Background: Chronic pelvic pain (CPP) in women causes significant disability and distress. Like other chronic pain conditions, psychosocial variables likely play as key a role in the development and maintenance of CPP as physiological ones. The purposes of this study were to use the Biopsychosocial model to determine the predictors of pain and quality of life (QOL) and to specifically examine to effect of baseline catastrophizing on 12-month pain and QOL. Methods: Secondary analysis of baseline and 12-month data collected from women presenting for CPP treatment (n = 673) at a tertiary referral center was performed. Questionnaires assessed medical symptoms, physical and mental health, abuse, trauma, catastrophizing and the main outcome measures of pain reports (McGill Pain Questionnaire) and QOL scores (adapted version of the Irritable Bowel Syndrome QOL Questionnaire). Results: Of the 673 enrolled, 401 completed baseline questionnaires. These women were predominantly middle aged (M = 35.68, SD = 9.87), married (66%), Caucasian (78%), and educated (M = 14.83, SD = 2.55). Two hundred seventy-two women completed questionnaires at baseline and 12 months and were similar in most characteristics but reported fewer incidents of trauma and abuse, improved physical health and fewer medical symptoms. Women experienced a significant reduction in pain (t (261) = 11.23, p < .001) and improved QOL (t (257) = 6.78, p< .001). Baseline catastrophizing was a predictor of baseline pain (R2 = .42, pβ = .46, p < .001) and baseline QOL (R2 = .79, p< .001; β = .71 p < .001) with similar results at 12-month follow-up. While baseline catastrophizing contributed only 3% of the variance it remained a significant predictor of 12-month pain (R2 = .39, p < .001; β = .18, p = .003). Unexpectedly, abuse and trauma histories were not significant predictors of pain or QOL. Conclusions: These findings contribute to the existing body of literature by confirming the complex nature of CPP and suggest that psychological processes such as catastrophizing play a vital role in CPP. Future research in CPP will benefit from the exploration of the contribution of psychological processes to CPP and the application of research from other pain conditions to gynecologic pain disorders.

The most effective and useful way to diagnose and subtype depression has been a long debated topic which even now does not have a definite answer. The biopsychosocial approach to diagnosis may be a solution to this problem by linking various etiologies to symptom presentation. The biopsychosocial model, in regard to depression, takes into account biological risk factors/contributors, psychological or cognitive risk factors/contributors, and social risk factors/contributors to depression when making diagnosis and subtyping determinations. However, the most effective way to use this model in the assessment, diagnosis, and treatment of depression is not yet clear. In this study, the utility of the biopsychosocial model as an effective approach to conceptualizing and treating depression was assessed by testing hypotheses that showed that etiological contributors are related to the presence and differential presentation of depression, and that these etiologically-based subtypes of depression respond differently to different forms of treatment. These hypotheses were tested using data from the National Comorbidity Survey - Replication (NCS-R). Results showed that the biopsychosocial model can effectively predict the presence, severity and chronicity of depression, and may inform specific biopsychosocially-based subtypes. No conclusions could be drawn regarding success in treatment based on the biopsychosocial model. Future directions for research based on the current study are discussed.

