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Psychological Profiles in Autoimmune Disease: Relationship to Demographic, Diagnostic, Disease Activity and Social Suppo...

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PSYCHOLOGICAL PROFILES IN AUTOIMMUNE DISEASE: RELATIONSHIP TO DEMOGRAPHIC, DIAGNOSTIC, DISEASE ACTIVITY AND SOCIAL SUPPORT MEASURES By REBECCA JUMP A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2005

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ii TABLE OF CONTENTS Page LIST OF TABLES...................................................... iii LIST OF FIGURES..................................................... iv ABSTRACT............................................................ v CHAPTER 1INTRODUCTION .................................................... 1 Systemic Lupus Erythematosus .......................................... 1 Sjgrens Syndrome, Scleroderma, and Polymyositis ......................... 3 Antinuclear Antibody Positive Patients .................................... 4 Psychological Distress and Illness........................................ 5 Disease-Related Fatigue ............................................... 7 Disease-Related Pain.................................................. 9 Cluster Profiling ..................................................... 10 Illness Burden and the Immune Response ................................. 11 Social Support ...................................................... 13 Study Rationale ..................................................... 14 Aims ............................................................. 16 Hypotheses ......................................................... 17 2METHODS ........................................................ 19 Participants......................................................... 19 Procedure.......................................................... 20 Measures.......................................................... 21 Analyses........................................................... 22 3RESULTS......................................................... 24 4DISCUSSION...................................................... 29 REFERENCES........................................................ 36 BIOGRAPHICAL SKETCH.............................................. 43

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iii LIST OF TABLES Table page 2-1Diagnostic breakdown of demographic information ...................... 19 3-1Description of response profiles ..................................... 25 3-2Crosstabulation matrix of response profiles across diagnostic categories ...... 26 3-3Values for biological markers of disease activities ....................... 27

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iv LIST OF FIGURES Figure page 1-1Preliminary four-cluster solution representing psychological profiles in autoimmune disease patients........................................ 16 3-1Replication four-cluster solution representing psychological profiles in autoimmune disease patients........................................ 24

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v ABSTRACT Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy PSYCHOLOGICAL PROFILES IN AUTOIMMUNE DISEASE: RELATIONSHIP TO DEMOGRAPHIC, DIAGNOSTIC, DISEASE ACTIVITY AND SOCIAL SUPPORT MEASURES By Rebecca Jump August 2005 Chair: Michael E. Robinson Major Department: Clinical and Health Psychology Autoimmune diseases (AD) are characterized by chronic inflammation that can affect a variety of tissues in systemic or organ-specific forms. The challenges inherent to managing a chronic medical illness place indivi duals at greater risk for psychological distress, which could lead to deleterious effects on immune and neuroendocrine functioning and contribute to disease progression. Relatively little is known about variations in psychological function and the degree to which heterogeneity exists across a variety of autoimmune diseases. Further, the differential contributions of disease-related factors and psychological function to illness response remain unclear. Using a cluster analytic approach, this study determined homogenous psychological subgroups in a sample of 393 rheumatology outpatients referred to an autoimmune disease clinic for suspected AD. Participants included individuals diagnosed with an AD as well as individuals testing positive for anti-nuclear antibodies (ANA positive). Psychological subgroups were determined empirically based on visual analogue measures of depression, anxiety, anger, confusion, pain, and fatigue. Psychological response profiles

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vi were subsequently examined in relation to demographic variables, diagnostic category, physician rated and immune measures of disease activity, and perceived social support. Results of the study provide support for substantial heterogeneity across in psychological function and illness response across the AD sample and within specific diagnostic groups. Psychological response profiles did not vary with respect to demographic variables, diagnosis, serological markers of disease activity, or physician-rated disease activity. Higher levels of perceived social support were associated with lower levels of mood disturbance and symptom reporting. Results suggest that personality, psychological, and/or social support factors may be stronger determinants of response to illness.

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1 CHAPTER 1 INTRODUCTION Autoimmunity refers to a breakdown in the immune system’s ability to maintain self-tolerance, resulting in an immune response directed against self-components of the body. Autoimmune diseases (AD) are charact erized by chronic inflammation in which the rate of tissue damage exceeds the body’s ability to repair the damage. There is wide variability across ADs in the tissues that are attacked and specific symptoms caused. Although an understanding of the mechanisms responsible for maintaining tolerance exists, the specific factors contributing to the pathogenesis of AD remain largely unknown (Parham, 2000). It is generally accepted that the cause of any given AD is multifactorial and that environmental and genetic factors play a role in susceptibility (Tizard, 1995). Autoimmune diseases are relatively common, affecting 2% to 3% of the population of developed countries (Parham, 2000) and 5% to 7% of adults in Europe and North America (Tizard, 1995). Two thirds of those affected are women. ADs can generally be divided into two types: organ-specific, where the immune response is directed toward a target antigen that is specific to a single organ or gland, and systemic, which involves a response directed across a broad array of organs and tissues (Kuby, 1991). Systemic Lupus Erythematosus Systemic lupus erythematosus (SLE) is a prototypical AD in which almost every tissue or organ may be affected. Its diagnosis depends on multisystem involvement and

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2 the presence of autoantibodies, which together form the diagnostic criteria for SLE (Tan et al., 1982). Systemic lupus erythematosus is thus a syndrome, rather than single disease entity, that exhibits considerable variation in disease manifestations between individual patients. The course of SLE generally involve s periods of intense flares and periods of remission (Parham, 2000). The overall prevalence of SLE varies between studies from 12.0 to 50.8 with an average of about 40 per 100,000 individuals (Hopkinson, Doherty, & Powell, 1994). The highest prevalence is found in African American females at a rate of 200 per 100,000. The incidence of lupus has been reported between 2.0 and 7.6 new cases per 100,000 per year (Johnson, Gordon, Palmer, & Bacon, 1995). It is evident that sex has a major influence on the likelihood of developing SLE, with a 90% female predominance over males (Rus & Hochberg, 2002). The predominance of female SLE patients is not well understood, although hormonal factors are believed to play an important etiological role (Tizard, 1995). Systemic lupus erythematosus is generally diagnosed according to the American College of Rheumatology's revised (Hochberg, 1997) criteria for SLE. The criteria include 11 items, 5 of which are composites of one or more abnormalities. In order to meet criteria for a diagnosis of SLE, patients must fulfill at least 4 criteria; however, no single criterion is essential (Wallace & Hahn, 2002). Laboratory diagnosis of SLE focuses to a large extent on antinuclear antibodies (Kuby, 1991). The absence of a clearly defined diagnostic marker for SLE contributes to the diagnostic challenge and can place patients at risk for misdiagnosis. The wide variation in disease manifestations across individuals with SLE contributes to the challenge of developing a uniform system for assessing level of disease

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3 activity. Consequently, the assessment of disease activity in SLE patients remains inconsistent within the rheumatology field. Over 60 systems for assessing disease activity exist, and agreement on a definition for SLE activity has not been achieved. In the United States, the most commonly used assessment system for disease activity is the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI; Bombardier, Gladman, Urowitz, Caron, & Chang, 1992), whereas in Europe, the British Aisles Lupus Assessment Group (BILAG; Symmons et al., 1988) system predominates (Wallace & Hahn, 2002). The economic impact of SLE has been estimated at a mean annual direct and indirect per patient cost of $10,530 in the United States in 1991 (Gironimi et al., 1996). Given the marked rise in health care costs in the last decade and an average prevalence of about 40 per 100,000, this translates into considerable annual health expenditure. In addition to growing health care costs, the economic impact of SLE is expected to rise exponentially as the percentage of African Americans (presently at 12.9%) and Hispanics (presently at 12.5%) continues to grow faster than the Caucasian population (U.S. Census Bureau, 2000). Sjgren’s Syndrome, Scleroderma, and Polymyositis A number of patients referred to specialists for suspected SLE are ultimately diagnosed with a different AD or are determ ined to have antinuclear antibodies (ANA) but not meet criteria for a specific AD. Among the systemic autoimmune conditions that share symptom overlap with SLE are Sjgren’s syndrome, scleroderma, and polymyositis. Similar to SLE, these conditions involve a response mounted by the immune system against tissues in the body. In the case of Sjgren’s syndrome, the immune system targets the salivary and lacrimal glands, leading to dryness in the mouth and eyes and complications including severe dental decay and corneal damage. The

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4 female to male ratio is 9:1, and the overall prevalence for Sjgren’s is 3% (Berkov, Beers, & Burs, 1999). Scleroderma, also known as systemic sclerosis, is an autoimmune condition involving overproduction of collagen that results in abnormal growth of connective tissues that support the skin and internal organs. Scleroderma occurs at a rate 7-12 times greater in females than males (National Institute of Arthritis and Musculoskeletal and Skin Diseases [NIAMS], 2001). Polymyositis is a connective tissue disorder characterized by inflammation and degenerative changes in muscles. Over time, this damage leads to symmetric weakness and muscle atrophy. This may be commonly associated with severe interstitial lung disease, which can rapidly lead to death. The female to male ratio is 2:1 with 2 to 10 new cases per one million (Berkov et al., 1999). Antinuclear Antibody Positive Patients Antinuclear antibody testing is one of several tests commonly ordered when a patient in primary care settings complains of chronic low energy, arthralgias, and myalgias (Blumenthal, 2002). Most patients referred to clinics specializing in rheumatologic or autoimmune conditions for suspected SLE have antinuclear antibodies. Antinuclear antibody testing is often used to screen for a diagnosis of lupus but has very low specificity (Illei & Klippel, 1999). Conversely, the absence of a positive ANA largely excludes the diagnosis of SLE as less than 4% of lupus patients have a negative ANA. In addition, up to 20% of healthy, asymptomatic individuals test ANA positive (Wallace & Hahn, 2002). Thus, many patients who test positive for ANA do not receive a diagnosis of SLE. Although some ANA positive patients are diagnosed with an alternate autoimmune disorder or another condition, others receive no diagnosis. Blumenthal (2002) reported that many patients testing positive for ANA ultimately receive a

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5 diagnosis of fibromyalgia syndrome (FMS) or an alternative pain syndrome. He argued that the prevalence of FMS is at least 20 times higher than that of lupus, which reduces the likelihood that a positive ANA will result in a diagnosis of lupus. Smart, Waylonis, and Hackshaw (1997) found that in a sample of 66 FMS patients, 20 (30%) were ANA positive. Al-Allaf, Ottewell, and Pullar (2002) investigated whether ANA positive FMS patients developed other symptoms of connective disease over a 2to 4-year follow-up period compared with ageand sex-matched ANA negative FMS and osteoarthritis (OA) patients. The ANA positive rates (12/137 [8.8%] in FMS and 20/225 [8.9%] in OA patients) were similar in both groups. At final assessment, one patient from the ANA positive FMS group was diagnosed with SLE, one patient from the ANA negative FMS group was diagnosed with Sjgren’s s yndrome, and one OA patient developed rheumatoid arthritis (RA). These results indicated that ANA status is not a good predictor of future development of AD. The ANA positive population, in the absence of AD, represents a unique and poorly defined group of patients. These patients range from asymptomatic to those suffering from FMS or an alternate pain condition. Psychological Distress and Illness The psychological aspects of SLE have not received extensive attention and remain poorly understood despite estimated rates for neuropsychiatric problems ranging from 33% to 60% and affective problem s from 50% to 80% (Dobkin et al., 1998). Psychological distress, which includes depressed or anxious mood, occurs commonly in medical disorders and has a significant effect on quality of life and coping with disease (Adams, Dammers, Saia, Brantley, & Gaydos, 1994). Psychological distress represents patients' interpretations of stress and their perceived impact (Ward, Marx, & Barry, 2002)

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6 and can be considered an intermediate measure in the relationship between stress and illness. Distress can impact health both indirectly, through health behaviors (e.g., compliance to medical regimens, poorer sleep, poorer nutrition) or directly through alterations in the central nervous, immune, endocrine, and cardiovascular systems (Kiecolt-Glaser, McGuire, Robles, & Glaser, 2002a). Physical health problems, particularly those that are chronic, are considered a significant risk factor for depression (Z eiss, Lewinsohn, Rhode, & Seeley, 1996). Many of the ADs, such as SLE, present a course of unpredictable symptom flares and remissions. A diagnosis of AD requires adjusting to a new array of medical, social, psychological, vocational, and financial challenges and stressors. Depression is the most common psychiatric problem in patients with SLE. In a review of the literature, Giang (1991) found that 31% to 52% of lupus patients who underwent a structured or semistructured interview were experiencing de pression. The factors contributing to the etiology and maintenance of depression in lupus patients are unclear and likely involve numerous biopsychosocial factors (Iverson, Sawyer, McCracken, & Kozora, 2001). Elevated levels of psychological distress have also been reported in scleroderma and Sjgren’s syndrome patients. Valtysdottir, Gudbjornsson, Lindqvist, Hallgren, and Hetta (2000) examined levels of anxiety, depression, well-being, and symptoms in 62 Sjgren’s patients compared with a group of healthy controls and a group of patient controls with RA. The results indicated significantly higher levels of anxiety and depression, and reduced physical and mental well-being in Sjgren’s patients compared with healthy controls. The Sjgren’s patients also reported significantly more symptoms than RA patients.

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7 Matsura and colleagues (2003) evaluated 50 patients with scleroderma for factors associated with depressive symptoms using the Beck Depression Inventory (BDI; Beck, 1967). Forty-six percent of the sample reported depressive symptoms ranging from mild to severe. Regression analyses revealed that high levels of hopelessness and low sense of coherence (coping ability and resilience in the face of stress) were the best predictors of depressive symptoms in this sample. Psychological distress affects morbidity in patients with comorbid medical illness in several ways. As Iverson et al. (2001) highlighted, depression can greatly impact functional status and degree of disability in the areas of social, occupational, educational, and recreational functioning. Depression has also been shown to influence patients' adherence to medical regimens. In addition to influencing overt behavioral functioning, there is also evidence that psychological distress is directly related to disease activity (Dobkin et al., 1998). However, it remains unknown as to whether psychological distress leads to increased SLE activity or if disease activity leads patients to become more depressed or anxious. Disease-Related Fatigue Fatigue is a commonly reported symptom in medical patients and one of the most widely reported symptoms in SLE. Zonana-Nacach and colleagues (2000) found that 85.7% of 223 participants with SLE reported fatigue; and Krupp, LaRocca, Muir, and Steinberg (1991) found fatigue to be reporte d in 80% of their SLE sample. Disabling fatigue is also a prominent feature of prim ary Sjgren’s syndrome (Lwin, Bishay, Platts, Booth, & Bowman, 2003) Fatigue is a primary contributor to functional disability and visits with health care providers. Belza, Henke,Yelin, Epstein and Gilliss (1993) reported

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8 a significant positive association between fatigue levels in RA patients and frequency of visits to their rheumatologists. Numerous factors have been associated with fatigue in SLE, including level of aerobic fitness, pain, medications, sleep problem s, and clinical and laboratory features of SLE (Zonana-Nacach et al., 2000). Depression al so is related strongly to fatigue (De Rijk, Schreurs, & Bensing, 1999) and a positive association between fatigue and depression has been reported in patients with SLE (Krupp et al., 1991). Although fatigue is sometimes viewed as a reflection of disease activity, it often persists despite decreases in disease activity, indicating that additional factors likely play a role in maintaining fatigue levels. Studies investigating fatigue and disease activity have provided inconsistent findings for a biologic explanation for fa tigue. Bruce, Mak, Hallett, Gladmann, and Urowitz (1999) found disease activity and damage accounted for only 4.8% and 4%, respectively, of the variance in fatigue scores in a sample of 81 lupus patients. Several studies (e.g., Tench, McCurdie, White, & D’Cruz, 2000; Zonana-Nacach et al., 2000) have shown weak associations between fatigue and disease activity. In contrast, Tayer, Nicassio, Weisman, Schuman, and Daly (2001) found that in a cross-sectional analysis of 81 SLE patients, disease status, helplessness, and depression are independently significant predictors of fatigue. In a longit udinal design testing the same variables, only disease status predicted future fatigue levels. Overall, these findings support the possibility that a combination of disease and psychosocial factors are capable of influencing fatigue levels. Several investigations have provided support for the role of psychological distress in the experience of fatigue in SLE. McKinley, Ouellette, and Winkel (1995)

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9 demonstrated that while disease activity did not exert a direct effect on fatigue, it did influence depression and sleep disruption, which may, in turn, exert a more direct effect on fatigue. Omdal, Waterloo, Koldingsnes, Husby, and Mellgren (2003) found in a sample of 57 SLE patients that affective and personality states as well as mental health status were significant predictors of fatigue. Fatigue, as with pain, appears to be a multidimensional construct with a significant psychological component. Disease-Related Pain Pain is among the most common reasons individuals seek medical care. It accounts for substantial levels of functional disability and contributes greatly to overall illness burden (Turk & Melzack, 1992), including visits to health care providers, medication expense, and work-related disability. Pain has been consistently linked with negative mood states (Robinson & Riley, 1999) and can enhance stress-related hormones and immune dysregulation (Kiecolt-Glaser, McGuire, Robles, & Glaser, 2002b). It appears that this triad of symptomology involving fatigue, pain, and distress (e.g., depression, anxiety) creates a negative spiral resulting in increasing levels of disability. Pain related to arthritis and arthralgias occurs in 95% of lupus patients at some point in the course of their illness (Schur, 1996). The relationship between pain and fatigue in chronic pain conditions has been firmly established (Belza et al., 1993; Wolfe, Hawley, & Wilson, 1996). Coping with unpredictable and severe amounts of pain requires additional physical and emotional endurance, which may further deplete energy and coping resources in lupus patients. Further, reduced levels of activity could result in muscle deconditioning, which, in turn, could contribute to increased levels of perceived fatigue (Belza et al., 1993; Robb-Nicholson et al., 1989) and increased level of pain.

