J Clin Psychol Med Settings (2015) 22:77–89 DOI 10.1007/s10880-015-9419-6
Illness Perceptions, Negative Emotions, and Pain in Patients with Noncardiac Chest Pain Jared I. Israel • Kamila S. White • Ernest V. Gervino
Published online: 22 January 2015 Springer Science+Business Media New York 2015
Abstract Illness-specific cognitions are associated with outcomes in numerous health conditions, however, little is known about their role in noncardiac chest pain (NCCP). NCCP is prevalent, impairing, and associated with elevated health care utilization. Our objective was to investigate the relations between illness perceptions, emotion, and pain in a sample of 196 adult patients diagnosed with NCCP. We found that negative illness perceptions were associated with greater anxiety, depression, chest pain, and painrelated life interference while controlling for the effects of demographic and pain-related variables. These results expand current NCCP theory and may inform future treatment development. Keywords Noncardiac chest pain Illness perceptions Anxiety Depression Pain-related impairment Health psychology
Introduction Chest pain is one of the most common complaints in medical settings (Blatchford, Capewell, Murray, & Blatchford, 1999; Kroenke, Arrington, & Mangelsdorff, 1990). However, over half of all patients presenting with chest pain are found to have no medically detectable J. I. Israel (&) K. S. White Department of Psychology, University of Missouri–St. Louis, One University Boulevard, 325 Stadler Hall, St. Louis, MO 63121, USA e-mail:
[email protected] E. V. Gervino Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
cardiac condition (Kroenke & Mangelsdorff, 1989; Mayou, Bryant, Forfar, & Clark, 1994) and are subsequently determined to have a syndrome known as noncardiac chest pain (NCCP; Eslick, Coulshed, & Talley, 2002). Similar to other diagnoses of exclusion, NCCP may include a heterogeneous set of presentations. Although the large majority of NCCP cases fall into the category of medically unexplained symptoms, a portion of NCCP cases are due to esophageal abnormalities (Kachintorn, 2005). To further complicate the matter, standard diagnostic procedures for NCCP have not been established. Long-term studies have found that NCCP symptoms and related impairments typically persist for years after initial evaluation (Beitman et al., 1991; Potts & Bass, 1993). NCCP is an impairing condition (Eslick, 2008). Patients with NCCP demonstrate reductions in quality of life and daily functioning that are significantly more severe than those observed in healthy controls (Lau, Hui, & Lam, 1996; Wong et al., 2002) and are comparable to what is reported by patients with cardiac disease (Cheung et al., 2009; Eifert, Hodson, Tracey, Seville, & Gunawardane, 1996). NCCP is also associated with an increased number of missed workdays (Eslick & Talley, 2004), and results show that rates of chest pain-related work absenteeism are similar in NCCP and cardiac disease groups (Cheung et al., 2009). Lastly, NCCP is related to elevated rates of health care utilization (Eslick, 2004; Mourad, Jaarsma, Hallert, & Stro¨mberg, 2012) Patients with NCCP exhibit high levels of psychological distress. Compared to both the general population as well as patients with cardiac disease, individuals with NCCP report more severe anxiety and depression (Fass & Achem, 2011; Webster, Norman, Goodacre, & Thompson, 2012) and are more likely to be diagnosed with a DSM-IV Axis-I disorder (Alexander, Prabhu, Krishnamoorthy, & Halkatti, 1994; Serlie, Erdman, Passchier, Trijsburg, & ten Cate,
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1995; White et al., 2008). Panic disorder in particular demonstrates strong similarities to the symptoms and experience of NCCP (Carter et al., 1992; Dammen, Arnesen, Ekeberg, & Friis, 2004). In addition to highlighting the level of psychological impairment that characterizes this population, these findings are relevant to the theoretical basis of NCCP. Psychological distress has been proposed as a key factor in the development and maintenance of this syndrome (Mayou, 1998). Indeed, evidence shows that higher levels of anxiety and depression are associated with more severe NCCP and greater NCCP-related impairment (Bass, Wade, Hand, & Jackson, 1983; Demiryoguran et al., 2006). Central to etiological theories of NCCP is the hypothesized interaction of psychological distress and numerous biological factors that predispose individuals to misinterpreting physical symptoms as signs of serious disease (White & Raffa, 2004). A growing collection of research has supported this conceptualization in demonstrating that patients with NCCP are especially fearful of and uniquely vigilant to cardiac sensations (Aikens, Zvolensky, & Eifert, 2001; White, Craft, & Gervino, 2010). Among the factors related to the experience of negative emotion and functional impairment in NCCP, maladaptive illness-specific cognitions have been found to play a key role. Individuals with NCCP engage in pain catastrophizing (Bradley, Scarinci, & Richter, 1991), the tendency to exaggerate pain-related danger (Sullivan et al., 2001). Further, these overemphasized interpretations of pain are associated with physical and psychosocial impairments (Shelby et al., 2009). Other research has found a direct link between perceiving cardiac sensations as uncontrollable and experiencing those sensations as intense and fear provoking (Zvolensky, Feldner, Eifert, Vujanovic, & Solomon, 2008). Eifert et al., (1996) have demonstrated that individuals with NCCP display stronger disease conviction than patients diagnosed with cardiac disease. Recent findings from NCCP samples have also shown an association between illness-specific beliefs and chest pain severity (Schroeder et al., 2012), depression, and health-related quality of life (Jonsbu, Martinsen, Morken, Moum, & Dammen, 2012). These studies have established the significance of cognitive processes in NCCP, however, continued investigation is needed to expand our understanding of the function of maladaptive illness beliefs. Psychological interventions have been developed and tested for NCCP with varying success rates, and several have included a focus on modifying illness-related thoughts. Outcomes from studies of cognitive behavioral therapy (CBT) for NCCP have supported the clinical efficacy of this approach (for review see White, 2010). An investigation of treatment mechanisms found that helping patients modify dysfunctional cognitions regarding pain
