ABSTRACT
Introduction Stress is currently considered a health risk factor. Numerous studies have shown that people with high levels of perceived stress present a greater number of complaints at both the physical and psychological levels. In this context, programs have been developed directed toward adequately coping with stress, and the effectiveness of these programs on the symptomatology of a psychological nature in healthy persons with a high level of perceived stress has been shown. However, there have been fewer studies that have shown whether this type of therapy affects the somatic symptomatology of healthy people in any way. On the other hand, programs for chronically ill patients directed toward achieving a better adaptation to their life conditions are equally effective. A population that presents considerably high levels of stress is the one consisting of people suffering from a chronic illness. Thus, through the immunological modulation it produces, the stress may be exacerbating the course of the disease. One prototype of this is systemic lupus erythematosus (SLE). SLE is a syndrome whose clinical expression depends on the degree to which there is a convergence of an immune regulation disorder and a strong genetic base, hormonal influence, and various exogenous agents. SLE can be manifested by general malaise, fever, fatigue, weight loss, skin rashes, joint inflammation, anemia, inflammation of the lymphatic glands, lowering of the defenses against infection, and cardiac, kidney, neurological, and pulmonary alterations. This autoimmune disease is usually associated with high levels of pain and impairment in different systems, producing high levels of stress in the patients who suffer from it. Nevertheless, although stress has already been shown to be one environmental factor that can produce a worsening in lupus symptoms, there have been no studies carried out with the objective of testing the effectiveness of stress management therapy and its physical and emotional consequences in these patients. For this reason, this study has a double objective: on the one hand, to corroborate, once again, the efficacy of cognitive-behavioural stress management therapy in the control of certain psychological processes and, on the other hand, to take one more step by testing whether there is a reduction in the perception of self-reported somatic symptoms both in healthy people and in those with a chronic disease. Material and method Fifty-two people participated in this study. Twenty-two were patients with lupus from the University Hospital in Granada. The other 30 were people without chronic diseases who attended the Psychological Attention Service at the University of Granada to receive therapy for coping with stress, as they claimed to have high levels of it. To evaluate the level of stress, we used the Stress Vulnerability Inventory by Beech, Burns and Scheefield, and the Scale of Recent Life Experiences (SRLE) by Kohn and Macdonald. To evaluate depression, we used the Beck Depression Inventory (BDI), and for anxiety, the Trait Anxiety Inventory (STAI-R) by Spielberger, Gorsuch and Lushene. For the self-reported somatic symptoms, we used the Revised Somatic Symptoms Scale (SSS-R) by Sandín, Valiente and Chorot. In addition, in the patients with SLE, the SLEDAI index, or Index of Activity of the Disease, was obtained. The therapy received was cognitive-behavioural in nature, and it was carried out during 13 sessions which were grouped in the following blocks: Conceptualization of the stress, cognitive restructuring; Deactivation techniques; Approaching the self-management of the pain; Social skills; Time control and organization; Personality pattern and its relationship with health; Anger management; Humour and optimism as coping strategies. Results Results showed that both groups presented a statistically significant reduction in stressful life experiences [F(1 .50) = 28.6; p<.000], vulnerability to stress [F(1 .50) = 1 05.25; p<0.000], depression [F(1 .50) = 68.33; p<0.000], and anxiety [F(1 .49) = 54.53; p<0.000] after the treatment. Moreover, the effect size of these variables was high in the group of patients with lupus and in the group of healthy patients, although it was higher in the latter group. Likewise, both groups presented a statistically significant improvement in the physical function, producing a reduction in the perceived somatic symptoms [F(1 .48) = 37.7; p<0.000] after the treatment. Furthermore, the effect of the treatment was high in both groups. Discussion This paper addresses a critically important issue: the effectiveness of cognitive-behavioral intervention in ameliorating psychosocial stress and enhancing the well-being of individuals with lupus and the group of people with high stress. In this improvement, there was not only a significant reduction in the score on vulnerability to stress and stressful life experiences, but a reduction in the levels of anxiety and depression and somatic symptoms. The findings of improvements in somatic symptoms suggest that this intervention might facilitate coping and change the cognitive appraisals of symptoms. Likewise, the impact of the intervention on psychosocial outcomes (depression, anxiety and perceived vulnerability to stress) may have implications for longer-term health behaviors and health outcomes. Although this reduction is significant in both groups, the effect size is greater in the group of people with high stress than in the group of lupus patients. Specifically, the somatic symptoms where a lower effect of the therapy was observed were the immunological, respiratory, musculoskeletal, and dermatological symptoms, which coincide with the most characteristic symptoms of lupus. This study supports, therefore, the importance of stress management programs not only to reduce the amount of stress, but also to improve the emotional variables and physical condition, both in people with chronic diseases and in healthy people with a high level of stress. The cognitive-behavior therapy is a new effective line of action in dealing with lupus, being necessary an overall integrated view of the patients with lupus, treating the clinical and psychological aspects.
