Coping with rheumatoid arthritis pain: catastrophizing as a maladaptive strategy

The present study examined catastrophizing in rheumatoid arthritis (RA) patients. Subjects were 223 RA patients who were participants in a longitudinal study. Each patient completed the Catastrophizing scale of the Coping Strategies Questionnaire (CSQ) on 2 occasions separated by 6 months (time 1, time 2). The Catastrophizing scale is designed to measure negative self-statements, castastrophizing thoughts and ideation (sample items = 'I worry all the time about whether it will end,' 'It is awful and I feel that it overwhelms me'). Data analysis revealed that the Catastrophizing scale was internally reliable (alpha = 0.91) and had high test-retest reliability (r = 0.81) over a 6 month period. Correlational analyses revealed that catastrophizing recorded at time 1 was related to pain intensity ratings, functional impairment on the Arthritis Impact Measurement scale (AIMS), and depression at time 2. Predictive findings regarding catastrophizing while modest were obtained after controlling for initial scores on the dependent variables, demographic variables (age, sex, socioeconomic status), duration of pain, and disability support status. Taken together, these findings suggest that catastrophizing is a maladaptive coping strategy in RA patients. Further research is needed to determine whether cognitive-behavioral interventions designed to decrease catastrophizing can reduce pain and improve the physical and psychological functioning of RA patients.     

Development of an observation method for assessing pain behavior in rheumatoid arthritis patients

Four studies examined the reliability and validity of a behavioral observation method for the assessment of pain associated with rheumatoid arthritis (RA). The major purpose of experiment 1 was to evaluate the interobserver reliability of the observation method. Two observers recorded the frequencies of pain behaviors displayed by 20 RA patients. Each of 3 types of reliability estimates indicated that the pain behavior could be reliably observed. The purpose of experiment 2 was to examine the concurrent validity of the observation system by correlating 53 patients' self-reports of pain with the frequencies of their pain behaviors. Significant and positive correlations were found between patients' total pain behavior and 3 self-report measures of pain and functional disability. Furthermore, unlike the self-reports of pain, total pain behavior was only minimally related to self-report of depression. Experiment 3 was performed in order to assess the observation method's construct validity. Naive observers viewed video recordings of 25 RA patients and made global estimates of patients' pain severity and unpleasantness. Highly significant and positive correlations were found between these global estimates and total pain behavior. In experiment 4, the pain behaviors of 11 RA patients were recorded prior to and immediately following cognitive-behavioral treatment for the reduction of RA pain. There was a significant decrease in total pain behavior from pretreatment to posttreatment. The data indicate that the observation method provides a reliable, valid, and relatively objective measure of RA patient pain behavior. Future validation studies of the observation method are discussed.     

Gender-Specific Effects of Depression on Functional Disability in Rheumatoid Arthritis: A Prospective Study

We examined the prospective impact of depression on objective ratings of disability as a function of gender in a sample of persons with rheumatoid arthritis. Forty-two individuals from an outpatient rheumatology clinic completed measures of depression, disability, and pain over the course of 1 year. A physician's assistant completed objective measures of functional disability following a routine physical examination. Results demonstrated a significant main effect for gender on Time 2 objective ratings of disability (after controlling for disease variables and self-report indices of pain and disability), indicating that physician assistants rated female participants as more disabled than male participants. Importantly, the interaction of gender and Time 1 depression contributed significant variance to Time 2 disability. Findings suggest that women, relative to men, may experience greater declines in functional capacity over time, independent of self-perceptions of pain and disability, and that depression plays a significant role in this process. Discussion focuses on treatment considerations for health care teams, with particular focus on women's adjustment of to RA.     

