Daily interpersonal events in pain patients: applying action theory to chronic illness

The mediating effect of social functioning on the relationship between catastrophizing and pain among patients with chronic low back pain

OBJECTIVE

Pain catastrophizing can be characterized as an interpersonal form of coping used to elicit support or empathy from others. Despite intentions of increasing support, catastrophizing can impair social functioning. While considerable work has addressed the relationship between catastrophizing and pain, limited empirical work has examined this relationship within a social context. First, we examined the role of catastrophizing as a potential contributor to group differences (chronic low back pain [cLBP] vs pain-free controls) in social functioning. Then we conducted a follow-up, exploratory analysis to examine the relationships between catastrophizing, social functioning, and pain within the subgroup of participants with cLBP.

METHODS

In this observational study, participants with cLBP (N = 62) and pain-free controls (N = 79) completed validated measures of pain, social functioning, and pain catastrophizing. A mediation analysis was conducted to examine whether catastrophizing mediated group differences (cLBP vs controls) in social functioning. A follow-up, exploratory mediation analysis then tested whether social functioning mediated the association between catastrophizing and pain within the subgroup of cLBP participants.

RESULTS

Participants with cLBP reported higher levels of pain, impaired social functioning, and higher catastrophizing compared to pain-free controls. Catastrophizing partially mediated the group difference in impaired social functioning. Additionally, social functioning mediated the association between higher catastrophizing and greater pain within the subgroup of cLBP participants.

CONCLUSIONS

We showed that impaired social functioning was driving the relationship between higher pain catastrophizing and worse pain among participants with cLBP. Interventions, such as cognitive behavioral therapy, should address catastrophizing in individuals with cLBP, while simultaneously improving social functioning.

Chronic Pain and Affective Experiences Associated with Daily Stressors and Uplifts

People with chronic pain often report greater reactivity to stress than those without pain. This finding is consistent with the kindling hypothesis, which states that continued exposure to stressors only heightens negative affect and dampens positive affect. Yet, people with chronic pain may also respond more positively to enjoyable activities, or uplifts, as well. Chronic pain is related to lower levels of well-being, and the fragility of positive affect model explains how individuals with lower levels of well-being often exhibit stronger, more positive responses to daily uplifts than their less distressed peers. Our study used the National Study of Daily Experiences to assess daily stressors, positive uplifts, and positive and negative affect across eight days among those with and without chronic pain. Participants (nChronicPain=658, nNoPain=1,075) were predominately Non-Hispanic White (91%), 56% female, and averaged 56 years old. Results revealed that people with chronic pain had lower levels of daily positive affect and higher levels of negative affect, yet the two groups did not vary in their stressor-related negative and positive affect. In contrast, having chronic pain was related to a greater increase in positive affect and greater decreases in negative affect on days with positive uplifts. Findings suggest that intervention efforts focusing on uplifts may be particularly helpful for people who report chronic pain.

Introversion and the frequency and intensity of daily uplifts and hassles

OBJECTIVE

There is reason to believe that introversion may relate to different patterns of negative and positive experiences in everyday life ("hassles" and "uplifts"), but there is little evidence for this based on reports made in daily life as events occur. We thus extend the literature by using data from ecological momentary assessments to examine whether introversion is associated with either the frequency or intensity of hassles and uplifts.

METHOD

Participants (N = 242) were community-dwelling adults (63% Black, 24% Hispanic; ages 25-65; 65% women) who completed baseline measures of personality and mental health, followed by reports of hassles and uplifts 5x/day for 14 days. We present associations between introversion and hassles/uplifts both with and without controlling for mood-related factors (neuroticism, recent symptoms of depression, and anxiety).

RESULTS

Introversion was associated with reporting less frequent and less enjoyable uplifts, but not with overall hassle frequency or unpleasantness; exploratory analyses suggest associations with specific types of hassles.

CONCLUSIONS

Our results expand understanding of the role of introversion in everyday experiences, suggesting an overall association between introversion and uplifts (but not hassles, broadly) in daily life. Better understanding of such connections may inform future research to determine mechanisms by which introversion relates to health.

Pain and Fatigue Variability Patterns Distinguish Subgroups of Fibromyalgia Patients

The current study examined between- and within-subject variability in pain-related symptoms as predictors of pain and fatigue, and identified patient subgroups on the basis of symptom variability characteristics. Two hundred fifty-six fibromyalgia (FM) patients completed daily diaries up to a period of 154 days and reported on symptoms of pain intensity, pain unpleasantness, fatigue, anxiety, and depressed mood. Measures of health status, quality of life, and somatic symptoms were obtained at baseline, and hierarchical linear modeling and cluster analyses were used. Significant intra- and interindividual variability in daily FM symptoms was observed. Higher levels of pain were associated with greater fluctuations in pain unpleasantness, fatigue, and depressed mood. Similar effects were observed for fatigue and individual variability in anxiety also emerged as a robust predictor. Three FM subgroups were revealed: low variability in symptoms (cluster 1), high symptom variability (cluster 2), and a mixed variability group characterized by low fluctuation in pain unpleasantness; moderate pain, fatigue, and depressed mood variability; and high anxiety variability (cluster 3). Cluster 3 exhibited lower social functioning and higher levels of pain, compared with cluster 1. These findings support the dynamic nature of FM pain and suggest the presence of FM subgroups on the basis of variation in mood and pain symptomatology.

