Kate Johnson

MONTREAL – Sleep problems are very common among individuals exposed to terrorist attacks, and new evidence suggests that sleep deficits are contributing to obesity in this traumatized population, researchers reported at the annual meeting of the International Society for Traumatic Stress Studies.

Disturbed sleep and traumatic nightmares are hallmark features of posttraumatic stress disorder (PTSD), said Brian Hall, a doctoral candidate at Kent (Ohio) State University and a clinical psychology intern at the Medical University of South Carolina, Charleston. "Sleep is a treatment-refractory target in PTSD. In folks who respond well to treatments for PTSD, sleep problems tend to be a residual issue."

In a study of 501 Israeli Jews living along the Gaza strip, Mr. Hall and his colleagues found that 47% had had at least one direct terrorist exposure involving the death of a relative, personal injury, the injury of a relative or close friend, or witnessing a rocket or terrorist attack with injuries or fatalities.

PTSD was present in 5.5% of this highly exposed cohort, and depression, in an additional 3.8%. Clinical sleep disturbance, assessed using the 18-item Pittsburgh Sleep Quality Index (PSQI), was present in 37.4% of the cohort, but reached 82% among those identified with PTSD, and 79% among those who were depressed. Overweight, assessed by body mass index (BMI), was present in 45% of the entire cohort, with 11% of the overweight group meeting criteria for obesity, he said at the meeting, cosponsored by Boston University.

Statistical analysis showed that although there was no direct effect of PTSD on BMI, sleep mediated this effect.

Further analysis of the same data revealed that females in the cohort were more prone to sleep problems than males (odds ratio, 1.45), as were individuals aged 50-64 years (OR, 2.07) and those older than age 65 years (OR, 4.45), reported Stevan Hobfoll, Ph.D., of Rush University Medical Center in Chicago, in a separate presentation about the same data.

Sleep problems can worsen the symptoms of PTSD and might exacerbate physical health problems such as cardiovascular disease, stroke, and diabetes, said Mr. Hall in an interview. "What I am trying to emphasize from a public health perspective is that interventions targeting sleep problems are important in PTSD."

Asked to comment on the findings, Jeffrey Knight, Ph.D., raised questions about them. "These things are all related, but to what degree and in what order? What do you do with the person in front of you?" said Dr. Knight, a clinical neuropsychologist at the National Center for PTSD, VA Boston Healthcare System, and Boston University. "What you have is a ball of symptoms traveling together as a unit – it’s like a soccer ball – and at any particular time it rolls over and you see certain facets, but the other parts are still operative. Sleep is a piece of the protocol, but whether it’s driven by anxiety or depression or nightmares, you need to address it differently."

None of the presenters reported having conflicts of interest.

MONTREAL – Sleep problems are very common among individuals exposed to terrorist attacks, and new evidence suggests that sleep deficits are contributing to obesity in this traumatized population, researchers reported at the annual meeting of the International Society for Traumatic Stress Studies.

Disturbed sleep and traumatic nightmares are hallmark features of posttraumatic stress disorder (PTSD), said Brian Hall, a doctoral candidate at Kent (Ohio) State University and a clinical psychology intern at the Medical University of South Carolina, Charleston. "Sleep is a treatment-refractory target in PTSD. In folks who respond well to treatments for PTSD, sleep problems tend to be a residual issue."

In a study of 501 Israeli Jews living along the Gaza strip, Mr. Hall and his colleagues found that 47% had had at least one direct terrorist exposure involving the death of a relative, personal injury, the injury of a relative or close friend, or witnessing a rocket or terrorist attack with injuries or fatalities.

PTSD was present in 5.5% of this highly exposed cohort, and depression, in an additional 3.8%. Clinical sleep disturbance, assessed using the 18-item Pittsburgh Sleep Quality Index (PSQI), was present in 37.4% of the cohort, but reached 82% among those identified with PTSD, and 79% among those who were depressed. Overweight, assessed by body mass index (BMI), was present in 45% of the entire cohort, with 11% of the overweight group meeting criteria for obesity, he said at the meeting, cosponsored by Boston University.

Statistical analysis showed that although there was no direct effect of PTSD on BMI, sleep mediated this effect.

Further analysis of the same data revealed that females in the cohort were more prone to sleep problems than males (odds ratio, 1.45), as were individuals aged 50-64 years (OR, 2.07) and those older than age 65 years (OR, 4.45), reported Stevan Hobfoll, Ph.D., of Rush University Medical Center in Chicago, in a separate presentation about the same data.

Sleep problems can worsen the symptoms of PTSD and might exacerbate physical health problems such as cardiovascular disease, stroke, and diabetes, said Mr. Hall in an interview. "What I am trying to emphasize from a public health perspective is that interventions targeting sleep problems are important in PTSD."

Asked to comment on the findings, Jeffrey Knight, Ph.D., raised questions about them. "These things are all related, but to what degree and in what order? What do you do with the person in front of you?" said Dr. Knight, a clinical neuropsychologist at the National Center for PTSD, VA Boston Healthcare System, and Boston University. "What you have is a ball of symptoms traveling together as a unit – it’s like a soccer ball – and at any particular time it rolls over and you see certain facets, but the other parts are still operative. Sleep is a piece of the protocol, but whether it’s driven by anxiety or depression or nightmares, you need to address it differently."

None of the presenters reported having conflicts of interest.

MONTREAL – Sleep problems are very common among individuals exposed to terrorist attacks, and new evidence suggests that sleep deficits are contributing to obesity in this traumatized population, researchers reported at the annual meeting of the International Society for Traumatic Stress Studies.

Disturbed sleep and traumatic nightmares are hallmark features of posttraumatic stress disorder (PTSD), said Brian Hall, a doctoral candidate at Kent (Ohio) State University and a clinical psychology intern at the Medical University of South Carolina, Charleston. "Sleep is a treatment-refractory target in PTSD. In folks who respond well to treatments for PTSD, sleep problems tend to be a residual issue."

In a study of 501 Israeli Jews living along the Gaza strip, Mr. Hall and his colleagues found that 47% had had at least one direct terrorist exposure involving the death of a relative, personal injury, the injury of a relative or close friend, or witnessing a rocket or terrorist attack with injuries or fatalities.

PTSD was present in 5.5% of this highly exposed cohort, and depression, in an additional 3.8%. Clinical sleep disturbance, assessed using the 18-item Pittsburgh Sleep Quality Index (PSQI), was present in 37.4% of the cohort, but reached 82% among those identified with PTSD, and 79% among those who were depressed. Overweight, assessed by body mass index (BMI), was present in 45% of the entire cohort, with 11% of the overweight group meeting criteria for obesity, he said at the meeting, cosponsored by Boston University.

Statistical analysis showed that although there was no direct effect of PTSD on BMI, sleep mediated this effect.

Further analysis of the same data revealed that females in the cohort were more prone to sleep problems than males (odds ratio, 1.45), as were individuals aged 50-64 years (OR, 2.07) and those older than age 65 years (OR, 4.45), reported Stevan Hobfoll, Ph.D., of Rush University Medical Center in Chicago, in a separate presentation about the same data.

Sleep problems can worsen the symptoms of PTSD and might exacerbate physical health problems such as cardiovascular disease, stroke, and diabetes, said Mr. Hall in an interview. "What I am trying to emphasize from a public health perspective is that interventions targeting sleep problems are important in PTSD."

Asked to comment on the findings, Jeffrey Knight, Ph.D., raised questions about them. "These things are all related, but to what degree and in what order? What do you do with the person in front of you?" said Dr. Knight, a clinical neuropsychologist at the National Center for PTSD, VA Boston Healthcare System, and Boston University. "What you have is a ball of symptoms traveling together as a unit – it’s like a soccer ball – and at any particular time it rolls over and you see certain facets, but the other parts are still operative. Sleep is a piece of the protocol, but whether it’s driven by anxiety or depression or nightmares, you need to address it differently."

None of the presenters reported having conflicts of interest.

MONTREAL – Predisposition is an important factor, but a traumatic event remains the necessary trigger in the development of posttraumatic stress disorder, a new study of identical twins indicates.

"Embedded within the diagnostic criteria of PTSD is a presumed causal event, but this assumption has come under scrutiny, as a recent study suggested that the symptoms of PTSD may merely represent general psychiatric symptoms that would have developed even in the absence of a trauma (J. Anxiety Disord. 2007;21:176-82)," explained Dr. Roger Pitman, director of the PTSD and psychophysiology laboratory at Massachusetts General Hospital and professor of psychiatry at Harvard Medical School, both in Boston.

Speaking at the annual meeting of the International Society for Traumatic Stress Studies, Dr. Pitman launched new evidence to support the widely held theory that trauma is central to the development of PTSD.

The study comprised 104 Vietnam combat veterans and their nonveteran identical twins. Of the veterans, 50s had PTSD and 54 did not, whereas none of the nonveteran identical twins had the disorder (J. Clin. Psychiatry 2010;71:1324-30).

"If the PTSD-affected veterans had predisposing vulnerability to psychopathology on a genetic or environmental basis, then that ought to be shared by their twins," he explained.

Psychometric measures – including the Symptom Checklist-90-Revised, the Clinician-Administered PTSD Scale (CAPS), and the Mississippi Scale for Combat-Related PTSD – were used to assess symptoms for all veterans and their twins. For the nonveterans, questions about combat trauma were replaced with questions about their most traumatic experience.

As expected, the evaluations revealed higher scores on all measures for the PTSD-affected veterans, compared with their identical twins. All nonveteran twins had scores similar to those of the veterans without PTSD.

"These results do not support the idea that the people with PTSD would have been symptomatic even without the traumatic event," Dr. Pitman said. "They do support the conclusion that the mental disorders found in PTSD result from a trauma."

About one-third of individuals who were exposed to a traumatic event will go on to develop PTSD, which suggests that certain people may have an underlying predisposition to developing the disorder, Dr. Pitman said.

"We called the twins of the PTSD-affected veterans ‘high risk’ because they had a shared familial environment and shared genes," he noted. Indeed, further analysis revealed certain "neurological soft signs" in these twins. "We found subtle abnormalities of the nervous system that were elevated in the veterans with PTSD, [compared with] the veterans without PTSD, and these were also elevated in the identical twins of the PTSD veterans," he reported. "The nonveterans were not symptomatic; we infer [that] the increased presence of these subtle abnormalities could make them more vulnerable to developing PTSD, but in order for this to occur, there would have to be a traumatic exposure."

When Dr. Harrison G. Pope Jr., coauthor of the 2007 paper that questioned the trauma-PTSD connection, was reached for comment, he said that Dr. Pitman’s study was not contradictory to that of Dr. Pope’s group. "[Our paper] showed that the symptom cluster of PTSD is not unique to victims of trauma, but can occur commonly in patients seeking treatment for depression, even if these patients have not experienced a trauma," said Dr. Pope, professor of psychiatry at Harvard Medical School, Boston, and director of the biological psychiatry laboratory at McLean Hospital in Belmont, Mass.

Specifically, Dr. Pope and his colleagues concluded that "the symptom cluster traditionally associated with PTSD may be nonspecific, in that it may frequently occur in the absence of trauma." By comparison, Dr. Pitman’s study "simply showed that trauma can cause these symptoms, to a much greater degree."

From a clinical perspective this means that "one should not automatically assume that all so-called PTSD symptoms are necessarily due to trauma. Therefore, when treating a patient who is a trauma victim and who also exhibits symptoms, one should reasonably consider both of these possibilities," he said.

The presenters had no conflicts to disclose.

MONTREAL – Predisposition is an important factor, but a traumatic event remains the necessary trigger in the development of posttraumatic stress disorder, a new study of identical twins indicates.

"Embedded within the diagnostic criteria of PTSD is a presumed causal event, but this assumption has come under scrutiny, as a recent study suggested that the symptoms of PTSD may merely represent general psychiatric symptoms that would have developed even in the absence of a trauma (J. Anxiety Disord. 2007;21:176-82)," explained Dr. Roger Pitman, director of the PTSD and psychophysiology laboratory at Massachusetts General Hospital and professor of psychiatry at Harvard Medical School, both in Boston.

Speaking at the annual meeting of the International Society for Traumatic Stress Studies, Dr. Pitman launched new evidence to support the widely held theory that trauma is central to the development of PTSD.

The study comprised 104 Vietnam combat veterans and their nonveteran identical twins. Of the veterans, 50s had PTSD and 54 did not, whereas none of the nonveteran identical twins had the disorder (J. Clin. Psychiatry 2010;71:1324-30).

"If the PTSD-affected veterans had predisposing vulnerability to psychopathology on a genetic or environmental basis, then that ought to be shared by their twins," he explained.

Psychometric measures – including the Symptom Checklist-90-Revised, the Clinician-Administered PTSD Scale (CAPS), and the Mississippi Scale for Combat-Related PTSD – were used to assess symptoms for all veterans and their twins. For the nonveterans, questions about combat trauma were replaced with questions about their most traumatic experience.

As expected, the evaluations revealed higher scores on all measures for the PTSD-affected veterans, compared with their identical twins. All nonveteran twins had scores similar to those of the veterans without PTSD.

"These results do not support the idea that the people with PTSD would have been symptomatic even without the traumatic event," Dr. Pitman said. "They do support the conclusion that the mental disorders found in PTSD result from a trauma."

About one-third of individuals who were exposed to a traumatic event will go on to develop PTSD, which suggests that certain people may have an underlying predisposition to developing the disorder, Dr. Pitman said.

"We called the twins of the PTSD-affected veterans ‘high risk’ because they had a shared familial environment and shared genes," he noted. Indeed, further analysis revealed certain "neurological soft signs" in these twins. "We found subtle abnormalities of the nervous system that were elevated in the veterans with PTSD, [compared with] the veterans without PTSD, and these were also elevated in the identical twins of the PTSD veterans," he reported. "The nonveterans were not symptomatic; we infer [that] the increased presence of these subtle abnormalities could make them more vulnerable to developing PTSD, but in order for this to occur, there would have to be a traumatic exposure."

When Dr. Harrison G. Pope Jr., coauthor of the 2007 paper that questioned the trauma-PTSD connection, was reached for comment, he said that Dr. Pitman’s study was not contradictory to that of Dr. Pope’s group. "[Our paper] showed that the symptom cluster of PTSD is not unique to victims of trauma, but can occur commonly in patients seeking treatment for depression, even if these patients have not experienced a trauma," said Dr. Pope, professor of psychiatry at Harvard Medical School, Boston, and director of the biological psychiatry laboratory at McLean Hospital in Belmont, Mass.

