A qualitative exploration of experiences of gender identity and gender questioning among adults with Klinefelter syndrome/XXY.

People with Klinefelter syndrome (KS/XXY) may be at higher risk of gender dysphoria than the general population and gender diversity needs greater recognition and consideration in services for people affected. This study aimed to give systematic insights into experiences of gender diversity among people with KS/XXY, which could inform more person-centered care for people with KS/XXY and contribute to practical guidance for healthcare professionals. We conducted individual, semi-structured interviews with 11 adults with diagnosed KS/XXY. The verbatim interview transcripts were analyzed using experiential reflexive thematic analysis, which identified four themes: (1) Experience of gender, which described participants' experiences of exploring and negotiating their gender identity; (2) Navigating expectations, which described how participants' gender uncertainty was associated with confusion, isolation, and shame, and how fears about other people's reactions caused participants to keep their gender identity secret; (3) Testosterone assumptions, which described how participants needed more discussion and counseling before testosterone replacement therapy (TRT), and how some benefited from treatment with alternative hormones to testosterone; and (4) A different approach, which described participants' experiences of care at gender identity clinics. The findings give new insights into the gender identity journeys of people with KS/XXY, from early attempts to understand and make sense of gender, through dealing with social pressures, the development of gender identities more congruent with feelings, and experiences with hormone replacement therapy. The practice implications include that there should be improved consideration of gender identity in care for KS/XXY, better psychological support for those affected by gender diversity, and more consideration given to alternatives to testosterone-based therapies. Future research could explore the experiences of gender identity among different groups of people with KS/XXY, the development of gender identity over time, the effects of TRT on gender identity, and healthcare providers' knowledge and attitudes about gender identity and KS/XXY.

Emotion Regulation and Psychological Dependence on Pain Medication among Hospital Outpatients with Chronic Spinal Pain: The Influence of Rumination about Pain and Alexithymia.

Objective: To examine the extent to which pain acceptance, pain catastrophising and alexithymia moderate associations between pain intensity and psychological pain medication dependence. Methods: Participants (106 hospital outpatients with chronic spinal pain) completed the Leeds Dependence Questionnaire (LDQ) to measure psychological dependence on pain medication, and the Chronic Pain Acceptance Questionnaire-8 (CPAQ-8), the Pain Catastrophising Scale (PCS) and the Toronto Alexithymia Scale-20 (TAS-20), plus the Depression, Anxiety and Stress Scale-21 (DASS-21). Results: Multiple linear regression showed that degree of psychological dependence (measured dimensionally across the range of LDQ scores) was associated with TAS subscale difficulty identifying feelings (DIF) (ß = 0.249, p = <0.002) and PCS subscale rumination (ß = 0.193, p = 0.030), independently of pain intensity and risk behaviors for medication misuse. The effect of pain intensity was moderated by rumination, with pain intensity more strongly associated with dependence when rumination was high (interaction ß = 0.192, p = 0.004). Logistic regression showed that the effect of pain intensity on severe dependence (measured categorically as LDQ score ≥ 20) was moderated by alexithymia, so that severe dependence was independently associated with the combination of intense pain and high alexithymia (interaction odds ratio = 7.26, 95% CIs = 1.63-32.42, p = 0.009). Conclusions: Rumination and alexithymia moderated the associations between pain intensity and psychological pain medication dependence, consistent with emotion regulation theory. This raises the possibility that specifically targeting rumination about pain and symptoms of alexithymia could potentially improve the effectiveness of psychological interventions for chronic pain and help people to avoid or reduce their psychological dependence on pain medication.

Pain attitudes and pain outcomes among people with bleeding disorders: Results from community voices in research.

