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Acceptance-based factors in chronic pain

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Acceptance-based factors in chronic pain
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A comparison between fibromyalgia and chronic pain patients in an internet support group sample
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Payne-Murphy, Jessica C. ( author )
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Chronic pain ( lcsh )
Acceptance and commitment therapy ( lcsh )
Fibromyalgia ( lcsh )
Acceptance and commitment therapy ( fast )
Chronic pain ( fast )
Fibromyalgia ( fast )
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Thesis (PhD) University of Colorado Denver
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Includes bibliographic references,
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Department of Psychology
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by Jessica C. Payne-Murphy

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Full Text
ACCEPTANCE-BASED FACTORS IN CHRONIC PAIN: A COMPARISON BETWEEN
FIBROMYALGIA AND CHRONIC PAIN PATIENTS IN
AN INTERNET SUPPORT GROUP SAMPLE
by
JESSICA C. PAYNE-MURPHY
B.A., Smith College, 1999
M.A., University of Colorado Denver, 2012
A thesis submitted to the
Faculty of the Graduate School of the
University of Colorado in partial fulfillment
of the requirements for the degree of
Doctor of Philosophy
Clinical Health Psychology Program
2015


This thesis for the Doctor of Philosophy
degree by
Jessica C. Payne-Murphy
has been approved for the
Clinical Health Psychology Program
by
Kevin S. Masters, Chair
Abbie O. Beacham, Advisor
David Albeck
Kristin M. Kilboum
Shandra Brown Levey


Payne-Murphy, Jessica C. (Ph.D., Clinical Health Psychology Program)
Acceptance-based Factors in Chronic Pain: A Comparison Between Fibromyalgia and Chronic
Pain Patients in an Internet Support Group Sample
Thesis directed by Associate Professor Abbie O. Beacham.
ABSTRACT
Fibromyalgia Syndrome (FM) is a chronic pain syndrome that is a challenging, enigmatic,
and costly condition for patients and the healthcare system. Higher levels of psychological
symptomatology are particularly prevalent in this population. Despite research efforts, FM
continues to be poorly understood and treatments have not been found to be wholly effective.
Acceptance and Commitment Therapy-based studies have shown promising findings in reducing
pain-related functional impairment in chronic pain and FM samples by targeting Acceptance of
pain and by utilizing Mindfulness techniques. To better examine the mechanisms that contribute
to greater psychopathology and disability, the study proposes to examine Acceptance,
Experiential Avoidance, Mindfulness and Perceived Disability in FM and a comparison group of
chronic pain (CP), in online support groups. This study aimed to examine cluster analyses for
each sample (FM vs. CP) by levels of Acceptance. Subsequently, a series of ANCOVAs were
conducted to examine overall group differences. Findings suggest significant main effects of
Acceptance levels on Mindfulness, Experiential Avoidance and Perceived Disability for both FM
and CP patients. Additionally, a significant interaction effect was found between Acceptance
level, pain type (FM and CP) and Perceived Disability, F(2, 440) = 12.96,p< .01. These findings
indicate that with increasing levels of Acceptance, CP patients perceptions of their own disability
decrease concordantly; however, FM patients perception decreases only slightly in comparison,
thereby continuing to perceive themselves as disabled in various life domains. Given these
findings as well as prior empirical evidence, further investigation is needed to fully address the
factors contributing to Perceived Disability among FM patients and why this differs from those
ill


with CP. Results also indicate that both Perceived Disability and Acceptance of Pain are key
treatment targets to improve existing multidimensional pain interventions for persons with FM.
The form and content of this abstract are approved. I recommend its publication.
Approved: Abbie O. Beacham
IV


ACKNOWLEDGEMENTS
Special thanks to the University of Colorado School of Medicine Department of Family
Medicine for their generous funding grants; to my advisor Dr. Abbie Beacham at Xavier
University; to Dr. Michael Marsiske, PhD at the University of Florida Department of Clinical and
Health Psychology for his assistance with statistical analyses; and the following members of the
University of Colorado Denver Health Psychology in Primary Care Lab: Dana Brown, M.A.,
Jessica Geller, M.S., and Carissa Kinman, M.A.
v


TABLE OF CONTENTS
CHAPTER
I. INTRODUCTION...................................................................1
II. REVIEW 01 HU] LITERATURE.......................................................3
Fibromyalgia Syndrome......................................................3
Etiology of Fibromyalgia...................................................3
Prevalence, Psychological Correlates, and Current Treatments for
Fibromyalgia...............................................................4
Fibromyalgia Prevalence and Treatment Costs...........................4
Psychological Correlates of Fibromyalgia.....................................5
Trauma and PTSD in Fibromyalgia.......................................6
Functional and Work Disability in Fibromyalgia........................7
Psychosocial Determinants of Perceived Disability.....................8
Treatment Approaches for Fibromyalgia...................................... 10
Pharmacological Treatments...........................................10
Multicomponent Treatments........................................... 11
Psychosocial Treatment Approaches for Fibromyalgia......................... 13
Operant Behavioral Therapy.......................................... 13
Cognitive and Cognitive-behavioral Therapy.......................... 15
Acceptance and Commitment Therapy for Fibromyalgia and Chronic
Pain.................................................................20
Chronic Pain Acceptance..............................................23
Experiential Avoidance and Fibromyalgia.....................................25
The Role of Mindfulness.....................................................30
Profding Pain and Fibromyalgia Patients to Improve Treatment Efficacy......36
Profiling Fibromyalgia and Chronic Pain Patients: Acceptance-Based
Approaches..................................................................38
vi


Purpose of the Present Study..................................................40
Study Hypotheses..............................................................41
III. METHOD.........................................................................43
Participants..................................................................43
Materials and Procedures......................................................44
Independent Variable Measures.................................................45
Demographics and Medical History.......................................45
Chronic Pain Acceptance................................................45
Post-Traumatic Stress Disorder Checklist...............................46
Dependent Variable Measures...................................................47
Acceptance and Action..................................................47
Five Facet Mindfulness Questionnaire...................................47
Pain Disability Index..................................................48
Data Analysis.................................................................49
Selection of Covariates................................................50
IV. RESUFTS.........................................................................52
Recruitment Accrual and Attrition.............................................52
Demographic Characteristics of the Participant Sample.........................53
Pain Characteristics of the Participant Sample................................55
Hypothesis One................................................................56
Hypothesis Two................................................................58
Hypothesis Three..............................................................59
Hypothesis Four...............................................................65
Supplemental Analyses.........................................................66
Interaction Effect Correlations........................................64
Multiple Imputation Analyses...........................................67
vii


ANCOVA Replication Using Imputed Dataset.
68
V. DISCUSSION......................................................................72
Sample Characteristics........................................................73
Representativeness of the Participant Sample..................................74
Hypothesis One................................................................75
Hypothesis Two................................................................78
Hypothesis Three..............................................................79
Mindfulness............................................................80
Experiential Avoidance.................................................81
Perceived Disability...................................................83
The Role of Trauma.....................................................84
Hypothesis Four.......................................................................85
Supplemental Analyses.........................................................88
Uimitations...................................................................89
Future Directions.............................................................91
Clinical Utility.......................................................92
Summary and Conclusions.......................................................93
REFERENCES............................................................................95
APPENDIX............................................................................. 124
A. Group Moderator Invitation to Post Study..................................124
B. Group Member Invitation to Participate................................... 125
C. Informed Postcard Consent.................................................126
D. Gift Card Incentive Lottery...............................................128
E. Additional Items for Chronic Low Back Pain Third Recruitment Wave.........129
F. Chronic Pain Acceptance Questionnaire (CPAQ)..............................130
viii


G. PTSD Checklist Civilian Version.............................................131
H. Acceptance and Action Questionnaire (AAQ-II)..................................133
I. Five Facet Mindfulness Questionnaire- Short Form..............................134
J. Pain Disability Index......................................................... 136
IX


LIST OF TABLES
TABLE
1. Demographic Characteristics of Sample by Data Collection Source......................54
2. Pain Characteristics of Sample by Data Collection Source............................57
3. CPAQ Mean Scores by Cluster- Fibromyalgia Sample....................................57
4. CPAQ Mean Score by Pain Type and Tertile.............................................58
5. CPAQ Mean Scores by Cluster Chronic Pain Sample....................................59
6. Analysis of Covariance of Mindfulness by Pain Type and Acceptance Tertile............60
7. Adjusted and Unadjusted Mean Mindfulness by Acceptance Tertile and Pain Type.........61
8. Analysis of Covariance of Experiential Avoidance by Pain Type and Acceptance
Tertile.............................................................................62
9. Adjusted and Unadjusted Mean Experiential Avoidance by Acceptance Tertile
and Pain Type.......................................................................63
10. Analysis of Covariance of Perceived Disability by Pain Type and Acceptance
Tertile.............................................................................64
11. Adjusted and Unadjusted Mean Perceived Disability by Acceptance Tertile
and Pain Type.......................................................................64
12. Logistic Regression Predicting Likelihood of Survey Non-Completion..................68
13. Comparison of Mean Mindfulness for Non-Imputed vs. Imputed Datasets.................69
14. Comparison of Mean Experiential Avoidance for Non-Imputed vs. Imputed
Dataset.............................................................................70
15. Comparison of Mean Perceived Disability for Non-Imputed vs. Imputed
Dataset.............................................................................71
x


LIST OF FIGURES
FIGURE
1. ACTHexaflex.........................................................................23
2. Participant Attrition and Survey Completion........................................52
3. Adjusted Means for Mindfulness by Acceptance Tertile and Pain Type.................61
4. Adjusted Means for Experiential Avoidance by Acceptance Tertile and Pain Type......63
5. Adjusted Means for Perceived Disability by Acceptance Tertile and Pain Type 1......65
6. Adjusted Means for Perceived Disability by Acceptance Tertile and Pain Type II.....66
7. Adjusted Means for Mindfulness by Acceptance Tertile and Pain Type Using Imputed
Dataset...........................................................................69
8. Adjusted Means for Experiential Avoidance by Acceptance Tertile and Pain Type Using
Imputed Dataset................................................................ 70
9. Adjusted Means for Perceived Disability by Acceptance Tertile and Pain Type Using
Imputed Dataset.................................................................71
xi


CHAPTER I
INTRODUCTION
Chronic pain is a common and debilitating health concern that is a significant financial
and emotional burden for an estimated 100 million Americans (Institute of Medicine of the
American Academies, [10M] 2011). Chronic pain is defined as three months or more of pain
without apparent biological value that has persisted beyond the normal tissue healing time
(International Association for the Study of Pain, 2011, p. 1). Prevalence of chronic pain is an
estimated 20-25% of the worlds population and 10-25% in the U.S. with more Americans
managing chronic pain than diabetes, coronary heart disease, stroke, and cancer combined
(American Academy of Pain Management, 2013; Goldberg & McGee, 2011; National Centers for
Health Statistics, 2006). The expense of chronic pain to the consumer and healthcare system is
also considerable with an estimated $635 billion in litigation, compensation, healthcare, and lost
productivity, or an approximate cost of $2000 annually for every American (IOM, 2011). Chronic
back pain is the leading cause of disability in American adults under 45 years of age and loss of
daily activity and work productivity due to pain are common issues in this population. A 2003
study indicated that 13% of nearly 30,000 randomly sampled working Americans missed
productive work time due to pain conditions in a proscribed two-week period (National Centers
for Health Statistics, 2006; Stewart, Ricci, Chee, Morganstein, & Lipton, 2003). Disability
compensation, healthcare costs, opioid dependence, and lost work productivity are significant
problems in chronic pain populations.
The etiology, type, location, and severity of pain vary greatly among those with chronic
pain; however, fibromyalgia is considered to be one of the most difficult to treat. Empirical
evidence suggests those with fibromyalgia have poorer outcomes across multiple life areas. When
compared to other chronic pain conditions, fibromyalgia patients have higher rates of mental
illness (Birtane, Uzunca, Ta$tekin & Tuna, 2007); increased costs of care; greater loss of
1


productivity (Boonen et al., 2007); and poorer quality of life (Wolfe, Michaud, Li, & Katz, 2010).
Fibromyalgia is relatively less common than other types of pain, as an estimated 2-3% of the U.S.
population carries this diagnosis (Croft, 2002; Fillingham et. al, 2009; Gran, 2003). In contrast,
lower back pain is the most common pain type (18%), followed by osteoarthritis (16%),
rheumatoid arthritis (6%), and migraine headache (3%) according to a 2010 internet-based study
of nearly 11,000 Americans (Johannes, Le, Zhou, Johnston, & Dworkin, 2010).
2


CHAPTER II
REVIEW OF THE LITERATURE
Fibromyalgia Syndrome
Fibromyalgia Syndrome (FM) is a chronic pain syndrome that is a challenging,
enigmatic, and costly condition for patients and the healthcare system. FM is defined by the
American College of Rheumatology as widespread pain throughout the body, fatigue, waking
unrefreshed, and/or cognitive symptoms contributing to an established symptom severity
threshold that has been experienced for at least three months (Wolfe & Hauser, 2011). In addition
to a chronic dull, achy pain, FM patients frequently experience other distressing symptoms such
as: sleep difficulties, headaches, balance disturbances, muscle spasms, tingling, numbness, bowel
and bladder problems, depression, anxiety, fibro fog or other cognitive impairments, and many
others (Arnold et al., 2008, p. 5; Bennett, Jones, Turk, Russell, & Matallana, 2007).
Etiology of Fibromyalgia
In comparison to those with chronic pain in which the location of pain is generally
limited to the site(s) of prior injury, physiological symptoms in FM have greater variation and are
thought to be from a different origin. Abnormal pain processing in the central nervous system,
called central sensitization or spinal cord hyper-reactivity, is believed to cause chronic
widespread pain and some researchers believe this process may occur even in the absence of
physical injury (Marcus & Deodhar, 2008; Perrot, Dickenson, & Bennett, 2008). Researchers
believe that spinal cord-brain communication is disrupted in those with FM such that pain signals
are also amplified (Clauw, Arnold, & McCarberg, 2011); with studies now consistently showing
significant hyperalgesia in those with FM when compared to controls (Clauw et al., 2011;
Petersel, Dror, & Cheung, 2011). Hyperalgesia, or heightened sensitivity to pain, contributes to
lower pain tolerance and higher pain severity ratings. The chronic hyper-stimulation of the
hypothalamic pituitary axis, the autonomic nervous systems sympathetic response, is another
3


predominant theory that attempts to explain pain, fatigue, and other flu-like symptoms found in
FM but not in other types of chronic pain with different etiologies (Mease, 2005). Lastly, a
genetic predisposition is thought to underlie many cases of FM, with current theory suggesting
trauma activates specific genes to cause symptom onset (Arnold et al., 2004). A person is eight
and a half times more likely to have FM given a relative was diagnosed as well (Arnold et al.,
2004). Results from a Swedish twin registry study (N= 15,950) further suggest incidence is
influenced by genetic variability: female monozygotic twins with fibromyalgia had a 0.29
concordance rate, whereas male monozygotic twins had a 0.14 concordance rate (Kato, Sullivan,
Evengard, & Pederson, 2006).
Prevalence, Psychological Correlates, and Current Treatments for Fibromyalgia
FM as a biopsychosocial condition in which both physiological and psychological
symptoms contribute to a patients experience. These include perceptions of pain severity,
functional disability, and quality of life. When compared to those with rheumatoid arthritis,
osteoarthritis, or chronic low back pain, fibromyalgia patients have poorer mental and physical
health and social functioning, more frequent stress-related increases in pain, and poorer overall
quality of life (Davis, Zautra, & Reich, 2001; Strombeck, Ekdahl, Manthorpe, Wikstrom, &
Jacobsson, 2000; Verbunt, Pemot, & Smeets, 2008).
Fibromyalgia Prevalence and Treatment Costs. Reports of FMs diagnostic prevalence
vary from worldwide estimates between 0.5-5.8% to 2 to 3% of adults in the United States and
United Kingdom (Croft, 2002; Fillingham et al., 2009; Gran, 2003). Prevalence increases with
age, peaking between the ages of 55 to 64, with women being diagnosed three times more often
than men (Marcus & Deodhar, 2011; McNally, Matheson, & Bakowsky, 2006). Healthcare
utilization and cost is significant with estimated expenditures of nearly $10,000 annually per FM
patient in the U.S. (Berger, Dukes, Martin, Edelsberg, & Oster, 2007). Costs of FM care are
approximately two to three times that of matched non-FM patients (Berger et al., 2007; Lachaine,
4


Beauchemin, & Landry, 2010; Thompson et al., 2011). In addition, those with more severe FM
symptoms were estimated to accumulate an additional $2000 in costs over a four-year period
(Thompson et al., 2011). Results of a 2010 longitudinal study examining insurance-reported
utilization and treatment expenditures suggest highest costs occur six months pre and post-
diagnosis following an FM diagnosis, when with approximately $7000 in annual healthcare
spending over a three-year period (Sanchez et al., 2011). Most studies only include costs
reimbursed to providers and patients deductibles and copayments; however, others estimate an
additional $100-$500 per month spent on over-the-counter medication (Bennett et al., 2007).
Despite comparatively lower prevalence rates among chronic illnesses, FM contributes significant
financial and time expense to patients and the healthcare system.
Psychological Correlates of Fibromyalgia
FM patients have some of the highest mental health comorbidity rates of all health
conditions, with greater prevalence reported in FM patients than in the general population, other
healthcare patients, and patients with most other chronic pain types. Wide discrepancies in mood
disorder rates in FM have been published, with reported prevalence ranging from 20 to 80%, 23
to 69% with depression (Fietta, Fietta & Manganelli, 2007; Thieme, Turk & Flor, 2004) and 13 to
63.8% with an anxiety disorder (Fietta et al., 2007). At its highest reported prevalence,
approximately 69% of FM patients seen in four tertiary-care centers (N= 73) met criteria for any
mood disorder within their lifetime, and 29% met criteria currently as measured by DSM-III-R
SCID interviews (Epstein, et al., 1999). According to this same study, FM patients lifetime and
current diagnoses included: any psychiatric disorder (81% lifetime; 48% current); major
depressive disorder (69; 23); any anxiety disorder (35; 27); simple phobia (17; 13), panic disorder
(17; 9); and social phobia (7; 9) (Epstein, et al., 1999). Despite a lack of consensus of psychiatric
prevalence as evidenced by a significant range reported in the literature, conservative estimates
still remain higher than community rates. When compared to DSM-V 12-month prevalence
5


population estimates, the numbers are significantly lower: major depressive disorder (7%);
specific phobia (7-9%); panic disorder (2-3%); and social anxiety disorder (7%) (American
Psychiatric Association, 2013).
Diagnostic rates are also higher in FM than in those with other healthcare patients,
notably those with other rheumatic conditions. Compared to healthcare patients without FM
(approximate N= 52,000), FM patients (approximate N = 2,600) were 2.9 to 3.6 times more
likely to carry a diagnosis of depression or anxiety (Weir et al., 2006). FM patients (n = 2733)
had the highest prevalence rates of depression, anxiety and substance abuse in a large study with
other patients with rheumatic diseases (i.e. lupus, rheumatoid arthritis, and noninflammatory
rheumatic disorders), almost double that of rheumatoid and noninflammatory rheumatic disorders
(Wolfe et al., 2010). Psychological correlates must be targeted in current FM treatments in order
to fully address the range of presenting symptomatology.
Trauma and PTSD in Fibromyalgia. In addition to mood disorders, findings also
suggest higher self-reports of adult or childhood victimization or trauma in FM patients. Studies
report 31.3 to 57% of those with FM endorsed trauma histories and/or symptoms of PTSD
(Bennett et al., 2007; Cohen et al., 2002; Sherman, Turk & Okifuji, 2000). In the first study to
rigorously evaluate PTSD symptoms in FM, 57% of 77 FM patients endorsed clinically
significant levels of symptoms including hyperarousal, and reexperiencing and avoidance of the
fearful experience (Cohen et al., 2002). More recently, an Internet study of over 2,500 FM
patients showed that 31.3% of participants reported emotional trauma as an event that triggered
their FM symptom onset, only second to chronic stress (41.9%) (Bennett et al., 2007). Among
types of trauma and life stressors, only physical and sexual assault/abuse (ORs = 1.38 and 1.41,
respectively), were significantly more likely to occur in FM patients (n = 341), but not emotional
abuse/neglect, life threatening trauma, or significant life stressors such as serious illness, death of
a child, or homelessness in another study (Haviland, Morton, Oda, & Fraser, 2010). A 2005 meta-
6


analyses showed moderate effect sizes, on average, indicating significant relationships between
abuse/neglect history and pain in both FM and CP patients across all nine reviewed studies
(Davis, Luecken, & Zautra, 2005).
FM patients report more trauma histories compared to those with other chronic illnesses,
as well as healthy people. Several studies indicate trauma histories or PTSD symptoms to be 3.1
times more common in those with FM than healthy controls (Ciccone, Elliott, Chandler, Nayak,
Raphael, 2005; Raphael, Janal, & Nayak, 2004). The finding that abuse/neglect prevalence was
significantly greater than healthy individuals was reported in Davis, Luecken, and Zautras 2005
study, and again suggests a correlation between abuse/trauma and pain in later life. When
compared to patients with multiple sclerosis and rheumatoid arthritis (N= 147), those with FM
showed significantly higher rates of physical and emotional abuse and neglect, with many
reporting a history of long-term victimization (Van Houdenhove et al., 2001).
Furthermore, those with PTSD symptomatology endorse significantly higher scores on pain
intensity, perceived disability, interference of pain in life activities, depressive symptomatology,
and overall affective distress (Sherman, Turk & Okifuji, 2000). Coping styles of FM patients with
PTSD also differ from non-PTSD FM patients such that they rely more on suppression to regulate
their emotions (p > .02) (Ablin, Cohen, Neumann, Kaplan, & Buskila, 2008). Despite higher
comorbidity of trauma/abuse histories in those with FM, surprisingly few FM interventions exist
to address processing of traumatic experiences, psychoeducation around PTSD and traumas
effect on pain, or suppression or avoidant coping styles (Leserman, 2005; Lumley, 2011). Given
high prevalence rates, trauma history and current PTSD symptomatology are critical factors when
examining affective processes and behaviors in FM. Specifically, associations among PTSD
symptoms and expression must be assessed when designing treatment approaches. For this
reason, symptoms of PTSD are assessed in the current study.
Functional and Work Disability in Fibromyalgia. The persistent pain, fatigue, sleep
7


difficulties and other noxious symptoms of FM frequently interfere with life activities, including
occupational and other areas of functioning. Functional disability is a serious concern in FM: an
estimated 25-50% of FM patients report significant work disability (Henriksson, Liedberg, &
Gerdle, 2005; Liedberg & Henriksson, 2002), and those who are employed express worries about
losing their jobs (Bennett et al., 2007). In a large Internet study of FM patients (N= 2596),
approximately half believed their symptoms prevented them from seeking gainful employment
and those who did work had more sick days, reduced hours and worried about their productivity
(Bennett et al., 2007). Additionally, 46.8% of 136 FM patients said they lost their jobs due to
their condition vs. 14.1% of control participants (n = 152) with other chronic diseases (Al-Allaf,
2007).
Pain, fatigue, muscle weakness and difficulties with memory and concentration are the
most frequently reported symptoms interfering with work activities according to a review of 21
studies of women with FM (Henriksson et al., 2005). Studies suggest that these symptoms appear
to be more debilitating in patients with FM, when compared to other patients who have chronic
medical diseases without the presence of FM. Compared to those with rheumatoid arthritis and
osteoarthritis, studies suggest similar to worse functional abilities in FM patients (Hawley &
Wolfe, 1991; Walker et al., 1997; White, Harth, & Teasell, 1995). This may be contributed by
FM patients frequent reports of high pain severity, widespread pain, sleep difficulties, greater
psychological distress, and poorer coping and sense of control (Walker et al., 1997; White et al.,
1995). Comparisons among patients with FM, rheumatoid arthritis, osteoarthritis, scleroderma or
systemic lupus erythematosus (N = 602) also show FM participants had the highest levels of
functional impairment, highest pain severity, most learned helplessness, and poorest overall
subjective health status (Callahan, 1989).
Psychosocial Determinants of Perceived Disability. Psychosocial factors play an
essential role in FM disability across various conceptualizations of disability found in the
8


literature. These largely include observable physical limitations, limitations in activities of daily
living (ADLs), and/or receipt of disability payments or workers compensation. Measuring
functional disability in FM patients, defined as the patterns of behavior arising from the loss or
reduction of ability to perform expected or specified social role activities, continues to be a
challenge for providers trying to assess functional status for work disability claims (Mannerkorpi
& Ekdahl, 2007, p. 4; Verbrugge & Jette, 1994).
Research suggests perception of ones own disability is complex and, as stated
previously, relies heavily on psychosocial influences. Perceived disability is a subjective account
of the degree of impairment patients have due to their pain within a range of voluntary and
obligatory life activities (Fordyce et al., 1984; Tait, Chibnall, & Krause, 1990). Because chronic
pain is one of the primary symptoms of FM, it stands to reason that studies examining the
limiting effects of chronic pain would lend understanding to FM perceived disability as well.
Therefore, studies looking closely at the processes of perceived disability within both FM and CP
populations are discussed herein.
Multiple findings indicate predictors of higher perceived disability in FM include low
self-efficacy, catastrophizing, fear of pain, and subsequent avoidance of activities for fear of
exacerbating pain (Dobkin et al., 2010; Karsdorp & Vlaeyen, 2009; Martin et al., 1996;
Severeijns, Vlaeyen, van den Hout, & Weber, 2001; Turk, Robinson, & Burwinkle, 2004).
Several studies suggest depression and emotional trauma contribute to higher perceived disability
as well (Aaron et al., 1997; Turk et al., 2004). Similarly, chronic pain studies suggest that fear of
pain, fear avoidance, lower self-efficacy, and depression contribute to both higher perceived and
actual disability (Crombez, Vlaeyen, Heuts, & Lysens, 1999; Denison, Asenlof, & Lindberg,
2004; Geisser, Haig, & Theisen, 2000, Swinkels-Meewisse, Roelofs, Oostendorp, Verbeek, &
Vlaeyen, 2006; Waddell, Newton, Henderson, Somerville, & Main, 1993). Surprisingly, fear of
pain is a stronger predictor of higher perceived disability than actual functional ability (Crombez
9


et al., 1999; Waddell et al., 1993). Additionally, higher pain intensity ratings correlate with higher
perceived disability, but not disability objectively-rated by observers (Alschuler, Theisen-
Goodvich, Haig, & Geisser, 2008). Findings suggest strong psychosocial determinants of both
perceived and actual physical disability in FM and CP samples, with apparently similar processes
affecting perceived physical limitations.
Treatment Approaches for Fibromyalgia
Fibromyalgia, as well as other types of CP, is considered a biopsychosocial condition that
requires dynamic and multidimensional treatment approaches. Although a cure does not exist for
FM, interventions that primarily target pain, mood, sleep, fatigue, functional status, and quality of
life are known to mitigate symptom severity (Hauser et al., 2009a). The use of one type of
therapy, specifically medication, however, is the most common and widely available treatment
option. Pharmacological and multicomponent interventions are briefly reviewed here, followed
by psychosocial therapies.
Pharmacological Treatments. Commonly prescribed medications for a range of FM
symptoms may only have up to 30-50% efficacy within short-term periods; long-term data are
lacking (Abeles, Solitar, Pillinger, & Abeles, 2008; Arnold, Keck, & Welge, 2000; Marcus &
Deodhar, 2008). Treatment targets of FM medications are primarily limited to pain, sleep, fatigue,
and depressed mood. Amitriptyline, a tricyclic antidepressant, serotonin and norepinephrine
reuptake inhibitors (SNRIs), and selective serotonin reuptake inhibitors (SSRIs) are thought to act
on the central nervous system by increasing serotonin and norepinephrine, thereby "reduc|ing|
pain signaling in those with FM (Abeles et al., 2008, p. 556). Notably, amitriptyline is widely
published as being one of the more effective FM treatments for pain, sleep and fatigue,
specifically, with some of the largest effect and sample sizes reported (Arnold et al., 2000; Hauser
et al., 2009b). Duloxetine, an SNRI that targets depressed mood, pain and sleep symptoms, is also
touted as one of the more effective medications (Arnold et al., 2000; Hauser et al., 2009b). A
10


2008 systematic review and 2009 meta-analysis including 18 randomized control studies with
1427 FM patients over an average of 8 weeks also suggest small effect sizes attributed to SNRIs
fluoxetine and milnacipran for pain, sleep, depression and quality of life (Hauser et al., 2009b;
Uceyler, Hauser, & Sommer, 2008). Antiepileptics (for pain-relieving effects), analgesics such as
nonsteroidal anti-inflammatories, muscle relaxants for pain and sleep, and sedative hypnotics for
sleep, are also commonly prescribed or used for FM symptoms, with reported varying efficacy
(Goldenberg, Burckhardt, & Crofford, 2004; Mease, Dundon, & Sarzi-Puttini, 2011).
Non-adherence to medication is a common occurrence in FM samples and higher
psychological distress (Dobkin, Sita, & Sewitch, 2006) and provider-patient discordance (Sewitch
et al., 2004) are reportedly determinants. In addition, among 2,569 FM patients polled, 27%
reported medication side effects worsened their FM symptoms (Bennett et al., 2007). These
deterrents to medication use and the need for patients to maintain treatment efficacy with long-
term use, contribute to only short-term efficacy in mitigating the impact of chronic symptoms,
furthering the need for non-pharmacological interventions (Marcus, 2009; van Koulil, et al.,
2007).
Multicomponent Treatments. Multicomponent approaches using medications, exercise
and psychosocial treatments are also prescribed to manage FM symptoms. Although small effect
sizes are seen in studies combining exercise, medications, and psychological or other non-
pharmacological interventions, these findings too suggest FM treatment approaches continue to
evolve in efforts to maximize treatment outcomes (Hauser et al., 2009a). Medications, aerobic
exercise, cognitive-behavioral treatment (CBT) and multicomponent treatments (one educational
or psychological therapy and one exercise component) are the front-runners for the most effective
therapies for FM that show short-term improvements in pain, fatigue, sleep, mood, and quality of
life (Hauser et al., 2009a). Although longitudinal research is still needed in this area, both the
2001 and 2005 (the American Pain Society (APS) and the Association of the Scientific Medical
11


Societies in Germany (AWMF)) international guidelines for FM treatment suggest aerobic
exercise, CBT, amitriptyline and multicomponent therapies produce the best outcomes according
to evidence-based studies (Hauser et al., 2010b).
A 2007 Cochrane review of 47 exercise interventions for fibromyalgia suggested the
optimal routine includes at least 20 minutes of aerobic exercise, which may be divided into two
separate 10-minute sets, two to three days a week (Busch et al., 2007; Hauser et al., 2010a).
Authors advise heart rate must be gradually increased to a moderate intensity level as to not
exacerbate symptoms. Researchers also suggest strengthening exercises should be completed two
to three times per week for eight to twelve repetitions each set. Lastly, emphasis is placed on
graduated increases of intensity to prevent setbacks and nonadherence (Abeles et al., 2008).
Findings indicate that exercise at this intensity significantly improves general health and physical
function but not pain, whereas strengthening exercises improve pain, mood, and general health
but not physical function (Busch et al., 2007).
In Hauser et al.s (2009a) meta-analysis of nine randomized control trials of
multicomponent therapies using aerobic exercise and CBT or education for FM (n = 700),
significant improvements with small effects were found at post-treatment in pain reduction,
depressed mood, fatigue, self-efficacy, and fitness. However, effects were not maintained at three
to four months or at six to twelve months. Authors suggest lack of long-term improvements may
be due to unknown exercise intensity ratings, unpublished specifics of the CBT and education
components, and the short duration of therapies: all were completed between 18 and 46 hours
(median = 24). One chronic back pain multicomponent intervention suggests that long-term
change is only maintained at greater than 100 hours of treatment (Hauser et al., 2009a). Most
recently, van Koulil et al.s 2010 randomized control treatment including greater than 100 hours
of exercise and CBT showed significant improvements with overall large effect sizes in pain,
fatigue, negative mood, anxiety, and functional disability at both at post treatment and at 6
12


months (n = 158).
Psychosocial Treatment Approaches for Fibromyalgia
Multicomponent therapies show much promise in addressing the complex symptom
presentation of FM patients; however, efficacious psychosocial approaches, whether combined
with exercise or other modalities, require further evaluation. The most widely studied and
effective FM psychosocial treatments are reviewed here.
Operant Behavioral Therapy. Operant behavioral therapy is one of the leading
approaches to FM and CP symptom management. This model is based on the Operant Learning
Theory of Pain, developed by Wilbert Fordyce in the 1970s (Fordyce, 1976). The concept of
pain behaviors is integral in this theory, suggesting that those with CP and FM display
particular behaviors when they are in pain such as avoiding activities, exercise or interactions
with others to communicate the existence of pain to others. This behavior may temporarily
decrease suffering but invariably maintains pain levels and lowers quality of life over time. These
behaviors are shaped by consequences, and are therefore subject to reinforcement (Turk &
Rudy, 1986, p. 761). Operant behavioral treatment specifically targets pain behaviors and works
to change the antecedents and consequences of the behavior to modify or shape them to be more
assertive and healthy (Thieme & Gracely, 2009). Three components are necessary for operant
therapy to be effective: 1) identify the behavior; 2) decide on the types of reinforcers that would
be most beneficial; and 3) establish enough control over the patients environment to shape
behavior via consequences and schedules of reinforcement (Fordyce, Fowler, Lehmann, &
DeLateur, 1968, p. 181). Common treatment targets include increasing physical activity and
reducing anxiety, healthcare utilization, and pain medication. Involving the patients significant
other is also an important addition to properly shape these new conditioned responses.
Operant behavioral therapy research for FM suggests significant improvements in several
key FM symptoms: physical functioning, pain behaviors, and healthcare-seeking behavior
13


(Thieme, Flor, & Turk, 2006; Thieme, Gromnica-Ihle, & Flor, 2003; Thieme, Turk, & Flor,
2007). Findings from Thieme, Gromnica-Ihle, & Flors 2003 study showed reductions in these
areas as well as pain intensity; affective distress; interference of pain in family, work and leisure,
medication use; and solicitous spouse behavior, or the partners attention to the patients pain; in
addition to increased sleep time; life control; and self-efficacy; at 15 month follow-up. FM
inpatient participants randomized to the operant behavior group (n = 40) received time contingent
schedules of medication use; increase in physical activity, training in assertive pain incompatible
behavior, and activities and training aimed to decrease pain behaviors and interference of pain in
lifes activities (p. 316). In contrast, the FM inpatients randomized to the physical therapy group
(n = 21) received antidepressants as well as seven different types of physical therapy exercises
(e.g. mud baths, muscle relaxation, etc.) that were described as usually applied in this type of
clinic setting in Germany (p. 316). Although the limitation of no control group was discussed,
results across these previously listed variables measured by the Multidimensional Pain Inventory
(MPI) showed greater improvements in the operant groups vs. physical therapy as evidenced by a
series of repeated measures ANOVAs. In particular, the highest effect sizes were found in the
operant group for pain intensity (ES =2.14), interference (ES = 2.50), life control (ES = 1.39),
affective distress (ES= 1.74), and self-efficacy (ES= 1.89) all from baseline to 15-month post
treatment.
In a follow-up randomized control study comparing operant behavioral treatment (n =
43), cognitive-behavioral therapy (n = 42), and an attention-control group (n = 40), operant
behavioral treatment was also found to show promising results (Thieme et al., 2006; Thieme et
al., 2007). Specifically, patients attended 15 weekly 2-hour sessions that were led by both a
psychologist and rheumatologist. Groups were limited to five patients each and spouses were
asked at attend at the first, fifth, ninth and 13th sessions. The manualized protocol emphasized
self-recognition of pain behaviors, followed by contingent positive reinforcement of non-pain
14


behavior and punishment of pain behaviors both practiced in the group and at home. Video
feedback and roleplaying was employed, as well as structured reduction of medication use and
increases in physical activity.
At six-month follow-up, clinically significant decreases in pain intensity and affective
distress in the operant behavioral group were reported, when compared to the attention-control
group. Sustained improvement in pain intensity was shown at twelve-month follow-up as well.
However, more notable differences were reported in the cognitive-behavioral group in affective
distress, catastrophizing, and active coping, such that these elements were targeted in these
participants (Thieme et al., 2006, Thieme et al., 2007). These findings suggest that operant
behavioral therapy is an effective tool to positively impact several important FM symptoms (e.g.,
pain behaviors, physical functioning, and medical utilization) but is less effective in improving
affective components or other symptoms such as sleep difficulties, mood, and quality of life when
compared to CBT.
Cognitive and Cognitive-behavioral Therapy. Cognitive-behavioral therapy (CBT;
Beck, 1976) is the dominant therapeutic modality for a range of psychological and medical
illnesses, with over 325 studies published since 2006. CBT for chronic pain and FM essentially
relies on three core concepts: 1) operant learning theory; 2) Melzack and Walls Gate Control
Theory; and 3) changing dysfunctional thoughts and beliefs to produce both improvements in
behavior and mood (Dozois & Dobson, 2001; Melzack & Wall, 1965; Thom, 2004). The Gate
Control Theory suggests that neural structures, in the dorsal hom of the spinal cord act as gates
that, with the influence of large nerve fibers, small nerve fibers, mood state and other cognitive
factors, can modify the speed of pain signaling to and from the brain, and thus modify perception
and experience of pain (Melzack & Wall, 1965). Specifically, the theory suggests the following:
1) afferent nerve transmission relaying signals from painful or non-painful stimuli are sent to the
dorsal hom; 2) large nerve fiber transmissions to this site tend to inhibit pain signaling in the
15


substantia gelatinosa (therefore closing the gate) and small nerve fiber transmissions to this site
tend to facilitate signaling (or open the gate); 3) a system of large-diameter fast-conducting
nerve fibers send nerve impulses from the brain to this site influencing the opening or closing of
the gate as well; and 4) when a threshold of T cells in the spinal cord is met, this signals the
brain to activate a complex series of neural processes that determine response to and perception
of the pain (Melzack, 1996; Wall, 1996). In effect, this multi-step signaling mechanism suggests
that past experiences and perception or thoughts of pain influence the experience of pain:
negative perception leads to worse physical experience of pain and vice-versa.
CBT for pain and FM aims to educate and train patients to recognize and reconceptualize
both maladaptive cognitions and behaviors that serve to maintain their pain experience. Training
patients to identify and change distorted thoughts and beliefs aids in reconceptualizing the
patients experience and improves patterns of thinking and mood over time. Catastrophizing, or
an exaggerated negative mental set brought to bear during painful experiences, is recognized
as a common maladaptive pattern of thinking in chronic pain and FM (Sullivan et al., 2001, p.
52). Patients with CP or FM who catastrophize also tend to feel helpless about controlling their
pain, ruminate about painful sensations, and expect bad outcomes (Thom, Boothby, & Sullivan,
2002, p. 128).
Researchers whose work focuses on catastrophizing in CP and FM suggest that these
thought patterns are correlated with increased disability, pain intensity, and depression and poorer
pain tolerance and patient satisfaction with their healthcare provider (Hassett, Cone, Patella, &
Sigal, 2000; Severeijns et al., 2001; Sullivan et al., 2001, Thom et al., 2002; Thom et al., 2004;
Tsui et al., 2012). Functional MRI studies in FM samples also suggest greater catastrophic
thinking activates brain areas involved in pain processing such as those related to attention to
pain, emotional aspects, and motor control (Burgmer et al., 2011; Gracely et al., 2004).
Interventions used to reduce catastrophizing and negative cognitions in FM and CP patients
16


strongly emphasize realistic appraisal of ones thoughts, identifying pain beliefs, challenging and
changing distorted thoughts, and employing more adaptive techniques to meet personal goals
(Thom, 2004; Thom et al., 2002). Several CP and FM short-term cognitive-behavioral
interventions that target catastrophizing and negative cognitions indicate improvements in these
areas as well as in depressive symptoms (Bennett et al., 1996; Creamer, Singh, Hochberg, &
Berman, 2000; Jensen, Turner, & Romano, 1994; Rodero, Garcia Campayo, Casanueva
Fernandez, & Sobradiel, 2008; Thom et al., 2002).
Other key elements of CBT for FM, specifically, are described here briefly. Education on
the physical and psychological processes of FM is important to explain the interplay of these two
in establishing and maintaining the pain experience. Goal setting for social, physical and work
activities helps to encourage healthy behaviors despite the presence of pain and other symptoms.
Activity pacing serves to balance overdoing and underdoing, a common cycle found in both
CP and FM patients (Bennett & Nelson, 2006). In combination with other techniques, relaxation
training (e.g. diaphragmatic breathing and progressive muscle relaxation) is suggested to improve
a variety of symptoms including sleep dysregulation (Glombieski et al., 2010), pain intensity
(Creamer et al., 2000) and catastrophizing (Vlaeyen et al., 1995). Assertiveness and
communication training are taught to set personal boundaries around activity and help manage
emotions and healthy relationships with loved ones and healthcare providers (Bennett & Nelson,
2006; Thom, 2004). Commonly, creative problem-solving strategies are also taught to anticipate
patients obstacles and to maintain treatment gains (Turk & Melzack, 2001). The therapist relies
on operant learning techniques, positive and negative reinforcement, to shape and extinguish
behaviors overtime.
Although CBT is a prevalent approach for FM symptom management, mixed empirical
efficacy is reported across multiple treatment targets. Largely, CBT for FM meta-analyses and
reviews suggest CBT is currently the most effective psychosocial treatment administered with
17


demonstrated advantages over other psychosocial modalities for short-term pain reduction and
self-efficacy (Bemardy, Fiiber, Kollner, & Hauser, 2010; Glombieski et al., 2010). However,
studies show variable CBT efficacy across multiple FM treatment targets: mood, sleep, fatigue,
functional status, and reduction of pain behaviors (Bennett & Nelson, 2006; Bemardy et al., 2010;
van Koulil et al., 2007). Bemardy et al.s 2010 meta-analysis suggests that CBT reduced
depression and increased self-efficacy, but no differences were found for pain, sleep, fatigue and
quality of life. Another 2010 meta-analysis of 23 randomized control trials of psychological
treatments for FM found that CBT (n studies = 8) was significantly better at improving short-term
pain intensity over other treatments, with a medium effect size (Hedges g = .60) (Glombieski, et
al., 2010). When combined with relaxation/biofeedback, CBT was also more effective for sleep
than other modalities as well (Glombieski, et al., 2010). CBT was equally effective in reducing
depressive symptoms when compared to relaxation, biofeedback, education, and eye movement
desensitization and reprocessing (EMDR) and but no advantages were indicated for
catastrophizing or functional status (Glombieski, et al., 2010). Similarly, Thieme and Gracelys
2009 review examining both CBT and operational behavioral therapies reported that those who
received CBT experienced a 42-54% decrease in pain. No other treatment targets were examined,
however. Promising findings were also reported in a 2004 FM treatment guideline and review:
authors strongly recommended the use of CBT, along with education, relaxation, or exercise
(Goldenberg, et al., 2004).
Other CBT reviews and studies urge further research is needed to find more effective FM
treatments. A 2006 review of 13 CBT for FM studies found no treatment advantages for CBT-
only when compared to education or exercise interventions (Bennett & Nelson, 2006). Likewise,
a 2007 review found the effects of CBT on pain, mood and disability to be limited and
positive outcomes largely disappear in the long-term (van Koulil et al., 2007, p. 571). Moderate
support for CBT was suggested in a 2003 review, adding that treatment effects were higher when
18


