Psychological distress and rheumatic disease

Clinical Features of Lewis-Sumner Syndrome: Can Trauma Precipitate Symptoms?

INTRODUCTION

Lewis-Sumner syndrome (LSS) is a demyelinating peripheral neuropathy described in 1982.

METHODS

We reviewed the charts of nine LSS patients in neurological care for their symptoms, response to different treatment regimens, and pattern of nerve involvement.

RESULTS

One patient had an Adie's pupil. Every patient studied had median nerve involvement. Seven of nine patients required intravenous immunoglobulin (IVIg) therapy and all showed improvement with IVIg. Four of nine patients received oral steroid therapy and had some improvement. Two of nine patients received azathioprine to little effect. Two of nine patients experienced significant trauma while receiving neurological follow-up and their symptoms worsened to a clinically significant degree afterward.

DISCUSSION

We noticed a possible association between trauma and symptom severity in cases of LSS with preexisting neurological follow-up. We hypothesize that physical trauma exacerbates LSS. To our knowledge, this is an unreported phenomenon.

Sweet and Sensitive: Sensory Processing Sensitivity and Type 1 Diabetes

OBJECTIVE

Sensory processing sensitivity (SPS) is a recently proposed construct that refers to a genetically influenced tendency to more strongly and deeply process a variety of information. The aim of the study was to examine whether SPS is associated with an autoimmune disease such as type 1 diabetes (T1D).

RESEARCH DESIGN AND METHODS

Participants were 128 adolescents (62 with T1D and 66 comparisons [without autoimmune disease]) and their parents who completed the Highly Sensitive Person Scale (HSPS) questionnaire, assessing SPS level.

RESULTS

Higher levels of SPS were found in the T1D group than in the comparison group. Furthermore, the frequency of SPS trait was significantly higher in the T1D group than in the comparison group.

CONCLUSIONS

T1D is associated with higher levels of SPS. Hence, there is a need to develop interventions, treatments, and care focused on the needs of T1D patients with SPS temperament, aimed at better treatment adherence. Furthermore, longitudinal research is needed to evaluate whether SPS is a risk factor in the development of T1D.

Long-term physical functioning and its association with somatic comorbidity and comorbid depression in patients with established rheumatoid arthritis: a longitudinal study

OBJECTIVE

To describe long-term physical functioning and its association with somatic comorbidity and comorbid depression in patients with established rheumatoid arthritis (RA).

METHODS

Longitudinal data over a period of 11 years were collected from 882 patients with RA at study inclusion. Patient-reported outcomes were collected in 1997, 1998, 1999, 2002, and 2008. Physical functioning was measured with the Health Assessment Questionnaire and the physical component summary score of the Short Form 36 health survey. Somatic comorbidity was measured by a questionnaire including 12 chronic diseases. Comorbid depression was measured with the Center for Epidemiologic Studies Depression Scale. We distinguished 4 groups of patients based on comorbidity at baseline.

RESULTS

Seventy-two percent of the patients at baseline were women. The mean ± SD age was 59.3 ± 14.8 years and the median disease duration was 5.0 years (interquartile range 2.0-14.0 years). For the total group of patients with RA, physical functioning improved over time. Patients with somatic comorbidity, comorbid depression, or both demonstrated worse physical functioning than patients without comorbidity at all data collection points. Both groups with comorbid depression had the lowest scores. Only patients with both somatic comorbidity and comorbid depression showed significantly less improvement in physical functioning over time.

CONCLUSION

Both somatic comorbidity and comorbid depression were negatively associated with physical functioning during an 11-year followup period. Furthermore, their combination seems to be especially detrimental to physical functioning over time. These results emphasize the need to take somatic comorbidity and comorbid depression into account in the screening and treatment of patients with RA.

The role of psychological distress and personality variables in the disablement process in rheumatoid arthritis

OBJECTIVE

To test whether psychological distress and personality variables mediate or moderate physical health-related quality of life (HRQOL) in rheumatoid arthritis (RA) patients.

