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  • 1.
    Bauducco, Serena
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Flink, Ida
    Örebro University, School of Law, Psychology and Social Work.
    Boersma, Katja
    Örebro University, School of Law, Psychology and Social Work.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Preventing sleep deficit in adolescents: Long-term effects of a quasi-experimental school-based intervention study2019In: Journal of Sleep Research, ISSN 0962-1105, E-ISSN 1365-2869, article id e12940Article in journal (Refereed)
    Abstract [en]

    Adolescents are at risk of sleep deficit, which has serious consequences for their daytime functioning. However, school-based interventions to improve sleep have shown limited success. This might be due to the content of the programmes (e.g., not targeting central factors such as daytime stress and technology use) or because changes have not been captured due to a lack of long-term follow-ups. Hence, the aim of this study was to evaluate the long-term effects of a school-based sleep education curriculum including time-management training. The study used a quasi-experimental design. Participants were 3,622 adolescents (mean age 13.7, 48% girls); 286 were in the intervention group and 3,336 were followed as a natural control group. Data were collected before the intervention and at a 1-year follow-up. We divided participants into three groups according to baseline sleep duration (calculated from self-reported bed- and wake times, minus sleep onset latency): insufficient (<7 hr), borderline (7-8 hr) and adequate (>8 hr). Adolescents in the intervention group were ~2 times less likely to report insufficient sleep at follow-up as compared to controls. Sleep knowledge improved significantly in the intervention group but there were no changes in emotional sleep hygiene (e.g., bedtime worry) and perceived stress. Surprisingly, technology use increased and behavioural sleep hygiene worsened in the intervention group. Although the mechanisms of change need further investigation, the results of this study point to potential long-term benefits of school-based sleep programmes.

  • 2.
    Bauducco, Serena
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Flink, Ida
    Örebro University, School of Law, Psychology and Social Work.
    Jansson-Fröjmark, Markus
    Stockholm University, Stockholm, Sweden.
    Linton, Steven
    Örebro University, School of Law, Psychology and Social Work.
    Sleep duration and patterns in adolescents: Correlates and the role of daily stressors2016In: Sleep Health, ISSN 2352-7218, E-ISSN 2352-7226, Vol. 2, no 3, p. 211-218Article in journal (Refereed)
    Abstract [en]

    Objectives: The first aim of this study was to assess the prevalence of sleep deficit in a large sample of adolescents. Second, the study aimed to assess whether short sleep duration in the sample was associated with emotional and behavioral problems. Lastly, the study aimed to investigate the association between daily stressors-bedtime activities and sleep duration.

    Design: Cross-sectional survey.

    Setting: The questionnaires were completed during school hours in 17 municipal junior high schools in Sweden.

    Participants: A total of 2767 adolescents aged 12 to 16 years, 48% girls.

    Measurements and Results: Sleep measures included total sleep time (TST) for schooldays and weekends, obtained as combined measures of self-reported bed-time, wake-time, and sleep onset latency. We used the new National Sleep Foundation's guidelines to operationalize sleep duration. Overall 12% of younger adolescents (age 12-13 years) and 18% of older adolescents (14-16 years) slept less than recommended (TST < 7 hours). Adolescents reporting nonrecommended TST also reported more behavioral (ie, norm-breaking behaviors) and emotional problems (ie, depression, anxiety, and anger), with effects in the small-medium range. Finally, adolescents reporting bedtime arousal and use of information and communication technology in bed were more likely to report TST < 7 hours. Stress at home (for younger adolescents) and stress of school performance (for older adolescents) were also associated with TST less than 7 hours.

    Conclusions: The new National Sleep Foundation's recommendations were informative in this context. Future sleep interventions need to target barriers to good sleep practices, such as use of information and communication technology, stress, and worry that may contribute to arousal at bedtime.

  • 3.
    Bauducco, Serena
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Flink, Ida
    Örebro University, School of Law, Psychology and Social Work.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Making room for sleep: A classroom based prevention program for adolescents2016Conference paper (Other academic)
  • 4.
    Bauducco, Serena
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Flink, Ida
    Örebro University, School of Law, Psychology and Social Work.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Prevalence, Incidence and Risk Factors for Sleep Deprivation in Adolescence: The Role of Technology and Stress2016Conference paper (Other academic)
    Abstract [en]

    Aim: The first aim of this study was to describe the prevalence and incidence of poor sleep duration (<7 hours) over a one year period in a large sample of adolescents. The second aim was to inform prevention about the influence of adolescents´ social context on sleep duration. Therefore, we wanted to describe the longitudinal association between the use of Information and Communication Technology (ICT) at bedtime and daily stressors (e.g. school performance, family and peer issues) and poor sleep duration.

    Method: Participants were high school students in the 7th and 8th grade (N = 2505; age range: 12-15 years, at baseline) from 17 public schools in three communities in middle Sweden. Students filled out questionnaires in school during the spring, 2014 and one year later (85% retention rate). Sleep measures included bed time (BT), wake up time (WUT), and sleep onset latency (SOL). Total sleep time was calculated as, BT + WUT - SOL.

    We calculated prevalence, incidence, and chronicity of poor sleep duration. Moreover, the effect of ICT and daily stressors on future sleep duration was estimated with odds ratios, controlling for gender.

    Results: Prevalence (18.6%), incidence (12.8%) and chronicity (50%) rates indicate that poor sleep duration was persistent and increased one year later. Moreover, adolescents who often used ICT at bedtime (OR = 1.21, p < .001) and reported more school stress (OR = 1.16, p = .02), were more likely to report poor sleep duration one year later.

    Conclusion: Because poor sleep duration is common and persists over time, it is crucial to intervene early to prevent chronic sleep deprivation. Sleep interventions with younger adolescence, before chronicity occurs, should focus on barriers to change, such as stress and use of technology. The results from this study have been used to develop an early school-based intervention.

  • 5.
    Bauducco, Serena V.
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Flink, Ida K.
    Örebro University, School of Law, Psychology and Social Work.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Making room for sleep: The evaluation of a preventive school-based program to improve adolescents´ sleepManuscript (preprint) (Other academic)
  • 6.
    Bauducco, Serena V.
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Tillfors, Maria
    Örebro University, School of Law, Psychology and Social Work.
    Özdemir, Metin
    Örebro University, School of Law, Psychology and Social Work.
    Flink, Ida K.
    Örebro University, School of Law, Psychology and Social Work.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Too tired for school?: the effects of insomnia on absenteeism in adolescence2015In: Sleep Health, ISSN 2352-7218, E-ISSN 2352-7226, Vol. 1, no 3, p. 205-210Article in journal (Refereed)
    Abstract [en]

    Objectives: Sleep has important consequences for a person's daytime functioning. Numerous studies have shown that insomnia predicts work absenteeism and work disability in adults, but only a few studies have examined this association in adolescents. This study aims to explore whether symptoms of insomnia in adolescents predict school absenteeism 1 year later, over and above known psychological risk factors for absenteeism.

    Design: The study used a longitudinal design with 2 measurement points over 1 year.

    Setting: The students completed questionnaires during school hours at baseline and again at follow-up.

    Participants: Students in the 10th to 12th grades in a Swedish upper secondary school were followed prospectively for 1 year (age, 16-20 years; N = 353; 48.1% girls).

    Measurements and results: We used logistic regression analyses, controlling for the known effects of psychological factors, and arrived at a model elucidating the role of insomnia. That is, besides symptoms of insomnia, the model included previous absenteeism, alcohol intoxication, school-related social phobia, social anxiety, depressive symptoms, somatic symptoms, and bully victimization. Symptoms of insomnia predicted school absenteeism 1 year later, over and above known risk factors for absenteeism. Adolescents reporting severe symptoms of insomnia were almost 3 times more likely than adolescents reporting no or low symptoms to report problematic absenteeism 1 year later. We did not find any gender difference.

    Conclusions: Our findings underscore the importance of sleep problems on adolescents' daytime functioning as measured by school absenteeism. Therefore, sleep may be an important target for preventive interventions with adolescents.

  • 7.
    Bergbom, Sofia
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Flink, Ida K.
    Örebro University, School of Law, Psychology and Social Work.
    Boersma, Katja
    Örebro University, School of Law, Psychology and Social Work.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Early psychologically informed interventions for workers at risk for pain-related disability: does matching treatment to profile improve outcome?2014In: Journal of occupational rehabilitation, ISSN 1053-0487, E-ISSN 1573-3688, Vol. 24, no 3, p. 446-457Article in journal (Refereed)
    Abstract [en]

    Purpose: This randomized controlled trial had two main aims. The first aim was to investigate the effect of early preventive, psychologically informed, interventions for pain-related disability. The second aim was explore whether people who are matched to an intervention specifically targeting their psychological risk profile had better outcomes than people who were not matched to interventions.

    Methods: A total of 105 participants were recruited from their workplace, screened for psychological risk factors and classified as being at risk for long-term pain-related disability. They were subgrouped into one of three groups based on their psychological profile. Three behaviorally oriented psychological interventions were developed to target each of the three risk profiles. Half of the participants were assigned a matched intervention developed to target their specific profile, and half were assigned an unmatched intervention. After treatment, repeated measure ANOVAs and χ2 tests were used to determine if treatments had an effect on primary and secondary outcomes including perceived disability, sick leave, fear and avoidance, pain catastrophizing and distress, and if matched participants had better outcomes than did unmatched.

    Results: Treatments had effects on all outcome variables (effect sizes d ranging between 0.23 and 0.66), but matched participants did not have better outcomes than unmatched.

    Conclusions: Early, preventive interventions have an impact on a number of outcome variables but it is difficult to realize a matching procedure. More in-depth research of the process of matching is needed.