Specifically, Dr. Pope and his colleagues concluded that "the symptom cluster traditionally associated with PTSD may be nonspecific, in that it may frequently occur in the absence of trauma." By comparison, Dr. Pitman’s study "simply showed that trauma can cause these symptoms, to a much greater degree."

From a clinical perspective this means that "one should not automatically assume that all so-called PTSD symptoms are necessarily due to trauma. Therefore, when treating a patient who is a trauma victim and who also exhibits symptoms, one should reasonably consider both of these possibilities," he said.

The presenters had no conflicts to disclose.

MONTREAL – Predisposition is an important factor, but a traumatic event remains the necessary trigger in the development of posttraumatic stress disorder, a new study of identical twins indicates.

"Embedded within the diagnostic criteria of PTSD is a presumed causal event, but this assumption has come under scrutiny, as a recent study suggested that the symptoms of PTSD may merely represent general psychiatric symptoms that would have developed even in the absence of a trauma (J. Anxiety Disord. 2007;21:176-82)," explained Dr. Roger Pitman, director of the PTSD and psychophysiology laboratory at Massachusetts General Hospital and professor of psychiatry at Harvard Medical School, both in Boston.

Speaking at the annual meeting of the International Society for Traumatic Stress Studies, Dr. Pitman launched new evidence to support the widely held theory that trauma is central to the development of PTSD.

The study comprised 104 Vietnam combat veterans and their nonveteran identical twins. Of the veterans, 50s had PTSD and 54 did not, whereas none of the nonveteran identical twins had the disorder (J. Clin. Psychiatry 2010;71:1324-30).

"If the PTSD-affected veterans had predisposing vulnerability to psychopathology on a genetic or environmental basis, then that ought to be shared by their twins," he explained.

Psychometric measures – including the Symptom Checklist-90-Revised, the Clinician-Administered PTSD Scale (CAPS), and the Mississippi Scale for Combat-Related PTSD – were used to assess symptoms for all veterans and their twins. For the nonveterans, questions about combat trauma were replaced with questions about their most traumatic experience.

As expected, the evaluations revealed higher scores on all measures for the PTSD-affected veterans, compared with their identical twins. All nonveteran twins had scores similar to those of the veterans without PTSD.

"These results do not support the idea that the people with PTSD would have been symptomatic even without the traumatic event," Dr. Pitman said. "They do support the conclusion that the mental disorders found in PTSD result from a trauma."

About one-third of individuals who were exposed to a traumatic event will go on to develop PTSD, which suggests that certain people may have an underlying predisposition to developing the disorder, Dr. Pitman said.

"We called the twins of the PTSD-affected veterans ‘high risk’ because they had a shared familial environment and shared genes," he noted. Indeed, further analysis revealed certain "neurological soft signs" in these twins. "We found subtle abnormalities of the nervous system that were elevated in the veterans with PTSD, [compared with] the veterans without PTSD, and these were also elevated in the identical twins of the PTSD veterans," he reported. "The nonveterans were not symptomatic; we infer [that] the increased presence of these subtle abnormalities could make them more vulnerable to developing PTSD, but in order for this to occur, there would have to be a traumatic exposure."

When Dr. Harrison G. Pope Jr., coauthor of the 2007 paper that questioned the trauma-PTSD connection, was reached for comment, he said that Dr. Pitman’s study was not contradictory to that of Dr. Pope’s group. "[Our paper] showed that the symptom cluster of PTSD is not unique to victims of trauma, but can occur commonly in patients seeking treatment for depression, even if these patients have not experienced a trauma," said Dr. Pope, professor of psychiatry at Harvard Medical School, Boston, and director of the biological psychiatry laboratory at McLean Hospital in Belmont, Mass.

Specifically, Dr. Pope and his colleagues concluded that "the symptom cluster traditionally associated with PTSD may be nonspecific, in that it may frequently occur in the absence of trauma." By comparison, Dr. Pitman’s study "simply showed that trauma can cause these symptoms, to a much greater degree."

From a clinical perspective this means that "one should not automatically assume that all so-called PTSD symptoms are necessarily due to trauma. Therefore, when treating a patient who is a trauma victim and who also exhibits symptoms, one should reasonably consider both of these possibilities," he said.

The presenters had no conflicts to disclose.

MONTREAL - Treatment of posttraumatic stress disorder with the beta-blocker propranolol might interrupt memory reconsolidation by inhibiting protein synthesis in the brain, reported researchers at the International Society for Traumatic Stress Studies.

"It does not erase memories, this is a misnomer," clarified Alain Brunet, Ph.D., of the department of psychiatry at McGill University and a researcher at the Douglas Mental Health Institute, both in Montreal.

Dr. Brunet presented several studies conducted by his group that suggest this pharmacologic interruption of memory might dampen emotional response to the information, presenting a promising treatment opportunity for posttraumatic stress disorder (PTSD).

Current treatment for PTSD is centered on psychotherapy that focuses on exposure to the traumatic memory and learning new responses to it, Dr. Brunet said. But a recent analysis found that only about one-third of patients treated this way experience a lasting, clinically meaningful improvement, he said.

Propranolol treatment takes a different approach. It is based on the notion that memories, once they are consolidated, can be retrieved, and they exist in a labile state during which they are susceptible to modification until they are reconsolidated. During the labile window of opportunity, which is believed to be several hours, administration of propranolol can strip the memory of its emotional meaning, making it less stressful, he explained.

In a randomized, controlled trial involving 19 chronic PTSD patients with an average symptom duration 10 years (J. Psychiatr. Res. 2008;42:503-6), Dr. Brunet and his colleagues asked the patients to recall their memory by writing a trauma script and outlining the details of their traumatic experience and the emotions they felt.

Nine patients were then given a two-dose regimen of fast-acting propranolol (40 mg) immediately after memory recall, followed by an extended-release propanolol dose (60 mg) 75 minutes later, and the other 10 patients received placebo. One week later, after reviewing their trauma script, patients’ physiologic responses to the memories were compared, using heart rate, skin conductivity, and corrugator electromyography (EMG) measurements.

Dr. Brunet reported significant differences between the placebo and treatment groups on heart rate and skin conductivity tests but not on EMG. There was a trend toward decreased symptoms, measured on the self-report Impact of Event Scale-Revised (IES-R).

The researchers also have completed two open-label studies using six weekly doses of propranolol in PTSD patients with a wide range of traumatic experiences.

One study with 35 subjects involved an initial dose of 0.67 mg/kg after memory recall, followed by a dose of 1.0 mg/kg 90 minutes later. Five subsequent weekly sessions involved both doses given concomitantly.

The second study with 7 subjects and 25 controls used an initial dose of 40 mg immediately after memory recall followed by 80 mg 90 minutes later. Five subsequent weekly sessions involved both doses concomitantly.

Remission rates at the end of the sixth weekly session were 86% for the first study and 71% for the second study, compared to 8% in controls.

The field of memory reconsolidation blockade is young when it comes to human studies, but there is substantial animal research to support it, commented Dr. Charles Marmar, professor and chair in the department of psychiatry at New York University Medical Center, who chaired a panel discussion after the session.

"The notion of building a pipeline from basic science, to translational studies in humans, to new treatments is very, very important in psychiatry," he said in an interview. "This work is pioneering. We should have some patience about this and appreciate that this is a new paradigm in mental health research.

"We believe this is the correct model for advancing the fight against stress, anxiety, depression, psychosis and dementia – and up until now we have not had the tools to do it."

Dr. Brunet had no disclosures to report.

MONTREAL - Treatment of posttraumatic stress disorder with the beta-blocker propranolol might interrupt memory reconsolidation by inhibiting protein synthesis in the brain, reported researchers at the International Society for Traumatic Stress Studies.

"It does not erase memories, this is a misnomer," clarified Alain Brunet, Ph.D., of the department of psychiatry at McGill University and a researcher at the Douglas Mental Health Institute, both in Montreal.

Dr. Brunet presented several studies conducted by his group that suggest this pharmacologic interruption of memory might dampen emotional response to the information, presenting a promising treatment opportunity for posttraumatic stress disorder (PTSD).

Current treatment for PTSD is centered on psychotherapy that focuses on exposure to the traumatic memory and learning new responses to it, Dr. Brunet said. But a recent analysis found that only about one-third of patients treated this way experience a lasting, clinically meaningful improvement, he said.

Propranolol treatment takes a different approach. It is based on the notion that memories, once they are consolidated, can be retrieved, and they exist in a labile state during which they are susceptible to modification until they are reconsolidated. During the labile window of opportunity, which is believed to be several hours, administration of propranolol can strip the memory of its emotional meaning, making it less stressful, he explained.

In a randomized, controlled trial involving 19 chronic PTSD patients with an average symptom duration 10 years (J. Psychiatr. Res. 2008;42:503-6), Dr. Brunet and his colleagues asked the patients to recall their memory by writing a trauma script and outlining the details of their traumatic experience and the emotions they felt.

Nine patients were then given a two-dose regimen of fast-acting propranolol (40 mg) immediately after memory recall, followed by an extended-release propanolol dose (60 mg) 75 minutes later, and the other 10 patients received placebo. One week later, after reviewing their trauma script, patients’ physiologic responses to the memories were compared, using heart rate, skin conductivity, and corrugator electromyography (EMG) measurements.

Dr. Brunet reported significant differences between the placebo and treatment groups on heart rate and skin conductivity tests but not on EMG. There was a trend toward decreased symptoms, measured on the self-report Impact of Event Scale-Revised (IES-R).

The researchers also have completed two open-label studies using six weekly doses of propranolol in PTSD patients with a wide range of traumatic experiences.

One study with 35 subjects involved an initial dose of 0.67 mg/kg after memory recall, followed by a dose of 1.0 mg/kg 90 minutes later. Five subsequent weekly sessions involved both doses given concomitantly.

The second study with 7 subjects and 25 controls used an initial dose of 40 mg immediately after memory recall followed by 80 mg 90 minutes later. Five subsequent weekly sessions involved both doses concomitantly.

Remission rates at the end of the sixth weekly session were 86% for the first study and 71% for the second study, compared to 8% in controls.

The field of memory reconsolidation blockade is young when it comes to human studies, but there is substantial animal research to support it, commented Dr. Charles Marmar, professor and chair in the department of psychiatry at New York University Medical Center, who chaired a panel discussion after the session.

"The notion of building a pipeline from basic science, to translational studies in humans, to new treatments is very, very important in psychiatry," he said in an interview. "This work is pioneering. We should have some patience about this and appreciate that this is a new paradigm in mental health research.

"We believe this is the correct model for advancing the fight against stress, anxiety, depression, psychosis and dementia – and up until now we have not had the tools to do it."

Dr. Brunet had no disclosures to report.

MONTREAL - Treatment of posttraumatic stress disorder with the beta-blocker propranolol might interrupt memory reconsolidation by inhibiting protein synthesis in the brain, reported researchers at the International Society for Traumatic Stress Studies.

"It does not erase memories, this is a misnomer," clarified Alain Brunet, Ph.D., of the department of psychiatry at McGill University and a researcher at the Douglas Mental Health Institute, both in Montreal.

Dr. Brunet presented several studies conducted by his group that suggest this pharmacologic interruption of memory might dampen emotional response to the information, presenting a promising treatment opportunity for posttraumatic stress disorder (PTSD).

Current treatment for PTSD is centered on psychotherapy that focuses on exposure to the traumatic memory and learning new responses to it, Dr. Brunet said. But a recent analysis found that only about one-third of patients treated this way experience a lasting, clinically meaningful improvement, he said.

Propranolol treatment takes a different approach. It is based on the notion that memories, once they are consolidated, can be retrieved, and they exist in a labile state during which they are susceptible to modification until they are reconsolidated. During the labile window of opportunity, which is believed to be several hours, administration of propranolol can strip the memory of its emotional meaning, making it less stressful, he explained.

In a randomized, controlled trial involving 19 chronic PTSD patients with an average symptom duration 10 years (J. Psychiatr. Res. 2008;42:503-6), Dr. Brunet and his colleagues asked the patients to recall their memory by writing a trauma script and outlining the details of their traumatic experience and the emotions they felt.

Nine patients were then given a two-dose regimen of fast-acting propranolol (40 mg) immediately after memory recall, followed by an extended-release propanolol dose (60 mg) 75 minutes later, and the other 10 patients received placebo. One week later, after reviewing their trauma script, patients’ physiologic responses to the memories were compared, using heart rate, skin conductivity, and corrugator electromyography (EMG) measurements.

Dr. Brunet reported significant differences between the placebo and treatment groups on heart rate and skin conductivity tests but not on EMG. There was a trend toward decreased symptoms, measured on the self-report Impact of Event Scale-Revised (IES-R).

The researchers also have completed two open-label studies using six weekly doses of propranolol in PTSD patients with a wide range of traumatic experiences.

One study with 35 subjects involved an initial dose of 0.67 mg/kg after memory recall, followed by a dose of 1.0 mg/kg 90 minutes later. Five subsequent weekly sessions involved both doses given concomitantly.

The second study with 7 subjects and 25 controls used an initial dose of 40 mg immediately after memory recall followed by 80 mg 90 minutes later. Five subsequent weekly sessions involved both doses concomitantly.

Remission rates at the end of the sixth weekly session were 86% for the first study and 71% for the second study, compared to 8% in controls.

The field of memory reconsolidation blockade is young when it comes to human studies, but there is substantial animal research to support it, commented Dr. Charles Marmar, professor and chair in the department of psychiatry at New York University Medical Center, who chaired a panel discussion after the session.

"The notion of building a pipeline from basic science, to translational studies in humans, to new treatments is very, very important in psychiatry," he said in an interview. "This work is pioneering. We should have some patience about this and appreciate that this is a new paradigm in mental health research.

"We believe this is the correct model for advancing the fight against stress, anxiety, depression, psychosis and dementia – and up until now we have not had the tools to do it."

Dr. Brunet had no disclosures to report.

Major Finding: Of the 18 first-born infants, only 1 survived until discharge, while 13 survived among the 22 latter-born infants.

Data Source: A series of 17 premature multifetal deliveries in which the first fetus was born at least 24 hours before the others.

Disclosures: Dr. Murji reported no conflicts of interest.