Abstract Introduction. The biopsychosocial model has developed over the last forty years since Melzac and Wall first stated the need to broaden the biomedical view of pain mechanisms. The biopsychosocial concept is now central in contemporary understanding of human health and functioning in general, and pain in particular. An extensive biopsychosocial literature on low back pain has emerged since the paradigm shift of nearly thirty years ago, and has been reflected in evidence-based clinical practice guidelines on musculoskeletal pain. The estimation of prognosis from an episode of low back pain is particularly important to clinicians, patients, employers and third party payers. The instruments currently available however, quantify prognostic factors from a biomedical perspective, rather than the contemporary biopsychosocial model. The successful development of the biopsychosocial instrument, reported in this thesis, fills this gap in measurement, and affirms the hypothesis advanced that it is feasible to develop a valid and reliable multidimensional index to estimate prognosis from a range of biopsychosocial variables, in low back pain. The thesis describes; • A review of pain mediation/modulation • A review of the literature on the biopsychosocial model to identify a range of variables for investigation • Consideration of different outcome measures as the gold standard criterion measure • The development of the BPIP, a novel biopsychosocial instrument designed for eventual clinical use, as a means of considering non specific low back pain from a biopsychosocial perspective, and informing prognosis in patients who do not have diagnosable levels of psychopathology Methods. The Biopsychosocial Index of Prognosis (BPIP) was developed from a content map derived from the International Classification of Functioning, Health and Disease (ICF) for use in non specific low back pain of variable duration. A prototype BPIP instrument was drafted, and a peer review process resulted in item reduction. The prototype BPIP instrument was then subjected to a twenty four hour test-retest assessment of stability, prior to assessment of the prototype BPIP’s validity and internal consistency. Questionnaire packs containing the prototype BPIP instrument, a range of other measurement instruments, an informed consent form and an instruction sheet were then issued. The data were captured at baseline, six weeks, and again at twelve weeks. Recruitment of respondents was originally intended to capture a homogeneous cohort drawn from general (medical) practice. Recruitment difficulties however resulted in two distinct cohorts, a larger Australian cohort (n = 91) and a smaller New Zealand cohort (n = 27). The larger Australian group was utilised as an elucidation cohort, and the smaller New Zealand cohort was treated as a small prospective validation of the BPIP. Item reduction was undertaken and resulted in an ordinal scale for correlation with the Roland and Morris Disability Index, the criterion measure. The resulting twenty four item BPIP scale was tested for internal consistency in both the Australian and New Zealand cohorts. The baseline data from the Australian elucidation cohort were then assessed for concurrent, predictive and construct validity against the twelve week data from The Roland and Morris Disability Index (RDQ), the selected criterion measure. The New Zealand cohort was treated as a small prospective validation of the BPIP scale, with the baseline data from the BPIP correlated with the change score from the baseline to twelve weeks, of the RDQ. Analysis was undertaken using the SPSS statistical package. Results. Correlation analysis of the baseline BPIP Australian data with the twelve week RDQ Australian data resulted in reducing the prototype scale to questions which correlated at or above 0.3, a total of twenty four questions were retained. Reliability coefficients for internal consistency of the twenty four item BPIP scale were: The Australian cohort, Cronbach’s Alpha = 0.8736. The New Zealand cohort, Cronbach’s Alpha = 0.8628. A further review of the correlation analysis of the baseline BPIP Australian data with twelve week RDQ Australian data for items that correlated at or above 0.4 resulted in further item reduction of the BPIP to twelve questions. Following this further item reduction, reliability coefficients for internal consistency were: The Australian cohort, Cronbach’s Alpha = 0.875. The New Zealand cohort, Cronbach’s Alpha = 0.776. Regression analysis of the Australian cohort based on the twelve item scale demonstrated that 61.7% of the variance in the RDQ score at twelve weeks was accounted for by the BPIP scale, with p = 0.0005. Regression analysis of the change score of the RDQ with the twelve item BPIP in the New Zealand cohort demonstrated that 78.2% of the variance in RDQ scores was accounted for by the BPIP scale, with p = 0.006. Forty five point five percent of the Australian cohort improved by more than 30%, (the proposed minimal clinically important difference of the RDQ), whilst 76.9% of the New Zealand cohort improved more than thirty percent. In a post hoc analysis of the Orebro data, the longer 25 item questionnaire accounted for 97.8% of the variance in the New Zealand cohort. Conclusion. The initial hypothesis that it would be feasible to develop a valid and reliable multidimensional instrument from a range of biopsychosocial variables into a valid instrument for estimating the prognosis of an episode of low back pain is supported by the results. The utility of a biopsychosocial instrument for routine clinical use lies in the potential to predict prognosis. As low back pain is typically a recurrent problem, information on both prognosis for recovery from episodes, and the likelihood of recurrences would be helpful to both clinician and patient. For the patient, a well communicated prognosis helps assure the patient about their future, reduces uncertainty about their pain, and establishes treatment goals within the domain of informed consent. From the clinician’s perspective, a prognostic approach shifts the focus from the pain history to future outcomes and provides a context for considering how risks of future pain and dysfunction may be reduced. The BPIP scale is a biopsychosocial, prognostic instrument, which accounts for a high degree of the variance in the RDQ scores in both cohorts. Pain amelioration and functional improvement are the two key aspects of prognosis which the BPIP has been demonstrated to be both valid and reliable in predicting at the clinically important three month time point from baseline assessment. The BPIP has been demonstrated in these cohorts, to provide a reliable estimate of prognosis from a biopsychosocial perspective. The reliability of the shortened BPIP scale remained acceptable, and allowed for the scale to be contained on a single A4 page, potentially increasing the clinical utility of the instrument. When BPIP score fails to change over time, psychosocial screening and intervention may be indicated. Future work will include further validation in other subgroups and clinical environments, identification of cut points for BPIP scores, and the performance of comparative studies of the relative value of different purported prognostic indices. The BPIP is the first instrument developed to specifically to estimate prognosis from an episode of low back pain, in primary care, within the contemporary biopsychosocial model.