  • 8.
    Bergbom, Sofia
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Flink, Ida K.
    Örebro University, School of Law, Psychology and Social Work.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Boersma, Katja
    Örebro University, School of Law, Psychology and Social Work.
    Manual för KBT vid långvarig muskuloskeletal smärta2010Other (Other academic)
  • 9.
    Boersma, Katja
    et al.
    Örebro University, School of Law, Psychology and Social Work. Center for Health and Medical Psychology.
    Södermark, Martin
    Department of Medical and Health Sciences, Pain and Rehabilitation Centre, Linköping University, Linköping, Sweden.
    Hesser, Hugo
    Department of Behavioural Sciences and Learning, Division of Psychology, Linköping University, Linköping, Sweden.
    Flink, Ida
    Örebro University, School of Law, Psychology and Social Work.
    Gerdle, Björn
    Department of Medical and Health Sciences, Pain and Rehabilitation Centre, Linköping University, Linköping, Sweden.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work. Center for Health and Medical Psychology.
    Efficacy of a transdiagnostic emotion-focused exposure treatment for chronic pain patients with comorbid anxiety and depression: a randomized controlled trial2019In: Pain, ISSN 0304-3959, E-ISSN 1872-6623, Vol. 160, no 8, p. 1708-1718Article in journal (Refereed)
    Abstract [en]

    The comorbidity between chronic pain and emotional problems has proven difficult to address with current treatment options. This study addresses the efficacy of a transdiagnostic emotion-focused exposure treatment ("hybrid") for chronic pain patients with comorbid emotional problems. Adults (n = 115) with chronic musculoskeletal pain and functional and emotional problems were included in a 2-centre, parallel randomized controlled, open-label trial comparing this treatment to an active control condition receiving a guided Internet-delivered pain management treatment based on CBT principles (iCBT). The hybrid treatment (n = 58, 10-16 sessions) integrates exposure in vivo for chronic pain based on the fear-avoidance model with an emotion-regulation approach informed by procedures in Dialectical Behavior Therapy. The iCBT (n = 57; 8 treatment modules) addresses topics such as pain education, coping strategies, relaxation, problem solving, stress, and sleep management using standard CBT techniques. Patient-reported outcomes were assessed before and after treatment as well as at a 9-month primary end point. Across conditions, 78% participants completed post-treatment and 81% follow-up assessment. Intent-to-treat analyses showed that the hybrid had a significantly better post-treatment outcome on pain catastrophizing (d = 0.39) and pain interference (d = 0.63) and significantly better follow-up outcomes on depression (d = 0.43) and pain interference (d = 0.51). There were no differences on anxiety and pain intensity. Observed proportions of clinically significant improvement favoured the hybrid on all but one comparison, but no statistically significant differences were observed. We conclude that the hybrid emotion-focused treatment may be considered an acceptable, credible, and efficacious treatment option for chronic pain patients with comorbid emotional problems.

  • 10.
    Ekdahl, Johanna
    et al.
    Department of Psychology, Mid Sweden University, Östersund, Sweden.
    Flink, Ida
    Örebro University, School of Law, Psychology and Social Work.
    Engman, Linnea
    Örebro University, School of Law, Psychology and Social Work.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Vulvovaginal pain from a fear-avoidance perspective: a prospective study among female university students in Sweden2018In: International Journal of Sexual Health, ISSN 1931-7611, E-ISSN 1931-762X, Vol. 30, no 1, p. 49-59Article in journal (Refereed)
    Abstract [en]

    Objectives: To examine how fear-avoidance influences vulvovaginal pain and sexual function over time.

    Method: At baseline and at 10-month follow-up, self-report measures for sexual- and fear avoidance factors were obtained from 483 female university students with and without self-reported vulvovaginal pain.

    Results: Individuals with pain at both times reported lower sexual function, and higher levels of fear-avoidance compared to the pain-free group. Fear-avoidance beliefs predicted the occurrence of vulvovaginal pain at follow up and the level of pain intensity.

    Conclusion: The results points to the relevance of the components of the fear-avoidance model in vulvovaginal pain over time.

  • 11.
    Engman, Linnea
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Flink, Ida
    Örebro University, School of Law, Psychology and Social Work.
    Ekdahl, J.
    Department of Psychology, Mid Sweden University, Östersund, Sweden.
    Boersma, Katja
    Örebro University, School of Law, Psychology and Social Work.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Avoiding or enduring painful sex?: A prospective study of coping and psychosexual function in vulvovaginal pain2018In: European Journal of Pain, ISSN 1090-3801, E-ISSN 1532-2149, Vol. 22, no 8, p. 1388-1398Article in journal (Refereed)
    Abstract [en]

    Background: Recurring vulvovaginal pain is common, with evident effects on affected women's lives. Little is known about how affected women cope with painful sexual activities and how coping relates to pain intensity and psychosexual functioning over time. This prospective study explored the impact of avoidance and endurance on sexual function over time. Additionally, patterns of coping were studied on an individual level to increase knowledge about coping and its relation to psychosexual functioning.

    Methods: One hundred and seventeen women, 18-35years old, with recurring vulvovaginal pain answered questionnaires at two measurement points, five months apart, assessing avoidance and endurance coping, pain intensity and psychosexual functioning. A multiple regression model explored the predictive value of avoidance and endurance on sexual function over time. Cluster analyses investigated patterns of coping and stability within the clusters. These subgroups were compared on psychosexual outcomes.

    Results: Avoidance at baseline was the only significant predictor of sexual function five months later. Distinct and stable subgroups with different patterns of coping were identified, where avoidance and endurance coping were used both separately and combined. Women who both avoided and endured had the most unfavourable outcomes in terms of psychosexual functioning.

    Conclusions: Avoidance of sexual activities was related to reduced sexual function over time, which calls for attention and clinical interventions targeting avoidance. Additionally, women who both avoid and endure sexual activities despite pain possibly need tailored interventions, as women with this coping pattern reported the lowest levels of psychosexual functioning.

    Significance: In this prospective study, avoidance of sexual activities predicted sexual function over time, when controlling for pain intensity. Subgroups of women using distinct patterns of coping were identified. Those who both avoided and endured had the lowest levels of psychosexual functioning.

  • 12.
    Engman, Linnea
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Flink, Ida
    Örebro University, School of Law, Psychology and Social Work.
    Ter Kuile, Moniek
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    CBT group treatment for vulvovaginal pain with partner involvement: a single case experimental design pilot2018Conference paper (Refereed)
    Abstract [en]

    Background: Recurring pain in the vulvovaginal regional induced by touch or pressure is thought to be the most frequent cause of superficial dyspareunia in premenopausal women. Its prevalence is 7-15% in community samples and has a serious impact on couples sexual function, sexual satisfaction, general psychological well-being and overall quality of life.

    The last decade of research suggests that psychological factors, such as fear of pain, catastrophizing, and avoidance behavior may contribute to the maintenance and exacerbation of dyspareunia. Conventional cognitive behavioral therapy (CBT) interventions aim at reducing pain, restoring sexual function and improving the romantic relationship by targeting the thoughts, emotions, behaviors and couple interactions associated with the experience of dyspareunia. Furthermore, given the interpersonal sexual context in which dyspareunia is most often triggered, relationship factors is an important area to address.

    Research Questions: The primary purpose is to evaluate whether a CBT group program with partner involvement improves pain during penetration in women with superficial dyspareunia. Secondary objectives are to evaluate women’s (and their partner’s) sexuality (sexual function & satisfaction), psychological adjustment (negative and positive penetration beliefs, pain coping behaviour) and relationship factors (relationship satisfaction). 

    Methods: The current study consists of a CBT group treatment program of 10 group sessions and 3 individual couple sessions distributed over a period of 6 months. The study will employ a single case experimental design with multiple baselines (N=6) where each individual represents a case and is randomized to a specific length of baseline. The primary and secondary outcomes will be measured weekly through both baseline and treatment phase to enable investigation of changes in outcome between the two phases. Additionally, secondary outcomes for both women and their partners are measured pre- and post-treatment. Single case experimental designs are recommended as a first step to investigate individual responses to psychological interventions as well as testing interventions as a pilot before implementing treatments in extensive RCT studies (Morley, 2017).

    Results: Data collection is in progress and will be completed early June 2018. The results of the study will be presented at the conference.

  • 13.
    Engman, Linnea
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Flink, Ida
    Örebro University, School of Law, Psychology and Social Work.
    Thomtén, Johanna
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Avoiding or enduring painful sex?: A longitudinal study of coping patterns and sexual function in women with vulvovaginal pain2017In: SSTAR (Society for Sex Therapy and Research) 42nd annual meeting, 2017Conference paper (Refereed)
    Abstract [en]

    Introduction: Recurring pain in the vulvar- or vaginal region induced by touch or pressure is common, affecting between 10-28% of women in reproductive age (e.g., Harlow et al., 2014). In addition to evident negative effects on sexual aspects such as frequency of sexual activity, sexual satisfaction and sexual function (for a review see Bergeron et al., 2015), vulvovaginal pain has an impact on women’s overall quality of life (Arnold et al., 2006). Despite these extensive consequences little is known about how women with vulvovaginal pain actually cope with sexual activities and the subsequent pain, and how their coping may affect the pain experience and sexual function over time. While avoidance (of pain associated activities) seem to be a commonly used strategy (for a review see Thomtén and Linton, 2013) amongst women with vulvovaginal pain, there is also evidence of endurance (of sexual activity despite pain) as a prevalent strategy (Brauer et al., 2014; Elmerstig et al., 2013).

     

    Method: The study used questionnaire data from female university students between 18 and 35 years old, with two measurement points of five months apart. Women who reported experiencing recurring vulvovaginal pain during the last six months, and who responded at both measurement points constitute the sample of the study (N=117). First, multiple regression analysis was executed to test whether avoidance and endurance coping had a predictive value of sexual function beyond the pain experience in itself. Then, cluster analyses based on the respondent’s answers to the CHAMP Sexual Pain Coping Scale (CSPCS) were performed at both time points. Finally, common pathways over time was investigated to explore whether the same coping was used at baseline and follow-up.