CBT was coupled with other modalities, such as physical activity, but could not be explained
(Williams, 2003).
Previous clinical studies suggest that CBT is not as effective for FM as it has been for
other types of chronic pain conditions. Moderate to large effects are reported on pain intensity,
health-related quality of life, and depression for CBT in chronic pain samples without FM
(Hoffman, Papas, Chatkoff, & Kems, 2007) and positive/active coping was increased as well
(Morley, et al., 1999). Additionally, multidisciplinary programs with CBT for CP without FM are
suggested to be superior to other active treatments in producing improved work-related outcomes
at both short and long-term follow-up (Hoffman et al., 2007).
Regarding FM studies, one commonly cited explanation for this mixed efficacy is the
lack of a unified definition of CBT across many trials, making outcomes difficult to compare
(Bennett & Nelson, 2006; Hassett & Gevirtz, 2009). Often FM studies will include different
durations and emphases on relaxation training, activity pacing, graded exercise, and/or
mindfulness-based therapy skills, a specific modality within relaxation. For example, among eight
CBT studies reviewed, three included Qi Gong, aerobic exercise or stretching and total
intervention duration ranged from 2.75 to 42 hours (Glombieski, et al., 2010). Other reasons for
disagreement regarding CBT efficacy are variation in 1) treatment targets (given FM symptom
complexity), 2) methodological quality, and 3) consistency of measures used to monitor change
over time (Bemardy et al., 2010; Sim & Adams, 2002). Within 14 of the CBT studies reviewed
by Bemardy et al. (2010), a range of 22 questionnaires were used to measure a median of seven
treatment targets.
In sum, both operant behavioral therapy and CBT continue to show some promising
outcomes for treatment of FM. However, the inconsistency among all reviewed studies indicates
that the field has yet to find potent interventions to improve functional outcomes despite the
considerable physical, cognitive, and affective symptoms of FM. This need exists aside from the
19


paucity of truly effective combinations of modalities that address FMs complex symptom
presentation. Many studies suggest that given the heterogeneity of CP and FM patients
symptomatology; tailoring protocols to patients would greatly enhance efficacy as well (Thieme
et al., 2006; Turk, 2005; van Koulil et al., 2007; Vlaeyen & Morley, 2005). In addition to
tailoring, research advancements and perhaps a reconceptualization of FM are needed to improve
interventions. Findings inform us that treatments that include active strategies that engage
behavior in those with FM are more effective treatment targets and better physiological and
psychological outcomes. Nevertheless, it may be possible that those patients who have
particularly complex symptom presentations would be more responsive to different approaches,
such as Acceptance and Commitment Therapy (ACT).
Acceptance and Commitment Therapy for Fibromyalgia and Chronic Pain.
Acceptance and Commitment Therapy (ACT; Hayes, 1994) is a third wave behavioral
therapy, which approaches relationships among cognitions, emotions, and behavior in a similar,
yet fundamentally different way from CBT. ACT is referred to as a third wave therapy because
it expands on behavioral theory and originated from Relational Frame Theory, which examines
the relationship between cognition and language (Hayes, Bames-Holmes, & Roche, 2001).
Relational Frame Theory explains that individuals develop operantly conditioned responses to
stimuli that are not directly conditioned to those responses, but are somehow similar and therefore
generalize to other, many times broader, contexts.
These relationships can be directly observed in those with many types of CP including FM.
A common cycle found in CP is avoiding tasks that may invoke more pain; however, as the
negative experience of pain continues, the range of activity becomes more and more limited for
fear of reexperiencing the pain. For example, one may begin to avoid climbing stairs after this
person noticed more pain the following day. This avoidance may then be generalized to walking
certain distances and over time, increasing activity restrictions that limit mobility, flexibility, and
20


even positive social interactions, which contributes to further deconditioning, activity avoidance,
and hence, worse pain and suffering. Negative interpretation of the pain experience and of the
patients sense of self also leads to justification for disengaging from adaptive and daily life
activity in an effort to control or avoid painful experiences and thus mov[es] them away from
healthy life functioning (McCracken & Eccleston, 2005, p. 164.) In sum, patients develop
generalized conditioned responses to particular stimuli, which alter their behavior, limit their
experiences, and ultimately, lead to poorer functioning.
ACT suggests that positive change comes from not only having awareness of ones
thoughts but also "creat| ing | greater psychological flexibility by teaching skills that increase an
individuals willingness to come into fuller contact with their experiences (Keng, Smoski &
Robins, 2011, p. 7). ACT also emphasizes committing to personal values that produce action-
based outcomes and living the kind of life the person most deeply chooses to live (Hayes &
Duckworth, 2006, p. 186). There are six core therapeutic processes of ACT that work in concert
with one another to reach the overall goal of psychological flexibility and creating a value-based
life while co-existing with hardships (Harris, 2009; see Figure 1). Those with FM are forced to
manage pain and many other bothersome symptoms on a daily basis; however, many manage to
live a valued life by engaging in meaningful activities despite their pain and suffering.
Psychological Flexibility is defined as the ability to contact the present moment more
fully as a conscious human being, and based on what the situation affords, to change or persist in
behavior in order to serve valued ends (Hayes & Strosahl, 2005; Fuoma, Hayes, & Walser,
2007, p. 17). Psychological Flexibility can be accessed in part by the Contacting the Present
Moment core process, which encourages individuals to be consciously connected to the present
by redirecting ones awareness back from the past or future. Self-as-Context then expands on
this to reframe ones thinking to recognize the mind as two distinct entities: the observing and the
thinking self. The observing self is thought to stay the same throughout life whereas the thinking
21


self changes constantly with shifting thoughts, feelings, plans, and judgments. The goal of this
process is to recognize oneself as an unchanging core being that has constantly changing and
infinite thoughts (Luoma et al., 2007).
Defusion means to observe and detach from negative thoughts and memories and treat
them dispassionately. After defusing from a thought, an individual is less likely to perceive this
thought as valid and true, thereby decreasing the believability, attachment and emotional
connection to it (Luoma et al., 2007). Acceptance supports the goal of opening oneself up to all
of the experiences of life, painful and joyful, as opposed to avoiding them, and Values helps
individuals define what is of most value to them in their lives and are committed and worked
towards in the Committed Action goal. Because it can be very challenging to detach
personally-attributed meanings from our own thoughts, an additional guideline is given to help
break up this cognitive defusion or melding of thought and meaning: Creative Hopelessness.
This is the ability to acknowledge that attempts to control thoughts and feelings are not only futile
but can also be self-destructive. This ability has also been described as a stance of self-
validation that not only reminds the individual that it is not beneficial to continue struggling but
also brings awareness of the new possibilities that come from self-validation (Luoma et al.,
2007, p. 29). A simple example of this is a person who experiences chronic pain and who believes
s/he is incapable of doing many things s/he once enjoyed doing, including those activities that are
not realistically hindered by pain. These thoughts represent psychological inflexibility and lead to
experiential avoidance, thus abandonment of certain activities and pushing away of thoughts.
Acceptance of CP has been defined as living with pain without reaction, disapproval or
attempts to avoid it (McCracken & Eccleston, 2003, p. 198.) Specifically, chronic pain
Acceptance requires a disengagement from struggling with pain, a realistic approach to pain and
pain-related circumstances, and an engagement in positive everyday activities (McCracken &
Eccleston, 2003, p. 198.)
22


Commitment and Behavior
Change Processes
Seif as
Context

Mindfulness and
Acceptance
Processes
Figure 1. ACT Hexaflex. Reprinted from Learning ACT: An Acceptance and Commitment
Therapy Skills-Training Manual for Therapists (p. 12) by J. B. Luoma, S. C. Hayes, & R. D.
Walser, 2007, Oakland, CA: New Harbinger Publications. Copyright 2007 by Jason B. Luoma,
Steven C. Hayes, and Robyn Walser.
Chronic Pain Acceptance. Chronic pain Acceptance is comprised of two factors: Pain
Willingness and Activity Engagement. Several studies have found the Chronic Pain Acceptance
23


Questionnaire (Geiser, 1992) to produce this two-factor structure: Pain Willingness and Activity
Engagement (Vowles, McCracken, McLeod, & Eccleston, 2008). Pain Willingness is defined as
ones degree of willingness to experience pain and related feelings and thoughts (McCracken &
Eccleston, 2005). Of these items, several include My thoughts and feelings about pain must
change before I can take important steps in my life, and Keeping my pain level under control
takes first priority whenever Em doing something (McCracken, Vowles, & Eccleston, 2004, p.
165). Activity Engagement is ones degree of willingness to engage in lifes activities, despite the
existence of pain (McCracken et al., 2004). The Activity Engagement items include Although
things have changed, I am living a normal life despite my chronic pain, and When my pain
increases, I can still take care of my responsibilities (McCracken et al., 2004, p. 165).
ACT studies have demonstrated efficacy and effectiveness in improving the affective and
functional outcomes of chronic pain, as well as other psychological conditions. Cross-sectional,
prospective, and intervention studies examining Acceptance and ACT suggest positive CP
outcomes. Higher self-ratings of Pain Willingness and Activity Engagement in chronic pain
samples have been associated with significantly lower levels of pain-related anxiety, depression-
related interference with functioning, and physical and psychosocial disability; and improved
work status (McCracken & Eccleston, 2003). Increased Pain Willingness has also been negatively
associated with the number of pain medications (McCracken & Eccleston, 2005).
Chronic pain intervention studies comparing ACT and treatment-as-usual groups also
suggest positive findings, with treatment effectiveness sustained over three-month follow-up.
Significant improvements were shown in psychosocial and physical disability, depression, pain
intensity, pain-related anxiety and the number of school and work absences and medical visits,
(Dahl, Wilson, & Nilsson, 2004; McCracken, et al., 2005; Vowles & McCracken, 2008;
McCracken, MacKichan, & Eccleston, 2007). Veehof and authors 2011 meta-analysis of seven
ACT and 15 mindfulness-based therapies suggest ACT interventions had a small effect (SMD =
24


.32) on depression, and more generally, effects on anxiety, pain, physical functioning, and quality
of life were reportedly similar to CBT intervention outcomes for chronic pain (Veehof, Oskam,
Schreurs, & Bohlmeijer, 2011). The authors assert that although CBT continues to be the standard
psychosocial treatment due to extensive empirical support, Acceptance-based therapies offer a
promising alternative to existing chronic pain management approaches.
Although only one ACT intervention has been conducted using a FM sample (Wicksell et
al., 2012), reductions in a range of psychosocial domains were found. In this randomized control
trial, female FM patients (n = 20) received 12 90-minute weekly groups sessions of ACT using a
standardized treatment protocol. The intervention taught the core processes of ACT and
emphasized reengaging with past-avoided situations, identifying core values, goal-setting and
expanding pain-relationship repertoires. Compared to waitlist controls (n= 16), patients who
received ACT self-reported improvements in perceived disability, depression, anxiety, mental
health quality of life, FM impact, and self-efficacy at post-treatment and three-to-four-month
follow-up, with moderate to large effect sizes maintained at follow-up. Pain intensity and
physical quality of life were not significantly improved, however. Differences in self-reports of
psychological inflexibility to pain indicate this measure mediated the differences in all
significantly changed variables, with the exception of mental health quality of life (Wicksell et
al., 2012). Taken together with these chronic pain studies, findings suggest that Acceptance-based
approaches may offer good clinical utility in treatment of FM and chronic pain.
Experiential Avoidance and Fibromyalgia
It is posited here that Experiential Avoidance is a significant factor that contributes to
poorer affective and functional outcomes in those with FM. Avoidance of unpleasant emotions,
thoughts, images, or experiences has been well documented as contributing to greater emotional
distress overtime, across many psychological disorders and theories (Chawla & Ostafin, 2007;
Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). One of the earliest mentions can be found in
25


psychodynamic and analytical psychology theories. Both Freud and Jung conceptualized
repression, or the suppression of memories or thoughts in the unconscious, to be a key
mechanism that contributes to abnormal behavior (Freud, 1910; Jung, 1910). In the case of
behavioral and exposure-based treatment for anxiety disorders, avoiding social situations or
feared stimuli (e.g. spiders, elevators, or heights) decreases anxiety in the short-term but
exacerbates psychopathology in the long run (Barlow, Allen, & Choate, 2004). Likewise, using
alcohol or drugs allows a person to temporarily avoid undesired emotions but over time can lead
to substance abuse or dependence especially when the need to avoid, coupled with substance-
induced physiological changes in the body, is enhanced (Hayes et al., 1996). Many psychological
interventions include avoidance as a key concept: dialectical behavior therapy (Linehan, 1993);
avoidance coping (Penley, Tomaka, & Wiebe, 2002); and reappraisal (Lazarus, 1991), to name a
few (Chawla & Ostafin, 2007; Hayes et al., 1996).
Similarly, Experiential Avoidance is a process that serves to remove both undesirable
external and internal experiences. Experiential Avoidance is defined as the phenomenon that
occurs when a person is unwilling to remain in contact with particular private experiences (e.g.
bodily sensations, emotions, thoughts, memories, behavioral predispositions) and takes steps to
alter the form of frequency of these events and the contexts that occasion them (Hayes et al.,
1996, p. 1155). Hayes, credited for developing Relational Frame Theory and ACT,
conceptualized and coined this term within the framework of these two theories and it is primarily
measured using the Action and Acceptance Questionnaire (AAQ; Bond et al., 2011, see Methods
section for full description). Experiential Avoidance is, in essence, the opposite of Acceptance, or
the active and aware embrace of private events that are occasioned by our history, without
unnecessary attempts to change their frequency or form, especially when doing so would cause
psychological harm (Luoma et al., 2007, p. 17). Heightened levels of Experiential Avoidance are
thought to contribute to the development of psychopathology over time in one or a combination
26


of three ways: 1) avoidance of a thought, emotion or object paradoxically draws more attention to
these phenomena; 2) classically conditioned avoidance behavior does not change significantly
when verbal affirmations are tried; and 3) avoidance can have short-term efficacy; however, those
attempts often lead to other problems, like agoraphobia and/or general exacerbation of the initial
avoided thoughts and/or symptoms (Chawla & Ostafin, 2007; Hayes et al., 1996).
Greater Experiential Avoidance contributes to both increased pain avoidance and the
constellation of symptoms and psychopathology that are uniquely found in FM. Both chronic pain
and FM patients often use Experiential Avoidance as short-term remedies for reducing the impact
of undesired experiences, particularly pain. Finks between Experiential Avoidance to acute pain
are found in healthy controls. For example, healthy controls with greater Experiential Avoidance
who underwent a standardized cold pressor test (i.e. placing their hand in ice water) indicated
significantly lower pain tolerance (Feldner et al., 2006; Zettle et al., 2012; Zettle et al., 2005) than
those with low Experiential Avoidance. These reported differences between high and low
Experiential Avoidance occurred regardless of pain threshold at study outset, such that no
significant differences were observed (Feldner et al., 2006; Zettle et al., 2012; Zettle et al., 2005).
Results also show that high Experiential Avoidance participants were more likely to use
catastrophizing (Zettle et al., 2012; Zettle et al., 2005) as a coping strategy during the acute pain
event, a maladaptive approach that has received much attention in the pain literature (Thom et al.,
2002). More broadly, these studies show that perception of and reaction to pain predict pain
tolerance and intensity. Specifically, and not unlike the processes found in perceived disability,
Experiential Avoidance paradoxically contributes to greater pain perception, despite the attempt
to temporarily brace or avoid pain.
Associations between mood, psychopathology, and Experiential Avoidance have also
been found, with high Avoiders experiencing more affective distress (Feldner, Zvolensky, Eifert,
& Spira, 2003; Gird & Zettle, 2009; Karekla, Forsyth, & Kelly, 2004). Meta-analyses results from
27


27 studies suggest Experiential Avoidance predicted a variety of psychopathology and negative
outcomes (i.e. overall mental health, anxiety, depression, future work absences and
performances), with a medium effect size (r = .42) (Bond et al., 2011; Hayes, Luoma, Bond,
Masuda, & Lillis, 2006). In a 2003 laboratory study examining Experiential Avoidance and
Acceptance approaches in a stress-inducing situation, healthy participants (n = 48) with no
history of anxiety disorder or panic received four inhalations of carbon-dioxide enriched air,
provoking bodily sensations that are known to cause anxiety in normal populations. Half of the
participants were instructed to simply observe their emotional state (Acceptance) and the other
half were told to inhibit their aversive feelings (Experiential Avoidance). Those who scored high
in Experiential Avoidance reported significantly higher levels of anxiety and affective distress,
despite no differences in physiological arousal from the low group. Secondly, they experienced
greater anxiety when attempting to suppress their emotions in comparison to simply observing
and accepting sensations (Feldner et al., 2003). Similar findings were reported in Karekla et al.s
(2004) laboratory study, as well as an additional study using dysphoric mood induction in healthy
samples (Gird & Zettle, 2009).
Further investigation of Experiential Avoidance and its contribution to psychopathology
suggests an additional dimension that is specific to FM: trauma. In a 2007 review of 28 studies
examining associations among FM, psychopathology and Experiential Avoidance, factor analyses
of Experiential Avoidance measures yielded two emerging factors: one in Experiential Avoidance
and another in trauma (Chawla & Ostafin, 2007). Experiential Avoidance and the persistent
effortful avoidance of distressing trauma-related stimuli after the event found in DSM-V criteria
for PTSD, conceptually overlap (APA, 2013, p. 271); however, multiple studies show this
relationship has not been clearly determined.
Ten studies examining the predictive value of Experiential Avoidance on 1) the severity
of trauma and posttraumatic disorder or its relationship to 2) history of child sexual abuse were
28


discussed in this 2007 review. In general, four studies showed that Experiential Avoidance either
predicted PTSD symptoms severity and depression/general psychological distress (Batten et al.,
2002; Marx & Sloan, 2002; Plumb, Orsillo, & Luterek, 2004); or mediated the relationship
between trauma and PTSD (Orcutt, Pickett, & Pope, 2005). Four studies did not show
Experiential Avoidance predicted trauma symptoms or severity, but did predict psychological
distress in those with trauma symptoms (Batten, 2001; Higgins, 2000; Polusny, Rosenthal, Aban,
& Follette, 2004; Tull, Gratz, Salters, & Roemer, 2004). Lastly, one study examining Experiential
Avoidance in a sample of rape victims indicated Experiential Avoidance did not predict PTSD
(Boeschen, Koss, Figueredo, & Coan, 2001). Review authors conjectured that inconsistencies in
the psychometric properties of the utilized measure may have clouded findings in this study
(Chawla & Ostafin, 2007). Although there appear to be relationships among Experiential
Avoidance, trauma history, and PTSD, these precise associations have yet to be illuminated.
To date, very few studies measuring Experiential Avoidance in FM have been published;
however, evidence of this process in this and other pain populations is reviewed herein. Pain fear
avoidance, or the avoidance of movements or activities based on fear, is a well-studied
phenomenon in pain populations that is thought to contribute to the pattern of muscle
deconditioning leading to increased pain (Lethem, Slade, Troup, & Bentley, 1983; Vlaeyen &
Linton, 2000, p. 317). Currently, only one study has compared pain fear avoidance and
Experiential Avoidance and found the two constructs to be correlated with a moderate effect size
(p < .01, r = .39) in a sample of chronic pain outpatients (n = 686) (Ramirez-Maestre, Esteve, &
Lopez-Martinez, 2014). Also, compared to those with low levels of avoidance (n = 214), FM
patients with higher pain fear avoidance (n = 145) self-reported more functional disability, severe
fatigue, worrying, hypervigilance, pain-related retreating and social patterns that reinforce fear
of pain (van Koulil et al., 2008, p. 215). Likewise, comparisons made among levels of pain fear
avoidance and low back pain, heterogeneous pain conditions, and inflammatory bowel disease
29


samples suggest that those with low back pain demonstrated the most consistent and significant
relationships among Experiential Avoidance and pain fear avoidance, pain intensity and pain fear
avoidance, and pain fear avoidance and negative mood (Esteve & Ramirez-Maestre, 2013).
Lastly, 31 of 38 (81.6%) FM patients self-reported significantly higher Harm Avoidance scores
than matched healthy controls in a study examining personality traits and temperament
(Anderberg, Forsgren, Ekselius, Marteinsdottir, & Hallman, 1999). Those FM patients with a
psychiatric diagnosis also scored higher on Harm Avoidance than those FM patients without such
a diagnosis (Cloninger, Svrakic, & Przybeck, 1993).
Despite the empirical evidence showing poorer affective and functional outcomes, only
one study to date examines Experiential Avoidance in FM patients. This 10-week intervention
applied exposure-based treatment to directly confront avoidance behavior and help process
traumatic memories (leading to relearning and symptom improvement) in FM patients with
trauma symptoms (Lumley et al., 2008). Although only few were recruited (n = 10) and fewer
completed therapy (n = 8), patients avoidance, hyperarousal, intrusions, life satisfaction and
affective distress improved at three-month follow-up, with large effect sizes reported. Small to
moderate effect sizes were also indicated for decreases in pain and disability.
Overall, findings suggest Experiential Avoidance is an important predictor of negative
outcomes in FM patients, particularly its role in processes that lead to perceived disability and
poor functional outcomes. Notably, the research shows that further work is needed to more fully
identify and understand these processes. Given this gap in the literature, it is not surprising that
current interventions are limited in treating FM.
The Role of Mindfulness
Mindfulness is also a key process in FM that has been associated with improved levels of
pain (Grossman, Tiefenthaler-Gilmer, Raysz & Kesper, 2007), depression (Sephton et al., 2007),
anxiety (Grossman et al., 2007), perceived stress (Weissbecker et al., 2002) and global well-being
30


(Kaplan, Goldenberg & Galvin-Nadeua, 1993) in those with FM. Positive chronic pain outcomes
(in patients without FM) from Mindfulness-based studies have also been reported (Kabat-Zinn et
al., 1982; Randolph, Caldera, Tacone, & Greak, 1999), specifically in pain reduction and mood,
and were maintained for up to 15 months (Kabat-Zinn et al., 1985). Mindfulness is thought to
benefit FM patients in several ways described here, particularly by attending to avoided stimuli,
thus counteracting Experiential Avoidance. Despite discussed theoretical associations among
Mindfulness, Experiential Avoidance, and ACT, empirical evidence of these precise relationships
is scarce and mechanisms of action remain unknown. The current study aims to further explore
Mindfulness role in FM symptom maintenance.
Various definitions of Mindfulness exist, with operationalizing mindfulness as a
technique, sometimes as a more general method or collection of techniques, sometimes as a
psychological process that can produce outcomes, and sometimes as an outcome in and of itself
(Hayes & Wilson, 2003). However, most definitions found in the literature focus on observation
and nonjudgment of thoughts and internal experiences in the present moment to attain a sense of
well-being (Block-Lemer, Salters-Pedneault, & Tull, 2005; Keng et al., 2011). Jon Kabat-Zinn,
PhD, the first researcher credited with empirically examining this process, offers a commonly
cited definition. Mindfulness includes paying attention in a particular way: on purpose, in the
present moment, and nonjudgmentally (Kabat-Zinn, 1994, p. 4). Since the early 1980s, studying
the effects or process of Mindfulness has primarily taken the form of Mindfulness-Based Stress
Reduction (MBSR) interventions; however, the psychological state of Mindfulness has also
received attention in the literature (and will be a focus in the current study). For purposes of fully
understanding the underlying processes of this state, MBSR and study findings are first reviewed
here.
The practices within MBSR were derived from Buddhist tradition, a specific sect called
Theravada Buddhism, of which mindfulness meditation plays a central role. This form of
31


meditation emphasizes a detached observation from one moment to the next, of a constantly
changing field of objects (Kabat-Zinn et al., 1982, p. 34). This training begins with focus on
ones breath, followed by a gradual increasing awareness of other stimuli/experiences with
concurrent focused attention and absence of evaluation or judgment. Maintaining this detached
observation and a steady quieting of the mind is a challenging task: much practice is needed to
develop this skill (Kabat-Zinn et al., 1982). Eight to 10 weekly sessions of two to 2.5 hours each
are offered as part of MB SR protocols (Baer etal., 2003; Keng etal., 2011). HathaYoga
postures, body scan visualizations, and teachings/guidance are also included, discussion of
participants experiences is encouraged, and outside practice of meditation skills is required
(Keng et ak, 2011). Clinicians trained by Kabat-Zinns group have led nearly all MBSR
interventions that have been published. MBSR studies rating post-intervention levels of trait
mindfulness, measured by self-report questionnaires, also indicate there are strong associations
among acquired or trait Mindfulness and various medical symptom and affective states. Given
promising results of MBSR, it has gained increasing recognition as an adjunctive therapy for
illness management (Baer et ak, 2003; Keng et ak, 2011).
FM studies using MBSR show improved outcomes across a range of physical and
affective symptoms. Results of the first published MBSR study using FM patients show 25-50%
of participants (n = 77) were rated clinically improved and 19% showed marked
improvement across varying measures following a 10-week protocol: pain, sleep, fatigue,
medical symptoms, coping strategies, and global well-being (Kaplan et al, 1993, p. 288).
Decreased affective distress and depression, but not improved functional disability or physical
symptoms, were found in two more recent studies. FM patients (N= 85) self-reported
improvements in perceived stress (r = -.64; p < .01) and depression (r = -.65 ;p< .01) but not in
pain, sleep or physical functioning as reported by the Fibromyalgia Illness Questionnaire (FIQ;
Burckhardt, Clark, & Bennett, 1991) after an eight-week MBSR program (Weissbecker et ak,
32


2002). A 2007 study also indicated significant reductions in somatic, cognitive and affective
symptoms of depression (all p's < .01) following an eight-week protocol. However, FM patients
(n = 42) FIQ self-reports of function, sleep and pain did not improve compared to an FM control
group (n = 33) (Sephton et al., 2007).
A 2007 study did report significant improvements in functional status, pain, sleep, and
cognitive abilities, however, as well as depression, anxiety, avoidance, and general affect
(Grossman et al., 2007). These FM participants (n = 39) improved both over time and these
changes were greater compared to an FM control group (n= 13). These changes were self-
reported following eight weeks of MBSR (effect sizes = 0.40-1.10) and were maintained at three-
month follow-up (effect sizes = 0.50-0.65) (Grossman et al., 2007). Reduced sympathetic
arousal, as measured by psychophysiological recordings in an FM sample (n = 24), was also a
notable finding after patients completed an eight-week program (Lush et al., 2009). This suggests
MBSR may help to dampen the chronic hyper-stimulation of the autonomic nervous systems
sympathetic response that has been found in FM patients, thereby decreasing this wear-and-tear
on the body and related symptoms (e.g. reduced orthostatic control) (Martinez-Lavin, Hermosillo,
Rosas, & Soto, 1998; Schmidt-Wilcke & Clauw, 2011). Unfortunately, known methodological
weaknesses (e.g. lack of control group, small sample sizes, high attrition) across these FM and
non-FM chronic pain studies limit the internal and external validity of these MBSR results (Baer
et al., 2003). However, given the challenges of treating FM, these results indicate MBSR offers a
promising adjunctive therapy to current modalities.
For CP and other symptoms of FM, several mechanisms of action of MBSR have been
proposed. Electroencephalogram (EEG) readings taken at pre- and post eight-week MBSR
training suggest there is more activation in brain regions that may be related to more adaptive
functioning to negative life events and stress (Davidson et al., 2003). A second finding from this
study indicates those who completed the MBSR training (n = 25) had better immune
33


responsiveness to influenza antibodies, when compared to non-MBSR completers (n = 16). By
extension, this left-side anterior activation and better immune functioning may then contribute to
better coping with chronic pain and other noxious symptoms of FM, as well as better resilience to
outside infection and/or less symptom expression.
Simple attention or exposure that is gained from steady observation is thought to aid in
detachment from suffering when it is coupled with a nonjudgmental attitude (Baer et al., 2003;
Keng et al., 2011). FM and CP patients often attribute negative emotions to their pain and
symptoms; however, a practiced nonjudgmental pattern of thinking contributes to desensitization
to the attached emotional experience (Baer et al., 2003; Keng et al., 2011). In essence, suffering is
reduced because the connection between the physical and resulting or remembered mental pain is
diminished (Kabat-Zinn, 1982). This continued openness or exposure to the pain experience,
coupled with a nonjudgmental attitude, directly counteracts Experiential Avoidance, thereby
increasing acceptance of pain. Secondly, researchers posit that a general emotional reactivity is
then also diminished through repeated un-pairing of physical and affect experience (Keng et al.,
2011).
Other researchers refer to this learned process as reperceiving (Shapiro, Carlson, Astin,
& Freedman, 2006). However, results following an eight-week MBSR program did not show
reperceiving mediated the relationship with Mindfulness and exposure, values clarification, self-
regulation, and cognitive and behavioral flexibility (Carmody, Baer, Lykins, & Olendzki, 2009).
Reperceiving, when added to Mindfulness scores, did suggest that there are associations between
these processes and exposure, values clarification, self-regulation, and cognitive and behavioral
flexibility. Although these relationships are not fully known, one theory is that the effect of
reperceiving may broaden/then enhance ones ability to engage in a variety of coping responses
(Baer et al., 2003, p. 129; Kabat-Zinn et al., 1982), as well as improve general behavioral self-
regulation (Chambers, Gullone, & Allen, 2009). Lastly, relaxation benefits of MBSR and values
34


clarification are thought to contribute to better outcomes as well, with the latter reinforcing
behavioral regulation (Baer et al., 2003).
As previously discussed, empirical findings exploring the precise relationships and
mechanisms of action between Mindfulness and Experiential Avoidance, and Mindfulness and
Acceptance are minimal, despite discussed theoretical associations (Block-Lemer et al., 2005;
Mitmansgruber, Beck, Hofer, & SchiiBlcr. 2009). Furthermore, the conceptual relationship
between these three metacognitive processes has been debated, and often become complicated
depending on whether Mindfulness is defined as a process (e.g., due to the patients mindful state,
his/her anxiety decreased) or the outcome of the process (e.g., an overall increase in the patients
ability to be mindful (or increased Acceptance) has increased his/hers psychological flexibility)
(Block-Lemer et al., 2005).
Several researchers have attempted to define and compare these phenomena. For
example, it is suggested that Mindfulness, named Contacting the Present Moment within the
ACT nomenclature, is one of the six core processes of ACT that work together to attain
psychological flexibility (Luoma et al., 2007). However, some researchers have conceptualized
the relationship between Mindfulness and ACT core processes to be closer to an amalgamation of
contact with the present moment, defusion, acceptance, and the transcendent sense of self as
opposed to the conceptualized self (Fletcher & Hayes, 2005, p. 321). Similarly, it is thought
that Mindfulness aids in changing the nature of the Experiential Avoidance process, which is
conceptualized as the inverse of Acceptance (Block-Lemer et al., 2005). Alternatively, it has been
suggested that the Acceptance technique deliteralization strongly resembles the decentering
technique found within Mindfulness (Block-Lemer et al., 2005, p. 83). Results from a 2008 study
also suggest that Experiential Avoidance and Mindfulness, according to the Mindfulness
Attention Awareness Scale (MAAS; Brown & Ryan, 2003) were negatively correlated (Henke,
2010; Jacobs, Kleen, De Groot, & A- Tjak, 2008). Given these empirical findings and theoretical
35


discussions in the literature, it appears that both Mindfulness and Acceptance have conceptually
similar underpinnings; however, there remains no consensus on the exact content of their overlap.
Only one study to date examines these concepts within a fibromyalgia sample (Henke,
2010). These data show several subscales on a Mindfulness measure, the Five Facet Mindfulness
Questionnaire (FFMQ; Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006); see Methods for full
description) correlate with the measure of Experiential Avoidance, the Acceptance and Action
Questionnaire (AAQ): nonjudging and nonreacting to inner experience, describing, and act aware
(Henke, 2010). However, these relationships, particularly in FM and CP samples, are unknown.
Given the promising results of these techniques, more research is needed to determine these
relationships to better inform targeted FM treatments.
Profiling Pain and Fibromyalgia Patients to Improve Treatment Efficacy
Leaders in the field suggest it may be useful to group patients based on dimensions of CP
patient characteristics to create better interventions, instead of the current practice of tailoring
treatments based on single physiological or psychological factors (Turk, 2005). This
multidimensional grouping approach has been suggested due to the complexity of the pain
experience and varied treatment response (Dworkin & LeResche, 1992; Turk & Rudy, 1988). To
date, only one grouping method based on cognitive, affective and behavioral variables has been
widely published: profiling using the West Haven Yale Multidimensional Pain Inventory (MPI;
Kems, Turk, & Rudy, 1985). The MPI measures intensity and impact of pain on work, social and
other life activities in this population across twelve domains of functioning (Wehmer, 1990) and
feelings of self-control, problem-solving abilities and patients perceptions of themselves (Kems,
et al., 1985). Currently, it is the most commonly used method of grouping CP patients by their
varying beliefs and behaviors.
The MPI has been utilized to identify various biopsychosocial aspects of CP patients
experiences given its seven subscales (Turk & Rudy, 1988). The multidimensional scales include:
36


1) pain severity and suffering; 2) perceptions of how pain interferes with their lives, including
interference with family and marital/couple functioning, and work, social and recreational
activities; 3) dissatisfaction with present levels of functioning in family relationships,
marital/couple relationship, work and social life; 4) appraisals of support received from
significant others; 5) perceived life control, incorporating perceived ability to solve problems and
feelings of personal mastery and competence; 6) affective distress including depressed mood,
irritability, and tension; and 7) activity levels (Turk & Melzack, 2001).
Cluster analysis produces more concise conceptualizations of patients and groups them
into three distinct profiles: Adaptive Copers, Dysfunctional and Interpersonally Distressed
(Turk & Rudy, 1988). Adaptive Coper patients report lower pain severity, lower interference with
everyday life due to pain, lower levels of affective distress, higher degree of life control and a
higher activity level. Conversely, high pain severity, marked interference, high affective distress,
low perception of life control, and a low activity level characterize patients in the Dysfunctional
group. Interpersonally Distressed patients demonstrate lower reported levels of social support,
lower scores on solicitous and distracting responses from significant others, and higher scores on
punishing responses (Rudy, Turk, Zaki, & Curtin, 1989).
Empirical support indicates these groups may predict outcomes for CP patients.
Differences between the Adaptive Coper and Dysfunctional groups, specifically, show
differences in work status, time spent in bed, use of pain medication, and affective distress and
seeking help, with Dysfunctional patients using more pain medications and negative coping
behaviors and demonstrating less active involvement in work and life activities (Turk & Melzack,
2001). Also, Dysfunctional groups showed greater treatment gains in pain intensity, depression,
negative cognitions and perceived interference of pain symptoms than Adaptive Copers and
Interpersonally Distressed Groups at six-month follow-up (Rudy, Turk, Kubinski, & Zaki, 1995).
Clinical application of profiles for use in clinical conceptualization and treatment has
37


been sparse despite theoretical advantages to profding CP patients by psychosocial
characteristics. Given these positive findings using the MPI and the complexity of CP conditions,
finding new ways to characterize patients for purposes of tailoring effective treatment
interventions is a worthwhile pursuit. Leading CP researchers have suggested there is ample
room for improvement in the efficacy of CBT in chronic pain; thereby opening the door for
additional approaches and interventions (Vlaeyen & Morley, 2005, p. 4). New methods of
profiling CP and FM patients based on key defining characteristics may inform the development
of more effective and tailored interventions for pain.
Profiling Fibromyalgia and Chronic Pain Patients: Acceptance-Based Approaches
Our understanding of the maintenance of CP and FM symptoms has been largely
informed by behavioral, cognitive, cognitive-behavioral and acceptance-based treatment
approaches. Evolving intervention study designs continue to suggest there is heterogeneity within
CP samples such that different therapies work more effectively for different individuals (Turk,
2005). Tailoring treatment to particular characteristics CP patients may hold has been proposed to
increase therapeutic gains (Costa & Pinto-Gouveia, 2010; Vowles et al., 2008). In fact, profiling
CP patients by identified characteristics, specifically those that are influential in promoting more
positive outcomes, may improve the efficacy and effectiveness of behavioral, cognitive,
cognitive-behavioral and acceptance-based treatment approaches.
To date, there are no studies examining ways of grouping FM patients using the
Acceptance construct. However, there are three recent studies that found similar Acceptance-
based clusters emerge in CP samples. Cluster analysis findings using a CP specialty treatment
outpatient sample (N = 641) showed three distinct clusters: 1) both low Activities Engagement
and Pain Willingness, 2) both high Activities Engagement and Pain Willingness, and 3) high
Activities Engagement and low Pain Willingness (Vowles et al., 2008). Specifically, this first, or
Low-Low group included respondents who self-reported few, if any, activities that they
38


engaged in, and they endorsed very little willingness to experience their pain. Cluster 2 or the
High-High group was comprised of participants who responded in the opposite manner: they
self-reported much higher engagement in lifes activities despite their pain and were much more
willing to experience their pain and all related emotions. Further comparisons showed this High-
High group also self-reported significantly lower pain, depression, pain-related anxiety,
physical and psychosocial disability, medical visits, medications, daily rest...and daily activity
than the first Low-Low group (Vowles et al., 2008, p. 288). This third group, high Activities
Engagement and low Pain Willingness, also differed from the two other groups on the following:
daily activity, physical disability, pain, medical visits, and classes of medication (Vowles et al.,
2008).
Results of the second and third studies also suggest better outcomes in this High-High
group vs. the Low-Low and further suggest the validity and reliability of these three clusters.
Three clusters also emerged in Costa and Pinto-Gouveias 2010 study, comprised of a mixed CP
outpatient primary care and tertiary care sample (N= 103). The High-High and Low-Low
groups were identical to Vowles et al.s findings; however, the third, mixed group differed
slightly, producing a medium Activities Engagement and low Pain Willingness cluster. As in
Vowles et al.s study, post-hoc analyses demonstrated lower levels of anxiety, depression, stress
and self-compassion in the High-High cluster compared to the Low-Low group. Interesting
differences emerged in the third, Medium Activities Engagement and low Pain Willingness
group: higher levels of depression, stress, self-judgment, and over-identification (versus
mindfulness) than the High-High, and lower levels of depression and stress than the Low-
Low.
The third study also produced three cluster groups (High-High, Low-Low, and
Medium-Medium,) thus again suggesting a slightly varied third group (Payne-Murphy &
Beacham, 2014). Participants were self-identified CP patients who were recruited via online CP
39


support groups (N= 300). Again, the poorest outcomes were found in the Low-Low group and
the best found in the High-High across Perceived Disability and Negative and Positive Affect.
Intuitively, the mixed cluster revealed moderate scores across these same measures of mood and
functional outcome.
The authors of these studies suggest this mixed group displays good enough
functioning but self-report poorer emotional and social well-being and perhaps have more
attachment to finding pain relief (low Pain Willingness) than the High Acceptance group. Results
indicate that Pain Willingness is therefore an important factor in supporting better psychosocial
functioning and both are needed to maintain optimal levels of positive affect, and physical and
psychosocial function. Findings from these studies provide further support for Acceptance as a
key factor in CP patients functional and affective outcomes. Furthermore, results suggest that
further investigation is warranted to leam about these relationships in order to improve
functioning and quality of life in those with either CP or FM.
Purpose of the Present Study
Given prior findings suggesting significant rates of psychological symptoms and higher
levels of Experiential Avoidance in FM, the current study examined ways in which these patients
respond to their symptoms. Via measures of Acceptance, Experiential Avoidance, and
Mindfulness, the study sought to ascertain the role of these constructs in study participants
perceived disability; and how subjective reports and perceptions differed from those with chronic
pain but without FM. The current study had two primary aims. First, to determine if the same
three cluster groups found in prior studies (Costa & Pinto-Gouveia, 2010; Payne-Murphy &
Beacham, 2014; Vowles et al., 2008) would emerge when cluster analysis was conducted on FM
and CP groups separately. Within this aim, we sought to determine whether cluster groups would
differ between FM and CP samples. Secondly, a series of two-way Analyses of Covariance were
conducted to determine if there were overall differences between the FM and the CP group on
40


Experiential Avoidance, Mindfulness, and Perceived Disability in each sample group (i.e. FM or
CP). These and subsequent analyses examined main effect differences by cluster group (Low-
Low, High-High and Medium-Medium) and by pain type (FM and CP); interaction effects
between cluster groups and pain type that are associated with levels of Experiential Avoidance,
Mindfulness, and Perceived Disability; and where differences lay between each of these groups.
Study Hypotheses
Hypothesis 1: It was hypothesized that the following three cluster groups would emerge in the
FM participant sample:
1) Low Activity Engagement Low Pain Willingness
2) High Activity Engagement High Pain Willingness
3) Moderate Activity Engagement Moderate Pain Willingness
Hypothesis 1 Analysis: K-means cluster analysis was conducted using both Activity Engagement
and Pain Willingness CPAQ subscales in the CP sample. If three similar cluster groups did not
emerge in this CP sample, tertile groups would be formed using the total score for the Chronic
Pain Acceptance Questionnaire reflecting High, Low and Medium tertile groups.
Hypothesis 2: It was hypothesized that the same following three cluster groups would emerge in
the CP participant sample:
1) Low Activity Engagement Low Pain Willingness
2) High Activity Engagement High Pain Willingness
3) Moderate Activity Engagement Moderate Pain Willingness
Hypothesis 2 Analysis: K-means cluster analysis was conducted using both Activity Engagement
and Pain Willingness CPAQ subscales in the CP sample. If three similar cluster groups did not
emerge in this CP sample, tertile groups would be formed using the total score for the Chronic
Pain Acceptance Questionnaire reflecting High, Low and Medium tertile groups.
41


Hypothesis 3: It was hypothesized that in the online FM support group sample, as well as the CP
support group sample, self-reported scores of Perceived Disability, Mindfulness and Experiential
Avoidance will differ overall by Acceptance level (Hi, Med, Low) group (main effect for group)
controlling for average pain rating in past week and degree of PTSD symptomatology. Covariate
selection is described below in Data Analysis section.
Hypothesis 3 Analysis: A series of three 2x3 between-subject analyses of covariance
(ANCOVAs) were conducted. Pain type, specifically FM or CP, served as a the first independent
variable with two levels, and Acceptance level group served as the second independent variable
with three levels (i.e. Low, High, and Medium). Perceived Disability, Mindfulness and
Experiential Avoidance served as dependent variables, one for each ANCOVA.
Hypothesis 4: It was hypothesized that an interaction effect would occur between tertile groups
(Low, High, Medium) and pain type (FM and CP). In total, three interaction effects, one per
ANCOVA, were predicted:
1) tertile group (IV) and pain type (IV) and Mindfulness (DV);
2) tertile group (IV) and pain type (IV) and Experiential Avoidance (DV)
3) tertile group (IV) and pain type (IV) and Perceived Disability (DV).
Hypothesis 4 Analysis: Results of the three 2x3 between-subject ANCOVAs would indicate if
there are interaction effects between group cluster and pain type for each dependent variable.
42


CHAPTER III
METHOD
The present study was an analysis of data gathered and conducted through the University
of Colorado Denver in Denver, Colorado. The study procedure and data collection was reviewed
and approved by the University of Colorado Denver Colorado Multiple Institutional Review
Board for all data collection waves.
Participants
Individuals who self-identified as having either FM or CP were recruited via online FM
and CP support groups on Yahoo! Groups and Facebook. An additional third wave of respondents
were recruited through an advertisement posted on Facebook that was marketed specifically to
general Facebook members who had chronic low back pain. Inclusion criteria for all waves
included: individuals with non-malignant (i.e., not cancer-related) chronic pain (pain duration > 3
months), are 18 years of age or older, and are able to read English. The following support groups
were excluded from the first and second data waves: a) 12 step; b) biofeedback; c) intervention-
based; d) prayer/religious; e) medication focused (e.g., Opioid, Oxy-Contin); f) malignant pain
(cancer); and g) those groups with a primary focus on litigation about their pain problem.
These three waves of data collection were conducted between April and September of
2014. The initial wave was conducted in Yahoo! Groups from March to April; the second from
online support groups on Facebook from May to June; and the third via an advertisement posted
on Facebook from August to September that targeted chronic low back pain respondents
exclusively, who were not identified as subscribing members of a support group. For specific
details of collection procedure and wave variations, refer to Materials and Procedure. The total
sample (N= 552; Mean age = 46.7 years, SD = 11.7) was primarily female (92.2%), Caucasian,
not of Hispanic origin (93.3%), married/partnered (66.6%), and well educated (M= 14.7 years,
SD = 3.0), with an average income ranging between $ 15k and $40k. Participants who self-
43


reported a diagnosis of FM comprised 68.3% of the total sample (n = 552) whereas those with
CP, without FM, was smaller (n= 175). The majority of the sample either reported having health
insurance or was in the process of obtaining this (88.3%). Mean years with either FM or CP were
14.4 (SD = 11.1) and average weekly pain intensity was 6.5/10 (.S'/) = 1.7). Specific variations in
descriptives between the two samples are presented in Tables 1 and 2.
Materials and Procedure
Materials and procedure were identical for the first two online support group data
collection waves on Yahoo! Groups and Facebook. An identical recruitment procedure was
previously successfully employed that specifically recruited chronic pain and chronic illness
online support group members from both Yahoo! Groups and Facebook (Payne-Murphy &
Beacham, 2014). For the current study, CP group selection was determined from the Yahoo!
Groups and Facebook search engines under the following key terms: fibromyalgia support
group, chronic pain support group, and low back pain. Group facilitators/moderators were
then contacted individually to propose research involvement (Appendix A). Once permission
from these group facilitators was granted, posting commenced to both open and closed groups
over the following six weeks, for three postings total, once every two weeks. The posting to
members included an invitation to participate in a brief online study on the group website
(Appendix B). Interested members were then directed to a REDCap survey site, which provided
instructions for survey completion and informed consent (Appendix C), and an optional page
requesting demographic information for those who wished to become eligible for the gift card
incentive lottery (Appendix D). All participants were encouraged to contact study staff by
electronic mail or telephone if they had any questions or concerns. The REDCap electronic data
capture tool is a secure, web-based application designed to support data capture for research
studies, providing 1) interface for validated data entry; 2) audit trails for tracking data and export;
44


and 3) automated export procedures for data download (Harris et al., 2009). All data were
collected and managed using REDCap, which was hosted at the University of Colorado Denver.
The third recruitment wave was targeted exclusively to those Facebook members who
clicked on an advertisement for adults with chronic low back pain. This additional recruitment
effort was conducted to provide better representation of low back pain patients among the CP
patient sample, as the first two recruitment waves indicated lower numbers of this pain patient
population. Given that this sample would have a higher probability of pregnancy-related low back
pain than the previously recruited support group members, three additional questions were used in
this version of the survey to exclude them (Appendix E). However, this survey was otherwise
identical to the first. This recruitment wave extended over five weeks time. The advertisement
was set to auto generate on Facebook members personal pages who had previously clicked on
topics related to chronic pain, low back pain, and/or purchasing history of pain relief items.
Again, REDCap was used to collect and manage the data and all other procedures used in the first
two waves were identical.
Independent Variable Measures
Demographics and Medical History. Participants responded to questions regarding
demographics and history of CP and FM such as the location of pain, initial causes of pain,
medication use, numbers of surgeries, and all types of treatments utilized. Participants self-
reported average pain intensity experienced in the past week by providing one numeric response
on an 11-point Likert-type scale ranging from 0 (no pain) to 10 (worst pain imaginable.)
Other health and lifestyle-related questions include substance use and pain-related legal
involvement. Pain type (either FM or CP) served as one of the independent variables.
Chronic Pain Acceptance. The Chronic Pain Acceptance Questionnaire (CPAQ) is a
brief, self-report measure of acceptance of chronic pain that was originally developed from the
Acceptance and Action Scale (AAQ; Hayes, Strosahl, Wilson, Bissett, Pistorello et al., 2004).
45


