63

Chapter 5

Applying the biopsychosocial model to the

management of rheumatic disease
Sarah Ryan RGN PhD MSc BSc FRCN Staffordshire Rheumatology Centre, Haywood Hospital, Stoke on Trent NHS Primary
Care Trust, Stoke on Trent, UK

Alison Carr PhD Nottingham University, City Hospital, Nottingham, UK

Patient health beliefs about disease and

treatment 71
The clinical consultation 72
Questionnaires for assessing adherence
and concordance 72

CHAPTER CONTENTS
Introduction 63
Section 1: The biopsychosocial model and its
importance in arthritis management 64
Section 2: The impact of rheumatological
conditions 64
Work 64
Leisure 65
Mood 65
Social support 65
Sexuality and body image 66
Section 3: Pain 66
Pain mechanisms 66
Pain receptors 66
Peripheral and central sensitization 67
Section 4: Health behaviour, coping and
concordance 67
The health belief model 68
Health locus of control 68
Social cognitive theory 69
Theory of planned behaviour 69
The self-regulatory model and illness beliefs 69
Commonalities between the social cognition
models (SCMs) 70
Health behaviours (coping, concordance,
health beliefs) 70
Coping 70
Concordance 71

2010 Elsevier Ltd

DOI: 10.1016/B978-0-443-06934-5.00005-X

Conclusion 73

KEY POINTS

Living with a rheumatological condition has the

potential to impact on physical, psychological and
social function.
Adopting a biopsychosocial approach can provide a
framework to identify the impact of illness.
Chronic pain is a multifaceted experience with
sensory, affective and cognitive components.
Psychological models help to explain health behaviour.
Understanding health behaviour can enhance
adherence with treatment and improve outcome.

INTRODUCTION
Living with a chronic condition, such as rheumatoid
arthritis (RA), impacts all functional domains.
Health professionals help patients develop coping
skills to minimise the conditions effects on physical
and psychological wellbeing. To do this effectively
health professionals must understand why and how
people adopt or reject certain health behaviours.
By utilising the biopsychosocial model of care,

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illness impact on physical, psychological and social

aspects of function is addressed and a wider range
of therapeutic options offered that have meaning
and relevance to the individual.
This chapter is divided into four sections
addressing: the biopsychosocial model; the impact
of arthritis; pain; and social cognition models that
help explain health behaviour.

SECTION 1: THE BIOPSYCHOSOCIAL

MODEL AND ITS IMPORTANCE IN
ARTHRITIS MANAGEMENT
Recognition that understanding patients beliefs,
feelings, thoughts and health behaviour is necessary to aid our understanding of the patients condition has led to a move from a disease model to a
biopsychosocial model of care, which acknowledges
the importance of psychological and social factors
as well as the physical impact of living with arthritis. For example, physical impact can include symptoms of pain, stiffness and fatigue. Psychological
effects may include feelings of frustration, low
mood and give rise to concerns about the future,
whilst social implications can include concerns
about work, role within the family and continuing
to engage in valued leisure activities.
Adopting a biopsychosocial approach to care
has increased the range of therapeutic options for
patients. Cognitive behavioural therapy (CBT), which
aims to identify and change maladaptive patterns of
thought and behaviour, is of benefit in patients with
RA. In newly diagnosed RA patients, CBT improves
a patients sense of control regarding their condition
and prevents development of negative illness perceptions (Sharpe et al 2003). CBT is also useful for
patients with depression (Parker et al 2003).
Other psychological interventions involve improving confidence in carrying out specific behaviours, i.e.
self efficacy, which will be discussed in Section 4. If a
person believes they can play an active role in managing some of the impact of their condition, through
employing strategies such as pacing, goal setting and
exercise, they are more likely to do so than a patient
with little or no such confidence. Active self-management is associated with higher levels of adherence.
Even if the intended goal is not achieved, the process
of striving for it leads to better outcomes (Jerant 2005).
Involving significant others in care management
can also have a positive effect on outcomes. If the
family is unaware why an individual is encouraged

to pace their activities, this may be perceived as

laziness and lead to family conflict. Spouses of
patients attending an education programme to
increase their knowledge of RA experienced a
change in their perceptions towards the condition,
which were largely negative before the programme
(Phelan et al 1994). The importance of the family on
outcome was illustrated in a study of the benefits
of behavioural interventions to minimise pain in
patients with RA. Intervention incorporating family
support was more effective in reducing pain than
the intervention with the family alone (Radojenic
et al 1992). Adopting a biopsychosocial model of care
ensures all factors influencing a patients ability to
manage and cope with their condition can be identified and, where possible, addressed.