INTRODUCTION: Among people with bleeding disorders (PwBD), pain is a major problem and pain treatments are often ineffective. Understanding of psychological factors involved in pain processing is limited. Maladaptive pain attitudes are associated with worse pain outcomes and adaptive pain attitudes are associated with better outcomes in high pain conditions, but relationships between pain attitudes and pain outcomes are so far unexplored among PwBD. AIM: To investigate relationships between pain attitudes and pain outcomes among PwBD. METHODS: Pain attitudes were measured with the Survey of Pain Attitudes, containing two adaptive scales (Control and Emotion) and five maladaptive scales (Disability, Harm, Medication, Solicitude, Medical Cure). Adults with bleeding disorders, who had pain, and were enrolled in Community Voices in Research were eligible. Participants (n = 72) completed an online survey. Cross sectional associations between pain attitudes and pain outcomes (pain and prescribed pain medication use) were investigated using logistic regression. RESULTS: After adjustment for covariates, greater Control attitudes were associated with lower odds of more severe pain, and greater Disability, Harm, and Medication attitudes were all associated with higher odds of more severe pain and with higher odds of any prescribed pain medication use and opioid pain medication use. CONCLUSIONS: We presented compelling evidence of relationships between pain attitudes and pain outcomes in PwBD, though corroboration is needed from other populations. Our findings suggest that modification of pain attitudes presents a possible avenue for interventions to improve pain outcomes and increase patient satisfaction with pain management.

An exploration of successful psychosocial adjustment to long-term in-centre haemodialysis.

OBJECTIVES: Haemodialysis extends life for people with end-stage kidney disease (ESKD) worldwide, but it imposes significant psychosocial burdens and there is little evidence about successful adjustment. This study aimed to improve understanding of successful psychosocial adjustment to in-centre haemodialysis (ICHD; dialysis in a hospital or satellite unit). METHODS: Individual semi-structured interviews were conducted with a purposive sample of 18 people with ESKD who had all received in-centre haemodialysis in the UK for at least 90 days in the last two years. An inductive thematic analysis was employed to identify themes from the verbatim interview transcripts. RESULTS: There were four themes: 1) reaching a state of acceptance, which described the importance of accepting the necessity of dialysis; 2) taking an active role in treatment, which described how being actively involved in treatment gave participants greater feelings of autonomy and control; 3) utilising social support networks, which described the benefits of instrumental and emotional support; and 4) building emotional resilience, which described the importance of optimism and positivity. CONCLUSIONS: The themes demonstrated elements of successful adjustment that could be targeted by interventions to promote psychological flexibility and positive adjustment among people receiving in-centre haemodialysis worldwide.

A non-injected opioid analgesia protocol for acute pain crisis in adolescents and adults with sickle cell disease.

Initial management of the acute pain crisis (APC) of sickle cell disease (SCD) is often unsatisfactory, and might be improved by developing a standardised analgesia protocol. Here, we report the first stages in developing a standard oral protocol for adolescents and adults. Initially, we performed a dose finding study to determine the maximal tolerated dose of sublingual fentanyl (MTD SLF) given on arrival in the acute care facility, when combined with repeated doses of oral oxycodone. We used a dose escalation algorithm with two dosing ranges based on patient's weight (<50 kg or >50 kg). We also made a preliminary evaluation of the safety and efficacy of the protocol. The study took place in a large tertiary centre in London, UK. Ninety patients in the age range 14-60 years were pre-consented and 31 treatment episodes were evaluated. The first 21 episodes constituted the dose escalation study, establishing the MTD SLF at 600 mcg (>50 kg) or 400 mcg (<50 kg). Further evaluation of the protocol indicated no evidence of severe opioid toxicity, nor increased incidence of acute chest syndrome (ACS). Between 0 and 6 hours, the overall gradient of reduction of visual analogue pain score (visual analogue scale (VAS)) was 0.32 centimetres (cm) per hour (95% confidence interval (CI) = 0.20 to 0.44, p < 0.001). For episodes on MTD SLF, there was median (interquartile range (IQR)) reduction in VAS score of 2.8 cm (0-4.2) and 59% had at least a 2.6-cm reduction. These results are supportive of further evaluation of this protocol for acute analgesia of APC in a hospital setting and potentially for supervised home management.

How healthcare providers' own death anxiety influences their communication with patients in end-of-life care: A thematic analysis.

Healthcare providers' own death anxiety can influence end-of-life communication. We interviewed nine palliative care health providers about their experiences of providing end-of-life care. Participants also completed the Revised Death Anxiety Scale. A thematic analysis of the interview transcripts identified one theme labeled "avoidant coping" and another labeled "death anxiety awareness"; each is presented in the context of the participants' own Revised Death Anxiety Scale scores. The findings show that avoidant death anxiety coping can compromise end-of-life communication, but that greater awareness of death anxiety can help overcome avoidant coping. The findings can inform potential improvements in healthcare practice and training.

