EFFECTS OF PSYCHOLOGICAL THERAPY ON PAIN

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1 ~~ 1105 EFFECTS OF PSYCHOLOGICAL THERAPY ON PAIN BEHAVIOR OF RHEUMATOID ARTHRITIS PATIENTS Treatment Outcome and Six-Month Followup LAURENCE A. BRADLEY, LARRY D. YOUNG, KAREN 0. ANDERSON, ROBERT A. TURNER, CARLOS A. AGUDELO, LISA K. McDANIEL, EDWARD J. PISKO, ELLIOTT L. SEMBLE, and TIMOTHY M. MORGAN A randomized clinical trial was performed to evaluate a psychological treatment intervention and a social support program, compared with a control program in which no adjunct treatment was rendered, and their effects upon pain behavior, affect, and disease activity of 53 patients with rheumatoid arthritis. The psychological intervention produced significant reductions in patients pain behavior and disease activity at posttreatment. Significant reductions were also observed in trait anxiety at posttreatment and 6-month followup. Relaxation training may have been the most important component of the psychological intervention. The social support program produced a significant reduction in trait anxiety only at posttreatment. This is the first well-controlled study to demonstrate reduced pain behavior, disease activity, and trait anxiety following psychological treatment. Several recent reports have described the effects of various psychological interventions upon the From the Sections on Medical Psychology and Rheumatology and the Center for Preventive Medicine and Biometry, Bowman Gray School of Medicine of Wake Forest University, Winston- Salem, North Carolina. Dr. Bradley s work was supported by Robert Wood Johnson Foundation grant Laurence A. Bradley, PhD: Section on Medical Psychology; Larry D. Young, PhD: Section on Medical Psychology; Karen 0. Anderson, PhD: Section on Medical Psychology; Robert A. Turner, MD: Section on Rheumatology; Carlos A. Agudelo, MD: Section on Rheumatology; Lisa K. McDaniel, MA: Section on Medical Psychology; Edward J. Pisko, MD: Section on Rheumatology; Elliott L. Semble, MD: Section on Rheumatology; Timothy M. Morgan, PhD: Center for Preventive Medicine and Biometry. Address reprint requests to Laurence A. Bradley, PhD, Section on Medical Psychology, Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, NC Submitted for publication March 25, 1986; accepted in revised form March 25, pain associated with rheumatoid arthritis (RA) and other rheumatic diseases (1-8). The current interest in psychological intervention is due in part to evidence that pain intensity is related to RA patients beliefs in their abilities to successfully cope with or control the effects of their disease (5,9). We have labeled these psychological interventions as cognitive-behavioral therapies or self-management therapies (10-12). Six previous investigations (147) have found that thermal biofeedback or other cognitive-behavioral therapies produced significant reductions in RA patients self-reported pain, functional disabilities, or joint involvement. Unfortunately, all of these studies have been affected detrimentally by critical methodologic difficulties, such as reliance upon patients selfreports of outcome or inadequate followup. The present study was designed to eliminate the methodologic problems associated with previous efforts, in that it included self-reported, physiologic, and behavioral measures of treatment outcome; a larger patient sample than those used in previous efforts; assessment of patients beliefs regarding their abilities to control RA symptoms; and a 6-month followup assessment. Patients who agreed to participate as subjects received appropriate medical therapy and were assigned randomly to 1 of 3 treatment groups: (a) biofeedback-assisted, cognitive-behavioral group therapy (CBT); (b) structured group social support therapy (SGT); or (c) no adjunct treatment (NAT). The primary difference between the CBT group and the SGT group was that only in the CBT group were subjects taught specific pain reduction and coping strategies. Thus, it was hypothesized that patients in the CBT group would show significant improvement on all outcome measures across assessment periods relative to patients in the SGT group and the NAT (control) Arthritis and Rheumatism, Vol. 30, No. 10 (October 1987)

2 1106 BRADLEY ET AL group. No outcome differences were expected between the SGT group and the control group, because no formal instruction in pain reduction or coping strategies was provided to the SGT subjects. PATIENTS AND METHODS Patients. One hundred sixty-nine patients who were seen in the Section on Rheumatology of the Bowman Gray School of Medicine and who fulfilled the American Rheumatism Association criteria for a diagnosis of definite or classic RA (13) were asked to participate as subjects. Sixty-eight patients provided informed consent and were randomly assigned to 1 of the 3 treatment groups. Fifty-three subjects (43 women, 10 men) completed all of the treatments as well as the pre- and posttreatment assessments associated with the investigation. These included 17 subjects in the CBT group, 18 subjects in the SGT group, and 18 NAT control subjects. Two of the original 68 subjects left the study prior to the completion of the pretreatment assessment, 11 subjects (6 CBT patients, 3 SGT patients, 2 NAT controls) withdrew prior to beginning the treatment phase of the study, and 2 subjects (1 SGT patient, 1 