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Coping with pain in rheumatoid arthritis Bishop, Carole Marie 1990

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COPING WITH PAIN IN RHEUMATOID ARTHRITIS by Carole Marie Bishop P.E., The U n i v e r s i t y of B r i t i s h Columbia, 1973 .A., The U n i v e r s i t y of B r i t i s h Columbia, 1981 ^ THESIS SUBMITTED IN PARTIAL FULFILLMENT FOR THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS i n THE FACULTY OF GRADUATE STUDIES Department of Psychology We accept t h i s t h e s i s as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA January 1990 ©Carole Marie Bishop, 1990 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of Psychology The University of British Columbia Vancouver, Canada Date January, 19ffP DE-6 (2/88) A b s t r a c t T h i s r e s e a r c h i n v e s t i g a t e d the r o l e of copi n g s t r a t e g i e s i n re d u c i n g the p a i n experience of rheumatoid a r t h r i t i s (RA) p a t i e n t s over a seven-day p e r i o d . S i x t y - t h r e e p a t i e n t s completed a t w i c e - d a i l y s t r u c t u r e d d a i r y c o n s i s t i n g o f an e i g h t s c a l e r e v i s i o n of the Ways of Coping (WOC), the d e p r e s s i o n s u b s c a l e of the A f f e c t s Balance S c a l e (ABS), and a p a i n v i s u a l analogue s c a l e (VAS). M u l t i v a r i a t e analyses f o r repeated measures i d e n t i f i e d two coping s t r a t e g i e s , S e l f - C a r e and P o s i t i v e R e a p p r a i s a l , as s i g n i f i c a n t l y e f f e c t i v e i n p a i n r e d u c t i o n . S e l f - C a r e i n c l u d e s b e h a v i o r a l attempts t o manage the symptoms of RA. P o s i t i v e R e a p p r a i s a l i n v o l v e s c o g n i t i v e e f f o r t s t o r e d e f i n e p a i n experience i n p o s i t i v e terms. The oth e r s i x coping s t r a t e g i e s a l s o demonstrated a t r e n d t o i n c r e a s e d use on days when p a i n decreased. These data imply t h a t i n t r a i n d i v i d u a l approaches i n examining the c o p i n g / p a i n a s s o c i a t i o n have p o t e n t i a l b e n e f i t f o r determ i n i n g a c a u s a l r e l a t i o n between coping and p a i n . i i i Table of Contents Page A b s t r a c t i i L i s t of Tables v L i s t of Appendices v i Acknowledgements v i i I n t r o d u c t i o n 1 Rheumatoid A r t h r i t i s 3 Pain i n Rheumatoid A r t h r i t i s 4 The Role of P s y c h o l o g i c a l Factors 5 Coping 8 Coping Theory 8 Coping S t r a t e g i e s f o r Pain 10 Coping w i t h Rheumatoid A r t h r i t i s 11 D e n i a l - l i k e S t r a t e g i e s 11 P l a n f u l Problem-Solving 14 Self-Care 16 P o s i t i v e Reappraisal 17 S e l f - C o n t r o l 19 S o c i a l Support 20 S o c i a l Comparison 22 Summary of Coping i n Rheumatoid A r t h r i t i s 23 Research Methodology 24 Research Questions and Hypotheses 26 Method 28 Subject S e l e c t i o n 28 P i l o t T e s t i n g 30 Measures 31 The Questionnaire 31 Demographic Data 31 A r t h r i t i s H i s t o r y 3 2 F u n c t i o n a l Status 3 2 The S t r u c t u r e d D a i l y Diary 3 3 A f f e c t s Balance Scale 35 Perception of Pain S e v e r i t y 36 Coping Scales 37 Re s u l t s 40 Con s t r u c t i o n of the Coping Measure 40 Ways of Coping 40 A d d i t i o n a l Coping Measure 41 D e s c r i p t i v e i n f o r m a t i o n on the Coping Scales 42 Pain S e v e r i t y 43 I n t r a i n d i v i d u a l Coping w i t h Pain 44 Disc u s s i o n 48 The Use of Coping S t r a t e g i e s 48 Future D i r e c t i o n s 53 Conclusion 55 References Tables Appendices V L i s t of Tables Table 1 Summary of Means Scores f o r D e s c r i p t i v e Data... 65 Table 2 Summary of C o r r e l a t i o n s with Depression 66 Table 3 Ways of Coping S c a l e s 67 Table 4 A d d i t i o n a l Coping S c a l e s 68 Table 5 I n t e r c o r r e l a t i o n s among the S c a l e s 69 Table 6 D e s c r i p t i v e S t a t i s t i c s f o r the S c a l e s 70 Table 7 Mean P a i n Ratings 71 Table 8 Means f o r Within-day P a i n Change by Group 72 Table 9 Means f o r Morning Pain by Group 73 Table 10 R e l a t i o n between Coping and P a i n Outcome 74 Table 11 Summary of O v e r a l l Coping Scores 75 Appendix A. Appendix B. Appendix C. L i s t of Appendices Procedures Patient Letter Patient Materials v i i Acknowledgements I would f i r s t l i k e to express my deepest respect and gratitude to my supervisor, Anita DeLongis f o r her guidance, expertise, and i n t e l l e c t u a l and emotional support during the course of t h i s work. I am t r u l y g r a t e f u l f or having had the chance to work with her on t h i s project. To my committee members, Darrin Lehman and Delroy Paulhus, my thanks for t h e i r valuable input i n the completion of t h i s t h e s i s . Many thanks also to Sherri Hancock for her help when i t was needed. Graitude i s also extended to the rheumatoid a r t h r i t s patients at the A r t h r i t i s Society who so f r e e l y gave of t h e i r time and knowledge, and to the A r t h r i t s Society of B.C. f o r allowing t h i s research to be conducted through the centre. F i n a l l y , to Elaine Burgess, my continued respect and appreciation for her support throughout the production of t h i s manuscript. 1 COPING WITH PAIN IN RHEUMATOID ARTHRITIS Introduction The experience of, and adjustment to, pain i n chronic disease has received much attention recently (Anderson, Bradley, Young, & McDaniel, 1985; Bradley, 1985; Brown, Nicassio, & Wallston, 1989; Revenson & Felton, 1989). Pain management i s considered a primary goal i n adaptation to chronic disease; independent of disease status, however, s a t i s f a c t o r y adjustment to pain constitutes a s i g n i f i c a n t problem for many patients (Baum, 1982). Of p a r t i c u l a r concern to health p r a c t i t i o n e r s are pain patients who r e l y on strategies that do not seem to a l l e v i a t e pain experience. Such indivi d u a l s often become seriously impaired by t h e i r pain and tend to lead ina c t i v e , i s o l a t e d and l i m i t e d l i v e s (Tan, 1982). The coping l i t e r a t u r e describes a number of coping strategies that may account f o r the considerable v a r i a t i o n i n the a b i l i t y of individuals to adapt to the various stresses of chronic i l l n e s s (Cohen & Lazarus, 1979). Chronic and acute pain of variable i n t e n s i t y i s considered a major consequence of rheumatoid a r t h r i t i s (RA) and i s a primary concern for adaptive functioning for RA patients (Kazis, Meenan & Anderson, 1983). As with other chronic diseases, the v a r i e t y of coping strategies that RA patients employ are presumed to be at l e a s t p a r t i a l l y responsible f o r the range of adjustment to pain found i n chronic pain patients (Brown et a l . , 1989). Few empirical investigations, however, have focused on how coping a f f e c t s pain experience i n adjusting to RA (Genest, 1983). Of these, most have been retrospective investigations focusing on the correlates of pain rather than on how individuals deal with continued pain experience (Auerbach, 1989). 2 The focus of the present study was to explore the coping processes rheumatoid a r t h r i t i s patients employ to manage t h e i r pain across time. Coping w i l l be examined with p a r t i c u l a r attention to the ro l e of s p e c i f i c strategies i n influencing pain over time. In the following sections, theory and research relevant to t h i s topic w i l l be reviewed, and the hypotheses generated based on t h i s l i t e r a t u r e w i l l be presented. This review begins with a b r i e f description of the medical aspects of rheumatoid a r t h r i t i s (RA) generated by that discussion. 3 Rheumatoid A r t h r i t i s RA i s a chronic autoimmune disease with both a r t i c u l a r and systemic consequences. I t i s one of the most widespread of the more than 100 rheumatic diseases, a f f e c t i n g approximately 1% of the general population (Anderson et a l . , 1985; Gardiner, 1980). Despite intensive investigation the etiology of RA remains unclear (Arnett et a l . , 1987): the most promising theory implicates v i r a l agents i n i t i a t i n g an inflammatory response that compromises the immune system (Rodnan & Schumacher, 1983). Although adult form of the disease occurs at any time past puberty, symptoms most commonly present between the t h i r d and f i f t h decades. The ov e r a l l sex r a t i o i s 3:1 i n favor of women although t h i s association varies by age. Onset for females i s most frequent during the child-bearing years with the sex r a t i o approaching equality by the eighth decade. Recurrent episodes of severe pain, fatigue, progressive j o i n t deterioration, and d i s f i g u r a t i o n t y p i f y the physical consequences of RA (Duthie, Brown, Truelove, Baragar, & Lawrie, 1964). Prodromal signs of the disease include non-specific symptoms such as fever, weight loss, fatigue, general weakness, and s t i f f n e s s . A r t i c u l a r involvement i s evidenced by pain, j o i n t s t i f f n e s s , decreased mobility and inflammation. I n i t i a l symptoms usually appear slowly over a matter of weeks or months; only 20% of patients experience abrupt onset. The disease can a f f e c t any of the 187 jo i n t s and associated para-articular structures: i n i t i a l l y those most commonly involved are the hands, wrists, knees and feet. E x t r a - a r t i c u l a r involvement i s not uncommon and may include vascular, cardiac and pulmonary manifestations although these features are r a r e l y of c l i n i c a l s i g n i f i c a n c e . 4 Functional status i s the most general c l i n i c a l marker of disease progression and i s commonly described by the stages i d e n t i f i e d by the ARA C l a s s i f i c a t i o n of Progression of Rheumatoid A r t h r i t i s (Steinbrocker, Traeger, & Battman, 1949). These stages are roughly characterized by: remission or a b i l i t y to perform normal a c t i v i t i e s (Class I ) , moderate r e s t r i c t i o n but not precluding most normal a c t i v i t i e s (Class I I ) , marked r e s t r i c t i o n and i n a b i l i t y to perform most a c t i v i t i e s of d a i l y l i v i n g (Class I I I ) , and confinement to bed or wheelchair (Class IV). In terms of functional capacity, predictions f o r the RA population are r e l a t i v e l y stable. Overall, 15% of the RA population are considered to achieve complete remission, 40% have moderate r e s t r i c t i o n s but are able to carry out normal a c t i v i t i e s , 30% are unable to perform most occupational or s e l f - c a r e r e s p o n s i b i l i t i e s , and 15% are non-ambulatory (Anderson et a l . , 1985). In summary, the c l i n i c a l course of RA i s inconsistent, unpredictable, and produces widely varying outcomes, v Longitudinal studies have found, nonetheless, that regardless of treatment, patient condition usually deteriorates as time progresses (Ragan & Farrington, 1962). Pain i n Rheumatoid A r t h r i t i s Chronic pain i s a major factor i n the lowered q u a l i t y of l i f e reported by RA patients, and i s responsible for much d i s t r e s s and impairment (Felton & Revenson, 1984). As a disease state, chronic pain i s a r e l a t i v e l y new concept, defined by "ongoing experience of embodied discomfort, quite often associated with neuromuscular pathologies, which f a i l s e ither to heal naturally or to respond to normal medical interventions" (Kotarba, 1983). 5 Other than symptomatic r e l i e f of j o i n t inflammation through pharmacological interventions, e f f e c t i v e medical strategies for managing RA pain are nonexistent (Bradley et a l . , 1985). As physicians prefer to avoid prescribing narcotic and s t e r o i d a l agents due to t h e i r s i g n i f i c a n t side e f f e c t s , m u l t i d i s c i p l i n a r y approaches that include psychosocial elements (e.g., coping) have been advanced as c r i t i c a l i n RA pain management (Keefe, 1982). RA i s s i m i l a r to other p a i n f u l diseases i n that there does not seem to be a fix e d r e l a t i o n of organic and immunological disease status to subjective d i s t r e s s . Reports of severe j o i n t pain without organic evidence as well as tissue damage without accompanying pain are common c l i n i c a l observations i n RA. In t h i s respect, RA shares properties with other chronic diseases i n which l e v e l of incapacity and pain experience varies widely (Melzack & Wall, 1982). This v a r i a t i o n also underscores the potential impact of psychological factors i n the experience of, report of, and adjustment to, such pain. The ro l e of psychological factors i n RA pain experience i s discussed i n the next section. The Role of Psychological Factors Not only i s RA recognized as a leading cause of d i s a b i l i t y , the l i t e r a t u r e i s unequivocal i n suggesting that i t also has adverse e f f e c t s on the a f f e c t i v e , behavioral and s o c i a l functioning of i t s sufferers (Gardiner, 1980). Coping with pain creates unusual psychological burdens i n addition to those experienced due to the physical consequences of the condition (Genest, 1983). Various aspects of the disease process i n a r t h r i t i s make i t p a r t i c u l a r l y s t r e s s f u l . As Weiner (1975) notes, adaptation to RA pain i s s i g n i f i c a n t l y affected by the i n e v i t a b i l i t y of the s i t u a t i o n . He 6 argues t h a t the f l u c t u a t i n g course of the d i s e a s e i n c r e a s e s the s u s c e p t i b i l i t y of a r t h r i t i c s t o e x p e r i e n c i n g p s y c h o l o g i c a l and p h y s i c a l d i f f i c u l t i e s beyond those expected by c l i n i c a l d i s e a s e s t a t u s . The RA l i t e r a t u r e bears t h i s out; RA s u f f e r e r s are t y p i f i e d by problems i n adjustment ( F e l t o n & Revenson, 1984; G a r d i n e r , 1980; F e l t o n , Revenson & H i n r i c h s e n , 1984). V a r i o u s authors have suggested t h a t the u n c e r t a i n t i e s a s s o c i a t e d w i t h e t i o l o g y , pathology and p r o g n o s i s i n RA produce a tendency i n RA p a t i e n t s t o view t h i s d i s e a s e as a c h r o n i c s t r e s s o r , thereby t a x i n g the p h y s i c a l , emotional and s o c i a l r e s o u r c e s needed t o d e a l w i t h p a i n (Aldwin & Revenson, 1987; A c h t e r b e r g - L a w l i s , 1982; Revenson & F e l t o n , 1989; Weiner, 1975). Of note i s the c o n s i s t e n t f i n d i n g t h a t p a i n s e l f - r e p o r t i n RA i s c o r r e l a t e d w i t h s e l f - r e p o r t of d e p r e s s i o n (Anderson e t a l . , 1985; F e l t o n e t a l . , 1984; L i a n g e t a l . , 1984). In a s e r i e s of s t u d i e s on mood and coping i n RA, F e l t o n and Revenson (1989) found