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10 Pain is a defining symptom in polymyositis and may also be important in scleroderma. Benrud-Larson and colleagues (2002) investigated the frequency and impact of pain, symptoms of depression, and social network characteristics on physical functioning and social adjustment in 142 patie nts with scleroderma. Sixty-three percent of patients reported mild or greater pain, and half of the sample reported mild or greater levels of depression. The results showed that pain was the strongest predictor of physical function, and depressive symptoms accounted for the greatest amount of variance in social adjustment. Their findings suggest that pain and depressive symptoms are important determinants of quality of life in scleroderma patients. Cluster Profiling Empirical approaches to classifyi ng homogenous psychological subgroups have been used extensively in chronic pain patients. This approach originated as an effort to counter assumption that pain patients represent a homogenous group and to determine whether treatment response could be improved by tailoring treatments to subgroups of patients based on specific characteristics (Turk & Okifuji, 2002). Using the Multidimensional Pain Inventory (MPI; Kerns, Turk, & Rudy, 1985), Turk and Rudy (1988) cluster analyzed patients’ responses and found three homogenous groups of pain patients: (a) dysfunctional, (b) interpersonally distressed, and (b) active copers. This classification system has been replicated in chronic low back pain (CLBP), head pain, FMS, and temporomandibular disorder (T MD). Additionally, subgroup differences were found in response to treatment, suggesting that the use of classification systems to tailor treatment approaches to specific subgroups may improve treatment efficacy. The Minnesota Multiphasic Personality Inventory (MMPI) has been found to be highly consistent in identifying subgroups within a variety of chronic pain populations,

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11 such as headache (Robinson, Geisser, Dieter, & Swerdlow, 1991), chronic musculoskeletal pain (Riley, Geisser, & Robinson, 1999) and TMD (Velly, Philippe, & Gornitsky, 2002). These findings provide additional evidence to suggest that within broad categories of pain conditions, distinct subgroups exist. Identification of such subgroups in AD could enhance our understanding of variability in responses to illness and its subsequent treatment. Illness Burden and the Immune Response In AD, the relationships between emotions, psychological distress, immune and neuroendocrine functioning, and disease manifesta tions are of particular interest. There is considerable evidence to suggest that emotional states can produce alterations in the immune response. It is currently accepted that the brain and the immune system share bidirectional communication and exert important regulatory control over one another. The existence of such neural-immune interactions provides a pathway by which psychological processes can influence and be influenced by immune function (Maier, Watkins, & Fleshner, 1994). Additionally, immunological alterations have been reported across a wide range of psychiatric disorders (Kiecolt-Glaser et al., 2002a). A growing body of evidence suggests a role for psychological distress in inducing, exacerbating, and affecting outco mes in SLE (Shapiro, 1997). Depressed immune responsiveness is characteristic of patients with SLE. Research has shown that psychological distress further dampens the immune response via activation of the hypothalamic-pituitary-adrenal (HPA) axis (Ader, Cohen, & Felton, 1995), which may result in more active disease. A 1999 study by Pawlak and colleagues demonstrated a distinct difference between the stress response of SLE patients and healthy controls following a stressful task (public speaking). Systemic lupus erythematosus patients

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12 showed significantly less pronounced increases in NK cell numbers compared to the controls. Additionally, NK cell activity increased in the controls but not in the SLE patients, indicating a blunted immune response to acute stress. Inflammation is linked to a variety of conditions associated with aging (Kiecolt-Glaser et al., 2002b) and is an impor tant feature in AD. Chronic inflammation and immune challenge associated with illness serve as physiologic stressors leading to activation of the HPA axis. Dysregulation of inflammatory mediators is commonly observed in ADs and has also been shown to correlate with psychological variables, such as depression. The majority of research to date in this area has focused on proinflammatory cytokines. Cytokines are low mo lecular weight protein substances released by cells that serve as intercellular signals to regulate the immune response to injury and infection (Parham, 2000). Cytokines have been proposed as the messengers between the brain and the immune system (Maier et al., 1994). Several studies have shown that patients with SLE display an altered cytokine profile (Jacobs et al., 2001). One pro-inflammatory cytokine that has received increased attention in a variety of medical and psychiatric populations is interleukin-6 (Il-6). Studies of the role of IL-6 in SLE have lead to relatively uniform results. Circulating Il-6 levels are elevated in patients with SLE, compared to those with inactive disease and healthy controls (Lacki, Leszczynski, Kelemen, Muller, & Mackiewicz, 1997). Il-6 also has shown a consistent relationship with depression across a number of studies. Maes and colleagues (1995) found elevated levels of Il-6 and soluble Il-6 receptors (sIl-6R) in patients with major depression (MD), whether active or in remission, suggesting that the upregulated production of Il-6 may be a trait marker for MD.

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13 Some researchers have proposed that psychological stress can instigate the inflammatory response. According to Black (2003), the inflammatory response is contained within the psychological stress response, which evolved later. The same neuropeptides mediate the body’s response to both stress and inflammation. Cytokines evoked by either a stress or inflammatory response may utilize similar pathways to signal the brain, signaling a cascade of hormones, neuropeptides, and cytokine activity. Negative affect has been identified as a key pathway for modifying immune processes. There is preliminary evidence that anxiety and depression enhance the production of pro-inflammatory cytokine s (Kiecolt-Glaser et al., 2002a). Immune modulation by psychosocial stressors and/or interventions can lead to health changes. Pro-inflammatory cytokines, such as Il-6, stimulate the release of acute phase reactants from the liver. Acute phase proteins, such as C-reactive protein (CRP) and complement proteins (C3 and C4) are part of the body’s innate immune inflammatory response to infection. Berk, Wadee, Kuschke, and O'Neill-Kerr (1997) compared levels of acute phase proteins (C3, C4 and CRP) in depressed versus nondepressed subjects according to DSM-III-R criteria and found significant elevations in C4 and CRP in the depressed group. These findings suggest the possibility of an underlying relationship between depression and inflammation in autoimmune patients. Furthermore, many physicians now believe that CRP can be used as an aid in assessing the risk of cardiovascular and peripheral vascular disease. The relationships among psychological factors and acute phase proteins have not been previously reported in AD populations. Social Support The benefits of social support have been given extensive consideration throughout the chronic illness literature. Social support is negatively correlated with psychological

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14 distress and has been shown to influence health behaviors, such as seeking medical care (Cohen, 1988). McCracken, Semenchuk, and Goetch (1995) found that good social support was related to perceptions of health and that seeking social support was associated with lower levels of pain, physical disability, psychological distress, and depression. Furthermore, social support can serve as a buffer during both acute and chronic stressors, thereby protecting the individual against immune dysregulation (Kiecolt-Glaser et al., 2002a). Two studies (Bae, Hashimoto, Karlson, Liang, & Daltroy, 2001; Sutcliffe et al., 1999) reported that higher levels of social support were associated with better physical and mental well-being in SLE patients. However, there are no studies to date that have examined the role of social support as a buffer against immune dysregulation in SLE, scleroderma, Sjgren’s syndrome, polymyositis, or ANA positive patients. Study Rationale The participants in this study shared common complaints and symptoms characteristic of suspected AD. Following medical evaluation, individuals were placed into a variety of categories ranging from ANA positive to having been diagnosed with one of many ADs. The assumption of heterogeneity in such a diverse population might lead to generic treatment approaches aimed at the “average” or “typical” patient. Another pitfall might be to assume that more severe illness equals more distressed or that adjustment to illness was similar across a variety of conditions. The purpose of this study was to explore the possibility that homogenous subgroups exist based on specific shared qualities. Identifying such subgroups offers the possibility to better understand variability in response to illness and to tailor treatment to subgroups based on specific characteristics.

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15 Relatively little is known about how individuals with ADs such as SLE, scleroderma and polymyositis and ANA positive patients vary with respect to psychological function and adjustment to illness. The level of heterogeneity across individuals, disease categories, and illness severity remains to be determined. To date, there are few reports describing the psychological characteristics of ANA positive patients. Across conditions, one might expect that those posing a greater threat to mortality, quality of life, and function would lead to higher levels of distress and greater coping challenges. Within disease categories, factors such as premorbid psychological status and disease severity could play important roles in current psychological adjustment and status. There are few studies to date that have attempted to elucidate the relationships among psychological factors and inflammatory mediators in ANA positive, SLE, and related autoimmune conditions. Further, no studies have investigated the relationship between psychosocial factors, pain, fatigue, and acute phase proteins in this population. Finally, although physician-rated measures of disease activity have been compared to individual psychological and self-rated symptoms, such as pain and fatigue, in SLE patients, the relationship between physician-rated disease activity and multivariate psychological response profiles has not been previously reported. The aim of this study was to contribute to the understanding of these relationships using an empirical clustering approach to examine how these variables are related. Using a cluster-analytic approach, a pilot study was conducted to determine whether unique patterns of psychological (depression, anxiety, confusion, and anger) and symptom (pain and fatigue) reports exist within an AD sample. The preliminary study was conducted on 279 participants to determine whether patients presenting in an AD

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16 -1.5 -1 -0.5 0 0.5 1 1.5 2F a tig u e Pa i n Depression A n xiety C o n f u sio n A n ger Pain/ Fatigue (n=66) Mod. Impact (n=77) High Impact (n=47) Low Imapct ( n=89 ) clinic could be classified into subgroups based on unique psychological response profiles. The cluster analysis revealed a f our-cluster solution. The four-cluster solution was chosen because it provided better group separation and more parsimonious interpretation. Figure 1-1 provides a graphical representation of the four clusters. Figure 1-1.Preliminary four-cluster solution representing psychological profiles in autoimmune disease patients The first cluster, “Pain/Fatigue” (n = 66), displayed moderate levels of pain and fatigue and low levels of distress. The “Moderate Impact” cluster, comprised of 77 participants, is characterized by moderate levels of pain, fatigue, and distress with an elevation in anxiety. The “High Impact” cluster (n = 47) displayed high distress and symptom levels, and the “Low Impact” cluster (n = 89) demonstrated low levels of symptoms and distress. Based on this pilot data indicating the presence of four distinct psychological response profiles in the AD sample, several aims were developed. Aims The initial aim of this study involved replicating the four-cluster solution using a larger sample. Secondly, this study sought to determine whether clusters are associated

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17 with demographic variables, including race, age, sex, and illness duration. Next, the concordance among psychological response profiles and diagnostic categories (ANA positive, SLE, Sjgren’s, polymyositis, and scleroderma) was examined. The relationship between psychological response profiles and biological markers was also examined to assess whether psychological response profiles predict serological markers of disease activity (urinary Il-6, CRP, C3, C4, albumin, and prealbumin). A secondary objective included determining whether psychological response profiles predict physician-rated levels of disease activity in SLE patients. The relationship between psychological response profiles and SLE Disease Activity Index (SLEDAI; Bombardier et al., 1992) was examined. Finally, the relationship between psychological response profiles and perceived social support was assessed. The results of this study provided preliminary evidence indicating whether psychological response profiles were determined primarily by disease process, indicating a pathophysiological basis for psychological functioning, or by psychosocial factors and predisposing personality traits, suggesting a psychological basis for individual responses to physical illness. Although, in reality, the answer likely lies in the middle of these extremes, this study provided insight into the differential contributions of these opposing hypotheses. Hypotheses •The same four-cluster solution found in the pilot study was repeated in a larger autoimmune disease clinic sample. •Equal representation of diagnosis across clusters was supportive of the notion that predisposing factors (personality, social support, etc.) predict psychological response to illness. A higher frequency of diagnosed AD in the more distressed profiles was supportive of disease severity determining psychological response.

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18 •Response profiles reflecting higher levels of pain, fatigue, and distress will be associated with increased activation of serological markers of disease activityNHigher levels of urinary Il-6, CRP, albumin, and prealbuminNLower levels of complement components (C3 and C4) •Response profiles reflecting higher levels of pain, fatigue, and distress will be associated with higher levels of physician-rated disease activity in SLE patients, supporting the notion that disease contributes to psychological response. Absence of significant differences between response profiles on disease activity scores would support the view that psychological response to illness may be independent of specific pathological processes. •Response profiles reflecting higher levels of pain, fatigue, and distress will be inversely associated with levels of perceived social support, thereby supporting the notion that greater social support serves as a buffer against the harmful effects of illness on psychological well-being.

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19 CHAPTER 2 METHODS Participants Participants in this study were 393 rheumatology outpatients recruited from the Autoimmune Disease Clinic at Shands Hospital in Gainesville, Florida. The mean age of the patients was 44.3 (SD = 13.7), and the mean duration since diagnosis was 8.0 (SD = 7.6) years. Patients were predominantly female (90.1%), and the majority of patients were Caucasian (64.1%). Patients were categorized according to primary diagnosis, although it should be noted that many patients met criteria for more than one autoimmune disorder. The largest proportion of patients was diagnosed with SLE (43%), followed by patients who were ANA positive (25.7%) but did not meet criteria for an autoimmune disease diagnosis. Diagnostic information is presented in Table 2-1. Table 2-1.Diagnostic breakdown of demographic information DiagnosisN% Duration (yrs) Edu (yrs) Age (yrs) Sex N (% total) Race N (% total) M (SD)M (SD)M (SD)FMWBO SLE1764510.5 (8.4) 13.5 (2.4) 41.3 (12.8) 162.0 (41.2) 14.0 (3.6) 89.0 (22.6) 62.0 (15.8) 25.0 (6.4) ANA POS101264.0 (4.5) 13.7 (2.5) 43.8 (13.7) 91.0 (23.2) 10.0 (2.5) 77.0 (19.6) 11.0 (2.8) 13.0 (3.3) Sjgren’s2676.8 (4.0) 14.0 (2.3) 52.8 (14.4) 24.0 (6.1) 2.0 (0.5) 25.0 (6.4) 1.0 (0.3) 0.0 (0.0) SSC2268.2 (6.1) 12.8 (3.3) 53.8 (10.4) 19.0 (4.8) 3.0 (0.8) 16.0 (4.1) 6.0 (1.5) 0.0 (0.0) Other68177.3 (8.3) 13.7 (2.4) 46.4 (13.8) 58.0 (14.8) 10.0 (2.5) 45.0 (11.5) 16.0 (4.1) 7.0 (1.8) Total3931008.0 (7.6) 13.6 (2.5)44.3 (13.7) 354.0 (90.1) 39.0 (9.9) 252.0 (64.1) 96.0 (24.4) 45.0 (11.5)

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20 Patients eligible for participation in this study were preselected based on participation in the large study examine factors contributing to the development of autoimmune disease (IRB#: 454). Patients were recruited by their treating physicians during routine medical visits. Eligibility was determined by each patient’s treating physician according to necessary criteria. Eligibility criteria included being 18 years or older, English-speaking, literate, and possessing a minimum education level of 8th grade. Both males and females from all racial/ethnic backgrounds were included. Participation was also contingent upon ability to provide consent. Patients with cognitive, emotional, or physical problems believed to interfere with his or her ability to provide consent were not permitted to participate. Written consent for research participation was obtained at the conclusion of routine visits. Procedure Recruitment took place during routine medical visits. Eligible participants were approached by his or her rheumatologist or tr ained research staff regarding participation in the study. The informed consent form was verbally reviewed prior to obtaining patients’ signatures to ensure complete understanding of their rights as research participants. Participation in this study did not interfere with routine rheumatologic care. Following their routine rheumatology visit, staff members escorted participants to the General Clinical Research Center (GCRC) at Shands Hospital for clinical laboratory tests. In addition to clinical laboratory tests ordered by their rheumatologist, biological samples were obtained exclusively for research purposes. At this time, participants completed the psychosocial questionnaire packet, consisting of a battery of self-report paper and pencil questionnaires. Instructions for completing the questionnaire were

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21 provided by a trained research assistant. The packet generally required 10 to 15 minutes to complete. Measures Standard demographic data were collected during each participant’s initial assessment. Information related to medical diagnosis and disease duration was recorded for research purposes after patients provided informed consent to participate in the study. Psychosocial Measures The assessment of distress and symptom levels includes seven visual analogue scales (VASs). Respondents were asked to indicate their level of functioning in each of the assessed domains by drawing a vertical line through one point on a 100 mm linear analogue scale. Scores were obtained by manual measurement of the VAS responses and range from 0-100. Each domain is anchored by the following descriptors: “None” and “Worst Imaginable.” The domains assessed by VASs in this study included depression, anxiety, anger, confusion, pain intensity, and fatigue. The use of VASs for assessing psychological distress and symptom domains in a brief format is not uncommon. The pain VAS (Price, McGrath, Rafii, & Buckingham, 1983) is a 100-mm line anchored by the descriptors, “No pain” to “Worst Pain Imaginable.” Adequate reliability and validity have been reported (Price et al., 1983). Social support was measured using the Perceived Social Support Scale (PSSS; Blumenthal, Burg, Barefoot, Williams, Haney, & Zimet, 1987). The PSSS is a 12-item scale employing a 7-point Likert response s cale ranging from 1 (Very Strongly Disagree) to 7 (Very Strongly Agree). This scale addr esses perceived support from family, friends, and significant others. Test-retest reliability was reported as 0.85 and Cronbach’s coefficient alpha was 0.88 (Blumenthal et al., 1987).

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22 Physician-Rated Disease Activity The SLE Disease Activity Index (SLEDAI; Bombardier et al., 1992) is a physician-rating scale consisting of 24 descriptors associated with nine organ systems. Clinical and laboratory measures of SLE activity are included. Items are weighted according to severity and life-threatening ite ms receive greater weights. The weighted items are summed to obtain an overall score. The range for possible scores is from 0 to 105. The SLEDAI has been validated and shown to be sensitive to changes over time (Fortin et al., 2000; Petri, Hellman & Hochberg, 1992). Biological Measures Urinary levels of IL-6 was measured using Enzyme-Linked Immunosorbent Assay (ELISA), an established method for determining cytokine levels. High-sensitivity CRP, C3, C4, albumin, and prealbumin will be measured by nephelometry on a BN Prospec II (Dade Behring) nephelometer. Nephelometry is a technique that uses analysis of light scattered by liquid to measure the size and concentration of particles in the liquid. Analyses All data analyses were performed using SPSS for windows (Version 11). Hierarchical cluster analysis (Ward’s Linkage) was employed to identify distinct subgroups underlying the data structure. In order to validate the stability of the cluster solution, the overall sample was split into halves using a random selection function within the statistical software. The four-cluster solution was replicated in both halves, lending further support to the validity of these four response profiles across AD patients. Following the empirical derivation of response profiles, the assigned cluster membership value (1-4) was used in subsequent analyses. Nonparametric chi square analyses and analyses of variance were the principle statistics used in these analyses. For

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23 all ANOVAs, significant F-tests were followed by post-hoc analyses using Tukey’s HSD to evaluate pairwise comparisons between response profiles on the dependent variable. Statistical significance was set at an alpha value of .05 for all analyses.

