Curr Sex Health Rep (2014) 6:20–29
DOI 10.1007/s11930-013-0008-0
FEMALE SEXUAL DYSFUNCTION AND DISORDERS (A GIRALDI AND L BROTTO, SECTION EDITORS)
Incorporating Mindfulness Meditation into the Treatment
of Provoked Vestibulodynia
Rosemary Basson & Kelly B. Smith
Published online: 6 December 2013
# Springer Science+Business Media, LLC 2013
Abstract Optimal therapy for the pain and sexual dysfunction
associated with provoked vestibulodynia (PVD) is unclear.
Commonly co-morbid with other chronic pain conditions,
PVD affects up to 18 % of premenopausal women. There is
usually subsequent persistent sexual dysfunction and sexual
dissatisfaction. We suggest that due to the documented under-
lying emotional stressors and subsequent sexual stress from
living with PVD, the current stress model of pain can usefully
guide therapy. Recent scientific data confirm a benefit from
mindfulness practice to reduce chronic pain and stress as well
as to ameliorate women’s sexual dysfunction. There is a ratio-
nale and preliminary evidence of benefit from a brief, small-
group therapy which emphasized mindfulness for the pain and
suffering of PVD. Modelled on similar programs for anxiety,
depression, and stress, an eight-week mindfulness-based cog-
nitive therapy program for PVD has been established.
Keywords Mindfulness . Mindfulness-based stress
reduction . Mindfulness-based cognitive therapy . Provoked
vestibulodynia . Vulvodynia . Genital pain . Dyspareunia .
Chronic pain . Neuroplasticity . Stress model of chronic pain .
Treatment . Mindful meditation
This article is part of the Topical Collection on Female Sexual
Dysfunction and Disorders
R. Basson (*)
Department of Psychiatry, University of British Columbia, Purdy
Pavilion UBC Hospital, 2221 Wesbrook Mall, Vancouver, BC,
Canada V6T 1Z9
e-mail: rosemary.basson@vch.ca
K. B. Smith
Department of Obstetrics & Gynaecology, University of British
Columbia, 2775 Laurel Street, 6th Floor, Vancouver, BC, Canada
V5Z 1M9
e-mail: Kelly.Smith@vch.ca
Introduction
Provoked vestibulodynia (PVD) is characterized by burning
pain from touch or pressure to the vestibule – the area con-
taining the vaginal and urethral openings, hymen, and adja-
cent edge of the inner surfaces of the labia minora. Marked
tenderness to cotton swab palpation of the vulvar vestibule
and physical findings limited to variable vulvar erythema
confirms the diagnosis. The most common type of
vulvodynia, PVD affects some 12–18 % of women of repro-
ductive age [1] and is the most common cause of premeno-
pausal dyspareunia (painful intercourse). Pain from the touch
and pressure involved in sexual activity causes extreme dis-
tress: penetration is painful, as is the movement of the penis
(or dildo or fingers). Often there is post-coital vestibulodynia
and temporarily painful urination. Nonsexual touch from tight
clothing seams, and insertion of speculum, tampon or diva cup
is also painful. Other chronic pain syndromes are common
including irritable bowel syndrome, temporomandibular joint
pain, fibromyalgia and interstitial cystitis [2, 3].
Provoked Vestibulodynia and Psychosexual Sequelae
Women with PVD report a substantial negative impact of the
pain on their sexual and psychological well-being. Difficulties
with sexual functioning, including problems of desire, arousal,
and orgasm, lead to high reported levels of sexual dissatisfac-
tion [4, 5]. Strong feelings of inadequacy as a sexual partner
and as a woman may be present, with women often describing
themselves as “broken” or “abnormal” [6, 7]. Affected women
also report feeling a low level of control over their pain [7] and
express pain-related hypervigilance, fear and catastrophizing
[8–11]. Among those who are of reproductive age, marked
anxiety about pregnancy and childbirth is often expressed in
the clinical setting [12]. Women’s fears include their possible
Curr Sex Health Rep (2014) 6:20–29
inability to conceive due to the pain from penetration, poten-
tial exacerbation of their pain from pregnancy and/or from
delivery, and that vaginal delivery would be complicated or
impossible because of PVD. Elevated levels of anxiety and
higher rates of depressive symptoms have been documented
among PVD-affected women in comparison to controls (see
Desrochers et al. [4] for review). While, historically, the role
that mental health factors have played in the etiology and
maintenance of PVD has been unclear, a recent study docu-
mented that women with an antecedent anxiety or mood
disorder were ten and three times more likely, respectively,
to develop chronic vulvar pain compared to women without
such a disorder [13•]. This same study also found that the rates
of new onset anxiety or mood disorder were seven times
greater among vulvar pain-affected women compared to con-
trols, i.e., psychiatric morbidity may be both a consequence of
vulvar pain and a risk factor for its development. Further
evidence of the distress experienced by women with PVD
includes reports of self-dislike, fear of negative evaluation,
negative self-picture, perfectionism, somatic preoccupation,
somatization, and harm avoidance [7, 14–17].