t h a t RA p a t i e n t s demonstrated the p o o r e s t p s y c h o l o g i c a l adjustment of f o u r c h r o n i c i l l n e s s groups i n c l u d i n g rheumatoid a r t h r i t i s , d i a b e t e s , h y p e r t e n s i o n , and cancer. In a r e c e n t review, B r a d l e y (1985) noted t h a t e l e v a t e d l e v e l s of d e p r e s s i o n on s t a n d a r d i z e d psychometric t e s t s measures such as the Beck Depression Inventory (BDI; Beck, 1976) c h a r a c t e r i z e the responses of rheumatoid a r t h r i t i s p a i n p a t i e n t s . The n o t i o n t h a t f i n d i n g s i n such measures as the BDI r e f l e c t c h a r a c t e r i s t i c s of RA s u f f e r e r s , however, has l a r g e l y been d i s c o u n t e d i n the l i t e r a t u r e (see Moos, 1964 f o r an account of the p r e v a i l i n g t h e o r y on p e r s o n a l i t y and RA). In f a c t , an a s s o c i a t i o n between d e p r e s s i o n and p a i n i s not r e s t r i c t e d t o RA: B r a d l ey (1985) concluded from the dominant l i t e r a t u r e t h a t s e l f - r e p o r t of d e p r e s s i o n r e p r e s e n t s a r e a c t i o n 7 t o the experience of any c h r o n i c , d i s a b l i n g i l l n e s s . N otwithstanding t h i s c o n c l u s i o n , the h i g h i n c i d e n c e of d e p r e s s i o n i n RA p a t i e n t s i s important i n t h a t d e p r e s s i o n i s l i k e l y t o i n f l u e n c e c o g n i t i o n and behavior, i n c l u d i n g p a i n and c o p i n g . As A c h t e r b e r g - L a w l i s (1982) p o i n t s out, RA p a i n p a t i e n t s demonstrate l e v e l s of d e p r e s s i o n t h a t may have a n e g a t i v e impact on both p e r c e p t i o n of p a i n and p a i n behavior as w e l l as on subsequent attempts t o develop new coping b e h a v i o r s or t o s a t i s f a c t o r i l y engage i n a c t i v i t i e s of d a i l y l i v i n g . S e v e r a l authors (Bandura, O'Leary, T a y l o r , G u i l l a r d , & Gossard, 1987; Bradley e t a l . , 1985; Bradley & Kay, 1985; O'Leary, Shoor, L o r i g , & Holman, 1987; Turner and Chapman, 1982; Weisenberg, 1987) emphasize the important r o l e of c o g n i t i o n s i n mediating e i t h e r emotional r e a c t i o n s (e.g., d e p r e s s i o n , avoidance) or b e h a v i o r a l responses (e.g., withdrawal) t o p a i n . C l e a r l y , the long-term impact of p a i n f o r RA p a t i e n t s r e q u i r e s a r e p e r t o i r e of c o p i n g b ehaviors t h a t are capable of meeting a wide v a r i e t y of t r a n s i t o r y and c h r o n i c demands. The growing body of evidence i n the c o p i n g l i t e r a t u r e suggests t h a t c o p i n g has a r o l e i n adjustment t o i l l n e s s - r e l a t e d s t r e s s : the ways i n d i v i d u a l s d e a l w i t h t h e i r d i s e a s e - r e l a t e d problems has been a s s o c i a t e d w i t h d i s e a s e p r o g r e s s i o n , r e c o v e r y and a d a p t a t i o n (Cohen & Lazarus, 1979; T a y l o r , Lichtman & Wood, 1984). C l a r i f i c a t i o n of the s p e c i f i c coping mechanisms t h a t are l i k e l y t o exacerbate or a l l e v i a t e p e r c e p t i o n of p a i n , however, i s u n r e s o l v e d i n both the g e n e r a l l i t e r a t u r e on p a i n c o n t r o l , and i n the r e s e a r c h on RA p a i n . Coping mechanisms t h a t have been i m p l i c a t e d as having the p o t e n t i a l t o a l t e r the emotional impact of RA p a i n are reviewed i n the f o l l o w i n g s e c t i o n s . 8 Coping  Coping Theory The mechanisms by which coping acts to influence outcome i n s t r e s s f u l s i t u a t i o n s have been examined within models that view coping as a dynamic, evolving process (Lazarus & Folkman, 1984). The l i t e r a t u r e addressing a process model of coping i s based on a paradigm of stress and coping that focuses on both cognitive and interpersonal factors (Lazarus & Folkman, 1984; Lazarus & DeLongis, 1983; Folkman & Lazarus, 1980). Folkman and Lazarus (1980) propose three main tenets for t h e i r theory: a r e l a t i o n or transaction between person and environment, a process of change over time or across situations i n the person/environment transaction, and f i n a l l y , the re-conceptualization of stress within a context of emotion. In t h i s model, coping refers to "constantly changing cognitive and behavioral e f f o r t s to manage s p e c i f i c external and/or in t e r n a l demands that are appraised as taxing or exceeding the resources of the person" (Lazarus & Folkman, 1984, p. 5). A major focus i n the coping l i t e r a t u r e i s represented by the two general functions of coping described by Lazarus and Folkman (1984) i n t h e i r transactional model. Research investigating the functional a t t r i b u t e s of emotion-focused and problem-focused coping has received much attention, la r g e l y due to the a p p l i c a b i l i t y of t h e i r model for coping with diverse s t r e s s f u l s ituations (see also Pear l i n , Lieberman, Menaghan, & Mullan, 1982). Problem-focused coping describes coping strategies geared toward the p r a c t i c a l management of the s i t u a t i o n . Emotion-focused coping, on the other hand, describes strategies oriented toward appraising the meaning of the s i t u a t i o n and regulating the 9 emotional impact of the s i t u a t i o n . For example, coping e f f o r t s characterized by an active, instrumental orientation seem to be more c h a r a c t e r i s t i c of individuals facing problems that are changeable (Folkman, Lazarus, Gruen, & DeLongis, 1986b) than they are of indiv i d u a l s faced with the stresses of chronic i l l n e s s or impending loss of l i f e (Taylor et a l . , 1984). Where encounters must be accepted, emotion-focused strategies such as distancing and escape-avoidance presumably allow adaptation without facing the aversive s i t u a t i o n . Data gathered using the Ways of Coping Scale, a widely used measure of coping assessing the cognitive, a f f e c t i v e and behavioral e f f o r t s individuals use to cope with stress (WOC; Folkman & Lazarus, 1980) have revealed that both types of coping functions are usually used i n coping with s t r e s s f u l s i t u a t i o n s . Coping strategies described by both functions were used approximately 98% of the time i n s t r e s s f u l situations encountered by community res i d i n g adults (Folkman & Lazarus, 1980) and college students (Folkman & Lazarus, 1985). For example, problem-focused coping was more prevalent during exam preparation whereas distancing strategies were more prevalent while waiting for examination r e s u l t s i n t h e i r college sample. Subsequent studies concur: i n d i v i d u a l s under stress generally employ more than one type of coping strategy at a time (Folkman, Lazarus, Dunkel-Schetter, DeLongis, & Gruen, 1986a). A process view of coping has been widely used as a model for examining the strategies in d i v i d u a l s employ while dealing with s i t u a t i o n a l stressors (see Lazarus & Folkman, 1984 for a review). This transactional model served as the t h e o r e t i c a l basis for 10 examining the processes RA patients i n t h i s study employed i n managing t h e i r pain. Coping Strategies f o r Pain The predominant approach i n the research on coping with pain follows the general trend i n stress research, targeting coping as a major factor i n adaptational outcome and focusing on emotion regulation as a key component of the coping process (Auerbach, 1989). The benefits of employing strategies that promote adjustment to pain, and the maladaptive consequences of suppressing dysphoric or negative emotions by employing de n i a l -l i k e coping strategies are the main concerns i n t h i s l i t e r a t u r e . While a transactional theory of coping makes no assumptions concerning what constitutes adaptive versus maladaptive coping, pain researchers are cl e a r , nonetheless, that cer t a i n coping e f f o r t s have both short-term and long-term adaptive s i g n i f i c a n c e f o r adjustment to painful disease (Turk & Rudy, 1986). These e f f o r t s may increase emotional d i s t r e s s accompanying the presence of pain, or they may reduce such d i s t r e s s . Previous research on pain i n chronic disease has indicated that indiv i d u a l s faced with persistent pain develop cer t a i n patterns of coping responses to help them t o l e r a t e , a l l e v i a t e , or manage t h e i r pain (Keefe et a l . , 1987). For some patients, entrenched patterns of coping that are used over prolonged periods of time may adversely a f f e c t functioning through reduced reliance on other strategies, thus increasing the impact of pain on behavior (Tan, 1982). While there are few studies d i r e c t l y assessing coping and pain experience i n RA patients, Baum (1982) suggests that a r t h r i t i c s may exert considerable influence over the course and severity of day-to-day symptoms through the employment of appropriate coping t a c t i c s even i f l i t t l e influence over the underlying disease process i s exercised. The most notable of those studies assessing the use and e f f i c a c y of coping strategies fo r pain management i n a r t h r i t i s are described next. Coping with Rheumatoid A r t h r i t i s  D enial-like Strategies The RA pain l i t e r a t u r e suggests that d e n i a l - l i k e strategies are used most frequently by RA sufferers to avoid provoking increases i n pain l e v e l (Keefe et a l . , 1987). According to t h i s research, attempts to avoid pain are characterized by e f f o r t s to increase the emotional distance from the s t r e s s f u l event. Although the e f f i c a c y of such strategies cannot be d i r e c t l y addressed using s e l f - r e p o r t data, studies using scales that tap d e n i a l - l i k e behaviors have found that such t a c t i c s are u n l i k e l y to r e s u l t i n appreciable pain reduction f o r RA patients (Felton and Revenson, 1984; Brown et a l . , 1989). Although such behaviors have been measured separately i n the l i t e r a t u r e , they do not seem to be distinguished by t h e i r influence on pain. However, two d e n i a l - l i k e strategies, Distancing and Escape-Avoidance, are notable for the i n t e r e s t they have generated i n the RA l i t e r a t u r e . This review w i l l focus on the findings i n t h i s l i t e r a t u r e regarding strategies t y p i f i e d by these two coping concepts. Distancing may be viewed as a cognitive e f f o r t to remove oneself emotionally from a s i t u a t i o n that causes d i s t r e s s . In a study on coping with various chronic i l l n e s s , Felton and Revenson (1987) noted that e l d e r l y i n d i v i d u a l s who perceived t h e i r i l l n e s s as having serious consequences found Distancing, a strategy described by Folkman et a l . , 1986a, p. 995 as " e f f o r t s to detach 12 oneself from the s i t u a t i o n " was the most prevalent coping strategy f o r these i n d i v i d u a l s . RA patients demonstrate a s i m i l a r pattern: d e n i a l - l i k e responses generally characterize the mechanisms these patients use i n managing t h e i r pain. For example, Felton et a l . (1984) found that, compared to hypertensive or diabetic patients, RA patients tended to r e l y on coping behaviors that minimized the severity of t h e i r i l l n e s s (Distancing) or diverted attention from t h e i r disease (Avoidance). Overall, these emotion-focused strategies were associated with both poorer i l l n e s s adjustment and greater negative a f f e c t for a r t h r i t i s patients but not for hypertensive or diabetic patients. Such strategies provided l i t t l e escape from chronic pain for RA patients as i t "brought about a vicious cycle of unhappiness, ruminations, and marginal acceptance of the i l l n e s s " (p. 352). These findings attes t to the importance of considering pain as a s i t u a t i o n a l element that requires coping behaviors which may be amenable to pain r e l i e f but are not b e n e f i c i a l for the contingencies of other medical problems where pain, for example, i s not prevalent. P h i l i p s (1987) views avoidance, a strategy that describes behavioral and cognitive e f f o r t s to escape or avoid a s i t u a t i o n , as a prominent feature of chronic pain behavior. Reliance on avoidance to cope with the stresses of RA i s corroborated by Lambert (1985) who found that RA patients completing the WOC favored avoidance-like mechanisms. Subjects using such strategies tended to report poorer adjustment. Of the ninety-two e l d e r l y women who completed the coping measure, subjects who used more avoidance-like strategies tended to demonstrate both lower morale and higher pain l e v e l s . Turner, Clancy, and V i t a l i a n o (1987) provided further evidence for the reliance of RA patients on avoidance i n coping with pain experience. These researchers used the McGill Pain Questionnaire (MPQ; Melzack, 1975) and a modified version of the Ways of Coping Checklist (WCCL; V i t a l i a n o , Russo, Carr, Maiuro, & Becker, 1985) to demonstrate the association between RA pain and coping strategies. Increases i n perception of pain resulted i n increases i n the use of d e n i a l - l i k e t a c t i c s : pain-stressed subjects used more avoidance and less problem- or action-oriented coping than did non-pain patients. In l i n e with the majority of the evidence i n the stress l i t e r a t u r e positing the e f f i c a c y of problem-solving strategies (see Lazarus & Folkman, 1984 for a review) Turner et a l . (1987) suggested that had problem-solving strategies been employed, such strategies could have been expected to provide increased benefit over avoidance behaviors fo r the pain management of these subjects. The studies c i t e d above suggest that d e n i a l - l i k e behaviors are frequently used strategies f o r managing RA pain that are unli k e l y to r e s u l t i n appreciable changes i n pain reduction. Although the mediating r o l e of cognitive appraisal was not examined i n t h i s study, the findings c i t e d above lend support to the t h e o r e t i c a l arguments of Lazarus and Folkman (1984) concerning the influence of appraisal on coping preference. As noted e a r l i e r , a number of authors have hypothesized that RA • sufferers view t h e i r p l i g h t as unchangeable (Achterberg-Lawlis, 1982). If t h i s i s the case, t a c t i c s that have the potential to manage (rather than a l t e r ) d i s t r e s s should be preferred by RA patients. D i s t i n c t from an explanation positing appraisal as the ratio n a l e for an emotion-focused coping preference i s the 14 p o s s i b i l i t y that pain may indeed be highly r e s i s t to s i g n i f i c a n t change. Whether pain i s indeed unchangeable or whether RA patients appraised t h e i