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attribution led to reductions in NCCP, independent of decreases in anxiety (Van Peski-Oosterbaan, Spinhoven, Van der Does, Bruschke, & Rooijmans, 1999). Pilot data from a CBT trial for patients with NCCP have also demonstrated that changes in illness perceptions mediated improvements in depression (Jonsbu, Martinsen, Morken, Moum, & Dammen, 2013). Moreover, studies from other patient populations have shown that illness perceptions are amenable to change, and that these cognitive changes are related to reduced stress, faster return to work, and improved well-being (Goodman, Morrissey, Graham, & Bossingham, 2005; Keogh et al., 2011; Petrie, Cameron, Ellis, Buick, Weinman, 2002). The present study utilized the Common Sense Model (CSM) of illness representations (CSM; Leventhal, Meyer, & Nerenz, 1980; Moss-Morris et al., 2002) to facilitate the examination of illness-specific cognitions in patients with NCCP. In addition to being validated in a wide range of patient populations (e.g., HIV, Diabetes, Arthritis, Irritable Bowel Syndrome), the CSM has been linked to an array of physical and mental health outcomes (Hagger & Orbell, 2003). This framework suggests that the way individuals understand their illness affects the experience of illnessrelated symptoms and impairments. As such, the CSM is highly relevant to our understanding of NCCP, a condition in which maladaptive beliefs play a central role. The function of cognitive factors in the development and maintenance of NCCP in conjunction with their potential role in the treatment of this condition makes exploring illness perceptions a critical next step. Although findings have shown that changes in illness perceptions are key to improvements in NCCP (Jonsbu et al., 2013), a treatment has yet to be designed that specifically targets this set of cognitions. Thus, further research into the function of illness perceptions may serve to inform future NCCP treatment. The aims of this study were to examine illness perceptions in patients with NCCP and to investigate the relations between those perceptions and a set of psychological and pain outcomes. Based on the literature, we hypothesize that maladaptive illness perceptions will be related to greater negative emotion (anxiety and depression), more severe chest pain, and increased pain-related interference over and above the effects of demographic (i.e., age, gender, and ethnicity) and painrelated variables (i.e., chest pain frequency, length of chest pain condition, and number of medical visits).
Method Participants The sample included 196 patients undergoing cardiac evaluation at a university-affiliated medical center. The
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cardiac evaluation included a general physical exam and an exercise stress test. Participant eligibility was defined by the following inclusion criteria: (1) minimum 18 years of age, (2) chief complaint of chest pain or discomfort, (3) negative results from a cardiac evaluation, and (4) English fluency. Approximately half of the sample was female (57 %), married (56 %), and working full-time (58 %). Most participants were Caucasian (85 %) and well-educated (63 % with a bachelor’s degree; 98 % with a high school diploma or equivalent degree). The sample’s level of educational attainment may be related to our study’s setting (i.e., academic medical center). However, several other studies have also involved highly educated samples of NCCP patients (e.g. Aikens et al., 1999; Esler et al., 2003; Shelby et al., 2009). Average age was 50 years (SD = 10.3). Participants varied in regard to chest pain frequency with roughly half reporting that pain occurs at least weekly. Duration of chest pain condition ranged from less than 1 week in 15 % of the sample to more than a year in 40 % (see Table 1). Roughly one-quarter (23 %) of participants endorsed having been treated for an emotional or psychological problem in the past year. Measures Demographic and Medical History Demographics and medical history were assessed using a self-report questionnaire. Information regarding sex, age, education, race/ethnicity, and socioeconomic status was collected in addition to a general medical history (e.g., current medications, major medical conditions, family history) and details concerning chest pain. Of the chest pain characteristics assessed in this questionnaire, duration of chest pain condition and frequency of chest pain were included as study variables. Patients answered the question, ‘‘How long have you had the pain?’’ by selecting from a 5-point scale ranging from 1 (Seven days or less) to 5 (More than one year). Patients responded to the question, ‘‘How often do you experience the chest pain?’’ by selecting from a 6-point scale ranging from 1 (Several times per day) to 6 (Never or rarely).