Pathophysiology of Provoked Vestibulodynia
The allodynia (pain from a non-noxious stimulus) and
hyperalgesia of the vestibule have been shown to reflect
central sensitization of the nervous system [18]. The latter
can be defined as an amplification of neural signaling within
the central nervous system (CNS) to elicit pain hypersensitiv-
ity. The changes in CNS structure and function reflect
neuroplasticity. Dorsal horn cell sensitivity to pain is modu-
lated by descending signals of inhibition and facilitation from
the brain, thus, changes within the CNS can allow increased
excitability of central nociceptive circuits [19]. In the past,
afferent nerve injury or repeated afferent nociceptor activity
was thought to be the major cause of central sensitization in
PVD - a previous model postulated ‘microtrauma’ to the
vestibule to be the primary event [20]. However, such trauma
is not documented and some 50 % of women have pain with
the first attempt at vaginal penetration (primary or ‘life-long’
PVD). Currently, the possibility is entertained that the in-
creased excitability of pain networks is the primary event in
a number of chronic pain syndromes [21] and ‘central sensi-
tization syndromes’ are conceptualized [19]. It is thought that,
given certain genetic susceptibility, repeated activation of
stress circuits can alter the pain modulating circuitry [22].
Thus, a noxious stimulus is not necessarily required to expe-
rience pain [19]. It is of note that women with PVD, as well as
often having co-morbid pain conditions, demonstrate both
hyperalgesia and decreased pain thresholds in non-genital
parts of the body [11, 18].
21
Stress Model of Pain
Humans and animals are generally highly resilient to even
extreme stress. Nevertheless, ongoing stress under some cir-
cumstances is currently considered to predispose to psychiat-
ric disorders and to chronic pain syndromes in adulthood [23].
Recent animal work suggests that prolonged exposure to high
levels of glucocorticoids can markedly influence activity of
glucocorticoid receptors and alter structure and function of
brain areas, including the hippocampus, that may predispose
to anxiety [24]. The 10-fold increased risk of vulvodynia in
women with prior clinical diagnosis of anxiety disorder has
been mentioned [13•]. The increased self-dislike, negative
self-picture, perfectionism, depression, pain catastrophizing,
hypervigilance and somatic preoccupation, somatization, and
harm avoidance [7, 14–17] in women with PVD compared to
controls, are considered to be emotional stressors [25]. Such
sources of emotional stress are typically observed to be long-
term as opposed to being simply reactions to the pain of PVD.
Recent research suggests a stress model of chronic pain [26•,
27•] focusing on allostasis, i.e., the physiological stability
maintained by various mechanisms within the body which
promote adaptation to stress even in the longer term. Allostatic
load/overload [28] depicts the wear and tear of body systems,
including the brain, from excessive stress. Given the debility
and negative consequences of recurrent pain, the stressors
produced by the pain condition itself maintain a vicious cycle.
This cycle may be particularly true for the sexual pain of PVD:
a stress-induced and maintenance model for the pain of PVD
has recently been described (see Fig. 1), [29••] similar to the
vicious cycle depicted for migraine [27•]. The personality
traits of negative self-evaluation and fear of negative evalua-
tion by others leads to the vulnerability to self-label as “sex-
ually substandard” or even “sexually inadequate”. The stress
model of pain posits that this sexual stress maintains the
heightened reactivity of the pain circuitry from ‘top- down’
modulation.
Stress-associated neuroplastic changes in brain structure
and function can reverse. In a recent study, prior to any
intervention, ratings of perceived stress in stressed but healthy
persons did not correlate with amygdala volume - the amyg-
dala features prominently in the stress response. However, an
eight-week mindfulness-based stress reduction program
allowed reduction in perceived stress, which correlated posi-
tively with decreases in right basolateral amygdala activity
[30].
