Everyday life with osteoarthritis or rheumatoid arthritis: independent effects of disease and gender on daily pain, mood, and coping

The effects of disease (form of arthritis) and gender on pain, mood, and pain coping strategies were examined in a prospective 30-day diary study of 71 patients with osteoarthritis (OA) and 76 with rheumatoid arthritis (RA). Diary instruments included joint pain ratings, POMS-B checklists for positive and negative mood, and the Daily Coping Inventory. Women's average daily pain was 72% greater than men's pain, and RA patients' average daily pain was 42% greater than OA patients' pain. Hierarchical Linear Models were estimated for (a) within-person associations between pain and next-day mood; coping and next-day pain; and coping and next-day mood; and (b) the independent effects of disease and gender on individual intercepts for pain, mood, and coping and on individual slopes for pain-coping-mood relations. Women, regardless of their disease, and RA patients, regardless of their gender, reported more daily pain. Women used more emotion-focused strategies each day than did men, regardless of their disease and even after controlling for their greater pain. Men were more likely than women to report an increase in negative mood the day after a more painful day. RA patients' pain worsened, but OA patients' pain improved, following a day with more emotion-focused coping. Implications for research and clinical practice are summarized.     

A multilevel structural equation modeling analysis of vulnerabilities and resilience resources influencing affective adaptation to chronic pain

The processes of individual adaptation to chronic pain are complex and occur across multiple domains. We examined the social, cognitive, and affective context of daily pain adaptation in individuals with fibromyalgia and osteoarthritis. By using a sample of 260 women with fibromyalgia or osteoarthritis, we examined the contributions of pain catastrophizing, negative interpersonal events, and positive interpersonal events to daily negative and positive affect across 30 days of daily diary data. Individual differences and daily fluctuations in predictor variables were estimated simultaneously by utilizing multilevel structural equation modeling techniques. The relationships between pain and negative and positive affect were mediated by stable and day-to-day levels of pain catastrophizing as well as day-to-day positive interpersonal events, but not negative interpersonal events. There were significant and independent contributions of pain catastrophizing and positive interpersonal events to adaptation to pain and pain-related affective dysregulation. These effects occur both between persons and within a person’s everyday life     

Daily fatigue in women with osteoarthritis, rheumatoid arthritis, and fibromyalgia

We examined between and within-person variability, affective correlates, and diagnostic differences in daily fatigue in women with rheumatoid arthritis (RA), osteoarthritis (OA), and fibromyalgia syndrome (FMS). Two hundred and fifty-five female patients recruited from the community served as participants for this project. The patients had a physician-confirmed diagnosis of RA (n=89), OA (n=76), or FMS (n=90). Individuals completed an initial questionnaire and up to 32 daily diaries assessing illness symptoms and psychosocial variables (i.e., fatigue, pain, sleep problems, depression, and affect). The primary outcome for the current project was variability in fatigue. We examined affective, pain, and sleep correlates of fatigue, and tested whether these relations varied by diagnosis. Results indicated that FMS patients had higher overall levels of and greater daily variability in fatigue compared with the other pain groups. For all patients, fatigue correlated highly with lower positive affect (PA). Moreover, day-to-day increases in fatigue were associated with decreases in PA, particularly among FMS patients, and with increases in negative affect (NA). Daily pain was associated with increased fatigue in all groups, although OA patients showed less pain reactivity than either FMS or RA patients. These findings indicate that fatigue is a common feature of rheumatologic conditions. Nonetheless, there are important differences between RA, OA, and FM patients in both the everyday manifestations and the biopsychosocial correlates of fatigue.     

Depression and Next-day Spillover of Negative Mood and Depressive Cognitions Following Interpersonal Stress

We hypothesized that individuals high in depression would experience a greater increase in depressive symptoms following daily interpersonal stress, as compared with their symptoms following noninterpersonal stress. Forty-six adult outpatients completed seven consecutive daily assessments of stressful events, appraisals of those events, depressive cognitions, and negative affect at the beginning of treatment. Although there were no same-day differences in reactions to interpersonal and noninterpersonal stressors, there was significant “spillover” of negative thoughts and affect following interpersonal stressors for those high in depression. In other words, for those high in depression, negative thoughts and affect increased to a greater degree on days following an interpersonal stressor, as compared to days following a noninterpersonal stressor. These findings suggest that delayed recovery from daily interpersonal stress might contribute to the maintenance of depressive symptoms.     

