identify qualified therapists, paucity of therapists with pain training, limited awareness of the psychological treatment modality, and poor insurance coverage.This report calls for transformation within psychology predoctoral and postdoctoral education and training and psychology continuing education to include and emphasize pain and pain management. A system for certification is needed to facilitate quality control and appropriate reimbursement. There is a need for systems to facilitate identification and access to practicing psychologists and therapists skilled in the treatment of pain.

    View details for DOI 10.1093/pm/pnv095

    View details for Web of Science ID 000373731000013

    View details for PubMedID 26803844

    View details for PubMedCentralID PMC4758272

  • Conflict of Interest, Part II: Pain Society Leadership and Industry Pain Medicine Schatman, M. E., Darnall, B. D. 2016; 17

    View details for DOI 10.1093/pm/pnv041

  • Social Disruption Mediates the Relationship Between Perceived Injustice and Anger in Chronic Pain: a Collaborative Health Outcomes Information Registry Study Annals of Behavioral Medicine Sturgeon, J. A., Carriere, J. S., Kao, M. J., Rico, T. J., Darnall, B. D., Mackey, S. C. 2016: 802–12

    Abstract

    Perceptions of pain as unfair are a significant risk factor for poorer physical and psychological outcomes in acute injury and chronic pain. Chief among the negative emotions associated with perceived injustice is anger, arising through frustration of personal goals and unmet expectations regarding others' behavior. However, despite a theoretical connection with anger, the social mediators of perceived injustice have not been demonstrated in chronic pain.The current study examined two socially based variables and a broader measure of pain interference as mediators of the relationships between perceived injustice and both anger and pain intensity in a sample of 302 patients in a tertiary care pain clinic setting.Data from the Collaborative Health Outcomes Information Registry (CHOIR) were analyzed using cross-sectional path modeling analyses to examine social isolation, satisfaction with social roles and activities, and pain-related interference as potential mediators of the relationships between perceived injustice and both anger and pain intensity.When modeled simultaneously, ratings of social isolation mediated the relationship between perceived injustice and anger, while pain-related interference and social satisfaction did not. Neither social variable was found to mediate the relationship between perceived injustice and pain intensity, however.The current findings highlight the strongly interpersonal nature of perceived injustice and anger in chronic pain, though these effects do not appear to extend to the intensity of pain itself. Nevertheless, the results highlight the need for interventions that ameliorate both maladaptive cognitive appraisal of pain and pain-related disruptions in social relationships.

    View details for DOI 10.1007/s12160-016-9808-6

    View details for PubMedCentralID PMC5127748

  • "The Opioid-Free Pain Relief Kit: 10 Simple Steps to Ease Your Pain" Darnall, B. D. Bull Publishing. 2016
  • Contributions of physical function and satisfaction with social roles to emotional distress in chronic pain: a Collaborative Health Outcomes Information Registry (CHOIR) study PAIN Sturgeon, J. A., Dixon, E. A., Darnall, B. D., Mackey, S. C. 2015; 156 (12): 2627-2633

    Abstract

    Individuals with chronic pain show a greater vulnerability to depression or anger than those without chronic pain, and also show greater interpersonal difficulties and physical disability. The current study examined data from 675 individuals with chronic pain during their initial visits to a tertiary care pain clinic using assessments from Stanford University's Collaborative Health Outcomes Information Registry (CHOIR). Using a path modeling analysis, the mediating roles of PROMIS Physical Function and PROMIS Satisfaction with Social Roles and Activities were tested between pain intensity and PROMIS Depression and Anger. Pain intensity significantly predicted both depression and anger, and both physical function and satisfaction with social roles mediated these relationships when modeled in separate 1-mediator models. Notably, however, when modeled together, ratings of satisfaction with social roles mediated the relationship between physical function and both anger and depression. Our results suggest that the process by which chronic pain disrupts emotional well-being involves both physical function and disrupted social functioning. However, the more salient factor in determining pain-related emotional distress appears to be disruption of social relationships, rather than global physical impairment. These results highlight the particular importance of social factors to pain-related distress, and highlight social functioning as an important target for clinical intervention in chronic pain.

