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Self-evaluation processes and adjustment to rheumatoid arthritis.

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1245
SELF-EVALUATION PROCESSES AND
ADJUSTMENT TO RHEUMATOID ARTHRITIS
SUSAN J. BLALOCK, BRENDA McEVOY DEVELLIS, ROBERT F. DEVELLIS,
and SUZANNE VAN H. SAUTER
In this study we examined whether the impact of
rheumatoid arthritis (RA) on psychological well-being is
mediated by the way patients evaluate their physical
abilities. The primary focus was on patients’ satisfaction
with their physical abilities and the types of comparisons
that patients make between themselves and other people
&e., social comparisons) when evaluating their abilities.
Seventy-fivewomen with RA were interviewed. Findings
indicate that satisfaction with one’s physical abilities
appears to mediate the relationship between physical
and psychological impairment. Furthermore, satisfaction was associated not only with one’s abilities per se,
but also with the types of comparisons patients made
when evaluating their abilities. These findings help
explain differences in the levels of psychological wellbeing noted among individuals with the same degree of
physical impairment.
From the Rehabilitation Program Office, School of Medicine, and the Department of Health Education, School of Public
Health, University of North Carolina at Chapel Hill.
Supported in part by an Arthritis Foundation Health Professions Traineeship, the Research Council of the University of
North Carolina at Chapel Hill, and NIH Multipurpose Arthritis
Center grant 5-P60-AR-30701-06.
Susan J. Blalock, PhD: Assistant Director for Education,
Rehabilitation Program Office, School of Medicine; Brenda McEvoy
deVellis, PhD: Associate Professor, Department of Health Education, School of Public Health; Robert F. deVellis, PhD: Assistant
Director, Rehabilitation Program Office, School of Medicine; Suzanne van H. Sauter, MD: Director, Rehabilitation Program Office,
School of Medicine.
Address reprint requests to Susan J. Blalock, PhD, Rehabilitation Program Office, School of Medicine, University of North
Carolina at Chapel Hill, CB #7200 Trailer 33, Chapel Hill, NC
27599-7200.
Submitted for publication January 26, 1988; accepted in
revised form April 14, 1988.
Arthritis and Rheumatism, Vol. 31, No. 10 (October 1988)
The psychological impact of rheumatoid arthritis (RA) is frequently substantial. For example, patients with RA exhibit more depression (for review,
see ref. 1) and lower self-esteem (2) than do persons in
the general population. These psychological manifestations are believed to result from the experience of
declining physical abilities and chronic pain (3). However, the magnitude of the relationship typically observed between physical and psychological impairment is quite modest (43, suggesting that factors
other than physical health status also influence one’s
ability to adjust to RA.
Although much research has been conducted in
an effort to identify factors that influence adjustment
to RA, with few exceptions, this research has been
atheoretical, and studies have not built upon each
other. Consequently, the mechanism through which
physical impairment may lead to a decreased level of
psychological well-being remains unknown. Moreover, little is known about how to help those who are
having difficulty adjusting to the disease.
The present investigation builds upon theory
and basic research data that suggest that the process of
self-evaluation may mediate the impact of physical
impairment on psychological well-being (6). Both theory and findings from previous research suggest that
individuals often evaluate the same objective events in
very different ways. For example, although two people
may have the same degree of physical impairment, one
person may view that impairment as a minor inconvenience and be completely satisfied with his or her
physical capabilities, whereas the other person may
view it as an insurmountable handicap and be quite
dissatisfied.
Although there have been no systematic studies
BLALOCK ET AL
1246
Ability
/
Satisfaction
With Ability
Psychological
Well-Being
Social
Comparisons
Figure 1. Schematic representation of the theoretical framework
for this study. According to this framework, a rheumatoid arthritis
patient’s level of psychological well-being is influenced by that
patient’s degree of satisfaction with his or her physical abilities, and
this degree of satisfaction is influenced both by the level of the
patient’s abilities and by the social comparisons made by the
patient.
of the processes by which individuals with RA evaluate their physical abilities, findings by Pincus and
colleagues (7) demonstrate that differences in individuals’ feelings of satisfaction with their physical abilities cannot be explained entirely by differences in
those abilities. This is an important observation because satisfaction with one’s abilities may have a more
direct effect on psychological well-being than the
abilities themselves (6). Thus, differences in individuals’ satisfaction with their physical abilities may account, in part, for the differences in levels of psychological well-being that have been noted among
individuals with the same degree of physical impairment.