The Influence of Social Problem-Solving Ability on the Relationship Between Daily Stress and Adjustment

This study examined the role of social problem solving as a moderator and a mediator of the relationship between daily stressful events and adjustment in a sample of 259 college students. Problem solving was assessed by the Social Problem-Solving Inventory-Revised, which provides scores for global problem-solving ability as well as five specific problem-solving dimensions, namely, positive problem orientation, negative problem orientation, rational problem solving (i.e., effective problem-solving skills), impulsivity/carelessness style, and avoidance style. Adjustment was assessed by using the scores for internalizing symptoms and externalizing symptoms from the Adult Self-Report. Because of significant gender differences on the major study variables, results were analyzed separately for men and women. The most consistent finding was for the importance of negative problem orientation as a moderator or a mediator of the relationship between daily stress and adjustment. In women, negative problem orientation, impulsivity/carelessness style, and avoidance style were all found to mediate internalizing and externalizing symptoms. In addition, positive problem orientation mediated internalizing symptoms. In men, negative problem orientation was found to be a moderator for externalizing symptoms and a mediator for internalizing symptoms. The gender differences and implications for clinical practice were discussed.     

Gender differences in pain, coping, and mood in individuals having osteoarthritic knee pain: a within-day analysis

This study examined gender differences in prospective within-day assessments of pain, pain coping, and mood in men and women having OA, and analyzed gender differences in dynamic relations between pain, mood, and pain coping. A sample of 64 women and 36 men diagnosed as having pain due to osteoarthritis of the knee(s) rated their pain, pain coping, and mood two times each day (once in the afternoon and once in the evening) for 30 days using a booklet format. Two gender differences were found in between person-analyses: women used more problem focused coping than men, and women who catastrophized were less likely than men to report negative mood. Several within-day and across-day gender differences were noted. First, women were much more likely to show a significant increase in pain over the day. Second, men were more likely than women to experience an increase in coping efficacy over the day. Third, men were more likely than women to use emotion-focused coping when their mood was more negative. Finally, men were more likely than women to experience an increase in negative mood and a decrease in positive mood in the morning after an evening of increased pain. Taken together, these findings underscore the importance of obtaining multiple daily assessments when studying gender differences in the pain experience.     

The Role of Mood States Underlying Sex Differences in the Perception and Tolerance of Pain

Abstract:   While sex differences in pain reporting are frequently observed, the reasons underlying these differences remain unclear. The present study examined sex differences in self-report and physiological measures of pain threshold and tolerance following the administration of two laboratory pain-induction tasks. The primary study aim centered on determining whether repeated exposure to such tasks would yield sex differences in terms of pain threshold and tolerance. In addition, it was hypothesized that if such differences did exist, negative mood states might account for changes in pain ratings, threshold, and/or tolerance in subsequent exposure to noxious stimuli. Recruited from a convenience sample, 66 participants (44 female and 22 male) were exposed to both thermal and cold noxious stimuli at three separate times, while psychophysiological and self-report data were collected. Because women outnumbered men 2:1, Fisher z transformations were performed to determine whether the observed associations between mood states and pain ratings differed. We found stronger associations between fatigue and thermal-heat pain ratings for men at their first and third exposure to the pain task compared to women ( z  = 2.11, P  < 0.05; z  = 3.14, P  < 0.001, respectively). Results indicated that women evidenced greater pain tolerance than men on both a behavioral and physiological level; however, they reported greater pain severity than men. Fatigue was also found to be particularly important to reports of pain severity in men and pain tolerance in response to noxious stimuli for women. Possible pathways in which mood states influenced these endpoints are discussed.     

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.     

Pain coping strategies and coping efficacy in rheumatoid arthritis: a daily process analysis

Data from daily diaries were used to analyze pain coping processes in rheumatoid arthritis patients. For 30 consecutive days, 53 individuals described the pain coping strategies they used that day and rated the efficacy of their coping, joint pain, and positive and negative mood. Relations among variables were examined across-persons and within-persons over time. At the across-persons level of analysis, (i) daily coping efficacy was unrelated to pain coping or pain intensity, and (ii) the more frequent daily use of a wide variety of pain coping strategies was correlated with greater pain. Within-person analyses provided unique information about the relations among coping, pain, and mood not apparent in the across-persons results. Specifically, these analyses showed that increases in daily coping efficacy were not only related to decreases in pain, but also to decreases in negative mood and increases in positive mood. Time-lagged effects of coping and coping efficacy were also found. Individuals who reported high levels of coping efficacy on one day had lower levels of pain on the subsequent day. The daily use of pain reduction efforts and relaxation strategies also contributed to an improvement in next-day pain and an enhancement of positive mood. The implications of these findings for the assessment of pain and coping in rheumatoid arthritis patients are discussed.     

