David Alan Williams - US grants

The proposed work seeks to understand the persisting association between socioeconomic status (SES) and morbidity and mortality in middle aged and older adults. It will examine the extent to which two psychosocial factors (social integration and health behaviors) are linked to SES and can explain SEs differentials in morbidity and mortality. The National Health and Nutrition Examination Surveys (NHANES) provide a unique opportunity to explore the determinants of SES variations in health status in a large, heterogeneous, nationally representative population. Secondary data analyses will utilize both cross-sectional morbidity data (of NHANESI, NHANESII and the Hispanic HANES) and the prospective morbidity and mortality data from the on-going follow-up of NHANESI participants. The size and scope of the population in the NHANES data will allow for careful analyses of the age patterning of SES differences in health status, as well as the assessment of sociocultural variations in the differential distribution and differential efficacy of psychosocial variables. The significance of this study must be assessed against the background of the extremely fragmentary evidence that is currently available about the causal dynamics that influence the SES gradient in morbidity and mortality in middle and late life.

DESCRIPTION (Adapted from applicant's abstract): This project will analyze existing national and regional population data to enhance our understanding of how racial minority status, socioeconomic status and stress combine with psychosocial risk factors and resources to affect the social distribution of psychiatric morbidity. The proposed research will consider in a more comprehensive way than has been done previously the extent to which major race-related stressful life events (self-reported discrimination), chronic ongoing perceptions of unfair treatment and racial belief systems combine with more traditional measures of stress and a broad range of social and psychological resources to affect mental health and to explain racial variation in health status. This work has the following specific aim: 1) To understand how race-related stressors, both chronic and acute, combine with other traditional measures of stress to affect mental health status; 2) To understand how discrimination is linked to socioeconomic status (SES) and social roles and can explain racial differences in mental health; 3) To identify possible casual priorities between mental health status and reports of racial/ethnic discrimination; 4) To understand how racial belief systems are linked to mental health; 5) To examine how various social and psychological resources for adapting to stress, such as social support, religious involvement, perceptions of mastery or control, self-esteem, John Henryism, and race-related resources (interracial contact, racial self-esteem), considered singly and in combination, affect perceptions of discrimination, other stress and health, and the relationships among them; and 6) To identify how varying responses to racial/ethnic discrimination are related to mental health status. The availability of these data provide an unprecedented opportunity to assess how specific characteristics limited to racial/ethnic status combine with socioeconomic status and psychosocial resources to affect the mental health of blacks and whites.

stress; racial /ethnic difference; prejudice; African American; steroid hormone metabolism; cortisol; coping; mental disorder diagnosis; cognition; community health services; mental health epidemiology; clinical research; interview; computer data analysis; human subject; questionnaires; saliva;

DESCRIPTION (Adapted from Applicant's Abstract): This proposal seeks five years of support for an epidemiologic survey of the prevalence and mental health consequences of torture in South Africa (SA). The study has seven specific aims: 1) To identify the prevalence and distribution of exposure to trauma during apartheid; 2) To estimate the mental health consequences of trauma exposure by studying the observed associations with appropriate use of targeted comparisons and statistical controls; 3) To study the effects of a series of hypothesized stress-diathesis variables in modifying the associations between stress exposure and mental health; 4) To examine the extent to which some coping resources that were originally protective of mental health during the years of apartheid are currently associated with poor mental health and heightened stress reactivity; 5) To investigate the impact of the Truth and Reconciliation Commission (TRC) on the mental health of South Africans; 6) To estimate the current prevalence and sociodemographic correlates of commonly occurring mental disorders in SA, the role impairments associated with these disorders, and adequacy of current treatment options; and 7) To study predictors of professional help-seeking among South Africans who currently have mental disorders. No nationally representative data exists on these issues in SA. The proposed study provides an unprecedented opportunity to enhance understanding of the mental health consequences of exposure to racial-political violence in the country of origin a short time after transition to majority rule. The project brings together an experienced multidisciplinary team with senior investigators that include the Dean of South Africa's National School of Public Health at MEDUNSA, the director of the first national survey of mental health in the United States, commissioners of the SA TRC, and survey research experts from the University of Michigan.