79 Table 1 Demographic and illness descriptives Mean (SD) or percentage Age
50.49 (10.55)
Female
57.2 %
Race/ethnicity African-American
11.3 %
Caucasian
84.5 %
Asian-American
0.5 %
Hispanic or Latino American Indian or Alaska native
2.1 % 0.5 %
Other
1%
Chest pain frequency Several times per day
9.8 %
Less than daily
9.8 %
About daily
9.8 %
About weekly
21.6 %
About monthly
19.1 %
Rarely
29.9 %
Chest pain total duration 1–7 days
15 %
8–31 days
4%
1–6 months
26 %
6–12 months
15 %
More than 12 months Number of medical visits in past year
40 % 5.28 (6.23)
Psychological treatment in past year
23.1 %
and depressed.’’ ‘‘I felt that I had lost interest in just about everything.’’) and anxiety (e.g., ‘‘I was in a state of nervous tension.’’ ‘‘I felt that I was close to panic.’’) have applied to them over the past week. Higher scores indicate higher levels of anxiety and depression. The DASS has been found to have adequate reliability and validity in nonclinical (Lovibond & Lovibond, 1995) and clinical samples (Anthony, Bieling, Cox, Enns, & Swinson, 1998). Only the depression and anxiety scales were used in the present study, as theory and prior research have highlighted their central role in the experience of NCCP (White et al., 2008). Both the DASS-Depression and DASS-Anxiety scales demonstrated good internal reliability (Cronbach’s a equaled .91 and .84, respectively).
Psychological Distress Chest Pain The Depression Anxiety Stress Scales (DASS) is a selfreport measure comprised of three 14-item scales that assess depression, anxiety, and stress (Lovibond & Lovibond, 1995). On a 4-point Likert scale ranging from 0 (Did not apply to me) to 3 (Applied to me very much or most of the time), participants rated the degree to which they believe statements regarding depression (e.g., ‘‘I felt sad
The West Haven Multidimensional Pain Inventory (MPI; Kern, Turks, & Rudy, 1985) is a 61-item self-report measure that assesses pain across three conceptually distinct domains: (1) perceptions of pain and pain-related consequences, (2) pain-related social experience, and (3) pain influence on daily activities.
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The MPI has been used extensively in the research and clinical evaluation of pain in a variety of medical populations (Bernstein, Jaremko, Hinkley, 1995) and has been found to have adequate reliability and validity (Kerns et al., 1985; Thompson, 1990). Two scales from the first domain were utilized. The pain-related interference scale demonstrated adequate internal reliability (Cronbach’s a = .70). This scale consists of nine questions, eight of which assess changes in functional impairment due to pain (e.g., ‘‘How much has your pain changed your ability to participate in recreational and other social activities?’’) on a 7-point Likert scale ranging from 0 (No change) to 6 (Extreme change). One question in this scale assesses overall interference (‘‘In general, how much does your pain problem interfere with your day to day activities?’’) on a 7-point Likert scale ranging from 0 (No interference) to 6 (Extreme interference). Higher scores indicate higher levels of painrelated interference. She pain severity scale is composed of only three items (e.g., ‘‘How severe has your pain been during the last week?’’ ‘‘How much suffering do you experience because of your pain?’’) and asks participants to respond on a 7-point Likert scale ranging from 0 (None) to 6 (Extreme). These items were combined with three additional selfreport items from the medical history questionnaire to improve the reliability of chest pain severity measurement. Specifically, scores from the two different measures were standardized (z-scores) and then averaged. The resulting six-item chest pain severity index demonstrated adequate internal reliability (Cronbach’s a = .67). Those three items from the medical history questionnaire were: ‘‘How intense is your chest pain at its worst?’’ ‘‘How bad does your chest pain usually hurt?’’ and ‘‘On average how intense have your chest pain episodes been in the past month?’’ The medical history items asked participants to score their chest pain on an 11-point Likert scale ranging from 0 (Not at all) to 10 (Extremely). Higher scores indicate more severe pain. Illness Perceptions The revised Illness Perception Questionnaire (IPQ-R; Moss-Morris et al., 2002) assesses illness-related beliefs as originally conceptualized by Leventhal’s CSM (Leventhal et al. 1980). The measure has demonstrated good reliability and validity (Moss-Morris et al., 2002) and has been used to investigate illness-related cognitions in a wide range of medical populations (Hagger & Orbell, 2003). The IPQ-R scales utilized in this study demonstrated good internal consistency (Cronbach’s a ranged from .79 to .89). For the purposes of this study, seven of the nine domains of illness perceptions were assessed. Timeline-chronic concerns predictions regarding illness duration (e.g., My chest pain will last for a long time.’’). Timeline-cyclical
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refers to views about the cyclical nature of the condition (e.g., ‘‘My symptoms come and go in cycles.’’). Consequences consist of beliefs about illness severity and the resulting effects on social and financial functioning (e.g., ‘‘My chest pain has major consequences on my life.’’). Treatment control is comprised of beliefs regarding the effectiveness of available medical care (e.g., ‘‘My treatment can control my chest pain.’’) and is differentiated from personal control (e.g., ‘‘Nothing I do will affect my chest pain.’’), which indicates the degree to which individuals feel personally capable of taking steps to affect their illness. Emotional representations are thoughts about the impact of illness on one’s mood (e.g., ‘‘When I think about my chest pain, I get upset.’’), and lastly, illness coherence is the degree to which individuals believe they understand their illness (e.g., ‘‘My chest pain is a mystery to me.’’). The authors of the IPQ-R suggest that the measure be adapted to fit the needs of the current study, and opting to not administer all nine subscales is common practice in illness perception research (e.g., Frostholm et al., 2007; Galli, Ettlin, Palla, Ehlert, & Gaab, 2010; Ireland, Reid, Powell, & Petrie, 2005). As NCCP is characterized entirely by chest pain and discomfort, the identity scale, used to assess which of a range of symptoms (e.g., sore eyes, headaches, dizziness) are associated with one’s illness, did not appear to be relevant. Similarly, because NCCP is overwhelmingly attributed to cardiac abnormality (Mayou, 1998), the causal subscale was not utilized. Participants rated the degree to which they agree or disagree with statements referring specifically to chest pain on a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Higher scores on the consequences, cyclical nature, timeline-chronic, and emotional representations dimensions correspond to stronger beliefs concerning negative consequences, a cyclical nature, a longer duration, and negative effects of mood. Higher scores on the personal control, treatment control, and illness coherence dimensions represent more positive beliefs regarding illness controllability and illness understanding. Procedure Data were collected as part of a larger, longitudinal study of the clinical course of NCCP. That larger study consisted of a baseline assessment as well as 6-, 12-, and 18-month follow-up assessments in which subjects were invited to participate in a clinical interview and complete self-report questionnaires. Our study utilizes data from the baseline session. Although a total of 229 patients participated in the larger study, 33 patients were excluded from our study because they only participated in the clinical interview and did not complete the questionnaires.