r p l i g h t as inevitable, the impact of employing d e n i a l - l i k e strategies f o r pain reduction i s not impressive. Conversely, Cohen and Lazarus (1979) argue that d e n i a l - l i k e strategies may have some adaptive s i g n i f i c a n c e . Lazarus (1985) suggested that the e f f i c a c y of denial may be influenced by a number of contingencies, and may, i n fa c t , be the most adaptive response. Denial of emotional d i s t r e s s may have l i t t l e u t i l i t y as i t does not r e l i e v e negative f e e l i n g s . On the other hand, denial of situ a t i o n s that are threatening may reduce emotional d i s t r e s s by " s h o r t c i r c u i t i n g threat" (p. 172). For example, i n RA, where d i r e c t action may be i r r e l e v a n t i f pain and d i s a b i l i t y are severe and medication i s of lim i t e d benefit, denying the r e a l i t y or existence of pain may be the most adaptive response. Whether denial i s of poten t i a l benefit for managing pain or not, conclusions regarding the adaptiveness of the strategies discussed above must be regarded with caution. F i r s t , the g e n e r a l i z a b i l i t y of r e s u l t s from these studies i s lim i t e d due to the retrospective nature of the analyses. Of greater importance, the causal ordering of the pain/coping r e l a t i o n i s unresolved from these data. In e f f e c t , t h i s ordering may be reversed; coping i s as l i k e l y to be an e f f e c t of experiencing pain as pain i s of coping. If a coping-leads-to-pain interpretation i s assumed, victim-blaming may occur when i n fac t the reverse i s true. As noted e a r l i e r , c o r r e l a t i o n a l research makes no claims for caus a l i t y , thus such studies may have revealed incomplete information regarding the use of strategies focusing on denial 15 f o r the p a i n / c o p i n g r e l a t i o n i n RA p a t i e n t s . The p r e s e n t study r e p r e s e n t s an attempt t o c l a r i f y the f u n c t i o n of d e n i a l - l i k e s t r a t e g i e s by a d d r e s s i n g coping a c r o s s time. P l a n f u l Problem-Solving Outside of the h e a l t h domain, p r o b l e m - s o l v i n g approaches t o d e a l i n g w i t h s t r e s s have demonstrated a s s o c i a t i o n s w i t h adjustment f o r a v a r i e t y of s t r e s s f u l s i t u a t i o n s (Coyne, Aldwin, & Lazarus, 1981). P l a n f u l p r o b l e m - s o l v i n g , a t a c t i c d e s c r i b e d as d e l i b e r a t e attempts t o a l t e r the s i t u a t i o n (e.g., "I made a p l a n of a c t i o n and f o l l o w e d i t " , Folkman e t a l . , 1986a, p. 995), i s regarded as e f f e c t i v e i n managing s t r e s s f u l s i t u a t i o n s . The h e a l t h - r e l a t e d l i t e r a t u r e , on the o t h e r hand, has not been as unequivocal (Parker e t a l . , 1988). Importantly, v a r i o u s d e f i n i t i o n s f o r b e h a v i o r s d e s c r i b e d as a c t i o n - , problem-, or i n s t r u m e n t a l l y - o r i e n t e d coping t a c t i c s have reduced the i n t e r p r e t a b i l i t y of the f i n d i n g s r e g a r d i n g problem-focused b e h a v i o r s i n i l l n e s s - r e l a t e d s i t u a t i o n s . In the few h e a l t h -r e l a t e d s t u d i e s i n c l u d i n g Information-seeking, a s t r a t e g y d e s c r i b i n g a s e a r c h f o r i n f o r m a t i o n and a d v i c e , the evidence p o i n t s t o i n f r e q u e n t use ( F e l t o n & Revenson, 1984). On the o t h e r hand, i n a c r o s s - s e c t i o n a l study, F e l t o n e t a l . (1984) found t h a t I n f o r m a t i o n - s e e k i n g was r e l a t e d t o decreases i n d e p r e s s i v e symptomatology. I n v e s t i g a t i o n s by Brown e t a l . (1989) p r o v i d e the o n l y i n f o r m a t i o n t o date r e g a r d i n g the p r o s p e c t i v e use of a c t i v e coping, a s e t of c o g n i t i v e and b e h a v i o r a l s t r a t e g i e s c h a r a c t e r i z e d by attempts "to c o n t r o l p a i n or f u n c t i o n d e s p i t e p a i n " (p.653). These authors d i s c o v e r e d t h a t p a t i e n t s who used a c t i v e c o p i n g s t r a t e g i e s r e p o r t e d l e s s p a i n , l e s s d e p r e s s i o n and 16 reduced functional impairment. E f f o r t s using d e n i a l - l i k e strategies were related to increased pain and depression. When such e f f e c t s were examined over a s i x month period, however, active coping did not buffer the negative e f f e c t of depression on pain. In t h e i r view, nothing seems to be p a r t i c u l a r l y e f f e c t i v e i n influencing pain reduction. Although these findings provide some longitudinal information regarding pain management, the extended time lag i n t h i s study may not be representative of coping on a time-to-time basis. Intervening variables are l i k e l y to have at l e a s t equal impact on pain report over extended periods of time. In summary, coping using problem-focused t a c t i c s has demonstrated e f f i c a c y for non-health related contexts, but has not been systematically examined i n individuals s u f f e r i n g from i l l n e s s - r e l a t e d s t r ess. Self-Care Butler, Damarin, Beaulieu, Schwebel, and Thorn (1989) propose that attention to the r e l a t i v e effectiveness of behavioral as well as cognitive e f f o r t s i n coping has merit i n explaining the u t i l i t y of coping i n pain management. That i s , i n i t i a t i n g changes or behaviors that help the person adhere to known b e n e f i c i a l behaviors (e.g., getting enough rest) or that allow the person to pursue regular a c t i v i t i e s describes t h i s strategy. Butler et a l . (1989) observed that using cognitive strategies alone f o r dealing with acute postsurgical pain was r e l a t i v e l y i n e f f e c t i v e regardless of the adaptive s i g n i f i c a n c e of the strategies used. For t h e i r sample, symptom management interventions (e.g., i n i t i a t i n g movement, adhering to r e h a b i l i t a t i o n programs) were postulated to have equal or greater influence than cognitive e f f o r t s on recovery. This finding has p a r t i c u l a r s i g n i f i c a n c e for the present investigation. Despite the a p p l i c a b i l i t y of the WOC to diverse situations, the WOC contains few items that describe behavioral or symptom management coping strategies. Latack (1986) suggests that the i n c l u s i o n of symptom management coping behaviors that focus on psychophysiological as well as s i t u a t i o n a l states i s a useful inc l u s i o n for measures that examine diverse types of stressors. In f a c t , cognitive-behavioral approaches to promoting adaptive responses to i l l n e s s - r e l a t e d stressors suggest both behavioral and cognitive techniques are c r i t i c a l f or adjustment (Parker et a l . , 1988; Turk, Meichenbaum, & Genest, 1983). While data on such approaches are encouraging, the factors a f f e c t i n g change i n such programs are generally unspecified, and comparisons across investigations are lim i t e d . Nonetheless, strategies r e f l e c t i n g behavioral Self-Care for coping with pain may have considerable impact for RA patients. Consideration of such t a c t i c s i s important i n the examination of the coping processes of t h i s population. Positive Reappraisal The impact of using a strategy that redefines pain experience i n a p o s i t i v e framework has also been advanced as a potent i a l mediator of chronic i l l n e s s experience (Kotarba, 1983). He suggested that a recognition of the f a i l u r e of somatic treatments to a l l e v i a t e chronic pain experience often leads to cognitive r e i n t e r p r e t a t i o n of the d i s t r e s s f u l elements of the condition. In t h i s view, the normalization of enduring s u f f e r i n g i s enhanced by f i t t i n g i t into one's b e l i e f system or by rei n t e r p r e t i n g pain experience into a po s i t i v e framework. He 18 proposes that the a b i l i t y to cope with chronic pain i s enhanced by the a v a i l a b i l i t y of a viable b e l i e f system as a resource, either for meaning or for instrumental action. This cognitive restructuring resembles a c o n s t e l l a t i o n of coping responses l a b e l l e d "Positive Reappraisal" by Folkman et a l . (1986a). Po s i t i v e reappraisal i s described by these authors as an attempt "to create p o s i t i v e meaning by focusing on personal growth" (p. 995). This strategy was found to be associated with s a t i s f a c t o r y outcomes fo r s t r e s s f u l situations i n t h e i r study of married couples. A study by Liang et a l . (1984) demonstrated b e n e f i c i a l e f f e c t s for the p o s i t i v e r e i n t e r p r e t a t i o n of pain experience. Half of the subjects i n two groups comprised of RA and SLE patients reported that t h e i r i l l n e s s had a p o s i t i v e emotional impact at times. Hope and an increased appreciation for relationships and for preferred a c t i v i t i e s were commonly reported by both of these groups of patients. Felton et a l . (1984) also found that cognitive restructuring was used more frequently by RA patients than by diabetic or cancer patients. Positive a f f e c t was associated with cognitive restructuring but was unrelated to medical diagnosis. Manne and Zautra (1989) reported the s u p e r i o r i t y of a strategy involving the r e i n t e r p r e t a t i o n of pain experience i n reducing subjective ratings of depressive a f f e c t compared with strategies involving attempts to d i v e r t attention from pain experience. Interpretation of the findings i n these studies using Po s i t i v e Reappraisal, however, i s problematic due to the retrospective nature of the data. As with other studies on pain and coping, causal ordering i s unknown. In general, the coping l i t e r a t u r e suggests that viewing a threatening s i t u a t i o n as a challenge (and applying p o s i t i v e cognitions) rather than as a threat should be of benefit i n coping with s t r e s s f u l s i t u a t i o n s . Despite Kotarba's b e l i e f that i t also has u t i l i t y i n pain management, the advantages of using t h i s strategy for chronic pain r e l i e f , however, needs v e r i f i c a t i o n . Methodological improvement i n the form of a prospective design should y i e l d a better understanding of the u t i l i t y of t h i s strategy. Self-Control Regulation and monitoring of feelings and actions has also been regarded as important i n attenuating health problems. S e l f -Control has been i d e n t i f i e d by Folkman et a l . (1986a) as a strategy that may be adaptive for stress management, although few studies have examined t h i s coping strategy f o r i n d i v i d u a l s i n pain. Self-Control i s defined by these authors as e f f o r t s to regulate d i s t r e s s through action ( t r i e d not to act too h a s t i l y ) and emotion ( t r i e d to keep my feelings to myself). Such s e l f -cognitions are promoted as useful s k i l l s for pain control i n cognitive-behavioral programs fo r RA and appear promising f o r t h i s population (Anderson & Rehm, 1984; Bradley et a l . , 198; O'Leary et a l . , 1987). In a recent study by Keefe et a l . (1987) on o s t e o a r t h r i t i s patients, e f f o r t s to regulate self-cognitions were related to decreased pain perception. Fifty-one o s t e o a r t h r i t i s patients were assessed on outcome measures of pain, health status, and psychological d i s t r e s s i n response to various coping strategies. Coping strategies, as measured by The Coping Strategy Questionnaire (Rosentiel & Keefe, 1985), including d i v e r t i n g attention, r e i n t e r p r e t i n g pain sensation, coping self-statements, ignoring pain, and praying explained only a small portion of the 20 v a r i a n c e i n p a i n r a t i n g s . A f a c t o r d e f i n e d as S e l f - C o n t r o l ( p e r c e p t i o n of a b i l i t y t o c o n t r o l and decrease pain) accounted f o r the l a r g e r p o r t i o n of the v a r i a n c e and y i e l d e d lower p a i n r a t i n g s f o r the p a i n measures. Anderson and Rehm (1984) a l s o examined the use of a S e l f -C o n t r o l s t r a t e g y i n t h r e e c h r o n i c i l l n e s s groups (RA, S i c k l e C e l l Anemia and C h r o n i c Back P a i n ) . They used c o r r e l a t i o n a l analyses t o i n v e s t i g a t e the r e l a t i o n between the number of b e h a v i o r a l s e l f - c o n t r o l methods used by each of these groups. P a i n i n t e n s i t y was weakly r e l a t e d (r=-.32) t o frequency of S e l f -C o n t r o l f o r RA p a t i e n t s , with s i m i l a r r e s u l t s (r=-.20) f o r the aggregated groups. Although the r e s u l t s of t h i s study are i n t e r e s t i n g , the i n t e r p r e t a b i l i t y of these f i n d i n g s i s l i m i t e d as the coping measure employed ( S e l f - C o n t r o l S c a l e ; Rosenbaum, 1980) assesses t e n d e n c i e s t o use s e l f - c o n t r o l b e h a v i o r s t o d e a l w i t h d i v e r s e r a t h e r than s p e c i f i c s t r e s s o r s . Despite t h i s l i m i t a t i o n and the f a c t t h a t the s t r a t e g y d e s c r i b e d as S e l f - C o n t r o l i s not w e l l - d e f i n e d i n the p a i n management l i t e r a t u r e , the evidence lends support t o the s u g g e s t i o n by Bradley e t a l . (1984) t h a t s e l f - c o n t r o l mechanisms may be of import t o RA p a t i e n t s . E v a l u a t i o n of the extent t o which t h i s s t r a t e g y i n f l u e n c e d p a i n r e p o r t over time was i n c l u d e d i n t h i s study on the s t r e n g t h of such i n f o r m a t i o n . Seeking S o c i a l Support Another s i t u a t i o n a l f a c t o r t h a t appears u s e f u l i n understanding i l l n e s s - r e l a t e d s t r e s s i s s o c i a l support. DeLongis, O'Brien, S i l v e r , & Wortman (1990) found t h a t the e f f i c a c y of a g i v e n s t r a t e g y f o r coping w i t h a p a r t i c u l a r s t r e s s f u l s i t u a t i o n depends h e a v i l y upon the responses of 21 involved others. During periods of stress or l i f e change people manage better when they can derive support from s o c i a l relationships (Cohen & McKay, 1984). Individuals who have access to a supportive network experience fewer negative health e f f e c t s related to stress than do individ u a l s who do not have s o c i a l support (Fiore, Coppel, Becker, and Cox, 1986). Kaplan and DeLongis (1983) examined the importance of s o c i a l support i n RA patients. They found that a stable marital r e l a t i o n s h i p was a s i g n i f i c a n t predictor of d i s a b i l i t y i n RA. Manne and Zautra (1989) also found that spousal support was related to adaptive functioning i n RA patients. Female patients with highly c