Body image mediates the impact of pain on depressive symptoms in patients with systemic lupus erythematosus

Objective

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease with treatment manifestations that can cause changes in appearance, including skin rashes, alopecia, vitiligo, and scars. SLE has been shown to adversely impact body image outcomes, and previous research has identified that greater disease activity is associated with worse body image outcomes which, in turn, are associated with greater depressive symptoms. For patients with SLE who also experience significant pain, poor body image outcomes may further compromise wellbeing and lead to greater depressive symptoms. The role of pain in body image has not been explored in SLE. Thus, the present study examined whether body image (specifically, body image-related quality of life) serves as a mediator of the relationship between pain and depressive symptoms among patients with SLE.

Methods

Multiple mediation analysis was used to examine the hypothesis that body image-related quality of life mediates the relationship between pain and depressive symptoms in a sample of patients with SLE ( N = 135) from an urban region in Los Angeles, California.

Results

The sample was predominately female (92.6%) with a mean disease duration of approximately 17 years. Approximately one-quarter of the sample had elevated depressive symptoms. Body image-related quality of life was a significant mediator in the relationship between pain and depressive symptoms. The model accounted for 51% of the total variance in depressive symptoms ( R2 = 0.51).

Conclusion

This cross-sectional study suggested that body image-related quality of life may mediate the effects of pain on depressive symptoms among patients with SLE.

Fatigue in systemic lupus: the role of disease activity and its correlates

OBJECTIVES

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that leads to a variety of negative health outcomes resulting from inflammation in various organ systems. Although treatment continues to advance, fatigue remains one of the most salient, poorly understood and addressed patient complaints. Understanding the mechanisms of fatigue can help guide the development of interventions to improve health outcomes. The aim of this research was to evaluate the contribution of six variables (disease activity, insomnia, depression, stress, pain and physical health) to fatigue in SLE without concomitant fibromyalgia (FM).

METHODS

A total of 116 ethnically diverse, primarily female participants (91%) with SLE, receiving care at university medical centers, completed assessments of disease activity and quality of life outcomes (FACIT-FT, Insomnia Severity Index, Perceived Stress Scale (PSS-4), Pain Inventory, Depression-PHQ-9, and LupusPRO-physical function). All patients met the American College of Rheumatology classification criteria for SLE and did not have a known diagnosis of FM. Multivariate linear and stepwise regression analyses were conducted with fatigue (FACIT-FT) as the dependent variable, and the above six variables as independent variables.

RESULTS

Mean (SD) age was 39.80 (13.87) years; 50% were African American, 21% Caucasian, 13% Hispanic, 9% Asian and 8% other. Mean (SD) FACIT-FT was 20.09 (12.76). Collectively, these six variables explained 57% of the variance in fatigue. In the multivariate model, depression, stress and pain were significantly and independently associated with fatigue, but not disease activity, sleep or physical health. Stress had the largest effect on fatigue (β 0.77, 95% CI 0.17-1.38, p = 0.01), followed by depression (β 0.66, 95% CI 0.21-1.10, p = 0.005). On stepwise regression analysis, only stress, depression and pain were retained in the model, and collectively explained 56% of the variance in fatigue. All three remained independent correlates of fatigue, with the largest contribution being stress (β 0.84, 95% CI 0.27-1.42, p = 0.005), followed by depression (β 0.79, 95% CI 0.44-1.14, p < 0.001) with fatigue.

CONCLUSION

Stress, depression and pain are the largest independent contributors to fatigue among patients with SLE, without concurrent FM. Disease activity, sleep and physical health were not associated with fatigue. The evaluation of stress, depression and pain needs to be incorporated during assessments and clinical trials of individuals with SLE, especially within fatigue. This stress-depression-fatigue model requires further validation in longitudinal studies and clinical trials. Significance and innovation: • Disease activity, sleep, pain, stress, depression, and physical health have been reported individually to be associated with fatigue in lupus. This analysis evaluated the role of each and all of these six variables collectively in fatigue among patients with SLE without a known diagnosis of FM. • Disease activity, sleep and physical health were not significantly related to fatigue, but depression, stress and pain were. • The results emphasize the need to evaluate and treat fatigue in individuals with SLE utilizing a biopsychosocial approach, particularly in the realm of clinical trials. Behavioral medicine interventions are shown to be most effective for the treatment of depression, stress and pain.

