Psychosocial risk factors in the development of fibromyalgia; and Compassion-Focused Therapy for chronic pain: mediators of improvement
Background: Chronic pain is a worldwide problem that can cause a great level of disability in a person’s life. The aetiology of conditions such as fibromyalgia is still under debate, and there are many biological, psychological and social hypotheses for its development. Past research in this area has explored the predictive impact of abuse and post-traumatic stress, but these are just some of the factors implicated in a wider picture. Psychological approaches to chronic pain have focused on Cognitive Behavioural Therapy and Acceptance and Commitment Therapy, two approaches that result in similar outcomes. Currently, very little research exists on Compassion-Focused Therapy (CFT) for chronic pain, even though the literature suggests conceptual overlaps between CFT and existing therapies. Objective: This thesis aims to reconcile existing information on the psychosocial risk factors that lead to the development of fibromyalgia (Chapter 1) and evaluate the suitability of an 11-week Compassion-Focused Therapy group intervention for adults with chronic pain (Chapter 2). Furthermore, this research also seeks to explore self-compassion, psychological flexibility and psychological inflexibility as potential mediators of improvement in outcome. Limited research and clinical resources can be better used by focusing on how therapies work, instead of if they work against similar treatments that have already proven efficacious. Methods: The evidence base for psychosocial risk factors in the development of fibromyalgia is systematically reviewed in Chapter 1. Electronic databases were searched for various descriptions of fibromyalgia, risk factors and observational study designs. Populations that included physical comorbidities were excluded. In Chapter 2, 122 participants attended the Pain Management Programme at the NHS Lothian Chronic Pain Service. Outcome measures were collected at three timepoints (pre, mid and post-group). One-way ANOVAs were used to evaluate the efficacy of the intervention, along with multiple regressions to perform mediation analysis. Results: 10 studies from a search of 889 potentially relevant studies met the inclusion criteria for systematic review. Most of these studies were deemed to be of good quality. Commonalities across studies included appropriate selection of control and comparison groups, valid random sampling techniques and adequate length to follow-up in the case of cohort studies. Studies, however, varied across their methods in ascertaining fibromyalgia and researchers relied on their own reports to establish outcomes. In Chapter 2, statistically significant improvements were demonstrated in measures of pain interference, anxiety, depression, psychological flexibility, psychological inflexibility, self-compassion and mental wellbeing by the end of the PMP. The largest improvements were found to occur in the second half of the PMP. Self-compassion was shown to mediate improvements in pain interference, whereas psychological flexibility and psychological inflexibility was shown to mediate improvements in depression and mental wellbeing. Neither predictor variable mediated improvements in anxiety. Discussion: Prospective cohort studies represent the best evidence for determining risk factors. Depression, anxiety, childhood adversity, work stress and low education were found to be risk factors for developing fibromyalgia. Based on these results, it is recommended that more conservative estimates of effect size be used. This research also provides evidence for the use of CFT as a group intervention for chronic pain. It can be concluded that pain interventions targeting psychological flexibility and psychological inflexibility are likely to be further improved by emphasising selfcompassion. CFT and ACT already share similar values, despite their differing theoretical backgrounds. Patients will be able to benefit from a combined approach since self-compassion, psychological flexibility and psychological inflexibility were shown to mediate improvement in different outcomes.