r i t i c a l spouses reported poorer adjustment and endorsed d e n i a l - l i k e coping strategies more frequently f o r managing RA than did patients with supportive spouses. I t i s increasingly recognized, however, that some support attempts may ac t u a l l y exacerbate the stress of the r e c i p i e n t , and that seeking s o c i a l support has d i f f e r e n t implications f o r adjustment than does receiving s o c i a l support (Rook, 1984). Support exchanges seem to r e s u l t i n either enhancement of the reci p i e n t ' s sense of s e l f - e f f i c a c y , or, under less i d e a l conditions, a reduction of the rec i p i e n t ' s sense of competence. Coyne, Wortman, and Lehman (1988), for example, hypothesized that c e r t a i n types of support attempts can lead to feelings of over-dependence and thus to decreased well-being. Cohen and McKay (1984) conclude that the evidence to date suggests that while s o c i a l support generally bolsters adjustment i n coping with stress, negative interactions may adversely a f f e c t coping behavior by causing the i n d i v i d u a l to focus on the negative aspects of the s t r e s s f u l s i t u a t i o n . These findings indicate that under c e r t a i n conditions s o c i a l support may act as a buffer or mediator of the e f f e c t s of stress. When stress (e.g., pain) i s experienced, the a v a i l a b i l i t y of supportive others for comfort should decrease the l i k e l i h o o d of i n e f f e c t i v e coping, and i t s negative consequences (DeLongis, Folkman, & Lazarus, 1988). The u t i l i t y of a strategy defined by seeking s o c i a l support for influencing pain perception seems important for RA sufferers; thus f a r , however, i t has not been tested for t h i s population on a prospective basis. Social Comparison Research on s o c i a l comparison as a strategy f o r enhancing i l l n e s s adjustment derives from Festinger's (1954) theory which postulates that i n d i v i d u a l s have a need to evaluate t h e i r a b i l i t i e s when faced with a threatening s i t u a t i o n . In the absence of objective c r i t e r i a , i n d i v i d u a l s may employ a coping mechanism t y p i f i e d by comparisons with others to enhance the appearance of advantage i n r e l a t i o n to the problematic s i t u a t i o n . Wood, Taylor, and Lichtman (1985) hypothesized that serious i l l n e s s leads i n d i v i d u a l s to cope by comparing t h e i r s i t u a t i o n to that of others with the same condition who are more severely affected. Of p a r t i c u l a r salience to t h i s investigation i s the finding by A f f l e c k , Tennen, F i f i e l d , and Rowe (1987) that rheumatoid a r t h r i t i s patients who reported the use of downward comparison cognitions (viewing the s e l f as better o f f than others i n a s i m i l a r situation) perceived themselves to be better adjusted to t h e i r disease. The types of s o c i a l comparison responses made by female RA patients and the r o l e comparisons played i n i l l n e s s adjustment were examined by Blalock and DeVellis (1989). They found that when self-evaluations of t h e i r 23 perceived a b i l i t y to perform a c t i v i t i e s of d a i l y l i v i n g were made, the majority of respondents were more l i k e l y to compare themselves with individuals not affected by RA than with other RA suf f e r e r s . When d i f f i c u l t i e s i n performing tasks were ac t u a l l y experienced, however, RA patients compared themselves with other, more severely affected RA patients most frequently. These authors concluded that the type of comparison that predominates appears to depend on the context i n which comparisons are made. Despite the retrospective biases of these studies, these findings are suggestive f o r the present study. Comparison processes seem to be a s a l i e n t coping mechanism for RA patients when downward comparisons are made for performance d i f f i c u l t i e s . The question of whether t h i s strategy also influences pain perception over time, however, i s unknown and was addressed i n t h i s study by examining the comparison strategies RA patients employed to manage t h e i r pain. Summary of Coping i n Rheumatoid A r t h r i t i s In general, the l i t e r a t u r e reveals that c e r t a i n types of coping strategies are associated with pain ratings i n RA patients (Keefe, 1982). Overall, a r t h r i t i c s seem to favor the use of d e n i a l - l i k e s t rategies, with strong indications that at l e a s t some of these strategies are maladaptive i n terms of pain cont r o l . Consistent with previous research on i l l n e s s coping using retrospective methodology, the use of d e n i a l - l i k e strategies i s generally counterproductive for reducing pain i n RA s u f f e r e r s . Strategies described as Positive Reappraisal, Social Support, Social Comparison, and Self-Control have a l l proven to be related to stress reduction i n i l l n e s s - r e l a t e d s i t u a t i o n s : the u t i l i t y of employing such strategies i n pain management for RA sufferers appears to be promising, although the data are inconclusive. The a p p l i c a b i l i t y of problem-focused strategies such as Self-Care and Planful Problem-solving, however, are more ambiguous. In non-health related s i t u a t i o n s , Planful Problem-solving has been consistently regarded as an appropriate means of dealing with diverse stressors. In health-related situations such e f f e c t s have generally not been supported although retrospective accounts, variable d e f i n i t i o n , and temporal considerations have lim i t e d i n t e r p r e t a b i l i t y . In e f f e c t , the u t i l i t y of a problem-solving approach to pain management has not been adequately tested to date. These findings, however, should be considered i n l i g h t of the methodology employed by prominent researchers i n the pain/coping r e l a t i o n . Research Methodology i n Coping Investigations of adaptation to stress have t r a d i t i o n a l l y bypassed examination of the e f f e c t s of coping on adaptation for short-term (daily) outcome i n favor of long-term outcome (Bolger, DeLongis, Kessler, & S c h i l l i n g , 1989). Outcome has t y p i c a l l y been defined by macro-level variables, such as the existence of chronic symptoms or conditions t y p i f i e d by depression or somatic i l l n e s s rather than by examining minor exacerbations i n symptoms of chronic conditions. The former, more common approach, however, reveals incomplete information regarding the actual processes indiv i d u a l s employ to manage s t r e s s f u l s i t u a t i o n s . Further, i n focusing on macro- rather than micro-level processes, the importance of r e l a t i v e l y small fluctuations i n pain and coping behavior cannot be addressed. Yet, i n terms of chronic disease, these fluctuations i n d a i l y functioning are important to understand i f we are to develop programs i n t e r t i a r y prevention. Further, with the exception of recent work by Stone and Neale (1984b), studies investigating the r e l a t i o n between coping and outcome have t y p i c a l l y f a i l e d to account for uncontrolled time lag between measurement of stress and outcome. As these researchers note, summarizing the e f f e c t s of coping over time blurs the d i s t i n c t i o n s among d i f f e r e n t strategies for dealing with a p a r t i c u l a r s i t u a t i o n . Such methods do not answer the question of how d a i l y fluctuations i n stress and coping a f f e c t outcome. Recent investigations i n stress and coping have adopted a diary methodology for addressing the importance of fluctuations i n s i t u a t i o n a l stress and i t s e f f e c t on the process of coping. In t h i s context, diary refers to a s e l f - r e p o r t instrument designed to capture within-subject fluctuations i n coping with s t r e s s f u l events i n a time-to-time sequence, allowing examination of events on a prospective basis. Structured diary formats o f f e r a number of advantages over survey or interview procedures (Bolger et a l . , 1989). F i r s t , t h i s methodology assesses i n t r a i n d i v i d u a l differences assumed to be separate from stable personality c h a r a c t e r i s t i c s or environmental factors that may mediate the e f f e c t s of coping. Further, diary methodology e f f e c t i v e l y records variat i o n s i n coping processes that may appear s t a t i c i n cross-individual report: such data advance a more credible argument about causation not possible with between-subjects information. Diary formats also o f f e r the potential for r i c h e r content and higher q u a l i t y data (Bolger et a l . , 1989; Stone & Neale, 1984b; Verbrugge, 1980). F i n a l l y , unlike retrospective reports, r e c a l l 26 error i s minimal i n d a i l y diary reports as time lapse between event and event report i s r e l a t i v e l y short. The importance of t h i s methodology for examining the coping/pain r e l a t i o n i n chronic i l l n e s s may be summarized as follows; i n t r a i n d i v i d u a l examination has the potential for increased s e n s i t i v i t y i n determination of the association between coping and outcome. Despite recent advances i n methodology, and the recognition that RA i s a disease that requires a f l e x i b l e coping repertoire for adaptive functioning, few studies have investigated the processes RA patients employ i n attempts to adjust to continuing pain (Genest, 1983). The present investigation extends past research on coping with chronic pain by employing a prospective methodology, and by employing twice-d a i l y (as opposed to once-per-day assessments) i n two ways. F i r s t , an i n t r a i n d i v i d u a l approach fo r examining the importance of fluctuations i n the pain and coping of rheumatoid a r t h r i t i s patients was employed. A twice-daily reporting period was adopted i n the present study to increase the l i k e l i h o o d of capturing small fluctuations i n within-day coping and pain. Research Questions and Hypotheses The objective of t h i s research was to investigate the proximate impact of coping on pain report i n RA patients. RA patients are highly conversant with the impact of pain; i t i s presumed that they have and use c e r t a i n techniques i n t h e i r coping repertoire that are e f f e c t i v e at least some of the time. The observation from the l i t e r a t u r e that c e r t a i n strategies are associated with pain report for diverse i l l n e s s groups implies that what pain sufferers a c t u a l l y think or do i n attempts to manage pain has some influence on perception of pain (Keefe, 1982). The following a p r i o r i hypotheses were advanced with respect to the trends noted i n the RA pain l i t e r a t u r e . 1. Higher scores i n Planful Problem-solving w i l l be associated with lower within-day pain increments. 2. Higher scores i n Positive Reappraisal w i l l be associated with lower within-day pain increments. 3. Higher scores i n Self-Control w i l l be associated with lower within-day pain increments. 4. Higher scores i n Self-Care w i l l be associated with lower within-day pain increments. 5. Higher scores i n Social Comparison w i l l be associated with lower within-day pain increments. Given the mixed findings i n the l i t e r a t u r e , no hypotheses were advanced for the strategies of Escape-Avoidance, Distancing, and Seeking Social Support. 28 Method Subject Selection The names of 327 Rheumatoid A r t h r i t i s patients r e s i d i n g i n the Lower Mainland were released by the A r t h r i t i s Society of B.C. (May 1988 to May 1989) and the P r o v i n c i a l Department of V i t a l S t a t i s t i c s (1980-1988) r e f e r r a l records following approval for t h i s study. Subject names were selected from information regarding RA diagnoses that was available from these two f a c i l i t i e s at the time of the study. Referrals made to the A r t h r i t i s Society p r i o r to 1988 as well as information on a l l other indiv i d u a l s i n the Lower Mainland diagnosed with RA was obtained from the central r e g i s t r y at the Department of V i t a l S t a t i s t i c s . These two sources granted access only to those patient names whose r e f e r r a l records indicated the names of t h e i r general p r a c t i t i o n e r s , r e s u l t i n g i n a reduction of the i n i t i a l pool of subjects from 327 to 286. Verbal consent from the general p r a c t i t i o n e r was also required, further reducing the available sample. Research c r i t e r i a for subject s e l e c t i o n included a l l English-speaking, non-hospitalized ambulatory adults diagnosed with probable, d e f i n i t e , or c l a s s i c a l RA currently r e s i d i n g i n the Lower Mainland. Patients i n B.C. are diagnosed according to the American Rheumatism Association C r i t e r i a (Rodnan & Schumacher, 1983). Diagnostic information was confirmed by the patients' physicians. Patients were considered i n e l i g i b l e i f a r t h r i t i s diagnosis did not adhere to ARA c l a s s i f i c a t i o n , i f the physician r e f e r r a l l i s t e d more than one rheumatic disease, or i f an incorrect or 29 unclear RA diagnosis was reported by the physician. Individuals whose records or physicians indicated other major co-morbidity defined by l i f e - t h r e a t e n i n g cancers, serious heart disease, or stroke complications that could compromise t h e i r a b i l i t y to p a r t i c i p a t e i n the study were also considered i n e l i g i b l e . Other researchers i n chronic i l l n e s s (Butler et a l . , 1989) use s i m i l a r exclusionary categories to reduce contamination from cognitive d e f i c i t s or coping with imminent loss of l i f e . Age range was r e s t r i c t e d to patients older than 25 years of age as i t was uncertain whether the i n i t i a l diagnosis for the few cases reported under 25 years was RA or Juvenile Rheumatoid a r t h r i t i s (JRA). C l i n i c a l manifestations of JRA appear s i m i l a r at early diagnosis but disease progression and prognosis i s highly d i f f e r e n t i a t e d (Rodnan & Schumacher, 1983). Physicians also requested that some patients be excluded from t h i s study due to acute RA, other serious i l l n e s s , family/individual problems, or other nonspecified reasons. A further 56 subjects were unavailable as a r e s u l t of the above exclusions, r e s u l t i n g i n a t o t a l of 230 indiv i d u a l s cleared for contact. Introductory l e t t e r s were sent out i n three batches of approximately 70 each, at three-week i n t e r v a l s . T h i r t y l e t t e r s were returned undeliverable, leaving a t o t a l of 200 i n d i v i d u a l s who were e l i g i b l e f o r personal contact. A l l 200 indiv i d u a l s were c a l l e d by telephone to