Patient-reported factors associated with degree of pain medication dependence and presence of severe dependence among spinal outpatients.

Aim: To identify risk factors for pain medication dependence. Materials & methods: Chronic spinal pain outpatients (n = 106) completed the Leeds Dependence Questionnaire (LDQ) and measures of potential risk factors. Participants with high (n = 3) and low (n = 3) dependence were interviewed. Results: Mean LDQ score was 11.52 (standard deviation 7.35) and 15/106 participants (14.2%) were severely dependent (LDQ ≥20). In linear regression, pain intensity (ß = 0.313, p < 0.001), being disabled by pain (ß = 0.355, p < 0.001), borrowing pain medication (ß = 0.209, p = 0.006), and emergency phone calls or clinic visits (ß = 0.169, p = 0.029) were associated with degree of dependence across the range of LDQ scores. In logistic regression, pain intensity (p = 0.001) and borrowing pain medication (p = 0.004) increased the odds of severe dependence. Interviewees described how their pain influenced their pain medication use and one described pain medication addiction. Conclusion: Interventions to reduce pain intensity and pain-related disability may reduce pain medication dependence.

This study examined painkiller dependence among 106 people with chronic spinal pain. Participants had mild to moderate dependence on average, but 14% (15/106) had severe dependence. Statistical analysis showed that having more intense pain, being disabled by pain, needing to borrow painkillers, and needing to make emergency phone calls or clinic visits because of pain were all related to increased dependence, and more intense pain and borrowing painkillers made severe dependence more likely. Six participants who were interviewed described how their pain influenced their painkiller use and they also described their concerns about using painkillers, including becoming addicted to painkillers. These findings can guide ways to help people with chronic spinal pain to reduce or avoid painkiller dependence.

Using patient feedback to adapt intervention materials based on acceptance and commitment therapy for people receiving renal dialysis.

BACKGROUND: Theory-based intervention materials must be carefully adapted to meet the needs of users with specific physical conditions. Acceptance and Commitment Therapy (ACT) has been adapted successfully for cancer, chronic pain, diabetes, irritable bowel syndrome, multiple sclerosis, and a range of other conditions, but not so far for people receiving renal haemodialysis. This paper presents findings from a study to adapt ACT-based intervention materials specifically for renal dialysis. METHODS: Draft written materials consisting of four stories depicting fictitious individuals who used ACT-related techniques to help overcome different challenges and difficulties related to dialysis were adapted using a systematic patient consultation process. The participants were 18 people aged 19-80 years, with chronic kidney disease and receiving renal dialysis. Individual, semi-structured interviews were conducted to elicit participants' views about how the content of the draft materials should be adapted to make them more realistic and relevant for people receiving renal dialysis and about how the materials should be presented and delivered to people receiving renal dialysis. The interview transcripts were analysed using a qualitative adaptation of the Delphi method in which themes are used as a framework for translating feedback into proposals for modifications. RESULTS: The analysis of patient feedback supported the use of patient stories but suggested they should be presented by video and narrated by real dialysis patients. They also indicated specific adaptations to make the stories more credible and realistic. Participant feedback was translated into proposals for change that were considered along with clinical, ethical and theoretical factors. The outcome was a design for a video-based intervention that separated the stories about individuals from the explanations of the specific ACT techniques and provided greater structure, with material organised into smaller chunks. This intervention is adapted specifically for people receiving renal dialysis while retaining the distinctive theoretical principles of ACT. CONCLUSIONS: The study shows the value of consulting patients in the development of intervention materials and illustrates a process for integrating patient feedback with theoretical, clinical and practical considerations in intervention design.

A randomized-controlled pilot trial of an online compassionate mind training intervention to help people with chronic pain avoid analgesic misuse.