DESCRIPTION (provided by applicant): This program brings together a multidisciplinary set of faculty from sociology, psychology, health behavior and health education, and biostatistics to provide research training in Psychosocial Factors in mental Health and Illness. Predoctoral and Postdoctoral Fellows are drawn both from the social sciences and from epidemiology and related biomedical sciences. The Training Program involves three elements: (1) limited and focused academic coursework; (2) a weekly Program Seminar attended by all trainees and principal faculty; and (3) intensive on-the-job research experience with one or more of many ongoing studies and relevant datasets available at the Survey Research Center or the School of Public Health. Trainees continue to develop skills acquired in their own graduate programs prior to becoming part of this Training Program. At the same time, they acquire some exposure and competence in material from other disciplines involved in the Program that are relevant to social research on mental health and illness. The goal is to foster interdisciplinary collaboration by providing a sufficiently complete body of common knowledge that a forum of common discussion exists. The Program Seminar, as well as several formal courses, provides settings in which students integrate their competence into a truly interdisciplinary perspective on mental health. The research placements are selected in such a way that interdisciplinary collaboration is required of each trainee. Methodologically, the Program focuses on the link between survey research and experimental interventions. Substantively, the Program focuses on the role of psychosocial factors in the etiology, and course of mental health and illness, including the study of life events, chronic role strains, resources for adapting to potential stressors (e.g., social support, personal competence), and the actual process of coping and adaptation. Trainees who complete the Program are prepared for research careers in the government, private or academic sectors.

[unreadable] DESCRIPTION: Belief in ones ability to control pain through personal effort is associated with better pain management, higher functional status, and better long-term adherence to treatment regimens. While beliefs in pain control appear to be low and stable over time in patients with Fibromyalgia Syndrome (FMS), recent literature and our own pilot investigations suggest that these beliefs may be malleable through behavioral interventions. Theoretically, any change in belief will need to be predicated upon experiencing newfound personal control; thus patients must actually experience successful personal pain control before such beliefs can change. Relatedly, we possess pilot data using functional MRI (fMRI) suggesting that patients with FMS who espouse a strong internal versus external locus of pain control process painful stimuli differently in the cortical brain regions responsible for the experience of pain. To date no clinical studies have specifically focused on beliefs in pain control as a target of treatment nor have studies been conducted that seek the most parsimonious behavioral approach for modifying these beliefs. Similarly, no studies to date have explored whether changing beliefs in pain control will alter central pain processing. Using a randomized controlled design, the proposed study seeks to test the effectiveness of two single modality non-pharmacological methods for modifying beliefs in personal pain control in patients with FMS: prescribed aerobic fitness, and relaxation training. These interventions will be compared to a standard care control condition. Based upon previous literature, both of these interventions should provide a foundation of success experiences attributable to personal effort that would facilitate changing beliefs in pain control. We posit that both interventions will be superior to a standard care only control condition. Moreover, we intend to confirm and extend our pilot fMRI imaging findings suggesting that different neural networks are used by individuals with varying loci of pain control, and then demonstrate that individuals who, through therapy, change their locus of control also have changes in their fMRI patterns of central pain processing. These findings will add to the emerging information on affective and cognitive involvement in higher order pain processing and begin to explain the mechanisms involved in the effectiveness of non-pharmacological interventions that modify beliefs about control. [unreadable] [unreadable]

DESCRIPTION (provided by applicant): Existing methods for assessing disease status and responsiveness to treatment in Fibromyalgia (FM) have been criticized on the grounds that (a) existing patient reported outcomes measures (PROs) fail to adequately assess the domains of relevance to patients with FM, (b) most existing instruments have been borrowed from other diseases and thus disease-specific PROs are largely undeveloped for FM, and (c) many of the existing measures have unfavorable psychometric properties and/or lack sufficient sensitivity to change. Thus, there is need for new methodologically sound PROs for FM that can be delivered in a traditional manner in the short term and via the more sensitive and efficient methodology associated with computer adaptive testing (CAT) in the longer term. Lack of consensus regarding the relevant assessment domains for FM has prevented the development of meaningful multi-dimensional instruments for FM;but recent agreement between projects within the WHO ICF initiatives and within OMERACT suggests that the time is right to initiate this type of instrument development. To this end, this proposal contains four aims: In the first, focus groups of FM patients will be conducted by the National Fibromyalgia Association (NFA) so as to generate disease-specific items that can supplement the more generic chronic illness item banks being developed by the NIH roadmap initiative PROMIS. Aim two will field test the disease-specific items along with the PROMIS item banks in a large representative sample of FM patients recruited through the NFA. A series of validation studies will be conducted under Aim three so as to support the use of the new disease- specific scales for administration in clinical trials in a traditional manner. Finally, under aim four, a CAT algorithm utilizing the combined PROMIS and FM disease-specific items will be developed and field tested. The final goal of this project will be the integration of the new FM-CAT module into the PROMIS network. The investigators of this proposal are already actively collaborating with ICF, OMERACT, and PROMIS, have track records in successful outcomes measurement development and advanced quantitative methods and possess clinical expertise in FM. The products resulting from this project will have direct applicability and utility in clinical trials involving FM and represent the next critical steps in refining the ability to identify useful and meaningful treatments for this refractory condition. This project is relevant to public health as it will provide a disease-specific measurement instrument to use in clinical trials thus leading to more effective methods for assessment and treatment of Fibromyalgia.