METHODS

In 168 RA patients the following self-report instruments were administered: the Health Assessment Questionnaire (HAQ), the General Health Questionnaire (GHQ), the Defence Style Questionnaire (DSQ), the Hostility and Direction of Hostility Questionnaire (HDHQ), and the Sense of Coherence (SOC) scale. A total of 152 patients with several rheumatological disorders [56 with systemic sclerosis (SSc), 56 with systemic lupus erythematosus (SLE) and 40 with Sjögren's syndrome (SS)] served as disease controls. The outcome measure was the physical scale of the World Health Organization Quality of Life Instrument, Short Form (WHOQOL-BREF). We used hierarchical regression to determine whether our data were consistent with the disablement process model.

RESULTS

In RA patients, sense of coherence was associated with physical HRQOL but the relationship was mediated by psychological distress. Self-sacrificing defence style moderated the relationship between pain and physical HRQOL: pain was associated with impaired physical HRQOL only in patients with predominant self-sacrificing defence style. Although psychological distress and personality variables were also associated with physical HRQOL in the disease control group, the moderating effects of personality on physical HRQOL were unique to RA. Thus, in RA, psychological distress, functional disability, and the interaction term between pain and self-sacrificing defence style were independently associated with physical HRQOL.

CONCLUSIONS

In RA patients, psychological distress mediated the association of personality variables with physical HRQOL but personality moderated the effects of pain on physical HRQOL and this could be relevant to psychological interventions.

Psychosocial factors, disease status, and quality of life in patients with rheumatoid arthritis

OBJECTIVE

To explore the interrelationships between the psychosocial and illness factors that determine the disease status of patients with rheumatoid arthritis (RA) and to identify how each factor is associated with quality of life (QOL).

METHODS

The study group comprised 120 RA outpatients who completed a series of health examinations and questionnaires. Disease severity, functional disability, counts of swollen and/or tender joints, duration of RA, frequency of arthritis surgery, and C-reactive protein level were assessed by rheumatologists. Self-report inventories completed by the patients were used to assess perceived degree of pain, fatigue (visual analogue scales), depression (Beck Depression Inventory-II), anxiety (Hospital Anxiety and Depression Scale), and social support (Social Support Questionnaire). Mental and physical components of health-related QOL were evaluated using the Short-Form 36 Health Survey.

RESULTS

After z-transformation of the data, a principal axis factor analysis was conducted. A four-factor structure was identified in which the components reflected psychosocial factors, disease activity, current symptoms, and physical functional status, respectively. There was no significant association between psychosocial factors and disease activity, while the other components were moderately correlated with each other. Multiple regression analysis revealed that physical QOL was determined by current symptoms and physical functions. Mental QOL was determined by psychosocial factors, current symptoms, and physical functions.

CONCLUSION

Disease activity was independent from psychosocial factors and failed to reflect the perceived physical and mental QOL of RA patients. Clinicians should therefore evaluate psychosocial factors, as well as subjective disease status, to improve the QOL of patients with RA.

Reactions to disability in patients with early versus established rheumatoid arthritis

OBJECTIVES

This study examined differences in reactions to disability between early and established rheumatoid arthritis (RA) patients, and whether these reactions were related to age, physical functioning, acceptance of illness, or self-efficacy.

METHODS

Thirty-four patients with early RA (< 2 years since diagnosis) and 84 patients with established RA (> 4 years since diagnosis) completed the Reactions to Impairment and Disability Inventory (RIDI), and measures of anxiety, depression, acceptance of illness, self-efficacy, and physical functioning.

RESULTS

Early RA patients reported greater future denial than established RA patients. Younger patients reported more hostility than older patients. Accepting the illness was uniquely related to less anger and hostility. Higher self-efficacy for pain specifically related to greater shock, while patients with poorer self-efficacy for other symptoms reported worse anxiety, depression, shock, and anger.

CONCLUSIONS

Denial may be a coping strategy in the early stages of RA: anxiety, depression, shock, and anger appear to persist. Longitudinal studies of RA patients from diagnosis are required to plan interventions timed to maximize patient benefit and optimize healthcare resource utilization.