Psychometric validation of the Arthritis Helplessness Index in systemic lupus erythematosus

Objective Helplessness is a relevant construct in systemic lupus erythematosus (SLE), an unpredictable chronic illness with no known cure characterized by relapsing and remitting features. However, no measure of helplessness has been validated in this population. The present study examined the structural validity, reliability, and convergent validity of the Arthritis Helplessness Index, a measure initially developed for rheumatoid arthritis populations, in a sample of patients with SLE. Methods Patients with SLE ( N = 136) receiving medical care at a private hospital completed the Arthritis Helplessness Index and other self-report measures. The structural validity of the Arthritis Helplessness Index was examined using confirmatory factor analysis. Internal consistency reliability was evaluated with Cronbach's coefficient alpha. Pearson product-moment correlations were used to examine convergent validity with measures of depression, anxiety and mastery. Results The five-item Arthritis Helplessness Index-Helplessness measure demonstrated a tenable factor structure (comparative fit index 0.98, root mean square error of approximation 0.06, standardized root mean residual 0.04). Internal consistency reliability was fair (α = 0.69). Convergent validity was evidenced by significant correlations with measures of depression, anxiety and mastery. Conclusion The five-item Arthritis Helplessness Index-Helplessness scale can confidently be used as a measure of helplessness in SLE.

The mediational role of helplessness in psychological outcomes in systemic lupus erythematosus

Objective Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that can result in disability and psychological distress. Although pain has been associated with depressive symptomatology and stress in SLE, a paucity of theoretical models have been used to explain the relationship between pain and psychological distress in this population. Thus, the present study examined helplessness as a mediator of the relationship between pain and psychological distress among patients with SLE. Methods Multiple mediation analysis was used to examine the hypothesis that learned helplessness mediates the relationship between pain and symptoms of anxiety, depression, and stress in a sample of patients with SLE ( N = 136) receiving medical care at Cedars Sinai Medical Center. Results The mean score on the Helplessness subscale was 14.5 ( SD = 5.4). Helplessness fully mediated the relationship between pain vitality and symptoms of anxiety (BCa 95% CI (-0.073, -0.015)), depression (BCa 95% CI (-0.502, -0.212)), and stress (BCa 95% CI (-0.063, -0.027)). Conclusion Participants reported a high level of perceived inability to control one's disease. Helplessness fully mediated the relationship between pain and measures of anxiety, depression, and perceived stress among patients with SLE.

The psychometric properties of the Perceived Stress Scale-10 among patients with systemic lupus erythematosus

Objective Systemic lupus erythematosus (SLE) is a chronic, multisystem autoimmune disease characterized by periods of remission and recurrent flares, which have been associated with stress. Despite the significance of stress in this disease, the Perceived Stress Scale-10 has yet to be psychometrically evaluated in patients with SLE. Methods Exploratory factor analysis was used to examine the structural validity of the Perceived Stress Scale-10 among patients with SLE ( N = 138) receiving medical care at Cedars Sinai Medical Center. Cronbach's coefficient alpha was used to examine internal consistency reliability, and Pearson product-moment correlations were used to examine convergent validity with measures of anxiety, depression, helplessness, and disease activity. Results Exploratory factor analysis provided support for a two-factor structure (comparative fit index = .95; standardized root mean residual = .04; root mean square error of approximation = .08). Internal consistency reliability was good for both factors (α = .84 and .86). Convergent validity was evidenced via significant correlations with measures of anxiety, depression, and helplessness. There were no significant correlations with the measure of disease activity. Conclusion The Perceived Stress Scale-10 can be used to examine perceived stress among patients with SLE.

A multi-group confirmatory factor analyses of the LupusPRO between southern California and Filipino samples of patients with systemic lupus erythematosus

