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American Pain Society
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Glenview, IL 60025
Costantino Benedetti, MD, Department Editor
Mark L. Elliott, PhD
Department editor's note: This is the fifth and final article in a series on pelvic and abdominal pain conditions in women. In three articles, John S. McDonald, MD, discussed the etiology and treatment of acute and chronic gynecological disorders (APS Bulletin, July/August 1995, November/December 1995, May/June 1996). In the January/February 1996 issue, Mark Elliott described the psychological implications of chronic pelvic pain. Here, he reviews intervention strategies found useful in dealing with these psychological factors.
In an earlier article in this series (Elliott, 1996), I discussed the impact of psychological factors in the development and exacerbation of chronic pelvic pain (CPP). This article will provide suggestions regarding the diagnosis and management of psychological factors common to patients with CPP. Many of these techniques are well known to professionals treating pain. I have attempted to highlight diagnostic and treatment examples that are common, if not unique, to CPP patients.
The treatment of CPP rarely involves psychological intervention until all medical diagnostic or intervention options have been exhausted. At that point, the patient with CPP is often transferred (i.e., “dumped") to a psychologist or psychiatrist to treat the “all in her head” problem. Communication among the mental health professional, the physician, and the patient is often limited or ineffective. Consequently, many CPP patients ignore psychological help and instead pursue medical treatment from a new physician with a new specialty that may “help” with the pain. Psychological consultation is usually a last resort and is attended to begrudgingly-and sometimes belligerently.
The aforementioned pattern is quite unfortunate. Pelvic pain research has shown that an integrated interdisciplinary or multidisciplinary approach from the onset can significantly enhance the efficacy of treatment. As early as 1977, Beard, Belsey, Lieberman, and Wilkinson recognized the importance of an interdisciplinary approach for successful treatment of CPP, but they did not include outcome measures. Beard, Reginald, and Pearce (1988) reported that women receiving “stress analysis” or “pain analysis” therapies (sample size not given) were significantly improved at the end of treatment compared to a minimal intervention control group. Interestingly, at 3-month follow-up differences were not maintained, but at 6 months improvement differences over controls returned. Kames, Rapkin, Naliboff, Afifi, and Ferrer-Brechner (1990) studied CPP patients (N=16) who were inappropriate for standard gynecological methods or who had not been successfully treated with these procedures. There were significant decreases in pain levels and improvements in work, social, and sexual activities for most subjects after a 6- to 8-week program of somatic and behavioral interventions. Peters et al. (1991) randomly assigned 106 CPP patients to one of two treatment groups. In the first group, psychological intervention was implemented only after organic etiology was ruled out via laparoscopy. In the second group, medical, psychological, dietary, environmental, and physiotherapy interventions received equal attention from the onset of treatment. At 1-year follow-up, the integrated approach provided significant improvement in pain experience, daily activity, and “associated symptoms” compared to the “standard” approach. Reading (1982-1983) advocated a multidisciplinary approach and suggested a means by which to talk with CPP patients about the nonsomatic characteristics and treatment of their pelvic pain. However, he provided limited information about a comprehensive treatment program.
The psychological evaluation of a patient with CPP is critical for the development of an effective treatment plan. Evaluation options are obviously limited to the resources available. Some clinics lack a mental health professional or psychometric testing. The increase in HMO and capitated health care has tragically decreased reimbursement and, thus, reduced the availability of psychological evaluation and treatment. Individual medical practitioners should find a mental health colleague in the community to involve in treatment whenever possible. It is most helpful when this collaboration is implemented from the onset of treatment and, ideally, the diagnostic process.
The psychological evaluation starts with a review of medical and psychological records. The medical history of a patient with CPP is essential for understanding her current psychological status. The patients that my colleagues and I see in our clinic are quite heterogeneous in their presenting symptoms. They have experienced multiple office visits and procedures, which may have caused significant emotional disruption. Initial clinic questionnaires are also important for the collection of psychological information and for helping patients feel less isolated in dealing with the problem. The breadth and depth of questions can normalize some of the patient's psychosocial concerns.
In our clinic, patients with CPP fill out two questionnaires. The first is our pain clinic questionnaire, which examines the etiology, characteristics, intervention attempts, and psychosocial impacts of the pain. The second questionnaire investigates sexual history and the impact of CPP on the patient's sexual and relationship functioning.
After review of available information, a psychological consultation or interview is implemented to collect information about psychological status and coping mechanisms. The patient's fear that the problem is “all in her head” should also be addressed.