In this study, we examined one factor, social
comparisons, that may influence satisfaction with
one’s physical abilities. According to theory, individuals often evaluate their abilities by comparing them
with those of other people (8). There is obviously a
wide range of people, some with far greater ability
than others, who might be used for comparison. Theoretically, if individuals choose to compare their abilities with those of others whose abilities are greater
than their own, they will be less satisfied with their
own abilities than if their comparison was with someone of lesser ability (9). Thus, the types of people with
whom individuals choose to compare themselves can
have a significant effect on their feelings of satisfaction. This observation suggests that knowledge of the
types of comparisons individuals make in evaluating
their physical abilities may lead to a better understanding of the variability in adjustment among individuals
with the same degree of physical impairment. Further,
to the extent that the types of comparisons that are
made can be changed, identification of the types of
comparisons that are most adaptive could provide a
mechanism for helping individuals who are having
difficulty adjusting to RA.
According to the conceptual framework guiding
this study (Figure I), satisfaction with one’s abilities is
influenced both by the ability per se, and by the types
of comparisons made in evaluating that ability (6).
Specifically, we expected greater satisfaction to be
associated with greater ability and with comparison
with other RA patients, rather than with persons who
do not have RA. Satisfaction, in turn, was expected to
have a direct effect on psychological well-being.
PATIENTS AND METHODS
Patient population. Criteria for inclusion in the study
were female sex, age 18 or older, diagnosis of probable,
definite, or classic RA according to the American Rheumatism Association criteria (lo), RA duration of 1 year or more,
and illness-related change in the ability to perform at least 1
of the following activities: writing, tying shoes, buttoning,
and openingklosing locks. A total of 147 patients were
identified through the records of a rheumatologist in private
practice. Sixteen patients could not be reached (3 had died,
and 13 had either moved from the area or the forwarding
address was not known). Of the 131 patients contacted, 99
(75.6%) agreed to participate. Thirteen of these patients did
not meet our criteria for inclusion, and 7 other patients were
unable to complete the interview (e.g., due to a hearing
deficit). Thus, interviews with 79 subjects were completed.
Data from 4 of these subjects were excluded from the
analyses because at the time of the interview, the interviewer believed that the subjects did not comprehend the
questions asked.
The study sample therefore consisted of 75 RA
patients, all of whom were women. Sociodemographic characteristics, findings from the Arthritis Impact Measurement
Scales (AIMS) (1 I), mean number of years since diagnosis of
RA, and the percentage of patients who were taking prednisone are presented in Table 1 .
Methods overview. All subjects participated in I
interview session that lasted approximately 60 minutes. The
interviews were conducted between March and June of 1986.
Most of the interviews (93%) were conducted in the subjects’
homes, and the rest were conducted at other locations of the
subjects’ choosing.
Measures included in the interview protocol constituted 2 primary categories: psychological well-being and
predictors of psychological well-being. Measures of physical
disability were included as control variables.
Measures of predictors of psychological well-being. To
limit the length of the interview, predictor variables were
measured in relation to a single ability, that of manual
dexterity. Three predictor variables were assessed: dexterity, satisfaction with dexterity, and social comparison preferences when evaluating one’s dexterity.