The role of stress in maintaining PVD and promoting
exacerbations of pain is clinically evident. Moreover, the
histology of the vulvar skin in PVD reflects stress-induced
changes including nociceptor proliferation as well as variably
increased numbers of mast cells and plasma cells [31–35]. The
skin itself has its own neuroendocrine system, which reacts to
stress concurrent with the systemic response [36]. Mast cells
22
Fig. 1 Circular model of provoked vestibulodynia to illustrate the
compounding effects of subsequent sexual dysfunction on overall
allostatic load: Stress responses of body and skin add to the skin patho-
physiology. (Reprinted from Basson [29••]; copyright 2012, John Wiley
and Sons; with permission.)
and plasma cells within the lymphoid tissue are activated by
the sympathetic nervous system or via stress hormones, and
lymphoid tissues are in close proximity to sensory nerve
endings allowing hypersensitivity and pain from the release
of multiple substances [37]. Stress also leads to antidromic
(backward) signals in sensory nerves, which release neuro-
transmitters to activate mast cells in the skin and to promote
nociceptor proliferation. In other words, thoughts and emo-
tions can influence descending signals to the spinal cord to the
peripheral nerves to modulate the complex neuroendocrinol-
ogy of the skin in response to stress [38].
Treatment of Provoked Vestibulodynia
Medical treatment of PVD has been unsatisfactory such that
an interdisciplinary biopsychosexual approach is currently
encouraged [39, 40]. Pain medications, both topical and oral,
are similar in analgesic benefit to placebos [41–43], as was
investigational botulinum toxin, which was statistically infe-
rior to placebo in reduction of sexual distress [44]. Although
rarely chosen by women, surgical vestibulectomy can be of
benefit; however, exclusion factors are numerous [45] and the
benefit is mostly in women with acquired as opposed to life-
long histories. There is some evidence of benefit from cogni-
tive behavioral therapy (CBT) which was sustained over the
two years of follow-up [46]. Catastrophic thinking, amenable
to CBT approaches, is particularly common in women with
PVD [47]. Learning to identify catastrophic thoughts but not
necessarily change them – rather to accept them as simply
mental events as opposed to truths - is a key component of
another cognitive therapy, namely mindfulness-based cogni-
tive therapy (MBCT). Given that another key component of
MBCT is acceptance, the lack of self-acceptance, which is
clinically apparent in women with PVD and confirmed by
studies showing an increased prevalence of type D
Curr Sex Health Rep (2014) 6:20–29
personality, self-dislike and fear of negative evaluation by
others, the distress associated with PVD may be particularly
amenable to MBCT.
Mindfulness
Mindfulness is an ancient meditative technique recently
adopted by Western medicine to benefit stress and chronic
pain [48]. Mindfulness involves paying attention “on purpose,
in the present moment, and nonjudgmentally” (p. 4) [49]. It is
cultivated through meditation, with the latter described as “the
intentional self-regulation of attention from moment to mo-
ment” (p. 125) [50]. Being mindful is to be aware, focused,
relaxed, and non-reactive: thoughts that enter consciousness
are noted but not followed. A non-judgmental/accepting atti-
tude to the present moment - observing the tendency to cling
(attach) onto pleasant feelings and avoid (find aversive) un-
pleasant feelings - is a fundamental component of mindful-
ness. Gradually awareness develops that all thoughts and
feelings, including painful physical sensations, are only tem-
porary brain phenomena. It has been described as
“uncoupling” of the physical sensation from the emotional
and cognitive experience of pain [51]. Mindfulness practice
can be considered to contain two styles: Focused Attention
(FA) or Shamatha - for example, directing attention to sensa-
tions in one area of the body - and Open Monitoring (OM) or
Vipassana, which is the non-directed awareness of any senso-
ry, emotional, or cognitive event occurring in the mind. Many
benefits may ensue from the practice of mindfulness, includ-
ing improved psychological (e.g., reduced rumination, in-
creased self-compassion) and physiological (e.g., decreased
cortisol, enhanced immune function), outcomes [52•].
Mindfulness and Stress
The Mindfulness –Based Stress Reduction (MBSR) program
designed 30 years ago to lessen the stress of living with
chronic disease is now widely used with continued benefit
[53–55] and the mechanisms of change are currently being
clarified [56]. Research confirms both a reduction of per-
ceived stress [57] and benefit to abnormal cortisol production
and other immune responses [52•] from mindfulness practice.