MONTREAL — Delayed-interval delivery when the initial delivery is extremely premature carries high maternal and infant morbidity, as well as a high infant mortality, reported Dr. Ally Murji of the University of Toronto's division of maternal-fetal medicine.

“Just because we can do something, it doesn't mean it should be done,” he said in an interview.

In a study that he presented at the meeting, Dr. Murji described a series of 17 premature multifetal deliveries in which the first fetus was born at least 24 hours before the others. The mean gestational age of the first delivery was 23 weeks and 2 days.

“In our series, this procedure was reserved for the threshold of viability – extremely premature infants,” he said in an interview, explaining that the majority of the initial deliveries were precipitated by preterm premature rupture of membranes (PPROM).

Among the 17 pregnancies, 12 were twin gestations, 4 were triplets, and one was a quadruplet pregnancy, said Dr. Murji.

Forty-one percent of the pregnancies had been conceived spontaneously, with the remainder being a result of either in-vitro fertilization (47%) or ovulation induction (12%). All infants were born vaginally, except for two of the latter-born infants. In the quadruplet delivery, two babies were born within minutes of each other, followed by a latency interval and then the birth of the other two. During the interval, 88% of mothers received antibiotics and 47% received tocolysis.

Of the 18 first-born infants, only 1 survived until discharge; 13 survived among the 22 latter-born infants – a survival rate of 59%. Mean birth weight was 468 g for first-born infants and 674 g for latter-born infants.

“Clearly there is a survival benefit in having an asynchronous delivery,” noted Dr. Murji. “But these babies are not out of the woods. When you look at the absolute weights these are very small babies – babies who are very fragile. The prognosis for these babies is already guarded.”

Indeed, the infants' average stay in the neonatal intensive care unit was 104 days. Twelve of the 13 infants had at least one morbidity, including retinopathy of prematurity, intraventricular hemorrhage, patent ductus arteriosus, or sepsis, and many of them had multiple comorbidities.

Maternal morbidity also was significant. The average age of the mothers was 31 years, and complications occurred in 71% of them, with intraamniotic infection being the most common (59%). Almost half of the mothers (47%) experienced two or more complications, with abruptio placentae, postpartum hemorrhage, and blood transfusions each occurring in 18% and septic pelvic thrombophlebitis and pulmonary edema each occurring in 6%.

The findings underscore the decisions that parents and physicians must face in contemplating delayed interval delivery in the context of premature delivery of the first baby.

“Outcomes in extremely premature deliveries are meager, at best. Although we can do asynchronous delivery, is it really reasonable? Yes, there is a clear survival benefit for the latter-born infant, but this survival benefit comes at the risk of maternal morbidity and the interval in our experience has only been 1 week. And these latter-born infants have significant morbidity because they're born so prematurely,” said Dr. Murji.

Major Finding: Of the 18 first-born infants, only 1 survived until discharge, while 13 survived among the 22 latter-born infants.

Data Source: A series of 17 premature multifetal deliveries in which the first fetus was born at least 24 hours before the others.

Disclosures: Dr. Murji reported no conflicts of interest.

MONTREAL — Delayed-interval delivery when the initial delivery is extremely premature carries high maternal and infant morbidity, as well as a high infant mortality, reported Dr. Ally Murji of the University of Toronto's division of maternal-fetal medicine.

“Just because we can do something, it doesn't mean it should be done,” he said in an interview.

In a study that he presented at the meeting, Dr. Murji described a series of 17 premature multifetal deliveries in which the first fetus was born at least 24 hours before the others. The mean gestational age of the first delivery was 23 weeks and 2 days.

“In our series, this procedure was reserved for the threshold of viability – extremely premature infants,” he said in an interview, explaining that the majority of the initial deliveries were precipitated by preterm premature rupture of membranes (PPROM).

Among the 17 pregnancies, 12 were twin gestations, 4 were triplets, and one was a quadruplet pregnancy, said Dr. Murji.

Forty-one percent of the pregnancies had been conceived spontaneously, with the remainder being a result of either in-vitro fertilization (47%) or ovulation induction (12%). All infants were born vaginally, except for two of the latter-born infants. In the quadruplet delivery, two babies were born within minutes of each other, followed by a latency interval and then the birth of the other two. During the interval, 88% of mothers received antibiotics and 47% received tocolysis.

Of the 18 first-born infants, only 1 survived until discharge; 13 survived among the 22 latter-born infants – a survival rate of 59%. Mean birth weight was 468 g for first-born infants and 674 g for latter-born infants.

“Clearly there is a survival benefit in having an asynchronous delivery,” noted Dr. Murji. “But these babies are not out of the woods. When you look at the absolute weights these are very small babies – babies who are very fragile. The prognosis for these babies is already guarded.”

Indeed, the infants' average stay in the neonatal intensive care unit was 104 days. Twelve of the 13 infants had at least one morbidity, including retinopathy of prematurity, intraventricular hemorrhage, patent ductus arteriosus, or sepsis, and many of them had multiple comorbidities.

Maternal morbidity also was significant. The average age of the mothers was 31 years, and complications occurred in 71% of them, with intraamniotic infection being the most common (59%). Almost half of the mothers (47%) experienced two or more complications, with abruptio placentae, postpartum hemorrhage, and blood transfusions each occurring in 18% and septic pelvic thrombophlebitis and pulmonary edema each occurring in 6%.

The findings underscore the decisions that parents and physicians must face in contemplating delayed interval delivery in the context of premature delivery of the first baby.

“Outcomes in extremely premature deliveries are meager, at best. Although we can do asynchronous delivery, is it really reasonable? Yes, there is a clear survival benefit for the latter-born infant, but this survival benefit comes at the risk of maternal morbidity and the interval in our experience has only been 1 week. And these latter-born infants have significant morbidity because they're born so prematurely,” said Dr. Murji.

Major Finding: Of the 18 first-born infants, only 1 survived until discharge, while 13 survived among the 22 latter-born infants.

Data Source: A series of 17 premature multifetal deliveries in which the first fetus was born at least 24 hours before the others.

Disclosures: Dr. Murji reported no conflicts of interest.

MONTREAL — Delayed-interval delivery when the initial delivery is extremely premature carries high maternal and infant morbidity, as well as a high infant mortality, reported Dr. Ally Murji of the University of Toronto's division of maternal-fetal medicine.

“Just because we can do something, it doesn't mean it should be done,” he said in an interview.

In a study that he presented at the meeting, Dr. Murji described a series of 17 premature multifetal deliveries in which the first fetus was born at least 24 hours before the others. The mean gestational age of the first delivery was 23 weeks and 2 days.

“In our series, this procedure was reserved for the threshold of viability – extremely premature infants,” he said in an interview, explaining that the majority of the initial deliveries were precipitated by preterm premature rupture of membranes (PPROM).

Among the 17 pregnancies, 12 were twin gestations, 4 were triplets, and one was a quadruplet pregnancy, said Dr. Murji.

Forty-one percent of the pregnancies had been conceived spontaneously, with the remainder being a result of either in-vitro fertilization (47%) or ovulation induction (12%). All infants were born vaginally, except for two of the latter-born infants. In the quadruplet delivery, two babies were born within minutes of each other, followed by a latency interval and then the birth of the other two. During the interval, 88% of mothers received antibiotics and 47% received tocolysis.

Of the 18 first-born infants, only 1 survived until discharge; 13 survived among the 22 latter-born infants – a survival rate of 59%. Mean birth weight was 468 g for first-born infants and 674 g for latter-born infants.

“Clearly there is a survival benefit in having an asynchronous delivery,” noted Dr. Murji. “But these babies are not out of the woods. When you look at the absolute weights these are very small babies – babies who are very fragile. The prognosis for these babies is already guarded.”

Indeed, the infants' average stay in the neonatal intensive care unit was 104 days. Twelve of the 13 infants had at least one morbidity, including retinopathy of prematurity, intraventricular hemorrhage, patent ductus arteriosus, or sepsis, and many of them had multiple comorbidities.

Maternal morbidity also was significant. The average age of the mothers was 31 years, and complications occurred in 71% of them, with intraamniotic infection being the most common (59%). Almost half of the mothers (47%) experienced two or more complications, with abruptio placentae, postpartum hemorrhage, and blood transfusions each occurring in 18% and septic pelvic thrombophlebitis and pulmonary edema each occurring in 6%.

The findings underscore the decisions that parents and physicians must face in contemplating delayed interval delivery in the context of premature delivery of the first baby.

“Outcomes in extremely premature deliveries are meager, at best. Although we can do asynchronous delivery, is it really reasonable? Yes, there is a clear survival benefit for the latter-born infant, but this survival benefit comes at the risk of maternal morbidity and the interval in our experience has only been 1 week. And these latter-born infants have significant morbidity because they're born so prematurely,” said Dr. Murji.

Montreal — Personality and attitude play a major role in shaping a patient's experience of chronic pain, and understanding this dynamic may help physicians overcome obstacles in treating some of their unresponsive patients, according to Michael Sullivan, Ph.D.

In fact, in recent studies, catastrophizing has emerged as “the most powerful psychological predictor of problematic pain outcomes,” said Dr. Sullivan, professor of psychology, medicine, and neurology at McGill University in Montreal.

In the context of pain, catastrophizing is defined as the tendency to worry and focus on the pain. Individuals who score high on the Pain Catastrophizing Scale (PCS), which was developed by Dr. Sullivan in 1995, tend to magnify and ruminate over their symptoms while feeling helpless about addressing them. “These individuals have an excessively alarmist attitude towards their pain and seem to have a lot more difficulty dealing with it,” he said at the meeting.

In the office setting, chronic pain patients who catastrophize “display more pain behavior such as holding, rubbing, guarding, as well as vocalizations such as moans and sighs,” he said at the meeting, which was sponsored by the International Association for the Study of Pain.

“Research shows that not only are catastrophizers going to have more difficulty in pain situations, they are also going to respond less well to the interventions that we offer them,” he said. In studies, Dr. Sullivan and his colleagues have shown that, compared with non-catastrophizers, catastrophizers are at greater risk of chronic pain following knee arthroplasty (Pain Res. Manag. 2008;13:335–41) and have more difficulty returning to work after whiplash injuries (J. Occup. Rehabil. 2007;17:305–15).

For patients whose chronic pain stems from an accident, perceptions of injustice also are common and can be expressed as anger or noncompliance. “Some of our recent research [Pain 2009;145:325–31] shows that perceptions of injustice are often associated with prolonged disability following a pain-related injury,” he said. For the treating physician, “validation techniques can be useful in reducing the negative impact of the catastrophizing patient's perceptions of injustice.”

By identifying catastrophizers early, physicians can avoid pitfalls that contribute to treatment failure in chronic pain. “There are some very concrete ways in which physicians could be reacting differently with these patients” to make patient management easier, he pointed out.

First and foremost, catastrophizers need to express their suffering and anxiety. “This person does have a story to tell and they need someone to listen. By not listening properly to that story initially, you are going to hear it again every time the patient comes, because the patient is going to feel that the doctor doesn't understand. So, increasing the time you initially spend with the patient can save a lot of headaches further down the line,” Dr. Sullivan explained.

Active listening has even been shown to reduce a patient's perception of pain, at least in the context of acute symptoms, said Dr. Sullivan, who has published several studies showing that allowing catastrophizers to disclose their fear and worry prior to routine dental hygiene procedures can reduce their perception of pain by as much as 50% (J. Indiana Dent. Assoc. 2000–2001;79:16–9; and Pain 1999;79:155–63).

Although a patient's basic personality is a challenge for physicians to work around, attitude – which is also an extremely powerful modifier of pain – is somewhat easier to mold, suggested Stefaan Van Damme, Ph.D., of the department of experimental clinical health and psychology at Ghent (Belgium) University.

In approaching pain control as a goal, chronic pain patients fall into two distinct categories: those who try to overcome it (assimilators) and those who accept it (accommodators). Both attitudes can be helpful or harmful, depending on how realistic pain control is for a particular patient, he said at the meeting.

“When pain is controllable, assimilative coping works. But when it is not controllable it can be maladaptive because it can exacerbate catastrophizing, hypervigilance, and distress,” he said. In a study, he demonstrated that, when attempts to avoid pain are unsuccessful, “individuals persist in their avoidance attempts, try harder, and narrow their focus of attention upon the problem to be solved” (Pain 2008;137:631–9).

Helping patients shift their focus from fighting to accepting their pain is particularly tricky for physicians, commented Dr. Sullivan, who is a psychologist. “I only get sent the patients when their pain has been long-standing. The concept of acceptance works when the pain has been there for 5 years,” he explained, “but for new-onset pain, acceptance is not the message that should be given by the doctor. This should only come up after we've offered everything else we can offer.”

Physicians should also be aware of their own personal psychology when dealing with catastrophizing patients, because catastrophizing personalities are not confined to the patient world. Physicians who are catastrophizers may inadvertently increase a patient's perception of suffering. “Some of our research suggests that if you're a catastrophizer you see 30% more pain in these individuals,” he said.

The speakers did not declare any conflicts of interest.

Montreal — Personality and attitude play a major role in shaping a patient's experience of chronic pain, and understanding this dynamic may help physicians overcome obstacles in treating some of their unresponsive patients, according to Michael Sullivan, Ph.D.

In fact, in recent studies, catastrophizing has emerged as “the most powerful psychological predictor of problematic pain outcomes,” said Dr. Sullivan, professor of psychology, medicine, and neurology at McGill University in Montreal.

In the context of pain, catastrophizing is defined as the tendency to worry and focus on the pain. Individuals who score high on the Pain Catastrophizing Scale (PCS), which was developed by Dr. Sullivan in 1995, tend to magnify and ruminate over their symptoms while feeling helpless about addressing them. “These individuals have an excessively alarmist attitude towards their pain and seem to have a lot more difficulty dealing with it,” he said at the meeting.

In the office setting, chronic pain patients who catastrophize “display more pain behavior such as holding, rubbing, guarding, as well as vocalizations such as moans and sighs,” he said at the meeting, which was sponsored by the International Association for the Study of Pain.

“Research shows that not only are catastrophizers going to have more difficulty in pain situations, they are also going to respond less well to the interventions that we offer them,” he said. In studies, Dr. Sullivan and his colleagues have shown that, compared with non-catastrophizers, catastrophizers are at greater risk of chronic pain following knee arthroplasty (Pain Res. Manag. 2008;13:335–41) and have more difficulty returning to work after whiplash injuries (J. Occup. Rehabil. 2007;17:305–15).