In our clinic, I meet with the CPP patient first. A family member or partner may be included if the patient wishes. During the consultation, we cover a range of topics. I introduce myself as a psychologist and codirector of the pelvic pain clinic and explain that John McDonald, MD, and I work as a team. I immediately state that having this meeting does not imply that we think the patient's pain is in her head. Most CPP patients are quite relieved to hear this. We then proceed to describe what she can expect during the first visit. I address questions and concerns regarding psychological or medical procedures. We then review the development and characteristics of the pain. It is important that we understand what activities or situations make the pelvic pain worse and under what conditions the pain is less intense. Previous intervention attempts (e.g., surgical, pharmacological, psychological) and the patient's experience with them are also reviewed. We discuss psychosocial, relationship, and sexual problems or stressors, as well as current coping skills and resources. Evidence of intense somatic focus and history of physical or sexual abuse merit special attention. Normalization of the psychosocial sequela to CPP is important. Every patient receives a brief didactic regarding the psychophysiology of emotions and the impact on nerves and muscles. This illuminates the vicious cycle of stress and emotions, muscle tension, and nerve changes.
When a psychologist is not on staff and a referral for evaluation or treatment is recommended, the physician must be sensitive to the patient's suspicion that she is being dumped or that the physician sees her pain as caused by psychopathology. The physician needs to take time to quell the patient's fears and to explain the psychophysiology of stress, as mentioned above. The physician can greatly enhance the interdisciplinary referral process by mentioning that other patients have successfully seen the psychologist and that such referrals are common.
In our clinic, the information provided during the initial psychological consultation is presented in a team meeting with the physician. Special circumstances are outlined. They may include fear of pelvic examination due to previous negative experiences, a phobia regarding needles, or an unsupportive, pressuring partner. The physician then examines the patient, reaches a medical diagnosis, and outlines medical intervention. Typically, the patient receives medical treatment on the first visit.
After the examination and intervention, the team meets to discuss medical and psychological factors and to develop a long-term treatment plan. The plan is then presented to the patient by the psychologist, the physician, or both. It is based on the individual findings for the patient and does not follow any particular formula. For example, some patients with CPP do not return to the psychology service after the consultation and, instead, receive unencumbered medical intervention. Other CPP patients receive comprehensive psychological testing followed by intensive psychotherapy and couple therapy, in conjunction with or before medical intervention.
The psychometric tools available to evaluate patients with pain are numerous. Each clinical setting has different needs, resources, and psychological expertise for working with CPP patients. These factors will direct the use of psychological testing. Clinicians new to the treatment of CPP may consider a comprehensive evaluation process until more familiarity is achieved. The psychological testing options presented below do not constitute an exhaustive list (for review, see Turner & Romano, 1990b; Steege, Stout, & Somkuti, 1993).
Structured instruments.
Projective personality instruments.
In our clinic, we use psychological testing sparingly. We most frequently administer the MMPI-2, which is common in the evaluation of pain patients (Turner & Romano, 1990b) and has been described for CPP patients (Wood, Wiesner, & Reiter, 1990). A CPP patient finding in our clinic is an elevation on 1(hypochondriasis) and 3 (hysteria), with less elevation on 2 (depression). This is commonly described as the “conversion V'' or seen as evidence of a conversion reaction (Keller & Butcher, 1991). We suggest caution when interpreting this configuration to CPP patients, who are very sensitive to a psychogenic diagnosis. This configuration, in our experience, is almost never consistent with a hysterical or conversion pain disorder. To us, it represents the common CPP characteristic of hypersensitivity to body function and pain, especially if there are elevations on 7 (psychasthenia) and 8 (schizophrenia). We often use the fairy tale “The Princess and the Pea” to describe this phenomenon to the patient. The BDI is used on occasion as a means to quantify changes in depression when the patient receives an antidepressant trial. We do not administer sexual or relationship tests; instead, we use the extensive interview information and initial clinic questionnaire. Projective personality testing is rarely used, but it definitely has merit under specific circumstances. We reserve the use of the Rorschach for situations in which interview or other psychological testing results cannot explain “primitive” psychological responses that are significantly decreasing treatment efficacy (e.g., for a patient with a borderline personality disorder).