Introduction Systemic lupus erythematosus (SLE) leads to a range of biopsychosocial health outcomes through an unpredictable and complex disease path. The LupusPRO is a comprehensive, self-report measure developed specifically for populations with SLE, which assesses both health-related quality of life and non-health related quality of life. Given its increasingly widespread use, additional research is needed to evaluate the psychometric integrity of the LupusPRO across diverse populations. The objectives of this study were to evaluate the performance of the LupusPRO in two divergent patient samples and the model fit between both samples. Methods Two diverse samples with SLE included 136 patients from an ethnically-diverse, urban region in southern California and 100 from an ethnically-homogenous, rural region in Manila, Philippines. All patients met the ACR classification criteria for SLE. Confirmatory factor analysis (CFAs) were conducted in each sample separately and combined to provide evidence of the factorial integrity of the 12 subscales in the LupusPRO. Results Demographic analyses indicated significant differences in age, disease activity and duration, education, income, insurance, and medication use between groups. Results of the separate CFAs indicated moderate fit to the data for the hypothesized 12-factor model for both the Manila and southern California groups, respectively [χ² (794) = 1283.32, p < 0.001, Comparative Fit Index (CFI) = 0.793; χ² (794) =1398.44, p < 0.001, CFI = 0.858]. When the factor structures of the LupusPRO in the southern California and Manila groups were constrained to be equal between the two groups, findings revealed that the factor structures of measured variables fit the two groups reasonably well [χ² (1697) = 2950.413, df = 1697, p < 0.000; CFI = 0.811]. After removing seven constraints and eight correlations suggested by the Lagrange multiplier test, the model fit improved significantly [χ² (15) = 147.165, p < 0.000]. Conclusions This research provides significant support for the subscale structure of the LupusPRO in two disparate cultural samples of SLE patients. Despite significant sociodemographic and clinical differences between the two samples, for the most part, the LupusPRO performed similarly in both samples.

Depression predicts self-reported disease activity in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an autoimmune disease that can significantly impact both physiological and psychological functioning. In order to examine the relationship between psychological functioning and disease activity in SLE, we administered instruments that collected sociodemographic information and measured indices of disease activity and psychosocial functioning from 125 adult Hispanic and White patients with SLE. Patients were recruited from four healthcare settings in the greater Southern California area. Both cross-sectional and longitudinal relationships between depression and disease activity were evaluated. Cross-sectional findings revealed that depression and ethnicity were independently correlated with self-reported disease activity. Longitudinally, depression alone predicted self-reported disease activity. These data suggest that depression may play a significant role in the health status of SLE patients and serve as an important target for clinical intervention.

Rheumatoid Arthritis Severity Scale: a brief, physician-completed scale not confounded by patient self-report of psychological functioning

OBJECTIVE

The purpose of this study was to develop a brief measure of severity for rheumatoid arthritis (RA) that would not be seriously confounded by psychological functioning. The Rheumatoid Arthritis Severity Scale (RASS), designed for use by physicians on their own patients, consists of three visual analogue scales: Disease Activity, Functional Impairment and Physical Damage.

METHODS

Ninety-four RA outpatients completed the Health Assessment Questionnaire (HAQ) Disability, Pain Severity, Health State subscales and the Symptom Checklist-90-Revised (SCL-90-R) Anxiety, Depression and Somatization subscales. Rheumatologists completed the RASS on their own patients.

RESULTS

Results suggest that the RASS is internally consistent (alpha=0.85) and valid. RASS Disease Activity, Functional Impairment, Physical Damage correlated with HAQ Disability (r=0.40, 0.68, 0.61; P<0.01), Pain (r=0.37, 0.34, 0.34; P<0.01) and Health State (r=-0.27, -0.36, -0.27; P<0.01). RASS Physical Damage uniquely predicted longer illness duration (years with RA). In contrast to the HAQ, RASS subscales shared less variance with anxiety, somatization and depression scores.

CONCLUSIONS

Preliminary data suggest that the RASS may be a quick, reliable, valid physician-completed RA severity scale that compares favourably with the longer, patient-completed HAQ.

Disease status predicts fatigue in systemic lupus erythematosus

OBJECTIVE

To investigate the relative contributions of disease status, helplessness, and depression to fatigue in patients with systemic lupus erythematosus (SLE) in a path-analytic framework.

METHODS

The disease status of 81 patients with SLE was evaluated by a clinical rheumatologist using the Systemic Lupus Activity Measure. Patients completed self-report measures of psychosocial data, depression, helplessness, and fatigue at 2 assessment periods, 3 months apart. SLE diagnoses were confirmed with patients' physicians.

RESULTS

The model proposed that SLE disease status would predict fatigue directly, and indirectly, through helplessness and depression. At Time 1, disease status, helplessness, and depression were significantly correlated with each other and with fatigue, with helplessness and depression partially mediating the relationship between disease status and fatigue. Longitudinal analyses showed that disease status at Time 1 predicted fatigue, regardless of helplessness and depression operating as mediators at either Time 1 or Time 2.

