Cognitive-behavioral approaches to pain management in rheumatoid arthritis.

The purpose of this article is to review the literature on the topic of cognitive-behavioral approaches to pain management for persons with rheumatoid arthritis. Existing studies offer support for the usefulness of cognitive-behavioral techniques, but methodologic limitations were identified. Although the core element in rheumatoid arthritis pain management is optimal rheumatologic care, an important role also exists for strategies that seek to reduce the cognitive-evaluative aspects of arthritis pain.

Biopsychosocial parameters of disease activity in rheumatoid arthritis.

The purpose of this study was to examine the applicability of a biopsychosocial model for estimating disease activity in rheumatoid arthritis (RA). Sixty-three patients with RA were evaluated at baseline, 3 months, and 6 months. Joint counts were collected as the measure of disease activity. Peripheral blood immunophenotypic subsets, demographic characteristics, and psychological measures were obtained and entered into hierarchical regression analyses, with the joint count as the dependent variable. Immunophenotypic subsets (that is, CD57+/CD16-, HLA-DR+) were predictive of disease activity at all three time intervals. At baseline and 3 months, psychological variables (that is, helplessness and depression) were significantly related to joint counts, and the full model was highly significant. The conclusion was that the biopsychosocial perspective is useful for estimating RA disease activity.

Relationship of pain behavior to disease activity and health status in rheumatoid arthritis.

The purpose of the study was to investigate the contributions of disease activity, health status, and self-efficacy to the pain behavior exhibited by patients with rheumatoid arthritis. Measures included the Arthritis Impact Measurement Scales, the Arthritis Self-Efficacy Scale, a visual analogue scale for pain, and the McGill Pain Questionnaire. Joint counts and ratings of pain behavior also were obtained. All measures were collected at both baseline and 6 months. Hierarchical multiple regression analyses revealed that disease activity, as measured by joint count, was significantly related to a modified pain behavior index at both time intervals. With joint count entered into the regression model, no other variable consistently increased the predictive accuracy of the model. There were no significant correlations between the modified pain behavior index and either the visual analogue scale for pain or the McGill Pain Questionnaire scores. The results suggest that pain behavior in male rheumatoid arthritis patients is more closely related to disease activity than to self-reported pain, health status, or perceived self-efficacy.

Psychological factors, immunologic activation, and disease activity in rheumatoid arthritis.

The purpose of this study was to use structural equation modeling techniques to examine potential interrelationships among psychological factors, immunologic activation, and disease activity in rheumatoid arthritis (RA). The subjects were 80 male patients with a diagnosis of classic or definite RA. Measures included the Beck Depression Inventory, the Arthritis Helplessness Index, and the Arthritis Impact Measurement Scales (AIMS) pain score. Joint counts and immunophenotypic analyses of peripheral blood lymphocytes also were collected. Path analysis showed that percentage of HLA-DR+ cells in the peripheral blood and helplessness were related to join count. In addition, joint count had an effect upon depression. Depression had an effect upon pain, but there was no reciprocal effect of pain upon depression. This study describes a preliminary path model of interrelationships among psychological factors, immunologic activation, and disease activity in RA.

Risk factors for depression in rheumatoid arthritis.

OBJECTIVE: To identify risk factors for the development of depression in persons with rheumatoid arthritis (RA). METHODS: Subjects were divided into depressed versus nondepressed groups on the basis of the Center for Epidemiologic Studies-Depression Scale; a range of psychological, pain-related, disease-related, and demographic variables were analyzed to predict depression. Both cross-sectional and longitudinal predictive models were examined. RESULTS: A series of analyses, including multiple logistic regression, found that the optimal predictors of depression in RA were average daily stressors, confidence in one's ability to cope, and degree of physical disability. The model was successfully cross-validated on separate data sets (i.e., same subjects at different time points). CONCLUSION: All of the identified risk factors for depression in RA are preventable to some extent and, therefore, should be addressed in comprehensive, rheumatology team care.

A biopsychosocial model of disability in rheumatoid arthritis.