Many CPP patients feel guilty that they are unable to pursue employment or to perform domestic tasks. They commonly describe a pattern of beginning to feel better, attempting to “catch up” on tasks, overworking, being unable to function for several days, and falling behind again. To break the cycle, we, like other pain clinicians, implement an hourly activity log, which can yield important information for treatment planning. We also implement a feelings/stress and pain log. The patient is asked twice daily to rate her levels of pain and three to five different emotions on a 0 to 5 scale, with 0 = none and 5 = highest level. Use of this tool is very helpful, because many CPP patients are so focused on their bodies and pain that they have not perceived the correlations with affective states. The initial consultation and psychometric testing (when available) identify the emotions that need to be recorded, such as anxiety, fear, rumination, anger, depression, or irritability. The CPP patient brings the logs to her next appointment for review and to update her records.
We choose psychological treatment modalities according to the individual needs of the patient. Such needs can vary dramatically among patients. We use an integrated hierarchical psychological approach that starts with the most basic interventions (i.e., behavior therapy) and moves to the next level (i.e., cognitive therapy) only if basic intervention attempts consistently prove insufficient to manage the pain or the psychological issue. Some CPP patients eventually need intensive psychodynamic therapy to help resolve problems or issues impeding pain treatment efficacy.
In our experience, the most effective treatment approach is a combination of instruction and specific homework assignments. CPP patients often become more motivated participants in treatment when they understand the theory behind medical and psychological intervention (e.g., nerve, muscle, and emotional interaction). Homework is both diagnostic and therapeutic. It can bring the problem areas to the surface and also teach more successful adaptive skills. Some authors advocate the use of a 10-session method to treat CPP, involving systematic use of cognitive behavioral therapy, sex therapy, and relaxation training or self-hypnosis techniques. Wood et al. (1990) provided helpful information about this program.
Numerous articles and books address the topic of behavioral therapy for pain (e.g., Fordyce, 1976; Fordyce, 1990), but none recommends programs specifically for CPP. An activity diary may be used to facilitate a structured behavioral plan that becomes more demanding as medical treatment unfolds. A CPP patient frequently needs a moderated, guided return to normal activities of daily living, whether she has been superstitiously decreasing activity because of pain and spurious correlations with activity or has been increasing activity to compensate for guilt from an inability to perform her family “duties.” The diary helps remind the patient of the maximum or minimum hourly levels of activity set in the therapy session.
Behavioral therapy can also help family members develop reinforcement patterns to decrease pain behaviors or secondary gain behaviors. For example, family members might help an interstitial cystitis patient plan and execute brief but increasing social visits from friends or trips to locations with easily accessible restrooms.
The use of progressive relaxation training (PRT), guided imagery, self-hypnosis, breathing exercises, biofeedback, and other similar techniques is well known for treating patients with pain (e.g., Blanchard & Ahles, 1990), but not specifically for treatment of pelvic pain. We use these techniques in combination. Patients receive a handout or an audiotape containing scripts for PRT, guided imagery, and breathing exercises. This approach is especially helpful for CPP patients who are terrified of the pelvic exam or phobic about trigger-point injections. We recently saw a woman who would gag and vomit at the sight of a needle. Her condition was diagnosed as postsurgical ilioinguinal trigger points, which would best respond to local anesthetic injections. We spent several sessions teaching her breathing exercises and PRT, after which she was able to manage her phobic reaction to needles and receive the necessary medical treatment.
We use biofeedback to help patients with CPP manage the muscle tension that increases their myofascial pain. In addition, biofeedback can help redirect the often intense somatic focus-the princess and the pea syndrome. Biofeedback and PRT are provided in conjunction with local anesthetic trigger-point injections to reduce muscle tension. CPP patients with somatization learn to focus on physical sensations in a more adaptive way.
These techniques (i.e., PRT, breathing, guided imagery) can also be used to “force” the CPP patient to take time out during the day to rest. Many CPP patients do not give themselves permission to use time in a way that is not “productive."
Resources for developing cognitive-behavioral techniques with pain patients are numerous (see Turk, Meichenbaum, & Genest, 1983; Gatchel & Turk, 1996; Turner & Romano, 1990a). None apply specifically to pelvic pain. These techniques are designed, for example, to teach the CPP patient skills to manage more adaptively the beliefs, thoughts, feelings, and stress that may exacerbate her experience of pain.
Many patients with CPP describe a spectrum of negative, pessimistic beliefs that often leads to catastrophizing. This problem is exacerbated by these patients' tendency also to ruminate. Research suggests that pessimistic beliefs are maladaptive and increase pain (Gil, Williams, Keefe, & Beckham, 1990). Nevertheless, these beliefs should initially be discussed as understandable, considering the patient's frustrating, disappointing experience during pursuit of treatment. The CPP patient needs didactic information regarding the exacerbating impact of these beliefs on her pain and the consequent reduction in the efficacy of treatment. We teach a skill called “neutrality,” which involves the patient's being aware of how she “predicts” and “prejudices” her present beliefs because of what has happened to her in the past. We attempt to help her put the past in perspective by taking into account changing circumstances or resources in order to update her beliefs. The patient is able to challenge past (maladaptive) beliefs by asking herself, “What information do I have in the present to support these conclusions or assumptions?”