CONCLUSION

The cross sectional findings revealed direct and indirect relationships between disease status and fatigue, with helplessness and depression as mediating variables. However, disease status was the only predictor of fatigue over time. Disease status also predicted Time 2 helplessness, which, in turn, was associated with Time 2 depression. Fatigue amelioration may be an important result of successful management of the underlying SLE process.

The role of generalized pain and pain behavior in tender point scores in fibromyalgia

OBJECTIVE

To determine and assess the significance of the independent role of pain, pain behavior, depression, and weekly stress in tender point scores in objectively diagnosed fibromyalgia (FM) patients.

METHODS

One hundred eleven patients with FM recruited from the community and private and university based clinics participated in a comprehensive evaluation of their pain, psychological distress, and pain behavior. Tender point assessment was carried out across 18 discrete sites according to American College of Rheumatology criteria. Pain was assessed with a composite index of 4 pain measures; psychological distress consisted of measures of stress and depression, and pain behavior was measured by an objective index derived from a 10 minute videotaped sequence in which 5 pain behaviors were recorded.

RESULTS

Multiple regression analyses revealed that high pain, high pain behavior, and shorter illness duration were related independently to tender point scores. Measures of depression and weekly stress were not independently related to tender point scores.

CONCLUSION

Tender point scores are related to generalized pain and pain behavior tendencies in patients with FM, and do not independently reflect generalized psychological distress.

Psychosocial factors associated with complementary treatment use in fibromyalgia

OBJECTIVE

To examine the frequency and predictors of reported complementary treatment use in a sample of 111 subjects with fibromyalgia (FM). The perspective was adopted that complementary treatment use represents a form of medical help-seeking that may be subject to a variety of biological, social, and psychological influences.

METHODS

Patients with FM were recruited from community and university based clinics and support groups throughout the greater San Diego, California, area. Patients participated in a comprehensive evaluation of their pain, psychological functioning, and disability prior to their potential involvement in a clinical trial designed to help them copy with their condition. They were also administered a rheumatological evaluation to verify their FM and a 20 item questionnaire to assess their use of complementary treatment strategies specifically for coping with FM.

RESULTS

Ninety-eight percent of the sample reported the use of at least one strategy over the preceding 6 months. Exercise, bed rest, vitamins, heat treatment, and spirituality/praying were the most frequently used strategies by subjects on a daily basis. Multiple regression analysis revealed that lower age, higher pain, and higher disability were uniquely associated with higher complementary treatment use. The Pain Rating Index, a measure of the subjective severity of pain from the McGill Pain Questionnaire, proved highly significant in explaining the relationship between pain and questionnaire scores. Pain coping strategies and quality of social support did not predict complementary treatment use.

CONCLUSION

The findings suggest that poor clinical status is a major predictor of complementary treatment use in FM. However, longitudinal research is recommended to clarify the relationship between clinical status and help-seeking patterns in patients with FM over time.

A comparison of behavioral and educational interventions for fibromyalgia

OBJECTIVE

To compare a comprehensive behavioral intervention with an education/control condition in the treatment of patients with fibromyalgia (FM), and to explore the role of mediators of clinical improvement in both groups.

METHODS

The effects of the behavioral and education/control interventions were evaluated across a 10 week treatment period and at 6 month followup on measures of pain, depression, disability, pain behaviors, and intervening variables. The behavioral intervention focused on the development of diverse pain coping skills, while the education/control condition presented information on a range of health related topic without emphasizing skill acquisition.

RESULTS

Although improvement across time was found in depression, self-reported pain behaviors, observed pain behaviors, and myalgia scores, no differences in these criteria were found between the behavioral and education/control conditions. Multiple regression analyses revealed that changes in helplessness and passive coping were associated with improvement in a number of clinical outcomes.

CONCLUSION

The findings illustrate the value of psychoeducational interventions in decreasing the psychological and behavioral effect of FM, and the value of reducing dysfunctional coping and helplessness in future intervention research.

Chronic life stress alters sympathetic, neuroendocrine, and immune responsivity to an acute psychological stressor in humans

OBJECTIVE

Life stress is hypothesized to alter the dynamic regulation of the autonomic, neuroendocrine, and immune systems. This study examined the effects of antecedent chronic life stress on psychological and physiological responsivity after acute challenge with a psychological stressor.

