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Predictors and mediators of outcome in CBT for chronic pain : The roles of psychological flexibility and PTSD

Åkerblom, Sophia LU (2018)
Abstract (Swedish)
Långvarig smärta är ett vanligt förekommande och tärande tillstånd som är bland de mest kostsamma hälsoproblemen för både individen och samhället som helhet. Kognitiv beteendeterapi (KBT) är den mest spridda psykologiska behandlingen för långvarig smärta. Även om metoden är evidensbaserad och rekommenderad ger den relativt blygsamma förbättringar för smärtrelaterad funktion och medföljande emotionella symtom. Det är nu allmänt vedertaget att ytterligare ansträngningar behövs för att förbättra effektiviteten av KBT för långvarig smärta. Mer specifikt har smärtforskare förordat studier som kan identifiera mekanismer genom vilka behandlingseffekterna erhålls (mediatorer) och egenskaper hos individen som predicerar förbättringar i dessa... (More)
Långvarig smärta är ett vanligt förekommande och tärande tillstånd som är bland de mest kostsamma hälsoproblemen för både individen och samhället som helhet. Kognitiv beteendeterapi (KBT) är den mest spridda psykologiska behandlingen för långvarig smärta. Även om metoden är evidensbaserad och rekommenderad ger den relativt blygsamma förbättringar för smärtrelaterad funktion och medföljande emotionella symtom. Det är nu allmänt vedertaget att ytterligare ansträngningar behövs för att förbättra effektiviteten av KBT för långvarig smärta. Mer specifikt har smärtforskare förordat studier som kan identifiera mekanismer genom vilka behandlingseffekterna erhålls (mediatorer) och egenskaper hos individen som predicerar förbättringar i dessa mekanismer och behandling överlag (prediktorer och moderatorer).
Mot den bakgrunden hade detta forskningsprogram som primärt syfte att undersöka om förändringar i psykologisk flexibilitet medierade behandlings-utfallen i ett multidisciplinärt och gruppbaserat KBT-program på en regional specialistenhet för smärtrehabilitering. Det sekundära syftet var att identifiera möjliga prediktorer av behandlingsutfall genom att fokusera på olika aspekter av psykologisk flexibilitet samt det outforskade inflytandet av posttraumatiskt stressyndrom (PTSD). Detta syfte omfattade även att undersöka relationerna mellan PTSD, smärtpresentation och psykologisk flexibilitet. Med denna inriktning hoppades vi ytterligare kunna belysa den psykologiska flexibilitets-modellens tillämplighet som en integrerande, övergripande modell som kan hjälpa till att definiera relevanta behandlingsprocesser för vuxna med långvarig smärta och psykiatriska problem.
Studie I undersökte om smärtrelaterad acceptans, från den psykologiska flexibilitetsmodellen, och andra variabler som tidigare föreslagits som mediatorer i standard-KBT medierade behandlingsutfallen vid avslut och 12-månaders uppföljning från KBT-programmet. Resultaten underströk den medierande rollen hos smärtrelaterad acceptans i förhållande till olika behandlingsutfall.
Studie II utvärderade de psykometriska egenskaperna hos de svenska översättningarna av original- och kortversionen av Committed Action Question¬naire samt generaliserbarheten av tidigare resultat kopplade till ändamålsenligt handlande. Resultaten stödde validiteten och reliabiliteten av de svenska versionerna, generaliserbarheten av tidigare resultat och relevansen av ändamålenligt handlande i förhållande till hälsa och funktion hos personer med långvarig smärta.
Studie III fokuserade på förekomsten av traumatiska erfarenheter, traumatyper och PTSD hos patienter som hade hänvisats till behandling av långvarig smärta och på relationen mellan PTSD och smärtrelaterad funktion före behandling. Höga nivåer av traumaexponering och PTSD påvisades för patienter med långvarig smärta. Förekomsten av PTSD hos dessa patienter förknippades med svårare kliniska karaktäristika och ökat behandlingsbehov.
Studie IV undersökte huruvida olika processer från den psykologiska flexibilitetsmodellen medierade relationen mellan PTSD och långvarig smärta. Resultaten indikerade att relationen medierades av smärtrelaterad acceptans, ändamålsenligt handlande och kognitiv fusion. Smärtrelaterad acceptans uppvisade den starkaste effekten av processerna från den psykologiska flexibilitetsmodellen.
Studie V studerade ifall emotionella svårigheter (inklusive PTSD) och olika aspekter av psykologisk flexibilitet predicerade smärtrelaterade behandlingsutfall vid 12-månaders uppföljning från KBT-programmet. Studien undersökte även om olika processer från den psykologiska flexibilitetsmodellen medierade behandlin¬gs¬¬¬utfallen. De enda signifikanta prediktorerna i förhållande till behandlingsutfallen visade sig vara psykologisk inflexibilitet och ändamålsenligt handlande. Alla tillgängliga aspekter av psykologisk flexibilitet medierade behandlingsresultaten.
