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Dr Christina Bryant
Centre for Women's Mental Health
Royal Women's Hospital
132 Grattan Street
Carlton VIC 3053
Tel + 61 3 8345 3906


8/06/2013
The submitted manuscript is a short communication paper examining the illness perceptions in a sample of women with chronic pelvic pain (CPP). Chronic pelvic pain is a debilitating and poorly understood condition and a major challenge to health-care professionals. There is a paucity of research exploring the cognitive aspects of patients� experience of CPP and this study presents some initial findings regarding CPP patients� conceptualisation and understanding of their pain experience and their levels of psychological distress. The Journal of Women�s Health, Issues and Care focuses on presenting research important to women�s health issues. Therefore, we believe our study will be of particular interest to your readers by adding to current literature on chronic pelvic pain.
Thank-you for your consideration,
Yours Sincerely,
Dr Christina Bryant  
Email:   HYPERLINK "mailto:Christina.Bryant@thewomens.org.au" Christina.Bryant@thewomens.org.au

The authors of this article had access to all study data, are responsible for all contents of the article, and had authority over manuscript preparation and the decision to submit the manuscript for publication. All listed authors have approved of the submission of the manuscript to the journal. There are no submitted, published or proposed papers reporting the same or overlapping data.
Title:
Illness perceptions and psychological distress in women with chronic pelvic pain  
Running Head:
Illness Perceptions in Chronic Pelvic Pain
Research Conducted: 
The University of Melbourne and The Royal Women�s Hospital
Authors: 
Dr Christina Bryant PhD
Olivia Fitzgibbon MA
Dr Angela Chia MBBS

Author for correspondence: 
Olivia Fitzgibbon
Centre for Women's Mental Health
Royal Women's Hospital
132 Grattan Street
Carlton VIC 3053
Australia
+61 405 700 895
 HYPERLINK "mailto:o.fitzgibbon@live.com" o.fitzgibbon@live.com







Abstract 
Objective: The aim of the present study was to examine the illness perceptions and levels of psychological distress in a sample of women experiencing chronic pelvic pain [CPP]. The study was conducted within the context of multidisciplinary treatment at a specialist chronic pelvic pain clinic. 
Methods: The participants were 31 women diagnosed with CPP. All participants completed a number of questionnaire measures including the Illness Perceptions Questionnaire Revised � Chronic Pain [IPQ-R-CP] and the Hospital Anxiety and Depression Scale [HADS]. 
Results: Participants perceived their pelvic pain to be a chronic and serious condition and had little understanding of the nature of their pain, believing it to be a �mystery�. In addition, participants endorsed psychosocial and �chance� factors to be causative of their pain. It was also found that perceptions of pain as unresponsive to personal control was associated with higher levels of anxiety. 
Conclusion:  Illness perceptions represent an important future direction for researchers wishing to gain a more comprehensive understanding of the experience of CPP and to use this knowledge to improve the efficacy of treatment. 
Keywords: Chronic Pelvic Pain, Illness Perceptions





Introduction 
Chronic Pelvic Pain [CPP] is a serious and debilitating condition, affecting a woman�s social relationships, employment opportunities, sexual functioning and self-esteem [1-3]. In about a one-third of cases, no underlying organic pathology can be identified, making CPP a perplexing and frustrating condition for both patients and medical professionals alike [4-5]. Research in this area has focussed predominately on exploring the association between CPP and factors such as childhood sexual abuse and depression [6-8]. However, the emphasis on exploring the affective and historical factors relevant to CPP has been identified as potentially stigmatising for women and unhelpful in the treatment of their condition [1,8].  
The Common Sense Model of Illness Perceptions, [9] has been used to explore how chronic pain patients conceptualise and understand their pain experience and how this conceptualisation affects their level of disability and psychological adjustment [10-13] but it has not been explored in patients with CPP. It has been found that patients who perceive their pain as unremitting, uncontrollable and as having serious consequences for their well-being experience greater pain severity, impaired functioning and significant psychological distress, as well as poorer adherence to and outcomes from pain-management and treatment programs [12, 14].
Given the lack of previous research on illness perceptions in CPP, the aim of the present study was to examine illness perceptions in a clinical sample as these beliefs may be particularly relevant in maintaining levels of distress, pain and dysfunction.

