History of abuse and its relationship to pain experience and depression in women with chronic pelvic pain

Integrated Care for Persons With Persistent Gynecologic Conditions

Persons with persistent gynecologic conditions frequently cope with complex biopsychosocial challenges and benefit from integrated behavioral health evaluation and treatment within gynecologic practices. Integrated care refers to the provision of behavioral health services within a health care setting which contributes to improved patient, provider, and practice outcomes, however, has not been commonly provided in traditional gynecologic practices. Several models of integrated behavioral health are reviewed. Each model holds specific applications in primary and specialty gynecology settings and may enhance the gynecologic patient experience. This article reviews current research supporting integrated care and describes implementation, funding, and evaluation to improve patient outcomes.

Adverse childhood experience is associated with an increased risk of reporting chronic pain in adulthood: a stystematic review and meta-analysis

Background: Adverse childhood experiences (ACEs) have been shown to negatively affect health in adulthood. Estimates of associations between ACEs and chronic painful conditions are lacking.Objectives: This systematic review and meta-analysis aimed to evaluate associations between exposure to ACEs and chronic pain and pain-related disability in adults.Methods: We searched 10 electronic databases from inception to February 2023. We included observational studies assessing associations between direct ACEs (childhood sexual, physical, emotional abuse, or neglect) alone or in combination with indirect ACEs (witnessing domestic violence, household mental illness), and adult chronic pain (≥3 months duration) and pain-related disability (daily activities limited by chronic pain). Pairs of reviewers independently extracted data and assessed study risks of bias. Random-effect models were used to calculate pooled adjusted odds ratios [aOR]. Tau square [T2], 95% prediction intervals [95%PI] and I2 expressed the amount of heterogeneity, and meta-regressions and subgroup meta-analyses investigated sources of heterogeneity (PROSPERO: CRD42020150230).Results: We identified 85 studies including 826,452 adults of which 57 studies were included in meta-analyses. Study quality was generally good or fair (n = 70). The odds of reporting chronic pain in adulthood were significantly higher among individuals exposed to a direct ACE (aOR, 1.45, 95%CI, 1.38-1.53). Individuals reporting childhood physical abuse were significantly more likely to report both chronic pain (aOR, 1.50, 95CI, 1.39-1.64) and pain-related disability (1.46, 95CI, 1.03-2.08) during adulthood. Exposure to any ACEs alone or combined with indirect ACEs significantly increase the odds of adult chronic painful conditions (aOR, 1.53, 95%CI, 1.42-1.65) and pain-related disability (aOR, 1.29; 95%CI, 1.01-1.66). The risk of chronic pain in adulthood significantly increased from one ACE (aOR, 1.29, 95%CI, 1.22-1.37) to four or more ACEs (1.95, 95%CI, 1.73-2.19).Conclusions: Single and cumulative ACEs are significantly associated with reporting of chronic pain and pain-related disability as an adult.

How life events are perceived to link to bodily distress: A qualitative study of women with chronic pelvic pain

Chronic pelvic pain (CPP) is highly prevalent among women and the condition is poorly understood. In addition to multiple symptoms from the pelvis, CPP patients frequently suffer bodily distress like musculoskeletal pain and negative emotional, behavioral, and sexual implications. This paper is based on a qualitative study including semi-structured interviews with eight women with CPP. Our project has been conducted within the framework of phenomenology, particularly shaped by the concept of embodiment. We discuss the link between the lived body and CPP and address the value of making the life experiences of the patient relevant to understand this complex condition.

Mediators of the association between childhood trauma and pain sensitivity in adulthood: a Multidisciplinary Approach to the Study of Chronic Pelvic Pain Research Network analysis

ABSTRACT

Urologic chronic pelvic pain syndrome (UCPPS) is a complex, debilitating condition in which patients often report nonpelvic pain in addition to localized pelvic pain. Understanding differential predictors of pelvic pain only vs widespread pain may provide novel pathways for intervention. This study leveraged baseline data from the Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network's Symptom Pattern Study to investigate the impact of childhood sexual and nonsexual violent trauma on pelvic and nonpelvic pain sensitivity among adult patients with UCPPS, as well as potential mediators of this association. Study participants who met inclusion criteria for UCPPS completed questionnaires assessing childhood and recent trauma, affective distress, cognitive dysfunction, and generalized sensory sensitivity. Experimental pain sensitivity was also evaluated using standardized pressure pain applied to the pubic region and the arm. Bivariate analyses showed that childhood violent trauma was associated with more nonviolent childhood trauma, more recent trauma, poorer adult functioning, and greater pain sensitivity at the pubic region, but not pain sensitivity at the arm. Path analysis suggested that childhood violent trauma was indirectly associated with pain sensitivity at both sites and that this indirect association was primarily mediated by generalized sensory sensitivity. More experiences of recent trauma also contributed to these indirect effects. The findings suggest that, among participants with UCPPS, childhood violent trauma may be associated with heightened pain sensitivity to the extent that trauma history is associated with a subsequent increase in generalized sensory sensitivity.

The Risk Factors of Chronic Pain in Victims of Violence: A Scoping Review

Violent situations are unfortunately very frequent in women and children all over the world. These experiences have long-term consequences for adult physical and psychological health. One of the most reported is chronic pain, defined in various sub-diagnoses and present in all types of violence. Unfortunately, the etiology of this condition is not clear and neither are the predisposing factors. The aim of this scoping review is to examine the literature trends about the probable risk factors of chronic pain in violence victims. Considering a bio-psycho-social model, it is possible to hypothesize the presence of all these aspects. The results will be discussed in the present article.