Two subscales also derive from this assessment: Activity Engagement and Pain Willingness.
Sample items include: Despite the pain, I am now sticking to a certain course in my life and I
would gladly sacrifice important things in my life to control this pain better (McCracken &
Eccleston, 2005, p. 165). The 20 items are rated on a 7-point Likert-type scale from 0 (never
true) to 6 (always true). This assessment has been found to be internally consistent (a = .78-
.82) and has moderate to high correlations with measures of Experiential Avoidance, patient
functioning and emotional distress (McCracken & Eccleston, 2005). Within the current sample,
internal consistency of all 20 items comprising the CPAQ total score is considered strong for both
the FM and CP groups (a = .85; a = .89, respectively). Activities Engagement and Pain
Willingness subscale scores will be used in both of the cluster analyses; however, tertiles based
on a total sum of Acceptance items will be used for the subsequent ANCOVAs. Good internal
consistency was also found within the current sample for both the Activities Engagement (a = .87
for FM; a = .90 for CP) and Pain Willingness (a = .74 for FM; a = .84 for CP) subscales. See
Appendix F.
Post-Traumatic Stress Disorder Checklist. The Post-Traumatic Stress Disorder
Checklist, Civilian Version (PCL-C; Weathers, Litz, Herman, Huska, & Keane, 1993) is a self-
report questionnaire that measures symptoms of Post-traumatic Stress Disorder (PTSD)
experienced in the past month. All 17 items in the Civilian version inquire about DSM-IV PTSD
symptoms that have occurred in relation to stressful experiences which refer to one or more
lifetime events. Response options range from 1 (not at all) to 5 (extremely) on a Likert-type
scale. A sum of all items (range total = 17-85) will be used to determine relative severity of
symptoms. Clinical utility has been described as good and reliability and validity reportedly range
from good to excellent (Hunsley & Mash, 2008). Results of a reliability analyses conducted on
the current sample demonstrate high internal consistency in both FM (a = .91) and CP (a = .95)
subsamples. See Appendix G.
46


Dependent Variable Measures
Acceptance and Action. The second version of the Acceptance and Action
Questionnaire (AAQ-II; Bond et al., 2011) assesses Experiential Avoidance, or the extent to
which an individual avoids a range of unpleasant experiences, for example, bodily sensations,
emotions, thoughts, memories, and behavioral predispositions and their efforts to change,
escape, avoid or extinguish them (Hayes et al., 1996, p. 4). This 7-item self-report has an internal
consistency reported at a = .84 (,78-.88) and a test-retest reliability of .81 at 3 months and .79 at
12 months. Internal consistency was assessed within the current sample, both for FM and CP
groups. Results suggest high consistency for the FM (a = .92) and CP sample (a = .93).
Satisfactory construct, predictive, convergent, incremental and discriminant validity have all been
reported as well (Hayes et al., 1996). Construct validity was also assessed in a sample of 144 CP
patients as measured by the theoretically related Chronic Pain Assessment Questionnaire (CPAQ)
and Mindfulness Attention Awareness Scale (MAAS) (Brown & Ryan, 2003; McCracken &
Eccleston, 2005; McCracken & Zhao-O'Brien, 2010). As described below, the CPAQ measures
acceptance of pain and pain-related avoidance and willingness, whereas the MAAS measures
mindfulness. Correlations among these measures ranged from r = .46 to .53 and indicate good
construct validity (McCracken & Zhao-O'Brien, 2010). The AAQ response options range from 1
(never true) to 7 (always true) and include such items as My painful memories prevent me
from having a fulfilling life and Im afraid of my feelings. A total score is derived from
summing the items (Hayes et al., 1996). See Appendix H.
Five Facet Mindfulness Questionnaire. The Five Facet Mindfulness Questionnaire -
Short Form (FFMQ-SF; Bohlmeijer, ten Klooster, Fledderus, Veehof & Baer, 2011) measures a
respondents degree of attentiveness to the present moment while having a nonjudging or
accepting attitude. The FFMQ-SF was based on the full-length, 39-item FFMQ (Baer et al., 2006)
which was developed by conducting an exploratory factor analysis among items from five
47


mindfulness questionnaires: the Mindfulness Attention Awareness Scale (MAAS); The Freiburg
Mindfulness Inventory (FMI); The Kentucky Inventory of Mindfulness Skills (KIMS); The
Cognitive and Affective Mindfulness Scale (CAMS); and The Mindfulness Questionnaire (MQ)
(Baer et al., 2006). Five facets emerged and are scored as separate subscales in the FFMQ:
observing, describing, acting with awareness, non-judging of inner experience, and non-reactivity
to inner experience. A shortened version has since been devised and normed on FM patients (n =
146), which includes the same five facets and consists of 24 items (Bohlmeijer et al., 2011). Self-
report items include: I find it difficult to stay focused on whats happening in the present, and
I disapprove of myself when I have illogical ideas. Response options range from 1 (never or
rarely never true) to 5 (very often or always true).
The authors report adequate to good construct, convergent, and discriminant validity and
internal consistency of all five facets (a range = .75-.81) within an FM sample (n = 146)
(Bohlmeijer et al., 2011). Reliability analyses conducted within the current study samples are
both consistent with and higher than these previous findings: a = .87 for the FM sample and a =
.85 for the CP group. Theoretically related variables of the following measures suggested
moderate correlations in the expected directions, demonstrating good construct validity:
acceptance (AAQ-II); openness to experiences (NEO-FFI); neuroticism (NEO-FFI); anxiety
(HADS-A); depression (CESD); and positive mental health (MHC-SF) (Bohlmeijer et al., 2011).
For the present study, a total score will also be derived from the FFMQ-SF, which is a sum of all
of the items (Van Dam, Earleywine, & Danoff-Burg, 2009). See Appendix I.
Pain Disability Index. The Pain Disability Index (PDI) (Pollard, 1984) is a brief, 7-item,
self-report measure, which assesses the degree to which individuals believe their pain interferes
with various activities in their daily lives. Specific areas include: occupation, family/home
responsibilities, sexual behavior, self-care, recreation, and social and life support activities. Items
are rated on a 0-10 scale ranging from no disability to total disability and are summed to
48


yield one total score. Internal consistency is high (a = .86); concurrent validity is strong (Tait et
al., 1990), and generally, psychometric properties have been reported as adequate and support its
utility (Turk & Melzack, 2001). For the current sample, results of reliability analyses suggesting
high internal consistency (a = .80 for FM; a = .91 for CP). See Appendix J.
Data Analysis
Hypothesis One was analyzed using hierarchical cluster (Wards method; Ward, 1963)
procedures using both the CPAQ Activities Engagement and Pain Willingness variables to
determine number of cluster groups in the FM sample. A hierarchical approach using Wards
method was chosen to closely follow previous methodology used in the previous study examining
CPAQ clusters (Payne-Murphy & Beacham, 2014), as well as the k-means method (Costa &
Pinto-Gouveia, 2010; Payne-Murphy & Beacham, 2014; Vowles et al., 2008). Following the
same procedures outlined in Hypothesis One, Hypothesis Two was tested using a k-means
hierarchical cluster (Wards method) with the CP sample.
Wards method is an iterative statistical approach used in cluster analysis that is the most
common of the minimum variance methods (Gore, 2000; Ward, 1963). At each step, a squared
sum of the distance between each data point and the mean of the cluster is calculated and the
lowest value is chosen (Gore, 2000; Tabachnick & Fidell, 2006). This procedure is repeated at
each step, such that the data point with the smallest distance between the cluster mean is given
priority until the largest distance is selected last. K-means partitioning is also an iterative
approach that is applied following the hierarchical (Wards) procedure. Using the existing
centroids determined by Wards method, the K-means approach first establishes a set number of
clusters followed by a reassignment of the centroids to these clusters by minimizing within-
cluster variability and maximizing between-cluster variability (Gore, 2000). The K-means method
was originally developed to compensate for one of the primary weaknesses of hierarchical
49


procedures: the inability to reassign a centroid to find better match as subsequent clusters are
made within the process (Gore, 2000).
Hypotheses Three and Four were tested by conducting a series of Analyses of Covariance
(ANCOVA's) to assess if and where significant differences lie among the three cluster groups
and pain type (FM and CP) for each of the following dependent variables: Perceived Disability,
Experiential Avoidance, and Mindfulness. Three ANCOVAs were conducted for each of the
three dependent variables. Total scores for the Pain Disability Scale (PDI), or Perceived
Disability; total scores on the Acceptance and Action Questionnaire (AAQ-II), or Experiential
Avoidance; and a total score on the Five Factor Mindfulness Questionnaire-Short Form (FFMQ-
SF) were employed as die continuous dependent variables for each of the three analyses. For all
three series of ANCOVAs, the tertile (Low, High, and Medium) groups served as the first
categorical independent variable and pain type (FM or CP) served as the second categorical
independent variable. A series of diree ANCOVAs were chosen because previous studies
examining similar variables employed this same method (Costa & Pinto-Gouveia, 2010; Vowles
et al., 2008). Secondly, due to a lack of empirical evidence suggesting Mindfulness, Acceptance,
and Perceived Disability form a linear composite or a single underlying constmct, a series of
ANCOVAs served to further illuminate the relationships among each of the dependent variables
individually (Huberty & Morris, 1989).
Selection of Covariates. Covariates included the following continuous variables: age,
average pain in the past week, years of education, and PTSD symptoms using the Post-traumatic
Stress Disorder Checklist, Civilian Version (PCL-C) were initially considered. These covariates
were chosen based on research suggesting higher rates of Experiential Avoidance and perceived
and actual disability have been correlated with older age (Leigh & Fries, 1992; Severeijns et al.,
2001; Turner, Franklin & Turk, 2000), pain severity (Bennett, 1996; Denison et al., 2004), PTSD
symptoms (Young Casey, Greenberg, Nicassio, Harpin, & Hubbard, 2007), and lower education
50


levels (Hagen, Holte, Tambs, & Bjerkedal, 2000; Senna, De Barros, Silva, Costa, Pereira,
Ciconelli, & Ferraz, 2004; Schmidt et al., 2007) in CP or FM samples. Therefore, age, years of
education, number of surgeries, and current level of pain were evaluated as potential covariates
for the study analyses. Results of several independent t-tests examining significant differences
between FM and CP samples suggest that only average pain severity level within the past week,
and PTSD symptom severity qualified as covariates. Therefore, only PCL-C scores and average
pain were used as covariates in ANCOVAs.
Assumptions for univariate analysis of covariance include absence of unequal sample
size, absence of outliers, absence of multicollinearity and singularity, normality of sampling
distributions, homogeneity of variance, linearity, homogeneity of regression, and reliability of
covariates (Tabachnick & Fidell, 2006). In regards to power, these 2x3 between-subjects
ANCOVAs each have two independent variables. According to Faul, Erdfelder, Lang, & Buchner
(2007), nearly 300 (N= 297) participants total are required to achieve a medium effect size, at a
.05 alpha level, with 80% power. The analyses as conducted met this criterion.
All analyses were conducted using Statistical Package for the Social Sciences (SPSS),
version 22 for Mac.
51


CHAPTER IV
RESULTS
Recruitment Accrual and Attrition
Significant attrition occurred throughout the course of the recruitment period, as shown in
Figure 2. Missing Values Analyses as well as Littles Missing Completely at Random (MCAR)
Test were conducted in SPSS to examine patterns of missing variables. Results of Littles MCAR
test evaluating the dependent, independent and covariate variables resulted in a chi-square =
341.8 (df = 12, p < .01). These results suggest that data are not missing at random. Results of the
Missing Value Analysis also suggest a consistent monotone missing structure (Little & Rubin,
1989) such that approximately 38% of all participants (n = 409) discontinued the survey before or
by the end of the demographic items, which were presented in the first half of the survey. The
decision was then made to exclude these noncompleters from analysis given their lack of
provided data beyond demographic responses. The remaining participants (n = 552) were enrolled
in the study and proposed analyses were then conducted.
Figure 2. Participant Attrition and Survey Completion
52


Demographic Characteristics of the Participant Sample
Descriptive statistics for Yahoo! Groups and Facebook participants, the samples of which
were recruited between March through September 2014, are shown in Table 1. Specifically, the
initial recruitment wave was conducted in Yahoo! Groups from March to April; the second from
online support groups on Facebook from May to June; and the third via an advertisement posted
on Facebook from August to September 2014, which targeted chronic low back pain respondents
exclusively, who were not identified as subscribing members of a support group. Specific details
regarding procedure and wave variations are described in Materials and Procedure.
Both Yahoo! Groups (n = 63) and Facebook participants (n = 489) were predominately
female (98.4% and 91.4% respectively), Caucasian, not of Hispanic origin (96.8%; 92.8%), and
well-educated (Yahoo!, mean years = 15.56 (SD = 3.38); Facebook, mean years = 14.57 (SD =
2.88). Despite having similar educational levels, results of an independent t-test suggest
significant differences, 1(548) = 2.49,/? < .05. No significant differences were found between the
two groups in regards to gender. According to chi-square test of independence results, significant
differences were also seen in ethnicity, (~/2 (4. N = 549) = 13.5,p< .01). The Yahoo! Groups
sample was comprised primarily of Caucasian adults (n = 61), followed by two individuals of
American Indian or Alaskan Native descent. Hispanic (n = 9), African American (n = 7), and
American Indian or Alaskan Native (n = 1) and Other adults (n = 18) comprised the remainder
of the Facebook sample. Although participants recruited from both websites were primarily
middle-aged (mean years = 52.94 and 45.9, respectively); a significant effect for age was detected
by independent t-test 1(550) = 4.57, p < .01. A chi-square test of independence was also
performed to examine the differences in type of employment. Overall, the majority of participants
in this sample were unemployed (not retired) (Yahoo! = 65.1%; Facebook = 58.1%) and no
differences were found between the two samples regarding occupational status. There were also
no significant differences found for income, with the majority of participants from the Yahoo!
53


Table 1
Demographic Characteristics of Sample by Data Collection Source
Characteristic Yahoo! Groups (n = 63) n (%) Facebook (n = 489) n (%) x2 P
Gender Male Female 1 (1.6) 62 (98.4) 42 (8.6) 447 (91.4) 3.80 .05
Income 15.93 .53
Below $5000 3(5) 27 (5.7)
$5000 -$14,999 12 (20) 65 (13.7)
$15,000-$29,999 8 (13.3) 114 (24.1)
$30,000 $49,999 11 (18.3) 84 (17.7)
$50,000 $69,999 9(15) 64 (13.5)
$70,000 $89,999 7(11.7) 45 (9.5)
$90,000-$109,999 4 (6.7) 22 (4.6)
Over $110,000 6(10) 53 (11.2)
Employment 5.60 .47
Working 1-39 hrs/wk 7(11.1) 90 (18.6)
Working 40+ hrs/wk 8 (12.7) 84(17.3)
Homemaker 4 (6.3) 33 (6.8)
Unemployed, looking 2 (3.2) 18 (3.7)
Unemployed, not looking 3 (4.8) 24 (4.9)
Retired 7(11.1) 29 (6)
Disabled 32 (50.8) 207 (42.7)
Ethnicity 13.5 <.01**
American Indian/Alaskan 2(3.2) 1 (-2)
Asian 0(0) 0(0)
Hispanic or Latino 0(0) 9(1.9)
Pacific Islander/Hawaiian 0(0) 0(0)
Black or African American 0(0) 7(1.4)
Caucasian 63 (96.8) 115 (92.8)
Other 0(0) 18 (3.7)
Mean (SD) Mean (SD) t P
Age (years) 52.94 9.85 Range: 31-75 45.90+ 11.69 Range: 18-76 4.57 Education (years) 15.56 + 3.38 Range: 12-25 14.57 + 2.88 Range: 4-25 2.5 <.05*
* p < .05 ** p < .01
54


sample earning between $5k and $14,999 (20%) and $30k and $49,999 (18.3%) and more
Facebook participants earning between $ 15k and $29,999 (24.1%) and $30k and $49,999
(17.7%) than in other salary categories.
Pain Characteristics of the Participant Sample
Descriptive statistics for all pain characteristics for both data collection sources are
shown in Table 2. Again, chi-square tests of independence and independent t tests were
conducted to determine if there were significant differences between the two data sources.
Bonferroni adjusted criterion alpha levels were applied to pain locations (p = .005 (.05/10)) and
the remaining pain characteristics (p = .02 (.05/3)). Participants were asked to record all areas
they experienced pain; therefore, more than one area may have been indicated per individual. All
results from chi-square tests of independence comparing the location of the participants pain and
the two data sources suggested no significant differences in accordance with adjusted criterion
levels.
Both samples endorsed more diagnoses of fibromyalgia (Yahoo! = 74.6%; Facebook =
67.5%) than chronic pain without fibromyalgia. The most common chronic pain type reported
among Yahoo! Groups participants included lower back (84.1%); lower limbs (79.4%); cervical
spine (69.8%); and upper extremities (65.7%). Most frequently endorsed areas within the
Facebook sample also included lower limbs (76.9%); lower back (71.2%); upper extremities
(70.0%); and cervical spine (67.5%).
Additionally, an independent t test with a Bonferroni adjusted alpha level of .02
(.05/3) was conducted to examine the differences in participants number of years they had
experienced pain (Years in Pain.) Results showed a significant difference in these number of
years between the two samples, t(550) = 3.58,p< .01. Yahoo! participants self-reported
significantly more years of pain (M= 19.08 (SI) = 12.29)) than Facebook (M= 13.83 (SI) =
10.77)). There were no significant differences reported for average weekly pain level between the
55


two groups, t(550) = -.14,p = .89. The current average weekly pain levels rated between zero and
10 on an 11-point Likert scale, fell between 6.43 (SD = 1.66) for the Yahoo! and 6.46 (.S'/) = 1.67)
for the Facebook participants. A greater number of pain-related surgeries were reported by the
Facebook sample (M = 3.58 (SI) = 4.0)) compared to Yahoo! (M= 2.86 (SI) = 2.29)); however,
no significant differences were found, 7(172) = -1.32,/? = .19.
Hypothesis One
Hypothesis One stated that the following three cluster groups would emerge in the FM
participant sample:
1) Low Activity Engagement Low Pain Willingness
2) High Activity Engagement High Pain Willingness
3) Moderate Activity Engagement Moderate Pain Willingness
Hierarchical cluster analysis using Wards method, followed by k-means cluster analysis
were conducted using Activity Engagement (AE) and Pain Willingness (PW) totals from the
Chronic Pain Acceptance Questionnaire (CPAQ). Again, this method was chosen to closely
follow prior methodology (Costa & Pinto-Gouveia, 2010; Payne-Murphy & Beacham, 2014;
Vowles et al., 2008). The AE/PW hierarchical cluster analysis using Wards method specified
five clusters (see Table 3); therefore, a follow-up k-means cluster analysis was not deemed
appropriate (Gore, 2000). According to Gore (2000), an iterative procedure such as the k-means
partitioning method, is only effective if provided the exact number of clusters. Due to failing to
see three clusters emerge, the k-means procedure was therefore unnecessary. These findings
indicate that hypothesis one was not supported. As indicated in Hypothesis 1, tertile groups were
then formed using the total score for the Chronic Pain Acceptance Questionnaire reflecting Low,
High and Medium tertiles. Descriptives for both the FM and CP tertiles are found in Table 4.
56


Table 2
Pain Characteristics of Sample by Data Collection Source
Characteristic Yahoo! Groups (n = 63) n (%) Facebook (n = 489) n (%) x2 P
Fibromyalgia vs. CP 47 (74.6) 330 (67.5) 1.3 .25
Pain Location
Lower Back 55 (84.1) 348 (71.2) 4.72 .03
Lower Limbs 50 (79.4) 376 (76.9) .19 .66
Upper Extremities 41 (65.7) 342 (70.0) .62 .43
Head/Face 24 (38.1) 250 (51.1) 3.79 .05
Cervical Spine 44 (69.8) 330 (67.5) .14 .71
Thoracic Spine 33 (52.4) 225 (46.0) .91 .34
Pelvic/Genital 18 (28.6) 130 (26.6) .112 .74
Full Body 30 (47.6) 227 (46.4) .03 .86
Pain Location: Other 5 (8.0) 33 (6.7) .12 .73
Mean (SD) Mean (SD) t P
Years in Pain 19.08 12.29 13.83 10.77 3.58 .00**
Range: 3-60 Range: 1-53
Current Average Weekly Pain Level: 0-10-point scale (10 = most)
6.43 1.66 6.46 1.67 -.14 .89
Range: 2-10 Range: 1-10
Number of Surgeries 2.86 2.29 3.58 4.0 -1.32 .19
Range: 1-10 Range: 0-27
* p < .005 using Bonferroni correction for nine chi-square tests of independence.
** p< 02 using Bonferroni correction for three independent t tests.
Table 3 CPAQ Mean Scores by Cluster- Fibromyalgia Sample
Cluster 1 (n = 78) Mean (SD) Cluster 2 (n = 66) Mean (SD) Cluster 3 (n = 34) Mean (SD) Cluster 4 (n = 82) Mean (SD) Cluster 5 ( = 71) Mean (SD)
Activity Engagement 30.1 (6.86) 32.8 (9.4) 13.35 (5.6) 16.6(6.9) 36.94 (7.8)
Pain Willingness 28.9 (5.24) 17.76 (4.9) 8.21 (3.8) 23.15 (5.1) 24.41 (7.3)
CPAQ Total Score 58.9(10.18) 50.56 (12.1) 66.97 (14.5) 39.72 (8.9) 61.35 (12.4)
57


Table 4
CPAQ Mean Score by Pain Type and fertile
Low High Medium
Fibromyalgia Sample size CPAQ Total Mean (.S'/)) 117 33.58 (11.0) 88 66.89(10.26) 126 51.29 (8.09)
Chronic Pain Sample size CPAQ Total Mean (SD) 36 36.36 (12.9) 73 72.15 (14.06) 40 51.68 (7.94)
Hypothesis Two
Hypothesis Two stated that the same three cluster groups would emerge in the CP
participant sample:
1) Low Activity Engagement Low Pain Willingness
2) High Activity Engagement High Pain Willingness
3) Moderate Activity Engagement Moderate Pain Willingness
Hierarchical cluster analysis using Wards method, followed by k-means cluster analysis
were conducted using Activity Engagement (AE) and Pain Willingness (PW) totals from the
Chronic Pain Acceptance Questionnaire (CPAQ). Again, this method was chosen to replicate the
prior methodology as closely as possible. The AE/PW hierarchical cluster analysis using Wards
method specified four clusters; therefore, a follow-up k-means cluster analysis was again not
deemed appropriate (Gore, 2000). As was found in Hypothesis 1, the current findings indicate
that this hypothesis was not supported. Descriptives for the CP clusters are shown in Table 5. As
stated in Hypothesis 2, tertile groups were formed using the total score for the Chronic Pain
Acceptance Questionnaire reflecting Low, High, and Medium tertiles. Please refer to Table 4 for
descriptives for both the CP and FM tertiles.
58


Table 5
CPAQ Mean Scores by Cluster Chronic Pain Sample
Cluster 1 (n = 64) Mean (.S'/)) Cluster 2 (n = 31) Mean (.S'/)) Cluster 3 (n = 25) Mean (.S'/)) Cluster 4 (n = 29) Mean (.S'/))
Activity Engagement 29.36 (7.22) 50.74 (5.3) 14.84 (5.2) 37.1 (6.9)
Pain Willingness 29.0 (6.63) 34.32 (7.1) 14.4 (7.9) 16.0 (5.35)
CPAQ Total Score 58.4 (8.37) 85.1 (10.4) 29.24 (7.51) 53.1 (9.5)
Hypothesis Three
Hypothesis Three stated that in the online FM support group sample, as well as the CP
support group sample, self-reported scores of Perceived Disability, Mindfulness and Experiential
Avoidance would differ overall by Acceptance level (Low, High, and Medium) group (main
effect for group) controlling for average pain rating in past week and degree of PTSD
symptomatology. Covariate selection was previously described in Data Analysis section.
A series of three 2x3 between-subjects analyses of covariance were performed. The first
was conducted on levels of Mindfulness as measured by the Five Facet Mindfulness
Questionnaire (FFMQ-SF), the second on levels of Experiential Avoidance as measured by the
Acceptance and Action Questionnaire (AAQ), and the third on levels of Perceived Disability via
the Pain Disability Index (PDI). The first set of independent variables consisted of pain type (FM
or CP) and the second set was tertile divisions of total Acceptance (i.e., Low, High, and Medium)
as measured by the CPAQ. These were factorially combined. As previously described, both
weekly pain average and PCL-C score were employed as covariates for all three ANCOVAs. All
analyses were performed by SPSS, which adjusts for unequal n by weighting cells by their sample
sizes.
Results of the evaluation of the assumptions of normality of sampling distributions,
linearity, absence of multicollinearity, homogeneity of regression and reliability of covariates
59


were satisfactory. Presence of outliers led to transformation (Bloms formula) of two of the three
dependent variables (AAQ and PDI), and the two covariates (average weekly pain severity and
PCL-C scores; Blom, 1958). No outliers remained after transformation; however, three outliers,
which were found in the FFMQ measure, were replaced with z-scores of 2.0, according to prior
method (Field, 2009). Levenes test for equality of variances was found to be violated for the
present analysis specifically when PDI served as the dependent variable, F(5, 429) = 2.60, p =
.03. However, transformation of the PDI via Bloms formula then rendered this assumption met,
as indicated by a non-significant Levenes test value, F(5, 442) = 1.28,p = .27. After adjustment
by covariates, Mindfulness varied significantly by Acceptance tertile, as indicated in Table 6,
F(2, 393) = 4.79,/? < .01. Using /// as the measure of effect size, Acceptance tertile accounted for
2% of the total variability in the Mindfulness score (/// = .02).
Table 6
Analysis of Covariance of Mindfulness by Chronic Pain Type and Acceptance Tertile
Source of Variance SS df MS F Vp
Chronic pain type (FM or CP) .08 1 .08 .12 .00
Acceptance tertile (Low, Med or High) 6.29 2 3.15 4.79 .02**
Interaction .25 2 .13 .19 .00
Covariates (adjusted for all effects)
Average weekly pain level 3.34 1 3.34 5.09 .01*
Post-traumatic symptom severity 76.33 1 76.33 116.08 23**
Error 258.42 393 .66
* p < .05 ** p < .01
The adjusted marginal means (see Table 7), are displayed in Figure 3 and show that the
lowest levels of Mindfulness were self-reported by participants in the Low Acceptance tertile;
highest levels of Mindfulness were self-reported by those in the High Acceptance tertile; and
moderate levels in the Medium tertile. No statistically significant main effect of chronic pain type
60


(FM or CP) emerged on Mindfulness.
Table 7
Adjusted and Unadjusted Mean Mindfulness by Acceptance fertile and Pain Type
Adjusted Mean (SE) Unadjusted Mean (SD)
Low Acceptance Fibromyalgia -.18 (.09) -.43 (.96)
Chronic Pain -.21 (.14) -.32 (1.05)
High Acceptance Fibromyalgia .12 (.09) .30 (1.01)
Chronic Pain .22 (.12) .55 (.81)
Med Acceptance Fibromyalgia .05 (.08) -,001(.80)
Chronic Pain .07 (.14) .10 (1.0)
Note. All data presented as z-scores.
0.25
0.2
0.15
0.1
0.05
0
-0.05
-0.1
-0.15
-0.2
-0.25
^

A


Low Acceptance
Med Acceptance
)! High Acceptance


Fibromyalgia
Chronic Pain
Figure 3. Adjusted Means for Mindfulness by Acceptance Tertile and Pain Type.
Similarly, a main effect of Acceptance tertile also emerged when Experiential Avoidance
was employed as the dependent variable, after adjustment by covariates, F(2, 436) = 8.39,p< .01
(see Table 8). Again, a small effect size was found between Acceptance tertile and Experiential
61


Table 8
Analysis of Covariance of Experiential Avoidance by Chronic Pain Type and Acceptance fertile
Source of Variance SS df MS F Vp2
Chronic pain type (FM or CP) .01 1 .01 .01 .00
Acceptance group (Low, Med or High) 7.52 2 3.76 8.4 04**
Interaction .33 2 .17 .37 .00
Covariates (adjusted for all effects)
Average weekly pain level .02 1 .02 .04 .00
Post-traumatic symptom severity 141.76 1 141.76 316.5 42**
Error 195.29 443 .45
* p < .05 ** p < .01
2
Avoidance, rjp = .04. Adjusted marginal means (see Table 9) are displayed in Figure 4 and show
that the highest levels of Experiential Avoidance were self-reported by participants in the Low
Acceptance tertile; lowest levels were self-reported by those in the High Acceptance tertile; and
moderate levels in the Medium tertile. After covariate adjustment, no statistically significant main
effect of chronic pain type (FM or CP) was found on Experiential Avoidance.
The third ANCOVA examined group differences among pain type and Acceptance tertile
on Perceived Disability via the Pain Disability Index (PDI). Following covariate adjustment,
results suggest a statistically significant main effect occurred between Perceived Disability and
Acceptance tertile, F(2, 440) = 12.96,p< .01 (Table 10). A significant main effect was also
found between Perceived Disability and pain type, F(l, 440) = 10.67,/? < .01. Again, small effect
sizes were found for both effects, rjp = .06 for Acceptance tertile and rjp = .02 for pain type
(Table 10). Adjusted marginal means (Table 11) are displayed in Figure 5 and show that the
highest levels of Perceived Disability were self-reported by participants in the Low Acceptance
tertile; lowest levels of Perceived Disability were self-reported by those in the High Acceptance
tertile; and moderate levels in the Medium tertile. Likewise, higher levels of Perceived Disability
62


were self-reported by FM participants when compared to the CP participants, both in die Low and
Med Acceptance tertiles. In contrast, CP participants reported higher levels of Perceived
Disability compared to those with FM in the Low Acceptance tertile but not in the High and
Medium tertiles.
Table 9
Adjusted and Unadjusted Mean Experiential Avoidance by Acceptance Tertile and Pain Type
Adjusted Mean (SE) Unadjusted Mean (.S'/))
Low Acceptance Fibromyalgia .18 (.07) .56 (.89)
Chronic Pain .23 (.12) .41 (1.07)
High Acceptance Fibromyalgia -.14 (.07) -.39 (.89)
Chronic Pain -.22 (.09) -.75 (.96)
Med Acceptance Fibromyalgia .01 (.07) ,11(.76)
Chronic Pain .06 (.11) .06 (.84)
Note. All data presented as z-scores.
Figure 4. Adjusted Means for Experiential Avoidance by Acceptance Tertile and Pain Type.
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Table 10
Analysis of Covariance ofPerceived Disability by Chronic Pain Type and Acceptance fertile
Source of Variance ss df MS F Vp
Chronic pain type (FM or CP) 6.88 1 6.88 10.67 .02**
Acceptance group (Low, Med or High) 16.71 2 8.36 12.96 .06**
Interaction 6.59 2 3.3 5.11 .02**
Covariates (adjusted for all effects)
Average weekly pain level 26.29 1 26.29 40.74 09**
Post-traumatic symptom severity 26.82 1 26.82 41.6 09**
Error 283.7 440 .65
* p < .05 ** p < .01
Table 11 Adjusted and Unadjusted Mean Perceived Disability by Acceptance fertile and Pain Type
Adjusted Mean (SE) Unadjusted Mean (.S'/))
Low Acceptance Fibromyalgia .26 (.08) .50 (.89)
Chronic Pain .37 (.14) .51 (.80)
High Acceptance Fibromyalgia .03 (.09) -.12 (.79)
Chronic Pain -.49 (.11) -.86 (1.11)
Med Acceptance Fibromyalgia .08 (.08) ,13(.82)
Chronic Pain -.36 (.12) -.35 (.93)
Note. All data presented as z-scores.
64


Hypothesis Four
Hypothesis Four stated that an interaction effect would occur between tertile groups
(Low, High, Medium) and pain type (FM and CP). In total, three interaction effects, one per
ANCOVA, were predicted:
1) tertile group (IV) and pain type (IV) and Mindfulness (DV);
2) tertile group (IV) and pain type (IV) and Experiential Avoidance (DV);
3) tertile group (IV) and pain type (IV) and Perceived Disability (DV).
Results of the first two 2x3 between-subject ANCOVAs indicated there were no
significant interaction effects between Acceptance tertile and pain type for Mindfulness and
Experiential Avoidance. However, a statistically significant interaction effect was found between
Perceived Disability, tertile group and pain type, F(2, 440) = 12.96,p < ,01(see Table 10). Again,
a small effect was detected, ///= .02 (Table 10). Please refer to Figure 6. Results indicate that as
Acceptance levels increase, Perceived Disability scores decrease overall; however, Perceived
65


Disability decreases more as Acceptance increases for those with CP as compared to FM
participants.
Supplemental Analyses
Interaction Effect Correlations. Follow up analyses were conducted to examine the
significant interaction effect between Perceived Disability, tertile group and pain type. Significant
associations were specifically found both between 1) Acceptance tertile group and Perceived
Disability for both pain types and 2) between type of pain and Perceived Disability at Medium
and High levels of Acceptance. For FM pain type, the association between Acceptance tertile and
Perceived Disability was significant and negative, rs(331) = -.28,p< .01, suggesting that as
Acceptance increases, Perceived Disability decreases for this sample. For CP pain type, this
association between Acceptance tertile and Perceived Disability was also significant and
negative, rs(149) = -.44, p < .01. Notably, the degree of the association is greater between CP pain
type and Acceptance tertile (-.44) when compared to the association between FM pain type and
66


Acceptance tertile (-.28). Likewise, this finding suggests that for CP participants, Acceptance
levels also increases as Perceived Disability decreases. For Low Acceptance, the association
between pain type and Perceived Disability was not significant, rs(152) = -.02,p = .81. However,
for Medium and High Acceptance, there was a significant negative association between pain type
and Perceived Disability, (rs(153) = -.24, p < .01, rs(164) = -34, p < .01, respectively). In both
Medium and High Acceptance groups, those with CP self-reported lower levels of Perceived
Disability (Adjusted Medium Mean = -.36; High Mean = -.49) when compared to FM (Adjusted
Medium Mean = .08; High Mean = .03).
Multiple Imputation Analyses. In regards to systematic missing data, analyses were
conducted to identify predictors of missing values. These predictors were then employed as
covariates to control for this missing pattern of data, followed by multiple imputation methods to
impute missing data using estimated patterns of variability within the current data set (Schafer &
Graham, 2002).
Stepwise logistic regression was first performed to identify demographic variables that
predicted membership in the non-completer participant group (n = 147) vs. the completer
participant group (n = 395). Non-completers were defined as those who were missing at least one
value within any of the dependent (Mindfulness, Experiential Avoidance or Perceived Disability)
or independent (pain type or Acceptance tertile) variables or covariates (PCL-C score and average
weekly pain severity). The model was statistically significant, %2 (6, N = 552) = 37.03,p< .01,
indicating that this model was able to distinguish between non-completers and completers.
Among all demographic variables included in the model, six significantly predicted likelihood of
non-completion of the survey, specifically age of participant in years (older); years of education
(fewer); primary ethnicity identified as other; absence of symptoms of tenderness to touch
experienced within the past seven days; bladder symptoms experienced within the past seven
days; and depressive symptoms within the past seven days (see Table 12). This model explained
67


between 6.5% (Cox and Snell R square) and 9.3% (Nagelkerke R square) of the variance in class
membership.
Multiple imputation was then performed specifying 10 imputations on the following
variables: pain type, Acceptance, Mindfulness, Experiential Avoidance, Perceived Disability,
PCL-C score, average weekly pain severity, and the aforementioned six predictor variables (see
Table 12). Specifically, six out of 13 variables were automatically selected by SPSS to impute
due to missing values: Mindfulness, Experiential Avoidance, Perceived Disability, Acceptance,
PCL-C score, and education level. In total, 11.6% (384 missing data points out of 3312 possible
values) of all data values were imputed. The numbers of missing and imputed values include:
education level (missing = 2; imputed = 20); Experiential Avoidance (49, 490); Acceptance (72,
720); Perceived Disability (75, 750); PCL-C score (87, 870); Mindfulness (99, 990).
Table 12
Logistic Regression Predicting Likelihood of Survey Non-Completion
Predictor B S.E. 95% Cl for Odds Ratio Lower e Upper
Years of education -.07* .04 .87 .93 1.00
Age in years .02* .01 1.00 1.02 1.04
Current depressive symptoms .51* .24 1.04 1.67 2.67
Current tenderness to touch _ 92** .24 .25 .40 .64
Current bladder problems .67** .25 1.21 1.96 3.17
Ethnicity Other \ 44** .52 1.53 4.22 11.67
Constant .66 .96 .52
x2 37.03
df 1
* p < .05 ** p < .01
ANCOVA Replication Using Imputed Dataset. The same three 2x3 ANCOVAs were
again performed using this imputed dataset and covaried for these six predictors, as well as
average weekly pain and PCL-C score, to replicate current study procedures. Across 10
68


imputations of the data, results suggest a significant main effect of Mindfulness on Acceptance
tertiles for four out of 10, with significance values ranging betweenp = .006 and .46. Among the
four results suggesting significance below the .05 level, partial eta squared values ranged from
.001 to .01. No significant main effect was seen for Mindfulness on pain type, nor was an
interaction effect detected. Adjusted and unadjusted means are shown in Table 13 and Figure 7.
Table 13
Comparison of Mean Mindfulness for Non-Imputed vs. Imputed Datasets
Non-Imputed Imputed*
Adj. M (SE) Unadj. M (SD) Adj. M (SE) Unadj. M
Low Acceptance Fibromyalgia -.18 (.09) -.43 (.96) -.11 (.09) -.38
Chronic Pain -.21 (.14) -.32 (1.05) -.05 (.16) -.16
High Acceptance Fibromyalgia .12 (.09) .30(1.01) .04 (.09) .27
Chronic Pain .22 (.12) .55 (.81) .23 (.13) .51
Med Acceptance Fibromyalgia .05 (.08) -,001(.80) .03 (.09) -.01
Chronic Pain .07 (.14) .10(1.0) .09 (.16) .06
Note. All data presented as z-scores.
* Values are pooled.
Figure 7. Adjusted Means for Mindfulness by Acceptance Tertile and Pain Type Using hnputed
Dataset.
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ANCOVA results examining group differences among Acceptance tertiles and pain type
within Experiential Avoidance suggest a significant main effect of tertile group for 9 out of 10
imputation series of the dataset, (p range = .00 .09; ///range = .01 .04). Mean comparisons
shown in Table 14 and Figure 8 show similar patterns found in the initial ANCOVA with non-
imputed data. Again, no main effect of pain type or interaction effect emerged for Experiential
Avoidance.
Table 14
Comparison of Mean Experiential Avoidance for Non-Imputed vs. Imputed Datasets
Non-Imputed Imputed*
Adj. M (SE) Unadj. M (.S'/)) Adj. M (SE) Unadj. M
Low Acceptance Fibromyalgia .18 (.07) .56 (.89) .09 (.07) .49
Chronic Pain .23 (.12) .41 (1.07) .20(46) .22
High Acceptance Fibromyalgia -.14 (.07) -.39 (.89) -.11 (.08) -.32
Chronic Pain -.22 (.09) -.75 (.96) -43(41) -.65
Med Acceptance Fibromyalgia .01 (.07) .11 (.76) .01 (.07) .11
Chronic Pain .06(41) .06 (.84) .14 (.12) .08
Note. All data presented as z-scores.
* Values are pooled.
Figure 8. Adjusted Means for Experiential Avoidance by Acceptance Tertile and Pain Type
Using Imputed Dataset.
70