Master of Science / Family Studies and Human Services / Joyce Baptist / This qualitative study explored 65 rural adolescents' perceptions of health issues and needs. Focus groups were conducted with adolescents in six rural communities in Kansas. Analysis of transcripts suggested that the adolescents’ face numerous health issues that strongly influence their behaviors and expressed need for assistance. Adolescent health issues stemmed across biological, psychological, and social factors. Major themes evolved around challenges pertaining to healthy choices in food and nutrition, physical activity, stress management, sexual health, perceptions of invincibility, and poor role-modeling. To improve well-being adolescents need privacy, effective conversations, accessible health services, reliable education, and prioritization of healthy lifestyles. Implications for clinical and research are discussed.

This thesis explores physical health outcomes of individuals that hold stigma against those with mental illness. The stigmatizer is mentioned in the literature as an individual that holds a stigma towards another group. In this thesis, stigma refers to those that hold prejudice and may express discrimination towards a targeted group. Two studies were conducted that looked at multiple demographic variables as well as symptomology and degree of stigma towards those with mental illness. The first study looked at overall stigma without the stereotypical psychosomatic symptoms (chest pain and abdominal pain). The second study looked at a second dimension of stigma (social distance) and included the psychosomatic symptoms. In the first study, results indicated that stigmatizers were more likely to be male (M = 1.53, SD = .51; r = .216, p < .01) and have higher socioeconomic status (M = 3.06, SD = .91; r = .22, p < .01). Health outcomes were not correlated in the first study. In the second study, results indicated that those with higher levels of stigma (M=45.13, SD=13.52) also had more symptoms (including chest pain and abdominal pain; M = 4.92, SD = 5.64; R2=.06, F(1,98)=6.58, p=.01). This trend was also true for stigma as determined by social distance (M=18.31, SD=7.02) and health (R2=.10, F(1,98)=10.74, p<.01). These results were consistent with the proposed hypothesis and the current literature of the stigmatizer as well as the biopsychosocial model of mental health.

This study evaluated an integrated treatment program that was provided for college women with self-identified eating problems, both clinical and subclinical, using both quantitative and qualitative methodologies. The treatment model is based upon the biopsychosocial model integrating treatment from each of these dimensions: biological, psychological, and social. Eleven college students were self-referred and participated in bi-weekly nutritional counseling (biological), bi-weekly individual psychotherapy (psychological), and weekly group psychotherapy (social) over the course of one college semester. Details concerning these therapies are included. An evaluation was performed of both behavioral and psychosocial outcomes using both quantitative and qualitative data. Data were organized within the framework of the biopsychosocial model. Quantitative data (Eating Disorders Inventory-2, Eating Disorders Inventory Symptom Checklist, Beck’s Depression Inventory, Rosenberg’s Self-Esteem Scale, Initial Questionnaire) indicated improvement in depression scores (biological/psychological), sense of effectiveness, impulse regulation, confidence in their ability to change (psychological), asceticism and body image (psychological/social), as well as a decrease in overexercise and binge eating. Recurrent themes that emerged through the qualitative data (individual interviews at the end of the treatment program and focus group interviews) included biological themes: changing eating patterns, need for general and personalized nutritional information; psychological themes: exploration of emotions, need to feel understood, setting goals, self care, need for personal understanding and identification of needs, and body image; and social themes: sharing with others, social connectedness, and family relations. These themes are discussed to provide a better understanding of the process of participating in this program for the participants as well as providing an evaluation of this program. Suggestions for future programs and research as well as issues concerning program delivery, methodology, and other considerations are explored. / Ph. D.