Pain Expectancy and Positive Affect Mediate the day-to-day Association Between Objectively Measured Sleep and Pain Severity Among Women With Temporomandibular Disorder

The majority of individuals with temporomandibular disorders (TMD) experience sleep disturbance, which can maintain and exacerbate chronic pain. However, the factors underlying the sleep-pain link have not been fully elucidated, especially beyond the laboratory. Sleep deprivation can induce threat interpretation bias, as well as impairment in positive affective functioning. Using both actigraphy and daily diaries, we examined whether morning pain expectancy and positive affect mediate the association between previous night's sleep disturbance and next-day overall pain severity. Total sleep time (TST) was selected as the primary measure of sleep. The sample included 144 women (mean age = 36 [SD = 11.1]) with TMD who displayed at least subclinical insomnia. Sleep was assessed for 14 days using actigraphy which was validated by concurrent sleep diaries. Daily diary assessments of pain-related experiences and affective states were conducted twice per day (ie, once upon participants’ waking and the other prior to going to sleep) for the same 14-day period. Multilevel structural equation modeling revealed that both morning pain expectancy (95% CI: -.0004, -.00003) and positive affect (95% CI: -.0005, -.000001) mediated the association between previous night's TST and next-day's overall pain severity, such that shorter previous night TST was associated with higher next-morning pain expectancy and lower positive affect, which in turn were associated with a greater level of next-day's overall pain severity while controlling for morning pain severity. Reducing exaggerated daily pain expectancy and up-regulating positive affect may be important intervention targets for disengaging the sleep-pain link among individuals with co-occurring TMD and sleep disturbance.PerspectiveThe daily link between previous night sleep duration and next day pain severity is mediated by morning pain expectancy and positive affect among women with temporomandibular disorder and sleep disturbance. Reducing pain expectancy and increasing positive affect may serve an important role in improving self-management of chronic pain.     

Evidence for sex differences in the relationships of pain, mood, and disability.

Disability demonstrates strong univariate associations with pain and negative mood. These relationships are more complex at the multivariate level and might be further complicated by sex differences. We investigated sex differences in the relationships of pain and negative mood to overall disability and to disability in specific functional domains. One hundred ninety-seven consecutive patients with low back, myofascial, neck, arthritis, and fibromyalgia pain were recruited from university pain clinics and completed measures of disability and negative mood. Overall disability and disability in voluntary activities were significantly associated with pain and negative mood (factor score) for both sexes. Significant sex differences emerged in the strength of the disability-mood relationship, with women evincing a stronger relationship. Disability in obligatory activities was also significantly related to pain and negative mood for both sexes; however, there were no sex differences in the strength of these relationships. Mediation analyses indicated that, in men, negative mood partially mediated the relationship between pain and both overall disability and disability in voluntary activities; mediation was not supported for disability in obligatory activities. In women, negative mood fully mediated the relationship between pain and all 3 types of disability. These data suggest that disability is more directly related to pain in men. In women, the effect of pain on disability appears to operate through negative mood. PERSPECTIVE: Results of this study demonstrate that sex differences exist in the relationships of pain, mood, and disability. Men and women might thus benefit from treatment interventions that differentially target these variables.     

Cognitive vulnerability to depressive symptoms among men and women

Previous research examining Beck's diathesis-stress model of depression has been conducted with combined samples of men and women or with female subjects alone. In the present study, the moderating effect of dysfunctional attitudes on the relations of depression with both social support and stressful life events was investigated separately for men and women. A large sample of subjects completed measures of depression twice, 3 months apart, as well as measures of dysfunctional attitudes, social support, and stressful life events. The results indicated that among women, the interaction of dysfunctional attitudes with social support, but not with stressful life events, significantly predicted the severity of subsequent depressive symptoms. In contrast, dysfunctional attitudes did not have either a main or a moderating effect among men. Potential subtypes of cognitive vulnerability to depression were also explored in this study, although the results suggested that the Dysfunctional Attitudes Scale may be best employed as a unitary measure of vulnerability to depressive symptoms in response to negative interpersonal experiences. These findings are discussed with reference to types of vulnerability and precipitating events, and to sex differences in the development and maintenance of depressive symptoms.Preparation of this article was facilitated by a Medical Research Council of Canada Studentship to the first author, and by Grant MA-8574 from the Medical Research Council of Canada to the second author.     