Women with rheumatoid arthritis: Non-vocational activities and quality of life

The aim of this study was to examine a possible relationship between partaking in non-vocational activities and health-related quality of life in women with rheumatoid arthritis (RA). Two questionnaires were completed by 45 women with RA aged from 25 to 80. The MOS Short-Form 36 (SF-36) measured the health-related quality of life and the Interest Checklist measured the amount of non-vocational activities performed. The present study revealed a significant decrease in non-vocational activities by the participants during the last 10 years. Mental health status seemed to be of greater importance than physical function to perform non-vocational activities in daily life. There were indications that a high number of activities performed correlated positively with scores on psychological well-being, and that a low amount of activities performed correlated with the psychological distress scores.

Self-reported arthritis and the menopause

OBJECTIVES

To determine the prevalence of self-reported arthritis in a population-based cohort of mid-aged women and to identify health, social and lifestyle factors associated with self-reported arthritis.

DESIGN

Cross-sectional population-based survey.

METHOD

Data were obtained from a telephone-administered questionnaire of 2001 Australian-born women between 45 and 55 years old and residing in Melbourne. Information was collected on demographics, lifestyle factors and health conditions.

RESULTS

The most commonly reported symptom in this cohort was aches and stiff joints, reported by 51.7% of the women; 34.4% of participants reported they had been diagnosed with arthritis. More postmenopausal women (39%) reported that they were diagnosed with arthritis compared to premenopausal women (27%, p < 0.001). Women who reported arthritis were more likely to be older (odds radio (OR), 1.09; 95% confidence interval (CI), 1.05-1.13), have a higher body mass index (OR, 1.04; CI, 1.02-1.07), be postmenopausal (OR, 1.88; CI, 1.33-2.66), have a higher negative mood (OR, 1.80; CI, 1.13-2.87), and report a decreased interest in sex (OR, 1.58; CI, 1.26-1.97).

CONCLUSIONS

Aches and stiff joints are the most frequently reported symptom of mid-aged women. Reported arthritis is associated with postmenopausal status, age, body mass index, less interest in sex and lowered mood. Further longitudinal research is needed to determine the role of these factors in the development and impact of arthritis.

Fatigue in patients with rheumatoid arthritis: British and Dutch nurses' knowledge, attitudes and management

AIM

This paper is a report of a study conducted to compare the knowledge, attitudes and current management of rheumatoid arthritis-related fatigue in British and Dutch rheumatology nurses.

BACKGROUND

After pain, fatigue is the most important symptom for patients with rheumatoid arthritis, but little is known about the current management of this fatigue by healthcare professionals.

METHODS

A questionnaire was mailed in 2007 to rheumatology nurses who were members of British Health Professionals in Rheumatology (N = 267) and the Dutch Society of Rheumatology Nurses (N = 227). Descriptive statistics, independent samples t-test and Pearson chi-square tests were used for statistical analysis.

RESULTS

A total of 494 nurses returned questionnaires (response rate 48%). In general, their knowledge about rheumatoid arthritis fatigue was in accordance with the literature and all indicated a positive attitude towards assessing and managing rheumatoid arthritis-related fatigue. However, respondents reported contradictory views about managing fatigue. Although they believed that other team members could help patients, they seldom referred patients on to other professionals. Although nurses believed that other advice besides pacing and balance between activity and rest might help, they did not offer this to patients. Despite acknowledging that there is poor communication about fatigue between patients and nurses, respondents reported that it is patients rather than nurses who raise the issue of fatigue in consultations.

CONCLUSION

British and Dutch rheumatology nurses are sympathetic but do not know how to manage rheumatoid arthritis-related fatigue. Strategies to support self-management for this fatigue, and to increase communication between healthcare professionals and patients, should be initiated to help improve patient outcomes for rheumatoid arthritis-related fatigue.

