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Rheumatoid arthritis RA is a long-term disorder significantly impairing the somatic, emotional, and psychological functioning of its sufferers. Previous research has shown that affected individuals are characterized by an increased level of anxiety and depression. Currently, there are two main treatment schemes for RA; the first uses anti-inflammatory drugs, and the second utilizes biologic agents.
This begs the question whether sufferers differ in intensities of pain, anxiety, and depression depending on the type of treatment and what the determinants of these affective states in patients treated using different methods are.
The study comprised 85 patients affected by RA including 57 receiving biologically inactive medication. Research participants filled out a set of questionnaires measuring levels of anxiety and depression, intensity of experienced pain, strategies of coping with pain, and ego resiliency. The collected data was analyzed through intergroup comparisons, calculating simple correlation coefficients, developing and solving regression equations.
The results imply that the choice of treatment differentiates the intensity of pain experienced by patients. Those receiving biologic agents reported lower levels of pain compared to those taking anti-inflammatory medication.
It has also been noted that there are distinct configurations of conditions conducive to anxiety and depression in both anti-inflammatory and biologic agent groups. The observed constellation of dependencies between variables indicates that the choice of treatment scheme differentiates pain levels. This confirms the assumption that pain intensity, coping strategies, and ego resiliency depend on the severity of anxiety and depression. Chronic illness is indicated by the World Health Organization as the leading cause of premature death in the world.
Chronic illness is defined by its slow progression and long duration, two traits which force patients to adapt to new, changed circumstances, and which affect most aspects of life, usually negatively, consequently significantly lowering health-related quality of life [ 2 ].
RA is the most common rheumatic disorder among connective tissue disorders. It is a persistent, progressive inflammatory process beginning in the synovial membrane, leading to the deformation and destruction of articular tissues, and the impairment of articulatory function [ 3 ]. Typical age of onset is between 40 and 60 years and incidence is 3 to 4 times higher in women than in men. A person affected by rheumatoid arthritis experiences numerous somatic problems, such as the deformation and deterioration of joints, chronic pain, fatigue, weight loss, and fever.
Besides these, the sufferer must also deal with psychological hardships, primarily marked by negative affect: anxiety, depression, feelings of loss, and social difficulties related to changes in fulfilling social roles [ 4 ]. The theoretical approach based on which we can understand the processes of adaptation to chronic disease is the Transactional Model of Stress and Coping [ 5 ]. This approach assumes that a stress transaction is a complex process in which a number of consecutive phases can be distinguished: the occurrence of an event, its cognitive evaluation, dealing with its consequences.
Additionally, the stress transaction process is modified by the available resources [ 6 ]. In this perspective, resources act as a mediator between the different stages of a stress transaction.
For example, due to its high mental resilience, a person is able to flexibly adjust coping strategies to the requirements of the situation [ 7 ]. In the proposed study, we investigated coping coping with pain , resources ego-resilience , and consequences pain, depression, and anxiety. A basic problem that RA patients must cope with is pain. As the disorder advances, pain levels usually increase [ 8 ]. The unpredictability of pain is one trait disrupting well-being; patients cannot predict the end of an ongoing episode of pain nor the onset of another one.
Individuals affected by RA experience anxiety and depressive symptoms to a greater degree than the general population. Its occurrence is explained through either neuroimmunobiological or psychological mechanisms. The neuroimmunobiological hypothesis points to proinflammatory cytokines, responsible for disrupting the serotoninergic system, as playing the dominant role in the development of depressive symptoms [ 15 ].
The psychological approach, on the other hand, assumes that increasing impairment resulting from gradual deterioration of joint function causes feelings of helplessness, powerlessness, and worthlessness, which contribute to the emergence and persistence of depressive symptoms.
Research on the consequences of depression in RA patients indicates that individuals exhibiting complex depressive symptoms are more susceptible to repeated recurrence of intense pain [ 16 — 18 ].
Experiencing depressive symptoms further hinders coping and living with illness, which manifests as frequent hospitalizations and medical appointments among other things [ 19 ]. The question remains open whether a lower mood and exhibiting symptoms of depression are antecedents sensitizing to pain, or consequences of pain [ 20 ].
Research results are inconclusive. A two-way dependency is described: on one side, the level of depression makes it possible to predict the degree of future physical and psychological impairment; on the other, physical limits caused by illness are predictors of future depression levels [ 21 ]. As such, the dependencies have the properties of a vicious cycle. Another emotional state typical for RA is anxiety. Some researchers suggest that symptoms of anxiety surpass depression levels in this group [ 22 , 23 ].
Frequently, the sufferer fears a relapse of illness accompanied by intense pain. In many cases, this fear escalates into panic. Since fear and anxiety function as motivators to avoid threatening circumstances [ 24 ], this may lead sufferers to avoid any situations where pain could be exacerbated, especially those connected with professional or everyday activity [ 25 ].
Using the transactional model of stress [ 5 , 26 ], potential determinants of anxiety and depression are the intensity of pain specific element of the stressful life event , strategies for coping with pain, and ego resiliency. Therefore, it becomes essential to isolate specific coping strategies, which provide affected individuals with the greatest relief from pain [ 27 ]. One classification of strategies of coping with pain was proposed by Rosenstiel and Keefe [ 28 ].