Problematic use of prescribed and over-the-counter analgesics is widespread and increasing among people with chronic pain, but the availability of preventative and treatment services is limited. We evaluated a 21-day online intervention based on compassionate mind training in a prospective, randomized-controlled trial. The participants were 73 adults with concerns about their use of analgesics for chronic pain conditions. Participants completed measures of analgesic use, misuse and dependence, plus self-criticism and self-reassurance (self-inadequacy, self-reassurance, and self-hate), cognitive impulsivity (negative urgency, lack of perseverance, lack of premeditation, sensation-seeking, and positive urgency) and behavioral impulsivity (delay discounting) at baseline, postintervention, and 1-week postintervention follow-up. Following baseline assessment, participants were randomized to compassionate mind training (CMT; n = 38) or relaxation music (n = 35), both delivered online. No adverse events or safety issues were reported and high participant retention and exercise completion rates showed that the intervention was acceptable to participants. Repeated measures analysis of variance showed that by comparison with relaxation music, the CMT group had reduced prescription analgesic use, F = 6.123, p = .015, analgesic dependence, F = 14.322, p < .001, self-hate, F = 12.218, p < .001, negative urgency, F = 7.323, p = .006, and lack of perseverance, F = 7.453, p = .001, from baseline to postintervention, and those improvements were maintained at follow-up. The results show that exercises based on CMT principles and techniques and delivered online can reduce analgesic use, risk of analgesic dependence, and some aspects of self-criticism and impulsivity. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Pain coping, pain acceptance and analgesic use as predictors of health-related quality of life among women with primary dysmenorrhea.

OBJECTIVES: Primary dysmenorrhea causes menstrual pain that affects women's quality of life (QoL) and analgesics are only moderately effective. Pain coping and pain acceptance influence QoL among people affected by other chronic pain conditions, so we examined pain coping, pain acceptance and analgesic use as predictors of QoL among women with primary dysmenorrhea. STUDY DESIGN: 145 women with primary dysmenorrhea completed an online survey including the Menstrual Symptoms Questionnaire (MSQ), the Coping Strategies Questionnaire (CSQ), the Chronic Pain Acceptance Questionnaire (CPAQ-8), questions about analgesic use, and the Short Form-12 (SF-12), a measure of physical and mental health-related QoL. RESULTS: In multiple regression, pain acceptance predicted better physical and mental QoL, whereas pain coping did not predict mental or physical quality of life. Being married or cohabiting and menstrual pain that was less severe and shorter in duration predicted better physical QoL, and those effects were mediated by pain acceptance. Being older at the onset of painful periods predicted better mental QoL and that effect was also mediated by pain acceptance. More severe menstrual pain and congestive rather than spasmodic dysmenorrhea predicted worse mental QoL but those effects were not mediated by other factors. Analgesic use did not predict physical or mental QoL. CONCLUSIONS: The results show the impact that menstrual pain has on women's quality of life, and suggest that initiatives to increase pain acceptance among women with menstrual pain are worthwhile. More research is needed to understand more fully the factors that influence health-related quality of life among women with menstrual pain.

Development and validation of the Satisfaction with Treatment for Pain Questionnaire (STPQ) among patients with sickle cell disease.

A brief measure of patient satisfaction with treatment for pain is needed to help improve the treatment of painful episodes caused by sickle cell disease (SCD), especially during and after the transition from paediatric to adult care. Focus groups of 28 adolescent and adult patients were consulted about the content, clarity and relevance of 30 potential items, resulting in an 18-item version. This was validated by analysing questionnaire responses from 120 patients aged 12-53 years. Confirmatory factor analysis and item analysis indicated five subscales with high internal reliability: 'Communication and Involvement' (6 items, α = 0·87); 'Respect and Dignity' (3 items, α = 0·82); 'Pain Control' (3 items, α = 0·91); 'Staff Attitudes and Behaviour' (4 items, α = 0·88); and 'Overall Satisfaction' (2 items, α = 0·85) plus a Total Satisfaction score (18 items, α = 0·96). High negative correlations with the Picker Patient Experience Questionnaire, a measure of problem experiences, indicated good convergent validity. Lower satisfaction scores among patients aged over 18 years, those admitted via the emergency department, those treated by non-specialist hospital staff, and those reporting more breakthrough pain indicated good concurrent validity. The questionnaire provides a convenient brief measure that can be used to inform and evaluate improvements in healthcare for adolescent and adult patients with SCD, and could potentially be adapted for other painful conditions.