Prevalence of gastroesophageal reflux disease symptoms and related factors in patients with rheumatoid arthritis

Gastroesophageal reflux disease (GERD) is common in patients with many chronic diseases, but has not been well recognized in rheumatoid arthritis (RA). We investigated the prevalence of GERD symptoms in 278 outpatients with RA and their association with such clinical factors as age, sex, height, weight, body mass index, medications drugs, and functional status evaluated by the Modified Health Assessment Questionnaire (MHAQ). GERD symptoms were evaluated by Frequency Scale for the Symptoms of GERD (FSSG). The mean FSSG score for all patients was 5.6, and 82 patients were considered to have GERD symptoms (FSSG score ≥8), thus the overall prevalence of GERD symptoms was 29.5%. MHAQ score and height were significantly higher and lower, respectively, and prednisolone usage was significantly more in the patients with GERD symptoms than those without. These three clinical factors were also significantly associated with GERD symptoms by univariate logistic regression. Multivariate logistic regression analysis demonstrated that MHAQ was the only clinical factor related to GERD symptoms. In conclusion, the prevalence of GERD symptoms in RA patients was high and strongly associated with decreased functional status, suggesting that physicians should pay attention to GERD symptoms in RA management, especially for patients with low functional status.     

Differential effects of age and illness duration on pain-depression and disability-depression relationships in rheumatoid arthritis

We examined the differential effects of age and illness duration on pain—depression and disability—depression relationships in a sample of patients diagnosed with rheumatoid arthritis (RA). Consistent with existing literature, main effect results indicated that shorter illness duration and greater perceived pain and functional disability all related to increased levels of depression. More importantly, multiple regression analyses revealed that illness duration moderated the observed disability—depression relationship. Specifically, perceived functional disability exerted a greater negative impact on levels of depression in patients with relatively shorter illness durations compared to patients with longer illness durations. Neither age nor illness duration moderated the association between pain and depression. In general, our findings suggest that age and illness duration differentially influence pain—depression and disability—depression relationships in RA. We conclude the paper with a discussion of treatment implications of our findings for persons with RA.     

Chronic musculoskeletal pain and functional status in juvenile rheumatoid arthritis: an empirical model

An empirical model is proposed and tested on variables hypothesized to influence functional status in 23 children with juvenile rheumatoid arthritis experiencing chronic musculoskeletal pain. Child psychological adjustment, family psychosocial environment, chronic musculoskeletal pain, and disease activity were entered into multiple regression analyses to statistically predict 4 functional status criterion variables: activities of daily living (ADL), activities involvement, school functioning, and social functioning. Predictor variable relationships were found for all 4 functional status criterion variables, suggesting initial support for this empirical model of functional status in children with juvenile rheumatoid arthritis experiencing chronic musculoskeletal pain.     

Litigation and employment status: effects on patients with chronic pain

In order to study the effects of compensation and litigation, 201 chronic pain patients were selected from a sample of 444: 99 were working, 15 were working and litigating, 53 were receiving Worker's Compensation, and 34 were receiving Worker's Compensation and litigating. Employment (working vs. Worker's Compensation) and litigation status (litigating vs. not litigating) were analyzed in a 2 x 2 factorial design with measures of pain, disability, psychological distress, and selected demographics as dependent variables. Compared to Worker's Compensation patients, working patients reported significantly less disability (down-time, days spent in bed, interference of pain in daily activities) and pain of a longer duration. Compared to litigating patients, non-litigating patients reported less pain (on the McGill Pain Questionnaire) and less disability (stopping activity, interference of pain in daily activities). On two measures of psychological distress (depression, anxiety), there were significant interactions: Worker's Compensation patients who were litigating reported less distress than non-litigants, while working patients who were litigating reported more distress than non-litigants. The results indicate clear differences in self-reports of disability associated with both employment and litigation status. They also suggest that litigation may function as a coping response for patients who are distressed by the adversarial nature of the Worker's Compensation system. Limitations of the study as well as suggestions for further research also are discussed.     

Is Coping Self-Efficacy Related to Psychological Distress in Early and Established Rheumatoid Arthritis Patients?