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Patients who underwent a cardiac evaluation and were found to have no medically detectable cardiac condition were invited to participate. This evaluation included a cardiac stress test in which an electrocardiogram (ECG) was used to measure participants’ cardiac functioning under physical stress induced through exercise. Patients were referred for a cardiac evaluation from a wide variety of sources, such as general practitioners, cardiologists, and the emergency department. Eligibility based on inclusion criteria was confirmed over the phone. Eligible participants provided informed consent and were asked to complete self-report questionnaires and participate in a clinical interview conducted by either a clinical psychology doctoral student or a licensed psychologist. Although encouraged to complete both, participants were allowed to do either the questionnaires or the interview. Participants completed the questionnaires at home and then returned them to the research office via prepaid envelope. All participants were compensated $25 for their time and effort. Institutional review boards at the University of Missouri–St. Louis, Boston University, and Beth Israel Deaconess Medical Center at Harvard Medical School approved this study. Statistical Analysis A set of descriptive analyses was conducted on all demographic (age, gender, education, and race/ethnicity), pain (MPI-Interference and chest pain severity index), psychological distress (DASS-Anxiety and DASS-Depression) and illness perception (IPQ-R scales) variables. Zero-order correlations were conducted between all independent and dependent variables as well as among IPQ-R scales. Independent samples t tests were used to compare illness perceptions between participants who had received any treatment for psychological or emotional problems in the past year and participants who had not. A series of hierarchical regression analyses were performed to evaluate the relations of IPQ-R scale scores to anxiety, depression, pain-related interference, and chest pain severity. A hierarchical approach allowed for examination of the relative contributions of illness perceptions to this set of outcomes over and above the variance accounted for by other relevant demographic and clinical variables. Independent variables were entered at three different steps: demographic variables (i.e., age, gender, and ethnicity) at step one, chest pain-related clinical variables (i.e., chest pain frequency, length of chest pain condition, and number of medical visits over the past year) at step two, and illness perceptions (i.e., IPQ-R scales) at step three. In these analyses, gender (1 = male, 0 = female) and race/ethnicity (1 = Caucasian, 0 = other categories of race/ethnicity) were dummy coded. The decision to code race/ethnicity in
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this way was based on the small number of participants in all categories of race/ethnicity other than Caucasian. At each step, predictors were entered simultaneously, and separate analyses were conducted for each outcome measure. Squared semipartial correlations are reported as an index of effect size for all predictors that were significant at step three, as this metric represents the percentage of total variance in the criterion variable uniquely accounted for by an independent variable relative to the entire model.
Results Descriptive and Preliminary Analyses Table 2 presents information regarding scores for the four outcome measures, anxiety (DASS-Anxiety), depression (DASS-Depression), pain-related interference (MPI-Interference), and chest pain severity (chest pain severity index), and also displays relationships among those variables. The majority of depression and anxiety ratings fell in the normal range. However, elevations in depression and anxiety were endorsed by 23 and 18 % of participants, respectively. Anxiety and depression did not differ by gender. Age was not associated with anxiety; however, depression was negatively related to age (r = -.16, p \ .05). Scores on the MPI-Interference scale and chest pain severity index did not differ as a function of age or gender. As shown in Table 3, illness perceptions did not differ between participants who had received treatment for psychological or emotional problems in the past year and participants who had not received such treatment. As expected, the outcome measures demonstrated significant small- to medium-sized positive correlations among each other. Table 4 presents correlations among IPQ-R scales, which varied by size and direction. These correlations were mostly in the expected direction, such that maladaptive illness perceptions demonstrated positive correlations among one another and negative correlations with adaptive illness perceptions. Similarly, adaptive illness perceptions were positively correlated. Few differences in IPQ-R scale scores by demographic variables were found. Greater age was significantly associated with lower scores on the IPQR Emotional Representations scale (r = -.21; p \ .05), and male gender was associated with higher scores on the IPQ-R Personal Control scale (r = .15; p \ .05). Lastly, minority race/ethnicity-status was significantly associated with higher scores on the IPQ-R Consequences scale (r = -.15, p \ .05). Table 5 shows that many IPQ-R scales were significantly correlated with anxiety, depression, chest pain
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82 Table 2 Dependent variable descriptive statistics and intercorrelations
** p \ .01
Table 3 Comparison of illness perceptions between participants who had received psychological treatment in past year and those who had not received such treatment
Bonferroni-adjusted p value of .007 was used Table 4 Illness perception descriptive statistics and intercorrelations
* p \ .05, ** p \ .01
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1 1. Anxiety (DASS-Anxiety)
3
4
Mean (SD)
-
2. Depression (DASS-Depression)
.58**
3. Pain-related interference (MPI-Interference)
.47**
.27**
4. Chest pain severity index
.43**
.36**
Timeline-chronic
– .57**
Range
4.20 (5.64)
0–31
5.62 (7.47)
0–37
14.83 (8.10)
0–46
–
Mean difference
–
.08 (3.67) -7.30–9.41
Std. error difference
d.f.
