Rheumatoid Arthritis: A Psychological Intervention Dissertation
319 /V Bid /Vd. /V RHEUMATOID ARTHRITIS: A PSYCHOLOGICAL INTERVENTION DISSERTATION Presented to the Graduate Council of the North Texas State University in Partial Fulfillment of the Requirements For the Degree of DOCTOR OF PHILOSOPHY By Phillip C. McGraw, M. A. Denton, Texas May, 1979
McGraw, Phillip C. , Rheumatoid Arthritis: cal Intervention. A Psychologi- Doctor of Philosophy (Clinical Psychology), May, 1979, 122 pp., 23 tables, 11 figures, references, 149 titles. A psychological intervention involving relaxation training and biofeedback training for the control of peripheral skin temperature was investigated in this study with 2 7 female rheumatoid arthritics as participants. A two-group design was used with the only difference being the direction in which participants were instructed to alter their peripheral skin temperature. A temperature increase group was to use biofeedback to achieve an increase in peripheral skin temperature, while a temperature decrease group was to achieve a decrease. tion training. Both groups received identical relaxa- Based on analysis of the temperature data, it was concluded that the biofeedback response was not learned. From electromyographic data, it was concluded that participants did learn to relax. The hypothesis that the two treatment components would have beneficial affects on the physical, functional, and psychological aspects of rheumatoid arthritis was answered partially. No differential effects as a function of biofeed- back training were found as the data for the temperature increase and temperature decrease groups were statistically combined in multiple analyses of variance for repeated
measures. Although no differential effects were obtained, numerous positive changes were found. Correlated with the relaxation training were decreases in reported subjective units of discomfort, percentage of time hurting, percentage of body hurting, and general severity of pain. Improved sleep patterns were reported as was increased performance of activities of daily living. Reductions were also found in psychological tension, and in the amount of time mood was influenced by the disease. Shifts were not found in imagery, locus of control, and other psychological dimensions. Con- stitutional improvements were also absent. Relaxation training was recommended as an adjunctive therapy and its implications were discussed. is suggested. Future research
TABLE OF CONTENTS Page LIST OF TABLES iv LIST OF ILLUSTRATIONS vii Dissertation Introduction 1 Clinical Description Stress and Other Diseases Proposed Treatment Components Biofeedback Verbal Relaxation Psychological Aspects of Adult Rheumatoid Arthritis Method 40 Subjects Apparatus Psychosocial Assessment Tools Physical/Functional Assessment Tools Equipment Procedure Results 49 Discussion 83 Appendices 91 References 105 in
LIST OF TABLES Table 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Page The Relationship Between Stress and Rheumatoid Arthritis 7 Data on the Efficacy of Verbal Relaxation Training 27 Analysis of Variance on Peripheral Skin Temperature for Increase and Decrease Training Groups 50 Analysis of Variance for Electromyographic Data Across Blocks 53 Analysis of Variance on Pre- and Posttreatment Discomfort Ratings for Increase and Decrease Training Groups Across Blocks 56 Analysis of Variance on Reported Percentage of Time Hurting Across Treatment 57 Analysis of Variance on Reported Percentage of Body Hurting Across Treatment 59 Analysis of Variance on Reported General Severity of Pain 61 Analysis of Variance on Reported Specific Pain Severity 63 Analysis of Variance of Data from Levinson's Locus of Control Scales 65 Analysis of Variance of Data from the Wallston et al. Locus of Control Internal and External Scales 66 Analysis of Variance on Image A Data from Raters 1 and 2 68 Analysis of Variance on the Reported Number of Hours Slept 69 Analysis of Variance on Reported Number of Times Awakened Per Night 71 IV
LIST OF TABLES—Continued Pa Table 15. 16. 17. 18. 19. 20. 21. 22. 9e Analysis of Variance on Reported Changes in Work-Related Activities 73 Analysis of Variance on Reported Changes in Leisure-Related Activities 74 Analysis of Variance on Reported Changes in Physical Activities 74 Analysis of Variance on Measured Changes in Walking Time 75 Analysis of Variance on Reported Changes in Functional Performance 77 Analysis of Variance on Observed Changes in the Number of Impaired Joints 78 Analysis of Variance on Changes in Psychological Configuration as Measured by the Profile of Moods State Test 78 Analysis of Variance on Reported Changes in Degree of Disease—Related Mood Affect v . 83
