The role of perceived and actual disease status in adjustment to rheumatoid arthritis

A. Groarke, R. Curtis, R. Coughlan1 and A. Gsel1

Department of Psychology, National University of Ireland and 1 Department of Rheumatology, University College Hospital, Galway, Ireland.

Correspondence to: A. Groarke, Department of Psychology, National University of Ireland, University Road, Galway, Ireland. E-mail: annmarie.groarke{at}nuigalway.ie


    Abstract
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Objectives. To examine the role and relative impact of illness perceptions, coping strategies and clinical disease indicators on adjustment in patients with rheumatoid arthritis.

Method. Participants were 75 women with rheumatoid arthritis. The Illness Perception Questionnaire (IPQ), the COPE questionnaire and the Arthritis Impact Measurement Scale (AIMS) were administered during a semistructured interview. Disease status was indicated by physician ratings of joint involvement and by the laboratory indices of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP).

Results. Statistically significant correlations (P<0.01) were in the expected direction. Various aspects of adjustment (good physical function, low pain and depression) were associated with perceptions of low illness identity, high control/cure, more serious illness consequences and long illness timeline. Low disease activity was related to good physical function. Depression was associated with high use of coping by denial and with less frequent use of five COPE strategies: active coping, planning, seeking instrumental social support, positive reinterpretation and growth, and acceptance. In hierarchical regression analysis, disease status explained variance in physical function (15%). Illness perceptions accounted for variance in all three adjustment outcomes, ranging from 22 to 27%. Coping variables did not add to the explanation of variance on adjustment.

Conclusions. Illness perceptions have significant implications for adaptation to illness and they outweigh the impact of medical disease status on depression, physical function and pain. Health interventions based on understanding and modifying perceptions of illness may prove useful in facilitating patient well-being.

KEY WORDS: Illness perceptions, Coping, Disease activity, Adjustment, Rheumatoid arthritis


    Introduction
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
In health psychology, research has examined the manner in which people cope with chronic illness. One of the interesting findings is that individuals can vary greatly in their adaptation to the same chronic disease. At any given level of pain and/or physical symptoms, some individuals with rheumatoid arthritis (RA), for example, seem to be minimally affected by their condition, whereas others demonstrate considerable functional impairment and poor psychological adjustment [1]. An important challenge to health professionals is to identify the factors that differentiate between those patients who do and those who do not successfully adjust to their condition.

Given the debilitating nature of a disease such as RA, several studies have investigated its impact on psychological distress. Numerous studies have indicated that depression can frequently accompany the RA disease process [2–6]. Many studies report a prevalence rate ranging from 20 to 35% [2, 3, 7–10].

Researchers have investigated a variety of disease variables [e.g. erythrocyte sedimentation rate (ESR), joint count, grip strength, radiological status, antinuclear antibodies] to determine if these factors can predict depression. Evidence from these studies varies from supporting a positive relationship [11–14] to suggesting relative independence between illness severity and psychological status [15–18]. Consequently the strength of this relationship remains unclear and warrants further investigation.

Confusion also remains in regard to the role of clinical measures of disease in predicting perceived disability. In some studies, objective clinical variables were also shown to predict functional status [19, 20]. In others, biochemical markers did not add to the discriminative power in either self-report or objective measures of functional outcome [21–23]. Findings are also variable in regard to the relative status of psychological and disease factors in self-reported functional impairment. Psychological state has sometimes equalled [24] or added to [20] the amount of variance explained by disease activity measures. In some studies it failed to predict function beyond disease [23] and in others it was revealed to be a more powerful predictor [22].

Overall, differences in psychological mood state and perceived functional status are not fully explained by variations in disease status, suggesting that additional explanatory variables are needed.

A recent approach to understanding adaptation to illness, the mental representation perspective, indicates that the manner in which people adapt to chronic health problems is influenced to a significant degree by their appraisal and perceptions of their illness. This research is guided by the ‘self-regulation’ model of responses to health threat [25, 26]. Several studies across a variety of illness contexts have identified five cognitive representations around which an illness experience is organized. There are beliefs about identity, which are ideas held about the illness label and the link with symptoms. This is typically measured in terms of how often each of a core list of symptoms is experienced as part of the patient's illness experience. The other dimensions concern beliefs about an illness in terms of its causes, consequences (beliefs about the illness severity and its likely impact on physical, social and psychological functioning), timeline (how long the illness will last) and controllability [27–32].

