Background: Chronic pain conditions particularly fibromyalgia (FM) are an important issue considering the demand that they place on health services and the negative impact on an individual’s well-being. Research regarding what impact FM may have on the various domains of health related quality of life is sparse. In addition, research identifying predictors relating to a person’s self-concept on pain outcomes such as quality of life and disability is scarce in a chronic pain population. Self-esteem has been linked to psychological adjustment in various chronic diseases (Chong et al, 2009) and is suspected to be a vulnerability factor in FM (Johnson et al., 1997; Michielsen et al., 2006). Research on self-compassion found that it is a significant predictor of increased psychological adjustment in people with chronic medical conditions (Wren, Somers, & Wright, 2011). The majority of research on self-compassion has been conducted in non-clinical samples. Identifying the predictive values of self-esteem and the self-compassion subscales (self-warmth and self-coldness) in relation to pain outcomes are useful provided they can be enhanced and utilised to inform intervention. Aims: This research portfolio had two aims, to systematically review and carry out a meta-analysis with the literature investigating the impact of FM on health related quality of life using the Short Form-36 version one and to investigate whether self-warmth, self-coldness and self-esteem act as predictors of quality of life and disability for individuals with chronic pain. Method: A systematic review and meta-analysis of studies which assessed the impact of FM on health related quality of life was undertaken. Sensitivity and subgroup analyses were conducted to address the level of heterogeneity in the studies. The empirical study comprised of a cross-sectional design in which 60 individuals with chronic pain were recruited from three NHS sites based in Fife and Lothian and a pain self-management group in Fife to complete six validated psychometric questionnaires: Self Compassion Scale (Neff, 2003), Rosenberg Self-Esteem Scale (Rosenberg, 1965), Brief Pain Inventory- Short Form (Cleeland, 1991), Pain Disability Questionnaire (Anagnostis, Gatchel, & Mayer, 2004), Hospital Anxiety and Depression Scale (Zigmond and Snaith, 1983) and Quality of Life Scale (Burckhardt, Woods, Schultz, & Ziebarth, 2003). Systematic Review Results: In total, 18 studies met the inclusion criteria of the systematic review and demonstrated that the health related quality of life of individuals with FM was lower compared to healthy controls on all eight subdomains of the SF-36 particularly Physical Role. It was found that Social Functioning was the subdomain least affected when comparing participants with FM to healthy controls. Empirical Project Results: Quality of life was lower than previous research with females reporting a higher level of quality of life than males. It was found that after controlling for demographic and clinical variables, self-warmth was the only significant predictor for quality of life but not on levels of disability. Neither self-coldness nor self-esteem were significant predictors on scores of quality of life or disability. Conclusion: The above studies expand literature on the nature of chronic pain and its outcomes such as health related quality of life. The meta-analysis evidenced that HRQoL was lower in individuals with FM than in healthy controls. The association between symptom severity and quality of life requires further investigation in FM. Psychological interventions targeting the development of self-warmth attributes and skills may have a beneficial effect in improving quality of life for people with chronic pain. While the systematic review highlighted that FM has a more significant impact physically rather than mentally in relation to quality of life, both studies highlighted the need for interventions to target the psychological adjustment of people with chronic pain conditions.

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The aim was to elucidate the social construction of chronic pain as a cause of work absence in the UK, focusing on negotiation of sickness certification and return to work, in the context of recent policies to tackle rising sick-listing rates, including a national educational programme about the health benefits of work, and introduction of the ‘fit note’. Following a literature review, two qualitative studies were conducted from a symbolic interactionist perspective. The first comprised semi-structured interviews with doctors and chronic pain patients, leading to a second study in which employers and employees with chronic pain were interviewed. Interviews were transcribed verbatim and analysed according to constructivist grounded theory principles. The first study revealed tensions in the doctor-patient relationship as the process of sickness certification was negotiated. The indeterminacy of chronic pain rendered the biomedical approach to diagnosis and assessment of capability for work problematic, while a shift to the psychosocial model could generate feelings of invalidation in patients. A wide range of moral and socio-cultural factors was invoked by doctors and patients to contest sick-listing decisions. The second study identified difficulties that can emerge when chronic pain patients return to work. Employees discussed how managers failed to understand their problems or make sustained adaptations; employers reported difficulty reconciling the needs of employees with organisational imperatives and argued that employees and doctors colluded in sanctioning low resilience. All stakeholder groups supported the fit note’s focus on capacity not incapacity, but were skeptical about whether it would surmount the tensions and difficulties that arise in sickness certification and return to work for chronic pain patients. Struggles for meaning and construction of identities are difficult for policy to address, but deeper understanding of the processes behind them and rich accounts of stakeholders’ views, may nudge the system towards more appropriate responses.