     

    Results: The multiple regression model exploring if pain, avoidance and endurance at baseline predicted sexual function at follow-up was significant, explaining 25% of the variance (F(2, 90) = 10.22, p < .001). Avoidance at baseline was the only significant predictor in the model, explaining unique variance of sexual function over time. The cluster analyses at baseline and follow up resulted in four distinct clusters respectively; Low scores, Avoidance, Endurance and High scores. The common pathways analyses, exploring typical pathways of change, revealed high stability within the clusters over time meaning that it was common for individuals in all clusters to use the same patterns of coping at both measurement points.

     

    Discussion: The results of the study further manifests findings from earlier research while also making an important attribution in quantifying coping strategies in relation to vulvovaginal pain. The study reveals a strong association between vulvovaginal pain and how women cope with sexual activities, the stability of the use of coping over time, as well as the connection between coping and sexual function.

     

    Utility/Limitations/Risks: Further knowledge about the relationship between coping and vulvovaginal pain will provide important theoretical and clinical implications regarding the development of the pain as well as potential clinical interventions.

     

    Behavioral learning objectives:

    After attending this poster presentation, the participants will be able to:

    1. Recognize the importance of avoidance coping in relation to sexual function

    2. Discuss the use of avoidance and endurance coping as a combined pattern

    3. Identify the stability of the use of coping patterns over time

     

    References:

    Arnold, L. D., Bachmann, G. A., Kelly, S., Rosen, R., & Rhoads, G. G. (2006). Vulvodynia: characteristics and associations with co-morbidities and quality of life. Obstetrics and gynecology, 107(3), 617.

     

    Bergeron, S., Corsini-Munt, S., Aerts, L., Rancourt, K., & Rosen, N. O. (2015). Female sexual pain disorders: a review of the literature on etiology and treatment. Current Sexual Health Reports, 7(3), 159-169.

     

    Brauer, M., Lakeman, M., Lunsen, R., & Laan, E. (2014). Predictors of task‐persistent and fear‐avoiding behaviors in women with sexual pain disorders. The journal of sexual medicine, 11(12), 3051-3063.

     

    Elmerstig, E., Wijma, B., & Swahnberg, K. (2013). Prioritizing the partner’s enjoyment: a population-based study on young Swedish women with experience of pain during vaginal intercourse. Journal of Psychosomatic Obstetrics & Gynecology, 34(2), 82-89.

     

    Harlow, B. L., Kunitz, C. G., Nguyen, R. H., Rydell, S. A., Turner, R. M., & MacLehose, R. F. (2014). Prevalence of symptoms consistent with a diagnosis of vulvodynia: population-based estimates from 2 geographic regions. American journal of obstetrics and gynecology, 210(1), 40-e1.

     

    Thomtén, J., & Linton, S. J. (2013). A psychological view of sexual pain among women: applying the fear-avoidance model. Women’s Health, 9(3), 251-263.

     

  • 14.
    Engman, Linnéa
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Flink, Ida
    Örebro University, School of Law, Psychology and Social Work.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Thomtén, Johanna
    Psykologiska institutionen, Mittuniversitetet, Östersund, Sweden.
    When sex hurts: Avoid, endure or try something different?2016In: IASR 42nd annual meeting, 2016Conference paper (Refereed)
    Abstract [en]

    Rationale/Background: Recurring vulvovaginal pain is a common problem among women, affecting between 8-30 % of women in reproductive age.  In addition to evident negative effects regarding sexual activities, -function and -satisfaction, vulvovaginal pain also has an impact on the individual’s daily life as well as overall quality of life. Despite these extensive consequences little is known about how women with vulvovaginal pain actually cope with sexual activities and the subsequent pain.

    Research Questions: The study aims to explore how women with vulvovaginal pain cope with sexual activities that has an impact on their pain, and whether certain ways to cope are more or less adaptive in regards to a spectrum of psychosexual aspects.

    Methods: The study is based on a student sample of women between 18 and 35 years old with recurring vulvovaginal pain (N=289). The CHAMP Sexual Pain Coping Scale (CSPCS) was created to measure coping behaviors among women with vulvovaginal pain. The scale was based on previous qualitative research where three apparent patterns of coping strategies has emerged; avoidance-, endurance- and alternative coping. Based on how the women responded to the avoidance- and endurance subscales of the CSPCS, cluster analysis resulted in four distinct groups of women with different profiles of coping. The coping subgroups were then compared in regards to several psychosexual factors.

    Results: The results showed that women suffering from vulvovaginal pain cope with sexual activities and the subsequent pain in different ways. Women who showed a pattern of high avoidance and endurance coping strategies reported significantly higher levels of pain, lower sexual function, less sexual satisfaction and lower quality of life. In contrast, women who reported low levels of avoidance and endurance coping strategies showed significantly lower levels of pain, higher sexual function, as well as a higher satisfaction with their sex life and life in general.

    Conclusions: The results of the study further manifests findings from earlier research while also making an important attribution in quantifying coping strategies in relation to vulvovaginal pain. Causal conclusions can not be drawn since the study is based on cross-sectional data. Hence, there is no knowledge to whether the coping strategy is a result of the individual’s current pain level or if the coping has an effect on the pain and associated psychosexual aspects. However, the study clearly reveals a strong association between vulvovaginal pain and how women cope with sexual activities. Future knowledge about this relationship will provide important theoretical and clinical implications regarding the development of the pain as well as potential clinical interventions.

  • 15.
    Engman, Linnéa
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Flink, Ida
    Örebro University, School of Law, Psychology and Social Work.
    Thomtén, Johanna
    Psykologiska institutionen, Mittuniversitetet, Östersund, Sweden.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    A longitudinal study of coping strategies in women with vulvovaginal pain2016In: EABCT 2016, The European Association for Behaviour and Cognitive Therapies , 2016Conference paper (Refereed)
    Abstract [en]

    Introduction: Recurring vulvovaginal pain is common, affecting between 8-30 % of women in reproductive age.  In addition to evident negative effects regarding sexual function and -satisfaction, vulvovaginal pain also has an impact on sufferers overall quality of life. Despite these extensive consequences little is known about how women with vulvovaginal pain actually cope with pain-triggering sexual activities. Knowledge about coping strategies in this area would give important clinical implications in both creating and targeting effective treatment interventions.

    Aims: The study aims to explore if the use of coping strategies in relation to pain-triggering sexual activities are stable over time, or if different strategies are used dependent of pain level or situation. A further aim is to explore the relationship between coping and a spectrum of psychosexual aspects over time.

    Method. The study consists of a student sample of women between 18-35 years old with recurring vulvovaginal pain who responded to a questionnaire at three separate time points (Base line: N=289; 6 months: N=153; 12 months: N= 126). Based on the CHAMP Sexual Pain Coping Scale (CSPCS), which measures avoidance- and endurance coping, cluster analysis was performed to group participants into distinct subgroups of individuals who reported similar coping strategies. The same procedure was performed at each assessment point to explore whether the individuals moved between the subgroups. Lastly the subgroups were compared in regards to several psychosexual factors.

    Discussion. The results will be discussed at the presentation when analyses are completed.

  • 16.
    Flink, Ida
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Boersma, Katja
    Örebro University, School of Law, Psychology and Social Work.
    Klein-Strandberg, Ester
    School of Law, Psychology and Social Work, Örebro University, Sweden.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Responding to social cues: An experimental paradigm exploring the link between context sensitivity and pain2019In: British Journal of Health Psychology, ISSN 1359-107X, E-ISSN 2044-8287, Vol. 24, no 2, p. 443-459Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: The term context sensitivity refers to whether a response is in tune with the ever changing demands of the context, while insensitivity is the lack of responding to these cues. To date, we know little about how well patients with pain respond emotionally to changes in the cues provided by the social context, that is, how emotionally context (in)sensitive they are and if this is related to problem severity. The aim of this experimental study was to test a method for determining levels of context sensitivity in individuals with subacute and chronic pain and to explore the link between context (in)sensitivity and pain-related problems. We operationalized context (in)sensitivity as participants' emotional responses (observed facial expressions and self-reported affect) and pain bothersomeness in these contexts and explored the association between these context-(in)sensitive social-emotional responses and pain-related problems.

    METHODS: Sixty-two participants with pain were cued to talk openly about three different topics consecutively in a counterbalanced order: (1) their pain, (2) a negative non-pain topic, and (3) a positive non-pain topic. We measured the participants' emotional responses (observed facial expressions and self-reported affect) and pain bothersomeness across these contexts and explored the effect of social-emotional responding on pain-related problems.

    RESULTS: The results showed that, irrespective of individuals' baseline levels of pain bothersomeness, positive affect, and negative affect, those who reacted with more negative affect and pain bothersomeness when prompted to discuss a positive topic had higher levels of pain-related problems. Moreover, those who showed more negative facial expressions and pain bothersomeness when prompted to discuss a negative non-pain topic also had higher levels of pain-related problems.

    CONCLUSIONS: These findings highlight a link between sensitivity to the social context and the severity of a pain problem. We showed that individuals with greater problem severity were less sensitive to social cues in their emotional responses, as compared to individuals with less pain-related problems. As predicted, context-insensitive responding appears to be most strongly associated with pain-related problems when dealing with negative emotions. Although the cross-sectional nature of the study prohibits causal conclusions, our findings demonstrate a link and future research is clearly needed to unravel the role of context sensitivity in the development of pain over time.

    Statement of contributionWhat is already known on this subject?

    • Responding to social cues seems to be important for adaptation to pain. The term context sensitivity refers to whether a response is in tune with the provided social cue. To date, we know little about how well patients with persistent pain respond emotionally to changes in the social context, that is, how context (in)sensitive they are and if this is linked to problem severity.

    What does this study add?

    • A test of a method for determining levels of context sensitivity in individuals with persistent pain.
    • Information about to what extent individuals with chronic pain respond context sensitively.
    • Knowledge on the link between social context sensitivity and level of pain problems.
  • 17.
    Flink, Ida K.
    Örebro University, School of Law, Psychology and Social Work.
    Stuck in mind: the role of catastrophizing in pain2011Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Pain catastrophizing emerges in the literature as one of the most important psychological determinants of both pain itself and the negative outcomes commonly associated with it. However, despite decades of research confirming the impact of catastrophizing, there are still areas that remain unexplored or in which the surface has only been scratched. The overall aim of this dissertation was to expand existing knowledge about catastrophizing and to advance the theoretical framework around the concept.