SECTION 2: THE IMPACT OF

RHEUMATOLOGICAL CONDITIONS
Patients are individuals with a life history, beliefs,
standards and expectations (Bendor 1999). RA cannot be considered solely in terms of its physical
consequences. The potential psychological, social
and economic impact must be considered.

WORK
Work disability can occur early in arthritis (Fex et al
1998). People with a musculoskeletal condition are
more likely to stop working if they:
are older
are female
have fewer years in education
have pain and co-morbidity
have limitations in function.

(Yelin 1995)
Cox (2004), focusing on the needs of newly
diagnosed RA patients, found that being able to
continue working was a major concern: The only
question I could think of, is the question I really
want answering - am I going to get back to work
full-time?. A National Rheumatoid Arthritis Society
(2003) survey showed 54% of participants attributed not being in full-time work to RA and 30% of
employed participants worked part-time because
of RA. Mancuso et al (2000) found those seemingly successfully employed still faced major challenges, made major adaptations in order to stay at
work and still perceived their jobs to be in jeopardy.

Chapter 5 Applying the biopsychosocial model to the management of rheumatic disease

Early intervention through liaison with employers, consideration of alternative ways of working,
work place assessment and if necessary retraining
is important to keep patients at work (see Ch. 9:
Occupational therapy). Vocational issues that may
need considering are shown in Box 5.1.

LEISURE
Engaging in a specific leisure activity will be influenced by the individuals level of motivation, and
the belief participation can be done to a reasonable
standard. The physical and psychological impact
of arthritis, such as pain, reduced muscle strength,
fatigue and reduced self esteem, may hinder both
the desire and ability to partake in leisure. Many
difficulties are faced participating in leisure (Fex
et al 1998, Hakkinen et al 2003, Wikstrom et al 2005).
Inaccessible facilities, lack of transport, absence of
support or negative attitudes from others may all
impact negatively on leisure (Specht et al 2002).

MOOD
Depression in RA is 23 times higher than in the
general population (Dickens & Creed 2001). Data
from baseline co-morbidity levels in over 7,000
patients starting biologic treatments found 19% had
a formal diagnosis of depression at any one time
(Hyrich et al 2006).
Depression in RA is linked to:
pain
functional disability:
work disability
poor adherence to treatment
lack of social support
low confidence in the ability to manage symptoms
high daily stresses

BOX 5.1 Vocational issues (Gordon et al 1997)

Flexible hours
Self paced activities
Shortened working weeks
Working at home
Rest/work schedule
Equipment and modifications to aid employment
Work space design and adaptation of the work
environment

(Dickens & Creed 2001, Lowe et al 2004, Sheehy

et al. 2006).
If depression is suspected it must be assessed and
treated. It is not acceptable to acknowledge it is associated with RA and not treat it. In Stoke-on-Trent in
the UK, a combined liaison psychiatry clinic run
by a liaison psychiatrist and a rheumatology nurse
consultant assesses for mental health problems and
advises on appropriate treatment. For depression
this involves anti-depressants and/or CBT.

SOCIAL SUPPORT
Interpersonal relationships contribute to physical,
psychological and social state wellbeing. Through
our social support systems we validate beliefs, emotions, action and seek information and advice. Core
activities carried out within social networks include:
Instrumental activitiescooking, cleaning,

financial management and shopping.

Nurturing activitiesmaking family
arrangements, maintaining family ties, looking
after family members and listening to others.
Ryan et al (2003) demonstrated that patients wanted
to remain active in both domains. Aspects of social
support enhancing control perceptions include:
remaining active in family activities
receiving ongoing support from family members

(and not just at the time of increased activity

such as a flare of the condition)
achieving a balance between support needs and
support provision.
Many inflammatory conditions are characterised
by unpredictability regarding symptom occurrence,
treatment efficacy and overall prognosis. Different
levels of support will be required from health professionals related to patients identified needs (Box 5.2).

