Fatigue in systemic lupus: the role of disease activity and its correlates.

OBJECTIVES: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that leads to a variety of negative health outcomes resulting from inflammation in various organ systems. Although treatment continues to advance, fatigue remains one of the most salient, poorly understood and addressed patient complaints. Understanding the mechanisms of fatigue can help guide the development of interventions to improve health outcomes. The aim of this research was to evaluate the contribution of six variables (disease activity, insomnia, depression, stress, pain and physical health) to fatigue in SLE without concomitant fibromyalgia (FM). METHODS: A total of 116 ethnically diverse, primarily female participants (91%) with SLE, receiving care at university medical centers, completed assessments of disease activity and quality of life outcomes (FACIT-FT, Insomnia Severity Index, Perceived Stress Scale (PSS-4), Pain Inventory, Depression-PHQ-9, and LupusPRO-physical function). All patients met the American College of Rheumatology classification criteria for SLE and did not have a known diagnosis of FM. Multivariate linear and stepwise regression analyses were conducted with fatigue (FACIT-FT) as the dependent variable, and the above six variables as independent variables. RESULTS: Mean (SD) age was 39.80 (13.87) years; 50% were African American, 21% Caucasian, 13% Hispanic, 9% Asian and 8% other. Mean (SD) FACIT-FT was 20.09 (12.76). Collectively, these six variables explained 57% of the variance in fatigue. In the multivariate model, depression, stress and pain were significantly and independently associated with fatigue, but not disease activity, sleep or physical health. Stress had the largest effect on fatigue (ß 0.77, 95% CI 0.17-1.38, p = 0.01), followed by depression (ß 0.66, 95% CI 0.21-1.10, p = 0.005). On stepwise regression analysis, only stress, depression and pain were retained in the model, and collectively explained 56% of the variance in fatigue. All three remained independent correlates of fatigue, with the largest contribution being stress (ß 0.84, 95% CI 0.27-1.42, p = 0.005), followed by depression (ß 0.79, 95% CI 0.44-1.14, p < 0.001) with fatigue. CONCLUSION: Stress, depression and pain are the largest independent contributors to fatigue among patients with SLE, without concurrent FM. Disease activity, sleep and physical health were not associated with fatigue. The evaluation of stress, depression and pain needs to be incorporated during assessments and clinical trials of individuals with SLE, especially within fatigue. This stress-depression-fatigue model requires further validation in longitudinal studies and clinical trials. Significance and innovation: • Disease activity, sleep, pain, stress, depression, and physical health have been reported individually to be associated with fatigue in lupus. This analysis evaluated the role of each and all of these six variables collectively in fatigue among patients with SLE without a known diagnosis of FM. • Disease activity, sleep and physical health were not significantly related to fatigue, but depression, stress and pain were. • The results emphasize the need to evaluate and treat fatigue in individuals with SLE utilizing a biopsychosocial approach, particularly in the realm of clinical trials. Behavioral medicine interventions are shown to be most effective for the treatment of depression, stress and pain.

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.

The mediational role of helplessness in psychological outcomes in systemic lupus erythematosus.

Objective Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that can result in disability and psychological distress. Although pain has been associated with depressive symptomatology and stress in SLE, a paucity of theoretical models have been used to explain the relationship between pain and psychological distress in this population. Thus, the present study examined helplessness as a mediator of the relationship between pain and psychological distress among patients with SLE. Methods Multiple mediation analysis was used to examine the hypothesis that learned helplessness mediates the relationship between pain and symptoms of anxiety, depression, and stress in a sample of patients with SLE ( N = 136) receiving medical care at Cedars Sinai Medical Center. Results The mean score on the Helplessness subscale was 14.5 ( SD = 5.4). Helplessness fully mediated the relationship between pain vitality and symptoms of anxiety (BCa 95% CI (-0.073, -0.015)), depression (BCa 95% CI (-0.502, -0.212)), and stress (BCa 95% CI (-0.063, -0.027)). Conclusion Participants reported a high level of perceived inability to control one's disease. Helplessness fully mediated the relationship between pain and measures of anxiety, depression, and perceived stress among patients with SLE.

Psychometric validation of the Arthritis Helplessness Index in systemic lupus erythematosus.