 Method
Participants
Participants were 31 women experiencing chronic pelvic pain and were recruited from the Chronic Pelvic Pain Clinic of The Royal Women�s Hospital Melbourne, Victoria, Australia. Twenty-eight participants completed the questionnaire prior to their initial assessment and 3 participants completed the questionnaire when they had been seen for their assessment session. 
Setting
The Chronic Pelvic Pain Clinic is a specialised service to which women are referred for the assessment and treatment of difficult to manage chronic pelvic pain. The clinic has a multidisciplinary team approach in which a pain specialist [anaesthetist], clinical psychologist, physiotherapist and a social worker assist women in the treatment and management of their pain. Patients are seen for an initial assessment and a number of individualised treatment sessions. The types of interventions offered and time-course for treatment are devised collaboratively by the multidisciplinary team in accordance with the needs of the women.  
Measures
Demographic information: Participants were asked to indicate their date of birth, country of birth, level of highest education, employment status, and relationship/marital status. 
The Hospital Anxiety and Depression Questionnaire [HADS]: This is a 14-item self-report measure used as a screening and severity measure for anxiety and depression in medical outpatients. In the current study, the Cronbach alpha was .76 for the Depression subscale and .80 for the Anxiety subscale. The current study used the cut-off of 8 for both subscales to indicate scores in the clinically significant range.
Illness Perceptions Questionnaire Revised � Chronic Pain [IPQ-R-CP]: This measure examines illness perceptions as proposed by Diefenbach and Leventhal [9] and has been modified for use with patients experiencing chronic pain [IPQ-R-CP]. We assessed 5 subscales from the IPQ-R-CP: Pain Consequences, Pain Coherence, Pain Timeline [cyclical], Pain Timeline [acute/chronic] Personal Control and Treatment Control.  For each item, participants indicate their degree of agreement with specific statements, using a five-point Likert-scale ranging from [1] strongly disagree, to 5 strongly agree [Moss-Morris et al., 2002]. The final section is the �cause� subscale and lists 18 possible factors for the onset of the pain, for example �overwork, �my personality�, �aging�, �pollution in the environment�. For the purpose of analysis factors in the cause subscale were collapsed into four categories; Psychosocial [6 factors], Immunity [7 factors], Risk [3 factors], or Chance [2 factors]. This measure has been well-validated and used extensively to examine the illness perceptions of people with a wide-range of illnesses [15]. Moss-Morris et al. [16] found the subscales of the IPQ-R to have good internal reliability [Cronbach s � ranging from .79-.89] and predictive validity in a large sample of chronic pain patients. 

Results
Sample Characteristics
The mean age of the participants was 37 [range = 18-69 years old]. Forty-eight percent were married or living with a partner, 45.6% were in paid employment and 51.6% had been educated beyond 18 years. Participants had been experiencing chronic pelvic pain for a mean of 7.9 years [range = 6 months to 24 years]. Seventy-one percent of the participants were born in Australia. 
Insert Table I about here
Psychological distress: Results from the HADS questionnaire demonstrated that participants in this sample experience high levels of psychological distress [Table 1]. Approximately half of the women scored in the clinical range for depression [45%], and a large proportion of women scored in the clinical range for anxiety [81%]. These mean scores were higher than normative medical outpatient samples [17] but comparable to other chronic non-malignant pain populations [18-19]. 
Illness perceptions: Table 1 indicates that participants indicated strong beliefs about the serious consequences of CPP and that their condition was likely to be chronic rather than temporary. They also appeared to have weak beliefs about the coherence of their CPP. For the cause subscale, Table 1 shows that one-third of the participants attributed the cause of their pain to psychosocial factors and one-quarter of participants attributed their pain to �chance or bad luck�.
Associations between psychological distress and pain beliefs: Table 2 shows the Pearson correlations between illness perceptions subscales [except cause] and depression and anxiety scores. One result to emerge as significant was the association between participants� anxiety levels and their scores on the personal control subscale of the IPQ. This suggests that participants with higher levels of anxiety view their chronic pelvic pain as less responsive to personal control.
Insert Table II about here