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24 -1.5 -1 -0.5 0 0.5 1 1.5 2F at ig u e Pain De p ression A n xiety Co n f us ion Ang e r High Impact (n=67) Low Impact (n=165) Pain/ Fatigue (n=80) Fatigue/ Distress ( n=62 ) CHAPTER 3 RESULTS This study was based on the empirical determination of patient subgroups from the AD clinic based on the following scores: fatigue, pain intensity, depression, anxiety, anger, and confusion. Complete data for this analysis was available for 374 participants. Results of the hierarchical cluster analysis revealed a four-cluster solution (Figure 3-1), which was determined quantitatively based on the percentage change in the agglomeration coefficients. Figure 3-1.Replication four-cluster solution representing psychological profiles in autoimmune disease patients Subgroups represent relatively unique response profiles derived from the multivariate combination of symptom and mood measures. Table 3-1 provides a summary of the response profiles. The “High Impact” cluster (N = 67) is characterized by

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25 high scores across all measures with particularly high (>1 SD from mean) elevations in pain and anxiety. The “Low Impact” cluster (N = 165), the highest frequency cluster, reflects low levels for all mood and symptom variables. The “Pain/Fatigue” cluster (N = 80) profile reflects significant fatigue, moderate pain and relatively low levels of distress and confusion. The “Fatigue/Distress” cluster (N = 62) is characterized by high levels of fatigue, depression, and anxiety. The increase in sample size from the pilot study (N = 279) to the full sample (N = 374) resulted in an altered distribution of participants across the four clusters, whereby a larger proportion (44%) of participants fell in the profile cluster representing low symptom and distress levels. Table 3-1.Description of response profiles ClusterNDescription 167High impact 2165Low impact 380Pain/Fatigue 462Fatigue/Distress Following the derivation of response profiles, a series of analyses were undertaken to examine whether profiles differed across demographic, diagnostic, and physiological variables. First, the relationship between response profiles and demographic variables was examined to determine whether race, sex, age, or illness duration predict psychological response profile. Nonparametric chi square analyses were used to examine the relationships of race and sex to response profiles. Results showed that racial background was proportionately distributed across the four psychological response profile membership, 2=5.76 (6), p = .450. Chi-square results for sex were significant, 2=8.49 (3), p =.037, indicating that men and women were disproportionately represented across clusters. Closer examination of the crosstabulation matrix revealed

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26 that no males were present in the “Fatigue/Distress” cluster. However, given the small number of males (9.9%, N = 39) in the sample, this finding has limited interpretive value. One-way analyses of variance (ANOVAs) were used to compare response profiles on age and duration since diagnosis Response profile groups did not differ on age ( F (3,370) =1.61, p = .188) or duration since diagnosis ( F (3,320) =0.81, p = .490). Thus, current age and time elapsed since being diagnosed are not predictive of symptom and mood response profiles. The second hypothesis concerned the concordance among psychological response profiles and diagnostic categories (ANA positive, SLE, scleroderma, Sjgren’s, and polymyositis, and other). The frequency of response profiles across diagnostic groups was assessed using nonparametric chi square tests. This analysis aimed to determine whether disease factors associated with a diagnosis of AD are associated with response profiles reflecting greater pain, fatigue and distress. The results revealed the proportionate distribution of diagnoses across the four response profiles, 2=5.24 (12), p =.950. This finding suggests that response profiles do not differ significantly between various autoimmune conditions (Table 3-2). Table 3-2.Crosstabulation matrix of response profiles across diagnostic categories Response profile (N)Total Diagnosis1234N (%) SLE28713629164 (43.8) ANA POS1848191499 (26.5) Sjgren’s3125525 (6.7) SSC3106221 (5.6) Other1524141265 (17.4) Total671658062374 (100.0) The next series of analyses examined whether psychological response profiles represent varying levels of disease activity. ANOVAs were used to test for differences in

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27 levels of disease activity as measured by a number of biological markers. Separate ANOVAs were conducted for urinary Il-6, hs CRP, C3, C4, albumin and prealbumin. A descriptive overview and results for these parameters is presented in Table 3-3. Table 3-3.Values for biological markers of disease activities VariableNRangeMeanSDFSig. Il-6*780.01 3683.50433.56792.150.9320.430 HsCRP*2960.15 108.008.0313.210.1300.944 C329724.10 261.00116.6534.402.1800.091 C42923.04 118.0021.2112.362.700.046+Prealbumin22110.40 60.4025.958.610.6950.556 Albumin2500.00 2048.0051.64211.690.3360.799 IV = response profile group *Values presented are based on raw data. Nonnormal distributions were transformed logarithmically for statistical analyses. +p <.05 Response profiles did not differ on mean levels of Il-6 ( F (3, 70) =0.932, p = .430), hsCRP ( F (3, 293) = .13, p = .944) or C3 ( F (3, 294) = 2.18, p = .091). Significant differences between groups were found for C4 ( F (3, 289) = 2.7, p = .046). Post-hoc tests using Tukey’s HSD revealed the “Low Impact” and “Pain/Fatigue” clusters differed significantly ( p =.045) on C4 values. This finding has limited value because correcting for multiple comparisons suggests this significant finding could be due to chance. There were no differences between prealbumin ( F (3, 218) = .695, p = .556) and albumin ( F (3, 247) = .336, p = .799) levels between response profiles. The collection of physician-rated SLE disease activity (SLEDAI) measures is limited to those patients carrying a diagnosis of SLE. Thus, patients diagnosed with SLE were selected to examine whether differences in total SLEDAI scores exist between response profile groups. The range for SLEDAI scores was 0 to 24 and the mean was 3.27 (SD=4.12). Forty-one percent of SLE patie nts received a SLEDAI score of greater

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28 than or equal to four. Due to the significant positive skew of the distribution, a square root transformation was performed to nor malize the data distribution. ANOVA revealed that SLEDAI scores did not differ significantly across response profiles ( F (3, 142) = .786, p = .504). The final hypothesis concerned the relationship between psychological response profiles and levels of perceived social support. Results of the ANOVA showed that psychological response profiles were associated with varying levels of social support ( F (3, 368) = 5.13, p = .002). Post-hoc analyses revealed that the “Low Impact” cluster reported significantly ( p = .001) higher levels of perceived social support than the “Fatigue/Distress” cluster.

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29 CHAPTER 4 DISCUSSION Unique subgroups of patients were determined empirically within a cohort of AD and ANA positive patients based on a similar response pattern. Psychological and symptom reporting profiles in this sample did not vary with respect to demographic characteristics, diagnostic categories, serological markers of disease activity, and physician-rated disease activity. Higher levels of perceived social support were associated with response profiles characterized by lower levels of mood and symptom reporting. The results of this study provide support for the presence of substantial heterogeneity in illness response and psychological functioning across a large sample of AD and ANA positive patients as well as within specific disease groups. Further, subgroups are independent of disease factors, including diagnosis, suggesting that personality, psychological, and/or social support factors are a stronger determinant of response to illness. Variations in psychological functioning within this illness population were expected to span the continuum from well-adjusted to highly distressed participants. The results of this study bring attention to the sizeable number of patients who are experiencing elevated levels of subjective distress. Eighteen percent of participants fell within the “High Impact” cluster profile, and 38% were characterized by some elevations in symptoms and/or distress. These results signify the role of perceived symptom and distress in overall illness coping and quality of life. At the same time, it is important to

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30 keep in mind that not all patients experiencing illness or symptoms reminiscent of a diagnosable disorder report compromised psychological functioning. Cluster profiles were compared on a number of variables, including demographic, diagnostic, disease activity, and social support measures. Race, age, and illness duration were evenly distributed across cluster profiles, indicating that these variables are not associated with differences in psychological response profiles. These results are consistent with other studies that have demonstrated a lack of association between measures of distress and demographic characteristics. For example, in a sample of RA patients, VanDyke and colleagues (2004) found no significant relationship between anxiety and illness duration. Similarly, Alarc on and colleagues (2004) demonstrated in a cohort of 364 SLE patients that age and ethnicity were not associated with the physical and mental subscales of the SF-36. Results of this study did indicate a significant effect for sex when compared across clusters; however, the disproportionately small number of males in the sample limits the ability to interpret this finding. Opposing hypotheses were presented with regard to the relationship between psychological profiles and diagnostic category. Across conditions, one might expect that conditions posing a greater threat to mortality, quality of life, and function would lead to higher levels of distress and greater coping challenges, thereby supporting that psychological response is determined to a large extent by disease severity. However, results demonstrated that response profiles were equally distributed across diagnostic categories, suggesting that coping profiles are independent of diagnosis. Equal representation of diagnoses across response clusters points to predisposing factors such as personality, social support, and coping style determining response profile membership.

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31 This finding provides meaningful implications for the treatment of patients with the various diagnoses under consideration in this study. For example, physicians who are biased toward assuming that worse disease is related to poor psychological adjustment or that a positive ANA titer in the absence of a diagnosable AD should be less psychologically threatening to the individual are at risk for underor over-interpreting psychological well-being based on disease threat or severity. The results of this study suggest that illness adjustment is not related to diagnosis. In fact, psychological functioning and/or perceived social support might be a more accurate predictor of how patients will respond to their illness. In this study, it is not possible to determine the extent to which psychological response to illness is based on premorbid factors versus factors that are activated or influenced in the presence of illness. Support for the idea that premorbid psychological function plays an important role in response to illness has been demonstrated through investigations of neuroticism and self-reported adjustment. Costa and McCrae (1987) found that patients scoring particularly high on neuroticism tend to report higher levels of self-reported psychological and physical sy mptoms, without suffering from worse clinical outcomes. Given that psychological distress influences perceived quality of life, behaviors that can affect health outcome (e .g., exercise, diet, and use of alcohol, drugs, and nicotine), and response to illness, subjective distress levels are important to consider when illness is present, regardless of diagnosis. Variations in psychological functioning were hypothesized to reflect differences in disease status as measured by serological markers of disease activity. This hypothesis was not supported. Response profiles characteri zed by higher levels of pain, fatigue, and distress were not associated with increased activation of serological markers of disease

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32 activity. Symptom profiles are not accounted for by underlying disease processes and appear to be better explained by premorbid psychological factors. Statistical significance was achieved for complement protein C4 between the “Low Impact” and “Pain/Fatigue” groups; however, the relationship was not in the anticipated direction. This finding is most likely the product of statistical chance due to the number of serological tests conducted. In sum, the weight of the evidence does not support an association between serological markers of disease activity and response profiles. Response profiles reflecting higher levels of pain, fatigue, and distress were not associated with higher levels of physician-rated disease activity in SLE patients, suggesting psychological response to illness ma y be independent of specific pathological processes. Another possible interpretation is that physician-ratings of disease activity are not congruent with patients’ perceptions of disease activity. Ward and colleagues (2002) found that changes in depression and anxiety were positively correlated with simultaneous changes in the patient global assessment of SLE activity but not with changes in SLEDAI scores. Furthermore, studies have found assessments of disease activity by patients and physicians are often discordant (Neville et al., 2000) and the SLEDAI is generally not responsive to changes in patients’ assessments of changes in disease activity (Chang, Abrahamowicz, Ferland, & Fortin, 2002). Thus, it seems possible that patients’ psychological adjustment to illness may depend more heavily upon subjective assessments of disease activity, which may not be associated with other measures of disease activity. The importance of interpersonal relationships in the maintenance of health has been widely reported. Poor social support is expected to increase the burden of illness experienced by the individual. DeVellis and colleagues (1986) reported less-supportive

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33 atmospheres play a role in the onset and exacerbation of autoimmune diseases. In the current study, the hypothesis that response profiles reflecting higher levels of pain, fatigue, and distress would be inversely associat ed with levels of perceived social support was supported. This finding is consistent with a large body of literature across numerous disease populations reporting that greater social support serves as a buffer against the harmful effects of illness on psychological well-being. This study provided an interesting approach to grouping patients into psychological response profiles. One of the objectives of cluster analysis is to reveal relationships among observations that were perhaps not possible using individual observations (Hair, Anderson, Tatham, & Black, 1998). This did not appear to be the case for the subgroups found in this study. The subgroups did not demonstrate meaningful relationships with expected vari ables, bringing into question the usefulness of determining subgroups within AD samples. The identification of patient subgroups is ultimately beneficial to the extent that they can be utilized in the understanding and treatment of individuals in each subgroup. This type of application has proven successful in the chronic pain literature (e.g., Sanders & Brenna, 1993; Swimmer, Robinson, & Geisser, 1992). Further research investigating treatment outcome differences across clusters is necessary to determine the possible benefits of using clustering techniques to identify subgroups of AD and ANA positive patients. The ability to identify patients who are highly distressed and at increased risk for poor outcomes would allow for the implementation of interventions that are more efficiently tailored to meet the individual’s needs. Future studies investigating whether diagnostic groups within a particular cluster (e.g., “High Impact“) are more or less amenable to improvements when a targeted

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34 psychological intervention is applied might help to elucidate relationships between disease and illness response. For example, if ANA patients in the “High Impact” cluster showed greater reductions in psychological distress than SLE patients from the same subgroup, one might suspect that high distress compounded by more severe underlying disease processes are less responsive to psychological intervention. The findings of this study must be considered in the context of several caveats. First, it is necessary to point out that the cluster analysis technique is a data reduction technique based on both objective and subjective considerations on the part of the researcher. Therefore, if another set of variab les had been chosen to include in the cluster analysis, the results could have been quite different. Similarly, it is possible that the variables selected to test predictive validity of the clusters were not the most appropriate in terms of their ability to discriminate between variations in psychological responses. For example, it is possible that the SLEDAI is not an accurate measure of disease activity or that it is not comprehensive and does not adequately capture the component of disease activity associated with symptom (i.e., pain and fatigue) intensity. An additional caveat relates to the a priori decision to include individuals representing a wide range of diagnostic groups. Although the ANA positive group presents clinically with many of the same complaints as patients who go on to be diagnosed with AD, it is possible that they are a distinct group with regard to response to illness. It is possible that the heterogeneity across the sample diluted the relationship of response profiles to disease-specific measures of function. Thus, future studies attempting to categorize patients based on response profiles might benefit from limiting their sample to a specific diagnostic category before broadening the scope to include multiple diagnoses.

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35 The cross-sectional design on which this study is based limits the exploration of relationships to a single point in time. The temporal relationship between disease activity and psychological functioning remains unclear, although some researchers have suggested that such relationships are not based on a simultaneous pattern of flux. Thus, it is possible that relationships between biological correlates of disease activity and psychological function can only be elucidated wh en the variables of interest are observed prospectively. Research in the area of relationships between psychosocial and immune parameters would benefit from longitudinal designs to account for temporal relationships that are not revealed within cross-sectional designs. Finally, the cohort sampled in this study included a relatively small number of men. It remains largely unknown as to whether men responded similarly to the women. These proportions did not allow for tests of gender differences. Future research is needed to better understand psychological response to AD in men and to test for gender differences in symptom reporting and illness response. Cluster profiles were not validated by demographic, diagnostic, or disease activity measures. Response profiles were related to perceived social support, the only psychosocial variable examined across cluster profiles, suggesting that psychosocial variables function in synchrony. Response to illness in this study was not dependent on disease activity or type, thereby providing greater support for the role of psychological and social support factors in determining response to illness.

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36 REFERENCES Adams, S. G., Dammers, P. M., Saia, T. L., Brantley, P. J., & Gaydos, G. R. (1994). Stress, depression and anxiety predict average symptom severity and daily symptom fluctuation in systemic lupus erythematosus. Journal of Behavioral Medicine, 17, 459-477. Ader, R., Cohen, N., & Felten, D. ( 1995). Psychoneuroimmunology: Interactions between the nervous system and the immune system. The Lancet, 345, 99-103. Alarcon, G. S., McGwin, G., Jr., Uribe, A., Friedman, A. W., Roseman, J. M., Fessler, B. J., Bastian, H. M., Baethge, B. A., Vila, L. M., & Reveille, J. D. (2004). Systemic lupus erythematosus in a multiethnic lupus cohort (LUMINA). XVII. Predictors of self-reported health-related quality of life early in the disease course. Arthritis and Rheumatism, 15;51 (3), 465-474. Al-Allaf, A. W., Ottewell, L., & Pullar, T. (2002). The prevalence and significance of positive antinuclear antibodies in patients with fibromyalgia syndrome: 2-4 years' follow-up. Clinical Rheumatology, 21 (6), 472-477. Bae, S. C., Hashimoto, H., Karlson, E. W., Liang, M. H., & Daltroy, L. H. (2001). Variable effects of social support by race, economic status, and disease activity in systemic lupus erythematosus. Journal of Rheumatology, 28 (6), 1245-1251. Beck, A. T. (1967). Depression: Clinical, experimental and theoretical aspects New York: Harper & Row. Belza, B. L., Henke, C. J., Yelin, E. H., Epstein, W. V., & Gilliss, C. L. (1993). Correlates of fatigue in older adults with rheumatoid arthritis. Nursing Research, 42 (2), 93-99. Benrud-Larson, L. M., Haythornthwaite, J. A ., Heinberg, L. J., Boling, C., Reed, J., White, B., & Wigley, F. M. (2002). The impact of pain and symptoms of depression in scleroderma. Pain, 95 (3), 267-275. Berk, M., Wadee, A. A., Kuschke, R. H., & O’Neill-Kerr, A. (1997). Acute phase proteins in major depression. Journal of Psychosomatic Research, 43 (5), 529-534. Berkov, R., Beers, M. H., & Burs, H. (Eds.) (1999). Merck manual of diagnosis and therapy (17th ed.). Whitehouse Station, NJ: Merck & Co.

