psychological stress as a predictor of psychological adjustment and health status in patients with...
TRANSCRIPT
Psychological stress as a predictor of psychological adjustment and
health status in patients with rheumatoid arthritis
Ruth Curtisa,*, AnnMarie Groarkea, Robert Coughlanb, Amina Gselb
aDepartment of Psychology, National University of Ireland, Galway University Rd., Galway, IrelandbDepartment of Rheumatology, University College Hospital, Galway, Ireland
Received 16 July 2004; received in revised form 1 October 2004; accepted 14 October 2004
Abstract
This study examined the extent to which perceived stress, social support, coping and clinical disease indicators predict physical,
psychological and social adjustment in patients with rheumatoid arthritis (RA). Participants were 59 women recruited at an outpatient clinic at
University College Hospital, Galway. A range of psychological measures was administered and disease status was assessed by physician
ratings of joint involvement and blood assays of inflammatory indices. Findings from correlational and hierarchical regression analyses
revealed a number of statistically significant relationships (p < .01). Perceived stress was a better predictor than disease severity of positive
and negative emotionality. Coping explained variability on positive and negative affect. Social support was linked to level of social activity.
Results demonstrated that disease status predicted illness related functioning but did not predict emotional or social adjustment. Results
suggest that a cognitive behavioural intervention to facilitate patient adjustment could usefully include management of stress and its appraisal,
the fostering of adaptive coping strategies and utilization of social support resources. It is concluded that improving patient adjustment to
rheumatoid arthritis has implications for medical care seeking.
# 2004 Elsevier Ireland Ltd. All rights reserved.
Keywords: Perceived stress; Coping; Social support; Rheumatoid arthritis
www.elsevier.com/locate/pateducou
Patient Education and Counseling 59 (2005) 192–198
1. Introduction
Stress has long been a focus among researchers interested
in psychosocial influences on health. Responses to stress are
many and include physiological changes, cognitive and
emotional reactions as well as behavioural responses [1]. In
medical contexts, for example, stress can alter health habits,
influence the recognition and reporting of symptoms and
indeed the seeking of medical care [2]. Stress has also been
associated with failure to comply with medical regimens
resulting in disease exacerbation [3]. Current approaches to
understanding stress emphasize the role of appraisal, in other
words, events are stressful to the extent that they are
perceived as such [4].
The transactional model of stress [5] when extended to
illness [6] highlights the important role of perceived stress,
* Corresponding author. Tel.: +353 91 524411x3002;
fax: +353 91 521355.
E-mail address: [email protected] (R. Curtis).
0738-3991/$ – see front matter # 2004 Elsevier Ireland Ltd. All rights reserved
doi:10.1016/j.pec.2004.10.015
coping style and perception of social support in adjustment to
chronic illness. In essence, the original model posits that the
perception that one is experiencing stress is a product of the
meaning of an event or situation and the evaluation of the
adequacy of coping resources and social support. Over the
past number of years, research findings increasingly indicate
that the symptoms and signs of rheumatoid arthritis (RA)
(persistent pain, joint stiffness and damage) produce not only
substantial physical disability but also have important
psychological and social sequelae [7]. Individuals can vary
greatly in their adaptation to the disease and this is not always
well explained by variations in the inflammatory activity [8].
Because RA has an immunological basis it can potentially be
influenced by factors that affect the immune system, for
example, psychological stress [9]. In a series of well-designed
studies, Zautra and coworkers have reported that people with
RA in comparison to people with osteoarthritis have a higher
psychological and physiological reactivity to stress [10,11].
Results such as these demonstrate the importance of further
understanding how stress impacts on people with RA.
.
R. Curtis et al. / Patient Education and Counseling 59 (2005) 192–198 193
Coping is increasingly recognized as an important variable
in understanding adjustment to arthritis. Chronically ill
persons report using more avoidant coping strategies such as
escape/avoidance [12] denial or behavioural disengagement
than active coping strategies like problem solving when
confrontedwith a stressful situation [13].Use of such avoidant
strategies is associated with increased psychological distress
[14], and may be a risk factor for adverse responses to illness
[15]. InpatientswithRAavoidant coping (e.g. denial) predicts
poor adjustment [16]. The majority of studies examining
coping in patients with RA focus primarily on disease related
stressors. Two previous studies, which assessed the effect of
generic coping on emotional adjustment, did not show
consistent results though using similar methodology [16,17].