For patients whose chronic pain stems from an accident, perceptions of injustice also are common and can be expressed as anger or noncompliance. “Some of our recent research [Pain 2009;145:325–31] shows that perceptions of injustice are often associated with prolonged disability following a pain-related injury,” he said. For the treating physician, “validation techniques can be useful in reducing the negative impact of the catastrophizing patient's perceptions of injustice.”

By identifying catastrophizers early, physicians can avoid pitfalls that contribute to treatment failure in chronic pain. “There are some very concrete ways in which physicians could be reacting differently with these patients” to make patient management easier, he pointed out.

First and foremost, catastrophizers need to express their suffering and anxiety. “This person does have a story to tell and they need someone to listen. By not listening properly to that story initially, you are going to hear it again every time the patient comes, because the patient is going to feel that the doctor doesn't understand. So, increasing the time you initially spend with the patient can save a lot of headaches further down the line,” Dr. Sullivan explained.

Active listening has even been shown to reduce a patient's perception of pain, at least in the context of acute symptoms, said Dr. Sullivan, who has published several studies showing that allowing catastrophizers to disclose their fear and worry prior to routine dental hygiene procedures can reduce their perception of pain by as much as 50% (J. Indiana Dent. Assoc. 2000–2001;79:16–9; and Pain 1999;79:155–63).

Although a patient's basic personality is a challenge for physicians to work around, attitude – which is also an extremely powerful modifier of pain – is somewhat easier to mold, suggested Stefaan Van Damme, Ph.D., of the department of experimental clinical health and psychology at Ghent (Belgium) University.

In approaching pain control as a goal, chronic pain patients fall into two distinct categories: those who try to overcome it (assimilators) and those who accept it (accommodators). Both attitudes can be helpful or harmful, depending on how realistic pain control is for a particular patient, he said at the meeting.

“When pain is controllable, assimilative coping works. But when it is not controllable it can be maladaptive because it can exacerbate catastrophizing, hypervigilance, and distress,” he said. In a study, he demonstrated that, when attempts to avoid pain are unsuccessful, “individuals persist in their avoidance attempts, try harder, and narrow their focus of attention upon the problem to be solved” (Pain 2008;137:631–9).

Helping patients shift their focus from fighting to accepting their pain is particularly tricky for physicians, commented Dr. Sullivan, who is a psychologist. “I only get sent the patients when their pain has been long-standing. The concept of acceptance works when the pain has been there for 5 years,” he explained, “but for new-onset pain, acceptance is not the message that should be given by the doctor. This should only come up after we've offered everything else we can offer.”

Physicians should also be aware of their own personal psychology when dealing with catastrophizing patients, because catastrophizing personalities are not confined to the patient world. Physicians who are catastrophizers may inadvertently increase a patient's perception of suffering. “Some of our research suggests that if you're a catastrophizer you see 30% more pain in these individuals,” he said.

The speakers did not declare any conflicts of interest.

Montreal — Personality and attitude play a major role in shaping a patient's experience of chronic pain, and understanding this dynamic may help physicians overcome obstacles in treating some of their unresponsive patients, according to Michael Sullivan, Ph.D.

In fact, in recent studies, catastrophizing has emerged as “the most powerful psychological predictor of problematic pain outcomes,” said Dr. Sullivan, professor of psychology, medicine, and neurology at McGill University in Montreal.

In the context of pain, catastrophizing is defined as the tendency to worry and focus on the pain. Individuals who score high on the Pain Catastrophizing Scale (PCS), which was developed by Dr. Sullivan in 1995, tend to magnify and ruminate over their symptoms while feeling helpless about addressing them. “These individuals have an excessively alarmist attitude towards their pain and seem to have a lot more difficulty dealing with it,” he said at the meeting.

In the office setting, chronic pain patients who catastrophize “display more pain behavior such as holding, rubbing, guarding, as well as vocalizations such as moans and sighs,” he said at the meeting, which was sponsored by the International Association for the Study of Pain.

“Research shows that not only are catastrophizers going to have more difficulty in pain situations, they are also going to respond less well to the interventions that we offer them,” he said. In studies, Dr. Sullivan and his colleagues have shown that, compared with non-catastrophizers, catastrophizers are at greater risk of chronic pain following knee arthroplasty (Pain Res. Manag. 2008;13:335–41) and have more difficulty returning to work after whiplash injuries (J. Occup. Rehabil. 2007;17:305–15).

For patients whose chronic pain stems from an accident, perceptions of injustice also are common and can be expressed as anger or noncompliance. “Some of our recent research [Pain 2009;145:325–31] shows that perceptions of injustice are often associated with prolonged disability following a pain-related injury,” he said. For the treating physician, “validation techniques can be useful in reducing the negative impact of the catastrophizing patient's perceptions of injustice.”

By identifying catastrophizers early, physicians can avoid pitfalls that contribute to treatment failure in chronic pain. “There are some very concrete ways in which physicians could be reacting differently with these patients” to make patient management easier, he pointed out.

First and foremost, catastrophizers need to express their suffering and anxiety. “This person does have a story to tell and they need someone to listen. By not listening properly to that story initially, you are going to hear it again every time the patient comes, because the patient is going to feel that the doctor doesn't understand. So, increasing the time you initially spend with the patient can save a lot of headaches further down the line,” Dr. Sullivan explained.

Active listening has even been shown to reduce a patient's perception of pain, at least in the context of acute symptoms, said Dr. Sullivan, who has published several studies showing that allowing catastrophizers to disclose their fear and worry prior to routine dental hygiene procedures can reduce their perception of pain by as much as 50% (J. Indiana Dent. Assoc. 2000–2001;79:16–9; and Pain 1999;79:155–63).

Although a patient's basic personality is a challenge for physicians to work around, attitude – which is also an extremely powerful modifier of pain – is somewhat easier to mold, suggested Stefaan Van Damme, Ph.D., of the department of experimental clinical health and psychology at Ghent (Belgium) University.

In approaching pain control as a goal, chronic pain patients fall into two distinct categories: those who try to overcome it (assimilators) and those who accept it (accommodators). Both attitudes can be helpful or harmful, depending on how realistic pain control is for a particular patient, he said at the meeting.

“When pain is controllable, assimilative coping works. But when it is not controllable it can be maladaptive because it can exacerbate catastrophizing, hypervigilance, and distress,” he said. In a study, he demonstrated that, when attempts to avoid pain are unsuccessful, “individuals persist in their avoidance attempts, try harder, and narrow their focus of attention upon the problem to be solved” (Pain 2008;137:631–9).

Helping patients shift their focus from fighting to accepting their pain is particularly tricky for physicians, commented Dr. Sullivan, who is a psychologist. “I only get sent the patients when their pain has been long-standing. The concept of acceptance works when the pain has been there for 5 years,” he explained, “but for new-onset pain, acceptance is not the message that should be given by the doctor. This should only come up after we've offered everything else we can offer.”

Physicians should also be aware of their own personal psychology when dealing with catastrophizing patients, because catastrophizing personalities are not confined to the patient world. Physicians who are catastrophizers may inadvertently increase a patient's perception of suffering. “Some of our research suggests that if you're a catastrophizer you see 30% more pain in these individuals,” he said.

The speakers did not declare any conflicts of interest.

Major Finding: Women randomized to early or late external cephalic version had nonsignificant differences in cesarean section rate (52% vs. 56%), with a trend toward more preterm deliveries in the early-version group.

Data Source: A study that randomized 1,532 women with breech presentations to either an early external cephalic version or a later version performed at 37 weeks.

Disclosures: Dr. Carson said he had no relevant disclosures. The trial was funded by the Canadian Institutes of Health Research.

MONTREAL — Early external cephalic version increases the likelihood of cephalic presentation at birth, but does not result in fewer cesarean sections compared with later cephalic version, based on the results of an international, multicenter, randomized controlled trial.

In addition, there was a trend toward greater risk of preterm birth when the procedure was done early, defined as between the 34th and 35th weeks, reported Dr. George Carson, one of the investigators on the Early External Cephalic Version 2 (ECV2) Trial.

“This is actually very disappointing,” he said in an interview at the meeting.

“It is worth trying to investigate why turning the baby didn't result in a reduction in cesarean sections. Obviously the purpose of this was not to turn the baby – it was to reduce cesarean sections – and that didn't happen, and that's disappointing.”

The study randomized 1,532 women with breech presentations to either an early version or a later version performed at 37 weeks. The primary end point was the rate of cesarean section, with a secondary end point of preterm birth.

“The concern was that in performing version one might precipitate preterm birth, and so this could be the adverse effect of the attempt to turn the baby,” noted Dr. Carson, director of maternal-fetal medicine at Regina (Sask.) General Hospital.

Baseline characteristics including parity, types of breech presentation, and anterior placenta were similar in both groups.

Cephalic presentation at the time of delivery, due to either successful external version or spontaneous version, was higher in the early-version group (59% vs. 51%), and the difference reached statistical significance, said Dr. Carson. However, there was not a statistically significant difference in the cesarean section rate: 52% in the early group and 56% in the late group.

“More women delivered vaginally than was anticipated in the delayed group – due to spontaneous conversion and a small number of women who decided to deliver vaginally even though their baby was still breech,” he said, adding that overall, the cesarean section rate was high.

“Very few of these were done for nonreassuring monitoring. They were done in places that do a lot of sections anyway, so being cephalic was not in any way a guarantee that one wouldn't have a section done,” he said.

The increased rate of preterm delivery in the early-version group (6.5% vs. 4.4% in the late group) was not statistically significant, but it strengthens the argument against attempting an early cephalic version, said Dr. Carson.

“What I tell the women that I am trying to do a version on is, if we don't do it … they've got about a 70% chance of a cesarean section. If we do it, that could be reduced to about 50%. But my chance of getting the fetus around is only about 50%.

“And if we push hard on the uterus, maybe we could make them deliver prematurely. It won't be very premature, but it's still better to be term than 35 weeks,” he said.

Major Finding: Women randomized to early or late external cephalic version had nonsignificant differences in cesarean section rate (52% vs. 56%), with a trend toward more preterm deliveries in the early-version group.

Data Source: A study that randomized 1,532 women with breech presentations to either an early external cephalic version or a later version performed at 37 weeks.

Disclosures: Dr. Carson said he had no relevant disclosures. The trial was funded by the Canadian Institutes of Health Research.

MONTREAL — Early external cephalic version increases the likelihood of cephalic presentation at birth, but does not result in fewer cesarean sections compared with later cephalic version, based on the results of an international, multicenter, randomized controlled trial.

In addition, there was a trend toward greater risk of preterm birth when the procedure was done early, defined as between the 34th and 35th weeks, reported Dr. George Carson, one of the investigators on the Early External Cephalic Version 2 (ECV2) Trial.

“This is actually very disappointing,” he said in an interview at the meeting.

“It is worth trying to investigate why turning the baby didn't result in a reduction in cesarean sections. Obviously the purpose of this was not to turn the baby – it was to reduce cesarean sections – and that didn't happen, and that's disappointing.”

The study randomized 1,532 women with breech presentations to either an early version or a later version performed at 37 weeks. The primary end point was the rate of cesarean section, with a secondary end point of preterm birth.

“The concern was that in performing version one might precipitate preterm birth, and so this could be the adverse effect of the attempt to turn the baby,” noted Dr. Carson, director of maternal-fetal medicine at Regina (Sask.) General Hospital.

Baseline characteristics including parity, types of breech presentation, and anterior placenta were similar in both groups.

Cephalic presentation at the time of delivery, due to either successful external version or spontaneous version, was higher in the early-version group (59% vs. 51%), and the difference reached statistical significance, said Dr. Carson. However, there was not a statistically significant difference in the cesarean section rate: 52% in the early group and 56% in the late group.

“More women delivered vaginally than was anticipated in the delayed group – due to spontaneous conversion and a small number of women who decided to deliver vaginally even though their baby was still breech,” he said, adding that overall, the cesarean section rate was high.

“Very few of these were done for nonreassuring monitoring. They were done in places that do a lot of sections anyway, so being cephalic was not in any way a guarantee that one wouldn't have a section done,” he said.

The increased rate of preterm delivery in the early-version group (6.5% vs. 4.4% in the late group) was not statistically significant, but it strengthens the argument against attempting an early cephalic version, said Dr. Carson.

“What I tell the women that I am trying to do a version on is, if we don't do it … they've got about a 70% chance of a cesarean section. If we do it, that could be reduced to about 50%. But my chance of getting the fetus around is only about 50%.

“And if we push hard on the uterus, maybe we could make them deliver prematurely. It won't be very premature, but it's still better to be term than 35 weeks,” he said.

Major Finding: Women randomized to early or late external cephalic version had nonsignificant differences in cesarean section rate (52% vs. 56%), with a trend toward more preterm deliveries in the early-version group.

Data Source: A study that randomized 1,532 women with breech presentations to either an early external cephalic version or a later version performed at 37 weeks.

Disclosures: Dr. Carson said he had no relevant disclosures. The trial was funded by the Canadian Institutes of Health Research.

MONTREAL — Early external cephalic version increases the likelihood of cephalic presentation at birth, but does not result in fewer cesarean sections compared with later cephalic version, based on the results of an international, multicenter, randomized controlled trial.

In addition, there was a trend toward greater risk of preterm birth when the procedure was done early, defined as between the 34th and 35th weeks, reported Dr. George Carson, one of the investigators on the Early External Cephalic Version 2 (ECV2) Trial.

“This is actually very disappointing,” he said in an interview at the meeting.

“It is worth trying to investigate why turning the baby didn't result in a reduction in cesarean sections. Obviously the purpose of this was not to turn the baby – it was to reduce cesarean sections – and that didn't happen, and that's disappointing.”

The study randomized 1,532 women with breech presentations to either an early version or a later version performed at 37 weeks. The primary end point was the rate of cesarean section, with a secondary end point of preterm birth.

“The concern was that in performing version one might precipitate preterm birth, and so this could be the adverse effect of the attempt to turn the baby,” noted Dr. Carson, director of maternal-fetal medicine at Regina (Sask.) General Hospital.

Baseline characteristics including parity, types of breech presentation, and anterior placenta were similar in both groups.

Cephalic presentation at the time of delivery, due to either successful external version or spontaneous version, was higher in the early-version group (59% vs. 51%), and the difference reached statistical significance, said Dr. Carson. However, there was not a statistically significant difference in the cesarean section rate: 52% in the early group and 56% in the late group.