BOX 5.2 Support that health professionals can

provide

Cognitive-discussing the individuals thoughts about

the situation
Affective-exploring the emotions connected to the
situation
Instrumental-e.g. arranging for a home assessment
and OT to evaluate and discuss problems in situ
Informational-providing advice on how to manage a
specific symptom, such as pain.

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SEXUALITY AND BODY IMAGE

Sexuality is an individual self-concept expressed as
feelings, attitude, beliefs and behaviour (RCN 2000).
RA features which impact negatively on sexuality and body image include joint pain and stiffness,
fatigue, low mood, physical changes and treatment
visibility, including splints (Hill et al 2003). Patients
indicate they would like the opportunity to discuss
sexuality concerns with healthcare professionals (Hill
et al 2003) but due to a lack of privacy, time, knowledge and skills, this often does not occur. Many types
of arthritis extensively affect peoples lives. Living
with chronic pain considerably contributes to this.

and pain experienced. But this does not explain the

variation in pain experience for a given stimulus or
injury. Why do some patients take longer to recover
from whiplash than others? Why does pain persist
beyond the time of tissue healing?
Melzack and Walls gate control theory of pain
(1965) revolutionised understanding of pain mechanisms (Fig. 5.1). This demonstrated that the transmission of pain messages could be modulated
within the spinal cord via descending messages
from the brain (our cognitions and emotions) or
altered by activating another source of sensory
receptor (e.g. exercise to release endorphins).

PAIN RECEPTORS

SECTION 3: PAIN
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue
damage, or described in terms of such damage
(International Association for the Study of Pain
(IASP) 1994). It is a common symptom across rheumatic conditions. It is a unique, subjective and unverifiable person experience (Turk & Melzack 1992).
Acute pain is often transient and the source of pain is
identifiable and treatable, e.g. active synovitis of the
knee. Chronic pain is an ongoing experience associated with a plethora of other symptoms including
anxiety, depression and sleep disturbance.
Patients with RA cite pain as their most important symptom (Minnock et al, 2003). Pain is associated with impaired quality of life, depression and
disability in both RA and OA (Spranglers et al 2000).
Chronic pain in fibromyalgia results in reduced physical activities, increased mood symptoms, withdrawal
from the workplace and increased use of health care
services (Hughes et al 2006). When helping patients
manage their pain, a biopsychosocial model aids
fully comprehending the pain experience and enables
planning care that is meaningful for the patient.

PAIN MECHANISMS
The specificity theory attributed to Descartes in
1664 reflects early understanding of pain mechanisms. In this model, skin pain receptors are activated by a painful stimulus and messages conveyed
to the brain enabling action to be taken, e.g. removing the hand from a fire. Pain is purely a physical
phenomenon with a direct relationship between
the amount of stimulation (damage) to nociceptors

Sensory receptors are situated in the tissues of the

skin, synovium of joints and arterial walls. These
are activated by various stimuli including:
mechanical changes: increased synovial fluid in

the joint cavity and proliferation of the inflamed

synovial tissues causes pain by distension and
stretching of the capsule
temperature changes
inflammatory changes: the release of
prostaglandin, bradykinin, histamine and
serotonin.
Peripheral sensory nerves transmit signals from
the peripheries to the central nervous system enabling stimulus identification. Alpha delta fibres
(thin and myelinated) transmit the sharp pain of
an acute injury and slower C-fibres (unmyelinated)
produce the dull aching pain of a more persistent
problem or the burning quality of neuropathic pain
(McCabe 2004).
Sensory nerves deliver information from the
peripheries to the dorsal horn where they terminate.

Descending
messages
from the brain

Spinal
cord

Pain gate

A Delta and C fibres

(excitatory)
A Beta fibres
(inhibitory)

Figure 5.1 A simplified diagram of the gate control theory

of pain.

