Depression and reactivity to stress in older women with rheumatoid arthritis and osteoarthritis

Depression, inflammation, and pain in patients with rheumatoid arthritis

OBJECTIVE

An association between depression and inflammation has been suggested. In patients with rheumatoid arthritis (RA), pain is a major symptom associated with depression and inflammation. We examined the independent associations between depression, the inflammation marker C-reactive protein (CRP) level, and pain in patients with RA.

METHODS

In total, 218 RA outpatients completed self-administered questionnaires, using the Beck Depression Inventory II to measure depressive symptoms and a visual analog scale to quantify their perceived pain. Functional disability and CRP level were also measured.

RESULTS

Depression scores were mildly and positively correlated with the CRP level (r = 0.46, P < 0.001). Both the depression score (standardized beta = 0.35, P < 0.001) and the CRP level (standardized beta = 0.35, P < 0.001) were significantly associated with pain, even after adjustment for clinical covariates in regression analysis. In logistic analysis, the combined effects on the risk of severe pain (pain score in the upper tertile) increased with depression scores and CRP levels linearly.

CONCLUSION

Depression severity and inflammation were associated with each other and appeared to have independent effects on perceived pain. Therefore, a clinical approach that takes into account both the body and the mind could have benefits and could enable optimal pain control.

Depression and Everyday Social Activity, Belonging, and Well-Being

Dysfunctional social behavior has been implicated in the experience of depression. People with greater depressive symptoms report more frequent negative social interactions and react more strongly to them. It remains unknown, however, whether reaction strength differs depending on whether social interactions are positive or negative. Drawing on socio-evolutionary models of depression (N. B. Allen & P. B. T. Badcock, 2003), we proposed that people with greater depressive symptoms should not only react more strongly to negative social interactions but also to positive social interactions and a sense of belonging. Using non-clinical samples, two daily process studies examined the role of depression in people's reactivity to social interactions in natural, ongoing, social contexts. In Study 1, the number of positive and negative social events showed a stronger relation to well-being among people with greater depressive symptoms. Study 2 extended this finding to perceptions of belonging in memorable social interactions, finding a stronger link between belonging and well-being among people with greater depressive symptoms. Together these studies provide the first indication that depressive symptoms may sensitize people to everyday experiences of both social rejection and social acceptance.

Depression and its correlation with in patients pain in the rheumatology service of a Mexican teaching hospital

The depressive symptoms are associated with chronic pain in this study. A cross-sectional study was performed. A visual analog scale was used to register pain intensity. Depressive symptoms were measured using the Center of Epidemiological Studies (CES-Dr) scale as modified by Eaton and reviewed for use in the Mexican population. The study included 245 patients, with a mean age of 46 years, 86.1% of whom were female. The prevalence of some degree of depression was 55.1%. Patients with fibromyalgia had the highest prevalence of symptoms of depression (78.38%) and major depression (29.73%). Stepwise multiple regressions indicated that the best model (r2 = 0.26) to predict the CES-Dr score included the global pain score (P < 0.0001) and education level (P < 0.004). The Cronbach's alpha of the CES-Dr was high (alpha = 0.888). There was moderate correlation (r = 0.442), P < 0.0001 of the CES-Dr numeric score with the intensity of global pain.

Adaptation to early knee osteoarthritis: the role of risk, resilience, and disease severity on pain and physical functioning

BACKGROUND

Radiographic joint changes are used to diagnose osteoarthritis; however, they alone do not adequately predict who experiences symptoms.

PURPOSE

To examine psychological risk and resilience factors in combination with an objective indicator of disease severity (knee X-rays) to determine what factors best account for pain and physical functioning in an early knee osteoarthritis (KOA) population.

METHODS

Structural equation modeling was used to analyze data from 275 men and women with early KOA.

RESULTS

Structural equation modeling yielded a fair to good fit of the data, suggesting that both risk and resilience were important in predicting pain and physical functioning over and above disease severity in the expected directions. Resilience's effect on pain was mediated through self-efficacy, suggesting that higher self-efficacy was linked to lower pain and better physical functioning.

CONCLUSIONS

Results provide an integrative model of adjustment to early KOA and may be important to the prevention of disability in this population.

Understanding the pain experience in hip and knee osteoarthritis--an OARSI/OMERACT initiative

OBJECTIVE

To examine the pain experience of people with hip or knee osteoarthritis (OA), particularly changes over time and most distressing features.

METHOD

Focus groups in individuals aged 40+ years with painful hip or knee OA obtained detailed descriptions of OA pain from early to late disease. A modified Patient Generated Index (PGI) was used to assess the features of OA pain that participants found most distressing. Content analysis was performed to examine response patterns; descriptive statistics were used to summarize PGI responses.

