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Objectives: Avoidance, persistence, and pacing are activity patterns that have different adaptive effects in chronic pain patients. Some inconsistent findings have been explained from a contextual perspective that underlines the purpose of the activity. In this way, avoidance, persistence, and pacing are multidimensional constructs, nuanced by their goals. This multidimensionality has been supported with a new instrument, the Activity Patterns Scale, in heterogeneous chronic pain samples. Owing to the clinical implications of this conceptualization, the complexity of the activity patterns and their relationships with health outcomes in fibromyalgia (FM), our aim was to explore the construct validity of this scale in this pain problem, testing its internal structure and the relationships with other constructs., Materials and Methods: The sample included 702 women with diagnosis of FM from tertiary (53.3%) and community settings (46.7%). Confirmatory factor analysis was conducted to test different factor structures of the activity patterns and Pearson correlation to explore the relationships with health outcomes and psychosocial variables., Results: A 6-factor structure showed acceptable fit indices (standardized root mean square residual=0.062; root mean-square error of approximation=0.066; comparative fit index=0.908). The highest significant relationships for health outcomes was between activity avoidance and FM impact (r=0.36) and excessive persistence and negative affect (r=0.41)., Discussion: Avoidance and persistence activity patterns are shown as multidimensional constructs but not pacing. The ongoing pain in these women may make it difficult to regulate their activity taking into account other goals not contingent on pain fluctuations., Competing Interests: This work was supported by Ministerio de Economía y Competitividad (grant reference PSI2016-79566-C2-1-R) and by Fondo de Investigación en Salud from the Instituto de Salud Carlos III cofinanced by the European Union through the Fondo Europeo de Desarrollo Regional (FEDER) (grant reference PI17/00858), Spain. The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Fibromyalgia (FM) is a highly disabling condition characterized by widespread chronic pain. Physical exercise, such as walking, has been recommended as the treatment of choice for FM. However, adherence to physical exercise tends to be poor. Pain is one of the main inhibitors to adhere to walking in FM patients. The main objective of this study has been to determine whether there is a clinical and psychosocial profile to help predict individual differences in adherence to walking in a sample of patients with FM with severe pain levels. In this cross-sectional study, the sample was composed of 172 women with FM and severe pain levels (> 7 in an 11-point numerical scale). Women were classified into two groups: (1) those who walked regularly and (2) patients who rarely or never walked. Group differences regarding clinical outcomes (e.g., FM impact, anxiety, depression, cognitive fusion, catastrophizing, affect, and personality), sociodemographic variables, and medical history were analyzed. Patients who walked despite pain significantly reported less impact of FM, anxiety, depression, catastrophizing, cognitive fusion, negative affect, openness to experience, agreeableness, and conscientiousness. The unique predictors of group membership (walking versus no walking) in a binary regression were FM impact and negative affect. The results show that adherence to exercise might be influenced and predicted by the clinical profile of the patient, which suggests that personalized motivational interventions should be addressed to this at-risk subgroup.

