Relationship between appearance and psychological distress in rheumatic diseases

Prevalence, Severity, and Measures of Anxiety in Rheumatoid Arthritis: A Systematic Review

OBJECTIVE

Many studies have reported high rates of anxiety in adults with rheumatoid arthritis (RA). The aim of this systematic review was to examine those findings and determine the overall prevalence, severity, and commonly used measures of anxiety in individuals with RA.

METHODS

Six databases were searched from January 2000 without restrictions on language/location, study design, or gray literature. All identified studies that examined anxiety prevalence and severity in adults with RA, as assessed with clinical diagnostic interview and/or standardized self-report measures, were considered for inclusion. Quality assessment of included studies was conducted using a modified Newcastle-Ottawa Evaluation Scale, and the findings were synthesized via a narrative approach.

RESULTS

Across the 47 studies (n = 11,085 participants), the sample size ranged from 60 to 1,321 participants with seven studies including healthy controls or groups with other health conditions. The studies were conducted across 23 countries, and anxiety prevalence ranged from 2.4% to 77%, predominantly determined with standardized self-report measures, of which Hospital Anxiety and Depression scale was used most frequently; only eight studies used a clinical diagnostic interview to confirm a specific anxiety diagnosis. Notable associations with anxiety in RA were physical disability, pain, disease activity, depression, and quality of life.

CONCLUSION

The reported prevalence of anxiety in RA varied widely potentially because of use of different self-report measures and cutoff points. Such cutoff points will need to be standardized to clinical thresholds to inform appropriate interventions for anxiety comorbidity in RA.

Process of Maintaining Self in Individuals Living With Systemic Sclerosis: A Grounded Theory Study of American Women

BACKGROUND

People with chronic illnesses may struggle to adapt psychologically to the illness experience and have feelings of identity loss, self-diminishment, and biographical disruption. This may limit people's ability to engage in optimal self-management. Systemic sclerosis is a debilitating, stigmatizing, and life-limiting progressive chronic illness with significant disfiguring effects. Little is known about the identity management process in people with disfiguring and debilitating conditions such as systemic sclerosis.

PURPOSE

The purpose of this study was to generate a grounded theory explicating the process of maintaining a sense of self in people living with systemic sclerosis.

METHODS

Fifteen women with systemic sclerosis were recruited to ensure representation of a range of illness duration and progression. Semi-structured interviews were conducted, transcribed, and analyzed using open, selective, and theoretical coding.

RESULTS

A basic social process of "maintaining self" was generated from the data that explained the women's experience of living with systemic sclerosis and how they tried to hold on to their identity. Three core categories were identified. Adapting to changes are the behaviors that participants struggled through to carry on with their everyday lives. Dismantling of self was a distressing internal process where participants lost their sense of self and purpose. Restoring self was a transformative process that allowed participants to rewrite and rebuild their biographies.

CONCLUSIONS

Findings suggest that the management of identity was important for understanding how people adapt to life with systemic sclerosis. This study can help nurses better understand how to support patients holistically with the management of systemic sclerosis.

What are the predictive factors of body image disturbance in patients with systemic lupus erythematosus? A cross-sectional study in China

OBJECTIVES

Patients with systemic lupus erythematosus (SLE) may experience body image disorders, which can adversely affect their physical and mental health. We aimed to assess the body-image-related quality of life of patients with SLE, explore the influencing factors and determine the potential predictors of body image disturbance (BID) in these patients.

DESIGN

Cross-sectional study.

SETTING

The department of rheumatology and immunology in Nantong.

PARTICIPANTS

A convenience sample of 230 patients with SLE.

INTERVENTIONS

The study survey included an assessment of demographic information and evaluations using the Body Image Disturbance questionnaire (BIDQ), Hospital Anxiety and Depression Scale, Multidimensional Fatigue Inventory-20 and Body Image Quality of Life Inventory (BIQLI).

PRIMARY AND SECONDARY OUTCOME MEASURES

BID scores and their possible predictors. Data were analysed using descriptive statistics, correlational analysis and stepwise multiple linear regression analysis.

RESULTS

The mean BIDQ score and the mean scores for anxiety, depression and fatigue were 23.04 (SD, SD=11.90), 6.94 (SD=4.53), 6.49 (SD=4.51) and 54.21 (SD=11.63), respectively. The mean BIQLI score was 0.31 (SD=16.59). The findings revealed significant correlations with education level, comorbidities, SLE Disease Activity Index (SLEDAI), anxiety, depression, fatigue and BIQLI. Fatigue, depression, presence of comorbidities and SLEDAI were predictors of worsening BID (p<0.05).

CONCLUSION

In our study, the relationship between BIDQ and anxiety, depression, and fatigue was analysed, and predictors of BID were defined. When formulating interventional measures, the patient's condition should be evaluated, and effective interventions should be implemented to improve the patient's body image and ultimately improve the patient's quality of life.

Chinese SLE Treatment and Research Group Registry (CSTAR) XIV: the subjective well-being of patients with systemic lupus erythematosus

Background

Systemic lupus erythematosus (SLE) can significantly influence patients’ quality of life and subjective well-being (SWB), but the relationships between clinical characteristics, SWB, and related psychological factors have been little studied.

Objective

To measure SWB in patients with SLE and examine how major clinical determinants, emotional variables, and related positive factors affect SWB.

Methods

Overall, 1,110 patients with SLE from the Chinese SLE Treatment and Research Group (CSTAR) and 198 age and gender-matched individuals from the general population without self-reported SLE were invited to complete questionnaires of SWB evaluated by the satisfaction with life scale (SWLS), emotional variables assessed by the patient health questionnaire-9 (PHQ-9), and general anxiety disorder-7 (GAD-7) and related positive factors assessed by the self-esteem scale (SES), general self-efficacy scale (GESE), and Connor-Davidson resilience scale (CD-RISC). The multivariate linear regression was used to examine the relationship between clinical manifestations and SWB.