Illness perceptions such as long timeline (perceiving the illness as chronic), high illness identity and consequences (i.e. reporting a high number of symptoms and high perceived illness severity), and low perceived illness control have been shown to predict depression [33–37], poor mental health [38–42] and poor reported physical health status [37, 40, 43–45] across a range of illness conditions. To date, however, only a small number of studies have adopted the self-regulation approach in order to understand the adaptive process in RA [34, 45–47].

Those who viewed their illness as serious and not amenable to control [46] or cure [34] were more depressed. While these studies controlled for illness severity in these relationships, it was based on self-report of functional status. One study [45] which did include objective measures of disease status was able to compare the relative predictive value of disease status and illness perceptions. In this study medical variables explained some of the variance (6%) in disease-specific functioning (Health Assessment Questionnaire) but illness perceptions, namely, the identity and control scale scores, explained a further 35% of the variance. Further research examining these relationships is needed.

Therefore, the purpose of the present study was to examine the role of mental representations of illness, as defined within the self-regulation framework, and the role of disease status in physical and psychological adjustment. A number of studies within the self-regulation approach have also compared the role of illness cognitions and illness coping in adjustment. While the model suggests that coping mediates the relationship between illness representations and outcome, these studies show evidence of direct paths from illness representations to outcome and suggest that illness perceptions are more strongly associated with adaptive outcome than is coping [38, 39, 41, 45].

A large number of investigations of coping and adjustment in patients with RA in the last two decades have used the stress-coping framework of Lazarus and Folkman [48]. The emphasis in many of these studies has been on coping with illness [e.g. 49–53]. Of interest in the present study is the role of generic or dispositional coping in people with RA; that is, how they deal with stressful situations in general. Two previous studies which assessed the effects of coping with stressors of everyday life on emotional adjustment in RA patients did not show consistent effects even though they used similar scales. In cross-sectional analyses, one study found that avoidant coping was associated with poor psychological adjustment [54], whereas it was not a significant determinant of mood in the other [55].

The present study therefore examines the role and relative impact of medical disease status and perceived disease status (i.e. illness perceptions) on depression, pain and physical function in patients with RA. It furthermore examines the role of dispositional coping strategies in explaining variance in these domains of adjustment.


    Patients and methods
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Participants were women who were attending an out-patient rheumatology clinic under the care of the consultant rheumatologist. Following hospital approval for the study, patients were invited to participate by letter. Ninety-six successive female patients with a diagnosis of RA according to the revised 1987 American College of Rheumatology criteria [56] were invited to participate, 75 (78.1%) agreed to take part. The study was restricted to patients who attended the government-funded medical health-care clinic. Only patients who were free from other major medical diseases were included. The psychological questionnaires were administered during a semistructured interview which took place following each patient's medical consultation. Blood samples were also taken by the medical team at the out-patient clinic at this time.

Measures
Illness perceptions were derived from four of the five scales of the Illness Perception Questionnaire (IPQ) [43].

  1. The Identity scale is composed of symptom items that the patient rates for frequency on a four-point scale ranging from ‘all the time’ to ‘never’.
    In the present study 11 symptoms were rated (e.g. pain, swelling of joints, evening fatigue, stiff joints). The scale was scored by summing the number of items endorsed at ‘occasionally’ or greater, so that the total score ranged from 0 to 11.The items from the other scales are presented in mixed order.
  2. Timeline is a three-item scale reflecting the patient's belief about how long the illness will last; higher scores indicate a more chronic timeline perception.
  3. Consequences contains seven items which refer to the perceived physical emotional and economic consequences of the illness. It assesses the impact of the disease on the patient's life and higher scores are indicative of more serious consequences.
  4. Cure/control is a six-item scale assessing belief about the potential for recovery and belief that the illness can be controlled by the self or by powerful others. High scores show a greater belief in effective control/cure.
  5. The Causes scale is measured with 10 items that refer to possible causes of an illness. A belief in a psychological cause could pertain to stress and a belief in a biological cause could pertain to pollution. It is not appropriate to sum all of the items as each item represents a specific causal belief. For this reason, these scores were not included in the statistical analyses of the present study.

The items from IPQ scales 2–5 are rated by the patient on a five-point scale ranging from ‘strongly disagree’ to ‘strongly agree’ (scored 1–5). After appropriate reverse scoring of items, scores for timeline, consequences and cure/control are obtained by summing all the scale items and dividing by the number of items. The IPQ scales have been shown to have good levels of reliability and validity [43, 57]. Data collected on several patient groups show satisfactory test–retest reliability for the scales (e.g. at 1 month coefficients range from 0.49 for timeline to 0.84 for identity) and alpha coefficients ranging from 0.82 to 0.89 for identity, 0.66 –0.73 for timeline, 0.79–0.82 for consequences and 0.61–0.73 for cure/control have been reported [39, 41, 43].