LIST OF ILLUSTRATIONS Pa Figure 1. 9e Peripheral skin temperature data for combined groups in Sessions 1-4 and 5-9, and plotted separately for Sessions 1-9 52 2. Electromyographic data for combined groups 55 3. Pre- and posttreatment discomfort ratings for combined groups . . . . . . . . . . 58 Percentage of time during which disease-related pain is experienced for combined groups 60 Percentage of the body experiencing diseaserelated pain for combined groups . . . . . . . . 62 Level of severity of pain generally being experienced across treatment course, rated on a 0-10 scale, for combined groups . . . . . . 64 4. 5. 6. . 7. Hours of sleep per night for combined groups 8. Number of times awake per night for combined groups . . . 9. 10. 11. . . 70 . 72 Performance on activities of daily living as measured on the functional evaluation for rheumatoid arthritis for combined groups . . . . 76 Level of tension experienced, as measured by the Profile of Moods Scale test, for combined groups 82 Percentage of time in which subject's mood was disease-affected for combined groups . . . . 84 vx
RHEUMATOID ARTHRITIS: A PSYCHOLOGICAL INTERVENTION Recent treatment strategies for many physical disorders reflect a trend toward an interdisciplinary health care approach {Williams & Gentry, 1977). It will be suggested that the treatment of arthritis, particularly rheumatoid arthritics, should include psychological intervention, A research review will be presented with special emphasis placed on the relationship of emotional factors, especially psychological stress, to the onset and progression of arthritis, as well as other biological disorders, A treatment strategy for rheumatoid arthritis will be described in which biofeedback and verbal relaxation training will be used to reduce the psychological stress and discomfort associated with that disease. Clinical Description Arthritis is estimated to be the chief cause of physical disability in 20-50 million Americans (Pelletier, 19 77; Weiner, 19 77), with approximately a quarter million new cases reported each year (Pelletier, 1977; Williams, 1974). Due to severe, chronic pain 17 million arthritics currently are receiving medical attention. Pelletier (19 77) reports that the economic impact of arthritis is profound in terms of lost wages and the expense of chronic medical care. Medical costs directly attributable to this disease amount to about four billion dollars per year and are growing rapidly.
Several major types of arthritis may be diagnosed, the incidence of each varying with factors such as the age and sex of the afflicted individual. Most arthritics (85%) are 45 years of age or older, and of these 60% have osteoarthritis. Rheumatoid arthritis affects the majority of arthritics who are 45 years or younger. An estimated five million Amer- icans fall into this latter diagnostic category, including approximately 200,000 children and over two million adolescents and young adults (Weiner, 1977). Significantly, rheu- matoid arthritis afflicts approximately three times more women than men. Certainly, of all forms of arthritis, rheumatoid arthritis is the most crippling. It is this subtype of dis- order which will be the concern in this paper. Although the term "rheumatoid arthritis" was first used in the middle of the nineteenth century, a detailed description of the disease has only recently began to emerge. Cur- rent clinical descriptions of rheumatoid arthritis characterize the disease as a generalized systemic illness (Williams, 1974). According to Williams, "multiple extra articular areas of involvement, the constitutional symptoms, and the interesting generalized prodromata often antedate the illness by years or months"(p. 31). Apparently, rheumatoid arthritis begins slowly, usually in one or two joints at a time. Shoulders, elbows, hips, wrists, fingers, knees, ankles, and feet are most commonly involved. Temporomandibular and cricoartenoid joints may
also be involved and are of some diagnostic significance in that they are rarely affected by diseases other than rheiumatoid arthritis. In some patients various prodromal sympltoms of fatigue, diffuse muscle stiffness, dysthesias or pare:sthesias may occur. A symmetrical pattern of joint involvemeent is not unusual, although cases of nonsymmetrical involve]ment are also seen. The ultimate severity of the disease can not reliably be predicted by the presence or absence of prodromata nor by the acuity of onset. As the disease progresses, complaints of joint pain at rest and on moving, swelling of the involved joints and stiffness after inactivity, and a pronounced limitation of motion are typical. Soft tissue or periarticular swelling near involved joints is also common. Muscular atrophy occurs at an alarming rate and subcutaneous nodules form in approximately one-fifth of all patients. severity of the symptoms may fluctuate over time. The The most common complaints of the rheumatoid concern chronic pain, and the often dramatic reduction of mobility seen in the more advanced stages. Underlying this symptomology there is also a predictable sequence of steps in the progression of the disease at the physiological level (Williams, 1974). Normally a joint interior is lined with a synovial membrane which secretes fluid as a lubricant. Rheumatoid arthritis affects the synovial cells causing them to multiply at an unnatural rate, thereby creating swelling. This tissue creeps into the joint, ultimately