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37 Black, P.H. (2003). The inflammatory response is an integral part of the stress response: Implications for atherosclerosis, insulin resistance, type II diabetes and metabolic syndrome X. Brain, Behavior & Immunity, 17 (5), 350-364. Blumenthal, D. E. (2002). Tired, aching, ANApositive: Does your patient have lupus or fibromyalgia. Cleveland Clinic Journal of Medicine, 69 (2), 143-152. Blumenthal, J. A., Burg, M. M., Barefoot, J., Williams, R. B., Haney, T., & Zimet, G. (1987). Social support, type A behavi or, and coronary artery disease. Psychosomatic Medicine, 49 (4), 331-340. Bombardier, C., Gladman, D. D., Urowitz, M. B., Caron, D., & Chang, C. H. (1992). Derivation of the SLEDAI: A disease activity index for lupus patients. The Committee on Prognosis Studies in SLE. Arthritis & Rheumatism, 35 630-640. Bruce, I. N., Mak, V. C., Hallett, D. C., Gladmann, D. D., & Urowitz, M. B. (1999). Factors associated with fatigue in patients with systemic lupus erythematosus. Annals of Rheumatic Disease, 58 379-381. Chang, E., Abrahamowicz, M., Ferland, D., & Fortin, P. R. (2002). Comparison of the responsiveness of lupus disease activity measures to changes in systemic lupus erythematosus activity relevant to patients and physicians. Journal of Clinical Epidemiology, 55 488-497. Cohen, S. (1988). Psychosocial models of the role of social support in the etiology of physical disease. Health Psychology, 7 269-297. Costa, P. T., Jr., & McCrae, R. R. (1987). Neuroticism, somatic complaints, and disease: Is the bark worse than the bite? Journal of Personality, 55 (2), 299-316. De Rijk, A. E., Schreurs, K. M. G., & Bensing, J. M. (1999). Complaints of fatigue: Related to too much as well as too little external stimulation? Journal of Behavioral Medicine, 22 (6), 549-573. DeVellis, R. F., DeVellis, B., McEvoy, H., Sauter, S. V., Harring, K., & Cohen, J. L. (1986). Predictors of pain and functioning in arthritis. Health Education Research: Theory and Practice, 1, 61–67. Dobkin, P. L., Fortin, P. R., Joseph, L., Esdaile, J. M., Danoff, D. S., & Clarke, A. E. (1998) Psychosocial contributions to mental and physical health in patients with systemic lupus erythematosus. Arthritis Care & Research, 11 (1), 23-31. Fortin, P. R., Abrahamowicz, M., Clarke, A. E., Neville, C., Du Berger, R., Fraenkel, L., & Liang, M. H. (2000). Do lupus disease activity measures detect clinically important change? Journal of Rheumatology, 27 (6), 1421-1428.

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38 Giang, D. W. (1991). Systemic lupus erythematosus and depression. Neuropsychiatry, Neuropsychology & Behavioral Neurology, 4 78-82. Gironimi, G., Clarke, A. E., Hamilton, V. H., Da noff, D. S., Bloch, D. A., Fries, J. F., & Esdaile J. M. (1996). Why health care costs more in the US: Comparing health care expenditures between systemic lupus erythematosus patients in Stanford and Montreal Arthritis & Rheumatism, 39 (6), 979-987. Hair, J. E., Jr., Anderson, R. E., Tatham, R. L., & Black, W. C. (1998). Multivariate data analysis (5th ed.). Upper Saddle River, NJ: Prentice Hall. Hochberg, M. C. (1997). Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus [letter]. Arthritis and Rheumatism, 40 1725. Hopkinson, N. D., Doherty, M., & Powell, R. J. (1994). Clinical features and racespecific incidence/prevalence rates of systemic lupus erythematosus in a geographically complete cohort of patients. Annals of Rheumatic Disease, 53 (10), 675-680. Illei, G. G., & Klippel, J. H. (1999). Why is the ANA result positive? Bulletin on Rheumatic Disease, 48 (1), 1-4. Iverson, G. L., Sawyer, D. C., McCracken L. M., & Kozora, E. (2001). Assessing depression in systemic lupus erythematosus: Determining reliable change. Lupus, 10 266-271. Jacobs, R., Pawlak, C. R., Mikeska, E., Meyer-Olson, D., Martin, M., Heijnen, C. J., Schedlowski, M., & Schmidt, R. F. (2001). Systemic lupus erythematosus and rheumatoid arthritis patients differ from healthy controls in their cytokine pattern after stress exposure. Rheumatology, 40 868-875. Johnson, A. E., Gordon, C. Palmer, R. G., & Bacon P. A. (1995). The prevalence and incidence of systemic lupus erythematosus in Birmingham, England: Relationship to ethnicity and country of birth Arthritis & Rheumatism 38 (4), 551-558. Kerns, R. D., Turk, D. C., & Rudy, T. E. (1985). The West Haven-Yale Multidimensional Pain Inventory (WHYMPI). Pain 23 (4), 345-356. Kiecolt-Glaser, J. K., McGuire, L., Robles, T. F., & Glaser, R. (2002a). Psychoneuroimmunology and psychosomatic medicine: Back to the future. Psychosomatic Medicine, 64, 15-28. Kiecolt-Glaser, J. K., McGuire, L., Robles T. F., & Glaser, R. (2002b). Emotions, morbidity, and mortality: New perspectives from psychoneuroimmunology. Annual Review of Psychology, 53, 83-107.

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39 Krupp, L. B., LaRocca, N. G., Muir, J., & St einberg, A. D. (1991). A study of fatigue in systemic lupus erythematosus. Journal of Rheumatology 17, 1450-1452. Kuby, J. (1991). Immunology (2nd ed.). New York: W. H. Freeman. Lacki, J., Leszczynski, P., Kelemen, J., Muller, W., & Mackiewicz. S. (1997). Cytokine concentration in serum of lupus erythematosus patients: The effect on acute phase response Journal of Medicine, 28 (1-2), 99-107. Lwin, C. T., Bishay, M., Platts, R. G., Booth, D. A., & Bowman, S. J. (2003). The assessment of fatigue in primary Sjgren’s syndrome. Scandinavian Journal of Rheumatology, 32 (10), 33-37. Maes, M., Meltzer, H. Y., Bosmans, E., Bergmans, R., Vandoolaeghe, E., Ranjan, R., & Desnyder, R. (1995). Increased plasma concentrations of interleukin-6, soluble interleukin-6, soluble interleukin-2 and transferrin receptor in major depression. Journal of Affective Disorders, 34 (4), 301-309. Maier, S. F., Watkins, L. R., & Fleshner, M. (1994). Psychoneuroimmunology: The interface between behavior, brain and immunity. American Psychologist, 1004-1017. Matsura, E., Ohta, A., Kanegae, F., Haruda, Y., Ushiyama, O., Koarada, S., Togashi, R., Tada, Y., Suzuki, N., & Nagasawa K. (2003). Frequency and analysis of factors closely associated with the development of depressive symptoms in patients with scleroderma. Journal of Rheumatology, 30 (8), 1782-1787. McCracken, L. M., Semenchuk, E. M., & Goetch, V. L. (1995). Cross-sectional and longitudinal analyses of coping responses and health status in persons with systemic lupus erythematosus. Behavioral Medicine, 20, 179-187. McKinley, P. S., Ouellette, S. C., & Winkel, G. H. (1995). The contributions of disease activity, sleep patterns and depression to fatigue in systemic lupus erythematosus. Arthritis & Rheumatism, 6, 826-834. Neville, C., Clarke, A. E., Joseph, L., Belisle, P. Ferland, D., Ferland, D., & Fortin, P. R. (2000). Learning from discordance in patient and physician global assessments of systemic lupus erythematosus disease activity. Journal of Rheumatology, 27, 675-679. National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). (2001). Health topics. Retrieved on September 5, 2003, from http://www.niams.nih.gov/hi/topics/scleroderma/scleroderma.htm Omdal, R., Waterloo, K., Koldingsnes, W., Husby, G., & Mellgren, S. I. (2003). Fatigue in patients with systemic lupus erythematosus: The psychosocial aspects. Journal of Rheumatology, 30 (2), 283-287

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40 Parham, P. (2000). The immune system. New York: Garland. Pawlak, C. R., Jacobs, R., Mikeska, E., Oc hsmann, S., Lombardi, M. S., Kavelaars, A., Heijnen, C. J., Schmidt, R. E., & Schedlowski, M. (1999). Patients with systemic lupus erythematosus differ from healthy controls in their immunological response to acute psychological stress. Brain, Behavior & Immunity, 13, 287-302. Petri, M., Hellmann, D., & Hochberg, M. (1992). Validity and reliability of lupus activity measures in the routine clinic setting. Journal of Rheumatology, 19 (1), 53-59. Price, D. D., McGrath, P. A., Rafii, A., & Buckingham, B. (1983). The validation of visual analogue scales as ratio scale measures for chronic and experimental pain. Pain, 17, 45-56. Riley, J. L., Geisser, M. E., & Robinsom, M. E. (1999). Empirical subgroups of the Coping Strategies Questionnaire-Revised: A multisample study. Clinical Journal of Pain, 15 (2), 111-116. Robb-Nicholson, L. C., Daltroy, L., Eaton, H., Ga il, V., Wright, E., Hartley, L. H., Schur, P. H., & Liang, M. H. (1989). Effects of aerobic conditioning in lupus fatigue: A pilot study. British Journal of Rheumatology, 28, 500-5. Robinson, M. E., Geisser, M. E. Dieter, J. N., & Swerdlow, B. (1991). The relationship between MMPI cluster membership and diagnostic category in headache patients. Headache, 31 (2), 111-115. Robinson, M. E., & Riley, J. L. (1999). The role of emotions in pain. In R. J. Gatchel & D. C. Turk (Eds.), Psychosocial factors in pain: Critical perspectives (pp.74-87). New York: Guilford. Rus, V., & Hochberg, M. C. (2002). The epidemiology of systemic lupus erythematosus. In D. J. Wallace & B. H. Hahn (Eds.), Dubois’ lupus erythematosus (pp. 65-83). Philadelphia: Lippincott, Williams & Wilkins. Sanders, S. H., & Brena, S. F. (1993). Empirically derived chronic pain patient subgroups: The utility of multidimensional clustering to identify differential treatment effects. Pain, 54, 51-56. Schur, P. (1996) General symptomology. In P. Schur (Ed.), The clinical management of systemic lupus erythematosus (2nd ed., p. 10). Philadelphia: Lippincott-Raven. Shapiro, H. S. (1997). Psychopathology in the patient with lupus. In D J. Wallace & B. H. Hahn (Eds.), Dubois’ lupus erythematosus (5th ed., pp. 755-782). Philadelphia: Lippincott, Williams & Wilkins.

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41 Smart, P. A., Waylonis, G. W., & Hackshaw, K. V. (1997). Immunologic profile of patients with fibromyalgia. A merican Journal of Physical Medicine & Rehabilitation, 76 (3), 231-234. Sutcliffe, N., Clarke, A. E., Levinton, C., Frost, C., Gordon, C., & Isenberg, D. A. (1999). Associates of health status in patients with systemic lupus erythematosus. Journal of Rheumatology, 26 (11), 2352-2356. Swimmer, G. I., Robinson, M. E., & Geisser, M. E. (1992). Relationship of MMPI cluster type, pain coping strategy, and treatment outcome. Clinical Journal of Pain, 8 (2), 131-137 Symmons, D. P., Coppock, J. S., Bacon, P. A., Bresnihan, B., Isenberg, D. A., Maddison, P., McHugh N, Snaith, M. L., & Zoma, A. S. (1988). Development and assessment of a computerized index of clinical disease activity in systemic lupus erythematosus. Members of the British Isles Lupus Assessment Group (BILAG). Quarterly Journal of Medicine, 69 927-937. Tan, E. M., Cohen, A. S., Fries, J. F., Masi, A. T., McShane, D. J., Rothfield, N. F., Schaller, J. G., Talal, N., & Winchester, R. J.. (1982). The 1982 revised criteria for the classification of systemic lupus erythematosus Arthritis & Rheumatism, 25 1271-1277. Tayer, W. G., Nicassio, P. M., Weisman, M. H., Schuman, C., & Daly, J. (2001). Disease status predicts fatigue in systemic lupus erythematosus. Journal of Rheumatology, 28 (9), 1999-2007. Tench, C. M., McCurdie, I., White, P. D., & D’Cruz, D. P. (2000). The prevalence and associations of fatigue in systemic lupus erythematosus. Rheumatology, 39, 1249-1254. Tizard, I. R. (1995). Immunology: An introduction (4th ed.). Philadelphia: Saunders. Turk D. C., & Melzack, R. (1992). The measurement of pain and the assessment of people experiencing pain. In D. C. Turk & R. Melzack (Eds.), Handbook of pain assessment (pp. 3-12). New York: Guilford. Turk, D. C., & Okifuji, A. (2002). Chronic pain. In A. J. Christensen & M. H. Antoni (Eds.), Chronic physical disorders: Behavioral medicine’s perspective (p. 182-187). Malden, MA: Blackwell. Turk, D.C., & Rudy, T. E. (1988). Toward an empirically derived taxonomy of chronic pain patients: Integration of psychological assessment data. Journal of Consulting & Clinical Psychology, 56, 233-238.

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42 U.S. Census Bureau (2000). U.S. census data 2000. Retrieved September 3, 2003, from http://www.census.gov/main/www/cen2000.html Valtysdottir, S. T., Gudbjornsson, B., Lindqvist, U., Hallgren, R., & Hetta J. (2000). Anxiety and depression in patients with primary Sjgren’s syndrome. Journal of Rheumatology 27 (1), 165-169. VanDyke, M. M., Parker, J. C., Smarr, K. L., Hewett, J. E., Johnson, G. E., Slaughter, J. R., & Walker, S. E. (2004). Anxiety in rheumatoid arthritis. Arthritis and Rheumatism, 51 (3), 408-412. Velly, A. M., Philippe, P., & Gornitsky, M. (2002). Heterogeneity of temporomandibular disorders: Cluster and case-control analyses. Journal of Oral Rehabilitation, 29 (10), 969-979. Wallace, D. J., & Hahn, B. H. (Eds.). (2002). Dubois’ systemic erythematosus (6th ed.). Philadelphia: Lippincott, Williams & Williams. Ward, M. M., Marx, A. S., & Barry, N. N. (2002). Psychological distress and changes in the activity of systemic lupus erythematosus. Rheumatology, 41, 184-188. Wolfe, F., Hawley, D. J., & Wilson, K. (1996). The prevalence and meaning of fatigue in rheumatic disease. The Journal of Rheumatology, 23 (8), 1407-1417. Zeiss, A. M., Lewinsohn, P. M., Rhode, P ., & Seeley, J. R. (1996). Relationship of physical disease and functional impairment to depression in older people. Psychology and Aging, 11 (4), 572-581. Zonana-Nacach, A., Roseman, J. M., McGwin, G., Jr., Friedman, A. W., Baethge, B. A., Reveille, J. D., & Alarcon, G. S. (2000). Systemic lupus erythematosus in three ethnic groups. VI: Factors associated with fatigue within 5 years of criteria diagnosis. Lupus, 9, 101-109.

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43 BIOGRAPHICAL SKETCH Rebecca Jump was born February 25, 1973, as the first of four children. She grew up on the Eastern Shore of Maryland in a small community on the Chesapeake Bay. She graduated from St. Michaels High School in 1991 and headed to the mountains of central Pennsylvania to attend Juniata College. As an undergraduate, she played varsity field hockey and spent one semester in Nancy, France, as part of a study abroad program. She graduated with a Bachelor of Science degree in biopsychology and French in 1995 and promptly headed back across the Atlantic Ocean to further indulge herself in French language and culture. She spent one year in a French language program for foreigners at the Universit de Lille III in Villeneuve d'Ascq, France. Upon her return from abroad in 1996, Rebecca began a master’s program in the General Experimental PsychologyHealth option at the University of Hartford in West Hartford, Connecticut. She spent an additional year in New England working full-time at the University of Connecticut Health Center as a research assistant for parallel studies involving women with fibromyalgia and rheumatoid arthritis. In 2000, Rebecca headed for the sunny south to begin her doctoral training in clinical and health psychology at the University of Florida where she specialized in adult medical psychology with a particular focus on chronic pain and rheumatic disease. In the next phase of her “East Coast Living” Rebecca ventured to Augusta, Georgia, to complete her predoctoral internship at the Medical College of Georgia/Veteran’s Affairs Medi cal Center Training Consortium. During this year of clinical training, Rebecca pursued an advanced specialization in the assessment

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44 and treatment of posttraumatic stress disorder (PTSD). Following the completion of her internship, Rebecca will return to the Univers ity of Florida to complete a postdoctoral fellowship in the Department of Clinical and Health Psychology. Her career goal is to obtain a position in a medical center specializing in the treatment of chronic pain/illness and PTSD. She also hopes to devote a portion of her time to research collaboration and supervision of trainees.