request t h e i r p a r t i c i p a t i o n . One hundred and s i x t y i n d i v i d u a l s i n i t i a l l y agreed to allow us to send materials to them, although 11 indiv i d u a l s c a l l e d to withdraw before they received the materials (Details of the procedures and the materials used are found i n Appendices A to D). One hundred and nine d i a r i e s were returned. Of these, twelve indiv i d u a l s returned the materials unused. Of the subjects not returning materials, approximately 25 subjects were contacted to determine t h e i r reasons f o r withdrawing from the study. The major reasons for withdrawal included either sudden RA or other-related i l l n e s s , leaving town, or unwillingness to complete the task. Although the requirements of the study were described i n d e t a i l to each subject and a p i l o t study did not reveal major problems, the actual time and energy necessary to complete the materials was reported by some individ u a l s to be a s i g n i f i c a n t deterrent. Of the 97 i n d i v i d u a l s p a r t i c i p a t i n g i n the study, two subjects met the exclusionary c r i t e r i a for l i f e - t h r e a t e n i n g i l l n e s s and were dropped from the analyses. Sixteen further d i a r i e s contained i n s u f f i c i e n t coping data and 18 other d i a r i e s where either no pain was reported (on more than half of the 14 time-points) or l i t t l e or no f l u c t u a t i o n i n pain was reported were also excluded. The f i n a l sample consisted of 63 subjects, a response rate of 32%, calculated from the 200 i n d i v i d u a l s available for contact by the researcher. P i l o t t e s t i n g In order to determine whether the materials were appropriate i n length and c l a r i t y f o r t h i s population, the questionnaire and diary were p i l o t e d p r i o r to i n i t i a t i o n of the study. Four patients from the available RA pool completed the questionnaire and a two-day portion of the diary. P i l o t subjects were: Subject 1: female, 43 years, Class II RA; Subject 2: male, 57 years, Class III RA; Subject 3: female 68 years, Class I RA; Subject 4: female, 37 years, Class II RA. I t was assumed that these subjects represented an adequate age and functional d i s a b i l i t y range to determine sources of problematic methodology. A l l f o u r p i l o t s u b j e c t s r e p o r t e d r e l a t i v e ease of a d m i n i s t r a t i o n , r e s u l t i n g i n minimal m o d i f i c a t i o n o f the measures f o r t h i s study. The q u e s t i o n n a i r e took about 20 minutes t o complete, and each d i a r y s e c t i o n r e q u i r e s between f i v e and t e n minutes f o r completion. N e i t h e r of these time requirements was seen as unreasonable by these respondents. Measures The Q u e s t i o n n a i r e The q u e s t i o n n a i r e c o n s i s t e d o f q u e s t i o n s c o n c e r n i n g b a s i c demographic data, a r t h r i t i s h i s t o r y , and f u n c t i o n a l s t a t u s . The measures i n c l u d e d i n the q u e s t i o n n a i r e are d e s c r i b e d below. Demographic Data General i n f o r m a t i o n r e g a r d i n g age, gender, m a r i t a l s t a t u s , and o c c u p a t i o n was requested (See Table 1 ) . The mean age of the sample was 56.5 years (sd = 14.1), with a range of 25 t o 81 ye a r s . Respondents were c h a r a c t e r i z e d by middle age t o e l d e r l y s u b j e c t s ; approximately t w o - t h i r d s o f the sample were between 42 years and 71 y e a r s . The mean ages of the females and males were s i m i l a r a t 55.9 ye a r s and 58.5 years r e s p e c t i v e l y . Seventy-nine per c e n t of the sample was female, and 73% of the s u b j e c t s were married. O c c u p a t i o n a l s t a t u s was coded a c c o r d i n g t o Trieman's (1977) Oc c u p a t i o n a l P r e s t i g e S c a l e . The sample was c h a r a c t e r i z e d by upper and middle SES. Forty-two percent of the sample were c l a s s i f i e d w i t h i n p r o f e s s i o n a l o r a d m i n i s t r a t i v e c a t e g o r i e s , 33% were c r a f t o r k i n d r e d workers, and 25% were l a b o r e r s o r s e r v i c e workers. In terms of work s t a t u s , 28.6 % were c u r r e n t l y g a i n f u l l y employed, 9.5% were homemakers, 68.3% were r e t i r e d , and 22.2% were unemployed or on l e a v e . A r t h r i t i s History H i s t o r i c a l information regarding years since diagnosis and concurrent medical conditions other than RA was requested from respondents. Mean length of time since RA diagnosis was 11 years, with a range of one to 41 years. F i f t y - f i v e percent of the patients reported no concurrent disease. Disease status f o r the remainder of the sample was evenly d i s t r i b u t e d among non-life threatening c i r c u l a t o r y , respiratory, i n f e c t i v e and metabolic ailments. Disease status and number of years since diagnosis was comparable f o r males and females. Functional Status The RA l i t e r a t u r e suggests l e v e l of functional d i s a b i l i t y i s negatively related to coping a b i l i t y (Anderson et a l . , 1985). Functional status, as distinguished from disease a c t i v i t y and health status, re f e r s to an indiv i d u a l ' s performance l e v e l i n a c t i v i t i e s of d a i l y l i v i n g (ADL). As highly dysfunctional patients were excluded from t h i s study and functional a b i l i t y was not expected to be a s i g n i f i c a n t source of variance, ADL performance was assessed for descriptive information only. Functional a b i l i t y was assessed using the D i f f i c u l t y i n Mobility Subscale of the Modified Stanford Health Assessment Questionnaire (MHAQ; Pincus, Summey, Soraci, Wallston, and Hummon, 1983). The MHAQ i s a modification of the Stanford Health Assessment Questionnaire (Fries, Spitz, & Kraines, 1980), consisting of f i v e dimensions assessing d i f f i c u l t y i n completing a c t i v i t i e s of d a i l y l i v i n g . Speigel et a l . (1988) suggest that where anticipated outcome i s improved function rather than c l i n i c a l assessment, the MHAQ i s r e f l e c t i v e of a reasonable picture of functional status i n patients with rheumatoid 33 a r t h r i t i s . Inter-instrument correlations of the MHAQ with other frequently used functional a b i l i t y scales (e.g., The A r t h r i t i s Impact Measurement Scale; Meenan, Gertman, & Mason, 1980) imply the MHAQ assesses the same dimensions (Fries, 1983). Subjects responded to eight questions presented with one of four options ranging from 1 ("without any d i f f i c u l t y " ) to 4 ("unable to do"). Scores were aggregated over the eight items i n the subscale and in d i v i d u a l mean scores were computed. Scores ranged from 1 to 3.5, with most scores c l u s t e r i n g around the grand mean of 1.81. This mean score corresponds to functional a b i l i t y ratings f o r patients with Class II disease status and indicates that while most subjects reported some functional d i f f i c u l t y , few saw themselves as severely impaired by t h e i r i l l n e s s . There were no gender differences i n functional a b i l i t y . The Structured Daily Diary The structured d a i l y diary booklet developed for t h i s study was designed according to protocols used i n other diary approaches for assessing coping with s t r e s s f u l s i t u a t i o n s (Bolger et a l . , 1989; DeLongis et a l . , 1988; Stone & Neale, 1984a&b), health status (Verbrugge, 1980). The once-per-day assessments of events usually employed i n such protocols examining a f f e c t or health often f a i l , however, to capture within-day reappraisals and subsequent changes i n coping e f f o r t . In fac t , the ef f e c t s of da i l y stress on mood do not seem to p e r s i s t beyond the day of occurrence (Bolger et a l . , 1989; Rehm, 1978). Eckenrode (1984) Observed that the most important determinant of mood was same day (concurrent) d a i l y stressors. More recently, DeLongis et a l . (1988) corroborated t h i s finding; they reported a lack of predic t i v e power f o r stress on subsequent mood, but noted a 34 s i g n i f i c a n t r e l a t i o n between d a i l y stress and both concurrent and subsequent minor health problems. Reports of high stress l e v e l s were associated with increases i n same-day and next-day physical symptoms as well as f o r same day mood disturbances. In consideration of the findings that within-day information may be more predictive of outcome than between-day information, twice d a i l y assessments over a period of seven days were used i n an attempt to better capture fluctuations i n pain and coping. 35 Affects Balance Scale Mood state i s recognized as an important influence on both mental and physical well-being (DeLongis et a l . , 1988). Baum (1982) notes that when depression appears as a response to chronic i l l n e s s , i t can subsequently increase not only the int e n s i t y of the disease as reported by the patient, but also the a v a i l a b i l i t y of perceived resources for dealing with the stressor. As noted i n the l i t e r a t u r e , depression i s regarded by some researchers as a symptomatic feature of chronic pain (Anderson et a l . , 1986; Gardiner, 1980). Further, there i s some preliminary evidence that mood influences pain and coping (Revenson & Felton, 1989). Brown et a l . (1989), however, suggest that the amount of variance explained by depression on coping e f f o r t s i s r e l a t i v e l y low (R 2 = .09) i n t h e i r study on RA patients). In consideration of the general findings regarding elevated l e v e l s of depression i n RA patients, depressive symptoms in t h i s sample were assessed for t h e i r potential e f f e c t s on the pain/coping association. The Depression Subscale of the Affects Balance Scale (ABS; Derogatis, 1975) was used i n t h i s study. This subscale i s intended to measure p r e v a i l i n g mood state and consists of f i v e items representing p o s i t i v e and negative a f f e c t . Based on t h e i r emotional state during that time period, subjects rated each of the items (e.g., helpless, worthwhile, depressed) on a 5-point scale ranging from 0 ("not at a l l " ) to 4 ("a l o t " ) . Derogatis (1975) reported meaningful variance for mood ef f e c t s as well as high i n t e r n a l consistencies for the use of the ABS. This group of patients generally reported very low le v e l s of depressive symptoms. The mean depression score by subject (over 14 t i m e p o i n t s ) was .63 (n = 59, sd = .58), w i t h a range of 0 t o 2.87. Depression was u n r e l a t e d t o p a i n s e v e r i t y ( r = .18), o v e r a l l c o p i n g ( r = -.15) and f u n c t i o n a l a b i l i t y ( r = .06). Table 2 summarizes t h i s i n f o r m a t i o n . Although mood e f f e c t s were not f u r t h e r c o n s i d e r e d f o r analyses as a r e s u l t of these f i n d i n g s , the u n c h a r a c t e r i s t i c a l l y low r a t e s of d e p r e s s i o n i n t h i s sample suggests two hypotheses. F i r s t , t h i s low r a t e of r e p o r t e d d e p r e s s i o n may t y p i f y a group of p a t i e n t s who are r e l a t i v e l y w e l l - a d j u s t e d t o t h e i r d i s e a s e . Second, although s o c i a l d e s i r a b i l i t y e f f e c t s were not addressed i n t h i s study, such e f f e c t s may have i n f l u e n c e d the responses of these s u b j e c t s . P e r c e p t i o n of P a i n S e v e r i t y P a i n s e v e r i t y was assessed u s i n g a v i s u a l analogue s c a l e (VAS) designed by Huskisson (1974) f o r s e l f - r e p o r t p a i n measurement. The use of such r a t i n g s c a l e s t o assess p a i n has been widely accepted i n s t u d i e s of c h r o n i c p a i n p a t i e n t s (Downie e t a l . , 1978; Huskisson, 1983; Keefe, 1982; Reading, 1987). Ac c o r d i n g t o these authors, the VAS i s s e n s i t i v e t o v a r i a t i o n s i n p a i n experience and has demonstrated both good r e l i a b i l i t y and good v a l i d i t y . D e s p i t e the f a c t t h a t v i s u a l analogue s c a l e s are l i m i t e d t o q u a n t i t a t i v e , u n i d i m e n s i o n a l assessments of p a i n experience, such r a t i n g s have the advantage of r e l i a b l y s c a l i n g an e v a l u a t i v e p e r c e p t i o n of p a i n i n ascending o r d e r . U n l i k e o t h e r p a i n measures such as the M c G i l l P a i n Q u e s t i o n n a i r e (Melzack, 1975), the VAS p r o v i d e s a measure of s u f f i c i e n t s i m p l i c i t y and b r e v i t y t o j u s t i f y i n c l u s i o n i n an extended d i a r y measure. The VAS r e q u i r e s respondents t o s e l e c t a p o i n t on a standard 10 cm. l i n e t h a t d e s c r i b e s the s e v e r i t y of t h e i r p a i n experience where the endpoints of the l i n e are defined by "no pain" and "severe pain". Subjects were asked to rate the severity of t h e i r a r t h r i t i s pain at each of 14 time points on a VAS scale and a standard rule ranging from 0 to 9 was employed for scoring purposes. In order to reduce the amount of missing data for analyses, missing pain values (.03%) were replaced with the individual's mean pain score. Both the methodological requirements of t h i s study and the psychometric properties of the scale suggest the VAS to be i d e a l l y suited for the purposes of t h i s investigation. Coping Scales As noted e a r l i e r , the Ways of Coping (WOC; Lazarus & Folkman, 1984) has been widely used to assess the use of coping strategies i n various contexts. The authors designed t h i s 68-item scale such that coping i s assessed by operationalizing and quantifying the strategies an i n d i v i d u a l might use to deal with a s t r e s s f u l event. Coping i s defined as a series of cognitive and behavioral attempts to manage circumstances that evoke responses exceeding current personal resources (Lazarus and Folkman, 1984). Coping processes are separated conceptually from coping outcome i n order to assess s t a b i l i t y or change i n attempts to regulate a s t r e s s f u l encounter. Numerous studies applying factor a n a l y t i c techniques to the WOC (Coyne et a l . , 1981; Folkman & Lazarus, 1985; Folkman et a l . , 1986b; V i t a l i a n o et a l . , 1985) have consistently demonstrated the emergence of several factors which may be grouped conceptually into problem-focused (management of the source of stress) and emotion-focused (cognitive and behavioral e f f o r t s to regulate emotional di s t r e s s ) coping functions. Other studies assessing 38 coping i n diverse groups have found that the WOC performs well despite varying factor structures (Felton, Revenson, & Hinrichsen, 1984). T y p i c a l l y , such analyses demonstrate the emergence of factors that have been grouped into a number of problem- and emotion-focused domains. The authors of the WOC contend that such variations lend support to the adaptive sig n i f i c a n c e of the s i t u a t i o n f o r the population i n question (Folkman & Lazarus, 1980). Although the u t i l i t y of the scale has been demonstrated i n numerous studies assessing fluctuations i n coping processes over the course of a s t r e s s f u l encounter, to date t h i s scale has not been used to assess pain i n RA patients on a day-to-day basis (Auerbach, 1989). The WOC has undergone a number of revisions by various authors (Lazarus & Folkman, 1985; V i t a l i a n o et a l . , 1985). A recent r e v i s i o n by Folkman et a l . (1986a) was used i n a study i n which c h e c k l i s t responses to the most s t r e s s f u l encounter experienced by married couples during the previous week were obtained. Folkman et a l . (1986a) report high i n t e r n a l r e l i a b i l i t i e s f o r each of the eight subscales (alpha c o e f f i c i e n t s range from .61 to .79) produced by the 50 items. Of p a r t i c u l a r import for the present study i s the consistency with which strategies described by Planful Problem-solving, Distancing, Escape-avoidance, Self-Control, S o c i a l Support and Po s i t i v e Reappraisal have been i d e n t i f i e d as important i n coping with stress. On the basis of the extant l i t e r a t u r e on coping with RA, items from each of these s i x scales were chosen for the coping measure used i n t h i s study. Four items loading highest on each of the Folkman et a l . (1986a) subscales as well as additional items r e f l e c t i n g these concepts from the o r i g i n a l (1980) pool of WCCL items were selected. Two other scales, Social Comparison and Behavioral Self-Care, were comprised of a subset of other items adapted from the 1980 scale on the basis of previous research suggesting the u t i l i t y of these two strategies i n dealing with i l l n e s s - r e l a t e d behaviors. Scale construction i s discussed i n the following section. 