Il dolore post-operatorio rappresenta un importante problema sanitario dal punto di vista dei pazienti, degli operatori sanitari e della società nel suo complesso, dati i costi sanitari che provoca. La presente tesi ha l’obbiettivo di identificare i fattori psicologici e psicosociali che ne influenzano lo sviluppo. Nel primo capitolo viene affrontata la complessità del dolore postoperatorio tramite un’esposizione delle prospettive teoriche sul tema. A partire dalla definizione di questo fenomeno, sono stati presi in rassegna i diversi potenziali predittori e sono state descritte le modalità attraverso le quali questi predittori influenzano l’esperienza del paziente. È stata data attenzione particolare al substrato fisiologico che collega i fattori psicologici e psicosociali alla percezione del dolore. Il secondo capitolo presenta una revisione sistematica della letteratura con meta-analisi sui fattori di rischio psicologici e psicosociali associati al dolore cronico postoperatorio. Sono state descritte le scelte metodologiche adottate, come l’impostazione di una ricerca il più possibile comprensiva e l’utilizzo di metodi di imputazione multipla per ridurre l’effetto dei dati. Dopo una selezione tra 6329 studi, sono stati utilizzati 63 articoli per costruire una sintesi narrativa delle ricerche sul tema. I risultati di 34 tra questi studi sono stati successivamente utilizzati per effettuare una meta-analisi. La sintesi narrativa ha permesso di evidenziare ottimismo, salute mentale e paure chirurgiche sono associate al dolore cronico post-chirurgico, mentre l’effetto di ansia, depressione e catastrofismo è maggiormente incerto. I risultati della meta-analisi, al contrario, evidenziano in modo chiaro che depressione, ansia, catastrofismo, paura del movimento, auto-efficacia e ottimismo sono predittori significativi del dolore cronico post-operatorio. Il terzo capitolo presenta i risultati di uno studio longitudinale prospettico volto a studare l’effetto di depressione, ansia, catastrofismo, auto-efficacia, funzioni esecutive e sensibilizzazione centrale sulle traiettorie del dolore post-operatorio acuto. Sono stati arruolati 145 pazienti in attesa di operazioni di protesi d’anca o di ginocchio presso l’ospedale Humanitas Pio X. Prima dell’operazione, i pazienti hanno completato un questionario volto ad indagare i predittori prima elencati. Durante i sette giorni successivi all’operazione, i pazienti hanno compilato un diario che permetteva di misurare l’intensità del dolore e il catastrofismo post-operatorio di stato. Infine, sono stati raccolti i dati su intensità e interferenza del dolore dopo un mese e tre mesi dall’operazione. Sono stati utilizzati modelli di curve di crescita per studiare l’impatto dei predittori sulle traiettorie del dolore e modelli di regressione multipla per individuare i predittori del dolore al follow-up. I risultati hanno permesso di evidenziare che, controllando per sesso, tipo di procedura chirurgica e intensità del dolore pre-operatorio, la sensibilizzazione centrale è associata all’intercetta delle traiettorie del dolore, la flessibilità cognitiva è associata alla loro pendenza, e che il catastrofismo di stato è una covariata del dolore post-operatorio. Al follow-up, l’intensità e l’interferenza del dolore sono risultate essere associate a sensibilizzazione centrale, distress emotivo e funzioni esecutive misurate durante il periodo pre-operatorio. Infine, vengono discusse le implicazioni cliniche e di ricerca di questi risultati. / Post-surgical pain is a major health issue from the perspective of patients, health professionals and the society as a whole. This thesis has the aim to identify psychological and psychosocial variables associated with chronic post-surgical pain, and to understand how these factors influence pain trajectories over time. In the first chapter, complexity of post-surgical pain is explored. Starting from the definition of this phenomenon, conceptualization by the biopsychosocial model is presented. To understand how predictors at different levels might influence the patient’s pain experience, pathophysiology of post-surgical pain is scrutinized, with a particular focus on the physiological substrate that can explain how psychological and psychosocial predictors can influence pain perception and modulation. Physiological, psychological and social risk factors for post-surgical pain are then presented. For each, potential mechanisms explaining association with this phenomenon are reviewed and discussed. The second chapter presents a systematic review of the literature with meta-analysis on psychological and psychosocial risk factors of chronic post-surgical pain. Methodological adjustments were adopted to ensure that the synthesis of research results was based on a comprehensive sets of studies, and to take into account the effect of non-significant estimates in case they were not reported by original studies. After a selection from 6329 records, 63 articles were included in a narrative synthesis and 34 studies were employed to perform a meta-analysis. The narrative synthesis of the literature showed that evidence about the effect of psychological predictors is heterogeneous, with few predictors, such as optimism, mental health and surgical fear, consistently associated with chronic post-surgical pain. In contrast, the meta-analysis showed that depression, anxiety, catastrophizing and, to a lesser extent, kinesiophobia, optimism and self-efficacy, have a weak but significant association with chronic post-surgical pain. Results are discussed in the context of the available literature. The third chapter presents the results of a longitudinal prospective study aimed at describing individual trajectories of pain intensity in patients who underwent knee or hip arthroplasty. The focus of this study was the analysis of pain as a process and in its relationship with central sensitization processes, executive functions and trait and state psychological variables. This study was performed with 145 patients listed for surgery at the hospital Humanitas Pio X, which were asked to complete a pre-surgical assessment, to fill a pain diary during the first seven days after surgery and to provide data about their pain after one and three months from surgery. Statistical analyses were performed employing a multilevel growth curve analysis for acute pain trajectories and multiple regressions for follow-up data. Multiple imputation procedures were employed to account for missing information. Results showed that, after controlling for sex, surgical procedure and pain intensity, central sensitization was a predictor of the intercept of pain trajectories, scores on the Trail Making Test Part B were associated with their slope, and that daily post-surgical catastrophizing was a significant covariate of pain intensity. Analyses of follow-up data confirmed the predictive role of central sensitization and showed that emotional distress, along with executive functions, is related with pain intensity and interference. Finally, research and clinical implications of the findings of these studies are discussed.