Chapter 5 Applying the biopsychosocial model to the management of rheumatic disease

This information is then interpreted by transmission cells (T-cells) transmitting information to the
local reflex circuits and the brain. When the Alpha
delta and C fibres are stimulated T cells are activated resulting in the substantia gelatinosa (SG)
being suppressed so that the pain gate opens and
messages pass to the brain to be perceived as pain.
When large fibres become activated (Alpha beta)
they suppress T cell activity and close the gate.
Alpha beta fibres transmit the sensation of touch.
Acupuncture and electrical nerve stimulation work
on the same principle and excite large fibre activity.
Nerve impulses descending from the brain can also
operate the gate.

CASE STUDY 5.1 POSSIBLE PAIN PATHWAYS IN

A CASE STUDY OF A PATIENT WITH RA (BASED ON
AN EXAMPLE BY McCABE 2004)
Mrs Jones is a 44-year-old women diagnosed with
RA 5 years ago. She works as a legal assistant in a
busy law firm. She has had to take time off which is
worrying her. Mrs Jones is married with no children.
Over the last 3 months she has experienced more early
morning stiffness (from 30 minutes to 2 hours) and
has pain and inflammation in both wrists and her right
knee. Mrs Jones describes her pain as burning and
tender to touch. The pain disturbs her sleep and she
has difficulty with mobility.
Peripheral mechanisms
The inflammatory process (demonstrated by swelling,
pain and stiffness) has generated peripheral
sensitization. Reporting burning pain indicates
activation of the C fibres or changes in the dorsal
horn resulting in central sensitization. Problems with
mobility may be due to changes in knee intra-articular
pressure.
Central mechanisms
Generalised tenderness indicates a lowering of
the Alpha beta fibre threshold and may have been
induced by the duration of symptoms. Changes in
proprioception due to knee swelling may create a
mismatch in the motor and sensory systems. This
mechanism has been proposed as an explanation for
the perception of stiffness in RA (Haigh et al 2003).
Other factors that may influence Mrs Jones pain are
her lack of sleep and work concerns.

PERIPHERAL AND CENTRAL

SENSITIZATION
The gate theory of pain is portrayed as a hardwired system but we know this is not the case
(McCabe 2004). If persistent stimulation occurs the
Alpha delta and C fibres will be activated by weak
non-noxious stimuli (Devor & Seltzer 1999). This
sensitization occurs in the peripheries due to tissue
damage or release of chemical inflammatory mediators (e.g. substance P) into the skin from damaged
C fibres and the increase in the activity of calcium
channels within the spinal cord. The presence of
allodynia (pain from a non noxious stimuli) and
hyperalgesia (increased response to a painful stimulus) can occur due to a lowering in the Alpha beta
threshold so that pain now becomes a painful stimulus (McCabe 2004).
Pain is affected by many physical, psychological and social factors. Effective pain control using a
variety of approaches is thus essential in biopsychosocial management of arthritis. These approaches
are discussed in subsequent chapters.

SECTION 4: HEALTH BEHAVIOUR,

COPING AND CONCORDANCE
Health behaviour refers to the ways in which people with arthritis perceive, understand and manage their condition. Understanding factors affecting
health behaviours, coping and concordance helps
maximise effective biopsychosocial management.
Influences on health behaviours include:
demographic factors, e.g. age, gender, culture,

socio-economic
social and environmental factors: e.g. access

to care and societal attitudes to illness and

treatment
personal factors, e.g. personality, emotions and
cognitions.
There are several psychological models, known
as social cognition models, developed to predict
and explain health behaviour. The most commonly
used are:
Health belief model (HBM)
Health locus of control (HLC)
Social cognitive theory
Theory of planned behaviour (TPB)
Self-regulatory model (SRM)

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Perceived susceptibility

Demographic
variables
Class, gender, age etc.

Perceived severity
Health motivation

Psychological
characteristics
Personality, peer group
pressure etc.

Action

Perceived benefits

Perceived barriers

Cues to action

Figure 5.2 The health belief model (adapted from Abraham and Sheeran 2005).

