Cognitive-behavioural and social factors do not predict recurrent secondary healthcare use in patients with fibromyalgia: a longitudinal study.

OBJECTIVES: Healthcare use in fibromyalgia (FM) is relatively high. Besides disease-related variables, cognitive-behavioural factors have been concurrently associated with healthcare use. It is unknown whether cognitive-behavioural and social factors also predict future healthcare use. The aim of this study was to identify cognitive-behavioural and social factors predicting recurrent secondary healthcare use in FM. METHODS: Using self-reported questionnaires, healthcare use, cognitive-behavioural, social, sociodemographic and disease-related variables including comorbidities were collected in 199 patients with FM, in a prospective longitudinal cohort spanning 18 months. Patients were recruited after receiving their diagnosis and protocolled treatment advice by a rheumatologist. Univariate and multivariate logistic regression models examined whether and which variables were predictors for recurrent secondary healthcare use. Internal validation was performed to correct for over-fit of the final multivariate model. RESULTS: Recurrent secondary healthcare use was lower than initial secondary healthcare use. Univariate analysis showed that having at least one comorbidity, depressive feelings, severe consequences of FM, low personal control and a high severity of fibromyalgia predicted recurrent secondary healthcare use. In the multivariate model, having at least one comorbidity was the only remaining predictor for recurrent secondary healthcare use. CONCLUSIONS: Our results suggest that the existence of comorbidities as communicated by the patient is the strongest warning signal for recurrent secondary healthcare use in FM. There seems no value in using cognitive-behavioural and social factors for early identification of patients with FM at risk for recurrent secondary healthcare use.

Can health care providers recognise a fibromyalgia personality?

OBJECTIVES: To determine if experienced health care providers (HCPs) can recognise patients with fibromyalgia (FM) based on a limited set of personality items, exploring the existence of a FM personality. METHODS: From the 240-item NEO-PI-R personality questionnaire, 8 HCPs from two different countries each selected 20 items they considered most discriminative of FM personality. Then, evaluating the scores on these items of 129 female patients with FM and 127 female controls, each HCP rated the probability of FM for each individual on a 0-10 scale. Personality characteristics (domains and facets) of selected items were determined. Scores of patients with FM and controls on the eight 20-item sets, and HCPs' estimates of each individual's probability of FM were analysed for their discriminative value. RESULTS: The eight 20-item sets discriminated for FM, with areas under the receiver operating characteristic curve ranging from 0.71-0.81. The estimated probabilities for FM showed, in general, percentages of correct classifications above 50%, with rising correct percentages for higher estimated probabilities. The most often chosen and discriminatory items were predominantly of the domain neuroticism (all with higher scores in FM), followed by some items of the facet trust (lower scores in FM). CONCLUSIONS: HCPs can, based on a limited set of items from a personality questionnaire, distinguish patients with FM from controls with a statistically significant probability. The HCPs' expectation that personality in FM patients is associated with higher levels for aspects of neuroticism (proneness to psychological distress) and lower scores for aspects of trust, proved to be correct.

Cost of illness and illness perceptions in patients with fibromyalgia.

OBJECTIVES: The disease impact and economic burden of fibromyalgia (FM) are high for patients and society at large. Knowing potential determinants of economic costs may help in reducing this burden. Cognitive appraisals (perceptions) of the illness could affect costs. The present study estimated costs of illness in FM and examined the association between these costs and illness perceptions. METHODS: Questionnaire data of FM severity (FIQ), illness perceptions (IPQ-R-FM), productivity losses (SF-HLQ) and health care use were collected in a cohort of patients with FM. Costs were calculated and dichotomised (median split). Univariate and hierarchic logistic regression models examined the unique association of each illness perception with 1) health care costs and 2) costs of productivity losses. Covariates were FM severity, comorbidity and other illness perceptions. RESULTS: 280 patients participated: 95% female, mean age 42 (SD=12) years. Annualised costs of FM per patient were €2944 for health care, and €5731 for productivity losses. In multivariate analyses, a higher disease impact (FIQ) and two of seven illness perceptions (IPQ-R-FM) were associated with high health care costs: 1) high scores on 'cyclical timeline' reflecting a fluctuating, unpredictable course and 2) low scores on 'emotional representations', thus not perceiving a connection between fibromyalgia and emotions. None of the variables was associated with productivity losses. CONCLUSIONS: Our study indicates that perceiving a fluctuating course and low emotional representation, which perhaps reflects somatic fixation, are associated with health care costs in FM. Future studies should examine whether targeting these illness perceptions results in reduction of costs.

Cognitive-behavioural therapy targeting fear of progression in an interdisciplinary care program: a case study in systemic sclerosis.

People living with chronic illness often report uncertainty about the future, fear of disease progression, fear of becoming physically disabled, and a reduced life expectancy as important sources of stress. However, little is known about psychological interventions targeting these concerns. The aim of this study is to illustrate an intervention to reduce emotional distress and concerns about the future in a patient with systemic sclerosis (SSc), a rare chronic rheumatic disease with serious consequences for most patients, and to present a preliminary report on its effectiveness using a single-case study design. Because of the complexity of symptoms and complaints due to SSc, the psychological intervention was embedded in an interdisciplinary care program also consisting of physical therapy, occupational therapy, and specialized nurse care.

Behavior change, acceptance, and coping flexibility in highly distressed patients with rheumatic diseases: feasibility of a cognitive-behavioral therapy in multimodal rehabilitation.

