Exploring the relationship between disease-related pain and cortisol levels in women with osteoarthritis.

OBJECTIVES: To determine if (1) Osteoarthritis (OA)-related pain is associated with the diurnal cortisol pattern and cortisol levels; (2) the diurnal pattern of cortisol varies with severity of OA pain and (3) the association between OA pain and cortisol is mediated by daily experience variables (DEV). DESIGN: In a community-based study of changes in regional and widespread pain among women with OA, participants (n = 31) completed daily diaries and collected three saliva samples daily for 7 days. Severity of OA-related pain was assessed by the validated Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale. Multilevel regression analyses estimated associations between OA pain and diurnal cortisol levels and slopes, controlling for body mass index (BMI), medication use, time and day. Mediation analyses examined DEV as potential mediators of the association between OA pain and cortisol. RESULTS: The mean age was 57 years and average BMI 31 kg/m2. Mean WOMAC pain subscale score was 8.8. Women with higher WOMAC pain scores had higher cortisol throughout the day. The estimated association of WOMAC with cortisol [ß 0.083(0.02, 0.15) P = 0.009] represents a ∼9% increase in cortisol for every unit increase in WOMAC pain score. Women with WOMAC pain scores ≥9 had higher cortisol levels than those with scores <9. Examination of DEV revealed no significant mediated associations between these relationships at the daily level. CONCLUSION: In women with OA, disease-related pain is positively associated with cortisol production, particularly with greater pain severity. Future studies should explore biologic mediating variables between OA pain and cortisol.

Field research on the relationship between stress and disease activity in rheumatoid arthritis.

We review empirical evidence from two field studies for the role of stressful life events in disease flare-ups among patients with rheumatoid arthritis (RA). RA patients were expected to be more vulnerable psychologically, and physiologically, to stressful events in their everyday lives than other arthritis patients without an autoimmune disease. Findings from two studies are reviewed both for their substantive contribution, but also to provide guidance on measurement issues in future field research of this kind. One study included 41 patients with RA, who were interviewed weekly and called to a clinic for blood work and joint examinations when their levels of interpersonal stress increased significantly. A second study used a similar design but included comparison samples of patients with osteoarthritis (OA) and healthy controls of similar age and the same gender as the RA sample. The findings provided support for the proposition that interpersonal stressors are predictive of increases in disease activity. Not all RA patients, however, showed these relationships, and there was evidence that some participants with OA who were depressed also showed higher disease activity following interpersonal stressors. Significant individual differences in the stress-disease relationship were uncovered that deserve greater attention in future studies. Important improvements in the assessment of stressful events and refinements in panel study design are also presented as guides to research on the role of stress in disease processes.

An examination of individual differences in the relationship between interpersonal stress and disease activity among women with rheumatoid arthritis.

OBJECTIVE: The effects of interpersonal stress on disease activity were examined for married women with rheumatoid arthritis (RA) who differ in the quality of their relationships with their spouses. METHODS: Measures of interpersonal events were collected weekly for 12 weeks and related to disease activity through a comparison of clinician ratings and immune markers taken at baseline and during a highly stressful week for 20 RA patients. Individual differences in marital relationship variables and illness characteristics were used to predict group differences in how stress affected disease activity. RESULTS: Significant elevations in total T cell activation (DR + CD3 cells), soluble interleukin-2 receptor (sIL-2R), and clinician's global ratings of disease activity were found during a week of significant interpersonal stress. However, women with better spousal relationships did not show increases in disease activity following an episode of interpersonal stress. In addition, patients taking low-dose prednisone showed greater reactivity to stress than patients not currently using glucocorticoid treatment. CONCLUSION: The results are consistent with the hypothesis that disease activity in RA increases following increases in interpersonal stress and that women with stronger marital relationships were less vulnerable to those stressors.

Interpersonal stress, depression, and disease activity in rheumatoid arthritis and osteoarthritis patients.

The relationships among interpersonal stressors, depression, coping inefficiency, hormones (prolactin, cortisol, and estradiol), and disease activity were examined. The sample comprised 33 women with rheumatoid arthritis (RAs; age 37-78) and 37 women with osteoarthritis (OAs; age 47-91), who served as controls. In a regression analysis, interpersonal conflict events accounted for more than twice as much variance in depression in RAs than in OAs. In the RA patients, the immune-stimulating hormones prolactin and estradiol were significantly positively correlated with interpersonal conflicts, depression, coping inefficacy, and clinician ratings of disease activity, suggesting that RAs are more reactive to interpersonal stressors than are OAs, both psychologically and physiologically.

