To Örebro University

Background and aims: Returning to work after periods of sick-leave due to chronic pain problems, involve a number of situations of interpersonal nature (e.g. meeting supervisors/insurance companies to adapt work setting to present functional level, receive help from colleagues, express pain, etc.). Since chronic pain has shown co-morbidity with social anxiety, it is of interest to investigate restraining factors in return to work among chronic pain sufferers from a social perspective. Catastrophizing is identified in both pain and social anxiety as a mechanism that might fuel a continuous bias in how situations are perceived (threat) and by hindering the development of functional behavior strategies. The presence of social anxiety in chronic pain patients might be seen as a stressor that limits the individuals' ability to effectively communicate pain-related needs to colleagues, and/or employers and therefore act as a hindering factor in return-to-work. Hence, the overall aim of this study was to examine the relationship between social anxiety, pain catastrophizing, and perceived ability to communicate pain-related needs to the work environment in a clinical pain population.

Methods: The study employed a cross-sectional design and involved 247 individuals with chronic pain (82.3% women; M-age = 44 years). Measures included the Pain catastrophizing Scale, the Social Phobia Screening Questionnaire and the communication of pain-related needs-subscale of the Return-To-Work Self-efficacy Questionnaire. Analyzes were run to examine whether social anxiety moderated the relation between pain catastrophizing, and perceived ability to communicate pain-related needs while controlling for pain severity/interference and sick leave.

Results: Social anxiety and pain catastrophizing correlated positively with each other and negatively with perceived ability to communicate pain-related needs. No support was obtained for a moderating effect of social anxiety. However, social anxiety and pain interference were each significant predictors of the individual's confidence in being able to communicate pain-related needs to the work environment.

Conclusions: In the context of pain and work-related communication, symptoms of social anxiety was identified as being of similar importance to the outcome as pain interference, while pain severity was not associated with the individual's confidence in communicating one's pain-related needs.

Implications: The results implicate that fears relating to pain-related social situations at work might be central in the process of return-to-work and rehabilitation in chronic pain.

Co-occurring pain and emotional difficulties are strikingly common and a true challenge in the clinic. Nearly all pain patients suffer from some kind of emotional distress. In the last decade, research in the field has started to focus on the role of underlying processes in concurrent problems with pain and emotional distress. This symposium is therefore focused on the link between pain and emotion and will highlight new perspectives on processes, theoretical as well as clinical. Talks will address the role of biological mechanisms, interpersonal contexts and the development of the new treatment approaches.

Poor emotion regulation has been pointed out as one core process, which may explain the high co-occurrence of pain and emotional distress. Current treatments have not succeeded in helping paon patients with high levels of emotional distress, and therefore a new treatment approach has been developed, based on emotion regulation theory and exposure techniques. Dr. Katja Boersma will describe the theory beind this new intervention and present preliminary data from an RCT in patients with chronic pain and emotional distress.

Another treatment approach with well documented effects in this area is ACT. However, large variability in treatment effects can be seen consistently across studies and predictors of outcome remain unclear. Few studies have yet investigated the role of biological processes in ACT. Dr. Rikard Wicksell will briefly describe ACT for patients with chronic pain, bring up recent findings on ACT and neuroscience, and discuss implications for future research and clinical development.

Pain-related fear is a salient emotion in many pain patients, which tend to lead to avoidance of movements or activities. Avoidance behaviors are negatively reinfrced as they lead to less pain for the moment; in the long run, however, it often results in inactivity and disuse. Furthermore, a change in neural response profile, so called cortical reorganization, occurs in cortical sensory and motor areas. Targeting immobilisation and cortical reorganisation, using cognitive behavioral, sensory, and motor strategies, may improve function in individuals with chronic pain. Dr. Kristoffer Bothelius will present findings in this area and discuss possible treatment implications.

One way of regulating pain and negative emotions is to share personal experiences with others. However, it is important to know where, when and with whom to share; in other terms, to be context sensitive. The opposite, context insensitivity, has been related to prolonged and exaggerated emotional distress. The theory, importance and potential clinical implications of context sensitivity in the area pf pain and emotional distress will serve the basis for the presentation by Dr. Ida Flink, and data from an ongoing project will be presented.

The link between pain and emotional distress may become extra salient when the pain occurs in an intimate interpersonal context. Vulvovaginal pain in women has been neglected in pain research, but is closely linked to emotional reactions such as fear and anxiety. Dr. Johanna Thomtén will describe the link between pain and emotional distress among women suffering from vulvovaginal pain, presenting data from an ongoing longitudinal project.

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.

Aim: Among women under 30 years of age, around 20% report recurrent sexual pain. Although the amount of studies investigating sexual pain has increased, little is known about the role of psychosocial factors. The present study used the fear-avoidance model from musculoskeletal pain as a theoretical frame of reference, and examined fear-avoidance beliefs, avoidance behaviors, pain catastrophizing and symptoms of anxiety and depression among women (18-35 years) reporting sexual pain.

Methods: The study was cross-sectional, based on a sample of 133 women, where 37 women (27.8%) reported sexual pain often or always.

Results: Women with pain reported higher levels of fear avoidance and pain catastrophizing as well as depression and anxiety, with fear avoidance and pain catastrophizing reaching similar levels as has been reported in other long-term pain populations. The level of anxiety and depression did not reach clinical levels. Fear-avoidance beliefs and pain catastrophizing were related to sexual pain and to pain intensity in the regression analysis.