Dexterity was defined as self-reported ability to
perform 4 of the activities assessed in the Dexterity Scale of
the AIMS: writing, buttoning, tying shoes, and (unflocking
locks ( I 1-13). We were concerned with the way people
evaluate abilities that have been altered by RA; therefore,
ADJUSTMENT TO RA
only those activities that an individual reported as having
been affected by RA (i.e., illness-affected activities) were
included in that patient’s dexterity index. Although the
number of activities affected by RA varied somewhat among
subjects, most subjects (84%) said that all 4 activities were
affected. To measure dexterity, subjects first were asked
how easily they could perform each of the illness-affected
activities. Responses were recorded on 4-point response
scales, where 1 = “cannot do at all” and 4 = “can do very
easily.” An index then was formed by summing the responses across illness-affected activities and dividing by the
number of activities that were affected. Cronbach’s alpha for
the index was 0.67.
Satisfaction with dexterity was measured by asking
subjects how satisfied they were with their ability to perform
each of the illness-affected activities. Responses were recorded on 5-point response scales, where 1 = “very dissatisfied” and 5 = “very satisfied.” An index was formed, as
before, by averaging across activities. Cronbach’s alpha for
this index was 0.82.
Two social comparison measures, both of which
assessed comparison preferences in relation to evaluating
one’s manual dexterity, were used. Creation of each measure involved a multistage procedure. The first social comparison measure, the desired performance comparison, assessed comparison preferences within the context of
establishing standards for how well one would like to be able
to perform. To arrive at this measure, subjects were told that
people often have ideas about how easily they would like to
be able to perform various activities and that one way these
ideas are formed is by comparisons with other people. A
series of closed-ended questions was then used to determine
the type of person with whom subjects would most likely
compare themselves (e.g., other women, others with RA,
other people their own age, people in general) if they wanted
to get a better idea of how easily they would like to be able
to perform the illness-affected activities. Responses were
categorized as either RA comparisons (i.e., comparisons
with others with RA) (score of 2) or non-RA comparisons
(i.e., comparisons with other types of people or with people
in general) (score of 1).
The second social comparison measure, the performance difficulty comparison, assessed comparison preferences within the context of experiencing performance difficulties. Subjects first were asked the following question:
“When you are having trouble performing these activities
(i.e., the illness-affected activities), how often do you think
about other people with RA?” The question then was
repeated, replacing the last phrase with, “how often do you
think about other people not affected by RA?” Responses to
these 2 questions were recorded on 4-point response scales,
where 1 = “very often” and 4 = “never.” The value for the
frequency of comparison with other RA patients was then
subtracted from the value for the frequency of Comparison
with people who do not have RA. The resulting score ranged
from +3 to -3, with positive values corresponding to more
frequent comparison with other RA patients.
Psychological well-being. Four measures of psychological well-being were used. First, depression was assessed
using the Center for Epidemiological Studies Depression
scale (CES-D) (14-16). This 20-item scale assesses the
1247
Table 1. Characteristics of the 75 patients with rheumatoid
arthritis
Characteristic
Age, years
Married
White
High school education
Employment status
Working full- or part-time
Homemaker
Retired
Disabled
Unemployed
Annual family income <$16,000*
Years since diagnosis
Taking prednisone
Arthritis Impact Measurement Scales
(0-10 scale)
Mobility
Household Activities
Physical Activities
Activities of Daily Living
Percentage of
patients with
characteristic Mean f SD
57.9
* 12.6
14.4
* 10.5
61
99
91
32
32
24
11
1
25
37
1.07 ?
1.40 t6.45 rt
0.90 rt
1.65
1.53
2.32
1.65
* Because of missing data, percentage based on 65 subjects.
frequency with which symptoms of depression were experienced during the preceding week. Cronbach’s alpha for this
scale was 0.90. Use of the CES-D with arthritis patients has
been questioned because of the inclusion of items that may
be influenced by somatic aspects of the disease; therefore,
all analyses involving this scale were made both with the
scale in its original form and with 4 potentially “somatic”
items (i.e., “I could not get going.” “I felt that everything I
did was an effort.” “My sleep was restless.” “I did not feel
like eating; my appetite was poor.”) deleted. The results
obtained with both versions of the scale were comparable;
therefore, only the findings for the analyses using the original
20-item scale are reported.