t
p
.02
.75
172
-.03
n.s.
Consequences
1.06
.78
172
1.35
n.s.
Personal control
1.97
.91
172
2.17
n.s.
Treatment control
.27
.67
166
.40
n.s.
Illness coherence
.50
.94
171
.54
n.s.
Timeline-cyclical
.62
.68
170
-.92
n.s.
Emotional representations
.31
.84
170
.37
n.s.
6
7
Mean
SD
1. Timeline-chronic
14.32
4.00
2. Consequences
12.73
4.26
3. Personal control
18.33
4.88
-.08
4. Treatment control
17.01
3.45
-.23**
.02
.58**
5. Illness coherence
13.17
5.07
-.25**
-.12
.40**
.39**
6. Timeline-cyclical
13.10
3.67
.14
.20**
.01
.17*
-.04
7. Emotional representations
16.49
4.66
.18*
.52**
.16*
.08
-.13
severity, and pain-related interference. IPQ-R Consequences and IPQ-R Emotional Representations were significantly associated with all of the dependent variables. IPQ-R Timeline-Chronic was significantly correlated with anxiety, pain-interference, and chest pain severity. IPQ-R Personal Control demonstrated a significant association with pain-interference, and IPQ-R timeline-cyclical with chest pain severity. IPQ-R Treatment Control and IPQ-R Illness Coherence were not significantly correlated with any of the dependent variables. All correlations between IPQ-R scales and dependent variables were in the expected direction. Hierarchical Regressions With regard to psychological distress, data in Tables 6 and 7 shows that illness perceptions made significant contributions to the prediction of DASS-Anxiety and DASSDepression. For DASS-Anxiety, there was significant variance associated with demographic and clinical variables in the first two steps of the equations, R2 = .14;
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2
1
2
3
4
5
.39** .14*
.28**
F(6,151) = 4.08; p \ .01; f2 = .16. After controlling for the effects of these variables, illness perceptions accounted for an additional 12.5 % of the variance (DR2) at step three, F-change(7,144) = 3.50; p-change \ .01. At this step, IPQ-R Consequences (b = .21; t = 2.34; p = .02) and IPQ-R Emotional effects (b = .21; t = 2.36; p = .02) were the only significant predictors, with squared semipartial correlations of .03 and .03, respectively. The final regression equation accounted for 27 % of the variance (R2) in DASS-Anxiety, F(13,144) = 3.98; p \ .01, and had a moderate effect size (f2 = .36). For DASS-Depression, there was again significant variance associated with the first two steps of the equations, R2 = .17; F(6,151) = 5.04; p \ .01; f2 = .20. At step three, illness perceptions made a significant contribution to the model, F-change(7,144) = 4.18; p-change \ .01, accounting for an additional 14.1 % of the variance (DR2). With all predictors entered, IPQ-R Emotional Representations (b = .32; t = 3.78; p \ .01), number of medical visits in the past year (b = .25; t = 3.33; p = .01), and race/ethnicity (b = -.18; t = -2.46; p = .02) were
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83
Table 5 Correlations between illness perceptions, covariates, and dependent variables IPQ-R scales Timelinechronic
Consequences
Personal control
Age
-.14
-.12
-.02
Gender Race/ethnicity
.01 -.13
.03 -.15*
.15* -.02
Treatment control
Illness coherence
Timelinecyclical
Emotional representations
Demographics .09
.07
-.09
-.21**
.04 -.09
-.01 .08
-.05 -.02
.04 -.12
Clinical variables Frequency
-.13
Total duration
.28**
Medical visits in past year
.10
-.03
\.01
.03
.11
.02
-.10
-.01
\.01
-.18*
-.14
.13
.04
-.02
\.01
.15
.11
.21**
.03
Dependent variables DASS-Anxiety
.18*
.35**
.02
-.03
-.09
.08
.31**
DASS-Depression
.06
.25**
.06
-.07
.03
.02
.32**
MPI-Interference
.16*
.42**
Chest pain severity index
.25**
.38**
.15* -.02
.11
.01
-.04
-.10
.11
.26**
.17*
.20**
* p \ .05, ** p \ .01 Table 6 Hierarchical regression analysis for DASSAnxiety
B
SE B
b
t
Step 1: demographics Age Gender Race/ethnicity
-.02 -.11
.04 .84
-.04 -.01
-.49 -.13
-2.33
1.21
-.15
-1.93
Step 2: clinical variables Frequency
-.45
.26
-.13
Total duration
-.10
.31
-.03
-.34
.11
.07
.13
-1.72
