The aim of the research was to develop (a) a well structured electronic medical record for a decision support system, and (b) logical algorithms for the diagnosis of Chronic Idiopathic Facial Pain (CIFP) and for educating trainees. This project started by validating the paper-based Facial Pain Proforma (FPP) with a panel of 3 experts. The FPP received a top grade consensus for history and examination. However, family relationships were considered too intrusive by one pain specialist and one clinical psychologist. A retrospective survey of 93 free hand pain histories taken by pain specialists (31 records), oral and maxillofacial registrars (12 records), senior house officers (31 records), and postgraduate students (19 records) were compared to the FPP. This revealed illegible data with many omissions. Medically trained surgeons produced good medical and examination data but overlooked important pain related and psychosocial data. Postgraduate students were often patient-led. A computerised FPP was developed as an electronic medical record - the Electronic Eastman Pain Proforma (EEPP) - using relational database software (Microsoft Access 97). The EEPP was validated for acceptability by clinicians and patients and compared to the free hand history (FH), and the FPP, (119 patients including 40 FH, 46 FPP, and 33 EEPP). Use of the EEPP did not diminish doctor-patient relationship. EEPP's history taking took 22 minutes compared to FPP (18 minutes) and FH (13 minutes). The average rating for EEPP was 2.8 out of 4. The design interface was rated as good. The clinicians were supportive for the concept of an electronic medical record. "Hand-crafted decision trees" were constructed by using expert knowledge and transcribed into "Diagnostic Rules". Machine learning technique were also used to induce comparable diagnostic trees from patient data (n=280). 5-fold cross validation of two induced decision trees showed diagnostic accuracy of 88% and 86%, with reasonable comprehensibility and high discriminative performance. The hand-crafted decision trees were validated using the same data. The resulting accuracy was 85% but comprehensibility was better than that of the induced decision trees. This work strongly supports the development and use of electronic medical records and a diagnostic decision tree system for clinical use.

Chronic widespread pain has been described as a major health problem in the Western world, but we know little about the experiences of people who live with this condition. The broad questions explored in this thesis are how people with chronic widespread pain experience, understand and give meaning to their 'condition', and how people with chronic widespread pain attempt to influence or exert control over their pain. The methods employed are located within a qualitative approach, using a 'psychosocial' perspective to explore individuals' experiences in a social context, and an interpretative perspective, to focus on the meanings and interpretations of participants. It also draws on a narrative approach, using the stories told by participants to illustrate the experience of chronic widespread pain in their everyday lives. Data was generated through lifegrid interviews, follow-up interviews, unstructured diaries and diary interviews with eight people with chronic widespread pain. In addition, five family members were interviewed. Findings focus on the experience of living with chronic widespread pain in the different realms in which pain arises, is experienced and managed, namely bodily, social, household, family and biographical. In exploring these areas, a number of themes recur which characterise the experience of living with chronic widespread pain. These themes include uncertainty, which manifests itself on a day-to-day basis and in the longer term; tensions arising in managing chronic widespread pain; the impact of experiencing and managing chronic widespread pain control on self and identity; and the effect of the invisible and contested nature of chronic widespread pain on sufferers' experiences.

Background: Chronic widespread pain (CWP), the cardinal feature of the chronic pain disorder fibromyalgia, is prevalent in the general population. Psychosocial status has repeatedly been shown to be associated with the onset of CWP, yet it does not explain all new cases of the disorder and other risk factors have been implicated. Physically traumatic events, such as a road traffic accident (RTA) may "trigger" symptom onset. There is evidence from family and twin studies to suggest that there is a genetic component to CWP. Genetic association (GA) studies of fibromyalgia have been methodologically weak. The overall aim of this thesis was to examine the relative contribution of psychosocial factors, physically traumatic events, and specific genetic polymorphisms in the onset of CWP. Methods: The EPidemiology of FUNctional Disorders (EPIFUND) study, a prospective population-based study, was used. Subjects (aged 25-65 years) were recruited from three general practices in Northwest England. Information was collected via postal survey at three time points over four years. At baseline (T1), psychosocial status was assessed using a number of validated scales. Pain status was assessed at T1 and at both followups (carried out at 15 months (T2) and 47 months (T3». CWP was classified using standard American College of Rheumatology criteria. Subjects free of CWP at T1 and with new onset CWP at T2 or T3 were identified. Regression techniques were used to investigate the relationships between psychosocial factors and traumatic events and CWP onset. At T3, subjects were also asked to provide a buccal swab sample from which DNA was extracted. A nested case-control study was conducted to investigate the GA of CWP (cases: CWP at ~ two time points; controls: free of pain at all three time points). Logistic regression models were used to analyse the relationship between genotype data and the presence of CWP. Results: 68% of eligible subjects participated at T1 (n=6791). At T2 and T3 the adjusted participation rate was 82% (n=3912) and 81% (n=2723), respectively. The onset rate of CWP was 10% (n=283) and 8% (n=145) at T2 and T3, respectively. High illness behaviour, somatic symptom, sleep problem, and depression scores were independent predictors of CWP onset at both 15 and 47 months of follow-up. Physically traumatic events did not independently predict the onset of CWP, although reporting a bone fracture, RTA, or childbirth, was univariately associated with CWP onset. The GA study (cases, n=153; controls, n=167) identified a number of associations between CWP and polymorphisms in genes on the hypothalamic-pituitary-adrenal axis and serotoninergic system. A number of these associations were moderated by psychosocial status (anxiety and depression). Conclusions: A psychosocial model for CWP onset that predicts the onset of CWP up to four years later has been established. Physically traumatic events do not appear to be important in the onset of CWP. Novel GAs with CWP have been identified. These findings highlight the multifactorial nature of CWP.

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