Factors affecting emotional instability in female rheumatoid arthritis outpatients with limited functional disorder

Abstract

We attempted to identify which background factors were the most important indicators of such psychological problems as emotional instability, a feeling of hopelessness, and suicidal tendencies in female rheumatoid arthritis (RA) outpatients with limited functional disorder. Among female RA patients aged 20 years and older who visited the outpatient clinic, 101 class I and II patients were selected as subjects for the present study. An original questionnaire and a psychological test (CMI) were given to those subjects who had given their written consent to such testing, and an analysis was carried out on 85 patients who returned all the written forms. Their emotional instability was related to factors such as “not being able to understand the nature of RA disease and its treatment,” “sense of value had changed after developing RA,” “nonuse of drugs,” and “duration of disease.” A feeling of hopelessness was related to “smoking,” and a suicidal tendency was related to “smoking” and “class I.” We identified a characteristic correlation between emotional instability and background factors in this study. Paying close attention to these factors may thus be useful in preventing the appearance of psychological problems as well as in developing effective early treatment strategies.     

Factors correlated with emotional instability in SLE outpatients

Eighty-four female outpatients with systemic lupus erythematosus (SLE) who are able to live on their own were investigated. We statistically analyzed the relationship between emotional instability based on psychological tests (Cornell Medical Index), and physical, medical, and social factors based on both our clinical records and original questionnaires. The emotional instability was related to not "working," an older "age at the time of SLE diagnosis," being "anxious about the adverse effects of steroids," or not "understanding the details of the disease and treatment at the time SLE treatment was started." No relationship with previously experienced physical factors was observed. In addition, no relationship with disease activity was observed either. We identified the characteristic correlation between emotional instability and medical and social factors in this study. Paying close attention to these factors may thus be useful in both preventing the appearance of psychological problems and developing effective early treatment strategies. Received: July 28, 1999 / Accepted: November 15, 1999     

Factors affecting depression and anxiety in female Japanese patients with rheumatoid arthritis

OBJECTIVE: In this study, we attempted to identify which background factors were the most important indicators regarding such psychological problems as depression and anxiety in female rheumatoid arthritis (RA) patients. METHODS: Among female RA patients aged 20 and older, who visited the outpatient clinic, and who met the Revised Criteria of the American Rheumatism Association for RA (ARA1987), 101 Class I and II patients were selected as subjects for the present study. Specially designed questionnaires and psychological tests were given to those subjects who had given their written consent for such testing, and a stepwise multiple logistic regression analysis was carried out on the 85 patients who returned all written forms. Those factors affecting psychological problems at a significance level of 5% or less were identified. RESULTS: It was shown that among sociodemographic factors, "a decrease in the frequency of going out socially after having RA" and "a higher education" worked as significantly associated variables for depression, while "a decrease in the number of friends after having RA" served as a significantly associated variable for trait anxiety. Significantly associated variables for state anxiety included "a decrease in the frequency of going out socially after having RA" and "a willingness to join an RA study group". CONCLUSION: The present study demonstrated that factors related to social interactions were significantly associated with depression and anxiety in Class I and II female RA outpatients.     

Suicide and euthanasia in late life

Epidemiological studies of suicide in the elderly indicate that, in the last few decades, there has been a relevant increase in suicide rates in old age in a number of Asian and Latin nations, with an almost parallel decrease in Anglo-Saxon counties. Mental disorders, particularly depression, physical illness, personality traits such as hostility, hopelessness, the inability to verbally express psychological pain and dependency on others, recent life events and losses are all factors that may contribute to suicide in later life. Compared with suicide in other age groups, mors voluntaris in late life is associated with the use of highly lethal methods, less ambivalence and impulsivity, and more determination and intent to die. Accordingly, elderly suicidal individuals are more likely than younger subjects to complete rather than attempt suicide. Some evidence suggests also that the characteristics of elderly individuals who attempt suicide may not overlap with those who complete suicide. Death thoughts and suicidal ideations are relatively rare among mentally healthy elderly adults, and are less predominant in this age bracket. However, whether elderly suicidal behaviour exists along a continuum, progressing in severity from death thoughts and suicidal ideation to suicide attempts and completed suicide, remains unclear. Assisted suicide and euthanasia in the elderly have been associated with the desire to escape chronic physical pain and suffering caused by terminal illness, and to relieve mental anguish and feelings of hopelessness, depression and extreme "tiredness of life." The role of the family and those treating chronically ill members is crucial in the final stages of life, particularly when autonomy and the ability of the elderly individual to make end-of-life decisions are compromised. The main aspects associated with these controversial phenomena, particularly from a transcultural perspective, are reviewed in this article.     