“More women delivered vaginally than was anticipated in the delayed group – due to spontaneous conversion and a small number of women who decided to deliver vaginally even though their baby was still breech,” he said, adding that overall, the cesarean section rate was high.

“Very few of these were done for nonreassuring monitoring. They were done in places that do a lot of sections anyway, so being cephalic was not in any way a guarantee that one wouldn't have a section done,” he said.

The increased rate of preterm delivery in the early-version group (6.5% vs. 4.4% in the late group) was not statistically significant, but it strengthens the argument against attempting an early cephalic version, said Dr. Carson.

“What I tell the women that I am trying to do a version on is, if we don't do it … they've got about a 70% chance of a cesarean section. If we do it, that could be reduced to about 50%. But my chance of getting the fetus around is only about 50%.

“And if we push hard on the uterus, maybe we could make them deliver prematurely. It won't be very premature, but it's still better to be term than 35 weeks,” he said.

MONTREAL – Personality and attitude play a major role in shaping a patient's experience of chronic pain, and understanding this dynamic may help physicians overcome obstacles in treating some of their unresponsive patients, according to Michael Sullivan, Ph.D.

In fact, in recent studies, catastrophizing has emerged as “the most powerful psychological predictor of problematic pain outcomes,” said Dr. Sullivan, professor of psychology, medicine, and neurology at McGill University in Montreal.

In the context of pain, catastrophizing is defined as the tendency to worry and focus on the pain. Individuals who score high on the Pain Catastrophizing Scale (PCS), which was developed by Dr. Sullivan in 1995, tend to magnify and ruminate over their symptoms while feeling helpless about addressing them. “These individuals have an excessively alarmist attitude toward their pain and seem to have a lot more difficulty dealing with it,” he said at the meeting.

In the office setting, chronic pain patients who catastrophize “display more pain behavior such as holding, rubbing, [and] guarding, as well as vocalizations such as moans and sighs,” he said at the meeting, sponsored by the International Association for the Study of Pain.

“Research shows that not only are catastrophizers going to have more difficulty in pain situations, they are also going to respond less well to the interventions that we offer them,” he said. In studies, Dr. Sullivan and his colleagues have shown that, compared with noncatastrophizers, catastrophizers are at greater risk of chronic pain following knee arthroplasty (Pain Res. Manag. 2008;13:335-41) and have more difficulty returning to work after whiplash injuries (J. Occup. Rehabil. 2007;17:305-15).

For patients whose chronic pain stems from an accident, perceptions of injustice also are common and can be expressed as anger or noncompliance. “Some of our recent research [Pain 2009;145:325-31] shows that perceptions of injustice are often associated with prolonged disability following a pain-related injury,” he said. For the treating physician, “validation techniques can be useful in reducing the negative impact of the catastrophizing patient's perceptions of injustice.”

By identifying catastrophizers early, physicians can avoid pitfalls that contribute to treatment failure in chronic pain. “There are some very concrete ways in which physicians could be reacting differently with these patients” to make patient management easier, he pointed out.

First and foremost, catastrophizers need to express their suffering and anxiety. “This person does have a story to tell and they need someone to listen. By not listening properly to that story initially, you are going to hear it again every time the patient comes, because the patient is going to feel that the doctor doesn't understand. So, increasing the time you initially spend with the patient can save a lot of headaches further down the line,” Dr. Sullivan explained.

Active listening has even been shown to reduce a patient's perception of pain, at least in the context of acute symptoms, said Dr. Sullivan, who has published several studies showing that allowing catastrophizers to disclose their fear and worry prior to routine dental hygiene procedures can reduce their perception of pain by as much as 50% (J. Indiana Dent. Assoc. 2000-2001;79:16-9; Pain 1999;79:155-63).

Although a patient's basic personality is a challenge for physicians to work around, attitude – which is also an extremely powerful modifier of pain – is somewhat easier to mold, suggested Stefaan Van Damme, Ph.D., of the department of experimental clinical health and psychology at Ghent (Belgium) University.

In approaching pain control as a goal, chronic pain patients fall into two distinct categories: those who try to overcome it (assimilators) and those who accept it (accommodators). Both attitudes can be helpful or harmful, depending on how realistic pain control is for a particular patient, he said at the meeting.

“When pain is controllable, assimilative coping works. But when it is not controllable, it can be maladaptive because it can exacerbate catastrophizing, hypervigilance, and distress,” he said. In a study, he demonstrated that, when attempts to avoid pain are unsuccessful, “individuals persist in their avoidance attempts, try harder, and narrow their focus of attention upon the problem to be solved” (Pain 2008;137:631-9).

Helping patients shift their focus from fighting to accepting their pain is particularly tricky for physicians, commented Dr. Sullivan, who is a psychologist.

“I only get sent the patients when their pain has been long-standing. The concept of acceptance works when the pain has been there for 5 years,” he explained, “but for new-onset pain, acceptance is not the message that should be given by the doctor. This should only come up after we've offered everything else we can offer.”

Physicians should also be aware of their own personal psychology when dealing with catastrophizing patients, because catastrophizing personalities are not confined to the patient world. Physicians who are catastrophizers may inadvertently increase a patient's perception of suffering.

“Some of our research suggests that if you're a catastrophizer you see 30% more pain in these individuals,” he said, and this could impact a physician's decisions about treatment intervention as well the physician's advice surrounding acceptance.

Disclosures: The speakers did not declare any conflicts of interest.

MONTREAL – Personality and attitude play a major role in shaping a patient's experience of chronic pain, and understanding this dynamic may help physicians overcome obstacles in treating some of their unresponsive patients, according to Michael Sullivan, Ph.D.

In fact, in recent studies, catastrophizing has emerged as “the most powerful psychological predictor of problematic pain outcomes,” said Dr. Sullivan, professor of psychology, medicine, and neurology at McGill University in Montreal.

In the context of pain, catastrophizing is defined as the tendency to worry and focus on the pain. Individuals who score high on the Pain Catastrophizing Scale (PCS), which was developed by Dr. Sullivan in 1995, tend to magnify and ruminate over their symptoms while feeling helpless about addressing them. “These individuals have an excessively alarmist attitude toward their pain and seem to have a lot more difficulty dealing with it,” he said at the meeting.

In the office setting, chronic pain patients who catastrophize “display more pain behavior such as holding, rubbing, [and] guarding, as well as vocalizations such as moans and sighs,” he said at the meeting, sponsored by the International Association for the Study of Pain.

“Research shows that not only are catastrophizers going to have more difficulty in pain situations, they are also going to respond less well to the interventions that we offer them,” he said. In studies, Dr. Sullivan and his colleagues have shown that, compared with noncatastrophizers, catastrophizers are at greater risk of chronic pain following knee arthroplasty (Pain Res. Manag. 2008;13:335-41) and have more difficulty returning to work after whiplash injuries (J. Occup. Rehabil. 2007;17:305-15).

For patients whose chronic pain stems from an accident, perceptions of injustice also are common and can be expressed as anger or noncompliance. “Some of our recent research [Pain 2009;145:325-31] shows that perceptions of injustice are often associated with prolonged disability following a pain-related injury,” he said. For the treating physician, “validation techniques can be useful in reducing the negative impact of the catastrophizing patient's perceptions of injustice.”

By identifying catastrophizers early, physicians can avoid pitfalls that contribute to treatment failure in chronic pain. “There are some very concrete ways in which physicians could be reacting differently with these patients” to make patient management easier, he pointed out.

First and foremost, catastrophizers need to express their suffering and anxiety. “This person does have a story to tell and they need someone to listen. By not listening properly to that story initially, you are going to hear it again every time the patient comes, because the patient is going to feel that the doctor doesn't understand. So, increasing the time you initially spend with the patient can save a lot of headaches further down the line,” Dr. Sullivan explained.

Active listening has even been shown to reduce a patient's perception of pain, at least in the context of acute symptoms, said Dr. Sullivan, who has published several studies showing that allowing catastrophizers to disclose their fear and worry prior to routine dental hygiene procedures can reduce their perception of pain by as much as 50% (J. Indiana Dent. Assoc. 2000-2001;79:16-9; Pain 1999;79:155-63).

Although a patient's basic personality is a challenge for physicians to work around, attitude – which is also an extremely powerful modifier of pain – is somewhat easier to mold, suggested Stefaan Van Damme, Ph.D., of the department of experimental clinical health and psychology at Ghent (Belgium) University.

In approaching pain control as a goal, chronic pain patients fall into two distinct categories: those who try to overcome it (assimilators) and those who accept it (accommodators). Both attitudes can be helpful or harmful, depending on how realistic pain control is for a particular patient, he said at the meeting.

“When pain is controllable, assimilative coping works. But when it is not controllable, it can be maladaptive because it can exacerbate catastrophizing, hypervigilance, and distress,” he said. In a study, he demonstrated that, when attempts to avoid pain are unsuccessful, “individuals persist in their avoidance attempts, try harder, and narrow their focus of attention upon the problem to be solved” (Pain 2008;137:631-9).

Helping patients shift their focus from fighting to accepting their pain is particularly tricky for physicians, commented Dr. Sullivan, who is a psychologist.

“I only get sent the patients when their pain has been long-standing. The concept of acceptance works when the pain has been there for 5 years,” he explained, “but for new-onset pain, acceptance is not the message that should be given by the doctor. This should only come up after we've offered everything else we can offer.”

Physicians should also be aware of their own personal psychology when dealing with catastrophizing patients, because catastrophizing personalities are not confined to the patient world. Physicians who are catastrophizers may inadvertently increase a patient's perception of suffering.

“Some of our research suggests that if you're a catastrophizer you see 30% more pain in these individuals,” he said, and this could impact a physician's decisions about treatment intervention as well the physician's advice surrounding acceptance.

Disclosures: The speakers did not declare any conflicts of interest.

MONTREAL – Personality and attitude play a major role in shaping a patient's experience of chronic pain, and understanding this dynamic may help physicians overcome obstacles in treating some of their unresponsive patients, according to Michael Sullivan, Ph.D.

In fact, in recent studies, catastrophizing has emerged as “the most powerful psychological predictor of problematic pain outcomes,” said Dr. Sullivan, professor of psychology, medicine, and neurology at McGill University in Montreal.

In the context of pain, catastrophizing is defined as the tendency to worry and focus on the pain. Individuals who score high on the Pain Catastrophizing Scale (PCS), which was developed by Dr. Sullivan in 1995, tend to magnify and ruminate over their symptoms while feeling helpless about addressing them. “These individuals have an excessively alarmist attitude toward their pain and seem to have a lot more difficulty dealing with it,” he said at the meeting.

In the office setting, chronic pain patients who catastrophize “display more pain behavior such as holding, rubbing, [and] guarding, as well as vocalizations such as moans and sighs,” he said at the meeting, sponsored by the International Association for the Study of Pain.

“Research shows that not only are catastrophizers going to have more difficulty in pain situations, they are also going to respond less well to the interventions that we offer them,” he said. In studies, Dr. Sullivan and his colleagues have shown that, compared with noncatastrophizers, catastrophizers are at greater risk of chronic pain following knee arthroplasty (Pain Res. Manag. 2008;13:335-41) and have more difficulty returning to work after whiplash injuries (J. Occup. Rehabil. 2007;17:305-15).

For patients whose chronic pain stems from an accident, perceptions of injustice also are common and can be expressed as anger or noncompliance. “Some of our recent research [Pain 2009;145:325-31] shows that perceptions of injustice are often associated with prolonged disability following a pain-related injury,” he said. For the treating physician, “validation techniques can be useful in reducing the negative impact of the catastrophizing patient's perceptions of injustice.”

By identifying catastrophizers early, physicians can avoid pitfalls that contribute to treatment failure in chronic pain. “There are some very concrete ways in which physicians could be reacting differently with these patients” to make patient management easier, he pointed out.

First and foremost, catastrophizers need to express their suffering and anxiety. “This person does have a story to tell and they need someone to listen. By not listening properly to that story initially, you are going to hear it again every time the patient comes, because the patient is going to feel that the doctor doesn't understand. So, increasing the time you initially spend with the patient can save a lot of headaches further down the line,” Dr. Sullivan explained.

Active listening has even been shown to reduce a patient's perception of pain, at least in the context of acute symptoms, said Dr. Sullivan, who has published several studies showing that allowing catastrophizers to disclose their fear and worry prior to routine dental hygiene procedures can reduce their perception of pain by as much as 50% (J. Indiana Dent. Assoc. 2000-2001;79:16-9; Pain 1999;79:155-63).

Although a patient's basic personality is a challenge for physicians to work around, attitude – which is also an extremely powerful modifier of pain – is somewhat easier to mold, suggested Stefaan Van Damme, Ph.D., of the department of experimental clinical health and psychology at Ghent (Belgium) University.

In approaching pain control as a goal, chronic pain patients fall into two distinct categories: those who try to overcome it (assimilators) and those who accept it (accommodators). Both attitudes can be helpful or harmful, depending on how realistic pain control is for a particular patient, he said at the meeting.

“When pain is controllable, assimilative coping works. But when it is not controllable, it can be maladaptive because it can exacerbate catastrophizing, hypervigilance, and distress,” he said. In a study, he demonstrated that, when attempts to avoid pain are unsuccessful, “individuals persist in their avoidance attempts, try harder, and narrow their focus of attention upon the problem to be solved” (Pain 2008;137:631-9).

Helping patients shift their focus from fighting to accepting their pain is particularly tricky for physicians, commented Dr. Sullivan, who is a psychologist.

“I only get sent the patients when their pain has been long-standing. The concept of acceptance works when the pain has been there for 5 years,” he explained, “but for new-onset pain, acceptance is not the message that should be given by the doctor. This should only come up after we've offered everything else we can offer.”

Physicians should also be aware of their own personal psychology when dealing with catastrophizing patients, because catastrophizing personalities are not confined to the patient world. Physicians who are catastrophizers may inadvertently increase a patient's perception of suffering.

“Some of our research suggests that if you're a catastrophizer you see 30% more pain in these individuals,” he said, and this could impact a physician's decisions about treatment intervention as well the physician's advice surrounding acceptance.

Disclosures: The speakers did not declare any conflicts of interest.

MONTREAL – Personality and attitude play a major role in shaping a patient’s experience of chronic pain, and understanding this dynamic may help physicians overcome obstacles in treating some of their unresponsive patients, according to Michael Sullivan, Ph.D.