We also help the patient develop a more adaptive data collection system. It is critical that we discuss the patient's belief system and the information she is using to create her assumptions. For example, younger CPP patients tend to develop strong pessimistic beliefs (leading to depression) about pregnancy after a physician recommends hysterectomy. We may need to facilitate collection of more data (e.g., a second opinion) or to correct entrenched misconceptions (e.g., that hysterectomy is always needed to correct pelvic pain).
Patients with CPP can present with a vast array of psychological or emotional states. They often experience symptoms characteristic of learned helplessness (the perceived or real inability to terminate noxious stimuli), including dysphoria, anhedonia, pessimism, and irritability. CPP patients need techniques to help them manage, not control, their feeling responses to the pain and to ineffective treatment approaches. As described in a previous article (Elliott, 1996), emotional states create neurochemical and hormonal changes that directly affect nerves and muscle and the perception of pain. Therefore, it is critical to help patients develop skills to manage these feelings in more efficacious ways.
We use a four-step approach that includes acknowledgment of the feelings; acceptance of the feelings, regardless of what they are; verbalization of the feelings, when appropriate; and active choice of something-anything-to do about the feelings. This approach helps the patient feel less a victim to her feelings and more effective in dealing with them. Psychological and physiological changes are then created that can positively affect pain.
The hostility common to CPP patients (Fry, Crisp, Beard, & McGuigan, 1993; Slocumb, Kellner, Rosenfeld, & Pathak, 1989) merits special comment. We attempt to teach patients that anger is not a primary emotion and to look for and manage its common antecedents (e.g., disappointment, embarrassment, sadness). For example, a patient with vulvar vestibulitis became very hostile and belligerent. Within in a few weeks, staff members were offended by her behavior and refused to work with her. The history revealed a similar pattern in other clinics. We confronted the patient and her husband with this behavior and slowly began to help her see the sadness and emotional pain that were causing this “barbed-wire defense."
Like other pain clinics, we have adapted the relapse-prevention model to work with our CPP patients. The model involves the patient's increasing her awareness of dysfunctional patterns, developing pattern-specific problem solving, and practicing the plan. We recently saw a CPP patient with endometriosis who was able to connect visits of her intrusive mother-in-law with significant increase in her pain. She described increasing tension in her abdomen and consequent pain as a visit approached. Pain escalation during visits was common. We were able to dissect both her belief system and previous coping attempts. We then developed a series of “if-then” options. She created signals to use with her husband that indicated different parts of the plan. If she rubbed her nose, for example, she and her husband were to convene in the kitchen to discuss how to manage the increasing stress. The patient was able to rehearse and role-play these signals and other coping mechanisms with a female staff member.
The use of psychodynamic techniques for the treatment of pain disorders (see Tunks & Merskey, 1990) has been controversial, at best. However, with continued awareness of the role of childhood trauma or neglect in the history of pain, especially pelvic pain, a more psychodynamic approach may become necessary.
The use of a comprehensive, dynamic psychosocial history can help the treatment of a CPP patient who has not responded to medical or psychological interventions. Childhood traumas, for example, require discussion in a supportive, open environment and must not be mistaken for false memories. Historical information can help the therapist and patient make important connections with present defenses or maladaptive behaviors that are exacerbating pelvic pain or making intervention ineffective. Initially, patients often need to be skeptical. The psychologist helps the patient see that past traumas can affect the present.
Having psychodynamic information can also help us develop treatment strategies to manage persistent “snags” or impediments to cognitive-behavioral homework. When other psychological interventions have failed, we explore the possibility that the patient cannot afford to give up her defenses. For example, patients with a history of sexual abuse may fear resolving their pelvic pain because the objectifying sexual expectations of their partners may return.
The psychodynamic model can also help us understand how some pain locations or pain behaviors can become entrenched as “ego-invested” defenses against childhood trauma and neglect. Recently, we saw a woman with multiple body-location complaints, including pelvic pain. During biofeedback and relaxation she began to decompensate psychologically. She reported an overwhelming influx of emotions and intrusive memories, as her body began to relax and muscle tension decreased. She had a history of multiple traumatic childhood events, including sexual abuse. She reported being “uptight” all her life and had never worked on her childhood abuse. We have just begun the process of helping her mourn these traumas and to manage the effect they have on current functioning and understandable defenses.