Two significant main effects and an interaction between pain type and Acceptance tertile
within Perceived Disability were found. Among all 10 imputations, a significant main effect was
seen for pain type (allp's < .05; /// range = .01 .03), as well as a main effect for Acceptance
tertile (all p's < .01; i//range = .02 .06). Results of seven out of 10 imputation series suggest a
significant interaction effect (p range = .00 -.12; /// range = .01 .02), with significant/? values <
.03. Mean comparisons are also displayed in Table 15 and Figure 9.
Table 15
Comparison of Mean Perceived Disability for Non-Imputed. vs. Imputed Datasets
Non-Imputed Imputed*
Adj. M (SE) Unadj. M (SD) Adj. M (SE) Unadj. M
Low Acceptance Fibromyalgia .26 (.08) 50 (.89) .29 (.10) A1
Chronic Pain .37 (.14) .51 (.80) .19 (.17) .36
High Acceptance Fibromyalgia .03 (.09) -.12 (.79) .05 (.09) -.12
Chronic Pain -.49 (.11) -.86 (1.11) -.44 (.14) -.70
Med Acceptance Fibromyalgia .08 (.08) ,13(.82) .11 (.17) .10
Chronic Pain -.36 (.12) -.35 (.93) -.48 (.16) -.34
Note. All data presented as z-scores.
* Values are pooled.
Figure 9. Adjusted Means for Perceived Disability by Acceptance Tertile and Pain Type Using
Imputed Dataset.
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CHAPTER V
DISCUSSION
Chronic pain is a debilitating health concern that is a significant financial and emotional
burden for approximately 100 million Americans (Institute of Medicine of the American
Academies, [IOM] 2011). Among the many types of CP; however, empirical evidence suggests
FM is one of the most difficult to treat and outcomes are poorer across multiple life areas. There
is currently a great need for improved treatment approaches, given a lack of broadly effective FM
interventions. Acceptance and Commitment Therapy (ACT) studies have shown promising
findings in reducing pain-related functional impairment in FM and CP samples by targeting
Acceptance of pain and by utilizing Mindfulness techniques. Prior study findings also suggest
that several key ACT concepts such as Experiential Avoidance and Mindfulness may be
particularly salient for FM due to the ways in which patients perceive their pain and functioning.
Furthermore, previous findings indicate that profiling CP patients by levels of Acceptance has
utility in identifying key influential traits and behaviors (i.e., positive affect, pain-related anxiety,
depressive symptoms, and perceived disability); therefore, profiling FM patients in this manner
may lead to more effective and targeted approaches.
The overarching purpose of this study was to examine the roles of Acceptance,
Experiential Avoidance, Mindfulness and Perceived Disability in FM and a comparison group of
CP participants in online support groups. This study aimed to conduct cluster analyses for each
sample (FM vs. CP) by levels of Acceptance. Given these two sets of respective clusters (FM and
CP), it was predicted that significant group differences would be seen in Experiential Avoidance,
Mindfulness and Perceived Disability, as indicated by a series of ANCOVAs which assessed
overall group differences by Acceptance level and pain type (FM and CP).
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Sample characteristics
Total online sample (N= 552; Mean age = 46.7 years, SD = 11.7) was primarily female
(92.2%), Caucasian, not of Hispanic origin (93.3%), married/partnered (66.6%), and well
educated (M= 14.7 years, SD = 3.0), with an average income ranging between $ 15k and $40k.
Those who self-reported a diagnosis of FM comprised 68.3% of the total sample (n = 377)
whereas those with CP, without FM, was smaller (n = 175). Mean years with either FM or CP
were 14.4 (SD = 11.1) and average weekly pain intensity was 6.5/10 (SD = 1.7; 10 = extreme
intensity). The majority of the sample either reported having health insurance or was in the
process of obtaining this (88.3%).
Compared to Yahoo! Groups (n = 63), more Facebook participants enrolled in the current
study (n = 489). Samples from both social media websites were predominately female (Yahoo!
Groups = 98.4% and Facebook = 91.4%), Caucasian, not of Hispanic origin (96.8%; 92.8%,
respectively), middle-aged (M= 52.94; 45.9 years) and well-educated (Yahoo!, mean years =
15.56 (SD = 3.38); Facebook, mean years = 14.57 (SD = 2.88). All participants were also
primarily unemployed (not retired) (Yahoo! =65.1%; Facebook = 58.1%) and had lower to
middle-ranging incomes (range = $5,000 to $49,999 annually). Yahoo! Groups participants were
significantly older, less ethnically diverse, and more educated but no differences were seen
between the two samples regarding occupational status or income.
These differences likely reflect variations in the type of online participant who utilize
Facebook or Yahoo! Groups. According to a 2014 Internet poll (N= 1597), 71% of adults online
use Facebook and more users are women (77% vs. 66% men), Hispanic (73%), White, non-
Hispanic (71%) and Black, non-Hispanic (67%), and tend to be younger, as more are aged 18 to
29 (87%) and 30-49 (73%) compared to those aged 50-64 (63%), and 65 and older (56%)
(Duggan, Ellison, Lampe, Lenhart, & Madden, 2014). These findings also suggest only slightly
more Facebook users are more educated (74% = college or greater vs. 70% high school or fewer
73


years) and earn a wide range of annual salaries: 77% = less than $30,000, 69% = 30k 49,999;
74% = 50k 74,999; and 72% earn 75k and greater. The current studys Facebook sample is
relatively consistent with these findings with the exception of ethnic diversity. Of note, younger
age of the typical Facebook user may be contributing to the significant contrast in age between
the current samples mean age (45.9 years) and that of the Yahoo! Groups participant (52.94
years). Comparison to Yahoo! Groups users cannot be made as no studies to date have been
published examining these characteristics.
Both samples in the current study endorsed more diagnoses of FM (Yahoo! = 74.6%;
Facebook = 67.5%) than CP without FM. Most commonly reported CP type among Yahoo!
Groups participants included lower back (84.1%); lower limbs (79.4%); cervical spine (69.8%);
and upper extremities (65.7%). Similarly, the Facebook sample endorsed the same primary
locations of pain: lower limbs (76.9%); lower back (71.2%); upper extremities (70.0%); and
cervical spine (67.5%). These findings are not surprising, given that the most prevalent sites of
bodily pain include lower limbs, back, lower back, upper extremities and head (Breivik, Collett,
Ventafridda, Cohen, & Gallacher, 2006; Tunks, Crook, & Weir, 2008). In regards to duration of
pain, Yahoo! participants reported significantly more years (M= 19.08 (.S'/) = 12.29)) than
Facebook (M= 13.83 (.S'/) = 10.77)). Conversely, Facebook members reported more pain-related
surgeries (M= 3.58 (SI) = 4.0)) compared to Yahoo! (M= 2.86 (SI) = 2.29)), but these
differences were not significant. No differences in average weekly pain severity were seen (6.43
(SD = 1.66) = Yahoo!; 6.46 (.S'/) = 1.67) = Facebook). Due to the relatively few available studies
examining Facebook or Yahoo! Groups CP online support groups, comparisons to the current
sample cannot be made.
Representativeness of the Participant Sample
Pain and demographic characteristics of the current sample varied slightly from other
general online FM and CP studies, but not substantially overall. Compared to a 2007 online poll
74


of FM patients (N= 2596) who responded to a survey on the National Fibromyalgia Association
website, the present studys FM sample is slightly younger (46.1 years vs. 47.3); more female
(97.9% vs. 96.8%); less ethnically diverse (91.2% Caucasian, non-Hispanic vs. 91.5%); similarly
partnered (67.1% vs. 64.2%); and possibly had more years in pain, but specific numbers were not
described (M= 15.5 vs. greater than 4 years = 75.5%) (Bennett et al., 2007). Annual household
income was lower for current FM participants: 49% earned between 5 and 49k vs. approximately
50% of respondents earned between 20 and 80k. More current FM participants also received
disability payments (46.1%) vs. the online poll (20% disability and 6% workmans
compensation).
Similarities between a second online sample of FM and CP participants further suggest
the current sample is largely representative (Lorig, Ritter, Laurent, & Plant, 2008). In comparison
to online participants enrolled in a self-management intervention for CP (N= 855; 50.3% = FM;
27.5% = rheumatoid arthritis; and 63.6% = osteoarthritis), the current sample was slightly
younger, (M= 46.7 vs. 52.4 years); slightly more female (92.2% vs. 90.2%); similarly less
ethnically diverse (93.3% vs. 92.3% Caucasian, non-Hispanic); similarly partnered/married
(66.6% vs. 68.3%); and only slightly less educated (M= 14.7 vs. 15.7 years). In sum, current
participants appeared to be a representative sample of FM and CP patients.
Hypothesis One
Hypothesis One stated that the following three cluster groups would emerge in the FM
sample: 1) Low Activity Engagement Low Pain Willingness; 2) High Activity Engagement -
High Pain Willingness; and 3) Moderate Activity Engagement Moderate Pain Willingness. This
hypothesis was not supported, as five clusters with varying means emerged from the hierarchical
cluster analysis using Wards method. Activity Engagement and Pain Willingness means found
within each of the five clusters suggest that two of the predicted groups emerged, the Low Low
cluster (Mean AE = 13.35 (5.6); Mean PW = 8.21 (3.8); see Table 3, cluster 3) and the Moderate-
75


Moderate cluster (Mean AE = 30.1 (6.9); Mean PW = 28.9 (5.2); see Table 3, cluster 1). Close
examination of the mean differences between the clusters suggests several other notable
differences. Overall, none of the AE or PW means reached High levels across all of the clusters
(AE and PW mean range = 8.21 36.94). Given that the means for the AE subscale for FM
participants ranged between 0 and 61, and PW mean values ranged from 0 to 46, this finding is
surprising. Secondly, the three remaining clusters can best be described as Moderate-Low
(Clusters 2 and 5) and Low-Moderate (Cluster 4). Given the lack of an established definition of
CPAQ means and their respective cluster designation given their value, these categorizations only
approximate their assignment. Compared to prior study findings found for CP participants (Costa
& Pinto-Gouveia, 2010; Payne-Murphy & Beacham, 2014; Vowles et al., 2008), these FM
clusters appear to be less differentiated with a tendency to represent only Moderate to Low mean
values. This finding suggests that a large enough sample of FM participants self-reporting High
mean AE or PW scores is not present in the current sample; therefore, the majority endorse less
Acceptance of their pain.
To date, this is the first study to examine cluster analysis using the Chronic Pain
Acceptance Questionnaire in FM patients. Without comparison data, it is difficult to conjecture
why these particular clusters emerged in the current study and why they differ from prior CP
samples. Specifically, it is unclear if the response pattern on the CPAQ differed in this FM
sample due to the unique characteristics of FM patients vs. those with CP but without FM; if
distinct differences within this particular FM sample contributed to these differences; or both of
these phenomena. To briefly explore these possibilities, a series of single sample t-tests were
conducted to explore a possible difference between the current study FM participants and a prior
studies FM samples (n = 91) using CPAQ Activity Engagement, Pain Willingness and Total
scores (Payne-Murphy & Beacham, 2014). Results suggest no significant differences between the
two samples in regards to these mean scores, p range .25-.99. Similarly, a second series of single
76


sample t-tests were conducted to compare current FM participants and those with CP in previous
studies across these same CPAQ ratings (Costa & Pinto-Gouveia, 2010; Payne-Murphy &
Beacham, 2014; Vowles et al., 2008). Results suggest current FM patients had significantly lower
Activity Engagement scores compared to all three; significantly higher scores on Pain
Willingness with the exception of one study (Payne-Murphy & Beacham, 2014); and mixed
values for Total Acceptance (Costa & Pinto-Gouveia, 2010; Payne-Murphy & Beacham, 2014;
Vowles et al., 2008). Although the comparisons herein may be rudimentary, they do suggest that
perhaps FM may differ from CP samples in unique ways, which contribute to different clusters;
however, further investigation is required to better assess this assumption. Perhaps the most
important aspect of these comparisons is to introduce the further exploration regarding
characteristics in FM populations.
Despite a lack of clear, meaningful clusters emerging here, two prior studies that were
conducted to better identify key affective and physiological characteristics within FM do suggest
the utility in profiling these patients to inform the design of future interventions. For example,
Loevinger et al.s (2011) study of FM patients (N= 107) suggested four cluster groups emerging
using both objective (physiological) and subjective (questionnaire) methods: those with 1) the
most pain and disability, significant history of maltreatment in childhood, and hypocortisolism; 2)
more physiological dysregulation and increased fatigue, pain, and disability; 3) intermediate pain
severity, biomarkers within normal ranges, and increased global functioning; and 4) decreased
disability and pain and increased psychological wellness (Loevinger, Shirtcliff, Muller, Alonso,
& Coe, 2011).
Similarly, de Souza et al.s 2009 study examined cluster analysis within an outpatient FM
sample (A =61) using responses on the Fibromyalgia Impact Questionnaire (FIQ; Burckhardt,
Clark, & Bennett, 1991; de Souza et al., 2009). Findings suggest two clusters emerged: those who
had 1) decreased anxiety, depression and morning tiredness symptoms but high levels pain,
77


stiffness and fatigue; and 2) high levels of pain, stiffness and fatigue and increased anxiety,
depression, and morning tiredness. Results indicate that the poorer functioning group also
reported more pain catastrophizing, pain-related interference on daily living, and perception of
life control. Findings of these studies again highlight 1) the hetereogeneity in FM samples; 2)
increased affective symptoms are associated with poorer pain ratings and disability; and 3)
underline the need for treatment approaches that vary according to these symptom differences.
Given these preliminary profiling attempts and meaningful clustering of CP groups, further
investigation of Acceptance profiling is needed in FM patients to better identify its utility.
If three clusters did not emerge, Hypothesis One stated that tertiles based on total
Acceptance scores would be formed. Tertile scores suggest CP participants reported greater
Acceptance of pain, as indicated by higher Acceptance scores in the CP vs. FM sample, (CP
Mean = 58.01, FM Mean = 49.18). This approximate 10-point contrast between FM and CP is
seen in other studies, with FM again endorsing lower scores: (M= 40.9, Rodero et al., 2010; M =
47.6, Rodero et al., 2013). CP sample means tend to hover closer to 50 (M= 50.6, Vowles et al.,
2007; M= 50.4, Vowles et al., 2008; M= 52.61, Costa & Pinto-Gouveia, 2010). Notably, the
current sample reflects overall higher Acceptance levels for both FM and CP.
Hypothesis Two
Hypothesis Two stated that the same three cluster groups would emerge in the CP
sample: 1) Low Activity Engagement Low Pain Willingness; 2) High Activity Engagement -
High Pain Willingness; and 3) Moderate Activity Engagement Moderate Pain Willingness by
conducting the identical analysis. This hypothesis was also not supported, as four clusters
emerged within the CP sample (refer to Table 4). Despite this difference, similar clusters did
emerge: one Low Low (cluster 3); one High High (cluster 2); and two Moderate Moderate
groups (clusters 1 and 4). In fact, cluster 1 most resembles the third group found in Payne-
Murphy & Beachanfs 2014 study, the Med-Med cluster, and cluster 4 is similar to Costa &
78


Pinto-Gouveias High Activity Engagement and Low Willingness group (2010). However,
given that three prior studies conducting CPAQ cluster analyses within CP samples found exactly
three nearly identical distinct groups (Costa & Pinto-Gouveia, 2010; Payne-Murphy & Beacham,
2014; Vowles et al., 2008), the current studys findings are surprising.
Again, a brief series of analyses were conducted to examine mean differences between
these samples to determine if there may be distinguishing factors within the current sample
contributing to these notable outcomes. Results of single sample t-tests using CPAQ Activity
Engagement, Pain Willingness and Total means of the current CP sample and these three prior
studies do suggest significant differences, however, with higher ratings found in the current
sample (allp < .05; Costa & Pinto-Gouveia, 2010; Payne-Murphy & Beacham, 2014; Vowles et
al., 2008). Also, a comparison of PDI scores between the current and prior studies CP
respondents indicates significantly lower perceived disability was found in the current sample (p
< .01; Payne-Murphy & Beacham, 2014). It is noteworthy that the current CP participants
reported greater Acceptance of their pain and they perceived themselves as less disabled in
comparison to previously studied patients. This result may offer useful explanation regarding why
three similar clusters did not emerge.
Secondly, previous discussion related to the reliability of cluster analysis has suggested
inconsistencies in the ability to reproduce similar clusters, which represents a weakness in this
type of analysis (Gore, 2000). Therefore, the current findings may be partly attributed to this.
Again, as in Hypothesis One, tertiles based on levels of Acceptance were then calculated for the
CP sample.
Hypothesis Three
Hypothesis Three stated that self-reported scores of Perceived Disability, Mindfulness
and Experiential Avoidance would differ overall by Acceptance level (Low, High, and Moderate)
group (main effect for Acceptance tertile) and by pain type (FM or CP; main effect for pain type)
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controlling for average pain rating in past week and degree of PTSD symptomatology. A series of
three 2x3 between-subjects analyses of covariance were performed. The first was conducted on
levels of Mindfulness as measured by the Five Facet Mindfulness Questionnaire (FFMQ-SF), the
second on levels of Experiential Avoidance as measured by the Acceptance and Action
Questionnaire (AAQ), and the third on levels of Perceived Disability via the Pain Disability Index
(PDI).
Mindfulness. Results of the ANCOVA using Mindfulness as the dependent variable
suggest that this hypothesis was partially supported: one main effect was found for Mindfulness
indicating these scores differed significantly by Acceptance tertiles. No main effect was seen for
Mindfulness by pain type (FM and CP). Highest Mindfulness scores were found in the High
Acceptance tertile group; the lowest are in the Low tertile; and moderate means are in the
Moderate tertile (see Table 7). These findings suggest that Mindfulness is an important factor
related to increasing levels of Acceptance in both FM and CP patients. Both prior research and
theory are concordant with this finding. In Costa and Pinto-Gouveias 2010 study, significant
differences were seen between levels of Mindfulness and the Low-Low and High-High
Acceptance clusters, also with the highest scores in the High-High and least in the Low-Low. As
previously described, there are minimal empirical findings delineating the precise relationships
and mechanisms of action between Mindfulness and Acceptance; however, current results
provide further support for these theoretical associations (Block-Lemer et al., 2005;
Mitmansgruber, Beck, Hofer, & SchuBlcr. 2009).
Notably, no significant differences were found in Mindfulness scores by pain type (FM
and CP). Given the greater variety of physical symptoms and higher rates of psychological
distress found in those with FM compared to CP, it is surprising that differences did not emerge,
with FM showing decreased levels. However, a review of prior FM studies assessing the role of
Mindfulness, coupled with the current findings, may suggest that its role appears to be 1) simply
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comparable in those with CP and 2) influential, but prior studies limitations and inconsistencies
in measuring Mindfulness obscure measuring its true impact and illuminating its mechanism of
action.
For example, in a 2014 systematic review of Mindfulness-based studies for FM patients,
10 studies were found to show positive associations with increased Mindfulness and
psychological and physical factors. These included reductions in anxiety, depression, somatic
complaints, and pain severity and improvements in self-reported quality of life (Henke & Chur-
Hanson, 2014). However, high attrition rates, small samples, lack of comparison groups, and
inconsistencies among treatment modalities (Mindfulness-Based Stress Reduction and Qi Gong)
were prevalent study limitations. Two randomized control studies among these 10 also suggest
that improvements seen in Mindfulness intervention participants were not significantly greater
than those in the active control comparison group (Astin, Berman, Bausell, Lee, Hochberg, &
Forys, 2003; Schmidt, Grossman, Schwarzer, Jena, Naumann, & Walach, 2011). Significant
improvements between the study arms were found, however, in the remaining study with an
active control group (Grossman et al., 2007). The authors conclude that these findings, overall,
suggest similar efficacy rates to mindfulness-based interventions for CP and that more
interventions of high quality are needed to better determine its impact in FM patients (Henke &
Chur-Hanson, 2014).
Given these findings, as well as previously discussed challenges in defining Mindfulness
across studies, it appears from the current results that although Mindfulness is positively
associated with Acceptance of pain, there are not significant differences in its role between those
with CP or FM. As prior studies have recommended (McCracken, Gauntlett-Gilbert, & Vowles,
2007), further investigation of its role and how it may aid in increasing Acceptance, is needed.
Experiential Avoidance. Results of the ANCOVA using Experiential Avoidance as the
dependent variable also suggest that this hypothesis was partially supported: one main effect was
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found for Experiential Avoidance indicating that these scores differed significantly by
Acceptance tertiles. No main effect was seen for Experiential Avoidance by pain type (FM and
CP). Table 9 shows that as Acceptance level increases, Experiential Avoidance decreases
respectively across all tertiles.
Although this appears to be the first study to compare Experiential Avoidance in an FM
and CP sample, the current findings are highly consistent with the sole existing study assessing
the relationship between Experiential Avoidance and Mindfulness in FM patients (Henke, 2011);
the two studies examining its role in CP samples (Esteve, Ramirez-Maestre, & Lopez-Martinez,
2012; Ramirez-Maestre, Esteve, & Lopez-Martinez, 2014); and lastly, its previously discussed
role in non-pain samples (Bond et al., 2011; Hayes et al., 2003; Gird & Zettle, 2009; Karekla,
Forsyth, & Kelly, 2004). In Henkes 2011 study, a significant and negative correlation (r = .67,p
< .01) was found between Experiential Avoidance and Mindfulness levels (as reported by the
AAQ and FFMQ) among online FM participants (n = 53). Preliminary studies investigating
Experiential Avoidance in CP samples, as measured by the AAQ, also show increased levels
associated with poorer functional and negative affect, including depressive and anxiety symptoms
and catastrophizing. Among a large outpatient sample diagnosed with chronic back pain (N =
686), significant negative correlations were also seen between Experiential Avoidance and
Acceptance (r = -.45) and between Experiential Avoidance and resilience (r = -.48) (ps < .05;
Ramirez-Maestre, Esteve, & Lopez-Martinez, 2014). Significant positive correlations were also
found in this same sample between Experiential Avoidance and pain intensity (r = .30);
functional disability (r = .22); depression (r = .30); anxiety (r = .44); catastrophizing (r = .51);
hypervigilance of pain (r = .40); fear avoidance beliefs (r = .40) and physical limitations due to
pain per the Roland-Morris Disability Questionnaire (r = .25), (all ps < .05; Roland & Morris,
1983). A second outpatient study (N= 299) examining CP participants self-reported symptoms
also showed positive and significant correlations between Experiential Avoidance and
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catastrophizing (r = .26; p < .01); pain intensity (r = 12: p < .05); anxiety (r = M: p < .01); and
depression (r=.\2;p< .05), respectively (Esteve, Ramirez-Maestre, & Lopez-Martinez, 2012).
Coupled with current findings, self-reported Experiential Avoidance appears to be an important
factor in the experience of patients with either FM or CP due to its relationship with affect and
physical functioning.
Similar to the present studys non-significant findings regarding Mindfulness and pain
type, it is surprising that no differences were found between FM and CP samples in regards to
Experiential Avoidance. As previously noted, there is only one FM intervention study addressing
fear avoidance behaviors (Lumley et al., 2008) and none examine Experiential Avoidance
directly; however, these two constructs are found to have positive associations with one another
in a CP sample (p < .01, r = .39; Ramirez-Maestre, Esteve, & Lopez-Martinez, 2014). Again,
further study of Experiential Avoidance is needed to illuminate its role regarding functional
outcomes within FM populations specifically.
Perceived Disability. Results of the ANCOVA using Perceived Disability as the
dependent variable suggest that this hypothesis was supported: two main effects were found, one
indicating that Perceived Disability scores significantly differed by Acceptance tertiles and the
second suggesting that scores differed by pain type (FM and CP). As predicted, Figure 5 shows
that as Acceptance level increases, Perceived Disability decreases. Prior CP studies have found
identical findings with significant group differences among Acceptance cluster groups and
Perceived Disability (Payne-Murphy & Beacham, 2014; Vowles et al., 2008). Specifically,
MANCOVA and ANCOVA results in these studies indicated significant group differences with
lowest Perceived Disability means found in the High-High AE-PW cluster; highest means in the
Low-Low AE-PW cluster; and moderate values in the mixed/moderate cluster.
Significant differences seen between pain type (CP and FM) herein are also highly
consistent with prior studies. Table 11 indicates that FM patients Perceived Disability is
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significantly greater than CP patients reports. Similarly, a 1997 study comparing patients with
either FM (n = 36) or rheumatoid arthritis (n = 36), found that FM patients had significantly
higher self-reports of disability functioning across 7 out of 10 subscales (i.e. physical, mental
health, social and role function) on the Short Form 36 (allp's < .01; Stewart, Hays, & Ware,
1988; Walker et al., 1997). In a second study examining predictors of disability in chronic low
back pain (n = 35), complex regional pain syndrome (n = 22), and FM patients (n = 54), those
with FM reported significantly greater disability according to Short Form-36 and Fibromyalgia
Impact Questionnaire scores (Burckhardt, Clark, & Bennett, 1991; Verbunt, Pemot, & Smeets,
2008). Follow-up analyses suggest FM patients reported disability was primarily due to mental
health ratings that indicated greater emotional distress, regardless of reported physical disability.
This finding for FM patients is also consistent with previously discussed empirical evidence
suggesting higher perceived disability is predicted by catastrophizing, fear of pain, low self-
efficacy, and avoidance of activities for fear of exacerbating pain in both FM and CP groups
(Dobkin et al., 2010; Karsdorp & Vlaeyen, 2009; Martin et al., 1996; Severeijns, Vlaeyen, van
den Hout, & Weber, 2001; Turk, Robinson, & Burwinkle, 2004). Discussion regarding pain type
differences will be further explored in Hypothesis Four section.
The Role of Trauma. Across all three ANCOVAs, post-traumatic symptom severity, as
self-reported by the PCL-C, was found to be significantly associated with group differences in
Acceptance. PCL-C mean scores for FM patients in the current study total 48.7 (SD = 13.9)
whereas CP patients scores were lower (M = 41.9 (SD = 16.5)). Results of an independent t-test
suggest these differences are significant, /(463) = 4.58,p < .01. Recommended cut-offs for the
use of the PCL-C in pain populations suggest a total score range of 36-44 is roughly equivalent to
a PTSD prevalence between 16 and 39% (VA National Center for PTSD, 2012). Therefore, prior
trauma and related symptoms in the current sample appear to be prevalent, with FM participants
reporting greater severity.
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Current findings are also highly concordant with research regarding trauma in FM,
Acceptance, and Experiential Avoidance. As previously cited, empirical evidence suggests 31.3
to 57% of those with FM endorse trauma histories and/or symptoms of PTSD (Bennett et al.,
2007; Cohen et al., 2002; Sherman, Turk & Okifuji, 2000). Furthermore, self-reported functional
disability was significantly higher in FM patients (n = 93) with trauma symptoms than FM
patients without trauma (Sherman, Turk & Okifuji, 2000). Approximately over 85% of FM
patients in this study with trauma had a high degree of disability whereas only 50% of those FM
patients without trauma symptoms had comparable levels (Sherman, Turk & Okifuji, 2000). As
discussed previously, prior findings also suggest that Experiential Avoidance either predicted
PTSD symptom severity and depression/general psychological distress (Batten et al., 2002; Marx
& Sloan, 2002; Plumb, Orsillo, & Luterek, 2004); or mediated the relationship between trauma
and PTSD (Orcutt, Pickett, & Pope, 2005). It is clear that trauma impedes FM patients ability to
optimize functioning. Although this is not the focus of the present study, it is clear from current
and prior findings that addressing PTSD symptoms are a critical element in future FM
interventions.
Hypothesis Four
Hypothesis Four stated that a total of three interaction effects would occur between tertile
groups (Low, High, Moderate) and pain type (FM and CP), one for each dependent variable
(Mindfulness, Experiential Avoidance and Perceived Disability). This hypothesis was partially
supported, as Perceived Disability was found to have an interaction effect. As levels of
Acceptance increased, FM and CP participants changed in regards to Perceived Disability levels,
with a trend towards less change in Perceived Disability across the tertiles in the FM group (see
Figure 6). Subsequent analyses further revealed this trend reflected significant differences
between the two pain groups such that the rate of Perceived Disability change across Acceptance
tertiles was indeed less in the FM (rs(331) = -.28,/? < .01) vs. the CP sample (rs(149) = -.44,/? <
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.01). Secondly, additional analyses indicate significant differences between pain type and
Perceived Disability at both the Moderate and High Acceptance levels but not at the Low tertile
(rs(152) = -.02,p = .81).
Taken together, these findings suggest that despite increases in Pain Acceptance, FM
participants perceptions of their own disability decreased very little when compared to
perceptions held by those with CP. This was an unanticipated finding given that prior research
suggests that interventions targeting increased Acceptance in FM contributed to significant
decreases in Perceived Disability at post-treatment and 3-month follow-up, with medium to large
effect sizes between the intervention and control group (d = .75 at post-treatment; d =.73 at 3-
month follow-up) (Wicksell et al., 2012). Results from a second ACT intervention study with
approximately 30% FM patients (n = 22) also suggest decreases in self-reported disability at 3-
month follow-up (d= .58; McCracken, Sato & Taylor, 2013). Therefore, current findings suggest
that the role of Acceptance may differ for FM in comparison to CP patients.
An important consideration regarding the current findings is the possibility that self-rated
Perceived Disability is accurately reflecting objective disability in both the FM and CP samples,
and FM participants had objectively higher rates of impairment, given empirical evidence of
increased physical and affective symptomatology. Given that the present study did not measure
functional disability with objective measures, coupled with the inherent and significant challenges
of objectively measuring physical disability, this theory cannot be assessed. However, for those
whose disability is perhaps objectively greater and accurately reflecting disability perceptions,
higher levels of Perceived Disability would be appropriately commensurate with Acceptance.
A second possibility is that FM participants were simply more likely to perceive
themselves as disabled regardless of physical limitations and higher levels of Acceptance.
Findings suggest that FM participants in the Moderate and High Acceptance tertiles overall
reported relatively higher Pain Willingness, that is, the willingness to accept pain and all related
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life impact, and higher Activity Engagement, or the act of engaging in valued life activities
despite pain and related sequelae. Perhaps higher ratings of Perceived Disability reflect a
perception that one is less physically capable (regardless of objective disability) but despite this
view, these individuals continue to engage in life activities and accept their pain, just as their CP
participant counterparts report. This finding also suggests that when we consider Acceptance as a
treatment target, the influence of Acceptance in FM differs from CP such that although it
continues to be predictably negatively associated with Perceived Disability, it is perhaps a less
potent predictor.
A third possibility is that there is secondary gain in reporting higher levels of Perceived
Disability regardless of Acceptance of ones pain for FM patients. Again, prior studies have
suggested more FM patients report greater Perceived Disability than those with CP (Verbunt,
Pemot, & Smeets, 2008; Walker et al., 1997; White et al., 2002). Study findings also suggest that
following receipt of disability payment or when involved in litigation pain, affective symptoms
tend to worsen in FM patients (Clauw, 2004; Hadler, 1996). Authors suggest this is related to the
challenges posed by the system: it is costly, distressing, and reinforces behaviors contrary to pain
rehabilitation. Patients are also indirectly and unintentionally encouraged to present as more ill to
be awarded benefits (Clauw, 2004; Hadler, 1996). Consistent with the theory of pain behaviors
(see operant behavioral therapy section herein), responses on the PDI serve not only to simply
state ones perceptions but also provide an opportunity to communicate deeply held beliefs about
his/her illness-related physical and emotional impairment, which have been previously expressed
to elicit support or positive attention. Perhaps when given this opportunity to communicate these
beliefs, FM patients reports may reference these prior or current perceptions that are positively
reinforced (i.e. via emotional support, financial via disability payment, or other), of which they
may or may not be fully cognizant.
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Supplemental Analyses
Given systematic missing data in the current study, a logistic regression was first
conducted to better determine the demographic variables contributing to predictors of attrition.
The following contributing factors were consistent with prior research: fewer years of education;
older age of participant; primary ethnicity identified as other; and absence of symptoms of
tenderness to touch; bladder symptoms; and depressive symptoms experienced within the past
seven days (Table 12). However, conclusive predictors of attrition from Internet studies have not
been published (Biller, Amstein, Caudill, Federman, & Guberman, 2000; Hart, 1982; Melville,
Casey, & Kavanagh, 2010).
Multiple imputation was then conducted to fully address the limitations presented by
missing data. Repeated analyses using imputation were found to be highly consistent with all
original analyses; variations from these are presented herein. ANCOVA results using
Mindfulness as the dependent variable showed very similar findings. Among the 10 imputed
datasets that were created in the multiple imputation procedure, four showed main effects on
Acceptance tertile. Effect sizes between the original and imputed analyses were also comparable:
rjp = .02 vs. rjp = .001 to .01, respectively. Just as the initial analyses had shown, no main or
interaction effect for pain type on Mindfulness was found. Likewise, nine out of 10 imputations
of the dataset that underwent ANCOVA analyses using Experiential Avoidance as the dependent
variable were significant, reflecting a main effect of Acceptance tertile. Small effect sizes were
comparable between initial and imputed analyses: rjp2 = .02 vs. /// = .001 to .04, respectively.
Again, no main or interaction effect of pain type was found for Experiential Avoidance, just as in
initial analyses.
Imputed results from the Perceived Disability ANCOVA show identical findings to the
initial analyses: significant main effects of both Acceptance tertile and pain type, as well as an
interaction effect. Across all three effects, all 10 of 10 analyses using imputed data were
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significant. All effect sizes were highly consistent with initial findings: /// = .06 vs. /// = .02 to
.06, respectively for the main effect of Acceptance; rjp2 = .02 vs. /// = .01 to .03 for the main
effect of Experiential Avoidance; and /// = .02 vs. /// = .01 to .02 for the interaction effect.
Overall, imputed results suggest that initial analyses do not significantly differ despite bias
contributed by attrition.
Limitations
The primary limitation in this study is systematic bias attributed to significant attrition,
which totaled 409 participants, approximately 37.7% of 1085 participants who originally initiated
the survey. Length of the survey was likely a primary deterrent (total questions = 314), which
may have taken participants up to 60 minutes to complete. More generally, attrition in online
survey research studies is a prevalent and significant problem (Eysenbach, 2005): an estimated
34% dropout is common, ranging from one to 87% for online studies (Joinson, 2007; Reips &
Musch, 2000). This was an anticipated challenge in the present study, and as previous research
has recommended, a gift card incentive was presented and demographic questions were posed at
the start of the survey, as opposed to the end, to encourage survey completion and convey a
message of full-disclosure on the part of the researcher (Frick, Bachtinger, & Reips, 1999; Reips
& Musch, 2000). Previous findings suggest a financial incentive increased online retention from
55% to 87% (Reips & Musch, 2000) and informing participants of this incentive and
demographic questions at survey start reduced dropout from 21.9 to 5.7% (Frick, Bachtinger, &
Reips, 1999).
To account for this bias in the current study, a logistic regression and multiple imputation
analyses were conducted, and covarying for the demographic variables that were found to
contribute to this bias was implemented, according to prior method (Schafer & Graham, 2002).
Specifically, this method minimizes the influence of bias and renders data Missing at Random in
order to meet the assumptions of multiple imputation analyses (Schafer & Graham, 2002).
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Full Text

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ACCEPTANCE BASED FACTORS IN CHRONIC PAIN: A COMPARISON BETWEEN FIBROMYALGIA AND CHRONIC PAIN PATIENTS IN AN INTERNET SUPPORT GROUP SAMPLE by JESSICA C. PAYNE MURPHY B.A., Smith College, 1999 M.A., University of Colorado Denver, 2012 A thesis submitted to the Faculty of the Graduate School of the University of Colorado in partial fulfillment of the requirements for the degree of Doctor of Philosophy Clinical Health Psychology Program 2015

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ii This thesis for the Doctor of Philosophy degree by Jessica C. PayneMurphy has been approved for the Clinical Health Psychology Program by Kevin S. Masters, Chair Abbie O. Beacham, Advisor David Albeck Kristin M. Kilbourn Shandra Brown Levey July 21 2015

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iii Payne Murphy, Jessica C. (Ph.D., Clinical Health Psychology Program) Acceptancebased F actors in Chronic Pain: A Comparison Between F ibromyalgia and C hronic Pain Patients in an Internet Support Group S ample Thesis directed by Associate Professor Abbie O. Beacham ABSTRACT Fibromyalgia Syndrome (FM) is a chronic pain syndrome that is a challenging, enigmatic, and costly condition for patients and the healthcare system. Higher levels of psychological symptomatology are particularly prevalent in this population. Despite resear ch efforts, FM continues to be poorly understood and treatments have not been found to be wholly effective. Acceptance and Commitment Therapy based studies have shown promising findings in reducing painrelated functional impairment in chronic pain and FM samples by targeting Acceptance of pain and by utilizing Mindfulness techniques. To better examine the mechanisms that contribute to greater psychopathology and disability, the study proposes to examine Acceptance, Experiential Avoidance, Mindfulness and P erceived Disability in FM and a comparison group of chronic pain (CP), in online support groups. This study aim ed to examine cluster analyses for each sample (FM vs. CP) by levels of Acceptance. Subsequently, a series of ANCOVAs were conducted to examine overall group differences. Findings suggest significant main effects of Acceptance levels on Mindfulness, Experiential Avoidance and Perceived Disability for both FM and CP patients. Additionally, a significant interaction effect was found between Acceptanc e level, pain type (FM and CP) and Perceived Disability, F (2, 440) = 12.96, p < .01. These findings indicate that with increasing leve ls of Acceptance, CP patients perceptions of their own disability decrease concordantly; however, FM patient s perception decreases only slightly in comparison, thereby continuing to perceive themselves as disabled in various life domains. Given these findings as well as prior empirical evidence, further investigation is needed to fully address the factors contrib uting to Perceived Disability among FM patients and why this differs from those

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iv with CP. Results also indicate that both Perceived Disability and Acceptance of Pain are key treatment targets to improve existing multidimensional pain interventions for persons with FM. The form and content of this abstract are approved. I recommend its publication. Approved: Abbie O. Beacham

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v ACKNOWLEDGEMENTS Special thanks to the University of Colorado School of Medicine Department of Family Medicine for their generous funding grants ; to my advisor Dr. Abbie Beacham at Xavier University; to Dr. Michael Marsiske, PhD at the University of Florida Department of Clinical and Health Psychology for his assistance with statistical analyses; and the following members of the University of Colorado Denver Health Psychology in Primary Care Lab: Dana Brown, M.A., Jessica Geller, M.S., and Carissa Kinman, M.A.

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vi TABLE OF CONTENTS CHAPTER I. INTRODUCTION................................................................................................................ 1 II. REVIEW OF THE LITERATURE...................................................................................... 3 Fibromyalgia Syndrome ............................................................................... .................... 3 Etiology of Fibromyalgia ................................................................................................. 3 Prevalence, Psychological Correlates, and Current Treatments for Fibromyalgia..................................................................................................................... 4 Fibromyalgia Prevalence and Treatment Costs.................................................... 4 Psychological Correlates of Fibromyalgia......................................................................... 5 Trauma and PTSD in Fibromyalgia...................................................................... 6 Functional and Work Disability in Fibromyal gia................................................. 7 Psychosocial Determinants of Perceived Disability ............................................. 8 Treatment Approaches for Fibromyalgia................................................................ .......... 10 Pharmacological Treatments................................................................................ 10 Multicomponent Treatments ................................................................................ 11 Psychosocial Treatment Approaches for Fibromyalgia............................................ ........ 13 Operant Behavioral Therapy ................ 13 Cognitive and C ognitive beha vioral Therapy.. .... 15 Acceptance and Commitment Therapy for Fibromyalgia and Chronic Pain.................. .................................................................................................... 20 Chronic Pain Acceptance..................................................................................... 23 Experiential Avoidance and Fibromyalgia.................................................... .............. ..... 25 The Role of Mindfulness .......................................................................................... ........ 30 Profiling Pain and Fibromyalgia Patients to Improve Treatment Efficacy.... ... 36 Profiling Fibromyalgia and Chronic Pain Patients: Acceptance Based Approaches....................................................................................................................... 38

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vii Purpose of the Present Study............................................................................................ 40 Study Hypotheses...................................................................................... ............ ........... 41 III. METHOD............................................................................................................................ 43 Participants...................................................................................................... .................. 43 Materials and Procedures.......................................................................................... ........ 44 Independent Variable Measures ........................................................................................ 45 Demographics and Medical History. ................................................................... 45 Chronic Pain Acceptance. .................................................................................... 45 Post Traumatic Stress Disorder Checklist.. ......................................................... 46 Dependent Variable Measures. ......................................................................................... 47 Acceptance and Action........................................................................................ 47 Five Facet Mindfulness Questionnaire. ............................................................... 47 Pain Disability Index............................ ............................................................... 48 Data Analysis........................................ ............................................................................ 49 Selection of Covariates....... ............................................................... .................. 50 IV RESULTS.......................................................................................................... ................. 52 Recruitment Accrual and Attrition ......................... .................................................. ........ 52 Demographic Characteristics of the Participant Sample............................... ................... 53 Pain Characteristics of the Participant Sample................................................................. 55 Hypothesis One............................................................................................. .................... 56 Hypothesis Two................................................................................................................ 58 Hypothesis Three .............................................................................................................. 5 9 Hypothesis Four ................................................................................................................ 65 Supplemental Analyses..................................................................................................... 66 Interaction Effect Correlations ............................................................................. 64 Multiple Imputation Analyses....................................... .............................. ........ 67

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viii ANCOVA Replication Using Imputed Dataset................................................... 68 V DISCUSSION ...................................................................................................................... 72 Sample Characteristics....................................................................... ............................... 73 Representativeness of the Participant Sample.................................... .............................. 74 Hypothesis One................................................................................................................. 75 Hypothesis Two................................................................................................................ 78 Hypothesis Three .............................................................................................................. 79 Mindfulness 80 Experiential Avoidance.... 81 Perceived Disability. 83 The Role of Trauma. 84 Hypothesis Four ........................................................................................................................... 85 Supplemental Analyses............................................................................................ .... ..... 88 Limi tations................................................................................................................... ..... 89 Future Directions.......................................................... ................................ .................... 91 Clinical Utility ..................................................................................................... 92 Summary and Conclusions ............................................................................................... 93 REFERENCES............................................................................................................................. 95 APPENDIX.................................................................................................................................. 124 A. Group Moderator Invitation to Post Study................................................................ 124 B. Group Member Invitation to Participat e .............. ................................................. 125 C. Informed Postcard Consen t ............................................................... 126 D Gift Card Incentive Lottery ............................................................... 128 E Additional Items for Chronic Low Back Pain Third Recruitment Wave...... 129 F. Chronic Pain Acceptance Questionnaire (CPAQ)..................................................... 130

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ix G PTSD Chec k list Civ i lian Version .......................................................................... 131 H Acceptance and Action Questionnaire (AAQ II) ................................... .................. 133 I Five Facet Mindfulness QuestionnaireShort Form ............................................. ..... 134 J. Pain Disability Index.................................................................................................. 136

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x LIST OF TABLES TABLE 1. Demographic Characteristics of Sample by Data Collection Source........... ............................. 54 2. Pain Characteristics of Sample by Data Collection Source....................................................... 57 3. CPAQ Mean Scores by Clust er Fibromyalgia Sample......................................................... 57 4. CPAQ Mean Score by Pain Type and Tertile............................................................................ 58 5. CPAQ Mean Scores by Cluster Chronic Pain Sa mple............................................................ 59 6. Analysis of Covariance of Mindfulness by Pain Type and Acceptance Tertile........................ 60 7. Adjusted and Unadjusted Mean Mindfulness by Acceptance Tertile and Pain Type............... 61 8. Analysis of Covariance of Experiential Avoidance by Pain Type and Acceptance Tertile..................................................................................................................................... 62 9. Ad justed and Unadjusted Mean Experiential Avoidance by Acceptance Tertile and Pain Type........................................................................................................................ 63 10. Analysis of Covariance of Perceived Disability by Pain Type and Acceptance Tertile ...................................................................................................................................... 64 11. Adjusted and Unadjusted Mean Perceived Disability by Accep tance Tertile and Pain Type........................................................................................................................ 64 12. Logistic Regression Predicting Likelihood of Survey Non Completion ................................. 68 13. Comparison of Mean Mindfulness for NonImputed vs. Imputed Datasets ............................ 69 14. Comparison of Mean Experiential Avoidance for NonImputed vs. Imputed Dataset.................................................................................................................................... 70 15. Comparison of Mean Perceived Disability for Non Imputed vs. Imputed Dataset.................................................................................................................................... 71

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xi LIST OF FIGURES FIGURE 1. ACT Hexaflex ... 23 2. Participant Attrition and Survey Completio n....... 52 3. Adjusted Means for Mindfulness by Acceptance Tertile and Pain Type. ........ 61 4. Adjusted Means for Experiential Avoidance by A cceptance Terti le and Pain Type........ ... 63 5. Adjusted Means for Perceived Disability by Acceptance Tertile and Pain Type I .............. 65 6. Adjusted Means for Perceived Disability by A cceptance Tertile and Pain Type II ......... 66 7. Adjusted Means for Mindfulness by Acceptance Tertile and Pain Type Using Imputed Dataset ...... 69 8. Adjusted Means for Experiential Avoidance by Acceptance Tertile and Pain Type Using Imputed Dataset ........ 70 9. Adjusted Means for Perceived Disability by Acceptance Tertile and Pain Type Using Imputed Dataset .......... 7 1

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1 CHAPTER I INTRODUCTION Chronic pain is a common and debilitating health concern that is a significant financial and emotional burden for an estimated 100 million Americans ( Institute of Medicine of the American Academies, [IOM] 2011) Chronic pain is defined as three months or more of pain without apparent biological value that has persisted beyond the normal tissue healing time ( International Association for the Study of Pain, 2011, p. 1) P revalence of chronic pain is an estimated 2025% of the worlds population and 1025% in the U.S. with more Americans managing chronic pain than diabetes, coronary heart disease, stroke, and cancer combined ( American Academy of Pain Management, 2013; Goldberg & McGee, 2011; National Centers for Health Statistics, 2006 ). The expense of chronic pain to the consumer and healthcare system is also consider able with an estimated $635 billion in litigation, compensation, healthcare, and lost productivity or an approximate cost of $2000 annually for every American (IOM, 2011). Chronic back pai n is the leading cause of disability in American adults under 45 years of age and l oss of daily activity and work productivity due to pain are common issues in this population. A 2003 study indicated that 13% of nearly 30,000 randomly sampled working Ameri cans missed productive work time due to pain conditions in a proscribed twoweek period ( National Centers for Health Statistics 2006; Stewart, Ricci, Chee, Morganstein, & Lipton, 2003) Disability compensation, healthcare costs opioid dependence, and lost work productivity are significant problems in chronic pain populations. The etiology, type, location and severity of pain vary greatly among those with chronic pain ; however, fibromyalgia is considered to be one of the most difficult to treat. Empirical evidence suggests those with fibr omyalgia have poorer outcomes across multiple life areas. When compared to other chronic pain conditions, fibromyalgia patients have higher rates of mental illness (Birtane, Uzunca, Ta tekin & Tuna, 2007); increased costs of care; greater loss of

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2 productiv ity (Boonen et al., 2007); and poorer quality of life (Wolfe, Michaud, Li & Katz, 2010). Fibromyalgia is relatively less common than other types of pain, as an estimated 2 3% of the U.S. population carries this diagnosis (Croft, 2002; Fillingham et. al, 2009; Gran, 2003). In contrast, lower back pain is the most common pain type (18%), followed by osteoarthritis (16%), rheumatoid arthritis (6%), and migraine headache (3%) according to a 2010 internet based study of nearly 11,000 Americans (Johannes, Le, Zh ou, Johnston, & Dworkin, 2010).