METHOD

Using a within-subject mixed design, male volunteers with (N = 12) and without chronic life stress (N = 11) were administered a 12-minute laboratory stressor (mental arithmetic) vs a video control.

RESULTS

Acute psychological stress induced subjective distress, increases of circulating concentrations of epinephrine, norepinephrine, beta-endorphin, adrenocorticotropic hormone (ACTH), and cortisol, and a selective redistribution of natural killer (NK) cells into the peripheral blood as compared with the video control condition. Although the two groups were almost identical at baseline in psychological, sympathetic, neuroendocrine, and immune domains, the chronic stress group showed greater subjective distress, higher peak levels of epinephrine, lower peak levels of beta-endorphin and of NK cell lysis, and a more pronounced redistribution of NK cells in response to the acute psychological challenge than the controls. Furthermore, the acute stressor induced a protracted decline in NK lysis per NK cell in the chronic stress group but had no effect in the controls.

CONCLUSIONS

In summary, when persons who are undergoing chronic life stress are confronted with an acute psychological challenge, an exaggerated psychologic and peak sympathomedullary reactivity occurs that is associated with decrements in individual NK cell function and is protracted beyond termination of the stressor and sympathomedullary recovery.

Illness self-schemas in depressed and nondepressed rheumatoid arthritis patients

This study examined the hypothesized illness self-schemas construct in persons with rheumatoid arthritis (RA). Biases in self-description, information processing, and schema-consistent illness behavior were examined in depressed and nondepressed persons with RA and compared with those of depressed and nondepressed controls. Major findings revealed that RA-depressed subjects exhibited pervasively negative self-description and biased processing of negative illness-related information. RA-nondepressed subjects demonstrated a bias for positive self-description and enhanced processing of positive illness-related information. Using regression analysis, the illness self-schema construct predicted unique variance in self-reported functional disability. Findings are reviewed in the context of previous research on self-schemas, chronic pain, and cognitive variables in chronic illness. Potential clinical implications and directions for future research are discussed. The illness self-schema construct has significant heuristic value which could guide further research on the psychosocial adjustment of individuals with chronic illnesses.

Pain coping mechanisms in fibromyalgia: relationship to pain and functional outcomes

OBJECTIVE

To evaluate the factor structure of the Coping Strategies Questionnaire (CSQ) in patients with fibromyalgia (FM) and to compare the factors derived from this measure, along with the active and passive pain coping scales of the Pain Management Inventory (PMI) in predicting pain, depression, quality of well being (QWB), and pain behavior concurrently and over time.

METHODS

One hundred twenty-two patients with FM were recruited from medical clinics, the community, and support groups. Eligible patients completed a battery of self-report measures of pain and psychosocial functioning at baseline assessment before random assignment to a clinical trial. A subset of 69 patients who completed the clinical trial were readministered the same battery 3 mo later. Data were analyzed within the baseline period, and from the baseline period to posttreatment to evaluate the predictive effects of coping strategies on clinical outcomes.

RESULTS

Principal components analysis of the CSQ revealed Coping Attempts (CA) and Pain Control and Rational Thinking (PCRT) factors, which have been found in other patient populations with chronic pain. Hierarchical multiple regression analyses revealed that high active coping and low PCRT contributed to higher concurrent pain, while low active coping and high passive coping were related to greater concurrent depression and pain behavior, respectively. Controlling for baseline scores on criterion measures, longitudinal multiple regression analyses demonstrated that high active coping and low PCRT scores contributed to greater pain, greater depression, and lower QWB at posttreatment, while low PCRT alone predicted greater pain behavior.

CONCLUSION

The results show the import of the pain coping construct in FM and highlight the negative contribution of low perceived control over pain and high active coping to a range of pain outcomes. The findings on low perceived control converge with data on other chronic pain populations, while the role of active coping appears to be detrimental in FM, in contrast to its positive effects in patients with rheumatoid arthritis.

The role of helplessness in the response to disease modifying drugs in rheumatoid arthritis

Fifty patients with rheumatoid arthritis participated in an assessment of their helplessness before and after a 3-month disease modifying drug trial. A multidimensional approach measuring helplessness was used, assessing cognitive, affective, and behavioral components. Both before and after the drug trial, helplessness indices accounted for a highly significant amount of variation in self-reported pain and functional disability. Moreover, Time 1 helplessness predicted greater flare activity after the drug trial. Helplessness indices, however, did not correlate with joint examination measures within time periods, nor did they predict change in these measures over the drug trial. The importance of the role of helplessness in subjective and objective measures of clinical status in persons undergoing drug therapy is discussed.