Objective Helplessness is a relevant construct in systemic lupus erythematosus (SLE), an unpredictable chronic illness with no known cure characterized by relapsing and remitting features. However, no measure of helplessness has been validated in this population. The present study examined the structural validity, reliability, and convergent validity of the Arthritis Helplessness Index, a measure initially developed for rheumatoid arthritis populations, in a sample of patients with SLE. Methods Patients with SLE ( N = 136) receiving medical care at a private hospital completed the Arthritis Helplessness Index and other self-report measures. The structural validity of the Arthritis Helplessness Index was examined using confirmatory factor analysis. Internal consistency reliability was evaluated with Cronbach's coefficient alpha. Pearson product-moment correlations were used to examine convergent validity with measures of depression, anxiety and mastery. Results The five-item Arthritis Helplessness Index-Helplessness measure demonstrated a tenable factor structure (comparative fit index 0.98, root mean square error of approximation 0.06, standardized root mean residual 0.04). Internal consistency reliability was fair (α = 0.69). Convergent validity was evidenced by significant correlations with measures of depression, anxiety and mastery. Conclusion The five-item Arthritis Helplessness Index-Helplessness scale can confidently be used as a measure of helplessness in SLE.

The psychometric properties of the Perceived Stress Scale-10 among patients with systemic lupus erythematosus.

Objective Systemic lupus erythematosus (SLE) is a chronic, multisystem autoimmune disease characterized by periods of remission and recurrent flares, which have been associated with stress. Despite the significance of stress in this disease, the Perceived Stress Scale-10 has yet to be psychometrically evaluated in patients with SLE. Methods Exploratory factor analysis was used to examine the structural validity of the Perceived Stress Scale-10 among patients with SLE ( N = 138) receiving medical care at Cedars Sinai Medical Center. Cronbach's coefficient alpha was used to examine internal consistency reliability, and Pearson product-moment correlations were used to examine convergent validity with measures of anxiety, depression, helplessness, and disease activity. Results Exploratory factor analysis provided support for a two-factor structure (comparative fit index = .95; standardized root mean residual = .04; root mean square error of approximation = .08). Internal consistency reliability was good for both factors (α = .84 and .86). Convergent validity was evidenced via significant correlations with measures of anxiety, depression, and helplessness. There were no significant correlations with the measure of disease activity. Conclusion The Perceived Stress Scale-10 can be used to examine perceived stress among patients with SLE.

A multi-group confirmatory factor analyses of the LupusPRO between southern California and Filipino samples of patients with systemic lupus erythematosus.

Introduction Systemic lupus erythematosus (SLE) leads to a range of biopsychosocial health outcomes through an unpredictable and complex disease path. The LupusPRO is a comprehensive, self-report measure developed specifically for populations with SLE, which assesses both health-related quality of life and non-health related quality of life. Given its increasingly widespread use, additional research is needed to evaluate the psychometric integrity of the LupusPRO across diverse populations. The objectives of this study were to evaluate the performance of the LupusPRO in two divergent patient samples and the model fit between both samples. Methods Two diverse samples with SLE included 136 patients from an ethnically-diverse, urban region in southern California and 100 from an ethnically-homogenous, rural region in Manila, Philippines. All patients met the ACR classification criteria for SLE. Confirmatory factor analysis (CFAs) were conducted in each sample separately and combined to provide evidence of the factorial integrity of the 12 subscales in the LupusPRO. Results Demographic analyses indicated significant differences in age, disease activity and duration, education, income, insurance, and medication use between groups. Results of the separate CFAs indicated moderate fit to the data for the hypothesized 12-factor model for both the Manila and southern California groups, respectively [χ2 (794) = 1283.32, p < 0.001, Comparative Fit Index (CFI) = 0.793; χ2 (794) =1398.44, p < 0.001, CFI = 0.858]. When the factor structures of the LupusPRO in the southern California and Manila groups were constrained to be equal between the two groups, findings revealed that the factor structures of measured variables fit the two groups reasonably well [χ2 (1697) = 2950.413, df = 1697, p < 0.000; CFI = 0.811]. After removing seven constraints and eight correlations suggested by the Lagrange multiplier test, the model fit improved significantly [χ2 (15) = 147.165, p < 0.000]. Conclusions This research provides significant support for the subscale structure of the LupusPRO in two disparate cultural samples of SLE patients. Despite significant sociodemographic and clinical differences between the two samples, for the most part, the LupusPRO performed similarly in both samples.

Depression predicts self-reported disease activity in systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) is an autoimmune disease that can significantly impact both physiological and psychological functioning. In order to examine the relationship between psychological functioning and disease activity in SLE, we administered instruments that collected sociodemographic information and measured indices of disease activity and psychosocial functioning from 125 adult Hispanic and White patients with SLE. Patients were recruited from four healthcare settings in the greater Southern California area. Both cross-sectional and longitudinal relationships between depression and disease activity were evaluated. Cross-sectional findings revealed that depression and ethnicity were independently correlated with self-reported disease activity. Longitudinally, depression alone predicted self-reported disease activity. These data suggest that depression may play a significant role in the health status of SLE patients and serve as an important target for clinical intervention.