Exploring the potential of a standardized test in physiotherapy: making emotion, embodiment, and therapeutic alliance count for women with chronic pelvic pain

Introduction

There has been an increased use of standardized measurements in health care meant to provide objective information to enhance the quality and effectivity of care. Patient performance tests are based on standardized predefined criteria with a limited focus. When facing multifaceted health conditions, information expanding the predefined criteria in a standardized test may be required to understand the patient's complex symptoms. Relying on test information based on measurements according to functional biology, one risks missing information communicated by the sensitive and expressive body of the individual patient. The aim of this article is to investigate how body, self and illness perception is constituted as a co-construction between a physiotherapist and a patient with complex symptoms, expanding the use of a standard physiotherapy test.

Methods

This qualitative study is based on video-recordings and in-depth interviews of seven women with the complex health condition chronic pelvic pain. The video recordings consist of the patients performing the Standard Mensendieck test pre- and post-treatment with Norwegian psychomotor physiotherapy. The interviews are based on the patients` and the physiotherapists` conversations while watching and elaborating on these video recordings. Empirical data is analyzed within the theoretical perspectives of phenomenology and enactive theory, especially focusing on the concepts of embodiment and intersubjectivity.

Results

Taking an embodied approach, considering the body as expressive, communicative, and vulnerable to the environment and context, the results show that through bodily expressions the patients experienced the test situation as demanding, thus providing information beyond what the test was intended to measure. Additionally, when administering a standardized test, the interaction between the therapist and the patient had an impact on the results. Sensitive attention towards the patients bodily expressive emotions as a vital part of the interaction, reinforced therapeutic alliance by ensuring the integrity and autonomy of the patient.

Discussion

Mutual communication, gave new insights regarding the patients' complex symptoms and reinforced their belief in themselves and their recovery processes. Applying the patient's expertise on herself and her life together with the professional expertise may make health care an interdependent practice where sensemaking is a co-construction of meaning between the patient and the health personnel.

What is the association between childhood adversity and subsequent chronic pain in adulthood? A systematic review

Background

Adverse childhood experiences and chronic pain are complex problems affecting millions of people worldwide, and result in significant healthcare utilisation. Our review aimed to determine known associations between adversity in childhood and chronic pain in adulthood.

Methods

We performed a prospectively registered systematic review (PROSPERO ID: 135625). Six electronic databases (Pubmed, Medline, Cochrane, Scopus, APA PsycNet, Web of Science) were searched from January 1, 2009 until May 30, 2022. Titles and abstracts were screened, and all original research studies examining associations between adverse childhood experiences and chronic pain in adulthood were considered for inclusion. Full texts were reviewed, and a narrative synthesis was used to identify themes from extracted data. Ten percent of studies were dual reviewed to assess inter-rater reliability. Quality assessment of study methodology was undertaken using recognised tools.

Results

Sixty-eight eligible studies describing 196 130 participants were included. Studies covered 15 different types of childhood adversity and 10 different chronic pain diagnoses. Dual reviewed papers had a Cohen's kappa reliability rating of 0.71. Most studies were of retrospective nature and of good quality. There were consistent associations between adverse childhood experiences and chronic pain in adulthood, with a 'dose'-dependent relationship. Poor mental health was found to mediate the detrimental connection between adverse childhood experiences and chronic pain.

Conclusion

A strong association was found between adverse childhood experiences and chronic pain in adulthood. Adverse childhood experiences should be considered in patient assessment, and early intervention to prevent adverse childhood experiences may help reduce the genesis of chronic pain. Further research into assessment and interventions to address adverse childhood experiences is needed.

Gynaecological care of women with chronic pelvic pain: Patient perspectives and care preferences

OBJECTIVE

To explore the experiences and care preferences of women with chronic pelvic pain, with or without a history of sexual trauma, seeking gynaecological care.

DESIGN

Qualitative study.

SETTING

Ambulatory endometriosis centre.

POPULATION OR SAMPLE

Women aged 18-55 years with chronic pelvic pain.

METHODS

Baseline demographics and sexual trauma history were obtained, and participants were assigned to focus groups according to a positive (four groups, 13 participants) or negative (two groups, nine participants) screen for a history of sexual trauma. The focus groups were led by a clinical psychologist and a gynaecological surgeon and consisted of semi-structured interviews. The interviews were audio-recorded and transcribed, and the transcripts were coded in NVivo 12.

MAIN OUTCOME MEASURES

Content analysis was used to derive themes according to the participants' own words.

RESULTS

Participants with chronic pelvic pain, with or without a history of sexual trauma, experienced delay in diagnosis and repetitive dismissals by clinicians. Participants' experiences of dismissals included: clinicians not listening, insufficient allocation of time to appointments and perceived redundant medical testing (i.e. sexually transmitted infection testing, urine cultures, ultrasounds). Participants identified clinician interactions as pivotal in coping with both pelvic pain and sexual abuse. Participants also provided feedback regarding trauma-informed practices and care delivery specific to patients with chronic pelvic pain.

CONCLUSION

Patients with chronic pelvic pain, with or without a history of sexual trauma, report negative experiences when interacting with the healthcare system. They have clear needs and preferences regarding gynaecological care and provide feasible suggestions for improving care delivery.

The association between adverse childhood experiences and peripartal pain experience

ABSTRACT

Adverse childhood experiences (ACEs) are associated with altered ongoing and evoked pain experiences, which have scarcely been studied for the peripartum period. We aimed to investigate how ACEs affect pain experience in pregnancy and labor. For this noninterventional trial with a short-term follow-up, pregnant women were divided into a trauma group (TG) with ACEs (n = 84) and a control group (CG) without ACEs (n = 107) according to the Childhood Trauma Questionnaire. Pain experience in pregnancy and labor was recorded by self-report and the German Pain Perception Scale. Pain sensitivity prepartum and postpartum was assessed by Quantitative Sensory Testing and a paradigm of conditioned pain modulation (CPM), using pressure pain thresholds (PPTs) and a cold pressor test. The TG showed higher affective and sensory scores for back pain and a more than doubled prevalence of preexisting back pain. Pelvic pain differences were nonsignificant. The TG also exhibited increased affective scores (1.71 ± 0.15 vs 1.33 ± 0.11), but not sensory scores for labor pain during spontaneous delivery. There were no group differences in prepartum pain sensitivity. While PPTs increased through delivery in the CG (clinical CPM), and this PPT change was positively correlated with the experimental CPM (r = 0.55), this was not the case in the TG. The association of ACEs with increased peripartal pain affect and heightened risk for preexisting back pain suggest that such women deserve special care. The dissociation of impaired clinical CPM in women with ACEs and normal prepartum experimental CPM implies at least partly different mechanisms of these 2 manifestations of endogenous pain controls.