40 R e s u l t s C o n s t r u c t i o n of the Coping Measure  Ways of Coping P r i o r t o f a c t o r a n a l y s i s , c o p i n g items t h a t were endorsed l e s s than 15% of the time were d e l e t e d from s c a l e c o n s t r u c t i o n . I n f r e q u e n t l y endorsed items were assumed t o be inadequate r e f l e c t i o n s o f coping o p t i o n s f o r t h i s sample. F u r t h e r , the frequency d i s t r i b u t i o n s f o r such items were not a c c e p t a b l e f o r f a c t o r a n a l y s i s . A f a c t o r a n a l y s i s was then performed on between-s u b j e c t mean s c o r e s d e r i v e d from the remaining WOC s c a l e items. An orthogonal (varimax) r o t a t i o n r e v e a l e d a f i v e - f a c t o r p r i n c i p a l a x i s s o l u t i o n when eig e n v a l u e s were r e s t r i c t e d t o a standard v a l u e g r e a t e r than one. The two f a c t o r s a c c o u n t i n g f o r the most v a r i a n c e were c o m p i l a t i o n s of items d e s c r i b e d i n the WOC by P l a n f u l P r o b l e m - s o l v i n g (the top t h r e e l o a d i n g items; F a c t o r 1, 22% of the v a r i a n c e ) and f o r F a c t o r 2, S e l f - C o n t r o l and D i s t a n c i n g items ( F a c t o r 2, 19% of the v a r i a n c e ) . The oth e r t h r e e f a c t o r s e s s e n t i a l l y r e p l i c a t e d the Folkman e t a l . (1986a) s u b s c a l e s of P o s i t i v e R e a p p r a i s a l , Escape-avoidance, and S o c i a l Support (11%, 12% and 10% of the v a r i a n c e , r e s p e c t i v e l y ) . Items l o a d i n g h i g h e s t on each of these f i v e f a c t o r s comprised the s c a l e s of P l a n f u l p r o b l e m - s o l v i n g , S e l f - C o n t r o l , P o s i t i v e R e a p p r a i s a l , S o c i a l Support and Escape-Avoidance. The s i x t h s c a l e used i n the coping measure, D i s t a n c i n g , was composed of the t h r e e next h i g h e s t l o a d i n g items on F a c t o r 2 f o l l o w i n g the S e l f -C o n t r o l items. F a c t o r l o a d i n g s f o r the WOC s c a l e s are r e p o r t e d i n Table 3. 41 Additional Coping Measure Items representing the concepts of s o c i a l comparison and s e l f - c a r e were treated separately from the WOC items i n scale construction. Factor analysis of only these eight items revealed that they separated into two factors, r e p l i c a t i n g the conceptual formation for the two strategies. These eight items were added to the coping measure i n the form of two subscales labeled S e l f -Care and Social Comparison. The f i n a l coping measure, consisting of 31 items, comprised the eight subscales (See Table 4 for a description of the subscale items). This measure was used to assess the cognitive and behavioral strategies rheumatoid a r t h r i t i s patients u t i l i z e d to cope with t h e i r pain over the course of a seven day period. Raw scores were used to calculate i n d i v i d u a l (within- and across-timepoint) and group means for each of the eight coping scales, and i n t e r n a l r e l i a b i l i t y t e s t i n g of these scales was performed, with alpha c o e f f i c i e n t s ranging from .58 to .93. V i t a l i a n o , Maiuro, Russo, and Becker (1987) proposed that the use of r e l a t i v e versus raw scores i n the compilation of the WOC subscales may r e s u l t i n a better understanding of i l l n e s s behavior where c l i n i c a l samples are compared with n o n - c l i n i c a l samples on coping behaviors. Although they argued that raw scores depress the r e l a t i o n between s p e c i f i c scales and o v e r a l l scales by disregarding the base r a t i o , the present study employed an ipsa t i v e methodology (each i n d i v i d u a l i s compared with his or her standard of reference) for evaluating coping processes and percentage scores were viewed as redundant for these data. Further, as preliminary analyses using raw and r e l a t i v e scores resulted i n s i m i l a r findings, raw scores were used f o r the remainder of the analyses. Intercorrelations among the coping scales were then computed to determine between scale associations. As noted i n Table 5, the in t e r c o r r e l a t i o n s among some of the scales i s f a i r l y high. In p a r t i c u l a r , i n t e r c o r r e l a t i o n s between the scales labeled Planful Problem-solving, Positive Reappraisal, Social Support and Social Comparison are highest with other scales, i n d i c a t i n g these four scales may not be represent conceptually d i s t i n c t coping strategies for t h i s sample. Subjects responded to a four-point scale ranging from "does not apply" to "used a l o t " . As the second category, "used not at a l l " also indicated non-endorsement, these categories were collapsed to form a three-point response set. Responses to 27,342 items were provided by subjects regarding t h e i r coping e f f o r t s . As Verbrugge (1980) notes, the opportunity for missing data i n diary methodology i s increased compared with other procedures although she reports low rates of missing data i n diary methodology. Missing coping items (accounting f o r 7% of the t o t a l coping responses) were assigned i n d i v i d u a l mean scores for the strategy i n question to reduce the amount of incomplete data. Descriptive Information on the Coping Scales The mean t o t a l coping score f o r a l l eight .strategies was 1.49 (sd = .28). Mean coping scores f o r each of the eight scales are presented i n Table 6. 43 Pain Severity The o v e r a l l between-subject mean pain score was 3.95 (sd = 1.39), with scores ranging from 0 to 8.5 (See Table 7). Previous pain had a s i g n i f i c a n t impact on subsequent pain. As expected, within-day pain ratings were highly correlated (r(63) = .79, p < .001). This r e s u l t i s consistent with findings from Eich, Reeves, Jaeger, and Redford (1985) who found that the memory of proximate pain episodes systematically influenced subsequent pain expectations. Their findings suggesting that high pain-to-pain associations are a l i n e a r function of preceding pain l e v e l o f f e r one explanation for high within-day pain c o r r e l a t i o n s . A l t e r n a t i v e l y , the p o s s i b i l i t y e xists that pain i s u n l i k e l y to fluctuate appreciably over the course of a day regardless of intervention. Some researchers suggest that chronic pain may simply not be amenable to appreciable change over the short-term (Kotarba, 1983). Although a hypothesis that the nature of pain i s r e l a t i v e l y unchangeable has not been d i r e c t l y addressed i n chronic pain research, the implications for t h i s study are important: pain f l u c t u a t i o n may not be related to coping choice by v i r t u e of the unalterable nature of pain i t s e l f . If pain i s amenable to change at a l l , examining pain on an i n t r a i n d i v i d u a l basis i s most l i k e l y to reveal whatever fluctuations occur. The data i n the present study corroborate findings i n other studies on pain and coping: pain change i s modest regardless of the coping strategies employed. Whichever of the two above explanation account for the high impact of previous pain on subsequent pain ratings, measures to control for the influence of previous pain were considered 44 necessary f o r t h i s study. The procedures used to account for t h i s variable are discussed i n the next section. Int r a i n d i v i d u a l Coping with Pain Bonferroni-stepped down Pearson product-moment correlations indicated average pain severity was unrelated to coping scores (r = - .12). While t h i s r e s u l t suggests a lack of r e l a t i o n between pain and coping, i t also supports the premise that within-day analyses cannot be treated i n the same manner as coping responses that are either assumed to be invariant (and measured only once) or that demonstrate between-person v a r i a t i o n . The main analysis consisted of an i n t r a i n d i v i d u a l analysis to determine i f there was a s i g n i f i c a n t difference i n the types of coping strategies used when pain decreased or increased over the course of the day. The prospective influence of morning coping e f f o r t s on changes i n pain severity report (morning to afternoon pain change) was the focus of in t e r e s t for t h i s study. To implement t h i s analysis, the independent variable (pain) was formed by aggregating the seven pain days for each i n d i v i d u a l into two groups. Average pain change scores for each i n d i v i d u a l were f i r s t calculated by computing the pain change from morning to afternoon for each of the seven days. The two groups were then formed according to a mean s p l i t where pain change f o r each of the seven days was compared with the individual's pain change mean. On days when pain increased more than the average pain change, assignment was made to the pain increment group. On days where pain increased less than the average pain change or when i t decreased, i n d i v i d u a l pain change scores were assigned to the pain decrement group. The pain increment group had a mean pain score of 4.55 (sd = 1.71) with scores ranging from 1.5 to 7.5. and the pain decrement group had a mean pain change score of 3.45 (sd = 1.58), with a range of .5 to 6.86. As Table 8 summarizes, a paired t - t e s t indicated the groups d i f f e r e d i n the amount of within-day pain change pain (t = 7.79, p < .001). On days when pain decreased, pain change was more marked than on days when pain increased. Change scores were considered appropriate for the formation of these two pain groups, and served as a p a r t i a l control for the morning/afternoon pain association. Differences i n morning pain between the increment and decrement pain groups were also examined (See Table 9). Mean group scores were calculated and a paired t - t e s t was performed, in d i c a t i n g these two means were s i g n i f i c a n t l y d i f f e r e n t (t = -9.00, p < .001). On days when pain increased the most, morning pain ratings were lower, ranging from .50 to 6.50. On days when pain decreased, morning pain was higher, with pain ratings ranging from 1.80 to 8.50. In order to account for the p o s s i b i l i t y that morning pain may have d i f f e r e n t i a l l y affected coping e f f o r t , morning pain was s t a t i s t i c a l l y entered into the multivariate analysis as a covariate. F i n a l l y , the eight dependent variables (morning coping scores) were calculated within each of the two pain groups and a MANOVA for repeated measures was performed using morning pain as a covariate. The multivariate t e s t s t a t i s t i c f or t h i s analysis was s i g n i f i c a n t (F(16, 106) = 1.75, rj = .049). Table 10 presents a summary of t h i s analysis. Univariate tests (df = 1, 62) revealed that the strategies defined by Positive Reappraisal and Self-Care had s i g n i f i c a n t within-day impact on pain severity ratings. Hypotheses 2 and 4, that Positive Reappraisal and S e l f -Care would be associated with lower pain increments were 46 supported. In comparison with the other strategies, subjects used these two strategies to a greater extent on days when pain decreased than they did on days when pain increased. The findings for Hypothesis 3, that Self-Control would be associated with lower pain, approached but did not a t t a i n s t a t i s t i c a l s i g n i f i c a n c e , demonstrating that t h i s strategy may have promise for e f f e c t i n g pain reduction i n circumscribed s i t u a t i o n s . Planful Problem-solving and Social Comparison, however, did not demonstrate the expected r e l a t i o n f or pain reduction, thus Hypotheses 1 and 5 were not supported by the data. Social Support, Distancing, and Escape-Avoidance had no d i f f e r e n t i a l e f f e c t s on subsequent pain. In summary, the use of selected coping strategies early i n the day was related to pain reduction i n the afternoon. Symptom management behaviors and po s i t i v e reframing techniques made a difference i n pain experience. F i n a l l y , although an a p r i o r i hypothesis concerning the o v e r a l l endorsement of coping strategies f o r t h i s population was not advanced, i t i s inte r e s t i n g to note the trend i n these data toward increased use of coping strategies on days when pain decreased (Nlow = 1.72, sd = .39) compared with days when pain increased (Nhigh = 1.65, sd = .31). Pearlin and Schooler (1978) have proposed that f l e x i b i l i t y i n coping has been linked to adaptive functioning i n a number of s t r e s s f u l s i t u a t i o n s . A repeated measures ANOVA resulted i n an F - s t a t i s t i c that approached the sig n i f i c a n c e l e v e l chosen for t h i s study (See Table 10). This r e s u l t suggests that o v e r a l l endorsement of coping strategies may also be linked to decreases i n within-day pain report. Multivariate analyses comparing the pain groups without covarying out morning pain resulted i n more powerful findings than the analyses reported using morning pain as a covariate. The o v e r a l l t e s t s t a t i s t i c was s i g n i f i c a n t (F(8, 55) = 2.62, rj = .02) fo r an analysis where pain was not included as a covariate. In terms of the s p e c i f i c strategies, Self-Control was s i g n i f i c a n t l y related to pain report (p_ = .039) as were the two strategies found to be related to pain report i n the conservative analyses, namely Self-Care and Positive Reappraisal. Further, the strategy of Escape-avoidance approached s i g n i f i c a n c e (j> = .12). This analysis suggests that the use of both Self-Control and Escape-avoidance strategies for managing pain also had some importance for subsequent pain experience. F i n a l l y , the o v e r a l l use of coping strategies on days when pain increased compared with days when pain decreased also had an impact on subsequent pain, lending further support to the premise that coping may reduce pain experience i n circumscribed s i t u a t i o n s . 