Objectives: Chronic pain is theoretically conceptualized from a biopsychosocial perspective. However, research into chronic pain still tends to focus on isolated, biological, psychological, or social variables. Simultaneous examination of these variables in the prediction of outcomes is important because communalities between predictors exist. Examination of unique contributions might help guide research and interventions in a more effective way., Methods: The participants were 114 individuals with chronic pain (mean age=58.81, SD=11.85; 58.8% women and 41.2% men) who responded to demographics (age and sex), pain characteristics (duration and sensory qualities), psychological (catastrophizing and perceived injustice), and social (marital adjustment) measures. Multivariate analyses were conducted to investigate their unique contributions to pain-related health variables pain severity, pain interference, disability, anxiety, and depressive symptoms., Results: Bivariate analyses evidenced significant associations between pain sensory qualities, catastrophizing, perceived injustice, and all health variables. In multivariate analyses, pain sensory qualities were associated with pain severity (β=0.10; 95% confidence interval [CI]=0.05, 0.14; t=4.28, P<0.001), while perceived injustice was associated with pain interference (β=0.08; 95% CI=0.03, 0.12; t=3.59, P<0.001), disability (β=0.25; 95% CI=0.08, 0.42; t=2.92, P=0.004), anxiety (β=0.18; 95% CI=0.08, 0.27; t=3.65, P<0.001), and depressive symptoms (β=0.14; 95% CI=0.05, 0.23; t=2.92, P=0.004). Age, sex, pain duration, and marital adjustment were not associated with health variables either in bivariate or in multivariate analyses (all P>0.010)., Discussion: As expected, communalities between biopsychosocial variables exist, which resulted in a reduced number of unique contributions in multivariate analyses. Perceived injustice emerged as a unique contributor to variables, which points to this psychological construct as a potentially important therapeutic target in multidisciplinary treatment of pain., Competing Interests: Preparation of this manuscript was supported by grant POSDOC/2016/15 from the Universitat Jaume I (Castellon de la Plana, Spain) and a research agreement with McGill University (Montreal, Canada). The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Informal care-giving by spouses has become frequent in chronic pain settings. However, the impact of pain on occupational, functional and health outcomes in spouses has not been systematically investigated., Aims: The goal of the present study was to examine the impact of pain on both patient and spousal outcomes., Methods: In the present study, the impact of chronic pain on 114 heterosexual dyads was explored (patients: 59% females, average age = 57.81 years, SD = 11.85; spouses: 41% females, average age = 57.32 years, SD = 12.15)., Results: Overall, both patients and spouses reported important consequences of pain on outcomes, including occupational status distribution of household chores and marital satisfaction). Almost 52% of spouses indicated a high-to-severe burden. A multivariate model with spouse and patient factors accounted for 37.8% of the variance of this burden. In the model, patient disability (β = 0.36, p = .002), spouses' change in occupational status (β = 0.26, p = .002) and spousal perception of marital adjustment (β = -0.36, p < .001) were uniquely associated with burden., Conclusions: The results indicate that the impact of chronic pain should be evaluated both for patients and spouses and point to patient and spouse factors that might contribute to spousal burden, which might help guide family interventions in a more effective manner., Significance: Research has shown that chronic pain poses a significant burden on individuals, which increases their reliance on others for assistance. However, the burden of informal care-giving assumed by spouses of patients with chronic pain has not been systematically investigated. This study offers new insights into the impact of chronic pain on patients and their spouses, which might provide empirical foundation for the development of new avenues for intervention aimed at promoting adjustment in patients with chronic pain and spouses who act as informal caregivers., (© 2020 European Pain Federation - EFIC®.)

Background: The usefulness of mHealth in helping to target face-to-face interventions for chronic pain more effectively remains unclear. In the present study, we aim to test whether the Pain Monitor mobile phone application (app) is well accepted by clinicians, and can help improve existent medical treatments for patients with chronic musculoskeletal pain. Regarding this last goal, we compared three treatment conditions, namely usual treatment, usual treatment with an app without alarms and usual treatment with an app with alarms. All treatments lasted one month. The three treatments were compared for all outcomes, i.e., pain severity and interference, fatigue, depressed mood, anxiety and anger., Methods: In this randomized controlled trial, the usual monitoring method (i.e., onsite; n = 44) was compared with daily ecological momentary assessment using the Pain Monitor app-both with ( n = 43) and without alarms ( n = 45). Alarms were sent to the clinicians in the presence of pre-established undesired clinical events and could be used to make treatment adjustments throughout the one-month study., Results: With the exception of anger, clinically significant changes (CSC; 30% improvement) were greater in the app + alarm condition across outcomes (e.g., 43.6% of patients experienced a CSC in depressed mood in the app + alarm condition, which occurred in less than 29% of patients in the other groups). The clinicians were willing to use the app, especially the version with alarms., Conclusions: The use of apps may have some benefits in individual health care, especially when using alarms to tailor treatments.