4 packing it, destroying the cartilage/ and covering the ends of the bone until erosion occurs, and the joint is rendered useless. In the most advanced stages joint deterioration may cause the formation of scar tissue which in turn produces a joint that is knobby, deformed, and completely immobilized. Peripheral manifestations such as vasomotor instability, exemplified by cold hands or excessive peripheral sweating are also common. While this physiological progression is, for the most part, universally accepted, no single treatment regimen is so widely endorsed (Williams, 1974). Chemotherapy is the most typical intervention, but even still there is no generally accepted pharmaceutical agent. Instead there are cur- rently five basic medication alternatives for rheumatoid arthritis (Carpenter & David, 19 76), each using a drug agent for symptom relief. Aspirin is used most frequently. Dos- ages are set at a "maintenance" level, i.e., the largest possible dosage that does not produce counterproductive side effects. Steroids, gold, penicillamine, and cytotoxins fol- low as alternative treatment (Johansson & Sullivan, 19 75; Weiner, 1977). Success rates, in terms of cure or stabiliza- tion within the five alternatives, vary but are generally quite low (Williams, 1974). Alternatives to chemotherapy also are available (Silverman in Freedman, Kaplan, & Sadock, 1975). A comprehensive inter- vention often requires a therapy team, which in addition to
a physician, involves a physiotherapist, physical therapist, occupational therapist, social worker, psychiatric nurse, and a psychiatrist or psychologist. The involvement of a psychologist in the treatment program may be extremely important since chronic pain and the loss of mobility may create serious problems of psychological functioning, including depression, frustration, apathy, and a helpless outlook (Pelletier, 1977; Weiner, 1977). These psychological symptoms may act to undermine compliance to the treatment regimen, blocking any intervention strategy. Further, psychological distress may antedate or exacerbate certain diseases, including rheumatoid arthritis (Pelletier, 19 77; Soloman & Moos, 1964; Williams, 19 74; Wolff, 196 8). Therefore, treatment must involve a process of ever-changing decisions and goals based on the patient's constantly shifting status of physical and psychosocial functioning (Katy, Vignos, & Moskowitz, 1968). The psychologist should minimize maladaptive emotional reactions, and provide an adjunctive treatment to insure compliance to a medical regime and hopefully aid the patient in the management of his or her pain. Unfortunately, psychologists are in no more agreement as to what to include in their treatment strategy than are their physician counterparts. One major problem for both psychologists and physicians is that criteria used in diagnosing the illness are many and varied, and often of a dysjunctive nature (Bennett & Burch,
1967; Kellgren, 1968; Ropes, Bennett, Cobb, Jacox, & Jesser, 1958; Weiner, 1977). As a result, research reports are incon- sistent, as are data obtained from etiology and pathogenesis investigations. Theories adhering to an epedimiological, physiological, genetic, or psychological causal basis are equally frequent, and often contradictory (King, 1955; Spergel, 1972; Weiner, 1977; Williams, 1968; Wolff, 1968). Although areas of psychological investigation have varied, historically the interest in the illness has been of a traditional nature. Relationships between rheumatoid arthritis and personality or traits, defense mechanisms and conflicts are among the most frequently researched areas. Excellent critical reviews of psychological research methodology in this area have been offered by King (1955), Moos (1964), and Scotch and Geiger (1962). More directly germane to the current paradigm, however, is the well-documented relationship between psychological stress and rheumatoid arthritis. Pellitier (19 77) and others (Cobb, 1959; Cormier & Wittkower, 1957; Crown, Crown, & Fleming, 1974; Meyerowitz, 1971; Weiner, 1977) report that the illness may begin, or exacerbations may occur, in association with conscious worry, grief, depression, or with exposure to various life events labeled by the patient as stressful. A review of Table 1 summarizes and leads to the conclusion that psychological stress may play some role in initiation or aggravation of symptomology.