control) dropped out during treatment. Two of the 53 subjects (1 CBT patient, 1 SGT patient) did not complete all portions of the followup assessment; their data were not included in the statistical analysis. The mean age * SD of the 53 subjects who completed all of the treatments was 50.09? years; the average duration of disease? SD was * years. The rheumatologists classified 5 subjects in functional class I, 28 subjects in functional class 11, and 20 subjects in functional class 111 (14). Procedure. Subjects assigned to the CBT group received 5 sessions of individual thermal biofeedback training to promote increased peripheral skin temperature at their most painful joints. They also participated in 10 small group meetings with family members or close friends. These meetings were led by 1 of 3 staff members from the Section on Medical Psychology. These group meetings included education, relaxation training, and instruction in behavioral goalsetting and use of self-rewards (1 1,15). Subjects assigned to the SGT group received 15 sessions of structured social support in small group meetings with their family members or close friends. These meetings were Ied by 1 of 3 Medical Psychology staff members and consisted of education, discussion of present coping strategies, and encouragement to develop improved coping methods (11,15). Treatment manuals for the social support and cognitive-behavioral group sessions are available upon request from the authors. Subjects assigned to the NAT cpntrol group had no contact with the Medical Psychology staff, other than that received by all subjects at each assessment period. To avoid influencing the outcomes, all subjects were instructed not to discuss their treatment group assignments or therapies with their rheumatologists or other patients. To mininiize attrition from the study, the CBT and SGT subjects received a monthly telephone call from their group leaders during the followup period. The group leaders discussed subjects recent coping successes and difficulties and encouraged them to continue to apply their newly learned coping strategies. Design. We used a 3 x 3 repeated-measures design with the between-subject factor of treatment group (CBT, SGT, NAT control) and the within-subject factor of assessment period (pretreatment, posttreatment, &month followup). Internal validity measures. Two measures of the internal validity of the investigation were assessed. The first consisted of three 7-point rating scales of subjects expectations for improvement and beliefs about the credibility of the cognitive-behavioral and social support interventions. These scales were administered to the CBT and the SGT subjects following their first treatment session. The second measure consisted of 1-week diaries of analgesic and arthritis-related medication intake; all subjects completed such diaries following each of the 3 assessments. Using a technique developed by Randich (4), subjects diary responses were examined for differences among treatment groups, with regard to changes in medication usage between assessment periods. Additions or deletions of second-line or remission-inducing drugs in subjects regimens were recorded at the posttreatment and followup assessments. Outcome measures. Several self-report, behavioral, and physiologic measures were evaluated at each assessment period. The self-report variables included the Trait Form of the State-Trait Anxiety Inventory (16), Depression Adjective Checklist (17), 10-cm visual analog scale ratings of paid intensity and pain unpleasantness, the Health Locus of Control Scale (18), and the Arthritis Helplessness Index (19). The latter 2 measures assess the extent to which persons believe they can control their general health outcomes and arthritis symptoms, respectively. A 5-point scale of disease activity level also was completed by the subjects and by their attending rheumatologists or rheumatology nurses (who were blinded concerning subjects treatment group assignments). The behavioral variable consisted of a frequency count of 7 pain behaviors (e.g., guarding, grimacing, sighing) displayed by subjects as they performed, for videorecording, a standardized, 10-minute sequence of sitting, standing, walking, and reclining maneuvers (20, 21). The videorecordings of subjects pain behaviors were independently scored by 2 trained observers who were blinded regarding subjects treatment condition assignments. The physiologic measures included changes in subjects peripheral skin temperature levels at their most painful joints, measured over 3-minute intervals at each assessment period. Following a 10-minute baseline period, subjects were instructed to attempt to raise their skin temperature levels both with and without auditory or visual feedback. Changes in skin temperatures were monitored using the same biofeedback laboratory equipment (Biolab 21 ; Cyborg, Boston, MA) on which subjects received training. The remaining physiologic variables consisted of subjects rheumatoid factor titers and erythrocyte sedimentation rates (Westergren), as well as the attending rheumatologists or their nurses evaluations of subjects grip strengths and number of tender joints (articular index). These 4 variables, in addition to the subjects and rheumatologists (or nurses ) ratings of subjects disease activity levels, composed the Rheumatoid Activity Index (RAI)(22).