The second measure of psychological well-being,
self-esteem, was measured using Rosenberg’s 10-item scale
(17). An alpha value of 0.86 was obtained for this scale. Life
satisfaction, the third measure of psychological well-being,
was measured by the Satisfaction with Life scale (18). The
alpha value for this scale was 0.81. The fourth measure in
this category, positive affect, was measured using the General Positive Affect subscale of the 18-item version of the
Mental Health Inventory (19). The alpha value for this scale
was 0.89.
Physical disability. A global measure of physical
disability was created from 4 scales from the AIMS: Physical
Activity, Mobility, Activities of Daily Living, and Household Activities (1 1-13). A principal components factor analysis of these scales revealed that they loaded on a single
factor (factor loadings range 0.62-0.93), which explained
68.6% of the total variance in the scale scores. Consequently, scale scores were standardized and summed to
BLALOCK ET AL
yield a single measure. Higher scores on this measure
correspond to higher levels of physical disability.
Predictor
RESULTS
Social comparison preferences. The two social
comparison measures used in the study were uncorrelated (point-biserial correlation 0.09, P not significant)
and suggest that the comparison preferences of individuals with RA are context-dependent. As shown in
Table 2, when establishing standards for desired performance, 72% of the subjects indicated a preference
for comparison with other persons who were not
affected by RA, whereas 28% showed a preference for
comparison with other RA patients. On the performance difficulty comparison measure, 44% of the
subjects (n = 33) compared themselves with individuals with RA and individuals without RA with equal
frequency. Consequently, their responses were ambiguous with respect to comparison preference. Of the
remaining subjects, whose responses indicated an unequivocal preference for comparison, 62% more frequently compared themselves with other RA patients,
and 38% more frequently compared themselves with
individuals not affected by RA. Thus, whereas responses to the desired performance comparison measure indicated a preponderance of comparisons with
others who were not characterized as having RA,
unequivocal responses to the performance difficulty
comparison measure favored comparisons with persons who have RA. The difference in these patterns of
responses was statistically significant (2 = 36.5, P <
0.005).
Simple correlations were obtained to determine
if either measure of social comparison preference was
related to duration of illness, age, education, dexterity, or the global measure of physical disability. No
significant correlations were observed.
Table 2. Social comparison preferences of patients with rheumdtoid arthritis (RA) when establishing standards for desired performance and when experiencing performance difficulties*
~
~
~
Table 3. Regression of satisfaction with dexterity on dexterity,
social comparison preference measures, and global physical disability in 75 rheumatoid arthritis patients*
Beta
Dexterity
Social comparison preference
Desired performance
Performance difficulty
Global physical disability
Partial r
Partial F
0.46
0.43
16.23f
-0.19
0.21
-0.22
-0.25
0.27
-0.22
4.77$
5.3s
3.609
* Partial r = correlation between individual predictor and satisfaction with dexterity, after controlling for other predictors in the
model. Partial F = F statistic associated with each beta and partial
r. For each partial F, df = 1,70. For overall model, R2 = 0.468,
F(4,70) = 15.40 (P < 0.0001).
t P < o.Ooo1.
t P < 0.05.
P P < 0.10.
Predictors of satisfaction with dexterity. Multiple
regression was used to examine the relationship of
satisfaction with one’s level of dexterity to one’s
dexterity and social comparison preferences; thus,
satisfaction was regressed on the dexterity and the
social comparison measures. In addition, the global
measure of physical disability was included in the
regression model as a control variable. As shown in
Table 3, the strongest predictor of satisfaction was
dexterity. After controlling for functioning, both social
comparison measures were significantly related to
satisfaction. Their relationships, moreover, were in
opposite directions. Greater satisfaction was associated with comparison with others not aEected by RA
when establishing standards for desired performance;
when experiencing performance difficulties, greater
satisfaction was associated with comparison with others who were affected by RA.
Table 4. Correlations between measures of psychological wellbeing and satisfaction with dexterity, dexterity, and global physical disability in patients with rheumatoid arthritis*
Satisfaction
Dexterity
-0.39t
-0.30t
0.27t
0.30t
Physical
disability
~~~
Comparison
preference
Desired
performance
Performance
difficulties t
Others without RA
Other RA patients
54 (72)
21 (28)
16 (38)
26 (62)
* Values are the number of patients (%).
i Individuals who compared themselves with equal frequency to
individuals with and those without RA (n = 33) were excluded from
this analysis because their responses were ambiguous with respect
to comparison preference.