Discussion
This is the first study to present findings on illness perceptions in women experiencing chronic pelvic pain. The results showed that participants generally believed their pelvic pain was a chronic condition with serious consequences for their relationships and adaptive functioning. Participants in this study also held weak illness coherence beliefs, indicating that they viewed their condition as a �mystery� and had little understanding of the nature of their symptoms. 
With regards to the cause subscale, the results show that participants endorsed psychosocial factors as causative of their pain, such as �stress/worry�, �family problems� and �overwork�. This is a new finding in the CPP literature, as the psychosocial stressors impacting upon a women�s experience of CPP have not previously been reported.  A significant proportion of participants attributed their pain to �chance or bad luck�, and this result is perhaps not surprising given that for the a significant proportion of CPP cases, no definitive organic pathology can be found, and women must learn to live with this perplexing and frustrating condition [20].
This study demonstrated that women with CPP experience high levels of psychological distress with nearly half of the participants scoring in the clinical range for depression and over 80% scoring in the clinical range for anxiety. This study confirms previous findings demonstrating the significant levels of psychological distress which exist in women with CPP [21-24].
It was found that participants� belief that pain was unresponsive to personal control was associated with higher levels of anxiety. The role of controllability beliefs in the experience of anxiety is an interesting finding to emerge from the current study. Previous research has demonstrated an association between illness perceptions and anxiety in patients with chronic fatigue syndrome [10], psoriasis [25] and irritable bowel syndrome [26] with beliefs about the serious consequences of an illness being the strongest predictor of anxiety in these studies. While a causal relationship between these two variables cannot be determined, it is possible that participants� belief that their pelvic pain is unresponsive to personal control leads to high levels of anxiety and motivates them to present for treatment [27]. 
A number of limitations need to be taken into consideration when interpreting the results of the current study. First, the small sample size reduced the study�s sensitivity and power to determine the relationship between illness perceptions and psychological distress. Nevertheless, the current study has a number of clinical implications. To date, little research has explored the cognitive attributions and beliefs women hold about their chronic pelvic pain or how these beliefs may be linked to levels of psychological distress. The present study confirms the high levels of anxiety and depressive symptoms which are present in women with CPP, indicating the need for simultaneous and integrated management of both physical pathology and psychological distress in this challenging population [28].  
Therefore, illness perceptions represent a potentially modifiable aspect of the pain experience and gaining a more comprehensive understanding of these beliefs in women with CPP could help to improve service delivery and functional outcomes in these patients.

Acknowledgements
We thank the women who participated in the study, and the clinical team at the Pelvic Pain Clinic for their support of this project. 

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(n = 31)HADS QuestionnaireHADS-D (Depression)7.55 (3.88)HADS-A (Anxiety)  10.71 (4.37)Illness Perceptions QuestionnaireTimeline (acute/chronic)3.80 (0.68)Consequence 3.84 (0.76)Personal Control3.04 (0.76)Treatment Control3.31 (0.60)Illness Coherence 2.85 (1.03)Timeline (cyclical)3.48 (0.96)Cause subscales IPQ % AggreementPsychosocial Factors 32.4%Risk Factors17.8%Immunity Factors               22.5%Chance or bad luck25.8%Table I. �HADS Questionnaire and the Illness Perceptions Questionnaire 
























Table II. - Pearson Product-Moment Correlations between psychological distress and pain belief variables.
 (n=31) HADS Anxiety HADS DepressionIPQ - Timeline .12-.04IPQ - Consequence.25-.00IPQ - Personal Control-.44*-.07IPQ - Treatment Control-.29-.12IPQ- Illness Coherence -.27.01IPQ- Timeline (cyclical).12-.18* p < .05. ** p <.01

 Study was approved by the University of Melbourne Ethics Committee and The Royal Women�s Hospital Human Ethics Committee 









Illness Perceptions in Chronic Pelvic Pain



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