RESULTS

Mean age of the 143 participants (52 hip OA; 91 knee OA) was 69.5 years (47-92 years); 60.8% were female and 93.7% Caucasian. Participants described two distinct types of pain - a dull, aching pain, which became more constant over time, punctuated increasingly with short episodes of a more intense, often unpredictable, emotionally draining pain. The latter, but not the former, resulted in significant avoidance of social and recreational activities. From PGI responses, distressing pain features were: the pain itself (particularly intense and unpredictable pain) and the pain's impact on mobility, mood and sleep.

CONCLUSIONS

Two distinct pain types were identified. Intermittent intense pain, particularly when unpredictable, had the greatest impact on quality of life.

The effects of anxiety and depression on weekly pain in women with arthritis

This study examined the effects of anxiety and depression on pain in women with rheumatoid arthritis (RA; n=82) or osteoarthritis (OA; n=88). Anxiety and depression symptoms were assessed at the beginning of the study. Arthritis pain, interpersonal stress, negative affect, and positive affect were assessed weekly for 11 consecutive weeks. Multilevel analyses were conducted to investigate direct, indirect, and interactive effects of anxiety and depression on weekly changes in pain. When entered separately into the prediction equations, anxiety and depression were both related to elevations in current and next week pain, although the effects were nearly twice as large for anxiety. In addition, both anxiety and depression were indirectly related to current pain through negative and positive affect and depression interacted with stress to predict current pain in the RA group. When entered together into the prediction equations, anxiety alone was still related to elevations in current and next week pain. In addition, anxiety alone was indirectly related to current pain through negative affect and depression alone was indirectly related to current pain through positive affect. These results highlight the need for careful study of the differential effects of anxiety and depression and treatments that target their unique mechanisms.

Quality of life in chronic musculoskeletal pain

This chapter reviews the impact of chronic musculoskeletal pain on patients' health-related quality of life. In addition to the physical health consequences, chronic musculoskeletal pain can have a profound negative impact on an individual's emotional and social well-being. Although efforts in the health sector are obviously of crucial importance in the management of chronic musculoskeletal pain, a high level of patient and societal involvement is key to reducing the burden of this condition. Patients should work in partnership with health-care professionals, actively participating in their care. Family members should encourage their loved ones to be as independent as possible. The employer of a person with chronic musculoskeletal pain has a vital role in returning him or her to work as soon as possible. Removing all barriers to the use of preventive and therapeutic services will help us to reduce the burden of musculoskeletal pain conditions on both patients and society.

Stress-related musculoskeletal pain

While stress is often considered by patients and clinicians alike as an important factor in the onset and maintenance of widespread musculoskeletal pain, the relationship is more complex than appears on initial consideration. The types of event that lead to stress need description, and the role of traumatic events are particularly important because of the shared association with post-traumatic stress disorder. The substantial overlap with psychiatric disorders and the role of stress in their aetiology must be assessed in patients. The lack of specificity of the symptoms of the different disorders used to describe widespread musculoskeletal pain may be explained by their shared aetiology, including neural sensitization and alterations of the hypothalamic-pituitary-adrenal (HPA) axis due to stress. Fear avoidance is a central stress-related perceptual characteristic and behavioural dimension in these disorders. Treatment depends on thorough assessment, including psychiatric diagnosis, avoiding simplistic attributions and implementing evidence-based treatments that are well documented.

Daily stress in elders with arthritis

This study examined whether social support perceived by older people with arthritis mediated the experience of daily stress related to the physical disability of arthritis. Seventy participants completed survey questionnaires. The data were analyzed using the three-step regression analysis procedure. Daily stress was significantly correlated with physical disability and social support. Increased physical disability led to more daily stress. Also, arthritic patients with increased physical disability perceived lower levels of social support. Social support decreased the effects of physical disability on daily stress and had a significant effect on daily stress. However, social support did not fully mediate the effect of physical disability on daily stress. Caregivers should recognize that social support has a limited role in alleviating the daily stress that arthritic patients experience from physical disability. Studies are needed to develop and test stress management programs targeting various sources of daily stress.

Depression History, Stress, and Pain in Rheumatoid Arthritis Patients

This study examined the role of past episodes of depression on pain reports for patients with rheumatoid arthritis (RA) before and during stress induction. A history of major depressive episodes was assessed by diagnostic interviews for 138 RA patients, 74 who later participated in a set of laboratory procedures designed to induce interpersonal stress. Patients were evaluated by a rheumatologist and then asked to report joint and bodily pain throughout the laboratory study. We found that RA patients with a history of two or more episodes of major depression had more pain at baseline, and exhibited higher pain in response to the stress induction than did RA patients with either only one episode or no history of depression. Such findings provide new insight in the dynamic relationships between depression, stress, and pain.