This thesis follows the research portfolio format and is carried out in part fulfilment of the academic component of the Doctorate in Clinical Psychology at the University of Edinburgh. An abstract provides an overview of the entire portfolio thesis. Chapter One contains a systematic review of published research exploring staff attitudes towards computerized cognitive behavior therapy (cCBT). Chapter Two is an empirical study examining a range of potential predictor variables on well-being outcomes from cCBT. Chapter one is prepared for Behavioural and Cognitive Psychotherapy, whereas chapter two is prepared for submission to the journal, Behaviour Research and Therapy. Both chapters follow the relevant author guidelines. Background: Evidence suggests that computerised cognitive behavioural therapy (cCBT) is both effective and efficacious in treating depression and anxiety. Numerous barriers to its implementation and uptake have been identified, however, including attitudinal variables and high patient attrition rates. Research examining predictors of response from cCBT have tended to adopt the pathological model of distress, focussing on symptom reduction rather than the promotion of well-being. Furthermore, exploration of possible predictors has tended to focus on a narrow range of factors (e.g. age, gender), neglecting key psychosocial variables (e.g. social identification, baseline distress) that could be exerting an effect. Aims: A systematic review examined staff attitudes towards cCBT for depression, anxiety, and comorbid depression and anxiety, focussing on three attitudinal domains: Perceived acceptability of cCBT; staff's self-reported intention to use cCBT in the future, and perceived advantages and disadvantages of cCBT for depression and/or anxiety. An experimental study was subsequently conducted, examining a range of potential predictors on well-being outcomes from a cCBT intervention utilising Beating the Blues. Method: A systematic search across five databases was conducted, followed by manual searches. Strict search criteria were applied, resulting in the identification of 15 studies. These were subjected to quality assessment, data extraction and synthesis. For the empirical study, data from 1354 participants was collected, with subgroup-analyses conducted on those completing measures of life and mental health satisfaction, functioning and well-being. Key potential predictors of interest were level of group identification, baseline distress, and socioeconomic deprivation. Results: Findings from the systematic review indicated that staff held relatively positive attitudes towards cCBT, with some ambivalence emerging in relation to perceived advantages and disadvantages of the intervention. The empirical study obtained significant effects of group identification on life and mental health satisfaction. A mediating impact of group identity on baseline distress emerged, whereas a moderating effect of baseline distress on deprivation was obtained for the functioning model. Discussion: The current findings demonstrated both positive and negative aspects of staff attitudes towards cCBT for depression and/or anxiety, whereas the empirical project established a clear link between social identification, baseline distress, and well-being. Results from both studies are discussed in terms of clinical implications relating to the uptake of cCBT.