An international study of analgesic dependence among people with pain in the general population.

BACKGROUND: Overuse of and dependence on analgesics (including opioids and other pain medications) are major international public health problems. OBJECTIVE: To identify influences on analgesic dependence among analgesic users in the general populations of different countries. METHODS: Online surveys of 1,283 people with pain in the UK, USA, Australia, Germany, Egypt and China/Macau/Hong Kong. RESULTS: Levels of analgesic overuse and dependence were highest in Egypt and lowest in China/Macau/Hong Kong. In every country except Egypt, frequency of pain and frequency of analgesic use were correlated with analgesic dependence, and scores on the Need subscale of the Pain Medication Attitudes Questionnaire (PMAQ) independently predicted analgesic dependence. In the UK, USA, Australia, and Germany, frequency of analgesic use mediated the effects of pain frequency or intensity, and Need scores mediated the effects of frequency of analgesic use. In Egypt, more recent pain, analgesic overuse, and the Emotion and Solicitude subscales of the Survey of Pain Attitudes independently predicted analgesic dependence. CONCLUSIONS: Across multiple countries, the impact of pain on analgesic dependence was mediated by frequency of analgesic use rather than overuse or abuse, and self-reported need for analgesics was the strongest independent predictor of dependence. Asking people directly about their feelings of needing analgesics could therefore identify those who could be helped to use analgesics less frequently, which should reduce their risk of dependence.

The invisible child: Sibling experiences of growing up with a brother with severe haemophilia-An interpretative phenomenological analysis.

INTRODUCTION: Haemophilia is an inherited chronic condition that causes bleeding in the joints and soft tissue. Healthy siblings growing up in the family of a person with haemophilia can be affected socially and psychologically. AIM: To explore qualitatively the experiences of healthy siblings who grew up with a brother with severe haemophilia. METHODS: Eleven healthy siblings (10 female, one male) who grew up with a brother with severe haemophilia A were recruited via the Haemophilia Society UK. The verbatim transcripts of individual semi-structured interviews were analysed using interpretative phenomenological analysis (IPA). RESULTS: Three themes were identified as follows: lack of parental attention, negative social emotions, and carrier status anxiety. Participants described having engaged in attention-seeking behaviours because they felt they lacked parental attention. They also described the resentment, anger and frustration they felt about the effect their brothers' haemophilia had on their lives. Female participants described the impact their carrier status or lack of it had on their lives. CONCLUSION: These findings could be translated into better advocacy and support for siblings through haemophilia centres. More research is also needed on how healthy siblings are affected by haemophilia, including studies guided by family systems theory.

Developing successful social support: An interpretative phenomenological analysis of mechanisms and processes in a chronic pain support group.

OBJECTIVE: The experience of long-term membership of a successful chronic pain support group (CPSG) was explored to identify; (i) factors associated with social support, and; (ii) ways that health care professionals (HCPs) could help CPSGs become more effective and supportive. DESIGN: Interpretative Phenomenological Analysis enabled exploration of participants' experiences of membership and rationales for continued attendance. MAIN OUTCOME MEASURES: Twelve participants (four males, eight females), recruited from a regional CPSG, completed semi-structured interviews lasting from 45 to 120 minutes. Following verbatim transcription, idiographic then cross-case analyses were undertaken. RESULTS: Three superordinate themes emerged: (1) Investing in the new normal; (2) The nurturing environment; (3) Growth facilitation through social evolution. Increased investment and identification with membership, generated snowballing social engagement, enhancing pain management/well-being through collective humour and peer-to-peer support. Explicit guidance by HCPs in early stages of group formation/development, and subsequent implicit influences on group attitudes and actions, promoted the group's development into its current healthy, supportive state. CONCLUSION: Contrary to stereotypes, membership offered positive respite from chronic pain through collective coping. Successful CPSGs forge an independent identity, fostering strong group investment and an ability to live well with chronic pain. HCPs can provide a stabilising foundation for CPSGs to develop positively and supportively.

Development and validation of a short-form Pain Medication Attitudes Questionnaire (PMAQ-14).