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Title: Psychological Profiles in Autoimmune Disease: Relationship to Demographic, Diagnostic, Disease Activity and Social Support Measures
Physical Description: Mixed Material
Copyright Date: 2008

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Source Institution: University of Florida
Holding Location: University of Florida
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PSYCHOLOGICAL PROFILES IN AUTOIMMUNE DISEASE:
RELATIONSHIP TO DEMOGRAPHIC, DIAGNOSTIC, DISEASE ACTIVITY
AND SOCIAL SUPPORT MEASURES














By

REBECCA JUMP


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


2005















TABLE OF CONTENTS
Page

LIST OF TABLES ..................................... ........ ....... iii

LIST OF FIGURES .......... ........................................... iv

ABSTRACT ................................................ ......... v

CHAPTER

1 INTRODUCTION .................................................1

Systemic Lupus Erythematosus ................ ...................... 1
Sjogren's Syndrome, Scleroderma, and Polymyositis ................... .... 3
Antinuclear Antibody Positive Patients ................ ................. 4
Psychological Distress and Illness ................ ................... .. 5
Disease-Related Fatigue ............... ............................ 7
Disease-Related Pain .............................................. 9
Cluster Profiling ..................................... ................ 10
Illness Burden and the Immune Response .............................. 11
Social Support ..................................... ................ 13
Study Rationale .......... ........................................... 14
A im s ............. ................................ .16
Hypotheses ......... ............................................... 17

2 METHODS ....... ............................................... 19

Participants ......... ...................................... ......... 19
Procedure ........ ............................................... .20
Measures ....... ................................................ .21
Analyses ................................................... 22

3 RESULTS ........... ................................ .24

4 DISCUSSION ........ ............................................ 29

REFERENCES ....... ............................................... 36

BIOGRAPHICAL SKETCH ........................................... 43















LIST OF TABLES


Table page

2-1 Diagnostic breakdown of demographic information ................... .. 19

3-1 Description of response profiles ..................................... 25

3-2 Crosstabulation matrix of response profiles across diagnostic categories ...... 26

3-3 Values for biological markers of disease activities ....................... 27















LIST OF FIGURES


Figure e

1-1 Preliminary four-cluster solution representing psychological profiles in
autoimmune disease patients .............. ................... 16

3-1 Replication four-cluster solution representing psychological profiles in
autoimmune disease patients .................................... 24















Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

PSYCHOLOGICAL PROFILES IN AUTOIMMUNE DISEASE:
RELATIONSHIP TO DEMOGRAPHIC, DIAGNOSTIC, DISEASE ACTIVITY
AND SOCIAL SUPPORT MEASURES

By

Rebecca Jump

August 2005

Chair: Michael E. Robinson
Major Department: Clinical and Health Psychology

Autoimmune diseases (AD) are characterized by chronic inflammation that can

affect a variety of tissues in systemic or organ-specific forms. The challenges inherent to

managing a chronic medical illness place individuals at greater risk for psychological

distress, which could lead to deleterious effects on immune and neuroendocrine

functioning and contribute to disease progression. Relatively little is known about

variations in psychological function and the degree to which heterogeneity exists across a

variety of autoimmune diseases. Further, the differential contributions of disease-related

factors and psychological function to illness response remain unclear. Using a cluster

analytic approach, this study determined homogenous psychological subgroups in a

sample of 393 rheumatology outpatients referred to an autoimmune disease clinic for

suspected AD. Participants included individuals diagnosed with an AD as well as

individuals testing positive for anti-nuclear antibodies (ANA positive). Psychological

subgroups were determined empirically based on visual analogue measures of

depression, anxiety, anger, confusion, pain, and fatigue. Psychological response profiles

v









were subsequently examined in relation to demographic variables, diagnostic category,

physician rated and immune measures of disease activity, and perceived social support.

Results of the study provide support for substantial heterogeneity across in psychological

function and illness response across the AD sample and within specific diagnostic

groups. Psychological response profiles did not vary with respect to demographic

variables, diagnosis, serological markers of disease activity, or physician-rated disease

activity. Higher levels of perceived social support were associated with lower levels of

mood disturbance and symptom reporting. Results suggest that personality,

psychological, and/or social support factors may be stronger determinants of response to

illness.















CHAPTER 1
INTRODUCTION

Autoimmunity refers to a breakdown in the immune system's ability to maintain

self-tolerance, resulting in an immune response directed against self-components of the

body. Autoimmune diseases (AD) are characterized by chronic inflammation in which

the rate of tissue damage exceeds the body's ability to repair the damage. There is wide

variability across ADs in the tissues that are attacked and specific symptoms caused.

Although an understanding of the mechanisms responsible for maintaining tolerance

exists, the specific factors contributing to the pathogenesis of AD remain largely

unknown (Parham, 2000). It is generally accepted that the cause of any given AD is

multifactorial and that environmental and genetic factors play a role in susceptibility

(Tizard, 1995).

Autoimmune diseases are relatively common, affecting 2% to 3% of the

population of developed countries (Parham, 2000) and 5% to 7% of adults in Europe and

North America (Tizard, 1995). Two thirds of those affected are women. ADs can

generally be divided into two types: organ-specific, where the immune response is

directed toward a target antigen that is specific to a single organ or gland, and systemic,

which involves a response directed across a broad array of organs and tissues (Kuby,

1991).

Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a prototypical AD in which almost every

tissue or organ may be affected. Its diagnosis depends on multisystem involvement and







2

the presence of autoantibodies, which together form the diagnostic criteria for SLE (Tan

et al., 1982). Systemic lupus erythematosus is thus a syndrome, rather than single disease

entity, that exhibits considerable variation in disease manifestations between individual

patients. The course of SLE generally involves periods of intense flares and periods of

remission (Parham, 2000).

The overall prevalence of SLE varies between studies from 12.0 to 50.8 with an

average of about 40 per 100,000 individuals (Hopkinson, Doherty, & Powell, 1994). The

highest prevalence is found in African American females at a rate of 200 per 100,000.

The incidence of lupus has been reported between 2.0 and 7.6 new cases per 100,000 per

year (Johnson, Gordon, Palmer, & Bacon, 1995). It is evident that sex has a major

influence on the likelihood of developing SLE, with a 90% female predominance over

males (Rus & Hochberg, 2002). The predominance of female SLE patients is not well

understood, although hormonal factors are believed to play an important etiological role

(Tizard, 1995).

Systemic lupus erythematosus is generally diagnosed according to the American

College of Rheumatology's revised (Hochberg, 1997) criteria for SLE. The criteria

include 11 items, 5 of which are composites of one or more abnormalities. In order to

meet criteria for a diagnosis of SLE, patients must fulfill at least 4 criteria; however, no

single criterion is essential (Wallace & Hahn, 2002). Laboratory diagnosis of SLE

focuses to a large extent on antinuclear antibodies (Kuby, 1991). The absence of a clearly

defined diagnostic marker for SLE contributes to the diagnostic challenge and can place

patients at risk for misdiagnosis.

The wide variation in disease manifestations across individuals with SLE

contributes to the challenge of developing a uniform system for assessing level of disease









activity. Consequently, the assessment of disease activity in SLE patients remains

inconsistent within the rheumatology field. Over 60 systems for assessing disease activity

exist, and agreement on a definition for SLE activity has not been achieved. In the United

States, the most commonly used assessment system for disease activity is the Systemic

Lupus Erythematosus Disease Activity Index (SLEDAI; Bombardier, Gladman, Urowitz,

Caron, & Chang, 1992), whereas in Europe, the British Aisles Lupus Assessment Group

(BILAG; Symmons et al., 1988) system predominates (Wallace & Hahn, 2002).

The economic impact of SLE has been estimated at a mean annual direct and

indirect per patient cost of $10,530 in the United States in 1991 (Gironimi et al., 1996).

Given the marked rise in health care costs in the last decade and an average prevalence of

about 40 per 100,000, this translates into considerable annual health expenditure. In

addition to growing health care costs, the economic impact of SLE is expected to rise

exponentially as the percentage of African Americans (presently at 12.9%) and Hispanics

(presently at 12.5%) continues to grow faster than the Caucasian population (U.S. Census

Bureau, 2000).

Sj6gren's Syndrome, Scleroderma, and Polymyositis

A number of patients referred to specialists for suspected SLE are ultimately

diagnosed with a different AD or are determined to have antinuclear antibodies (ANA)

but not meet criteria for a specific AD. Among the systemic autoimmune conditions that

share symptom overlap with SLE are Sjogren's syndrome, scleroderma, and

polymyositis. Similar to SLE, these conditions involve a response mounted by the

immune system against tissues in the body. In the case of Sjogren's syndrome, the

immune system targets the salivary and lacrimal glands, leading to dryness in the mouth

and eyes and complications including severe dental decay and corneal damage. The









female to male ratio is 9:1, and the overall prevalence for Sjogren's is 3% (Berkov,

Beers, & Burs, 1999). Scleroderma, also known as systemic sclerosis, is an autoimmune

condition involving overproduction of collagen that results in abnormal growth of

connective tissues that support the skin and internal organs. Scleroderma occurs at a rate

7-12 times greater in females than males (National Institute of Arthritis and

Musculoskeletal and Skin Diseases [NIAMS], 2001). Polymyositis is a connective tissue

disorder characterized by inflammation and degenerative changes in muscles. Over time,

this damage leads to symmetric weakness and muscle atrophy. This may be commonly

associated with severe interstitial lung disease, which can rapidly lead to death. The

female to male ratio is 2:1 with 2 to 10 new cases per one million (Berkov et al., 1999).

Antinuclear Antibody Positive Patients

Antinuclear antibody testing is one of several tests commonly ordered when a

patient in primary care settings complains of chronic low energy, arthralgias, and

myalgias (Blumenthal, 2002). Most patients referred to clinics specializing in

rheumatologic or autoimmune conditions for suspected SLE have antinuclear antibodies.

Antinuclear antibody testing is often used to screen for a diagnosis of lupus but has very

low specificity (Illei & Klippel, 1999). Conversely, the absence of a positive ANA

largely excludes the diagnosis of SLE as less than 4% of lupus patients have a negative

ANA. In addition, up to 20% of healthy, asymptomatic individuals test ANA positive

(Wallace & Hahn, 2002). Thus, many patients who test positive for ANA do not receive a

diagnosis of SLE.

Although some ANA positive patients are diagnosed with an alternate

autoimmune disorder or another condition, others receive no diagnosis. Blumenthal

(2002) reported that many patients testing positive for ANA ultimately receive a









diagnosis of fibromyalgia syndrome (FMS) or an alternative pain syndrome. He argued

that the prevalence of FMS is at least 20 times higher than that of lupus, which reduces

the likelihood that a positive ANA will result in a diagnosis of lupus. Smart, Waylonis,

and Hackshaw (1997) found that in a sample of 66 FMS patients, 20 (30%) were ANA

positive.

Al-Allaf, Ottewell, and Pullar (2002) investigated whether ANA positive FMS

patients developed other symptoms of connective disease over a 2- to 4-year follow-up

period compared with age- and sex-matched ANA negative FMS and osteoarthritis (OA)

patients. The ANA positive rates (12/137 [8.8%] in FMS and 20/225 [8.9%] in OA

patients) were similar in both groups. At final assessment, one patient from the ANA

positive FMS group was diagnosed with SLE, one patient from the ANA negative FMS

group was diagnosed with Sjogren's syndrome, and one OA patient developed

rheumatoid arthritis (RA). These results indicated that ANA status is not a good predictor

of future development of AD. The ANA positive population, in the absence of AD,

represents a unique and poorly defined group of patients. These patients range from

asymptomatic to those suffering from FMS or an alternate pain condition.

Psychological Distress and Illness

The psychological aspects of SLE have not received extensive attention and

remain poorly understood despite estimated rates for neuropsychiatric problems ranging

from 33% to 60% and affective problems from 50% to 80% (Dobkin et al., 1998).

Psychological distress, which includes depressed or anxious mood, occurs commonly in

medical disorders and has a significant effect on quality of life and coping with disease

(Adams, Dammers, Saia, Brantley, & Gaydos, 1994). Psychological distress represents

patients' interpretations of stress and their perceived impact (Ward, Marx, & Barry, 2002)









and can be considered an intermediate measure in the relationship between stress and

illness. Distress can impact health both indirectly, through health behaviors (e.g.,

compliance to medical regimens, poorer sleep, poorer nutrition) or directly through

alterations in the central nervous, immune, endocrine, and cardiovascular systems

(Kiecolt-Glaser, McGuire, Robles, & Glaser, 2002a).

Physical health problems, particularly those that are chronic, are considered a

significant risk factor for depression (Zeiss, Lewinsohn, Rhode, & Seeley, 1996). Many

of the ADs, such as SLE, present a course of unpredictable symptom flares and

remissions. A diagnosis of AD requires adjusting to a new array of medical, social,

psychological, vocational, and financial challenges and stressors. Depression is the most

common psychiatric problem in patients with SLE. In a review of the literature, Giang

(1991) found that 31% to 52% of lupus patients who underwent a structured or semi-

structured interview were experiencing depression. The factors contributing to the

etiology and maintenance of depression in lupus patients are unclear and likely involve

numerous biopsychosocial factors (Iverson, Sawyer, McCracken, & Kozora, 2001).

Elevated levels of psychological distress have also been reported in scleroderma

and Sjogren's syndrome patients. Valtysdottir, Gudbjornsson, Lindqvist, Hallgren, and

Hetta (2000) examined levels of anxiety, depression, well-being, and symptoms in 62

Sjogren's patients compared with a group of healthy controls and a group of patient

controls with RA. The results indicated significantly higher levels of anxiety and

depression, and reduced physical and mental well-being in Sjogren's patients compared

with healthy controls. The Sjogren's patients also reported significantly more symptoms

than RA patients.









Matsura and colleagues (2003) evaluated 50 patients with scleroderma for factors

associated with depressive symptoms using the Beck Depression Inventory (BDI; Beck,

1967). Forty-six percent of the sample reported depressive symptoms ranging from mild

to severe. Regression analyses revealed that high levels of hopelessness and low sense of

coherence (coping ability and resilience in the face of stress) were the best predictors of

depressive symptoms in this sample.

Psychological distress affects morbidity in patients with comorbid medical illness

in several ways. As Iverson et al. (2001) highlighted, depression can greatly impact

functional status and degree of disability in the areas of social, occupational, educational,

and recreational functioning. Depression has also been shown to influence patients'

adherence to medical regimens. In addition to influencing overt behavioral functioning,

there is also evidence that psychological distress is directly related to disease activity

(Dobkin et al., 1998). However, it remains unknown as to whether psychological distress

leads to increased SLE activity or if disease activity leads patients to become more

depressed or anxious.

Disease-Related Fatigue

Fatigue is a commonly reported symptom in medical patients and one of the most

widely reported symptoms in SLE. Zonana-Nacach and colleagues (2000) found that

85.7% of 223 participants with SLE reported fatigue; and Krupp, LaRocca, Muir, and

Steinberg (1991) found fatigue to be reported in 80% of their SLE sample. Disabling

fatigue is also a prominent feature of primary Sjogren's syndrome (Lwin, Bishay, Platts,

Booth, & Bowman, 2003). Fatigue is a primary contributor to functional disability and

visits with health care providers. Belza, Henke,Yelin, Epstein and Gilliss (1993) reported









a significant positive association between fatigue levels in RA patients and frequency of

visits to their rheumatologists.

Numerous factors have been associated with fatigue in SLE, including level of

aerobic fitness, pain, medications, sleep problems, and clinical and laboratory features of

SLE (Zonana-Nacach et al., 2000). Depression also is related strongly to fatigue (De

Rijk, Schreurs, & Bensing, 1999) and a positive association between fatigue and

depression has been reported in patients with SLE (Krupp et al., 1991). Although fatigue

is sometimes viewed as a reflection of disease activity, it often persists despite decreases

in disease activity, indicating that additional factors likely play a role in maintaining

fatigue levels.

Studies investigating fatigue and disease activity have provided inconsistent

findings for a biologic explanation for fatigue. Bruce, Mak, Hallett, Gladmann, and

Urowitz (1999) found disease activity and damage accounted for only 4.8% and 4%,

respectively, of the variance in fatigue scores in a sample of 81 lupus patients. Several

studies (e.g., Tench, McCurdie, White, & D'Cruz, 2000; Zonana-Nacach et al., 2000)

have shown weak associations between fatigue and disease activity. In contrast, Tayer,

Nicassio, Weisman, Schuman, and Daly (2001) found that in a cross-sectional analysis of

81 SLE patients, disease status, helplessness, and depression are independently

significant predictors of fatigue. In a longitudinal design testing the same variables, only

disease status predicted future fatigue levels. Overall, these findings support the

possibility that a combination of disease and psychosocial factors are capable of

influencing fatigue levels.

Several investigations have provided support for the role of psychological distress

in the experience of fatigue in SLE. McKinley, Ouellette, and Winkel (1995)









demonstrated that while disease activity did not exert a direct effect on fatigue, it did

influence depression and sleep disruption, which may, in turn, exert a more direct effect

on fatigue. Omdal, Waterloo, Koldingsnes, Husby, and Mellgren (2003) found in a

sample of 57 SLE patients that affective and personality states as well as mental health

status were significant predictors of fatigue. Fatigue, as with pain, appears to be a

multidimensional construct with a significant psychological component.

Disease-Related Pain

Pain is among the most common reasons individuals seek medical care. It

accounts for substantial levels of functional disability and contributes greatly to overall

illness burden (Turk & Melzack, 1992), including visits to health care providers,

medication expense, and work-related disability. Pain has been consistently linked with

negative mood states (Robinson & Riley, 1999) and can enhance stress-related hormones

and immune dysregulation (Kiecolt-Glaser, McGuire, Robles, & Glaser, 2002b). It

appears that this triad of symptomology involving fatigue, pain, and distress

(e.g., depression, anxiety) creates a negative spiral resulting in increasing levels of

disability.

Pain related to arthritis and arthralgias occurs in 95% of lupus patients at some

point in the course of their illness (Schur, 1996). The relationship between pain and

fatigue in chronic pain conditions has been firmly established (Belza et al., 1993; Wolfe,

Hawley, & Wilson, 1996). Coping with unpredictable and severe amounts of pain

requires additional physical and emotional endurance, which may further deplete energy

and coping resources in lupus patients. Further, reduced levels of activity could result in

muscle deconditioning, which, in turn, could contribute to increased levels of perceived

fatigue (Belza et al., 1993; Robb-Nicholson et al., 1989) and increased level of pain.









Pain is a defining symptom in polymyositis and may also be important in

scleroderma. Benrud-Larson and colleagues (2002) investigated the frequency and

impact of pain, symptoms of depression, and social network characteristics on physical

functioning and social adjustment in 142 patients with scleroderma. Sixty-three percent

of patients reported mild or greater pain, and half of the sample reported mild or greater

levels of depression. The results showed that pain was the strongest predictor of physical

function, and depressive symptoms accounted for the greatest amount of variance in

social adjustment. Their findings suggest that pain and depressive symptoms are

important determinants of quality of life in scleroderma patients.