Depression and anxiety are common psychiatric disturbances in Parkinson's disease (PD). Past studies have demonstrated a relationship between depression and cognitive decline in PD; however, the unique influence of anxiety has not been well studied. The objective of the present study was to differentiate the unique influences of depression and anxiety on cognitive functioning in PD. Sixty-eight cognitively intact PD patients with mild to moderate motor disease severity completed self-report questionnaires and neuropsychological tests. Two hierarchical regression analyses were conducted with executive functioning performance as the criterion variable, and two additional hierarchical regression analyses were conducted with memory performance as the criterion variable. Depression and anxiety, as measured by the Depression Anxiety and Stress Scales (DASS), served as predictors for all analyses. Each set of analyses examined the amount of added, unique variance accounted for by anxiety when depression was entered as the first predictor, and also examined the amount of added, unique variance accounted for by depression when anxiety was entered as the first predictor. It was found that depression significantly predicted delayed recall memory performance when entered as the first and second predictor. In contrast, anxiety did not significantly predict performance on any of the cognitive measures. Two DASS subscales assess for the physical symptoms of anxiety, and these subscales were not significantly correlated with any cognitive variables. However, the DASS subscales tapping into non-physical aspects of anxiety were significantly associated with several cognitive variables. Patients may have endorsed physical symptoms of anxiety due to the symptoms associated with PD, and not as a result of the genuine presence of anxiety. This could have masked a potential relationship between anxiety and cognitive functioning in PD, and suggests that specific components of anxiety may be associated with cognition in PD. Future adaptation of the DASS may be necessary to differentiate the unique influences of depression and anxiety in PD patients.

The numbers of people with spinal cord injuries (SCI) in Thailand are increasing. Thai rehabilitation care focuses treatment on acute care with little attention to the lives of clients after discharge from institutions. To date, there has been no research on rehabilitation outcomes and factors relevant to these issues for people with SCI at home and in the community in Thailand. The purpose of this study was to identify and compare the outcomes of functional status, depression, anxiety and stress, and health status of people with SCI, both at discharge and at three months post-discharge from hospital. One hundred twenty-one participants with SCI were recruited from ten major hospitals in Thailand. Data was collected at 48 hours pre-discharge and again at three months post-discharge using the Functional Independence Measure (FIM), the Depression, Anxiety, and Stress Scale (DASS), and the SF-36 Health Survey. The results demonstrated that mean scores of functional status at discharge were significantly higher than at three months post-discharge. Depression and anxiety scores at discharge were significantly lower than depression and anxiety scores at three months postdischarge. Stress score had not significantly changed from discharge to post-discharge. Health status scores at discharge were also higher than at three months post-discharge on eight subscales. Factors relevant to or predicting functional status were marital status, attendant care, number of architectural barriers, fulfilled occupational therapy (OT) needs, and number of different services required but not received. Factors predicting depression, anxiety and stress were marital and economic status, age at onset, education level, duration of disability, fulfilled OT needs, number of different services received, and numbers of different service required but not received. / Factors predicting health status were marital status, economic status, age at onset, education level, duration of disability, attendant care, number of architectural barriers, fulfilled OT needs, number of different services received, and number of different services required but not received. Some predictive factors are culture-specific, but on others, rehabilitation professionals could ease the transition from hospital to home for people with SCI.