Life stress and lymphocyte alterations among patients with rheumatoid arthritis.

The relation between life stress and immune parameters was investigated for 33 female rheumatoid arthritis (RA) patients interviewed during three routine monthly clinic checkups. Life stress from major and minor events, coping efficacy, and self-reported psychological distress were assessed, and immunofluorescence of T-cells and B-cells was performed on the blood drawn during each visit. Small stressful events were positively related to the proportion of circulating B-cells, psychological distress was inversely related to proportion of circulating T-cells, and major life events were associated with lower T-helper/T-suppressor cell ratios.

Arthritis and perceptions of quality of life: an examination of positive and negative affect in rheumatoid arthritis patients.

The utility of measuring both positive and negative affective states for assessing rheumatoid arthritis (RA) patients was examined in 3 independent samples of male and female RA patients (Sample A: 179 women, 48 men; Sample B: 177 women, 24 men; Sample C: 134 women, 38 men). Confirmatory factor analyses of each sample indicated that positive and negative affect constituted separate, negatively correlated factors. The relations among disease variables, coping, and affects were consistent with a model in which coping mediates the relationship between disease variables and positive and negative affect. Patients with higher pain and limitation from RA had higher levels of maladaptive coping, and maladaptive coping was associated with lower positive affect and higher negative affect. Those RAs with higher activity limitation also reported less adaptive coping, which was associated with less positive affect.

The examination of myofascial face pain and its relationship to psychological distress among women.

In this study, 110 female myofascial face pain patients were assessed monthly for 10 months on measures of pain, distress, and stressful life events. D. A. Kenny and A. J. Zautra's (1995) structural equation model for examining the separate trait, state, and error components of the variables was used to analyze the data. Both pain and distress had sizable trait variance, and the trait components were correlated. The 2 variables also showed sizable state variance, and the states of pain covaried with states of distress. A significant time-lagged relationship between the 2 variables was found: Increases in distress led to elevations in pain 1 month later. Stressful life events arising from major social roles were also associated with greater distress, but not pain. Illness events unrelated to the pain syndrome were associated with both pain and distress.

Stressful life events' effects on rheumatoid arthritis disease activity.

A 53-year-old female rheumatoid arthritis (RA) patient endured 2 unexpected family deaths during a 12-week study investigating the prospective relationships between stressful small life events, negative affect, and disease activity. Her disease went into temporary remission the same week as the deaths. She was identified as a case study participant, and weekly data collection was extended to 1 year. Clinical exams verified a large decrease in disease status immediately after the major losses. In addition to major events, negative affect and small events were found to serve as independent arthritis symptom predictors within this patient. Major events were associated with decreased symptoms. Negative affect and small events related to symptom increases. Subsequent between-subjects analyses conducted on 25 participants from the parent project probed for generalizability. The substantive findings from the case study were supported: Major life events and small life events functioned as opposing predictors of RA disease states.

Coping success and its relationship to psychological distress for older adults.

The role of coping success on psychosocial distress was investigated in 147 older adults who experienced a major health problem and 82 older adults who reported a major loss in the past 6 months. Home interviews provided data on satisfaction with coping efforts and negative changes associated with events. Significant predictors of coping success were identified and controlled for in subsequent analyses predicting mental health. Efficacy in coping with loss was associated with less psychological distress. Coping efficacy interacted with coping efforts in predicting distress for those with health downturns; efficacy in coping was associated with less distress only for those who were actively engaged in coping. Analyses of longitudinal data replicated the cross-sectional findings for coping with loss.

Spouse criticism and support: their association with coping and psychological adjustment among women with rheumatoid arthritis.

