Davis Seth N P, Bergeron Sophie, Bois Katy, Sadikaj Gentiana, Binik Yitzchak M, Steben Marc
*Department of Psychology, Université de Montréal ‡Department of Psychology, McGill University §Centre Hospitalier de l'Univerisité de Montréal, Montreal †Faculty of Medicine, University of Toronto, Toronto, Canada.
Clin J Pain. 2015 Apr;31(4):333-41. doi: 10.1097/AJP.0000000000000128.
Provoked vestibulodynia (PVD) is a common genital pain disorder in women that is associated with sexual dysfunction and lowered sexual satisfaction. A potentially applicable cognitive-behavioral model of chronic pain and disability is the fear-avoidance model (FAM) of pain. The FAM posits that cognitive variables, such as pain catastrophizing, fear, and anxiety lead to avoidance of pain-provoking behaviors (eg, intercourse), resulting in continued pain and disability. Although some of the FAM variables have been shown to be associated with PVD pain and sexuality outcomes, the model as a whole has never been tested in this population. An additional protective factor, pain self-efficacy (SE), is also associated with PVD, but has not been tested within the FAM model.
Using a 2-year longitudinal design, we examine (1) whether initial levels (T1) of the independent FAM variables and pain SE were associated with changes in pain, sexual function, and sexual satisfaction over the 2-year time period; (2) the prospective contribution of changes in cognitive-affective (FAM) variables to changes in pain, and sexuality outcomes; and (3) whether these were mediated by behavioral change (avoidance of intercourse).
A sample of 222 women with PVD completed self-report measures of FAM variables, SE, pain, sexual function, and sexual satisfaction at time 1 and at a 2-year follow-up. Structural equation modeling with Latent Difference Scores was used to examine changes and to examine mediation between variables.
Questionnaires included the Pain Catastrophizing Scale, McGill Pain Questionnaire, Trait Anxiety Inventory, Pain Self-Efficacy Scale, and Global Measure of Sexual Satisfaction, Female Sexual Function Index.
Participants who reported higher SE at T1 reported greater declines in pain, greater increases in sexual satisfaction, and greater declines in sexual function over the 2 time points. The overall change model did not support the FAM using negative cognitive-affective variables. Only increases in pain SE were associated with reductions in pain intensity. The relationship between changes in SE and changes in pain was partially mediated through changes in avoidance (more intercourse attempts). The same pattern of results was found for changes in sexual satisfaction as the outcome, and a partial mediation effect was found. There were no significant predictors of changes in sexual function other than T1 SE.
Changes in both cognitive and behavioral variables were significantly associated with improved pain and sexual satisfaction outcomes. However, it was the positive changes in SE that better predicted changes in avoidance behavior, pain, and sexual satisfaction. Cognitive-behavior therapy is often focused on changing negative pain-related cognitions to reduce avoidance and pain, but the present results demonstrate the potential importance of bolstering positive self-beliefs as well. Indeed, before engaging in exposure therapies, SE beliefs should be assessed and potentially targeted to improve adherence to exposure strategies.
诱发性前庭疼痛障碍（PVD）是女性常见的生殖器疼痛疾病，与性功能障碍和性满意度降低有关。一种可能适用的慢性疼痛和残疾的认知行为模型是疼痛的恐惧回避模型（FAM）。FAM认为，认知变量，如疼痛灾难化、恐惧和焦虑会导致回避引发疼痛的行为（如性交），从而导致持续的疼痛和残疾。虽然一些FAM变量已被证明与PVD疼痛和性结果相关，但该模型作为一个整体从未在该人群中进行过测试。另一个保护因素，疼痛自我效能感（SE），也与PVD相关，但尚未在FAM模型中进行测试。
采用为期2年的纵向设计，我们研究（1）FAM独立变量和疼痛SE的初始水平（T1）是否与2年期间疼痛、性功能和性满意度的变化相关；（2）认知情感（FAM）变量的变化对疼痛和性结果变化的前瞻性贡献；以及（3）这些是否通过行为改变（避免性交）介导。
222名患有PVD的女性样本在时间1和2年随访时完成了FAM变量、SE、疼痛、性功能和性满意度的自我报告测量。使用具有潜在差异分数的结构方程模型来检查变化并检查变量之间的中介作用。
问卷包括疼痛灾难化量表、麦吉尔疼痛问卷、特质焦虑量表、疼痛自我效能量表和性满意度总体测量、女性性功能指数。
在T1报告较高SE的参与者在两个时间点报告疼痛下降幅度更大、性满意度增加幅度更大以及性功能下降幅度更大。总体变化模型不支持使用负性认知情感变量的FAM。只有疼痛SE的增加与疼痛强度的降低相关。SE变化与疼痛变化之间的关系部分通过回避变化（更多性交尝试）介导。作为结果的性满意度变化也发现了相同的结果模式，并且发现了部分中介效应。除了T1 SE之外，没有其他显著的性功能变化预测因素。
认知和行为变量的变化均与疼痛和性满意度改善结果显著相关。然而，是SE的积极变化更好地预测了回避行为、疼痛和性满意度的变化。认知行为疗法通常侧重于改变与疼痛相关的负性认知以减少回避和疼痛，但目前的结果也证明了增强积极自我信念的潜在重要性。事实上，在进行暴露疗法之前，应该评估SE信念并可能将其作为目标以提高对暴露策略的依从性。