Timeline-chronic
.03
.12
.02
-2.24
Consequences
.28
.12
.21
-2.34* -2.22
Medical visits in past year
Values are from the final regression equation * p \ .05, ** p \ .01
.03
.12
.02
Treatment control
-.06
.19
-.04
–.34
Illness coherence
-.02
.09
-.01
-.17
Timeline-cyclical
.02
.13
.01
-2.17
Emotional representations
.25
.11
.21
-2.36*
significantly related to DASS-Depression, with squared semipartial correlations of .07, .05, and .03, respectively. The final regression equation accounted for 31 % of the variance (R2) in DASS-Depression, F(13,144) = 4.92; p \ .01, and had a large effect size (f2 = .45). In regard to pain outcomes, Tables 8 and 9 show that illness perceptions demonstrated significant relationships with both MPI-Interference and the chest pain severity index. For MPI-Interference, there was significant variance associated with the demographic and pain variables entered in the first two steps of the equations, R2 = .14;
DR2
F-change
.08
.08
4.20*
.14
.06
3.74*
.27
.13
3.50**
-1.75
Step 3: IPQ-R scales
Personal control
R2
F(6,152) = 3.99; p \ .01; f2 = .16. The addition of illness perceptions at step three, F-change(7,145) = 4.74; pchange \ .01, accounted for an additional 16 % of the variance (DR2). At step three, only IPQ-R Consequences (b = .36; t = 4.02; p \ .01) and chest pain frequency (b = -.23; t = -3.19; p \ .01) were significantly related to MPI-Interference, with squared semipartial correlations of .08 and .05, respectively. The final regression equation accounted for 30 % of the variance (R2) in MPI-Interference, F(13,145) = 4.71; p \ .01, and had a large effect size (f2 = .42).
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84 Table 7 Hierarchical regression analysis for DASSDepression
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B
SE B
b
t
Step 1: demographics Age
-.05
.05
1.20
1.10
.08
-3.90
1.59
-.18
Gender Race/ethnicity
-.07
.34
-.07
.55
.40
.10
1.37
Medical visits in past year
.28
.09
.25
-3.33**
-.30
.16
-.16
-1.84
Consequences
.22
.16
.12
1.41
Personal control
.09
.15
.06
-.50
.25
-.21
.18
.12
.12
-.20 .52
.16 .14
-.09 .32
-1.23 -3.78**
b
t
Illness coherence
* p \ .05, ** p \ .01
Table 8 Hierarchical regression analysis for MPIInterference
Timeline-cyclical Emotional representations
B
SE B
Gender Race/ethnicity
.01
.05
.01
.40
1.07
.03
-1.08
1.56
-.05
-.70*
* p \ .05, ** p \ .01
-1.05
.33
-.23
-3.19**
.10
.39
.02
.26
.13
.08
.11
1.50
123
-.09
.16
-.05
.62
.15
.36
-4.02**
.14
4.18**
R2
DR2
F-change
.03
.03
1.76
.14
.10
6.04**
.30
.16
4.74**
–.55
Personal control
.03
.15
.02
-2.18
Treatment control
.34
.24
.14
-1.39
Illness coherence
.04
.12
.03
.35
Timeline-cyclical Emotional representations
.21 .02
.16 .14
.10 .01
-1.31 -.15
For the chest pain severity index, the first two steps of the equations were significant, R2 = .14; F(6,150) = 3.92; p \ .01; f2 = .16. After controlling for the effects of demographic and clinical variables, illness perceptions, Fchange(7,143) = 3.44; p-change \ .01, accounted for an additional 12.5 % of the variance (DR2) at step three. With all predictors entered, only IPQ-R Consequences (b = .34; t = 3.75; p \ .01) and chest pain frequency (b = -.19; t = -2.57; p = .01) were significantly related to the chest pain severity index, with squared semipartial correlations of .07 and .03, respectively. The final regression equation accounted for 26 % of the variance (R2) in the chest pain
.31
.37
Step 3: IPQ-R scales
Values are from the final regression equation
5.29**
.12
Medical visits in past year
Consequences
.09
1.53
Total duration
Timeline-chronic
.17
.58
Step 2: clinical variables Frequency
4.41**
–2.02*
Step 1: demographics Age
.08
-.97
Step 3: IPQ-R scales
Values are from the final regression equation
.08 1.10
-.33
Treatment control
F-change
-2.46*
Total duration
Timeline-chronic
DR2
-.87
Step 2: clinical variables Frequency
R2
severity index, F(13,143) = 3.87; p \ .01, and had a moderate effect size (f2 = .35).