Abstract Background: Cognitive Behaviour Therapy, (CBT) is well established as an effective treatment for depression. Its applicability in routine public mental health practice is however unknown, as most published studies excluded participants with suicide risk or if co-morbid with other disorders such as schizophrenia or bipolar affective disorder. Clients of public mental health services are characterised by symptom severity, chronic course of illness, treatment resistance and / or co-morbidity. In order to determine whether CBT has utility in routine public mental health practice, it is important to find out whether symptoms of depression (and anxiety) in this client population will respond to a course of CBT provided as part of standard care. Aims and Hypotheses: This effectiveness study aimed to ascertain if CBT is effective in treating depressed and/or anxious symptoms when such symptoms exist within the clinically more complex population found within Community Mental Health Services / Settings, (CMHSs). It was hypothesised that clients receiving CBT would show reliable and clinically significant improvement in symptoms of depression and anxiety but that the amount of improvement would be less than that reported in efficacy studies with less complex client groups. Method: This was a repeated measures, uncontrolled intervention study with results benchmarked against published data. Forty six adult clients of the Inner North Brisbane Mental Health Service (INBMHS) with diagnoses of Depression and / or Anxiety, in isolation or in conjunction with Schizophrenia, Bipolar affective disorder, or a Personality Disorder were treated with an eight (8) session manualised CBT program as part of routine clinical care. Standardised measures of depression, anxiety and stress were taken at time of referral, time of the commencement of treatment, time of treatment completion and at six-month post completion of treatment. Results: Participants showed reliable and statistically significant improvement in self reported symptoms from commencement to completion of treatment. Gains were retained at follow-up. Effect sizes were in the moderate to large range and improvements were clinically significant for approximately one third of the participants. Conclusions: CBT seems to be an effective treatment for depression and anxiety where such symptoms exist within a mental health population. Further research addressing the limitations of this study would add strength to the argument that the mental health population could benefit from the broad availability of such treatment.

The purpose of the present study was to investigate the relationship between false memory and trait anxiety, depression and personality characteristics with emotionally valenced material (positive, depression related, threat related and neutral). Participants were 131 Middle East Technical University students. Four groups (depressed, anxious, mixed and control) were formed in order to differentiate the effects of trait anxiety and depression. Beck Depression Inventory (BDI) and Trait Form of State Trait Anxiety Inventory (STAI-I) were administered. In order to measure false memory creation, a variant of Deese-Roediger-McDermott (DRM) paradigm was used. It was hypothesized that the anxious group would produce more false memories for threat related words as compared to other groups. In addition, the depressed group was expected to display higher levels of false memory for depression related words as compared to other groups. One-way MANOVA was used to analyze the data. The results showed that there was a group difference only in terms of threat related words&rsquo / accuracy. Also people were categorized as &ldquo / low&rdquo / and &ldquo / high&rdquo / in the six personality characteristics as measured by Big Five Questionnaire. It was hypothesized that people high in openness to experience would commit less false memories as compared to people low in the trait. This was true for only positive material. Further, other personality characteristics were analyzed in order to discover the relationship between false memory and personality. The results were discussed in terms of relevant literature.