Introducción Actualmente, el estrés se considera un factor de riesgo para la salud. Diversos estudios ponen de manifiesto que altos niveles de estrés presentan mayor número de quejas, tanto en el nivel físico como psicológico. En este contexto, se han desarrollado programas dirigidos a un adecuado afrontamiento del estrés, que han resultado eficaces en la modificación de variables emocionales. Sin embargo, no se ha estudiado la eficacia de la terapia en la mejoría de síntomas somáticos. Por otra parte, existen enfermedades en que, por la modulación inmunológica que produce, el estrés puede actuar exacerbando el curso de ésta. Un prototipo de lo anterior es el lupus eritematoso sistémico (LES), enfermedad de carácter autoinmune que suele conllevar importantes niveles de dolor y deterioro de diferentes sistemas, con lo que a su vez produce altos niveles de estrés en los pacientes que lo padecen. También está ampliamente demostrado que el estrés puede actuar como exacerbador de la enfermedad. Pese a ello, no se ha llevado a cabo ningún estudio que tenga como objetivo comprobar la eficacia de la terapia de afrontamiento al estrés por sus consecuencias físicas y emocionales. Por ello, el objetivo de este estudio ha sido valorar la eficacia de la terapia cognitivo-conductual en el manejo del estrés para comprobar si disminuye la percepción de los síntomas somáticos autoinformados, tanto en personas sanas como en personas con lupus. Material y método En este estudio han participado 52 personas, de las cuales 22 eran pacientes con lupus y 30 eran personas con alto estrés. Para evaluar el nivel de estrés hemos utilizado el Inventario de Vulnerabilidad al Estrés y la Escala de Experiencias Vitales Recientes (SRLE); para evaluar la depresión, el Inventario de Depresión de Beck (BDI); para la ansiedad, el Inventario de Ansiedad Rasgo (STAI-R); y para los síntomas somáticos autoinformados, la Escala de Síntomas Somáticos-Revisada (ESS-R). Además, en los pacientes con LES, se obtuvo el índice SLEDAI o índice de actividad de la enfermedad. Ambos grupos se evaluaron en las diferentes variables psicológicas descritas previamente antes y después del tratamiento. La terapia recibida fue de tipo cognitivo-conductual y se desarrolló a lo largo de 13 sesiones de hora y media. Resultados Los resultados mostraron que ambos grupos presentaban una reducción estadísticamente significativa en experiencias vitales estresantes [F(1 .50) = 28.6; p<0.000], vulnerabilidad al estrés [F(1.50) = 105.25; p<0.000], depresión [F(1.50) = 68.33; p<0.000] y ansiedad [F(1 .49)=54.53; p<0.000] después del tratamiento. El tamaño del efecto en estas variables fue alto tanto en el grupo de pacientes con lupus como en el grupo de personas sanas, siendo mayor en este último. Asimismo, ambos grupos presentaron una mejora estadísticamente significativa de la función física y se produjo una disminución de los síntomas somáticos percibidos [F(1 .48) = 37.7; p<0.000] después del tratamiento. Además, aunque es alto en ambos grupos, el efecto del tratamiento es mayor en el grupo de personas con alto estrés percibido. Discusión Nuestros datos indican que la terapia de afrontamiento del estrés influye positivamente tanto en el grupo de personas con alto estrés como en el grupo de pacientes de lupus. En dicha mejoría disminuyen de forma significativa las puntuaciones de vulnerabilidad al estrés, experiencias vitales estresantes, ansiedad y depresión. Por otro lado, con respecto a los síntomas somáticos experimentados por ambos grupos, los resultados muestran un descenso de la percepción de los mismos. Aunque esta disminución es significativa, el tamaño del efecto es mayor en el grupo de personas con alto estrés. Este estudio apoya, por tanto, la importancia de un programa de afrontamiento del estrés no sólo para disminuir la cantidad de estrés, sino para mejorar las variables emocionales y el estatus físico tanto en personas con enfermedades crónicas como en personas sanas, pero con alto estrés.
ABSTRACT
The positive effects of hydroxychloroquine in treating systemic lupus erythematosus is well known. Hydroxychloroquine is a well tolerated and safe drug even during pregnancy and breast feeding, and it has a low cost. Retinopathy is the most serious side-effect associated with its use since irreversible blindness can occur; therefore, an appropriate monitoring of the eye by an ophthalmologist becomes essential. The remarkable effectiveness of hydroxychloroquine to control disease activity has been demonstrated; and there is also evidence suggesting that this drug contributes to prevent damage accrual and to improve survival in lupus patients. Besides the immunomodulating and immunosuppressant properties of hydroxychloroquine, it also has beneficial effects on lipid and glucose metabolism as well as antithrombotic effects that could contribute to prevent arteriosclerosis in these patients
La utilidad de la hidroxicloroquina en el tratamiento del lupus eritematoso sistémico está ampliamente demostrada. Es un fármaco seguro (incluso durante el embarazo y la lactancia), bien tolerado y económico. La retinopatía asociada a su uso es el único efecto adverso realmente peligroso por cuanto puede provocar ceguera irreversible, que puede evitarse mediante un adecuado control oftalmológico. Existen suficientes datos que respaldan el notable efecto que tiene la hidroxicloroquina sobre el control de la actividad de la enfermedad. También hay hallazgos que sugieren que disminuye el daño acumulado en los pacientes lúpicos y podría aumentar su supervivencia. Las propiedades de la hidroxicloroquina parecen ir más allá de su efecto inmumodulador e inmunosupresor. Así, tiene efectos beneficiosos sobre el metabolismo lipídico y glucémico y efectos antitrombóticos que podrían contribuir a prevenir la aterosclerosis