Cluster Profiling

Empirical approaches to classifying homogenous psychological subgroups have

been used extensively in chronic pain patients. This approach originated as an effort to

counter assumption that pain patients represent a homogenous group and to determine

whether treatment response could be improved by tailoring treatments to subgroups of

patients based on specific characteristics (Turk & Okifuji, 2002). Using the

Multidimensional Pain Inventory (MPI; Kerns, Turk, & Rudy, 1985), Turk and Rudy

(1988) cluster analyzed patients' responses and found three homogenous groups of pain

patients: (a) dysfunctional, (b) interpersonally distressed, and (b) active copers. This

classification system has been replicated in chronic low back pain (CLBP), head pain,

FMS, and temporomandibular disorder (TMD). Additionally, subgroup differences were

found in response to treatment, suggesting that the use of classification systems to tailor

treatment approaches to specific subgroups may improve treatment efficacy.

The Minnesota Multiphasic Personality Inventory (MMPI) has been found to be

highly consistent in identifying subgroups within a variety of chronic pain populations,









such as headache (Robinson, Geisser, Dieter, & Swerdlow, 1991), chronic

musculoskeletal pain (Riley, Geisser, & Robinson, 1999) and TMD (Velly, Philippe, &

Gornitsky, 2002). These findings provide additional evidence to suggest that within

broad categories of pain conditions, distinct subgroups exist. Identification of such

subgroups in AD could enhance our understanding of variability in responses to illness

and its subsequent treatment.

Illness Burden and the Immune Response

In AD, the relationships between emotions, psychological distress, immune and

neuroendocrine functioning, and disease manifestations are of particular interest. There is

considerable evidence to suggest that emotional states can produce alterations in the

immune response. It is currently accepted that the brain and the immune system share

bidirectional communication and exert important regulatory control over one another.

The existence of such neural-immune interactions provides a pathway by which

psychological processes can influence and be influenced by immune function (Maier,

Watkins, & Fleshner, 1994). Additionally, immunological alterations have been reported

across a wide range of psychiatric disorders (Kiecolt-Glaser et al., 2002a).

A growing body of evidence suggests a role for psychological distress in

inducing, exacerbating, and affecting outcomes in SLE (Shapiro, 1997). Depressed

immune responsiveness is characteristic of patients with SLE. Research has shown that

psychological distress further dampens the immune response via activation of the

hypothalamic-pituitary-adrenal (HPA) axis (Ader, Cohen, & Felton, 1995), which may

result in more active disease. A 1999 study by Pawlak and colleagues demonstrated a

distinct difference between the stress response of SLE patients and healthy controls

following a stressful task (public speaking). Systemic lupus erythematosus patients









showed significantly less pronounced increases in NK cell numbers compared to the

controls. Additionally, NK cell activity increased in the controls but not in the SLE

patients, indicating a blunted immune response to acute stress.

Inflammation is linked to a variety of conditions associated with aging

(Kiecolt-Glaser et al., 2002b) and is an important feature in AD. Chronic inflammation

and immune challenge associated with illness serve as physiologic stressors leading to

activation of the HPA axis. Dysregulation of inflammatory mediators is commonly

observed in ADs and has also been shown to correlate with psychological variables, such

as depression. The majority of research to date in this area has focused on pro-

inflammatory cytokines. Cytokines are low molecular weight protein substances released

by cells that serve as intercellular signals to regulate the immune response to injury and

infection (Parham, 2000). Cytokines have been proposed as the messengers between the

brain and the immune system (Maier et al., 1994).

Several studies have shown that patients with SLE display an altered cytokine

profile (Jacobs et al., 2001). One pro-inflammatory cytokine that has received increased

attention in a variety of medical and psychiatric populations is interleukin-6 (11-6).

Studies of the role of IL-6 in SLE have lead to relatively uniform results. Circulating 11-6

levels are elevated in patients with SLE, compared to those with inactive disease and

healthy controls (Lacki, Leszczynski, Kelemen, Muller, & Mackiewicz, 1997). 11-6 also

has shown a consistent relationship with depression across a number of studies. Maes and

colleagues (1995) found elevated levels of 11-6 and soluble 11-6 receptors (sIl-6R) in

patients with major depression (MD), whether active or in remission, suggesting that the

upregulated production of 11-6 may be a trait marker for MD.









Some researchers have proposed that psychological stress can instigate the

inflammatory response. According to Black (2003), the inflammatory response is

contained within the psychological stress response, which evolved later. The same

neuropeptides mediate the body's response to both stress and inflammation. Cytokines

evoked by either a stress or inflammatory response may utilize similar pathways to signal

the brain, signaling a cascade of hormones, neuropeptides, and cytokine activity.

Negative affect has been identified as a key pathway for modifying immune

processes. There is preliminary evidence that anxiety and depression enhance the

production of pro-inflammatory cytokines (Kiecolt-Glaser et al., 2002a). Immune

modulation by psychosocial stressors and/or interventions can lead to health changes.

Pro-inflammatory cytokines, such as 11-6, stimulate the release of acute phase reactants

from the liver. Acute phase proteins, such as C-reactive protein (CRP) and complement

proteins (C3 and C4) are part of the body's innate immune inflammatory response to

infection.

Berk, Wadee, Kuschke, and O'Neill-Kerr (1997) compared levels of acute phase

proteins (C3, C4 and CRP) in depressed versus nondepressed subjects according to

DSM-III-R criteria and found significant elevations in C4 and CRP in the depressed

group. These findings suggest the possibility of an underlying relationship between

depression and inflammation in autoimmune patients. Furthermore, many physicians now

believe that CRP can be used as an aid in assessing the risk of cardiovascular and

peripheral vascular disease. The relationships among psychological factors and acute

phase proteins have not been previously reported in AD populations.

Social Support

The benefits of social support have been given extensive consideration throughout

the chronic illness literature. Social support is negatively correlated with psychological







14

distress and has been shown to influence health behaviors, such as seeking medical care

(Cohen, 1988). McCracken, Semenchuk, and Goetch (1995) found that good social

support was related to perceptions of health and that seeking social support was

associated with lower levels of pain, physical disability, psychological distress, and

depression. Furthermore, social support can serve as a buffer during both acute and

chronic stressors, thereby protecting the individual against immune dysregulation

(Kiecolt-Glaser et al., 2002a).

Two studies (Bae, Hashimoto, Karlson, Liang, & Daltroy, 2001; Sutcliffe et al.,

1999) reported that higher levels of social support were associated with better physical

and mental well-being in SLE patients. However, there are no studies to date that have

examined the role of social support as a buffer against immune dysregulation in SLE,

scleroderma, Sjogren's syndrome, polymyositis, or ANA positive patients.

Study Rationale

The participants in this study shared common complaints and symptoms

characteristic of suspected AD. Following medical evaluation, individuals were placed

into a variety of categories ranging from ANA positive to having been diagnosed with

one of many ADs. The assumption of heterogeneity in such a diverse population might

lead to generic treatment approaches aimed at the "average" or "typical" patient. Another

pitfall might be to assume that more severe illness equals more distressed or that

adjustment to illness was similar across a variety of conditions. The purpose of this study

was to explore the possibility that homogenous subgroups exist based on specific shared

qualities. Identifying such subgroups offers the possibility to better understand variability

in response to illness and to tailor treatment to subgroups based on specific

characteristics.









Relatively little is known about how individuals with ADs such as SLE,

scleroderma and polymyositis and ANA positive patients vary with respect to

psychological function and adjustment to illness. The level of heterogeneity across

individuals, disease categories, and illness severity remains to be determined. To date,

there are few reports describing the psychological characteristics of ANA positive

patients. Across conditions, one might expect that those posing a greater threat to

mortality, quality of life, and function would lead to higher levels of distress and greater

coping challenges. Within disease categories, factors such as premorbid psychological

status and disease severity could play important roles in current psychological adjustment

and status.

There are few studies to date that have attempted to elucidate the relationships

among psychological factors and inflammatory mediators in ANA positive, SLE, and

related autoimmune conditions. Further, no studies have investigated the relationship

between psychosocial factors, pain, fatigue, and acute phase proteins in this population.

Finally, although physician-rated measures of disease activity have been compared to

individual psychological and self-rated symptoms, such as pain and fatigue, in SLE

patients, the relationship between physician-rated disease activity and multivariate

psychological response profiles has not been previously reported. The aim of this study

was to contribute to the understanding of these relationships using an empirical clustering

approach to examine how these variables are related.

Using a cluster-analytic approach, a pilot study was conducted to determine

whether unique patterns of psychological (depression, anxiety, confusion, and anger) and

symptom (pain and fatigue) reports exist within an AD sample. The preliminary study

was conducted on 279 participants to determine whether patients presenting in an AD










clinic could be classified into subgroups based on unique psychological response

profiles. The cluster analysis revealed a four-cluster solution. The four-cluster solution

was chosen because it provided better group separation and more parsimonious

interpretation. Figure 1-1 provides a graphical representation of the four clusters.

2

1.5

1

0.5 --Pain/ Fatigue
(n=66)
0 --I- Mod. Impact
(n=77)
-0.5 High Impact
(n=47)
-1 -X Low Imapct
(n=89)
-1.5





Figure 1-1. Preliminary four-cluster solution representing psychological profiles in
autoimmune disease patients

The first cluster, "Pain/Fatigue" (n = 66), displayed moderate levels of pain and

fatigue and low levels of distress. The "Moderate Impact" cluster, comprised of 77

participants, is characterized by moderate levels of pain, fatigue, and distress with an

elevation in anxiety. The "High Impact" cluster (n = 47) displayed high distress and

symptom levels, and the "Low Impact" cluster (n = 89) demonstrated low levels of

symptoms and distress. Based on this pilot data indicating the presence of four distinct

psychological response profiles in the AD sample, several aims were developed.

Aims

The initial aim of this study involved replicating the four-cluster solution using a

larger sample. Secondly, this study sought to determine whether clusters are associated









with demographic variables, including race, age, sex, and illness duration. Next, the

concordance among psychological response profiles and diagnostic categories (ANA

positive, SLE, Sjogren's, polymyositis, and scleroderma) was examined. The relationship

between psychological response profiles and biological markers was also examined to

assess whether psychological response profiles predict serological markers of disease

activity (urinary 11-6, CRP, C3, C4, albumin, and prealbumin). A secondary objective

included determining whether psychological response profiles predict physician-rated

levels of disease activity in SLE patients. The relationship between psychological

response profiles and SLE Disease Activity Index (SLEDAI; Bombardier et al., 1992)

was examined. Finally, the relationship between psychological response profiles and

perceived social support was assessed.

The results of this study provided preliminary evidence indicating whether

psychological response profiles were determined primarily by disease process, indicating

a pathophysiological basis for psychological functioning, or by psychosocial factors and

predisposing personality traits, suggesting a psychological basis for individual responses

to physical illness. Although, in reality, the answer likely lies in the middle of these

extremes, this study provided insight into the differential contributions of these opposing

hypotheses.

Hypotheses

The same four-cluster solution found in the pilot study was repeated in a larger
autoimmune disease clinic sample.

Equal representation of diagnosis across clusters was supportive of the notion that
predisposing factors (personality, social support, etc.) predict psychological
response to illness. A higher frequency of diagnosed AD in the more distressed
profiles was supportive of disease severity determining psychological response.









Response profiles reflecting higher levels of pain, fatigue, and distress will be
associated with increased activation of serological markers of disease activity

o Higher levels of urinary 11-6, CRP, albumin, and prealbumin
o Lower levels of complement components (C3 and C4)

Response profiles reflecting higher levels of pain, fatigue, and distress will be
associated with higher levels of physician-rated disease activity in SLE patients,
supporting the notion that disease contributes to psychological response. Absence
of significant differences between response profiles on disease activity scores
would support the view that psychological response to illness may be independent
of specific pathological processes.

Response profiles reflecting higher levels of pain, fatigue, and distress will be
inversely associated with levels of perceived social support, thereby supporting
the notion that greater social support serves as a buffer against the harmful effects
of illness on psychological well-being.















CHAPTER 2
METHODS

Participants

Participants in this study were 393 rheumatology outpatients recruited from the

Autoimmune Disease Clinic at Shands Hospital in Gainesville, Florida. The mean age of

the patients was 44.3 (SD = 13.7), and the mean duration since diagnosis was 8.0

(SD = 7.6) years. Patients were predominantly female (90.1%), and the majority of

patients were Caucasian (64.1%). Patients were categorized according to primary

diagnosis, although it should be noted that many patients met criteria for more than one

autoimmune disorder. The largest proportion of patients was diagnosed with SLE (43%),

followed by patients who were ANA positive (25.7%) but did not meet criteria for an

autoimmune disease diagnosis. Diagnostic information is presented in Table 2-1.

Table 2-1. Diagnostic breakdown of demographic information
Duration Edu Age Sex Race
Diagnosis N % (yrs) (yrs) (yrs) N (% total) N (% total)
M (SD) M(SD) M(SD) F M W B O
SLE 176 45 10.5 13.5 41.3 162.0 14.0 89.0 62.0 25.0
(8.4) (2.4) (12.8) (41.2) (3.6) (22.6) (15.8) (6.4)
ANAPOS 101 26 4.0 13.7 43.8 91.0 10.0 77.0 11.0 13.0
(4.5) (2.5) (13.7) (23.2) (2.5) (19.6) (2.8) (3.3)
Sjogren's 26 7 6.8 14.0 52.8 24.0 2.0 25.0 1.0 0.0
(4.0) (2.3) (14.4) (6.1) (0.5) (6.4) (0.3) (0.0)
SSC 22 6 8.2 12.8 53.8 19.0 3.0 16.0 6.0 0.0
(6.1) (3.3) (10.4) (4.8) (0.8) (4.1) (1.5) (0.0)
Other 68 17 7.3 13.7 46.4 58.0 10.0 45.0 16.0 7.0
(8.3) (2.4) (13.8) (14.8) (2.5) (11.5) (4.1) (1.8)
Total 393 100 8.0 13.6 44.3 354.0 39.0 252.0 96.0 45.0
(7.6) (2.5) (13.7) (90.1) (9.9) (64.1) (24.4) (11.5)









Patients eligible for participation in this study were preselected based on

participation in the large study examine factors contributing to the development of

autoimmune disease (IRB#: 454). Patients were recruited by their treating physicians

during routine medical visits. Eligibility was determined by each patient's treating

physician according to necessary criteria. Eligibility criteria included being 18 years or

older, English-speaking, literate, and possessing a minimum education level of 8th grade.

Both males and females from all racial/ethnic backgrounds were included. Participation

was also contingent upon ability to provide consent. Patients with cognitive, emotional,

or physical problems believed to interfere with his or her ability to provide consent were

not permitted to participate. Written consent for research participation was obtained at

the conclusion of routine visits.

Procedure

Recruitment took place during routine medical visits. Eligible participants were

approached by his or her rheumatologist or trained research staff regarding participation

in the study. The informed consent form was verbally reviewed prior to obtaining

patients' signatures to ensure complete understanding of their rights as research

participants. Participation in this study did not interfere with routine rheumatologic care.

Following their routine rheumatology visit, staff members escorted participants to

the General Clinical Research Center (GCRC) at Shands Hospital for clinical laboratory

tests. In addition to clinical laboratory tests ordered by their rheumatologist, biological

samples were obtained exclusively for research purposes. At this time, participants

completed the psychosocial questionnaire packet, consisting of a battery of self-report

paper and pencil questionnaires. Instructions for completing the questionnaire were







21

provided by a trained research assistant. The packet generally required 10 to 15 minutes

to complete.

Measures

Standard demographic data were collected during each participant's initial

assessment. Information related to medical diagnosis and disease duration was recorded

for research purposes after patients provided informed consent to participate in the study.

Psychosocial Measures

The assessment of distress and symptom levels includes seven visual analogue

scales (VASs). Respondents were asked to indicate their level of functioning in each of

the assessed domains by drawing a vertical line through one point on a 100 mm linear

analogue scale. Scores were obtained by manual measurement of the VAS responses and

range from 0-100. Each domain is anchored by the following descriptors: "None" and

"Worst Imaginable." The domains assessed by VASs in this study included depression,

anxiety, anger, confusion, pain intensity, and fatigue.

The use of VASs for assessing psychological distress and symptom domains in a

brief format is not uncommon. The pain VAS (Price, McGrath, Rafii, & Buckingham,

1983) is a 100-mm line anchored by the descriptors, "No pain" to "Worst Pain

Imaginable." Adequate reliability and validity have been reported (Price et al., 1983).

Social support was measured using the Perceived Social Support Scale (PSSS;

Blumenthal, Burg, Barefoot, Williams, Haney, & Zimet, 1987). The PSSS is a 12-item

scale employing a 7-point Likert response scale ranging from 1 (Very Strongly Disagree)

to 7 (Very Strongly Agree). This scale addresses perceived support from family, friends,

and significant others. Test-retest reliability was reported as 0.85 and Cronbach's

coefficient alpha was 0.88 (Blumenthal et al., 1987).









Physician-Rated Disease Activity

The SLE Disease Activity Index (SLEDAI; Bombardier et al., 1992) is a

physician-rating scale consisting of 24 descriptors associated with nine organ systems.

Clinical and laboratory measures of SLE activity are included. Items are weighted

according to severity and life-threatening items receive greater weights. The weighted

items are summed to obtain an overall score. The range for possible scores is from 0

to 105. The SLEDAI has been validated and shown to be sensitive to changes over time

(Fortin et al., 2000; Petri, Hellman & Hochberg, 1992).

Biological Measures

Urinary levels of IL-6 was measured using Enzyme-Linked Immunosorbent

Assay (ELISA), an established method for determining cytokine levels. High-sensitivity

CRP, C3, C4, albumin, and prealbumin will be measured by nephelometry on a BN

Prospec II (Dade Behring) nephelometer. Nephelometry is a technique that uses analysis

of light scattered by liquid to measure the size and concentration of particles in the liquid.

Analyses

All data analyses were performed using SPSS for windows (Version 11).

Hierarchical cluster analysis (Ward's Linkage) was employed to identify distinct

subgroups underlying the data structure. In order to validate the stability of the cluster

solution, the overall sample was split into halves using a random selection function

within the statistical software. The four-cluster solution was replicated in both halves,

lending further support to the validity of these four response profiles across AD patients.