Ce mémoire intitulé étude qualitative des obstacles et des leviers à l'utilisation du guide de pratique"Clinique des Lombalgies interdisciplinaires en Première ligne" est présenté par Anne-Marie Côté à la faculté de Faculté de médecine et des sciences de la santé et des Faculté des sciences de la santé de l'Université de Sherbrooke en vue de l'obtention du grade Maître ès sciences. Les maux de dos sont une problématique qui touche une très grande majorité de la population à un moment où à un autre de la vie. Afin d'améliorer les soins qui sont offerts aux personnes souffrant de lombalgie, plusieurs organismes à travers le monde ont développé des guides de pratique clinique (GPC). Malgré la publication de ces guides, un écart semble persister entre la pratique des professionnels de la santé et celle qui est supportée par les GPC. Afin d'améliorer l'adhésion des professionnels de la santé aux GPC, la littérature recommande de mettre en place une stratégie d'implantation appropriée afin d'en promouvoir l'utilisation. À cet effet, les stratégies d'implantation qui tiennent compte des obstacles et des leviers à l'utilisation d'un GPC semblent plus efficaces afin de modifier les habitudes de pratique des cliniciens. En 2006, le guide de pratique Clinique des Lombalgies Interdisciplinaire en Première ligne (CLIP) a été développé au Québec. Afin de bien préparer l'implantation de CLIP, l'objectif principal de ce projet de recherche est d'identifier les obstacles et les leviers à l'utilisation du guide CLIP, tels que perçus par les physiothérapeutes québécois. Pour ce faire, un devis descriptif utilisant une méthodologie qualitative a été retenu. L'étude a été faite auprès d'un échantillon de 16 physiothérapeutes, présentant des caractéristiques socioprofessionnelles variées. Les participants ont utilisé le GPC sur une période de six semaines avec deux patients souffrant de lombalgie. Les physiothérapeutes ont ensuite participé à une entrevue semi-structurée afin d'identifier les obstacles et les leviers à l'utilisation du guide CLIP. Une analyse de contenu thématique a été effectuée à l'aide d'une grille de codage mixte. Le guide d'entrevue et la grille de codage ont été élaborés à partir d'un cadre conceptuel basé sur le Modèle d'adhésion des médecins aux guides de pratique clinique. Des obstacles et des leviers à l'utilisation du guide CLIP découlant du guide en soi, des cliniciens et de l'environnement humain et organisationnel ont été identifiés par les participants. Ces obstacles et leviers se regroupent essentiellement autour de quatre grands noyaux centraux, soit (1) la compréhension du guide de pratique; (2) la compatibilité entre les pratiques recommandées dans le guide et celles des physiothérapeutes; (3) la pertinence du guide perçue par les physiothérapeutes; et (4) l'accord des physiothérapeutes avec le guide de pratique. À travers ces quatre grands thèmes, le transfert d'un modèle biomédical vers un modèle biopsychosocial dans le cadre de la prise en charge des patients lombalgiques semble limiter l'utilisation du guide CLIP par les physiothérapeutes.Ce transfert semble influencé entre autres par les attentes des patients, telles que perçues par les physiothérapeutes, ainsi que par le sentiment de compétence des participants par rapport au modèle biopsychosocial. Les participants considèrent également que le guide CLIP ne reflète pas l'ensemble de leur pratique courante. Ils craignent donc une mauvaise représentation de la physiothérapie auprès de leurs pairs. Les différents obstacles et leviers à l'utilisation du guide CLIP identifiés par les physiothérapeutes permettront d'ajuster le guide préalablement à son implantation à plus large échelle. Ainsi, la stratégie d'implantation qui sera mise en place devra tenter d'agir sur les quatre grands noyaux centraux qui influencent l'utilisation du guide CLIP par les physiothérapeutes.

Psychological and contextual factors play an important role in the development and maintenance of chronic spine-related pain, and effective treatment of pain-related conditions requires an understanding of how these factors contribute to pain and disability. The present study examined the relative contributions of spine pathology, psychological complications, and demographic factors to perceived pain intensity and disability in patients with chronic spine-related pain. Because most patients were assessed in the context of a compensable injury, exaggeration of symptoms and disability was systematically controlled for using multiple validity indicators. A high prevalence of psychological complications was observed in the present sample. Analysis indicated that psychological factors were not significantly related to pain intensity, but were significantly related to reported pain-related disability. Further, psychological factors were found to predict pain-related disability beyond demographics, medical findings, and pain intensity. Clinical implications of these findings are discussed.

