Predictors of psychological distress and well-being in women with chronic musculoskeletal pain: Two sides of the same coin?
Alexa Hubera, Anna Lisa Sumana, Giovanni Biasib, Giancarlo Carlia
This is an interesting article on the concepts of wellbeing and distress. Distress is often considered a key element in whether someone has ‘good quality of life’ (see my post from a day or so ago), but in this article, the relationship between psychological distress and well-being was explored, and the predictors of both in patients with chronic nonmalignant pain are identified.
Why would we be bothered about distress and how is it measured? Distress is not a particularly well-defined concept, but is often referred to in the same breath as ‘eustress’ and ‘distress’ (see this entry in Wikipedia for an exploration of several theories relevant to stress and coping). If its used in this way, it often refers to suffering (which is about negative judgements of a situation or event), and is distinct from depression. Using Loeser’s onion rings model of pain, it’s the emotional judgement of pain that negatively impact on the individual.
In this article, however, the authors refer to two traditions and the impact these traditions have on our ideas about wellbeing. To quote ‘[the] hedonic approach focuses on happiness, while the eudaimonic approach defines well-being in terms of the degree to which a person is fully functioning, which may or may not be accompanied by feeling good.’
This reminds me of the traditional WHO definition of health – which is not simply the absence of disease!
One of the reasons I was drawn to this study was the statement by the authors that ‘To date, few studies on well-being in patients suffering from chronic pain have been published’. (Of course I’d argue that experiencing chronic pain may be mandatory, but ‘suffering’ is optional!) This is precisely the point I’ve been trying to make for some time in that most of our knowledge about people experiencing chronic pain is drawn from people who are seeking treatment. People who live well despite having chronic pain are not studied often and hence we know relatively little about them.
So, getting down to the nuts and bolts of this study: 69 women recruited from a University Hospital Rheumatology centre. The majority of them met criteria for fibromyalgia, while the remainder had widespread pain, and many of them also experienced other conditions associated with central sensitisation syndrome (e.g. psoriasis, irritable bowel syndrome, headache, fatigue).
They all completed a raft of measures, but the ones I want to focus on are those assessing distress:
The Symptom Check List-90 (SCL-90) measures psychiatric symptoms and psychological distress and has been used often in this type of research.
The State–Trait Anxiety Inventory Form Y (STAI-Y) consists of two scales measuring state (STAT-Y1) and trait anxiety (STAT-Y2), respectively. It’s been used in many studies of anxiety in different patient and community groups.
The Multidimensional Affect and Pain Survey (MAPS)was used to measure pain-related emotional suffering and well-being. It consists of 101 descriptors within 30 clusters, grouped into three scales.
1. The Somatosensory Pain scale measures somatosensory pain sensations, and its results weren’t considered in this study.
2. The Emotional Pain scale (EP) measures pain-related emotional suffering within eight areas: Physical Illness, Depressed Mood, Self-Blame, Anger, Anxiety, Fear, Apathy, and Fatigue.
3. The Well-Being scale (WB) measures aspects of wellbeing in five clusters. The first two clusters—Mentally Engaged (e.g.,“interested”) and Physically Active (e.g., “vigorous”)— measure healthy activities and follow the eudaimonic tradition (which defines well-being in terms of functioning, not happiness).
The third and fourth clusters—Affiliative Feelings (e.g.,“sympathetic”) and Positive Affect (e.g., “happy”)—measure happy thoughts and really within the hedonic tradition. The fifth cluster, Treatable Illness, measures to what extent the patient believes that his/her illness is “curable” or “manageable” and represents a separate dimension of well-being.
(Just a comment – I’m not sure of the relationship between this measure and measures of acceptance such as those being studied by McCracken and others).
The other variables included in this study were ‘general epidemiological–anamnestic questionnaire, six measures of physical symptoms (tender point count, pain area, pain intensity, fatigue, stiffness, and physical disability).
Now for some statistics – not particularly challenging ones, so don’t panic!
Pearson correlation coefficients were used to assess the relationships between measures of well-being and psychological distress, applying Bonferroni adjusted α levels.
These showed only three physical symptoms—pain intensity (VAS), number of positive tender points, and physical disability (FIQ)— showed meaningful correlations with psychological distress and/or well-being.
A hierarchical multiple regression analysis was carried out to separately predict each of the six measures of well-being (WB-4 and each of the five WB clusters) and three measures of psychological distress (MAPS EP, STAI-Y2, and SCL-90 GSI). ‘Predictors were entered in the following order in five steps: (a) age; (b) pain duration (i.e., time passed since the onset of pain symptoms); (c) pain intensity; (d) number of positive tender points; and (e) physical disability.‘ Just so you know, several of these were mathematically transformed to make the stats assumptions work (which may affect the rigour of the results), but at least they told you about it!
Well, almost half the participants reached the cut-off score for trait anxiety, and many of them also reached the score for high distress. They sound fairly like the people that get referred to Burwood Pain Management Centre.
In terms of psychological distress, higher age and more physical disability emerged as the two most important predictors of psychological distress, each making unique contributions.
‘Both Pearson correlations (and multiple regression demonstrated that wellbeing (as measured by WB-4) was significantly predicted from low physical disability alone, and was independent of age, pain duration, pain intensity, and tender point count.’
What does this actually mean?
The results really show that the relationship between psychological distress and pain-related symptoms, may be mediated by the patient’s limitations in the capacity to perform daily household chores (ie disability).
We know that disability is influenced by a whole range of factors including the responses of significant others – and the cognitive interpretation of the meaning of those limitations, such as the disparity between what the person believes is expected of them as compared with what they believe they are capable of. It’s not simply about pain intensity.
Wellbeing, on the other hand, decreased with higher disability but, in contrast to psychological distress, was independent of age, pain intensity, and tender point count.
Now the finding that well-being was independent of pain intensity is an important result of this study.
Yesterday I quoted from Katz where it was assumed that if pain intensity alone was reduced, ‘quality of life’ would improve. I wouldn’t want to equate ‘quality of life’ with ‘wellbeing’ – but the dimensions are similar, and suggest that it’s simply not enough to reduce pain without simultaneously addressing other issues that are important to the individual.
As the authors state ‘Our findings suggest that, in patients with chronic musculoskeletal pain, well-being is related to aspects of physical disability that are not directly linked with pain. The results are in line with the literature demonstrating that the negative impact of chronic pain on physical functioning and work status is moderated by cognitive and psychosocial factors, such as pain catastrophizing and pain-related fear of movement.’
They add ‘Results are consistent with the view that pain behavior, rather than pain per se, should be the target of treatment’. Not news to many of us, but perhaps to those clinicians with a somewhat simplistic (or perhaps simply a biomedical) viewpoint, it may be surprising.
I’m also keen to support their contention that psychological wellbeing should be measured as an outcome quite distinct from a reduction in psychological distress. It’s a new concept for health care – to think that along with ways to reduce distress, clinicians could also consider ways to enhance wellbeing – and that this can occur in the absence of a focus on pain reduction.
It makes me think that the emerging field of positive psychology is something that pain management clinicians could well start to view more seriously. My post from the other day on counting blessings comes to mind. And for those of us working in the field for the long term – it might make our work just a little lighter and more fun!
HUBER, A., SUMAN, A., BIASI, G., CARLI, G. (2008). Predictors of psychological distress and well-being in women with chronic musculoskeletal pain: Two sides of the same coin?. Journal of Psychosomatic Research, 64(2), 169-175. DOI: 10.1016/j.jpsychores.2007.09.005