In fact, in recent studies, catastrophizing has emerged as “the most powerful psychological predictor of problematic pain outcomes,” said Dr. Sullivan, professor of psychology, medicine, and neurology at McGill University in Montreal.

In the context of pain, catastrophizing is defined as the tendency to worry and focus on the pain. Individuals who score high on the Pain Catastrophizing Scale (PCS), which was developed by Dr. Sullivan in 1995, tend to magnify and ruminate over their symptoms while feeling helpless about addressing them. “These individuals have an excessively alarmist attitude towards their pain and seem to have a lot more difficulty dealing with it,” he said at the World Congress on Pain.

In the office setting, chronic pain patients who catastrophize “display more pain behavior such as holding, rubbing, guarding, as well as vocalizations such as moans and sighs,” he said at the meeting, which was sponsored by the International Association for the Study of Pain.

“Research shows that not only are catastrophizers going to have more difficulty in pain situations, they are also going to respond less well to the interventions that we offer them,” he said. In studies, Dr. Sullivan and his colleagues have shown that, compared with noncatastrophizers, catastrophizers are at greater risk of chronic pain following knee arthroplasty (Pain Res. Manag. 2008;13:335-41) and have more difficulty returning to work after whiplash injuries (J. Occup. Rehabil. 2007;17:305-15).

For patients whose chronic pain stems from an accident, perceptions of injustice also are common and can be expressed as anger or noncompliance. “Some of our recent research [Pain 2009;145:325-31] shows that perceptions of injustice are often associated with prolonged disability following a pain-related injury,” he said. For the treating physician, “validation techniques can be useful in reducing the negative impact of the catastrophizing patient’s perceptions of injustice.”

By identifying catastrophizers early, physicians can avoid pitfalls that contribute to treatment failure in chronic pain. “There are some very concrete ways in which physicians could be reacting differently with these patients” to make patient management easier, he pointed out.

First and foremost, catastrophizers need to express their suffering and anxiety. “This person does have a story to tell and they need someone to listen. By not listening properly to that story initially, you are going to hear it again every time the patient comes, because the patient is going to feel that the doctor doesn’t understand. So, increasing the time you initially spend with the patient can save a lot of headaches further down the line,” Dr. Sullivan explained.

Active listening has even been shown to reduce a patient’s perception of pain, at least in the context of acute symptoms, said Dr. Sullivan, who has published several studies showing that allowing catastrophizers to disclose their fear and worry prior to routine dental hygiene procedures can reduce their perception of pain by as much as 50% (J. Indiana Dent. Assoc. 2000-2001;79:16-9; and Pain 1999;79:155-63).

Although a patient’s basic personality is a challenge for physicians to work around, attitude – which is also an extremely powerful modifier of pain – is somewhat easier to mold, suggested Stefaan Van Damme, Ph.D., of the department of experimental clinical health and psychology at Ghent (Belgium) University.

In approaching pain control as a goal, chronic pain patients fall into two distinct categories: those who try to overcome it (assimilators) and those who accept it (accommodators). Both attitudes can be helpful or harmful, depending on how realistic pain control is for a particular patient, he said at the meeting.

“When pain is controllable, assimilative coping works. But when it is not controllable it can be maladaptive because it can exacerbate catastrophizing, hypervigilance, and distress,” he said. In a study, he demonstrated that, when attempts to avoid pain are unsuccessful, “individuals persist in their avoidance attempts, try harder, and narrow their focus of attention upon the problem to be solved” (Pain 2008;137:631-9).

Helping patients shift their focus from fighting to accepting their pain is particularly tricky for physicians, commented Dr. Sullivan, who is a psychologist. “I only get sent the patients when their pain has been long-standing. The concept of acceptance works when the pain has been there for 5 years,” he explained, “but for new-onset pain, acceptance is not the message that should be given by the doctor. This should only come up after we’ve offered everything else we can offer.”

Physicians should also be aware of their own personal psychology when dealing with catastrophizing patients, because catastrophizing personalities are not confined to the patient world. Physicians who are catastrophizers may inadvertently increase a patient’s perception of suffering. “Some of our research suggests that if you’re a catastrophizer you see 30% more pain in these individuals,” he said, and this could impact a physician’s decisions about treatment intervention as well their advice surrounding acceptance.

The speakers did not declare any conflicts of interest.

MONTREAL – Personality and attitude play a major role in shaping a patient’s experience of chronic pain, and understanding this dynamic may help physicians overcome obstacles in treating some of their unresponsive patients, according to Michael Sullivan, Ph.D.

In fact, in recent studies, catastrophizing has emerged as “the most powerful psychological predictor of problematic pain outcomes,” said Dr. Sullivan, professor of psychology, medicine, and neurology at McGill University in Montreal.

In the context of pain, catastrophizing is defined as the tendency to worry and focus on the pain. Individuals who score high on the Pain Catastrophizing Scale (PCS), which was developed by Dr. Sullivan in 1995, tend to magnify and ruminate over their symptoms while feeling helpless about addressing them. “These individuals have an excessively alarmist attitude towards their pain and seem to have a lot more difficulty dealing with it,” he said at the World Congress on Pain.

In the office setting, chronic pain patients who catastrophize “display more pain behavior such as holding, rubbing, guarding, as well as vocalizations such as moans and sighs,” he said at the meeting, which was sponsored by the International Association for the Study of Pain.

“Research shows that not only are catastrophizers going to have more difficulty in pain situations, they are also going to respond less well to the interventions that we offer them,” he said. In studies, Dr. Sullivan and his colleagues have shown that, compared with noncatastrophizers, catastrophizers are at greater risk of chronic pain following knee arthroplasty (Pain Res. Manag. 2008;13:335-41) and have more difficulty returning to work after whiplash injuries (J. Occup. Rehabil. 2007;17:305-15).

For patients whose chronic pain stems from an accident, perceptions of injustice also are common and can be expressed as anger or noncompliance. “Some of our recent research [Pain 2009;145:325-31] shows that perceptions of injustice are often associated with prolonged disability following a pain-related injury,” he said. For the treating physician, “validation techniques can be useful in reducing the negative impact of the catastrophizing patient’s perceptions of injustice.”

By identifying catastrophizers early, physicians can avoid pitfalls that contribute to treatment failure in chronic pain. “There are some very concrete ways in which physicians could be reacting differently with these patients” to make patient management easier, he pointed out.

First and foremost, catastrophizers need to express their suffering and anxiety. “This person does have a story to tell and they need someone to listen. By not listening properly to that story initially, you are going to hear it again every time the patient comes, because the patient is going to feel that the doctor doesn’t understand. So, increasing the time you initially spend with the patient can save a lot of headaches further down the line,” Dr. Sullivan explained.

Active listening has even been shown to reduce a patient’s perception of pain, at least in the context of acute symptoms, said Dr. Sullivan, who has published several studies showing that allowing catastrophizers to disclose their fear and worry prior to routine dental hygiene procedures can reduce their perception of pain by as much as 50% (J. Indiana Dent. Assoc. 2000-2001;79:16-9; and Pain 1999;79:155-63).

Although a patient’s basic personality is a challenge for physicians to work around, attitude – which is also an extremely powerful modifier of pain – is somewhat easier to mold, suggested Stefaan Van Damme, Ph.D., of the department of experimental clinical health and psychology at Ghent (Belgium) University.

In approaching pain control as a goal, chronic pain patients fall into two distinct categories: those who try to overcome it (assimilators) and those who accept it (accommodators). Both attitudes can be helpful or harmful, depending on how realistic pain control is for a particular patient, he said at the meeting.

“When pain is controllable, assimilative coping works. But when it is not controllable it can be maladaptive because it can exacerbate catastrophizing, hypervigilance, and distress,” he said. In a study, he demonstrated that, when attempts to avoid pain are unsuccessful, “individuals persist in their avoidance attempts, try harder, and narrow their focus of attention upon the problem to be solved” (Pain 2008;137:631-9).

Helping patients shift their focus from fighting to accepting their pain is particularly tricky for physicians, commented Dr. Sullivan, who is a psychologist. “I only get sent the patients when their pain has been long-standing. The concept of acceptance works when the pain has been there for 5 years,” he explained, “but for new-onset pain, acceptance is not the message that should be given by the doctor. This should only come up after we’ve offered everything else we can offer.”

Physicians should also be aware of their own personal psychology when dealing with catastrophizing patients, because catastrophizing personalities are not confined to the patient world. Physicians who are catastrophizers may inadvertently increase a patient’s perception of suffering. “Some of our research suggests that if you’re a catastrophizer you see 30% more pain in these individuals,” he said, and this could impact a physician’s decisions about treatment intervention as well their advice surrounding acceptance.

The speakers did not declare any conflicts of interest.

MONTREAL – Personality and attitude play a major role in shaping a patient’s experience of chronic pain, and understanding this dynamic may help physicians overcome obstacles in treating some of their unresponsive patients, according to Michael Sullivan, Ph.D.

In fact, in recent studies, catastrophizing has emerged as “the most powerful psychological predictor of problematic pain outcomes,” said Dr. Sullivan, professor of psychology, medicine, and neurology at McGill University in Montreal.

In the context of pain, catastrophizing is defined as the tendency to worry and focus on the pain. Individuals who score high on the Pain Catastrophizing Scale (PCS), which was developed by Dr. Sullivan in 1995, tend to magnify and ruminate over their symptoms while feeling helpless about addressing them. “These individuals have an excessively alarmist attitude towards their pain and seem to have a lot more difficulty dealing with it,” he said at the World Congress on Pain.

In the office setting, chronic pain patients who catastrophize “display more pain behavior such as holding, rubbing, guarding, as well as vocalizations such as moans and sighs,” he said at the meeting, which was sponsored by the International Association for the Study of Pain.

“Research shows that not only are catastrophizers going to have more difficulty in pain situations, they are also going to respond less well to the interventions that we offer them,” he said. In studies, Dr. Sullivan and his colleagues have shown that, compared with noncatastrophizers, catastrophizers are at greater risk of chronic pain following knee arthroplasty (Pain Res. Manag. 2008;13:335-41) and have more difficulty returning to work after whiplash injuries (J. Occup. Rehabil. 2007;17:305-15).

For patients whose chronic pain stems from an accident, perceptions of injustice also are common and can be expressed as anger or noncompliance. “Some of our recent research [Pain 2009;145:325-31] shows that perceptions of injustice are often associated with prolonged disability following a pain-related injury,” he said. For the treating physician, “validation techniques can be useful in reducing the negative impact of the catastrophizing patient’s perceptions of injustice.”

By identifying catastrophizers early, physicians can avoid pitfalls that contribute to treatment failure in chronic pain. “There are some very concrete ways in which physicians could be reacting differently with these patients” to make patient management easier, he pointed out.

First and foremost, catastrophizers need to express their suffering and anxiety. “This person does have a story to tell and they need someone to listen. By not listening properly to that story initially, you are going to hear it again every time the patient comes, because the patient is going to feel that the doctor doesn’t understand. So, increasing the time you initially spend with the patient can save a lot of headaches further down the line,” Dr. Sullivan explained.

Active listening has even been shown to reduce a patient’s perception of pain, at least in the context of acute symptoms, said Dr. Sullivan, who has published several studies showing that allowing catastrophizers to disclose their fear and worry prior to routine dental hygiene procedures can reduce their perception of pain by as much as 50% (J. Indiana Dent. Assoc. 2000-2001;79:16-9; and Pain 1999;79:155-63).

Although a patient’s basic personality is a challenge for physicians to work around, attitude – which is also an extremely powerful modifier of pain – is somewhat easier to mold, suggested Stefaan Van Damme, Ph.D., of the department of experimental clinical health and psychology at Ghent (Belgium) University.

In approaching pain control as a goal, chronic pain patients fall into two distinct categories: those who try to overcome it (assimilators) and those who accept it (accommodators). Both attitudes can be helpful or harmful, depending on how realistic pain control is for a particular patient, he said at the meeting.

“When pain is controllable, assimilative coping works. But when it is not controllable it can be maladaptive because it can exacerbate catastrophizing, hypervigilance, and distress,” he said. In a study, he demonstrated that, when attempts to avoid pain are unsuccessful, “individuals persist in their avoidance attempts, try harder, and narrow their focus of attention upon the problem to be solved” (Pain 2008;137:631-9).

Helping patients shift their focus from fighting to accepting their pain is particularly tricky for physicians, commented Dr. Sullivan, who is a psychologist. “I only get sent the patients when their pain has been long-standing. The concept of acceptance works when the pain has been there for 5 years,” he explained, “but for new-onset pain, acceptance is not the message that should be given by the doctor. This should only come up after we’ve offered everything else we can offer.”

Physicians should also be aware of their own personal psychology when dealing with catastrophizing patients, because catastrophizing personalities are not confined to the patient world. Physicians who are catastrophizers may inadvertently increase a patient’s perception of suffering. “Some of our research suggests that if you’re a catastrophizer you see 30% more pain in these individuals,” he said, and this could impact a physician’s decisions about treatment intervention as well their advice surrounding acceptance.

The speakers did not declare any conflicts of interest.

MONTREAL – Psychological interventions such as cognitive behavioral therapy and hypnosis can alter how the brain processes pain, thereby reducing patients’ perception of pain, judging from findings from brain-imaging studies reported recently at the World Congress on Pain.

“This shows how mind and body can work in unison, and one can influence the other,” said Dr. Magdalena Naylor, a psychiatrist and lead investigator of one of the studies performed at the MindBody Medicine Research Clinic and Brain Imaging Program of the University of Vermont, Burlington.

The study, presented as a poster, used functional MRI (fMRI) to show that cognitive behavioral therapy can alter dysfunctional neural circuitry associated with chronic pain. Nine women with chronic pain resulting from low back pain or knee or hip osteoarthritis underwent fMRI before and after an 11-week CBT program for reducing pain and catastrophizing. The women’s mean age was 57.5 years; their pain had an average duration of 11 years.

At baseline, amygdala reactivity in the subjects was different from that of healthy controls when they viewed emotionally upsetting photographs from IAPS (International Affective Picture System). However, this difference disappeared after CBT, with the subjects showing reduced activity in somatosensory, frontal, and limbic areas that are associated with emotional and sensory processing, and increased activation in the left insula, she said. At the same time, the subjects reported decreased pain and better coping. Total Pain Experience scores decreased in correlation with decreased activation in the middle temporal gyrus, and scores on the coping strategies questionnaire subscale of attention diversion. Their score on the Beck Depression Inventory also improved in correlation with decreased activation in the superior frontal gyrus and postcentral gyrus. Dr. Naylor reported that her group has also recently published evidence of reduced pain symptoms and opioid use in a similar population ( J. Pain 2010 July 8 [doi:10.1016/j.jpain.2010.03.019]).