    View details for DOI 10.1097/j.pain.0000000000000313

    View details for Web of Science ID 000365598300028

    View details for PubMedID 26230739

  • "Compassion Cultivation in Chronic Pain May Reduce Anger, Pain, and Increase Acceptance: Study Review and Brief Commentary". Health care. Current reviews Darnall, B. D. 2015; 3 (2)

    View details for PubMedID 26985456

  • Toward the Healthiest Symbiosis. Pain medicine Darnall, B. D., Schatman, M. E. 2015; 16 (7): 1254-1255

    View details for DOI 10.1111/pme.12828_3

    View details for PubMedID 26133016

  • The Relationship Between Industry and Pain Societies, Part 1: Demystification and Legitimization of Continuing Medical Education PAIN MEDICINE Darnall, B. D., Schatman, M. E. 2015; 16 (7): 1251-1251

    View details for DOI 10.1111/pme.12828

    View details for Web of Science ID 000358017000004

    View details for PubMedID 26138746

  • Protecting the infant from unknown risks. Pain medicine Darnall, B. D., Schatman, M. E. 2015; 16 (4): 631-632

    View details for DOI 10.1111/pme.12718_4

    View details for PubMedID 25832321

  • Sub-clinical range of pain catastrophizing moderates the effect of pain intensity on opioid prescription Sharifzadeh, Y., Darnall, B., Kao, M., Mackey, S. CHURCHILL LIVINGSTONE. 2015: S16–S16

    View details for Web of Science ID 000352748600065

  • Opioid use and lactation: protecting the child in the context of maternal pain care. Pain medicine Darnall, B. D., Schatman, M. E. 2015; 16 (4): 628-?

    View details for DOI 10.1111/pme.12718

    View details for PubMedID 25766069

  • Physical and psychological correlates of fatigue and physical function: a Collaborative Health Outcomes Information Registry (CHOIR) study. journal of pain Sturgeon, J. A., Darnall, B. D., Kao, M. J., Mackey, S. C. 2015; 16 (3): 291-8 e1

    Abstract

    Fatigue is a multidimensional construct that has significant implications for physical function in chronic non-cancer pain populations but remains relatively understudied. The current study characterized the independent contributions of self-reported ratings of pain intensity, sleep disturbance, depression, and fatigue to ratings of physical function and pain-related interference in a diverse sample of treatment-seeking individuals with chronic pain. Methods: These relationships were examined as a path modeling analysis of self-report scores obtained from 2,487 individuals with chronic pain from a tertiary care outpatient pain clinic.Our analyses revealed unique relationships of pain intensity, sleep disturbance, and depression with self-reported fatigue. Further, fatigue scores accounted for significant proportions of the relationships of both pain intensity and depression with physical function and pain-related interference, and accounted for the entirety of the unique statistical relationship between sleep disturbance and both physical function and pain-related interference.Fatigue is a complex construct with relationships to both physical and psychological factors that has significant implications for physical functioning in chronic non-cancer pain. The current results identify potential targets for future treatment of fatigue in chronic pain, and may provide directions for future clinical and theoretical research in the area of chronic non-cancer pain.Fatigue is an important physical and psychological variable that factors prominently in the deleterious consequences of pain intensity, sleep disturbance, and depression for physical function in chronic non-cancer pain.