OBJECTIVE: To test and cross-validate a model using disease activity, pain, and helplessness to predict future psychological and physical disability in persons with rheumatoid arthritis (RA) across time. METHODS: Measures of disease activity, pain, helplessness, psychological function, and physical function were collected from 63 males with RA at baseline, 3 months, and 6 months. Path analytic methods were used to examine longitudinal relationships among these variables. RESULTS: Path analysis revealed that pain and helplessness were significant mediators of the relationship between disease activity and future disability in RA; the predictive model withstood two cross-validations. CONCLUSION: The findings suggest that pain and helplessness are key biopsychosocial variables that affect the development of disability in RA.

Implications of depression in rheumatoid arthritis: do subtypes really matter?

OBJECTIVE: To examine depressive disorders and health status in patients with rheumatoid arthritis (RA), controlling for potential confounds. METHOD: Subjects (n = 426) completed measures of depressive symptoms (Center for Epidemiological Studies Depression Scale [CES-D]) and health status (Arthritis Impact Measurement Scales 2 [AIMS2]), via cross-sectional survey. Subjects (n = 299) with few depressive symptoms (CES-D < or = 10) were not evaluated further. Subjects with CES-D > or = 11 were interviewed using the Primary Care Evaluation of Mental Disorders to diagnose major depressive disorder (MDD; n = 46), dysthymic disorder (DD; n = 21), or minor depressive disorder (MND; n = 18). RESULTS: Regression analyses examined differences between the depressive disorders on AIMS2 subscales. Health status scores were similar between the depressive disorder subcategories; significant differences were found between MDD and MND on AIMS2 Physical scores and MDD and DD on AIMS2 Symptom scores. CONCLUSION: Regarding health status, presence of depression itself seems to overshadow differences between depression subtypes; antidepressant treatments/referrals for persons with concomitant RA and any depressive disorder subtype appear warranted.

A confirmatory factor analysis of the Center for Epidemiologic Studies Depression Scale in rheumatoid arthritis patients: additional evidence for a four-factor model.

OBJECTIVE: To examine the factor structure of the Center for Epidemiologic Studies Depression Scale (CES-D) in a sample of patients with rheumatoid arthritis (RA), testing all of the alternative models suggested by the previous evidence. METHODS: The CES-D was administered to a group of RA patients (n = 685) during a structured telephone interview. The telephone interview was repeated 6 months later (n = 537) and 12 months later (n = 453). Confirmatory factor analyses were conducted to test alternative models. RESULTS: The correlated 4-factor model and the second-order 4-factor model were the best fitting models. CONCLUSION: The factor structure of the CES-D previously found in the general population was replicated in an RA sample. The results are consistent with previous evidence of criterion contamination in the CES-D when used in an RA sample and provide support for the view that a single summary score may not be the most informative index of the CES-D.

Stress management in rheumatoid arthritis: what is the underlying mechanism?

OBJECTIVE: To test whether change in cognitive-behavioral variables (such as self-efficacy, coping strategies, and helplessness) is a mediator in the relation between cognitive behavior therapy and reduced pain and depression in persons with rheumatoid arthritis (RA). METHODS: A sample of patients with RA who completed a stress management training program (n = 47) was compared to a standard care control group (n = 45). A path analysis testing a model including direct effects of comprehensive stress management training on pain and depression and indirect effects via change in cognitive-behavioral variables was conducted. RESULTS: The path coefficients for the indirect effects of stress management training on pain and depression via change in cognitive-behavioral variables were statistically significant, whereas the path coefficients for the direct effects were found not to be statistically significant. CONCLUSION: Decreases in pain and depression following stress management training are due to beneficial changes in the arenas of self-efficacy (the belief that one can perform a specific behavior or task in the future), coping strategies (an individual's confidence in his or her ability to manage pain), and helplessness (perceptions of control regarding arthritis). There is little evidence of additional direct effects of stress management training on pain and depression.

The importance of enhancing self-efficacy in rheumatoid arthritis.