THE HEALTH BELIEF MODEL

HEALTH LOCUS OF CONTROL

This model is based on two aspects of health behaviour (Fig. 5.2):

The Health Locus of Control model is based on

Rotters Social Learning Theory (Rotter 1954). It
proposes that health behaviours are predicted by
the extent to which an individual believes they can
perform the behaviour and that it will be effective.
Individuals with an internal locus of control (LOC)
are more likely to take action to manage their symptoms than an individual with more external LOC
who believes their symptoms are a result of chance
and looks to other sources, such as the doctor, to
manage their symptoms. However, this model has
been tested in a wide range of therapeutic areas
with conflicting results.
The most widely used measure is the Multiple
Health Locus of Control (MHLC) Scale (Wallston
et al 1978), evaluating beliefs about health behaviours
in general, and the variance in results might relate
to individuals holding different beliefs depending
on the situation. For example, an individual might
have a high internal LOC for weight loss (i.e. they
believe they are responsible and have the ability to
reduce their weight) but a high external LOC for
managing their arthritis, believing this is the doctors responsibility. Ryan et al (2003) found that
within a medical consultation, contrary to the HLC
model, an external LOC increased the patients perceived control over their ability to live with their
arthritis. This may be because patients view their
condition as too unpredictable and mutifacted to
manage without external professional support and
view the consultation as a partnership where their
issues could be voiced and management appropriate to their needs provided.

1. The perception of threats to health based on an

estimation of perceived susceptibility to illness
and severity of illness consequences.
2. An evaluation of the behaviour required to avoid/
reduce these threats including the benefits, efficacy
and costs of engaging in health behaviours.
Cues to action can trigger performance of health
behaviours if the underlying beliefs about threat
perception and behavioural evaluation are favourable (Becker et al 1977).
Take, for example, a patient whose RA is affecting ability to work. They believe that without some
form of drug treatment they will become progressively disabled (high threat). They know there are
several treatment options. Despite concerns about
medications (costs) they believe some are very
effective (benefits). Media reports of a new wonder
treatment for RA may prompt them to seek treatment (cues to action).
The HBM has been used as a basis for the Beliefs
about Medicine Questionnaire (Horne et al 1999).
This focuses on the perceived threat of illness and
medication and the consequences of taking or not
taking medication. It has been used to explain/
predict adherence to medication. For example, if
arthritis pain is perceived as severe and medication is perceived as effective and relatively safe,
patients are more likely to take it to manage their
pain (Horne, Mitchell, Weinman, 2001 personal
communication).

Chapter 5 Applying the biopsychosocial model to the management of rheumatic disease

In an attempt to make the HLC a stronger predictor of health behaviour it has been adapted to
include: the value the individual places on their
health and the extent to which an individual is confident in carrying out behaviours they believe will
be effective. In other words, for an individual to
engage in health behaviour, such as exercise, they
need to value their health, believe they are responsible for it, be confident they can exercise and believe
exercise will be effective.

SOCIAL COGNITIVE THEORY

In this model health behaviour is seen as the result
of three sets of beliefs:
1. Beliefs that there are consequences to threats or
events that occur without personal involvement
or action (situational-outcome expectancies).
This involves an evaluation of the health risk and
individuals perception of their susceptibility to
that risk.
2. Beliefs that behaviour will result in specific
outcomes (action-outcome expectancies).
3. Beliefs that behaviours are within the
individuals control and they have the ability to
perform the behaviour (self-efficacy).
Self-efficacy (SE) has a direct effect on behaviour:
an individuals beliefs that he/she can perform
a behaviour predict performance of it. It can also
influence intention to perform a behaviour. Studies
have demonstrated individuals intend to perform
behaviours they are confident they can achieve
(Bandura 1992, Schwarzer 1992).
Self-efficacy has been widely applied in arthritis to:
1. Explain health behaviours: a high SE for
medication and exercise improves adherence to
medicines and leads to participation in exercise.
2. Understand the relationship between physical
and psychological factors e.g. a higher SE is
related to less pain, joint stiffness and fatigue,
improved function and better mood.
3. As a basis for interventions to help patients
manage or cope with their arthritis.
Questionnaire measures of self-efficacy include the
Generalised Self-Efficacy Scale (GSES) (Barlow

et al 1996): measures belief in ability across

a range of situations and is not specific to
musculoskeletal pain.
Arthritis Self-Efficacy Scale (Barlow et al 1997):
assesses self-efficacy in people with arthritis and

has three subscales: belief in ability to control

pain, function and other symptoms.
Rheumatoid Arthritis Self-Efficacy Scale (RASE)
(Hewlett et al 2001): evaluates individuals
beliefs in their ability to perform specific health
behaviours rather than their actual ability or
their outcome expectancy.