Biopsychosocial contributions to the management of arthritis disability. Blueprints from an NIDRR-sponsored conference

The contributions of MACs and RRTCs to the generation of arthritis-related biopsychosocial research over the last 15 years have been enormous. However, the assimilation of biopsychosocial concepts into mainstream clinical practice, professional education, and public awareness will require a sustained national effort.

Longitudinal relationships among pain, sleep problems, and depression in rheumatoid arthritis

This research evaluated the relationship between pain and sleep problems, and the role of pain and sleep problems in depression, in a sample of 242 patients who had been diagnosed with definite or classical rheumatoid arthritis (RA). Patients completed the Pain scale of the Arthritis Impact Measurement Scales, the Center for Epidemiological Studies Depression Scale, and self-reports of sleep disturbance at two data waves over a 2-year interval. Cross-sectional multiple regression analysis revealed that the sleep problems variable was independently associated with depression at Time 1. Longitudinal multiple regression analyses demonstrated that prior pain predicted subsequent adverse changes in sleep problems, whereas sleep problems did not affect pain over time, and prior pain and the interaction of high pain and high sleep problems were independently associated with depression from Time 1 to Time 2. These data suggest that pain may exacerbate sleeping difficulty in RA patients, and that both factors may contribute to depression over time.

Pain coping strategies and depression in rheumatoid arthritis

A study was conducted to examine the role of pain episodes and the role of active and passive pain coping strategies in predicting depression in 287 patients with rheumatoid arthritis (RA). The independent effects of pain and pain coping strategies, as well as the interaction effects between pain and pain coping strategies on depression, were evaluated cross-sectionally and prospectively over a 6-month interval. The cross-sectional findings revealed that pain, passive coping, and the interaction between pain and passive coping contributed independent variance, all accounting for higher depression. Of principal interest was the finding that the frequent use of passive pain coping strategies in the face of high pain contributed to the most severe level of depression over time. These results were obtained after controlling for the potentially confounding effects of prior depression, functional disability, and medication status. These data imply that there may be a potential benefit of developing techniques to reduce the use of passive pain coping strategies to deal with chronic arthritis pain in cognitive-behavioral pain management programs.

Pain coping strategies and depression in rheumatoid arthritis

A study was conducted to examine the role of pain episodes and the role of active and passive pain coping strategies in predicting depression in 287 patients with rheumatoid arthritis (RA). The independent effects of pain and pain coping strategies, as well as the interaction effects between pain and pain coping strategies on depression, were evaluated cross-sectionally and prospectively over a 6-month interval. The cross-sectional findings revealed that pain, passive coping, and the interaction between pain and passive coping contributed independent variance, all accounting for higher depression. Of principal interest was the finding that the frequent use of passive pain coping strategies in the face of high pain contributed to the most severe level of depression over time. These results were obtained after controlling for the potentially confounding effects of prior depression, functional disability, and medication status. These data imply that there may be a potential benefit of developing techniques to reduce the use of passive pain coping strategies to deal with chronic arthritis pain in cognitive-behavioral pain management programs.

Correlates of a clinical classification schema for the arthritis helplessness subscale

We examined the categorization of the helplessness subscale of the Arthritis Helplessness Index (AHI) into clinical ranges analogous to laboratory values, and the predictive validity of these cutoff scores over a 2-year period. Data were obtained via questionnaires mailed every 6 months over 5 time periods to 368 patients who had been diagnosed as having rheumatoid arthritis. The results demonstrate that patients classified as low helpless were distinct from those classified as normal. In turn, those classified normal were distinct from high helpless patients on numerous measures of beliefs, affect, behavior, and symptom severity. Even after 2 years, the 5-item helplessness subscale identified distinct clinical courses for these 3 groups.

Factor structure of the Arthritis Helplessness Index

The factor structure of the Arthritis Helplessness Index (AHI) was examined using principal components factor analysis with varimax rotation. Data for the initial factor analysis came from a longitudinal study of 368 patients with rheumatoid arthritis (RA). Two slightly negatively correlated (r = -0.21) subscales emerged: internality and helplessness. This analysis was cross-validated twice. Findings reveal that the 2 subscales of the AHI are more reliable and valid than the total score. The 5 item helplessness subscale, in particular, appears to be a highly valid indicator of the degree to which patients with RA feel overwhelmed by their disease.