    The role of catastrophizing was explored in three distinct areas: during pain in childbirth, in exposure treatment for back pain patients, and in a problem solving context. The findings from the three studies confirmed the vital role of catastrophizing in these areas. Firstly, catastrophizing played a critical role in pain in childbirth; women who catastrophized reported labor pain as more intense and the subsequent recovery period as longer than women who did not catastrophize. Secondly, catastrophizing was identified as a moderator of treatment effect in exposure in vivo for back pain patients with pain-related fear; patients who catastrophized were not helped by the exposure. Thirdly, catastrophizing played a role in a problem solving context; although this is in line with contemporary models such as the misdirected problem solving model, the results suggested a somewhat different pathway to this previous model. Taken together, these findings underscore the instrumental role of catastrophizing in diverse areas and imply a need for catastrophzing to be assessed and addressed in clinical contexts. In addition, the findings highlight a need for further development of the theoretical framework around catastrophizing as well as treatment interventions that directly target catastrophizing. Based on these needs, a new model of catastrophizing was proposed – a model of catastrophizing from a process perspective. In this model, the proposed function of catastrophizing is to down-regulate negative affect, as a form of internal avoidance. The model is a complement to existing theoretical models and provides a framework for developing treatment interventions that directly target catastrophizing, for example by problem solving skills training. Successful interventions for people who catastrophize would lead to several gains – for the individual in less suffering and increased ability to handle pain problems, and for society as a whole in reduced costs for health care for these individuals.

    List of papers
    1. Pain in childbirth and postpartum recovery: the role of catastrophizing
    Open this publication in new window or tab >>Pain in childbirth and postpartum recovery: the role of catastrophizing
    2009 (English)In: European Journal of Pain, ISSN 1090-3801, E-ISSN 1532-2149, Vol. 13, no 3, p. 312-316Article in journal (Refereed) Published
    Abstract [en]

    This prospective study investigated how pain catastrophizing was related to labor pain intensity and physical recovery after childbirth. Eighty-eight women giving birth for the first time completed the first questionnaire before delivery. Eighty-two of those returned the second questionnaire after delivery. Participants were classified as catastrophizers (n=38) or non-catastrophizers (n=44) based on their scores on the Pain Catastrophizing Scale. Comparison of the groups showed that catastrophizers anticipated and experienced more intense pain (p<.0125) and had poorer physical recovery (p<.0125), measured as the level of self-reported functioning in activities of daily living, than non-catastrophizers. These results extend the association between catastrophizing and pain, to pain and recovery in childbirth and provide support for the fear-avoidance model. It is concluded that pain catastrophizing plays a role in the experience of pain in childbirth and postpartum recovery. Further research is needed to identify appropriate interventions for catastrophizing women during the latter part of pregnancy.

    Place, publisher, year, edition, pages
    Amsterdam: Elsevier, 2009
    National Category
    Psychology
    Research subject
    Psychology
    Identifiers
    urn:nbn:se:oru:diva-5886 (URN)10.1016/j.ejpain.2008.04.010 (DOI)000264243300013 ()18515162 (PubMedID)
    Available from: 2009-03-02 Created: 2009-03-02 Last updated: 2017-12-13Bibliographically approved
    2. Catastrophizing moderates the effect of exposure in vivo for back pain patients with pain-related fear
    Open this publication in new window or tab >>Catastrophizing moderates the effect of exposure in vivo for back pain patients with pain-related fear
    2010 (English)In: European Journal of Pain, ISSN 1090-3801, E-ISSN 1532-2149, Vol. 14, no 8, p. 887-892Article in journal (Refereed) Published
    Abstract [en]

    This investigation was an initial attempt to explore psychological factors that might help or hinder the effect of exposure in vivo for patients with musculoskeletal pain and pain-related fear. The study was based on data from a randomized-controlled trial for patients with non-specific spinal pain (Linton et al., 2008).

    First, catastrophizing, anxiety, and depression were studied as possible treatment moderators. We found evidence that catastrophizing was a moderator of treatment outcome in exposure. When further exploring the nature of the relationship between catastrophizing and outcome, the results showed that the exposure was effective only for patients with low or moderate levels of catastrophizing. High catastrophizers did not improve from the treatment. On the other hand, anxiety was a general predictor of poor outcome, and not a specific moderator of outcome in exposure. In contrast, depression was not significantly related to outcome.

    Next, patients were divided into high change participants and low change participants based on their improvement in disability after treatment in order to investigate the change in psychological variables during treatment. Descriptive data indicated that high change participants had large improvements across treatment on depression, anxiety, catastrophizing, and fear-avoidance beliefs whereas low change participants virtually did not change at all on these variables across treatment.

    These findings denote that catastrophizing is a moderator of treatment outcome in exposure whereas several psychological variables might be important for the treatment process

    National Category
    Psychology
    Research subject
    Psychology
    Identifiers
    urn:nbn:se:oru:diva-13430 (URN)10.1016/j.ejpain.2010.02.003 (DOI)000281141400017 ()
    Available from: 2011-01-11 Created: 2011-01-11 Last updated: 2018-02-23Bibliographically approved
    3. Understanding catastrophizing from a misdirected problem-solving perspective
    Open this publication in new window or tab >>Understanding catastrophizing from a misdirected problem-solving perspective
    2012 (English)In: British Journal of Health Psychology, ISSN 1359-107X, E-ISSN 2044-8287, Vol. 17, no 2, p. 408-419Article in journal (Refereed) Published
    Abstract [en]

    Objectives.  The aim is to explore pain catastrophizing from a problem-solving perspective. The links between catastrophizing, problem framing, and problem-solving behaviour are examined through two possible models of mediation as inferred by two contemporary and complementary theoretical models, the misdirected problem solving model (Eccleston & Crombez, 2007) and the fear-anxiety-avoidance model (Asmundson, Norton, & Vlaeyen, 2004).

    Design.  In this prospective study, a general population sample (n= 173) with perceived problems with spinal pain filled out questionnaires twice; catastrophizing and problem framing were assessed on the first occasion and health care seeking (as a proxy for medically oriented problem solving) was assessed 7 months later.

    Methods.  Two different approaches were used to explore whether the data supported any of the proposed models of mediation. First, multiple regressions were used according to traditional recommendations for mediation analyses. Second, a bootstrapping method (n= 1000 bootstrap resamples) was used to explore the significance of the indirect effects in both possible models of mediation.

    Results.  The results verified the concepts included in the misdirected problem solving model. However, the direction of the relations was more in line with the fear-anxiety-avoidance model. More specifically, the mediation analyses provided support for viewing catastrophizing as a mediator of the relation between biomedical problem framing and medically oriented problem-solving behaviour.

    Conclusion.  These findings provide support for viewing catastrophizing from a problem-solving perspective and imply a need to examine and address problem framing and catastrophizing in back pain patients.

    Place, publisher, year, edition, pages
    Wiley-Blackwell, 2012
    National Category
    Psychology
    Research subject
    Psychology
    Identifiers
    urn:nbn:se:oru:diva-19741 (URN)10.1111/j.2044-8287.2011.02044.x (DOI)000301175800011 ()22106932 (PubMedID)2-s2.0-84858025240 (Scopus ID)
    Available from: 2011-10-06 Created: 2011-10-06 Last updated: 2017-12-08Bibliographically approved
  • 18.
    Flink, Ida K.
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Bergbom, Sofia
    Örebro University, School of Law, Psychology and Social Work.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Boersma, Katja
    Örebro University, School of Law, Psychology and Social Work.
    Manual för exponering in vivo för rörelserädsla vid långvarig muskuloskeletal smärta2010Other (Other academic)
  • 19.
    Flink, Ida K.
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Boersma, Katja
    Örebro University, School of Law, Psychology and Social Work.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Catastrophizing moderates the effect of exposure in vivo for back pain patients with pain-related fear2010In: European Journal of Pain, ISSN 1090-3801, E-ISSN 1532-2149, Vol. 14, no 8, p. 887-892Article in journal (Refereed)
    Abstract [en]

    This investigation was an initial attempt to explore psychological factors that might help or hinder the effect of exposure in vivo for patients with musculoskeletal pain and pain-related fear. The study was based on data from a randomized-controlled trial for patients with non-specific spinal pain (Linton et al., 2008).

    First, catastrophizing, anxiety, and depression were studied as possible treatment moderators. We found evidence that catastrophizing was a moderator of treatment outcome in exposure. When further exploring the nature of the relationship between catastrophizing and outcome, the results showed that the exposure was effective only for patients with low or moderate levels of catastrophizing. High catastrophizers did not improve from the treatment. On the other hand, anxiety was a general predictor of poor outcome, and not a specific moderator of outcome in exposure. In contrast, depression was not significantly related to outcome.

    Next, patients were divided into high change participants and low change participants based on their improvement in disability after treatment in order to investigate the change in psychological variables during treatment. Descriptive data indicated that high change participants had large improvements across treatment on depression, anxiety, catastrophizing, and fear-avoidance beliefs whereas low change participants virtually did not change at all on these variables across treatment.