Depression
Self-esteem
Life satisfaction
Positive affect
0.24t
0.36t
0.38t
0.21
0.11
-0.22
-0.263:
-0.03
* All scales are scored so that higher values reflect more of the
attribute described by the variable name (e.g., higher values on the
depression scale reflect greater levels of depression). Correlations
are Pearson product moment correlations.
t P < 0.01.
t P < 0.05.
1249
ADJUSTMENT TO RA
Predictors of psychological well-being. Correlations between the 4 measures of psychological wellbeing and dexterity, satisfaction with dexterity, and
the global measure of physical disability are presented
in Table 4.A multivariate regression was performed to
test our hypothesis that the relationship between physical ability and psychological well-being is mediated by
satisfaction with one’s level of physical ability. The 4
psychological well-being measures were simultaneously regressed on dexterity, satisfaction with dexterity,
and the global measure of physical disability. Wilks’
lambdas were then computed to assess the overall
relationship between each predictor and the composite
criterion variable composed of the 4 measures of
well-being. The overall relationship between satisfaction and the composite criterion variable was significant (Wilks’ lambda = 0.85, multivariate F[4,68] =
2.95, P < 0.03); however, neither dexterity nor the
global measure of physical disability was related to the
criterion variable.
The univariate relationships between satisfaction and each measure of well-being were then examined. After controlling for dexterity and physical disability, greater satisfaction was associated with less
depression ( p = -0.37, partial r = -0.30, P < 0.01),
higher positive affect ( p = 0.44, partial r = 0.35, P <
0.01), and greater satisfaction with life ( p = 0.26,
partial r = 0.22, P < 0.07). However, the relationship
between satisfaction and self-esteem was not significant ( p = 0.10, partial r = 0.08, P not significant).
Because dexterity and the global measure of
physical disability were highly correlated (r = -0.63,
P < O.OOOl), the nonsignificant relationships between
these 2 variables and psychological well-being may
have been due to multicollinearity. To rule out this
possibility, 2 additional multivariate regressions were
performed. In each regression, the 4 measures of
psychological well-being were simultaneously regressed on satisfaction and either dexterity or the
global measure of physical disability. The analyses
yielded results comparable with those described
above, in that, after controlling for satisfaction, neither dexterity nor the global measure of physical
disability was a significant predictor of psychological
well-being.
Finally, to determine whether there was a direct
relationship between social comparisons and psychological well-being, independent of satisfaction with
dexterity, the 4 measures of psychological well-being
were simultaneously regressed on satisfaction with
dexterity and the 2 social comparison measures. After
controlling for satisfaction, neither comparison measure was significantly related to psychological wellbeing.
DISCUSSION
Our findings suggest that the relationship between physical impairment and psychological impairment is mediated by the degree of satisfaction or
dissatisfaction with one’s physical abilities. Even after
controlling for dexterity and a global measure of
physical disability, satisfaction with dexterity was
significantly related to psychological well-being. Conversely, after controlling for satisfaction, there was no
relationship between psychological well-being and either dexterity or the global measure of physical disability.
The observation that satisfaction appears to
mediate the relationship between physical and psychological impairment is important because it suggests
that deterioration in one’s physical capabilities does
not invariably lead to a decreased level of psychological well-being. Rather, decreased well-being appears
to result only when physical impairment first results in
dissatisfaction with one’s physical abilities. Consequently, differences in satisfaction with one’s ability
may account, in part, for the variation in psychological
well-being noted among individuals with the same
degree of physical impairment (20). The question then
becomes: What factors determine how satisfied or
dissatisfied individuals are with their physical abilities?
Not surprisingly, we found that the strongest
predictor of satisfaction with ability (in this case,
dexterity) was self-reported ability. In general, individuals with greater ability were more satisfied. However, satisfaction was also related to the types of social
comparisons individuals made when evaluating their
ability.