Cognitive Bias in Men's Processing of Negative Social Information: The Role of Social Anxiety,Toughness as a Masculine Role Norm,and Their Interaction

Cognitive approaches to social anxiety focus on a person's tendency to make biased judgments for threat-relevant stimuli. This notion was tested relative to whether men's adherence to a toughness male role norm moderates the relation between social anxiety and biased judgments for negative interpersonal events. For negative interpersonal events not involving male role norms, results indicated that only social anxiety was related to probability estimates, while for cost estimates there was a unique association for social anxiety and a significant social anxiety by toughness interaction such that men who were high in both made greater cost estimates. For events involving explicit male role norms, social anxiety and toughness evidenced unique relationships with probability estimates. For cost estimates, in addition to unique associations for social anxiety and toughness, there was a significant interaction, which showed that men high in both characteristics gave the highest cost ratings.     

Transient Effects of Sleep on Next-Day Pain and Fatigue in Older Adults With Symptomatic Osteoarthritis

Poor sleep quality has been associated with greater pain and fatigue in people living with osteoarthritis (OA). The objective of this micro-longitudinal study was to determine whether sleep impacts the diurnal pattern of next-day OA-related pain and fatigue. Community-dwelling older adults (≥65 years) with hip and/or knee OA provided data over 5 days using daily diaries and wrist-worn actigraphs. Pain and fatigue intensity were measured on awakening, at 11 am, 3 pm, 7 pm, and bedtime. Subjective previous night sleep quality was measured on awakening. Multilevel linear regression models examined interactions between sleep variables and time of next-day symptom reports. One hundred sixty participants provided 785 days of data (median age = 71 years; 62% female). Analysis of time interaction effects identified an association between poor sleep quality and more morning pain and fatigue. Although the effect on awakening was more pronounced for fatigue, differences in both symptoms attributable to sleep quality attenuated as the day progressed. Investigation of actigraphy-based sleep parameters revealed no significant interactions with time of symptom measurement. These findings observed in a sample of older adults with mild-to-moderate OA symptoms warrant further investigation in a sample with more severe symptoms and more pronounced sleep dysfunction and/or sleep disorders.PerspectiveThis article investigates the impact of sleep on next-day pain and fatigue of older adults with OA. On awakening from a night of poor quality sleep, pain and fatigue intensity were heightened. However, the effect was not sustained throughout the day, suggesting the morning may be an optimal time for symptom interventions.     

How Do Fluctuations in Pain,Fatigue, Anxiety,Depressed Mood,and Perceived Cognitive Function Relate to Same-Day Social Participation in Individuals With Spinal Cord Injury?

ObjectiveThis study aimed to examine same-day associations of pain, fatigue, depressed mood, anxiety, and perceived cognitive function with social participation in the daily lives of adults with spinal cord injury (SCI).DesignObservational study used a combination of baseline surveys and 7 end-of-day (EOD) diaries.SettingGeneral community.ParticipantsIndividuals with SCI (N=168; mean age, 49.8y; 63% male, 37% female).Main Outcome MeasuresPatient-Reported Outcomes Measurement Information System short form measures (Ability to Participate in Social Roles and Activities, Pain Intensity, Depression, Anxiety, Cognitive Function Abilities) were adapted for daily administrations as EOD diaries.ResultResults of multivariable model showed that daily increases in fatigue (B=?0.10; P=.004) and depressive symptoms (B=?0.25; P=<.001) and decreases in perceived cognitive function (B=0.11; P=<.001) were significantly related to worse same-day social participation. Daily fluctuations in anxiety and pain were unrelated to same-day social participation.ConclusionsThis is the first study that shows within-person associations of common SCI symptoms with social participation in the daily lives of adults with SCI. Results from the current study may help to develop more effective individualized treatments of symptoms and symptom effect aimed at improving social participation.     