The study aimed to explore associations between coping self-efficacy and psychological distress in early and established rheumatoid arthritis (RA) patients. Two samples differing in disease duration were collected at outpatient rheumatology clinics in Eastern Slovakia. The first sample consisted of 146 established patients with disease duration of 12 years or more (age?=?58.02 SD?=?10.38 years; disease duration?=?16.08 SD?=?3.60 years; 86 % women) and the second sample consisted of 102 early RA patients with disease duration of 4 years or less (age?=?53.25 SD?=?12.32; disease duration = 2.8 SD?=?1.23 years; 75 % women). The patients underwent a routine rheumatology check and completed questionnaires regarding functional disability, neuroticism and extraversion, coping self-efficacy and psychological distress. The data were analyzed using hierarchical linear regression models. Coping self-efficacy was significantly negatively associated with psychological distress in both samples with the strongest association with anxiety in the early RA group. These associations remained significant after controlling for sociodemographic, disease related and personality variables. Psychological distress was further associated with disease activity, functional disability, neuroticism and extraversion. However, different patterns in respect to anxiety and depression with the duration of RA was observed. Coping self-efficacy accounted for a unique variance in psychological distress even after controlling for the influence of disease activity, functional status and personality traits. The strongest association was observed with anxiety in early RA patients. As a result, management and intervention programs increasing self-efficacy for coping strategies might be beneficial for reducing anxiety and depression especially during the early phase of the disease.     

Physiological and psychological variables related to functional status in chronic obstructive pulmonary disease.

The relationship of selected physiological and psychological variables to functional status in patients with chronic obstructive pulmonary disease (COPD) was investigated in this study. There has been limited exploration of the relative contribution of these variables to the performance of activities of daily living in this population. A convenience sample of 104 outpatients with COPD participated in the study. The independent variables were causal attributions, depressed mood, self-esteem, pulmonary function, and exercise capacity, and the dependent variable was functional status. There was a significant difference in functional status between those who did and those who did not ask the question, "Why me?" (p = .03). In addition, the remaining psychological variables and both physiological variables were significantly correlated with functional status (p less than or equal to .01). To identify the combination of study variables most predictive of functional status a multiple regression analysis was performed. The combined variables of exercise capacity and depression best predicted functional status (p less than .0001). It is concluded that both physiological and psychological factors are important in understanding functional status in this population.     

Relative Contributions of Attributional Style and Arthritis Helplessness to Depression in Rheumatoid Arthritis: A Longitudinal Investigation

We examined the relative efficacy of disease-specific and disease-unrelated appraisals of helplessness in predicting depression in rheumatoid arthritis over the course of 1 year. Forty-two individuals from an outpatient rheumatology clinic completed measures of depression, disease-unrelated causal attributions, arthritis-specific helplessness, pain, and disability. Results revealed that disease-unrelated causal attributions, assessed at Time 1 contributed significant variance to depression assessed at Time 2, after controlling for initial levels of depression and concurrent disease status variables. Arthritis-specific helplessness did not relate to subsequent levels of depression. In general, our findings indicated that causal attributions for disease-unrelated events were more reliable predictors of depression in rheumatoid arthritis than was arthritis-specific helplessness. Discussion of the implications of our findings for future research follows from the results.     

Impact of low back pain on functional limitations, depressed mood and quality of life in patients with rheumatoid arthritis

Low back pain (LBP) and rheumatoid arthritis (RA) are common orthopedic problems, but there is little information on the importance of LBP in RA patients. The aim of this study was to investigate how LBP affects functional limitations, depressed mood, and quality of life in patients with RA. A complex questionnaire was answered by 281 RA patients, including questions about their RA and their experience of LBP. Functional limitations were assessed using the Hannover Activities of Daily Living questionnaire (ADL), depressed mood using the Center for Epidemiological Studies Depression Scale (CES-D) and health-related quality of life using the Short Form 12 health questionnaire (SF-12). The prevalence of LBP in RA patients was 53.4%. RA patients with LBP displayed a significantly higher degree of disability and depression than RA patients without LBP. There were no differences between the two groups with regard to the duration of RA, the number of operations or medication. LBP is an important factor for the physical and psychological behavior of RA patients. Therefore, the onset of LBP should not be overlooked or underestimated.     