3 PAIN BEHAVIOR IN RA 1107 Table 1. group Subjects age, duration of disease, and socioeconomic status as a function of treatment Treatment group* Factor NAT SGT CBT F-ratio P Age * * Duration of disease * f lo.oo? Socioeconomic statust * * * NAT = no adjunct treatment (control group); SGT = subjects provided with structured group social support therapy; CBT = subjects provided with biofeedback-assisted, cognitive-behavioral group therapy. Values are the mean * SD. t Socioeconomic status was measured with the revised Duncan Socioeconomic Index. Posttreatment questionnaire. At the end of the final treatment session, the CBT and SGT subjects were asked to list the aspects of the treatment program they found most meaningful or helpful in coping with RA. Statistical methods. Three major sets of statistical analyses were performed. First, subjects age, gender, socioecomonic status (measured by the revised Duncan Socioeconomic Index), functional class, and duration of disease were entered in one-way analysis of variance or chi-square analysis to determine if there were any initial differences in these variables among the treatment groups. The sample sizes in this investigation allowed detection of a difference of 1.08 SD between the largest and smallest means, with 80% power at the 0.05 level of significance using analysis of variance. Second, the CBT and SGT subjects expectancy and credibility ratings were entered in separate one-way analyses of variance. Using these analyses, differences of 0.95 SD between the largest and smallest means could be detected with 80% power at the 0.05 significance level. Next, changes in subjects medication usage within each treatment group between pretreatment and posttreatment and between posttreatment and followup were entered in separate chisquare analyses. Finally, all of the outcome measures were entered in separate 3 x 2 (treatment group x assessment period) repeated measures analysis of covariance, in which the pretreatment value of each measure served as the covariate. These analyses had 80% power, at the 0.05 significance level, to detect differences of 1.08 and 1.10 SD between the largest and smallest adjusted mean values, at posttreatment and followup, respectively. The distributions on each outcome measure for which a significant F-value was obtained were tested for extreme skew and outliers relative to a normal distribution (23). In order to test the study s hypotheses, I-tailed t-tests were used to perform comparisons among the treatment group means on each outcome measure at posttreatment and at followup. In addition to the statistical analysis described above, 2 of the investigators independently categorized by content the CBT and the SGT subjects responses to the posttreatment questionnaire. The number of times that subjects endorsed each response category was then recorded. RESULTS Demographic measures. There were no differences among the treatment groups with regard to age, duration of disease, socioeconomic status, or the distribution of subjects within each functional class (Tables 1 and 2). There was, however, a small but statistically significant (P = 0.03) tendency for men to be underrepresented within the SGT group. Internal validity measures. The means 2 SD of the CBT subjects and SGT subjects expectancy and credibility ratings following the first treatment session are shown in Table 3. There were no between-group differences on these ratings. The chi-square analysis of changes in subjects medication usage showed that there were no systematic differences among the treatment groups between pretreatment and posttreatment (x2[10] = 14.40, P = 0.15) or between posttreatment and followup (x2 [lo] = 9.08, P = 0.50). Additional chi-square analysis showed there were no systematic differences among the treatment groups in the addition Table 2. Distribution of subjects according to sex, functional class, and treatment group Sex Male Female Total Functional class$ Class I Class I1 Class I11 Total Treatment group* NAT SGT CBT XZt Pt * See Table 1 for definitions. t Chi-square and P values refer to females versus males, or functional class I1 versus functional classes I and 111. $ See ref. 14.