Prevalence, severity and impact of chronic pain among a representative cross-sectional study of New Zealand high school students

AIM

To report the prevalence of self-reported chronic pain and severity among young people in New Zealand and explore the relationships between pain and mental health, substance use, socialisation and school engagement.

METHODS

Prevalence of self-reported chronic pain frequency and severity are reported from an anonymous, representative cross-sectional self-administered health and well-being questionnaire by students aged 12-18 years in New Zealand. Multivariable models exploring chronic pain and mental health, substance use, socialisation and school engagement are reported controlling for age, sex, ethnicity, socio-economic status, disability and history of sexual abuse.

RESULTS

Overall, 22.8% (95% confidence interval (CI) 21.2-24.5) of young people reported chronic pain for 6 months or more, with 3.2% (95% CI 3.1-4.5) reporting severe pain weekly or more often. Females and rural adolescents were more likely to report chronic and severe pain. Asian youth reported less pain than other ethnic groups. Increased severity of pain was associated more with poorer daily functioning and socialising than with frequency of pain. Severe pain occurring weekly or more often was more common among students who had a disability (2.3% 95% CI 1.8-2.7 vs. 9.8%, 95% CI 7.2-12.5) or a history of sexual abuse (2.4% 95% 1.9-2.9 vs. 8.5%, 95% CI 6.3-10.5). Those reporting chronic pain had higher proportions of self-reported significant depressive symptoms, lower well-being, lower school engagement and lower access to health care, particularly for those reporting higher levels of intensity and frequency of pain.

CONCLUSIONS

Chronic pain is common in adolescent populations, and has a significant association with decreased daily functioning, socialising, school engagement and mental well-being. Adolescents with chronic pain report significant unmet health-care needs.

A Multidisciplinary Pelvic Pain Clinic: Integrated Health Psychology in a Specialty Care Setting

Purpose: Chronic pelvic pain (CPP) is a relatively common health problem, impacting around 25 million women globally. This study details the development of a multidisciplinary women's CPP clinic at a major U.S. academic medical center, and examines associations between mood, pain symptoms, and trauma history. Materials and Methods: Data were collected from 96 subjects, including self-report measures (Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and Brief Trauma Questionnaire), pain intensity ratings, psychiatric diagnoses, and relevant medical history. Results: Most subjects reported at least one traumatic experience. Nearly half of subjects met criteria for an anxiety disorder and/or a depressive disorder. Most subjects were diagnosed with pelvic floor dysfunction, and more than half were referred to physical therapy. Women with abdominal/pelvic surgery history reported more traumatic experiences than women without surgical history. Women with a history of sexual abuse reported trying more medications and seeking care from a greater number of providers. Many reported pain duration of >2 years. Conclusions: Study findings related to mental health and trauma support a multidisciplinary CPP approach that includes a clinical health psychology component. Future research may investigate the therapeutic processes that apply to this population to identify targeted efficacious interventions.

The Experiences of Persistent Pain Among Women With a History of Intimate Partner Violence: A Systematic Review

Women experience persistent pain at higher rates than men; however, women are less likely to be provided with adequate or appropriate care and more likely to have their pain experiences dismissed. The purpose of this review is to consider the complex interaction of the biopsychosocial factors in the experience of persistent pain in order to inform improved models of care. Given persistent pain is among the most frequently reported health consequences of intimate partner violence (IPV), this review focused on studies exploring the association between persistent pain and IPV. Three reviewers independently and systematically searched seven databases. Qualitative and quantitative studies describing the association between IPV and persistent pain published between January 2000 and June 2018 were included. Twelve studies met the inclusion criteria. The included studies demonstrated that a history of IPV places an additional burden on women who experience persistent pain that cannot be explained by an underlying psychological condition. Health care practitioners should be aware of this phenomena to ensure diagnosis, assessment, and treatment plans are targeted accordingly. Future policy directives and research should account for and seek to elucidate this additional burden.

Adverse Childhood Experiences (ACEs) and Internalizing Mental Health, Pain, and Quality of Life in Youth With Chronic Pain: A Longitudinal Examination

The aims of this longitudinal study were to 1) identify categories of adverse childhood experiences (ACEs) (ie, neglect, abuse, household dysfunction in childhood) that increase risk for internalizing mental health problems, pain-related impairment, and poorer quality of life and 2) examine the moderating role of posttraumatic stress symptoms (PTSS) in these associations, in a clinical sample of youth with chronic pain. At 2 timepoints, youth (N = 155; aged 10-18 years) completed measures of exposure to ACEs, PTSS, depressive and anxiety symptoms, pain intensity, pain interference, and quality of life. Multivariate analyses of variance, linear mixed modeling, and moderation analyses were conducted. Results from cross-sectional and longitudinal analyses were similar; youth with a history of 3+ ACEs reported significantly higher PTSS, depressive and anxiety symptoms, and poorer quality of life than youth with no ACE history. Results also revealed differences in functioning between youth exposed to different types of ACEs (ie, maltreatment only, household dysfunction only, both, none). Finally, PTSS was found to moderate the association between ACEs and anxiety and depressive symptoms. Findings underscore the influence that ACEs can have on the long-term functioning of youth with chronic pain as well as the important role of current PTSS in this association. PERSPECTIVE: This study found that the risk of poorer outcomes imposed by ACEs at baseline remains longitudinally and that posttraumatic stress symptoms (PTSS) moderate the relationship between ACEs and anxiety and depressive symptoms in youth with chronic pain. These results underscore the importance of assessing for ACEs and PTSS alongside chronic pain in youth.