Attitudes to pain medication are important aspects of adjustment to chronic pain. They are measured by the 47-item Pain Medication Attitudes Questionnaire (PMAQ). To measure those attitudes more quickly and easily, we developed and evaluated a 14-item PMAQ using data from 3 separate surveys of people with pain in the general population. In survey 1, participants (n = 295) completed the 47-item PMAQ and measures of pain, analgesic use, analgesic dependence, and attitudes to self-medication. For each of the 7 PMAQ scales, the 2 items that best preserved the content of the full parent scales were identified using correlation and regression. The 2-item and full parent scales had very similar relationships with other measures, indicating that validity had been maintained. The resulting 14-item PMAQ was then completed by participants in survey 2 (n = 241) and survey 3 (n = 147), along with the same other measures as in survey 1. Confirmatory factor analysis showed that the 14-item PMAQ retained the 7-factor structure of the 47-item version, and correlations with other measures showed that it retained the validity of the 47-item version. The PMAQ scale Need was the most significant independent predictor of analgesic dependence in each of 4 separate multiple regression analyses. This short form of the PMAQ allows attitudes to pain medications to be measured in a valid and more efficient way.

Reflecting the transition from pain management services to chronic pain support group attendance: An interpretative phenomenological analysis.

OBJECTIVES: Transitioning from clinical care to community-based self-management represents a significant challenge, throughout which social support can facilitate health adjustment and quality of life. However, community-centred, peer-led support structures are often underused. This study aimed to investigate the decision-making processes involved in the choice to attend a chronic pain support group (CPSG) following discharge from a Pain Management Programme. DESIGN: An in-depth, qualitative analysis was undertaken using interpretative phenomenological analysis, exploring participants' subjective experiences, decision-making, and rationale for initial CPSG attendance. METHODS: Twelve participants (four males, eight females) were recruited from a regional CPSG and completed semi-structured interviews lasting between 45 and 120 min. Interviews were transcribed verbatim and analysed idiographically before a cross-case analysis was completed. RESULTS: Analysis of transcripts resulted in three superordinate themes: (1) The thirst for comparative friendship; (2) conjecture and the imminent choice; (3) progressive pain management. These themes reflect a desire for empathic, socially comparative friendships and the search for a forum in which to enhance pain self-management strategies, yet also internal conflict over initial CPSG attendance. CONCLUSION: Social support and associated friendships are attractive to prospective CPSG members and are conceptualized as opportunities to engage in social comparison and nurture self-care. The first visit to the support group presents a significant hurdle, but can be facilitated by managing the transition between therapeutic care and CPSG attendance. Clinicians can challenge preconceptions, foster positive viewpoints regarding the group and support collective decision-making to attend. Following initial attendance, psychosocial well-being was enhanced. Statement of contribution What is already known on this subject? Social support functions as a protective buffer against declining health. Joining a peer-led support group can be initially intimidating and the first visit presents a significant hurdle. What does this study add? Participants are predominantly attracted to support groups due to the opportunity to develop new friendships. Health-related peer groups function as fora for social comparison, enhancing self-esteem and self-efficacy. Experience of pain management programmes primes willingness to attend support groups. The initial decision to attend is difficult but facilitated by collective, group decision-making processes. Health care professionals dynamically prime the transition towards peer support structures.

Effects of a pain self-management intervention combining written and video elements on health-related quality of life among people with different levels of education.

Combining written and video material could increase the impact of health education for people with less education, but more evidence is needed about the impact of combined materials in different formats, especially in the context of chronic pain self-management. This study tested the impact of combining written information about self-managing chronic joint pain, which used language at a high reading level, with a DVD containing narrative video material presented directly by patients, using language at a lower reading level. Physical and mental health-related quality of life (36-Item Short Form Health Survey) was measured among 107 men with hemophilia before and 6 months after being randomly assigned to receive an information booklet alone or the booklet plus the DVD. Analysis of covariance was used to compare health outcomes between randomized groups at follow-up, using the baseline measures as covariates, with stratified analyses for groups with different levels of education. The DVD significantly improved mental health-related quality of life among those with only high school education. Video material could therefore supplement written information to increase its impact on groups with less education, and combined interventions of this type could help to achieve health benefits for disadvantaged groups who are most in need of intervention.

