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Psychosocial factors and disease outcomes in rheumatoid arthritis Old problems new solutions and a future agenda.

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EDITORIAL
PSYCHOSOCIAL FACTORS AND DISEASE OUTCOMES IN
RHEUMATOID ARTHRITIS: OLD PROBLEMS, NEW SOLUTIONS, AND
A FUTURE AGENDA
LAURENCE A. BRADLEY
The psychosocial dimensions of rheumatoid
arthritis (RA) have received considerable attention
since the mid-1970s. It is now generally accepted that
the psychological state represents an independent
component of health status. It also has been suggested
that psychosocial factors are associated with disease
outcomes such as functional disability and pain. However, progress in defining these relationships has often
been hindered by measurement problems and other
methodologic and conceptual weaknesses.
Peck and colleagues (1) have made an important
contribution to the resolution of some of the measurement difficulties. They used a multi-trait, multi-method
approach to assess the validity of the Health Assessment Questionnaire (HAQ) disability index and Beck
Depression Inventory (BDI). It was found that, although patients’ responses to these instruments were
positively correlated, the HAQ and BDI measure
different constructs. Indeed, the independence of
these instruments was increased when only the items
in the BDI’s “dysphoric mood” component were used
to evaluate depression.
The study by Peck et a1 represents a major
advance in the measurement of functional disability
and depression among RA patients. Nevertheless,
there remain many unresolved issues concerning the
relationships among psychosocial variables and disease outcomes. The following represents a brief summary of several other recent advances that have been
From the Departments of Psychology and Medicine, The
University of Alabama at Birmingham.
Laurence A. Bradley, PhD.
Address reprint requests to Laurence A. Bradley, PhD,
Department of Psychology, The University of Alabama at Birmingham, Birmingham, AL 35294.
Arthritis and Rheumatism, Vol. 32, No. 12 (December 1989)
made in this area and of issues that should be considered by investigators in the fields of rheumatology and
the psychosocial aspects of disease.
Validity of measurement instruments
The contamination of psychosocial measures
with “disease-related’’ items is a serious problem with
many measurement instruments, since many of these
instruments were originally validated with psychiatric
patients. Reports of physical symptoms may reflect
emotional distress among psychiatric patients but may
represent accurate self-descriptions among RA patients. In addition to Peck and coworkers’ study of the
BDI (l), Pincus and colleagues (2) demonstrated that
the relationship between the Minnesota Multiphasic
Personality Inventory Depression scale score and a
patient’s functional disability is spuriously inflated
by the inclusion of items that primarily reflect RA
symptoms.
It also has been recognized that the validity of
self-report measures of pain intensity are compromised by their correlation with depression. My
colleagues and I therefore developed a behavioral
observation method of pain measurement (3) that is
relatively free of the influence of anxiety and depression when patient behavior is recorded on videotape
by a trained technician. However, when the method is
used to make “live” observations of behavior during
patient-doctor interactions, pain behavior is associated with affective distress (4). We have suggested
that, although the videotape procedure is more complex than the live observation method, the former
should be used for research that requires a measure
that is independent of emotional disturbance (e.g.,
clinical intervention trials).
1612
Investigators of the psychosocial aspects of
disease should continue to revise their measurement
instruments in order to improve their validity. Attention should also be directed toward new self-report
measures of psychological processes that have been
validated with medical patient samples, such as the
Millon Behavioral Health Inventory (5). At present,
videotaped recordings of patient behavior appear to be
the best method for measuring pain independent of
affect among RA patients. However, investigators
should begin to examine alternative verbal methods,
such as Gracely’s Descriptor Differential Scale (6)and
the multidimensional scaling techniques described by
Clark and associates (7), for distinguishing between
the sensory and affective dimensions of pain.
Psychosocial predictors of functional
disability
Univariate analyses have demonstrated that
several psychosocial factors are associated with functional disability. However, much confusion currently
exists regarding the relative power of psychosocial,
demographic, and disease activity variables in predicting disability. Investigators recently have used various
forms of stepwise and hierarchical multiple regression
techniques to address this issue. It is important to
note, however, that these regression techniques have
different underlying philosophies and are not equivalent methods. Stepwise regression is an exploratory
procedure that is used to form the best linear combination of predictors within a particular subject sample.