The importance of child abuse and neglect in adult medicine

The risk for adverse consequences and disease due to the trauma of child abuse or neglect is easily assessed using the self-administered modified ACEs questionnaire. Exposure to child maltreatment is endemic and common. At least one out of every ten USA adults has a significant history of childhood maltreatment. This is a review of the literature documenting that a past history of childhood abuse and neglect (CAN) makes substantial contributions to physical disease in adults, including asthma, chronic obstructive pulmonary disease, lung cancer, hypertension, stroke, kidney disease, hepatitis, obesity, diabetes, coronary artery disease, pelvic pain, endometriosis, chronic fatigue syndrome, irritable bowel syndrome, fibromyalgia, and auto immune diseases. Adults who have experienced child maltreatment have a shortened life expectancy. The contribution of CAN trauma to these many pathologies remains largely underappreciated and neglected compared to the attention given to the array of mental illnesses associated with child maltreatment. Specific pathophysiolologic pathways have yet to be defined. Clinical recognition of the impact of past CAN trauma will contribute to the healing process in any disease but identifying specific effective therapies based on this insight remains to be accomplished. Recommendations are made for managing these patients in the clinic. It is important to incorporate screening for CAN throughout adult medical practice now.

Vulvodynia-It Is Time to Accept a New Understanding from a Neurobiological Perspective

Vulvodynia is one the most common causes of pain during sexual intercourse in premenopausal women. The burden of vulvodynia in a woman's life can be devastating due to its consequences in the couple's sexuality and intimacy, in activities of daily living, and psychological well-being. In recent decades, there has been considerable progress in the understanding of vulvar pain. The most significant change has been the differentiation of vulvar pain secondary to pathology or disease from vulvodynia. However, although it is currently proposed that vulvodynia should be considered as a primary chronic pain condition and, therefore, without an obvious identifiable cause, it is still believed that different inflammatory, genetic, hormonal, muscular factors, etc. may be involved in its development. Advances in pain neuroscience and the central sensitization paradigm have led to a new approach to vulvodynia from a neurobiological perspective. It is proposed that vulvodynia should be understood as complex pain without relevant nociception. Different clinical identifiers of vulvodynia are presented from a neurobiological and psychosocial perspective. In this case, strategies to modulate altered central pain processing is necessary, changing the patient's erroneous cognitions about their pain, and also reducing fear avoidance-behaviors and the disability of the patient.

Depression Partially Mediates the Association of Adverse Childhood Experiences with Pain Intensity in Patients with Chronic Pelvic Pain Syndrome: Results from a Cross-Sectional Patient Survey

OBJECTIVE

Adverse childhood experiences (ACEs), such as emotional and physical maltreatment, are linked to chronic pelvic pain syndrome (CPPS) in adults. Psychological factors are important in understanding CPPS. We aimed to determine the nature and frequency of ACEs in male and female patients with CPPS and to investigate whether somatic symptoms and psychological comorbidities mediate the relationship of ACE severity with pain intensity.

DESIGN

Cross-sectional study.

SETTING

Interdisciplinary outpatient clinic for CPPS in Hamburg, Germany.

SUBJECTS

Individuals with CPPS (n = 234) who were 18 to 84 years of age.

METHODS

Using a self-administered questionnaire, we assessed the history of ACEs (ACE Scale), pain intensity (McGill Pain Questionnaire), somatic symptoms (Patient Health Questionnaire-15]), depression (Patient Health Questionnaire-9), and anxiety (Generalized Anxiety Disorder Scale). Parallel mediation analysis was conducted to examine whether the association of ACE severity with pain intensity is mediated by somatic symptoms, depression, and anxiety.

RESULTS

Emotional abuse and neglect were reported more than twice as often as physical abuse and neglect (37.2% vs 17.1%). Depression partially mediated the association of ACE severity with pain intensity in the whole study population. In sex-stratified analyses, different patterns of associations were observed, but somatic symptoms predicted pain intensity in both sexes.

CONCLUSIONS

Emotional maltreatment was highly prevalent, supporting an increased consideration of psychological factors in CPPS and indicating the need to screen for ACEs in patients with CPPS. Findings further suggest that depression and somatic symptoms may be important targets for therapeutic interventions in patients with CPPS who have a history of childhood adversity.

How Might We Screen for Psychological Factors in People With Pelvic Pain? An e-Delphi Study

OBJECTIVE

Persistent pelvic pain (PPP) is a complex condition often influenced by psychological factors that can alter treatment outcomes. These factors are potentially modifiable; however, currently there is no instrument to screen for them. The purpose of this study was to determine: (1) which psychological factors should be screened in individuals with PPP, and (2) the most appropriate statements to represent these psychological factors.

METHODS

The study used a focus group design followed by an electronic-Delphi (e-Delphi) process. A focus group consisting of 8 experts was conducted to determine the relevant psychological factors to screen. These results informed round 1 of the e-Delphi process, consisting of a panel of 14 pain/pelvic pain experts. The e-Delphi process consisted of 3 rounds of online surveys and 2 teleconference discussions to establish consensus on the most appropriate statement to screen for each of the psychological factors.

RESULTS

The focus group identified 13 relevant psychological factors. During the e-Delphi process, relevant screening statements were assessed using a 100-point allocation system. Experts could reword and suggest new statements. Statements were assessed for consensus and stability and were eliminated as the rounds progressed if they met the exclusion criteria. At the termination of round 3, there were 15 statements remaining.