Typically, MBSR is given as an eight-week program but
ongoing practice is needed. Randomized clinical trials indi-
cate that stress reduction may not be seen until two to six
months later [58]. Reducing the effects of the multiple
stressors of women with PVD may markedly influence the
top-down regulation of the documented heightened pain
responsivity throughout their nervous systems [11], as well
as benefit the vestibular skin neuroendocrine responses. The
stress from self-judgment so evident in women with PVD [7,
Curr Sex Health Rep (2014) 6:20–29
14–17] is particularly amenable to mindfulness therapy. A
recent study in healthy volunteers found a positive association
between the describing facet on the Five Facet Mindfulness
Questionnaire and gray matter volume in the right anterior
insula [59]. The describing facet includes both the ability to
find words to describe one’s feelings and to be non-
judgmental. The researchers suggested the increased insular
volume may reflect more awareness of one’s own stressful
state and more ability to cognitively temper emotions. Lower
amygdala activity in persons with higher ‘describing scores’
was also implied from this research: this finding may reflect
heightened cognitive control of emotional responses by the
prefrontal cortex.
Mindfulness-Based Cognitive Therapy
MBCT [60] is adapted from MBSR and was originally devel-
oped to prevent relapse in persons who had experienced major
depression. Combining mindfulness skills training with cog-
nitive therapy, MBCT is delivered in group format over eight
weekly, two hour sessions. The cognitive aspects of MBCT
involve cultivating a “decentered” approach to one’s thoughts,
in which thoughts are viewed as mental events that arise and
pass as opposed to factual representations of oneself and
reality. In this manner, and with training in the redirection of
attention to other present moment experiences, depressive
patterns of thought can be prevented [50]. The encouragement
inherent in traditional CBT to change those thoughts that, on
careful scrutiny, are maladaptive is absent. There is evidence
that MBCT does indeed reduce the risk of depressive relapse,
particularly in persons with more than two episodes of previ-
ous depression [61]. Since its development, MBCT has been
widely applied and has shown benefits for a variety of condi-
tions, including the following that may be particularly relevant
for PVD: anxiety disorders [48, 62, 63] current depression
[63], and recurrent pain [64]. Additionally, preliminary results
suggest that MBCT may also be helpful for women experienc-
ing fertility problems and related stress [65].
Mindfulness and Pain
Controlled studies have shown mindfulness therapy (MT) to
decrease pain intensity in fibromyalgia and irritable bowel
syndrome, both of which are frequently comorbid with PVD
[66, 67]. Behavioural study of short-term mindfulness training
confirms reduction of experimental pain above and beyond
distraction and relaxation [68]. Imaging studies suggest MT
may lead to altered pain processing when a painful stimulus is
given even when practitioners are not formally meditating [69,
70]. Brain imaging during pain in long-term Zen practitioners
suggested inhibition of evaluation, elaboration, and emotional
23
reactivity (deactivation of dorsolateral prefrontal cortex,
orbitofrontal cortex, medial prefrontal cortex, amygdala and
hippocampus) and more attention to sensation (i.e., more
activity in pain areas) compared to controls [70]. A recent
review found imaging data to date supported the historical
findings that mindfulness training enables a person to accept
an affective state (or pain) as an ‘object’ of attention, and that
this was related to enhanced ability to engage frontal cortical
structures to dampen amygdala activation [71].
Of particular clinical relevance is evidence that even brief
MT is effectively analgesic [72]. When experience is taken
into consideration, there is some evidence that OM practice is
more beneficial to analgesia than FA [73]. However, if both
OM and FA are implemented even over a short training [68,
72], benefit has been demonstrated.
Research is also emerging on mindfulness- associated
changes at the molecular level. Cardiac vagal tone has been
used as a proxy for physical health. The vagus nerve mediates
the variability in heart rate in response to respiration and to
various mind states. Participating in six-week training in a
loving kindness mindfulness practice, led to increased positive
emotions associated with increased vagal tone, this effect
mediated by increased perceptions of social connections
[74]. Separate research showed that invoking the relaxation
response (the counterpart of the stress response ), by mindful-
ness practices over an eight week period, was associated with
enhanced expression of genes associated with energy metab-
olism, mitochondrial function, insulin secretion and telomere
maintenance [75].
