Targeting distress in rheumatic diseases

Psychological distress is highly prevalent in patients with rheumatic diseases. It is associated with a variety of negative outcomes, including pain, fatigue, disability, and maladaptive cognitive behavioural coping strategies. In this thesis, psychological distress was studied both as an outcome measure and as a therapeutic target in the context of multidisciplinary rehabilitation. The longitudinal role of coping in psychological distress was systematically reviewed, a questionnaire to assess coping flexibility was described and initially validated, and the effectiveness of multidisciplinary rehabilitation programmes for selected patients with rheumatic diseases and high levels of psychological distress were evaluated. Various coping strategies were categorised into a hierarchical taxonomy to systematically examine the longitudinal association between coping and psychological distress in rheumatoid arthritis (RA). The evidence for the prognostic value of coping strategies for subsequent changes in psychological distress in RA turned out to be weak. Contrary to previous cross-sectional findings, active-oriented engagement strategies (e.g., problem solving) were not associated with a decrease in psychological distress over time. Some support was found for the usefulness of identifying avoidant-oriented coping strategies (e.g., helplessness, resting, wishful thinking) among patients in routine clinical practice as these coping strategies may forecast poor adjustment to RA. The coping flexibility questionnaire (COFLEX) was developed to assess coping flexibility. Evaluation of conventional multidisciplinary treatment programmes indicated that poor psychological well-being is common among patients in multidisciplinary rehabilitation and that psychological distress was under-recognised and not adequately considered in treatment. Programmes to target psychological distress through a group-based cognitive-behavioural therapy (CBT) within a multidisciplinary rehabilitation setting are, however, scarce. Because of the potentially fluctuating disease course of rheumatic diseases and because of the weak evidence for the prognostic value of separate coping strategies for subsequent changes in psychological distress, a CBT was developed promoting coping flexibility. The development of the CBT was further guided by evidence-based cognitive therapy principles, by the dual-process coping model that stresses the fit between characteristics of the situation and the employed coping strategy, and by empirical evidence on the role of acceptance in the adjustment to a chronic illness. The integration and feasibility of this acceptance-oriented CBT within multidisciplinary rehabilitation is extensively described in this thesis. The potential effectiveness of the CBT to decrease psychological distress and to improve acceptance and coping flexibility was examined in a longitudinal observational proof-of-concept study. The acceptance-oriented CBT was effective in improving patient’s psychological well-being and quality of life, but coping flexibility did not significantly change. The majority of the highly distressed patients showed decreased levels of psychological distress, large improvements in illness acceptance, and improved quality of life. In conclusion, psychological distress is prevalent among patients with rheumatic diseases in multidisciplinary rehabilitation. The proof-of-concept intervention study suggested the reversibility of distress by yielding preliminary support for the beneficial effects of an acceptance-oriented CBT embedded in multidisciplinary rehabilitation for selected patient with rheumatic diseases and high levels of psychological distress.