Area; Auditory; Autoimmune; Autoimmune Process; Bladder; Brain; Brain region; Burning vulva; CNS processing; Care, Health; Caring; Central Lobe; Characteristics; Chronic Fatigue Disorder; Chronic Fatigue Syndrome; Chronic Fatigue and Immune Dysfunction Syndrome; Chronic Fatigue-Fibromyalgia Syndrome; Clinical; Clinical Evaluation; Clinical Testing; Code; Coding System; Colitis, Mucous; Colon, Irritable; Condition; Control Groups; Diagnosis; Diagnostic Findings; Diffuse; Diffuse Myofascial Pain Syndrome; Discomfort of Vulva; Disease; Disorder; Distress; Drugs; Elements; Encephalomyelitis, Myalgic; Encephalon; Encephalons; Epidemiologic Research; Epidemiologic Studies; Epidemiological Studies; Epidemiology Research; Esthesia; Evaluation; Factors, Psychological; Fatigue; Female; Fibromyalgia; Fibromyositis-Fibromyalgia Syndrome; Fibrositis; Frequencies (time pattern); Frequency; Functional Imaging; Functional Magnetic Resonance Imaging; Headache, Migraine; Healthcare; Heating; Imaging Procedures; Imaging Techniques; Individual; Infectious Mononucleosis-Like Syndrome, Chronic; Inferior; Inflammatory; Insula; Insula of Reil; Irritable Bowel Syndrome; Island of Reil; Lack of Energy; Lead; Left; Link; Loudness; Low Back Ache; Low Back Pain; Low Backache; Lumbago; MPD syndrome; MR Imaging; MR Tomography; MRI; MRI, Functional; Magnetic Resonance Imaging; Magnetic Resonance Imaging Scan; Magnetic Resonance Imaging, Functional; Measures; Medical Imaging, Magnetic Resonance / Nuclear Magnetic Resonance; Medical Records; Medication; Method LOINC Axis 6; Methodology; Methodology, Research; Methods; Methods and Techniques; Methods, Other; Michigan; Migraine; Morbidity; Morbidity - disease rate; NMR Imaging; NMR Tomography; Nerve Cells; Nerve Unit; Nervous; Nervous System, Brain; Neural Cell; Neurobiology; Neurocyte; Neurons; Neurosciences; Nociception; Nuclear Magnetic Resonance Imaging; Numbers; Outcome; Pain; Pain Threshold; Pain Tolerance Level; Painful; Participant; Patient Self-Report; Patients; Pb element; Pharmaceutic Preparations; Pharmaceutical Preparations; Phenotype; Physiologic Imaging; Population; Postviral Fatigue Syndrome; Pressure; Pressure- physical agent; Procedures; Process; Psychological Factors; Psychology, Physiologic; Psychology, Physiological; Psychophysiological; Psychophysiology; Rate; Recruitment Activity; Reporting; Research; Research Methodology; Research Methods; Response to stimulus physiology; Rheumatism, Muscular; Royal Free Disease; Sampling; Self-Report; Sensation; Sensory; Sensory Process; Signs and Symptoms; Site; Stimulus; Structure; Symptoms; Syndrome; TMJ Diseases; TMJ Disorders; TMJD; Technics, Imaging; Techniques; Temporo-mandibular joint disorder; Temporomandibular Disorders; Temporomandibular Joint Diseases; Temporomandibular Joint Disorders; Temporomandibular joint disorder; Test Result; Testing; Urinary System, Bladder; Urologist; Urology; Vulval discomfort; Vulvar discomfort; Vulvodynia; Woman; Zeugmatography; auditory stimulus; base; central nervous system processing; central pain; chronic pain; chronic painful condition; chronic pelvic pain; chronic pelvic pain syndrome; clinical test; cortical pain; disease/disorder; drug/agent; experiment; experimental research; experimental study; fMRI; fibromyalgia syndrome; heavy metal Pb; heavy metal lead; myofascial pain dysfunction syndrome; neural; neural mechanism; neurobiological; neurobiological mechanism; neuroimaging; neuromechanism; neuronal; nociceptive; non-drug therapy; non-drug treatment; nondrug therapy; nondrug treatment; pain tolerance; perceptual stimulus; physicochemical phenomena related to the senses; pressure; psycho-physiological; psychologic; psychological; psychological distress; recruit; relating to nervous system; research clinical testing; research study; response; sensory integration; sensory stimulus; spastic colon; stimulus/response; tool; urinary bladder; urologic; urological