Mindfulness and Women’s Sexual Dysfunction
There has been growing interest and empirical attention paid
to the incorporation of mindfulness in the treatment of sexual
difficulties. Compared to controls, women with sexual diffi-
culties, such as those with low sexual desire and arousal, have
lower self-image and more anxious thoughts – even when
those with depression or an anxiety disorder are excluded
from study [76]. A common theme of their heightened self-
criticism is “not being normal” and worry about their sexual
performance is a typical source of anxiety [77]. These same
tendencies are frequently reported by women with PVD.
Mindfulness practice, with its focus on nonjudgmental aware-
ness and acceptance of the present moment, can help to lessen
the distractions, worries, and self-criticisms that often underlie
sexual problems. As women learn to notice the distracting,
critical thoughts and become increasingly able to resist their
former tendency to engage those thoughts and follow them, so
they begin to experience more sexual pleasure, response, and
reward during sexual encounters.
While only a small number of studies have been published
in the area of mindfulness and sexuality, the results from these
24
studies are compelling. Studies conducted by Brotto and col-
leagues indicate that a brief, three-session intervention incor-
porating mindfulness skills for gynecological cancer survivors
with distressing sexual desire and/or arousal difficulties was
associated with significant improvements in various aspects of
sexual function, including increased arousal, desire, orgasm,
and satisfaction, and significantly reduced sexual distress [78,
79]. Women also reported an increased ability to perceive signs
of genital arousal. Qualitative interviews with women who
participated in the Brotto et al. [78] study indicated that the
mindfulness component of the treatment program was unani-
mously perceived to be the most helpful [80].
Positive results of a similar three-session intervention have
also been found in women with non-cancer related sexual
desire and/or arousal problems, whereby significant improve-
ments in sexual desire and distress were noted following
group treatment [81]. Among women who felt that their
sexual difficulties/distress were related to a history of sexual
abuse, mindfulness-based treatment has been shown to have a
greater effect compared to CBT on the level of concordance
(i.e., agreement) between women’s mental and genital arousal
upon exposure to an erotic film [82]. Research conducted by
other groups supports the beneficial effects of mindfulness for
women’s sexuality: among a small group of women with
heterogeneous sexual concerns, Mize and Iantaffi [83] report-
ed that all women found the mindfulness component of a
body-oriented group therapy to be helpful and transferable
to their sexual experiences. In addition, women with a regular
mindfulness meditation practice reported in a recent qualita-
tive study that their practice enhanced their sexual lives by, for
example, allowing for deeper emotional connection with part-
ners and greater physical pleasure during sex [84].
Mindfulness and PVD
With evidence that mindfulness training reduces stress and
anxiety, decreases pain intensity, and improves mood, sexual
difficulties and sexual distress, its incorporation into the treat-
ment of PVD appears extremely promising. In the Buddhist
Psychological Model - used to explain the process of mind-
fulness and its underlying mechanisms - attachment and aver-
sion to transient physical sensations, feeling, and cognitions
are thought to promote suffering [85•]. The previously men-
tioned “uncoupling” [51] of physical, emotional, and cogni-
tive components of pain by paying attention to, rather than
avoiding or being averse to, the ever-changing sensations that
comprise the pain experience encourages a curious and more
accepting stance. Physical sensations, emotions, and thought
‘sensations’ become observed as temporary events. This ob-
servation can help a woman with PVD attend to her pain with
less reactivity and self-judgment, which in turn may counter
the underlying stress-induced pathophysiology in the CNS
Curr Sex Health Rep (2014) 6:20–29
and skin. Recent review [86] of epigenetic changes underlying
chronic pain notes how such changes are potentially reversible
and raises the question of how the experience, stress and
memory of pain affect patterns of gene expression in the brain
might be reversed. It is possible that changing the experience
of pain may reverse some of those changes. Because women
with PVD typically experience both pain and comorbid “shut-
ting down” [29••] of their sexual response, mindfulness may
be particularly well-suited to treat this condition. Mindfulness
encourages self-acceptance, including sexual self-acceptance,
as well as tuning into bodily and cognitive-emotional sensa-
tions with curiosity and without reaction. In addition to its
other noted effects, mindfulness practice can help women
increase their awareness of physical sensations that may be
pleasurable (e.g., during non-penetrative sexual activities) and
in doing so may allow women to experience pain-reducing
arousal and more rewarding sexual experiences.