4 1108 BRADLEYETAL Table 3. Subjects mean outcome expectancy and treatment credibility ratings as a function of treatment mouu Treatment group* Rating scale SGT CBT F-ratio P How confident are you that this 5.11? f treatment will successfully help you cope more effectively with your rheumatoid arthritis? How successful do you feel this 4.94 f treatment will be in decreasing the extent to which rheumatoid arthritis interferes with your worwsocia1 life? How confident would you be in 5.94 f f recommending this treatment to a friend who suffered with rheumatoid arthritis? Total ratings 16.00? t I9 * Rated on a scale of 1-7, where 1 = most negative, 4 = moderate, and 7 = most positive. Values are the mean f SD. See Table I for definitions. or deletion of second-line drugs between pretreatment and posttreatment (x2[2] = 2.81, P = 0.25) or between posttreatment and followup (x2[2] = 4.00, P = 0.15). Outcome measures. There was a significant main effect of treatment group on subjects mean 17- Post-Treatment FO I 10 W- U p Figure 1. Total pain behavior scores (mean 2 SEM) as a function of treatment group and assessment period. Scores were adjusted to remove the effects of the pretreatment covariate. = group that received cognitive-behavioral group therapy (n = 17); = group that received structured group social support therapy (n = 18); 0 = control group, which received no adjunct therapy (n = 18). I displays of pain behavior (F[2,47] = 3.11, P = 0.05, w2 = 0.09), in which the CBT subjects displayed significantly less pain behavior than the SGT and NAT subjects, only at posttreatment (P < 0.03) (Figure 1). Similarly to the results of the analysis of pain behavior, CBT subjects produced significantly lower pain intensity (P < 0.005) and pain unpleasantness (P < 0.05) ratings than the SGT subjects, only at posttreatment (Figures 2A and B). A significant interaction between the independent variables was found on subjects mean Rheumatoid Activity Index scores (F[2,48] = 5.35, P < 0.01, w2 = 0.05). The CBT subjects produced significantly lower RAI scores relative to the SGT subjects (P < 0.001) and NAT subjects (P < 0.02), only at posttreatment (Figure 3). In addition, the NAT subjects produced significantly lower RAI scores at posttreatment than did the SGT subjects (P < 0.05). Subjects scores on each RAI component also were entered in a 3 x 2 analysis of covariance. There were significant interactions between the independent variables on subjects assessment of disease activity (F[2,48] = 3.19, P < 0.05, w2 = 0.04), rheumatologists or nurses assessment of disease activity (F[2,48] = 3.83, P < 0.03, w2 = 0.03), and the articular index (F[2,48] = 6.08, P = 0.005, w2 = 0.05). There also were significant main effects of assessment period on grip strength (F[1,48] = 17.95, P < 0.001, w2 = 0.08) and rheumatoid factor titer (F[1,48] = 6.80, P < 0.02, w2 = 0.05), in which subjects in all groups showed increased disease activity across assessments.

5 PAIN BEHAVIOR IN RA 1109 B6 5 TT-r FoI low-u p Follow-Up Figure 2. A, Pain intensity ratings and B, pain unpleasantness ratings (mean t SEM) as a function of treatment group and assessment period. Ratings were adjusted to remove the effects of the pretreatment covariate. See Figure 1 for definitions. There was a nearly significant main effect of treatment group on subjects mean scores on the Trait Form of the State-Trait Anxiety Inventory (F[2,47] = 2.97, P = 0.06, w2 = 0.10) (Figure 4). The CBT (P < 0.03) and the SGT (P < 0.01) subjects produced lower anxiety ratings than the NAT subjects at posttreatment. At followup, however, only the CBT subjects reported significantly lower anxiety levels than the NAT controls (P < 0.05). A nearly significant main effect of assessment period on subjects mean Depression Adjective Checklist scores (F[1,48] = 3.52, P = 0.07, w2 = 0.02) was found (Figure 5). Subjects in all groups reported increased depression across assessments. A nearly significant main effect of treatment group was found whereby the CBT subjects, using auditory or visual biofeedback, tended to produce greater mean changes in skin temperature at their most painful joints than did the SGT subjects or NAT subjects (F[2,47] = 2.55, P = 0.09, w2 = 0.07) (Figure 6). The only significant comparison, however, was found at posttreatment between the CBT and SGT subjects (P < 0.03). The analysis of covariance produced no signif- icant findings on subjects Health Locus of Control Scale scores, Arthritis Helplessness Index scores, or changes in skin temperature levels at their most painful joints without the use of biofeedback. There were no between-group differences on these measures at posttreatment or followup. The adjusted means k SD for each of the outcome measures described above are shown in Table 4. It should be noted that none of the significant main effects or interactions found on these measures were due to extreme outliers or skew in the distributions. The treatment program components that the CBT and the SGT subjects identified as most meaningful or helpful are shown in Table 5. Percentage effective agreement on the classification of subjects responses was 0.88 for the SGT group and 0.91 for the CBT subjects. Eighty-one percent of the CBT subjects identified the relaxation and imagery training as helpful to them. In addition, at least 30% of the CBT subjects found that they were aided by group discussions, instruction in setting and achieving goals, biofeedback training, and learning to better pace daily activities. The only treatment components endorsed by at least 30% of the SGT subjects were group