Discussion We examined illness perceptions in a large sample of adult patients with NCCP and investigated the relationships between those cognitions and a set of psychological and pain outcomes. Results indicated that beliefs that one’s life was impacted by illness (i.e., consequences) were associated with higher anxiety as well as greater pain-related life
J Clin Psychol Med Settings (2015) 22:77–89 Table 9 Hierarchical regression analysis for chest pain severity index
85
B
SE B
\.01
.03
b
t
Step 1: demographics Age
.01
.14
Gender
-.66
.53
-.09
-1.24
Race/ethnicity
-.62
.77
-.06
-.81
Step 2: clinical variables -.42
.16
-.19
Total duration
Frequency
.16
.20
.06
.81
Medical visits in past year
.07
.04
.12
1.57
.05
.08
.05
.61
Consequences Personal control
Values are from the final regression equation * p \ .05, ** p \ .01
.29
.08
.34
-.05
.07
-.06
F-change
.04
.04
2.04
.14
.10
5.62**
.26
.13
3.44**
3.75** -.62
Treatment control
.08
.12
.07
.64
Illness coherence
-.03
.06
-.04
-.47
Timeline-cyclical Emotional representations
.07 -.04
.08 .07
.07 -.05
.94 -.60
interference and chest pain severity. Perceptions that illness negatively affects one’s mood (i.e., emotional representations) were associated with higher anxiety and depression. Participants endorsed coherent profiles of illness perceptions, such that negative beliefs were directly related to one another and inversely related to positive beliefs. Similarly, positive beliefs were directly associated with one another. For example, appraisals of a more chronic timeline were associated with more negative beliefs regarding consequences as well as weaker perceptions of treatment effectiveness. Similar patterns of illness perceptions have been found in patients diagnosed with coronary artery disease (Stafford, Beck, & Jackson, 2009), irritable bowel syndrome (Rutter & Rutter, 2002), and chronic pain (MossMorris et al., 2002). Several small correlations were exceptions to this pattern and although unexpected, none were contradictory. Specifically, stronger perceptions of personal control were related to stronger beliefs in both consequences and negative emotional effects. These small correlations may reflect doubts about self-efficacy. Stronger perceptions of personal control indicate that a patient believes personal actions have the potential to positively affect the illness. These perceptions do not speak to whether individuals are confident in their ability to carry out those actions. That is, it may be that those patients who believe their condition could be improved through personal action also feel they are incapable of taking personal action and therefore expect worse outcomes. Also, stronger held beliefs of treatment control were associated with stronger perceptions that one’s illness is cyclical. This small-sized association may
DR2
-2.57*
Step 3: IPQ-R scales Timeline-chronic
R2
reflect the belief that although treatment is beneficial, the effects are transitory. As mentioned above, beliefs about consequences and negative emotional effects demonstrated meaningful relations to a variety of psychological and pain outcomes. Stronger perceptions of illness consequences were associated with higher levels of anxiety as well as greater painrelated interference and more severe chest pain. This scale assesses specific beliefs regarding illness-related impairments in social and financial functioning as well as generalized perceptions that one’s illness is ‘‘serious’’ and ‘‘has major consequences.’’ As such, it is somewhat unclear whether the consequences dimension is simply a reflection of perceptions of impairment or if this scale also taps into fears that chest pain is life threatening. Additionally, stronger beliefs in the negative emotional effects of one’s illness were associated with worse anxiety and depression. This finding is not unexpected as several of the items on the emotional representations scale refer specifically to feeling anxious or depressed. Illness perceptions accounted for significant variance in outcomes after controlling for the effects of demographic factors (i.e., age, gender, and race/ethnicity) and clinical factors known to be associated with NCCP: length of illness, frequency of chest pain, and number of medical visits in past year (Eslick, 2008; Fass & Achem, 2011). Our findings are similar to those from other studies involving a range of medical populations in which perceptions of consequences and emotional effects were identified as important factors in a myriad of mental and physical health outcomes (Hagger & Orbell, 2003).
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Illness-related clinical variables and demographic factors were also associated with outcomes. Number of medical visits in the past year was positively associated with depression, and chest pain frequency was positively associated with pain-related interference and negatively associated with chest pain severity. In addition, minority racial/ethnic status was associated with greater depression and pain-related interference. While racial and ethnic disparities in cardiovascular disease are well documented (Mensah, Mokdad, Ford, Greenlund, & Croft, 2005), little is known about the role of race and ethnicity in NCCP, and additional research in this area is sorely needed. The significance of illness perceptions in this sample is consistent with existing NCCP research and theory. Although little research has been done on illness perceptions in NCCP, existing data suggests that they are generally negative, and that these negative perceptions affect outcomes. In a study of patients referred to a rapid access chest pain clinic, those diagnosed with NCCP reported weaker perceptions of treatment control, personal control, and illness understanding compared to those with a cardiac diagnosis (Robertson, Javed, Samani, & Khunti, 2008). Another study found that beliefs in a chronic timeline and doubts regarding treatment efficacy predicted low reassurance at one-month follow-up in patients newly diagnosed with NCCP (Donkin et al., 2006). As previously mentioned, there are also recent results linking maladaptive illness perceptions in NCCP patients to more severe chest pain (Schroeder et al., 2012). Further, negative illness perceptions fit with theoretical conceptualizations of NCCP, in which beliefs regarding the detrimental effects of chest pain have been proposed as a cognitive factor in the maintenance of this condition (Eifert, 1992). Perceptions of illness consequences and emotional effects may be particularly important for NCCP patients as they relate to catastrophic thinking. Catastrophizing appears to play a key role in the development of NCCP (Mayou, 1998), however, research in this area has been limited to pain-specific catastrophizing and its effect on misinterpreting bodily sensations (Bradley et al., 1991; Shelby et al., 2009). IPQ-R Emotional Representations may be viewed as a specific variety of illness consequences. While IPQ-R Consequences concerns the more general impacts of illness, the IPQ-R Emotional Representations scale refers to the more specific impact of illness on emotional functioning. As such, it is interesting to consider whether these two different, yet theoretically and empirically related constructs (Pearson’s r of .52 in this study and .53 in Moss-Morris et al., 2002) are an indication of a higher-order catastrophizing factor. In other words, does an underlying trait catastrophizing process contribute to the state catastrophizing that occurs in both the misinterpretation of bodily sensations and the negative appraisal