Coping strategies were assessed with the COPE inventory [58], which is based in part on the Lazarus model of stress [48]. Five scales measure conceptually distinct aspects of problem-focused coping: (i) active coping (taking action to remove the stressor); (ii) planning; (iii) suppression of competing activities (suppressing one's attention to other activities in order to concentrate more completely on dealing with the stressor); (iv) restraint coping (coping passively by holding back one's coping attempts until they can be of use); and (v) seeking of instrumental social support. Five scales measure aspects of what are viewed as emotion-focused coping: (i) seeking emotional social support; (ii) positive reinterpretation and growth (making the best of the situation by growing from it); (iii) acceptance; (iv) denial; and (v) turning to religion. The remaining three scales measure (i) focusing on and venting emotions (increased awareness of one's emotional distress and a tendency to discharge those feelings); (ii) behavioural disengagement; and (iii) mental disengagement. (psychological or behavioural withdrawal from the goal with which the stressor is interfering). The COPE inventory can be used to assess dispositional coping (typical responses to stressors) or it can be used to assess situational coping (responses to a specific situation or during a specific time period). Each subscale contains four items and responses are made using a four-point Likert scale (such as 1 = I usually don’t do this at all; 4 = I usually do this a lot). Scores on each scale range from 4 to 16. The higher the score, the more often the coping strategy is used. The psychometric properties of the COPE are robust [58].

Disease status was measured by physician ratings of joint involvement, swollen joint count and tender joint count, and biochemical laboratory tests of ESR and C-reactive protein (CRP). Based on these data, patients were also classified as having active disease status or inactive disease status by the rheumatologist. A global assessment of disease severity status as mild, moderate or severe was also provided.

The Arthritis Impact Measurement Scale (AIMS) [59] was used to assess physical function, pain and depression. The AIMS is a 63-item questionnaire. Eight of the scales can be grouped into three broad components of health status: (i) physical function, which includes mobility (ability to move around the community), physical activity (lower extremity function), physical dexterity (upper extremity functions), household activities (basic household tasks) and activities of daily living (basic self-care activities); (ii) psychological status (which includes a depression scale and an anxiety scale); and (iii) pain. Each subscale score is positioned on a 0–10 range on which lower scores represent better health status. The physical function, pain and depression scales were used in the present study. The AIMS has been subjected to a number of careful psychometric evaluations and it is considered to be a valid and reliable measure [57, 59].

Statistical analyses
Statistical analysis was carried out using the SPSS for Windows statistical software package (version II). Bivariate relationships between adjustment and the disease and psychological characteristics were examined using Pearson correlation coefficients. Hierarchical regression analysis was used to identify the sets of variables significantly related to the adjustment indices. This allows 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. The level required for significance was set at (two-tailed) to avoid the risk of chance results.


    Results
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Participants had a mean age of 60.1 yr (S.D. 12.1) and a mean illness duration of 12.6 yr (S.D. 10.8). The majority were married (61%) and some were widowed (17%). More of the group were living in a rural area (55%) than an urban one.

The descriptive statistics are shown in Table 1. Examination of the mean scores for the illness perceptions show that these RA patients report a moderate to high number of illness symptoms on the identity scale. They tend to view their illness as moderately serious and controllable. They view the timeline of their illness as long-term. This is in line with the mean IPQ scale scores for a sample of RA patients reported by the authors of the questionnaire [43]. Scores on the COPE show that this group of patients most frequently use three emotion-focused coping strategies. The strategy of turning to religion was used most often, followed by the use of acceptance and positive reinterpretation and growth respectively. Although normative data are lacking, the authors of the COPE [58] presented data for the dispositional version from a sample of University students (n = 1030). Overall, the mean scores were similar to those obtained in this study. In terms of rank order, the three strategies used most often were planning (12.5), positive reinterpretation and growth (12.4), and active coping (11.8). The difference between the RA patients and the general group was greatest on two scales, namely turning to religion (13.1 vs 8.8) and seeking instrumental social support (9.6 vs 11.5) respectively.


