A.W.M. Evers

Pain coping and social support as predictors of long-term functional disability and pain in early rheumatoid arthritis

Pain-related avoidance factors and social resources, as assessed by pain coping and social support, are supposed to have lasting effects on functional disability and pain in chronic pain disorders. As a follow-up to a prospective study demonstrating short-term effects after one year (Behaviour Research and Therapy, 36, 179-193, 1998), the role of pain coping and social support at the time of diagnosis was investigated in relationship to the long-term course of functional disability and pain after three and five years in 78 patients with rheumatoid arthritis (RA), taking into account personality characteristics of neuroticism and extraversion, clinical status and use of medication. In line with findings at the one-year follow-up, results showed that more passive pain coping predicted functional disability at the three-year, but not the five-year follow-up. In addition, low levels of social support at the time of diagnosis consistently predicted both functional disability and pain at the three and five-year follow-ups. Results indicate that pain coping and social support, assessed very early in the disease process, can affect long-term functional disability and pain in RA, and suggest that early interventions focusing on pain-related avoidance factors and social resources for patients at risk may beneficially influence long-term outcomes in RA.

Tailored cognitive-behavioral therapy in early rheumatoid arthritis for patients at risk: a randomized controlled trial.

&NA; Recent developments in chronic pain research suggest that effectiveness of cognitive‐behavioral therapy (CBT) may be optimized when applying early, customized treatments to patients at risk. For this purpose, a randomized, controlled trial with tailor‐made treatment modules was conducted among patients with relatively early rheumatoid arthritis (RA disease duration of <8 years), who had been screened for psychosocial risk profiles. All participants received standard medical care from a rheumatologist and rheumatology nurse consultant. Patients in the CBT condition additionally received an individual CBT treatment with two out of four possible treatment modules. Choice of treatment modules was determined on the basis of patient priorities, which resulted in most frequent application of the fatigue module, followed by the negative mood, social relationships and pain and functional disability modules. Analyses of completers and of intention‐to‐treat revealed beneficial effects of CBT on physical, psychological and social functioning. Specifically, fatigue and depression were significantly reduced at post‐treatment and at the 6‐month follow‐up in the CBT condition in comparison to the control condition, while perceived support increased at follow‐up assessment. In addition, helplessness decreased at post‐treatment and follow‐up assessment, active coping with stress increased at post‐treatment, and compliance with medication increased at follow‐up assessment in the CBT condition in comparison to the control condition. Results indicate the effectiveness of tailor‐made CBT for patients at risk in relatively early RA, and supply preliminary support for the idea that customizing treatments to patient characteristics may be a way to optimize CBT effectiveness in RA patients.

The Psychological Burden of Skin Diseases: A Cross-Sectional Multicenter Study among Dermatological Out-Patients in 13 European Countries

The contribution of psychological disorders to the burden of skin disease has been poorly explored, and this is a large-scale study to ascertain the association between depression, anxiety, and suicidal ideation with various dermatological diagnoses. This international multicenter observational cross-sectional study was conducted in 13 European countries. In each dermatology clinic, 250 consecutive adult out-patients were recruited to complete a questionnaire, reporting socio-demographic information, negative life events, and suicidal ideation; depression and anxiety were assessed with the Hospital Anxiety and Depression Scale. A clinical examination was performed. A control group was recruited among hospital employees. There were 4,994 participants––3,635 patients and 1,359 controls. Clinical depression was present in 10.1% patients (controls 4.3%, odds ratio (OR) 2.40 (1.67–3.47)). Clinical anxiety was present in 17.2% (controls 11.1%, OR 2.18 (1.68–2.82)). Suicidal ideation was reported by 12.7% of all patients (controls 8.3%, OR 1.94 (1.33–2.82)). For individual diagnoses, only patients with psoriasis had significant association with suicidal ideation. The association with depression and anxiety was highest for patients with psoriasis, atopic dermatitis, hand eczema, and leg ulcers. These results identify a major additional burden of skin disease and have important clinical implications.

Cognitive–behavioural therapies and exercise programmes for patients with fibromyalgia: state of the art and future directions

This review provides an overview of the effects of non-pharmacological treatments for patients with fibromyalgia (FM), including cognitive–behavioural therapy, exercise training programmes, or a combination of the two. After summarising and discussing preliminary evidence of the rationale of non-pharmacological treatment in patients with FM, we reviewed randomised, controlled trials for possible predictors of the success of treatment such as patient and treatment characteristics. In spite of support for their suitability in FM, the effects of non-pharmacological interventions are limited and positive outcomes largely disappear in the long term. However, within the various populations with FM, treatment outcomes showed considerable individual variations. In particular, specific subgroups of patients characterised by relatively high levels of psychological distress seem to benefit most from non-pharmacological interventions. Preliminary evidence of retrospective treatment analyses suggests that the efficacy may be enhanced by offering tailored treatment approaches at an early stage to patients who are at risk of developing chronic physical and psychological impairments.

Delirium in critically ill patients: Impact on long-term health-related quality of life and cognitive functioning.

