Psychological adjustment to chronic pain has been recently explored within three separate frameworks: a behaviour-focused account of chronic pain acceptance within the broader remit of Acceptance and Commitment Therapy; an emotion-focused approach with various research programs investigating the role of anger, fear, depression and also shame and positive emotions in chronic pain; and a cognitionfocused perspective more recently reframed in terms of illness perceptions as part of a wider model of response to health threats, the Self-Regulatory Model. Although these frameworks have broad areas of overlap, limited research has been directed at integrating acceptance, emotions and illness perceptions into a common, comprehensive account of psychological adjustment to chronic pain. Such an account would be beneficial both for providing a parsimonious approach that would guide further research and for developing pain management interventions that would take advantage of existing research from all three domains. The aim of the present thesis was to explore the possibility of integrating these separate areas by studying the relationships between the main concepts (acceptance, emotions, and illness perceptions) in the context of chronic pain. Based on a review of the relevant conceptual and methodological issues of each domain, a theoretical analysis of the similarities and differences between them was developed, with particular emphasis on the potential of existing models to support an integrative account. This analysis provided specific hypotheses regarding each domain and the interrelationships between them, which were investigated in a longitudinal study on a heterogeneous sample of 265 chronic pain patients using the services of the NHS Lothian Pain Clinic and several patient support organisations. Data were collected via postal and online questionnaires at 3 time points, at 41/2-month intervals (21% attrition rate). Validated questionnaires were used to measure the relevant constructs, with additional questions obtaining information regarding health status, medical history and demographics. The confirmatory analysis (employing a variety of statistical procedures, from correlation to multiple regression, factor analysis, cluster analysis and structural equation modeling) largely confirmed the expected relations within and between domains and was also informative regarding the most suitable data reduction methods. A detailed psychometric analysis of the questionnaires used offered a complementary view on the theoretical and methodological issues involved. An additional exploratory analysis focused on identifying the comparative characteristics of acceptance, emotions, and illness perceptions in predicting health status indicators, controlling for contextual factors such as medical history and demographics. Although no significant longitudinal changes were identified in most parameters (confirming the clinical observation of chronic pain as a stable condition), the longitudinal data allowed an analysis of the stability of the concepts and of the magnitude of their relationships in this patient sample. The analysis of intra- and interpersonal variation via hierarchical longitudinal modeling confirmed the stability of the data, highlighted the necessity of studying variation at both levels, and revealed interesting moderation effects, explained via the proposed concept of ‘discrimination ability’ and several alternative mechanisms. These results can be considered as first steps towards an integrative model of psychological adjustment to chronic pain. It is proposed that the behavioural, cognitive and emotional aspects need further conceptual clarification and these future efforts can be supported by the Cognitive-Affective Model of the Interruptive Function of Pain, within the wider framework of the Self-Regulatory Model.

Thesis (M.Soc.Sc. Psychology)--University of Waikato, 2008. / Title from PDF cover (viewed May 28, 2008) Includes bibliographical references (p. 94-100)

Engaging in 150+ minutes of moderate to vigorous exercise is a recommended self-management strategy for arthritis. Considering the low levels of exercise among individuals with arthritis, national calls have been made for investigation of theory-based processes important for adherence. Self-regulation may be a key process important for persisting with exercise plans in the face of arthritis pain anxiety. The present study examined relationships based upon a known model (Fear Avoidance [FA] model) used to understand self-regulatory behavioral responses to pain anxiety – an unexamined relationship in the arthritis and exercise literature. Primary study purposes involved examination of predictors (pain, pain anxiety, and pain acceptance) of maladaptive and adaptive self-regulatory responses among adults with arthritis who exercise. The secondary purpose examined whether participants who met the recommended dose of exercise over a two-week period significantly differed in their pain cognitions and self-regulatory responses to pain anxiety compared to less active counterparts. Participants were 136 adults (Mage = 49.75 ± 13.88years) with self-reported medically-diagnosed arthritis. Online surveys of pain cognitions and demographics were completed at baseline, followed by self-reported exercise two weeks later. Hierarchical multiple regression analyses illustrated that: (a) pain anxiety was a significant, positive predictor of the use of maladaptive self- regulatory responses (p < .001) and (b) the interaction of pain anxiety x pain acceptance was a significant predictor of the adaptive self-regulatory responses relationship (p < .05). Follow-up analyses illustrated that pain acceptance was a moderator of the pain anxiety – adaptive self-regulatory responses relationship. Participants with higher pain acceptance used adaptive responses less frequently when anxiety was lower than participants with lower acceptance. When pain anxiety was higher, both higher and lower pain acceptance was associated with the more frequent use of adaptive self-regulatory responses. A MANOVA analysis illustrated that participants meeting the recommended exercise dose had significantly lower pain anxiety, higher pain acceptance, and used maladaptive self-regulatory responses less compared to the group not meeting the dose (p’s ≤ .01). Taken together, findings provide the first ever support for FA model predictions in the arthritis – exercise domain. The results of this observational study suggest a next step could be an extended longitudinal study design with multiple time periods of assessment (e.g., measures once a month over a six-month period). Observing the relationships over time would provide a better understanding of within-person changes in the psychosocial variables relative to exercise. Such research would provide a profile of individuals’ levels of anxiety, acceptance, and self-regulatory responses when they either decrease or completely avoid exercise and when they adhere. Obtaining a social cognitive profile of people at risk for exercise avoidance may be a useful tool in the future to identify those who are in need of intervention to deal with their pain anxiety.