OBJECTIVE: To examine relationships among changes in self-efficacy and changes in other clinically relevant outcome measures. METHOD: Subjects (n = 44) were participants in a prospective, randomized stress-management study followed over 15 months. Outcome measures included self-efficacy, depression, pain, health status, and disease activity. RESULTS: Correlational analyses revealed significant associations between changes in self-efficacy (particularly total self-efficacy) and changes in selected measures of depression, pain, health status, and disease activity. The observed associations were not due to changes in medication regimen or to nonadherence to the stress-management program. CONCLUSIONS: Evidence is provided that induced changes in self-efficacy following a stress-management program were significantly related to other clinically important outcome measures.

Mood states and disease activity in patients with systemic lupus erythematosus treated with bromocriptine.

We tested mood states in patients with systemic lupus erythematosus (SLE) treated with the prolactin-lowering drug, bromocriptine. Bromocriptine was given to seven patients in an open-label study to test its effects on active SLE. Two independent measures of SLE activity, the SLE Activity Measure (SLAM) and the SLE Disease Activity Index (SLEDAI), were scored and the Symptom Questionnaire (SQ) mood survey was administered at entry and at 6 monthly follow-up visits. The SLAM and SLEDAI scores improved significantly during treatment. Two of the four mood scales in the SQ (Anxiety Scale and Anger-Hostility Scale) showed significant improvement compared to the entry value at least once during treatment. Significant improvement was also observed in the Total Distress Score, which is the sum of the four scales and is a more sensitive measure of distress than the score of an individual scale. Depression, anxiety, somatic complaints, and total distress correlated positively with SLAM and/or SLEDAI scores. The Anxiety Scale and the Total Distress Score improved with treatment and did correlate positively with SLE activity. In contrast, the Anger-Hostility Scale improved with treatment but did not correlate with SLE activity.

Age, depressive symptoms, and rheumatoid arthritis.

OBJECTIVE: To examine the relationship between age and depression in persons with rheumatoid arthritis (RA). METHODS: Two separate outpatient cohorts of persons with RA were studied. In both studies, the Center for Epidemiological Studies Depression Scale was administered to all subjects, and the prevalence of depressive symptoms was determined by age group. In the second study, data on additional measures of disease activity, pain, life stress, and coping were collected for use in multiple linear regression analyses. RESULTS: In both samples, a significant correlation between age and depression was found; younger persons (age < or = 45 years) with RA were significantly more depressed, even after controlling for potentially confounding variables such as sex, marital status, antidepressant medication, arthritis medication, functional class, and disease duration. CONCLUSION: The findings show that younger persons with RA are at higher risk for depressive symptoms than their older counterparts.

Predictors of subjective fatigue among individuals with rheumatoid arthritis.

OBJECTIVE: To examine a range of variables potentially associated with rheumatoid arthritis (RA)-related fatigue and to determine which variables best predict subjective fatigue. METHODS: Measures of fatigue, disease activity, pain, and various psychosocial factors were gathered from 73 individuals with RA. Correlations between fatigue and other variables were examined, and the "best" predictors of fatigue were determined with multiple regression analyses. RESULTS: Many of the variables that were significantly correlated with fatigue had a psychosocial character. Moreover, the "best" predictors of increased fatigue were higher levels of pain, more depressive symptoms, and female sex. Longer symptom duration, less perceived adequacy of social support, and less disease activity were significant predictors of fatigue, over and above the "best" model. CONCLUSION: RA-related fatigue appears to be strongly associated with psychosocial variables, apart from disease activity per se. Correspondingly, treatment of fatigue may be enhanced by interventions that address relevant cognitive and behavioral dimensions.

Relationship of self-efficacy to pain behavior.

Our purpose was to examine the effects of self-efficacy on the pain behaviors exhibited by patients with rheumatoid arthritis (RA). Seventy-two patients with RA were assessed using a standardized videotaping procedure for rating specific pain behaviors such as limps, facial grimaces, and guarded movements. Patients also completed questionnaires measuring self-efficacy and depression. Hierarchical regression was used to assess the relationship between self-efficacy and pain behavior after the effects of demographic characteristics and disease activity were statistically controlled. Higher self-efficacy was found to be related to fewer pain behaviors. In contrast, depression was found to be unrelated to pain behavior. Our results indicate that the pain behaviors that patients with RA exhibit are related to their self-efficacy, not solely to their disease activity.