THEORY OF PLANNED BEHAVIOUR

The Theory of Planned Behaviour (TPB) is an
extension of the Theory of Reasoned Action (TRA)
(Fishbein & Ajzen 1975, Ajzen & Fishbein 1980).
Both models are based on the premise that individuals make logical, reasoned decisions to engage
in specific behaviours by evaluating the information available to them. The performance of a behaviour is determined by the individuals intention to
engage in it (influenced by the value the individual
places on the behaviour, the ease with which it can
be performed and the views of significant others)
and the perception that the behaviour is within his/
her control. In RA a TPB model based on attitudes,
social support, self efficacy and intention was moderately successful in predicting and explaining self
management of arthritis (Strating et al 2006). Whilst
no validated questionnaires are available, a comprehensive guide to developing measures of TPB
components is given in Ajzen (1991). A challenge in
TPB measurement is the difficulty in conceptualising and capturing attitudes.

THE SELF-REGULATORY MODEL AND

ILLNESS BELIEFS
The Self-Regulatory model (SRM) (Leventhal et al
1997) describes how biological, psychological and
social factors interact to influence how individuals
perceive their symptoms and illness and the health
behaviours they subsequently adopt (Fig. 5.3).
These perceptions, or illness representations, are
a set of beliefs, emotions and disease experiences
which individuals use to evaluate information
about their disease and to regulate their subsequent
behaviour. The SRM differs from the other social
cognition models in placing equal importance on
the emotional reaction to health threats.
Studies of peoples illness representations have
identified five categories of illness beliefs:
Symptoms/identity (recognising the symptoms

as associated with illness)

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Health threat representations

Identify what is it?
Cause why did it happen?
Timeline how long will it last?
Consequences what will happen?
Cure/control what can be done?

Interpretation of
information
Symptom perception
Social constructs

Procedural coping
responses
Approach response
Avoidance response

Outcome appraisal
Was response successful
or is a change needed?

Emotional representations e.g.

Fear
Depression
Helplessness

Figure 5.3 The self-regulatory model (adapted from Hobro et al 2004).

Timeline (beliefs about how long the illness

will last)
Consequences (beliefs about the outcome of the
illness)
Control/cure (beliefs about the extent to which
the illness can be treated/controlled and the role
of the individual in managing the illness)
Causes (beliefs about the causes of illness).
The illness perceptions questionnaire (IPQ)
(Weinman et al 1996) was originally developed
to quantify these. It has been used to understand
patients responses to illness and predict or explain
treatment adherence. It has since been revised to
improve its psychometric properties (Moss-Morris
et al 2002) and consists of eight categories:
symptoms/identity
timeline acute/chronic
timeline cyclical
consequences
personal control

COMMONALITIES BETWEEN THE SOCIAL

COGNITION MODELS (SCMs)
Whilst there are many similarities between these,
the main differences are the underlying psychological theory. There are specific patient-completed
questionnaires available to capture each construct
and they can be, and often are, used in combination. However, this is not always helpful. For example, in a study of patients with either OA or RA
self-efficacy, but not locus of control, was associated
with health status in patients with RA, whilst in
patients with OA, locus of control was a better predictor of health status (Cross et al 2006). It is unclear
how findings can be meaningfully interpreted in a
clinical setting. Moreover, interventions aimed at
changing behaviour (such as promoting exercise,
increasing medication adherence) may draw on
several SCMs. The most commonly applied theories are Social Cognitive Theory and the Health
Belief Model, with increasing interest in the SelfRegulatory Model.

treatment control
emotional representations (emotional responses

to the illness)
coherence (the extent to which patients
understand or comprehend illness).
In addition to use in research, it could be used in
practice to identify misperceptions of treatment/
illness or lack of understanding affecting adherence
to treatment/lifestyle advice that might be addressed
through educational interventions.