    View details for DOI 10.1016/j.jpain.2014.12.004

    View details for PubMedID 25536536

  • Physical and Psychological Correlates of Fatigue and Physical Function: A Collaborative Health Outcomes Information Registry (CHOIR) Study. journal of pain Sturgeon, J. A., Darnall, B. D., Kao, M. J., Mackey, S. C. 2015; 16 (3): 291-298 e1

    Abstract

    Fatigue is a multidimensional construct that has significant implications for physical function in chronic non-cancer pain populations but remains relatively understudied. The current study characterized the independent contributions of self-reported ratings of pain intensity, sleep disturbance, depression, and fatigue to ratings of physical function and pain-related interference in a diverse sample of treatment-seeking individuals with chronic pain. Methods: These relationships were examined as a path modeling analysis of self-report scores obtained from 2,487 individuals with chronic pain from a tertiary care outpatient pain clinic.Our analyses revealed unique relationships of pain intensity, sleep disturbance, and depression with self-reported fatigue. Further, fatigue scores accounted for significant proportions of the relationships of both pain intensity and depression with physical function and pain-related interference, and accounted for the entirety of the unique statistical relationship between sleep disturbance and both physical function and pain-related interference.Fatigue is a complex construct with relationships to both physical and psychological factors that has significant implications for physical functioning in chronic non-cancer pain. The current results identify potential targets for future treatment of fatigue in chronic pain, and may provide directions for future clinical and theoretical research in the area of chronic non-cancer pain.Fatigue is an important physical and psychological variable that factors prominently in the deleterious consequences of pain intensity, sleep disturbance, and depression for physical function in chronic non-cancer pain.

    View details for DOI 10.1016/j.jpain.2014.12.004

    View details for PubMedID 25536536

  • Compassion Cultivation in Chronic Pain May Reduce Anger, Pain, and Increase Acceptance: Review and Commentary Health Care: Current Reviews Darnall, B. D. 2015; 3 (1)
  • Urine drug screening: necessary or alienating? Pain medicine Darnall, B. D., Schatman, M. E. 2014; 15 (12): 1999-?

    View details for DOI 10.1111/pme.12604

    View details for PubMedID 25376375

  • Urine drug screening: opioid risks preclude complete patient autonomy. Pain medicine Darnall, B. D., Schatman, M. E. 2014; 15 (12): 2001-2002

    View details for DOI 10.1111/pme.12604_4

    View details for PubMedID 25376661

  • Intrathecal Opioids for Chronic Nonmalignant Pain: A Case Study and the Search for Balance PAIN MEDICINE Schatman, M. E., Darnall, B. D. 2014; 15 (8): 1268-1268

    View details for DOI 10.1111/pme.12494

    View details for Web of Science ID 000342630800005

    View details for PubMedID 25091712

  • Minimize opioids by optimizing pain psychology. Pain management Darnall, B. D. 2014; 4 (4): 251-253

    View details for DOI 10.2217/pmt.14.18

    View details for PubMedID 25300380

  • Compassion meditation training for people living with chronic pain and their significant others: a pilot study and mixed-methods analysis Ruchelli, G., Chapin, H., Darnall, B., Seppala, E., Doty, J., Mackey, S. CHURCHILL LIVINGSTONE. 2014: S117–S117

    View details for Web of Science ID 000334648700465

  • Stanford-NIH Pain Registry: open source platform for large-scale longitudinal assessment and tracking of modern patient-reported outcomes Kao, M., Weber, S., Cook, K., Garrick, O., Pacht, T., Darnall, B., Mackey, S. CHURCHILL LIVINGSTONE. 2014: S40–S40

    View details for Web of Science ID 000334648700158

  • Stanford-NIH Pain Registry: catalyzing the rate limited step of psychometrics with modern patient-reported outcomes Kao, M., Cook, K., Olson, G., Pacht, T., Darnall, B., Weber, S., Mackey, S. CHURCHILL LIVINGSTONE. 2014: S3–S3

    View details for Web of Science ID 000334648700012

  • Less Pain, Fewer Pills: Avoid the dangers of prescription opioids and gain control over chronic pain Darnall, B. D. Bull Publishing. 2014
  • Pilot study of a compassion meditation intervention in chronic pain. Journal of compassionate health care Chapin, H. L., Darnall, B. D., Seppala, E. M., Doty, J. R., Hah, J. M., Mackey, S. C. 2014; 1