48 Discussion The main findings of t h i s study outline the importance of coping for pain change when t h i s association i s examined within an i n t r a i n d i v i d u a l framework. In general, these r e s u l t s support the premise that within-day fluctuations are useful i n measuring coping e f f i c a c y f o r individ u a l s experiencing pain. S p e c i f i c a l l y , i n t r a i n d i v i d u a l analyses indicated that perception of pain i n t e n s i t y i s p a r t i a l l y explained by v a r i a b i l i t y i n coping. Two coping strategies were dominant i n influencing a reduction i n pain report. Pain reduction was distinguished by the strategies described as Pos i t i v e Reappraisal and Self-Care. Self-Control, a strategy focusing on regulation of feelings and action, also approached s i g n i f i c a n c e i n r e l a t i o n to pain reduction. On the other hand, expected associations among pain and other emotion-and problem-oriented strategies found i n previous research were not substantiated. Escape-avoidance, Distancing, Social Support, Social Comparison, and Planful Problem-solving were not associated with s i g n i f i c a n t fluctuations i n within-day pain. The implications of these findings w i l l be discussed i n t h i s section. The Use of Coping Strategies As Tan (1982) points out, many ch r o n i c a l l y i l l people somehow eventually come to terms with a deteriorating s i t u a t i o n by e f f e c t i n g some coping mechanisms that work to a l l e v i a t e the worst of the d i s t r e s s f u l s i t u a t i o n . Pain for the subjects i n t h i s study had long-term impact; the mean length of time since diagnosis was f a i r l y long (11 years). Presumably these individuals are highly conversant with those coping techniques that are most l i k e l y to a l l e v i a t e d i s t r e s s . This premise i s supported by the present data: the most important findings i n 49 t h i s study underscore the e f f i c a c y of c e r t a i n coping strategies i n reducing pain experience. The two strategies associated with pain reduction, Self-Care and Positive Reappraisal w i l l be discussed f i r s t . Exercising behavioral Self-Care was important i n influencing pain experience; employment of t h i s t a c t i c resulted i n a s i g n i f i c a n t reduction i n pain. This strategy was defined by behavioral elements and a c t i v i t i e s that cognitive-behavioral pain reduction programs suggest are useful to RA patients i n pain management (Bradley et a l . , 1984). The importance of t h i s f inding for pain control corroborates findings i n such programs fo r the u t i l i t y of strategies that d i r e c t l y manage symptoms. Treatment interventions have demonstrated the importance of s e l f - c a r e behaviors f o r managing pain: t h i s study demonstrates that patients use some se l f - c a r e strategies as part of t h e i r coping repertoire outside of treatment programs. Other s e l f - c a r e strategies may also be important i n coping with RA pain, and warrant further consideration. Positive Reappraisal also proved to be highly e f f e c t i v e i n e f f e c t i n g pain reduction. Increases i n the use of cognitions that reframe the pain experience i n a more p o s i t i v e l i g h t resulted i n decreases i n pain ^experience. This finding i s of p a r t i c u l a r importance as i t presents the f i r s t evidence i n the l i t e r a t u r e for a prospective association between Pos i t i v e Reappraisal and outcome. The combination of Positive Reappraisal and Self-Care strategies i n e f f e c t i n g pain reduction mirrors the consistency with which other forms of problem-focused coping and Positive Reappraisal appear together i n other studies (Folkman et a l . , 1986a; Folkman & Lazarus, 1985). Redefining pain experience 50 may f a c i l i t a t e or i n i t i a t e a form of coping that has potential benefits for the i n d i v i d u a l . I t could be argued that some posi t i v e thinking i n the face of severe pain or hardship might prove necessary for i n i t i a t i n g appropriate, pain-reducing actions. I t could also be argued, as Lazarus (1985) proposes, that e f f o r t s to avoid disengagement and to mobilize the necessary vi g i l a n c e to r e s i s t such behaviors requires a r e l a t i v e l y p o s i t i v e outlook. Although Planful Problem-solving, Social Support, S e l f -Control, Social Comparison, Distancing or Escape-Avoidance only showed trends toward si g n i f i c a n c e , i t i s nonetheless useful to discuss these trends i n l i g h t of the pr e v a i l i n g coping l i t e r a t u r e . The r e s u l t s for Planful Problem-solving support other data i n the l i t e r a t u r e on health-related behaviors. Planful Problem-solving, as described by the items used i n t h i s study, was not related to pain reduction for t h i s group of RA patients. The notion that adaptive tasks are accomplished at d i f f e r e n t times i n successful coping (Lazarus, 1985) o f f e r s some explanation f o r the infrequent use of problem-oriented strategies. Infrequent use may be related to the chroni c i t y of s t r e s s f u l s i t u a t i o n s : over time, people are l i k e l y to know what to do to deal with an aversive s i t u a t i o n and do not require the kind of mindful planning assessed by the scale used here. Social comparison theory suggests that downward comparisons can be used to advantage i n health-related s i t u a t i o n s . Although the findings i n t h i s study did not support t h i s premise for RA pain, the trend i s suggestive of some u t i l i t y for t h i s strategy. As with the Self-Care Scale, the Social Comparison Scale 51 As with the Self-Care Scale, the Social Comparison Scale represents a f i r s t attempt to capture the coping e f f o r t s of RA patients on a prospective basis. As the Social Comparison scale included items r e f l e c t i n g both downward and upward comparisons, the scale may not have adequately r e f l e c t e d the constructs important f o r i l l n e s s - r e l a t e d behaviors. As Manne and Zautra (1989) point out, the impact of RA may require extra needs fo r s o c i a l support i n order to adapt to the varied demands of the i l l n e s s . Patients i n t h i s sample endorsed support-seeking items r e l a t i v e l y infrequently, preferring to reduce interpersonal communication regarding t h e i r pain, and to increase intrapersonal distancing to pain perception. Although there was a trend to seeking comfort from others on days when pain decreased, support-seeking did not have a s i g n i f i c a n t e f f e c t on pain experience. As noted i n the review, s o c i a l support has d i f f e r e n t e f f e c t s depending on the reactions of others. In t h i s study, however, s o c i a l support was defined by attempts to seek out others. Neither the impact of negative compared with p o s i t i v e responses to support appeals nor the impact of r e c i p r o c a l exchanges rather than one-way requests f o r support were considered. The importance of these factors i s unresolved i n t h i s study, and suggests further investigation. Self-Control, t y p i f i e d by attempts to "keep pain from i n t e r f e r i n g with other things" (Folkman et a l . , 1986a, p. 995), although not s t a t i s t i c a l l y s i g n i f i c a n t , also demonstrated a trend to e f f e c t i v e pain reduction. As noted e a r l i e r , e f f o r t s describing self-monitoring behaviors that work to minimize the impact of pain are t a c t i c s that have been c i t e d i n the cognitive-behavioral l i t e r a t u r e as e f f e c t i v e i n pain management. 52 F i n a l l y , the two strategies most frequently discussed i n the RA pain l i t e r a t u r e , Distancing and Escape-Avoidance, were i n e f f e c t i v e i n terms of reducing pain experience. Despite the premise by Lazarus (1985) that d e n i a l - l i k e strategies may have a p o s i t i v e r o l e i n reducing pain experience i n circumscribed situations, no such e f f e c t s for these strategies were found. However, these strategies were also not associated with increases i n pain experience, contrary to findings i n other studies. Despite P h i l i p s ' (1987) contention that avoidance i s always maladaptive, i t may be the case, as patients report, that at times nothing a l l e v i a t e s pain of the type and c h r o n i c i t y experienced by RA s u f f e r e r s . Perhaps the importance of d e n i a l -l i k e strategies for the patients i n t h i s study stems not from the r e l a t i v e lack of u t i l i t y of the strategies i n reducing pain experience, but from t h e i r usefulness i n preventing worsening pain experience, thereby allowing the i n d i v i d u a l to function with less d i s t r e s s . 53 Future directions This study was suggestive of a number of important issues that need to be addressed i n the research on coping with pain i n rheumatoid a r t h r i t i s . Some authors have argued that age-related variables have impact on coping preferences (Lazarus & Delongis, 1983). An age-related approach may be useful i n further understanding the pain/coping r e l a t i o n i n RA patients. Assuming ce r t a i n types of coping are generally maladaptive overlooks the potential of such strategies to e f f e c t p o s i t i v e adjustment i n circumscribed s i t u a t i o n s . Mechanisms that are seemingly "maladaptive" for non-pain sufferers may prove to be the only method of l i v i n g with severe, chronic pain. For example, i f pain i s not p a r t i c u l a r l y responsive to any type of coping, denial may serve to keep up morale and reduce immediate d i s t r e s s . Inquiry into the situations where denial has adaptive si g n i f i c a n c e may be a worthwhile enterprise. The impact of pain during the period i n which coping was assessed also deserves consideration for an understanding of the conditions under which coping acts to reduce pain experience. S p e c i f i c a l l y , morning pain l e v e l may have had some impact on the implementation of coping responses. The p o s s i b i l i t y that high l e v e l s of morning pain was d i f f e r e n t i a l l y responsible for i n i t i a t i n g coping responses has some i n t u i t i v e appeal f o r explaining the increases i n coping on days when pain reductions were reported compared with days when pain increases were reported. The p o s s i b i l i t y that adequate attention to coping i s not i n i t i a t e d unless pain i s of s u f f i c i e n t d i s t r e s s for the ind i v i d u a l also suggests an important research focus. 54 Future e f f o r t s should a l s o be d i r e c t e d t o the c o n s t r u c t i o n of s c a l e s t h a t more adequately r e f l e c t the concepts most r e l e v a n t t o coping i n RA p a t i e n t s . The consequences of high i n t e r c o r r e l a t i o n s among the present s c a l e s i n c l u d e d reduced power f o r f i n d i n g d i f f e r e n c e s between the s t r a t e g i e s i n pain r e p o r t . The l a c k of d i s t i n c t i o n among the coping s c a l e s may have been p a r t i a l l y a t t r i b u t a b l e t o a general coping e f f o r t r e s u l t i n g i n high i n t e r s c a l e c o r r e l a t i o n s . C o l l a p s i n g s c a l e s according t o f a c t o r i n f o r m a t i o n may have d i s t i n g u i s h e d pain r e d u c t i o n t o a grea t e r degree. Future d i r e c t i o n s should i n c l u d e the development of more orthogonal s c a l e s , t h a t more d i r e c t l y r e f l e c t coping w i t h RA. A number of sample l i m i t a t i o n s i n t h i s study a l s o r e s t r i c t s the g e n e r a l i z a b i l i t y of these f i n d i n g s . A high a t t r i t i o n r a t e due t o d i f f i c u l t i e s i n o b t a i n i n g permission t o contact p o t e n t i a l p a r t i c i p a n t s may have r e s u l t e d i n a r e s t r i c t e d sample. S t r i n g e n t e x c l u s i o n a r y c r i t e r i a a l s o compromised sample s i z e . The considerable task demands may a l s o have had impact on the types of i n d i v i d u a l s who were w i l l i n g t o complete t h i s study. 55 Conclusion The central issue i n t h i s study concerned the u t i l i t y of an i n t r a i n d i v i d u a l prospective approach for explaining the usefulness of employing s p e c i f i c coping strategies for coping with pain. In t h i s study, examination of the pain-coping r e l a t i o n was most revealing where coping was evaluated i n terms of pain f l u c t u a t i o n . The u t i l i t y of an i n t r a i n d i v i d u a l approach was highlighted i n the present study by the o v e r a l l lack of r e l a t i o n between pain and coping when assessed from a between-subjects compared with an within-subjects approach. The usefulness of multiple reporting periods i s also established i n the l i t e r a t u r e : the si g n i f i c a n c e of within-day reports i s v e r i f i e d i n t h i s study. Although pain was affected by coping, fluctuations i n pain experience were r e l a t i v e l y small; twice-per-day assessments increased the p r o b a b i l i t i e s of capturing such changes. F i n a l l y , although the design of t h i s study did not lend i t s e l f to a s t r i c t i n t r a i n d i v i d u a l analysis, the quasi-prospective nature of the data advances a stronger argument concerning the causal nature of the coping/pain r e l a t i o n for RA patients than has been proposed by previous findings i n the RA l i t e r a t u r e . In conclusion, the present findings strongly suggest that c e r t a i n types of coping strategies have impact f o r reducing subsequent pain experience. 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Journal of  Personality and Social Psychology. 