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of illness-related impact? In his review of catastrophic cognitions in panic disorder, Cox (1993) discussed the possibility of trait catastrophizing as a shared cognitive factor between panic disorder and hypochondriasis as well as highlighted research in attentional biases that support the notion of a generalized catastrophic cognitive style in patients with panic disorder. These findings may also provide direction in the development of future NCCP interventions. While cognitive behavioral treatments for NCCP have shown favorable results, there are opportunities for improvement (Esler & Bock, 2004). Given their relation to an important set of health outcomes in patients with NCCP, incorporating perceptions of illness consequences and emotional effects as targets for cognitive restructuring may be a valuable treatment strategy. The majority of cognitive behavioral treatments for NCCP are based in correcting patients’ misattributions that chest pain stems from a dangerous cardiac condition. However, attempts to help patients understand NCCP as a ‘‘psychological condition’’ are often unsuccessful (Esler & Bock, 2004). Treatment focused on negative perceptions of chest pain-effects may help patients develop more accurate, reality-based beliefs about the impacts of their condition while avoiding a debate about the precise source of chest pain. Furthermore, although our findings may be somewhat intuitive, they underscore that helping NCCP patients cope more effectively with their condition very likely involves assisting these patients in forming adaptive beliefs concerning the impact of their condition. A growing body of evidence has demonstrated the clinical utility of illness perception-focused interventions in a number of patient groups. In a brief CBT intervention for patients who had suffered myocardial infarction, treatment participants evidenced greater positive change in beliefs concerning the consequences, controllability, and chronic timeline of their condition as well as less frequent angina symptoms and a faster return to work as compared to controls (Petrie et al., 2002). Similarly, a CBT-based intervention for patients with systemic lupus erythematosus was shown to improve participants’ perceptions of treatment control and emotional effects as well as reduce perceived stress (Goodman et al., 2005). Lastly, findings from a trial of a family-based intervention for patients with poorly controlled type 2 diabetes demonstrated that the intervention resulted in improved perceptions of treatment effectiveness, personal control, and illness understanding as well as better adherence to dietary and exercise recommendations. Modest improvements in A1c level were also reported in treatment participants (Keogh et al., 2011). Although these studies involved patients whose illnesses had identified etiologies, CBT may be even more important in cases with medically unexplained symptoms.
J Clin Psychol Med Settings (2015) 22:77–89
Several study limitations warrant attention. First, the cross-sectional nature of this study cannot determine directionality. Second, generalizability of these results is restricted due to an inadequately diverse sample, particularly in regard to ethnicity and severity of depression and anxiety. Although a proportion of study participants reported significant anxiety and depression, the average emotional distress in this sample was commensurate with non-clinical samples of medical patients (Janssen et al., 2010; Mitchell et al., 2011). Third, without a matched comparison group, it is not certain these findings are distinctly associated with NCCP. Fourth, although participants underwent a medical examination, it is possible that the examination failed to detect gastroesophageal complications associated chest pain. More detailed information regarding chest pain origin may have been useful to include in our analyses as a covariate. Fifth, our measure of chest pain severity did not demonstrate a high Cronbach’s a. However, for a scale of only six items, none of which overlap in content, this scale’s internal reliability appears to be adequate, and its use seems appropriate (John & Benet-Martinez, 2000). Nonetheless, findings regarding this variable should be interpreted with some degree of caution. Continued research efforts regarding the role of cognitive factors in NCCP are needed to guide treatment development and further expand our theoretical understanding of this syndrome. While the CSM provides a clinically meaningful and empirically supported framework with which to explore the role of illness perceptions, investigating other cognitive variables outside this model may prove valuable. In particular, future studies should examine beliefs about symptom unpredictability, as this is a major factor in the development and maintenance of panic disorder (Craske, 1991). Additional research is also needed on the relation between illness-specific cognitions in NCCP and key health-behaviors, such as cardiac arousal avoidance and excessive health care utilization, both of which contribute to the maintenance of this condition and the impaired quality of life that results. Acknowledgments This article was supported in part by Grants from the National Institute of Mental Health (MH63185) and the University of Missouri–St. Louis (University Research Award) awarded to Kamila S. White. Conflict of Interest Jared I. Israel, Kamila S White, and Ernest V. Gervino declare that they have no conflict of interest. Human and Animal Rights and Informed Consent All procedures followed were in accordance with the ethical standards of the responsible committees on human experimentation of the University of Missouri–St. Louis, Boston University, and Beth Israel Deaconess Medical Center at Harvard Medical School and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all patients for being included in the study.
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