Individual differences in emotional processing and reactivity to pain among older women with rheumatoid arthritis

The purpose of the current study was to determine whether the relationship between pain and emotion may be better understood by identifying people who are more vulnerable to emotional dysregulation and those who are able to regulate emotion. Data were collected from 81 women diagnosed with rheumatoid arthritis. We assessed affect intensity, emotion regulation, active coping, neuroticism as well as weekly reports of pain, positive affect, and negative affect. Results indicated that the joint effects of emotion regulation and emotional intensity predicted emotional responses to pain. The current study suggests that the emotional impact of pain is related to emotional intensity which can be tempered by the ability to regulate emotion.

Arthritis and pain. Psychosocial aspects in the management of arthritis pain

The purpose of this review is to summarize psychosocial factors associated with arthritis pain and highlight recent evidence for psychosocial approaches to managing arthritis pain. By definition, psychosocial factors refer to two dimensions of experience: the psychological (cognitive, affective) and social (interacting with others, engaging in life activities). Psychosocial factors influence the perception of pain and the presence of pain influences psychological well-being and social participation. After discussing the impact of arthritis pain on participation in work, family life, and leisure, evidence for psychosocial interventions is summarized, emphasizing reviews and studies published from January 2000 to August 2006.

The role of illness uncertainty on coping with fibromyalgia symptoms

This study examined the role of illness uncertainty in pain coping among women with fibromyalgia (FM), a chronic pain condition of unknown origin. Fifty-one FM participants completed initial demographic and illness uncertainty questionnaires and underwent 10-12 weekly interviews regarding pain, coping difficulty, and coping efficacy. Main outcome measures included weekly levels of difficulty coping with FM symptoms and coping efficacy. Multilevel analyses indicated that pain elevations for those high in illness uncertainty predicted increases in coping difficulty. Furthermore, when participants had more difficulty coping, they reported lower levels of coping efficacy. Results were consistent with hypothesized effects. Illness uncertainty accompanied by episodic pain negatively influenced coping efficacy, an important resource in adaptation to FM.

Predictors of depression in a sample of 1,021 primary care patients with osteoarthritis

OBJECTIVE

Although there is a strong relationship between depression, chronic pain, and physical activity, there are few findings regarding the prevalence and predictors of depression in patients with osteoarthritis (OA). The goal of the present study was to assess the prevalence and severity of depression in a large sample of patients with OA and to reveal predictors of depression.

METHODS

Patients were approached consecutively in 75 general practices. Of 1,250 distributed questionnaires, 1,021 were returned and analyzed. Besides sociodemographic data, medication and comorbidities, depression, and arthritis were assessed using the Patient Health Questionnaire (PHQ-9) and the Arthritis Impact Measurement Scale. A stepwise multiple linear regression analysis with the PHQ-9 score as the dependent variable was performed.

RESULTS

On the PHQ-9, 19.76% of men and 19.16% of women achieved a score of >or=15, indicating at least a moderately severe depression. Significant sex differences could not be revealed. The strongest predictor for depression severity was perceived pain (beta = 0.243, P < 0.001) and few social contacts (beta = 0.218, P < 0.001). Further predictors were physical limitation of the lower body (beta = 0.157, P < 0.001) and upper body (beta = 0.163, P < 0.001), age (beta = -0.168, P < 0.001), and body mass index (beta = 0.080, P = 0.020).

CONCLUSION

These findings suggest an increased prevalence of depression among patients with OA and emphasize the need for recognition and appropriate treatment. Most of the revealed predictors are influenceable and should be potential targets in a comprehensive treatment of OA to interrupt the vicious circle of pain, physical limitation, and depression.

The role of work stress as a moderating variable in the chronic pain and depression association

OBJECTIVE

This article aims to examine the role of work stress as a moderating variable in the chronic pain-depression association, as well as sex differences in this link.

METHODS

The analyses were carried out using the Canadian Community Health Survey Cycle 1.1. Key variables were chronic pain conditions (fibromyalgia, arthritis/rheumatism, back problems, and migraine headaches), work stress, and depression. The total sample comprises 78,593 working individuals.

RESULTS

In this working sample, 7.6% met criteria for major depression, but the prevalence increased to 12% in those also reporting chronic pain. Both depression and comorbid chronic pain and depression were twice as prevalent in women as in men. Having a chronic pain condition and overall work stress emerged as the strongest predictors of depression. Unexpectedly, however, none of the work stress domains moderated the chronic pain and depression association.

CONCLUSION

The impact of work stress should be considered in the etiology and management of major depression.