Research consistently demonstrates that social support
reduces psychological distress such as depression and
anxiety during times of stress [18], and has shown that it
promotes psychological adjustment to chronic illnesses
including RA [19]. A number of studies have examined the
relationship of social support to health and psychological
outcomes of persons with arthritis and found that patients
with higher daily emotional support experienced much
higher levels of emotional well-being and were less
depressed [20]. Furthermore lower network size leads to
decreased levels of social activity for people with RA [21].
With regard to adjustment indices studied, much of the
research to date has concentrated on the important aspects of
physical functioning and negative affective concomitants of
the disease, for example depression, and it tends to neglect
positive mood [22], and social adjustment. Evidence from
studies, however, examining the link between illness activity
and depression are inconclusive varying from supporting a
positive relationship [23], to suggesting a relative indepen-
dence between them [24]. Investigation of normal emotional
processes—using, for example, the two-dimensional model
of positive and negative affect proposed byWatson et al. [25],
is likely to be more appropriate for explicating the emotional
impact of chronic illness [26]. When coping studies in RA
have included a measure of positive affect, findings are
inconsistent. Some report that active or problem-solving
coping has no effect on negative affect and instead operates to
increase positive affect [12], whereas others fail to find a
relationship between this type of coping and positive affect
[27]. Further research is therefore needed which compares
the relative influence ofmedical and psychological factors on
depression in RA and that extends the range of outcomes to
include social adjustment and positive affect.
Therefore, the purpose of the present study was to
examine the role and relative impact of, psychological stress,
coping, social support and disease status on physical,
psychological and social adjustment in womenwith RA. The
specific hypotheses are
Hypothesis 1. High levels of perceived stress will be asso-
ciated with poor physical, psychological and social adjust-
ment.
Hypothesis 2. Low adaptive and high avoidant coping will
be associated with poor physical, psychological and social
adjustment.
Hypothesis 3. Low level of social support will be asso-
ciated with poor physical, psychological and social adjust-
ment.
Hypothesis 4. Level of disease activity will be largely
unrelated to psychological mood status in patients with RA.
2. Method
2.1. Participants
Participants were a group of 59 of a possible 62 women
attending an outpatient clinic at University College Hospital
Galway who agreed to participate, the majority of whom
were from a rural background. They had a mean age of 60
and illness duration of 13 years. They were a middle aged to
elderly group with a fairly well established disease history.
2.2. Procedure and measures
The following psychological measures based on their
robust psychometric properties were administered during a
2-hour semi-structured interview. Perceived Stress Scale
(PSS) [28] based on Lazaras and Folkmans’ [5] concept of
appraisal was designed to tap the degree to which
respondents found their lives unpredictable, uncontrollable
and overloaded. It is a 14-item scale, which refers to events
occurring in the previous month. Respondents are asked to
indicate howoften they thought or felt a certainway on a five-
point Likert scale ranging from 0 = never to 4 = very often.
Scores can range from 0 to 56 with higher scores indicating
more perceived stress. Internal consistency as measured by
Cronbach’s alpha was 0.75. Test–retest reliability over 6
weeks was 0.55. Cohen et al. [28] also showed evidence of
concurrent and predictive validity for the PSS.
The COPE [29], which includes a range of 15 emotion
focused (e.g. turning to religion) and problem focused (e.g.
planning) strategies assessed coping style. Each subscale
consists of four items. This inventory was developed on
theoretical grounds drawing from the Lazarus’ model of
stress [5] and a model of behavioural self-regulation. Five
scales measure conceptually distinct aspects of problem-
focused coping (active coping, planning, suppression of
competing activities, restraint coping, seeking of instru-
mental social support). Five scales measure aspects of what
are viewed as emotion-focused coping (seeking of emotional
social support, positive reinterpretation and growth, accep-
tance, denial and turning to religion). Three scales measure
the coping responses of focus on and venting of emotion,
behavioural disengagement and mental disengagement).
