Floris W. Kraaimaat

Beyond unfavorable thinking: the illness cognition questionnaire for chronic diseases.

The literature on chronic diseases recognizes the role of illness cognition as a mediator between stress and illness. Few conceptualizations and instruments, however, give an indication of both unfavorable and favorable ways of adjusting to an uncontrollable long-term stressor, such as a chronic disease. The authors propose 3 generic illness cognitions that reflect different ways of reevaluating the inherently aversive character of a chronic condition: helplessness as a way of emphasizing the aversive meaning of the disease, acceptance as a way to diminish the aversive meaning, and perceived benefits as a way of adding a positive meaning to the disease. A self-report instrument, the Illness Cognition Questionnaire, was developed to assess these cognitions across different chronic diseases. The results support the reliable and valid assessment of these illness cognitions in patients with rheumatoid arthritis and multiple sclerosis and indicate the maladaptive function of helplessness and the adaptive function of acceptance and perceived benefits for the long-term physical and psychological health of patients with a chronic disease.

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.

Pain-coping strategies in chronic pain patients: psychometric characteristics of the pain-coping inventory (PCI).

This article presents a series of studies aimed at validating a comprehensive pain-coping inventory (PCI) that is applicable to various types of patients with chronic pain. Item and scale analyses were performed for patients with rheumatoid arthritis (RA), patients with chronic headache, and pain clinic outpatients. The following 6 scales were derived from a simultaneous component analysis: Pain Transformation, Distraction, Reducing Demands, Retreating, Worrying, and Resting, all of which were internally reliable. A higher order factor analysis grouped the PCI scales into active (transformation, distraction, reducing demands) and passive (retreating, worrying, resting) pain-coping dimensions. Differences in use of strategy found between RA patients and headache patients indicated that the PCI scales were sufficiently sensitive to measure differences between groups. Concurrent validity was assessed for patients with RA and patients with fibromyalgia and predictive validity was assessed for patients with recently diagnosed RA after 1 and 3 years. In both analyses the validity of the scales was supported, in particular the predictive validity of passive coping scales for future outcomes.

Psychosocial Predictors of functional change in recently diagnosed rheumatoid arthritis patients.

In order to examine the influence of active and passive pain-coping strategies and social support characteristics on the change in functional status in the first stage of the disease in rheumatoid arthritis patients, self-report data and clinical and laboratory measures were collected from 91 patients (70% female, mean age 57 yr) shortly after diagnosis and 1 yr later. Multiple regression analyses indicated that, after taking the influence of demographic variables, disease activity and pain into account, a decrease in functional status (mobility, self-care, grip strength) after 1 yr could be predicted by an initially more frequent use of the passive pain-coping strategies of worrying and resting. A decrease in mobility could be additionally predicted by an initially smaller social network. Results indicate the impact of passive pain-coping strategies and social network characteristics for the prognosis of functional outcome in the first stage of the disease and suggest the early manifestation of avoidance mechanisms, including behavioral, cognitive-emotional and social components, in face of a chronic stressor.

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.

Quality of life in elderly subjects with pain in the hip or knee

This study examines the quality of life (QOL) of community living elderly people aged 55-74 with chronic, episodic or sporadic pain in the hip or knee and of a reference group without pain (total n=306). Firstly, it was hypothesized that the experienced QOL is lower in people with more chronic pain. Secondly, the potential mediating and moderating roles of disability and of coping with problems in general on the relationship between pain chronicity and QOL were assessed. A Visual Analogue Scale was used to assess global QOL. Physical as well as psychosocial disability was assessed with the Sickness Impact Profile (SIP). Coping with problems in general was assessed with the Utrecht Coping List. As expected, a significantly lower QOL was found in people with more chronic pain (p=0.045). The difference in QOL between the group with chronic pain and a reference group without pain was 10%. A multivariate regression model showed that physical and especially psychosocial disability are mediators in the relationship between pain chronicity and QOL and that ‘seeking social support’ as a coping style is a more important predictor of the experienced QOL than either pain chronicity or physical disability. No moderating role of the style of coping with problems was found.

The effect of cognitive behavior therapy in patients with rheumatoid arthritis

In order to examine the effectiveness of cognitive behavioral therapy for patients with rheumatoid arthritis (RA) three patients groups were studied: a cognitive behavioral therapy group (CBT), an occupational therapy group (OT), and a waiting-list control group. The CBT received a comprehensive, 10-session treatment package that taught progressive relaxation, rational thinking and the differential use of pain coping strategies. CBT resulted in minor changes in pain coping behavior at posttreatment, while CBT and OT showed an increase of knowledge of RA. No therapeutic effects with regard to health status were demonstrated at posttreatment and at 6 months follow-up. Clinical and laboratory measures of disease activity revealed progressive deterioration of the patients during the course of the study. It is suggested that the ineffectiveness of CBT might be due to the progressive course of RA in the patients studied, as well as to the rather small changes in coping behavior.

Stress-vulnerability factors as long-term predictors of disease activity in early rheumatoid arthritis.

OBJECTIVE Stress-vulnerability factors were studied for their ability to predict long-term disease activity in early rheumatoid arthritis. METHODS In a prospective study involving 78 recently diagnosed rheumatoid arthritis (RA) patients, the role of personality characteristics (neuroticism, extraversion), physical and psychological stressors (chronic, disease-related stressors of functional disability, pain, disease impact on daily life, as well as major life events), coping and social support at the time of diagnosis was examined to predict changes in clinical indicators of disease activity 1, 3 and 5 years later. RESULTS While stress-vulnerability factors failed to predict disease activity at the 1-year follow-up, disease activity at the 3- and 5-year follow-ups was predicted by coping and social support at the time of diagnosis, after adjusting for disease activity at first assessment, other biomedical and psychosocial factors and use of medication. Low levels of social support predicted increased disease activity at the 3-year follow-up, and high avoidance coping predicted increased disease activity at the 3- and 5-year follow-ups. CONCLUSION Findings indicate the potential prognostic value of avoidance coping and social support for the long-term course of disease activity in early RA and suggest that the effects of these vulnerability factors predominantly operate in the long term.