Sometimes adult life circumstances, including the loss of control associated with pelvic pain, can replicate negative childhood family environments. This replication can cause the expression of primitive emotions and necessitate strong defenses. Some of these defenses, like projections of her punitive parents onto staff, can make history collection and treatment difficult. The patient's distrust and fear associated with the dangerous vulnerability of “being known” may cause her to look for surgical answers. Sometimes the end result is that the patient is passed between and within medical specialties and that she ends up disfigured and still without relief from her pain.
Sex therapy is a series of systematic, hierarchical exercises designed to decrease performance anxiety and spectatoring (the negative, critical monitoring of sexual response), while enhancing adaptive sensual and sexual expression. Many couples that include a woman who has experienced CPP need a systematic, structured period of becoming reacquainted to be able to return to a satisfying sex life. My previous article (Elliott, 1996) illuminated the frequency and breadth of sexual disturbance among CPP patients. The treatment of these sexual dysfunctions or disorders involves the use of sensate focus, as developed by Masters and Johnson (1970). The patient is instructed to focus on sensations (e.g., temperature, texture, pressure) for her own interest, as an antidote to performance anxiety and spectatoring. The patient can perform sensate focus exercises with a partner, when available, or alone. Breasts and genitals are initially off-limits to produce a more conducive environment for practice. Therapy proceeds over time to intercourse.
Vaginismus, the involuntary, reflexive spasm of the pubococcygeous muscle resulting from real or perceived threats of penetration, deserves a special treatment note. Unfortunately, Sarazin and Seymour (1991) in their discussion of vagi-nismus stated, “Many patients can break the cycle with one limited pelvic exam, done with extreme gentleness” (p. 35). This surprising statement does not agree with our experience.
Treatment of vaginismus almost always requires the use of progressive dilators and is very successful. We use a box of Young's adult dilators, starting with the smallest (#11/2). Pediatric dilators for women with vaginismus are rarely needed. The patient is first taught to redescribe her pain using other words (e.g., stretching, pinching, stinging). She is also instructed to do seven to 10 repetitions of Kegel exercises two to three times a day. The exercises involve contracting the pelvic floor muscles, holding for 1 second, and then releasing. The first dilator is inserted with the help of an artificial lubricant twice per day for 15 minutes. Kegel exercises are always done just before and then during the insertion of the dilator. Over the next days and weeks, she progresses to 30 minutes, then 1 or 2 hours, and finally she sleeps overnight with the dilator. After the second overnight, she progresses to the next size dilator and repeats the same process. When the final dilator (usually #4) is started, a decision is made as to whether the partner will come into treatment to help the transition from the dilator to the penis. In about 50% of our cases, the partner becomes involved in specific exercises to help with intercourse.
Like sexual problems, the relationship problems that develop during CPP (e.g., animosity, abandonment, hurt feelings, limited communication, separate lives) can also require a structured set of skills to facilitate reacquaintance. We use an adapted version of the cognitive-behavioral skills described above to help couples manage accumulated negative feelings and to increase communication efficacy. Patients in our clinic who have experienced dyspareunia for extended periods often need comprehensive sexual and relationship intervention. The couple conference is important in this process. Partners of CPP patients often need a professional to explain the physical and psychological aspects of CPP. This meeting may reduce the longstanding distrust, anger, and distance caused by the prior absence of a specific diagnosis and the ineffectiveness of earlier intervention attempts.
Group therapy has proven to be a productive, cost-effective modality for pain patients (Tunks & Merskey, 1990). Groups for CPP patients can be peer-led or facilitated by a professional. CPP patients can benefit from discussion with other patients suffering from the same problem and undergoing the same treatment experiences. Clinicians should be prepared and available to address the questions and frustration-and sometimes hostility-that develop during a peer group meeting.
Patients experiencing pelvic pain often present with an array of psychological and physical symptoms. This complex group of patients and symptoms require a multidisciplinary approach. It is my hope and that of John McDonald, the other author in this series of articles on pelvic pain, that our articles have broadened understanding of this common and debilitating problem. We strongly encourage the pursuit of more focused research and treatment strategies to help patients suffering with chronic pelvic pain.
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Mark Elliott is assistant professor in the Department of Anesthesiology and codirector of the Pelvic Pain Clinic at The Ohio State University, Columbus, OH.