Examined whether psychological adjustment of women with rheumatoid arthritis would be related to the support and criticism the patient received from the husband. Interviews were conducted with the husbands of 103 women with rheumatoid arthritis. Spouse interviews were content coded for critical remarks. Wives completed a revised version of the Ways of Coping Scale and a scale of the perceived supportiveness of the spouse. Husbands completed rating scales assessing their perceived vulnerability to illness and the degree of burden they experienced in providing assistance to their wives. Path analyses revealed that patient adjustment was significantly related to the attitude of the spouse. Patients with a highly critical spouse engaged in more maladaptive coping behaviors and reported a poorer psychological adjustment. Independent of spousal criticism, patients who perceived their spouse as being supportive engaged in more adaptive coping. A path model was fit to the data that suggested that the spouse may affect adjustment indirectly through influencing the patient's selection of adaptive or maladaptive coping responses.

Major life events and minor stressors: identifying mediational links in the stress process.

Whether the relationship between major life events and distress is mediated through minor stressors was examined in three stress groups: those who (a) experienced the death of a spouse, (b) divorced, or (c) were the parent of a child with asthma. Each of these major stress groups was compared with a control group. Path analyses conducted by aggregating the data cross major stress groups indicated that major life events exert both a direct influence on distress and an indirect influence through minor stressors. On the other hand, the nature of the mediational relation linking major life events with psychological distress through minor stressors was found to vary as a function of the major life stress situation under consideration. Methodological and theoretical implications for the study of stress processes are discussed.

Some everyday life consequences of disability and bereavement for older adults.

The study analyzed daily event differences between groups experiencing the major stressors of conjugal bereavement and physical disability, and analyzed the association of everyday events with self-reports of mental health for different groups across a 3-month time span. Monthly interviews were conducted with 61 recently conjugally bereaved, 62 recently physically disabled, and 123 matched-comparison older adults between the ages of 60 and 80. The purpose of these interviews was to obtain a comprehensive assessment of the monthly frequencies of everyday life events. Self-reports of mental health were obtained from paper-and-pencil measures filled out after each interview. Causal models were used to analyze the best-fitting structure of event/mental health relationships for the first 3 monthly interviews. Undesirable events showed uniformly adverse effects on mental health. Desirable events benefited the psychological well-being of the disabled the most and had no positive effects on the mental health of the bereaved. The bereaved also evidenced less stability over time than other groups in the frequency of small undesirable events.

Coping and adaptation to facial pain in contrast to other stressful life events.

This article investigates whether coping with chronic pain influences adaptation to other negative life events using data on Temporomandibular Pain and Dysfunction Syndrome (TMPDS) patients (N = 99) and nonpatient controls (N = 98). It is found that cases cope very differently with pain than with other stressful events and that cases and controls do not differ on coping with nonpain events, with 2 exceptions. Cases view nonfateful events as more outside their control and they have more negative changes in usual activities following negative events. This excess of negative change is associated with greater demoralization and physical exhaustion. It is concluded that coping with repeated pain episodes leaves cases vulnerable to stressful events. Alternative interpretations, especially those involving the role of preexisting personality differences, are discussed.

A perceived control intervention for at-risk older adults.

Models of event causation and affective processes were used to design an experimental intervention for older adults. Ss were 2 at-risk populations, recently disabled and recently bereaved, each with matched nonrisk controls. Ss were randomly assigned to a placebo-contact group, a no-contact control group, or a 4-session, 10-week intervention focused on enhancing perceived control. Dependent variables assessed were personal mastery, psychological well-being and distress, positive and negative affect, and measures of daily events and activities. The intervention was nested within a 16-month longitudinal assessment of stress and adaptation processes in a large sample of community residents. The intervention had mixed effects on reports of personal mastery, but it significantly increased engagement in desirable activities and significantly decreased psychological distress and negative affect. Effects tended to be short-lived, however. Effects of the intervention tended to be particularly significant for the disabled group.

Psychological impact of illness downturns: a comparison of new and chronic conditions.

Older adults (N = 166) who had chronic arthritis, a chronic vision problem, new arthritis symptoms, or a new vision problem were compared with older adult controls on psychological distress and well-being. The psychological impact of new versus chronic illness stressors, and stressors associated with arthritis versus vision loss, were examined. The chronic arthritis group had the greatest psychological distress, the least well-being and the greatest self-reported pain. Results supported an additivity theory approach to chronic illness and not an anticipatory coping approach. Differences in level of pain accounted in part for elevations in distress but did not explain differences between groups in psychological well-being. Positive affect was found to be the indicator of well-being that best differentiated groups.

Activity, event transactions, and quality of life in older adults.