Application of an algorithm for the diagnosis of asthma in Chinese families: limitations and alternatives for the phenotypic assessment of asthma in family-based genetic studies

Phenotype assessment is a crucial issue in gene mapping studies of asthma. Recently, Panhuysen and coworkers proposed an algorithm to define the asthma phenotype in gene mapping family-based studies. We classified members of 2,756 Chinese families ascertained on the basis of the presence of two or more siblings and no more than one parent with asthma using a slightly modified version of the aforementioned algorithm. Among 4,097 Chinese parents, 404 (9.9%) were classified as having "definite asthma," 284 (6.9%) as "probable asthma," 1,193 (29.1%) as "unclassifiable obstructive airway disease, " 626 (15.3%) as "COPD," and 1,590 (38.8%) as "unaffected" (no obstructive airway disease). Among 6,424 Chinese offspring, 1,065 (16.6%) were classified as having "definite asthma," 820 (12.8%) as "probable asthma," 1,996 (31.1%) as "unclassifiable obstructive airway disease," 228 (3.5%) as "COPD," and 2,315 (36%) as "unaffected." The use of the algorithm proposed by Panhuysen and coworkers in a Chinese population with a high prevalence of smoking would result in the exclusion of subjects with asthma who smoke or who have severe airflow obstruction from linkage analysis, as well as in an inability to explore any potential interactions between genetic factors and cigarette smoking in the pathogenesis of asthma. In the absence of a "gold standard," definitions of asthma that incorporate a combination of respiratory symptoms, increased airway responsiveness or bronchodilator response, and a physician's diagnosis of asthma are reasonable. The choice of a particular diagnostic algorithm for family-based genetic studies of asthma should be made according to factors such as the prevalence of smoking in the study population. Genetic studies of intermediate phenotypes related to asthma, which are objectively defined and may be influenced by a smaller number of genes, continue to be of great importance.     

Relationship between psychological factors and arthralgia in patients with rheumatoid arthritis

Various factors were assessed in terms of their contribution to arthralgia in a rheumatoid arthritis patient. Eighty-two outpatients (62 women and 20 men) with rheumatoid arthritis (RA) were examined with respect to the subjective degree of arthralgia, age, disease duration, dysfunction, steroid dose, steroid period, depression, anxiety, extroversion, neurotic disorder, and number of caretakers. The results were explained on the basis of stepwise regression analysis and psychological and clinical data. We analyzed results of a correlation coefficient test on the mutual relationship between variables. Stepwise regression analysis was performed to assess factors of arthralgia in terms of "depression," "mean activity," "morning stiffness," and "steroid dose." Depression is a factor of arthralgia as shown in this study, but it is clear that other factors are also involved. Anxiety was a factor distinct from the activity of RA. The factor contributing most to arthralgia was found to be depression, whereas anxiety had no effect. Received: January 31, 2001 / Accepted: August 3, 2001     

Quality of life profiles in the first years of rheumatoid arthritis: results from the EURIDISS longitudinal study