They distinguished seven strategies: diverting attention, reinterpreting pain sensations, catastrophizing, ignoring pain sensations, praying and hoping, coping self-statements, and increasing activity levels. The strategies are assigned to three factors: cognitive coping and suppression, diverting attention and substitute activities, and catastrophizing.
Ego resiliency is another potentially significant condition. Ego resiliency is considered to be one of the most important positive strategies for adapting to stressful situations, as it is assigned the role of managing coping strategy choice [ 11 , 30 ].
In the context of illness, individuals with a high level of ego resiliency use more effective compared to low-resiliency individuals crisis-coping techniques; they are therefore more capable of balancing the positive and negative emotions that they experience and exhibit a higher overall degree of self-control.
A relationship between ego saliency and a tendency to choose strategies involving active coping has also been noted, which translates into increased efficacy and feelings of agency. The pathogenesis of rheumatoid arthritis is not fully identified. This process manifests in the presence of immune complexes in the synovial fluid, synthesized with the involvement of the rheumatoid factor RF , that is, antibodies against IgG.
It is assumed that the rheumatoid factor initiates and maintains the inflammatory process in joints, though how and why it starts and sustains the course of illness remains an unknown. One popular hypothesis is that of viruses or bacteria triggering [ 31 , 32 ].
Because the primary cause of rheumatoid arthritis has not been discovered, treatment is symptomatic. The goal of pharmacological therapy is to halt the progress of disease and so induce remission. The drugs used over the course of RA largely have analgesic, anti-inflammatory, or immunosuppressive properties. They can modify the course of the underlying condition most desirable or merely ease the symptom-related pain, providing relief to patients.
There are two basic groups of medication. The first are analgesic and anti-inflammatory drugs, including nonsteroidal anti-inflammatory drugs NSAIDs and glucocorticosteroids GCs. The second are drugs modifying the course of the illness, including biologically active substances. Biologic agents are currently the newest and most advanced form of treatment. Because there are currently two main methods of pharmacologically treating RA, i.
Additionally, is the level of anxiety and depression determined by a different configuration of psychological variables? An average of The participants were treated using biologic agents 57 participants, The study was anonymous and voluntary. It used a questionnaire method. The basic descriptive statistics of the variables measured and the reliability factors are collected in Table 1. Hospital Anxiety and Depression Scale HADS [ 33 ]: it is made up of two independent subscales, estimating the intensity of anxiety and depression.
The scale consists of 14 statements e. The study participants respond to each statement by choosing one of four possible answers e. Participants estimate how much each statement applies to them and choose the most appropriate response on a four-point scale, where 1 indicates it does not apply at all and 4 indicates it applies very strongly.
Participants respond using a seven-point scale marking frequency of undertaking the described action, whose extremes are 0 never do and 7 always do that e. Patients estimated what intensity of pain they felt during the day and at night using two point scales.
They marked the appropriate pain level on a horizontal centimeter-long line marking the space between 1 no pain and 10 worst pain imaginable. The first step in the analysis was to determine whether RA patients in biological and nonbiological treatments differ in the intensity of pain and levels of anxiety and depression they experience. The choice was motivated by the fact that pain is one of the most troubling physical symptoms of RA, while anxiety and depression are the most disruptive psychologically.
The analysis showed that patients undergoing biological treatment exhibited lower pain levels compared to patients treated using standard methods. They were characterized not just by lower overall pain levels, but also lower night and daytime pain.
The second stage of analysis was to ascertain the determinants of anxiety and depression for biological and nonbiological treatment groups, separately for each group. This was done in two ways: through calculating simple correlation coefficients for the measured variables and through developing and solving regression equations. Anxiety and depression were placed on the dependent variable side of the regression equation, while the independent variables were daytime pain level, nighttime pain level, ego resiliency, cognitive coping, coping through catastrophizing, and coping through diverting attention.
The analysis of depression correlates for biological and nonbiological treatments indicates that there are different factors for either group. Among patients treated using biologic agents, depression levels are related to three variables. Two of the variables under consideration turned out to be significant for both treatment groups: overall pain and ego resiliency.
Calculating correlation coefficients made it possible to identify four variables determining the level of anxiety in patients treated with biologic agents.
The first conclusion that can be drawn from the analyses relates to differences found in pain experienced by patients treated with biologic agents and anti-inflammatory drugs. Analysis results showed that patients receiving biologic agents experience lower levels of pain, both during the day and at night. The noted differences were strong. This shows that using biologically active medication alleviates one of the main symptoms of rheumatoid arthritis, pain, which lets it be assumed that a deferred consequence may be a decrease in depressive symptoms.
This assumption is founded on the observation made by Zautra and collaborators [ 19 ], who noted that different affective systems were linked to different RA symptoms pain or impairment. In patients for whom the dominating symptom was pain, an increase in its level leads to an increase in negative affect, without any effect on positive affect. Therefore, using biologic agents should mitigate the vicious cycle mechanism over time.
Based on research, the mechanism can be expected to run as follows: pain, appearance of negative affect primarily depressive symptoms , difficulties in everyday activities including treatment-related activities, which exacerbates the pain. Disrupting this process with an effective form of treatment biologic agents which lowers pain levels allows speculation that in the long term, levels of depression will also be lowered and effective function will be increased.
The pain experience results indicate which patient group is exposed to greater severity of pain.
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