The Pelvic Pain Bias Assessment: a new assessment of interpretation bias specific to pelvic pain

must be acknowledged. First, relevance ratings for the scenarios were obtained only from participants with endometriosis. Sufficient validity can be inferred given the selected scenarios received likelihood ratings of above 25% on average, from the whole sample; however, future research could investigate scenario relevance in specific pelvic pain–related condition subsamples. Nonetheless, the rigour of our task development and stimuli selection is a strength. The sample were a convenience sample recruited through social media and although the study was advertised without mentioning pain, we cannot exclude the possibility that people with menstrual pain were more motivated to participate. There was a high rate of comorbidity among those reporting pelvic pain and gynaecological conditions, and diagnoses were self-reported and, therefore, not confirmable. Separating out effects within and between conditions is, therefore, difficult yet because these conditions often co-occur, there may be little clinical or research utility in doing so. Further research could investigate rates of pelvic pain bias in specific conditions if indicated by strong theoretical or clinical rationale. There are also limitations in forced choice compared to open ended responding in that either response option may not reflect an individual's interpretation.50 To minimise the impact of this, scenarios for which possible solutions were rated as particularly unlikely to occur relative to another were removed in our development phase. Nevertheless, the current design allowed us to investigate biases in those with and without self-reported pelvic pain–related conditions who were recruited through the same methods and well matched. Given that we used a statistical method to choose relevant items for the final assessment tool based on the endometriosis sample, the very large effects observed may be overestimated. However, this limitation is mitigated because the PPBA can also differentiate between those with other pelvic pain–related conditions and those without. 4.2. Implications To our knowledge, this study presents the first tool for assessing pelvic pain specific interpretation bias. The PPBA relates more strongly to pain and menstrual symptoms than psychological distress, demonstrating good construct validity. Although biological differences across primary and secondary pelvic pain–related conditions must be considered (eg, fertility impacts in endometriosis and adenomyosis compared to CPP alone), our findings shed light on pelvic pain specific interpretation bias as a shared psychosocial factor across conditions, associated with worse pelvic pain and menstrual symptoms. The PPBA should, therefore, be considered in multidisciplinary biopsychosocial assessment of pelvic pain–related difficulties. Further, considering interpretation bias as part of multidisciplinary management of pelvic pain is important given it is posed as a central driver of pain experiences.14,64 Low cost, accessible, and highly scalable interpretation bias interventions exist and may be relevant for people with pelvic pain. Specifically, training individuals to make benign rather than condition consistent interpretations of ambiguous information through Cognitive Bias Modification for Interpretation has led to improved pain outcomes among individuals with chronic pain.53 Further, the PPBA could be adapted to assess other cognitive biases, such as memory bias. Participants could recall the solutions to the PPBA scenarios. This could provide insight into whether individuals with pain-related distress are more likely to remember pain threat–related interpretations, thereby reinforcing negative cognitive patterns. Assessing memory bias in conjunction with interpretation bias may help clarify whether these biases operate independently or synergistically, which could inform the development of more comprehensive cognitive models and interventions.63 5. Conclusion We rigorously developed 27 ambiguous PPBA scenarios that are psychometrically sound and exhibit good internal consistency, test–retest reliability, and construct validity. Using these scenarios, we demonstrated a strong interpretation bias in people with chronic pelvic pain and gynaecological conditions, adding to the growing body of evidence regarding biased interpretation styles in people living with painful conditions. These findings provide a promising avenue as a potential modifiable treatment target in pelvic pain. Conflict of interest statement The authors have no conflict of interest to declare. Supplemental digital content Supplemental digital content associated with this article can be found online at https://links.lww.com/PAIN/C424.

The authors gratefully acknowledge the participants who gave their valuable time contributing to this research. This work was supported by an Australian Government Research Training Program scholarship awarded to B.P., an Australian Research Council (ARC) Grant DE230100206 awarded to J.T., and an NHMRC Investigator Grant (2017628—G215120) awarded to R.M. The funding sources do not have any authority over the research, data, or arising publications. Data availability statement: Deidentified data are available from the authors.

Pelvic pain; Interpretation bias; Cognitive bias; Pain; Menstruation; Endometriosis; Adenomyosis; PCOS; Chronic pelvic pain