Results

Life satisfaction was significantly lower (p < 0.001) in patients with SLE than in the general population. Active skin involvement (OR = 0.923, 95% CI = 0.868–0.981, p < 0.05) was negatively associated with life satisfaction scores, and age at enrollment (OR = 1.160, 95% CI = 1.092–1.230, p < 0.001) were positively associated with life satisfaction scores in the multivariate regression model. The cumulative organ damage was significantly associated with depression (OR = 1.085, 95% CI = 1.022–1.153, p < 0.01) and the loss of self-esteem (OR = 1.067, 95% CI = 1.004–1.133, p < 0.05).

Conclusion

SWB provides useful insight into the impact of SLE on psychological health and opportunities to improve quality of life and clinical care.

Anxiety and depression prevalence and their risk factors in lupus nephritis patients: A case–control study

Introduction

Anxiety and depression exhibit a high prevalence in systemic lupus erythematosus (SLE) patients, while this issue is seldom explored in lupus nephritis (LN). Hence, the current study aimed to investigate the prevalence of anxiety and depression, and the risk factors for these mental disorders in LN patients.

Methods

Fifty LN patients, 50 non‐LN SLE patients, and 50 health control (HCs) were enrolled. The Hospital Anxiety and Depression Scale (HADS) for anxiety (HADS‐A) score and HADS for depression (HADS‐D) score were evaluated.

Results

HADS‐A score was highest in LN patients (median 7.0, interquartile range [IQR]: 6.0–10.0), followed by non‐LN SLE patients (median 6.0, IQR: 5.0–8.0), and lowest in HCs (median 5.0, IQR: 3.0–7.0) (p < .001). Besides, the anxiety rate was most frequent in LN patients (38.0%), followed by non‐LN SLE patients (28.0%), least common in HCs (12.0%) (p = .011). HADS‐D score was highest in LN patients (median 7.5, IQR: 6.0–11.0), followed by non‐LN SLE patients (median 6.0, IQR: 5.0–8.3), and lowest in HCs (median 4.0, IQR: 2.0–6.3) (p < .001). Similarly, the depression rate was most prevalent in LN patients (50.0%), subsequently the non‐LN SLE patients (30.0%), and rarest in HCs (10.0%) (p < .001). Furthermore, in LN patients, age (p = .009), LN activity index (p = .020), alopecia (p = .023), 24 h proteinuria (p = .044), and C‐reactive protein (p = .049) were independently correlated with higher anxiety risk; meanwhile, age (p = .001) and LN activity index (p = .009) were independently correlated with higher depression risk.

Conclusion

Anxiety and depression are highly prevalent, which link to aging, alopecia, inflammation, and severe renal involvement in LN patients.

Prevalence and biopsychosocial factors associated with depressive symptoms among patients living with systemic lupus erythematosus in clinical settings in urban Thailand

BACKGROUND

Depressive symptoms are globally recognized as a significant mental health problem in patients with chronic disease, particularly those with systemic lupus erythematosus (SLE). The purpose of this study was to estimate the prevalence and examine biopsychosocial factors of depressive symptoms among patients with SLE.

METHODS

This cross-sectional study was conducted among 185 participants diagnosed with SLE and received treatment for at least 3 months, aged 18-59 years attending the outpatient clinic of a university hospital, Bangkok, Thailand. Depressive symptoms were measured by the Thai version of the Patient Health Questionnaire-9. We assessed Demographic data, the Systemic Lupus Erythematosus Activity Index, the Systemic Lupus International Collaborating Clinics Damage Index, Numeric Rating Scale, Fatigue Severity Scale, Body Image Scale, and the ENRICHD Social Support Instrument. Data were collected from March to May 2021. Multivariable logistic regression was used to analyze the data.

RESULTS

The proportion of the participants with depressive symptoms was 43.2%, which 8.1% of those patients presented moderate to severe depressive symptoms. In a multivariable logistic regression model, SLE patients with depressive symptoms were more likely to be severe pain (aOR = 12.11, 95% CI: 1.35, 108.46), fatigue (aOR = 2.36, 95%CI: 1.08, 5.14), taking prednisolone ≥15 mg daily (aOR = 5.75, 95%CI: 1.76, 18.80), low satisfied of body image (aOR = 12.49, 95%CI: 2.23, 69.80), and low social support (aOR = 17.96, 95% CI: 1.86, 173.77). Disease flare, organ damage, and family income sufficiency did not significantly increase the risk of depressive symptoms in patients with SLE.

CONCLUSIONS

The findings highlight depressive symptoms in patients with SLE. Therefore, the health professional should be concerned about the perception of body image, level of social support, fatigue, and pain while treating patients with SLE. Public health screening programs to identify depressive symptoms in patients with SLE are needed. In addition, a high dose of prednisolone should be considered if required, along with monitoring.

A Structural Equation Model of Health-Related Quality of Life in Chinese Patients With Rheumatoid Arthritis

Background: The aim of this study was to examine how body image, Disease Activity Score in 28 joints, the feeling of being anxious, depression, fatigue, quality of sleep, and pain influence the quality of life (QoL) in patients with rheumatoid arthritis (RA). Methods: A multicenter cross-sectional survey with convenience sampling was conducted from March 2019 and December 2019, 603 patients with RA from five hospitals were evaluated using the Body Image Disturbance Questionnaire, Disease Activity Score in 28 joints, Hospital Anxiety and Depression Scale, Fatigue Severity Scale, Pittsburgh Sleep Quality Index, Short Form 36 Health Survey, and Global Pain Scale. The relationship between quality of life and other variables was evaluated by using the structural equation model (SEM). Results: A total of 580 patients were recruited. SEM fitted the data very well with a root mean square error of approximation (RMSEA) of 0.072. Comparative fit index of 0.966, and Tucker-Lewis index of 0.936. The symptoms and the normalized factor load of six variables showed that the normalized factor load of pain was 0.99. Conclusions: The QoL model was used to fit an SEM to systematically verify and analyze the population disease data, biological factors, and the direct and indirect effects of the symptom group on the QoL, and the interactions between the symptoms. Therefore, the diagnosis, treatment and rehabilitation of RA is a long-term, dynamic, and complex practical process. Patients' personal symptoms, needs, and experiences also vary greatly. Comprehensive assessment of patients' symptoms, needs, and experiences, as well as the role of social support cannot be ignored, which can help to meet patients' nursing needs, improve their mood and pain-based symptom management, and ultimately improve patients' QoL.