The Patient Reported Outcomes in Lupus (PATROL) study: role of depression in health-related quality of life in a Southern California lupus cohort.

UNLABELLED: This study examines the relationship between psychosocial factors, ethnicity, disease activity and quality of life in systemic lupus erythematosus. METHODS: One hundred and twenty-five adult Caucasian and Hispanic lupus patients were recruited from four Southern California medical centers. Linear regression analysis was performed to assess the correlation of ethnicity, socioeconomic factors (age, income), and disease activity (patient and physician reported), as well as psychological (depression, internality, helplessness) variables with quality of life (QOL) as measured by the Short Form (SF)-36. Hierarchical multiple regression analysis was then used to determine the stepwise contribution of the above determinants on the eight domains of the SF-36 questionnaire. RESULTS: Depression negatively correlated with QOL in both Caucasians (r -0.488 to -0.660) and Hispanics (r -0.456 to -0.723). Patient-reported disease activity was moderately related (r -0.456 to -0.698) to seven of the eight SF-36 domains in Hispanics, and none in Caucasians. Physician-reported disease activity, measured by SLEDAI, did not correlate with QOL among Hispanics or Caucasians. When linear and hierarchical regression was used, depression significantly correlated (p < 0.0001) with the majority of the SF-36 domains, except general health, while age had a significant effect in only one domain of the SF-36, physical functioning (p < 0.0001). CONCLUSION: Depression, and not disease activity, appears to have a major influence on quality of life in both Hispanic and Caucasian patients in this lupus cohort.

Pain coping strategies and depression in rheumatoid arthritis.

A study was conducted to examine the role of pain episodes and the role of active and passive pain coping strategies in predicting depression in 287 patients with rheumatoid arthritis (RA). The independent effects of pain and pain coping strategies, as well as the interaction effects between pain and pain coping strategies on depression, were evaluated cross-sectionally and prospectively over a 6-month interval. The cross-sectional findings revealed that pain, passive coping, and the interaction between pain and passive coping contributed independent variance, all accounting for higher depression. Of principal interest was the finding that the frequent use of passive pain coping strategies in the face of high pain contributed to the most severe level of depression over time. These results were obtained after controlling for the potentially confounding effects of prior depression, functional disability, and medication status. These data imply that there may be a potential benefit of developing techniques to reduce the use of passive pain coping strategies to deal with chronic arthritis pain in cognitive-behavioral pain management programs.

Longitudinal relationships among pain, sleep problems, and depression in rheumatoid arthritis.

This research evaluated the relationship between pain and sleep problems, and the role of pain and sleep problems in depression, in a sample of 242 patients who had been diagnosed with definite or classical rheumatoid arthritis (RA). Patients completed the Pain scale of the Arthritis Impact Measurement Scales, the Center for Epidemiological Studies Depression Scale, and self-reports of sleep disturbance at two data waves over a 2-year interval. Cross-sectional multiple regression analysis revealed that the sleep problems variable was independently associated with depression at Time 1. Longitudinal multiple regression analyses demonstrated that prior pain predicted subsequent adverse changes in sleep problems, whereas sleep problems did not affect pain over time, and prior pain and the interaction of high pain and high sleep problems were independently associated with depression from Time 1 to Time 2. These data suggest that pain may exacerbate sleeping difficulty in RA patients, and that both factors may contribute to depression over time.

Emigration stress and language proficiency as correlates of depression in a sample of Southeast Asian refugees.

This research evaluated a stress management, coping skills model of adjustment in the analysis of depression in a sample of Laotian refugees living in the southeastern United States. Stressful events and experiences during emigration and a lack of English proficiency were associated with depressive symptoms, while demographic variables and social support were not. English proficiency also significantly reduced the impact of acculturative stressors on depression, suggesting that language skill may act as a stress buffer in the new cultural environment.

Social class and family size as determinants of attributed machismo, femininity, and family planning: a field study in two South American communities.