6 1110 BRADLEYETAL x 100 a, -0 t 90 h c.s z s a, c 40-0 a, iii Post-Treatment -I- Follow-Up Figure 3. Rheumatoid Activity Index scores (mean t SEM) as a function of treatment group and assessment period. Scores were adjusted to remove the effects of the pretreatment covariate. See Figure I for definitions. discussions and learning coping strategies for RA from other group members. DISCUSSION The results of the present study demonstrate that a psychological group therapy program produces significant reductions in patients' displays of pain behavior and RAI scores at posttreatment, relative to a social support group program or no adjunct treatment. The analysis of the RAI components indicates that the intervention produced its most positive effects on the articular index and the disease activity ratings. None of these effects were associated with systematic differences among the treatment groups in age, duration of disease, socioeconomic status, functional class, medication changes, or initial treatment-related attitudes. There was a significant tendency for men to be - underrepresented in the social support group; however, all of the significant differences between the CBT subjects and the NAT subjects were replicated in the comparisons of the CBT subjects and SGT subjects, with the exception of those on trait anxiety. The CBT and the SGT subjects produced nearly equivalent trait anxiety scores at each assessment. The positive effects of the cognitive-behavioral intervention, then, were not due to between-group differences in gender or other demographic or internal validity measures, and were consistent with those produced by psychological treatments in previous studies (1-.5,7). There were 3 findings that were not consistent with our hypotheses. First, the CBT and the SGT subjects showed equivalent reductions in trait anxiety at posttreatment. Only the CBT subjects were able to maintain their improvement relative to that of the controls during followup, but this appeared to be due to spontaneous improvement by the NAT subjects, as well as a moderate increase in anxiety among the SGT subjects. Thus, it is not certain whether professional 6o r 8 a 50 " I TI Post-Treatment FoI low-u p Figure 4. Percentile scores (mean? SEM) on the trait form of the State-Trait Anxiety Inventory (STAI) as a function of treatment group and assessment period. Scores were adjusted to remove the effects of the pretreatment covariate. See Figure 1 for definitions.

7 PAIN BEHAVIOR IN RA 1111 intervention was superior to social support in helping RA patients maintain reduction in anxiety. The second unexpected finding was that, although the CBT subjects displayed significantly less pain behavior at posttreatment than subjects in the other groups, their ratings of pain intensity and unpleasantness did not differ from those of the NAT subjects. Given the strong relationship between selfreports of pain and depression (20), the equivalent levels of depression among the treatment groups at posttreatment may have contributed to the absence of differences between the CBT and NAT subjects in their pain ratings. The third unexpected finding was that all subjects tended to show increased depression from T T, T Tt nent FoI IOW-UP Figure 6. Changes in skin temperature levels (mean 2 SEM) as a function of treatment group and assessment period. Scores were adjusted to remove the effects of the pretreatment covariate. See Figure 1 for definitions. Post-treat me Follow-Up Figure 5. Percentile scores (mean 2 SEM) on the Depression Adjective Checklist as a function of treatment group and assessment period. Scores were adjusted to remove the effects of the pretreatment covariate. See Figure 1 for definitions. posttreatment to followup. This tendency, however, was due primarily to a large increase in depression among the NAT subjects. Several important theoretical questions are raised by this study. First, what factors might account for the improvements shown by the CBT subjects? In the absence of a component analysis of the cognitivebehavioral intervention, it is necessary to rely upon the posttreatment questionnaire to generate hypotheses that may be tested in future work. Eighty-one percent of the CBT subjects identified relaxation and imagery training as one of the most helpful components of treatment. It previously has been reported that psychological treatments that emphasized relaxation training produced significant posttreatment reductions in patients' pain and joint involvement (1 3, The only study of relaxation training that has produced negative results (8) was one in which medical person-

8 1112 BRADLEY ET AL Table 4. Adjusted means f SD of all outcome measures as a function of treatment group and assessment period* Posttreatment Assessment period Followup Outcome measure NAT SGT CBT NAT SGT CBT Total pain behavior score Pain intensity rating Pain unpleasantness rating Rheumatoid Activity Index Subject assessment of disease activityt Rheumatologist or nurse assessment of disease activityt Articular indext Grip strengtht Rheumatoid factor titert Erythrocyte sedimentation rate (Westergren)t Trait anxiety score Depression Adjective Checklist score Change in skin temperature with biofeedback Change in skin temperature without biofeedback Health Locus of Control Scale score Arthritis Helplessness Index t f f f t t f ? f f f f t t f f f f t f f f f t f f f f f f f f t f f f t f f t 4.10 * Values are the mean 2 SD. See Table 1 for definitions. t Raw scores were transformed prior to analysis, using tables provided by Davis et a1 122) f f f f t f t f f t f f f f t ? f f f t f t f t f f f f f f f f t f t f f t f t f f f f t 4.46 nel (psychiatric residents) provided the training; however. they lacked