Psychosomatic Features, Compliance and Complementary Therapies in Rheumatoid Arthritis

This review highlights the issue of psychosomatic conditions in rheumatoid arthritis, paying special attention to new researches and trends in this field. Emerging concepts in all the major parts of the problem are covered consecutively, from the impact of chronic musculoskeletal pain on the emotional state to disease influence over quality of life, socio-psychological, and interpersonal relationships. Chronic pain is closely related to emotional responses and coping ability, with a pronounced positive effect of psychotherapeutic interventions, family and social support on it. Psychosexual disorders, anxiety, depression also commonly coexist with rheumatoid arthritis, leading to further decrease in quality of life, low compliance, and high suicide risk. Influence of psychosomatic conditions on the overall treatment effect is usually underestimated by rheumatologists and general practitioners. Psychosomatic considerations are of great importance for up-to-date management of rheumatoid arthritis, as they strongly influence the quality of life, compliance, and thereby disease outcomes. Two major approaches of psychological rehabilitation exist, both coping with pain through the regulation of emotion and psychotherapeutic intervention, which not only helps patients in coping with the disease, but also aimed at improving the overall adaptation of the patient. It includes techniques of relaxation, cognitive-behavioral therapy, and biofeedback therapy. Current data about the efficacy of the additional correcting therapies for patients with rheumatoid arthritis, both emerging and common ones, are discussed in the review.

Sexual Health and Dysfunction in Patients With Rheumatoid Arthritis: A Cross-sectional Single-Center Study

Introduction

An increased risk of sexual health problems is seen among patients with chronic illnesses. The background is likely to be multifactorial, but it remains poorly understood.

Aim

To investigate the sexual health and functioning of patients with rheumatoid arthritis (RA) and to examine gender differences, general population comparisons, and possible somatic, psychological, and disease-specific determinants.

Methods

A cross-sectional study using a digital questionnaire distributed among 380 patients diagnosed with RA in a Danish university hospital outpatient setting.

Main Outcome Measure

A range of patient-reported outcomes were obtained, including scores from the validated rating scale Changes in Sexual Functioning Questionnaire. Furthermore, individual medical record information was collected.

Results

A total of 329 patients (250 women and 79 men) were included (age range: 25–73 years; mean age: 57.2 years). The Changes in Sexual Functioning Questionnaire scoring indicated an overall sexual dysfunction in 33.8% of men and 58.1% of women.More than one-third (37.6%) of patients felt that RA had made their sex life more complicated, and 32.4% feared that this might someday be the case. In total, 29.2% patients had experienced sexual problems due to their RA treatment. Of the respondents who experienced RA-related fatigue, 46.5% reported that this impacted negatively on their sexual activity. The risk of one or more sexual health adversities was significantly correlated with female gender, older age, moderate or severe depression, moderate to moderately high loneliness, more than 2 comorbidities, and a fatigue score above 75 out of 100 on a visual analogue scale. Compared to the general population, significantly fewer patients with RA considered their sex life important, and significantly fewer patients appraised their current sex life as good or very good. Moreover, significantly more women with RA (32.1%) than women from the general population (15.7%) had not had any sex life during the past year. A vast majority of patients with RA (93.5% of women and 85.5% of men) had not discussed sexual issues with a health-care professional during the last 5 years. Of all, 32.5% would like health-care professionals to address sexual topics in the consultation occasionally.

Conclusion

Sexual dysfunction is highly prevalent in patients with RA, but the problems are not regularly addressed in consultations provided by the rheumatology department.

Bay LT, Graugaard C, Nielsen DS, et al. Sexual Health and Dysfunction in Patients With Rheumatoid Arthritis: A Cross-sectional Single-Center Study. Sex Med 2020;8:615–630.

"Mastering a New Life Situation" - Patients' Preferences of Treatment Outcomes in Early Rheumatoid Arthritis - A Longitudinal Qualitative Study

PURPOSE

To explore patients' preferred treatment outcomes during their first two years with rheumatoid arthritis (RA).

PATIENTS AND METHODS

A qualitative, longitudinal, multicenter study with interviews at two time points was performed in Sweden. Individual interviews were conducted at time point 1 with 31 patients with RA, defined as disease duration of ≤1 year and treatment for 3-7 months. Seven focus group interviews and five individual interviews were conducted at time point 2 with 22 patients 12-20 months after treatment initiation. The interviews were analyzed using the Qualitative Analysis Guide of Leuven. A core category with four related concepts emerged.

RESULTS

The core finding of patient-preferred treatment outcomes was "mastering a new life situation". Patients preferred to experience control of the disease by controlling the symptoms and by experiencing absence of disease. To experience autonomy by regaining former activity level, experiencing independence, and being empowered was another preferred outcome. Patients preferred to regain identity through being able to participate, experience well-being, and regain former self-image. To experience joy in everyday life through vitality and believing in the future was another preferred outcome. Patients' preferences developed over time from the acute phase of controlling the symptoms and wanting to return to the life they lived prior to diagnosis, to a more preventive way of self-management and empowerment to master the new life situation.

CONCLUSION

The patients' preferred treatment outcomes during the first two years with RA were to master their new life situation and changed from a preference to return to a life lived prior disease onset, to a preference of living with quality of life, despite RA. This study increases the understanding of patients' preferred treatment outcomes in the early disease course and can be a foundation for tailoring interventions to be more person-centered and to improve long-term treatment outcomes.

Body image mediates the impact of pain on depressive symptoms in patients with systemic lupus erythematosus

Objective

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease with treatment manifestations that can cause changes in appearance, including skin rashes, alopecia, vitiligo, and scars. SLE has been shown to adversely impact body image outcomes, and previous research has identified that greater disease activity is associated with worse body image outcomes which, in turn, are associated with greater depressive symptoms. For patients with SLE who also experience significant pain, poor body image outcomes may further compromise wellbeing and lead to greater depressive symptoms. The role of pain in body image has not been explored in SLE. Thus, the present study examined whether body image (specifically, body image-related quality of life) serves as a mediator of the relationship between pain and depressive symptoms among patients with SLE.