OBJECTIVE: To describe the development and feasibility of the integration of a cognitive-behavioral therapy (CBT) within a multimodal rehabilitation program for highly distressed patients with rheumatic diseases. METHODS: Development included the detailed specification of the theoretical and empirical-based underpinnings of the CBT and the comprehensive description of its design and content. Feasibility was assessed by percentage of eligible patients, attrition and attendance rates, and patient satisfaction. RESULTS: The developed CBT component seeks to decrease psychological distress and improve activities and participation across multiple life domains by accomplishing behavior change, acceptance, and coping flexibility. Motivational interviewing was applied to endorse patients' own reasons to change. Forty percent (35/87) of the eligible patients were admitted to the program. Attendance rate (>95%) was high. Patient satisfaction ranged from 6.8 to 8.0 (10-point scale). CONCLUSION: Integrating CBT within a multimodal rehabilitation program is feasible. An acceptable proportion of the intended patient sample is eligible and patient's attendance and satisfaction is high. PRACTICE IMPLICATIONS: Patients with impaired physical and psychosocial functioning despite adequate medical treatment pose a great challenge. Their treatment outcome may be improved by screening and selecting highly distressed patients and offering them a CBT embedded in multimodal rehabilitation program.

The coping flexibility questionnaire: development and initial validation in patients with chronic rheumatic diseases.

Coping flexibility may be beneficial for the adjustment in the context of a progressive and unpredictable course of chronic rheumatic diseases. The aim of this study was to develop and initially validate a self-report measure that assesses coping flexibility. Study participants were 147 outpatients with chronic rheumatic diseases (73% women, mean age 59 (range 20-79) years). Principal axis factoring analysis with oblique rotation was applied and internal consistency was determined. To investigate the initial validity of the coping flexibility questionnaire (COFLEX), hypothesised correlations with psychological and physical adjustment outcomes, pain, and coping strategies were examined. Factor analysis yielded a two-factor model of coping flexibility with acceptable internal consistency: versatility, the capability of switching between assimilative and accommodative coping strategies according to personal goals and situational demands (α = .88) and reflective coping, the capability of generating and considering coping options, and appraising the suitability of a coping strategy in a given situation (α = .70). Versatility was correlated with adaptive ways of coping and psychological adjustment, but not with physical adjustment and pain. Reflective coping was correlated with both adaptive and maladaptive ways of coping, but it was not correlated with adjustment outcomes. In conclusion, the current study suggests acceptable internal consistency of the COFLEX. Preliminary evidence of the validity of the versatility dimension is indicated, while the validity of reflective coping could not be firmly established. The associations of versatility with favourable adjustment to the disease warrant future confirmatory and validity research in larger samples of patients with chronic rheumatic diseases.

Tailored cognitive-behavioral therapy and exercise training for high-risk patients with fibromyalgia.

OBJECTIVE: The treatment of patients with fibromyalgia (FM), a high-prevalence chronic pain condition with a high impact on both patients and society, poses a great challenge to clinicians due to a lack of effective treatments. In view of the large individual variability in outcome, selecting patients at risk of long-term dysfunction and offering tailored treatment may be promising for beneficial treatment effects. METHODS: High-risk patients were selected and classified into 2 groups (pain-persistence and pain-avoidance groups) and subsequently randomized in groups to either a treatment condition (TC) or a waiting list control condition (WLC). Treatment consisted of 16 sessions of cognitive-behavioral therapy (CBT) and exercise training in groups, tailored to the patient's specific cognitive-behavioral pattern, delivered within 10 weeks. Physical and psychological functioning and impact of FM were assessed at baseline, posttreatment, and 6-month followup. Treatment effects were evaluated using a linear mixed model. RESULTS: The treatment effects were significant for all primary outcomes, showing significant differences in physical (pain, fatigue, and functional disability) and psychological (negative mood and anxiety) functioning, and impact of FM for the TC in comparison with the WLC. Effect sizes in the TC were overall large, and reliable change indices indicated a clinically relevant improvement among the TC. CONCLUSION: The presented results demonstrate for the first time that tailored CBT and exercise training for high-risk patients with FM is effective in improving short- and long-term physical and psychological functioning, indicating that tailoring treatment is likely to promote beneficial outcomes in FM and reduce the burden for patients and society.

Partner participation in cognitive-behavioral self-management group treatment for patients with rheumatoid arthritis.

OBJECTIVE: To determine if participation of the spouse of patients with rheumatoid arthritis in cognitive-behavioral oriented self-management training aimed at improving disease related cognitions and coping with pain has additional benefits for the patients. METHODS: A total of 59 couples were randomly assigned to 2 conditions. In the experimental condition the couples participated in a group program aimed at restructuring disease related cognitions and decreasing passive coping. In the control condition, only the patient participated. Disease status, self-reported physical and psychological functioning, coping, disease related cognitions, and marriage characteristics were assessed prior to the intervention and 2 weeks and 6 months postintervention. A general linear model with repeated measures was used to test for differences between conditions. RESULTS: In both conditions, similar positive changes in disease activity, cognitions, coping, and physical and psychological functioning were observed. Patients reported a decrease in potential support. There were no differences between conditions. However, at the followup assessment patients in the experimental condition reported more improvement of disease related communication with their spouse. CONCLUSION: No evidence was found for additional beneficial effects of spouse participation in the cognitive-behavioral oriented self-management group treatment.