Conclusion: The data are in line with, and give further support to, a fear-avoidance perspective in female sexual pain, emphasizing the role of fear and avoidance of pain/sex.

Background and aims: Female genital pain is a debilitating problem that negatively affects several aspects of the life of women. Several studies present figures of prevalence indicating that the problem affects nearly 20% of young women. However, many women fail to consult health care and the estimated prevalence therefore remains insecure. Historically, genital pain was commonly viewed as either physiological or psychosexual. Although the current field of research and clinical expertise in general agree upon a biopsychosocial conceptualization, less is known about the manifestation of the problem in everyday life and the experience of seeking health care among afflicted women. The objectives of the present study was to examine genital pain in a general female population living in Sweden cross-sectionally in terms of prevalence, sexual function, sexual satisfaction and help seeking, and to identify possible predictors of genital pain among women.

Methods: The study was a population-based study using a postal questionnaire administered to 4052 women (age 18--35). Of these 944 (response rate: 23%) took part in the study.

Results: Genital pain of six months duration was reported by 16.1% of the women. Women with pain more commonly reported fungal infections, other pain problems, sexual dysfunctions and symptoms of anxiety than pain-free women and in addition lower sexual satisfaction. There were no differences in sexual frequency. Pain was most commonly reported during sexual intercourse, but many women also experienced pain during non-sexual activities, with pain durations of several hours after the pain eliciting activity was interrupted. Of those reporting pain, 50% had sought care for their pain. The most common was to counsel a doctor and to receive topical treatment. However, the experienced effects of the treatments were on average low. In the explanatory model, fungal infections, and sexual dysfunctions were associated with genital pain.

Conclusions: The study had a low response rate, but still indicates that genital pain is common and negatively affects several aspects of women' life, not just sexual activities. Although many women report pro-longed pain experiences, many fail to consult health care and among those who seek care the effects of treatment are on average poor. There are strong associations between sexual dysfunctions (lack of sexual arousal, vaginal muscle tension hindering intercourse) and genital pain that, based on previous findings in this field of research, might be viewed in terms of circular maintaining processes.

Implications: Female genital pain is not just limited to the sexual context, but often negatively affects several situations in women' life. The size of the problem calls for immediate development of preventive interventions and treatment programs that focus on sexual education and to encourage a healthy sexuality among women and their partners. There is a need to identify methods in order to assemble evidence based interventions of female genital pain. Such methods are currently lacking, resulting in poor treatment options for women with pain.

© 2013 Scandinavian Association for the Study of Pain.

Background and aims: The problem of sexual pain is an area that has been shamefully ignored by both the pain community and the health service authorities. Although about 40% of women report such pain and 30% report it during their last intercourse, sexual pain has historically not even been considered a pain problem. The objectives of the present study was to present a background to the problem of female sexual pain, further elaborate on the problem and offer some direction for how advances might be concretely made.

Discussion: Genital pain is common and many women describe pain during several non-sexual activities. Therefore describing the pain strictly as a sexual problem, threatens to lose important information about the experience of pain which will be misleading both in assessment and treatment. Instead, seeing the problem as a multidimensional pain condition with debilitating sexual consequences is suggested. It has become apparent that although biological aspects are central in the experience of genital pain, psychological and social aspects may play a major role. The fear avoidance model which has played a major role in our understanding of the development of chronic musculoskeletal pain, also seems to be applicable in genital pain conditions. However, one has to be aware of certain differences when comparing genital pain from musculoskeletal conditions. In addition, there is a lack of established guidelines for assessing or treating unexplained genital pain conditions, and there is a risk of not acknowledging the role of socio-cultural context on how female sexuality is viewed. The problem of recurrent sexual pain is a highly volatile, personal, and socially weighted experience. Because of the lack of understanding of the mechanisms, it is a risk of over-emphasizing the role of vaginal penetration in the assessment and treatment of female sexual pain and clinicians may simply fail to investigate sexual function from a broader perspective. Conclusions and implications: There is a growing interest in the problem of female genital pain and associated problems with sexual pain. However, research predominately refers to the field of sex research, and the involvement from the pain community has to date been relatively low. There is an immediate need to identify the psychosocial mechanisms involved in the transition from acute to chronic genital pain in women and to address these components in treatment using established methods. Since sexual pain is far more than pain during vaginal penetration, there is a risk of treatment interventions being oriented towards performance in terms of a narrowly defined sexual behavior instead of focusing on valued activities, meaning and pleasure for the individual. Assessment and treatment have to include a broad perspective on pain and on sex. © 2014 Scandinavian Association for the Study of Pain.

Aim: The purpose of this paper is to examine how well research findings on dyspareunia (intercourse pain) fit the fear-avoidance (FA) model on pain.

Results: The evidence suggests that the experience of pain in dyspareunia functions similarly to the pain reported in other pain conditions. There are also accumulating data showing that the central mechanisms of the FA model, such as catastrophizing, fear, hypervigilance and disability, are central to the experience of sexual pain. However, there are also some potential differences between sexual pain and other pain conditions that demand further attention in terms of the role of the partner, specific emotional consequences of avoidance and the effect of hypervigilance on sexual arousal.

Conclusion: The results demonstrate the relevance of the FA model in sexual pain. They also imply that treatment methods for fear and avoidance in other pain conditions offer new avenues for treating sexual pain problems in the clinic. Future studies should focus on expanding how the mechanisms in the FA model contribute to sexual pain, as well as how treatments based on the model may be applied clinically.