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TABLE 1. Means and standard deviations of study variables and bivariate correlations between illness perceptions, coping, disease indicators and three measures of adjustment

 
On the AIMS, this group of RA patients showed fairly good physical function and reported a moderate level of pain. As a group they did not display very significant levels of depression. These mean scores were very similar to those found with other samples of RA patients [60, 61]. Using a cut-off score on the AIMS [3], with a score of ≥3, 39% of the sample would be classified with possible depression. Using a cut-off score of ≥4, 27% would be classified with probable depression.

Information on disease activity was available for 74 patients. Logarithmic transformation was carried out on the CRP results to correct for skew. Physician ratings showed that the majority were in an inactive disease phase (58%). Over one-quarter (26%) were in the severe disease range. Slightly more than this (29%) were described as having mild disease. The largest number of patients (45%) were in the moderate range.

Correlations of illness perceptions, coping and disease status with adjustment
Correlations between the independent and dependent variables are presented in Table 1. Only statistically significant values at or beyond the 0.01 level were entered. Illness identity was associated with physical function, pain and depression such that the more symptoms which are reported the poorer the status on these dimensions. More serious illness consequences were associated with more physical dysfunction and higher reported pain. Correlations between control/cure and outcomes show that patients who perceive their illness as more controllable report less physical dysfunction, pain and depression. A long illness timeline was associated with poor physical function.

Use of the strategy of coping by planning was associated with better overall physical function. More depression was associated with less frequent use of five COPE strategies: active coping, planning, seeking instrumental social support, positive reinterpretation and growth, and acceptance and with frequent use of denial as a means of coping. The table shows that a higher level of CRP and greater joint involvement were associated with poor physical functioning.

Regression analyses
Hierarchical multiple regression analyses were performed to assess the relative contributions of demographic, medical disease status and psychological variables in predicting adjustment measures. In an endeavour to minimize the number of coping predictors entered into the regression analysis, a principal components factor analysis was conducted on the 13 subscales of the COPE inventory.

Using a cut-off factor loading of ≥0.60 yielded three factors, which were interpretable as (i) adaptive coping, (ii) avoidant coping, and (iii) seeking social support and venting emotions. No item loaded on more than one factor using this criterion. Factor 1 was composed of planning (r = 0.82), acceptance (r = 0.74), active coping (r = 0.73), restraint coping (r = 0.69), suppression of competing activities (r = 0.69), and positive reinterpretation and growth (r = 0.67). Factor 2 was composed of denial (r = 0.82) and mental disengagement (r = 0.75). Factor 3 was seeking emotional social support (r = 0.74), seeking instrumental social support (r = 0.62) and focusing on and venting of emotions (r = 0.64). Factor 1 explained 29% of the variance, Factor 2 explained 17% and Factor 3 explained 14% of the variance. Scores on each factor were obtained by multiplying the raw scale scores by their relevant weightings and summarizing the results. So the 13 COPE scales yielded three factor scores. Pearson product moment correlations between the three COPE factors and the three adjustment indices showed that depression was associated with lower use of adaptive coping strategies (r = –0.30, P<0.01) and frequent use of avoidance strategies (r = 0.31, P<0.01).

The results of the hierarchical regression analyses are presented in Table 2. The adjusted R2 value denotes the amount of variance explained by the variable set; an adjusted R2 change value can be computed by subtracting the variance explained on a set from the amount of variance explained on the preceding set. This R2 change value provides the amount of incremental variance explained. In order to control for the influence of age and illness duration, these variables were entered into the regression in step 1. Disease status characteristics (ESR and joint count) were entered in step 2. To minimize the number of variables entered into the analysis, it was decided to drop the CRP variable as it had to be transformed to correct for skewness. Moreover, a greater number of the studies reviewed, examining the impact of psychological and disease factors on adjustment, used the index of ESR [5, 7, 14–17, 19–22, 24] than used the index of CRP [18, 23]. The four illness perception subscales were entered in step 3 and the three COPE scale factor scores were included in step 4.


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TABLE 2. Hierarchical multiple regression analyses explaining adjustment by demographic variables, disease indicators, illness perceptions and coping

 
Physical function
Table 2 shows that disease status characteristics accounted for a significant proportion of the physical functioning variance after the effects of age and illness duration had been accounted for (adjusted R2 change = 0.15, P<0.01). The ß or standardized correlation coefficients showed that the degree of joint involvement had the greater impact (ß = 0.41, P<0.001), with a higher joint count indicative of poor physical function. The illness perception set of variables accounted for a significant proportion of the variance over and above that attributable to demographic and disease status variables (adjusted R2 change = 0.23, P<0.001). Of the four aspects of illness perceptions, perceived consequences had the greatest impact; the more serious the consequences the poorer the reports of physical function (ß = 0.32, P<0.01). The coping variables did not add anything further to the explanation of variance in physical functioning.