Mindfulness is often used clinically with couples living
with PVD [87]. For example, the pairing of mindfulness and
pelvic floor physiotherapy has been promoted in the literature
[88], whereby mindful awareness and acceptance of thoughts
and emotions are encouraged during placement of vaginal
inserts (a common component of pelvic floor physiotherapy
for PVD). By promoting non-judgmental awareness of her
experience as she works with vaginal inserts, the need to strive
for a particular outcome is reduced and a woman’s ability to
experience penetration in a “positive, desired, and controlled
way” (p. 25 [88]) may be enhanced.
It is only recently that mindfulness for PVD has been
empirically evaluated. Indeed, the only mindfulness-based
program to have been developed and tested to date is the
“IMPROVED” (Integrated Mindfulness for Provoked
Vestibulodynia) program (Basson et al., IMPROVED unpub-
lished manual). Designed as a brief, four-session group ther-
apy for women with PVD, the IMPROVED program com-
bined elements of mindfulness skills, psychoeducation, sex
therapy, and CBT and it was repeatedly emphasized that the
program was just the beginning of an ongoing approach to
living with PVD. Women were encouraged to practice their
acquired skills at home throughout the program and to devel-
op their own personal, ongoing mindfulness practice.
Brotto et al., recently evaluated the effects of IMPROVED
compared to waitlist post detailed assessment, on a variety of
pain-related, sex-related, and quality of life-related endpoints at
six weeks post-treatment, and six-month follow-up [89]. Sig-
nificant increases in pain self-efficacy, reduced vestibular
allodynia on examination and reduced pain catastrophizing,
hypervigilance, sexual distress, and symptoms of depression
were reported at four to six week follow-up assessments. Fur-
ther improvements in all of these variables except mood were
reported at a six-month follow-up. Changes in mindfulness
domains were also followed. Increased ability to observe sen-
sations and to act with awareness was present post treatment.
 Curr Sex Health Rep (2014) 6:20–29

Table 1 Overview of 8-session MBCT program for women with PVD: MP = mindfulness practice; JKZ = Jon Kabat Zinn

wk Brief MP Theme& extended MP Information on PVD, Pain, Stress, Sexuality & MP Home Activities

1 n/a
2 Mindful eating (See, taste,
smell Raisin)
3 Seeing Leaf
4 Listening-Music
5 Listening-Ocean sounds
6 Mindful eating (strong
tasting mint)
7 Mindfulness of breath
8 Mindful eating (See, taste,
smell Raisin)
Focusing on the present moment. Mindful
eating (raisin)
Heighten awareness of physical sensations
& emotions without judgment. Body scan.
Notice sensation & mental impression of
same. Extended mindfulness of breath
Heighten accepting awareness of thought.
Thought Stream
Notice sensation & mental impression
of same. Extended mindfulness of breath
Staying with an unpleasant experience:
separate pain from suffering. Provoking
mild pain, observing pleasant physical
sensation
Increasing awareness of physical sensations.
Staying with physical sensations
Acceptance of all that is- including self-
acceptance -leading to compassion for
ourselves. Loving kindness
PVD diagnosis, pathophysiology, role of stress, prevalence.
The “snowball” - an exercise to note repercussions of
PVD; non-penetrative sex & communication.
Challenges to MP. Pain physiology- role of emotions,
thoughts, physical sensations, and individual characteristics.
Mindfulness for pain.
CBT model & viewing thoughts as just mental events.
Neuro-imaging in chronic pain.
Thought biases, how to work with thoughts during MP. Stress
physiology within the skin.
Sex response cycles& impact of PVD; MP and sexual response.
‘Two arrows’ of pain. Paradox of letting go of the goal to
control pain. ‘Sometimes Penetration’ concept. Changes
in brain function & anatomy from MP.
Discussion on lovable partnerships. Radical acceptance.
CBT review. Personal MP intentions after program ends.
Review underlying principles of psychological treatments
for PVD. Relapse prevention. Linking MP to everyday life.
10 minutes daily mindful eating; own “snowball’;
consider non-penetrative sex
Body Scan 6/7 days; 10 minutes mindful
activity daily
Apply CBT model to experience or anticipation
of pain. Body scan 6/7 days
Log thought biases; thought stream 7/7 days;
10 minutes mindful activity daily
Mindfulness of breath 6/7 days; personal sex
response cycle with & without pain
Listen to/ begin ‘two arrows’ adaptation of JKZ’s
mindful invoking of pain. Consider pros and
cons of sometimes including penetrative sex
Listen to radical acceptance recordings. Physical
sensations MP. MP intentions.