HEALTH BEHAVIOURS (COPING,

CONCORDANCE, HEALTH BELIEFS)

Coping
Coping is the ability to generate and maintain psychological well-being despite living with a serious
condition (Folkman 1997) and is linked to better psychological adjustment outcomes (Smith et al 1997).

Chapter 5 Applying the biopsychosocial model to the management of rheumatic disease

People with arthritis live with the physical, social

and economic consequences of the disease over
long periods and may have to cope with uncertainty
about long term outcome as well as unpredictability of recurrent fluctuations in disease activity. How
people with RA cope has been shown to influence
current and long-term psychological and physical
adjustment (Burckhardt et al 1997, Smith & Wallston
1992, Smith et al 1997, Zautra & Manne 1992).
Coping behaviours have been extensively studied in chronic disease and are typically classified
as active (good) coping strategies, such as information-seeking and self management, and passive
(bad) coping strategies, such as catastrophising
and wishful thinking. In arthritis studies, effective
coping has been equated with perceived control
over arthritis and its impact on daily life (Felton &
Revenson 1984) and with self efficacy for pain and
other arthritis symptoms (Keefe et al 1997, Lefebvre
et al 1999). Coping behaviours are influenced by the
individuals appraisal of the threat and the coping
options available. Whilst it is assumed that active
coping behaviours are more effective in helping
patients adapt to and manage their condition, there
is more evidence to support ineffectiveness of passive coping.
Questionnaires which identify coping strategies:
Ways of coping scale (Folkman & Lazarus 1988):

a 42-item questionnaire assessing three coping

domains: emotion-focused coping, problemfocused coping and the seeking of social support
(Felton & Revenson 1984).
Coping strategies questionnaire (Rosenstiel &
Keefe 1983): a 44-item questionnaire with seven
subscales and two effectiveness items assessing
pain coping strategies. Subscales are grouped
into Active (coping self-statements, diverting
attention, ignoring pain sensations, interesting
activity level and reinterpreting the pain
sensation) and Passive coping (catastrophising
praying and hoping)
Arthritis Helplessness Index (Nicassio et al
1985): a 15-item disease-specific measure of
coping measuring perceptions of ability to
control arthritis.
London Coping with Rheumatoid Arthritis scale
(Newman et al 1990): has 36 coping strategy
items assessing frequency of use. Results are used
to identify and group individuals with similar
coping patterns rather than pre-defining if each
coping strategy alone is helpful or unhelpful.

Concordance
Concordance describes a partnership between the
health professional and patient in which both work
together to agree optimal treatment based on a balance of treatment risks and benefits and compatibility with the patients goals and preferences.
Concordance is increasingly used instead of compliance which is viewed as excluding patients from
being equal partners in treatment decisions. It is
unclear how frequently concordance occurs in clinical practice. It is limited by many factors including:
Difficulties interpreting information about

relative risks and benefits of treatment (for both

health professionals and patients)
Lack of training for health professionals in
achieving concordance
Lack of time and resources
Some patients do not want an active role in
treatment decision making.
Treatment decisions based on concordance may
increase effective use of treatment.
Between 3070% of patients take their medication
according to the prescribed regimen (Conrad 1985,
Donovan & Blake 1992, Hill et al 2001, Viller et al
1999). Figures are similar for non-pharmacological
interventions such as exercise (OReilly et al 1999).
Factors influencing how patients use treatments are
complex and often independent of age, gender or
disease severity (Kraag et al 1994, Rejeski et al 1997).
They include:
patients beliefs about disease and treatments
patients expectations of treatment
use of alternative healthcare (e.g. complementary

therapies)
interpretation of the risks of treatment
the quality of the relationship between patient

and doctor
patients knowledge and understanding of

treatment
treatment factors such as the complexity

of the regimen e.g. adherence with weekly

bisphosphonates in osteoporosis is higher than
with daily bisphosphonates (Carr et al 2006).