Following the empirical derivation of response profiles, the assigned cluster

membership value (1-4) was used in subsequent analyses. Nonparametric chi square

analyses and analyses of variance were the principle statistics used in these analyses. For







23

all ANOVAs, significant F-tests were followed by post-hoc analyses using Tukey's HSD

to evaluate pairwise comparisons between response profiles on the dependent variable.

Statistical significance was set at an alpha value of .05 for all analyses.
















CHAPTER 3
RESULTS

This study was based on the empirical determination of patient subgroups from

the AD clinic based on the following scores: fatigue, pain intensity, depression, anxiety,

anger, and confusion. Complete data for this analysis was available for 374 participants.

Results of the hierarchical cluster analysis revealed a four-cluster solution (Figure 3-1),

which was determined quantitatively based on the percentage change in the

agglomeration coefficients.

2

1.5



0.5 40- High Impact
(n=67)
0 Low Impact
(n=165)
-0.5 ~ Pain/ Fatigue
(n=80)
-1 Fatigue/ Distress
(n=62)
-1.5






Figure 3-1. Replication four-cluster solution representing psychological profiles in
autoimmune disease patients

Subgroups represent relatively unique response profiles derived from the

multivariate combination of symptom and mood measures. Table 3-1 provides a

summary of the response profiles. The "High Impact" cluster (N = 67) is characterized by









high scores across all measures with particularly high (>1 SD from mean) elevations in

pain and anxiety. The "Low Impact" cluster (N = 165), the highest frequency cluster,

reflects low levels for all mood and symptom variables. The "Pain/Fatigue" cluster (N=

80) profile reflects significant fatigue, moderate pain and relatively low levels of distress

and confusion. The "Fatigue/Distress" cluster (N = 62) is characterized by high levels of

fatigue, depression, and anxiety. The increase in sample size from the pilot study

(N = 279) to the full sample (N = 374) resulted in an altered distribution of participants

across the four clusters, whereby a larger proportion (44%) of participants fell in the

profile cluster representing low symptom and distress levels.

Table 3-1. Description of response profiles
Cluster N Description
1 67 High impact
2 165 Low impact
3 80 Pain/Fatigue
4 62 Fatigue/Distress

Following the derivation of response profiles, a series of analyses were

undertaken to examine whether profiles differed across demographic, diagnostic, and

physiological variables. First, the relationship between response profiles and

demographic variables was examined to determine whether race, sex, age, or illness

duration predict psychological response profile. Nonparametric chi square analyses were

used to examine the relationships of race and sex to response profiles. Results showed

that racial background was proportionately distributed across the four psychological

response profile membership, X2=5.76 (6), p = .450. Chi-square results for sex were

significant, X2=8.49 (3), p=.037, indicating that men and women were disproportionately

represented across clusters. Closer examination of the crosstabulation matrix revealed









that no males were present in the "Fatigue/Distress" cluster. However, given the small

number of males (9.9%, N = 39) in the sample, this finding has limited interpretive value.

One-way analyses of variance (ANOVAs) were used to compare response

profiles on age and duration since diagnosis. Response profile groups did not differ on

age (F (3,370) =1.61, p = .188) or duration since diagnosis (F (3,320) =0.81, p = .490).

Thus, current age and time elapsed since being diagnosed are not predictive of symptom

and mood response profiles.

The second hypothesis concerned the concordance among psychological response

profiles and diagnostic categories (ANA positive, SLE, scleroderma, Sjogren's, and

polymyositis, and other). The frequency of response profiles across diagnostic groups

was assessed using nonparametric chi square tests. This analysis aimed to determine

whether disease factors associated with a diagnosis of AD are associated with response

profiles reflecting greater pain, fatigue and distress. The results revealed the

proportionate distribution of diagnoses across the four response profiles, X2=5.24 (12),

p=.950. This finding suggests that response profiles do not differ significantly between

various autoimmune conditions (Table 3-2).

Table 3-2. Crosstabulation matrix of response profiles across diagnostic categories
Response profile (N) Total
Diagnosis 1 2 3 4 N (%)
SLE 28 71 36 29 164 (43.8)
ANAPOS 18 48 19 14 99 (26.5)
Sjogren's 3 12 5 5 25 (6.7)
SSC 3 10 6 2 21 (5.6)
Other 15 24 14 12 65 (17.4)
Total 67 165 80 62 374 (100.0)

The next series of analyses examined whether psychological response profiles

represent varying levels of disease activity. ANOVAs were used to test for differences in









levels of disease activity as measured by a number of biological markers. Separate

ANOVAs were conducted for urinary 11-6, hsCRP, C3, C4, albumin and prealbumin. A

descriptive overview and results for these parameters is presented in Table 3-3.

Table 3-3. Values for biological markers of disease activities
Variable N Range Mean SD F Sig.
I1-6* 78 0.01 3683.50 433.56 792.15 0.932 0.430
HsCRP* 296 0.15- 108.00 8.03 13.21 0.130 0.944
C3 297 24.10- 261.00 116.65 34.40 2.180 0.091
C4 292 3.04- 118.00 21.21 12.36 2.700 .046+
Prealbumin 221 10.40- 60.40 25.95 8.61 0.695 0.556
Albumin 250 0.00 2048.00 51.64 211.69 0.336 0.799

IV = response profile group
* Values presented are based on raw data. Nonnormal distributions were transformed
logarithmically for statistical analyses.
p<.05

Response profiles did not differ on mean levels of 11-6 (F (3, 70) =0.932, p =

.430), hsCRP (F (3, 293) = .13, p = .944) or C3 (F (3, 294) = 2.18, p = .091). Significant

differences between groups were found for C4 (F (3, 289) = 2.7, p = .046). Post-hoc tests

using Tukey's HSD revealed the "Low Impact" and "Pain/Fatigue" clusters differed

significantly (p=.045) on C4 values. This finding has limited value because correcting for

multiple comparisons suggests this significant finding could be due to chance. There

were no differences between prealbumin (F (3, 218)= .695, p = .556) and albumin (F

(3, 247) = .336, p = .799) levels between response profiles.

The collection of physician-rated SLE disease activity (SLEDAI) measures is

limited to those patients carrying a diagnosis of SLE. Thus, patients diagnosed with SLE

were selected to examine whether differences in total SLEDAI scores exist between

response profile groups. The range for SLEDAI scores was 0 to 24 and the mean was

3.27 (SD=4.12). Forty-one percent of SLE patients received a SLEDAI score of greater









than or equal to four. Due to the significant positive skew of the distribution, a square

root transformation was performed to normalize the data distribution. ANOVA revealed

that SLEDAI scores did not differ significantly across response profiles

(F (3, 142) = .786,p= .504).

The final hypothesis concerned the relationship between psychological response

profiles and levels of perceived social support. Results of the ANOVA showed that

psychological response profiles were associated with varying levels of social support

(F (3, 368) = 5.13, p = .002). Post-hoc analyses revealed that the "Low Impact" cluster

reported significantly (p = .001) higher levels of perceived social support than the

"Fatigue/Distress" cluster.















CHAPTER 4
DISCUSSION

Unique subgroups of patients were determined empirically within a cohort of AD

and ANA positive patients based on a similar response pattern. Psychological and

symptom reporting profiles in this sample did not vary with respect to demographic

characteristics, diagnostic categories, serological markers of disease activity, and

physician-rated disease activity. Higher levels of perceived social support were

associated with response profiles characterized by lower levels of mood and symptom

reporting. The results of this study provide support for the presence of substantial

heterogeneity in illness response and psychological functioning across a large sample of

AD and ANA positive patients as well as within specific disease groups. Further,

subgroups are independent of disease factors, including diagnosis, suggesting that

personality, psychological, and/or social support factors are a stronger determinant of

response to illness.

Variations in psychological functioning within this illness population were

expected to span the continuum from well-adjusted to highly distressed participants. The

results of this study bring attention to the sizeable number of patients who are

experiencing elevated levels of subjective distress. Eighteen percent of participants fell

within the "High Impact" cluster profile, and 38% were characterized by some elevations

in symptoms and/or distress. These results signify the role of perceived symptom and

distress in overall illness coping and quality of life. At the same time, it is important to









keep in mind that not all patients experiencing illness or symptoms reminiscent of a

diagnosable disorder report compromised psychological functioning.

Cluster profiles were compared on a number of variables, including demographic,

diagnostic, disease activity, and social support measures. Race, age, and illness duration

were evenly distributed across cluster profiles, indicating that these variables are not

associated with differences in psychological response profiles. These results are

consistent with other studies that have demonstrated a lack of association between

measures of distress and demographic characteristics. For example, in a sample of RA

patients, VanDyke and colleagues (2004) found no significant relationship between

anxiety and illness duration. Similarly, Alarcon and colleagues (2004) demonstrated in a

cohort of 364 SLE patients that age and ethnicity were not associated with the physical

and mental subscales of the SF-36. Results of this study did indicate a significant effect

for sex when compared across clusters; however, the disproportionately small number of

males in the sample limits the ability to interpret this finding.

Opposing hypotheses were presented with regard to the relationship between

psychological profiles and diagnostic category. Across conditions, one might expect that

conditions posing a greater threat to mortality, quality of life, and function would lead to

higher levels of distress and greater coping challenges, thereby supporting that

psychological response is determined to a large extent by disease severity. However,

results demonstrated that response profiles were equally distributed across diagnostic

categories, suggesting that coping profiles are independent of diagnosis. Equal

representation of diagnoses across response clusters points to predisposing factors such

as personality, social support, and coping style determining response profile membership.









This finding provides meaningful implications for the treatment of patients with

the various diagnoses under consideration in this study. For example, physicians who are

biased toward assuming that worse disease is related to poor psychological adjustment or

that a positive ANA titer in the absence of a diagnosable AD should be less

psychologically threatening to the individual are at risk for under- or over-interpreting

psychological well-being based on disease threat or severity. The results of this study

suggest that illness adjustment is not related to diagnosis. In fact, psychological

functioning and/or perceived social support might be a more accurate predictor of how

patients will respond to their illness.

In this study, it is not possible to determine the extent to which psychological

response to illness is based on premorbid factors versus factors that are activated or

influenced in the presence of illness. Support for the idea that premorbid psychological

function plays an important role in response to illness has been demonstrated through

investigations of neuroticism and self-reported adjustment. Costa and McCrae (1987)

found that patients scoring particularly high on neuroticism tend to report higher levels of

self-reported psychological and physical symptoms, without suffering from worse

clinical outcomes. Given that psychological distress influences perceived quality of life,

behaviors that can affect health outcome (e.g., exercise, diet, and use of alcohol, drugs,

and nicotine), and response to illness, subjective distress levels are important to consider

when illness is present, regardless of diagnosis.

Variations in psychological functioning were hypothesized to reflect differences

in disease status as measured by serological markers of disease activity. This hypothesis

was not supported. Response profiles characterized by higher levels of pain, fatigue, and

distress were not associated with increased activation of serological markers of disease









activity. Symptom profiles are not accounted for by underlying disease processes and

appear to be better explained by premorbid psychological factors. Statistical significance

was achieved for complement protein C4 between the "Low Impact" and "Pain/Fatigue"

groups; however, the relationship was not in the anticipated direction. This finding is

most likely the product of statistical chance due to the number of serological tests

conducted. In sum, the weight of the evidence does not support an association between

serological markers of disease activity and response profiles.

Response profiles reflecting higher levels of pain, fatigue, and distress were not

associated with higher levels of physician-rated disease activity in SLE patients,

suggesting psychological response to illness may be independent of specific pathological

processes. Another possible interpretation is that physician-ratings of disease activity are

not congruent with patients' perceptions of disease activity. Ward and colleagues (2002)

found that changes in depression and anxiety were positively correlated with

simultaneous changes in the patient global assessment of SLE activity but not with

changes in SLEDAI scores. Furthermore, studies have found assessments of disease

activity by patients and physicians are often discordant (Neville et al., 2000) and the

SLEDAI is generally not responsive to changes in patients' assessments of changes in

disease activity (Chang, Abrahamowicz, Ferland, & Fortin, 2002). Thus, it seems

possible that patients' psychological adjustment to illness may depend more heavily upon

subjective assessments of disease activity, which may not be associated with other

measures of disease activity.

The importance of interpersonal relationships in the maintenance of health has

been widely reported. Poor social support is expected to increase the burden of illness

experienced by the individual. DeVellis and colleagues (1986) reported less-supportive









atmospheres play a role in the onset and exacerbation of autoimmune diseases. In the

current study, the hypothesis that response profiles reflecting higher levels of pain,

fatigue, and distress would be inversely associated with levels of perceived social support

was supported. This finding is consistent with a large body of literature across numerous

disease populations reporting that greater social support serves as a buffer against the

harmful effects of illness on psychological well-being.

This study provided an interesting approach to grouping patients into

psychological response profiles. One of the objectives of cluster analysis is to reveal

relationships among observations that were perhaps not possible using individual

observations (Hair, Anderson, Tatham, & Black, 1998). This did not appear to be the

case for the subgroups found in this study. The subgroups did not demonstrate

meaningful relationships with expected variables, bringing into question the usefulness of

determining subgroups within AD samples.

The identification of patient subgroups is ultimately beneficial to the extent that

they can be utilized in the understanding and treatment of individuals in each subgroup.

This type of application has proven successful in the chronic pain literature (e.g., Sanders

& Brenna, 1993; Swimmer, Robinson, & Geisser, 1992). Further research investigating

treatment outcome differences across clusters is necessary to determine the possible

benefits of using clustering techniques to identify subgroups of AD and ANA positive

patients. The ability to identify patients who are highly distressed and at increased risk

for poor outcomes would allow for the implementation of interventions that are more

efficiently tailored to meet the individual's needs.

Future studies investigating whether diagnostic groups within a particular cluster

(e.g., "High Impact") are more or less amenable to improvements when a targeted









psychological intervention is applied might help to elucidate relationships between

disease and illness response. For example, if ANA patients in the "High Impact" cluster

showed greater reductions in psychological distress than SLE patients from the same

subgroup, one might suspect that high distress compounded by more severe underlying

disease processes are less responsive to psychological intervention.

The findings of this study must be considered in the context of several caveats.

First, it is necessary to point out that the cluster analysis technique is a data reduction

technique based on both objective and subjective considerations on the part of the

researcher. Therefore, if another set of variables had been chosen to include in the cluster

analysis, the results could have been quite different. Similarly, it is possible that the

variables selected to test predictive validity of the clusters were not the most appropriate

in terms of their ability to discriminate between variations in psychological responses.

For example, it is possible that the SLEDAI is not an accurate measure of disease activity

or that it is not comprehensive and does not adequately capture the component of disease

activity associated with symptom (i.e., pain and fatigue) intensity.

An additional caveat relates to the a priori decision to include individuals

representing a wide range of diagnostic groups. Although the ANA positive group

presents clinically with many of the same complaints as patients who go on to be

diagnosed with AD, it is possible that they are a distinct group with regard to response to

illness. It is possible that the heterogeneity across the sample diluted the relationship of

response profiles to disease-specific measures of function. Thus, future studies

attempting to categorize patients based on response profiles might benefit from limiting

their sample to a specific diagnostic category before broadening the scope to include

multiple diagnoses.







35

The cross-sectional design on which this study is based limits the exploration of

relationships to a single point in time. The temporal relationship between disease activity

and psychological functioning remains unclear, although some researchers have

suggested that such relationships are not based on a simultaneous pattern of flux. Thus, it

is possible that relationships between biological correlates of disease activity and

psychological function can only be elucidated when the variables of interest are observed

prospectively. Research in the area of relationships between psychosocial and immune

parameters would benefit from longitudinal designs to account for temporal relationships

that are not revealed within cross-sectional designs.

Finally, the cohort sampled in this study included a relatively small number of

men. It remains largely unknown as to whether men responded similarly to the women.

These proportions did not allow for tests of gender differences. Future research is needed

to better understand psychological response to AD in men and to test for gender

differences in symptom reporting and illness response.

Cluster profiles were not validated by demographic, diagnostic, or disease activity

measures. Response profiles were related to perceived social support, the only

psychosocial variable examined across cluster profiles, suggesting that psychosocial

variables function in synchrony. Response to illness in this study was not dependent on

disease activity or type, thereby providing greater support for the role of psychological

and social support factors in determining response to illness.















REFERENCES


Adams, S. G., Dammers, P. M., Saia, T. L., Brantley, P. J., & Gaydos, G. R. (1994).
Stress, depression and anxiety predict average symptom severity and daily symptom
fluctuation in systemic lupus erythematosus. Journal ofBehavioral Medicine, 17,
459-477.

Ader, R., Cohen, N., & Felten, D. (1995). Psychoneuroimmunology: Interactions
between the nervous system and the immune system. The Lancet, 345, 99-103.

Alarcon, G. S., McGwin, G., Jr., Uribe, A., Friedman, A. W., Roseman, J. M., Fessler,
B. J., Bastian, H. M., Baethge, B. A., Vila, L. M., & Reveille, J. D. (2004). Systemic
lupus erythematosus in a multiethnic lupus cohort (LUMINA). XVII. Predictors of
self-reported health-related quality of life early in the disease course. At Ih inti and
Rheumatism, 15;51(3), 465-474.

Al-Allaf, A. W., Ottewell, L., & Pullar, T. (2002). The prevalence and significance of
positive antinuclear antibodies in patients with fibromyalgia syndrome: 2-4 years'
follow-up. Clinical Rheumatology, 21(6), 472-477.

Bae, S. C., Hashimoto, H., Karlson, E. W., Liang, M. H., & Daltroy, L. H. (2001).
Variable effects of social support by race, economic status, and disease activity in
systemic lupus erythematosus. Journal ofRheumatology, 28(6), 1245-1251.

Beck, A. T. (1967). Depression: Clinical, experimental and theoretical aspects. New
York: Harper & Row.

Belza, B. L., Henke, C. J., Yelin, E. H., Epstein, W. V., & Gilliss, C. L. (1993).
Correlates of fatigue in older adults with rheumatoid arthritis. Nursing Research,
42(2), 93-99.