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10 The consistent reports of stress as an antedater to flare-ups of rheumatoid arthritis are rare exceptions to the usually contradictory evidence reported in the arthritis literature. Unfortunately, a hypothesis of arthritic pathegene- sis connecting psychological with physiological functioning must await elucidation of the exact site at which the process begins. Clarification of the interaction would also require discovery of a pathogenetic agent. Currently a variety of hypotheses exist, all attempting to describe the physiological initiating agent. Major hypotheses include infection by virus (Kilroy, 1970; Phillips & Christian, 1970; Warren, Marraor, Liebes, & Hollins, 1969) or bacteria (Duthie, Brown, Knox, & Thompson, 1975; Sharp, 1.971), immunopathology, i.e., rheumatoid factors (specifically antibodies directed against the body's own healthy blood cells)(Kellgren & Ball, 1959; Lawrence, Valkenburg, Tuxford, & Collard, 1971), and vascular lesions (Schumacher, 1975). Without a full understanding of the nature of the interaction between the psychological and biological aspects of rheumatoid arthritis, effective treatment and prevention is unlikely. However, psychological stress is believed to be an important piece of the elusive puzzle, and reduction of that stress a significant treatment adjunct. Stress and Other Diseases The relationship of psychological stress to somatic disease has been recognized for over 2000 years. In the
11 fourth century B.C., Hippocrates prescribed rest and relaxation for both physiological and psychological complaints (Silverman, in Freedman et al., 1975). Persian texts written in the twelth century A.D. have noted the effects of inhibited aggression, grief, sorrow, shock, and general emotional stress on the course of disease (Shafii, 1973). These early revelations anticipated development of the more recent study of "psychosomcitic" (American Psychiatric Association, DSM-II, 1968), and "beihavioral" (Williams & Gentry, 1977) medicine. In behavioral medicine, the relation of a patient's attitudes and behavior to the progression of his or her disease is emphasized. Innovative uses of traditional psy- chological principles are directed toward the elimination or reduction of nonproductive emotionality with the belief that the control of stress will increase the probability of successful somatic recovery. It seems logical that stress reduction would be of benefit to some physiological complaints more than others. However, predicting the diseases which would be the most responsive to psychological intervention has been a very speculative venture (Alexander, 1950; Freedman et al., 1975; French & Alexander, 1941; Pelletier, 1977; Williams, 1968; Williams & Gentry, 1977). Although results are often inconsistent or contradictory, some findings follow an identifiable pattern. Most notably, there appears to be considerably more evidence that
12 psychological stress may exacerbate a patient's disease rather than cause or antedate the initial acquisition of that disease (Weiner, 1977; Wolff, 1968). Accordingly, Wolff maintains that disease processes should not be considered to be psychogenic simply because of a hypothesized origin based on psychological conflict. Instead the individual's "way of life" may be an exacerbating factor without specifically being considered causal. He further hypothesized genetic influences to be of primary importance, with the individual's attitudes and emotional life, in part, determining penetrance. However, attempts to achieve greater specificity by delineating personality profiles for each disorder have failed (Williams, 196 8; Wolff, 1968; Spergel, 1972). Of more direct relevance to the cur- rent project is Spergel's explanation of a patient's response to his or her disease. He maintains this response is largely dependent on the premorbid manner in which an individual may have handled a variety of life problems. Unfortunately, efforts to differentially predict the onset of, or reaction to, a specific disease, based on prior behavioral patterns elicited by stress, have met with little success (Spergel, 1972; Williams, 1968). These failures concern specific pre- diction, however, and do not obscure the importance of psychological stress to the progression of a disease, whatever its nature. The following studies will serve to empirically
13 demonstrate the existance of this important, although incompletely understood, relationship. Holmes and Rahe (1967) constructed a "social readjustment scale" which could be used to quantify and predict the effects of psychological stress on disease. An economic and cultural cross-section of several hundred people were recruited to assess the stressfulness of 43 common "life events," The participants assigned each item a stress value based on the predicted amount of adjustment needed to cope with that event. These tabulated stress values (labeled as Life Change Units) ranged from a high of 100 (death of spouse) to a low of 11 (minor violations of the law) , The authors found that an individual who had accumulated 200 or more life change units in a single year was later more likely than a similar person with fewer life changes to succumb to myocardial disorder. These results were interpreted as clearly supporting the relationship between psychological stress and onset of disease. Although the Holmes and Rahe study is correlational, with an alternate interpretation of the data being that early and undiagnosed psychiatric or physiological disturbances may themselves lead to stressful life changes, a caution to therapists is recommended: Treatment programs should be avoided which might elevate an individual above the 200 unit level. While the work of Holmes and Rahe began by focusing on psychological stressors and subsequently monitoring the associated incident of disease, others have begun by first looking
14 at a particular disease and then searching retrospectively for a premorbid personality configuration, or the presence of certain conflicts which might, consistently antedate that disease. Treuting (1962) tried to delineate such a profile for patients with diabetes mellitus. Theorizing that emo- tional stresses could precipitate the disease, Treuting hypothesized that diabetes would be disproportionately represented among highly stressed populations, such as soldiers in wartime. However, the data did not support this belief (Hinkle & Wolff, 1952) and Treuting therefore theorized that perhaps only certain personality types would succumb to diabetes mellitus when under stress. Attempts to delineate a premorbid personality specific to the diabetic, however, were also unsuccessful (Treuting, 1962). Although Treuting's data did not verify the hypothesized relationship between personality type, stress, and the onset of diabetes mellitus, more positive results have been found regarding the effect of stress on those already afflicted. Schless and von Laveren (196 4) confirmed earlier findings by Rosen and Lidz (1949), that stress can aggravate diabetes, either through physiological change or by leading the patient to neglect the proper management of his or her disease. Hinkle et al. (1952) have demonstrated that a stressful interview designed to threaten the dependency, affectional, and emotional needs of a diabetic, elevate blood ketosis. A sim- ilar stress-produced metabolic shoft also is found in nondiabetics.