Rheumatologists' knowledge, attitude and current management of fatigue in patients with rheumatoid arthritis (RA)

To describe rheumatologists' knowledge, attitude and current management of fatigue in patients with rheumatoid arthritis (RA), a postal questionnaire was sent to all rheumatologists (N = 204) and trainees (N = 49), members of the Dutch Society of Rheumatology. The overall response rate was 44% (N = 110). In general, rheumatologists' knowledge about RA-related fatigue was in accordance with the literature but they perceive a lack of their own knowledge about aetiology and evidence-based interventions to prevent and treat fatigue. The majority of the rheumatologists believe that fatigue is a multi-disciplinary diagnosis and is preferably managed by the nurse specialist (34%). Assuming that the patient will raise the issue, most of the rheumatologists pay attention to fatigue during the first consultation and less often during follow-up consultations. There is a need for knowledge about causes and treatments for RA-related fatigue to ensure that patient outcomes are improved.

The impact of arthritis on daily life with the patient perspective in focus

BACKGROUND

Rheumatoid arthritis (RA) often has a major impact on many areas of an individuals' life. The unpredictability of the prognosis as well as the day-to-day symptoms make it impossible to plan ahead. The aim of this study was to identify the domains of concern in the early course of RA.

METHODS

Interviews were carried out according to the focus group method. Twenty-three patients with RA, aged between 27 and 67 years and with a disease duration ranging from 1 to 5 years, were included. Four groups were established, the composition of which was based on age, gender and social situation.

RESULTS

Arthritis had a major impact on daily life of the patients, especially on the way they performed activities. It also strongly influenced their mood and social life. The participants tried to cope by 'dosing their activities', 'using new strategies' or to 'stretching their limits'. Their sense of helplessness and uncertainty led to both 'anger' and 'depression'. When activities could no longer be maintained, the role positioning in the family also changed.

CONCLUSION

The results of this study support the view that more psychosocial support is required to encourage the recently diagnosed RA patient in the new situation of having a chronic disease.

Depressive symptoms in early rheumatoid arthritis: a comparative longitudinal study

Our objective was to investigate symptoms of depression in early rheumatoid arthritis (eRA) patients, and follow them longitudinally during a 3-year prospective study of 73 Hungarian and 45 Austrian early rheumatoid arthritis patients. Compared to validated national population data, mild symptoms of depression were detected in Hungarian early rheumatoid arthritis patients, which were independent of corticosteroid use. In the Hungarian subgroup, the Beck Depression Inventory scores were found to be stable during follow-up. Except at the baseline visit, depressive symptoms and functional status, as measured by the Health Assessment Questionnaire, were correlated. Significant differences were detected between Austrian and Hungarian patients despite of their geographical and cultural proximity. The mean depression score was higher in the Hungarian when compared to the Austrian patients. Depression is an important feature of early rheumatoid arthritis. Studies assessing depression in rheumatoid arthritis patients must be based on validated national data of normal population.

Health-related quality of life among self-reported arthritis sufferers: effects of race/ethnicity and residence

OBJECTIVE

We evaluated differences in health-related quality of life (HRQoL) for African Americans and Caucasians with self-reported arthritis residing in rural and urban areas of a southern state.

METHODS

1,191 individuals completed a telephone survey, which included the 12-Item Short Form Health Survey (SF-12). Participants were stratified into groups: African American/rural, Caucasian/rural, African American/urban, and Caucasian/urban. We evaluated differences and associations in HRQoL for the four groups.

RESULTS

Multivariable linear regression models revealed that being an African American rural resident was associated with worse self-reported mental health on the SF-12 even after adjusting for multiple confounding variables. In contrast, multivariable linear regression models revealed that being a Caucasian rural resident was associated with worse physical health SF-12 scores.

CONCLUSIONS

The study revealed differences in HRQoL on the mental and physical health functioning scales of the SF-12 for African American rural and Caucasian rural residents. Researchers assessing HRQoL in arthritis patients should consider using a race/residence product term in their analyses.

Psychological distress and personality traits in early rheumatoid arthritis: a preliminary survey

OBJECTIVES

To investigate psychiatric manifestations, personality traits, and ego mechanisms of defense involved in early rheumatoid arthritis (RA).

METHODS

Twenty-two unselected early RA outpatients with disease duration less than 1 year participated in the study. The majority of participants were females (72.7%), married (81.8%), aged 51.0+/-14.6 years. Thirty-four subjects matched for age, sex and educational level served as "healthy" controls. General Heath Questionnaire, Symptom Distress Checklist, Defense Style Questionnaire and Hostility and Direction of Hostility Questionnaire were used; disease activity was estimated by disease activity for 28-joint indices score.