Hierarchical regression is used to test hypotheses
regarding the predictive power of independent variables after controlling for the influence of variables that
have already been entered in the analysis.
Stepwise and hierarchical regression techniques
have tended to produce conflicting results. Stepwise
procedures usually have indicated that psychological
factors, such as denial of emotional distress, are highly
associated with disability (8). However, hierarchical
regression procedures typically have indicated that psychosocial variables, such as cognitive distortions, are
only moderately correlated with disability after controlling for demographic factors and disease activity (9).
The findings produced by hierarchical regression might be due to the role that demographic factors
(i.e., education and socioeconomic status) appear to
play as surrogates for the psychosocial variables that
are associated with functional disability (10). Further-
BRADLEY
more, most of the psychosocial variables examined
thus far have consisted of anxiety, depression, cognitive distortions, and denial. Future analyses should
include more positive variables such as self-efficacy
and coping strategies. Emphasis should be placed on
testing models of functional disability derived from
theory and empirical findings using hierarchical regression or other confirmatory multivariate procedures.
Predictors of psychological adjustment
Social psychologists have begun to use confirmatory multivariate procedures to evaluate the degree
to which cognitive factors predict psychological adaptation to RA. These investigators have tended to find
complex relationships among these cognitive factors,
disability, and psychological well-being. For example,
Blalock and associates (1 1) reported that well-being
was enhanced by satisfaction with one’s functional
ability. Satisfaction, in turn, was dependent on (a)
comparing oneself with persons without RA in establishing functional ability standards and (b) comparing
oneself with other RA patients when experiencing
difficulty in functional ability.
Several investigators have found that patients’
use of negative coping strategies such as catastrophizing (12) and escapist fantasies (13) is associated with
poor psychological status. Recently, Manne and Zautra (14) elegantly demonstrated with path analysis that
female RA patients’ use of escapist fantasies was
influenced by high functional disability, both directly
and indirectly through critical spouse responses. Psychological adjustment was negatively associated with
these escapist fantasies and was positively associated
with information-seeking strategies and attempts to
derive meaning from the illness. These latter strategies
were directly influenced by sympathetic spouse responses.
It is clear that progress is being made in identifying the predictors of psychological adjustment. The
studies described above have tested theory-driven
hypotheses regarding a variety of cognitive variables.
However, it has been difficult to integrate the psychological adjustment studies into the literature on rheumatic disease because the studies have tended to
appear in social and clinical psychology journals that
usually are not read by arthritis health professionals.
This is an unfortunate situation, since these clinically
oriented health professionals would benefit from
greater exposure to the theories and data analysis
methods used by the social psychologists. The work of
EDITORIAL
the latter, in turn, probably would be enriched by
interaction with the arthritis health professionals.
Psychosocial factors and immune parameters
The study of psychoneuroimmunology , or interactions among the nervous, endocrine, and immune
systems, is probably the most controversial area of
rheumatic disease research. Nonetheless, there now is
evidence that immune responses in laboratory animals
may be classical~y conditioned (15) and that the neuropeptjde substance p is involved in the inflammatory
responses of RA patients (16). A recent longitudinal
investigation (17) also concluded that stressful life
events are associated with negative changes in cellular
and humoral immune responses. Similarly, a psychosocial intervention study (18) demonstrated that perceived
levels of ability to manage RA pain are positively correlated with the number of T suppressor cells and negatively associated with helper: suppressor cell ratios at the
end of treatment.
The major problem with the findings reviewed
above is that little is known of their clinical significance. In addition, it has not been possible to identify
the mechanisms that mediate the relationships that
have been found between immune system responses
and perceived self-efficacy or stressful life events.
Nevertheless, psychoneuroimmunology is a fascinating research area that may help us to better understand
the pathophysiology of RA and improve our treatment
methods (15).
Conclusions
It has been difficult to delineate the relationships among psychosocial variables and disease outcomes because of flawed measurement instruments,
the use of inappropriate statistical methods, and a lack
of theoretical models. However, progress is being
made in solving these problems, especially in the areas
of measurement and prediction of psychological adjustment. I anticipate that improvements also will be
made in the prediction of functional disability, particularly as clinically oriented investigators become more
familiar with the theories and statistical methods used
by social psychologists. Psychoneuroimmunology is a
new research area, but it already offers models and
testable hypotheses that may lead to improved pharmacotherapy and behavioral treatment methods.