Pain
The hierarchical regression analysis indicated that only the illness perception set (step 3) accounted for a significant proportion of variance in perceived pain (adjusted R2 change = 0.22, P<0.001). The ß coefficients revealed that, of the illness perceptions, differences in control/cure had the most impact on perceived pain. The less control/cure, the greater the reported pain (ß = 0. 35, P<0.01). Coping variables did not add further to the explanation of pain.

Depression
The results of the regression analysis indicate that the disease status set failed to add a significant contribution to the explanation of variability in depressive symptoms. Illness perceptions (step 3) proved to be the best predictor of depression (adjusted R2 change = 0.27, P<0.001). Coping variables failed to contribute a significant increment to the explanation of variance in depression beyond the P<0.05 level.

In sum, the demographic variables failed to explain a significant amount of variability in any outcome. Disease status contributed a significant increment in the proportion of variance explained on one index only: physical functioning. Illness perceptions made a significant contribution to the explanation of variance in all three outcomes. Coping variables failed to make a contribution to explaining variance in any domain.


    Discussion
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 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Disease status and adjustment
The twin issues of the prevalence of depression and the relationship of depression to medical disease severity have been an important concern in the rheumatological research literature. Despite a plethora of assessment tools, there is a consensus that the prevalence of depression is higher in patients with RA than in the general population, and that clinicians therefore should be alert for depressive comorbidity among their patients. Interestingly, the 27% prevalence of depression in this study sample for probable depression (cut-off score of 4 on the AIMS) and 39% for possible depression (cut-off score of 3) is close to the rates of between 21 and 34% reported in the literature [2, 3, 7–10]. They are also in line with the results of those [3] who, using these cut-off points on the AIMS, found a prevalence rate of 20% for probable depression and 37% for possible depression.

On a cautionary note, it must be pointed out that, while its cut-off points for depression were derived on the basis of comparison rates with the well established CES-D Depression Scale [3], the AIMS was not designed for individual case detection but rather for screening the prevalence of probable non-psychotic psychiatric morbidity in a sample. Scores obtained by patients on the depression scale of the AIMS (mean 2.9, S.D. 2.0) show that the majority are not reporting depressive symptoms to a significant extent.

Many studies have investigated the association between medical measures of rheumatic disease severity and depressed mood. These studies are often based on an assumption that those with more severe illness are more likely to report psychological distress. Despite repeated investigation of this putative relationship, the evidence remains equivocal. In the present study, when two disease variables (ESR and joint involvement) were used as predictors in hierarchical analyses, they failed to add a significant contribution to the explanation of variance in depressive symptoms. In keeping with these findings, disease activity was not associated with depression in a number of investigations [15, 16, 17, 18].

A question posed frequently in the research literature is whether those with more active disease report more physical disability. Surprisingly, the effects of disease status on reported pain are included far less often. In the present investigation the disease indices of high CRP and joint involvement were correlated with poor physical functioning. In hierarchical analysis, the disease set (ESR and joint involvement) explained 15% of the variance on physical functioning. The findings of this study concur with those showing that disease status can add to the prediction of variability in self-reported functional status [19, 20, 22, 24]. Surprisingly, disease status failed to predict variance in reported pain. Of course, this finding may reflect limitations in the assessment of pain. The AIMS pain scale is a four-item scale assessing the general frequency of pain in the previous month. Perhaps a more comprehensive measure of pain would yield different findings.

Illness perceptions and adjustment
The present study investigated the relationships between illness perceptions and three indices of adjustment. High illness identity (symptoms) and a perception that the illness is not amenable to control by self or others were related to poor physical and psychological adjustment. Perceptions that the illness will last a long time and has serious consequences were associated with poor physical adjustment. The importance of the set of illness perceptions relative to other sets of variables in predicting adjustment was shown. When entered on the third step, after disease status, illness perceptions contributed a significant increment in the proportion of variance explained on all three outcomes. They explained variance on physical functioning (23%), pain (22%) and depression (27%).

The findings of this study support previous research conducted within a self-regulation framework, which has demonstrated a consistent association between illness perceptions and psychological and functional adjustment in a variety of illnesses [5, 34, 38, 43, 44, 45].