    Abstract

    The emergence of anger as an important predictor of chronic pain outcomes suggests that treatments that target anger may be particularly useful within the context of chronic pain. Eastern traditions prescribe compassion cultivation to treat persistent anger. Compassion cultivation has been shown to influence emotional processing and reduce negativity bias in the contexts of emotional and physical discomfort, thus suggesting it may be beneficial as a dual treatment for pain and anger. Our objective was to conduct a pilot study of a 9-week group compassion cultivation intervention in chronic pain to examine its effect on pain severity, anger, pain acceptance and pain-related interference. We also aimed to describe observer ratings provided by patients' significant others and secondary effects of the intervention.Pilot clinical trial with repeated measures design that included a within-subjects wait-list control period. Twelve chronic pain patients completed the intervention (F= 10). Data were collected from patients at enrollment, treatment baseline and post-treatment; participant significant others contributed data at the enrollment and post-treatment time points.In this predominantly female sample, patients had significantly reduced pain severity and anger and increased pain acceptance at post-treatment compared to treatment baseline. Significant other qualitative data corroborated patient reports for reductions in pain severity and anger.Compassion meditation may be a useful adjunctive treatment for reducing pain severity and anger, and for increasing chronic pain acceptance. Patient reported reductions in anger were corroborated by their significant others. The significant other corroborations offer a novel contribution to the literature and highlight the observable emotional and behavioral changes in the patient participants that occurred following the compassion intervention. Future studies may further examine how anger reductions impact relationships with self and others within the context of chronic pain.

    View details for PubMedID 27499883

    View details for PubMedCentralID PMC4972045

  • Proinflammatory cytokines and DHEA-S in women with fibromyalgia: impact of psychological distress and menopausal status JOURNAL OF PAIN RESEARCH Sturgeon, J. A., Darnall, B. D., Zwickey, H. L., Wood, L. J., Hanes, D. A., Zava, D. T., Mackey, S. C. 2014; 7: 707-716

    Abstract

    Though fibromyalgia is not traditionally considered an inflammatory disorder, evidence for elevated inflammatory processes has been noted in this disorder in multiple studies. Support for inflammatory markers in fibromyalgia has been somewhat equivocal to date, potentially due to inattention to salient patient characteristics that may affect inflammation, such as psychiatric distress and aging milestones like menopause. The current study examined the relationships between proinflammatory cytokines and hormone levels, pain intensity, and psychological distress in a sample of 34 premenopausal and postmenopausal women with fibromyalgia. Our results indicated significant relationships between interleukin-8 and ratings of pain catastrophizing (r=0.555, P<0.05), pain anxiety (r=0.559, P<0.05), and depression (r=0.551, P<0.05) for postmenopausal women but not premenopausal women (r,0.20 in all cases). Consistent with previous studies, ratios of interleukin-6 to interleukin-10 were significantly lower in individuals with greater levels of depressive symptoms (r=-0.239, P<0.05). Contrary to previous research, however, dehydroepiandrosterone sulfate did not correlate with pain intensity or psychological or biological variables. The results of the current study highlight the importance of psychological functioning and milestones of aging in the examination of inflammatory processes in fibromyalgia.

    View details for DOI 10.2147/JPR.S71344

    View details for Web of Science ID 000364591400001

    View details for PubMedID 25506243

  • From Catastrophizing to Recovery: a pilot study of a single-session treatment for pain catastrophizing JOURNAL OF PAIN RESEARCH Darnall, B. D., Sturgeon, J. A., Kao, M., Hah, J. M., Mackey, S. C. 2014; 7: 219-226