Excessive Reassurance Seeking as a Mediator of Sociotropy and Negative Interpersonal Life Events

The Interpersonal Theory of Depression suggests that depressed individuals have behavioral patterns that alienate people in their environment, thereby reducing social support and maintaining their depression. Excessive reassurance seeking has been implicated as such a behavior. A model was tested in which excessive reassurance seeking mediates the relationships between sociotropy and increases in negative interpersonal life events as well as sociotropy and depressive symptoms. Participants consisted of 110 undergraduate students. Measures were given at two time points 6 weeks apart assessing sociotropy, excessive reassurance seeking, negative interpersonal life events, and depressive symptoms. Results suggested that excessive reassurance seeking mediated the predicted relationship between sociotropy and negative interpersonal life events, but did not mediate the relationship between sociotropy and depressive symptoms. The implications for these findings in the interactional nature of depression are discussed.     

Well-being among 50-year-old people. The population study "50-year-old people in Kungs?r"

Self-assessed well-being has been shown to be related to earlier medical events and to be a predictor of mortality. 50-year-old men and women (n = 314) in Kungs?r were invited to an examination for traditional risk factors for cardiovascular diseases and different aspects of self-assessed well-being. The differences between men and women concerning their well-being could not explain the differences in the expected mortality between the sexes. A well-developed social network and physical exercise were the most positive determinants of well-being, while drug intake, angina pectoris, and smoking were the most negative.     

Pain Acceptance in People With Chronic Pain and Spinal Cord Injury: Daily Fluctuation and Impacts on Physical and Psychosocial Functioning

Daily fluctuation in pain acceptance and its impact on the physical and psychosocial functioning of individuals living with spinal cord injury (SCI) and chronic pain has not been examined. We used end-of-day diaries and multilevel modeling to examine the moderating effect of within- and between-person pain acceptance on associations between pain and physical and psychosocial functioning. Individuals with SCI and chronic pain (N = 124) completed 7 days of end-of-day diaries, which included measures of pain acceptance, pain intensity, pain catastrophizing, pain interference, participation in social roles and activities, depressive symptoms, and positive affect and well-being. We found within-person variability in pain acceptance (28% of the total variance) and a significant moderating effect of daily fluctuation in pain acceptance on the same-day pain intensity-social roles and activities association. Within-person changes in pain acceptance were also associated with daily changes in pain interference, depressive symptoms, and positive affect and well-being, adjusting for pain intensity and catastrophizing. Findings highlight the potential for daily or momentary assessments of pain acceptance to enhance understanding of how psychological flexibility may contribute to pain-related outcomes. Future studies could further investigate stable and variable characteristics of pain acceptance and their individual contribution to physical and psychosocial functioning.PerspectiveDaily fluctuations in pain acceptance and their association with physical and psychosocial functioning were observed in the lives of individuals with SCI and chronic pain. These findings may guide future studies to inform the development of effective, pain acceptance-focused individualized treatment approaches for chronic pain management in people with SCI.     

Social support among persons with multiple sclerosis

The source and magnitude of perceived social support functions and structure were examined in relation to illness duration, gender, and presence or absence of spouses among 200 persons with multiple sclerosis. The associations between social support variables and a health index, ADL level of functioning, also were examined. Significant gender differences were shown for perceived availability of affect, affirmation, and aid functions. A significant change in the network property, average frequency of relationships, occurred over the chronic illness trajectory. Low to moderate correlations were observed between a number of activities of daily living and both perceived social support functions and network size, particularly for women. Implications for professional staff who provide health services for persons with MS are presented. Further study regarding lower levels of perceived social support in women than men and low levels of informational support in both men and women is suggested.     

Personality,appraisal, and adaptational outcomes in HIV seropositive men and women

A cross-sectional exploratory design was used to assess the relationships of personality, socioeconomic status, and appraisal with functional and emotional outcomes in 77 men and 50 women with HIV infection. Multiple regression analysis showed that, among men, socioeconomic status moderated the negative relationship between self-esteem and disruption in usual activities. Consistent with Lazarus and Folkman's (1984) theory, appraisal of HIV threat mediated the negative relationship between self-esteem and mood disturbance for men and women, and the positive relationship between self-esteem and purpose in life for women. Appraisal did not mediate between personality variables and disruption in usual activities or life satisfaction for men or women. ©1995 John Wiley & Sons, Inc.