Vulvodynia is characterised by persistent vulvar pain which can be spontaneous, arise from touch or pressure (Provoked Vestibulvodynia; PVD) or a combination of both. The lifetime prevalence of Vulvodynia ranges from 10–28%, and it is associated with significant impacts on women’s physical, social, sexual, and emotional functioning. Despite its prevalence and wide-ranging impacts, the causes of this condition are unknown, and biomedical treatments have resulted in poor and unsatisfactory improvements in pain and sexual function. This suggests the need for a wider conceptualisation and approach to treatment in this population, one that incorporates psychosocial factors. Previous research indicates that exploring psychosocial factors and applying psychological interventions may be beneficial in people with persistent pain. Relatedly, the Psychological Flexibility (PF) model and the treatment most directly linked to this -- Acceptance and Commitment Therapy (ACT) -- have growing evidence for their relevance and effectiveness in persistent pain. However, understanding of psychosocial factors in Vulvodynia is currently limited, and PF and ACT have not been applied to this population. The purpose of this thesis was to explore psychosocial factors in Vulvodynia, including PF, and to develop and test an ACT-based intervention in this population. This thesis comprises four studies: 1) a systematic review, 2) a cross-sectional network analysis study, 3) a longitudinal study, 4) a single-case experimental design intervention study.
Study 1: The systematic review investigated the relationship between psychosocial factors and pain and sexual functioning in women with Vulvodynia. Twenty-one observational/experimental studies were included and comprised only of women with PVD. Significant associations between psychosocial factors and outcomes in PVD were found. Some psychosocial factors were consistent with the general pain literature. These included depression, anxiety, self-efficacy, catastrophising, pain anxiety, and pain acceptance. However, some of the identified psychosocial factors were unique to PVD compared to more general pain literature. These included body-exposure anxiety/avoidance during intercourse, attention to sexual cues, painful intercourse self-efficacy, partner hostility and solicitousness and penetration cognitions. Overall, the systematic review highlights the need to consider psychosocial factors in the treatment of this condition, and treatments may need to be tailored to appreciate the particular importance of interpersonal and sex-related aspects in Vulvodynia. Limitations of the literature include the exclusive focus on PVD, that the variables examined lacked a guiding and integrating theoretical model, and the studies did not examine the complexity of inter-relationships between psychosocial factors and multiple outcomes simultaneously.
Study 2: To begin to address some of the identified limitations, this cross-sectional study examined the association between PF (pain acceptance, present-moment-awareness, and committed action), body-exposure anxiety, unmitigated sexual communion, and perceived injustice with pain and sexual outcomes and depression through network analysis. A sample of 349 women with Vulvodynia (112 provoked, 237 spontaneous/mixed subtype) was recruited online. Networks were computed for the total sample and the subtypes separately to explore potential differences. The results showed that perceived injustice, pain acceptance, and depression were “central” factors in all models. Similarly, PF facets were relevant for all networks. However, depression was more central in the network for mixed/spontaneous Vulvodynia, and body-exposure anxiety was most central for the provoked subtype. Overall, perceived injustice, depression, and PF may play a meaningful role in Vulvodynia, but there are differences across subtypes. Mood-related factors may be more important in women with spontaneous/mixed Vulvodynia and intercourse-related aspects in PVD. Tailored treatment approaches are suggested, and psychological treatment focused on PF and injustice is indicated, regardless of the subtype.
Study 3: Building on the cross-sectional findings, this study examined the prospective association between facets of PF (as in study 2), body-exposure anxiety during intercourse, and perceived injustice with the pain and sexual outcomes and depression. Women with Vulvodynia were recruited online and completed self-report measures at baseline (n=349) and again after three months (n=244), overlapping with the COVID-19 pandemic. From baseline to three months, there were significant decreases in pain intensity, pain interference, present-moment-awareness, committed action, and a significant increase in depression. In regression analyses, pain acceptance significantly predicted pain interference at three months, and committed action significantly predicted depression at three months. Overall, this study provides preliminary evidence that two facets of PF prospectively predict two important areas for women with Vulvodynia. Psychosocial approaches that foster PF, such as ACT, may represent a promising avenue for treatment in this population.
Study 4: This multiple baseline single-case experimental design (SCED) evaluated whether an online ACT programme, combined with a Vulvodynia-specific manual, improved pain and sexual outcomes and depression in Vulvodynia. The study also explored whether the intervention led to changes in possible processes of therapeutic change. During baseline and treatment phases, 7 participants completed daily self-report measures of outcomes and process variables. Full-length assessments of these variables were also completed. Visual inspection, Tau and Tau-U scores and analyses of clinically significant change suggested improvements in pain interference, pain intensity, sexual functioning and sexual satisfaction for some individuals. However, participants had highly individual treatment effects. Limited improvement was found in depression. Pain acceptance, committed action, and perceived injustice emerged as potential mechanisms of change for some individuals. These results suggest that an online ACT-based approach may help to improve pain and sexual outcomes in some people with Vulvodynia. Future investigations using SCEDs and ACT-based interventions in this population are warranted.
Discussion: This thesis provides evidence for a set of psychosocial factors in women with Vulvodynia, including facets of PF, and for the potential utility of using an online ACT-based idiographic approach in this population. The thesis findings suggest a multi-layered understanding of psychosocial processes in Vulvodynia is needed. Psychological Flexibility provides a companion set of functional processes, alongside interpersonal and social experiences which together influence Vulvodynia outcomes. These psychosocial factors may be individually varying and subtype-specific. This multi-layered understanding can guide future research and refine our understanding of this condition. Use of idiographic approaches may enable further understanding of individual and subtype differences in this population.