    Abstract

    Pain catastrophizing (PC) - a pattern of negative cognitive-emotional responses to real or anticipated pain - maintains chronic pain and undermines medical treatments. Standard PC treatment involves multiple sessions of cognitive behavioral therapy. To provide efficient treatment, we developed a single-session, 2-hour class that solely treats PC entitled "From Catastrophizing to Recovery" [FCR].To determine 1) feasibility of FCR; 2) participant ratings for acceptability, understandability, satisfaction, and likelihood to use the information learned; and 3) preliminary efficacy of FCR for reducing PC.Uncontrolled prospective pilot trial with a retrospective chart and database review component. Seventy-six patients receiving care at an outpatient pain clinic (the Stanford Pain Management Center) attended the class as free treatment and 70 attendees completed and returned an anonymous survey immediately post-class. The Pain Catastrophizing Scale (PCS) was administered at class check-in (baseline) and at 2, and 4 weeks post-treatment. Within subjects repeated measures analysis of variance (ANOVA) with Student's t-test contrasts were used to compare scores across time points.All attendees who completed a baseline PCS were included as study participants (N=57; F=82%; mean age =50.2 years); PCS was completed by 46 participants at week 2 and 35 participants at week 4. Participants had significantly reduced PC at both time points (P<0001) and large effect sizes were found (Cohen's d=0.85 and d=1.15).Preliminary data suggest that FCR is an acceptable and effective treatment for PC. Larger, controlled studies of longer duration are needed to determine durability of response, factors contributing to response, and the impact on pain, function and quality of life.

    View details for DOI 10.2147/JPR.S62329

    View details for Web of Science ID 000364587600005

    View details for PubMedID 24851056

    View details for PubMedCentralID PMC4008292

  • Upscheduling of Hydrocodone: Convenience and Access vs Patient Safety Measures PAIN MEDICINE Schatman, M. E., Darnall, B. D. 2013; 14 (11): 1627-1627

    View details for DOI 10.1111/pme.12257

    View details for Web of Science ID 000327011600004

    View details for PubMedID 24238351

  • Medical marijuana: a viable tool in the armamentaria of physicians treating chronic pain? A case study and commentary. Pain medicine Schatman, M. E., Darnall, B. D. 2013; 14 (6): 799-?

    View details for DOI 10.1111/pme.12137

    View details for PubMedID 23647910

  • A Pendulum Swings Awry: Seeking the Middle Ground on Opioid Prescribing for Chronic Non-Cancer Pain PAIN MEDICINE Schatman, M. E., Darnall, B. D. 2013; 14 (5)

    View details for Web of Science ID 000319279800032

    View details for PubMedID 23581746

  • Medical and Psychological Risks and Consequences of Long-Term Opioid Therapy in Women PAIN MEDICINE Darnall, B. D., Stacey, B. R., Chou, R. 2012; 13 (9): 1181-1211

    Abstract

    Long-term opioid use has increased substantially over the past decade for U.S. women. Women are more likely than men to have a chronic pain condition, to be treated with opioids, and may receive higher doses. Prescribing trends persist despite limited evidence to support the long-term benefit of this pain treatment approach.To review the medical and psychological risks and consequences of long-term opioid therapy in women.Scientific literature containing relevant keywords and content were reviewed.Long-term opioid use exposes women to unique risks, including endocrinopathy, reduced fertility, neonatal risks, as well as greater risk for polypharmacy, cardiac risks, poisoning and unintentional overdose, among other risks. Risks for women appear to vary by age and psychosocial factors may be bidirectionally related to opioid use. Gaps in understanding and priorities for future research are highlighted.