CONCLUSION

The final list of 15 statements will assist clinicians in screening for psychological factors and is an important step for clinicians in providing psychologically informed care to people with PPP. Future research should determine the psychometric properties of the statements to determine their clinical utility as a questionnaire.

IMPACT

This study has refined a list of statements to help screen for psychological factors in individuals with PPP. Developed robustly using an e-Delphi method, this list is an important first step forward for clinicians to provide psychologically informed care to these individuals.

The Effects of a Life Stress Emotional Awareness and Expression Interview for Women with Chronic Urogenital Pain: A Randomized Controlled Trial

OBJECTIVE

Women with chronic urogenital pain (CUP) conditions have elevated rates of lifetime trauma, relational stress, and emotional conflicts, but directly assessing and treating psychological stress is rarely done in women's health care settings. We developed and tested the effects on patients' somatic and psychological symptoms of a life stress interview that encourages disclosure about stressors and uses experiential techniques to increase awareness of links between stress, emotions, and symptoms.

METHODS

In this randomized trial, women with CUP recruited at a multidisciplinary women's urology center received either a single 90-minute life stress interview (N = 37) or no interview (treatment-as-usual control; N = 25). Self-report measures of pain severity (primary outcome), pain interference, pelvic floor symptoms, and psychological symptoms (anxiety and depression) were completed at baseline and six-week follow-up.

RESULTS

Differences between the life stress interview and control conditions at follow-up were tested with analyses of covariance, controlling for baseline level of the outcome and baseline depression. Compared with the control condition, the interview resulted in significantly lower pain severity and pelvic floor symptoms, but the interview had no effect on pain interference or psychological symptoms.

CONCLUSIONS

An intensive life stress emotional awareness expression interview improved physical but not psychological symptoms among women with CUP seen in a tertiary care clinic. This study suggests that targeting stress and avoided emotions and linking them to symptoms may be beneficial for this complex group of patients.

Predictors of Depression, Anxiety and Stress Indicators in a Cohort of Women with Chronic Pelvic Pain

OBJECTIVE

Establishing predictors of mental health outcomes is a crucial precursor to the development and assessment of psychological interventions for women with chronic pelvic pain (CPP). The objective of this study was to identify predictors of depression, anxiety and stress in a cohort of women with CPP.

DESIGN

Cross-sectional analytic study.

METHODS

Pre-treatment questionnaires were collected from 212 women with CPP, who had attended a private specialist pelvic pain clinic over a period of 18 months. Multivariate linear regression with backwards elimination was used to determine the best joint predictors of depression, anxiety and stress scores on the Depression, Anxiety and Stress Scale-21 item (DASS 21).

RESULTS

Of 19 potential predictor variables, seven key predictors of depression, anxiety and stress indicators were identified. Higher depression scores were associated with higher current pain severity, a history of stabbing pains, prior experience of a sexually distressing event, having experienced pain as a child, and never having been pregnant before. Higher anxiety scores were associated with higher current pain severity, a history of stabbing pains, prior experience of a sexually distressing event, younger age of menarche, and younger age. Predictors of high-stress scores were higher current pain severity, a history of stabbing pains, prior experience of a sexually distressing event, and being younger.

CONCLUSION

We have identified several important predictors of mental health in women with CPP. Using this information, psychological assessment and treatment for these women may be better tailored to client needs.

Adverse Childhood Experiences and Symptoms of Urologic Chronic Pelvic Pain Syndrome: A Multidisciplinary Approach to the Study of Chronic Pelvic Pain Research Network Study

Background

Adverse Childhood Experiences (ACEs) such as sexual and physical violence, serious illness, and bereavement have been linked to number of chronic pain conditions in adulthood, and specifically to urologic chronic pelvic pain syndrome (UCPPS).

Purpose

We sought to characterize the prevalence of ACEs in UCPPS using a large well-characterized cohort in comparison with a group of healthy controls. We also sought to determine the association of ACE severity with psychological factors known to impact pain and to determine whether ACEs are associated with patterns of improvement or worsening of symptom over a year of naturalistic observation.

Methods

For longitudinal analyses we used functional clusters identifying broad classes of (a) improved, (b) worsened, and (c) stable groups for genitourinary pain and urinary symptoms. We employed a mediation/path analysis framework to determine whether ACEs influenced 1 year outcomes directly, or indirectly through worse perceptions of physical well-being.

Results

ACE severity was elevated in UCPPS (n = 421) participants compared with healthy controls (n = 414; p < .001), and was most strongly associated with factors associated with complex chronic pain, including more diffuse pain, comorbid functional symptoms/syndromes, and worse perceived physical well-being (all p < .001). Finally, worse physical well-being mediated the relationship between ACE severity and less likelihood of painful symptom improvement (OR = .871, p = .007)) and a greater likelihood of painful symptom worsening (OR = 1.249, p = .003) at 1 year.

Conclusions

These results confirm the association between ACEs and UCPPS symptoms, and suggest potential targets for therapeutic interventions in UCPPS.

Clinical Trial registration

NCT01098279.

Child Abuse and Neglect as Risk Factors for Comorbidity Between Depression and Chronic Pain in Adulthood

It is estimated that comorbidity between depression and chronic pain reaches more than half of the depressed adult patients around the world. Evidence indicates that some stressors, such as early-life stress (ELS), mediate the co-occurrence of depression and chronic pain. This study aimed to assess whether ELS or any of its subtypes could be considered as risk factors for comorbidity between depression and chronic pain. For this purpose, 44 patients in depressive episode were evaluated, in which 22 were diagnosed with depression and chronic pain, and the other 22 patients were diagnosed with depression but without chronic pain. Results had shown that ELS occurrence is more significant among depressive patients with chronic pain compared with those without pain. When subtypes of ELS were evaluated, the group of depressive patients with pain showed significantly higher prevalence of emotional neglect than those depressive participants without pain. Data analysis has shown that severity of the depressive symptoms has a significant impact on the total score of childhood trauma, emotional abuse, physical abuse, emotional neglect, and physical neglect, and that emotional abuse, sexual abuse, and physical neglect have significant impact on the severity of depression. In conclusion, our findings indicate that ELS can be considered as a risk factor for the comorbidity between depression and chronic pain.