Managing multiple goals during fertility treatment: An interpretative phenomenological analysis.

This study investigated how men and women made sense of multiple goals during fertility treatment. Both members of three heterosexual couples participated in two or three semi-structured interviews over 6 months, producing 14 accounts, which were analysed using interpretative phenomenological analysis. The goal of biological parenthood dominates assumptions in infertility research, but its importance varied between participants, who balanced that goal with retaining emotional well-being, avoiding financial difficulties and maintaining their relationship. These themes are discussed in the context of the self-regulation model, which allows fertility treatment experiences to be conceptualised more broadly than do other models.

Predictors of painkiller dependence among people with pain in the general population.

OBJECTIVES: Self-medication with painkillers is widespread and increasing, and evidence about influences on painkiller dependence is needed to inform efforts to prevent and treat problem painkiller use. DESIGN: Online questionnaire survey. PARTICIPANTS: People in the general population who had pain and used painkillers in the last month (N = 112). MEASUREMENTS: Pain frequency and intensity, use of over-the-counter and prescription painkillers, risk of substance abuse (Screener and Opioid Assessment for Patients with Pain [SOAPP] scale), depression, anxiety, stress, alexithymia, pain catastrophizing, pain anxiety, pain self-efficacy, pain acceptance, mindfulness, self-compassion, and painkiller dependence (Leeds Dependence Questionnaire). RESULTS: In multiple regression, the independent predictors of painkiller dependence were prescription painkiller use (ß 0.21), SOAPP score (ß 0.31), and pain acceptance (ß -0.29). Prescription painkiller use mediated the influence of pain intensity. Alexithymia, anxiety, and pain acceptance all moderated the influence of pain. CONCLUSIONS: The people most at risk of developing painkiller dependence are those who use prescription painkillers more frequently, who have a prior history of substance-related problems more generally, and who are less accepting of pain. Based on these findings, a preliminary model is presented with three types of influence on the development of painkiller dependence: 1) pain leading to painkiller use, 2) risk factors for substance-related problems irrespective of pain, and 3) psychological factors related to pain. The model could guide further research among the general population and high-risk groups, and acceptance-based interventions could be adapted and evaluated as methods to prevent and treat painkiller dependence.

Dyslexia, authorial identity, and approaches to learning and writing: a mixed methods study.

BACKGROUND: Dyslexia may lead to difficulties with academic writing as well as reading. The authorial identity approach aims to help students improve their academic writing and avoid unintentional plagiarism, and could help to understand dyslexic students' approaches to writing. AIMS: (1) To compare dyslexic and non-dyslexic students' authorial identity and approaches to learning and writing; (2) to compare correlations between approaches to writing and approaches to learning among dyslexic and non-dyslexic students; (3) to explore dyslexic students' understandings of authorship and beliefs about dyslexia, writing and plagiarism. SAMPLE: Dyslexic (n= 31) and non-dyslexic (n= 31) university students. METHOD: Questionnaire measures of self-rated confidence in writing, understanding of authorship, knowledge to avoid plagiarism, and top-down, bottom-up and pragmatic approaches to writing (Student Authorship Questionnaire; SAQ), and deep, surface and strategic approaches to learning (Approaches and Study Skills Inventory for Students; ASSIST), plus qualitative interviews with dyslexic students with high and low SAQ scores. RESULTS: Dyslexic students scored lower for confidence in writing, understanding authorship, and strategic approaches to learning, and higher for surface approaches to learning. Correlations among SAQ and ASSIST scores were larger and more frequently significant among non-dyslexic students. Self-rated knowledge to avoid plagiarism was associated with a top-down approach to writing among dyslexic students and with a bottom-up approach to writing among non-dyslexic students. All the dyslexic students interviewed described how dyslexia made writing more difficult and reduced their confidence in academic writing, but they had varying views about whether dyslexia increased the risk of plagiarism. CONCLUSIONS: Dyslexic students have less strong authorial identities, and less congruent approaches to learning and writing. Knowledge to avoid plagiarism may be more salient for dyslexic students, who may benefit from specific interventions to increase confidence in writing and understanding of authorship. Further research could investigate how dyslexic students develop approaches to academic writing, and how that could be affected by perceived knowledge to avoid plagiarism.