    View details for DOI 10.1111/j.1526-4637.2012.01467.x

    View details for Web of Science ID 000308713600011

    View details for PubMedID 22905834

  • Pain Characteristics and Pain Catastrophizing in Incarcerated Women with Chronic Pain JOURNAL OF HEALTH CARE FOR THE POOR AND UNDERSERVED Darnall, B. D., Sazie, E. 2012; 23 (2): 543-556

    Abstract

    Chronic pain in incarcerated women is understudied and poorly described. Study objectives were to describe pain characteristics, correlates, and predictors in a convenience sample of incarcerated women with chronic pain. A survey packet that included the Brief Pain Inventory Short Form (BPI-SF) and the Pain Catastrophizing Scale (PCS) was distributed to all inmates at a state prison for women. Those who self-identified as having chronic pain ≥4 on a 0-10 numeric rating scale were invited to complete the survey. Demographics and medical and psychiatric diagnoses were abstracted by chart review. Participants (N=159) rated their current and average pain intensity as severe. Pain catastrophizing was found to predict average pain intensity and level of pain-related interference in functioning. Pain catastrophizing is treatable with behavioral intervention in the general population. Findings suggest that pain catastrophizing may be an important target for research and treatment in incarcerated women with chronic pain.

    View details for Web of Science ID 000303427600007

    View details for PubMedID 22643606

  • Sex Differences in Long-term Opioid Use Cautionary Notes for Prescribing in Women ARCHIVES OF INTERNAL MEDICINE Darnall, B. D., Stacey, B. R. 2012; 172 (5): 431-432

    View details for Web of Science ID 000301381300012

    View details for PubMedID 22412108

  • HOME-BASED SELF-DELIVERED MIRROR THERAPY FOR PHANTOM PAIN: A PILOT STUDY JOURNAL OF REHABILITATION MEDICINE Darnall, B. D., Li, H. 2012; 44 (3): 254-260

    Abstract

    To test the feasibility and preliminary efficacy of self-delivered home-based mirror therapy for phantom pain.Uncontrolled prospective treatment outcome pilot study.Forty community-dwelling adults with unilateral amputation and phantom pain > 3 on a 0-10 numeric rating scale enrolled either during a one-time study visit (n = 30) or remotely (n = 10).Participants received an explanation of mirror therapy and were asked to self-treat for 25 min daily. Participants completed and posted back sets of outcomes questionnaires at months 1 and 2 post-treatment. Main outcome was average phantom pain intensity at post-treatment.A significant reduction in average phantom pain intensity was found at month 1 (n = 31, p = 0.0002) and at month 2 (n = 26, p = 0.002). The overall median percentage reduction at month 2 was 15.4%. Subjects with high education (> 16 years) compared with low education (< 16 years) (37.5% vs 4.1%) had greater reduction in pain intensity (p = 0.01).These findings support the feasibility and efficacy of home-based self-delivered mirror therapy; this low-cost treatment may defray medical costs, therapy visits, and the patient travel burden for people with motivation and a high level of education. More research is needed to determine methods of cost-effective support for people with lower levels of education.

    View details for DOI 10.2340/16501977-0933

    View details for Web of Science ID 000305492600011

    View details for PubMedID 22378591

  • Hysterectomy and Predictors for Opioid Prescription in a Chronic Pain Clinic Sample PAIN MEDICINE Darnall, B., Li, H. 2011; 12 (2): 196-203

    Abstract

    To describe the prevalence of hysterectomy for women aged 18-45 seeking treatment at a chronic pain clinic, to describe patient characteristics (pain intensity, age, smoking status, hormone replacement status, and psychosocial factors) based on opioid and hysterectomy status, and to determine whether hysterectomy status predicted receipt of opioid prescription.Retrospective cross-sectional chart review.Total 323 new female patients aged 18-45 who completed the Brief Pain Inventory-Short Form at initial evaluation at a chronic pain clinic during a 12-month period (July 2008-June 2009).Data were collected from the Brief Pain Inventory and medical charts. Variables included opioid prescription, average pain intensity, pain type, age, hysterectomy status, smoking status, and pain-related dysfunction across domains measured by the Brief Pain Inventory. The association of opioid prescription with hysterectomy and other factors were determined by logistic regression.Prevalence of hysterectomy was 28.8%. Average pain intensity was not associated with either hysterectomy or opioid prescription status. However, hysterectomy and high levels of pain-related dysfunction were significantly and independently associated with opioid prescription after adjusting for age and pain intensity. More than 85% of women with hysterectomy and high pain-related dysfunction had opioid prescription.Hysterectomy may confer risk for pain-related dysfunction and opioid prescription in women 45 and younger. More research is needed to understand 1) how patient characteristics influence prescribing patterns and 2) the specific medical risks and consequences of chronic opioid therapy in this population.