Chronic pelvic pain improvement: impact on quality of life and mood

Women with chronic pelvic pain (CPP) frequently suffer from mood disturbances and reduced quality of life. Whether pain improvement ameliorates mood and quality of life is still unclear, and it was investigated in an observational prospective study performed in a cohort of 117 of the outpatient services for endometriosis and chronic pelvic pain at a University Hospital. Depending on disease, women were treated either by surgery or by the administration of an estrogen-progestin or a progestin alone. Pain during menses, between menses and at intercourse was evaluated by a 100 mm visual analog (VAS) scale. Quality of life was evaluated by the SF-36 questionnaire, state of anxiety by the Y-1 form of the State-Trait Anxiety Inventory (STAI-Y1) and depression the Self Evaluating Depression Scale (SDS). Women were 34.2 ± 8.1 years old. After a mean follow-up period of 10.0 ± 9.1 months, and independently on treatment (43.6% surgery), pain during menses (-28.2 ± 36.8; p<.0001), between menses (-11.3 ± 37.1; p<.002) and at intercourse (-8.3 ± 35.4; p<.02) decreased. SF-36 increased (3.3 ± 16.2; p<.03), STAI slightly decreased (-1.9 ± 8.6; p<.02), while depression did not change (-0.7 ± 7.8; p=.36). Pain changes were not related to changes of SF-36 or mood scores. In women with CPP, prolonged pain amelioration, has little impact on mood, particularly on depression. The data support the need for a multidisciplinary approach to women with CPP.

Anxiety and depression in women with and without chronic pelvic pain: prevalence and associated factors

Objectives: To investigate the prevalence of anxiety, depression and mixed anxiety and depressive disorder (MADD) and factors associated with these conditions in women with chronic pelvic pain (CPP) compared to a pain-free control group.

Methods: A cross-sectional study was conducted with 100 women with CPP and 100 without CPP. The Hospital Anxiety and Depression Scale (HADS) was used to evaluate the presence of anxiety and depression. Sociodemographic, behavioral and clinical characteristics were investigated. Fisher’s exact test was used to compare characteristics between groups. A log-binomial regression model was used, with adjustment for age, skin color, schooling, body mass index and pain. Prevalence ratios (PR), together with their 95% confidence intervals (CI), were calculated to investigate factors associated with anxiety, depression and MADD.

Results: The prevalence of anxiety was 66% in the CPP group and 49% in the controls (p=0.02). Depression was identified in 63% of the women with CPP and in 38% of the controls (p<0.01). MADD was present in 54% of the CPP group and in 28% of the controls (p<0.01). In the adjusted analysis, CPP (PR=1.3; 95%CI: 1.1–1.6), physical abuse (PR=1.5; 95%CI: 1.2–1.8) and sexual abuse (PR=1.5; 95%CI: 1.1–1.8) were independently associated with anxiety. Women of 25 to 34 years of age were less likely to have anxiety (PR=0.6; 95%CI: 0.4–0.8). CPP (PR=1.6; 95%CI: 1.2–2.2), physical abuse (PR=1.3; 95%CI: 1.1–1.7) and sexual abuse (PR=1.7; 95%CI: 1.3–2.2) were independently associated with depression. CPP (PR=1.9; 95%CI: 1.3–2.7), smoking (PR=1.5; 95%CI: 1.1–2.1), physical abuse (PR=1.4; 95%CI: 1.1–1.9) and sexual abuse (PR=1.4; 95%CI: 1.1–1.8) were independently associated with MADD.

Conclusions: The prevalence of anxiety, depression and MADD was higher in women with CPP compared to the pain-free controls. Factors associated with mental disorders were identified. The independent association between CPP and anxiety, depression and MADD was noteworthy. These findings suggest that systematic management of psychological factors could contribute towards improving the mental health of these women.

Unpacking the Influence of Abuse and Depression on Grades among Urban Ethnic Minority Adolescents and Young Adults

BACKGROUND

Both depression and a history of abuse have known negative consequences on the overall health of adolescents and young adults (AYAs). Research is not clear, however, on the interactive influence of abuse and depression on academic achievement, especially among AYAs of color.

OBJECTIVE(S)

This study aims to assess the interactive influence of abuse and depression on academic grades among African American and Latino AYAs.

METHODS

The study sample was made up of 476 predominantly urban African American and Latino youth ages 14 to 24. Study participants completed a demographic questionnaire (which included self-reported grades) and the Beck Depression Inventory for Primary Care-Fast Screen. Screenings for abuse were done through three structured methods using the Childhood Maltreatment Interview Schedule-Short Form, a short-structured questionnaire, and a face-to-face unstructured interview with a clinical provider.

FINDINGS

Depression had a significant main effect on grades, while abuse did not. Abuse and depression had a significant interactive effect on grades in that non-depressed adolescents who reported abuse had an almost four point higher average grade score than their non-depressed counterparts who did not report abuse.

CONCLUSIONS

Our findings highlight an unexpected effect in AYAs of color with a history of abuse but no history of depression, suggesting that perhaps there is something intrinsic to this group's resilience or their support systems that protects both against depression and supports their academic achievement. In conclusion, abuse alone does not serve as a predictor of grade achievement. Further work should be done to determine influential factors behind this relationship, with recommendations for school-based counselors and medical providers to screen for depression along with abuse in AYAs in order to determine how best to support this population.