Utifrån resultaten i studierna verkar teoretisk integration inom KBT-fältet kunna understödjas av ett processfokuserat tillvägagångssätt som inkluderar den psykologiska flexibilitetsmodellen. Modellen förefaller ha en transdiagnostisk och transsituationell tillämplighet på flera sätt. Dess processer spänner över flera problemområden med bakgrund dels i det somatiska fältet och långvarig smärta, dels i det psykiatriska fältet och PTSD. Processerna tycks inte enbart vara användbara för behandlingar som är specifikt uppbyggda kring psykologisk flexibilitet utan även för bredare KBT-behandlingar.
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Abstract
Chronic pain is a commonly occurring and debilitating condition, and among the costliest health problems for both the individual and society at large. Cognitive behavioral therapy (CBT) is the most widely-disseminated psychological treatment for chronic pain. Even though it is recommended and evidence-based, it yields quite modest improvements in pain-related functioning and accompanying symptoms of emotional distress. It is now generally acknowledged that further efforts are needed to improve the efficacy of CBT for chronic pain. Specifically, pain researchers have called for studies to identify mechanisms that underlie changes in treatment outcomes (mediators) and characteristics of the individual that predict improvements in these... (More)
Chronic pain is a commonly occurring and debilitating condition, and among the costliest health problems for both the individual and society at large. Cognitive behavioral therapy (CBT) is the most widely-disseminated psychological treatment for chronic pain. Even though it is recommended and evidence-based, it yields quite modest improvements in pain-related functioning and accompanying symptoms of emotional distress. It is now generally acknowledged that further efforts are needed to improve the efficacy of CBT for chronic pain. Specifically, pain researchers have called for studies to identify mechanisms that underlie changes in treatment outcomes (mediators) and characteristics of the individual that predict improvements in these mechanisms and treatment overall (predictors and moderators).
To address this call, the primary aim of this research program was to study whether changes in psychological flexibility mediated outcomes in a multi-disciplinary, group-based CBT program delivered at a regional specialist unit for pain rehabilitation. The secondary aim was to identify possible predictors of outcome by focusing on facets of psychological flexibility as well as the understudied influence of posttraumatic stress disorder (PTSD). This aim also included investigation of the relationships between PTSD, pain presentation, and psychological flexibility. With these two aims, we hoped to shed further light on the validity of the psychological flexibility model as an integrating, overarching model that can help define relevant treatment processes for adults presenting with chronic pain and psychiatric problems.
Study I investigated whether pain-related acceptance, from the psychological flexibility model, and other variables posited as potential mediators in standard CBT mediated changes in pain-related outcomes measured at post-treatment and 12-month follow-up from the CBT program. The results highlighted the mediating role of pain-related acceptance across different indices of outcome.
Study II evaluated the psychometric properties of the Swedish-language versions of the full length and shortened version of the Committed Action Questionnaire, as well as the generalizability of previous results related to committed action. The results supported the validity and reliability of the Swedish-language versions of the measure, the generalizability of earlier findings, and the relevance of committed action to health and functioning in individuals with chronic pain.
Study III focused on the prevalence of traumatic experiences, trauma types, and PTSD in patients referred for treatment of chronic pain, and the relationship between PTSD and pain-related functioning prior to treatment. High rates of traumatic exposure and PTSD were found for chronic pain patients. The presence of PTSD in these patients was associated with worse clinical characteristics and an increased need for treatment.
Study IV examined whether various processes from the psychological flexibility model mediated the relationship between PTSD and chronic pain. Results indicated that the relationship was mediated by pain-related acceptance, committed action, and cognitive fusion, where pain-related acceptance constituted the most influential mediator from the psychological flexibility model.
Study V analysed whether indices of emotional distress (including PTSD) and different facets of psychological flexibility predicted pain-related outcomes at 12-month follow-up from the CBT program. Furthermore, it examined whether changes in processes from the psychological flexibility model mediated changes in pain-related outcomes. The only significant predictors of outcomes turned out to be psychological inflexibility and committed action. All available facets of psychological flexibility had mediating effects on treatment outcomes.
Based on the results from these studies, theoretical integration within the CBT field may be facilitated by a process-focused approach including the psychological flexibility model. This model seems to be transdiagnostically and trans-situationally applicable in several ways. Its processes span problem areas with diverse backgrounds from the somatic field and chronic pain to the psychiatric field and PTSD, and appear useful not only to treatments specifically built around targeting psychological flexibility but also more broadly in CBT treatments.