    View details for DOI 10.1111/j.1526-4637.2010.01038.x

    View details for Web of Science ID 000287200000003

    View details for PubMedID 21223499

    View details for PubMedCentralID PMC3076049

  • Pilot Study of Inflammatory Responses Following a Negative Imaginal Focus in Persons With Chronic Pain: Analysis by Sex/Gender GENDER MEDICINE Darnall, B. D., Aickin, M., Zwickey, H. 2010; 7 (3): 247-260

    Abstract

    Recent evidence suggests that differential stress and immune responses may play a role in the sex/gender disparity for pain. Pain pathology and psychological stress are both associated with elevated levels of proinflammatory cytokines.This pilot study tested a negative imaginal focus to assess whether it would elicit a proinflammatory cytokine response and whether responses would vary by sex/gender.Adults with chronic musculoskeletal pain were recruited from an outpatient, multidisciplinary pain clinic in Portland, Oregon, between 2007 and 2008. All participants underwent a psychologist-guided 10-minute focus on the negative aspects of their pain condition and the imagined worsening of their pain; no control group was used. Serum collected at baseline and postfocus (1, 2, and 2.5 hours) was assayed for interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha). Cortisol was assayed at each time point and at 15 minutes postfocus.Thirty-six outpatients (aged 26-62 years; 23 women, 13 men) participated in the study. Compared with men, women displayed greater negative emotional expression during the experiment, and this in turn mediated their IL-6 inflammatory responses. Relative to men, the IL-6 response trajectory was delayed for women. The IL-6 and TNF-a findings suggest women's maximal cytokine responses were not captured by the final time point.This pilot study provides preliminary evidence that women with chronic pain may experience increased and delayed inflammatory responses following negative emotional expression induced by thinking negatively about their pain condition. The findings have implications for pain catastrophizing research. This early-phase research suggests that the timing and duration of the cytokine response are critical factors to consider in future pain research.

    View details for DOI 10.1016/j.genm.2010.06.003

    View details for Web of Science ID 000279749600007

    View details for PubMedID 20638630

  • Sex and gender in psychoneuroimmunology research: Past, present and future BRAIN BEHAVIOR AND IMMUNITY Darnall, B. D., Suarez, E. C. 2009; 23 (5): 595-604

    Abstract

    To date, research suggests that sex and gender impact pathways central to the foci of psychoneuroimmunology (PNI). This review provides a historical perspective on the evolution of sex and gender in psychoneuroimmunology research. Gender and sexually dimorphic pathways may have synergistic effects on health differences in men and women. We provide an overview of the literature of sex and gender differences in brain structure and function, sex steroids, gender role identification, hypothalamic-pituitary-adrenal axis function, genetics, immunology and cytokine response. Specific examples shed light on the importance of attending to sex and gender methodology in PNI research and recommendations are provided.

    View details for DOI 10.1016/j.bbi.2009.02.019

    View details for Web of Science ID 000267274000005

    View details for PubMedID 19272440

    View details for PubMedCentralID PMC2740642

  • Self-Delivered Home-Based Mirror Therapy for Lower Limb Phantom Pain AMERICAN JOURNAL OF PHYSICAL MEDICINE & REHABILITATION Darnall, B. D. 2009; 88 (1): 78-81

    Abstract

    Home-based patient-delivered mirror therapy is a promising approach in the treatment of phantom limb pain. Previous studies and case reports of mirror therapy have used a therapist-guided, structured protocol of exercises. No case report has described treatment for either upper or lower limb phantom pain by using home-based patient-delivered mirror therapy. The success of this case demonstrates that home-based patient-delivered mirror therapy may be an efficacious, low-cost treatment option that would eliminate many traditional barriers to care.