15 If such data are accurate, then a treatment strategy designed to alleviate the stress reaction in favor of a more homostatic, relaxed state could have a positive effect on the diabetic's symtomatology. Fowler, Budzynski, and Vendenbergh (19 76) supported such an observation by using electromyographic biofeedback relaxation training, and verbal relaxation tapes with a 20-year-old chronic diabetic. Decreased levels of maintenance medication and fewer episodes of ketosis resulted. The average dose of insulin needed for normal functioning was dramatically reduced (approximately 50%) and the patient described herself as decreasing in emotionality and in diabetic fluctuations. Such findings can be interpreted as suggesting that not only does stress play an important role in the progression or symptomatology of diabetes, but also that its impact may be effectively controlled via psychological intervention. Similar results have been obtained for other endocrine disorders as well. For example, Koran and Hamburge (in Freedman et al., 1975) report the presence of high levels of psychological stress in more than 50% of the patients being treated for Cushing's syndrome. Mason's (1968a) review of numerous human and animal studies summarizes reports of consistently high levels of adrenal production of relevant corticosteroids by organis
matoid arthritis afflicts approximately three times more women than men. Certainly, of all forms of arthritis, rheumatoid arthritis is the most crippling. It is this subtype of dis-order which will be the concern in this paper. Although the term "rheumatoid arthritis" was first used in the middle of the nineteenth century, a detailed descrip-
What is rheumatoid arthritis? Rheumatoid arthritis is a type of arthritis where your immune system mistakenly targets your own body. It especially affects the lining of the joints between your bones. Early symptoms include swelling, heat, tenderness, pain or stiffness in your joints. Rheumatoid arthritis (RA) can occur at any age and is the second
The pathogenic role of rheumatoid factor in rheumatoid arthritis The first autoantibody in rheumatoid arthritis (RA), rheumatoid factor (RF), was described by Waaler in 1940, who reported the hemag glutinating activity of a serum from a patient with RA [1]. RFs were named by Pike in 1949 due to their association with RA [2] and were
the diagnosis of early Rheumatoid Arthritis. Rheumatoid factors (RFs) are antibodies specific enough to be used as diagnostic and prognostic markers of rheumatoid arthritis (RA). They often appear many years before the onset of clinical RA. Rheumatoid factors are antibodies directed against the Fc portion of IgG. Rheumatoid factors (RF) are .
Rheumatoid Arthritis Diagnosis and Management Lydia Gedmintas, MD, MPH Associate Physician Division of Rheumatology, Department of Medicine . Sparks JA, et al. Rheumatoid arthritis and mortaliyt among women during 36 years of oprospective follow-up: results from the Nurses' Health Study. Arthritis Care Res (Hoboken), 2016: 68(6): 753-62.
Rheumatoid arthritis affects different people in different ways. In some cases, the disease may disappear, or may come and go ('flare') for many years. For other people, the symptoms and disability may slowly worsen over time. If left untreated, rheumatoid arthritis may lead to damage to joints that cannot be repaired. Other parts
Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically . M05.279 Rheumatoid vasculitis with rheumatoid arthritis of unspecified ankle and foot M05.29 Rheumatoid vasculitis with rheumatoid arthritis of multiple sites . Orencia (abatacept) Last review: January 1, 2020
What Is Rheumatoid Arthritis? Rheumatoid arthritis, or RA, is a chronic (long-term) disease that causes inflammation of the joints and other tissues. Joints become stiff, swollen and painful. If the inflammation is not controlled, it can damage joints and organs. That's why it's important to get prompt diagnosis and proper treatment of RA.
Algae: Lectures -15 Unit 1: Classification of algae- comparative survey of important system : Fritsch- Smith-Round Ultrastructure of algal cells: cell wall, flagella, chloroplast, pyrenoid, eye-spot and their importance in classification. Structure and function of heterocysts, pigments in algae and Economic importance of algae. Unit 2: General account of thallus structure, reproduction .