These subscales were derived from a factor analysis of
R. Curtis et al. / Patient Education and Counseling 59 (2005) 192–198194
items. The two remaining sub-scales, alcohol/drug use and
humour, were developed after the other scales and are
regarded as more exploratory. The dispositional version of
the COPE was employed in the present study. This approach
asks respondents to indicate the extent to which they make
use of each coping response when they experience stressful
events. Responses are made using a four-point Likert scale
(viz., 1 = I usually do not do this at all, 4 = I usually do this a
lot). Scores on each scale range from 4 to 16. The
psychometric properties of the COPE are sound [29]. Given
the sample size in the present study and the fact that there are
13 COPE scales a factor analysis was carried out to reduce
the number of coping strategies analysed which resulted in
two broad categories namely an adaptive and an avoidant
factor.
The social support survey [30] is a brief multidimensional
scale. It measures emotional/informational support, tangible
support, positive social interaction and affectionate support.
It also gives a total social support score, a composite of these
subscales and a single item measure of structural support
(number of close friends and relatives) and marital status.
For each item, patients were asked to indicate how often
each kind of support was available to them if they needed it.
Response choices were ‘‘none of the time’’, ‘‘a little of the
time’’, ‘‘some of the time’’, ‘‘most of the time’’ and ‘‘all of
the time’’. The subscales are reliable (all alphas > .91) and
are fairly stable across time.
The Positive and Negative Affect Scale (PANAS) [31]
was also used as a measure of adjustment. This scale was
developed as a brief measure of the predisposition to
experience negative and positive mood states. The scale
consists of 20 adjectives, 10 of which describe positive
moods (e.g. excited, enthusiastic, inspired) and 10 which
describe negative moods (e.g. distressed, guilty, hostile). On
a five-point scale from ‘‘very slightly or not at all’’ to
‘‘extremely’’, respondents rate the extent to which the items
reflect their feelings. Scores are derived by adding ratings for
the 10 positive adjectives to obtain the PA score, and by
adding those for the 10 negative adjectives to obtain the NA
score. Both scales show good internal consistency exceeding
0.84. Total scores for each affect scale range from 10 to 50.
The PANAS has proven psychometric properties [31,32].
The Arthritis Impact Scale (AIMS) was used to assess
physical, psychological and social functioning [33].
Adjustment scores were derived from three of the main
scales of the inventory, namely, physical function, social
activity and depression. A physical function score can be
obtained from combining scores on the mobility, physical
activity, dexterity, household activities and activities of daily
living subscales. Since there are differing numbers of items
across the sub-scales, the authors have provided a normal-
ization procedure whereby each sub-scale is positioned on a
0–10 range on which lower scores represent better health
status. The AIMS is a validated, reliable and sensitive
questionnaire commonly applied to rheumatic diseases
particularly RA [32,33].
Blood samples were taken by the medical team in the
outpatient clinic following each patient interview to
assess inflammatory indices Erythrocyte Sedimentation
Rate (ESR) and C-Reactive Protein (CRP). Levels of
joint involvement and ratings of disease activity and
severity for each patient were also provided by the same
Consultant Rheumatologist. The majority of the samples
were in an inactive phase 58% versus 42% and the majority
were mild to moderate (90% versus 10% severe) in disease
status.
2.3. Statistical analysis
Pearson correlation coefficients were used to assess the
relationship between disease indicators and psychological
variables with adjustment.
Hierarchical regression analyses were used to identify
sets of variables significantly related to adjustment. This
allows an examination of the influence of a set of variables
entered collectively on a dependent variable when the effects
of prior sets of variables are held constant. To avoid Type 1
error the level required for significance was set at 0.01 (two
tailed).