    View details for DOI 10.1097/PHM.0b013e318191105b

    View details for Web of Science ID 000262027100011

    View details for PubMedID 19096290

  • Depressive symptoms and mental health service utilization among persons with limb loss: results of a national survey. Archives of physical medicine and rehabilitation Darnall, B. D., Ephraim, P., Wegener, S. T., Dillingham, T., Pezzin, L., Rossbach, P., MacKenzie, E. J. 2005; 86 (4): 650-658

    Abstract

    To describe the prevalence of depressive symptoms, risk factors, and mental health service utilization in a national limb-loss sample.Cross-sectional survey.Participants were interviewed by telephone.A stratified sample by etiology of 914 persons with limb loss, derived from people who contacted the Amputee Coalition of America from 1998 to 2000.Not applicable.Center for Epidemiologic Study Depression Scale (CES-D 10-item), pain bothersomeness, characteristics of the amputation, sociodemographics, and mental health service utilization.Prevalence for significant depressive symptoms (CES-D score, >/=10) was 28.7%. Risk factors included being divorced or separated, living at the near-poverty level, having comorbid conditions, being somewhat bothered or extremely bothered by back pain and phantom limb pain, and having residual limb pain for persons aged 18 to 54. Having higher education was a buffer against depressive symptoms. Almost 22% of the sample and 44.6% of persons with significant depressive symptoms received mental health service in the previous year. For persons with significant depressive symptoms, 32.9% reported needing mental health service but not receiving them, and 67.1% reported not needing mental health service.Depressive symptoms are prevalent among persons with limb loss. Proper management of pain and medical comorbidity may mitigate depressive symptoms. Education about depressive symptoms and treatment options may improve receipt of mental health service among persons with limb loss reporting significant levels of depressive symptoms.

    View details for PubMedID 15827913

  • Depressive symptoms among persons with and mental health service utilization limb loss: Results of a national survey Rehabilitation Psychology Winter Conference Darnall, B. D., Ephraim, P., Wegener, S. T., Dillingham, T., Pezzin, L., Rossbach, P., MacKenzie, E. J. W B SAUNDERS CO-ELSEVIER INC. 2005: 650–58

    View details for DOI 10.1016/j.apmr.2004.10.028

    View details for Web of Science ID 000228237300006

  • Modification of the cognitive model for bulimia via path analysis on a Brazilian adolescent sample ADDICTIVE BEHAVIORS Darnall, B. D., Smith, J. E., Craighead, L. W., Lamounier, J. A. 1999; 24 (1): 47-57

    Abstract

    Eating disturbances in middle-class Brazilian adolescents attending three high schools (one Military, two Private schools) were investigated. Participants from both Private schools were similar to U.S. samples on the EAT-26. Path analysis on the Private schools revealed the following. Higher body weight leads to weight concerns most strongly through greater discrepancy from the ideal, but it also leads directly to weight concern. Thus, both the reality of being heavier and the perception that one is larger than ideal (which could be due to being heavier and/or having a thin ideal) contribute to weight concern. Greater weight concern is associated most directly with lower self-esteem, which in turn is associated with endorsing greater importance of weight and shape. Importance of weight and shape contributes most powerfully to eating pathology through dieting, but this variable has a modest direct effect as well. These paths were not significant for the Military school sample in which participants reported lower levels of weight concern, dieting, body dissatisfaction, and a larger ideal figure. However, the Military sample rated importance of weight and shape as high as did Private-school participants. The results provide support for variables identified as important in the cognitive model of bulimia and suggest the model may be enhanced by including body weight and one's perceived ideal body shape as additional variables.

    View details for Web of Science ID 000077732100004

    View details for PubMedID 10189972