Table Of ContentRecent Research in Psychology
Mary L. Pritchard
Psychological Aspects of
Rheumatoid Arthritis
Springer-Verlag
New York Berlin Heidelberg
London Paris Tokyo Hong Kong
Mary L. Pritchard
Department of Psychology
Washington Singer Laboratories
University of Exeter
Exeter EX4 4QG
United Kingdom
With 4 Illustrations.
Library of Congress Cataloging-in-Publication Data
Pritchard, Mary L.
Psychological aspects of rheumatoid arthritis I Mary L. Pritchard.
p. cm.-(Recent research in psychology)
Includes bibliographical references.
I. Rheumatoid arthritis-Psychological aspects. I. Title.
II. Series.
[DNLM: I. Arthritis, Rheumatoid-psychology. WE 346 P961p]
RC933.P697 1990
616.7'227'0019-dc20 89-21615
Printed on acid-free paper.
© 1989 by Springer-Verlag New York Inc.
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Camera-ready copy provided by the author.
9 8 7 6 5 432 1
ISBN-13: 978-0-387-97116-2 e-ISBN-13: 978-1-4613-9666-6
001: 10.1007/978-1-4613-9666-6
For Mom, Dad and Andy
PREFACE
The main research described in this book is concerned with assessing the
interrelationship of psychological adjustment, compliance with medical
advice and use of unorthodox treatments in a sample of rheumatoid
arthritic out-patients. Basically this research is comprised of four
components: two pilot studies; the development and postal administration
of an illness knowledge assessment questionnaire; and a 'follow-up'
correlational study.
pilot study 1, which involved interviews with 18 patients, was a 'question
seeking' study - the aim being to develop research questions of relevance
to the Subject sample. The findings of this study suggested that poor
illness knowledge and consequent misconceptions was contributing to
psychological distress and affecting health behaviour among patients.
In pilot study 2 a sample of 17 patients were questioned in detail - but
using open-ended questions - about their understanding of their condition
and treatment. The results of this study supported the impression gained
in pilot study 1, that patients were typically ill-informed about their
illness and tended, in the absence of correct information, to overestimate
"the risks associated with rheumatoid arthritis and underestimate the value
of treatments.
This latter study also identified a number of specific misconceptions
patients held about rheumatoid arthritis and these were incorporated into
a multiple-choice illness knowledge assessment questionnaire, which was
then sent to a sample of 170 rheumatoid arthritics living in Exeter and
outlying areas - 128 usable replies were obtained. Following item and
factor analysis of the data obtained from this and a second sample of 114
patients (from Torbay) a 27 item multiple-choice questionnaire was
'arrived at'.
Seventy-five of the Exeter patients (randomly selected) who had returned
questionnaires were followed-up with interviews, for what comprised the
main study. In these interviews patients were questioned about their use,
experience, and evaluation of conventional medical treatments and
unorthodox treatments; and their emotional reactions to rheumatoid
arthritis. Additionally patients completed a pain locus of control scale
viii
(BPCQ); the General Health Questionnaire; the McGill Pain Questionnaire
and a series of visual analogue pain scales; and a disability assessment
index. Basic demographic and illness history data was also collected.
Factor analysis of this data revealed a core of five/six main factors.
These were concerned with: physical and psychological distress;
non-compliance with conventional medical treatment; use of 'home' or
personally supervised unorthodox treatments; use of faith related
unorthodox treatments or intrapsychic coping stategies; and there was also
a factor which most probably reflects the quality of the doctor-patient
relationship and on which loaded, among other things, ratings of
conventional medical treatment, illness knowledge, socio-economic status,
and use of unorthodox practitioners.
The best correlates of psychological distress were pain, the 'chance'
scale of the BPCQ, and ratings of the helpfulness of conventional medical
treatment. Correlates of compliance included helpfulness ratings of
conventional medical treatment, socio-ecomonic status and depression.
Use of 'home' unorthodox treatments appeared to reflect a need for
self-help and involvement. Use was greatest amongst female patients; was
positively associated with anxiety, minding taking conventional medical
drugs, the practice of exercise, and duration of illness; and was
negatively associated with depression, pain variability, and a 'powerful
other' locus of pain control orientation.
Female patients were also more likely to use faith related unorthodox
treatments (e.g. prayer, faith healer). Other variables associated with
the use of faith include: illness knowledge, age, ratings of conventional
medical treatment, and the experience of benefits as result of having
rheumatoid arthritis. Unorthodox practitioner use was also negatively
associated with ratings of conventional medical treatment, but in contrast
to the use of faith, was negatively associated with illness knowledge.
Users of unorthodox practitioners (chiropractors and acupuncturists) also
tended to be of lower socio-economic status than non-users, and have
higher 'chance' and 'internal' locus of pain control scores.