The aim of the present study was to investigate the relationship between the stressors of the caregiving process and the health related outcomes (depression, anxiety, and general psychological health) in caregivers of children with leukemia. Caregiver Stress Model was used as the conceptual framework for the study. In order to measure the stressors of the caregivers, caregiver well-being scale was adapted to Turkish culture as the study 1 by using the caregivers of family members with various chronic illnesses. The analyses showed that Turkish version of the caregiver well-being scale had satisfactory psychometric properties for Turkish caregivers. The sample of the study 2 was composed of 100 caregivers of children with leukemia, who were treated at oncology or hematology departments of hospitals in Ankara and izmir, Turkey. Nine mediation models were tested using problem focused coping, emotion focused coping, and social support as mediators. The models included primary stressors (caregiving tasks and basic needs) and secondary stressors (interpersonal relationships and role strain) as independent variables / and depression, anxiety, and general psychological health as dependent variables. The findings suggested that emotion focused coping and social support were significant mediators of the relationships between the stressors and the outcomes, however, problem focused coping was not a significant mediator. Different patterns of significant relationships were found between the primary stressors, secondary stressors, and the outcome variables. However, caregiving tasks was not significantly predicting of any of the outcome variables. The strengths and limitations, as well as the implications of the findings, were discussed.

This study aimed at revealing the role of the family functioning, coping styles, and basic personality characteristics on depression and anxiety symptoms of mothers. The participants were 155 mothers, having at least one child and living in Ankara. Beck Depression Inventory, Mc Master Family Assessment Device, Trait Anxiety Inventory, Basic Personality Traits Inventory, and The Ways of Coping Inventory were administered in addition to the demographic form. Firstly, it was expected that, there would be significant differences in depression and anxiety levels of the participants&rsquo / who have different income and education levels, different number of children, and different ages. Secondly, it was expected that, there would be significant differences in family functions, coping strategies, and personality traits of participants&rsquo / who have different income and education levels, different number of children, and different ages. Lastly, Associates of depression and anxiety were examined via regression analyses. According to the result of regression analyses, regarding the depression, low income level, high level of neuroticism, and low level of negative valence traits, problems of general functioning of family and using less problem focused coping strategy were found to be associated with the depression level of mothers. With regard to the anxiety symptoms, low income level, low level of extraversion, conscientiousness, neuroticism, and openness to experience, problems of general functioning of family, and using less problem focused and emotion focused coping strategies were found to be associated with anxiety levels of mothers. These findings were discussed with reference to the relevant literature. Future research topics were suggested and clinical implications of the study were stated.

The aim of the present study was to investigate the role of metacognition as a mediator of the relationship between smoking dependence and depression/anxiety/ negative impact of life experiences. A sample of 202 adult smokers completed the following questionnaires: Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Life Experiences Survey (LES), Meta-Cognitions Questionnaire-30 (MCQ-30), and Fagerstr&ouml / m Test of Nicotine Dependence (FTND). The path analyses were used to test a mediation model in which depression, anxiety, or negative impact of life experiences was the predictor of metacognition, which in turn was a predictor of smoking dependence. Twelve mediation models were tested using total scores of metacognition, and its factors including positive beliefs about worry, negative beliefs about worry, lack of cognitive confidence, beliefs about need to control thoughts, and cognitive self-consciousness as mediator variables. The models included depression, anxiety, or negative impact of life experiences as independent variables / and smoking dependence as dependent variable. The results suggested that neither total metacognition score nor the individual metacognitive dimensions did mediate the relationship between smoking dependence and depression/anxiety/negative impact of life experiences. The results and limitations, as well as the implications of these findings, were discussed by referring to the relevant literature.

The purpose of the current study was to examine the path of parental acceptancerejection/ control, personality traits, coping strategies and psychological distress consequently. For the purpose of this study, 444 adults (134 male, 308 female, and 2 unknown) between the ages of 17 and 35 (M = 21.60, SD = 2.77) participated in the current study. The data was collected by a questionnaire battery including a Demographic Variable Sheet, Mother and Father Forms of Parent Acceptance- Rejection/Control Questionnaire, Beck Depression Inventory, Trait Anxiety Inventory, The Ways of Coping Inventory, and Basic Personality Traits Inventory. The three sets of hierarchical multiple regression analyses were conducted to reveal the significant associates of psychological distress. As expected, the results of the current study revealed that parental rejection, different personality traits and different coping strategies had associated with psychological distress as depression and trait anxiety. Following findings and the relevant literature, the limitations, therapeutic implications of the current study, and the suggestion for future research were discussed.