    These findings denote that catastrophizing is a moderator of treatment outcome in exposure whereas several psychological variables might be important for the treatment process

  • 20.
    Flink, Ida K.
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Boersma, Katja
    Örebro University, School of Law, Psychology and Social Work.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Changes in catastrophizing and depressed mood during and after early cognitive behaviorally oriented interventions for pain2014In: Cognitive Behaviour Therapy, ISSN 1650-6073, E-ISSN 1651-2316, Vol. 43, no 4, p. 332-341Article in journal (Refereed)
    Abstract [en]

    Catastrophizing and depressed mood are risk factors for poor outcome in treatments for pain and appear to act as mediators for favorable outcome. However, little is known about how catastrophizing and depressed mood co-occur within individuals and how these patterns change during treatment, which is the focus of the current study. The study uses data from a randomized controlled trial about early cognitive behaviorally oriented interventions for patients with nonspecific spinal pain (N = 84). Cluster analyses were used to extract subgroups of individuals with similar scoring patterns on catastrophizing and depressed mood at pretreatment, mid-treatment, posttreatment, and at 6 months' follow-up. To track individual progress, the clusters were linked over time. The analyses revealed four clusters: "low depression and catastrophizing", "high depression and catastrophizing", "high depression", and "high catastrophizing". There was little individual transition from one scoring pattern to another across time, not at least for those scoring high on both depressed mood and catastrophizing. Moreover, high stability within this cluster was related to low levels of psychological flexibility at baseline. It is concluded that catastrophizing and depressed mood at the start of treatment were likely to remain high despite a cognitive behavioral intervention and that a lack of psychological flexibility may have a role.

  • 21.
    Flink, Ida K.
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Boersma, Katja
    Örebro University, School of Law, Psychology and Social Work.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Pain catastrophizing as repetitive negative thinking: a development of the conceptualization2013In: Cognitive Behaviour Therapy, ISSN 1650-6073, E-ISSN 1651-2316, Vol. 42, no 3, p. 215-223Article in journal (Refereed)
    Abstract [en]

    Pain catastrophizing is a well-known concept in the pain literature and has been recognized as one of the most powerful psychological determinants of negative outcomes for pain problems. However, relatively little effort has been put into developing its theoretical underpinnings. More specifically, the intrinsic function of catastrophizing is not explicitly dealt with in contemporary theoretical models. The aim of this article is to add to existing models by proposing a development of the conceptualization of catastrophizing that stresses its function as an emotion regulator. We argue that catastrophizing can be conceptualized as a form of negative repetitive thinking, which is abstract, intrusive, and difficult to disengage from. It has been argued that repetitive negative thinking is a form of ineffective problem solving that functions to downregulate negative affect and that it can be regarded as an avoidant coping strategy because it impedes processing of emotional and somatic responses. Thus, in our conceptualization, catastrophizing is proposed to be a form of problem-solving behavior that functions to reduce negative emotion triggered by pain, and other related stimuli. Furthermore, we argue that catastrophizing is preferably regarded as a process where cognitions, emotions, and overt behavior are intertwined and not viewed as separate entities. To underscore the latter, we suggest the term catastrophic worry. Our intention with this development of the conceptualization is to give rise to new ideas for research and clinical practice and to revitalize discussions about the theoretical framework around pain-related catastrophizing.

  • 22.
    Flink, Ida K.
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Boersma, Katja
    Örebro University, School of Law, Psychology and Social Work.
    MacDonald, Shane
    Örebro University, School of Law, Psychology and Social Work.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Understanding catastrophizing from a misdirected problem-solving perspective2012In: British Journal of Health Psychology, ISSN 1359-107X, E-ISSN 2044-8287, Vol. 17, no 2, p. 408-419Article in journal (Refereed)
    Abstract [en]

    Objectives.  The aim is to explore pain catastrophizing from a problem-solving perspective. The links between catastrophizing, problem framing, and problem-solving behaviour are examined through two possible models of mediation as inferred by two contemporary and complementary theoretical models, the misdirected problem solving model (Eccleston & Crombez, 2007) and the fear-anxiety-avoidance model (Asmundson, Norton, & Vlaeyen, 2004).

    Design.  In this prospective study, a general population sample (n= 173) with perceived problems with spinal pain filled out questionnaires twice; catastrophizing and problem framing were assessed on the first occasion and health care seeking (as a proxy for medically oriented problem solving) was assessed 7 months later.

    Methods.  Two different approaches were used to explore whether the data supported any of the proposed models of mediation. First, multiple regressions were used according to traditional recommendations for mediation analyses. Second, a bootstrapping method (n= 1000 bootstrap resamples) was used to explore the significance of the indirect effects in both possible models of mediation.

    Results.  The results verified the concepts included in the misdirected problem solving model. However, the direction of the relations was more in line with the fear-anxiety-avoidance model. More specifically, the mediation analyses provided support for viewing catastrophizing as a mediator of the relation between biomedical problem framing and medically oriented problem-solving behaviour.

    Conclusion.  These findings provide support for viewing catastrophizing from a problem-solving perspective and imply a need to examine and address problem framing and catastrophizing in back pain patients.

  • 23.
    Flink, Ida K.
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Engman, Linnea
    Örebro University, School of Law, Psychology and Social Work.
    Ter Kuile, Moniek M.
    Department of Psychosomatic Gynaecology and Sexology, Leiden University Medical Center, Leiden, The Netherlands.
    Thomtén, Johanna
    Department of Psychology, Mid Sweden University, Östersund, Sweden.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Coping with pain in intimate situations: Applying the avoidance-endurance model to women with vulvovaginal pain2017In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 17, no October 2017, p. 302-308Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND AIMS: Chronic vulvovaginal pain is strikingly common and has a serious impact on women's lives. Nevertheless, there are few longitudinal studies focusing on mechanisms involved in the pain development. One area of interest is how women cope with sexual activities and how this affects their pain. In this study, avoidance and endurance coping behaviors were explored as possible mediators of the relation between catastrophizing and pain, cross-sectionally and longitudinally.

    METHODS: 251 women (18-35 years old) with vulvovaginal pain were recruited in university settings and filled out questionnaires about their pain, catastrophizing and coping behaviors at two occasions, with five months in between. Multiple mediation models were tested, exploring avoidance and endurance as mediators of the relation between catastrophizing and pain.

    RESULTS: The results showed that avoidance was an influential mediator of the link between catastrophizing and pain. Using multiple mediation models we found that although the indirect effects of both avoidance and endurance were significant cross-sectionally, only avoidance was a significant mediator in the combined model exploring associations over time.

    CONCLUSIONS: This study indicates that the strategies women with vulvovaginal pain use for coping with sexual activities are important for the course of pain. Avoidance and, to a lesser degree, endurance strategies were identified as important mediators of the effects of catastrophizing on pain. When exploring the links over time, only avoidance emerged as a significant mediator.

    IMPLICATIONS: In this longitudinal study, catastrophizing was linked to vulvovaginal pain, via avoidance and endurance of sexual activities. Hence, targeting catastrophizing early on in treatment, as well as addressing coping, may be important in clinical interventions.

  • 24.
    Flink, Ida K.
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Engman, Linnea
    Örebro University, School of Law, Psychology and Social Work.
    Thomten, Johanna
    Department of Psychology, Mid Sweden University, Östersund, Sweden.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    The role of catastrophizing in vulvovaginal pain: Impact on pain and partner responses over time2017In: Journal of applied biobehavioral research, ISSN 1071-2089, E-ISSN 1751-9861, Vol. 22, no 1, article id UNSP e12093Article in journal (Refereed)
    Abstract [en]

    The aim of this prospective study was to explore the role of catastrophizing in vulvovaginal pain. The study entails two research questions. The first question was whether catastrophizing predicts the occurrence of vulvovaginal pain. The second question focused on exploring the links between catastrophizing, partner responses and pain. Five hundred and ten women filled out questionnaires at two measurement points, 10months apart. The women were divided into three groups based on levels of catastrophizing. To study the first research question, the groups were used as predictors of pain at follow-up. To study the second research question, the groups were compared regarding their perceived solicitous partner responses. Subsequently, two mediation models were tested to explore whether catastrophizing mediated the relationship between solicitous partner responses and pain, cross-sectionally and longitudinally. Baseline levels of catastrophizing distinguished between pain and no pain 10months later. High catastrophizers reported higher levels of solicitous partner responses than low catastrophizers. The mediation analyses revealed catastrophizing as a significant mediator between solicitous partner responses and pain, cross-sectionally and over time. The findings support catastrophizing as being an important factor in women with vulvovaginal pain, cross-sectionally and over time.

  • 25.
    Flink, Ida K.
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Mroczek, Magdalena Z.
    Örebro University, School of Law, Psychology and Social Work.
    Sullivan, Michael J. L.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Pain in childbirth and postpartum recovery: the role of catastrophizing2009In: European Journal of Pain, ISSN 1090-3801, E-ISSN 1532-2149, Vol. 13, no 3, p. 312-316Article in journal (Refereed)
    Abstract [en]

    This prospective study investigated how pain catastrophizing was related to labor pain intensity and physical recovery after childbirth. Eighty-eight women giving birth for the first time completed the first questionnaire before delivery. Eighty-two of those returned the second questionnaire after delivery. Participants were classified as catastrophizers (n=38) or non-catastrophizers (n=44) based on their scores on the Pain Catastrophizing Scale. Comparison of the groups showed that catastrophizers anticipated and experienced more intense pain (p<.0125) and had poorer physical recovery (p<.0125), measured as the level of self-reported functioning in activities of daily living, than non-catastrophizers. These results extend the association between catastrophizing and pain, to pain and recovery in childbirth and provide support for the fear-avoidance model. It is concluded that pain catastrophizing plays a role in the experience of pain in childbirth and postpartum recovery. Further research is needed to identify appropriate interventions for catastrophizing women during the latter part of pregnancy.

  • 26.
    Flink, Ida K.
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Nicholas, Michael K.
    Boersma, Katja
    Örebro University, School of Law, Psychology and Social Work.
    Linton, Steven J.
    Örebro University, School of Health and Medical Sciences.
    Reducing the threat value of chronic pain: A preliminary replicated single-case study of interoceptive exposure versus distraction in six individuals with chronic back pain2009In: Behaviour Research and Therapy, ISSN 0005-7967, E-ISSN 1873-622X, Vol. 47, no 8, p. 721-728Article in journal (Refereed)
    Abstract [en]

    This paper describes a preliminary experimental evaluation of a technique intended to help people suffering from chronic back pain and low pain acceptance to alter the aversiveness or threat value of their persisting pain. Using a multiple baseline cross-over design six individuals with chronic back pain were taught to use a form of interoceptive exposure as well as a relaxation/distraction breathing-based technique in the presence of their pain. Half the participants used one method for three weeks, and then crossed over to the other method for a further three weeks. The other half did the reverse. Assessments were conducted at pre/post treatment and at a three month follow-up. Daily monitoring of pain-related distress was also completed. The results indicated moderately high improvements in pain acceptance across most participants and corresponding declines in pain-related distress. No clear differences occurred between conditions, but the changes on disability and catastrophising scales for most cases were consistent with those reported after more substantial interventions. The study raises some important clinical and methodological issues that could inform future research in this area.