Benrud-Larson, L. M., Haythomthwaite, J. A., Heinberg, L. J., Boling, C., Reed, J.,
White, B., & Wigley, F. M. (2002). The impact of pain and symptoms of depression
in scleroderma. Pain, 95(3), 267-275.

Berk, M., Wadee, A. A., Kuschke, R. H., & O'Neill-Kerr, A. (1997). Acute phase
proteins in major depression. Journal ofPsychosomatic Research, 43(5), 529-534.

Berkov, R., Beers, M. H., & Burs, H. (Eds.) (1999). Merck manual of diagnosis and
therapy (17th ed.). Whitehouse Station, NJ: Merck & Co.









Black, P.H. (2003). The inflammatory response is an integral part of the stress response:
Implications for atherosclerosis, insulin resistance, type II diabetes and metabolic
syndrome X. Brain, Behavior & Immunity, 17(5), 350-364.

Blumenthal, D. E. (2002). Tired, aching, ANA-positive: Does your patient have lupus or
fibromyalgia. Cleveland Clinic Journal of Medicine, 69(2), 143-152.

Blumenthal, J. A., Burg, M. M., Barefoot, J., Williams, R. B., Haney, T., & Zimet, G.
(1987). Social support, type A behavior, and coronary artery disease. Psychosomatic
Medicine, 49(4), 331-340.

Bombardier, C., Gladman, D. D., Urowitz, M. B., Caron, D., & Chang, C. H. (1992).
Derivation of the SLEDAI: A disease activity index for lupus patients. The
Committee on Prognosis Studies in SLE. Arthritis & Rheumatism, 35, 630-640.

Bruce, I. N., Mak, V. C., Hallett, D. C., Gladmann, D. D., & Urowitz, M. B. (1999).
Factors associated with fatigue in patients with systemic lupus erythematosus. Annals
ofRheumatic Disease, 58, 379-381.

Chang, E., Abrahamowicz, M., Ferland, D., & Fortin, P. R. (2002). Comparison of the
responsiveness of lupus disease activity measures to changes in systemic lupus
erythematosus activity relevant to patients and physicians. Journal of Clinical
Epidemiology, 55, 488-497.

Cohen, S. (1988). Psychosocial models of the role of social support in the etiology of
physical disease. Health Psychology, 7, 269-297.

Costa, P. T., Jr., & McCrae, R. R. (1987). Neuroticism, somatic complaints, and disease:
Is the bark worse than the bite? Journal ofPersonality, 55(2), 299-316.

De Rijk, A. E., Schreurs, K. M. G., & Bensing, J. M. (1999). Complaints of fatigue:
Related to too much as well as too little external stimulation? Journal of Behavioral
Medicine, 22(6), 549-573.

DeVellis, R. F., DeVellis, B., McEvoy, H., Sauter, S. V., Harring, K., & Cohen, J. L.
(1986). Predictors of pain and functioning in arthritis. Health Education Research:
Theory and Practice, 1, 61-67.

Dobkin, P. L., Fortin, P. R., Joseph, L., Esdaile, J. M., Danoff, D. S., & Clarke, A. E.
(1998) Psychosocial contributions to mental and physical health in patients with
systemic lupus erythematosus. A/ iil ii% Care & Research, 11(1), 23-31.

Fortin, P. R., Abrahamowicz, M., Clarke, A. E., Neville, C., Du Berger, R., Fraenkel, L.,
& Liang, M. H. (2000). Do lupus disease activity measures detect clinically important
change? Journal ofRheumatology, 27(6), 1421-1428.









Giang, D. W. (1991). Systemic lupus erythematosus and depression. Neuropsychiatry,
Neuropsychology & Behavioral Neurology, 4, 78-82.

Gironimi, G., Clarke, A. E., Hamilton, V. H., Danoff, D. S., Bloch, D. A., Fries, J. F., &
Esdaile J. M. (1996). Why health care costs more in the US: Comparing health care
expenditures between systemic lupus erythematosus patients in Stanford and
Montreal. At ith iti\ & Rheumatism, 39(6), 979-987.

Hair, J. E., Jr., Anderson, R. E., Tatham, R. L., & Black, W. C. (1998). Multivariate data
analysis (5th ed.). Upper Saddle River, NJ: Prentice Hall.

Hochberg, M. C. (1997). Updating the American College of Rheumatology revised
criteria for the classification of systemic lupus erythematosus [letter]. Ai i/l iti, and
Rheumatism, 40, 1725.

Hopkinson, N. D., Doherty, M., & Powell, R. J. (1994). Clinical features and race-
specific incidence/prevalence rates of systemic lupus erythematosus in a
geographically complete cohort of patients. Annals of Rheumatic Disease, 53(10),
675-680.

Illei, G. G., & Klippel, J. H. (1999). Why is the ANA result positive? Bulletin on
Rheumatic Disease, 48(1), 1-4.

Iverson, G. L., Sawyer, D. C., McCracken L. M., & Kozora, E. (2001). Assessing
depression in systemic lupus erythematosus: Determining reliable change. Lupus, 10,
266-271.

Jacobs, R., Pawlak, C. R., Mikeska, E., Meyer-Olson, D., Martin, M., Heijnen, C. J.,
Schedlowski, M., & Schmidt, R. F. (2001). Systemic lupus erythematosus and
rheumatoid arthritis patients differ from healthy controls in their cytokine pattern
after stress exposure. Rheumatology, 40, 868-875.

Johnson, A. E., Gordon, C. Palmer, R. G., & Bacon P. A. (1995). The prevalence and
incidence of systemic lupus erythematosus in Birmingham, England: Relationship to
ethnicity and country of birth. Arthritis & Rheumatism 38(4), 551-558.

Kerns, R. D., Turk, D. C., & Rudy, T. E. (1985). The West Haven-Yale
Multidimensional Pain Inventory (WHYMPI). Pain 23(4), 345-356.

Kiecolt-Glaser, J. K., McGuire, L., Robles, T. F., & Glaser, R. (2002a).
Psychoneuroimmunology and psychosomatic medicine: Back to the future.
Psychosomatic Medicine, 64, 15-28.

Kiecolt-Glaser, J. K., McGuire, L., Robles, T. F., & Glaser, R. (2002b). Emotions,
morbidity, and mortality: New perspectives from psychoneuroimmunology. Annual
Review ofPsychology, 53, 83-107.









Krupp, L. B., LaRocca, N. G., Muir, J., & Steinberg, A. D. (1991). A study of fatigue in
systemic lupus erythematosus. Journal ofRheumatology 17, 1450-1452.

Kuby, J. (1991). Immunology (2nd ed.). New York: W. H. Freeman.

Lacki, J., Leszczynski, P., Kelemen, J., Muller, W., & Mackiewicz. S. (1997). Cytokine
concentration in serum of lupus erythematosus patients: The effect on acute phase
response. Journal of Medicine, 28(1-2), 99-107.

Lwin, C. T., Bishay, M., Platts, R. G., Booth, D. A., & Bowman, S. J. (2003). The
assessment of fatigue in primary Sj gren's syndrome. Scandinavian Journal of
Rheumatology, 32(10), 33-37.

Maes, M., Meltzer, H. Y., Bosmans, E., Bergmans, R., Vandoolaeghe, E., Ranjan, R., &
Desnyder, R. (1995). Increased plasma concentrations of interleukin-6, soluble
interleukin-6, soluble interleukin-2 and transferring receptor in major depression.
Journal of Affective Disorders, 34(4), 301-309.

Maier, S. F., Watkins, L. R., & Fleshner, M. (1994). Psychoneuroimmunology: The
interface between behavior, brain and immunity. American Psychologist, 1004-1017.

Matsura, E., Ohta, A., Kanegae, F., Haruda, Y., Ushiyama, O., Koarada, S., Togashi, R.,
Tada, Y., Suzuki, N., & Nagasawa K. (2003). Frequency and analysis of factors
closely associated with the development of depressive symptoms in patients with
scleroderma. Journal ofRheumatology, 30(8), 1782-1787.

McCracken, L. M., Semenchuk, E. M., & Goetch, V. L. (1995). Cross-sectional and
longitudinal analyses of coping responses and health status in persons with systemic
lupus erythematosus. Behavioral Medicine, 20, 179-187.

McKinley, P. S., Ouellette, S. C., & Winkel, G. H. (1995). The contributions of disease
activity, sleep patterns and depression to fatigue in systemic lupus erythematosus.
Arthritis & Rheumatism, 6, 826-834.

Neville, C., Clarke, A. E., Joseph, L., Belisle, P. Ferland, D., Ferland, D., & Fortin, P. R.
(2000). Learning from discordance in patient and physician global assessments of
systemic lupus erythematosus disease activity. Journal ofRheumatology, 27,
675-679.

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). (2001).
Health topics. Retrieved on September 5, 2003, from
http://www.niams.nih.gov/hi/topics/scleroderma/scleroderma.htm.

Omdal, R., Waterloo, K., Koldingsnes, W., Husby, G., & Mellgren, S. I. (2003). Fatigue
in patients with systemic lupus erythematosus: The psychosocial aspects. Journal of
Rheumatology, 30(2), 283-287









Parham, P. (2000). The immune system. New York: Garland.

Pawlak, C. R., Jacobs, R., Mikeska, E., Ochsmann, S., Lombardi, M. S., Kavelaars, A.,
Heijnen, C. J., Schmidt, R. E., & Schedlowski, M. (1999). Patients with systemic
lupus erythematosus differ from healthy controls in their immunological response to
acute psychological stress. Brain, Behavior & Immunity, 13, 287-302.

Petri, M., Hellmann, D., & Hochberg, M. (1992). Validity and reliability of lupus activity
measures in the routine clinic setting. Journal of Rheumatology, 19(1), 53-59.

Price, D. D., McGrath, P. A., Rafii, A., & Buckingham, B. (1983). The validation of
visual analogue scales as ratio scale measures for chronic and experimental pain.
Pain, 17, 45-56.

Riley, J. L., Geisser, M. E., & Robinsom, M. E. (1999). Empirical subgroups of the
Coping Strategies Questionnaire-Revised: A multisample study. Clinical Journal of
Pain, 15(2), 111-116.

Robb-Nicholson, L. C., Daltroy, L., Eaton, H., Gail, V., Wright, E., Hartley, L. H., Schur,
P. H., & Liang, M. H. (1989). Effects of aerobic conditioning in lupus fatigue: A pilot
study. British Journal ofRheumatology, 28, 500-5.

Robinson, M. E., Geisser, M. E. Dieter, J. N., & Swerdlow, B. (1991). The relationship
between MMPI cluster membership and diagnostic category in headache patients.
Headache, 31(2), 111-115.

Robinson, M. E., & Riley, J. L. (1999). The role of emotions in pain. In R. J. Gatchel &
D. C. Turk (Eds.), Psychosocialfactors inpain: Critical perspectives (pp.74-87).
New York: Guilford.

Rus, V., & Hochberg, M. C. (2002). The epidemiology of systemic lupus erythematosus.
In D. J. Wallace & B. H. Hahn (Eds.), Dubois'lupus eiy IwhiniI,,n\ (pp. 65-83).
Philadelphia: Lippincott, Williams & Wilkins.

Sanders, S. H., & Brena, S. F. (1993). Empirically derived chronic pain patient
subgroups: The utility of multidimensional clustering to identify differential
treatment effects. Pain, 54, 51-56.

Schur, P. (1996) General symptomology. In P. Schur (Ed.), The clinical management of
systemic lupus e~iyheinuIIti\ (2nd ed., p. 10). Philadelphia: Lippincott-Raven.

Shapiro, H. S. (1997). Psychopathology in the patient with lupus. In D J. Wallace & B.
H. Hahn (Eds.), Dubois' lupus e)yihen tuI,%Ii (5th ed., pp. 755-782). Philadelphia:
Lippincott, Williams & Wilkins.









Smart, P. A., Waylonis, G. W., & Hackshaw, K. V. (1997). Immunologic profile of
patients with fibromyalgia. American Journal ofPhysical Medicine & Rehabilitation,
76(3), 231-234.

Sutcliffe, N., Clarke, A. E., Levinton, C., Frost, C., Gordon, C., & Isenberg, D. A.
(1999). Associates of health status in patients with systemic lupus erythematosus.
Journal ofRheumatology, 26(11), 2352-2356.

Swimmer, G. I., Robinson, M. E., & Geisser, M. E. (1992). Relationship of MMPI
cluster type, pain coping strategy, and treatment outcome. Clinical Journal ofPain,
8(2), 131-137

Symmons, D. P., Coppock, J. S., Bacon, P. A., Bresnihan, B., Isenberg, D. A.,
Maddison, P., McHugh N, Snaith, M. L., & Zoma, A. S. (1988). Development and
assessment of a computerized index of clinical disease activity in systemic lupus
erythematosus. Members of the British Isles Lupus Assessment Group (BILAG).
Quarterly Journal of Medicine, 69, 927-937.

Tan, E. M., Cohen, A. S., Fries, J. F., Masi, A. T., McShane, D. J., Rothfield, N. F.,
Schaller, J. G., Talal, N., & Winchester, R. J.. (1982). The 1982 revised criteria for
the classification of systemic lupus erythematosus. At til iti% & Rheumatism, 25,
1271-1277.

Tayer, W. G., Nicassio, P. M., Weisman, M. H., Schuman, C., & Daly, J. (2001). Disease
status predicts fatigue in systemic lupus erythematosus. Journal ofRheumatology,
28(9), 1999-2007.

Tench, C. M., McCurdie, I., White, P. D., & D'Cruz, D. P. (2000). The prevalence and
associations of fatigue in systemic lupus erythematosus. Rheumatology, 39,
1249-1254.

Tizard, I. R. (1995). Immunology: An introduction (4th ed.). Philadelphia: Saunders.

Turk D. C., & Melzack, R. (1992). The measurement of pain and the assessment of
people experiencing pain. In D. C. Turk & R. Melzack (Eds.), Handbook ofpain
assessment (pp. 3-12). New York: Guilford.

Turk, D. C., & Okifuji, A. (2002). Chronic pain. In A. J. Christensen & M. H. Antoni
(Eds.), Chronic physical disorders: Behavioral medicine's perspective (p. 182-187).
Malden, MA: Blackwell.

Turk, D.C., & Rudy, T. E. (1988). Toward an empirically derived taxonomy of chronic
pain patients: Integration of psychological assessment data. Journal of Consulting &
Clinical Psychology, 56, 233-238.









U.S. Census Bureau (2000). U.S. census data 2000. Retrieved September 3, 2003, from
http://www.census.gov/main/www/cen2000.html.

Valtysdottir, S. T., Gudbjornsson, B., Lindqvist, U., Hallgren, R., & Hetta J. (2000).
Anxiety and depression in patients with primary Sj ogren's syndrome. Journal of
Rheumatology 27(1), 165-169.

VanDyke, M. M., Parker, J. C., Smarr, K. L., Hewett, J. E., Johnson, G. E., Slaughter,
J. R., & Walker, S. E. (2004). Anxiety in rheumatoid arthritis. At til iti, and
Rheumatism, 51(3), 408-412.

Velly, A. M., Philippe, P., & Gornitsky, M. (2002). Heterogeneity of temporomandibular
disorders: Cluster and case-control analyses. Journal of Oral Rehabilitation, 29(10),
969-979.

Wallace, D. J., & Hahn, B. H. (Eds.). (2002). Dubois'systemic c(I lyi/hinnt, (6th ed.).
Philadelphia: Lippincott, Williams & Williams.

Ward, M. M., Marx, A. S., & Barry, N. N. (2002). Psychological distress and changes in
the activity of systemic lupus erythematosus. Rheumatology, 41, 184-188.

Wolfe, F., Hawley, D. J., & Wilson, K. (1996). The prevalence and meaning of fatigue in
rheumatic disease. The Journal ofRheumatology, 23(8), 1407-1417.

Zeiss, A. M., Lewinsohn, P. M., Rhode, P., & Seeley, J. R. (1996). Relationship of
physical disease and functional impairment to depression in older people. Psychology
andAgi.ng. 11(4), 572-581.

Zonana-Nacach, A., Roseman, J. M., McGwin, G., Jr., Friedman, A. W., Baethge, B. A.,
Reveille, J. D., & Alarcon, G. S. (2000). Systemic lupus erythematosus in three
ethnic groups. VI: Factors associated with fatigue within 5 years of criteria diagnosis.
Lupus, 9, 101-109.















BIOGRAPHICAL SKETCH

Rebecca Jump was born February 25, 1973, as the first of four children. She grew

up on the Eastern Shore of Maryland in a small community on the Chesapeake Bay. She

graduated from St. Michaels High School in 1991 and headed to the mountains of central

Pennsylvania to attend Juniata College. As an undergraduate, she played varsity field

hockey and spent one semester in Nancy, France, as part of a study abroad program. She

graduated with a Bachelor of Science degree in biopsychology and French in 1995 and

promptly headed back across the Atlantic Ocean to further indulge herself in French

language and culture. She spent one year in a French language program for foreigners at

the Universite de Lille III in Villeneuve d'Ascq, France. Upon her return from abroad in

1996, Rebecca began a master's program in the General Experimental Psychology-

Health option at the University of Hartford in West Hartford, Connecticut. She spent an

additional year in New England working full-time at the University of Connecticut

Health Center as a research assistant for parallel studies involving women with

fibromyalgia and rheumatoid arthritis. In 2000, Rebecca headed for the sunny south to

begin her doctoral training in clinical and health psychology at the University of Florida

where she specialized in adult medical psychology with a particular focus on chronic

pain and rheumatic disease. In the next phase of her "East Coast Living" Rebecca

ventured to Augusta, Georgia, to complete her predoctoral internship at the Medical

College of Georgia/Veteran's Affairs Medical Center Training Consortium. During this

year of clinical training, Rebecca pursued an advanced specialization in the assessment







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and treatment of posttraumatic stress disorder (PTSD). Following the completion of her

internship, Rebecca will return to the University of Florida to complete a postdoctoral

fellowship in the Department of Clinical and Health Psychology. Her career goal is to

obtain a position in a medical center specializing in the treatment of chronic pain/illness

and PTSD. She also hopes to devote a portion of her time to research collaboration and

supervision of trainees.