Methods

Multiple mediation analysis was used to examine the hypothesis that body image-related quality of life mediates the relationship between pain and depressive symptoms in a sample of patients with SLE ( N = 135) from an urban region in Los Angeles, California.

Results

The sample was predominately female (92.6%) with a mean disease duration of approximately 17 years. Approximately one-quarter of the sample had elevated depressive symptoms. Body image-related quality of life was a significant mediator in the relationship between pain and depressive symptoms. The model accounted for 51% of the total variance in depressive symptoms ( R2 = 0.51).

Conclusion

This cross-sectional study suggested that body image-related quality of life may mediate the effects of pain on depressive symptoms among patients with SLE.

Fear Assessment in Inflammatory Rheumatic diseases (FAIR) questionnaire: a cross-cultural adaptation and validation to the Turkish language

In chronic inflammatory rheumatic diseases (CIRD), it is important to understand patients' fears towards their disease in order to improve patient-physician dialog, to raise the quality of care offered, and to optimize treatment adherence. In this study, we aimed to translate the Fear Assessment in Inflammatory Rheumatic diseases (FAIR) questionnaire into Turkish and evaluate its psychometric properties in patients with CIRD. One hundred fifteen patients filled the provided socio-demographic information form, FAIR-Tr questionnaire, Hospital Anxiety and Depression Scale (HADS), and Beck's Hopelessness Scale (BHS). For the analysis of short-term reliability, 50 patients re-filled the FAIR-Tr questionnaire 1 week later. Internal consistency was evaluated with Cronbach's α coefficient and test-retest reliability was evaluated with intraclass correlation coefficients (ICC). Construct validity analysis was investigated based on the correlation with HADS and BHS. All patients found FAIR-Tr easily understandable and acceptable. FAIR-Tr internal consistency (Cronbach's α = 0.93) and test-retest reliability (ICC = 0.91) were excellent. Psychometric validation was proved upon observing high correlation with HADS (Anxiety, r = 0.77; Depression, r = 0.70) and moderate correlation with BHS (r = 0.65). FAIR-Tr is a questionnaire that has excellent internal consistency and test-retest reliability. The successful correlation with HADS and BHS supported its psychometric validity in terms of evaluating the fear in CIRD cases. We think that FAIR-Tr is a specific scale that can help to evaluate the disease- and treatment-related fears of the Turkish patients with CIRD and may be useful in both routine practice and clinical studies.

Understanding the disease burden and unmet needs among patients with cutaneous lupus erythematosus: A qualitative study

Background

Cutaneous lupus erythematosus (CLE) is a rare dermatologic autoimmune disease marked by photosensitive lesions that can vary in appearance depending on the subtype. The extent to which CLE affects a patient’s quality of life (QoL) has not been fully characterized. Focus groups were conducted to explore patients’ perspectives of how CLE has affected their lives and to understand the unmet needs in regards to CLE treatment and care.

Methods

This qualitative study involved three focus groups with a total of 19 patients with CLE. A moderator guide containing open-ended questions was used to assess how CLE affects overall QoL. The focus groups were audio-recorded with notetaking. Data were content-analyzed to identify emergent themes.

Results

Four themes emerged as important to patients with CLE: disease sequelae, social interactions, functioning, and unmet needs. Most patients reported decreased QoL due to signs and symptoms such as dyspigmentation and scarring. Having CLE negatively affected patients’ mental health and personal relationships and led to negative coping strategies, such as recreational drug use. Issues related to body image were also elicited by patients. Patients cited unmet needs including lack of treatments to improve chronic skin lesions of CLE and inadequate patient education on living with CLE.

Conclusions

Providers can look for signs of QoL impairment in patients with CLE by asking questions related to body image, mental health, social isolation, and coping mechanisms. Future QoL measures can include the effect of CLE-specific attributes such as scarring and dyspigmentation to empower patients’ voices in determining therapeutic efficacy in future clinical trials. Findings from our study have added a new understanding of daily experiences that were elicited directly from patients with CLE.

Development of a Rheumatology-specific Patient Concerns Inventory and Its Use in the Rheumatology Outpatient Clinic Setting

Objective.

Successful management of rheumatic conditions involves increasing complexity of care. Delivering this in a holistic way is a growing challenge. The aim of our study was to develop a Patient Concerns Inventory (PCI) and assess it in the rheumatology clinic setting.

Methods.

This observational exploratory study occurred with 2 phases. In phase I, the PCI was developed after a systematic literature search, expert opinion, and 3 patient focus group discussions. In phase II, the PCI was piloted in a general rheumatology clinic.

Results.

Fifty-four patients were assessed in the pre-PCI group and 51 in the post-PCI group. Median (IQR) duration of consultation was 8 min (5–14) without PCI and 15 min (10–20) with PCI. The pre-PCI group raised 335 concerns from 50 patients, median (IQR) of 5 (3–10) per patient, rising post-PCI to 521 concerns, median (IQR) of 9 (5–16) from 51 patients, p = 0.002. Additional concerns predominantly arose from “physical and functional well-being” and “social care and well-being” domains. Most patients rated their experience with their doctor in the consultation as excellent or outstanding across all 11 questions in the questionnaire, both before and after the introduction of the PCI to the clinic setting.

Conclusion.

The PCI is a useful holistic needs assessment tool for rheumatology clinics. Although its use may initially prolong the consultation slightly, patients can raise a significantly higher number of concerns, which does not occur at the expense of patient satisfaction. This may help in identifying areas of unmet needs that previously went unnoticed.

A systematic review of prevalence, disease characteristics and management of systemic lupus erythematosus in Australia: identifying areas of unmet need

BACKGROUND

Few epidemiological studies of systemic lupus erythematosus (SLE) have been conducted in Australia, and current management practice and levels of unmet need in this country are not well characterised.

AIM

To perform a systematic literature review to identify Australia-specific information on SLE, particularly areas of unmet need.