Background: Fibromyalgia (FM) is a prevalent and highly disabling chronic pain syndrome. However, differences among patients regarding how pain impacts on daily life are remarkable. The main aim of this study was to identify clinical and pain-related cognitive variables characterizing patients reporting high adaptability despite experiencing severe chronic pain., Methods: Two hundred and eighty-three Spanish patients with FM with high levels of pain were classified into 2 groups: (1) those reporting low impact of the syndrome, and (2) those with moderate-to-high impact. Perceived stress, anxiety, and depressive symptoms along with pain catastrophizing, psychological inflexibility, and perceived control over pain were evaluated. Differences in sociodemographics, years with FM, past/current major depressive disorder comorbidity, and health-related economic costs (ie, medications, use of medical services, lost productivity due to sick leave) were also assessed. Stepwise logistic regression analyses predicting group membership from clinical variables and pain-related cognitive processes as predictors were performed., Results: Lower stress, anxiety, and depressive symptoms, along with reduced pain catastrophism, psychological inflexibility, and perceived control over pain, were found in the low-impact group. Significant predictors of group membership (low-impact vs. moderate-to-high impact) in regression analyses were "cognitive fusion" (psychological inflexibility), "helplessness" (pain catastrophizing), and depressive symptomatology, together with pain intensity and other FM symptoms., Conclusions: The present study provides further evidence on resilience resources in chronic pain by identifying some variables (ie, reduced depressive symptomatology, pain catastrophizing, and psychological inflexibility) differentially characterizing a profile of patients with FM who are especially able to adapt to high levels of pain., (© 2019 World Institute of Pain.)

Introduction: Chronic pain has become a matter of public health concern due to its high prevalence and because public costs associated with treatment and disability increase each year. Research suggests that limitations in the traditional assessment of chronic pain patients limit the effectiveness of current medical treatments. The use of technology might serve change patient traditional monitoring into ecological momentary assessments, which might be visualised by physicians live. This study describes a randomised control trial designed to test the utility of a technology-based solution for pain telemonitoring consisting of a smartphone app for patients and a web application for physicians. The goal of this study will be to explore whether this combination of eHealth and mHealth improves the effectiveness of existing pain treatments., Methods and Analysis: Participants will be 250 patients randomly assigned to one of these two conditions: treatment-as-usual (TAU) and TAU +app+ web. All participants will receive the usual treatment for their pain. Only the TAU +app+ web group use Pain Monitor app, which generates alarms that are sent to the physicians in the face of previously established undesired events. Physicians will be able to monitor app reports using a web application, which might result in an adjustment of treatment. We anticipate that the use of Pain Monitor plus the therapist web will result in a reduction of pain intensity and side effects of the medication. Improvements on secondary outcomes, namely fatigue, mood, pain interference, rescue medication use and quality of life, are also expected. Mixed repeated-measure multivariate analyses of variances will be conducted to investigate whether there are differences between preassessment and postassessment scores as a function of the experimental condition., Ethics and Dissemination: Ethical approval from the Hospital General Universitari de Castellon was obtained. The findings will be published in peer-reviewed journals., Trial Registration Number: NCT03606265., Competing Interests: Competing interests: The intellectual property of the Pain Monitor app is owned by coauthors CS-R, DC, IZ and AG-P., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Objectives: Social factors have demonstrated to affect pain intensity and quality of life of pain patients, such as social support or the attitudes and responses of the main informal caregiver. Similarly, pain has negative consequences on the patient's social environment. However, it is still rare to include social factors in pain research and treatment. This study compares patient and caregivers' accuracy, as well as explores personality and health correlates of empathic accuracy in patients and caregivers., Materials and Methods: The study comprised 292 chronic pain patients from the Pain Clinic of the Vall d'Hebron Hospital in Spain (main age = 59.4 years; 66.8% females) and their main informal caregivers (main age = 53.5 years; 51.0% females; 68.5% couples)., Results: Patients were relatively inaccurate at estimating the interference of pain on their counterparts (t = 2.16; p = 0.032), while informal caregivers estimated well the patient's status (all differences p > 0.05). Empathic accuracy on patient and caregiver status did not differ across types of relationship (i.e., couple or other; all differences p > 0.05). Sex differences in estimation only occurred for disagreement in pain severity, with female caregivers showing higher overestimation (t = 2.18; p = 0.030). Patients' health status and caregivers' personality were significant correlates of empathic accuracy. Overall, estimation was poorer when patients presented higher physical functioning. Similarly, caregiver had more difficulties in estimating the patient's pain interference as patient general and mental health increased (r = 0.16, p = 0.008, and r = 0.15, p = 0.009, respectively). Caregiver openness was linked to a more accurate estimation of a patient's status (r = 0.20, p < 0.001), while caregiver agreeableness was related to a patient's greater accuracy of their caregivers' pain interference (r = 0.15, p = 0.009)., Conclusions: Patients poorly estimate the impact of their illness compared to caregivers, regardless of their relationship. Some personality characteristics in the caregiver and health outcomes in the patient are associated with empathic inaccuracy, which should guide clinicians when selecting who requires more active training on empathy in pain settings., Competing Interests: The authors declare no conflict of interest to disclosure.