OBJECTIVE: The aim of this study was to examine the quality of life (QoL) profiles of patients with early rheumatoid arthritis (RA) and to relate these to disease and impairment variables as indicated, respectively, by erythrocyte sedimentation rate (ESR) and by tender joint count (Ritchie Articular Index), fatigue, and pain. METHODS: The present study uses part of the European Research on Incapacitating Disease and Social Support data of 573 patients with recently diagnosed RA (268 from the Netherlands, 216 from Norway, and 89 from France). A series of clinical and psychosocial data were collected on 4 (the Netherlands, France) and 3 (Norway) occasions, with 1-year intervals separating the waves of data collection. RESULTS: Of the disease activity (ESR) and impairment variables (tender joint count, fatigue, pain), fatigue was identified as the consequence of disease that differentiated best on a series of QoL aspects such as disability, psychological well-being, social support, and "overall evaluation of health." Next came pain and tender joint count, and ESR showed by far the least differentiating ability. A principal-component analysis on the QoL measures used in this study yielded one general factor measuring "overall QoL." After rotation, two separate factors were encountered, one referring to the physical domain and the other to the psychological and social domains of QoL. Again, the QoL of RA patients experiencing much fatigue appeared to decline the most. CONCLUSIONS: Because of the highly variable nature of RA, impairments, activities of daily living (ADL) and instrumental ADL restrictions, and psychosocial distress can vary erratically. In particular, "fatigue" as measured over a period of 2 to 3 years distinguished best among RA patients as shown by their QoL profiles. Although the physical domain was most affected, the significant effect of RA on the psychosocial domain should not be underestimated.     

Will Genetic Profiling Make a Difference in Clinical Trial Outcomes?

What stimulated me to write this editorial was an article I read in USA Today written by Lois Hatton, who is a writer and columnist based in Brookings, South Dakota and author of "Inspiration for a Lifetime." The article, "'Black' Cherokees fight for heritage," told of a black Yankton Sioux who says he is seen as a black by other Sioux while on the reservation, but as an Indian by blacks who do not live on the reservation.     

Clinical management of acute and chronic cocaine poisoning

At the Haight-Ashbury Free Medical Clinics in San Francisco, the recreational use of cocaine is on a precipitous incline of popularity. Intensified symptoms of intoxication and the possibility of overdose parallel the current fad of smoking "freebase." We examined the "cocaine reaction," an adrenergic storm affecting CNS, respiratory and cardiovascular systems, which may proceed to generalized collapse and death within minutes. The physiologic and pharmacologic mechanisms of the reaction are elaborated, and a logical algorithm of treatment is outlined. The psychodynamics of the "armed" cocaine personality is discussed, as is the proper psychological approach to these patients. A specific indicated technical and pharmacologic approach, as well as several caveats of therapy that have been clinically developed in the treatment of several hundred cases of cocaine overdose, are presented.     

Medical futility: its meaning and ethical implications

The notion of medical futility has quantitative and qualitative roots that offer a practical approach to its definition and application. Applying these traditions to contemporary medical practice, we propose that when physicians conclude (either through personal experience, experiences shared with colleagues, or consideration of published empiric data) that in the last 100 cases a medical treatment has been useless, they should regard that treatment as futile. If a treatment merely preserves permanent unconsciousness or cannot end dependence on intensive medical care, the treatment should be considered futile. Unlike decision analysis, which defines the expected gain from a treatment by the joint product of probability of success and utility of outcome, our definition of futility treats probability and utility as independent thresholds. Futility should be distinguished from such concepts as theoretical impossibility, such expressions as "uncommon" or "rare," and emotional terms like "hopelessness." In judging futility, physicians must distinguish between an effect, which is limited to some part of the patient's body, and a benefit, which appreciably improves the person as a whole. Treatment that fails to provide the latter, whether or not it achieves the former, is "futile". Although exceptions and cautions should be borne in mind, we submit that physicians can judge a treatment to be futile and are entitled to withhold a procedure on this basis. In these cases, physicians should act in concert with other health care professionals, but need not obtain consent from patients or family members.     