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3 CHAPTER II REVIEW OF THE LITERATURE Fibromyalgia Syndrome Fibromyalgia Syndrome (FM) is a chronic pain syndrome that is a challenging, enigmatic, and costly condition for patients and the healthcare system FM is defined by the American College of Rheumatology as widespread pain throughout the body, fatigue, waking unrefreshed, and /or cognitive symptoms c ontributing to an established symptom severity threshold that has been experienced for at least three months (Wolfe & H user 2011 ). In addition to a chronic dull, achy pain, FM patients frequently experie nce other distressing symptoms such as: sleep difficulties, headaches, balance disturbances, muscle spasms, tingling, numbness, bowel and bladder problems, depression, an xiety, fibro fog or other cognitive impairments, and many other s (Arnold et al., 2008, p. 5; Bennett, Jones, Turk, Russell, & Matallana, 2007 ). Etiology of Fibromyalgia In comparison to those with chronic pain i n which the location of pain is generall y limited to the site(s) of prior injury physiological symptom s in FM have greater variation and are thought to be from a different origin. Abnormal pain processing in the central nervous system, called central sensitization or spinal cord hyper reactivity, is believed to cause chronic widespread pain and some researchers believe this process may occur even in the absence of physical injury ( Marcus & Deodhar, 2008; Perrot, Dickenson, & Bennett 2008). Researchers believe that spinal cord brain communication is disrupted in those with FM such that pain signals are also amplified (Clauw, Arnold, & McCarberg, 2011); with studies now consistently showing significant hyperalgesia in those with FM when compared to controls (Clauw et al., 2011; Petersel, Dror, & C heung, 2011). Hyperalgesia, or heightened sensitivity to pain, contributes to lower pain tolerance an d higher pain severity ratings. T he chronic hyper stimulation of the hypothalamic pituitary axis t he autonomic nervous systems sympathetic response, is a nother

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4 predominant theory that attempts to explain pain, fatigue, and other flulike symptoms found in FM but not in other types of chronic pain with different etiologies (Mease, 2005). Lastly, a genetic predisposition is thought to underlie many cases of FM, with current theory suggesting trauma activates specific genes to cause symptom onset (Arnold et al., 2004). A person is eight and a half times more likely to have FM given a relative was diagnosed as well (Arnold et al., 2004). Results from a Swedi sh twin r egistry study ( N = 15,950) further suggest incidence is influenced by genetic variability: female monozygotic twins with fibromyalgia had a 0.29 concordance rate, whereas male monozygotic twins had a 0.14 concordance rate (Kato, Sullivan, Evengrd, & Pederson, 2006). Prevalence, Psychological Correlates, and Current Treatments for Fibromyalgia FM as a biopsychosocial condition in which both physiological and psychological symptoms contribute to a patient s experience These include perceptions of pain severity functional disa bility, and quality of life. When compared to those with rheumatoid arthritis osteoarthritis or chronic low back pain, fibromyalgia patients have poorer mental and physical health and social functioning, more frequent stressrelated increases in pain, and poorer overall quality of life ( Davis, Zautra, & Reich, 2001; Strombeck, Ekdahl, Manthorpe, Wikstrom, & Jacobsson, 2000 ; Verbunt, Pernot, & Smeets, 2008). Fibromyalgia Prevalence and Treatment Costs. Reports of FMs diagnost ic prevalence vary from worldwide estimates between 0.55.8% to 2 to 3% of adults in the United States and United King dom (Croft, 2002; Fillingham et al 2009; Gran, 2003). P revalence increases with age, peaki ng be tween the ages of 55 to 64, with w omen be ing diagnosed three times more often than men (Marcus & Deodhar, 2011; McNally, Matheson, & Bakowsky, 2006). Healthcare utilization and cost is significant with estimated expenditures of nearly $10,000 annually per FM patient in the U.S. ( Berger, Dukes, Martin, Edelsberg, & Oster, 2007). Costs of FM care are approximately two to three times that of matched nonFM patients (Berger et al., 2007; Lachaine,

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5 Beauchemin, & Landry, 2010; Thompson et al., 2011). In addition, t hose with more severe FM symptoms were estimated to accumulate an additiona l $2000 in costs over a four year period (Thompson et al., 2011 ). Results of a 2010 longitudinal study examining insurance reported utilization and treatment expenditures suggest highest costs occur six months pre and post diagnosis following an FM diagnosis, when with approximately $7000 in annual healthcare spending over a threeyear period (Sanchez et al., 2011) Most studies only include costs reimbursed to providers and patients deductibles and copayments; h owever, others estimate an additional $100$500 per month spent on over the counter medication (Bennett et al., 2007). Despite comparatively lower prevalence rates among chronic illnesses, FM contributes significant financial and time expense to patients and the healthcare system. Psychological Correlates of Fibromyalgia FM patients have some of the highest mental health comorbidity rates of all health conditions, with greater prevalence reported in FM patients than in the general population, other healthcare pat ients, and patients with most other chronic pain types. Wide discrepancies in mood disorder rates in FM have been published, with reported prevalence ranging from 20 to 80%, 23 to 69% with depression ( Fi etta, Fietta & Manganelli, 2007 ; Th ieme, Turk & Flor, 2004) and 13 to 63.8% with an anxiety disorder (Fietta et al., 2007). At its highest reported prevalence approximately 69% of FM patients seen in four tertiarycare centers ( N = 73) met criteria for any mood disorder within their lifetime, and 29% met cr iteria currently as measured by DSM IIIR SCID interview s (Epstein, et al., 1999). According to this same study, FM patients l ifetime and current diagnoses included : any psychiatric disorder (81% lifetime; 48% current); major depressive disorder (69; 23); any anxiety disorder (35; 27); simple phobia (17; 13), panic disorder (17; 9); and social phobia (7; 9) (Epstein, et al., 1999). Despite a lack of consensus of psychiatric prevalence as evidenced by a significant range reported in the literature, conserva tive estimates still remain higher than community rates. When compared to DSM V 12month prevalence

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6 population estimates the numbers are significantly low er : major depressive disorder (7 %); specific phobia (79% ); panic disorder (2 3%); and social anxiety disorder (7 % ) (American Psychiatric Associati on, 2013). Diagnostic rates are also higher in FM than in those with other healthcare patients, notably those with other rheumatic conditions. Compared to healthcare patients without FM (approximate N = 52,000), FM patients (approximate N = 2,600) were 2.9 to 3.6 times more likely to carry a diagnosis of depression or anxiety (Weir et al., 2006). FM patients ( n = 2733) had the highest prevalence rates of depression, anxiety and substance abuse in a large study with other patients with rheumatic diseases (i.e. lupus, rheumatoid arthritis, and noninflammatory rheumatic disorders), almost double that of rheumatoid and noninflammatory rheumatic disorders (Wolfe et al., 2010). Psychological correlates must be targeted in current FM treatments in order to fully address the range of presenting symptomatology. Trauma and PTSD in Fibromyalgia. In addition to mood disorders, f indings also suggest higher self reports of adult or childhood victimization or traum a in FM pat ients Studies report 31.3 to 57 % of those with FM endor sed trauma histories and/or symptoms of PTSD ( Bennett et al., 2007; Cohen et al., 2002; Sherman, Turk & Okifuji, 2000) In the first study to rigorously evaluate PTSD symptoms in FM, 57% of 77 FM pati ents endorsed clinically significant levels of symptoms including hyperarousal, and reexperiencing and avoidance of the fearful experience (Cohen et al., 2002 ). More recently, an I nternet study of over 2,500 FM patients showed that 31.3% of participants re ported emotional trauma as an event that triggered their FM symptom onset, only second to chronic stress (41.9%) (Bennett et al., 2007). A mong types of trauma and life stressors, only physical and sexual assault/abuse (ORs = 1.38 and 1.41, respectively), w ere significantly more likely to occur in FM patients ( n = 341), but not emotional abuse/neglect, life threatening trauma, or significant life stressors such as serious illness, death of a child, or homelessness in another study ( Haviland, Morton, Oda, & F raser, 2010). A 2005 meta

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7 analyses showed moderate effect sizes, on average, indicating significant relationships between abuse/ neglect history and pain in both FM and CP patients across all nine reviewed studies ( Davis, Luecken, & Zautra, 2005). FM patie nts report more trauma histories compared to those with ot her chronic illnesses as well as healthy people Several studies indicate trauma histories or PTSD symptoms to be 3.1 times more common in those with FM than healthy controls (Ciccone, Elliott, Cha ndler, Nayak, Raphael, 2005; Raphael, Janal, & Nayak, 2004) The finding that abuse/neglect prevalence was significantly great er than healthy individuals was reported in Davis, Luecken, and Zautras 2005 study, and again suggests a correlation between abuse/trauma and pain in later life. When compared to patients with multiple sclerosis and rheumatoid arthritis ( N = 147 ) those with FM showed significantly higher rates of physical and emotional abuse and neglect, with many reporting a history of long term v ictimization (Van Houdenhove et al. 2001) Furthermore, those with PTSD symptomatology endorse significantly higher scores on pain intensity, perceived disability, interference of pain in life activities, depressive symptomatology, a nd overall affective distress (Sherman, Turk & Okifuji, 2000). Coping styles of FM patients with PTSD also differ from nonPTSD FM patients such that they rely more on suppression to regulate their emotions ( p > .02) (Ablin, Cohen, Neumann, Kaplan, & Buskila, 2008). Despite h igher comorbidity of trauma/abuse histories in those with FM, surprisingly few FM interventions exist to address processing o f traumatic experiences, psycho education around PTSD and traumas effect on pain, or suppression or avoidant coping styles (Leserman, 2005; Lumley, 2011). Given high prevalence rates, trauma history and current PTSD symptomatology are critical factors when examining affective processes and behaviors in FM. Specifically, associations among PTSD symptoms and expression must be assessed when designing treatment approaches F or this reason, symptoms of PTSD are assessed in the current study. Functional and Work Disability in Fibromyalgia The persistent pain, fatigue, sleep

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8 difficulties and other noxious symptoms of FM frequently interfer e with life activities, including occupational and other areas of functioning. Functional disability is a serious concern in FM: a n estimated 25 50% of FM patients report significant work disabili ty (Henriks son, Liedberg, & Gerdle 2005; Liedberg & Henri k s son, 2002 ) and those who are employed express worries about losing their jobs ( Bennett et al., 2007). In a large Internet study of FM patients ( N = 2596), approximately half believed their symptoms prevented them from seeking gainful employment and those who did work had more sick days, reduced hours and worried about their product ivity (Bennett et al., 2007). Additionally, 46.8% of 136 FM patients said they lost their job s due to their condition vs. 14.1% of control participants ( n = 152) with other chronic diseases (Al A llaf, 2007) Pain, fatigue, muscle weakness and difficulties with memory and concentration are the most frequently reported symptoms interfering with work activities according to a review of 21 studie s of women with FM (Henriksson et al., 2005). Studies suggest that these symptoms appear to be more debilitating in patients with FM, when compared to other patients who have chronic medical diseases without the presence of FM. Compared to those with rheumatoid arthritis and osteoarthritis, stu dies suggest similar to worse functional abilities in FM patients ( Hawley & Wolfe, 1991; Walker et al., 1997; White, Harth, & Teasell, 1995). This may be contributed by FM patients frequent reports of high pain severity, widespread pain, sleep difficulties, greater psychological distress, and poorer copi ng and sense of control (Walker et al., 1997 ; White et al. 1995). Comparisons among patients with FM, rheumatoid arthritis, osteoarthritis, scleroderma or systemic lupus erythematosus ( N = 602) also show F M participants had the highest levels of functional impairment, highest pain severity, most learned helplessness, and poorest overall subjective health status ( Callahan 1989). Psychosocial Determinants of Perceived Disability. Psychosocial factors play a n essential role in FM disability across various conceptualizations of disability found in the

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9 literature. These largely include observable physical limitations, limitations in activities of daily living (ADLs), and/or receipt of disability payments or wor kers compensation. Measuring functional disability in FM patients, defined as the patterns of behavior arising from the loss or reduction of ability to perform expected or specified social role activities, continues to be a challenge for providers trying to assess functional status for work disability claims (Mannerkorpi & Ekdahl, 2007, p. 4; Verbrugge & Jette, 1994). Research suggests perception of ones own disability is complex and, as stated previously, relies heavily on psychosocial influences. Perce ived disability is a subjective account of the degree of impairment patients have due to their pain within a range of voluntary and obligatory life activities (Fordyce et al., 1984; Tait, Chibnall, & Krause, 1990). Because chronic pain is one of the primar y symptoms of FM, it stands to reason that studies examining the limiting effects of chronic pain would lend understanding to FM perceived disability as well. Therefore, studies looking closely at the processes of perceived disability within both FM and CP populations are discussed herein. Multiple findings indicate predictors of higher perceived disability in FM include low self efficacy, catastrophizing, fear of pain, and subsequent avoidance of activities for fear of exacerbating pain (Dobkin et al., 2010; Karsdorp & Vlaeyen, 2009 ; Martin et al., 1996; Severeijns, Vlaeyen, van den Hout, & Weber, 2001 ; Turk, Robinson, & Burwinkle, 2004). Several studies suggest depression and emotional trauma contribute to higher perceived disability as well (Aaron et al., 1997 ; Turk et al. 2004). Similarly, chronic pain studies suggest that fear of pain, fear avoidance, lower self efficacy, and depression contribute to both higher perceived and actual disability (Crombez, Vlaeyen, Heuts, & Lysens, 1999; Denison, Asenlo f, & Lindberg, 2004; Geisser, Haig, & Theisen, 2000, Swinkels Meewisse, Roelofs, Oostendorp, Verbeek, & Vlaeyen, 2006; Waddell, Newton, Henderson, Somerville, & Main, 1993). Surprisingly, fear of pain is a stronger predictor of higher perceived disability than actu al functional ability (Crombez

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10 et al. 1999; Waddell et al., 1993). Additionally, higher pain intensity ratings correlate with higher perceived disability, but not disability objectively rated by observers (Alschuler, Theisen Goodvich, Haig, & Gei sser, 2008). Findings suggest strong psychosocial determinants of both perceived and actual physical disability in FM and CP samples, with apparently similar processes affecting perceived physical limitations Treatment Approaches for Fibromyalgia Fibromya lgia, as well as other types of CP is considered a biopsychosocial condition that require s dynamic and multidimensional treatment approaches Although a cure does not exist for FM, interventions that primarily target pain, mood, sleep, fatigue, functional status, and quality of life are known to mitigate symptom severity ( Huser et al ., 2009a). The use of one type of therapy specifically medication, however, is the most common and widely avail able treatment option. Pharmacological and multicomponent inter ventions are briefly reviewed here, followed by psychosocial therapies Pharmacological Treatment s C ommonly prescribed medications for a range of FM symptoms may only have up to 3050% eff icacy within short term periods; long term data are lacking ( Abele s, Solitar, Pillinger, & Abeles 2008; Arnold, Keck, & Welge, 2000; Marcus & Deodhar, 2008). Treatment targets of FM medications are primarily limited to pain, sleep, fatigue, and depressed mood. Amitriptyline, a tricyclic antidepressant, serotonin and nor epinephrine reuptake inhibitors ( SNRIs) and selective serotonin reuptake inhibitors (SSRIs) are thought to act on the central nervous system by increasing serotonin and norepinephrine, thereby reduc[ing] pain signaling in those with FM (Abeles et al., 2008 p. 556). Notably, amitriptyline is widely published as being one of the more effective FM treatments for pain, sleep and fatigue, specifically, with some of the largest effect and sample sizes reported (Arnold et al., 2000; Huser et al., 2009b). D ulo xetine, an SNRI that targets depressed mood, pain and sleep symptoms is also touted as one of the more effective medications (Arnold et al., 2000; Huser et al., 2009b). A

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11 2008 systematic review and 2009 meta analysis including 18 randomized control studi es with 1427 FM patients over an average of 8 weeks also su ggest small effect sizes attributed to SNRIs fluoxetine and milnacipran for pain, sleep, depression and quality of life ( Huser et al., 2009b; Uceyler, Huser & Sommer, 2008). Antiepileptics (for painrelieving effects) analgesics such as nonsteroidal anti inflammatories, muscle relaxants for pain and sleep, and sedative hypnotics for sleep, are also commonly prescribed or used for FM symptoms, with reported varying efficacy ( Goldenberg, Burckhardt, & Crofford, 2004; Mease, Dundon, & Sarzi Puttini, 2011) Non adherence to medication is a comm on occurrence in FM samples and higher psychological distress (Dobkin, Sita, & Sewitch, 2006) and provider patient discordance (Sewitch et al., 2004) are repo rted ly determinants In addition, a mong 2,569 FM patients polled, 27% reported medication side effects worsened their FM symptoms (Bennett et al., 2007). These deterrents to medication use and the need for patients to maintain treatment efficacy with long term use, contribute to only short term efficacy in mitigating the impact of chronic symptoms, furthering the need for nonpharmacological interventions ( Marcus, 2009; v an Koulil, et al., 2007). Multicomponent Treatment s Multicomponent a pproaches using m edications, exercise and psychosocial treatments are also prescribed to man age FM symptoms. Although small effect sizes are seen in studies combining exercise, medications, and psychological or other nonpharmacological interventions, these findings too sugg est FM treatment approaches continue to evolve in efforts to maximize treatment outcomes ( Huser et al., 2009a) Medications, aerobic exercise, cognitive behavioral treatment (CBT) and multicomponent treatments (one educational or psychological therapy a nd one exercise component) are the front runners for the most effective therapies for FM that show short term improvements in pain, fatigue, sleep, mood, and quality of life ( Huser et al., 2009a). Although longitudinal research is still needed in this are a, both the 2001 and 2005 ( the American Pain Society (APS) and the Association of the Scientific Medical

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12 Societies in Germany (AWMF)) international guidelines for FM treatment suggest aerobic exercise, CBT, amitriptyline and multicomponent therapies produc e the best outcomes according to evidencebased studies ( Huser et al., 2010b). A 2007 Cochrane review of 47 exercise interventions for fibromyalgia suggested the optimal routine includes at least 20 minutes of aerobic exercise, which may be divided int o two separate 10 minute sets, two to three days a week (Busch et al., 2007; Huser et al., 2010a ). Authors advise heart rate must be gradually increased to a moderate intensity level as to not exacerbate symptoms. Researchers also suggest s trengthening exercises should be completed two to three times per week for eight to tw elve repetitions each set. Lastly, emphasis is placed on graduated increase s of intensity to prevent setbacks and nonadherence (Abeles et al., 2008). Findings indicate that exercise at this intensity significantly improves general health and physical function but not pain, whereas strengthening exercises improve pain, mood, and general health but not physical function (Busch et al., 2007). In Huser et al.s ( 2009a ) meta analysis of ni ne randomized control trials of multicomponent therapies using aerobic exercise and CBT or education for FM ( n = 700), significant improvements with small effects were found at post treatment in pain reduction, depressed mood, fatigue, self efficacy, and f itness. However, effects were not maintained at three to four mont hs or at six to twelve months. Authors suggest lack of long term improvements may be due to unknown exercise intensity ratings, unpublished specifics of the CBT and education components, and the short duration of therapies: all were completed between 18 and 46 hours (median = 24). One chronic back pai n multicomponent intervention suggest s that longter m change is only maintained at greater than 100 hours of treatment ( Huser et al., 2009a). M ost recently, van Koulil et al.s 2010 randomiz ed control treatment including greater than 100 hours of exercise and CBT showed significant improvements with overall large effect sizes in pain, fatigue, negative mood, anxiety, and functional disability at both at post treatm ent and at 6

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13 months ( n = 158). Psychosocial Treatment Approaches for Fibromyalgia Multicomponent therapies show much promise in addressing the complex symptom presentation of FM patients; however, e fficacious psychosocial approaches, whether combined with exercise or other mo dalities, require further evaluation T he most widely studied and effective FM psychosocial treatments are reviewed here. Operant Behavioral T herapy. Operant b ehavioral t herapy is one of the leading approach es to F M and CP symptom management. This model is based on the Operant Learning Theory of Pain developed by Wilbert Fordyce in the 1970s (Fordyce, 1976). The concept of pain behaviors is integral in this theory, suggest ing that those with CP and FM display pa rticular behaviors when they are in pain such as avoiding activities, exercise or interactions with others to communicate the existence of pain to others This behavior may temporarily decrease suffering but invariably maintain s pain levels and lower s qual ity of life over time. These behaviors are shaped by consequences, and are therefore subject to reinforcement (Turk & Rudy, 1986, p. 761). Operant behavioral treatment specifically targets pain behaviors and works to change the antecedents and consequences of the behavior to modify or shape them to be more assertive and healthy (Thieme & Gracely, 2009). Three components are necessary for operant therapy to be effective: 1) identify the behavior; 2) decide on the types of reinforcers that would be most beneficial; and 3) est ablish enough control over the patients environment to shape behavior via consequences and schedules of reinforcement (Fordyce, Fowler, Lehmann, & DeLateur, 1968, p. 181). Common treatment targets include increasing physical activity an d reducing anxiety, healthcare utilization, and pain medication. Involving the patients significant other is also an important addition to properly shape t hese new conditioned responses. Operant behavioral therapy r esearch for FM suggests significant imp rovements in several key FM symptoms: physical functioning pain behaviors, and healthcareseeking behavior

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14 (Thieme, Flo r, & Turk, 2006; Thieme, Gromnica Ihle, & Flor, 2003; Thieme, Turk, & Flor, 2007). Findings from Thieme, Gromnica Ihle, & Flors 2003 st udy showed reductions in these areas as well as pain intensity; affective distress; interference of pain in family, work and leisure medication use ; and solicitous spouse behavior, or the partners att ention to the patients pain; in addition to increased sleep time; life control; and self efficacy; at 15 month follow up. FM inpatient participants randomized to the operant behavior group ( n = 40 ) received time contingent schedules of medication use; increase in p hysical activity, training in assertive pai n incompatible behavior, and activities and training aimed to decrease pain behaviors and interference of pai n in lifes activities (p. 316 ). In contrast, the FM inpatients randomized to the physical therapy group ( n = 21) received antidepressants as well as seven different types of physical therapy exercises (e.g. mud baths, muscle relaxation, etc.) that were described as usually applied in this type of clinic setting in Germany (p. 316). Although the limitation of no control group was discussed, r esult s across these previously listed variables measured by the Multidimensional Pain Inventory (MPI) showed greater improvements in the operant groups vs. physical therapy as evidenced by a series of repeated measures ANOVAs. In particular, the highest effect sizes were found in the operant group for pain intensity ( ES = 2.14), interference ( ES = 2.50), life control ( ES = 1.39), affective distress ( ES = 1.74), and self efficacy ( ES = 1.89) all from baseline to 15month post treatment. In a follow up r andomize d control study comparing operant behavioral treatment ( n = 43), cognitive behavioral therapy ( n = 42), and an attentioncontrol group ( n = 40), operant behavioral treatment was also found to show promising results (Thieme et al., 2006 ; Thieme et al., 2007). Specifically, patients attended 15 weekly 2 hour sessions that were led by both a psychologist and rheumatologist. Groups were limited to five patients each and spouses were asked at attend at the first, fifth, ninth and 13th sessions. The manualized pr otocol emphasized self recognition of pain behaviors, followed by contingent positive reinforcement of nonpain

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15 behavior and punishment of pain behaviors both practiced in the group and at home Video feedback and roleplaying was employed, as well as structured reduction of medication use and increases in physical activity. At six month follow up, c lin ically significant decreases in pain intensity and affective distress in the operant behavioral group were reported, when compared to the attentioncontrol g roup. Sustained improvement in pain intensity was shown at twelve month follow up as well. However, more notable differences were reported in the cognitive behavioral group in affective distress, catastrophizing, and active cop ing such that these elements were targeted in these participants (Thieme et al., 2006, Thieme et al., 2007). These findings suggest that operant behavioral therapy is an effective tool to positively impact several important FM symptoms ( e.g., pain behaviors, physical functioning, and medical utilization) but is less effective in improving affective components or other symptoms such as sleep di fficulties, mood, and quality of life when compared to CBT Cognitive and C ognitive behavioral T herapy. Cognitive behavioral therapy (CBT; Beck, 1976) is the dominant therapeutic modality for a range of psychological and medical illness es, with over 325 studies published since 2006. CBT for chronic pain and FM essentially relies on three core concepts: 1) operant learning theory; 2) Melzack and Wa lls Gate Control Theory; and 3) changing dysfunctional thoughts and beliefs to produce both improvements in behavior and mood (Dozois & Dobson, 2001; Melzack & Wall, 1965 ; Thorn 2004 ) The Gate Control T heory suggests that neural structures in the dorsa l horn of the spinal cord act as gates that, w ith the influence of large nerve fibers, small nerve fibers, mood state and other cognitive factors, can modify the speed of pain signaling to and from the brain and thus modify perception and experience of pain (Melzack & Wall, 1965) Specifically, the theory suggests the following: 1) afferent nerve transmission relaying signals from painful or nonpainful stimuli are sent to the dorsal horn; 2) large nerve fiber transmissions to this site tend to inhibit p ain signaling in the

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16 substantia gelatinosa (therefore closing the gate) and small nerve fiber transmissions to this site tend to facilitate signaling (or open the gate); 3) a system of largediameter fast conducting nerve fibers send nerve impulses from the brain to this site influencing the opening or closing of the gate as well; and 4) when a threshold of T cells in the spinal cord is met, this signals the brain to activate a complex series of neural processes that determine response to and percepti on of the pain (Melzack, 1996; Wall, 1996). In effect, this multistep signaling mechanism suggests that past experiences and perception or thoughts of pain influence the experience of pain: negative perception leads to worse physical experience of pain an d vice versa. CBT for pain and FM aims to educate and train patients to recognize and reconceptualize both maladaptive cognitions and behaviors that serve to maintain their pain experience. Training patients to identify and change distorted thoughts and be liefs aids in reconceptualizing the patients experience and improves patterns of thinking and mood over time Ca tastrophizing, or an exaggerated negative mental set brought to bear during painful experiences is recognized as a common maladaptive patt ern of thinking in chronic pain and FM (Sullivan et al., 2001, p. 52). Patients with CP or FM who catastrophize also tend to feel helpless about controlling their pain, ruminate about painful sensations, and expect bad outcomes (Thorn, Boothby, & Sulliva n, 2002, p. 128). Researchers whose work focuses on catastrophizing in CP and FM suggest that these thought patterns are correlated with increased disability, pain intensity, and depression and poorer pain tolerance and patient satisfaction with their hea lthcare provider ( Hassett, Cone, Patella, & Sigal 2000; Sever e ijns et al., 2001; Sullivan et al., 2001, Thorn et al., 2002; Thorn et al., 2004; Tsui et al., 2012). Functional MRI studies in FM samples also suggest greater catastrophic thinking activates b rain areas involved in pain processing such as those related to attention to pain, emotional aspects, and motor control ( Burgmer et al., 2011; Gracely et al., 2004). Interventions used to reduce catastrophizing and negative cognitions in FM and CP patients

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17 strongly emphasize realistic appraisal of ones thoughts, identifying pain beliefs, challenging and changing di storted thoughts and employing more adaptive techniques to meet personal goals (Thorn 2004 ; Thorn et al. 2002). Several CP and FM short term cognitive behavioral interventions that target catastrophizing and negative cognitions indicate improvements in these areas as well as in depressive symptoms ( Bennett et al., 1996; Creamer, Singh, Hochberg, & Berman, 2000; Jensen, Turner, & Romano, 1994 ; R odero, Garca Campayo, Casanueva Fernndez, & Sobradiel, 2008; Thorn et al., 2002). Oth er key elements of CBT for FM, specifically, are described here briefly. Education on the physical and psychological processes of FM is important to explain the interpla y of these two in establishing and maintaining the pain experience. Goal setting for social, physical and work activities helps to encourage healthy behaviors despite the presence of pain and other symptoms. Activity pacing serves to balance overdoing an d underdoing, a common cycle found in bot h CP and FM patients (Bennett & Nelson, 2006) In combination with other techniques, r elaxation training (e.g. diaphragmatic breathing and progre ssive muscle relaxation ) is suggested to improve a variety of sympto ms including sleep dysregulation (Glombieski et al., 2010) pain intensity ( Creamer et al., 2000) and catastrophizing (Vlaeyen et al., 1995) Assertiveness and communication training are taught to set personal boundaries around activity and help manage emo tions and healthy relationships with loved ones and healthcare providers (Bennett & Nelson, 2006; Thorn, 2004 ). Commonly, creative problem solving strategies are also taught to anticipate patients obstacles and to maintain treatment gains (Turk & Melzack, 2001). The therapist relies on operant learning techniques, positive and negative reinforcement, to shape and extinguish behaviors over time. Although CBT is a prevalent approach for FM symptom management, mixed empirical efficacy is reported across mult iple treatment targets Largely, CBT for FM meta analyses and reviews suggest CBT is currently the most effective psychosocial treatment administered with

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18 demonstrated advantages over other psychosocial modalities for short term pain reduction and self eff icacy ( Bernardy, Fber, Kllner & Huser 2010 ; Glombieski et al., 2010). However, studies show variable CBT efficacy across multiple FM treatment targets: mood, sleep, fatigue, functional status, and reduction of pain behaviors ( Bennett & Nelson 2006; B ernardy et al., 2010; v an Koulil et al., 2007). Bernardy et al. s 2010 meta analysis suggests that CBT reduced depression and increased self efficacy, but no differences were found for pain, sleep, fatigue and quality of life. Another 2010 meta analysis of 23 randomized control trials of psychological treatmen ts for FM found that CBT ( n studies = 8) was significantly better at improving shortterm pain intensity over other treatments with a medium effect size (Hedges g = .60) (Glombieski, et al., 2010) W hen combined with relaxation/biofeedback, CBT was also more effective for sleep than other modalities as well (Glombieski, et al., 2010). CBT was equally effective in reducing depressive symptoms when compared to relaxation, biofeedback, education, and eye movement desensitization and reprocessing (EMDR) and but no advantages were indicated for catastrophizing or functional status (Glombieski, et al. 2010) Similarly, Thieme and Gracelys 2009 review examining both CBT and operational behavioral therapies reported that those who received CBT experienced a 42 54% decrease in pain. N o other treatment targets were examined however Promising find ings were also reported in a 2004 FM treatment guideline and review: authors strongly recommended the use of CBT, a long with education, relaxation, or exercise (Goldenberg, et al., 2004) Other CBT reviews and studies urge further research is needed to find more effective FM treatments. A 2006 review of 13 CBT for FM studies found no treatment advantages f or CBT only when compared to education or exercise interventions (Bennett & N elson, 2006). Likewise, a 2007 review found the effects of CBT on pain, mood and disability to be limited and positive outcomes largel y disappear in the long term (v an Koulil et al., 2007 p. 571) Moderate support for CBT was suggested in a 2003 review, adding that treatment effects were higher when

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19 CBT was coupled with other modalities, such as physical activity, but could not be explained (Williams, 2003). Previous clinical studies sug gest that CBT is no t as effective for FM as it has been for other types of chronic pain conditions Moderate to large effects are reported on pain intensity, health related quality of life, and depression for CBT in chronic pain samples without FM (Hoffman Papas, Chatkoff, & Kerns 2007) and positive/active coping was increased as well ( Morley, et al., 1999). Additionally, multidisciplinary programs with CBT for CP without FM are suggested to be superior to other active treatments in producing improved workrelated outcomes at both short and long term follow up (Hoffman et al., 2007). Regarding FM studies, o ne commonly cited explanation for this mixed efficacy is the lack of a unified definiti on of CBT across many trials, making outcomes difficult to compar e (Bennett & Nelson, 2006; Hassett & Gevirtz, 2009). Often FM studies will include different durations and emphases on relaxation training, activity pacing, graded exercise, and/or mindfulness based therapy skills, a specific modality within relaxation. Fo r example, among eight CBT studies reviewed, three included Qi Gong, aerobic exercise or stretching and total intervention duratio n ranged from 2.75 to 42 hours (Glombieski, et al., 2010). O ther reasons for disagreement regarding CBT efficacy are variation in 1) treatment targe ts (given FM symptom complexity ) 2) methodological quality, and 3) consistency of measures used to monitor change over time ( Bernardy et al., 2010; Sim & Adams, 2002) Within 14 of the CBT studies reviewed by Bernardy et al. (2010), a range of 22 questionna ires were used to measure a median of seven treatment targets. In sum, both operant behavioral therapy and CBT continue to s how some promising outcomes for treatment of FM H owever, the inconsistency among all reviewed studies indi cates that the field has yet to find potent interventions to improve functional outcomes despite the considerable physical, cognitive and affective symptoms of FM. This need exists aside from the

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20 paucity of truly effective combinations of modalities that address FMs complex symptom presentation. Many studies suggest that given the heterogeneity of CP and FM patients symptomatology ; tailoring protocols to patients would greatly enhance efficacy as well ( Thieme et al. 2006; Turk, 2005; v an Koulil et al., 2007; Vlaeyen & Morley, 2005 ) In addition to tailoring, research advancements and perhaps a reconceptualization of FM are needed to improve interventions. Findings inform us that treatments that include active s trategies that engage behavior in those with FM are more effective treatment targets and better physiological and psychological outcomes. Nevertheless, i t may be possible that those patients who ha ve particularly complex symptom presentations would be more responsive to different approaches such as Acceptance and Commitment Therapy (ACT). Acceptance and Commitment Therapy for Fibromyalgia and Chronic Pain Acceptance and Commitment Therapy (ACT; Hayes, 1994) is a third wave behavioral therapy, which approaches relationships among cognitions, emotions, and behavior in a similar, yet fundamentally different way from CBT. ACT is referred to as a third wave therapy because it expands on behavioral theory and originated from Re lational Frame Theory which examines the relationship between cognition and language (Hayes, Barnes Holmes, & Roche, 2001). Relational Frame Theory explains that individuals develop operantly conditioned responses to stimuli that are not directly conditioned to those responses, but are somehow similar and therefore generalize to other, many times broader, contexts. These relationships can be directly observed in those with many types of CP including FM. A common cycle found in CP is avoiding tasks that may invoke more pain; however, as the negative experience of pain continue s, the range of activity becomes more and more limited for fear of reexperiencing the pain. For example, o ne may begin to avoid climbing stairs after this person noticed more pain the following day. This avoidance may then be generalized to walking certain distances and over time, i ncreasing activity restrictions that limit mobility, flexibility, and

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21 even positive social interactions, which contributes to further deconditioning, activity avoidance, and hence, worse pain and suffering Negative interpretatio n of the pain experience and of the patients sense of self also leads to justification for disengaging from adaptive and daily life activity in an effort to control or avoid painful experiences and thus mov[es] them away from healthy life functioning (McCracken & Eccleston, 2005, p. 164.) In sum, patients develop generalized conditioned responses to particular stimuli, whic h alter their behavior, limit their experiences, and u ltimately lead to poorer functioning. ACT suggests that positive change comes from not only having awareness of ones thoughts but also creat[ing] greater psychological flexibility by teaching skills that increase an individuals willingness to come into fuller contact with their experiences (Keng, Smoski & Robins, 2011, p. 7). ACT also emphasizes committing to personal values that produce actionbased outcomes and living the kind of life the person most deeply chooses to live ( Hayes & Duckworth, 2006, p. 186 ) There are six core therapeutic processes of ACT that work in concert with one another to reach the overall goal of psychological flexibility and creating a value based life while co existing with hardships (Harris, 2009; see Figure 1 ) Those with FM are forced to manage pain and many other bothersome symptoms on a daily basis; however, many manage to live a valued life by engaging in meaningful activities despite their pain and suffering. Psychological Flexibility is defined as the ability to contact the present moment more fully as a conscious human being, and based on what the situation affords, to change or persist in behavior in order to serve valued ends (Hayes & Strosahl, 2005; Luoma, Hayes, & Walser, 2007, p. 17). Psychological Flexibility can be accessed in part by the Contacting the Present Moment core process, which encourages individuals to be consciously connected to the present by redirect ing ones awareness back from the past or future. Self asContext then expands on this to reframe ones thinking to recognize the mind as two distinct entities: the observing and the thinking self. The observing self is thought to stay the same throughout life whereas the thinking

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22 self changes constantly with shifting thoughts, feelings, plans, and judgments. The goal of this process is to recognize oneself as an unchanging core being that has constantly changing and infinite thoug hts (Luoma et al., 2007) Defusion means to observe and detach from negative th oughts and memories and treat them dispassionately After defusing from a thought, an individual is less likely to perceive this thought as valid and true, thereby decreasi ng the believability, attachment and emotional connection to it (Luoma et al., 2007). Acceptance supports the goal of opening oneself up to all of the experiences of life, painful and joyful, as opposed to avoiding them, and Values helps individuals de fine what is of most value to them in their lives and are committed and worked towards in the Committed Action goal. Because it can be very challenging to detach personally attributed meanings from our own thoughts, an additional guideline is given to he lp break up this cognitive defusion or melding of thought and meaning: Creative H ope lessness. This is the ability to acknowledge that attempts to control thoughts and feelings are not only futile but can also be self destructive. This ability has also be en described as a stance of self validation that not only reminds the individual that it is not beneficial to continue struggling but also brings a wareness of the new possibilities that come from self validation ( Luoma et al. 2007, p. 29 ) A simple ex ample of this is a person who experiences chronic pain and who believes s/he is inc apable of doing many things s/he o nce enjoyed doing including those activities that are not realistically hindered by pain. These thoughts represent psychological inflexibi lity and lead to experiential avoidance, thus abandonment of certain activities and pushing away of thoughts. Acceptance of CP has been defined as living with pain without reaction, disapproval or attempts to avoid it (McCracken & Eccleston, 2003, p. 198.) Specifically, chronic pain Acceptance requires a disengagement from struggling with pain, a realistic approach to pain and painrelated circumstances, and an engagement in positive everyday activities (McCracken & Eccleston, 2003, p. 198.)