RESULTS

Seven patients (31.8%) presented psychological distress scores indicative of possible psychiatric caseness, expressing obsessive-compulsive symptoms and depression, as compared to six (17.6%) of controls. Social dysfunction distress and somatization were prominent psychiatric manifestations in early RA group. Early RA patients tend to adopt a less adaptive defense style than controls. Although disease activity was not correlated to psychological distress, a significant association between disease activity and patients' defensive style was observed: as the disease is exacerbated, there was a shift from "non-adaptive" to "immature image distorting or borderline" defense style, suggesting a rather fragile underlying personality structure.

CONCLUSION

Psychological distress is a relatively common experience in early RA. Social dysfunction, along with the less adaptive defense style, which under the stress of the disease exacerbation turns to "borderline", underlines the importance of a careful assessment and consultation in early RA patients in order to face the distress shortly after diagnosis and highlights potential risk factors for future adaptation to exacerbations of the disease.

Psychological stress as a predictor of psychological adjustment and health status in patients with rheumatoid arthritis

This study examined the extent to which perceived stress, social support, coping and clinical disease indicators predict physical, psychological and social adjustment in patients with rheumatoid arthritis (RA). Participants were 59 women recruited at an outpatient clinic at University College Hospital, Galway. A range of psychological measures was administered and disease status was assessed by physician ratings of joint involvement and blood assays of inflammatory indices. Findings from correlational and hierarchical regression analyses revealed a number of statistically significant relationships (p<.01). Perceived stress was a better predictor than disease severity of positive and negative emotionality. Coping explained variability on positive and negative affect. Social support was linked to level of social activity. Results demonstrated that disease status predicted illness related functioning but did not predict emotional or social adjustment. Results suggest that a cognitive behavioural intervention to facilitate patient adjustment could usefully include management of stress and its appraisal, the fostering of adaptive coping strategies and utilization of social support resources. It is concluded that improving patient adjustment to rheumatoid arthritis has implications for medical care seeking.

Clinical assessment of the osteoarthritis patient

It is becoming apparent that the disease process of osteoarthritis should be regarded separately from the clinical syndrome of joint pain, use-related stiffness and disability. The latter may best be approached as a chronic regional pain disorder that requires attention to physical, psychological and social factors as well as those related to the disease process. This chapter sets out to look at some of the practical implications of taking this view for the clinical assessment. Starting with the syndrome of hip, knee or hand pain in older adults in the community, we consider what leads people to consult, what the important features to assess might be, the role of imaging in the clinical assessment of osteoarthritis, and finally how a management plan could be formulated. The usefulness of assessing clinical osteoarthritis as a regional pain disorder is uncertain. Even if this were demonstrated, the concept of osteoarthritis as a structural disease should be retained as an integral part.

Identification of case complexity and increased health care utilization in patients with rheumatoid arthritis

OBJECTIVES

To document biopsychosocial profiles of patients with rheumatoid arthritis (RA) by means of the INTERMED and to correlate the results with conventional methods of disease assessment and health care utilization.

METHODS

Patients with RA (n = 75) were evaluated with the INTERMED, an instrument for assessing case complexity and care needs. Based on their INTERMED scores, patients were compared with regard to severity of illness, functional status, and health care utilization.

RESULTS

In cluster analysis, a 2-cluster solution emerged, with about half of the patients characterized as complex. Complex patients scoring especially high in the psychosocial domain of the INTERMED were disabled significantly more often and took more psychotropic drugs. Although the 2 patient groups did not differ in severity of illness and functional status, complex patients rated their illness as more severe on subjective measures and on most items of the Medical Outcomes Study Short Form 36. Complex patients showed increased health care utilization despite a similar biologic profile.

CONCLUSIONS

The INTERMED identified complex patients with increased health care utilization, provided meaningful and comprehensive patient information, and proved to be easy to implement and advantageous compared with conventional methods of disease assessment. Intervention studies will have to demonstrate whether management strategies based on INTERMED profiles can improve treatment response and outcome of complex patients.