ACKNOWLEDGEMENTS
I should like to thank all the patients who participated in this research,
and Dr Richard Jacoby, their consultant, for their cooperation and
affability. Thanks also to members of the Social Work, Physiotherapy, and
Occupational Therapy departments at the Princess Elizabeth Orthopaedic
Hospital for their help.
I am also grateful to many people in the department of Psychology at
Exeter University, for their advice and guidance, but in particular to
Mr Keith Nichols and Professors J. Richard Eiser and Paul Kline.
Finally, I wish to thank Andy, my Mother and Father, and friends,
especially Marie, for their forbearance, encouragement and support.
This research was funded by the Medical Research Council.
COI!1'1'ENTS l
vii
PREFACE
ix
ACKNOWLEDGEMENTS
CHAPTER 1 INTRODUCTION
RHEUMATOID ARTHRITIS
PSYCHOLOGICAL ISSUES IN RHEUMATOID ARTHRITIS 5
PLAN OF THE BOOK 6
CHAPTER 2 PSYCHOLOGICAL DISTRESS IN lUIBUMATOID ARTHRITIS 7
INCIDENCE AND NATURE OF DISTRESS 7
EXPLAINING PSYCHOLOGICAL DISTRESS IN RHEUMATOID ARTHRITIS -
RESPONSE OR ANTECEDENT? 8
PREDICTORS OF PSYCHOLOGICAL DISTRESS IN RHEUMATOID ARTHRITIS 15
Demographic and Disease Related Factors 15
Coping 20
Control 23
Illness Knowledge 26
POSITIVE REACTIONS TO ILLNESS 31
xii
CHAPTER 3 COMPLIANCE WITH MEDICAL ADVICE 33
INCIDENCE OF NON-COMPLIANCE 33
PROBLEMS WITH COMPLIANCE RESEARCH 34
FACTORS ASSOCIATED WITH COMPLIANCE 37
Health Beliefs 37
Knowledge 40
The Doctor-Patient Relationship 43
Health Locus of Control 45
PATIENT KNOWLEDGE 47
The Adequacy of Patient Knowledge 47
Why Do Patients Know So Little? 48
CHAPTER 4 UNORTHODOX TREATMENT USE 54
INTRODUCTION 54
LIMITATIONS OF RESEARCH ON UNORTHODOX TREATMENT USE 56
WHY DO PEOPLE TURN TO UNORTHODOX TREATMENTS? 58
The Sophistication Hypothesis 58
The Legitimisation and Psychological Needs Theories 63
Dissatisfaction with Conventional Medical Care 64
The Pulling Power of Unorthodox Treatments 68
THE DIMENSIONALITY OF UNORTHODOX TREATMENT USE 72
CHAPTER 5 PILOT STUDY 1 - AN EXPLORATION OF PSYCHOLOGICAL
ISSUES IN RHEUMATOID ARTHRITIS 76
METHOD 76
Subjects 77
RESULTS AND DISCUSSION 77
Emotional Reactions to Illness 77
Effects on Life 79
Pain 80
Role and Effects of Stress 81
Reac"t:ions of Families 82
The Doctor-Patient Relationship 83
Knowledge and Misconceptions 84
xiii
CHAPTER 6 PATIENTS' KNOWLEDGE AND MISCONCEPTIONS ABOUT
THEIR ILLNESS 86
PILOT STUDY 2 86
Subjects 87
Results and Discussion 88
(1) The Disease Process and General Knowledge about
Rheumatoid Arthritis 88
(2) Knowledge about Treatments 93
(3) Prognosis 97
CONCLUSIONS 100
POSTAL QUESTIONNAIRE STUDY 101
Subjects 108
Analysis and Results 109
( 1) Patients' Knowledge and Misconcep-tions about Rheumatoid
Arthritis as Assessed by the Questionnaire 110
(2) The Questions Patients Asked 113
CHAPTER 7 METHODOLOGY OF THE MAIN CORRELATIONAL STUDY 116
SUBJECTS 116
INTERVIEW SCHEDULE 116
Compliance 117
Use of Unorthodox Treatments 117
Exercise Habits 118
Medical Treatment 118
Emotional Reactions to Rheumatoid Arthritis 118
Demographic Details and Illness History 118
QUESTIONNAIRES 118
Beliefs about Pain Control Questionnaire (BPCQ) 118
General Health Questionnaire (GHQ -60) 120
McGill Pain Questionnaire (MPQ) 121
Pain Assessment Questionnaire (PAQ) 122
Disability Index of the Health Assessment Questionnaire 123
STATISTICAL ANALYSES 124
Interpretation of Factors 129
Description:The main research described in this book is concerned with assessing the interrelationship of psychological adjustment, compliance with medical advice and use of unorthodox treatments in a sample of rheumatoid arthritic out-patients. Basically this research is comprised of four components: two pilot