Development of the combined assessment of residential environments (CARE) profiles

AIM

This paper reports the development and initial testing of the combined assessment of residential environments (CARE) profiles, which identify the frequency of positive events over a specified time based on the perceptions of residents, relatives and staff in care home settings.

BACKGROUND

Despite the well-known benefits of positive events for subjective well-being, little is known about the nature of positive events experienced by residents, relatives and staff in care homes. There is also a dearth of tools capable of systematically evaluating how frequently these events occur in this context.

METHODS

The CARE profiles were developed and tested between February 2004 and June 2005 with a combined sample of 372 residents, relatives and staff drawn from 11 care homes. An Event Frequency Approach was adopted to create three questionnaires (residents, relatives and staff), each containing 30 consensually valid positive events. The thematic content of these events was balanced for each questionnaire using the Senses Framework as a theoretical model. Once completed, the CARE profiles were tested in four care homes.

RESULTS

Test data from the CARE profiles were used to produce a bar chart showing median frequencies of positive events experienced by residents, relatives and staff during the timeframe in question (e.g. 1 month). These profiles were shown to be internally consistent, with alpha scores ranging from 0.70 to 0.89 for residents, 0.91 to 0.94 for relatives and 0.78 to 0.92 for staff.

CONCLUSION

We envisage that feedback from the CARE profiles will both reinforce good care home practice and identify areas for change based on the experiences of all major stakeholders. However, further development of the profiles is needed if the experiences of cognitively impaired residents are to be included in the assessment process.

Anxiety and depression in patients with rheumatoid arthritis

Rheumatoid arthritis (RA) mostly follows a painful, progressively disabling course, and individuals with RA experience more psychological distress than healthy individuals. The objective of the present study is to examine the prevalences of accompanying anxiety and depression in RA cases. The study included 82 RA cases and 41 age- and sex-matched healthy volunteers as the control group. Psychiatric examinations of all cases of the patient and control groups were performed according to DSM-IV criteria. Hamilton Anxiety Scale or Hamilton Depression Scale was applied to those who were found to have anxiety or depression. Total prevalence of anxiety, depression, and mixed anxiety-depressive disorder was found to be 70.8% (n=58) in the patient group and 7.3% (n=3) in the control group, and the difference was significant (p<0.001). Of the RA patients, 41.5% (n=34) was found to have depression, 13.4% (n=11) anxiety, and 15.9% (n=13) mixed anxiety-depressive disorder. The disease duration in patients with anxiety was shorter than the RA patient with depression (p<0.05). The disease duration was positively correlated with the degree of depression and negatively correlated with the degree of anxiety (r=0.341, p<0.05; r=-0.642, p<0.05, respectively). The results of our study suggest that prevalences of anxiety and mainly depression, increase in RA cases. When the clinical picture in RA cases becomes complicated with anxiety or depression, some problems at patients' adaptation and response to treatment may be possible. RA cases should be monitored for accompanying anxiety or depression during follow-up.

Health psychology: psychological adjustment to chronic disease

Chronic diseases carry important psychological and social consequences that demand significant psychological adjustment. The literature is providing increasingly nuanced conceptualizations of adjustment, demonstrating that the experience of chronic disease necessitates adaptation in multiple life domains. Heterogeneity in adjustment is apparent between individuals and across the course of the disease trajectory. Focusing on cancer, cardiovascular disease, and rheumatic diseases, we review longitudinal investigations of distal (socioeconomic variables, culture/ethnicity, and gender-related processes) and proximal (interpersonal relationships, personality attributes, cognitive appraisals, and coping processes) risk and protective factors for adjustment across time. We observe that the past decade has seen a surge in research that is longitudinal in design, involves adequately characterized samples of sufficient size, and includes statistical control for initial values on dependent variables. A progressively convincing characterization of risk and protective factors for favorable adjustment to chronic illness has emerged. We identify critical issues for future research.

Hostility and pain are related to inflammation in older adults

Chronically elevated systemic inflammation has a dramatic impact on health for older individuals. As stress-related responses, both hostility and pain perception may contribute to inflammation which in turn may maintain negative emotion and pain over time. We used structural equation modeling to examine the degree to which trait hostility and pain were uniquely associated with C-reactive protein (CRP) and serum IL-6 levels over a 6-year span in a sample of older adults. The sample included 113 present or former caregivers of a spouse with dementia and 101 non-caregivers. After accounting for depression, health behaviours, and other risk factors, which were also assessed longitudinally, pain and, to a lesser extent, hostility were uniquely associated with plasma levels of CRP but not IL-6. When examined separately, the association between pain and CRP was significant only for caregivers, while the association between hostility and CRP was comparable for the two groups. These findings suggest that hostility may play a role in a cycle of inflammation among older adults, and that pain may be particularly problematic for those under chronic stress. Our results also shed light on inflammation as a mechanism underlying the effects of hostility on cardiovascular disease morbidity and mortality.