Complex Regional Pain Syndrome (CRPS) is a chronic neuropathic pain condition associated with significant alterations in the somatosensory and motor cortex brain regions. Cognitive-affective alterations have recently been recognized in patients suffering with CRPS, however, relatively little neuroimaging research has been done to examine these dimensions. Moreover, many children and adolescents suffer from CRPS, but very little is known about the impact of this condition on brain states in the pediatric population. The aim of this paper is to assess the structural brain differences between children with CRPS and healthy controls and to examine to what degree fear level influences such differences. This study is part of a larger investigation that integrates functional and structural brain differences to evaluate fear-related brain circuitry in patients with CRPS. Thirty-seven patients with CRPS were age and gender matched with 35 healthy controls. The two groups underwent structural magnetic resonance imaging (MRI) scans as well as completed the Fear of Pain Questionnaire, child report (FOPQ). To examine gray matter differences, voxel-based morphometry (VBM) and cortical thickness (CT) analysis was completed. Patients with CRPS in this study had an average age of 13.2 (SD=2.7) and were predominantly female (73%). Of the 35 patients who completed FOPQ, 49% reported clinically significant pain-related fear. Compared with healthy controls, CRPS patients had significantly less in gray matter (GM) volume in pain- and fear-related brain regions, including the dorsolateral prefrontal gyrus, motor and somatosensory cortex, anterior and posterior cingulate cortex, nucleus accumbens, putamen, amygdala, and hippocampus. Furthermore, gray matter decreases in regions such as anterior midcingulate cortex, nucleus accumbens, and putamen were associated with elevated pain-related fear in patients. Differences in gray matter volume in fear-circuitry areas could potentially be one mechanism by which abnormal fear learning and extinction develops in youth suffering with CRPS. Further research examining brain changes post-treatment is needed to determine if treatments that target improving pain and fear levels are associated with concomitant normalization of brain structures.

This study aims to contextualise my own photographic practice in relation to the interaction between mundane and sacred landscapes and the role that the transformative alchemy of light has on our perception of the ordinary. Reference will be made to the development of the genre of landscape photography, with particular reference to the selective aesthetic of pristine Wilderness, as embodied in the work of Ansel Adams, through the ‘man-altered’ landscapes of the New Topographics and Mark Klett’s rephotographic project, to discuss an aesthetic of the everyday. Reference will also be made to the benefits to health and wellbeing that can be achieved as a result of engaging in a state of mindfulness (Crane), also known as optimal experience or flow (Csikszentmihalyi) through photographic practice. Rather than narrowing the focus of the study by excluding relevant information to make the research less complex, the thesis comprises information from a diverse range of disciplines encompassing both the more obviously creative subjects of photography, aesthetics and poetry and areas such as health care. Given the parameters of the PhD process in relation to the breadth of the research undertaken, the specific study of each diverse element is, of necessity, not as detailed as it may have been had a single, more specifically defined, area of research been the entire focus of the research. The inclusive nature of the research presented in this thesis offers unique insights by providing direct comparisons and establishing new relationships between the theoretical and methodological approaches of a range of differing disciplines. While a written thesis forms part of the dissemination of the research findings the images that have emerged as a result of engagement with the study will be exhibited as an integral element of the outcome. The images that have been created as a result of the research process will take their place as objects within the world, offering viewers potential new ways of perceiving and experiencing what Rancière refers to as the ‘splendour of the insignificant’ within the landscape of their own everyday lives.