“Our work shows that CBT decreases emotional vulnerability to negative emotions and pain, which go together,” said Dr. Naylor in an interview. “With CBT, these patients are not as emotionally dysregulated.”

Her group is now examining brain structure – specifically thickness of cortices – with similar results. “It’s well documented that patients with chronic pain have thinner cortices, and this is correlated with the duration of pain. So we are very happy to see that with CBT we can reverse this structural damage.”

Hypnosis is another psychological intervention that has been shown to alter pain processing and perception of pain, reported Dr. Marie-Elisabeth Faymonville during a workshop at the meeting. Dr. Faymonville, an anesthesiologist from the University Hospital Li?ge (Belgium), uses hypnosedation, a combination of hypnosis and local anesthesia, to help surgical patients avoid general anesthesia. Findings from functional neuroimaging studies by her group and others have shown that patients under hypnosis show changes in neuronal activity in the presence of painful stimuli, she reported. In one recent study, her group showed that under hypnosis, painful stimuli failed to elicit cerebral activity in the pain network (Neuroimage 2009;47:1047-54).

“Increased functional connectivity between S1 and the prefrontal cortex may represent a top-down modulation of pain,” she noted.

Although Dr. Faymonville’s work demonstrates the impact of hypnosis on acute pain perception, another study presented as a poster at the conference showed the beneficial effect of hypnosis on chronic pain. The study included 41 patients with persistent idiopathic orofacial pain, “that is, pain in the mouth or face which cannot be explained by any kind of known disease,” explained Lene Baad-Hansen, D.D.S., the coinvestigator of the study, in an interview.

The subjects were randomized to five 1-hour sessions of active hypnotic intervention (22 subjects), which included progressive relaxation, guided imagery, and suggestions of controlling and changing pain perception, or to the same number of sessions but with progressive relaxation alone (19 subjects). Quantitative sensory testing (QST) involving the subjects’ ratings of psychophysical stimuli (such as cold, warm, tactile, and pin-prick) was performed on all subjects both before and after the intervention.

Subjective reporting showed that those who had undergone hypnosis reported a 33% reduction in orofacial pain, compared with a 3% reduction in the control group. However, the QST tests showed no differences between the groups either before or after the intervention. “Despite clear clinical pain relief, hypnosis does not influence somatosensory sensitivity, said Dr. Baad-Hansen of the department of clinical oral physiology in the dental school at Aarhus (Denmark) University.

None of the researchers reported any conflicts of interest.

MONTREAL – Psychological interventions such as cognitive behavioral therapy and hypnosis can alter how the brain processes pain, thereby reducing patients’ perception of pain, judging from findings from brain-imaging studies reported recently at the World Congress on Pain.

“This shows how mind and body can work in unison, and one can influence the other,” said Dr. Magdalena Naylor, a psychiatrist and lead investigator of one of the studies performed at the MindBody Medicine Research Clinic and Brain Imaging Program of the University of Vermont, Burlington.

The study, presented as a poster, used functional MRI (fMRI) to show that cognitive behavioral therapy can alter dysfunctional neural circuitry associated with chronic pain. Nine women with chronic pain resulting from low back pain or knee or hip osteoarthritis underwent fMRI before and after an 11-week CBT program for reducing pain and catastrophizing. The women’s mean age was 57.5 years; their pain had an average duration of 11 years.

At baseline, amygdala reactivity in the subjects was different from that of healthy controls when they viewed emotionally upsetting photographs from IAPS (International Affective Picture System). However, this difference disappeared after CBT, with the subjects showing reduced activity in somatosensory, frontal, and limbic areas that are associated with emotional and sensory processing, and increased activation in the left insula, she said. At the same time, the subjects reported decreased pain and better coping. Total Pain Experience scores decreased in correlation with decreased activation in the middle temporal gyrus, and scores on the coping strategies questionnaire subscale of attention diversion. Their score on the Beck Depression Inventory also improved in correlation with decreased activation in the superior frontal gyrus and postcentral gyrus. Dr. Naylor reported that her group has also recently published evidence of reduced pain symptoms and opioid use in a similar population ( J. Pain 2010 July 8 [doi:10.1016/j.jpain.2010.03.019]).

“Our work shows that CBT decreases emotional vulnerability to negative emotions and pain, which go together,” said Dr. Naylor in an interview. “With CBT, these patients are not as emotionally dysregulated.”

Her group is now examining brain structure – specifically thickness of cortices – with similar results. “It’s well documented that patients with chronic pain have thinner cortices, and this is correlated with the duration of pain. So we are very happy to see that with CBT we can reverse this structural damage.”

Hypnosis is another psychological intervention that has been shown to alter pain processing and perception of pain, reported Dr. Marie-Elisabeth Faymonville during a workshop at the meeting. Dr. Faymonville, an anesthesiologist from the University Hospital Li?ge (Belgium), uses hypnosedation, a combination of hypnosis and local anesthesia, to help surgical patients avoid general anesthesia. Findings from functional neuroimaging studies by her group and others have shown that patients under hypnosis show changes in neuronal activity in the presence of painful stimuli, she reported. In one recent study, her group showed that under hypnosis, painful stimuli failed to elicit cerebral activity in the pain network (Neuroimage 2009;47:1047-54).

“Increased functional connectivity between S1 and the prefrontal cortex may represent a top-down modulation of pain,” she noted.

Although Dr. Faymonville’s work demonstrates the impact of hypnosis on acute pain perception, another study presented as a poster at the conference showed the beneficial effect of hypnosis on chronic pain. The study included 41 patients with persistent idiopathic orofacial pain, “that is, pain in the mouth or face which cannot be explained by any kind of known disease,” explained Lene Baad-Hansen, D.D.S., the coinvestigator of the study, in an interview.

The subjects were randomized to five 1-hour sessions of active hypnotic intervention (22 subjects), which included progressive relaxation, guided imagery, and suggestions of controlling and changing pain perception, or to the same number of sessions but with progressive relaxation alone (19 subjects). Quantitative sensory testing (QST) involving the subjects’ ratings of psychophysical stimuli (such as cold, warm, tactile, and pin-prick) was performed on all subjects both before and after the intervention.

Subjective reporting showed that those who had undergone hypnosis reported a 33% reduction in orofacial pain, compared with a 3% reduction in the control group. However, the QST tests showed no differences between the groups either before or after the intervention. “Despite clear clinical pain relief, hypnosis does not influence somatosensory sensitivity, said Dr. Baad-Hansen of the department of clinical oral physiology in the dental school at Aarhus (Denmark) University.

None of the researchers reported any conflicts of interest.

MONTREAL – Psychological interventions such as cognitive behavioral therapy and hypnosis can alter how the brain processes pain, thereby reducing patients’ perception of pain, judging from findings from brain-imaging studies reported recently at the World Congress on Pain.

“This shows how mind and body can work in unison, and one can influence the other,” said Dr. Magdalena Naylor, a psychiatrist and lead investigator of one of the studies performed at the MindBody Medicine Research Clinic and Brain Imaging Program of the University of Vermont, Burlington.

The study, presented as a poster, used functional MRI (fMRI) to show that cognitive behavioral therapy can alter dysfunctional neural circuitry associated with chronic pain. Nine women with chronic pain resulting from low back pain or knee or hip osteoarthritis underwent fMRI before and after an 11-week CBT program for reducing pain and catastrophizing. The women’s mean age was 57.5 years; their pain had an average duration of 11 years.

At baseline, amygdala reactivity in the subjects was different from that of healthy controls when they viewed emotionally upsetting photographs from IAPS (International Affective Picture System). However, this difference disappeared after CBT, with the subjects showing reduced activity in somatosensory, frontal, and limbic areas that are associated with emotional and sensory processing, and increased activation in the left insula, she said. At the same time, the subjects reported decreased pain and better coping. Total Pain Experience scores decreased in correlation with decreased activation in the middle temporal gyrus, and scores on the coping strategies questionnaire subscale of attention diversion. Their score on the Beck Depression Inventory also improved in correlation with decreased activation in the superior frontal gyrus and postcentral gyrus. Dr. Naylor reported that her group has also recently published evidence of reduced pain symptoms and opioid use in a similar population ( J. Pain 2010 July 8 [doi:10.1016/j.jpain.2010.03.019]).

“Our work shows that CBT decreases emotional vulnerability to negative emotions and pain, which go together,” said Dr. Naylor in an interview. “With CBT, these patients are not as emotionally dysregulated.”

Her group is now examining brain structure – specifically thickness of cortices – with similar results. “It’s well documented that patients with chronic pain have thinner cortices, and this is correlated with the duration of pain. So we are very happy to see that with CBT we can reverse this structural damage.”

Hypnosis is another psychological intervention that has been shown to alter pain processing and perception of pain, reported Dr. Marie-Elisabeth Faymonville during a workshop at the meeting. Dr. Faymonville, an anesthesiologist from the University Hospital Li?ge (Belgium), uses hypnosedation, a combination of hypnosis and local anesthesia, to help surgical patients avoid general anesthesia. Findings from functional neuroimaging studies by her group and others have shown that patients under hypnosis show changes in neuronal activity in the presence of painful stimuli, she reported. In one recent study, her group showed that under hypnosis, painful stimuli failed to elicit cerebral activity in the pain network (Neuroimage 2009;47:1047-54).

“Increased functional connectivity between S1 and the prefrontal cortex may represent a top-down modulation of pain,” she noted.

Although Dr. Faymonville’s work demonstrates the impact of hypnosis on acute pain perception, another study presented as a poster at the conference showed the beneficial effect of hypnosis on chronic pain. The study included 41 patients with persistent idiopathic orofacial pain, “that is, pain in the mouth or face which cannot be explained by any kind of known disease,” explained Lene Baad-Hansen, D.D.S., the coinvestigator of the study, in an interview.

The subjects were randomized to five 1-hour sessions of active hypnotic intervention (22 subjects), which included progressive relaxation, guided imagery, and suggestions of controlling and changing pain perception, or to the same number of sessions but with progressive relaxation alone (19 subjects). Quantitative sensory testing (QST) involving the subjects’ ratings of psychophysical stimuli (such as cold, warm, tactile, and pin-prick) was performed on all subjects both before and after the intervention.

Subjective reporting showed that those who had undergone hypnosis reported a 33% reduction in orofacial pain, compared with a 3% reduction in the control group. However, the QST tests showed no differences between the groups either before or after the intervention. “Despite clear clinical pain relief, hypnosis does not influence somatosensory sensitivity, said Dr. Baad-Hansen of the department of clinical oral physiology in the dental school at Aarhus (Denmark) University.

None of the researchers reported any conflicts of interest.

MONTREAL — Uptake of human papillomavirus vaccination is too slow, say some experts, while others still question whether enough is known about the risk-benefit ratio to deem the vaccine truly necessary.

In an industry-sponsored symposium held during the meeting, Dr. William Fisher, a consultant to Merck & Co., strongly urged physicians to make HPV vaccination a routine part of their practice. There are about 100 strains of HPV virus, with 15 considered oncogenic. HPV strains 16 and 18 are responsible for about 70% of cervical cancer, while strains 6 and 11 are responsible for genital warts. Merck's Gardasil vaccine targets all four strains, while Cervarix (GlaxoSmithKline PLC) targets the oncogenic strains 16 and 18.

“HPV vaccine would seem to be a very reasonable form of protection for both men and women who may be sexually active in an environment characterized by a very high level of HPV and in which infection is very common,” as the infection may have serious health consequences for the individual and his or her partner, said Dr. Fisher, professor of psychology and of obstetrics and gynecology at the University of Western Ontario, London.

To illustrate the prevalence of HPV infection, Dr. Fisher noted a 25% rate of infection with high-risk oncogenic strains of HPV among Canadian teenage girls, aged 15–19 years, in a low-risk family practice setting who were negative for HPV the previous year (CMAJ 2003;168:421–5). Similarly, among a group of 621 university-age women tested every 6 months for 2 years, the rate of newly acquired high- and low-risk HPV strains was 13% at 1 year, and 29% and 24% at 2 years (Cancer Epidemiol. Biomarkers Prev. 2003;12:485–90).

“We couldn't be talking more clearly about a sociosexual epidemic,” he said. “This is a social disease on steroids,” said Dr. Fisher, who is also with the center for health, intervention, and prevention at the University of Connecticut, in Storrs.

In a recent study involving young Canadian couples, HPV was present in 64% of new couples and the oncogenic HPV-16 strain was the most common strain found at baseline.

Concordance of strains was 41% at baseline and grew to 68% at 6 months, he said (Epidemiology 2010;21:31–7). “There's no doubt in new relationships that HPV is rapidly becoming part of the sociocultural landscape,” Dr. Fisher said. While there is a well-established link between high-risk HPV and gynecologic cancers, HPV-related head and neck cancers are “probably the newest sexually transmitted infections on the radar,” he said.

In a Swedish study, the prevalence of oncogenic HPV strains in head and neck cancer biopsies was found to have increased from 23% in the 1970s to 77% by 2005 (Int. J. Cancer 2009;125:362–6).

In addition, a 2010 study shows that the risk of HPV-related head and neck cancer, while increased with six or more coital partners (odds ratio, 1.25), more than triples with more than four oral-genital partners (OR, 3.36). “Oral-genital sex is the new handshake, and it is actually likely that people have more oral-genital partners than coital partners,” Dr. Fisher added.

Yet while Canadian and U.S. authorities recommend HPV vaccination in young girls and women, and school-based vaccination programs are offered across Canada, such recommendations have not resulted in mass vaccination, he said. A recent study suggests that only about one-third of American girls, aged 13–17 years, have been vaccinated (Am. J. Prev. Med. 2010;38:525–33).

Dr. Marie Plante, president of the Society of Gynecologic Oncologists of Canada, said that as a gynecologic oncologist she sees the downside of such low vaccination rates. “We treat women with cervical cancer…. I've got several of them in their 20s and early 30s and it ruins their lives, and they can't have children sometimes. So we see the frustrating part because it could have been prevented,” said Dr. Plante, chief of the gynecologic oncology division at Laval University in Quebec City. She estimated that about 50% of cervical cancer cases she sees are in women whose regular screening had failed to identify the disease.