Objective:To examine the impact of delirium during intensive care unit stay on long-term health-related quality of life and cognitive function in intensive care unit survivors. Design:Prospective 18-month follow-up study. Setting:Four intensive care units of a university hospital. Patients:A median of 18 months after intensive care discharge, questionnaires were sent to 1,292 intensive care survivors with (n = 272) and without (n = 1020) delirium during their intensive care stay. Measurements and Main Results:The Short Form-36v1, checklist individual strength-fatigue, and cognitive failure questionnaire were used. Covariance analysis was performed to adjust for relevant covariates. Of the 915 responders, 171 patients were delirious during their intensive care stay (median age 65 [interquartile range 58–85], Acute Physiology and Chronic Health Evaluation II score 17 [interquartile range 14–20]), and 745 patients were not (median age 65 [interquartile range 57–72], Acute Physiology and Chronic Health Evaluation II score 13 [interquartile range 10–16]). After adjusting for covariates, no differences were found between delirium and nondelirium survivors on the Short Form-36 and checklist individual strength-fatigue. However, survivors who had suffered from delirium reported that they made significantly more social blunders, and their total cognitive failure questionnaire score was significantly higher, compared to survivors who had not been delirious. Survivors of a hypoactive delirium subtype performed significantly better on the domain mental health than mixed and hyperactive delirium patients. Duration of delirium was significantly correlated to problems with memory and names. Conclusions:Intensive care survivors with delirium during their intensive care unit stay had a similar adjusted health-related quality of life evaluation, but significantly more cognitive problems than those who did not suffer from delirium, even after adjusting for relevant covariates. In addition, the duration of delirium was related to long-term cognitive problems.

A systematic review of bio-psychosocial risk factors for an unfavourable outcome after lumbar disc surgery

The objective of this systematic review is to summarize scientific evidence concerning the predictive value of bio-psychosocial risk factors with regard to the outcome after lumbar disc surgery. Medical and psychological databases were used to locate potentially relevant articles, which resulted in the selection of 11 studies. Each of these studies has a prospective design that examined the predictive value of preoperative variables for the outcome of lumbar disc surgery. Results indicated that socio-demographic, clinical, work-related as well as psychological factors predict lumbar disc surgery outcome. Findings showed relatively consistently that a lower level of education, a higher level of preoperative pain, less work satisfaction, a longer duration of sick leave, higher levels of psychological complaints and more passive avoidance coping function as predictors of an unfavourable outcome in terms of pain, disability, work capacity, or a combination of these outcome measures. The results of this review provide preliminary opportunities to select patients at risk for an unfavourable outcome. However, further systematic and methodologically high quality research is required, particularly for those predictors that can be positively influenced by multidisciplinary interventions.

Continued disability and pain after lumbar disc surgery: the role of cognitive-behavioral factors.

Abstract Cognitive‐behavioral factors are considered important in the development of chronic disability and pain in patients with low back pain. In a prospective cohort study of 277 patients undergoing surgery for lumbosacral radicular syndrome, the predictive value of preoperatively measured cognitive‐behavioral factors (fear of movement/(re)injury, passive pain coping, and negative outcome expectancies) for disability and pain intensity at 6 weeks and 6 months after surgery was investigated, taking into account the effect of possible confounding variables. Higher levels of cognitive‐behavioral factors were found to be associated with a worse outcome at both 6 weeks and 6 months. These associations remained significant after controlling for possible confounding variables (preoperative disability and pain intensity, age, gender, educational level, duration of complaints, neurological deficits, and intake of analgesics) and pain intensity 3 days postoperatively. In multiple regression analyses, the cognitive‐behavioral factors independently predicted different outcomes. Fear of movement/(re)injury predicted more disability and more severe pain at 6 weeks and more severe pain at 6 months; passive pain‐coping strategies predicted more disability at 6 months; and negative outcome expectancies predicted more disability and more severe pain at both 6 weeks and 6 months. The findings support the potential utility of preoperative screening measures that include cognitive‐behavioral factors for predicting surgical outcome, as well as studies to examine the potential benefits of cognitive‐behavioral treatment to improve surgical outcome.

Predicting Emotional Response to Unsuccessful Fertility Treatment: A Prospective Study

The predictive value of a comprehensive model with personality characteristics, stressor related cognitions, coping and social support was tested in a sample of 187 nonpregnant women. The emotional response to the unsuccessful treatment was predicted out of vulnerability factors assessed before the start of the treatment. The results indicated the importance of neuroticism as a vulnerability factor in emotional response to a severe stressor. They also underlined the importance of helplessness and marital dissatisfaction as additional risk factors, and acceptance and perceived social support as additional protective factors, in the development of anxiety and depression after a failed fertility treatment. From clinical point of view, these results suggest fertility-related cognitions and social support should receive attention when counselling women undergoing IVF or ICSI treatment.

Determinants of Psychological Distress and Its Course in the First Year After Diagnosis in Rheumatoid Arthritis Patients

In order to examine determinants of psychological distress and its course in the first year after diagnosis in rheumatoid arthritis patients, self-report data and clinical and laboratory measures were collected in 91 patients (70% female, mean age 57 years) shortly after diagnosis and 1 year later. Multiple regression analysis indicated that sex, pain and functional status, disease impact on daily life, life events, and perceived social support were related to psychological distress (anxiety and depressed mood) shortly after diagnosis. Coping strategies were related to distress levels only 1 year later. Multiple regression analysis of change in anxiety and depressed mood revealed that a decrease of psychological distress after 1 year could be predicted by male sex, an initially less severe inflammatory activity and an initially more extended social network. In addition, a decrease in distress was related to parallel improvements in clinical status. Results indicate the importance of a multimodal assessment of demographic variables, clinical and life stressors and social resources for the understanding of distress and the identification of risk factors in the first stage of the disease. Personal coping resources appear to become more important predictors of distress in a later phase of the disease.

How stress gets under the skin: cortisol and stress reactivity in psoriasis

Background  Psychological stressors might contribute to the severity of chronic inflammatory diseases such as psoriasis by dysregulating hypothalamic–pituitary–adrenal (HPA) axis activity.