Master of Arts - Arts / Background: With the increasing prevalence of stroke in developing countries, like South Africa, the long-term care of stroke patients living with disabilities has substantial consequences for caregivers and their respective families. Method: This study investigated caregiver perceptions of their experiences, as well as familial implications due to the incidence of stroke within the family system. The assessment, in the form of a semi-structured interview, described the experiences post-stroke as perceived by six primary caregivers. It additionally addressed the challenges the South African context adds to these experiences. This was conceptualised within a systems and biopsychosocial framework, enabling the caregiver and family to be considered in a comprehensive and holistic manner. Results: Prominent themes associated with the caregiving of a stroke patient included: role changes, relationship disruptions within the family system, occupational and social implications, fatigue, anxiety, depression, as well as financial problems. An additional sub theme was that the emotional impact on the family system was greater in cases where younger children were involved. However, social support increased the caregivers’ ability to cope and this additionally assisted the rest of the family in their adjustment. Caregiver experiences were exacerbated by the inadequate support structures available within the South African context, with the lack of post-stroke education being an issue of great concern. Conclusions: Practical implications of this study are discussed, along with considerations of the limitations of the study and suggestions for future research.

Chronic pain has been identified as a major and underestimated health care problem, with extensive individual, social and economic ramifications. It has been estimated that the annual economic cost of chronic pain in Australia exceeds AU$34 billion. The available epidemiological evidence suggests chronic pain is a relatively common health problem in Australia which is a significant public health issue. Chronic pain is a complex phenomenon which is not easily defined. However, it is important to consider the ways in which chronic pain is conceptualised, as this can have significant implications for the individual in terms of how they think about their pain, and the way they are treated within the health care system and the broader society. In the late nineteenth and early twentieth centuries, pain was predominantly considered a symptom of a biological problem in the body. Absence of physical disease was thought to indicate pain was the result of aberrant psychological processes. However, chronic pain proved resistant to this ‘mind-body’ approach, and the lack of efficacy of many biomedical interventions, combined with an apparently increasing prevalence of chronic pain, pointed to the inadequacy of purely biomedical approaches to pain treatment. The latter part of the twentieth century saw the recognition of pain as a multidimensional experience influenced by the interaction of numerous biological, psychological and social factors. Consequently, the biopsychosocial model of health, which emphasised such a ‘holistic’ perspective, gained substantial recognition in the pain management domain, and was endorsed as the preferred model of pain management. This has contributed to the development of new approaches to chronic pain treatment, particularly in the area of cognitive behavioural therapy and the establishment of multidisciplinary pain centres. There is evidence, however, that the ‘promise’ of the multidimensional conceptualisation and treatment of chronic pain has not been realised in the daily lives of people with chronic pain. Review of the literature indicates a tendency for research and practice to focus on the biological and psychological aspects of chronic pain, while minimising social environmental factors, such as the health care system and cultural belief systems regarding pain, which may also be significant. This thesis proposes that in order to more comprehensively respond to the complex phenomenon of chronic pain, it is necessary to further develop the social domain of the biopsychosocial model. A study was conducted to explore and describe individual experiences of living with chronic pain, as a basis for improving knowledge about the influence of the social environment on the individual. The thesis focuses not only on the individual descriptions of living with chronic pain, but also on the inter-relatedness between the individual and their social environment. Further, this thesis uses a process of critical interpretive analysis to identify aspects of the social environment which can exert a constraining or enabling effect on the individual with chronic pain. The thesis draws on critical realism theory, particularly the morphogenetic approach developed by Archer (1995), to guide the analysis process and to develop potential strategies for addressing identified social disadvantages. The integration of the individual stories of living with chronic pain with an interpretive analysis process, and the underlabouring philosophical perspective of critical realism, provided the framework to investigate the influence of the social environment on individual experience of living with chronic pain. In this thesis, a journey metaphor is used as an overarching framework to tie together the three principal themes identified through the analysis of the interview transcripts. The themes focused on the biomedical, psychological and cultural paths that participants followed in search of understanding and cure for their pain; the social suffering they experienced through lack of understanding and legitimation of their condition; and the identification and development of strategies for living with chronic pain. The thesis highlights the critical importance of focusing not only on the individual with chronic pain but also on the social environment within which the individual lives, and the ways in which these domains intersect and influence each other. The social environment was found to condition the individual and others in society, including health care practitioners, in relation to how they think and behave regarding pain, which in turn can have enabling or constraining consequences for the individual with pain. In particular, cultural beliefs about ‘normal’ pain, and the material structures of the health care system and employment and work places, were found to have a potentially negative impact on the individual with pain. It is concluded that these aspects of society will continue to exert constraining influences on people’s lives until the focus of policy and practice is expanded to include not just the individual with pain, but also the social environment in which they live. To address this, a number of policy and practice improvements are suggested.