Uncertainty of Illness Relationships with Mental Health and Coping Processes in Fibromyalgia Patients

Fibromyalgia syndrome (FMS) is a chronic musculoskeletal pain condition poorly understood in terms of etiology and treatment by both physicians and patients. This condition of "uncertainty of illness" was examined as a variable involved in the adjustment of FMS patients, relating it to their depression, anxiety, affect, and coping styles. Fifty-one community-residing FMS patients provided self-report information on subsets of adjustment variables. Both cross-sectional and more dynamic longitudinal analyses showed that illness uncertainty was significantly associated with anxiety, negative affect, and avoidant and passive coping. Its positive relationship with depression was eliminated when a control variable, pain helplessness, was included as a covariate. Longitudinally, illness uncertainty interacted with interpersonally stressful daily events in predicting reports of reduced positive affect, suggesting that illness uncertainty acts as a risk factor for affective disturbances during stressful times. Implications of these results for therapeutic interventions are discussed.

Depression in rheumatoid arthritis patients: demographic, clinical, and psychological predictors

OBJECTIVE

To confirm the prevalence of depression in a sample of rheumatoid arthritis (RA) patients; to identify the most significant predictors of depression in RA and to explore patients attitudes to medication in relation to depression.

METHODS

A cross-sectional survey was used to collect data from 134 RA patients (77% female, 23% male). Participants were divided into depressed and nondepressed groups based on their scores on the Center for Epidemiological Studies-Depression (CES-D) scale. Discriminant analysis was conducted to identify the predictors that would best categorise patients into those two groups.

RESULTS

Twelve predictors correctly classified 80% of patients into depressed or nondepressed groups. The strongest predictors of depression were high tension and low self-esteem followed by the perceived impact of RA, fatigue, passive coping, pain, and physical disability. Other predictors included medication effectiveness and importance as well as perceived lack of control over pain.

CONCLUSION

Both physical and psychological factors have an impact on depression in RA. The key predictors identified in this study need to be considered within the regular RA management as possible cues to depression development.

Mental disorders in a population sample with musculoskeletal disorders

Background

Studies using clinical and volunteer samples have reported an elevated prevalence of mood disorders in association with rheumatoid arthritis and osteoarthritis. Clinical studies using anxiety rating scales have reported inconsistent results, but studies using diagnostic instruments have reported that anxiety disorders may be even more strongly associated with arthritis than is depression. One study reported an association between lifetime substance use disorders and arthritis.

Methods

Data from iteration 1.2 of the Canadian Community Health Survey (CCHS) were used. This was a large-scale national Canadian health survey which administered the World Mental Health Composite International Diagnostic Interview to a sample of 36,984 subjects randomly selected from the national population. In the CCHS 1.2, subjects were asked whether they had been diagnosed by a health professional with arthritis or rheumatism.

Results

Subjects reporting arthritis or rheumatism had an elevated prevalence of mood, anxiety and substance use disorders. The strength of association resembled that seen in an omnibus category reporting any chronic condition, but was weaker than that seen with back pain or fibromyalgia. The effect of arthritis or rheumatism interacted with age, such that the odds ratios became smaller with increasing age. Mood and anxiety disorders, along with arthritis or rheumatism made an independent contribution to disability.

Conclusion

Arthritis is associated with psychiatric morbidity in the general population, and this morbidity is seen across a variety of mental disorders. The strength of association is consistent with that seen in persons with other self-reported medical conditions.

Mental and physical comorbid conditions and days in role among persons with arthritis

OBJECTIVE

To estimate the prevalence of comorbidity among people with arthritis in the US adult population and to determine the role of comorbidity in accounting for the association of arthritis with days out of role (a measure of inability to work or carry out normal activities).

METHODS

Data come from the National Comorbidity Survey Replication (NCS-R), a nationally representative household survey of 9,282 respondents ages 18 and older carried out in 2001 to 2003. Arthritis was assessed by self-report in a chronic-conditions checklist, along with a wide range of other physical conditions. Mental and substance use disorders were ascertained with the World Health Organization Composite International Diagnostic Interview (CIDI). Number of days out of role was assessed for the 30 days before the interview.

RESULTS

Arthritis was reported by 27.3% of respondents, 80.9% of whom also reported at least one other physical or mental disorder, including 45.6% with another chronic pain condition, 62.3% with another chronic physical condition, and 24.3% with a 12-month mental disorder. Arthritis was significantly associated with days out of role, but comorbidity explained more than half of this association. No significant interactions were found between arthritis and the other conditions in predicting days out of role.