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Please use this url to cite or link to this publication:
author
supervisor
opponent
  • Professor Linton, Steven, Örebro University
organization
publishing date
type
Thesis
publication status
published
subject
keywords
The psychological flexibility model, cognitive behavioral therapy (CBT), chronic pain, mediator, predictor, posttraumatic stress disorder (PTSD)
pages
170 pages
defense location
Palaestra auditorium, Paradisgatan 4, Lund
defense date
2018-05-25 10:00
ISBN
978-91-7753-650-5
978-91-7753-649-9
language
English
LU publication?
yes
id
582ffa90-677c-4a4f-a186-a3df9dc2c5e2
date added to LUP
2018-05-04 13:27:41
date last changed
2018-11-21 21:39:41
@phdthesis{582ffa90-677c-4a4f-a186-a3df9dc2c5e2,
  abstract     = {Chronic pain is a commonly occurring and debilitating condition, and among the costliest health problems for both the individual and society at large. Cognitive behavioral therapy (CBT) is the most widely-disseminated psychological treatment for chronic pain. Even though it is recommended and evidence-based, it yields quite modest improvements in pain-related functioning and accompanying symptoms of emotional distress. It is now generally acknowledged that further efforts are needed to improve the efficacy of CBT for chronic pain. Specifically, pain researchers have called for studies to identify mechanisms that underlie changes in treatment outcomes (mediators) and characteristics of the individual that predict improvements in these mechanisms and treatment overall (predictors and moderators). <br/>To address this call, the primary aim of this research program was to study whether changes in psychological flexibility mediated outcomes in a multi-disciplinary, group-based CBT program delivered at a regional specialist unit for pain rehabilitation. The secondary aim was to identify possible predictors of outcome by focusing on facets of psychological flexibility as well as the understudied influence of posttraumatic stress disorder (PTSD). This aim also included investigation of the relationships between PTSD, pain presentation, and psychological flexibility. With these two aims, we hoped to shed further light on the validity of the psychological flexibility model as an integrating, overarching model that can help define relevant treatment processes for adults presenting with chronic pain and psychiatric problems. <br/>Study I investigated whether pain-related acceptance, from the psychological flexibility model, and other variables posited as potential mediators in standard CBT mediated changes in pain-related outcomes measured at post-treatment and 12-month follow-up from the CBT program. The results highlighted the mediating role of pain-related acceptance across different indices of outcome.<br/>Study II evaluated the psychometric properties of the Swedish-language versions of the full length and shortened version of the Committed Action Questionnaire, as well as the generalizability of previous results related to committed action. The results supported the validity and reliability of the Swedish-language versions of the measure, the generalizability of earlier findings, and the relevance of committed action to health and functioning in individuals with chronic pain.<br/>Study III focused on the prevalence of traumatic experiences, trauma types, and PTSD in patients referred for treatment of chronic pain, and the relationship between PTSD and pain-related functioning prior to treatment. High rates of traumatic exposure and PTSD were found for chronic pain patients. The presence of PTSD in these patients was associated with worse clinical characteristics and an increased need for treatment.<br/>Study IV examined whether various processes from the psychological flexibility model mediated the relationship between PTSD and chronic pain. Results indicated that the relationship was mediated by pain-related acceptance, committed action, and cognitive fusion, where pain-related acceptance constituted the most influential mediator from the psychological flexibility model. <br/>Study V analysed whether indices of emotional distress (including PTSD) and different facets of psychological flexibility predicted pain-related outcomes at 12-month follow-up from the CBT program. Furthermore, it examined whether changes in processes from the psychological flexibility model mediated changes in pain-related outcomes. The only significant predictors of outcomes turned out to be psychological inflexibility and committed action. All available facets of psychological flexibility had mediating effects on treatment outcomes.<br/>Based on the results from these studies, theoretical integration within the CBT field may be facilitated by a process-focused approach including the psychological flexibility model. This model seems to be transdiagnostically and trans-situationally applicable in several ways. Its processes span problem areas with diverse backgrounds from the somatic field and chronic pain to the psychiatric field and PTSD, and appear useful not only to treatments specifically built around targeting psychological flexibility but also more broadly in CBT treatments.<br/>},
  author       = {Åkerblom, Sophia},
  isbn         = {978-91-7753-650-5 },
  keyword      = {The psychological flexibility model,cognitive behavioral therapy (CBT),chronic pain,mediator,predictor,posttraumatic stress disorder (PTSD)},
  language     = {eng},
  pages        = {170},
  school       = {Lund University},
  title        = {Predictors and mediators of outcome in CBT for chronic pain : The roles of psychological flexibility and PTSD},
  year         = {2018},
}