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23 Figure 1. ACT Hexaflex Reprinted from Learning ACT: An Acceptance and Commitment Therapy Skills Training Manual for Therapists (p. 12 ) by J. B. Luoma, S. C. Hayes, & R. D. Walser, 2007, Oakland, CA: New Harbinger Publications. Copyright 2007 by Jason B. Luoma, St even C. Hayes, and Robyn Walser. Chronic Pain Acceptance. C hronic pain Acceptance is comprised of two factors : Pain Willin gness and Activity Engagement. Several studies have found t he Chronic Pain Acceptance

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24 Questio nnaire ( Geiser 1992) to produce thi s two factor structure: Pain Willingness and Activity Engagement ( Vowles, McCracken, McLeod, & Eccleston, 2008) Pain Willingness is defined as ones degree of willingness to experience pain and related feelings and thoughts (McCracken & Eccleston, 2005). Of t hese items, several include My thoughts and feelings about pain must change before I can take important steps in my life, and Keeping my pain level under control takes first priority whenever Im doing something (McCracken, Vowles, & Eccleston, 2004, p. 165) Activity Engagement is ones degree of willingness to engage in lifes activities, despite the existence of pain (McCracken et al., 2004). The Activity Engagement items include Although things have changed, I am living a normal life despite my chronic pain, and When my pain increases, I can still take care of my responsibilities (McCracken et al., 2004, p. 165) ACT studies have demonstrated efficacy and effectiveness in improving the affective and functional outcomes of chronic pain, as w ell as other psychological conditions. Cross sectional, prospective, and intervention studies examining Acceptance and ACT suggest positive CP outcomes. Higher self ratings of Pain Willingness and Activity Engagement in chronic pain samples have been assoc iated with significantly lower levels of pain related anxiety, depressionrelated interference with functioning, and physical and psychosocial disability; and improved work status (McCracken & Eccleston, 2003) Increased Pain Willingness h as also been negatively associated with the number of pain medications (McCracken & Eccleston, 2005) Chronic pain i ntervention studies comparing ACT and t reatment as usual groups also suggest positive findings, with treatment effectiveness sustai ned over three month f ollow up. Si gnificant improvements were shown in psychosocial and physical disability depression, pain intensity, painrelated anxiety and the number of school and work absences and medical visits, ( Dahl, Wilson, & Nilsson, 2004; McCracken, et al., 2005; Vowles & McCracken, 2008; McCracken, MacKichan, & Eccleston, 2007). Veehof and authors 2011 meta analysis of seven ACT and 15 mindfulness based therapies suggest ACT interventions had a small effect (SMD =

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25 .32) on depression, and more generally, eff ects on anxiety, pain, physical functioning, and quality of life were reportedly similar to CBT intervention outcomes for chronic pain (Veehof, Oskam, Schreurs, & Bohlmeijer, 2011). The authors assert that although CBT continues to be the standard psychosocial treatment due to extensive empirical support Acceptancebased therapies offer a promising alternative to existing chronic pain management approaches Although only one ACT intervention has been conducted using a FM sample ( Wicksell et al., 2012), reductions in a range of psychosocial domains were found. In this randomized control trial, female FM patients ( n = 20) received 12 90minute weekly groups sessions of ACT using a standardized treatment protocol. The intervention taught the core processes of ACT and emphasized reengaging with past avoided situations, identifying core values, goal setting and expanding painrelationship repertoires. Compared to waitlist controls ( n = 16), patients who received ACT self reported improvements in perceived disabil ity, depression, anxiety, mental health quality of life, FM impact, and self efficacy at post treatment and three to four month follow up, with moderate to large effect sizes maintained at follow up. Pain intensity and physical quality of life were not sig nificantly improved, however Differences in self reports of psychological inflexibility to pain indicate this measure mediated the differences in all significantly changed variables, with the exception of mental health quality of life (Wicksell et al., 20 12) Taken together with these chronic pain studies, findings suggest that Acceptancebased approaches may offer good cli nical utility in treatment of FM and chronic pain Experiential Avoidance and Fibromyalgia It is posited here that Experiential A voidan ce is a significant factor that contributes to poorer affective and functional outcomes in those with FM Avoidance of unpleasant emotions, thoughts, images, or experiences has been well documented as contributing to greater emotional distress over time a cross many psychological disorders and theories (Chawla & Ostafin, 2007; Hayes, Wilson, Gifford, Follette, & Strosahl, 1996) One of t he earliest mentions can be found in

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26 psychodynamic and analytical psychology theories Both Freud and Jung conceptualized repression or the suppression of memories or thoughts in the unconscious, to be a key mechanism that contri butes to abnormal behavior (Freud, 1910 ; Jung, 1910 ). I n the case of behavioral and exposure based treatment for anxiety disorders, avoiding social situations or feared stimuli (e.g. spiders, elevators, or heights) decreases anxiety in the short term but exacerbates psychopatho logy in the long run (Barlow, Allen, & Choate, 2004). Likewise, using alcohol or drugs allows a person to temporarily avoid undesired emotions but over time can lead to substance abuse or dependence especially when the need to avoid, coupled with substance induced physiological changes in the body, is enhanced (Hayes et al. 1996) Many psychological interventions include avoidan ce as a key concept : dialectical behavior therapy (Linehan, 1993); avoidance coping (Penley, Tomaka, & Wiebe, 2002); and reappraisal (Lazarus, 1 991), to name a few (Chawla & Ostafin, 2007; Hayes et al., 1996). Similarly, Experiential A voidance is a process that serves to remove both undesirable external and internal experiences. Experiential Avoidance is defined as the phenomenon that occurs when a person is unwilling to remain in contact with particular private experiences (e.g. bodily sensations, emotions, thoughts, memories, behavioral predispositions) and takes steps to alter the form of frequency of these events and the contexts that occasion them ( Hayes et al., 1996, p. 1155). Hayes, credited for developing Relational Frame Theory and ACT, conceptual ized and coined this term within the framework of these two theories and it is primarily measured using the Action and Acceptance Questionnaire (AAQ ; Bond et al., 2011, see Methods section for full description) Experiential Avoidance is, in essence, the opposite of Acceptance, or the active and aware embrace of private events that are occasioned by our history, without unnecessary attempts to change their frequency or form, especially when doing so would cause psychological harm (Luoma et al., 2007, p. 1 7). Heightened levels of Experiential Avoidance are thought to contribute to the development of psychopathology over time in one or a combination

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27 of three ways: 1) avoidance of a thought, emotion or object paradoxically draws more a ttention to these phenom ena ; 2) classically conditioned avoidance behavior does not change significantly when verbal affirmations are tried; and 3) avoidance can have short term efficacy; however, those attempts often lead to other problems, like agoraphobia and/or general exacer bation of the initial avoided thought s and/or symptoms (Chawla & Ostafin, 2007; Hayes et al., 1996). Greater Experiential Avoidance contributes to both increased pain avoidance and the constellation of symptoms and psychopathology that are uniquely found i n FM. Both chronic pain and FM patients often use Experiential Avoidance as short term reme dies for reducing the impact of undesired experiences, particularly pain. Links between Experiential Avoidance to acute pain are found in healthy controls. For example, hea lthy controls with greater Experiential Avoidance who underwent a standardized cold pressor test (i.e. placing their hand in ice water) indicated significantly lower pain tolerance ( Feldner et al. 2006 ; Zettle et al., 2012; Zettle et al., 2005 ) tha n those with low Experiential Avoidance. These reported differences between high and low Experiential Avoidance occurred regardless of pain threshold at study outset, such that no significant differences were observed ( Feldner et al. 2006; Zettle et al., 2012; Zettle et al., 2005) Results also show that high Experiential Avoidance participants were more likely to use catastrophizing ( Zettle et al., 2012; Zettle et al., 2005) as a coping strategy during the acute pain event a maladaptive approach that has received much attention in the pain literature (Thorn et al., 2002) More broadly these studies show that perception of and reaction to pain predict pain tolerance and intensity Specifically, and not unlike the processes found in perceived disability, E xperiential Avoidance paradoxically contributes to greater pain perception despite the attempt to temporarily brace or avoid pain. Associations between mood, psychopathology, and Experiential Avoidance have also been found, with high Avoiders experiencing more affective distress ( Feldner, Zvolensky, Eifert, & Spira, 2003; Gird & Zettle, 2009; Karekla, Forsyth, & Kelly, 2004) Meta analyses results from

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28 27 studies suggest Experiential Avoidance predicted a variety of psychopathology and negative outcomes ( i.e. overall mental health, anxiety, depression, future work absences and performances), with a medium effect size ( r = .42) (Bond et al., 2011; Hayes, Luoma, Bond, Masuda, & Lillis, 2006). In a 2003 laboratory study examining Experiential Avoidance and Ac ceptance approaches in a stressinducing situation, healthy participants ( n = 48) with no history of anxiety disorder or panic received four inhalations of carbondioxide enriched air, provoking bodily sensations that are known to cause anxiety in normal populations. Half of the participants were instructed to simply observe their emotional state (Acceptance) and the other half were told to inhibit their aversive feelings ( Experiential Avoidance ). Those who scored high in Experiential Avoidance reported sig nificantly higher levels of anxiety an d affective distress, despite no differences in physiological arousal from the low group. S econdly, they experienced greater anxiety when attempting to suppres s their emotions in comparison to simply observing and accepting sensations (Feldner et al., 2003) Similar findings were reported in Karekla et al.s (2004) laboratory study, as well as a n addi tional study using dysphoric mood induction in healthy samples ( Gird & Zettle, 2009). Further investigation of Experiential Avoida nce and its contribution to psychopathology suggest s an additional dimension that is specific to FM : trauma. In a 2007 review of 28 studies examining associations among FM, psychopathology and Experiential Avoidance, factor analyses of Experiential Avoidance measures yielded two emerging factors: one in Experiential Avoidance and another in trauma (Chawla & Ostafin, 2007). Experiential Avoidance and the persistent effortful avoidance of distressing traumarelated stimuli after the event found in DSMV cri teria for PTSD, conceptually overlap (APA, 2013, p. 271 ) ; however, multiple studies show this relationshi p has not been clearly determined. Ten studies examining the predictive value of Experiential Avoidance on 1) the severity of traum a and posttraumatic disorder or its relationship to 2) history of child sexual abuse were

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29 discussed in this 2007 review. In general, four studies showed that Experiential Avoidance either predi cted PTSD symptoms severity and depression/ general psychologic al distress (Batten et al., 2002; Marx & Sloan, 2002; Plumb Orsillo, & Luterek, 2004); or mediated the relationship between trauma and PTSD (Orcutt, Pickett, & Pope, 2005) Four studies did not show Experiential Avoidance predicted trauma symptoms or severity, but did predic t psychological distress in those with trauma symptoms (Batten, 2001; Higgins, 2000; Polusny, Rosenthal, Aban, & Follette, 2004; Tull Gratz, Salters, & Roemer, 2004 ) Lastly, one study examining Experiential Avoidance in a sample of rape victims indicated Experiential Avoidance did not predict PTSD (Boeschen Koss, Figueredo, & Coan, 2001). R eview authors conjectured that inconsistencies in the psy chometric properties of the utilized measure may have clouded findings in this study (Chawla & Ostafin, 2007). Although there appear to be relationships among Experiential Avoidance, trauma history, and PTSD, these precise associations have yet to be illuminated. To date, very few studies measuring Experiential A voidance in FM have been published; however, evide nce of thi s process in this and other pain populations is reviewed herein. Pain fear avoidance, or the avoidance of movements or activities based on fear, is a well studied phenomenon in pain populations that is thought to contribute to the pattern of muscl e deconditioning leading to increased pain (Lethem, Slade, Troup, & Bentley, 1983; Vlaeyen & Linton, 2000, p. 317) Currently only one study has compared pain fear avoi dance and Experiential Avoidance and found the two constructs to be correlated with a moderate effect size ( p < .01 r = .39) in a sample of chronic pain outpatients ( n = 686) (Ramirez Maestre, Esteve, & Lopez Martinez, 2014). Also, c ompared to those with low levels of avoidance ( n = 214), FM patients with higher pain fear avoidance ( n = 145) self reported more functional disability, severe fatigue, worrying, hypervigilance, painrelated retreating and social patterns that reinforce fear of pain (van Koulil et al., 2008, p. 215). Likewise, comparisons made among levels of pain fear avoid ance and low back pain, heterogeneous pain conditions, and inflammatory bowel disease

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30 samples suggest that those with low back pain demonstrated the most consistent and significant relationships among Experiential Avoidance and pain fear avoidance, pain intensity and pain fear avoidance, and pain fear avoidance and negative mood ( Esteve & RamirezMaestre, 2013). Lastly, 31 of 38 (81.6%) FM patients self reported significantly higher Harm Avoidance scores than matched healthy controls in a study examining pe rsonality traits and temperament (Anderberg, Forsgren, Ekselius, Marteinsdottir, & Hallman, 1999). Those FM patients with a psychiatric diagnosis also scored higher on Harm Avoidance than those FM patients without such a diagnosis (Cloninger, Svrakic, & Pr zybeck, 1993). Despite the empirical evidence showing poorer affective and functional outcomes, only one study to date examine s Experiential A voidance in FM patient s. This 10week intervention applied exposure based treatment to directly confront avoidanc e behavior and help process traumatic memories (leading to relearning and symptom improvement) in FM patients with trauma symptoms (Lumley et al., 2008). Although only few were recruited ( n = 10) and fewer completed therapy ( n = 8), patients avoidance, hy perarousal, intrusions, life satisfaction and affective distress improved at three month follow up, wit h large effect sizes reported Small to m oderate effect sizes were also indicated for decreases in pain and disability. Overall, findings suggest Experiential Avoidance is an important predictor of n egative outcomes in FM patients, particularly its role in processes that lead to perceived disability and poor functional outcomes. Notably, the research shows that further work is needed to more fully identify and understand these processes. Given this gap in the literature, it is not surprising that c urrent interventions are limited in treating FM The Role of Mindfulness Mindfulness is also a key process in FM that has been associated with improve d levels of pain ( Grossman, Tiefenthaler Gilmer, Raysz & Kesper 2007), depres sion (Sephton et al., 2007), anxiety ( Grossman et al., 2007), perceived stress (Weissbecker et al., 2002) and global well being

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31 (Kaplan, Goldenberg & Galvin Nadeua, 1993) in those wi th FM. Positive chronic pain outcomes ( in patients without FM) from Mindfulness based studies have also been reported (Kabat Zinn et al., 1982; Randolph, Caldera, Tacone, & Greak, 1999), specifically in pain reduction and mood, and were maintained for up to 15 months (Kabat Zinn et al., 1985). Mindfulness is thought to benefit FM patients in several ways described here, particularly by attending to avoided stimuli, thus counteracting Experiential Avoidance. Despite discussed theoretical associations among Mindfuln ess, Experiential Avoidance, and ACT, empirical evidence of these precise relationships is scarce and mechanism s of action remain unknown. The current study aims to further explore Mindfulness role in FM symptom maintenance. Various de finitions of Mindfu lness exist with operationalizing mindfulness as a technique, sometimes as a more general method or collection of techniques, sometimes as a psychological process that can produce outcomes, and sometimes as an outcome in and of itself (Hayes & Wilson, 2 003). However, most definitions found in the literature focus on observation and nonjudgment of thoughts and internal experiences in the present moment to attain a sense of well being ( Block Lerner, SaltersPedneault, & Tull, 2005; Keng et al. 2011) Jon Kabat Zinn, PhD, the first researcher credited with empirically examining this process, offers a commonly cited definition Mindfulness includes paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally (Kabat Zinn, 1994, p. 4). Since the early 1980s, studying the effects or process of Mindfulness has primarily taken the form of Mindfulness B ased Stress Red uction (MBSR) interventions; however, the psychological state of Mindfulness has also received attention in the lit erature ( and will be a focus in the current study ) For purposes of fully understanding the underlying processes of this state, MBSR and study findings are first reviewed here. The practices within MBSR were derived from Buddhist tra dition, a specific sec t called Therava da Buddhism, of which mindfulness meditation plays a central role. This form of

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32 meditation emphasizes a detached observation from one moment to the next, of a constantly changing field of objects (Kabat Zinn et al., 1982, p. 34). This tra ining begins with focus on ones breath, followed by a gradual increasing awareness of other stimuli/ experiences with concurrent focused attention and absence of evaluation or judgment Maintaining this detached observation and a steady quieting of the min d is a challenging task: much practice is needed to develop this skill (Kabat Zinn et al., 1982) Eight to 10 weekly sessions of two to 2.5 hours each are offered as part of MBSR protocols (Baer et al., 2003; Keng et al., 2011) Hatha Yoga postures, body s can visualizations, and teachings/guidance are also included, discussion of participants experiences is encouraged, and outside practice of medit ation skills is required (Keng et al., 2011). Clinicians trained by Kabat Zinns group have led nearly all MBS R interventions that have been published. MBSR studies rating post intervention levels of trait mindfulness, measured by self report questionnaires, also indicate there are strong associations among acquired or trait Mindfulness and various medical symptom and affective states. Given promising results of MBSR it has gained increasing recognition as an adjunctive therapy for illness management (Baer et al., 2003 ; Keng et al., 2011) FM studies using MBSR show improved outcomes across a range of physical and affective symptoms. Results of the first published MBSR study using FM patients show 2550% of participants ( n = 77) were rated clinically improved and 1 9% showed marked improvement acro ss varying measures following a 10 week protocol: pain, sleep, fatigue, medical symptoms, coping strategies, and global well being (Kapl an et al, 1993, p. 288). Decreased affective distress and depression, but not improved functional disability or physical symptoms, were found in two more recent studies. FM patie nts ( N = 85) self reported improvements in perceived stress ( r = .64; p < .01) and depression ( r = .65; p < .01) but not in pain, sleep or physical functioning as reported by the Fibromyalgia Illness Questionnaire (FIQ; Burc khardt, Clark, & Bennett, 1991) aft er an eight week MBSR program (Weissbecker et al

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33 2002). A 2007 study also indicated significant reductions in somatic, cognitive and affective symptoms of depression (all ps < .01) following an eight week protocol However, FM patient s ( n = 42) FIQ sel f reports of function, sle ep and pain did not improve compared to an FM control group ( n = 33) (Sephton et al., 2007). A 2007 study did report s ignificant improvements in f unctional status, pain, sleep, and cognitive abilities, however, as well as depression, anxiety, a voidance, and general affect ( Grossman et al., 2007) These FM participants ( n = 39) improved both over time and these changes were greater compared to an FM control group ( n = 13). These changes wer e self reported following eight weeks of MBSR (effect sizes = 0.401.10) and were maintained at three month follow up (effect sizes = 0.500.65) ( Grossman et al., 2007). Reduced sympathetic arousal, as measured by psychophysiological recordings in a n FM sample ( n = 24 ), was also a notable finding after patients completed an eight week program (Lush et al., 2009). This suggests MBSR may help to dampen the chronic hyper stimulation of the autonomic nervous systems sympathetic response that has been found in FM patients thereby decreasing this wear and tear on the body and related symptoms (e.g. reduced orthostatic control) (Martnez Lavn, Hermosillo, Rosas, & Soto, 1998; Schmidt Wilcke & Clauw, 2011 ) Unfortunately, known methodological weaknesses (e.g. lack of control group, small sample sizes, h igh attrition ) across these FM and nonFM chronic pain studies limit the internal and external validity of these MBSR results (Baer et al., 2003). However, given the challenges of treating FM, these results indicate MBSR offers a promising adjunctive thera py to current modalities For CP and other symptoms of FM, s everal mechanisms of action of MBSR have been proposed. Electroencephalogram (EEG) r eadings taken at preand post e ight week MBSR training suggest there is more activation in brain regions that may be related to more adaptive functioning to negative life events and stress (Davidson et al ., 2003) A second finding from this study indicates those who completed the MBSR training ( n = 25) had better immune

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34 respons iveness to influenza antibodies, when compared to nonMBSR completers ( n = 16). By extension, this left side anterior activation and better immune functioning may then contribute to better coping with chronic pain and other noxious symptoms of FM as well as better resilience to outside infec tion and/or less symptom expression. Simple attention or exposure that is gained from steady observation is thought to aid in detachment from suffering when it is coupled with a nonjudgmental attitude (Baer et al., 2003; Keng et al., 2011). FM and CP pati ents often attribute negative emotions to their pain and symptoms; however, a practiced nonjudgmental patte rn of thinking contributes to desensitization to the attached emotional experience (Baer et al., 2003; Keng et al., 2011). In essence, suffering is r educed because the connection between the physical and resulting or remembered mental pain is diminished (Kabat Zinn, 1982). This continued openness or exposure to the pain experience, coupled with a nonjudgmental attitude, directly counteracts Experientia l Avoidance, thereby increasing acceptance of pain. Secondly, researchers posit that a general emotional reactivity is then also diminished through repeated unpairing of physical and affect experience (Keng et al., 2011). Other researchers refer to thi s learned process as reperceiving (Shapiro, Carlson, Astin, & Freedman, 2006). However, results following an eight week MBSR program did not show reperceiving mediated the relationship with Mindfulness and exposure, values clarification, self regulation, and cognitive and behavioral flexibility (Carmody, Baer, Lykins, & Olendzki, 2009). Reperceiving, when added to Mindfulness scores, did suggest that there are associations between these processes and exposure, values clarification, self regulation, and cognitive and behavioral flexibility. Although these relationships are not fully known, one theory is that the effect of reperceiving may broaden/then enhance ones ability to engage in a variety of coping responses (Baer et al., 2003, p. 129; Kabat Zinn e t al., 1982), as well as improve general behavioral self regulation (Chambers Gullone, & Allen, 2009). Lastly, relaxation benefits of MBSR and values

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35 clarification are thought to contribute to better outcomes as well, with the latter reinforcing behaviora l regulation (Baer et al., 2003). As previously discussed, empirical findings exploring the precise relationships and mechanisms of action between Mindfulness and Experiential Avoidance, and Mindfulness and Acceptance are minimal despite discussed theore tical associations ( Block Lerner et al., 2005; Mitmansgruber, Beck, Hfer, & Schler 2009). Furthermore, the conceptual relationship between the se three metacognitive processes has been debated, and often become complicated depending on whether Mindfulne ss is defined as a process (e.g ., due to the patients mindful state, his/her anxiety decreased) or the outcome of the process (e.g ., an overall increase in the patients ability to be mindful (or increased Acceptance) has increased his/ hers psychological flexibility) (Block Lerner et al., 2005). Several researchers have attempted to define and compare these phenomena. For example, it is suggested that Mindfulness named Contacting the Present Moment w i thi n the ACT nomenclature, is one of the six core p rocesses of ACT that work together to attain psychological flexibility (Luoma et al., 2007). However, some researchers have conceptualized the relationship between Mindfulness and ACT core processes to be closer to an amalgamation of contact with the present moment, defusion, acceptance, and the transcendent sense of self as opposed to the conceptualized self (Fletcher & Hayes, 2005, p. 321 ). Similarly, it is thought that Mindfulness aids in changing the nature of the Experiential Avoidance process, whi ch is conceptualized as the inverse of Acceptance (Block Lerner et al. 2005). Alternatively, it has been suggested that the Acceptance technique deliteralization strongly resembles the decentering technique found within Mindfulness ( Block Lerner et al ., 2005, p. 83). Results from a 2008 study also suggest that Experiential Avoidance and Mindfulness, according to the Mindfulness Attention Awareness Scale (MAAS; Brown & Ryan, 2003) were negatively correlated (Henke 2010; Jacobs, Kleen, De Groot, & A Tj ak, 2008) Given these empirical findings and theoretical

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36 discussions in the literature, it appears that both Mindfulness and Acceptance have conceptually similar underpinnings; however, there remains no consensus on the exact content of their overlap On ly one study to date examines these concepts within a fibromyalgia sample (Henke, 2010). These data show several subscales on a Mindfulness measure, the Five Facet Mindfulness Questionnaire (FFMQ; Baer, Smith, Hopkins, Krietemeyer, & Toney 2006) ; se e Meth ods for full description) correlate with the measure of Experiential Avoidance, the A cceptance and A ction Q uestionnaire (AAQ) : nonjudging and nonreacting to inner experience, describing, and act aware (Henke, 2010). However, these relationships, particular ly in FM and CP samples, are unknown. Given the promising results of these techniques, more research is needed to determine these relationships to better inform targeted FM treatments. Profiling Pain and Fibromyalgia Patients to Improve Treatment Efficacy Leaders in the field suggest it may be useful to group patients based on dimensions of CP patient characteri stics to create bett er interventions, instead of the current practice of tailoring treatments based on single physiologic al or psychological factors (Turk, 2005). This multidimensional grouping approach has been suggested due to the complexity of the pain experience and varied treatment response (Dworkin & LeResche, 1992; Turk & Rudy 1988). To date, only one grouping method based on cognitive, affect ive and behaviora l variables has been widely published: profiling using the West Haven Yale Multidimensional Pain Inventory (MPI; Kerns, Turk, & Rudy, 1985) The MPI measures intensity and impact of pain on work, social and other life activities in this population across twelve domains of functioning (Wehmer, 1990) and feelings of self control problem solving abilities and patients perceptions of themselves (Kerns, et al., 1985) Currently, it is the most commonly used method of grouping CP patients by their varying beliefs and behaviors. The MPI has been utilized to identify various biopsychosocial aspects of CP patients experiences given it s seven subscales (Turk & Rudy, 1988). The multidimensional scales include:

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37 1) pain severity and suffering; 2) perceptions of how pain interferes with their lives, including interference with family and marit al/couple functioning, and work, social and rec reational activities; 3) dissatisfaction with present levels of functioning in family relationships, marital/couple relationship, work and social life; 4) appraisals of support received from significant others; 5) perceived life control, incorporating perceived ability to solve problems and feelings of personal mastery and competence; 6) affective distress including depressed mood, irritability, and tension; and 7) activity levels (Turk & Melzack, 2001) Cluster analysis produces more concise conceptualiza tions of patients and groups them into three distinct profiles: Adaptive Copers, Dysfunctional and Interpersonally Di stressed (Turk & Rudy, 1988). Adaptive Coper patients report lower pain severity, lower interference with everyday life due to pain, lower levels of affective distress, higher degree of life control and a higher activity level. Conversely, high pain severity, marked interference, high affective distress, low perception of life control, and a low activity level characterize patients in t he Dysfunctional group. Interpersonally Distressed patients demonstrate lower reported levels of social support, lower scores on solicitous and distracting responses from significant others, and higher scores on punishing responses (Rudy, Turk, Zaki, & Curtin, 1989) Empirical support indicates these groups m ay predict outco mes for CP patients. Differences between the Adaptive Coper and Dysfunctional groups, specifically, show differences in work status, time spent in bed, use of pain medication, and affective distress and seeking help, with Dysfunctional pati ents using more pain medications and negative coping behaviors and demonstrating less active involvement in work and life activities (Turk & Melzack, 2001). Also, Dysfunctional groups showed greater treatment gains in pain intensity, depression, negative cognitions and perceived interference of pain symptoms than Adaptive Copers and Interpersonally Distressed Groups at six month follow up (Rudy, Turk, Kubinski, & Zaki, 1995). Clinical application of profiles for use in clinical conceptualization and tre atment has

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38 been sparse d e spite th eoretical advantages to profiling CP patients by psychosocial characteristics. G iven the se positive findings using the MPI and the complexity of CP conditions, finding new ways to characterize patients for purposes of tailoring effective treatment interven tions is a worthwhile pursuit. L eading CP researchers have suggested there is ample room for improvement in the efficacy of CBT in chronic pain; ther eby opening the door for additional approaches and interventions ( Vlaeyen & Morley, 2005, p. 4). New methods of profiling CP and FM patients based on key defining characteristics may inform t he development of more effective and tailored interventions for pain. Profiling Fibromyalgia and Chronic Pain Patients: AcceptanceBased Approaches Our unders tanding of the maintenance of CP and FM symptoms has been largely informed by behavioral, cognitive, cognitive behavioral and acceptancebased treatment approaches. Evolving intervention study designs continue to suggest there is heter ogeneity within CP samples such that different therapies work more effectively for different individuals (Turk, 2005). Tailoring treatment to particular characteristics CP patients may hold has been proposed to increase therapeutic gains (Costa & Pinto Gou veia, 2010; Vowles et al., 2008). In fact, profiling CP patients by identified characteristics, specifically those that are influential in promoting more positive outcomes, may improve the efficacy and effectiveness of b ehavioral, cognitive, cognitive beha vioral and acceptancebased treatment approaches. To date, there are no studies examining ways of grouping FM patients using the Acceptance construct H owever, there are three recent studies that found similar Accept ance based clusters emerge in CP samples. Cluster analysis findings using a CP specialty treatment outpatient sample ( N = 641) showed three distinct clusters: 1) both low Activities Engagement and Pain Willingness, 2) both high Activities Engagement and Pain Willingness, and 3) high Activities E ngagement and low Pain Willingness ( Vowles et al., 2008). S pecifically, this first, or Low Low group included respondents who self reported few, if any, activities that they

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39 engaged in, and they endorsed very little willingness to experience their pain. Cluster 2 or the High High group was comprised of participants who responded in the opposite manner: they self reported much higher engagement in lifes activities despite their pain and were much more willing to experience their pain and all related emo tions. Further comparisons showed this High High group also self reported significantly lower pain, depression, painrelated anxiety, physical and psychosocial disability, medical visits, medications, daily restand daily activity than the first Low L ow group (Vowles et al., 2008, p. 288). This third group, high Activities Engagement and low Pain Willingness, also differed from the two other groups on the following: daily activity, physical disability, pain, medical visits, an d classes of medication ( Vowles et al., 2008). Results of the second and third studies also suggest better outcomes in this High High group vs. the Low Low and further suggest the validity and reliability of these three clusters. Three clusters also emerged in Costa and Pinto Gouveia s 2010 study, comprised of a mixed CP outpatient primary care and tertiary care sample ( N = 103). T he High High and Low Low groups were identical to Vowles et al.s findings; however, the third, mixed group differed slightly, producing a mediu m Activities Engagement and low Pain Willingness cluster. As in Vowles et al.s study, post hoc analyses demonstrated lower levels of anxiety, depression, stress and self compassion in the High High cluster compared to the Low Low group. Interesting di ffere nces emerged in the third, Medium Activities Engagement and low Pain Willingness group: higher levels of depression, stress, self judgment, and over identification (versus mindfulness) than the HighHigh , and lower levels of depression and stress th an the Low Low. The third study also produced three cluster groups (High High, Low Low, and Medium Medium,) thus again suggesting a slightly varied third group (Payne Murphy & Beacham, 2014). Participants were self identified CP patients who were recruited via online CP

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40 support groups ( N = 300). Again, the poorest outcomes were found in the Low Low g roup and the best found in the High High across Perceived Disability and Negative and Positive Affect. Intuitively, the mixed cluster revealed moderate scores across these same measures of mood and functional outcome. The authors of these studies suggest this mixed group displays good enough functioning but self report poorer emotional and social well being and perhaps have more attachmen t to fin ding pain relief (low Pain Willingness ) t han the High Acceptance group. Results indicate that Pain Willingness is therefore an important factor in supporting better psychosocial functioning and both are needed to maintain optimal levels of positive affect, and physical and psychosocial function. Findings from these studies provide further support for Acceptance as a key factor in CP patients functional and affective outcomes. Furthermore, results suggest that further investigation is warranted to learn about the se relationships in order to improve functioning and quality of life in those with either CP or FM. Purpose of the Present S tudy Given prior findings suggesting sign ificant rates of psychological symptoms and higher levels of Experiential Avoidance in FM, the current study examine d ways in which these patients respond to their symptoms Via measures of Acceptance, Experiential Avoidance, and Mindfulness, the study sought to ascertain the role of these constructs in study participants perceived disability ; and how subjective reports and perceptions differ ed from those with chronic pain but without FM The current study had two primary aims. First, to determine if the same three clu ster groups found in prior studies ( Costa & Pinto Gouveia 2010; Payne Murphy & Beacham, 2014; Vowles et al., 2008) would emerge when cluster analysis was conducted on FM and C P grou ps separately Within this aim, we sought to determine whether cluster groups would differ between FM and C P samples. Secondly, a series of two way Analyses of Covariance were conducted to determine if there we re overall differences between the FM and the C P group on

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41 Experiential Avoidance, Mindfulness, and Perceived Disability in each sample group (i.e. FM or CP) These and subsequent analyses ex amine d main effect differences by cluster group (Low Low, High High and Medium Medium) and by pain type (FM and C P) ; interaction effects between cluster groups and pain type that are associated with levels of Experiential Avoidance, Mindfulness, and Percei ved Disability ; and where differences lay between each of these groups. Study Hypotheses Hypothesis 1: It was hypothesized that the following three cluster groups would emerge in the FM participant sample: 1) Low Activity Engagement Low Pain Willingness 2) H igh Activity Engagement High Pain Willingness 3) Moderate Activity Engagement Moderate Pain Willingness Hypothes is 1 Analysis: K means cluster analysis was conducted using both Activity Engagement and Pain Willingness CPAQ subscales in the CP sample. If three similar cluster groups did not emerge in this CP sample, tertile groups would be formed using the total score for the Chronic Pain Acceptance Questionnaire reflecting High, Low and Medium tertile groups. Hypothesis 2: It was hypothesized that the same following three clus ter groups would emerge in the CP participant sample: 1) Low Activity Engagement Low Pain Willingness 2) High Activity Engagement High Pain Willingness 3) Moderate Activity Engagement Moderate Pain Willingness Hypothesis 2 Anal ysis: K means cluster analysis was conducted using both Activity Engagement and Pain Willingness CPAQ subscales in the CP sample. If three similar cluster group s did not emerge in this CP sample, tertile groups would be formed using the total score for the Chronic Pain Acceptance Questionnaire reflecting High, Low and Medium tertile groups.

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42 Hypothesis 3: It was hypothesized that in the online FM support group sample, as well as the CP support group sample, self reported scores of Perceived Disability, Mindf ulness and Experiential Avoidance will differ overall by Acceptance level (Hi, Med, Low) group (main effect for group) controlling for average pain rating in past week and degree of PTSD symptomatology. Covariate selection is described below in Data Analysis section. Hypothesis 3 Analysis: A series of three 2 x 3 between subject analyses of covariance (ANCOVAs) were conducted. Pain type, specifically FM or CP, served as a the first independent variable with two levels, and Acceptance level group served as the second independent variable with three levels (i.e. Low, High, and Medium) Perceived Disability, Mindfulness and Experiential Avoidance served as dependent variables, one for each ANCOVA. Hypothesis 4: It was hypothesized that an interaction effect would occur between tertile groups (Low, High, Medium) and pain type (FM and CP). In total, three interaction effects, one per ANCOVA, were predicted: 1) tertile group (IV) and pain type (IV) and Mindfulness (DV); 2) tertile group (IV) and pain type (I V) and Experiential Avoidance (DV) 3) tertile group (IV) and pain type (IV) and Perceived Disability (DV). Hypothesis 4 Analysis: Results of the three 2 x 3 between subject ANCOVAs would indicate if there are interaction effects between group cluster and pain type for each dependent variable.

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43 CHAPTER III METHOD The present study was an analysis of data gathered and conducted through the University of Colorado Denver in Denver, Colorado. The study procedure and data collection was reviewed and appr oved by the University of Colorado Denver Colorado Multiple Institutional Review Board for all data collection waves. Participants Individuals who self identified as having either FM or CP were recruited via online FM and CP support groups on Yahoo! Groups and Facebook. An additional third wave of respondents were recruited through an advertisement posted on Facebook that was marketed specifically to general Facebook members who had chronic low back pain. Inclusion criteria for all waves included: individu als with nonmalignant (i.e., not cancer related) chronic pain (pain duration 3 months), are 18 years of age or older, and are able to read English. The following support groups were excluded from the first and second data waves: a) 12 step; b) biofeedback; c) interventionbased; d) prayer/religious; e) medication focused (e.g., Opioid, OxyContin); f) malignant pain (cancer); and g) those groups with a primary focus on litigation about their pain problem. These three waves of data collection were conducted between April and September of 2014. The initial wave was conducted in Yahoo! Groups from March to April; the second from online support groups on Facebook from May to June; and the third via an advertisement posted on Facebook from August to September that targeted chronic low back pain respondents exclusively, who were not identified as subscribing members of a support group. For specific details of collection procedure and wave variations, refer to Materials and Procedure. The total sample ( N = 552 ; Mean age = 46.7 years, SD = 11.7) was primarily female (92.2 %), Cauca sian, not of Hispanic origin (93.3 %), married/partnered (66 .6 %), and well educated ( M = 14.7 years, SD = 3.0), with an average income ranging between $15k and $40k. Participants who self -

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44 reported a diagnosis of FM comprised 68.3% of the total sample ( n = 552) whereas those with CP, without FM, was smaller ( n = 175 ). The majority of the sample either reported having health insurance or was in the process of obtaining this (88.3 %). Mean ye ar s with either FM or CP were 14.4 ( SD = 11.1 ) and avera ge weekly pain intensity was 6.5/10 ( SD = 1.7) Specific variations in descriptives between the two samples are presented in Tables 1 and 2 Materials and Procedure Materials and procedure were identi cal for the first two online support group data collection waves on Yahoo! Groups and Facebook. An identical recruitment procedure was previously successfully employed that specifically recruited chronic pain and chronic illness online support group member s from both Yahoo! Groups and Facebook (Payne Murphy & Beacham, 2014). For the current study, CP group selection was determined from the Yahoo! Groups and Facebook search engines un der the following key terms: fibromyalgia support group, chronic pain su pport group, and low back pain. G r oup facilitators/moderators were then contacted individually to propose research involvement (Appendix A) Once permission from these group facilitators wa s granted, posting commenced to both open and closed groups over the following six weeks, for three postings total, once every two weeks. The posting to members include d an invitation to participate in a brief online study on the group website (Appendix B) Interested members w ere then directed to a REDCap survey site, which provided instructions for survey completion and informed consent (Appendix C) and an optional page requesting demographic inf ormation for those who wished to become eligible for the gift card incentive lott ery (Appendix D ) All p articipants were en couraged to contact study staff by electronic mail or telephone if they had any questions or concerns. The REDCap electronic data capture tool is a secure, web based application designed to support data capture for research studies, providing 1) interface for validated data entry; 2) audit trails for tracking data and export;

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45 and 3) automated expor t procedures for data download (Harris et al., 2009). All data were collected and managed using REDCap, which was hosted at the University of Colorado Denver. Th e third recruitment wave was targeted exclusively to those Facebook members who clicked on an advertisement for adults with chronic low back pain. This additional recruitment effort was conducted to provide better representation of low back pain patients among the CP patient sample, as the first two recruitment waves indicated lower numbers of this pain patient population. Given that this sample would have a higher probability of pregnancy related low back pain than the previously recruited support group me mbers, three ad ditional questions were used in this version of the survey to exclude them (Appendix E ). However, t his survey was otherwise identical to the first. This recruitment wave ex tended over five weeks time. The advertisement was set to auto gener ate on Facebook members personal pages who had previously clicked on topics related to chronic pain, low back pain, and/or purchasing history of pain relief items. Again, REDCap was used to collect and manage the data and all other procedures used in the first two waves were identical. Independent Variable Measures Demographics and Medical History. Participants responded to questions regarding demographics and history of CP and FM such as the location of pain, initial causes of pain, medication use, numbe rs of surgeries, and all types of treatments utilized. Participants self reported average pain intensity experienced in the past week by providing one numeric response on an 11point Likert type scale ranging from 0 (no pain) to 10 (worst pain imaginabl e.) Other health and lifestyle related questions include substance use and pain related legal involvement. Pain type (either FM or CP) served as one of the independent variables. Chronic Pain Acceptance. The Chronic Pain Acceptance Questionnaire (CPAQ) i s a brief, self report measure of acceptance of chroni c pain that was originally developed from the Acceptance and Action Scale (AAQ ; Hayes, Strosahl, Wilson, Bissett, Pistorello et al., 2004 ).

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46 Two subscales also derive from this assessment: Activity En gagement and Pain Willingness. Sample i tems include: Despite the pain, I am now sticking to a certain course in my life and I would gladly sacrifice important things in my life to control this pain better (McCracken & Eccleston, 2005, p. 165) The 20 items are rated on a 7 point Likert type scale from 0 (never true) to 6 (always true). This assessment has been found t .82) and has moderate to high correlations with measures of Experiential A voidance, patient functioning and emotional distress (McCracken & Eccleston, 2005) Within the current sample, internal consistency of all 20 items comprising the CPAQ total score is considered strong for both ; respectively). Activities Engagement and Pain Willingness subscale scores will be used in both of the cluster analyses; however, tertiles based on a total sum of Acceptance items will be used for the subsequent ANCOVAs Good in ternal consistency was also found within the current sample for both the Activities Engagement ( for FM; for CP) and Pain Willingness ( for FM; for CP) subscales. See Appendix F Post Traumatic Stress Disorder Checklist. The Post Traumatic Stress Disorder Checklist, Civilian Version (PCL C; Weathers, Litz, Herman, Huska, & Keane, 1993) is a self report questionnaire that measures symptoms of Post traumatic Stress Disorder (PTSD) experienced in the past month. All 17 items in the Civilian version inquire about DSM IV PTSD symptoms that have occurred in relation to stressf ul experiences which refer to one or more lifetime events. Response options range from 1 (not at all) to 5 (extremely) on a Likert type scale. A sum of all items (range total = 17 85) will be used to determine relative severity of symptoms. Clinical u tility has been described as good and reliability and validity reportedly range from good to excellent (Hunsley & Mash, 2008). Results of a reliability analyses conducted on .95) subsamples. See Appendix G

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47 D ependent Variable Measures Acceptance and Action. The second version of the Acceptance and Action Questionnaire (AAQ II; Bond et al., 2011) assesses Experiential Avoidance, or the extent to which an individual avoi ds a range of unpleasant experiences, for example, bodily sensations, emotions, thoughts, memories, and behavioral predispositions and their efforts to change, escape, avoid or extinguish them (Hayes et al., 1996, p. 4). This 7item self report has an in te rnal .88) and a test retest reliability of .81 at 3 months and .79 at 12 months. Internal consistency was assessed within the current sample, both for FM and CP Satisfactory construct, predictive, convergent, incremental and discriminant validity have all been reported as well (Hayes et al., 1996). Construct validity was also assessed in a sample of 144 CP patients as measured by the t heoretically related Chronic Pain Assessment Questionnaire (CPAQ) and Mindfulness Attention Awareness Scale (MAAS) (Brow n & Ryan, 2003; McCracken & Eccleston, 2005; McCracken & Zhao O'Brien, 2010) As described below, the CPAQ measures acceptance of pain and pain related avoidance and willingness, whereas the MAAS measures mindfulness. Correlations among these measures ran ged from r = .46 to .53 and indicate good construct validity ( McCracken & Zhao O'Brien, 2010) The AAQ response options range from 1 ( never true ) to 7 ( always true ) and include such items as My painful memories prevent me from having a fulfilling life and Im afraid of my feelings. A total score is derived from summing the items (Hay es et al., 1996). See Appendix H Five Facet Mindfulness Questionnaire. The Five Facet Mindfulness Questionnaire Short Form (FFMQ SF; Bohlmeijer, ten Klooster, Fledder us, Veehof & Baer, 2011) measures a respondents degree of attentiveness to the present moment while having a nonjudging or accepting attitud e. The FFMQ SF was based on the full leng th, 39item FFMQ (Baer et al. 2006) which was developed by conducting an exploratory factor analysis among items from five

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48 mindfulness questionnaires : the Mindfulness Attention Awareness Scale (MAAS); The Freiburg Mindfulness Inventory (FMI); The Kentucky Inventory of Mindfulness Skills (KIMS); The Cognitive and Affective Mindf ulness Scale (CAMS); and The Mindfulness Questionnaire (MQ) (Baer et al., 2006) Five facets emerged and are scored as separate subscales in the FFMQ: observing, describing, acting with awareness, nonjudging of inner experience, and nonreactivity to inne r experience. A shortened version has since been devised and normed on FM patients ( n = 146), which includes the same five facets and consists of 24 items (Bohlmeijer et al., 2011). S elf report items include: I find it difficult to stay focused on whats happening in the present, and I disapprove of myself when I have illogical ideas. Response options range from 1 (never or rarely never true) to 5 (very often or always true). The authors report adequate to good c onstruct, convergent, and discrimina nt validity and internal consistency of all five facets range = .75 .81) within an FM sample ( n = 146) (Bohlmeijer et al., 2011) Reliability analyses conducted within the current study sample s are both consistent with and higher than .85 for the CP group. Theoretically related variables of the following measures suggested moderate correlations in the expected directions, demonstrating good construct validity: acceptance (AAQ II); openness to experiences (NEO FFI); neuroticism (NEO FFI); anxiety (HADS A); depression (CESD); and positive mental health (MHC SF) (Bohlmeijer et al., 2011). For the present study, a total score will also be derived from the FFMQ SF, which is a s um of all of the items (Van Dam, Earleywine, & Danoff Burg, 2009). See Appendix I Pain Disability Index. The Pain Disability Index (PDI) (Pollard, 1984) is a brief, 7item, self report measure, which assesses the degree to which individuals believe their pain interferes with various activities in their daily lives. Specific areas inc lude: occupation, family/home responsibilities, sexual behavior, self care, recreation, and social and life support activities. Items are rated on a 0 10 scale ranging from no disability to total disability and are summed to

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49 yield one total score. Inte rnal consistency is high ( al., 1990), and generally, psychometric properties have been reported as adequate and support its utility (Turk & Melzack, 2001). For the current sample, results of reliability analyses suggesting high inter Data Analysis Hypothesis O ne was analyzed using hierarchical cluster (Wards method ; Ward, 1963) procedures using both the CPAQ Activities Engagement and Pain Willingness variables to determ ine number of cluster groups in the FM sample. A hierarchical approach using Wards method was chosen to closely follow previous methodology used in the previous study examining CPAQ clusters (PayneMurphy & Beacham, 2014), as well as the k means method ( C osta & Pinto Gouveia, 2010; Payne Murphy & Beacham, 2014; Vowles et al., 2008). Following the same pro cedures outlined in Hypothesis One, Hypothesis Two was tested using a k means hierarchical cluster (Wards method) with the CP sample. Wards method is an iterative statistical approach used in cluster analysis that is the most common of the minimum variance methods ( Gore, 2000; Ward, 1963 ). At each step, a squared sum of the distance between each data point and the mean of the cluster is calculated and t he lowest value is chosen ( Gore, 2000; Tabachnick & Fidell, 2006). This procedure is repeated at each step, such that the data point with the smallest distance between the cluster mean is given priority until the largest distance is selected last. K means partitioning is also an iterative approach that is applied following the hierarchical (Wards) procedure. Using the existing centroids determined by Wards method, the K means approach first establishes a set number of clusters followed by a reassignment of the centroids to these clusters by minimizing within cluster variability and maximizing between cluster variability ( Gore, 2000) The K means method was originally developed to compensate for one of the primary weaknesses of hierarchical

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50 procedures: the inability to reassign a centroid to find better match as subsequent clusters are made within the process ( Gore, 2000). Hypotheses Three and Four were tested by conducting a series of Analyses of Covariance (ANCOVAs) to assess if and where significant diff erences lie among the three cluster groups and pain type (FM and CP) for each of the following dependent variables: Perceived Disability, Experiential Avoidance, and Mindfulness. Three ANCOVAs were conducted for each of the three dependent variables. Tota l scores for the Pain Disability Scale (PDI), or Perceived Disability; total scores on the Acceptance and Action Questionnaire (AAQ II), or Experiential Avoidance; and a total score on the Five Factor Mindfulness Questionnaire Short Form (FFMQ SF) were emp loyed as the continuous dependent variables for each of the three analyses. For all three series of ANCOVAs, the t ertile (Low, High, and Medium ) groups served as the first categorical independent variable and pain type (FM or CP) served as the second categorical independent variable. A series of three ANCOVAs were chosen because previous studies examining similar variables employed this same method ( Costa & Pinto Gouveia, 2010; Vowles et al., 2008). Secondly, due to a lack of empirical evidence suggesting Mindfulness, Acceptance, and Perceived Disability form a linear composite or a single underlying construct, a series of ANCOVAs served to further illuminate the relationships among each of the dep endent variables individually ( Huberty & Morris, 1989) Se lection of Covariates Covariates included the following continuous variables: age, average pain in the past week, years of education, and PTSD symptoms using the Post traumatic Stress Disorder Checklist, Civilian Version (PCL C) were initially considered. These covariates were chosen based on research suggesting higher rates of Experiential Avoidance and perceived and actual disability have been correlated with older age (Leigh & Fries, 1992; Severeijns et al., 2001; Turner, Franklin & Turk, 2000), pain se verity (Bennett, 1996; Denison et al., 2004), PTSD symptoms (Young Casey, Greenberg, Nicassio, Harpin, & Hubbard, 2007), and lower education

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51 levels (Hagen, Holte, Tambs, & Bjerkedal, 2000; Senna, De Barros, Silva, Costa, Pereira, Ciconelli, & Ferraz, 2004; Schmidt et al., 2007) in CP or FM samples. Therefore, age, years of education, number of surgeries, and current level of pain were evaluated as potential covariates for the study analyses. Results of several independent t tests examining significant diffe rences between FM and CP samples suggest that only average pain severity level within the past week, and PTSD symptom severity qualified as covariates. Therefore, only PCL C scores and average pain were used as covariates in ANCOVA s. A ssumptions for univa riate analysis of covariance include absence of unequal sample size, absence of outliers, absence of multicollinearity and singularity, normality of sampling distributions, homogeneity of variance, linearity, homogeneity of regression, and reliability of c ovariates (Tabachnick & Fidell, 2006) In regards to power, these 2 x 3 betweensubjects ANCOVAs each have two independent variables. According to Faul, Erdfelder, Lang, & Buchner (2007) nearly 300 ( N = 297) participants total are required to achieve a medium effect size, at a .05 alpha level, with 80% power. The analyses as conducted met this criterion. All analyses were conducted using Statistical Package for the Social Sciences (SPSS), version 22 for Mac.