Objectives: Ecological momentary assessment has been recommended in the management of chronic pain. Smartphone apps might be a useful tool for that purpose. This goal of this study was to develop and test a multidimensional smartphone app for adults with chronic pain. A multidisciplinary team developed the app content after a series of meetings, considering clinical guidelines for pain measurement. The content included pain intensity and interference, fatigue, mood, perceived health status, activity level, side effects of the medication, use of rescue medication, and pain-related sychological constructs (catastrophizing, acceptance, fear, and coping)., Methods: Thirty-eight participants (21 to 59 y) used the app, called Pain Monitor, twice a day during 30 consecutive days. Patients completed a set of well-established measures at the beginning and end of the study via paper-and-pencil. Weekly phone assessments were also made for pain intensity, pain interference, fatigue, and mood., Results: Construct validity was revealed by moderate-to-strong correlations between app content and traditional measures. Feasibility was supported by high compliance (between 70% and 82%) and high acceptability and ease of use. Both side effects of the medication and use of rescue medication were found to be useful tools to guide treatment., Discussion: The new assessment protocol in the app allows for an easy and rapid multidimensional assessment of chronic pain patients.

Background: Past decades have seen a surge of studies investigating the role of spouses in chronic illness. The present study explored an interpersonal model of health-related quality of life in chronic pain settings. Spouse personality was tested as a moderator of pain intensity-to-health associations in patients with chronic pain., Methods: This is a cross-sectional study. Participants were 185 noncancer chronic pain patients and their spouses. Patients were mostly females (58.4%). Mean age was approximately 56 years for patients and spouses. Patients completed a measure of pain intensity, health-related quality of life, and personality. Spouses also reported on their personality characteristics. Spouse personality was used as the moderator in the relationship between patients' pain intensity and health status. Patient personality was used as a covariate in the moderation analyses., Results: Spouse neuroticism moderated the relationship between pain intensity and physical health status, while spouse introversion moderated the pain-to-mental health association., Conclusions: Results support the idea that the relationship between a chronic stressor, namely, chronic pain, and health-related quality of life may be complex and contextually determined by spousal characteristics. Clinical implications are discussed in the context of couples.

Background: Chronic pain has become a major health problem across the world, especially in older adults. Unfortunately, the effectiveness of medical interventions is modest. Some have argued that assessment strategies should be improved if the impact of medical interventions is to be improved. Ecological momentary assessment using smartphones is now considered the gold standard in monitoring in health settings, including chronic pain. However, to the best of our knowledge, there is no randomized controlled trial to show that telemonitoring using a smartphone app can indeed improve the effectiveness of medical treatments in adults with chronic pain. The goal of this study will be to explore the effects of using a smartphone app for telemonitoring adults with chronic pain., Methods: The study will be a randomized controlled trial with three groups: treatment as usual (TAU), TAU+app, and TAU+app+alarms. All groups will receive the adequate treatment for their pain, which will be prescribed the first day of study according to clinical guidelines. Assessment in the TAU group will be the usual at the Pain Clinic, that is, a paper-and-pencil evaluation at the onset of treatment (beginning of study) and at follow up (end of study, 30 days later). The other two groups (TAU+app and TAU+app+alarms) will be assessed daily using Pain Monitor, a smartphone app developed by our multidisciplinary team. Telemonitoring will only be made in the TAU+app+alarms group. For this group, physicians at the Pain Clinic may decide to adjust pain treatment in response to alarms. Telemonitoring is not the usual practice at the Pain Clinic and will not occur in the other two groups (TAU and TAU+app), so no changes in treatment are expected in these groups after the first appointment. The total sample size will be 150, with 50 patients in each group. The assessment protocol will be the same in all groups and will include pain intensity and side effects of the medication (primary outcomes), together with several pain-related variables like pain interference, activity level, use of rescue medication, pain catastrophizing, and pain acceptance, among others., Discussion: We believe that the present trial has important clinical implications. We think that telemonitoring using ecological momentary assessment is crucial to improve current interventions for pain. The armamentarium of available treatments for pain is large, so physicians can turn to different treatments or dosages in the presence of an undesired event. The use of the app for telemonitoring can allow for this rapid detection of unwanted events, thus improving patient safety (i.e., withdrawal of treatment causing side effects) and augmenting treatment effectiveness (i.e., changing an ineffective treatment or dosage). In a time when smartphones are a mainstream technology, we should take advantage of them in the promotion of health care., Trial Registration: ClinicalTrials.gov, NCT03247725 . Registered on 25 July 2017.