Begin personal MP, to review with clinician in
4–6 weeks
25
26
Qualitative interviews with 14 of the women provided fur-
ther support for the beneficial effects of IMPROVED [90••].
Women reported a decreased sense of isolation, positive psy-
chological outcomes such as reduced PVD-related anxiety, an
increased sense of self-efficacy and self-acceptance, and a
positive impact of the therapy on their intimate relationships.
The mindfulness aspect of IMPROVED was particularly noted
to help women more acceptingly address challenges in their
relationships. Women also reported an increased ability to view
thoughts as just thoughts, and spoke of being more accepting of
their remaining pain following the intervention.
Barriers to ongoing skills practice following completion of
IMPROVED were also noted in the interviews, namely stress
and an inability to prioritize skills practice. A need for addi-
tional, ongoing professional help was also reported, and only a
small number of women continued to regularly practice the
skills they acquired in-group. Based on the feedback received
from participants and the promising findings of the four-
session program, the IMPROVED treatment for PVD has
been expanded and revised (Basson et al., unpublished MBCT
treatment manual). The expanded version of IMPROVED
now aligns with other established mindfulness-based pro-
grams (e.g., MBSR; MBCT) in that it involves eight sessions
spaced one week apart. The expanded version combines ele-
ments of both Vipassana and Shamatha traditions and is an
MBCT that accordingly integrates mindfulness and cognitive
therapy skills. In contrast to change-oriented CBT skills, the
new IMPROVED introduces acceptance-based skills:
thoughts are identified as mental events that, like other bodily
sensations, are temporary and ever-changing as opposed to
problematic cognitions that need to be challenged and
changed. Each session involves at least one extended formal
mindfulness practice, followed by a detailed, thematic inquiry
that is considered an extension of the formal mindfulness
practice and serves to understand how women are directing
their attention, address challenges that arise, and highlight the
commonalities experienced by the women during the practice.
Its relevance to PVD is also discussed. Sessions 2–8 also
begin with an additional brief mindfulness practice. Informa-
tion on current understanding of chronic pain, sexual re-
sponse, and sexual partnerships in the context of PVD is
incorporated into the program: much of the detail is outlined
in the women’s manuals such that most in-session time is
focused on skills acquisition. Suggested activities for home
practice are outlined at the end of each session and reviewed in
detail the following week. Table 1 provides a brief description
of the eight-session MBCT treatment program.
Conclusions
The evidence of women’s decreased pain thresholds distant
from the genital areas and the frequent co-morbidity of PVD
Curr Sex Health Rep (2014) 6:20–29
with other chronic pain syndromes encourages a chronic pain
approach to the management of PVD. In keeping with the
current stress model of chronic pain, the proposed mainte-
nance of pain from the stress of experiencing subsequent
debilitating sexual dysfunction necessitates provision of ther-
apy known to benefit sexual difficulties as well as providing
stress-reduction skills more generally. There is early scientific
evidence that mindfulness practice benefits these three under-
lying facets of PVD: the pain, the stress – both antecedent and
subsequent - and the sexual dysfunction. We suggest that
mindfulness may particularly target the typical predisposing
factor of marked negative self-evaluation and lack of self-
acceptance that is only exacerbated by acquiring the sexual
disabilities. Preliminary evidence suggests that a brief inter-
vention that included mindfulness practice along with CBT
skills and education benefits PVD-related pain and sexual
function. An eight-week MBCT program modelled on similar
programs for stress-reduction and depression is in progress.
Acknowledgments Rosemary Basson has received grant support from
the Canadian Institutes of Health Research and National Vulvodynia
Association.
Kelly B. Smith has received grant support from the Canadian Institutes
of Health Research and National Vulvodynia Association, has had travel
expenses covered by the Michael Smith Foundation for Health Research,
has received postdoctoral fellowship awards from the Michael Smith
Foundation for Health Research and Canadian Pain Society, and was a
paid employee of the Multidisciplinary Vulvodynia Program.
Compliance with Ethics Guidelines
Conflict of Interest Rosemary Basson and Kelly B. Smith declare that
they have no conflict of interest.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
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