Characteristics of women with chronic pelvic pain referred to physiotherapy treatment after multidisciplinary assessment: a cross-sectional study

Background and aims

Chronic pelvic pain (CPP) in women is a complex condition that can seriously impact health and quality of life. Clinical guidelines for CPP place great demands on healthcare professionals, as they require both specialized knowledge about the pelvic area and knowledge of the mechanisms of chronic pain. To ensure best possible assessment and treatment of these women it is important to bring about more knowledge of the special CPP features. The purpose of this paper is to describe the characteristics of women with CPP evaluated at the University Hospital of North Norway, and further referred to physiotherapy. The frequency of having a history of abuse or previous pelvic surgery will also be reported, and analyses performed to investigate if subjective health status differs between women with and without these experiences.

Methods

We collected cross-sectional data from 62 women with CPP aged 20–65 (mean age 38.0), referred to physiotherapy after assessment by medical specialists. Data were collected by semi-structured interviews for demographic variables and medical history, and self-administered questionnaires on pain intensity, sexual function, urinary incontinence (UI), anal incontinence (AI), obstructed defecation syndrome (ODS), subjective health complaints (SHC) and symptoms of anxiety and depression.

Results

Pain duration of more than 10 years was reported by 42%, mean pain score was 4.7/10, and analgesics were used weekly by 48%. Previous pelvic or abdominal surgery was reported by 71%, and sick leave >12 weeks the last year by 34%. Reduced sexual desire was reported by 78%, dyspareunia by 73%, UI by 54%, AI by 23%, and obstructed defecation syndrome (ODS) by 34%. More than 90% reported musculoskeletal or pseudoneurologic complaints. Anxiety and depression scores defined as requiring treatment were reported by 40%. Abuse was reported by 50%, and associated with significantly more reports of ODS (p=0.02), more SHC (p=0.02) and higher anxiety scores (p=0.009). Analgesic use and sick leave were significantly higher both among women with a history of abuse (p=0.04 and p=0.005) and among those with previous surgery (p=0.04 and p=0.02). Women with previous surgery reported significantly lower pain intensity during intercourse than those without previous surgery (p=0.008).

Conclusions

Women with CPP have complex symptoms and high scores for both physical and psychological complaints. Women exposed to abuse have especially high scores related to analgesic use, sick leave, ODS, anxiety and SHC. Women with previous surgery report more analgesic use and sick leave, and lower pain intensity during intercourse, than those without previous surgery.

Implications

This study illustrates the complexity of CPP and highlights the need for health professionals to have specialized knowledge of the possible features of the condition. Previous abuse seems to be more associated with poor scores on several health outcomes than surgery, but this needs to be investigated further.

Psychotherapy With Somatosensory Stimulation for Endometriosis-Associated Pain: The Role of the Anterior Hippocampus

BACKGROUND

Endometriosis is a gynecological disorder affecting 6%-10% of all women in their reproductive age. There is an emerging view in the literature that psychological trauma plays a central role in the pathogenesis of pelvic pain, one of the core symptoms of endometriosis. Here we report central nervous system mechanisms of a novel combination of psychotherapy and somatosensory stimulation that has recently shown remarkable effects in reducing pain, anxiety, and depressive symptoms in these patients.

METHODS

We conducted a randomized controlled trial; 67 patients with severe endometriosis-associated pain (maximum pain: 7.6 ± 2.0, average pain: 4.5 ± 2.0 on a 10-point numeric rating scale) were included in the study and randomly allocated to intervention (35 patients) or waitlist control (32 patients) groups. Resting-state functional magnetic resonance imaging was used to assess brain connectivity of these patients at baseline, after 3 months of therapy, and after 6 months. The analysis focused on the hippocampus.

RESULTS

We identified a cortical network comprising the right anterolateral hippocampus-a region modulating the hypothalamic-pituitary-adrenal axis-and somatosensory, viscerosensory, and interoceptive brain regions. Regression analysis showed that reduction in connectivity predicted therapy-induced improvement in patients׳ anxiety.

CONCLUSIONS

We have identified a putative neurobiological mechanism underlying the potent combination of psychotherapy and somatic stimulation in treating symptoms of endometriosis.

They Didn't Believe Her Pain: My Education in Interpersonal Violence

In my first year of medical school, I began to care for patients who were survivors of interpersonal violence. As I transitioned from didactics to clinical experiences, I was struck by how common the hidden threads of physical and sexual violence were in my patients' stories of chronic pain, depression, and poor health outcomes. Their symptoms often seemed intangible and challenging to treat, unable to fit neatly into typical diagnostic and therapeutic algorithms. In response, I saw clinicians become frustrated and dissatisfied with their ability to treat these patients. Better care for survivors may begin simply with believing our patients' pain.

History of childhood maltreatment and symptoms of anxiety and depression in women with chronic pelvic pain

OBJECTIVE

To determine the prevalence of physical, sexual and emotional abuse and physical and emotional neglect suffered by women with chronic pelvic pain (CPP) during childhood and whether these occurrences are associated with symptoms of pain, anxiety and depression.

METHODS

A case-control study was conducted on 154 women older than 18 years, 77 of them healthy and 77 with CPP. A history of sexual, physical, and emotional abuse and physical and emotional neglect was determined using the Childhood Trauma Questionnaire (CTQ). Anxiety and depression symptoms were determined using the Hospital Anxiety and Depression (HAD) scale. Pain intensity was determined using a visual analog scale (VAS). The quantitative variables were compared by the Wilcoxon test, and the qualitative variables were compared by the Chi-square test or exact Fisher test when appropriate. Correlation between the CTQ, HAD and VAS scores was estimated by the Spearman's p coefficient. Independent association of the variables with the presence of CPP was determined by logistic multiple regression analysis.