A multidimensional assessment of activity and subjective well-being based on a cognitive model of event causation was tested in a sample of 60 older adults. Activity was conceptualized as involving the occurrence of an event, the presence or absence of a response to that event, and the hedonic tone of the outcome of that transaction. Events were categorized as to whether the environment or the individual initiated them: demands or desires, respectively. Well-being was conceptualized as having two independent components, positive and negative, assessed by positive and negative mood scales and general well-being and quality-of-life scales. Analyses showed that older adults who were responsive to events reported more positive well-being, but high responding was also associated with negative aspects of well-being. Demands interacted with desire responding and outcome; affective outcomes of desired actions were significantly influenced by the occurrence of demand events. Results are interpreted in an expanded model of activity theory.

Effects of disability and bereavement on the mental health and recovery of older adults.

We investigated the role of two major stressors, recent disability and conjugal bereavement, in older adults' self-reports of mental health and recovery from stress. A sample of 246 older adults between the ages of 60-80 was interviewed monthly for 3 months by trained elderly interviewers; Month-10 interview data were also analyzed. Control subjects, who were not experiencing the stressors, were carefully selected from a sample of adults matched on age, sex, and socioeconomic status. Dependent variables were psychological distress and psychological well-being, each with component subscales. The disabled group evidenced significantly lower positive well-being and significantly greater distress than did the other groups. Bereaved subjects demonstrated high levels of depression compared with the disabled subjects, but showed less anxiety. Bereaved subjects showed recovery on several indicators of mental health, but disabled subjects continued to show considerable psychological upset in comparison with the other groups.

Health downturns and predictors of suicidal ideation: an application of the Baumeister model.

Suicidal thoughts and attempts have been studied from a number of perspectives, but only recently has an attempt been made to incorporate many different psychological perspectives into one framework. Baumeister (1990) has integrated personality and social psychological perspectives into one sequential model, moving from instigating events to a final stage of suicidal thoughts. Employing a sample of older adult subjects undergoing the stresses of a recent health downturn, this study tested a four-stage model of suicidal ideation based on many of the components proposed by Baumeister. Structural equation modeling achieved a good fit to the data. Results are discussed in terms of the importance of including life events, particularly poor health, and cognitive variables such as confusions in thinking, in understanding suicidal ideation.

Stressful life events, psychological distress, coping, and parenting of divorced mothers: a longitudinal study.

This was a prospective longitudinal study of the relationships among life stress, psychological distress, coping, and parenting behaviors in a sample of divorced custodial mothers. First, the differential effects of major events and daily stressors on psychological distress and parenting were explored. Second, the mediational links among stress, distress, and 3 dimensions of parenting behaviors were studied. Third, 3 coping strategies were studied as moderators of the relationship between distress and parenting. The results showed that both major and small events had significant effects on parental distress, with the effects of daily negative events being greater than those of major events. Parental distress mediated the relationships between stressful life events and parental acceptance of their children's behaviors. Parental coping strategies moderated the relationship between mothers' psychological distress and mothers' discipline practice.

Interplay of concurrent positive and negative interpersonal events in the prediction of daily negative affect and fatigue for rheumatoid arthritis patients.

OBJECTIVE: The purpose of this study was to examine the interaction of daily concurrent positive interpersonal events (PIE) and negative interpersonal events (NIE) on the daily experience of negative affect and fatigue in a sample of men and women with rheumatoid arthritis. Two hypotheses were made. The blunting hypothesis predicted that NIE would nullify the beneficial influence of PIE on outcome measures, and the buffering hypothesis predicted that PIE would offset the adverse influence of NIE. DESIGN: Participants completed up to 30 consecutive daily diaries. Multilevel modeling was used to examine the day-to-day dependencies among study variables. MAIN OUTCOME MEASURES: The primary outcomes were daily negative affect and fatigue. RESULTS: In support of the blunting hypothesis, on days when NIE were diminished, PIE were associated with a greater reduction in fatigue. In contrast, consistent with the buffering hypothesis, on days when PIE were elevated, NIE were associated with a lesser increase in negative affect. CONCLUSION: The examination of concurrent PIE and NIE provides a unique perspective on the role of interpersonal events in affective and physiological outcomes, beyond that which can be gained from the examination of either type of event in isolation.