CONCLUSION

Comorbidity is the rule rather than the exception among people with arthritis. Comorbidity accounts for most of the days out of role associated with arthritis. The societal burden of arthritis needs to be understood and managed within the context of these comorbid conditions.

“What do you expect? You're just getting older”: A comparison of perceived osteoarthritis-related and aging-related health experiences in middle- and older-age adults

OBJECTIVE

To compare the health experiences of middle- and older-age adults with moderate osteoarthritis (OA) symptoms with experiences of individuals with no chronic health conditions. Similarities and differences in health changes, the meaning of these changes, and their impact were examined.

METHODS

Sixteen focus groups (10 OA, 6 control) were conducted with 53 women and 37 men (age 39-88 years). OA participants were recruited from practitioners' offices and The Arthritis Society, Ontario Division. Additional OA participants and controls were recruited from community centers and newspaper advertisements. All participants were asked about changes in health, the impact of these changes, and self-management strategies. Participants also completed standardized measures including demographic information; the Short Form 36; Western Ontario and McMaster Universities Osteoarthritis Index; and Disabilities of the Arm, Shoulder and Hand questionnaire.

RESULTS

Differences in the depth, breadth, and meaning of symptoms such as pain, stiffness, and fatigue were reported with little overlap between OA and control groups. OA was often seen as part of a normal aging process requiring acceptance, not treatment. However, younger OA participants reported more distress and frustration managing the disease. OA participants reported an impact of their health on work, leisure, social activities, and relationships that was described as upsetting compared with controls.

CONCLUSION

This study illuminates personal and social factors associated with OA by comparing health experiences of individuals with OA and controls. It highlights directions for future research that can improve our understanding of the needs of individuals with OA and can help link individuals' health status to the broader framework of their lives.

Dynamic approaches to emotions and stress in everyday life: Bolger and Zuckerman reloaded with positive as well as negative affects

A decade ago, Bolger and Zuckerman (1995) incorporated personality into the study of daily life events and psychological distress. Their approach put an entirely new cast on research and theorizing in this area. In their work, they focused on the predominantly negative personality trait of Neuroticism. In this article we extend their work to include theory and measurement of positive events and indicators of well-being. Integrating these research strands offers the possibility of a comprehensive yet highly sensitive and dynamic approach to the study of emotions, stress, and health in everyday life.

Psychological stress as a predictor of psychological adjustment and health status in patients with rheumatoid arthritis

This study examined the extent to which perceived stress, social support, coping and clinical disease indicators predict physical, psychological and social adjustment in patients with rheumatoid arthritis (RA). Participants were 59 women recruited at an outpatient clinic at University College Hospital, Galway. A range of psychological measures was administered and disease status was assessed by physician ratings of joint involvement and blood assays of inflammatory indices. Findings from correlational and hierarchical regression analyses revealed a number of statistically significant relationships (p<.01). Perceived stress was a better predictor than disease severity of positive and negative emotionality. Coping explained variability on positive and negative affect. Social support was linked to level of social activity. Results demonstrated that disease status predicted illness related functioning but did not predict emotional or social adjustment. Results suggest that a cognitive behavioural intervention to facilitate patient adjustment could usefully include management of stress and its appraisal, the fostering of adaptive coping strategies and utilization of social support resources. It is concluded that improving patient adjustment to rheumatoid arthritis has implications for medical care seeking.

Predictors of distress and depression in elders with arthritic pain

AIM

The aim of this paper is to report the findings of a study testing a theory of chronic pain, with financial hardship added as a contextual stimulus.

BACKGROUND

Arthritis is highly prevalent among older people, resulting in severe pain and suffering. A previous study testing a theory of chronic pain in elders with arthritis found that pain, disability and social support explained only 35% of the variance in their emotional distress. It is possible that demands, other than chronic pain, such as financial hardship, also contribute to these elders' stress and depression.

METHOD

The theory was tested with 235 elders with arthritis using a secondary data analysis strategy. Data were obtained from the study of Ageing, Status, and Sense of Control carried out in 1998 in the United States of America. Variables were constructed from original questionnaires.

RESULTS

The hypothesized model fitted the data only moderately well (chi2 = 40.04, d.f = 6, P < 0.0001; CFI = 0.88; NFI = 0.88). Disability and financial hardship positively predicted distress, while social support and age had a reverse impact on distress, which explained 24% of the variance in distress. This means that elders with higher levels of disability, more financial hardship, less social support or younger age are likely to have higher levels of distress. Distress alone explained 33% of the variance in depressive symptoms. A data-derived model was created with excellent fit (chi2 = 3; d.f. = 4; P = 0.56; CFI = 1.00; NFI = 0.99), showing that disability, social support, financial hardship and age predicted distress (R2 = 0.24). Pain, disability and distress predicted depression (R2 = 0.44).