Chronifizierende Faktoren bei Patienten mit Schmerzen durch einen lumbalen Bandscheibenvorfall

Using a biopsychosocial model of chronic radicular pain, we conducted a prospective study on the predictability of the therapy outcome in 41 lumbar disc patients from the Department of Neurology, University of Kiel. Before therapy, all patients had an extensive neurological and psychological examination. The criteria for the therapy outcome werepersistent pain and theduration of hospital stay in days. As for the psychological predictors, we examined the amount of depression as a state variable (Beck Depression Inventory BDI), depression as a trait variable (Giessen test), several paincoping modes (Hoppe scale) and the general health locus of control. As somatic predictors, we assessed the duration of pain before treatment, the number of previous operations, motoric paresis and the patient's age. The results indicated that the BDI was the best predictor of persistent pain and of the duration of hospital stay as well. The sensitivity and specificity were more than 90%. Patients with a BDI score >9 remained 8 days longer in the hospital than patients with lower BDI scores. In contrast to this, depression as a personality dimension allowed no correct prediction of patients with persistent pain. Thus, only the situational aspect of a depressive state is a relevant risk factor for chronicity. Overt pain behavior, avoidance behavior and fatalistic control expectations are the best predictors of persistent pain besides the BDI. Patients with persistent pain when discharged from the hospital had significantly more overt pain behavior preoperatively than patients without pain. They admitted that they changed their posture more often; they groaned, grimaced, or rubbed the painful area more often. Thus, these data confirm the operant conditioning theory of Fordyce within a prospective design. Furthermore, patients with strong avoidance behavior in pain situations and with fatalistic health expectations remained 8 to 10 days longer in the hospital. Regarding the somatic factors, only paresis is a significant predictor of these criteria. Patients with clear paresis showed more pain and a longer duration of hospital stay. In general, there was no significant correlation between the organic and psychological predictors, so independent psychological screening and the prospect of psychological interventions are necessary measures to prevent persistent pain in lumbar disc patients.     

Decreasing Pain and Depression in a Health Promotion Program for People With Rheumatoid Arthritis

Purpose: To examine whether a comprehensive health promotion program for rheumatoid arthritis (CHPPRA) could alleviate patients' pain, depression, and functional disability.
Design: A quasi-experimental design, nonequivalent control group pretest-posttest design and a preexperimental design, one-group pretest-posttest design were used. The study was conducted in Korea.
Methods: Outcome variables (pain, depression, and functional disability) and objectives (the practice of pain-management behaviors, regular exercise, and psychosocial coping strategies) were measured in 36 Korean outpatients diagnosed with rheumatoid arthritis (RA). ANOVA/MANOVA and the Wilcoxon signed rank test were used to analyze data.
Findings: Participants in CHPPRA had reduced pain and depression, but did not show improvements in functional disability. In the intervention group, pain management and psychosocial coping skills were significantly improved, but exercise was not significantly altered after participating in CHPPRA.
Conclusions: Although this study was limited in design, the results can be reference data for designing, using, and evaluating programs for people with RA.     

Predictors of pain catastrophizing in women with rheumatoid arthritis

Catastrophizing has been conceptualized as an appraisal, a cognitive distortion, and a coping mechanism in the psychosocial literature. Regardless of its conceptualization, catastrophizing has been associated with negative psychological and physical outcomes in numerous studies, including our intervention study with 90 women with rheumatoid arthritis. Because of catastrophizing's robust relationship with negative outcomes, predictors of catastrophizing as a pain coping behavior were investigated in this sample, using data collected from two points in time before the intervention. Using Lazarus and Folkman's stress and coping theoretical framework to guide the analyses, variables with a proximal relationship to catastrophizing in the framework were examined for significant associations with pain catastrophizing using correlational analyses. Subsequent stepwise regression involving all variables from Time 1 with significant associations resulted in a model that explained 63% of the variance in Time 2 pain catastrophizing scores. The four predictors in this model were dispositional pessimism, passive pain coping, venting (as a pain coping behavior), and arthritis helplessness. Potential clinical implications related to these predictors are also discussed. Knowledge about predictors of catastrophizing may enhance efforts to address this maladaptive pattern through educational and therapeutic approaches.     