PIP: A study was conducted to determine the way in which stereotypes of machismo and femininity are associated with family size and perceptions of family planning. A total of 144 adults, male and female, from a lower class and an upper middle class urban area in Colombia were asked to respond to photographs of Colombian families varying in size and state of completeness. The study illustrated the critical role of sex-role identity and sex-role organization as variables having an effect on fertility. The lower-class respondents described parents in the photographs as significantly more macho or feminine because of their children than the upper-middle-class subjects did. Future research should attempt to measure when this drive to sex-role identity is strongest, i.e., when men and women are most driven to reproduce in order to "prove" themselves. Both lower- and upper-middle-class male groups considered male dominance in marriage to be directly linked with family size. Perceptions of the use of family planning decreased linearly with family size for both social groups, although the lower-class females attributed more family planning to spouses of large families than upper-middle-class females. It is suggested that further research deal with the ways in which constructs of machismo and male dominance vary between the sexes and among socioeconomic groups and the ways in which they impact on fertility.^ieng

Illness self-schemas in depressed and nondepressed rheumatoid arthritis patients.

This study examined the hypothesized illness self-schemas construct in persons with rheumatoid arthritis (RA). Biases in self-description, information processing, and schema-consistent illness behavior were examined in depressed and nondepressed persons with RA and compared with those of depressed and nondepressed controls. Major findings revealed that RA-depressed subjects exhibited pervasively negative self-description and biased processing of negative illness-related information. RA-nondepressed subjects demonstrated a bias for positive self-description and enhanced processing of positive illness-related information. Using regression analysis, the illness self-schema construct predicted unique variance in self-reported functional disability. Findings are reviewed in the context of previous research on self-schemas, chronic pain, and cognitive variables in chronic illness. Potential clinical implications and directions for future research are discussed. The illness self-schema construct has significant heuristic value which could guide further research on the psychosocial adjustment of individuals with chronic illnesses.

Progressive relaxation, EMG biofeedback and biofeedback placebo in the treatment of sleep-onset insomnia.

This paper describes a study in which progressive relaxation, EMG frontalis biofeedback, and a biofeedback placebo manipulation were compared in the treatment of severe insomnia with 40 chronically sleep-disturbed adult patients. Progressive relaxation and EMG biofeedback led to significant reductions in both reported sleep-onset latency and depressive symptomatology. However, when compared individually with the biofeedback placebo group, neither progressive relaxation nor EMG biofeedback emerged as significantly more effective on the sleep-onset latency measure. The clinical improvement in the biofeedback placebo group suggests that expectancies related to the ability to relax may contribute to the therapeutic effectiveness of relaxation strategies, even with chronic, severely disturbed insomniacs. Improvement in sleep-onset latency was not significantly related to reductions in frontalis EMG activity either within or between groups, a finding which raises questions concerning the clinical role and importance of physiological relaxation in the treatment of sleep-onset disturbance.

Factor structure of the Arthritis Helplessness Index.

The factor structure of the Arthritis Helplessness Index (AHI) was examined using principal components factor analysis with varimax rotation. Data for the initial factor analysis came from a longitudinal study of 368 patients with rheumatoid arthritis (RA). Two slightly negatively correlated (r = -0.21) subscales emerged: internality and helplessness. This analysis was cross-validated twice. Findings reveal that the 2 subscales of the AHI are more reliable and valid than the total score. The 5 item helplessness subscale, in particular, appears to be a highly valid indicator of the degree to which patients with RA feel overwhelmed by their disease.

Acute paranoid disorder in a Southeast Asian refugee.

The clinical course of a 23-year-old male Vietnamese refugee who was seen for psychiatric evaluation and treatment after a self-inflicted abdominal stab wound is described. His attempted suicide was precipitated by a rejection of his romantic advances by an American woman and teasing by fellow co-workers that he was a Communist spy. Central to the development of paranoid delusions in this patient was the fact that he had been a member of the Communist forces in Cambodia and feared deportation. Emigration and acculturative stressors were seen as contributing significantly to this patient's paranoid disorder.

The role of generalized pain and pain behavior in tender point scores in fibromyalgia.

OBJECTIVE: To determine and assess the significance of the independent role of pain, pain behavior, depression, and weekly stress in tender point scores in objectively diagnosed fibromyalgia (FM) patients. METHODS: One hundred eleven patients with FM recruited from the community and private and university based clinics participated in a comprehensive evaluation of their pain, psychological distress, and pain behavior. Tender point assessment was carried out across 18 discrete sites according to American College of Rheumatology criteria. Pain was assessed with a composite index of 4 pain measures; psychological distress consisted of measures of stress and depression, and pain behavior was measured by an objective index derived from a 10 minute videotaped sequence in which 5 pain behaviors were recorded. RESULTS: Multiple regression analyses revealed that high pain, high pain behavior, and shorter illness duration were related independently to tender point scores. Measures of depression and weekly stress were not independently related to tender point scores. CONCLUSION: Tender point scores are related to generalized pain and pain behavior tendencies in patients with FM, and do not independently reflect generalized psychological distress.