An important concern of the present study was to identify the factors related to physical adjustment. The study found that illness perceptions explained 23% of the variance in physical functioning over and above the 15% explained by disease status. This shows that, in line with a number of other studies, psychological variables are associated with variability in functional ability beyond that explained by disease factors [20, 22, 24, 45]. The findings thus indicate that not only is an assessment of medical disease status useful when considering reports of physical disability, but the importance of including psychological measures is underscored by the fact that illness perceptions account for a greater proportion of the variance in this disability. The present data also show that it was the illness perceptions and not disease status that explained the variance in pain. So while disease activity was responsible for poor physical functioning, illness perceptions such as endorsing serious illness consequences and low illness control/cure were more responsible than the objective disease measures for high pain reports. In the clinical setting, it might be important, then, not to assume that reports of pain always reflect increased disease activity. The illness perception set was the only variable set to account for variance on depression. It appears that it is the perception of one's disease rather than actual medical disease that explains variability in mood status.

Coping and adjustment
Patients with RA most frequently use the emotion-focused coping strategies of turning to religion, acceptance and positive reinterpretation and growth to deal with stress. A similar reliance on emotion-focused strategies was found for people with RA in previous research [49]. Emotion-focused coping involves efforts to regulate the emotions experienced because of the stressful event. Problem-focused coping involves efforts to confront and deal with the stressor. Emotion-focused strategies usually occur if a stressor must be tolerated and is not amenable to direct action. While reliance on emotion-focused strategies might be expected in an illness context, it is interesting that this trend also emerges when patients are asked how they respond to stress in general. The similarity in response style could, of course, have also arisen if patients chose to respond in the context of their experience of illness-related stress.

Correlational analyses showed that coping was mainly related to emotional adjustment. The one exception was the relationship between use of coping by planning with better overall physical function. The infrequent use of two adaptive emotion-focused strategies (positive reinterpretation and growth, and acceptance) and three problem-focused strategies (active coping, planning, seeking instrumental social support) and the use of an avoidant emotion-focused denial strategy was associated with depressive symptoms. These findings are in line with those of a number of previous studies on coping and adjustment [49–54].

In hierarchical analysis, when the three coping factors were entered into the regression equation at the final step they failed to explain variance on adjustment beyond the 0.05 level. This finding concurs with those suggesting that illness perceptions are more strongly associated with adaptive outcome than is coping [38, 39, 41, 45]. While mediation was not tested in the present study, the finding that illness perceptions were more strongly associated with adjustment than was coping suggests that illness perceptions may have a direct impact on adjustment rather than being mediated by coping, as suggested in the self-regulation model. A central focus of this study was to identify the factors that predict adjustment in patients with RA. While the overall group profile shows moderately good adjustment, the results did show that a sizeable minority of patients report depressive symptoms. It is important that this emotional distress is detected and treated, as it could well interfere with optimal medical treatment and adherence to medical directives. The importance of depression to the clinician lies in its probable relation to increased distress about illness symptoms, increased pain complaints and requests for pain medication, and more frequent physician visits or clinic attendances. The present analysis demonstrated that illness perceptions explain a significant amount of the variation in adjustment. It may be helpful, therefore, to assess the concordance of the patient's view of the consequences and control of his/her condition with the medical perspective of its control, consequences and prognosis.

The results of this study add to the growing literature suggesting that the perceptions that chronically ill patients hold of their illness can influence their psychological and physical well-being. The study, however, has a number of limitations, which must be considered when interpreting results. The cross-sectional nature of this study makes it impossible to draw conclusions about the causal direction of the relationships observed between illness perceptions and physical function, pain and depression. A prospective research design would help to delineate these relationships. Generalization of the findings is limited by potential selectivity bias, in that only those well enough to attend an out-patient clinic and who were willing to participate in the study were included. Despite these shortcomings, the data suggest that patients’ illness perceptions or beliefs may be important determinants of adjustment to their chronic illness, and it seems they may better explain variability in adaptive outcome among RA patients than actual disease status. The assessment of these perceptions may then be helpful in identifying patients who could benefit from intervention programmes to facilitate adaptation to their illness condition. This points to an optimistic view of rehabilitation and suggests that improvements in reported physical and psychological well-being can be facilitated by changing psychological factors rather than awaiting improvement in medical status.


    Acknowledgments
 
We are very grateful to the medical and nursing staff at the rheumatology out-patient clinic for their involvement and cooperation in the study. We would like to extend a special thanks to the participants, who gave up a considerable amount of their time to take part in the project.

The authors have declared no conflicts of interest.


    References
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 

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Submitted 1 December 2003; revised version accepted 12 May 2004.



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