Sex differences in the heritability of alcohol problems

Genetic factors may have a role in defining more coherent clinical phenotypes and subtypes in the DSM-V. Research has demonstrated that there are gender differences in the patterns of alcohol consumption, specific symptom endorsement, withdrawal effects, and rates of alcohol use disorders (AUD). We examined the sex-specific heritability of diagnostic symptoms for alcohol-related problems in a community-based sample of twin pairs (males: n = 519; females: n = 613) using a biometrical analytic strategy to estimate the genetic and environmental components of AUD symptoms. Five of the seven symptoms of alcohol problems demonstrated sex-differences in heritability. Three of the seven symptoms examined had significant heritability in female twins only: "increased risk of injury or harm," "emotional problems related to drinking," and "the desire to drink." In males, a different pattern was observed, with four of the seven examined symptoms demonstrating heritability: "Increased chance of injury or harm," "spending more time using alcohol or getting over its effects," "using larger amounts for longer periods of time than intended," and "the need to use more alcohol to get the same effect." These data suggest that alcohol problems in females and males may be etiologically distinct, and that diagnostic criteria and therapeutics might be enhanced if these sex differences were taken into consideration.     

Systemic rheumatoid vasculitis: a review

OBJECTIVES: To review the most recent information on the incidence, clinical course, pathology, pathogenesis, diagnosis, and treatment of rheumatoid vasculitis (RV), including the still scanty data on the use of biologics. METHODS: PubMed and MEDLINE databases (1950-2006) were searched for the key words "vasculitis" and "rheumatoid arthritis"; and "rheumatoid arthritis" and "extra-articular manifestations." All relevant articles in English and French were reviewed. Additional words used in follow-up research include "anti-TNF," "rituximab," "IL-1 receptor antagonists," and "CTLA-4 Ig," all in conjunction with "vasculitis." Pertinent secondary references were also retrieved. RESULTS: RV is an inflammatory condition of the small- and medium-sized vessels that affects a subset of patients with established rheumatoid arthritis (RA) (approximately 1 to approximately 5%). It has a vast array of clinical manifestations with a predilection for the skin (peripheral gangrene, deep cutaneous ulcers) and the peripheral nervous system (mononeuritis multiplex). Because of the lack of specific signs and symptoms, the diagnosis relies on the exclusion of other causes of similar lesions (diabetes, atherosclerosis, drug reactions, infection, neoplasias) and, ideally, on the histopathological demonstration of necrotizing vasculitis. Despite the availability of a host of promising new drugs for the treatment of RA, no clinical trials have tested their efficacy in RV; therefore, its management remains largely empirical. CONCLUSIONS: Although RV has apparently been decreasing over the last 2 decades, possibly as a consequence of the more energetic approach to the management of RA currently used, it remains an important complication of RA that needs to be promptly recognized and treated.     

Takotsubo cardiomyopathy, or broken-heart syndrome

Takotsubo cardiomyopathy mimics acute coronary syndrome and is accompanied by reversible left ventricular apical ballooning in the absence of angiographically significant coronary artery stenosis. In Japanese, "takotsubo" means "fishing pot for trapping octopus," and the left ventricle of a patient diagnosed with this condition resembles that shape. Takotsubo cardiomyopathy, which is transient and typically precipitated by acute emotional stress, is also known as "stress cardiomyopathy" or "broken-heart syndrome."Herein, we describe the clinical angiographic characteristics of 4 patients who exhibited this syndrome, and we review the existing literature and propose reasons to conduct prospective studies.     

Social support,social disability,and psychological well-being in rheumatoid arthritis

Purpose. Rheumatoid arthritis (RA) is a disease that may lead to social disability. As a consequence, the psychological well-being of RA patients can be strained. Social support is a possible moderator of the relation between social disability and psychological well-being. The focus of the present study is on the main effect versus the buffering effect of social support. Methods. Data on 54 RA patients were gathered by means of a 2-hr interview at the patient's home. Results. Receiving more daily emotional support positively related to greater psychological well-being; whereas problem-oriented emotional support negatively related to some aspects of psychological well-being. People receiving more social companionship turned out to be less depressed. Conclusion. The assumption was confirmed that social support has a major effect on psychological well-being. A buffering effect of social support was not demonstrated.     

