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I the Role of Attention, Catastrophizing, And The Role of Attention, Catastrophizing, and Anxiety in the Experience of Chronic Pain: Imaging Pain in Women With and Without Vestibulodynia By Katherine Stella Sutton A thesis submitted to the Department of Psychology in conformity with the requirements for the Degree of Doctor of Philosophy Queen’s University Kingston, Ontario, Canada January, 2013 Copyright © Katherine Stella Sutton, 2013 i Abstract Provoked Vestibulodynia (PVD) is the most common form of chronic vulvar pain, affecting 12% of women in the general population. Research has demonstrated that women with PVD display both allodynia and hyperalgesia to pain at vulvar and non-vulvar sites, as well as reduced psychosocial functioning. The goal of this study was to use a multi-method approach (interview, questionnaires, sensory testing, and fMRI) to examine group differences between women with PVD (N=15) and healthy control women (N=15). Results will allow for improved understanding of the interaction between psychosocial and neurobiological underpinnings of this disorder, which can contribute to the creation of better treatment strategies. Variables included psychophysical and psychosocial measures, as well as neural activations associated with painful pressure, painful words, and psychosocial functioning. Differences between subgroups of PVD, based on temporal onset, were also examined. There were no robust group differences in neural activation during the application of pain or pain words. This finding is consistent with many studies that match groups on pain intensity ratings, as opposed to amount of pressure applied. Painful pressures and painful words resulted in greater neural activation than neutral words or touch; however, there were no group differences for the word conditions. Women with PVD reported increased psychosocial dysfunction, including higher levels of anxiety and catastrophizing. Significant correlations were found between these psychosocial variables and areas of the brain associated with pain modulation and attention (e.g., PFC). Examination of PVD subgroups revealed differences in neural correlates of anxiety and catastrophizing during painful stimulation. This finding adds to the literature suggesting that women with primary PVD experience greater dysfunction than women with secondary PVD. Overall, these studies support findings of pain processing in the general pain literature, as well as supporting PVD as a chronic pain condition. They also add to the development of a greater understanding of the interaction between psychophysical and psychosocial components of chronic pain by examining their relationship with neural activations. Future research should examine brain functioning in ii PVD women pre- and post-treatment as well as examining neural correlates of other psychosocial variables that contribute to the pain experience (e.g., somatization). iii Acknowledgements I would like to start by thanking my supervisor, Dr. Caroline Pukall, for all of her hard work and dedication to her students in Sexual Health Research Lab. She has provided me with many wonderful opportunities throughout my time at Queen’s, and her support and feedback have been invaluable. I would also like to thank my committee members, Dr. Ingrid Johnsrude and Dr. Dean Tripp. Dr. Johnsrude has provided invaluable guidance for me as I broached a new methodological field of study for my dissertation. Dr. Tripp has been very generous with his time, and I am thankful to him for stepping in part way through this process. I would like acknowledge the financial support from SSHRC, OGS, and the Violet Head Scholarship. I am very grateful for the financial assistance provided during the course of my doctoral dissertation. A big thank you also to the members of the Sexual Health Research Lab: to my amazing lab- mates for their support and consultations, and to the wonderful volunteers and research assistants that have helped, both with this thesis and other projects throughout the years. A special thank you to the lab coordinator, Paulina Ezer, for her cheerful and very competent help. Thank you also to Conor Wild and Sophie Lafaille for their patience and assistance with the imaging portion of my thesis – I could not have done this without you both. A very special thank you to all of my amazing friends for holding me together during this long process. To those of you who have worked with me and beside me at my coffee shop office/lab, thank you for all of the memories – I will miss our work dates tremendously. Also, thank you to those who meet every Friday afternoon for all of your weekly support and supervision. Dr. Tony Eccles, thank you for introducing me to this ritual, and for bringing a piece of sanity to my week. Last, and most important, I would like to thank my family. First, thank you to my parents for their continued and unwavering support, and their pride and encouragement of my accomplishments, both big iv and small. Also, to my sister Sammy, who could not be any further from me geographically, but is always held close in my heart. Her sense of humor and updates are always a refreshing break from work. Thank you to Reza for his amazing support, encouragement, and never-ending patience with my work load. v Table of Contents Abstract ......................................................................................................................................................... ii Acknowledgements ...................................................................................................................................... iv Table of Contents ......................................................................................................................................... vi List of Tables ............................................................................................................................................... ix List of Figures .............................................................................................................................................. xi List of Abbreviations .................................................................................................................................. xii Chapter 1. Introduction ........................................................................................................................... 1 Chapter 2. Literature Review .................................................................................................................. 5 2.1. Vulvodynia .................................................................................................................................... 5 2.2. Provoked Vestibulodynia .............................................................................................................. 7 2.2.1. Diagnosis ............................................................................................................................... 7 2.2.2. Etiology ................................................................................................................................. 9 2.2.3. Psychosocial Functioning ................................................................................................... 11 2.2.4. Primary versus Secondary PVD ............................................................................................ 7 2.2.5. Treatment Approaches ........................................................................................................ 12 2.2.6. PVD: A Chronic Pain Condition ......................................................................................... 13 2.3. What is Pain? .............................................................................................................................. 13 2.4. Chronic Pain ................................................................................................................................ 19 2.5. Quantitative Sensory Testing ...................................................................................................... 22 2.6. Neuroimaging ............................................................................................................................. 24 2.6.1. Structural Neuroimaging ..................................................................................................... 25 2.6.2. Functional Neuroimaging ................................................................................................... 27 2.7. From Acute to Chronic Pain: The Role of Psychology .............................................................. 29 2.7.1. Chronification of Pain ......................................................................................................... 29 2.7.2. Affective Aspects of Pain ................................................................................................... 32 2.7.3. Cognitive Aspects of Pain ................................................................................................... 35 2.8. Current Study .............................................................................................................................. 41 Chapter 3. Research Questions and Hypotheses ................................................................................... 43 3.1. Study 1 ........................................................................................................................................ 43 3.2. Study 2 .......................................................................................................................................
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