To minimize the number of coping predictors entered in
the regression analyses, given the sample size, a principal
components factor analysis was conducted on the subscales
of the COPE. Using a cutoff loading of �.60 yielded two
factors adaptive coping (mean = 43.2, S.D. = 4.6) and
avoidant coping (mean = 10.5, S.D. = 3.7). The adaptive
factor included planning, acceptance, active coping, positive
reinterpretation and growth and seeking instrumental social
support while the avoidant factor consisted of denial and
behavioural disengagement.
3. Results
The descriptive data in Table 1 demonstrate that the
patients experienced moderate rather than high levels of
perceived stress and that they reported relatively high levels
of overall social support. On adjustment indices they
perceive the impact of their disease as moderate on physical
and social functioning and as a group do not display a very
significant level of affective distress. Turning to religion,
acceptance and active planning are some of the key coping
strategies utilized by these women as shown by the mean
values in Table 1. For example, the group mean for turning to
religion is 12.94 out of a possible 16.
Correlations between the independent and dependent
variables are presented in Table 2. High perceived stress was
related to high scores on depression and negative affect. It
was related to low positive affect. High social support was
associated with high levels of social activity. Adaptive
coping was related to good social activity and high positive
affect whereas avoidant coping was linked to high negative
affect.
R. Curtis et al. / Patient Education and Counseling 59 (2005) 192–198 195
Table 1
Descriptive data of study variables
Variable Test range Mean S.D.
Perceived stress 0–56 22.04 8.80
Social support 19–90 71.18 16.80
COPE 4–16
Active coping 10.47 2.90
Planning 11.32 2.94
Seeking instrumental social support 10.82 3.56
Seeking emotional social support 10.33 3.50
Suppression of competing activities 9.94 3.10
Turning to religion 12.94 4.26
Positive reinterpretation and growth 10.88 2.96
Restraint coping 10.43 3.29
Acceptance 12.24 2.52
Focus on and venting emotions 9.58 3.81
Denial 6.55 2.74
Mental disengagement 8.24 2.50
Behavioural disengagement 7.05 2.62
AIMS 1–10
Total physical function 3.46 2.30
Social activity 4.16 1.96
Depression 2.98 2.35
PANAS 10–50
Negative affect 18.25 7.27
Positive affect 32.89 7.91
Disease status
Erythrocyte sedimentation rate (ESR) 34.93 29.38
Joint count 7.69 3.67
Finally, a high joint involvement was indicative of poor
physical function and low positive affect.
The results of the hierarchical regression analyses are
presented in Table 3.
Adj. R2 value denotes the amount of variance explained
by a variable set. Adj. R2 change can be computed by
subtracting the variance explained on a variable set from the
amount of variance explained on the preceding set. This Adj.
R2 change value provides the amount of incremental
variance explained. In this instance, it helps to ascertain
the relative predictive value of age and disease duration
variable, disease status (ESR and joint count), perceived
stress and social support on the five adjustment indices. This
order allows for an estimate of additional variance explained
by social support over and above that explained by perceived
stress.
Table 2
Pearson product moment correlations between perceived stress, social support, c
Perceived stress Social support Adap
Physical function .12 �.01 .11
Social activity .11 �.37** �.34
Depression .41*** �.31 �.00
Positive affect �.41** .25 .47
Negative affect .66*** �.15 �.00
Note: high scores on AIMS indicate poor adjustment N = 59.** p < .01.*** p < .001.
3.1. Physical function
The disease set was the only one to explain a significant
proportion of the variance on physical function (14%) (Adj.
R2 change = .14). The b correlation coefficients in Table 3
show that it is the degree of joint involvement that had the
greater impact.
3.2. Social activity
Table 3 shows that only social support (Step 4) accounted
for variance in social activity (Adj. R2 change = .12) the bvalue (�.42) showing that high support was indicative of
high social activity.
3.3. Depression
Perceived stress proved to be the most significant
predictor of depression (Adj. R2 change = .14). The b
coefficient shows that high stress was connected to high
depression.
3.4. Positive and negative affect
Table 3 indicates that of the variables entered, perceived
stress explained 42% of the variance on negative affect (Adj.