“As much as I am very critical of the push from the companies [to market their vaccines], I will tell you that honestly I think the vaccine is safe,” Dr. Plante continued. However, “it is not necessary,” she said. “It does not guarantee 100% protection. It's an option you have to reduce the chances that you develop precancerous cells. In most cases this will be treated quickly and won't take your life away.” Importantly, the vaccine also reduces the potentially significant burden of genital warts, the experience of which is “amazingly negative”—it's “terrible and painful,” she added.

Last year a prominent editorial and article in JAMA questioned the medical arguments for vaccination, as well as the ethics of aggressive marketing campaigns from pharmaceutical companies (2009;302:795–6, 781-6). “If the potential benefits are substantial, most individuals would be willing to accept the risks. But the net benefit of the HPV vaccine to women is uncertain. Even if persistently infected with HPV, a woman most likely will not develop cancer if she is regularly screened,” wrote Dr. Charlotte Haug, editor-in-chief of the Journal of the Norwegian Medical Association.

In their article, Sheila Rothman, Ph.D., and David Rothman, Ph.D., of Columbia University, New York, noted that in 2006, Merck's Gardasil “was named the pharmaceutical 'brand of the year' for building a 'market out of thin air.'”

Alan Cassels, a drug policy researcher at the University of Victoria (B.C.), was critical. “It's not a slam dunk that if you get the HPV vaccine you'll be prevented from developing cancer,” he said in an interview. He compared the vaccine to cholesterol-lowering drugs. “Yes, we can prove that a drug lowers cholesterol, but the question is whether it prevents heart attacks and strokes. So, while the HPV vaccine may prevent transmission of the virus, will that really result in [fewer] cancers? We won't know for 10 or 20 years down the road.”

Given the uncertainty of benefit, or the duration of efficacy, Mr. Cassels cautioned that the risks of any intervention should be minimal, which is not the case with the HPV vaccine.

As of Jan. 31, 2010, there were 49 U.S. reports of death among females who had received Gardasil, according to the Centers for Disease Control and Prevention. Twenty-eight of these reports have been confirmed and 21 remain unconfirmed. In the 28 confirmed reports, “there was no unusual pattern or clustering to the deaths that would suggest that they were caused by the vaccine,” according to a CDC statement.

Disclosures: Merck sponsored the symposium. Dr. Fisher disclosed that he has been a consultant for Merck, Boehringer Ingelheim, and Bayer. Dr. Plante reported having no conflicts of interest.

MONTREAL — Uptake of human papillomavirus vaccination is too slow, say some experts, while others still question whether enough is known about the risk-benefit ratio to deem the vaccine truly necessary.

In an industry-sponsored symposium held during the meeting, Dr. William Fisher, a consultant to Merck & Co., strongly urged physicians to make HPV vaccination a routine part of their practice. There are about 100 strains of HPV virus, with 15 considered oncogenic. HPV strains 16 and 18 are responsible for about 70% of cervical cancer, while strains 6 and 11 are responsible for genital warts. Merck's Gardasil vaccine targets all four strains, while Cervarix (GlaxoSmithKline PLC) targets the oncogenic strains 16 and 18.

“HPV vaccine would seem to be a very reasonable form of protection for both men and women who may be sexually active in an environment characterized by a very high level of HPV and in which infection is very common,” as the infection may have serious health consequences for the individual and his or her partner, said Dr. Fisher, professor of psychology and of obstetrics and gynecology at the University of Western Ontario, London.

To illustrate the prevalence of HPV infection, Dr. Fisher noted a 25% rate of infection with high-risk oncogenic strains of HPV among Canadian teenage girls, aged 15–19 years, in a low-risk family practice setting who were negative for HPV the previous year (CMAJ 2003;168:421–5). Similarly, among a group of 621 university-age women tested every 6 months for 2 years, the rate of newly acquired high- and low-risk HPV strains was 13% at 1 year, and 29% and 24% at 2 years (Cancer Epidemiol. Biomarkers Prev. 2003;12:485–90).

“We couldn't be talking more clearly about a sociosexual epidemic,” he said. “This is a social disease on steroids,” said Dr. Fisher, who is also with the center for health, intervention, and prevention at the University of Connecticut, in Storrs.

In a recent study involving young Canadian couples, HPV was present in 64% of new couples and the oncogenic HPV-16 strain was the most common strain found at baseline.

Concordance of strains was 41% at baseline and grew to 68% at 6 months, he said (Epidemiology 2010;21:31–7). “There's no doubt in new relationships that HPV is rapidly becoming part of the sociocultural landscape,” Dr. Fisher said. While there is a well-established link between high-risk HPV and gynecologic cancers, HPV-related head and neck cancers are “probably the newest sexually transmitted infections on the radar,” he said.

In a Swedish study, the prevalence of oncogenic HPV strains in head and neck cancer biopsies was found to have increased from 23% in the 1970s to 77% by 2005 (Int. J. Cancer 2009;125:362–6).

In addition, a 2010 study shows that the risk of HPV-related head and neck cancer, while increased with six or more coital partners (odds ratio, 1.25), more than triples with more than four oral-genital partners (OR, 3.36). “Oral-genital sex is the new handshake, and it is actually likely that people have more oral-genital partners than coital partners,” Dr. Fisher added.

Yet while Canadian and U.S. authorities recommend HPV vaccination in young girls and women, and school-based vaccination programs are offered across Canada, such recommendations have not resulted in mass vaccination, he said. A recent study suggests that only about one-third of American girls, aged 13–17 years, have been vaccinated (Am. J. Prev. Med. 2010;38:525–33).

Dr. Marie Plante, president of the Society of Gynecologic Oncologists of Canada, said that as a gynecologic oncologist she sees the downside of such low vaccination rates. “We treat women with cervical cancer…. I've got several of them in their 20s and early 30s and it ruins their lives, and they can't have children sometimes. So we see the frustrating part because it could have been prevented,” said Dr. Plante, chief of the gynecologic oncology division at Laval University in Quebec City. She estimated that about 50% of cervical cancer cases she sees are in women whose regular screening had failed to identify the disease.

“As much as I am very critical of the push from the companies [to market their vaccines], I will tell you that honestly I think the vaccine is safe,” Dr. Plante continued. However, “it is not necessary,” she said. “It does not guarantee 100% protection. It's an option you have to reduce the chances that you develop precancerous cells. In most cases this will be treated quickly and won't take your life away.” Importantly, the vaccine also reduces the potentially significant burden of genital warts, the experience of which is “amazingly negative”—it's “terrible and painful,” she added.

Last year a prominent editorial and article in JAMA questioned the medical arguments for vaccination, as well as the ethics of aggressive marketing campaigns from pharmaceutical companies (2009;302:795–6, 781-6). “If the potential benefits are substantial, most individuals would be willing to accept the risks. But the net benefit of the HPV vaccine to women is uncertain. Even if persistently infected with HPV, a woman most likely will not develop cancer if she is regularly screened,” wrote Dr. Charlotte Haug, editor-in-chief of the Journal of the Norwegian Medical Association.

In their article, Sheila Rothman, Ph.D., and David Rothman, Ph.D., of Columbia University, New York, noted that in 2006, Merck's Gardasil “was named the pharmaceutical 'brand of the year' for building a 'market out of thin air.'”

Alan Cassels, a drug policy researcher at the University of Victoria (B.C.), was critical. “It's not a slam dunk that if you get the HPV vaccine you'll be prevented from developing cancer,” he said in an interview. He compared the vaccine to cholesterol-lowering drugs. “Yes, we can prove that a drug lowers cholesterol, but the question is whether it prevents heart attacks and strokes. So, while the HPV vaccine may prevent transmission of the virus, will that really result in [fewer] cancers? We won't know for 10 or 20 years down the road.”

Given the uncertainty of benefit, or the duration of efficacy, Mr. Cassels cautioned that the risks of any intervention should be minimal, which is not the case with the HPV vaccine.

As of Jan. 31, 2010, there were 49 U.S. reports of death among females who had received Gardasil, according to the Centers for Disease Control and Prevention. Twenty-eight of these reports have been confirmed and 21 remain unconfirmed. In the 28 confirmed reports, “there was no unusual pattern or clustering to the deaths that would suggest that they were caused by the vaccine,” according to a CDC statement.

Disclosures: Merck sponsored the symposium. Dr. Fisher disclosed that he has been a consultant for Merck, Boehringer Ingelheim, and Bayer. Dr. Plante reported having no conflicts of interest.

MONTREAL — Uptake of human papillomavirus vaccination is too slow, say some experts, while others still question whether enough is known about the risk-benefit ratio to deem the vaccine truly necessary.

In an industry-sponsored symposium held during the meeting, Dr. William Fisher, a consultant to Merck & Co., strongly urged physicians to make HPV vaccination a routine part of their practice. There are about 100 strains of HPV virus, with 15 considered oncogenic. HPV strains 16 and 18 are responsible for about 70% of cervical cancer, while strains 6 and 11 are responsible for genital warts. Merck's Gardasil vaccine targets all four strains, while Cervarix (GlaxoSmithKline PLC) targets the oncogenic strains 16 and 18.

“HPV vaccine would seem to be a very reasonable form of protection for both men and women who may be sexually active in an environment characterized by a very high level of HPV and in which infection is very common,” as the infection may have serious health consequences for the individual and his or her partner, said Dr. Fisher, professor of psychology and of obstetrics and gynecology at the University of Western Ontario, London.

To illustrate the prevalence of HPV infection, Dr. Fisher noted a 25% rate of infection with high-risk oncogenic strains of HPV among Canadian teenage girls, aged 15–19 years, in a low-risk family practice setting who were negative for HPV the previous year (CMAJ 2003;168:421–5). Similarly, among a group of 621 university-age women tested every 6 months for 2 years, the rate of newly acquired high- and low-risk HPV strains was 13% at 1 year, and 29% and 24% at 2 years (Cancer Epidemiol. Biomarkers Prev. 2003;12:485–90).

“We couldn't be talking more clearly about a sociosexual epidemic,” he said. “This is a social disease on steroids,” said Dr. Fisher, who is also with the center for health, intervention, and prevention at the University of Connecticut, in Storrs.

In a recent study involving young Canadian couples, HPV was present in 64% of new couples and the oncogenic HPV-16 strain was the most common strain found at baseline.

Concordance of strains was 41% at baseline and grew to 68% at 6 months, he said (Epidemiology 2010;21:31–7). “There's no doubt in new relationships that HPV is rapidly becoming part of the sociocultural landscape,” Dr. Fisher said. While there is a well-established link between high-risk HPV and gynecologic cancers, HPV-related head and neck cancers are “probably the newest sexually transmitted infections on the radar,” he said.

In a Swedish study, the prevalence of oncogenic HPV strains in head and neck cancer biopsies was found to have increased from 23% in the 1970s to 77% by 2005 (Int. J. Cancer 2009;125:362–6).

In addition, a 2010 study shows that the risk of HPV-related head and neck cancer, while increased with six or more coital partners (odds ratio, 1.25), more than triples with more than four oral-genital partners (OR, 3.36). “Oral-genital sex is the new handshake, and it is actually likely that people have more oral-genital partners than coital partners,” Dr. Fisher added.

Yet while Canadian and U.S. authorities recommend HPV vaccination in young girls and women, and school-based vaccination programs are offered across Canada, such recommendations have not resulted in mass vaccination, he said. A recent study suggests that only about one-third of American girls, aged 13–17 years, have been vaccinated (Am. J. Prev. Med. 2010;38:525–33).

Dr. Marie Plante, president of the Society of Gynecologic Oncologists of Canada, said that as a gynecologic oncologist she sees the downside of such low vaccination rates. “We treat women with cervical cancer…. I've got several of them in their 20s and early 30s and it ruins their lives, and they can't have children sometimes. So we see the frustrating part because it could have been prevented,” said Dr. Plante, chief of the gynecologic oncology division at Laval University in Quebec City. She estimated that about 50% of cervical cancer cases she sees are in women whose regular screening had failed to identify the disease.

“As much as I am very critical of the push from the companies [to market their vaccines], I will tell you that honestly I think the vaccine is safe,” Dr. Plante continued. However, “it is not necessary,” she said. “It does not guarantee 100% protection. It's an option you have to reduce the chances that you develop precancerous cells. In most cases this will be treated quickly and won't take your life away.” Importantly, the vaccine also reduces the potentially significant burden of genital warts, the experience of which is “amazingly negative”—it's “terrible and painful,” she added.

Last year a prominent editorial and article in JAMA questioned the medical arguments for vaccination, as well as the ethics of aggressive marketing campaigns from pharmaceutical companies (2009;302:795–6, 781-6). “If the potential benefits are substantial, most individuals would be willing to accept the risks. But the net benefit of the HPV vaccine to women is uncertain. Even if persistently infected with HPV, a woman most likely will not develop cancer if she is regularly screened,” wrote Dr. Charlotte Haug, editor-in-chief of the Journal of the Norwegian Medical Association.

In their article, Sheila Rothman, Ph.D., and David Rothman, Ph.D., of Columbia University, New York, noted that in 2006, Merck's Gardasil “was named the pharmaceutical 'brand of the year' for building a 'market out of thin air.'”

Alan Cassels, a drug policy researcher at the University of Victoria (B.C.), was critical. “It's not a slam dunk that if you get the HPV vaccine you'll be prevented from developing cancer,” he said in an interview. He compared the vaccine to cholesterol-lowering drugs. “Yes, we can prove that a drug lowers cholesterol, but the question is whether it prevents heart attacks and strokes. So, while the HPV vaccine may prevent transmission of the virus, will that really result in [fewer] cancers? We won't know for 10 or 20 years down the road.”

Given the uncertainty of benefit, or the duration of efficacy, Mr. Cassels cautioned that the risks of any intervention should be minimal, which is not the case with the HPV vaccine.

As of Jan. 31, 2010, there were 49 U.S. reports of death among females who had received Gardasil, according to the Centers for Disease Control and Prevention. Twenty-eight of these reports have been confirmed and 21 remain unconfirmed. In the 28 confirmed reports, “there was no unusual pattern or clustering to the deaths that would suggest that they were caused by the vaccine,” according to a CDC statement.

Disclosures: Merck sponsored the symposium. Dr. Fisher disclosed that he has been a consultant for Merck, Boehringer Ingelheim, and Bayer. Dr. Plante reported having no conflicts of interest.