METHODS

MEDLINE, EMBASE and the Cochrane Library were searched (1 January 1990 to 29 November 2013). All articles on prevalence, disease characteristics, management and outcomes of SLE in Australia were included.

RESULTS

There is limited published information on SLE in Australia. Of 24 articles included, 18 described results from observational studies, three were narrative reviews, one was a clinical update, and two were medical education articles. In remote regions, SLE was reported to be more prevalent in Aboriginal Australians than non-Aboriginal Australians; information in urban populations is lacking. Asian Australians may be more affected by SLE than non-Asian Australians. Pregnancy outcomes may also be adversely affected. Many Australians with SLE may experience high levels of unmet need, including delayed diagnosis, ongoing symptoms, flares, depression/anxiety, sleeping difficulty and decreased quality of life. Published guidance on the SLE management in Australia is limited and dated.

CONCLUSIONS

Published information on SLE in Australia is limited, but suggests that ethnicity may affect the prevalence and disease characteristics and that many Australians with SLE have unmet needs. Improvements in diagnosis, treatment and management are needed to alleviate these needs. Up-to-date guidance on the management of SLE would benefit healthcare professionals and patients.

Comparisons of Body Image Perceptions of a Sample of Black and White Women with Rheumatoid Arthritis and Fibromyalgia in the US

OBJECTIVE

To explore the disease-related, body image (BI) perceptions of women diagnosed with, rheumatoid arthritis (RA) and fibromyalgia (FM).

METHODS

A purposive sample of twenty-seven females participated in individual semi-structured phone interviews to elicit BI perceptions relative to pain, activity limitations and coping measures. Sessions were digitally recorded, transcribed verbatim, and content analyzed.

RESULTS

Body image perceptions relative to 5 major themes emerged in the analysis. They focused on Pain, Disease Impact on Physical and Mental Function, Weight, Diseased-Induced Fears and, Coping measures. Pain was a common experience of all participants. Other troubling factors verbalized by participants included dislike and shame of visibly affected body parts, and disease-induced social, psychological and physical limitations. RA participants thought that manifested joint changes, such as swelling and redness, undergirded their prompt diagnosis and receipt of health care. Contrarily, women with fibromyalgia perceived that the lack of visible, disease-related, physical signs led to a discounting of their disease, which led to delayed health care and subsequent frustrations and anger. All but one participant used prayer and meditation as a coping measure.

CONCLUSION

The body image perceptions evidenced by the majority of participants were generally negative and included specific focus on their disease-affected body parts (e.g. joints), mental function, self-identity, health care experiences, activity limitations and overall quality of life. Given the global effect of RA and FM, assessment and integration of findings about the BI perceptions of individuals with FM and RA may help define suitable interdisciplinary strategies for managing these conditions and improving participants' quality of life.

The implications of body-image dissatisfaction among kidney-transplant recipients

The role that body image plays in the psychological adjustment of kidney-transplant recipients is an understudied issue. In the current study, the association between three variables - (a) body-image dissatisfaction, (b) quality of life (QOL), and (c) psychological distress - was investigated. The research participants were 45 kidney-transplant recipients who were under follow-up care at the Transplant Unit of the Tel-Aviv Medical Center (Israel). Body image, psychological distress, and QOL were measured using self-report questionnaires [Body-Image Ideals Questionnaire (BIIQ), Brief Symptoms Inventory (BSI), and SF-12]. Medical and background data were collected from medical and administrative records. The findings indicated an association between higher level of body-image dissatisfaction and a decrease in several quality-of-life dimensions (role emotional, physical pain, general health, and social functioning), and with an increase in psychological distress. These findings highlight the importance of body-image dissatisfaction as a factor that is associated with QOL and psychological distress among kidney-transplant recipients. Body image warrants further attention and should be screened and treated among those who demonstrate high levels of dissatisfaction.

Prevalence and severity of depression and anxiety in patients with systemic lupus erythematosus: An epidemiologic study in Iranian patients

OBJECTIVES

We aimed to evaluate the prevalence of depression and anxiety in patients with systemic lupus erythematosus (SLE) and explore their association with demographic and clinical features.

METHODS

In this cross-sectional study, 166 SLE patients in rheumatology center of Shariati hospital, Tehran University of Medical Sciences were enrolled. SLE disease activity index (SLEDAI) and Beck and Cattell inventories for evaluation of depression and anxiety were completed for each patient.

RESULTS

The mean age of patients was 33.1 ± 11.1 years and 92.2% of them were female. Two patients (1.2%) had only depression (without anxiety), while 36 patients (21.6%) had only anxiety (without depression). Meanwhile, 105 patients (63.3%) had mixed depression-anxiety and 23 patients (13.8%) did not have either depression or anxiety. Mean daily dose of prednisolone and number of administered drugs did not show significant difference between different subgroups of patients. In assessment of clinical and therapeutic items, no significant correlation between severity of depression (P = 0.65) and anxiety (P = 0.36) with daily dose of prednisolone in SLE patients was observed. There was no significant association between SLEDAI and severity of depression or anxiety. Occupational status had significant correlation with severity of depression and anxiety (P = 0.005).On the contrary, no significant correlation between number of administered drugs and severity of depression and anxiety was present.

CONCLUSION

This study indicated the high prevalence of depression and anxiety among SLE patients and reinforced the need of a comprehensive psychiatric work-up in SLE.

Association between mental health disorders and sexual dysfunction in patients suffering from rheumatic diseases

INTRODUCTION

Sexual functioning may be notoriously affected in patients suffering from rheumatic diseases, yet the extent to which physical and/or psychological factors contribute to sexual dysfunction in this particular group of patients remains underinvestigated.

AIM

This cross-sectional study aimed at investigating whether an association exists between psychological status (anxiety, depression) and sexual dysfunction, independently of other physical factors, in patients with rheumatic disorders.