R2 change = .42) and 13% on positive affect (Adj. R2
change = .13). The b coefficients show that those with a high
level of stress show high negative and low positive affect.
3.5. Coping
A second series of hierarchical regression analyses was
carried out with coping (adaptive and avoidant factors)
entered in Step 4 instead of social support (not shown in
table). This order again allows for an estimate of additional
variance explained by coping over and above that explained
by perceived stress.
The coping set failed to explain variance on physical or
social adjustment but explained variance on two of the
psychological outcomes, negative and positive affect.
Coping explained an additional 10% of variance on
negative affect (F = 9.4; P < .001; Adj. R2 = .54; Adj. R2
change = .10) over the 44% explained by stress when
oping, clinical disease indicators and adjustment outcomes
tive coping Avoidant coping Joint count ESR
.12 .44*** .006** �.03 .28 .05
7 .13 .23 �.03*** �.15 �.34** �.14
2 .43*** .09 .04
R. Curtis et al. / Patient Education and Counseling 59 (2005) 192–198196
Table 3
Hierarchical multiple regression analysis explaining adjustment by demographic disease variables, stress and social support
Predictors Adjustment measures
AIMS PANAS
Physical function Social activity Depression Positive affect Negative affect
b F Adj. R2 b F Adj. R2 b F Adj. R2 b F Adj. R2 b F Adj. R2
Step 1
Demographics 2.1 .043 .24 �.03 1.4 .01 .46 �.02 .07 �.03
Age �.04 �.09 .00 �.03 �.04
Illness duration .32 .10 .29 �.08 .10
Step 2
Disease 3.8** .185 1.8 0.1 1.7 .05 1.7 .05 .04 �.08
ESR .08 �.05 �.02 .12 .01
Joint count .41** .33 �.19 �.29 �.15
Step 3
Perceived stress .05 3.1 .171 �.04 .96 �.003 .42** 3.4** .19 �.38** 3.1** .18 .71*** 8.4*** .42
Step 4
Social support �.009 2.5 .153 �.42** 2.2** .12 .02 2.8 .17 �.02 2.5 .16 .03 6.8 .41
** p < .01*** p < .001.
entered on Step 3. Coping explained 19% of variance on
positive affect (F = 5.0; P < .001; Adj. R2 = .36; Adj. R2
change = .19) beyond the 17% explained by perceived stress
on Step 3. The b values suggest that it is the use of avoidant
strategies, which is contributing to high negative affect
(adaptive b = .13 ns; avoidant b = .28, P < .01). Conversely,
it is the use of adaptive strategies that are contributing more
to high positive affect (adaptive b = .47, P < .001; avoidant
b = �.17 ns).
4. Discussion and conclusion
4.1. Discussion
The present study examined the role and relative impact
of perceived stress, social support, coping and disease status
on physical, social and psychological adjustment in Irish
women with RA.
Correlational and hierarchical regression analyses
showed that perceived stress was related to the three
affective domains, depression, positive and negative affect.
This is in line with Zautra’s finding for example, that
perceived stress has a strong relationship with depression in
women with RA [10] and that high levels of stress were
related to poor psychological adjustment in such patients
[34]. An important finding here is that low perceived stress
was related to positive affect having controlled for disease
status, age and duration of disease and not just to an absence
of negative affect. Other studies have reported that the
presence of positive affect reduces the size of the relation-
ship between pain and negative affect in patients with RA
[35] so it is an important variable to include in future studies.
Stress did not have a role to play in explaining variability
in either physical or social adjustment. So, even though high
stress predicts emotional distress, in this study it is not linked
to physical symptomatology such as reports of greater
physical dysfunction. Caution, however, must be exercised
in interpreting these results as there is the issue of
differentiating stress appraisal from psychological distress
which ideally should involve controlling for initial emo-
tional status of participants [36] which would require a
prospective design.