Patient health beliefs about disease and

treatment
Many patients with RA and OA do not initially
interpret their symptoms as evidence of disease but

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instead attribute them to stress, or more commonly,

normalise them in terms of their age and activities
(Goodwin et al 1999, Hampson 1994, Sakalys 1997).
Even where patients interpret their symptoms as evidence of underlying disease, their family, friends and
even health professionals may not. In a study of newly
referred patients with RA, more than 50% reported
that family, friends or doctors had normalised, minimised or disbelieved their symptoms (Sakalys 1997).
RA patients beliefs have been associated with
medication use (Neame & Hammond 2005). In general, patients perform costbenefit analyses on their
prescribed medication (Donovan 1991) and are more
likely to take this when their perception of the necessity for medication (effectiveness and the perceived
consequences of untreated illness) outweighs concerns about it (side-effects, addiction and development of tolerance) (Horne & Weinman 1999, Neame
& Hammond 2005). Sixty percent of patients with RA
report fear of side-effects is a major factor influencing
their decisions to alter dose or frequency (Donovan &
Blake 1992). Patients often allow themselves a trial of
treatment during which they adhere to the treatment
regimen, evaluating its effectiveness against their
beliefs and expectations (Donovan & Blake 1992).
Where outcome does not meet expectations, they may
be more likely to change regimen or stop treatment.

BOX 5.3 Stepwise model of a consultation to

improve adherence (from Daltroy 1993)
Step 1 The patient is encouraged to express all concerns
Step 2 The patients concerns are discussed
Step 3 Doctor and patient share their models (beliefs)
of disease and symptoms
Step 4 Doctor and patient share their goals for
treatment
Step 5 Treatment goals are agreed and priorities
are set
Step 6 Doctor and patient share their models (beliefs)
of treatment
Step 7 Potential barriers to adherence are identified
Step 8 Plans are made to overcome these
Step 9 The doctor provides written information on
disease and the treatment regimen, annotated
with individual patients detail/concerns

STUDY ACTIVITIES

THE CLINICAL CONSULTATION

High levels of non-adherence may occur if interventions have not addressed underlying health and treatment beliefs driving patient behaviour. It would be
useful within the clinical consultation if patients beliefs
about illness and treatment are elicited, their expectations of treatment are identified and realistic treatment
goals negotiated (Carr & Donovan 1998, Horne 1999).
A consultation guide has been developed based on the
evidence for factors influencing adherence (Daltroy
1993) but its effectiveness in promoting adherence or
concordance has not been evaluated (Box 5.3).
Concordance, i.e. an equal partnership between
patient and health professional in which treatment
goals are negotiated on the basis of patient preference
and priorities, is promoted by addressing these.

Questionnaires for assessing adherence and

concordance
Whilst useful in identifying how patients take their
medicines (de Klerk et al 1999), their usefulness in

Take a case history from a patient with a

rheumatological condition and identity its
psychological and social impact using a
biopsychosocial approach.
Using the gate control theory of pain, record how
you would explain to a patient how their thoughts
can affect their perception of pain.
After reading section 4, list the factors that may
influence whether a patient will engage in a specific
health behaviour, such as exercise.

promoting adherence is limited because they provide

little information about why patients take their
medications in this way, or why they choose not
to follow their prescribed treatment regimen at all.
Established, validated questionnaires that elicit
some of the health beliefs underlying adherence can
be used to identify misperceptions and reasons for
non-adherence. These include the IPQ and IPQ-R
(Moss-Morris et al 2002, Weinman et al 1996) and
the Beliefs about Medication Questionnaire (Horne
et al 1999).
Understanding theories of health behaviour
and factors influencing coping and concordance
enhance effectiveness of treatment and planning
and delivering effective patient education.

Chapter 5 Applying the biopsychosocial model to the management of rheumatic disease

CONCLUSION
The ways in which people with arthritis perceive,
understand and manage their condition, how active
they are, which treatments they use, whether and
how they take their prescribed medication and how
they cope with the symptoms of their arthritis, are
influenced by a complex interaction of many factors.
By increasing the health professionals knowledge
in this area a relationship based on concordance
principles can be introduced into clinical care and

patients will be able to cope more effectively with

the physical, psychological and social impact of
their condition.

USEFUL WEBSITES
http://www.healthtalkonline.org
http://www.britishpainsociety.org/patienthome.htm
http://www.expertpatients.nhs.uk

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