METHODS

A total of 509 consecutive rheumatologic patients, aged 54.7 ± 14.2 years, 423 female and 86 male, were studied. Female and male sexual function was evaluated with the Female Sexual Dysfunction Index (FSFI) and the International Index of Erectile Function (IIEF) questionnaire, respectively. The Hamilton Anxiety Scale and the Zung Self-Rating Depression Scale were used to detect presence of anxiety and depression, respectively.

MAIN OUTCOME MEASURES

Sexual dysfunction affected 69.9%, anxiety 37.5%, and depression 22% of our patients.

RESULTS

A strong and negative correlation was found between anxiety and both FSFI (r = -0.169, P < 0.001) and IIEF score (r = -0.304, P = 0.004). Similarly, depressive symptomatology was strongly and negatively correlated with both FSFI (r = -0.178, P < 0.001) and IIEF score (r = -0.222, P = 0.04). In the logistic regression analysis, apart from increasing age and female sex, depression (P = 0.027) and anxiety (P = 0.049) were identified as the only predictors of sexual dysfunction, even after adjustment for a variety of physical factors.

CONCLUSIONS

Mental distress and sexual dysfunction are extremely common in rheumatologic patients. Sexual dysfunction is significantly associated with anxiety and depression in both men and women and may be independently predicted by their presence in this group of patients. Physicians dealing with rheumatologic patients should be aware of these results and incorporate screening and treatment of the above comorbidities in the global assessment of their patients, in order to alleviate the disease-emerging mental and physical burden and improve their quality of life.

Alexithymia, mood states and pain experience in systemic lupus erythematosus and rheumatoid arthritis

This prospective study aims to examine alexithymia, mood states and pain experience in systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) patients. We enrolled 49 patients with SLE or RA. All patients were evaluated through a set of questionnaires: (1) the Toronto Alexithymia Scale-20 (TAS), (2) the Profile of Mood States (POMS) and (3) visual analogue scale (VAS) and Questionario Italiano sul Dolore, self-report measures to assess pain intensity. Alexithymia was more prevalent in RA (44 %) than in SLE (37.5 %). The mean values of VAS were significantly higher in RA than in SLE population (p < 0.05). A linear relation between TAS and VAS values has been found in SLE (R = 0.714, p < 0.0001). The mean values of POMS regarding all negative dimensions of mood were higher in SLE than in RA. There was a linear relationship between TAS and POMS values in SLE patients (R = 0.7, p < 0.001). We found a high prevalence of alexithymia in SLE and RA. The chronic pain is influenced by emotional status as documented by a linear relation between TAS and VAS values in SLE patients. The difficulty in reporting emotional responses in these patients seems to be mediated by negative mood states.

Body Image and Self-Esteem in Patients with Rheumatoid Arthritis

INTRODUCTION

The study was conducted in order to investigate the effect of disease-related variables such as socio-demographic characteristics, disease complaints and use of necrosis factor (anti-TNF) on the body image and self-esteem in patients with rheumatoid arthritis.

METHOD

The data was collected by an Introductory Information Form, Body Image Scale (PfP) BIS and the Coopersmith Self-Esteem Inventory (SEI) in 120 patients with rheumatoid arthritis and in 120 healthy controls. One-way analysis of variance, Tukey HDS analysis, t-test, Kruskal-Wallis test, the Mann-Whitney U test, and Pearson's and Spearman's correlation coefficients were used to compare the data.

RESULT

60% of the control group were in the 20-44 year-age group, 75% were women and 30.8% had a bachelor's degree or above, while 60% of patient group were in the 20-44 year-age group, 71.7% were women and 36.7% had a bachelor's degree or higher education level. We observed that the body satisfaction and self-esteem levels were higher in the 20-44 age group, in those with a bachelor's degree or higher education and in the patients who had no additional disease and who did not use anti-TNF. The body satisfaction and self-esteem levels were lower in those who had been receiving treatment for longer than 5 years, who had changes in hands and body, who had gait disturbance and who had changes in family and working life.

CONCLUSION

The assessment of the psychosocial needs with a holistic approach and training programs for body image and self-esteem would be advisable for patients with rheumatoid arthritis who are aged 45-59 years, who have low self-esteem, who have additional diseases, who use anti-TNF, who have changes in hands and body and who have primary-school education.

Depressive symptoms are prevalent in childhood-onset systemic lupus erythematosus (cSLE)

Background

Depressive symptoms are common in adolescence and young adulthood; however, their prevalence in childhood-onset systemic lupus erythematosus (cSLE) is unknown.

Objective

The objective of this study was to examine the prevalence of depressive symptoms and their association with disease characteristics in children, adolescents, and young adults with cSLE.

Methods

A cross-sectional sample of patients with cSLE between 10 to 24 years old completed standardized depression inventories. Demographics and disease characteristics were collected.

Results

Total depression inventory scores reported were below standard cut-off values for depression. However, 26% (10/38) of children and adolescents, and 44% (seven of 16) of young adults had scores at or above established cut-offs for elevated depression symptoms. Physical symptoms of depression were endorsed most frequently. There were no differences in depressive symptoms by disease characteristics including disease duration, health-related quality of life inventory scores, antiphospholipid antibody status, and a history of renal involvement or neuropsychiatric SLE (NPSLE). However, two patients had a history of depression as an NPSLE manifestation of their SLE. In the children and adolescents, prednisone dose was associated with negative self-esteem ( r = 0.37, p = 0.04) and somatic depressive symptoms ( r = 0.39, p = 0.02), but we did not observe a significant association in the young adults.

Conclusion

Depressive symptoms in cSLE are frequent, although similar to the high prevalence rates in the general population. Physical symptoms are most frequently endorsed. Further study will determine if serial evaluations are recommended for early detection in this at-risk population.

The impact of appearance concerns on depression and anxiety in rheumatoid arthritis

OBJECTIVES

Increased levels of anxiety and depression are commonly reported by patients with rheumatoid arthritis (RA) in comparison to the general population. Rather than the clinical features of the disease, this difference has been attributed to psychosocial factors. Patients with RA can develop joint swelling and disfigurement as a direct result of the disease, and experience concerns about their altered appearance. This study aimed to identify if appearance-specific issues contribute to our understanding of mood in RA, over and above demographic, functional and generalized psychosocial measures.