PROJECT SUMMARY / ABSTRACT PHENOTYPING AND OUTCOMES CORE (POC) The University of Michigan Fibromyalgia CORT proposes that presence of centralized pain will render individuals less responsive to analgesic therapies aimed at peripheral/nociceptive pain (surgery, biologics, opioids) and that this centralized pain phenotype has stereotypical clinical and neurobiological features similar to FM even when it is co-morbid with other musculoskeletal pain conditions with disparate underlying pain mechanisms. The Specific Aims of the CORT supported by the POC are as follows: 1) To demonstrate that the current 2011 FM Survey Criteria serve as a strong surrogate of pain centralization and strongly predict non- responsiveness to therapies generally effective for treating peripherally-based pain, including a) surgery intended to relieve pain (hip arthroplasty, carpal tunnel release), b) administration of a biologic agent to treat an autoimmune disorder (rheumatoid arthritis), and c) acute perioperative administration of opioids; 2) To demonstrate that in all three cohorts individuals with the highest FM scores will have similar neurobiological findings of pain centralization on quantitative sensory testing (QST) and neuroimaging; 3) To develop and pilot test a shorter and more predictive self-report measure of pain centralization; and 4) To explore the clinical and mechanistic features of two important subsets of centralized pain: top-down (i.e. previously termed primary FM) vs. bottom-up (i.e. previously termed secondary FM). Specifically, the POC will be responsible for the following: (1) Assessment of treatment outcomes for each treatment cohort, (2) Phenotyping/characterization of each patient cohort, the FM control group, and the healthy control group, (3) Development of a latent construct of centralized pain based upon self-report, QST, and neuroimaging findings, (4) Development and validation of a new clinically applicable measure of centralization, and (5) Exploration of two potential subtypes of centralization along with the development of self-report items that may assess those subtypes.

PROJECT SUMMARY / ABSTRACT Chronic spinal pain is associated with loss of function and significant disability. When spine pain is comorbid with fibromyalgia, symptom severity and disability are amplified. Interventions capable of improving functional status, reducing symptoms, and enhancing well-being are critically needed. Both medications and cognitive- behavioral therapy (CBT) have demonstrated similar, modest effects for reducing symptoms in chronic pain. Behavioral treatments for chronic pain like CBT act predominantly by decreasing negative states rather than by Resilience-based interventions target the enhancement of positive emotions and well-being rather than focusing solely on negative emotions and behaviors. Although relatively under-used in chronic pain populations, resilience-based interventions have been used successfully in other clinical settings including depression, cardiovascular disease, diabetes, and HIV. promoting positive states associated with resilience. Thus, adding resilience-enhancing strategies to CBT for pain holds promise for further enhancing the effectiveness of CBT. In addition, most current behavioral interventions require specialized training and as such are not widely available. Medical assistants (MAs) are well-positioned in the healthcare system to play a pivotal role in helping individuals with chronic pain improve their functional abilities through innovative self-management strategies. The MA-led self-management programs proposed herein leverage the unique training and capabilities of MAs, while considering minimizing costs and maintaining the flow of clinical practice. The benefits of resilience- enhanced CBT that targets increasing patient well-being are also expected to extend beyond pain to potentially include genomic effects. Telomere shortening is predictive of disease and mortality and is considered an index for premature cellular aging. Our pilot data suggest that in addition to age and other physical and psychological stressors, inadequately managed pain can also affect telomere attrition. Thus, in addition to demonstrating the efficacy of online CBT self-management with resilience-enhancing activities (CBTRE), this application seeks to evaluate the impact of CBTRE on telomere health. Our central hypothesis is that our MA-supported CBTRE program will demonstrate superior efficacy to standard MA-supported online CBT self-management (eCBT) alone (Aim 1) through the enhancement of well-being (Aim 2). Both the CBTRE and eCBT interventions will improve telomere health with greater benefits being attributable to the CBTRE condition due to the mediating benefits of well-being (Aim 3). Therefore, we will conduct a randomized controlled trial of 300 individuals with spinal pain who also meet fibromyalgia criteria to investigate the effectiveness of the CBTRE program in promoting functional status, improved symptoms, and genomic health using resources already in most medical settings (i.e., MAs). By demonstrating the ability of this self-management intervention to improve physical function, pain and other symptoms, as well as telomere health, we hope to improve the options available for the care of millions of people who suffer with chronic spinal pain.