  • 27.
    Flink, Ida
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Klein Strandberg, Ester
    School of Law, Psychology, and Social Work, Örebro University, Örebro, Sweden.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Context sensitive regulation of pain and emotion: Development and initial validation of a scale for context insensitive avoidance2017In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 17, p. 220-225, article id S1877-8860(17)30182-9Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND AIMS: Context insensitivity has been put forward as a potential mechanism explaining the high co-occurrence of pain and emotional distress. In the pain literature, the concept has only been introduced at a theoretical level and an assessment tool for exploring its impact is lacking. In an interpersonal setting, a core aspect of context sensitivity and insensitivity concerns when to disclose and when to avoid expressing pain and related distress. Both context insensitive disclosure and context insensitive avoidance may hamper interpersonal support and fuel the problem. This exploratory study describes an attempt to develop a self-report instrument to assess tendencies to disclose vs. avoid expressions of pain and related distress, as well as self-perceived adjustment of disclosure vs. avoidance to the context.

    METHODS: A pool of items was systematically developed to assess different aspects of context insensitivity, including disclosure vs. avoidance of expression. 105 participants with persistent pain were recruited at pain rehabilitation clinics (80% of the sample) and in a university setting (20% of the sample). The participants responded to the pool of items as well as to a number of validated self-report instruments covering pain, pain-related disability, pain catastrophizing, emotion regulation tendencies, self-compassion and pain acceptance. The analyses explored the factorial structure of the initial instrument, as well as the criterion and construct validity.

    RESULTS: The analyses confirmed a stable underlying structure of the initial scale, with four distinct factors explaining 64.4% of the total variance. However, the criterion and construct validity could only be confirmed for one of the factors, which contained items reflecting context insensitive avoidance of expression. Consequently, only this factor, demonstrating very good internal consistency, was kept in the final version of the instrument which was named context insensitive avoidance (CIA).

    CONCLUSIONS: We found support for the final version of our instrument, capturing one prominent aspect of context insensitivity. Avoidance of expression was related to higher ratings of pain, disability, catastrophizing and suppression as well as to lower levels of self-compassion. We encourage further studies to explore the impact of context insensitive avoidance for regulating pain and associated negative emotions. Yet, more research is needed that goes beyond self-report and includes other aspects of context. It is urgent to develop systematic ways for assessing context insensitivity, as it will enhance our understanding of regulatory strategies as potential transdiagnostic mechanisms in pain and emotion.

    IMPLICATIONS: This tool for assessing contextually insensitive avoidance of expression could potentially be used both clinically and in future research to advance our understanding of comorbid problems with pain and emotional distress. Further research is needed to develop methods for assessing other aspects of context insensitivity to fully understand its impact in patients suffering from pain.

  • 28.
    Flink, Ida
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Linton, Steven
    Örebro University, School of Law, Psychology and Social Work.
    Pain, sleep and catastrophizing: The conceptualization matters : Comment on Wilt JA et al. “A multilevel path model analysis of the relations between sleep, pain, and pain catastrophizing in chronic pain rehabilitation patients”2016In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 10, p. 119-121Article in journal (Refereed)
  • 29.
    Flink, Ida
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Hantera smärta2007In: Smärtguide för dig som är amputerad / [ed] Gunilla Åhrén, Stockholm: Riksförbundet för trafik- och polioskadade (RTP) , 2007, p. 19-24Chapter in book (Other academic)
  • 30.
    Flink, Ida
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Hantera smärta2007In: Smärtguide för dig med polioskada / [ed] Gunilla Åhrén, Stockholm: Riksförbundet för trafik- och polioskadade (RTP) , 2007, p. 23-28Chapter in book (Other academic)
  • 31.
    Flink, Ida
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Hantera smärta2009In: Smärtguide för dig med whiplashskada / [ed] Gunilla Åhrén, Stockholm: Personskadeförbundet RTP , 2009, p. 23-28Chapter in book (Other academic)
  • 32.
    Flink, Ida
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Peters, Madelon
    Department of Clinical Psychological Science, Maastricht University, The Netherlands.
    Bergbom, Sofia
    Örebro University, School of Law, Psychology and Social Work.
    Bergman, Marie
    Center for Health and Medical Psychology (CHAMP), School of Law, Psychology, and Social Work, Örebro University, Örebro, Sweden.
    Ekstrand, Karin
    Center for Health and Medical Psychology (CHAMP), School of Law, Psychology, and Social Work, Örebro University, Örebro, Sweden.
    Carstens-Söderstrand, Johan
    Örebro University, School of Law, Psychology and Social Work.
    Tillfors, Maria
    Örebro University, School of Law, Psychology and Social Work.
    Dwelling on a successful task: Does how or why influence affect?2018In: Journal of Experimental Psychopathology, ISSN 2043-8087, E-ISSN 2043-8087, Vol. 9, no 3, article id UNSP 047915Article in journal (Refereed)
    Abstract [en]

    Repetitive negative thinking (RNT) has been identified as a key maintaining process of emotional difficulties. However, the consequences of repetitive thinking may depend on whether negative thoughts or feelings are processed in an abstract, evaluative mode, or in a concrete, process-focused mode. In recent years an increasing number of studies has also explored the effect of processing mode in relation to positive events, yielding inconsistent results. So far, the studies using positive material have not examined the interaction between trait rumination and processing mode. Consequently, the purpose of this study was to further explore the effects of abstract vs. concrete mode of processing on positive affect and negative affect in the context of a success task in a sample scoring high on trait rumination. 62 participants were randomly assigned to abstract vs. concrete processing training prior to a success task. The results showed that positive affect increased whereas negative affect and state RNT decreased after the success task in both groups. However, abstract vs. concrete processing did not have an effect on outcome. The findings indicate that processing mode does not influence outcome in the context of a success task.

  • 33.
    Flink, Ida
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Sfyrkou, Christina
    Örebro University, School of Law, Psychology and Social Work.
    Persson, Bob
    Institution of Law, Psychology and Social Work, Örebro University, Örebro, Sweden.
    Customized CBT via internet for adolescents with pain and emotional distress: A pilot study2016In: Internet Interventions, ISSN 2214-7829, Vol. 4, p. 43-50Article in journal (Refereed)
    Abstract [en]

    The aim of this pilot study was to explore the effects of an early and customized CBT intervention, mainly delivered via internet, for adolescents with coexisting recurrent pain and emotional distress (low mood, worry, and/or distress). The intervention was based on a transdiagnostic approach, to concurrently target pain and emotional distress. A single case experimental design (SCED) was employed with six participants, 17-21 years old, who were recruited via school health care professionals at the student health care team at an upper secondary school in a small town in Sweden. The intervention consisted of 5-9 modules of CBT, delivered via internet in combination with personal contacts and face to face sessions. The content and length of the program was customized depending on needs. The effects of the program were evaluated based on self-report inventories, which the participants filled out before and after the intervention and at a six month follow-up. They did also fill out a diary where they rated symptoms on a daily basis. The results were promising, at least when considering changes during the intervention as well as pre- and posttest ratings. However, the results were more modest when calculating the reliable change index (RCI), and most of the treatment effects were not sustained at the follow-up assessment, which raises questions about the durability of the effects. Taken together, this study indicates that this type of program is promising as an early intervention for adolescents with pain and concurrent emotional distress, although the outcomes need to be explored further, especially in terms of long-term effects.

  • 34.
    Flink, Ida
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Smeets, Elke
    Department of Clinical Psychology Science, Maastricht University, Maastricht, The Netherlands.
    Bergbom, Sofia
    Örebro University, School of Law, Psychology and Social Work.
    Peters, Madelon L.
    Department of Clinical Psychology Science, Maastricht University, Maastricht, The Netherlands.
    Happy despite pain: pilot study of a positive psychology intervention for patients with chronic pain2015In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 7, p. 71-79Article in journal (Refereed)
    Abstract [en]

    Background and purpose: Dealing with chronic pain is difficult and affects physiological as well as psy-chological well-being. Patients with chronic pain are often reporting concurrent emotional problems such as low mood and depressive symptoms. Considering this, treatments need to involve strategies for improving mood and promoting well-being in this group of patients. With the rise of the positive psy-chology movement, relatively simple intervention strategies to increase positive feelings, cognitions, and behaviours have become available. So far, the evidence for positive psychology techniques mainly comes from studies with healthy participants, and from studies with patients expressing emotional problems such as depression or anxiety as their main complaint. This study describes an initial attempt to explore the potential effects of a positive psychology intervention in a small sample of patients suffering from chronic pain.

    Methods: A replicated single case design was employed with five participants. The participants started to fill out daily self-reports and weekly questionnaires two weeks before the intervention started, and continued throughout the intervention. In addition, they filled out a battery of questionnaires at pretest, posttest, and at a three months follow-up. The instruments for assessment were selected to cover areas and constructs which are important for pain problems in general (e.g. disability, life satisfaction, central psychological factors) as well as more specific constructs from positive psychology (e.g. compassion, savoring beliefs).

    Results: The results on pre and post assessments showed an effect on some of the measures. However, according to a more objective measure of reliable change (Reliable Change Index, RCI), the effects were quite modest. On the weekly measures, there was a trend towards improvements for three of the par-ticipants, whereas the other two basically did not show any improvement. The daily ratings were rather difficult to interpret because of their large variability, both between and within individuals. For the group of participants as a whole, the largest improvements were on measures of disability and catastrophizing.