METHODS

A total of 89 patients with RA completed a series of psychosocial questionnaires measuring demographics, physical function, general cognitive processes and a number of appearance-specific concepts, to determine the contribution of appearance concerns to mood.

RESULTS

Hierarchical linear regression suggested that living status, optimism, social support and appearance-related social anxiety and avoidance are associated with levels of depression. The relationship between social support and depression was found to be mediated by appearance-related social anxiety and avoidance. Optimism remained the only variable significantly associated with anxiety.

CONCLUSION

These findings confirm the role of optimistic cognitions and a supportive environment in determining the mood of patients with RA and also establishes a possible link between depression and appearance concerns in this population. Interventions targeting social support, optimism and social anxiety and avoidance in relation to appearance are key in the improvement of depression in this patient group.

Body image as a predictor of psychopathology in surgical patients with colorectal disease

OBJECTIVE

This study aimed to test the relevance of a cognitive behavioural model of body image in a prospective study of colorectal surgery patients and to determine if pre-existing body image disturbance influenced psychological adjustment following surgery.

METHODS

Sixty-seven adult consecutive colorectal surgery patients completed measures assessing psychopathology, body image related beliefs and health related quality of life during pre-admission for surgery using a questionnaire battery. Each participant was followed up three months after surgery.

RESULTS

Depression and anxiety were positively correlated with body image disturbance and self evaluation at baseline. Those patients who went on to receive stomas experienced a significant deterioration in their body image that was not observed in those whose surgery did not result in the formation of a stoma. In the regression analysis, body image disturbance was a significant predictor of baseline levels of depression and emotional quality of life. Initial levels of body image disturbance remained a significant predictor of depression and anxiety at follow up assessment after medical variables and baseline levels of depression and anxiety, respectively, had been controlled for.

CONCLUSION

Our findings support the hypothesis that pre-existing vulnerabilities in body image influence emotional adjustment during the recovery phase following surgery. Further research on screening for body image disturbance in surgical patients in order to promote adjustment is warranted.

A brief assessment tool for body image in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) may adversely affect body image in multitude ways. Development and validation of a brief and valid SLE specific body image tool were undertaken. Eleven items were identified on interview of 21 SLE patients for the Body Image Lupus Scale (BILS v1.0). The tool was administered to 70 SLE patients. Based on analysis, feedback, and refinement of items, the final iteration BILS v1.2 with five items was administered to 233 SLE patients along with validated body image measures (Situational Inventory of Body Image Dysphoria and Body Image Quality of Life Inventory) and health-related quality of life measures for a subsample. The BILS scores' had an internal consistency reliability of .94. It correlated with both the referent body image measures, and with health-related quality of life. It differentiated participants by health status and disease activity. Test-retest reliability estimates exceeded .90. These results support the psychometric properties of BILS.

Locus of control and lupus: patients' beliefs, perspectives, and disease activity

Patients with lupus often experience a high degree of psychological symptoms such as anxiety, depression, and mood disorders that can influence their beliefs and perceptions of their illness. The purpose of the study was to examine how a patient's self-reported psychosocial needs (depression and anxiety) and beliefs about how much control they have over their health (health locus of control) influences their perception of disease chronicity and acuity. The study findings were based on a survey of 378 patients self-diagnosed with lupus.

The relationship between body image disturbance and distress in colorectal cancer patients with and without stomas

OBJECTIVE

This study aimed to investigate the effect of having a stoma on body image in patients with colorectal cancer and to determine whether disturbances in body image predicted distress.

METHODS

A prospective analysis of 79 colorectal cancer patients. Patients were assessed within 9 weeks of surgery and followed up at the end of adjuvant treatment. Body image disturbance, depressive symptoms, anxiety, and general distress were measured at baseline and follow-up.

RESULTS

Patients who received stomas had poorer body image, which worsened over time. Although there were no differences between stoma groups on anxiety or depressive symptoms, those with a late stoma were most depressed. Body image was a strong predictor of initial levels of anxiety, depression, and distress and subsequent anxiety and distress.

CONCLUSIONS

These results confirm that stomas negatively impact on the body image of patients with colorectal cancer. Importantly, those whose body image is most disturbed are at risk for experiencing more anxiety and depression. These results underscore the importance of assessing and treating body image disturbance in colorectal patients who receive a stoma.

Psychosocial dimensions of SLE: implications for the health care team

Background:

The purpose of this exploratory study was threefold, ie, to clarify the unique psychosocial challenges facing those living with systemic lupus erythematosus (SLE), to distinguish which sociodemographic variables impact the lives of SLE patients, and generate knowledge regarding the way patients perceive SLE medication regimens.

Methods:

This was a cross-sectional exploratory study in 378 patients diagnosed with SLE and receiving services from the SLE Lupus Foundation in New York City. In addition to sociodemographic variables, the instrument used consisted of two scales, ie, the Systemic Lupus Erythematosus Needs Questionnaire (SLENQ) and the Multidimensional Health Locus of Control Scale, as well as questions regarding subjective perceptions of side effects from SLE medication.

Results:

The highest general cause of self-reported depressive and anxious feelings was changes in appearance due to SLE, and limitations in physical abilities due to SLE (primarily from muscle and joint pain). The higher the sense of control over SLE, the less likely respondents were to report feeling depressed and anxious. African-American and Hispanic SLE patients reported a higher level of unmet psychological needs due to SLE than did their other ethnic counterparts. Weight gain and hair loss were the most likely medication side effects and also the most likely causes of SLE-related depression and anxiety.

Conclusion:

Those living with SLE are at risk for feelings of depression and anxiety. African-American and Hispanic women are at higher risk for these emotional states. Comprehensive assessment across the disciplines should screen this group of patients for depression and anxiety, and be prepared to refer them to patient education and social work counseling as indicated.

'If I didn't have RA I wouldn't give them house room': the relationship between RA, footwear and clothing choices

OBJECTIVES

The aim of this study was to develop a greater understanding of the impact of RA on women's self-image and self-presentation via an exploration of their clothing choices.