RESULTS

The prevalence of childhood maltreatment was 77.9% and 64.9%, respectively, for women with CPP and healthy women (p = 0.07). Emotional neglect was more frequent among women with CPP than among healthy women (58.4% versus 41.5%, p = 0.04). There was a moderate correlation between anxiety and depression symptoms and CTQ scores for women with CPP. Unemployment (OR = 4.15, 95% CI 1.73-9.94; OR_adj =  3.30, 95% CI 1.26-8.55) was independently associated with the presence of CPP.

CONCLUSIONS

Women with CPP reported emotional neglect abuse more frequently than healthy women. There was a direct correlation between maltreatment scores and anxiety and depression scores. On the other hand, CPP was independently associated only with unemployment.

Integrative Women's Health

This article addresses the common women's health concerns of menopause-related symptoms, premenstrual syndrome, and chronic pelvic pain. Each can be effectively addressed with an integrative approach that incorporates interventions such as pharmaceuticals, nutraceuticals, mind-body approaches, acupuncture, and lifestyle modification.

Factors Associated with Severity of Irritable Bowel Syndrome Symptoms in Patients with Endometriosis

OBJECTIVE

This study sought to examine factors associated with severity of irritable bowel syndrome (IBS) by using the Birmingham IBS symptom scale in patients presenting with endometriosis to a tertiary referral centre.

METHODS

A prospective research cohort of patients presenting to a tertiary referral centre for endometriosis was evaluated for the presence and severity of IBS between December 2013 and April 2015. Patients with endometriosis had a diagnosis of IBS by using the Rome III criteria and were evaluated for severity of IBS symptoms by using the Birmingham IBS symptom scale. Multifactorial variables, including stage of endometriosis at the time of previous surgery, clinical examination findings, mood disorder questionnaire scores, and lifestyle factors, were evaluated using the t test and Spearman rank correlation test.

RESULTS

A total of 194 of 373 (52%) women with confirmed endometriosis had a diagnosis of IBS. Factors associated with severity of IBS symptoms in patients with endometriosis included lower-stage endometriosis (P = 0.004), presence of mood disorders (P <0.001), tenderness on physical examination (P ≤ 0.001), a history of sexual assault (P ≤ 0.02), and presence of sleep disturbance (P ≤ 0.01). Evaluation of the subscales of the Birmingham IBS symptom scale revealed a strong association between the previously identified factors and the pain subscale.

CONCLUSION

Using the Birmingham IBS symptom scale, our study revealed more severe IBS symptoms in patients with lower-stage endometriosis and identified other variables highly associated with severity of IBS. Continued research is required to characterize further the clinical importance of IBS symptoms in patients with endometriosis-associated pelvic pain.

The psychological profile of women presenting to a multidisciplinary clinic for chronic pelvic pain: high levels of psychological dysfunction and implications for practice

Objective

Chronic pelvic pain (CPP) is widely acknowledged as a common problem with significant consequences for those diagnosed with this condition. There is a lack of studies with good sample size that provide a comprehensive psychological profile of women presenting to specialist chronic pain clinics. Therefore, the objective of this study was to describe the psychological profile of a representative sample of women presenting with CPP at a tertiary referral center.

Design

This was a cross-sectional study. Women were asked to complete a questionnaire assessing symptoms of anxiety and depression, pain severity and interference, pain self-efficacy and catastrophizing beliefs, and sexual functioning.

Methods

One-hundred and seventy-five women with CPP were recruited when they attended their initial assessment at a specialist CPP clinic of the Royal Women’s Hospital, a public hospital in Melbourne, Australia.

Results

Over 75% of the participants had experienced pain for longer than 2 years. Fifty-three percent of women experienced either moderate or severe anxiety, and 26.7% experienced moderate-to-severe depression. There were strong correlations between depressive symptoms and pain interference, pain catastrophizing and self-efficacy beliefs.

Conclusion

Our findings confirm previous evidence for high levels of psychological distress and functional impairment associated with this condition, and extend these findings by including measures that are highly relevant to treatment planning, such as thinking styles and pain self-efficacy. Therefore, treatment of this complex condition needs to be holistic, and a multidisciplinary approach is likely to be the best way to achieve this.

Does a history of bullying and abuse predict lower urinary tract symptoms, chronic pain, and sexual dysfunction?

PURPOSE

To investigate associations of bullying and abuse with pelvic floor symptoms, urogenital pain, and sexual health characteristics of women presenting to a multidisciplinary women's urology center.

METHODS

Retrospective review of a prospective database. Patients completed questions about bullying, abuse, sexual health and validated questionnaires including the Pelvic Floor Dysfunction Inventory (PFDI-20), Overactive Bladder Questionnaire (OAB-q), and visual analog scale (VAS 0-10) for genitourinary pain. Statistical analyses included Chi-squared and t tests, which compared victims of bullying and/or abuse to non-victims.

RESULTS

Three hundred and eighty patients were reviewed. Three hundred and thirty-eight had data on bullying and abuse history. Out of 380, 94 (24.7 %) reported that they were victims of bullying. Out of 380, 104 (27.4 %) reported that they were victims of abuse. Women with a history of bullying and abuse had increased overall pain scores compared to those without a history of either. Women with a history of abuse and bullying had increased PFDI-20, POPDI, and UDI-6 scores compared to women who were not bullied or abused. There was no difference in being sexually active or in sexual satisfaction between the groups. Patients with a history of abuse and bullying had the greatest percentage of dyspareunia (p = 0.009).

CONCLUSIONS

Women with a history of bullying, abuse, or both predict increased pelvic floor distress, urological symptoms, increased urogenital pain, and increased dyspareunia. Clinicians should screen for exposure to bullying or abuse in order to provide comprehensive resources to address these psychosocial issues.