    Conclusions: The results of this preliminary study indicate that a positive psychology intervention may have beneficial effects for some chronic pain patients. Although it is not to be expected that a limited positive psychology intervention on its own is sufficient to treat pain-related disability in chronic patients, our findings suggest that for some it may be an advantageous complement to enhance the effects of other interventions.

  • 35.
    Flink, Ida
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Thomtén, Johanna
    Örebro University, School of Law, Psychology and Social Work. Department of Psychology, Mid Sweden University, Östersund, Sweden.
    Engman, Linnea
    Örebro University, School of Law, Psychology and Social Work.
    Hedström, Stina
    Center for Health and Medical Psychology (CHAMP), Institution of Law, Psychology, and Social Work, Örebro University, Örebro, Sweden.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Coping with painful sex: Development and initial validation of the CHAMP Sexual Pain Coping Scale2015In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 9, p. 74-80Article in journal (Refereed)
    Abstract [en]

    Background and purpose: Recurrent vulvar pain is a common and debilitating condition which has received remarkably little attention in pain research. For instance, little is known about how these women cope with sexual activities, and there are no structured assessment tools. The purpose of this study was to explore coping strategies in this group, with a view to develop a measure to assess how women with vulvar pain cope with sexual activities.

    Methods: The current study is based on a subsample from a longitudinal study about vulvar pain in a student sample consisting of women between 18 and 35 years old (N = 964). Only data from the ones reporting recurrent vulvar pain during the last six months (N = 289) were used in the analyses. First, the CHAMP Sexual Pain Coping Scale (CSPCS) was created, with the aim of assessing how women with vulvar pain cope with sexual activities. The scale was inspired by previous research on women with vulvar pain as well as well-known coping strategies in other pain populations. Second, the psychometric properties of the scale were explored by analyzing the factor structure and internal reliability. Third, validity features were examined in terms of criterion validity and construct validity.

    Results: The analyses supported a three-factor solution, embracing the strategies endurance, avoidance and alternative coping. The internal reliability of the subscales turned out to be good, and the criterion validity was supported for all three subscales. The construct validity was clearly supported for the endurance and the avoidance subscales, but not for the alternative coping subscale.

    Conclusions: The findings support the CSPCS as an instrument for assessing how women with vulvar pain cope with sexual activities. The strategies endurance, avoidance and alternative coping correspond with findings from earlier research. Endurance reflects a tendency to engage in and continue with sexual activities despite pain, while attempting to minimize or suppress thoughts of pain. Avoidance, on the other hand, involves efforts to stay away from sexual activities, in particular vaginal penetration, because of fear of pain. Alternative coping refers to endeavours to find alternative sexual activities that do not necessarily involve vaginal penetration. Even though this first study indicates that the CSPCS may be psychometrically sound, more studies are needed to confirm the psychometric properties and clinical application of this instrument. In particular, the construct validity of the alternative coping subscale needs to be further evaluated.

    Implications: A valid instrument for assessing strategies for coping with sexual activities in this population has important clinical implications, since it provides a method that may enhance assessment procedures, be used in research, and stimulate the development of treatment.

  • 36.
    Hedman-Lagerlöf, Maria
    et al.
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Andersson, Erik
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Hedman-Lagerlöf, Erik
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Wicksell, Rikard K.
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden; Functional Area Medical Psychology, Karolinska University Hospital Solna, Stockholm, Sweden.
    Flink, Ida
    Örebro University, School of Law, Psychology and Social Work.
    Ljótsson, Brjánn
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden; Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Approach as a key for success: Reduced avoidance behaviour mediates the effect of exposure therapy for fibromyalgia2019In: Behaviour Research and Therapy, ISSN 0005-7967, E-ISSN 1873-622X, Vol. 122, article id UNSP 103478Article in journal (Refereed)
    Abstract [en]

    Fibromyalgia (FM) is a prevalent chronic pain disorder associated with large suffering and substantial societal costs. Pain-related avoidance behaviour and hypervigilance to bodily symptoms are common in FM and contribute in maintaining and exacerbating the disorder. Exposure therapy targeting avoidance behaviours and hypervigilance has shown promise in the treatment of FM. The present study investigated mediators of treatment outcome in exposure therapy for FM. We used data from a randomised trial, where 140 participants were allocated to 10-week Internet-delivered exposure therapy or to a waiting-list control condition. The main outcome variable (FM symptoms) and the hypothesized mediators (FM-related avoidance behaviour, mindful non-reactivity and FM-related worry) were measured weekly throughout treatment. Mediation analyses were conducted using linear mixed effects models with bootstrap replication and time-lagged analysis. Results indicated that all three process variables were significant mediators of FM severity. However, in the time-lagged analyses, only FM-related avoidance behaviour displayed a unidirectional relationship over time with FM symptoms, suggesting a causal effect. Thus, results illustrate that changes in avoidance behaviour mediate the outcome of exposure on FM symptoms, which implies that avoidance behaviour is an important treatment target in exposure therapy.

  • 37.
    Hedman-Lagerlöf, Maria
    et al.
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Hedman-Lagerlöf, Erik
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Axelsson, Erland
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Ljótsson, Brjánn
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Engelbrektsson, Johanna
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Hultkranz, Sofia
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Lundbäck, Karolina
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Björkander, Daniel
    Department of Psychology, Stockholms Universitet, Stockholm, Sweden.
    Wicksell, Rikard
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Flink, Ida
    Örebro University, School of Law, Psychology and Social Work.
    Andersson, Erik
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Internet-Delivered Exposure Therapy for Fibromyalgia: A Randomized Controlled Trial2018In: The Clinical Journal of Pain, ISSN 0749-8047, E-ISSN 1536-5409, Vol. 34, no 6, p. 532-542Article in journal (Refereed)
    Abstract [en]

    Background: Fibromyalgia (FM) is a common and disabling chronic pain disorder, for which existing pharmacological and psychological treatments have yet yielded insufficient effects. Previous literature has shown that exposure therapy may be an effective treatment for chronic pain. This study constitutes the first randomized controlled trial evaluating exposure therapy for FM.

    Methods: A total of 140 participants with diagnosed FM were randomized to a 10-week Internet-delivered exposure treatment (iExp; n=70) or a waitlist control condition (WLC; n=70). Primary outcome measure were FM symptoms and impact, and secondary outcome measures were fatigue, disability, quality of life, pain-related distress and avoidance behaviors, insomnia, depression, and anxiety.

    Results: Data retention was high (100% data completion at posttreatment for primary outcome, 96% at 6-month follow-up and 94% at 12-month follow-up). Results showed that participants in the iExp group made large and superior improvements compared with WLC on FM symptoms and impact (B, ?1.93; z, ?10.14; P<0.001, betweengroup Cohen d=0.90), as well as all secondary outcomes (betweengroup Cohen d ranging from 0.44 to 1.38) with sustained results.

    Conclusions: We conclude that iExp seems to be an efficacious treatment for FM compared with no treatment, and the results also highlight the potential increase of accessibility by using the Internet format to deliver psychological treatments for these patients. Future trials with active control conditions are warranted.

  • 38.
    Hedman-Lagerlöf, Maria
    et al.
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Hedman-Lagerlöf, Erik
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Ljótsson, Brjánn
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Wicksell, Rikard K.
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden; Functional Area Medical Psychology, Karolinska University Hospital Solna, Sweden.
    Flink, Ida
    Örebro University, School of Law, Psychology and Social Work.
    Andersson, Erik
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Cost-Effectiveness and Cost-Utility of Internet-Delivered Exposure Therapy for Fibromyalgia: Results From a Randomized, Controlled Trial2019In: Journal of Pain, ISSN 1526-5900, E-ISSN 1528-8447, Vol. 20, no 1, p. 47-59Article in journal (Refereed)
    Abstract [en]

    Fibromyalgia (FM) is a prevalent and debilitating chronic pain disorder associated with a substantial economic burden. Although there are several studies investigating the effectiveness of psychological treatments such as cognitive-behavioral therapy for FM, studies on cost-effectiveness are scarce. The aim of the present study was to investigate the cost-effectiveness of Internet-delivered exposure therapy (iExp) for FM. We used health economic data from a recently conducted randomized, controlled trial, where 140 participants were randomized to either iExp or a waitlist control (WLC) condition. Economic data were collected at pre-treatment, post-treatment, and at the 1-year follow-up. Treatment effectiveness in relation to costs were analyzed using both a societal perspective (including all direct and indirect costs) and a health care unit perspective (including only the direct treatment costs). Bootstrapped net benefit regression analyses were also conducted, comparing the difference in costs and effects between iExp and WLC, within different willingness-to-pay scenarios. Results showed that the incremental cost-effectiveness ratio was -$15,295, indicating that iExp was highly cost-effective as each successfully treated case (treatment responder) was associated with a substantial net reduction in costs. The robustness of the results was tested in 2 different sensitivity analyses, where iExp remained cost-effective, even in a willingness-to-pay-scenario of $0. We conclude that iExp is a cost-effective treatment that generates large societal cost savings.

    PERSPECTIVE: Health-economic evaluations of psychological interventions for FM are scarce. This study is a cost-effectiveness analysis of Internet-delivered exposure therapy for patients with FM. Results showed that iExp was highly cost-effective compared with no treatment, where each successfully treated case generated a substantial societal cost saving.