A controlled study of lymphocyte subsets in rheumatoid arthritis.

The purpose of this study was to determine if patients with rheumatoid arthritis (RA) exhibited unique patterns of peripheral blood lymphocyte (PBL) subsets in comparison to patients with osteoarthritis (OA) and, further, if such differences related to disease activity or nondisease factors. Data from 63 RA patients and 47 OA patients revealed that the RA patients had lower absolute numbers of CD2+ and CD4+ lymphocytes. Small differences also were found in selected B-cell subsets and subsets of lymphocytes expressing CD16 and/or CD57 antigens. Further analysis revealed that these differences were due primarily to the effects of cytotoxic medications in the RA group. However, there were also alterations in some subsets independent of medication groups. PBL subsets in RA patients did not relate to chronic low-dose prednisone or measures of disease activity. This study demonstrated the need to control carefully for variables such as age and medication in immunophenotypic investigations of RA.

Psychological screening in rheumatoid arthritis.

Our objective was to examine the utility of the Symptom Checklist-90-R (SCL-90-R) as a psychological screening instrument for patients with rheumatoid arthritis (RA). Subjects were 81 male and 3 female patients with classic or definite RA who were categorized into 3 anatomic stage groups based on roentgenograms. Erythrocyte sedimentation rates, joint counts, and the SCL-90-R were obtained on all subjects. In addition, rheumatologists were surveyed, and items were analyzed to identify potential disease related items on the SCL-90-R. Both the survey and the item analyses supported the utility of the SCL-90-R as a psychological screening instrument in a population with RA.

Pain control and rational thinking. Implications for rheumatoid arthritis.

In this study, we examined the factor structure of the Coping Strategies Questionnaire and studied the relevance of the coping process to health status in rheumatoid arthritis patients. The 2 factors of the questionnaire that were analyzed were Coping Attempts and Pain Control and Rational Thinking. The Pain Control and Rational Thinking factor was related to pain and psychological status, even after demographic variables and disease severity were statistically controlled. In addition, increases in Pain Control and Rational Thinking scores were related to improvements in pain, psychological status, and health status. Implications for the psychological care of rheumatoid arthritis patients are discussed.

Pain management in rheumatoid arthritis patients. A cognitive-behavioral approach.

To examine the effectiveness of a cognitive-behavioral pain management program for patients with rheumatoid arthritis, three patient groups were studied: a cognitive-behavioral group (CB), an attention-placebo group, and a control group. The CB group received a comprehensive, 12-month pain management program that taught coping strategies such as problem-solving techniques, relaxation training, strategies for attention diversion, and training in family dynamics and communication. Dependent measures included pain, coping strategies, psychological status, functional status, and disease status. Data analysis at 12 months revealed benefits for the CB group in the area of enhanced coping strategies. Specifically, the CB subjects showed significantly greater use of coping strategies and significantly more confidence in their ability to manage pain. The findings are discussed in terms of the importance of enhanced self-efficacy and personal control for patients with rheumatoid arthritis.

Effects of stress management on clinical outcomes in rheumatoid arthritis.

OBJECTIVE: To examine the effects of stress-management training on clinical outcomes in persons with rheumatoid arthritis (RA). METHODS: Patients with RA (n = 141) were randomly assigned to 1 of 3 groups: a stress management group, an attention control group, or a standard care control group. The stress management and the attention control groups received a 10-week intervention followed by an additional 15-month maintenance phase. RESULTS: The stress management group showed statistically significant improvements on measures of helplessness, self-efficacy, coping, pain, and health status. Selected beneficial effects were still detectable at the 15-month followup evaluation. CONCLUSION: The data indicated that stress management interventions are capable of producing important clinical benefits for persons with RA.