Pain catastrophizing is known to contribute to physical and mental functioning, even when controlling for the effect of pain intensity. However, research has yet to explore whether the strength of the relationship between pain catastrophizing and pain-related outcomes varies across pain intensity levels (i.e., moderation). If this was the case, it would have important implications for existing models of pain and current interventions. The present investigation explored whether pain intensity moderates the relationship between pain catastrophizing and pain-related outcomes. Participants were 254 patients (62% women) with heterogeneous chronic pain. Patients completed a measure of pain intensity, pain interference, pain catastrophizing, and physical and mental health. Pain intensity moderated the relationship between pain catastrophizing and pain interference and between pain catastrophizing and physical health status. Specifically, the strength of the correlation between pain catastrophizing and these outcomes decreased considerably as pain intensity increased. In contrast, pain intensity did not moderate the relationship between pain catastrophizing and mental health. Study findings provide a new insight into the role of pain intensity (i.e., moderator) in the relationship between pain catastrophizing and various pain-related outcomes, which might help develop existent models of pain. Clinical implications are discussed in the context of personalized therapy., Competing Interests: The authors declare no conflict of interests.

Introduction: Living with a patient with chronic pain is now known to have a negative impact on physical and mental health of the caregivers. Research indicates that adaptive coping strategies can reduce the burden that pain has on patients. Yet, it is unknown whether coping strategies can also affect the physical and mental health of the spouses of patients with chronic pain. In the present research, we investigated the role of coping strategies used by spouses of patients with pain in the relationship between the pain intensity of the patients and the physical and mental health of their spouses., Methods: The study comprised 195 heterosexual couples. About 41% of spouses were females., Results: Our results showed that being older, having a lower educational level, having a negative orientation toward problems, and using impulsive strategies to cope when in difficult situations contributed to poorer physical health of spouses. A poorer mental health status of spouses was associated with being negatively oriented toward problems, being a female, and being a caregiver of mentally distressed patient. In addition, it was found that the impulsive-careless coping strategy used by the spouses moderated the relationship between patients' pain severity and physical health of their spouses. At low levels of patients' pain intensity as rated by spouses, spouses reported similar levels of physical health irrespective of coping ratings. Conversely, at high levels of patients' pain intensity as rated by spouses, poorer physical health was reported by spouses scoring high on impulsive-careless coping., Discussion: Implications for clinical practice are discussed. Our findings suggest that screening for coping strategies used by spouses of patients with pain might complement clinical interventions aimed at promoting the physical and mental health of patients and their partners.

Despite several models of coping have been proposed in chronic pain, research is not integrative and has not yet identified a reliable set of beneficial coping strategies. We intend to offer a comprehensive view of coping using the social problem-solving model. Participants were 369 chronic pain patients (63.78% women; mean age 58.89 years; standard deviation = 15.12 years). Correlation analyses and the structural equation model for mental health revealed potentially beneficial and harmful problem-solving components. This integrative perspective on general coping could be used to promote changes in the way patients deal with stressful conditions other than pain., (© The Author(s) 2014.)

Among the potential range of irrational beliefs that could be used as predictors of physical and mental health, catastrophizing is the process that has received most attention in chronic pain research. Other irrational processes such as demandingness, low frustration tolerance, and self-downing have rarely been studied. The goal of this study was to explore whether this wider range of beliefs is associated with health in chronic pain patients beyond catastrophizing. A total of 492 chronic pain patients completed a measure of irrational beliefs, a measure of physical and mental health, and a numerical rating scale designed to assess pain intensity and interference. Irrational processes were more strongly associated with mental than with physical health. Low frustration tolerance and self-downing were found to be significantly related to mental health even after controlling for the effect of catastrophizing. Processes other than catastrophizing appear to have potentially important relationships with the mental health of people with chronic pain. These results may offer new intervention targets for practitioners.