49, 1169-1183. 65 Table 1 Summary of Mean Scores for Descriptive Data Females Males Total Gender 50 (79%) Married 35 (70%) Age 55.98 Functional A b i l i t y 1.81 Years since diagnosis 11.06 Occupation Professional 23 (46%) Craft/Semi-professional 16 (32%) Service/Labor 11 (22%) 13 (21^ 11 (85^ 58.55 I. 81 II . 08 5 (38%) 3 (23%) 5 (38%) 56 (sd = 1 (sd 11 (sd = 15) 63 46 .14 14, .81 = .53) .07 = .99) 44.5% 30% 25.5% Work Status Gai n f u l l y employed 13 (26%) Homemaker 6 (12%) Retired 19 (38%) Unemployed\on leave 11 (22%) No response 1 4 (31%) 0 6 (46%) 3 (23%) 27% 9% 49% 22% 66 Table 2 Summary of Correlations with Depression r Overall pain r a t i n g Total coping score Functional a b i l i t y .18 .15* .06' ft N = 59 E > .10* 67 Table 3 Ways of Coping Scales Scale Factor Loadings Factor 1 Scale 1: Planful Problem-solving alpha = .93 I made a plan and followed i t . .86 Concentrated on what I had to do; the next step. .85 I knew what had to be done so doubled my e f f o r t s to make things work. .78 Scale 2: Self-Control alpha = .91 Tried to keep the pain to myself .81 Kept others from knowing how bad things were. .78 Tried to keep my pain from i n t e r f e r i n g too much. .63 Factor 2 Scale 3: Distancing alpha = .84 Didn't l e t i t get to me; refused to think about i t too much..80 Made l i g h t of the s i t u a t i o n ; refused to get serious about i t . .79 Went on as i f nothing happened. .78 Factor 3 Scale 4: P o s i t i v e Reappraisal alpha = .78 Told myself things to make me f e e l better. .74 Took pride i n my a b i l i t y for deal with the s i t u a t i o n . .69 Reminded myself I am doing the best I can. .62 Turned to prayer or s p i r i t u a l thoughts. .45 Changed or grew as a person i n a good way. .32 Rediscovered what i s important i n l i f e . .31 Factor 4 Scale 5: Escape-Avoidance alpha = .58 Tried to make myself f e e l better by drinking, smoking .60 Wished the s i t u a t i o n would go away or be over with. .58 Slept or napped more than usual. .82 Took t r a n q u i l i z e r s , sedatives or other drugs. .46 Factor 5 Scale 6: Social Support alpha = .80 Sought company of family or friends. .78 Talked to somecme aBbut how I f e l t . .74 Accepted sympathy and understanding from someone. .73 Table 4 Additional Coping Scales Scale Factor Loadings Factor 1 Scale 7: Social Comparison alpha = .86 I thought about someone who i s i n a worse s i t u a t i o n . .89 Thought how a person I would admire would handle t h i s and used that as a model. .81 Reminded myself how much worse i t could be. .72 Realized how, i n some ways, I am more fortunate than others. .76 Factor 2 Scale 8: Self-Care alpha = .76 Pursued a hobby or a c t i v i t y I enjoy. .89 Did some form of physical exercise or a c t i v i t y . .79 Treated myself to something s p e c i a l . .71 Practised meditation, biofeedback, relaxation, etc. .38 Table 5 Intercorrelations among the Scales Scale 1 2 3 4 5 6 1 Problem-solving 2 Self-Control .53** 3 Distancing .44** .69** 4 Reappraisal .66** .58** .42* 5 Social Comparison .40** .38 .10 .73** 6 Social Support .48** .38 .26 .66** .53** 7 Self-Care .57** .39* .38 .64** .52** .63** 8 Escape-avoidance .31 .37 .18 .53** .42* .54** * E < .05 ** E < ' 0 1 Table 6 Descriptive S t a t i s t i c s for the Coping Scales Scale Mean sd Self-Control 1.69 .44 Distancing 1.63 .41 Planful Problem-solving 1.48 .45 Self-Care 1.43 .27 Social Comparison 1.41 . 38 Social Support 1.40 .39 Avoidance 1.39 .30 Po s i t i v e Reappraisal 1.35 .33 71 Table 7 Mean Pain Ratings Overall Pain Morning Pain Afternoon Pain Mean 3.95* 3.93A 3.97 A sd 1.39 1.55 1.39 t(63) = 1.48, Ap > .10 72 Table 8 Means f o r Within-day Pain Change by Group Group Pain Decrement Pain Increment Mean 3.45 4.55 sd 1.58 1.71 Range . 5 - 6 . 4 8 1 . 5 - 7 . 5 t(63) = 7.79 p_ < .001 73 Table 9 Means for Morning Pain by Group Group Pain Increment Pain Decrement Mean 3.13 4.80 sd 1.47 1.57 Range .50 to 6.50 1.80 to 8.50 t(63) = -9.00 p. <.001 74 Table 10 Relation between Coping and Pain Outcome Covarying out Pain Univariate Tests Group Pain Increment Means Pain Decrement F E Self-Control 1.63 1.75 2.14 .13 Distancing 1.62 1.63 .16 .85 Planful Problem-solving 1.48 1.50 .20 .82 Self-Care 1.39 1.48 3.61 .03* Social Comparison 1.40 1.42 .47 .63 Social Support 1.36 1.47 .83 .44 Avoidance 1.36 1.40 1.59 .21 Positive Reappraisal 1.33 1.38 3.80 .03* Hotelling's T=.53 F(16, 106) = 1.746 p. = .049 75 Table 11 Summary of O v e r a l l Coping Scores Group Pain Increment Pain Decrement Mean 1.65 1.72 sd .31 .39 F ( l , 62) = 3.79 E = -056 Appendix A Procedure Patient Contact Following physician approval, potential respondents were sent l e t t e r s informing them of the purpose of the study (Appendix B). A member of the research team i n i t i a t e d telephone contact approximately one week following the l e t t e r date. In addition to the author, undergraduate psychology students participated i n the study as telephone interviewers. These students were trained i n procedure and administration for a l l aspects of data c o l l e c t i o n . They also participated i n an extensive (15 hour) interview t r a i n i n g program developed by the Inst i t u t e f o r Social Research (Guenzell, Berkman, & Cannel, 1983). It was expected that respondents would be more l i k e l y to remain i n the study i f a good rapport was established between the interviewer and the respondent. To t h i s end, respondents were randomly paired with telephone interviewers and communications with the respondent was directed to the designated interviewer where possible. Respondents were encouraged to c a l l t h e i r interviewer (at the Stress and Coping Research O f f i c e at U.B.C.) regarding concerns with the study. A standard s c r i p t for the telephone contact was followed. If the patient was interested i n p a r t i c i p a t i n g i n the study, they were briefed regarding the study. Respondents were given f u l l i n structions regarding procedures for completing the tasks and task materials were mailed to the respondent. Respondents received a package containing an i n s t r u c t i o n sheet with t h e i r interviewer's name and the Research O f f i c e Lab phone number, an informed voluntary consent form with a pre-stamped envelope, a b r i e f questionnaire, a twice d a i l y seven-day diary, and a pre-stamped envelope i n which to return the questionnaire and diary (See Appendix C for the questionnaire and diary materials). A l l respondent materials were coded by number i n order to protect patient c o n f i d e n t i a l i t y . Respondents were requested to complete and return the consent form immediately upon receipt, and to return the questionnaire and diary together following completion of the diary. I t should be noted that t h i s study was part of a larger research project consisting of the diary measure (and c o r o l l a r y items) and a structured interview to be completed at a l a t e r date. Only the materials of i n t e r e s t for t h i s study are reproduced here. 80 Naae ( p r i n t ) : . Personal I d e n t i f i c a t i o n Nuaber: A r t h r i t i s B a r r e n P r o j e c t V o l u n t a r y Cagsent Fore This study exaalnes the Mays In which people cope w i t h the stresses assoc ia ted w i t h chron I l l n e s s . The study c o n s i s t s of two t a s k s : ~ ~ (1 ) Completion of a seven-day ' d i a r y ' t o do at hoae and then send to the r e s e a r c h e r s . T d i a r y asks quest ions about your aood, g e n e r a l h e a l t h , and d a l l y s t r e s s e s or h a s s l e , and takes about 10 a lnutes to complete. (2) An Interview of approximately 90 a l n u t e s In length t o be conducted by a aeaber o f t i research t eaa . The Interview c o n s i s t s o f quest ions regarding your f e e l i n g s abo y o u r s e l f as w e l l as questions concerning h e a l t h and other l i f e events and w i l l I conducted about a aonth f o l l o w i n g r e c e i p t o f your d i a r y . Your voluntary Inforaed consent i s r e q u i r e d p r i o r t o p a r t i c i p a t i o n 1n t h i s s t u d y . P l e a read the f o l l o w i n g s e c t i o n c a r e f u l l y before s i g n i n g below. I understand that t h i s consent l a no way binds ao t o coaple te the study, ' and I aay w l t h d r ; at any t1ae , without e x p l a n a t i o n , t aa a l s o aware t h a t p a r t i c i p a t i o n In t h i s s tudy does IK a f f e c t any aspect o f ay n e d l c a l c a r e . 1 have been f u l l y Inforaed of the procedures Involve and v o l u n t a r i l y consent t o p a r t i c i p a t e 1n the A r t h r i t i s Research Pro jec t conducted by u Psychology Oepartaent a t U . B . C . S igned: Date : May we contact you In the F a l l to p a r t i c i p a t e In t h i s study again? ED B COMPLETE THE NEXT THREE SECTIONS (A. 8 . and C) AND SEND WITH THIS CONSENT FORM TO UBC A . S . A . P . 81 RA Personal I d e n t l f l e t Ion Nuaber NO SECTION A A l Are you c u r r e n t l y married? YES I f you are married, i n what year were you married? A2 Oo you have any c h i l d r e n ? YES (Answer below) NO (Go t o A3) How aany? How aany daughters? . How aany sons?. How o4d? 3 How o l d ? . How aany s t i l l l i v e at hoae?. A3 What Is/was your occupation? A4 What Is your h ighest l e v e l o f education? (Mark w i t h an ' I ' ) GRADE SCHOOL HIGH SCHOOL C0LLE6E/UNIVERSITY P0ST6RA0UATI0N A 4 a . What (grade/year/degree) d i d you coaple te? AS What i s your current work/occupation s t a t u s ? (Mark a l l which apply) WORK l i t HOME WORKING RETIREO SICK LEAVE LAID OFF UNEMPLOYED ON STRIKE f u l l - t i m e or P a r t - t i m e ? . A6 I n what year were yoa bora? 19_ 82 mim ti' tfTMms HISTORY B l Looking b«ck. In what year d i d you f i r s t have sy»pto«i of RA? RA COOC What were the symptoms you had? •  82 In what year were you diagnosed? 8 3 Have any of your Immediate f a m i l y M a t e r s been diagnosed w i t h rheumatoid a r t h r i t i s ? [YESJ [wj (GO t o BS) Who? How o l d were they when f i r s t diagnosed? 64 Do you have any other Medical c o n d i t i o n , a i lment , o r Impairment o t h e r t h a n «rthr«tit> NO YES I f YCS. p l e a s e d e s c r i b e : . When d i d I t s t a r t ? BS The fo l lowing ques t ions are about the treatments you've had f o r your a r t h r i t i s . BJA Have you had surgery f o r a r t h r i t i s ? 0 (Go t o Quest ion 8SB) 83 How does having a r t h r i t i s a f f e c t s ~ y o u r d a l l y l i f # now? T h l i i . . ' . r a t e d In t e r - s of d i f f i c u l t y on a s c a l e ' o f l t o I . It you III L%1\W t o a c t i v i t y a r a t i n g of I . I f you have tone d i f f i c u l t y . J I J t I t J * ii "Jl'W* 9 2 ¥ # t h « a r a t i n g of J . and If you are unable to do t h a t ac t v f t y . • r l i f n j I f V * U t , c ' Can y o u : Dress y o u r s e l f , i n c l u d i n g t y i n g shoelaces and doing buttons? Get i n and out of bed? Cut your food? Ha Ik outdoors on f l a t ground? Nash and dry your e n t i r e body? l e n d down and l i f t ob jects f r o a the f l o o r ? Ope a eost doors? Get 1» and out o f a car? Oegree of D i f f i c u l t y W i t h o u t N [With Sow W i t h M u c h (unable t o do 84 START OA* HORNING Oatt. T I M . 1. N I H III M l Su Day| I j COMPLETE AT OR AFTER LUNCH Below ts • l i s t of words d e s c r i b i n g the way to which you have had any of these f e e l i n g mmber that best describes how you f e l t t h l f e e l i n g , and do not sk ip any I tees . SOMET NEVER RARELY l a . E x c i t e d 0 1 lb. Nervous 0 1 1c. Sad e 1 I d . I r r i t a b l e 0 1 l e . Energet ic 0 1 I f . Hopeless 0 1 l o - T l a l d 0 1 i g - Resentful 0 1 l h . A c t i v e 0 1 11. Worthless 0 1 1J. Tense 0 1 Ik . Angry 0 1 11. Vigorous 0 1 Im Miserable 0 1 In Anxious 0 1 lo Enraged 0 1 »P l i v e l y 0 1 lq Unhappy • 1 l r A f r a i d • 1 Is B i t t e r B 1 eople s o M t l M S f e e l . Iridic t h i s M r n t n g by ear-king an • o r n l n g . Mark only one nu NES fREQUI te the degree ' X * over the ber f o r each NTLY ALMA 85 How s e v e r e was your p a i n f r o a a r t h r i t i s t h i s morning? No pain severe p a i n He would l i k e to f i n d out what you d i d to cflfiA w i t h your a r t h r i t i s p a i n t h i s n o r n l n g . Please Indicate a l l the things you d i d to help you deal w i t h t h i s p a i n by c i r c l i n g the appropriate number. 0 * does not a p p l y 1 • not at a l l 2 • soae 3 • a l o t Took I t out on o t h e r ( s ) . 0 Hade l i g h t of the s i t u a t i o n , refused to be upset. 0 O l d n ' t l e t It get to ne; r e f u s e d to th ink about I t too auch. o 1 thought about how a person I adalre would handle the s i t u a t i o n and used that as a a o d e l . „ _ 0 Real ized 1 brought the p r o b l e a on n y s e l f T "** " ~ — * „ Expressed anger. 0 I l e t ay f e e l i n g s out somehow. 0 Concentrated on what I had t o do-the next s tep. 0 Got profess iona l h e l p . 0 Talked to soaeone about how I was f e e l i n g . 0 Changed or grew as a person In a good way. 0 Kept others f roa knowing how bad It was. 0 Prepared ayse l f f o r the w o r s t . 0 Tr ied to keep ay pa in to a y s e l f . 0 C r i t i c i z e d or lec tured a y s e l f . 0 Rediscovered what Is important In l i f e . 0 Went on as If nothing had happened. 0 Reminded a y s e l f how auch worse things could be. 0 T r i e d to aake a y s e l f f e e l b e t t e r by e a t i n g , d r i n k i n g , smoking, e t c . 0 Wished the s i t u a t i o n would go away or soaehow be over w i t h . 0 Pursued a hobby or l e i s u r e a c t i v i t y I en joy. 0 Oaydreaat or had fantas ies about how things might turn o u t . 0 Hade a plan of a c t i o n and f o l l o w e d I t . 0 Turned to prayer or s p i r i t u a l thoughts. 0 Sought coapany of f a a l l y o r f r i e n d s . 0 S lept or napped more than u s u a l . 0 P r a c t i s e d transcendental a e d l t a t l o n , biofeedback, or r e l a x a t i o n techniques, e t c . 0 Accepted sympathy and understanding f r o a soaeone. 0 Rea l ized how, i n soae ways, I ' a more for tunate than o t h e r s . 0 Tr ied something I d i d n ' t t h i n k would work, but at least I was d o i n g something. n Took t r a n q u i l l i z e r s , s e d a t i v e s or other drugs . 0 Old soae form of p h y s i c a l e x e r c i s e or a c t i v i t y . 0 Treated a y s e l f t o something s p e c i a l (sauna, aassage, shopping t r i p , e t c . ) 0 Took p r i d e In ay a b i l i t y t o d e a l with ay s i t u a t i o n . 0 Reminded a y s e l f I am doing t h e best I can . 0 T r i e d to keep ay pa in f r o a I n t e r f e r i n g w i t h other things too auch. • I thought about someone I know who Is 1n a worse s i t u a t i o n . 0 Accepted i t , since nothing c o u l d be done. • I ISM vfcit I M to to increisetf ay efforts lo like things work. Tottf lyMlf things to kelp te f « l better. n 

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