  • 39.
    Jansson-Fröjmark, Markus
    et al.
    Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.
    Harvey, Allison G.
    Department of Psychology, University of California, Berkeley, CA, USA.
    Flink, Ida
    Örebro University, School of Law, Psychology and Social Work.
    Psychometric properties of the Insomnia Catastrophizing Scale (ICS) in a large community sample2019In: Cognitive Behaviour Therapy, ISSN 1650-6073, E-ISSN 1651-2316Article in journal (Refereed)
    Abstract [en]

    The purpose was to investigate the psychometric properties of the Insomnia Catastrophizing Scale (ICS) including factorial validity and internal consistency as well as discriminative and convergent validity. Associations with sleep parameters and daytime impairment are also examined. Drawn from a randomly selected sample of the general population, 1615 participants completed a survey on insomnia-related nighttime and daytime symptoms, health outcomes and psychological processes, including the ICS. A one-factor solution was supported for both the nighttime catastrophizing (11 items) and daytime catastrophizing (6 items) subscales. Both subscales displayed high internal consistencies (α > 0.90) and accounted for 59.1-70.1% of the variance. The insomnia disorder group had significantly higher scores than participants without insomnia on the two subscales and on the individual items. Cutoffs were established for both subscales with acceptable sensitivity and specificity. Both subscales displayed adequate convergent validity with measures indexing worry, cognitive pre-sleep arousal and anxiety. The two subscales were also significantly associated with nighttime and daytime insomnia symptoms. The ICS is a reliable and valid scale for the assessment of insomnia-related catastrophizing. Future research is needed to examine the test-retest reliability and treatment sensitivity of the ICS.

  • 40.
    Jansson-Fröjmark, Markus
    et al.
    Örebro University, School of Law, Psychology and Social Work. Stockholm University, Stockholm, Sweden.
    Harvey, Allison G.
    Psychology Department, Berkeley University, Berkeley CA, USA.
    Flink, Ida K.
    Örebro University, School of Law, Psychology and Social Work.
    Psychometric properties of the Insomnia Catastrophising Scale2012In: Journal of Sleep Research, ISSN 0962-1105, E-ISSN 1365-2869, Vol. 21, no Suppl. 1, p. 168-168Article in journal (Refereed)
    Abstract [en]

    Objectives:  Few questionnaires have been developed and validated to specifically index insomnia-specific cognitive mechanisms. The purpose of this study was to investigate the psychometric properties of a newly developed instrument, the Insomnia Catastrophising Scale (ICS). We seek to examine the factorial validity and internal consistency, discriminative and convergent validity along with associations with anxiety, depression, sleep parameters, and daytime impairment.

    Methods: Participants (n = 1803) from a randomly selected sample of the general population completed a survey that probed demographics, night-time symptoms, daytime impairment, anxiety and depression.  The ICS was also administered. Excluding those with a sleep disorder other than insomnia, the study sample consisted of 1558 participants.  

    Results: Of the twenty original ICS items, three were removed due to low communality. Exploratory factor analysis of the eleven items indexing night-time catastrophising indicated a one-factor solution (59.1% variance), strong primary loadings, and high internal consistency (α = .92). Analysis of the six items indexing daytime catastrophising indicated a one-factor solution (70.1% variance), strong primary loadings, and high internal consistency (α = .91). The internal consistency for the total ICS was .95. At scale-, subscale-, and item-levels significant mean differences were noted between three groups which differed on insomnia symptomatology; the insomnia disorder group (n = 113) reported significantly higher scores than the poor sleep (n = 247) and normal sleep groups (n = 1157), and the poor sleep group exhibited significantly higher scores than the normal sleep group. Receiver operating characteristics analyses indicated that when using an optimal cut-off for the ICS, the sensitivity was 84.1% (detecting those with insomnia disorder) and specificity was 81.5% (detecting those with normal sleep). The ICS was significantly associated with anxiety and depression (ρ = .44-.54), total wake time (η = .38), total sleep time (η = .29), sleep quality (ρ = .49), and daytime impairment (ρ = .57).

    Conclusion: The ICS can be considered as a reliable and valid questionnaire for indexing insomnia-specific catastrophising. The use of the ICS is recommended in research and clinical settings for assessing insomnia-related catastrophising.  

  • 41.
    Jansson-Fröjmark, Markus
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Flink, Ida K.
    Örebro University, School of Law, Psychology and Social Work.
    Granberg, Sarah
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Audiological Research Centre, Örebro University Hospital, Örebro, Sweden.
    Danermark, Berth
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Audiological Research Centre, Örebro University Hospital, Örebro, Sweden.
    Norell-Clarke, Annika
    Örebro University, School of Law, Psychology and Social Work.
    Cognitive-behavioral therapy for insomnia co-morbid with hearing impairment: a randomized controlled trial2012In: Journal of clinical psychology in medical settings, ISSN 1068-9583, E-ISSN 1573-3572, Vol. 19, no 2, p. 224-234Article in journal (Refereed)
    Abstract [en]

    The purpose of the current study was to examine the effects of cognitive behavior therapy (CBT-I) for insomnia on patients with insomnia co-morbid with hearing impairment. A randomized controlled design was used with a 3-month follow-up. Thirty-two patients with insomnia co-morbid with hearing impairment were randomized to either CBT-I or a waitlist condition (WLC). The primary outcome was insomnia severity. Secondary outcomes were sleep diary parameters, dysfunction, anxiety, and depression. Compared to WLC, CBT-I resulted in lower insomnia severity at post-treatment and at follow-up (d = 1.18–1.56). Relative to WLC, CBT-I also led, at both assessment points, to reduced total wake time (d = 1.39) and increased sleep restoration (d = 1.03–1.07) and sleep quality (d = 0.91–1.16). Both groups increased their total sleep time, but no significant group difference emerged. Compared to WLC, CBT-I resulted in higher function (d = 0.81–0.96) and lower anxiety (d = 1.29–1.30) at both assessment points. Neither CBT-I nor WLC led to improvement on depression. Based on the Insomnia Severity Index, more CBT-I (53–77%) than WLC participants (0–7%) were treatment responders. Also, more CBT-I (24%) than WLC participants (0%) remitted. In patients with insomnia co-morbid with hearing impairment, CBT-I was effective in decreasing insomnia severity, subjective sleep parameters, dysfunction, and anxiety. These findings are in line with previous results on the effects of CBT-I in other medical conditions.

  • 42.
    Linton, Steven J.
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Boersma, Katja
    Örebro University, School of Law, Psychology and Social Work.
    Flink, Ida K.
    Örebro University, School of Law, Psychology and Social Work.
    Kognitiv beteendeterapi2010In: Smärta och smärtbehandling / [ed] Mads Werner, Ido Leden, Stockholm: Liber , 2010, 2, p. 482-487Chapter in book (Other academic)
  • 43.
    Linton, Steven J.
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Flink, Ida
    Örebro University, School of Law, Psychology and Social Work.
    Hälsopsykologi i vården2016Book (Other (popular science, discussion, etc.))
  • 44.
    Linton, Steven J.
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Flink, Ida
    Örebro University, School of Law, Psychology and Social Work.
    Sömn, dröm, mardröm: kunskap och verktyg för god sömn2018Book (Other (popular science, discussion, etc.))
  • 45.
    Linton, Steven J.
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Flink, Ida K.
    Örebro University, School of Law, Psychology and Social Work.
    12 verktyg i KBT: från teori till färdighet2010 (ed. 1)Book (Other academic)
  • 46.
    Linton, Steven J.
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Flink, Ida K.
    A cognitive behavioral approach to chronic pain rehabilitation2010Conference paper (Refereed)
  • 47.
    Linton, Steven J.
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Flink, Ida K.
    Örebro University, School of Law, Psychology and Social Work.
    Bergbom, Sofia
    Örebro University, School of Law, Psychology and Social Work.
    Beteendeanalys steg för steg: grunden till en effektiv KBT-behandling2013 (ed. 1)Book (Other academic)
  • 48.
    Linton, Steven J.
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Flink, Ida K.
    Bergbom, Sofia
    Boersma, Katja
    Örebro University, School of Law, Psychology and Social Work.
    Manual för målbaserad aktivitetesträning vid långvarig muskuloskeletal smärta2010Other (Other academic)
  • 49.
    Linton, Steven J.
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Flink, Ida K.
    Örebro University, School of Law, Psychology and Social Work.
    Schrooten, Martien G. S.
    Örebro University, School of Law, Psychology and Social Work.
    Wicksell, Rikard K.
    Behavior Medicine Pain Treatment Service, Karolinska University Hospital, Sweden.
    Understanding co-occuring emotion and pain: The role of context sensitivity from a transdiagnostic perspectiveIn: Journal of Contemporary Psychotherapy, ISSN 0022-0116, E-ISSN 1573-3564Article in journal (Refereed)
  • 50.
    Linton, Steven J.
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Flink, Ida K.
    Örebro University, School of Law, Psychology and Social Work.
    Schrooten, Martien G. S.
    Örebro University, School of Law, Psychology and Social Work.
    Wiksell, Rikard
    Behavior Medicine Pain Treatment Services, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Understanding Co-occurring Emotion and Pain: The Role of Context Sensitivity from a Transdiagnostic Perspective2016In: Journal of Contemporary Psychotherapy, ISSN 0022-0116, E-ISSN 1573-3564, Vol. 46, no 3, p. 129-137Article in journal (Refereed)
    Abstract [en]

    Co-occurring emotional distress and chronic pain are a true challenge in the clinic. This combination of symptoms is quite common but associated with poor treatment results, frequent relapses and costly dysfunction. This paper describes a transdiagnostic approach to the problem by focusing on psychological processes that drive both the emotional as well as the pain problem. Avoidance and context (in)sensitivity are suggested as potential transdiagnostic factors that might be targeted in treatment. Since both pain and distress are aversive, they may be avoided. This may be helpful in the short-term, but paradoxically the avoidance maintains the problem in the long-term. Context sensitivity concerns how well our responses are in tune with the changing demands of the environment. We propose that context insensitivity may drive emotional distress and pain problems. We present data that show that disclosure of pain is important emotionally, but that it is also a challenge to respond in manner that is sensitive to the social context. Indeed, disclosing how we feel emotionally or concerning pain might be helpful in some situations, but enhance the problem in others. Finally, we outline a hybrid treatment that combines exposure for pain (feared movements) and emotions (disclosure) with context sensitivity training. While such new treatments are promising, there remains a dire need for more clinical research to test and improve treatments for co-occurring emotional distress and pain.

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