CONCLUSIONS

The results partially supported the theory. Exploring the possibility of using depression as part of the control process and removing gender as a residual stimulus may lead to further refinement of the theory. The findings allow nurses to have a better understanding of the experiences of elders with arthritis, and thus to offer appropriate care to meet their needs.

Affect and pain in rheumatoid arthritis: Do individual differences in affective regulation and affective intensity predict emotional recovery from pain?

BACKGROUND

Individual differences in adaptation to rheumatoid arthritis are not fully accounted for by illness severity or duration of symptoms.

PURPOSE

In this study, we assessed differences in affect regulation and affect intensity as variables that might be important for identifying women with rheumatoid arthritis who are resilient versus those who have disrupted moods following pain exacerbations.

METHOD

Specifically, affective regulation, affect intensity, active coping, neuroticism and weekly reports of pain, positive affect, and negative affect were assessed in a sample of 81 women diagnosed with rheumatoid arthritis.

RESULTS

Our results indicated that affective regulation, affect intensity, and active coping played important but distinct roles in the ebb and flow of negative and positive affect. In particular, active coping was related to positive affect, whereas affective regulation and affect intensity showed interactive effects, moderating the prospective relationship between pain and negative affect and pain and positive affect.

CONCLUSION

Overall, this study suggests that recovery from rheumatoid arthritis pain can be swift, except for those women who have difficulty regulating strong unpleasant affect.

Positive affect as a source of resilience for women in chronic pain

A sample of 124 women with osteoarthritis or fibromyalgia, or both, completed initial assessments for demographic data, health status, and personality traits and 10-12 weekly interviews regarding pain, stress, negative affect, and positive affect. Multilevel modeling analyses indicated that weekly elevations of pain and stress predicted increases in negative affect. Both higher weekly positive affect as well as greater positive affect on average resulted in lower negative affect both directly and in interaction with pain and stress. Finally, increases in weekly negative affect and higher average negative affect related to greater levels of pain in subsequent weeks. In contrast, higher levels of overall positive affect predicted lower levels of pain in subsequent weeks.

Psychological approaches to understanding and treating disease-related pain

Psychologists are increasingly involved in the assessment and treatment of disease-related pain such as pain secondary to arthritis or cancer. This review is divided into four sections. In the first section, we provide a conceptual background on this area that discusses the limitations of the biomedical model of disease-related pain and traces the evolution of psychosocial theories of pain. In the second section, we discuss special issues and challenges involved in working with persons having disease-related pain, including the reluctance of some persons to report pain and to become involved in psychological treatments for pain. Section three provides an overview of psychosocial research conducted on arthritis pain and cancer pain that addresses both psychosocial factors related to pain and psychosocial interventions for pain management. In the final section, we describe important future directions, including strategies for disseminating psychosocial treatments and disparities in pain management.

Fibromyalgia: evidence for deficits in positive affect regulation

OBJECTIVE

Fibromyalgia (FMS) is characterized by chronic pain, high psychiatric comorbidity, and the absence of observable pathology. Our objective was to examine positive and negative affective indices, both at the trait and contextual levels, in FMS compared with a chronic pain control group, osteoarthritis (OA).

METHODS

The sample consisted of 126 female FMS (87) and OA (39) patients from the community. Participants answered a self-report questionnaire assessing demographic and personality variables and were interviewed regarding average pain, affect, anxiety, and depression. Participants were then interviewed weekly for up to 12 weeks regarding pain, affect, fatigue, perceived interpersonal stress (IS), and positive interpersonal events (PE).

RESULTS

FMS participants reported lower levels of positive affect (p < .01) and extraversion (p < .01) than OA participants. There were no significant differences between groups in negative affect, depression, anxiety, or neuroticism after controlling for age and average pain. At the weekly level, FMS participants reported lower levels of positive affect (p < .01), but not negative affect. Furthermore, during weeks of elevated IS, FMS participants evidenced steeper declines in positive affect than OA participants (p < .01).

CONCLUSIONS

Despite the predominance of literature focusing on psychologic disturbance in FMS, these analyses identified dysfunctional positive affect regulation as a key feature of FMS. FMS status was uniquely characterized by lower levels of positive affect, especially during stressful weeks. These findings challenge current conceptualizations of FMS and point to new directions for interventions that focus on improving positive affective resources, especially during times of stress.