Having a child who is suffering with chronic pain can profoundly impact a parent’s life. Reciprocally, parent cognitive, emotional, and behavioral responses to their child’s chronic pain can influence the child pain experience. We developed the Parent Risk and Impact Screening Measure (PRISM) to assess parent physical and emotional functioning, behavioral responses to child pain, and impact on daily life due to their child’s chronic pain. In an effort to validate this screening tool, we examined the PRISM in relation to existing measures of parent distress, parent behavior, and child functioning. The 30-item PRISM was administered via RedCAP survey to 112 parents of children with persistent pain presenting to a multidisciplinary pain clinic at Boston Children’s Hospital. Parents also completed the Patient Reported Outcomes Measurement Information System (PROMIS-29), Bath Adolescent Pain Questionnaire-Parental Impact Questionnaire (BAQ-PIQ), Adult Responses to Children’s Symptoms (ARCS), and Pain Catastrophizing Scale (PCS). Children completed the Functional Disability Inventory (FDI), Fear of Pain Questionnaire (FOPQ), and Pediatric Quality of Life Inventory (PedsQL). Parents were predominantly mothers (84%), married (74%), and college- educated (70%). Their children (ages 8-18) were predominantly female (88%) and endorsed daily pain (84%; Mean=6/10). PRISM total scores were strongly correlated with parent general symptoms of depression, anxiety, fatigue, social restrictions, and pain interference (PROMIS-29; r=0.47, 0.54, 0.59, 0.57, 0.38). PRISM total scores were also highly associated with parent pain-specific domains including self-blame and helplessness (BAP-PIQ; r=0.62), parent behavior (BAP-PIQ; r=0.54), and protective responses (ARCS; r=0.59). For child outcomes, higher PRISM scores correlated with more disability (FDI; r=0.49), higher fear of pain (FOPQ; r=0.53), and lower functioning within emotional, social, and psychosocial domains (PedsQL; r=0.36, 0.34, 0.48). Altogether the PRISM tool appears to be a brief and clinically important means of screening parent distress and behaviors associated with child pain-related dysfunction. Future work will include item level analysis with the goal of reducing the length of this screening tool.

OBJECTIVES: This study compared mother, father, and child self-reported pain sensitivity and psychosocial functioning during an intensive pediatric pain rehabilitation treatment. METHODS: Twenty children with chronic pain and their parents were enrolled in an intensive pediatric pain rehabilitation center and completed measures of pain sensitivity, fear of pain, pain catastrophizing, functional disability, and current and usual pain ratings at admission and discharge. RESULTS: Bivariate correlations and one-way ANOVAs were used. Pain sensitivity and psychosocial variables for mother, father, and child decreased from admission to discharge. There was no correlation between pain sensitivity and psychosocial variables and no significant main effect for time. CONCLUSIONS: Results indicate a need for a larger sample to further explore the relationship between these variables.

Mindfulness is a cognitive attribute that is associated with better health and well-being. Fibromyalgia is a neurosensory disorder primarily characterized by chronic pain and comorbid depression, leading to an increased risk for alcohol-related problems. Empirical literature confirms mindfulness has beneficial associations with chronic pain, depression, alcohol-related problems, and fibromyalgia. Mindfulness may lead to better health and well-being by facilitating self-monitoring, objective reperceiving, and purposeful changing of health-related behaviors. It was hypothesized that higher levels of mindfulness would be related to lower levels of chronic pain and depressive symptoms, and, in turn, to fewer alcohol-related problems among individuals with fibromyalgia. Cross-sectional data was collected from 287 participants, and statistically analyzed using parallel mediation models. Hypotheses were only partially supported; mindfulness had an inverse relationship with alcohol-related problems, as hypothesized, although the relationship was not mediated by chronic pain or depressive symptoms.

The American College of Rheumatology (ACR) 1990 criterion classifies fibromyalgia as a clinical syndrome characterized by chronic widespread muscular pain and tenderness with hyperalgesia to pressure over 11/18 tender points of at least 3 months duration. Fibromyalgia is characterized by chronic widespread musculoskeletal pain and is associated with fatigue and cognitive dysfunction. The cause of fibromyalgia is unknown, but it has been shown to demonstrate sensitization of the central nervous system pain pathways by demonstrating lower pain pressure thresholds and reduced conditioned pain modulation (CPM). Pain and fatigue associated with fibromyalgia can interfere with daily function, work, and social activities. Without greater understanding of the interaction of pain, fatigue and function, we are limited in our ability to improve these symptoms for individuals with fibromyalgia. We designed three experiments to examine the relationship of pain, fatigue and function in individuals with fibromyalgia. Regression analyses demonstrated significant models that included pain, fatigue and fear of movement for prediction of function and quality of life in individuals with fibromyalgia and healthy controls. The fatigue study (cognitive fatigue, physical fatigue and dual fatigue task) demonstrated that people with fibromyalgia show enhanced pain and fatigue to both cognitive and physical fatigue tasks and reduced function in the physical fatigue task in comparison to healthy controls. Our final study showed active TENS restores CPM, decreases deep tissue pressure pain, decreases pain and fatigue during movement for individuals with fibromyalgia.