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52 CHAPTER IV RESULTS Recruitment Accru al and Attrition Significant attrition occurred throughout the course of the recruitment period, as shown in Figure 2. Missing Values Analyses as well as Littles Missing Completely at Random (MCAR) Test were conducted in SPSS to examine patterns of missi ng variables. Results of Littles MCAR test evaluating the dependent, independent and covariate variables resulted in a chi square = 341.8 (df = 72, p < .01). These results suggest that data are not missing at random Results of the Missing Value Analysis also suggest a consistent monotone missing structure (Little & Rubin, 1989) such that approximately 38% of all participants ( n = 409) discontinued the survey before or by the end of the demographic items, which were presented in the first half of the surve y. The decision was then made to exclude these noncompleters from analysis given their lack of provided data beyond demographic responses. The remaining participants ( n = 552) were enrolled in the study and proposed analyses were then conducted. Figure 2. Participant Attrition and Survey Completion

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53 Demographic Characteristics of the Participant Sample Descr ip tive statistics for Yahoo! Groups and Facebook participants, the samples of which were recruited between March through September 2014, are shown in Table 1 Specifically, the initial recruitment wave was conducted in Yahoo! Groups from March to April; the second from online support groups on Facebook from May to June; and the third via an advertisement posted on Facebook from August to September 2014, which targeted chronic low back pain respondents exclusively, who were not identified as subscribing members of a support group. S pecific details regarding procedure and wave variations are described in Materials and Procedure. Both Yahoo! Groups ( n = 63 ) and Facebook participants ( n = 489 ) were predominately female (98.4% and 91.4% respectively), Caucasian, not of Hispanic origin (96.8%; 92.8 % ) and well educated (Yahoo! mean years = 15.56 ( SD = 3.38 ); Facebook mean years = 14.57 ( SD = 2.88). Despite h aving similar educational levels, results o f an independent t test suggest significant differences t (548) = 2.49, p < .05. No significant differences were found between the two groups in regards to gender According to chi square test of independence resu lts, s ignificant differences were also seen in ethnicity, ( 2 (4, N = 549) = 13.5, p < .01). The Yahoo! Groups sample was comprised primarily of Caucasian adults ( n = 61), followed by two individuals of American Indian or Alaskan Native descent. Hispanic ( n = 9), African American ( n = 7), and American Indian or Alaskan Native ( n = 1) and Other adults ( n = 18) comprised the remainder of the Facebook sample. Although participants recruited from both websites were primar ily middle aged (mean years = 52.94 an d 45.9, respectively); a significant effect for age was detected by independent t test t (550) = 4.57, p < .01. A chi square test of independence was also performed to examine the differences in type of employment. Overall, the majority of participants in t his sample were unemployed (not retired) (Yahoo! = 65.1%; Facebook = 58.1%) and no differences were found between the two samples regarding occupational status. There were also no significant differences found for income, with the majority of participants from the Yahoo!

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54 Table 1 Demographic Characteristics of Sample by Data Collection Source ______________________________________________________________________________ Characteristic Yahoo! Groups ( n = 63) Facebook ( n = 489) n (%) n (%) 2 p Gender 3.80 .05 Male 1 (1.6) 42 (8.6) Female 62 (98.4) 447 (91.4) Income 15.93 .53 Below $5000 3 (5) 27 (5.7) $5000 $14,999 12 (20) 65 (13.7) $15,000 $29,999 8 (13.3) 114 (24.1) $30,000 $49,999 11 (18.3) 84 (17.7) $50,000 $69,999 9 (15) 64 (13.5) $70,000 $89,999 7 (11.7) 45 (9.5) $90,000 $109,999 4 (6.7) 22 (4.6) Over $110,000 6 (10) 53 (11.2) Employment 5.60 .47 Working 1 39 hrs/wk 7 (11.1) 90 (18.6) Working 40+ hrs/wk 8 (12.7) 84 (17.3) Homemaker 4 (6.3) 33 (6.8) Unemployed, looking 2 (3.2) 18 (3.7) Unemployed, not looking 3 (4.8) 24 (4.9) Retired 7 (11.1) 29 (6) Disabled 32 (50.8) 207 (42.7) Ethnicity 13.5 <.01** American Indian/Alaskan 2 (3.2) 1 (.2) Asian 0 (0) 0 (0) Hispanic or Latino 0 (0) 9 (1.9) Pacific Islande r/Hawaiian 0 (0) 0 (0) Black or African American 0 (0) 7 (1.4) Caucasian 63 (96.8) 115 (92.8) Other 0 (0) 18 (3.7) Mean ( SD ) Mean ( SD ) t p Age (years) 52.94 9.85 45.90 11.69 4.57 <.01** Range: 3175 Range: 1876 Education (years) 15.56 3.38 14.57 2.88 2.5 <.05* Range: 1225 Range: 425 p < .05 ** p < .01

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55 sample earning between $5k and $14,999 (20%) and $30k and $49,999 (18.3%) and m ore Facebook participants earning between $15k and $29,999 (24.1%) and $30k and $49,999 (17.7%) than in other salary categories Pain Characteristics of the Participant Sample Descriptive statistics for all pain characteristics for both data collect ion sources are shown in Table 2. Again, chi square tests of independence and independent t tests were conducted to determine if there were significant differences between the two data sources. Bonferroni adjusted criterion alpha levels were applied to pain loc ations ( p = .005 (.05/10)) and the remaining pain characteristics ( p = .02 (.05/3)). Participants were asked to record all areas they experienced pain; therefore, more than one area may have been indicated per individual. All results from chi square tests of independence comparing the location of the participants pain and the two data sources suggested no significant differences in accordance with adjusted criterion levels. Both samples endorsed more diagnoses of fibromyalgia (Yahoo! = 74.6%; Facebook = 67.5%) than chronic pain without fibromyalgia. The most common chronic pain type reported among Yahoo! Groups participants included lower back (84.1%); lower limbs (79.4%); cervical spine (69.8%); and upper extremities (65.7%). Most frequently endorsed area s within the Facebook sample also included lower limbs (76.9%); lower back (71.2%); upper extremities (70.0%); and cervical spine (67.5%). Additionally, an independent t test with a Bonferroni adjuste d alpha level of .02 (.05/3) was conducted to examine the differences in participants number of years they had experienced pain (Years in Pain.) Results showed a significant difference in these number of years between the two samples, t (550) = 3.58, p < 01. Yahoo! participants self reported significantly more years of pain ( M = 19.08 ( SD = 12.29)) than Facebook ( M = 13.83 ( SD = 10.77)). There were no significant differences reported for average weekly pain level between the

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56 two groups, t (550) = .14, p = .89. The current average weekly pain l evels rated between zero and 10 on an 11point Likert scale, fell between 6.43 ( SD = 1.66) for the Yahoo! and 6.46 ( SD = 1.67) for the Facebook participants. A greater number of painrelated surgeries were reported by the Facebook sample ( M = 3.58 ( SD = 4.0)) compared to Yahoo! ( M = 2.86 ( SD = 2.29)); however, no significant differences were found, t (172) = 1.32, p = .19. Hypothesis One Hypothesis One stated that the following three cluster groups would emerge in the F M participant sample: 1) Low Activity Engagement Low Pain Willingness 2) High Activity Engagement High Pain Willingness 3) Moderate Activity Engagement Moderate Pain Willingness Hierarchical cluster analysis using Wards method, followed by kmeans clu ster analysis were conducted using Activity Engagement (AE) and Pain Willingness (PW) totals from the Chronic Pain Acceptance Questionnaire (CPAQ). Again, this method was c hosen to closely follow prior methodology ( Costa & Pinto Gouveia, 2010; Payne Murphy & Beacham, 2014; Vowles et al., 2008). The AE/PW hierarchical cluster analysis using Wards method specified five clusters (see Table 3) ; therefore, a follow up kmeans cluster analysis was not deemed appropriate (Gore, 2000). According to Gore (2000), a n iterative procedure such as the k means partitioning method, is only effective if provided the exact number of clusters. Due to failing to see three clusters emerge, the k means procedure was therefore unnecessary. These findings indicate that hypothesis one was not supported. As indicated in Hypothesis 1, tertile groups were then formed using the total score for the Chronic Pain Acceptance Questionnaire reflecting Low, High and Medium tertiles. Descriptives for both the FM and CP tertiles are found in Ta ble 4

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57 Table 2 Pain Characteristics of Sample by Data Collection Source ______________________________________________________________________________ Yahoo! Groups ( n = 63) Facebook ( n = 489 ) Characteristic n (%) n (%) 2 p Fibromyalgia vs. CP 47 (74.6) 330 (67.5) 1.3 .25 Pain Location Lower Back 55 (84.1 ) 348 (71.2) 4.72 .03 Lower Limbs 50 (79.4 ) 376 (76.9) .19 .66 Upper Extremities 41 (65.7) 342 (70.0) .62 .43 Head/Face 24 (38.1 ) 250 (51.1) 3.79 .05 Cervical Spine 44 (69.8 ) 330 (67.5) .14 .71 Thoracic Spine 33 (52.4 ) 225 (46.0) .91 .34 Pelvic/Genital 18 (28.6 ) 130 (26.6) .112 .74 Full Body 30 (47.6 ) 227 (46.4) .03 86 Pain Location: Other 5 (8.0 ) 33 (6.7 ) .12 .73 Mean ( SD ) Mean ( SD ) t p Years in Pain 19.08 12.29 13.83 10.77 3.58 .00** Range: 3 60 Range: 1 53 Current Average Weekly Pain Level: 0 10 point scale (10 = most) 6.43 1.66 6.46 1. 67 .14 .89 Range: 2 10 Range: 1 10 Number of Surgeries 2.86 2.29 3.58 4.0 1.32 .19 Range: 1 10 Range: 0 27 p < .005 using Bonferroni correction for nine chi square tests of independence. ** p < .02 using Bonferroni correction for three independent t tests. Table 3 CPAQ Mean Sc ores by Cl uster Fibromyalgia Sample Cluster 1 Cluster 2 Cluster 3 C luster 4 Cluster 5 ( n = 78) ( n = 66) ( n = 34) ( n = 82 ) ( n = 71) Mean ( SD ) Mean ( SD ) Mean ( SD ) Mean ( SD ) Mean ( SD ) Activity Engagement 30.1 (6.86) 32.8 (9.4) 13.35 (5.6 ) 16.6 (6.9) 36.94 (7.8 ) Pain Willingness 28.9 (5.24) 17.76 (4.9) 8.21 (3.8) 23.15 (5.1) 24.41 (7.3 ) CPAQ Total Score 58.9 (10.18) 50.56 (12.1) 66.97 (14.5) 39.72 (8.9) 61.35 (12.4 )

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58 Table 4 CPAQ Mean Score by Pain Type and Tertile Low Hi gh Medium Fibromyalgia Sample size 117 88 126 CPAQ Total Mean ( SD ) 33.58 (11.0) 66.89 (10.26 ) 51.29 (8.09) Chronic Pain Sample size 36 73 40 CPAQ Total Mean ( SD ) 36.36 (12.9) 72.15 (14.06) 51.68 (7.94) Hypothesis Two Hypothesis Two stated that the same three cluster groups would emerge in the CP parti cipant sample: 1) Low Activity Engagement Low Pain Willingness 2) High Activity Engagement High Pain Willingness 3) Moderate Activity Engagement Moderate Pain Willingness Hierarchical cluster analysis using Wards method, followed by kmeans cluster analysis were conducted using Activity Engagement (AE) and Pain Willingness (PW) totals from the Chronic Pain Ac ceptance Questionnaire (CPAQ). Again, this method was chosen to replicate the prior methodology as closely as possible. The AE/PW hierarchical cluster analysis using Wards method specified four clusters; therefore, a follow up kmeans cluster analysis was again not deemed appropriate (Gore, 2000) As was found in Hypothesis 1, t he current findings indicate that this hypothesis was not supported. Des criptives for the CP clusters are shown in Table 5. As stated in Hypothesis 2, tertile groups w ere formed using the total score for the Chronic Pain Acceptance Questionnaire reflecting Low, High, and Medium tertiles Please refer to Table 4 for descriptive s for both the CP and FM tertiles.

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59 Table 5 CPAQ Mean S cores by Cluster Chronic Pain Sample Clus ter 1 Cluster 2 Cluster 3 Cluster 4 ( n = 64) ( n = 31) ( n = 25) ( n = 29) Mean ( SD ) Mean ( SD ) Mean ( SD ) Mean ( SD ) Activity Engagement 29.36 (7.22) 50.74 (5.3) 14.84 (5.2) 37.1 (6.9) Pain Willingness 29.0 (6.63) 34.32 (7.1) 14.4 (7.9) 16.0 (5.35) CPAQ Total Score 58.4 (8 .37) 85.1 (10.4) 29.24 (7.51) 53.1 (9.5) Hypothesis Three Hypothesis Three stated that in the online FM support group sample, as well as the CP support group sample, self reported scores of Perceived Disability, Mind fulness and Experiential Avoidance would differ overall by Acceptance level ( Low, Hi gh and Medium ) group (main effect for group) controlling for average pain rating in past week and degree of PTSD symptomatology. Covariate selection was previously describ ed in Data Analysis section. A series of three 2 x 3 between subjects analyses of covariance were performed. The first was conducted on levels of Mindfulness as measured by the Five Facet Mindfulness Questionnaire (FFMQ SF), the second on levels of Experie ntial Avoidance as measured by the Acceptance and Action Questionnaire ( AAQ) and the third on levels of Perceived Disability via the Pain Disability Index ( PDI ) The first set of i ndependent variables consisted of pain type (FM or CP) and the second set w as tertile divisions of total Acceptance ( i.e., Low, High, and Medium ) as measured by the CPAQ. These were factorially combined. As previously described, both weekly pain average and PCL C score were employed as covariates for all three ANCOVAs. All analyses were per formed by SPSS, which adjusts for unequal n by weight ing cells by their sample sizes. Results of the evaluation of the assumptions of normality of sampling distributions, linearity, absence of multicollinearity, homogeneity of regression and re liability of covariates

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60 were satisfactory. Presence of outliers led to transformation (Bloms formula) of two of the three depende nt variables ( AAQ and PDI ), and the two covariates ( average weekly pain severity and PCL C scores ; Blom, 1958) No outliers re mained after transformation; however, three outliers which were found in the FFMQ measure, were replaced with z scores of 2.0, a ccording to prior method (Field, 2009). Levenes test for equality of variances was found to be violated for the present analys is specifically when PDI served as the dependent variable, F (5, 429) = 2.60, p = .03. However, transformation of the PDI via Bloms formula then rendered this assumption met as indicated by a nonsignificant Levenes test value, F (5, 442 ) = 1.28, p = .27. Aft er adjustment by covariates, Mindfulness varied significantly by Acceptance terti le, as indicated in Table 6 F (2 393 ) = 4.7 9, p < .01. Using p 2 as the measure of effect size, Acceptance tertile accounted for 2% of the total variability in the Mindfulness score ( p 2 = .02). Table 6 Analysis of Covariance of Mindfulness by Chronic Pain Type and Acceptance Tertile Source of Variance SS df MS F p 2 Chronic pain type (FM or CP) .08 1 .08 .12 .00 Acceptance tertile (Low, Med or High) 6.29 2 3.15 4.79 .02** Interaction .25 2 .13 .19 .00 Covariates (adjusted for all effects) Average weekly pain level 3.34 1 3.34 5.09 .01* Post traumatic symptom severity 76.33 1 76.33 116.08 .23** Error 258.42 393 .66 p < .05 ** p < .01 The adjust ed marginal means (see Table 7 ), are displayed in Figure 3 and show that the lowest levels of Mindfulness were self reported by participants in the Low Acceptance tertile; highest levels of Mindfulness were self reported by those in the High Acceptance tertile; and moderate levels in the Medium tertile. No stati stically significant main effect of chronic pain type

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61 (F M or CP) emerged on Mindfulness. Table 7 Adjusted and Unadjusted Mean Mindfulness by Ac ceptance Tertile and Pain Type Adjusted Mean ( SE ) Unadjusted Mean ( SD ) Low Acceptance Fibromyalgia .18 (.09) .43 (.96) Chronic Pain .21 (.14) .32 (1.05) High Acceptance Fibromyalgia .12 (.09) .30 (1.01) Chronic Pain .22 (.12) .55 (.81) Med Acceptance Fibromyalgia .05 (.08) .001(.80) Chronic Pain .07 (.14) .10 (1.0 ) Note All data presented as zscores. Figure 3. Adjusted M eans for Mindfulness by Acceptance Tertile and Pain Type. Similarly, a main effect of Acceptance tert ile also emerged when Experiential Avoidance was employed as the dependent variable, after adjustment by covariates, F (2, 436) = 8.39, p < .01 (see Table 8 ). Again, a small effect size was found between Acceptance tertile and Exper iential -0.25 -0.2 -0.15 -0.1 -0.05 0 0.05 0.1 0.15 0.2 0.25Chronic Pain Fibromyalgia Low Acceptance Med Acceptance High Acceptance

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62 Table 8 Analys is of Covariance of Experiential Avoidance by Chronic Pain Type and Acceptance Tertile Source of Variance SS df MS F p 2 Chronic pain type (FM or CP) .01 1 .01 .01 .00 Acceptance group (Low, Med or High) 7.52 2 3.76 8.4 .04** Interaction .33 2 .17 .37 .00 Covariates (adjusted for all effects) Average weekly pain level .02 1 .02 .04 .00 Post traumatic symptom severity 141.76 1 141.76 316.5 .42** Error 195.29 443 .45 p < .05 ** p < .01 Avoidance p 2= .04. A djuste d marginal means (see Ta ble 9 ) are displayed in Figure 4 and show that the highest levels of Experiential Avoidance were self reported by participants in the Low Acceptance tertile; lowest leve ls were self reported by those in the High Acceptance tertile; and moderate levels in the Medium tertile. After covariate adjustment, n o statistically significant main effect of chronic pain type (FM or CP) was found on Experiential Avoidance The third AN COVA ex amined group differences among pain type and Acceptance tertile on Perceived Disability via the Pain Disability Index (PDI) Following covariate adjustment results suggest a statistically significant main effect occurred between Perceived Disabilit y and Acceptance tertile, F (2, 440) = 12.96, p < .01 (Table 10) A significant main effect was also found between Perceived Disability and pain type, F (1, 440) = 10.67, p < .01 Again, small effect sizes were found for both effects p 2= .06 for Acceptance tertile and p 2= .02 for pain type (Table 10). Adjusted marginal means (Table 11) are displayed in Figure 5 and show that the highest levels of Perceived Disability were self reported by participants in the Low Acceptance tertile; lowest levels of Perceiv ed Disability were self reported by those in the High Acceptance tertile; and moderate levels in the Medium tertile. Likewise, higher levels of Perceived Disability

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63 were self reported by FM participants when compared to the CP participants, both in the Low and Med Acceptance tertiles. In contrast, CP participants reported higher levels of Perceived Disability compared to those with FM in the Low Acceptance tertile but not in the High and Medium tertiles. Table 9 Adjusted and Unadjusted Mean Experiential A voidance by Acceptance Tertile and Pain Type Adjusted Mean ( SE ) Unadjusted Mean ( SD ) Low Acceptance Fibromyalgia .18 (.07) .56 (.89) Chronic Pain .23 (.12) .41 (1.07) High Acceptance Fibromyalgia .14 (.07) .39 (.89) Chronic Pain .22 (.09) .75 (.96) Med Acceptance Fibromyalgia .01 (.07) .11(.76) Chronic Pain .06 (.11) .06 (.84) Note. All data presented as zscores. Figure 4. Adjusted Means for Experiential Avoidance by Acceptance Tertile and Pain Type. -0.25 -0.2 -0.15 -0.1 -0.05 0 0.05 0.1 0.15 0.2 0.25 0.3Fibromyalgia Chronic Pain Low Acceptance Med Acceptance High Acceptance

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64 Table 10 Analysis of Covariance of Perceived Disability by Chronic Pain Type and Acceptance Tertile Source of Variance SS df MS F p 2 Chronic pain type (FM or CP) 6.88 1 6.88 10.67 .02** Acceptance group (Low, Med or High) 16.71 2 8.36 12.96 .06** Interaction 6.59 2 3.3 5.11 .02** Covariates (adjusted for all effects) Average weekly pain level 26.29 1 26.29 40.74 .09** Post traumatic symptom severity 26.82 1 26.82 41.6 .09** Error 283.7 440 .65 p < .05 ** p < .01 Tab le 11 Adjusted and Unadjusted Mean Perceived Disability by Acceptance Tertile and Pain Type Adjusted Mean ( SE ) Unadjusted Mean ( SD ) Low Acceptance Fibromyalgia .26 (.08) .50 (.89) Chronic Pain .37 (.14 ) .51 (.80) High Acceptance Fibromyalgia .03 (. 09) .12 (.79) Chronic P ain .49 ( .11) .86 ( 1.11 ) Med Acceptance Fibromyalgi a .08 (. 08) .13(.82 ) Chronic Pain .36 (.12) .35 (.93 ) Note. All data presented as zscores.

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65 Figure 5. Adjusted Means for Perceived Disability by Acceptance Tertile and Pain Type I. Hypothesis Four Hypothesis Four stated that an interaction effect would occur between tertile groups (Low, High, Medium) and pain type (FM and CP). In total, three interaction effects, one per ANCOVA, were predicted: 1) tertile group (IV) and pain type (IV) and Mindfulness (DV); 2) tertile group (IV) and pain type (IV) and Experiential Avoidance (DV) ; 3) tertil e group (IV) and pain type (IV) and Perceived Disability (DV). Results of the first two 2 x 3 betweensubject ANCOVAs indicated there were no significant interaction effects between Acceptance tertile and pain type for Mindfulness and Experiential Avoida nce How ever, a statistically significant interaction effect was fou nd between Perceived Disability, tertile group and pain type F (2, 440) = 12.96, p < .01 (see Table 10 ) Again, a small effect was detected, p 2= .02 (Table 10). Please refer to Figure 6 Results indicate that a s Acceptance levels in crease, Perceived Disability scores decrease overall ; however, Perceived -0.6 -0.5 -0.4 -0.3 -0.2 -0.1 0 0.1 0.2 0.3 0.4 0.5Fibromyalgia Chronic Pain Low Acceptance Med Acceptance High Acceptance

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66 Disability decreases more as Acceptance increases for those with CP as compared to FM parti cipants. Figure 6. Adjusted Means for Perceived Disability by Acceptance Tertile and Pain Type II Supplemental Analyses Interaction Effect Correlations. Follow up analyses were conducted to examine the significant interaction effect between Perceived Disability, tertile group and pain type Sig nificant associat ions were specifically found both between 1) Acceptance tertile group and Perceived Disability for both pain types and 2) between type of pain and Perceived Disability at Medium and High levels of Acceptance. For FM pain type, the association between Acceptance tertile and Perceived Disability was significant and negative rs(331) = .28, p < .01, suggesting that as Acceptance increases, Perceived Disability decreases for this sample. For CP pai n type, this association between Acceptance tertile and Perceived Disability was also significant and negative rs(149) = .44, p < .01. Notably, the degree of the association is greater between CP pain type and Acceptance tertile ( .44) when compared to t he association between FM pain type and -0.6 -0.5 -0.4 -0.3 -0.2 -0.1 0 0.1 0.2 0.3 0.4 0.5Low Acceptance Med Acceptance High Acceptance Fibromyalgia Chronic Pain

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67 Acceptance tertile ( .28). Likewise, this finding suggests that for CP partic ipants, Acceptance levels also increases as Perceived Disability decreases. For Low Acceptance, the association between pain type and Perce ived Disability was not significant, rs(152) = .02, p = .81. However, for M edium and H igh Acceptance, there was a sig nificant negative association between pain type and Perceived Disability, ( rs(153 ) = .24, p < .01, rs(164 ) = .34, p < .01, respectively) In both Medium and High Acceptance groups those with CP self reported lower levels of Perceived Disability (Adjusted Medium Mean = .36; High M ean = .49) when compared to FM (Adjusted Medium M ean = .08 ; High M ean = .03). Multiple Imputation Analyses. In regards to systematic missing data, analyses were conducted to identify predictors o f missing values. T hese predictors were then employed as covariates to control for this missing pattern of data, followed by multiple imputation methods to impute missi ng data using estimated patterns of variability within the current data set (Schafer & Graham, 2002) Stepwise l ogistic regression was first performed to identify demographic variables that predicted membership in the noncompleter participant group ( n = 1 47) vs. the completer participant group ( n = 395). Non completers were defined as those who we re missing at least one value within any of the dependent (Mindfulness, Experiential Avoidance or Perceived Disability) or independent (pain type or Acceptance tertile ) variables or covariates (PCL C score and average weekly pain severity). The model was statistically significant, 2 (6, N = 552) = 37.03, p < .01 indicating that this model was able to distinguish between noncompleters and completers. Among all demographic variables included in the model, six significantly predicted likelihood of noncompletion of the survey, specifically age of participant in years (older) ; years of education (fewer) ; primary ethnicity identified as other; absence of symptoms of tenderness to touch experienced within the past seven days; bladder symptoms experienced within the past seven days; and depressive symptoms within the past seven days (see Table 12) This model explained

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68 between 6.5% (Cox and Snell R square) and 9.3% ( Nagelkerke R square) of the variance in class membership. Multiple imputation was then performed specifying 10 imputations on the following variables : pain type, Acceptance, Mindfulness, Experiential Avoidance, Perceived Disability, PCL C score, average w eekly pain severity, and the aforementioned six predictor variables (see Table 12). Specifically, six out of 13 variables were automatically selected by SPSS to impute due to missing values: Mindfulness, Experiential Avoidance, Perceive d Disability, Accept ance PCL C score, and education level. In total, 11.6% (384 missing data points out of 3312 possible values) o f all data values were imputed. The numbers of missing and imputed values include: education level (missing = 2; imputed = 20); Experiential Avoidance (49, 490); Acceptance (72, 720); Perceived Disability (75, 750); PCL C score (87, 870); Mindfulness (99, 990). Table 12 Logistic Regression Predicting Likelihood of Survey NonCompletion 95% CI for Odds Ratio Predictor B S.E. Lower eB Upper Years of education .07* .04 .87 .93 1.00 Age in years .02 .01 1.00 1.02 1.04 Current depressive symptoms .51* .24 1.04 1.67 2.67 Curren t tenderness to touch .92** .24 .25 .40 .64 Current bladder problems .67** .25 1.21 1.96 3.17 Ethnicity O ther 1.44 ** .52 1.53 4.22 11.67 Constant .66 .96 .52 2 37.03 df 1 p < .05 ** p < .01 ANCOVA Replication Using Imputed Dataset. The same three 2 x 3 ANCOVAs were again performed using this imputed dat aset and covaried for these six predictors, as well as average weekly pain and PCL C score, to replicate current study procedures Across 10

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69 imputations of the data, r esults suggest a significant ma in effect of Mindfulness on Acceptance tertiles for four out of 10, with significance values ranging between p = .006 and .46. Among the four results suggesting significance below the .05 level, partial eta squared values ranged from .001 to .01. No signif icant main effect was seen for Mindfulness on pain type, nor was an interaction effect detected. Adjusted and unadjusted means are shown in Table 13 and Figure 7. Table 13 Comparison of Mean Mindfulness for Non Imputed vs. Imputed Datasets Non Imputed Imputed* Adj. M ( SE ) Unadj. M ( SD ) Adj. M ( SE ) Unadj. M Low Acceptance Fibromyalgia .18 (.09) .43 (.96) .11 (.09) .38 Chronic Pain .21 (.14) .32 (1.05) .05 (.16) .16 High Acceptance Fibromyalgia .12 (.09) .30 (1.01) .04 (.09) .27 Chronic Pain .22 (.12) .55 (.81) .23 ( .13) .51 Med Acceptance Fibromyalgia .05 (.08) .001(.80) .03 (.09) .01 Chronic Pain .07 (.14) .10 (1.0) .09 ( .16) .06 Note. All data presented as zscores. *Values are pooled. Figure 7. Adjusted Means for Mindfulness by Acceptance Tertile and Pain Type Using Imputed Dataset. -0.15 -0.1 -0.05 0 0.05 0.1 0.15 0.2 0.25 Fibromyalgia Chronic Pain Low Acceptance Med Acceptance High Acceptance

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70 ANCOVA results examining group differences among Acceptance tertiles and pain type within Experiential Avoidance suggest a significant main effect of tertile group for 9 out of 10 imputation series of the dataset, ( p range = .00 .09 ; p 2 range = .01 .04) Mean comparisons shown in Table 14 and Figure 8 show similar patterns found in the initial ANCOVA with non imputed data. Again, no main effect of pain type or interaction effect emerged for Experiential Avoidance. Table 14 Comparison of Mean Experiential Avoidance for Non Imputed vs. Imputed Datasets Non Imputed Imputed* Adj. M ( SE ) Unadj. M ( SD ) Adj. M ( SE ) Unadj. M Low Acceptance Fibromyalgia .18 (.07) .56 (.89) .09 (.07) .49 Chronic Pain .23 (.12) .41 (1.07) .20 (.16) .22 High Acceptance Fibromyalgia .14 (.07) .39 (.89) .11 (.08) .32 Chronic Pain .22 (.09) .75 (.96) .13 (.11) .65 Med Acceptance Fibromyalgia .01 (.07) .11 (.76) .01 (.07) .11 Chronic Pain .06 (.11) .06 (.84) .14 (.12) .08 Note. All data presen ted as zscores. *Values are pooled. Figure 8. Adjusted Means for Experiential Avoidance by Acceptance Tertile and Pain Type Using Imputed Dataset. -0.15 -0.1 -0.05 0 0.05 0.1 0.15 0.2 0.25Fibromyalgia Chronic Pain Low Acceptance Med Acceptance High Acceptance

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71 Two significant main effect s and an interaction between pain type and Acceptance tertile within Perceive d Dis ability were found. Among all 10 imputatio ns, a significant main effect was seen for pain type (all ps < .05; p 2 range = .01 .03), as well as a main effect for Acceptance tertile (all p s < .01 ; p 2 range = .02 .06). Results of seven out of 10 i mputation series suggest a significant interaction effect ( p range = .00 .12; p 2 range = .01 .02), with significant p values < .03. Mean comparisons are also displayed in Table 15 and Figure 9. Table 15 Comparison of Mean Perceived Disability for Non Imputed vs. Imputed Datasets Non Imputed Imputed* Adj. M ( SE ) Unadj. M ( SD ) Adj. M ( SE ) Unadj. M Low Acceptance Fibromyalgia .26 (.08) 50 (.89) .29 (.10) .47 Chronic Pain .37 (.14) .51 (.80) .19 (.17) .36 High Acceptance Fibromyalgia .03 (.09) .12 (.79) .05 (.09) .12 Chronic Pain .49 (.11) .86 (1.11) .44 (.14) .70 Med Acceptance Fibromyalgia .08 (.08) .13(.82) .11 (.17) .10 Chronic Pain .36 (.12) .35 (.93) .48 (.16) .34 Note. All data presented as zscores. *Values are pooled. Figure 9. Adjusted Means for Perceived Disability by Acceptance Tertile and Pain Type Using Imputed Dataset. -0.6 -0.5 -0.4 -0.3 -0.2 -0.1 0 0.1 0.2 0.3 0.4Fibromyalgia Chronic Pain Low Acceptance Med Acceptance High Acceptance

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72 CHAPTER V DISCUSSION Chronic pain is a debilitating health co ncern that is a significant financial and e motional burden for approximately 100 million Americans ( Institute of Medicine of the American Academies, [IOM] 2011 ) Among the many types of CP ; however, empirical evidence suggests FM is one of the most difficult to treat and outcomes are poorer across multiple life areas. There is currently a great need for improved treatment approaches, given a lack of broadly effective FM interventions Acceptance and Commitment Therapy (ACT) studies have shown promising findings in reducing pain r elated functional impairment in FM and CP samples by targeting Acceptance of pain and by ut ilizing Mindfulness techniques. Prior study findings also suggest that several key ACT concepts such as Experiential Avoidance and Mindfulness may be particula rly salient for FM due to the ways in which patients perceive their pain and functioning. Furthermore, previous findings indicate that profiling CP patients by levels of Acceptance has utility in identifying key influential traits and behaviors ( i.e., posi tive affect, pain related anxiety, depressive symptoms, and perceived disability) ; therefore, profiling FM patients in this manner may lead to more effective and targeted approaches. The overarching purpose of this study was to examine the roles of Accep tance, Experiential Avoidance, Mindfulness and Perceived Disability in FM and a co mparison group of CP participants in online support groups. This study aimed to conduct cluster analyses for each sample (FM vs. CP) by levels of Acceptance. Given these two sets of respective clusters (FM and CP), it was predicted that significant group differences would be seen in Experiential Avoidance, Mindfulness and Perceived Disability as ind icated by a series of ANCOVAs which assessed overall group differences by Acceptance level and pain type (FM and CP).

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73 Sample characteristics T otal online sample ( N = 552; Mean age = 46.7 years, SD = 11.7) was primarily female (92.2%), Caucasian, not of Hispanic origin (93.3%), married/partnered (66.6%), and well educated ( M = 1 4.7 years, SD = 3.0), with an average income ranging between $15k and $40k. Those who self reported a diagnosis of FM comprised 68.3% of the total sample ( n = 377 ) whereas those with CP, without FM, was smaller ( n = 175). Mean years with either FM or CP we re 14.4 ( SD = 11.1) and average weekly pain intensity was 6.5/10 ( SD = 1.7; 10 = extreme intensity) T he majority of the sample either reported having health insurance or was in the process of obtaining this (88.3%). Compared to Yahoo! Groups ( n = 63), m ore Facebook participants enrolled in the current study ( n = 489) Samples from both social media websites were predominately female ( Yahoo! Groups = 98.4% and Facebook = 91.4%), Caucasian, not of Hispanic origin (96.8%; 92.8% respectively ), middle aged ( M = 52.94; 45.9 years) and well educated (Yahoo!, mean years = 15.56 ( SD = 3.38); Facebook, mean years = 14.57 ( SD = 2.88). All participants were also primarily unemployed (not retired) (Yahoo! = 65.1%; Facebook = 58.1%) and had lower to middle ranging inc omes (range = $5,000 to $49,999 annually). Yahoo! Groups participants were significant ly older, less ethnically diverse, and more educated but no differences were seen between the two samples regarding occupational status or income. These differences like ly reflect variations in the type of onli ne participant who utilize Facebook or Yahoo! Groups. According to a 2014 Internet poll ( N = 1597) 71% of adults online use Facebook and more users are women (77% vs. 66% men), Hispanic (73%), White, nonHispanic ( 71%) and Black, nonHispanic (67%), and tend to be younger, as more are aged 18 to 29 (87%) and 3049 (73%) compared to those aged 5064 (63%), and 65 and older (56%) ( Duggan, Ellison, Lampe, Lenhart, & Madden, 2014 ) These findings also suggest only s ligh tly more Facebook users are more educated (74% = college or greater vs. 70% high school or fewer

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74 years) and earn a wide range of annual salaries : 77% = less than $30,000, 69% = 30k 49,999; 74% = 50k 74,999; and 72% earn 75k and greater The current stu dys Facebook sample is relatively consistent with these findings with the exception of ethnic diversity. Of note, younger age o f the typical Facebook user may be contributing to the significant contrast in age between the current samples mean age (45.9 y ears) and that of the Yahoo! Groups participant (52.94 years). Comparison to Yahoo! Groups users cannot be made as n o studies to date have been publishe d examining these characteristics. Both samples in the current study endorsed more diagnoses of FM (Yah oo! = 74.6%; Facebook = 67.5%) than CP without FM M ost common ly reported CP type among Yahoo! Groups participants included lower back (84.1%); lower limbs (79.4%); cervical spine (69.8%); and upper extremities (65.7%). Similarly, the Facebook sample endor sed the same primary locations of pain: lower limbs (76.9%); lower back (71.2%); upper extremities (70.0%); and cervical spine (67.5%) These findings are not surprising, given that the most prevalent sites of bodily pain include lower limbs, back, lower back, upper extremities and head (Breivik, Collett, Ventafridda, Cohen, & Gallacher, 2006 ; Tunks, Crook, & Weir, 2008). In regards to duration of pain, Yahoo! participants reported significantly more years ( M = 19.08 ( SD = 12.29)) than Facebook ( M = 13.83 ( SD = 10.77)). Conversely, Facebook members reported more pain related surgeries ( M = 3.58 ( SD = 4.0)) compared to Yahoo! ( M = 2.86 ( SD = 2.29)) but these differences were not significant No differences in average weekly pain severity were seen (6.43 ( SD = 1.66) = Yahoo!; 6.46 ( SD = 1.67) = Facebook). Due to the relatively few available studies examining Facebook or Yahoo! Groups CP online support groups comparisons to the current sample cannot be made. Representativeness of the Participant Sample Pain an d demographic characteristics of the current sample varied slightly from other general online FM and CP studies, but not substantially overall Compared to a 2007 online poll

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75 of FM patients ( N = 2596) who responded to a survey on the National Fibromyalgia Association website, the present studys FM sample is slightly younger (46.1 years vs. 47.3); more female (97.9 % vs. 96.8% ); less ethnically diverse (91.2% Caucasian, non Hispanic vs. 91.5%); similarly partnered (67.1% vs. 64.2%) ; and possibly had more yea rs in pain, but specific numbers were not described ( M = 15.5 vs. greater than 4 years = 75.5%) (Bennett et al., 2007). Annual household income wa s lower for current FM participants: 49 % earned between 5 and 49k vs. approximately 50% of respondents earne d between 20 and 80k. More current FM participants also received disability payments ( 46.1% ) vs. the online poll (20% disability and 6% workmans compensation). Similarities between a second online sample of FM and CP participants further suggest the cur rent samp le is largely representative (Lorig, Ritter, Laurent, & Plant, 2008). In comparison to online participants enrolled in a self management intervention for CP ( N = 855; 50.3% = FM; 27.5% = rheumatoid arthritis; and 63.6% = osteoarthritis), the curre nt sample was slightly younger, ( M = 46.7 vs. 52.4 years); slightly more female (92.2% vs. 90.2%); similarly less ethnically diverse (93.3% vs. 92.3% Caucasian, nonHispanic); similarly partnered/married (66.6% vs. 68.3%); and only slightly less educated ( M = 14.7 vs. 15.7 years). In sum, current participants appeared to be a representative sample of FM and CP patients. Hypothesis One Hypothesis One stated that the following three cluster groups would emerge in the FM sample: 1) Low Activity Engagement Low Pain Willingness; 2) High Activity Engagement High Pain Willingness; and 3) Moderate Activity Engagement Moderate Pain Willingness. This hypothesis was not supported, as five clusters with varying means emerged from the hierarchical cluster analysi s using Wards method. Activity Engagement and Pain Willingness means found within each of the five clusters suggest that two of the predicted groups emerged, the Low Low cluster (Mean AE = 13.35 (5.6); Mean PW = 8.21 (3.8); see Table 3, cluster 3) and t he Moderate -

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76 Moderate cluster (Mean AE = 30.1 (6.9); Mean PW = 28.9 (5.2); see Table 3, cluster 1) Close examination of the mean differences between the clusters suggest s several other notable differences. Overall none of the AE or PW means reached High l evels across all of the clusters (AE and PW mean range = 8.21 36.94). Given that the means for the AE subscale for FM participants ranged between 0 and 61, and PW mean values ranged from 0 to 46, this finding is surprising. Secondly, the three remaining clusters can best be described as ModerateLow (Clusters 2 and 5) and Low Moderate (Cluster 4). Given the lack of an established definition of CPAQ means and their respective cluster designation given their value, these categorizations only approximate the ir assignment. Compared to prior study findings found for CP participants (Costa & Pinto Gouveia, 2010; Payne Murphy & Beacham, 2014; Vowles et al., 2008) these FM clusters appear to be less differentiated with a tendency to represent only Moderate to Low mean values. This finding suggests that a large enough sample of FM participants self reporting High mean AE or PW scores is not present in the current sample ; therefore, the majority endorse less Acceptance of their pain. To date, this is the first stud y to examine cluster analysis using the Chronic Pain Acceptance Questionnaire in FM pati ents. Without comparison data it is difficult to conjecture why these particular clusters emerged in the current study and why they differ from prior CP samples. Speci fically, it is unclear if the response pattern on the CPAQ differed in this FM sample due to the unique characteristics of FM patients vs. those with CP but without FM ; if distinct differences within this particular FM sample c ontributed to these differenc es; or both of these phenomena. To briefly explore these possibilities, a series of single sample t tests were conducted to explore a possible difference between the current study FM participants and a prior stud ies FM samples ( n = 91) using CPAQ Activity Engagement, Pain Willingness and Total scores (PayneMurphy & Beacham, 2014). R esults suggest no significant differences between the two samples in regards to these mean scores, p range .25 .99. Similarly, a second series of single

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77 sample t tests were cond ucted to compare current FM participants and those with CP in previous studies across these same CPAQ ratings (Costa & Pinto Gouveia, 2010; Payne Murphy & Beacham, 2014; Vowles et al., 2008) Results suggest current FM patients had significantly lower Acti vity Engagement scores compared to all three ; significantly higher scores on Pain Willingness with the exception of one study (Payne Murphy & Beacham, 2014); and mixed values for Total Acceptance ( Costa & Pinto Gouveia, 2010; Payne Murphy & Beacham, 2014; Vowles et al., 2008). Although the comparisons herein may be rudimentary, they do suggest that perhaps FM may differ from CP samples in unique ways, which contribute to different clusters; however, further investigation is required to better assess this assumption. Perhaps the most important aspect of these comparisons is to introduce the further exploration regarding characteristics in FM populations. Despite a lack of clear, meaningful clusters emerging here, two prior studies that were conducted to bet ter identify key affective and physiological characteristics within FM do suggest the utility in profiling these patients to inform the design of future interventions For example, Loevinger et al.s (2011) study of FM patients ( N = 107) suggested four cluster groups emerging using both objective (physiological) and subjective (questionnaire) methods : those with 1) the most pain and disability, significant history of maltreatment in childhood, and hypocortisolism; 2) more physiological dysregulation and inc reased fatigue, pain, and disability; 3) intermediate pain severity, biomarkers within normal ranges, and increased global functioning; and 4) decreased disability and pain and increased psychological wellness ( Loevinger, Shirtcliff, Muller, Alonso, & Coe, 2011). Similarly, de Souza et al.s 20 09 study examined cluster analysis within an outpatient FM sample ( N = 61) using responses on the Fibromyal gia Impact Questionnaire (FIQ; Burckhardt, Clark, & Bennett, 1991; de Souza et al., 2009). Findings suggest t wo clusters emerged: those who had 1) decreased anxiety, depression and morning tiredness symptoms but high levels pain,

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78 stiffness and fatigue; and 2) high levels of pain, stiffness and fatigue and increased anxiety, depression, and morning tiredness. Re su lts indicate that the poorer functioning group also reported more pain catastrophizing, painrelated interference on daily living, and perception of life control Findings of these studies again highlight 1) the hetereogeneity in FM samples; 2) increased a ffective symptoms are associated with poorer pain ratings and disability; and 3) underline the need for treatment approaches that vary according to these symptom differences. Given these preliminary profiling attempts and meaningful clustering of CP groups further investigation of Acceptance profiling is needed in FM patients to better identify its utility. If three clust ers did not emerge, Hypothesis One stated that tertiles based on total Acceptance scores would be formed. T ertile scores suggest CP par ticipants reported greater Acceptance of pain, as indicated by highe r Acceptance scores in the CP vs. FM sample ( CP Mean = 58.01, FM Mean = 49.18) This approximate 10point contrast between FM and CP is seen in other studies, with FM again endorsing lowe r scores: ( M = 40.9, Rodero et al., 2010; M = 47.6, Rodero et al., 2013) CP sample means tend to hover closer to 50 ( M = 50.6, Vowles et al., 2007; M = 50.4, Vowles et al., 2008; M = 52.61, Costa & PintoGouveia, 2010). Notably, the current sample reflect s overall higher Acceptance levels for both FM and CP. Hypothesis Two Hypothesis Two stated that the same three cluster groups would emerge in the CP sample: 1) Low Activity Engagement Low Pain Willingness; 2) High Activity Engagement High Pain Willing ness; and 3) Moderate Activity Engagement Moderate Pain Willingness by conducting the identical analysis. This hypothesis was also not supported, as four clusters emerged within the CP sample ( refer to Table 4 ) Despite this difference, similar clusters did emerge: one Low Low (cluster 3); one High High (cluster 2); and two Moderate Moderate groups (clusters 1 and 4). In fact, cluster 1 most resembles the third group found in Payne Murphy & Beacham s 2014 study, the Med Med cluster and cluster 4 is similar to Cost a &