In correlational analysis, high social support was related
to good social adjustment similar to other research findings
in patients with RA [37,38]. In hierarchical regression
analyses, social support was the best predictor of social
activity (frequency of contact with friends and social outings
in the last month). This is an interesting finding focusing as it
does on the quantitative rather than the qualitative nature of
social support and is in line with Evers and colleagues’
finding that those with smaller social networks experience a
decrease in mobility [16]. Social support was not related to
nor did it predict depression, anxiety, positive or negative
affect and this contrasts with those studies that have found
strong relationships between these variables [19,20,39]. A
possible explanation may be that this group of women
reported relatively high levels of social support and
moderate levels of stress and affective distress.
In correlational analysis, adaptive coping was linked to
good social adjustment and high positive affect while
avoidant coping was associated with high negative affect
concurring with previous findings in patients with RA
[12,40]. Descriptive data indicated that turning to religion,
for example, was a commonly used strategy, which is
interesting as Keefe et al. have pointed out that patients with
RA who reported frequent daily spiritual experiences had
higher levels of positive mood, lower levels of negative
mood and higher levels of social support [41]. In hierarchical
regression analyses, the coping set predicted variance on
R. Curtis et al. / Patient Education and Counseling 59 (2005) 192–198 197
negative and positive affect. It seemed that it was the
frequent use of adaptive strategies such as acceptance or
active coping that had the strongest association with high
positive affect. Acceptance means that the patient accepts
the reality of the stressful situation and active coping means
taking active steps to alter the source of stress and its effects.
Similarly it is the frequent use of avoidant coping, for
example, denial that is related to negative emotionality.
When disease status was examined it would appear that it
was a significant predictor of perceived physical function-
ing. While correlational analysis did find a relationship
between high joint involvement and low positive affect,
when joints and ESR were entered into hierarchical
regression analysis as a set, they failed to reach significance
on this outcome. Disease status did not predict any variance
in social or psychological adjustment and in this study seems
to be relatively independent of them. These findings are in
keeping with those that show that disease activity measures
were not related to depression [11]. It is important, therefore,
for clinicians, to be aware that depression is not always
related to disease activity, hence, other variables must be
involved. It would seem from this study that psychosocial
variables are more important than patients’ level of disease
activity in understanding their positive and negative
emotional status.
This study, however has a number of limitations which
must be considered in interpreting the results. The cross-
sectional nature of the study makes it impossible to draw
conclusions about the causal direction of the relationships
observed between perceived stress and emotional adjust-
ment and between social support and social activity. A
prospective research design would facilitate further delinea-
tion of these issues. Generalization of findings to the entire
RA patient population is limited both by the modest sample
size and by the potential selectivity bias as only those well
enough to attend an outpatient clinic were included.
4.2. Conclusion
In sum, results demonstrate that perceived stress is a
better predictor than disease status of emotional distress and
positive affect in patients with RA. The manner in which
people cope with general life stress did not predict illness
related functioning or social adjustment but it seems to have
an important role to play in predicting negative and positive
mood state. These results indicate that future studies should
include an analysis of those factors that enhance positive
affect in patients with RA. High social support predicted
good social activity and interrogating this aspect of patients’
lives may bear fruit as enhancing their social integration may
have the added benefits of greater social activity. Finally,
disease status predicted perceived physical functioning but
did not predict emotional or social adjustment. To further
advance our understanding of psychosocial factors in
chronic illness in general it has recently been proposed
that patients should be selected as participants in research
studies as soon as possible after their diagnosis [42].
4.3. Practice implications
Overall, results indicate that mood status is not related to
disease status. This is an important finding as other research
reports that it is often emotional distress that bring repeated
surgery visits because medical personnel are considered to
be good confidants [3]. Results suggest that a cognitive
behavioural intervention to facilitate patient adjustment
could usefully include management of stress and its
appraisal, the fostering of adaptive coping strategies and
utilization of social support resources to promote social
integration. In improving patient adjustment to rheumatoid
arthritis it is envisaged that reliance on physicians for
emotional rather than disease related problems will
diminish.
Acknowledgements
We are very grateful to the medical and nursing staff at
the outpatient rheumatology clinic for their involvement and
cooperation. We thank the participants who gave a
considerable amount of time to the project.
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