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Purpose: Individuals with fibromyalgia and obesity experience significant impairment in physical functioning. Pain catastrophizing, kinesiophobia, and pain acceptance have all been identified as important factors associated with the level of disability. The objective of this study was to evaluate the role of pain catastrophizing, kinesiophobia, and pain acceptance as mediators of the association between perceived pain severity and physical functioning in individuals with fibromyalgia and obesity. Patients and Methods: In this cross-sectional study, 165 women with fibromyalgia and obesity completed self-report questionnaires of perceived pain severity (ie, Numeric Pain Rating Scale), pain catastrophizing (ie, Pain Catastrophizing Scale), kinesiophobia (ie Tampa Scale of Kinesiophobia), pain acceptance (ie, Chronic Pain Acceptance Questionnaire), and perceived physical functioning (ie, Physical Functioning subscale of the Fibromyalgia Impact Questionnaire). In addition, a performance-based test (ie, 6-minute walking test) was conducted to assess objective physical functioning. Two multiple mediation analyses were performed. Results: Pain acceptance and kinesiophobia mediated the relationship between pain severity and self-reported physical functioning. Pain catastrophizing and kinesiophobia mediated the relationship between pain severity and performance-based functioning. Conclusion: Pain acceptance, kinesiophobia, and pain catastrophizing should be addressed in rehabilitative intervention to improve physical functioning. Interestingly, the subjective and objective aspects of physical functioning are influenced by different factors. Therefore, interventions for women with fibromyalgia and obesity should focus on factors related to both subjective and performance-based physical functioning. [ABSTRACT FROM AUTHOR]

Impaired physical functioning is one of the most critical consequences associated with fibromyalgia, especially when there is comorbid obesity. Psychological factors are known to contribute to perceived (i.e., subjective) physical functioning. However, physical function is a multidimensional concept encompassing both subjective and objective functioning. The contribution of psychological factors to performance-based (i.e., objective) functioning is unclear. This study aims to investigate the contribution of pain catastrophizing and pain acceptance to both self-reported and performance-based physical functioning. In this cross-sectional study, 160 participants completed self-report measures of pain catastrophizing, pain acceptance, and pain severity. A self-report measure and a performance-based test were used to assess physical functioning. Higher pain catastrophizing and lower pain acceptance were associated with poorer physical functioning at both self-reported and performance-based levels. Our results are consistent with previous evidence on the association between pain catastrophizing and pain acceptance with self-reported physical functioning. This study contributes to the current literature by providing novel insights into the role of psychological factors in performance-based physical functioning. Multidisciplinary interventions that address pain catastrophizing and pain acceptance are recommended and might be effective to improve both perceived and performance-based functioning in women with FM and obesity. [ABSTRACT FROM AUTHOR]

Differences in fibromyalgia impact on functioning exist and appear to be influenced by numerous factors, including symptomatology severity, as well as the cognitive profile of the individual. The contribution of these elements, however, tends to be explored in a fragmented manner. To address this issue, we tested a comprehensive structural equation model in which associations of cognitive fusion and pain catastrophizing with function limitations are investigated through fibromyalgia symptomatology (i.e., fatigue, pain severity, and depression) in 231 women with fibromyalgia. In the model, cognitive fusion and two catastrophizing components (magnification and helplessness) were associated with poorer functioning indirectly through fibromyalgia symptomatology. Only the rumination component of catastrophizing had a direct association with functional limitations. All fibromyalgia symptoms were linked to increased functional limitations. A parsimonious model with significant associations only obtained an excellent fit (S-B χ2 = 774.191, df = 543, p < 0.001; CFI = 0.943; RMSEA = 0.043; CAIC = −2724.04) and accounted for 50% of the variance of functional limitations. These results suggest that the relationship between psychological cognitive processes, fibromyalgia symptomatology, and functional limitations is complex and support the need for comprehensive models such as the present. The findings are discussed in the context of personalized psychological treatments (i.e., the need to address certain cognitive processes according to the problematic symptomatology or outcome). [ABSTRACT FROM AUTHOR]