experience in the treatment of RA patients. Thus, the replication of the positive findings (13) in the present study suggests that relaxation training may have been the treatment component primarily responsible for the reductions in pain and disease activity. Currently, it is not possible to identify what may mediate the relationship between relaxation training and reduced pain and joint involvement. One study, however, has found that relaxation training and guided imagery similar to that used in the present investigation produced significant increases in natural killer (NK) cell activity in elderly subjects (24). Natural killer cells may have important immunoregulatory functions, including suppression of antibody production (25). Decreased synovial fluid NK cell function in RA has been correlated with increased disease activity (26). An increase in NK cell activity following relaxation training, therefore, could have an ameliorating effect on RA disease activity. The potential relationships among relaxation training, NK cell function, RA disease activity, and pain should be examined in future work. A second question raised by the present study concerns the minor role that biofeedback training appeared to play in the CBT subjects improvements. The magnitudes of the CBT subjects temperature increases with feedback were small, and these subjects did not display increased temperature control without feedback. Therefore, they probably could not control peripheral skin temperature levels in their own environments to help control pain. Nevertheless, 31% of the CBT subjects identified biofeedback training as one of the most useful components of the treatment program. It may be that for some individuals, biofeedback contributes to the learning of relaxation skills or provides objective proof that they can learn to alter a physiologic response that may be related to their symptoms. In order to achieve a better understanding of the contributions of these treatments to patient improvement, future studies should include comparisons of the efficacy of biofeedback and relaxation training. The third question raised by this study is whether the statistically significant changes produced by the cognitive-behavioral intervention were clinically meaningful. The omega-square (02) statistic indicated that the treatment effects generally accounted for 5-10% of the variance in the outcome measures. Nevertheless, the posttreatment effects of the cogni-

9 PAIN BEHAVIOR IN RA 1113 Table 5. Rheumatoid arthritis (RA) treatment program components identified as most meaningful or helpful by CBT subjects versus those identified as most meaningful or helpful by SGT subjects* CBT subjects SGT subjects Component % Component % Relaxation and imagery training 81 Discussions or developing friendships with group members ~ ~~ 71 Discussions with others who have RA 56 Learning how other group members cope with RA 41 Learning skills to help achieve desired goals 44 Learning to deal more realistically with or more freely express feelings about RA 24 Biofeedback training 31 Developing better understanding of my behavior s effect on the family or developing more involvement with the family 24 Learning to better pace daily activities 31 Learning to cope better with stress or depression 18 Learning better communication skills 19 Learning to become less selfish or developing greater empathy for others 18 Developing increased self-esteem 19 Learning to think more positively about RA 12 Learning to reduce stress or anxiety 13 Receiving encouragement to exercise 12 Providing hope for the future 13 Providing greater awareness of my attitudes toward illness or problems resulting from illness 13 * Values are the percentages of subjects who identified each component as one of the most meaningful or helpful. See Table 1 for definitions tive-behavioral intervention resulted in pain behavior scores that were 37% lower than those of the SGT subjects and 34% lower than those of the controls. A recent meta-analysis (27) of 15 randomized, controlled trials indicated that the average increment in pain reduction produced by adding psychological or educational treatments to pharmacologic therapy was 16%. The improvement in pain documented in the present study, then, was substantially greater than changes produced by the previous investigations. While this improvement was moderate in magnitude, it was limited by the clinical characteristics of RA and the large reductions in pain generally produced by pharmacologic therapy (27). Thus, the reduction in pain behavior appears to have clinical as well as statistical significance. Finally, the results of the present study raise the question of what factors might account for the CBT subjects failure to maintain their treatment gains. One important factor may be that there was a great deal of variation among subjects in application of their coping skills after treatment was terminated, despite continued telephone contact by the group leaders. To examine this possibility, we plan to conduct a 12-month followup of subjects in all groups, and to ask the CBT subjects to report the degree to which they have continued to use their coping strategies. In summary, this study demonstrates that psychological treatment produces short-term, beneficial effects upon RA patients pain and disease activity levels. It also provides the first evidence that improvements in trait anxiety may be maintained for 6 months following treatment. We will attempt in future studies to better identify the factors that may mediate treatment outcome or improve the maintenance of treatment gains.

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