1613
Despite the optimism regarding the advances
that are being made, researchers of psychosocial issues face a great challenge in making their findings
relevant to those involved in RA patient care. How
can one measure depression and pain in a valid manner
within a busy clinic? What psychosocial variables
should be addressed in interventions aimed at improving psychological well-being or functional disability?
certain immunosuppressive medications be
administered to patients in accordance with classic
conditioning principles? The ultimate value of psychosocial research will depend upon whether these and
similar questions can be addressed successfully in the
future.
REFERENCES
1 . Peck JR, Smith TW, Ward JR, Milano R: Disability and
depression in rheumatoid arthritis: a multi-trait, multimethod investigation. Arthritis Rheum 32: 1100-1 106,
1989
2. Pincus T, Callahan LF, Bradley LA, Vaughn WK,
Wolfe F: Elevated MMPI scores for hypochondriasis,
depression, and hysteria in patients with rheumatoid
arthritis reflect disease rather than psychological status.
Arthritis Rheum 29: 1456-1466, 1986
3. McDaniel LK, Anderson KO, Bradley LA, Young LD,
Turner RA, Agudelo CA, Keefe FJ: Development of an
observation method for assessing pain behavior in rheumatoid arthritis patients. Pain 24: 165-184, 1986
4. Anderson KO, Bradley LA, Turner RA, Agudelo CA,
Pisko EJ, Salley AN: Observation of pain behavior in
rheumatoid arthritis patients during physical examination: relationship to disease activity and psychological
variables. Submitted for publication
5 . Millon T, Green CJ, Meagher RB: Millon Behavioral
Health Inventory. Minneapolis, Interpretive Scoring
Systems, 1982
6. Gracely RH, Kwilosz DM: The Descriptor Differential
Scale: applying psychophysical procedures to clinical
pain assessment. Pain 35279-288, 1988
7. Clark WC, Janal MN, Carroll JD: Multidimensionalpain
requires multidimensional scaling, The Measurement of
Pain. Edited by JD Loeser, CR Chapman. New York,
Raven Press, 1989
8. McFarlane AC, Brooks PM: Determinants of disability
in rheumatoid arthritis. Br J Rheumatol 27:7-14, 1988
9. Smith TW, Peck JR, Milano RA, Ward JR: Cognitive
distortion in rheumatoid arthritis: relation to depression
and disability. J Consult Clin Psycho1 56:412416, 1988
10. Callahan LF, Pincus T: Formal education level as a
significant marker of clinical status in rheumatoid arthritis. Arthritis Rheum 31:1346-1357, 1988
1614
1 1 . Blalock SJ, De Vellis B, De Vellis RF, van H Sauter S:
Self-evaluation processes and adjustment to rheumatoid
arthritis. Arthritis Rheum 31:1245-1251, 1988
12. Keefe FJ, Brown GK, Wallston KA, Caldwell DS:
Coping with rheumatoid arthritis pain: catastrophizing
as a maladaptive strategy. Pain 3751-56, 1989
13. Revenson TA, Felton BJ: Disability and coping as
predictors of psychological adjustment to rheumatoid
arthritis. J Consult Clin Psychol 57:344-348, 1989
14. Manne SL, Zautra AJ: Spouse criticism and support:
their association with coping and psychological adjustment among women with rheumatoid arthritis. J Pers
SOCPsychol 56:608-617, 1989
BRADLEY
15. Ader R, Cohen N: CNS-immune system interactions:
conditioning phenomena. Behav Brain Sci k379-426,
1985
16. Lotz M, Vaughan JH, Carson DA: Effects of neuropeptides on production of inflammatory cytokines by human
monocytes. Science 241:1218-1221, 1988
17. Zautra AJ, Okun MA, Robinson SE, Lee D, Roth SH,
Emmanual J: Life stress and lymphocyte alterations
among patients with rheumatoid arthritis. Health Psychol 8:l-14, 1989
18. O’Leary A, Shorr S, Lorig K, Holman H: A cognitivebehavioral treatment for rheumatoid arthritis. Health
Psychol 7527-544, 1988
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