The psychosocial adjustment of the Amerasian refugees. Findings from the Personality Inventory for Children

The purpose of this study was to investigate the psychosocial adjustment of 24 Amerasian youths who had immigrated to the United States in 1983 and 1984. The Personality Inventory for Children (PIC) was translated into Vietnamese and administered to 18 mothers of Amerasian youths in a social service agency in a large southern city. Respondents reported significant mood disturbance and psychological distress in their children. Specifically, the depression, somatization, withdrawal, and psychosis subscales of the PIC were clinically elevated for the entire group. An evaluation of individual profiles revealed marked tendencies toward somatization and withdrawal. These findings are consistent with other studies on the psychosocial adjustment of Southeast Asian refugees.

Emigration stress and language proficiency as correlates of depression in a sample of Southeast Asian refugees

This research evaluated a stress management, coping skills model of adjustment in the analysis of depression in a sample of Laotian refugees living in the southeastern United States. Stressful events and experiences during emigration and a lack of English proficiency were associated with depressive symptoms, while demographic variables and social support were not. English proficiency also significantly reduced the impact of acculturative stressors on depression, suggesting that language skill may act as a stress buffer in the new cultural environment.

The measurement of helplessness in rheumatoid arthritis. The development of the arthritis helplessness index

We describe the development of the Arthritis Helplessness Index (AHI), a self-report instrument designed to measure patients' perceptions of loss of control with arthritis. The participants in this research were 219 patients with rheumatoid arthritis (RA) who completed a quantity of mailed materials, including the AHI, functional measures and other psychological scales. Significant evidence of reliability and validity of the AHI was found. Greater helplessness correlated with greater age, lesser education, lower self-esteem, lower internal health locus of control, higher anxiety, and depression, and impairment in performing activities of daily living using a health assessment questionnaire. Over one year, changes in helplessness correlated with changes in difficulty in performing activities of daily living. The AHI appears to be a useful measure for further studies in RA and a valuable clinical tool in monitoring the psychological status of patients with RA.

Insomnia: nonpharmacologic management by private practice physicians

We report a survey investigation on the perceived value of behavioral assessment and the use of nonpharmacologic treatment of insomnia by 159 physicians in private practice in Davidson County, Tennessee. They generally attributed limited value to behavioral assessment, and reported infrequent use of nonpharmacologic treatment. However, the more patients the physicians saw with insomnia as the chief symptom, the more they tended to value behavioral assessment and other diagnostic procedures. Endorsement of behavioral assessment and all other diagnostic practices was in turn related to the use of behavioral treatment techniques. We suggest that a lack of awareness of the value of alternative assessment and treatment strategies may account for physicians' limited use of nonpharmacologic approaches to this common yet frequently serious medical problem.

Acute paranoid disorder in a Southeast Asian refugee

The clinical course of a 23-year-old male Vietnamese refugee who was seen for psychiatric evaluation and treatment after a self-inflicted abdominal stab wound is described. His attempted suicide was precipitated by a rejection of his romantic advances by an American woman and teasing by fellow co-workers that he was a Communist spy. Central to the development of paranoid delusions in this patient was the fact that he had been a member of the Communist forces in Cambodia and feared deportation. Emigration and acculturative stressors were seen as contributing significantly to this patient's paranoid disorder.

Progressive relaxation, EMG biofeedback and biofeedback placebo in the treatment of sleep-onset insomnia

This paper describes a study in which progressive relaxation, EMG frontalis biofeedback, and a biofeedback placebo manipulation were compared in the treatment of severe insomnia with 40 chronically sleep-disturbed adult patients. Progressive relaxation and EMG biofeedback led to significant reductions in both reported sleep-onset latency and depressive symptomatology. However, when compared individually with the biofeedback placebo group, neither progressive relaxation nor EMG biofeedback emerged as significantly more effective on the sleep-onset latency measure. The clinical improvement in the biofeedback placebo group suggests that expectancies related to the ability to relax may contribute to the therapeutic effectiveness of relaxation strategies, even with chronic, severely disturbed insomniacs. Improvement in sleep-onset latency was not significantly related to reductions in frontalis EMG activity either within or between groups, a finding which raises questions concerning the clinical role and importance of physiological relaxation in the treatment of sleep-onset disturbance.