Quality of life in rheumatoid arthritis patients

AIM: To study quality of life (QL) in patients with rheumatoid arthritis (RA). MATERIAL AND METHODS: Questionnaire survey (MCA, BIPQ, AIMS, MHAQ) covered 190 RA patients (mean age 47.7 +/- 1.4 years). Many of them were group II invalids. All the patients had slow-progressive polyarthritis, articular and seronegative RA prevailed. Most of the patients had articular and seronegative RA with first-degree activity, x-ray stage II and third-degree deficiency of the articular function. RESULTS: It is shown that RA patients have subnormal quality of life. Its deterioration was related to clinical parameters: duration of the disease and its activity, invalidity, X-ray stage, articular and locomotor functions, psychological status. Hypochondriac, apathical and neurastenic reactions to the disease occurred most frequently. Euphoric reaction to the disease was a positive factor for QL. Changes in social status were essential for QL in RA patients. CONCLUSION: QL is an integral indicator of health status in RA patients. It can be estimated basing on only one questionnaire--AIMS as it includes all the necessary components.     

Social participation in early and established rheumatoid arthritis patients

Purpose: The aim of the study was to examine whether rheumatoid arthritis (RA) patients with different levels of restriction in social participation differ in disease related as well as psychosocial variables and whether a similar pattern can be found among early and established RA patients.

Method: Two samples of RA patients with early (n?=?97; age?=?53?±?12.3 years; disease duration?= 2.8?±?1.2 years; 76% women) and established (n?=?143; age?=?58?±?10.3 years; disease duration?= 16.1?±?3.6 years; 86% women) were collected. The pattern of differences for the patients with different level of participation restriction (no restriction, mild, moderate or high restriction) was explored by the Jonckheere–Terpstra test. Results: Significant differences were found between patients with different levels of social participation restrictions in both samples in pain, fatigue, functional disability, anxiety, depression and mastery. Generally, it was found that patients with higher restrictions experienced more pain and fatigue, more anxiety and depression and reported lower mastery. Similar pattern of differences concerning disease activity and self-esteem was found mainly in the established group. Conclusions: The study shows that the level of perceived restrictions in social participation are highly relevant regarding the disease related variables such as pain, fatigue and functional disability as well as psychological status and personal resources in both early and established RA.

• Implications for Rehabilitation

• Supporting involvement and participation of individuals with rheumatoid arthritis is important for decreasing the impact of RA symptoms on everyday life.

• Recognition and empowerment of individual resources such a mastery and self-esteem of RA patients could be beneficial for overcoming restrictions in participation.

     

Individual differences in the day-to-day variability of pain, fatigue, and well-being in patients with rheumatic disease: associations with psychological variables

This report examines day-to-day variability in rheumatology patients' ratings of pain and related quality-of-life variables as well as predictors of that variability. Data from 2 studies were used. The hypothesis was that greater psychological distress (i.e., depression and anxiety) and poorer coping appraisals (i.e., higher pain catastrophizing and lower self-efficacy) are associated with more variability. Electronic daily diary ratings were collected from 106 patients from a community rheumatology practice across 28 days (study 1) and from 194 osteoarthritis patients across 7 days (study 2). In multilevel modeling analyses, substantial day-to-day variability was evident for all variables in both studies, and individual patients differed considerably and somewhat reliably in the magnitude of their variability. Higher levels of depression significantly predicted greater variability in pain, as well as in happiness and frustration (study 1). Lower self-efficacy was associated with more variability in patients' daily satisfaction with accomplishments and in the quality of their day (study 2). Greater pain catastrophizing and higher depression predicted more variability in interference with social relationships (study 2). Anxiety was not significantly associated with day-to-day variability. The results of these studies suggest that individual differences in the magnitude of symptom fluctuation may play a vital role in understanding patients' adjustment to pain. Future research will be needed to examine the clinical utility of measuring variability in patients' pain and well-being, and to understand whether reducing variability may be an important treatment target.     

