Pain among women : Prospective population studies from a biopsychosocial perspective on pain

This thesis focuses on the role of different psychosocial factors in the course of pain over time in a general population sample of women in Sweden. The main aim was to identify and quantify such factors as predictors of pain, pain-related disability and quality of life within a biopsychosocial framework for the understanding of the pain experience over time. The studies were based on baseline (BL) and follow-up (FU) measures with 12 months apart among 2,300 women living in Sweden, and included physical and psychological health and socio-economic status. Study I investigated associations between socio-economic status (SES) at baseline and pain and pain-related disability at follow-up, and additionally a possible mediating role of depressive symptoms in such associations. The results indicated that educational level, financial strain and occupational level were associated with pain over time. Symptoms of depression were related to all pain-and SES factors, and might be understood as a mediating factor within this context. The results of Study II showed a link between symptoms of burnout at baseline and several pain-locations. Additionally, among women with pain, the characteristics of the pain experience and pain-related disability were associated with level of burnout over time. Study III focused on the sub sample of women reporting pain at follow-up, and examined possible predictors of their perceptions of quality of life (QOL). Several psychosocial factors were associated with QOL, and seemed to be more important predictors than the characteristics of pain in terms of intensity and frequency. These factors were burnout, emotional distress, and social support. Study IV was an attempt to sum up the results of the previous studies by analysing predictors of the course of pain, i.e. by comparing women that developed pain from BL to FU with those that remained pain-free and to compare women with sustained pain with those who recovered from pain during the assessment period. These analyses showed symptoms of posttraumatic stress (PTSD) to be associated with reporting emerging pain, while pain variables, educational level and social support were related to sustained pain. The results of the four studies in this thesis indicate that psychosocial factors and their interplay with the characteristics of pain can be identified and described in a female sample, with a broad definition of pain, and that these factors play a central role in the experience of pain and its impact on the everyday life of these women. There may be several possible paths leading to the development of persistent pain among women and the identification of risk factors is complicated by never-ending interactions between biological, psychological and social processes. At an early stage, prior to pain development, several risk factors may cluster together (e.g. SES, depression), and work as indicators of, e.g. dysfunctional coping in relation to pain. In the first contact with health care and among primary care personnel the identification of such indicators is crucial so as to find women at risk for prolonged pain conditions. General indicators might then be more easily distinguishable than certain individual behaviour characteristics widely accepted as risk factors for pain and disability (e.g. fear-avoidance). To spread the knowledge of general factors in the first line of health care is therefore of great importance in preventive work. Finally, the results demonstrated that many women report pain with characteristics that to a great extent affect their lives and through interactions with psychological and social health might have grave consequences for perceptions of quality of life.