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79 Pinto Gouveia s High Activity Engagement and Low Willingness group (2010) However, g iven that three p rior studies conducting CPAQ cluster analyses within CP samples found exactly three nearly identical distinct groups (Costa & PintoGouveia, 2010 ; Payne Murphy & Beacham, 2014; Vowles et al., 2008), the current studys findings are surprising. Again, a brief series of analyses were conducted to examine mean differences between these samples to determine if there may be distinguishin g factors within the current sample contributing to these notable outcomes. Results of single sample t tests using CPAQ Activity Engagement Pain Willingness and Total means of the current CP sample and these three prior studies do suggest significant diff erences, however, with higher ra tings found in the current sample (all p < .05; Costa & PintoGouveia, 2010; Payne Murphy & Beacham, 2014; Vowles et al., 2008). Also, a comparison of PDI scores between the current and prior stud ie s CP respondents indicate s significantly lower perceived disability was found in the current sample ( p < .01; Payne Murphy & Beacham, 2014). It is noteworthy that the current CP participants report ed greater Acceptance of their pain and they perceived themselves as less disab led in comparison to previously studied patients. This result may offer useful explanation regarding why three similar clusters did not emerg e. Secondly, previous discussion related to the reliability of cluster analysis has suggested inconsisten cies in the abi lity to reproduce similar clusters, which represents a weakness in this type of analysis ( Gore, 2000 ). Therefore, the current findings may be partly attributed to this. Again, as in Hypothesis One, tertiles based on levels of Acceptance were then calculated for the CP sample. Hypothesis Three Hypothe sis Three stated that self reported scores of Perceived Disability, Mindfulness and Experiential Avoidance would differ overall by Accepta nce level (Low, High, and Moderate ) group (main effect for Acceptance tertile ) and by pain type (FM or CP; main effect for pain type )

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80 controlling for average pain rating in past week and degree of PTSD symptomatology. A series of three 2 x 3 betweensubjects analyses of covariance were performed. The first was conducted on lev els of Mindfulness as measured by the Five Facet Mindfulness Questionnaire (FFMQ SF), the second on levels of Experiential Avoidance as measured by the Acceptance and Action Questionnaire (AAQ), and the third on levels of Perceived Disability via the Pain Disability Index (PDI). Mindfulness Results of the ANCOVA using Mindfulness as the dependent variable suggest that this hypothesis was partially supported: one main effect was found for Mindfulness indicating these scores differed significantly by Accept ance tertiles. No main effect was seen for Mindfulness by pain type (FM and CP). Highest Mindfulness scores were found in the High Acceptance tertile group; the lowest are i n the Low tertile; and moderate means are in the M oderate tertile (see Table 7) Th ese findings suggest that Mindfulness is an important factor related to increasing levels of Acceptance in both FM and CP patients. Both prior research and theory are concordant with this finding. In Costa and PintoGouveias 2010 study, significant differences were seen between levels of M indfulness and the Low Low and High High Acceptance clusters, also with the highest scores in the High High and least in the Low Low. As previously described, there are minimal empirical findings delineating the precise r elationships and mechanisms of action between Mindfulness and Acceptance; however, current results provide further support for these theoretical associations (Block Lerner et al., 2005; Mitmansgruber, Beck, Hfer, & Schler 2009). Notably, no significant differences were found in Mindfulness scores by pain type (FM and CP). Given the greater variety of physical symptoms and higher rates of psychological distress found in those with FM compared to CP, it is surprising that differences did not emerge, with FM showing decreased levels. However, a review of prior FM studies assessing the role of Mindfulness, coupled with the current findings, may suggest that its r ole appears to be 1) simply

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81 comparable in those with CP and 2) influential, but prior studies li mitations and inconsistencies in measuring Mindfulness obscure measuring its true impact and illuminating its mechanism of action. For example, in a 2014 systematic review of Mindfulnessbased studies for FM patients, 10 studies were found to show positiv e associations with increased Mindfulness and psyc hological and physical factors. These include d reductions in anxiety, depression, somatic complaints, and pain severity and improvements in self reported quality of life (Henke & Chur Hanson, 2014). However high attrition rates, small samples, l ack of comparison groups, and inconsistencies among treatment modalities (MindfulnessB ased Stress Reduction and Qi Gong ) were prevalent study limitations Two randomized control studies among these 10 also suggest t hat improvements seen in Mindfulness intervention participants were not significantly greater than those in the active control comparison group ( Astin, Berman, Bausell, Lee, Hochberg, & Forys 2003; Schmidt, Grossman, Schwarzer, Jena, Naumann, & Walach, 2011). Significant improvements between the study arms were found, however, in the remaining study with an active control group ( Grossman et al., 2007) The authors conclude that these findings overall, suggest similar efficacy rates to mindfulness based in terventions for CP and that more interventions of high quality are needed to better determine its impact in FM patients (Henke & Chur Hanson, 2014). Given these findings, as well as previously discussed challenges in defining Mindfulness across studies, i t appears from the current results that although Mindfulness is positively associated with Acceptance of pain, there are not significant differences in its role between those with CP or FM. As prior studies have recommended (McCracken, GauntlettGilbert, & Vowles, 2007) further investigation of its role and how it may aid in increasing Acceptance is needed. Experiential Avoidance. Results of the ANCOVA using Experiential Avoidance as the dependent variable also suggest that this hypothesis was partially supported: one main effect was

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82 found for Experiential Avoidance indicating that these scores differed significantly by Acceptance tertiles. No main effect was seen for Experiential Avoidance by pain type (FM and CP). Table 9 shows that as Acceptance level increase s Experiential Avoidance decreases respectively across all tertiles Although this appears to be the first study to compare Experiential Avoidance in an FM and CP sample, the current findings are highly consistent with the sole existing study assessing the relationship between Experiential Avoidance and Mindfulness in FM patients (Henke, 2011); the two studies examining its role in CP samples ( Esteve, Ramrez Maestre, & Lpez Martnez, 2012; Ramrez Maestre, Esteve, & Lpez Martnez, 2014) ; and la stly its previously discussed role in nonpain samples (Bond et al., 2011; Hayes et al., 2003; Gird & Zettle, 2009; Karekla, Forsyth, & Kelly, 2004). In Henkes 2011 study, a significant and negative correlation ( r = .67, p < .01) was found between Experi ential Avoidance and Mindfulness levels (as reported by the AAQ and FFMQ) among online FM participants ( n = 53) P reliminary studies investigating Experiential Avoidance in CP samples, as measured by the AAQ, also show increased levels associated with poor er functional and negative affect including depressive and anxiety symptoms and catastrophizing Among a large outpatient sample diagnosed with chronic back pain ( N = 686) significant negative correlations were also seen between Experiential Avoidance an d Acceptance ( r = .45) and between Experiential Avoidance and resilience ( r = .48) ( ps < .05 ; RamrezMaestre, Esteve, & LpezMartnez, 2014 ). Significant positive correlations were also found in this same sample between Experiential Avoidance and pain intensity ( r = .30); functional disability ( r = .22); depression ( r = .30); anxiety ( r = .44); catastrophizing ( r = .51 ); hypervigilance of pain ( r = .40); fear avoidance beliefs ( r = .40) and physical limitations due to pain per the Roland Morris Disabil ity Questionnaire ( r = .25), ( all ps < .05 ; Roland & Morris, 1983) A second outpatient study ( N = 299) examining CP participant s self report ed symptoms also showed positive and significant correlations between Experiential Avoidance and

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83 catastrophizing ( r = .26; p < .01); pain intensity ( r = .12; p < .05); anxiety ( r = .17; p < .01 ); and depression ( r = .12; p < .05), respectively ( Esteve, Ramrez Maestre, & Lpez Martnez, 2012). Coupled with current findings, self reported Experiential Avoidance appe ar s to be an important factor in the experience of patients with either FM or CP due to its relationship with affect and physical functioning. Similar to the present studys nonsignificant findings regarding Mindfulness and pain type, it is surprising that no differences were found between FM and CP samples in regards to Experiential Avoidance. As previously noted, there is only one FM intervention study addre ssing fear avoidance behaviors ( Lumley et al., 2008) and none examine Experiential Avoidance direct ly ; however, these two constructs are found to have positive associations with one another in a CP sample ( p < .01, r = .39; Ramirez Maestre, Esteve, & LopezMartinez, 2014). Again, further study of Experiential Avoidance is needed to illuminate its role r egarding functional outcomes within FM populations specifically. Perceived Disability. Results of the ANCOVA using Perceived Disability as the dependent variable suggest that this hypothesis was supported: two main effects were found, one indicating that P erceived Disability scores significantly differed by Acce ptance tertiles and the second suggesting that s cores differed by pain type (FM and CP). As predicted, Figure 5 shows that as Acceptance level increases, Perceived Disability decreases. Prior CP stud ies have found identical findings with significant group differences among Acceptance cluster groups and Perceived Disability (Payne Murphy & Beacham, 2014; Vowles et al., 2008). Specifically, MANCOVA and ANCOVA results in these studies indicated significant group differences with lowest Perceived Disability means found in the Hig hHigh AE PW cluster; highest means in the Low Low AE PW cluster; and moderate values in the mixed/moderate cluster. Significa nt differences seen between pain type ( CP and FM ) her ein are also highly consistent with prior studies Table 11 indicate s that FM patients Perceived Disability is

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84 significantly greater than CP patients reports. Similarly, a 1997 study comparing patients with either FM ( n = 36) or rheumatoid arthritis ( n = 36), found that FM patients had significantly higher self reports of disability functioning across 7 out of 10 subscales (i.e. physical, mental health, social and r ole function) on the Short Form 36 (all ps < .01; Stewart, Hays, & Ware, 1988; Walker et a l., 1997). In a second study examining predictors of disability in chronic low back pain ( n = 35), complex regional pain syndrome ( n = 22), and FM patients ( n = 54), those with FM reported significantly greater disability accor ding to Short Form 36 and Fib romyalgia Impact Questionnaire scores ( Burckhardt, Clark, & Bennett, 1991; Verbunt, Pernot, & Smeets, 2008). Follow up analyses suggest FM patients reported disability was primarily due to mental health ratings that indicated greater emotional distress, r egardless of reported physical disability. This finding for FM patients is also consistent with previously discussed empirical evidence suggesting higher perceived disability is predicted by catastrophizing, fear of pain, low self efficacy, and avoidance o f activities for fear of exacerbating pain in both FM and CP groups (Dobkin et al., 2010; Karsdorp & Vlaeyen, 2009; Martin et al., 1996; Severeijns, Vlaeyen, van den Hout, & Weber, 2001; Turk, Robinson, & Burwinkle, 2004). Discussion regarding pain type di fferences will be further explored in Hypothesis Four section. The Role of Trauma. Across all three ANCOVAs, post traumatic symptom severity as self reported by the PCL C, was found to be significantly associated with group differences in Acceptance. P CL C mean scores for FM patients in the current study total 48.7 ( SD = 13.9) whereas CP patients scores were lower ( M = 41.9 ( SD = 16.5)). Results o f an independent t test suggest these differences are significant, t (463) = 4.58, p < .01. Recommended cut offs for the use of the PCL C in pain populations suggest a total score range of 3644 is roughly equivalent to a PTSD prevalence between 16 and 39% ( VA National Center for PTSD 2012 ). Therefore, prior trauma and related sympto ms in the current sample app ear to be prevalent, with FM participants reporting greater severity.

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85 Current findings are also highly concordant with research regarding trauma in FM, Acceptance, and Exper iential Avoidance. As previously cited, empirical evidence suggests 31.3 to 57% of those with FM endorse trauma histories and/or symptoms of PTSD (Bennett et al., 2007; Cohen et al., 2002; Sherman, Turk & Okifuji, 2000). Furthermore, self reported functional disability w as significantly higher in FM patients ( n = 93) with trauma symptom s than FM patients without trauma (Sherman, Turk & Okifuji, 2000). A pproximately over 85% of FM patients in this study with trauma had a high degree of disability whereas only 50% of those FM patients without trauma symptoms had comparable levels (Sherman, Turk & Okifuji, 2000). As discussed previously, prior findings also suggest that Experiential Avoidance either predicted PTSD symptom severity and depression/general psychological distress (Batten et al., 2002; Marx & Sloan, 2002; Plumb, Orsillo, & Lutere k, 2004); or mediated the relationship between trauma and PTSD (Orcutt, Pickett, & Pope, 2005). It is clear that t rauma impedes FM patients ability to optimize functioning. Although this is not the focus of the present study, it is clear from curr ent and prior findings that addressing PTSD symptoms are a critical element in future FM interventions. Hypothesis Four Hypothesis Four stated that a total of three interaction effects would occur between t ertile groups (Low, High, Moderate ) and pain type (FM and CP), one for each dependent variable (Mindfulness, Experiential Avoidance and Perceived Disability). This hypothesis was partially supported as Perceived Disability was found to have an interaction effect. A s levels of Acceptance increased, FM and CP par tic ipants changed in regards to Perceived Disability levels, with a trend towards less change in Perceived Disability across the tertiles in the FM group (see Figure 6) Subsequent analyses further revealed this trend reflected significant differences betw een the two pain groups such that the rate of Perceived Disability change across Acceptance tertiles was indeed less in the FM (rs(331) = .28, p < .01) vs. the CP sample (rs(149) = .44, p <

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86 .01). Secondly, additional analyses indicate significant differe nces between pain type and Perceived Disability at both the M oderate and High Acceptance levels but not at the Low tertile (rs(152) = .02, p = .81). Taken together, these findings suggest that despite i ncreases in Pain Acceptance FM participants percepti ons of their own disability decreased very little when compared to perceptions held by those with CP. This was an unanticipated finding given that prior research suggests that interventions targeting increased Acceptance in FM contributed to significant decreases in Perceived Disability at post treatment and 3month follow up, with medium to large effect sizes between the intervention and control group ( d = .75 at post treatment; d =.73 at 3month follow up) ( Wicksell et al., 2012). Results from a second ACT intervention study with approximately 30% FM patients ( n = 22) also suggest decreases in self reported disability at 3 month follow up ( d = .58; McCracken, Sato & Taylor, 2013) Therefore, current findings suggest that the role of Acceptance may diffe r for FM in comparison to CP patients. An important consideration regarding the current findings is the possibility that self rated Perceived Disability is accurately reflecting objective disability in both the FM and CP samples, and FM participants had o bjec tively higher rates of impairment, given empirical evidence of increased physical and affective symptomatology Given that the present study did not measure functional disability with objective measures coupled with the inherent and significant challe nges of objectively measuring physical disability, this theory cannot be assessed However, for those whose disability is perhaps objectively greater and accurately reflecting disability perceptions, higher levels of Perceived Disability would be appropria tely commensurate with Acceptance. A second possibility is that FM participants were simply more likely to perceive themselves as disabled regardless of physical limitations and higher levels of Acceptance. Findings suggest that FM participants in the Moderate and High Acceptance tertiles overall reported relatively higher Pain Willingness, that is, the willingness to accept pain and all related

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87 life impact, and higher Activity Engagement, or the act of engaging in valued life activities despite pain and r elated sequelae. Perhaps higher ratings of Perceived Disability reflect a perception that one is less physically capable (regardless of objective disability) but despite this view, these individuals continue to engage in life activities and accept their pa in, just as their CP participant counterparts report This finding also suggests that when we consider Acceptance as a treatment target, the influence of Acceptance in FM differs from CP such that although it continues to be predictably negatively associ ated with Perceived Disability, it is perhaps a less potent predictor. A third possibility is that there is secondary gain in reporting higher levels of Perceived D isability regardless of Acceptance of ones pain for FM patients Again, prior studies have suggested more FM patients report greater P erceived D isability than those with CP ( Verbunt, Pernot, & Smeets, 2008; Walker et al., 1997; White et al., 2002). Study findings also suggest that following receipt of disability payment or when involved in liti gation pain affective symptoms tend to worsen in FM patients (Clauw, 2004 ; Hadler, 1996) Authors suggest this is related to the challenges posed by th e system : it is costly, distressing, and reinforces behaviors contrary to pain rehabilitation. P atients are also indirectly and unintentionally en couraged to present as more ill to be awarded benefits (Clauw, 2004; Hadler, 1996). Consistent with the theory of pain behaviors (see operant behavioral therapy section herein) responses on the PDI serve not only to simply state ones perceptio ns but also provide an opportunity to communicate deeply held beliefs about his/her illnessrelated physical and emotional impairment which have been previously expressed to elicit support or positive attention. Perhaps when given this opportunity to communicate these beliefs, FM patients reports may reference these prior or current perceptions that are positively reinforced (i.e. via emotional support financial via disability payment, or other), of which they may or may no t be fully cognizant.

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88 Supplemental Analyses Given systematic missing data in the current study a logistic regression was first conducted to better determine the demographic variables contributing to predictors of attrition. The following contributing fa ctors were consistent with prior research: fewer years of education; older age of participant; primary ethnicity identified as other; and absence of symptoms of tenderness to touch; bladder symptoms; and depressive symptoms experienced within the past seven days ( Table 12 ). H owever, conclusiv e predictors of attrition from I nternet studies have not been published ( Bi ller, Arnstein, Caudill, Federm a n, & Guberman, 2000; Hart, 1982; Melville, Casey, & Kavanagh, 2010 ). Multiple imputation was then conducted to fully addres s the limitations presented by missing data. Repeated analyses using i mputation were found to be high ly consistent with all original analyses; variations from these are presented herein. ANCOVA results using Mindfulness as the dependent variable show ed very similar findings. Among the 10 imputed datasets that were created in the multiple imputation procedure, four showed main effects on Acceptance tertile. Effect sizes between the original and imputed analyses were also comparable: p 2 = .02 vs p 2 = .001 to .01, respectively. Just as the initial ana lyses had shown, no main or interaction effect for pain type on Mindfulness was found. Likewise, nine out of 10 imputations of the dataset tha t underwent ANCOVA analyses using Experiential Avoidance as the dependent variable were significant, reflecting a main effect of Acceptance tertile. Small effect sizes were comparable between initial and imputed analyses: p 2 = .02 vs. p 2 = .001 to .04, respectively. Again, no main or interaction effect of pai n type was found for Experiential Avoidance just as in initial analyses. Imputed results from the Perceived Disability ANCOVA show identical findings to the initial analyses: significant main effects of both Acceptance tertile and pain type, as well as an interaction effect. Ac ross all three effects, all 10 of 10 analyses using imputed data were

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89 significant. All effect sizes were highly consistent with initial findings: p 2 = .06 vs. p 2 = .02 to .06, respectively for the main effect of Acceptance; p 2 = .02 vs. p 2 = .01 to .03 for the main effect of Experiential Avoidance; and p 2 = .02 vs. p 2 = .01 to .02 for the interaction effect. Overall, imputed results suggest th at initial analyses do not significantly differ despite bias contributed by attrition. Limitations The primary limitation in this study is systematic bias attributed to significant attrition, which totaled 409 participants approximately 37.7% of 1085 par ticipants who originally initiated the survey Length of the survey was likely a primary deterrent (total questions = 314) which may have taken participants up to 60 minutes to complete. More generally, attrition in online survey research studies is a prevalent and significant problem ( Eysenbach, 2005) : an estimated 34% dropout is common, ranging from one to 87% for online studies ( Joinson, 2007; Reips & Musch, 2000). This was an anticipated challenge in the present study, and as pr evious research has reco mmended, a gift card incentive was presented and demographic questions were posed at the start of the survey, as opposed to the end, to encourage survey completion and convey a message of full disclosure on the part of the researcher (Frick, Bachtinger, & Reips, 1999; Reips & Musch, 2000) Previous findi ngs suggest a financial incentive increased online retention from 55% to 87% (Reips & Musch, 2000) and informing participants of this incentive and demographic questions at survey start reduced dropout from 21.9 to 5.7% (Frick, Bachtinger, & Reips, 1999). To account for this bias in the current study a logistic regression and multiple imputation analyses were conducted, and covarying for the demographic variables that were found to contribute to this bias w as implemented, according to prior method ( Schafer & Graham, 2002). Specifically, this method minimizes the influence of bias and renders data Missing at Random in order to meet the assumptions of multiple imputation analyses ( Schafer & Graham, 2002).

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90 Fort unately, the current studys i nitial analyses were found not to differ significantly from the imputed analyses. A second limitation was the collection of retrospective self reports from participants. Retrospective data is found to contribute to inaccuracies in self report s : therefore, prospective data collection is preferable, in which participants are assessed and followed over time ( Kazdin, 2003). S pecifically ecological momentary assessment using smartphone or wristwatch technology may help to reduce recall bias ( Shiffman, Stone & Hufford, 2008). To strengthen future study designs, inclusion of collateral assessments such as semistructured questionnaires administered to participants significant others or health providers may be particularly helpful i n a CP population due to the complex contributions of affective, physical and pain behaviors. Utilizing behavioral/objective measures would also strengthen this study design, particularly physical performance assessments to measure objective disability, as previously noted. For example, isodynamic lifting and pushpull tasks (Rudy, Lieber, Boston, Gourley, & Baysal, 2003), or ecological momentary assessment using technology that records movement and randomly alerts participants to report their current activ ities in real time there by assessing active engagement and not simply their intentions or past reported activities, which are subject to bias ( Shiffman, Stone & Hufford, 2008) These measures would also help to verify subjective ratings and provide conver gent validity, particularly because all data collection was conducted online (Kazdin, 2003). It should be noted that enrolling online participants is self limiting as well, such that FM and CP patients who are not members of support group or Internet user s more generally, are naturally excluded from participation. However, because online recruitment was an intentional feature of the current study, the enrolled sample did appear to be representative given reported comparisons, with the exception of minorit y representation. Because this was particular ly low in the current study, special recruitment efforts should be made to widen enrollment to minority

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91 participants in the future Lastly, prior research conducting cluster analysis has described inconsistenc ie s in reproducing the same clusters: therefore, the limitations of this type of methodology may have contributed to difficulties in three clusters emerging (Gore, 2000). Future Directions Further investigation is needed to determine the underlying factors that contribute to the present findings to better inform multidimensional treatment designs for FM. An important first step is to examine the components of Pain Acceptance, specifically Activity Engagement and Pain Willingness scores, within both the FM and CP samples to see if differences can further illuminate the differing mechanisms of Acceptance between the two pain types. A closer examination of these and other characteristics within the M oderate and High Acceptance tertile groups may also be particu larly informative, such that one factor may be more salient than another for FM vs. CP patients. Given findings that Perceived Disability significantly differed by pain type and Acceptance tertile, future areas of exploration might examine how these value s differed relative to objectively rated disability, as previously discussed. Alternative measures assessing sick role, pain behaviors, and valued life activities via the Valued Living Questionnaire, which assesses important life goals and confidence to wo rk towards them ( Jensen, Vowles, Johnson, & Gertz, 2015), may better inform these Perceived Disability discrepancies found in the FM sample as well. In terms of reducing attrition, future attempts to narrow the number of questions posed in online survey s w ill likely encourage retention. Results from p rior research encourage increased staff contact (i.e. via email, telephone, or inperson) as well (Buhrman et al., 2004; Guttberg, 2007). Lastly, efforts to increase availability of online study and treatment approaches for CP and FM are critical, such that they report commensurate outcomes and are a more affordable and accessible alternative for CP patients experiencing significant physical symptoms and

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92 psychological distress (Macea et al., 2010). Given early findings suggesting the efficacy of ACT interventions for FM patients ( McCracken et al., 2013; Wicksell et al., 2012), further work must 1) build to both identify these key treatment targets and profile patients based on these specific characteristics of this population, given known heterogeneity; and 2) provide accessible and affordable de livery of treatment approaches, of which online methods are a viable and increasingly popular alternative. Clinical Utility. P rofiling CP patients based on characterist ics and constructs that are found to improve functional and affective outcomes is a well known theoretical discussion in the pain literature (Turk, 2005) T here remain s to be a substantive literature supporting design and implement ation of more effective profile based pain interventions. Current study findings support prior research efforts to promote these tailored interventions such that clustering better identified patients with CP according to degrees of Activity Engagement and Pain Willingness, constructs which have been demonstrated to improve outcomes for both CP and FM patients in intervention studies ( Veehof, Oskam, Schreurs, & Bohlmeijer, 2011; Wicksell, 2014). Despite CP patients clustering into four instead of the predicted three groups, these cl usters clearly differentiated these patients in similar ways compared to prior studies and may be considered to be clinically meaningful. Clustering CP patients using either Total Pain Acceptance ratings or AE and PW subscores has clear implications for im proving perceptions of ones own disability, as well as Experiential Avoidance and Mindfulness, as indicated by current findings. Administering the CPAQ, a brief 20item measure, to clinical patients would aid in quickly identifying patients degree of pai n willingness and engagement into these three or four groups which can thereby readily inform case conceptualization and treatment planning for behavioral intervention Additionally, building this questionnaire administration and cluster assignment into c linical procedures will serve to better identify greater numbers of patients by these constructs, thereby informing tailored practice based individual or group interventions given cluster membership.

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93 FM clusters were not as definitive however, and current findings and comparisons to other FM and CP samples suggest that more investigation must be done to determine the unique ways in which Acceptance impacts and serves FM patients. Given current findings for FM participants and comparison to other CP sample s, future clinical efforts should emphasize increasing engagement in valued activities, despite the presence of pain, as well as exploring the mechanisms that underlie his/her perceptions of disabilit y to better determine how this influences Pain Acceptanc e and ultimately, adaptive functioning. Summary and Conclusions Overall study aims were to determine the roles of Acceptance, Mindfulness, Experiential Avoidance, and Perceived Disability in FM and CP patients. We initially conducted two cluster analyses on FM and CP online support group members, respectively, based on self reported levels of Pain Acceptance, specifically Activity Engagement (AE) and Pain Willingness (PW). Predicted clusters did not emerge, suggesting AE and PW present differently in FM pa tients in comparison to those with CP These results also suggested that the current CP sample differed from prior studies findings as well although four clusters were si milar to the hypothesiz ed three Subsequent results of a series of ANCOVAs and foll ow up correlations indicated that although both Acceptance level was positively associated with Mindfulness and negatively associated with Experiential Avoidance, there were no significant differences between these scores and pain type (FM or CP). Therefor e, this supports prior findings that Mindfulness and Experiential Avoidance are significantly associated with Acceptance of pain, but do not appear to be as uniquely salient to the FM experience as we had predicted. Results of the ANCOVA and follow up corr elations examining the role of Perceived Disability, however, did reveal significant differences in scores by Acceptance tertiles (High, Low and Medium) and pain type (FM or CP). These f indings indicate that with increasing levels of Acceptance, CP patient s perceptions of their own disability decrease concordantly; however, FM patients perception decreases only

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94 slightly in comparison, thereby continuing to perceive themselves as disabled in various life domains. Given these findings as well as prior empi rical evidence, further investigation is needed to fully address the factors contributing to Perceived Disability among FM patients and to further explore why this differs from those with CP. Implications from these results include 1) Acceptance is an impo rtant psychological concept that predicts Perceived Disability differently between online CP and FM samples; 2) Acceptancebased profiling is an important method of characterizing those with FM and CP; and 3) Acceptancebased profiling used to inform online interventions provides both CP populations and the field with an alternative and affordable approach that may improve the efficacy and effectiveness of existing multidimensional pain treatments.

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123 Transition from acute to chronic pain and disability: a model including cognitive, affective, and trauma factors. Pain 134(1), 6979. Zettle, R. D., Barner, S. L., Gird, S. R., Boone, L. T., Renollet, D. L., & Burdsal, C. A. (2012 ). A Psychological biathlon: The relationship between level of experiential avoidance and perseverance on two challenging tasks. The Psychological Record 62 (3), 433. Zettle, R. D., Hocker, T. R., Mick, K. A., Scofield, B. E., Petersen, C. L., Song, H., & Sudarijanto, R. P. (2005). Differential strategies in coping with pain as a function of level of experiential avoidance. The Psychological Record, 55 (4), 1.

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124 APPENDIX A GROUP MODERATOR INVI TATION TO POST STUDY V e r s i on O ne: W e a r e r e s ea r che r s from t he U ni ve r s it y of Co l o r ado D enver conduc ti ng a st udy on pe rs ons w it h ch r on i c pain W e w oul d li ke t o po s t a t o t a l of 3 i nv it a tions t o g r oup m e m be r s t o t ake an onli ne s u r v e y The s u r vey w i l l t ake 3045 mi nu t es and w i l l add r e s s behav i o r a l p s ycho s oc i a l and m e di cal as pec t s of ch r on i c pain and t he fi nd i ngs w il l f urt h e r our unde r s t and i ng of t he ch r on i c pain expe ri ence. If members choose to participate in the study, they will have the opportunity to enter a drawing for one of up to ten $50 Amazon.com or Amazon.eu gift cards. A copy of the Internet survey is attached for your review: [link here]. V e r s i on T w o: W e a r e r e s ea r che r s conduc ting a st udy on pe rs ons w it h ch r on i c pain. W e w ou l d l i ke t o po s t 3 i nvita ti ons t o g r oup m e m be r s t o t ake an on li ne s u r v e y If mem bers choose to participate in the study, they will have the opportunity to enter a drawing for one of up to ten $50 Amazon.com or Amazon.eu gift cards. A copy of the Internet survey is attached for your review: [link here]. The fi ndi ngs of t h i s st udy w i l l f ur t her our unde rst an d i ng of t he ch r on i c pain expe ri ence. V e r s i on Th r ee: W e a r e r e s ea r che r s st ud yi ng pe rs ons w it h ch r on i c p ain W e w oul d l i ke t o i nv it e g r oup m e m be r s t o t ake an on l i ne s u r v e y If members choose to participate in the study, they will hav e the opportunity to enter a drawing for one of up to ten $50 Amazon.com or Amazon.eu gift cards. A copy of the Internet survey is attached for your review: [link here]. The fi n di ngs of t hi s s t udy w il l f u rt he r our unde r s t and i ng of ch r oni c p ain.

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125 APPENDIX B GROUP MEMBER INVITAT ION TO PARTICIPATE Y ou are i nvited t o t ake part i n a research s t ud y : AcceptanceBased Factors in Chronic Pain: A Comparison Between Fibromyalgia and Low Back Pain Patients in an Internet Support Group Sample (COM IRB N o: 133263) T h i s s t ud y i s be i ng l ed by Jessica PayneMurphy, M.A. at t h e Un i vers i t y of Co l orado Denve r T he s t ud y i nvo l ves answer i ng a ser i es of on li ne ques tionna i res des i gned t o i ncrease unders t an di ng of chron i c pain. W e are i nv iting par t i c i pa nt s ( age 18 and o l d er) who have been and are curren t l y managing low back pain or fibromyalgia for at l east 3 m on t hs t o c o m p l e t e an onlin e surv e y It i s an ti c i pa t ed t hat t h i s surv e y w ill t ake approxi m a t e l y 30 45 m i nu t es of y o ur t i m e t o c o m p l e t e. If you choose t o participate in the study, you will have the opportunity to enter a drawing for one of up to ten $50 Amazon.com or Amazon.eu gift cards. In addi ti on, w e request t hat y o u forward / share t he surve y li nk t o o t her i ndi v i dua l s w it h chronic low back pain or fibr omyalgia w ho m a y w i sh t o par t i c i pa t e i n t h i s st ud y so t hat t he y m a y have t he oppor t unity t o ass i st us i n ga t h er i ng i nfo r m a t i on about chron i c pain and on li ne support groups. P l ease c li ck on t he fo ll ow i ng link i f y ou are i n t erest ed i n l earn i ng m or e about t h e resea r ch s t ud y :

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126 APPENDIX C INFORMED POSTCARD CO NSENT Study Title: AcceptanceBased Factors in Chronic Pain: A Comparison Between Fibromyalgia and Low Back Pain Patients in an Internet Support Group Sample Principal Investigator: Jessica PayneMurphy, M.A. COMIRB No: 13 3263 Version Date: 12/27/13 Y ou are being asked to be in this research study because you have been managing low back pain or fibromyalgia for at least three months and you are at least 18 years of age. This study is designed t o learn more about peoples experiences of chronic pain. Up to 600 people will participate in the study. If you join the study, you will complete a series of online questionnaires that asks questions about your health behaviors, such as exercise, tobacco, alcohol, and drug use ; pain ; your mental health; and psychological topics. Most people complete the online questionnaire in 3045 minutes. The foreseeable risks to you for taking part in the online questionnaire are expected to be minimal. However, ans wering questions about health, mental health, and psychological topics may cause some psychological/emotional distress. This will likely be temporary. Should you feel the need to talk with someone, you may contact the National Suicide Hotline at 1800273 8255. There may be risks the researchers have not thought of. Your rese arch information will be completely anonymous. The results from the research may be shared at a meeting or published in articles. However, information from the study will be combined with information from all persons who participate in the study. Although there is no immediate benefit to you for completing the questionnaire, information gained from the study will increase our understanding of peoples experience of chronic pain. Increased knowledge about people with chronic pain may help improve treatments and outcomes. If you choose to participate in the study, you will have the opportunity to enter a drawing for one of up to ten $50 Amazon.com or Amazon.eu gift cards. In order to enter the drawing, you will need to enter your name and email address when you click on this hyperlink. Providing this information is entirely optional, but necessary if you would like to be entered in the drawing. Your name and email address will not be used for any purpose other than emailing you the gift card, should your name be chosen in the drawing. It will not cost you anything to be in the study. Every effort will be made to protect your privacy and confidentiality by securing your personal contact information and responses via an institutional server that is encrypted a nd password protected.

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127 You have a choice about being in this study. You do not have to be in this study if you do not want to be. If you have questions, you can call Jessica PayneMurphy at (303) 5569765. You can call and ask questions at any time. You may have questions about your rights as someone in this study. If you have questions, you can call the Multiple Institutional Review Board (IRB). Their number is (303) 724 1055. By completing this survey, you are agreeing to participate in this resea rch study.

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128 APPENDIX D GIFT CARD INCENTIVE LOTTERY As a thank you for your time and participation, we would like to offer you the opportunity to be entered into a drawing for 1 of 10 $50 Amazon.com or Amazon.eu gift cards (1 gift card pe r every 30 50 participants). Please note that the information you provide us will not be used for any other purpose than to send you the gift card, should you be selected in the drawing. If you do not wish to provide us with this information, that is perf ectly okay. Please answer the following questions if you would like to be eligible for the drawing. Again, thank you so much for completing this survey! What is your preferred email address? (We would _____________________________ commu nicate your winning status and would send (PREFERRED EMAIL) your Amazon gift card to this address.) What city and country do you reside? ____________________________ (CITY COUNTRY) If ran domly selected for the prize, would you prefer ____________________________ we send you an Amazon.com (North America (PRIZE PREFERENCE) participants, typically) or Amazon.eu (for EU participants) gift card? Thank you for completi ng this form! You are now eligible for the gift card drawing. If you win, we will be in touch with you by email to send you your gift card. Thank you!

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129 APPENDIX E ADDITIONAL ITEMS FOR CHRONIC LOW BACK PAI N THIRD RECRUITMENT WAVE [If re spondents indicated their gender is female, the following item appeared:] 1. Are you currently pregnant? [If yes, the following item appeared:] 2. Is your chronic pain primarily due to your pregnancy? [If yes, this statement is presented:] Because your chro nic low back pain is primarily due to your pregnancy, you do not meet study criteria to continued participating, nor are you eligible for the gift card lottery. We truly appreciate your time and efforts. To exit, please close the browser.

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130 APPENDIX F CHRONIC PAIN ACCEPTANCE QUESTIONNAIRE (CPAQ) Directions: below you will find a list of statements. Please rate the truth of each statement as it applies to you. Use the following rating scale to make your choices. For instance, if you believe a statement is Always True, you would write a 6 in the blank next to that statement ______________________________________________________________________________ 0 1 2 3 4 5 6 Never Very Seldom Sometimes Often Almost Always true rarely true true true always true true true 1. I am getting on with the business of living no matter what my level of pain is 2. My life is going well, even though I have chronic pain 3. Its OK to e xperience pain 4. I would gladly sacrifice important things in my life to control this pain better 5. Its not necessary for me to control my pain in order to handle my life well 6. Although things have changed, I am living a normal life despite my chronic pain 7. I need to concentrate on getting rid of my pain 8. There are many activities I do when I feel pain 9. I lead a full life even though I have chronic pain 10. Controlling pain is less important than any other goals in my life 11. My thoughts and feel ings about pain must change before I can take important steps in my life 12. Despite the pain, I am now sticking to a certain course in my life 13. Keeping my pain level under control takes first priority whenever Im doing something 14. Before I can make any serious plans, I have to get some control over my pain 15. When my pain increases, I can still take care of my responsibilities 16. I will have better control over my life if I can control my negative thoughts about pain 17. I avoid putting myself in situations where my pain might increase 18. My worries and fears about what pain will do to me are true 19. Its a relief to realize that I dont have to change my pain to get on with my life 20. I have to struggle to do things when I have pain

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131 APPENDIX G P TSD CHEC K LIST CIV I LIAN VERSION (PCL C) Instruction to pa tient: Bel ow is a list of probl e ms and com pl a ints that people sometimes have i n response to stressful life exper ien c es. Pleas e read eac h one ca r e fu lly put an X i n the box to i ndi c a te h o w mu c h y ou ha ve b e en bother e d by t hat problem in the last m ont h. No. Not at all 1 A little bit 2 Mod er a tely 3 Quite a bit 4 Extreme ly 5 1. Re peat e d, disturbi ng m e mo ri es, thoug hts, or im a ges of a stressful ex p e r i ence from the past? 2. Re p eat e d disturb i ng d r ea m s of a stressful expe r ien c e from the past? 3. Sud den l y acti ng or feel i ng as i f a stressful exper i ence w e re hap pe n i ng aga in (as if you w e r e reli v i ng it)? 4. Feel i ng very upset w h e n something re m inded you of a stressful e xp e ri e nce from the past? 5. Having phy s ic a l reacti o n s (e. g ., heart pou ndi ng, troub l e br e a th i ng, or s w eat i ng ) w hen s ometh i ng reminded y ou of a stressful ex pe r i ence from the past? 6. Avoid th i n ki n g ab o ut or talki n g ab o ut a stressful expe r ien c e from the past or avoid ha ving f e eli ng s related to it? 7. Avoid activities or situations b e cau s e th e y r e m i nd you of a stressful e x pe ri e nce f rom the past? 8. T rouble r e m e mber i ng i m p o rt a n t parts of a stressful expe r ien c e from the past? 9. Loss of inter est in things t h at you us e d to en j oy? 10. Feel i ng distant or cut off from other p e o p le? 11. Feel i ng e m ot io nally n u mb or be i ng u na b le to have lovi ng fee l i ngs for those close to y ou? 12. Feel i ng as if y o ur future w i l l s o meh o w be cut short? 13. T rouble fall i ng or staying a s l e ep? 14. Feel i ng irritable or hav i ng an g ry outbursts?

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132 15. Having diffic u lty concentrat i ng? 16. Being su p er a l er t or w a t c hful on gua r d? 17. Feel i ng jumpy or eas il y start le d? PCL M for DSM IV (11/1/94) W eathers, Litz, Huska, & Ke a ne Nat i onal C e nter for P T SD Behav i oral Sc i ence D ivis i on T his is a Government do c um e nt in the p ublic dom a in.

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133 APPENDIX H ACCEPTANCE AND ACTIO N QUESTIONNAIRE (AAQ II) B e low y ou wi l l fi nd a list of s t a t e me nts. P le a se ra t e ho w true e a ch s t a t e me nt is f or y ou b y circl ing a num be r ne x t to it. Use t he sca le be l ow to m a ke y our ch oi c e Never True Very seldom true Seldo m true So m eti m es true Frequentl y true Almost Always True Al way s True 1. My painful experiences m e m or i e s make it di f fic ult fo r m e t o live a life t ha t I wo u ld v a l ue 1 2 3 4 5 6 7 2. Im a fraid o f my f e e l i ng s. 1 2 3 4 5 6 7 3. I wor r y ab o u t no t be i n g a ble t o c ontrol my w or r ies a nd f ee l i ng s. 1 2 3 4 5 6 7 4. M y pa in fu l m e m o r i e s prev e nt m e f rom ha vi ng a f ulfi l l i ng lif e 1 2 3 4 5 6 7 5. E m o ti on s c au se p r o b lems in m y lif e 1 2 3 4 5 6 7 6. It s ee m s like m o s t peopl e a r e ha ndl in g t he ir lives be t t e r t ha n I a m 1 2 3 4 5 6 7 7. W o r r ies ge t in t h e w a y o f my s u cc e ss. 1 2 3 4 5 6 7

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134 AP PENDIX I 5 FACET QUESTIONNAIRE: SHORT FORM Below is a collection of statements about your everyday experience. Using the 1 5 scale below, please indicate, in the box to the right of each statement, how frequently or infrequently you have had each experi ence in the last month (or other agreed time period). Please answer according to what really reflects your experience rather than what you think your experience should be. Never or Not often Sometimes true Of ten Very often very rarely true true sometimes not true true or always true 1 2 3 4 5 1 Im good at finding the words to describe my feelings DS 2 I can easily put my beliefs, opinions, and expectations into words DS 3 I watch my feelings without getting carried away by them NR 4 I tell myself that I shouldnt be feeling the way Im feeling /NJ 5 Its hard for me to find the words to describe what Im thinking /DS 6 I pay attention to physical experiences, such as the wind in my hair or sun on my face OB 7 I make judgments about whether my thoug hts are good or bad. /NJ 8 I find it difficult to stay focused on whats happening in the present moment /AA 9 When I have distressing thoughts or images, I dont let myself be carried away by them NR 10 Generally, I pay attention to sounds, such as clocks ticking, birds chirping, or cars passing OB 11 When I feel something in my body, its hard for me to find the right words to describe it /DS 12 It seems I am running on automatic without much awareness of what Im doing /AA 13 When I have d istressing thoughts or images, I feel calm soon after NR 14 I tell myself I shouldnt be thinking the way Im thinking /NJ

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135 15 I notice the smells and aromas of things OB 16 Even when Im feeling terribly upset, I can find a way to put it into words D S 17 I rush through activities without being really attentive to them /AA 18 Usually when I have distressing thoughts or images I can just notice them without reacting NR 19 I think some of my emotions are bad or inappropriate and I shouldnt feel t hem /NJ 20 I notice visual elements in art or nature, such as colors, shapes, textures, or patterns of light and shadow OB 21 When I have distressing thoughts or images, I just notice them and let them go NR 22 I do jobs or tasks automatically without being aware of what Im doing /AA 23 I find myself doing things without paying attention /AA 24 I disapprove of myself when I have illogical ideas /NJ

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136 APPENDIX J PAIN DISABILITY INDE X (PDI) The rating scales below are designed to measure the d egree to which several aspects of your life are presently disrupted by chronic pain. In other words, we would like to know how much your pain is preventing you from doing what you would normally do, or from doing it as well as you normally would. Respond t o each category by indicating the overall impact of pain in your life, not just when the pain is at its worst. For each of the 7 categories of life activity listed, please circle the number on the scale which describes the level of disability you typically experience. A score of 0 means no disability at all, and a score of 10 signifies that all of the activities in which you would normally be involved have been totally disrupted or prevented by your pain. (1) Family/Home Responsibilities: This category r efers to activities related to the home or family. It includes chores or duties performed around the house (e.g. yard work) and errands or favors for other family members (e.g. driving the children to school). 0 1 2 3 4 5 6 7 8 9 10 No Total Disability Disability (2) Recreation: This category includes hobbies, sports, and other similar leisure time activities. 0 1 2 3 4 5 6 7 8 9 10 No Total Disability Disability (3) Social Activity: This category refers to activities, which involve participation with fr iends and acquaintances other than family members. It includes parties, theater, concerts, dining out, and other social functions. 0 1 2 3 4 5 6 7 8 9 10 No Total Disability Disability (4) Occupation: This category refers to activities that ar e a part of or directly related to ones job. This includes nonpaying jobs as well, such as that of a housewife or volunteer worker. 0 1 2 3 4 5 6 7 8 9 10 No Total Disability Disability (5) Sexual Behavior: This category refers to the frequency and quality of ones sex life. 0 1 2 3 4 5 6 7 8 9 10 No Total Disability Disability

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137 (6) Self Care: This category includes activities which involve personal maintenance and independent daily living (e.g. taking a shower, driving, getting dressed, etc.). 0 1 2 3 4 5 6 7 8 9 10 No Total Disability Disability (7) Life Support Activity: This category refers to basic lifesupporting behaviors such as eating, sleeping, and breathing. 0 1 2 3 4 5 6 7 8 9 10 No Total Disability Disabili ty