PERSPECTIVE

FM patients show significant intra- and interindividual variability in pain, mood, and fatigue. Subgroups in mood and pain-related variability emerged, with phenotypic clusters differing across levels of pain intensity and social functioning. Better understanding of the processes affecting pain variability may facilitate targeted treatments for the control of pain.

Fatigue and factors related to fatigue in rheumatoid arthritis: a systematic review

OBJECTIVE

Although patients with rheumatoid arthritis (RA) experience fatigue, little is known about its causes and consequences, and a fully developed theoretical model explaining the experience of fatigue in RA is lacking. Our goal was to systematically review studies in RA that examined factors related to fatigue to gain more insight into its possible causes and consequences.

METHODS

Medline, Web of Science, Scopus, and PsycINFO were searched for relevant studies. All studies with RA samples about the relationship between fatigue and other variables that defined dependent and independent variables and used multivariate statistical methods were preliminarily included. After reviewing 129 full texts, we identified 25 studies on possible causes of fatigue and 17 studies on possible consequences of fatigue.

RESULTS

The studies found possible causes of fatigue in illness-related aspects, physical functioning, cognitive/emotional functioning, and social aspects. Additionally, being a woman was related to higher levels of fatigue. Inflammatory activity showed an unclear relationship with fatigue in RA. Possible consequences of fatigue were also found among illness-related aspects, physical functioning, cognitive/emotional functioning, and social aspects. The strongest evidence for a relationship between fatigue and other variables was found regarding pain, physical functioning, and depression.

CONCLUSION

This review summarizes the current knowledge in the field in order to inform future research on causes and consequences of fatigue in RA. However, the results are based on cross-sectional and longitudinal studies with different designs and different fatigue scales. For a better identification of causal associations between fatigue in RA and related factors, longitudinal prospective designs with adequate fatigue measurements are suggested.

Influence of the structure of mood in the assessment of rheumatoid arthritis through the visual analog scale for pain, HAQ and DAS28

OBJECTIVE

To analyze the effect of the structure of mood over the following assessment tools for rheumatoid arthritis: visual analog scale (VAS) for pain, HAQ and DAS28.

PATIENTS AND METHODS

We studied 86 patients with recent onset rheumatoid arthritis, of which 75.7% were female, with a mean age at disease onset of 55 years. All patients were administered the Spanish version of the PANAS questionnaire that evaluates the components of positive (PA) and negative mood (AN). Patients belonged to the registry of new-onset arthritis in our center so clinical information was available for 282 patients visits. To determine the effect of PA and AN on each of the dependent variables we performed three multivariate linear regression models using generalized linear models through the Stata glm command 10.1.

RESULTS

The mean score for PA and AN in our patients was similar to that described for the healthy Spanish population. The high scores on the subscale of AN were associated with worse scores in both the VAS for pain and the HAQ. By contrast, high scores on PA were associated with better outcomes of disease activity measured by DAS28.

CONCLUSION

The structure of mood may influence the tools we use for evaluating patients with rheumatoid arthritis, so it might be advisable to include the PANAS questionnaire as part of that assessment.

Resilience: a new paradigm for adaptation to chronic pain

Chronic pain is an affliction that affects a large proportion of the general population and is often accompanied by a myriad of negative emotional, cognitive, and physical effects. However, current pain adaptation paradigms do not account for the many chronic pain patients who demonstrate little or no noticeable impairment due to the effects of chronic pain. This paper offers resilience as an integrative perspective that can illuminate the traits and mechanisms underlying the sustainability of a good life and recovery from distress for individuals with chronic pain.

Patients with medically unexplained symptoms and their significant others: illness attributions and behaviors as predictors of patient functioning over time

OBJECTIVE

Previous research suggests that medically unexplained symptoms (MUS) are maintained in an interpersonal context. The current study examined MUS concurrently and prospectively by measuring specific interpersonal predictors of symptom severity and health care use.

METHODS

A total of 127 patients with MUS and their significant others were recruited through primary care offices and assessed with self-report questionnaires and structured interviews about illness attributions, illness behavior and responses, relationship quality, symptom severity, and health care use at baseline and 6-month follow-up.

RESULTS

Illness attributions and interpersonal illness behaviors of patients with MUS were cross-sectionally associated with illness attributions and responses of the patients' significant others. Relationship quality was related to specific illness behaviors and responses. Symptom severity at baseline was predicted by patients' somatic illness attributions. Symptom severity at 6-month follow-up was predicted by somatic illness attributions of patients and withdrawal of patients' significant others at baseline, but these predictors became insignificant when correcting for baseline symptomatology. Health care use at baseline was predicted by a greater amount of coping behavior and higher anxiety scores of patients, and health care use at 6-month follow-up was predicted by more attention-seeking behaviors and health care use of patients at baseline.

CONCLUSION

The results document the interpersonal influences on the maintenance of MUS. The perspective of significant others should be considered for enhancement of psychological approaches to the treatment of patients with MUS.

Clinical action: Introduction to the special section on the action perspective in clinical psychology

Action theory (AT) is an emerging theoretical and empirical paradigm that is based on multiple perspectives. The common denominator of these perspectives is their depiction of the individual as actively shaping his or her interpersonal environment. The purpose of this special section is to evaluate the impact of AT on clinical psychology. To that effect, articles that focus on a broad range of topics, including stress and depression, chronic pain, child and adolescent development, clinical case formulation, psychotherapy for suicidal patients, and public mental health policy in relation to recovery from psychosis have been assembled. Presenting novel conceptualizations and data on the ways in which individuals actively shape their environment, these articles highlight the potential of AT for improving clinical science and practice.