Loneliness in everyday life: cardiovascular activity, psychosocial context, and health behaviors

Prior lab research revealed higher basal total peripheral resistance (TPR) and lower cardiac output (CO) in lonely than in nonlonely young adults. In this study, experience sampling was used to obtain ambulatory blood pressure; impedance cardiography: and reports of activities, appraisals, interactions, and health behaviors. Results confirmed that loneliness predicted higher TPR and lower CO during a normal day. Loneliness did not predict differences in time spent alone, daily activities, or health behaviors but did predict higher stress appraisals and poorer social interactions. Independent of loneliness, interaction quality contributed to TPR. Loneliness differences were not mediated by depressed affect or neuroticism. Social support mediated loneliness differences in stress and threat. Concomitants of loneliness were comparable for men and women.

Testing a theory of chronic pain

BACKGROUND

Chronic pain is highly prevalent among older people with arthritis, with depression as its major outcome. The psychopathological process of chronic pain and its outcomes in older people with arthritis have not been the subject of extensive research. The purpose of this study was to test a middle-range theory of chronic pain derived from the Roy Adaptation Model, a nursing theory whose validity has not been tested in the context of chronic pain.

METHODS

The study used a convenience sample of 71 older people with arthritis. Two subscales of the Arthritis Impact Measurement Scales were used to measure pain and physical disability. Social support was measured by Part II of the Personal Resource Questionnaire, and the Elderly Daily Stress scale was used to measure daily stress. Participants also completed the 10-item Center for Epidemiological Studies of Depression scale. Univariate analysis, correlation, and path analysis were used to analyse the data.

RESULTS

Overall, the data supported the hypothesized model in which pain, disability, social support, age, and gender are predictors of daily stress and daily stress further predicts depression. The direct effects of chronic pain, disability, and social support accounted for 37% of the variance of daily stress, which in turn predicted 35% of the variance of depression. Age and gender had no influence on daily stress. The chi-square index suggested a fit between the data and the model, and therefore the current model is temporarily accepted. Other fit indices also showed a good fit of the model to the data. To simplify the model, a revised version was developed.

CONCLUSIONS

This study validated a middle-range theory to explain the effects of chronic pain in older people with arthritis and highlights the importance of chronic pain in the development of depression.

The Impact of Disease Activity on the Quality of Life, Mental Health Status, and Family Dysfunction in Colombian Patients With Rheumatoid Arthritis

This study investigated the relationship between activity of disease, mental health status, quality of life, and family dysfunction in northwestern Colombian patients with rheumatoid arthritis (RA). Seventy-nine patients completed a 2-phase study that included physical examination (objective measurement of disease activity according to adapted American College of Rheumatology criteria) and a pretested questionnaire that sought information on helplessness, disability, depression, anxiety, quality of life, arthritis self-efficacy for pain, and other symptoms, as well as family dysfunction and socioeconomic status. Nineteen patients (24%) had active RA, 48 (61%) had moderately active RA, and 12 (15%) were in remission. Symptoms of depression, helplessness, disability, pain, anxiety, lower quality of life, and self-efficacy were associated with RA activity regardless of age, sex, and duration of the disease. Symptoms of depression were directly correlated with anxiety, helplessness, pain, and disability and inversely correlated with quality of life and self-efficacy. Although family dysfunction was present in 39% of patients, no associations between family dysfunction, activity of RA, mental health variables, socioeconomical status or quality of life were observed. These results indicate that RA activity significantly influences mental health status and quality of life in this population. Accordingly, a holistic conception of therapy should guide the treatment of patients with RA.

Interpersonal workplace stressors and well-being: a multi-wave study of employees with and without arthritis

The within-person influence of interpersonal stressors on affective well-being and physical well-being was investigated for 109 women with and without arthritis. Participants were interviewed on a weekly basis for 12 consecutive weeks, and the prospective data were analyzed by using hierarchical linear modeling. Overall, interpersonal workplace stressors independently predicted both well-being outcomes. Interpersonal stressors outside the workplace were related to negative affect but not to arthritis symptoms. Compared with healthy controls, arthritis patients' ratings of negative affect were equally reactive to workplace stressors. Neuroticism did not moderate stressor reactivity for either dependent variable but did predict mean levels of negative affect. The data support the hypothesis that the psychosocial environment of the workplace contributes unique effects on well-being.

Recent advances and future directions in the biopsychosocial assessment and treatment of arthritis

This article provides an overview of the emerging literature on biopsychosocial assessment and treatment for two of the most common forms of arthritis: osteoarthritis and rheumatoid arthritis. The article is divided into 3 parts. In the 1st part, the basic elements of the biopsychosocial approach to assessing and treating persons having arthritis is described. In the 2nd part, the authors evaluate studies of biopsychosocial approaches to the assessment of arthritis pain and disability. Six research areas are reviewed: learned helplessness, depression, stress, pain coping, self-efficacy, and the social context of arthritis. The 3rd part of the article reviews studies that testing the efficacy of biopsychosocial treatment approaches for persons having osteoarthritis and rheumatoid arthritis.