The impact of clinical, morphological, psychosocial and work-related factors on the outcome of lumbar discectomy

In a prospective controlled trial on 46 patients undergoing lumbar discectomy, three classes of variables (medical data including MRI-identified morphological abnormalities, general psychological factors and psychosocial aspects of work) were analyzed with regard to their predictive value for the outcome of lumbar disc surgery at 2 year follow-up. Multiple regression analyses were used to identify the best predictor variables of four different outcome measures (i.e. pain relief, reduction of disability in daily activities, return to work and surgical outcome). MRI-identified nerve root compromise and social support from the spouse were independent predictors of pain relief 2 years after surgery (R2 = 0.40, P < 0.01). Return to work 2 years after surgery was best predicted by depression and occupational mental stress (R2 = 0.36, P < 0.001). MRI-identified extent of herniation and depression were significant predictors of a good surgical outcome after lumbar discectomy (R2 = 0.61, P < 0.001). This study has demonstrated that the outcome of discectomy is critically dependent on which outcome variables are selected and that different sorts of predictor variables have a distinct influence on the various outcome variables. Obvious morphological alterations (i.e. disc extrusions, nerve root compromise) proved to be significant predictors of postoperative pain relief and improvement of disability in daily activities justifying a surgical treatment approach in these cases. The most important finding of this study was that return to work was not influenced by any clinical findings or MR-identified morphological alterations, but solely by psychological factors (i.e. depression) and psychological aspects of work (i.e. occupational mental stress).     

Predictors of quality of life in oncology outpatients with pain from bone metastasis

The relationship between pain and quality of life (QOL) in cancer patients is complex due to the number and the diversity of factors that can influence pain and QOL. The aims of this study of oncology outpatients with pain from bone metastasis were: 1) to determine the extent to which pain characteristics (i.e., severity, duration, meaning of pain, and perceived availability and efficacy of pain relief), psychological distress (i.e., depression), physical functioning, social functioning and QOL are intercorrelated, and 2) to determine which of these variables are important predictors of QOL. A total of 157 oncology outpatients completed questionnaires that evaluated pain, QOL, depression, physical functioning, and social functioning at the time of enrollment into a randomized clinical trial that evaluated the effectiveness of a psychoeducational intervention to improve cancer pain management. Pearson product moment correlation coefficients were calculated to examine the relationships among the study variables. A blockwise, hierarchical multiple regression analysis was performed to determine which variables were the most important predictors of QOL. Meaning of pain was significantly correlated with all the other variables, in particular pain intensity and duration. The most important factors that predicted QOL were depression, social functioning, and physical functioning. Depression proved to be the most important predictor of QOL.     

The contribution of pain and depression to self-reported sleep disturbance in patients with rheumatoid arthritis

The objective of this article is to assess the contribution of disease activity, pain, and psychological factors to self-reported sleep disturbance in patients with rheumatoid arthritis (RA), and to evaluate whether depression mediates the effects of pain on sleep disturbance. The sample included 106 patients with confirmed RA who participated in an assessment of their disease activity, pain, psychological functioning, and sleep disturbance during a baseline evaluation prior to participating in a prospective study to help them manage their RA. Self-measures included the Rapid Assessment of Disease Activity in Rheumatology, the SF-36 Pain Scale, the Helplessness and Internality Subscales of the Arthritis Helplessness Index, the Active and Passive Pain Coping Scales of the Pain Management Inventory, the Center for Epidemiological Studies Depression Scale, and the Pittsburgh Sleep Quality Index. Hierarchical multiple regression analysis confirmed that higher income, pain, internality, and depression contributed independently to higher sleep disturbance. A mediational analysis demonstrated that depression acted as a significant mechanism through which pain contributed to sleep disturbance. Cross-sectional findings indicate that pain and depression play significant roles in self-reported sleep disturbance among patients with RA. The data suggest the importance of interventions that target pain and depression to improve sleep in this medical condition.