With respect to the types of comparisons that
seem to be most adaptive, our findings were surprising. Based on theory (9) and research involving individuals coping with other chronic health problems
(21), we expected comparison with other RA patients
to be associated with greater satisfaction with one’s
own abilities. These types of comparisons should lead
one to recognize that there are others whose condition
is the same as, or worse than, one’s own, which, in
turn, should cause individuals to feel better about their
own situation. We found support for this prediction,
but only when comparison preferences were assessed
1250
within the context of experiencing performance difficulties. In contrast, when establishing standards for
desired performance, comparison with individuals not
affected by RA was associated with greater satisfaction.
One explanation for these findings is that individuals with RA may campare themselves with others
not affected by RA in an effort to minimize the severity
of their condition by focusing on the similarities between themselves and people without RA (8). When
experiencing performance difficulties, however, the
dissimilarities between individuals who have RA and
those who do not have RA are likely to be quite
salient. Consequently, comparisons with individuals
not affected by RA may draw attention to the ways in
which individuals with RA are disadvantaged relative
to those who do not have the illness. Under these
circumstances, comparisons with other RA patients,
particularly those more severely affected, may help
individuals to put their own limitations into perspective.
The finding that satisfaction is related to the
types of social comparisons individuals make is important because patients acquire a great deal of social
comparison information in the process of seeking
medical care. For example, physicians often tell patients how they are doing in comparison with other RA
patients. Unfortunately, at present, little is known
about the effects this type of information may have on
the way people evaluate their own abilities. As more is
learned about the types of social comparisons that are
most adaptive, this knowledge can provide guidance
for physicians and other health care providers concerning the types of social comparison information
they provide to patients.
More research is needed, however, before such
guidance can be provided. First, because our findings
indicate that certain types of comparisons may be
adaptive in one situation but not in another, research
that examines comparison preferences in a variety of
illness-related contexts (e.g., rehabilitation following
surgery) is needed. Second, because our study was
focused exclusively on a single ability (dexterity),
more research is needed to determine if our findings
can be generalized to the way people evaluate other
abilities (e.g., other physical abilities, coping ability).
Ideally, studies using longitudinal designs could help
resolve the causal ambiguity inherent in crosssectional designs such as the one used in this study.
Third, research is needed that examines the
effects of providing individuals with certain types of
BLALOCK ET AL
social comparison information. As Affleck et a1 (22)
noted, although certain types of social comparisons
may be very adaptive when they occur spontaneously,
when these comparisons are provided for us, there
may be a different effect. For example, individuals
may take comfort in recognizing that the RA they have
is not as severe as that of most people with RA, but
may feel that the seriousness of their condition is being
discounted if a physician makes the same observation.
Finally, research that examines the effect of
self-evaluation processes on motivation and behavior
is needed. Theory and basic research suggest that
individuals’ evaluations of their abilities have a major
influence in this area (6). For example, if an individual
is completely satisfied with a low level of performance,
there will be little motivation to try to improve. On the
other hand, extreme dissatisfaction can also suppress
motivation if one sees little hope for improvement.
Thus, the optimal level of satisfaction for maintaining
efforts to improve one’s abilities lies somewhere between these two points. From this perspective, our
finding that satisfaction is associated with the types of
social comparisons individuals make has behavioral
implications. By selecting people not affected by RA
as a performance standard, individuals may motivate
themselves to overcome the limitations imposed by
their illness. By comparing themselves with others
also affected by RA when they are experiencing performance difficulties, they may avoid a sense of hopelessness. This specific account of how social comparisons operate motivationally is, of course, speculative.
However, it suggests mechanisms by which social
comparisons can influence behavior and illustrates
why this is a particularly important area for future
research.
ACKNOWLEDGMENTS
We thank Shirley Rodgers and Drs. Franc A. Barada
and Robert A. Harrell for their cooperation and referral of
the patients for this study. We also thank Drs. John B.
Winfield and Robert S. Sandler for helpful comments on an
earlier draft of the manuscript.
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