Background: In recent years Acceptance and Commitment Therapy (ACT) has gained increasing status as a promising approach to treating chronic pain physical functioning and psychological well-being. The basic premise of ACT as applied to chronic pain is that while pain hurts, it is the struggle with pain that causes suffering. This approach aims to restore effective and adaptive functioning for an individual within a context of continuing pain so that the individual can live a more vital and meaningful life. There is a growing empirical support for the effectiveness of ACT however research has relied on self-reported quantitative outcomes, focused on addressing changes in pain intensity and the physical and psychological impact of chronic pain. There appears to be a gap in the literature on the exploration of the experience of attending an ACT programme for chronic pain from the patient’s perspective. Aim: This study sought to explore the experience of attending an ACT programme for chronic pain within an outpatient NHS hospital setting. Furthermore the study sought to explore the modulating factors influencing clients learning and understanding of the construct of acceptance from the perspective of the participants. Additionally, the experience of attending a group based ACT intervention was explored. Methodology: A qualitative methodology was chosen for the project. The study used a purposive sample of twelve participants, who had all attended the Luton & Dunstable Hospital ACT 8 week outpatient programme for chronic pain. The participants were interviewed through the use of a semi structured interviews, and the transcripts were transcribed and then analysed using Thematic Analysis. Identified themes were further organised using the tool of Thematic Network Analysis. Results: Three global themes emerged from the analysis of the data. The first global theme encompassed the participant’s pre-programme expectations and this theme highlighted the participant’s feelings of hope and hopelessness prior to attending the programme. The second global theme demonstrated the on-going process of living with chronic pain and highlighted the benefits and barriers to adopting and ACT based approach to chronic pain. Finally the third global theme addressed the experience of a group based intervention and included the positive and negative aspects of this experience for the participants. Clinical Implications & Conclusion: Based on the results of this study a number of clinical implications were highlighted in relation to the future development of ACT programmes for chronic pain. These included suggestions in relation to engaging participants in such programmes. Notably, timing issues, validation of physical symptoms, and consideration of the potential barriers to acceptance and understanding of the benefits of adopting and ACT group based pain management approach were discussed.

The current literature highlights the significant role of psychological factors including cognitive (pain related thoughts and beliefs) and acceptance components (pain willingness, activity engagement, psychological inflexibility) in the management of chronic pain. The research is however in the preliminary stages in terms of investigating the specific relationships that exist between these psychological processes in their ability to predict adjustment to pain. This study aims to extend the current findings by investigating the relationships between several cognitive and acceptance components in their ability to predict emotional and physical adjustment in the context of chronic pain. The hypotheses that cognitive and acceptance components mediate the relationship between pain severity and pain adjustment, and also that acceptance mediates the relationship between cognitive components and pain adjustment will be tested. Method The study employed a cross-sectional survey-based design, including 214 chronic pain patients recruited from an NHS pain clinic. Participants completed a series of self-report questionnaires measuring pain severity, fear of movement beliefs, pain self-efficacy beliefs, pain catstrophising, acceptance and psychological flexibility, pain disability, and depression and anxiety. Structural Equation Modeling was used in order to conduct path analyses, investigating the complex relationships between these variables in predicting physical and emotional adjustment to chronic pain. Results The results from a Confirmatory Factor Analysis indicated that a three factor model comprising pain, cognitive and acceptance components as separate latent variables had a poor fit and therefore could not be used in further analysis. The results of path analyses showed that pain self-efficacy was the only variable to have a strong mediating influence between pain and physical adjustment. Findings also supported a nested path model demonstrating that acceptance, catastrophising and self-efficacy were mediators between pain and emotional adjustment, and that acceptance was also a mediator for pain catastrophising and a partial mediator for pain self-efficacy in their relationship with emotional adjustment. Conclusions The importance of pain self-efficacy specifically in predicting physical adjustment to pain is highlighted. A more complex model however is required to explain emotional adjustment, with acceptance playing a more prominent role in comparison with other variables. The findings also provide support for both Cognitive and Acceptance-based interventions in improving adjustment to living with chronic pain. Given the preliminary nature of these findings, further research employing similar statistical methods are required to provide further support.

abstract: The present study examined the association of pain intensity and goal progress in a community sample of 132 adults with chronic pain who participated in a 21 day diary study. Multilevel modeling was employed to investigate the effect of morning pain intensity on evening goal progress as mediated by pain's interference with afternoon goal pursuit. Moderation effects of pain acceptance and pain catastrophizing on the associations between pain and interference with both work and lifestyle goal pursuit were also tested. The results showed that the relationship between morning pain and pain's interference with work goal pursuit in the afternoon was significantly moderated by a pain acceptance. In addition, it was found that the mediated effect differed across levels of pain acceptance; that is: (1) there was a significant mediation effect when pain acceptance was at its mean and one standard deviation below the mean; but (2) there was no mediation effect when pain acceptance was one standard deviation above the mean. It appears that high pain acceptance significantly attenuates the power of nociception in disrupting one's work goal pursuit. However, in the lifestyle goal model, none of the moderators were significant nor was there a significant association between pain interference with goal pursuit and goal progress. Only morning pain intensity significantly predicted afternoon interference with lifestyle goal pursuit. Further interpretation of the present findings and potential explanations of those inconsistencies are elaborated on discussion. Limitations and the clinical implication of the current study were considered, along with suggestions for future studies. / Dissertation/Thesis / M.A. Psychology 2014