Patterns of background factors related to early RA patients’ conceptions of the cause of their disease

The aim of the present study was to identify patterns of background factors related to the early RA patients’ conceptions of the cause of the disease. Conceptions from a qualitative study formed the basis for the stratification of 785 patients from the Swedish EIRA study answering a question about their own thoughts about the cause to RA. Logistic regression analyses were used to explore the associations between patients’ conceptions and relevant background factors: sex, age, civil status, educational level, anti-cyclic citrullinated peptide antibody (anti-CCP) and smoking habits. The results were presented as odds ratios (OR) with 95% confidence intervals (CI). A conception of family-related strain was strongly associated with being young (OR 0.50; 95% CI 0.33–0.78 for age 58–70 vs. 17–46), female (OR 0.38; 95% CI 0.25–0.60 for male vs. female) and having a high level of education (OR 2.15; 95% CI 1.54–3.01 for university degree vs. no degree). A conception of being exposed to climate changes was associated with being male (OR 1.99; 95% CI 1.24–3.22 for male vs. female), having a low level of education (OR 0.33; 95% CI 0.18–0.58 for university degree vs. no degree) and positive Anti-CCP (OR 1.72; 95% CI 1.03–2.87 for positive vs. negative Anti-CCP). Linking patients’ conceptions of the cause of their RA to background factors potentially could create new opportunities for understanding the complexity of the aetiology in RA. Furthermore, this information is important and relevant in the care of patients with early RA.     

Drug abuse, hopelessness, and suicidal behavior.

This study focused on assessing variables which may differentiate suicidal drug abusers from nonabusers. Data from a sample of drug abusing (n = 86) and nonabusing (n = 298) suicide attempters were subjected to a stepwise multiple regression analysis to identify factors related to suicidal intent. The analysis revealed that in our sample of suicide attempters, drug abuse status was not a significant contributor to the severity of suicidal intent. However, it was found that hopelessness accounted for a significant proportion of the variance of intent. The findings suggest that hopelessness among drug abusers, an important determinant of suicidal behavior, presents an important target for therapeutic intervention.     

Environmental factors and the outcome of rheumatoid arthritis

The outcome of rheumatoid arthritis (RA) is influenced by both genetic and non-genetic (environmental) factors. Treatment is the most important environmental factor which influences RA outcome. This chapter considers non-treatment environmental influences on the outcome of RA. There is evidence that socio-economic factors (such as level of formal education and area of residence), smoking, diet and psychological factors may affect the levels of pain and physical disability experienced by RA patients. More work is needed in order to understand the mechanisms underlying these associations. Smoking may also adversely affect radiological outcome in the longer term. It is possible that pregnancy may improve the outcome of RA. Contrary to popular lay opinion, there is no evidence that the weather has any influence on RA.     

Granted, undecided, withdrawn, and refused requests for euthanasia and physician-assisted suicide

BACKGROUND: The aims of this study were to obtain information about the characteristics of requests for euthanasia and physician-assisted suicide (EAS) and to distinguish among different types of situations that can arise between the request and the physician's decision. METHODS: All general practitioners in 18 of the 23 Dutch general practitioner districts received a written questionnaire in which they were asked to describe the most recent request for EAS they received. RESULTS: A total of 3614 general practitioners responded to the questionnaire (response rate, 60%). Of all explicit requests for EAS, 44% resulted in EAS. In the other cases the patient died before the performance (13%) or finalization of the decision making (13%), the patient withdrew the request (13%), or the physician refused the request (12%). Patients' most prominent symptoms were "feeling bad," "tiredness," and "lack of appetite." The most frequently mentioned reasons for requesting EAS were "pointless suffering," "loss of dignity," and "weakness." The patients' situation met the official requirements for accepted practice best in requests that resulted in EAS and least in refused requests. A lesser degree of competence and less unbearable and hopeless suffering had the strongest associations with the refusal of a request. CONCLUSIONS: The complexity of EAS decision making is reflected in the fact that besides granting and refusing a request, 3 other situations could be distinguished. The decisions physicians make, the reasons they have for their decisions, and the way they arrived at their decisions seem to be based on patient evaluations. Physicians report compliance with the official requirements for accepted practice.