METHODS

Located within a qualitative symbolic interactionist approach, 15 women with RA (age range 38-74 years, disease duration 1-47 years) each participated in two interviews. The first explored the impact of RA on their feelings about their bodies and their appearance; the second explored the factors that informed their clothing choices and the way they presented themselves. All interviews were digitally recorded and transcribed verbatim, digital photographs of the women's clothes and shoes were taken. Data were analysed jointly by both authors using thematic network analysis.

RESULTS

Shoes were identified as greatly influencing the women's clothing choices and how they presented themselves. Three themes were identified that explored the structural and symptomatic impact of RA on the women's feet, the strategies they had developed to resolve their footwear needs outside of prescription footwear and the significant impact that footwear had on their clothing choices and self-presentation. Insights from these data highlight the polarity that exists between the clinical, functional attitudes towards shoes and their social status.

CONCLUSION

While aesthetic issues challenge the acceptability of prescription footwear, problems also exist with the functionality and comfort of footwear available on high streets. A more collaborative approach to the design of footwear is required for both prescription and mainstream footwear to meet the needs of women with RA.

Pitfalls and opportunities in measuring patient outcomes in lupus

Health outcomes and their measures used as end points in systemic lupus erythematosus (SLE) patient care and clinical trials have been varied and are still evolving. Although significant reductions in morbidity and mortality in SLE have been achieved, the medications approved for SLE have remained the same during the past 50 years. Despite the pressing need, aggressive advocacy in the community, and advances in drug development and testing in SLE, no medications have met US Food and Drug Administration guidelines for a new indication claim approval for SLE. This may be attributable to its multisystemic, remitting, and relapsing nature, and difficulty in identifying useful end points and appropriate tools to measure them. Thus, it is pivotal to identify and validate appropriate global, disease-specific, and perhaps organ-specific health outcomes for clinical research. This article reviews recent physician- and patient-generated health outcomes in SLE.

Body image in patients with rheumatoid arthritis

We investigated body image in patients with rheumatoid arthritis (RA), correlating it with self-esteem, function, and quality of life. Forty-three RA patients and 39 control individuals from the community between 18 and 70 years of age and paired for gender, age, and body mass index (BMI) were evaluated. Patients were assessed for body image [Body Dysmorphic Disorder Examination (BDDE)], self-esteem (Rosenberg Self-Esteem Scale), function [Health Assessment Questionnaire (HAQ)] and quality of life [Short Form-36 (SF-36)]. The RA group had a mean age of 51.6 years, BMI 26.01, and disease duration 12.2 years. Most participants were categorized in functional class I. The BDDE score of the RA group (51.8) was significantly higher than in the control group (22.6) (p < 0.001). Rosenberg Self-Esteem Scale, HAQ and some SF-36 subscales were worse in the RA group than in the control group. These scores had a direct correlation with body image scores (p < 0.001). Individuals with RA had a worse body image than individuals without this condition. Body image was directly correlated with self-esteem, function, and quality of life.

Body image and self-esteem in somatizing patients

AIM

The aim of the present study was to determine dissatisfaction with body appearance and bodily functions and to assess self-esteem in somatizing patients.

METHODS

Body image and self-esteem were investigated in 128 women; 34 of those had diagnosed somatoform disorders, 50 were breast cancer patients with total mastectomy surgery alone, and 44 were healthy subjects. Body image and self-esteem were assessed using the Body Cathexis Scale and Rosenberg Self-Esteem Scale.

RESULTS

The two clinical groups did not differ from one another (z = -1.832, P = 0.067), but differed from healthy controls in terms of body image (somatizing patients vs healthy controls, z = -3.628, P < 0.001; total mastectomy patients vs healthy controls, z = -3.172, P = 0.002). They also did not differ significantly in terms of self-esteem (z = -0.936, P = 0.349) when depressive symptoms were controlled. No statistically significant difference was observed between total mastectomy patients and healthy controls in terms of self-esteem (z = -1.727, P = 0.084). The lower levels of self-esteem in somatizing patients were largely mediated by depressive symptoms. Depressed and non-depressed somatizing patients differed significantly from healthy controls with respect to their self-esteem and body image.

CONCLUSIONS

Somatizing patients who were dissatisfied with their bodily functions and appearance had lower levels of self-esteem and high comorbidity of depression. In clinical practice it is suggested that clinicians should take into account psychiatric comorbidity, self-esteem, and body image in somatizing patients when planning treatment approaches.

Factor structure of the arthritis body experience scale (ABES) in a U.S. population of people with osteoarthritis (OA), rheumatoid arthritis (RA), fibromyalgia (FM) and other rheumatic conditions

Objective

To examine the psychometric properties of the Arthritis Body Experience Scale (ABES) in a US sample of people with osteoarthritis, rheumatoid arthritis, fibromyalgia and other rheumatic conditions.

Methods

The ABES, with the scoring direction modified, was phone-administered to 937 individuals who self-identified as having one or more arthritis conditions based on a validated, US, national survey assessment tool. Descriptive statistics of demographic variables and factor analysis of scale items were conducted. Scale dimensionality was assessed using principal component analysis (PCA) with oblique rotation. Criteria for assessing factors were eigenvalues > 1, visual assessment of scree plot, and structure and pattern matrices.

Results

The predominantly female (74.2%) and Caucasian (79.9%) sample had a mean age of 61.0 ± 13.1 years, and a mean BMI of 30.2 ± 7.1. Major arthritis conditions reported were rheumatoid arthritis, osteoarthritis and fibromyalgia. A three-factor structure with cronbach alpha values of .84, .85 and .53 was elicited, and accounted for 72% of the variance.

Discussion

Compared to the two-factor structure evidenced by the original ABES scale in a sample of UK adults, the data from this sample evidenced a three-factor structure with higher variance. The third factor’s cronbach alpha of .53 was low and could be improved by the addition of salient questions derived from further qualitative interviews with patients with arthritis and other rheumatic conditions and from current literature findings.

Conclusion

The observed psychometrics indicate the scale usefully assesses body image in populations with arthritis and related conditions. However, further testing and refinement is needed to determine its utility in clinical and other settings.