changes between pain and adjustment variables at high, moderate and low levels of negative, solicitous and distracting spousal responses.

Transcription

1 ; 2010 Lower Urinary Tract SPOUSAL SUPPORT DECREASES THE IMPACT OF PAIN IN WOMEN WITH IC/PBlS GINTING ET AL. BJUI Spousal support decreases the negative impact of pain on mental quality of life in women with interstitial cystitis/painful bladder syndrome Jessica V. Ginting, Dean A. Tripp*, J. Curtis Nickel, Mary Pat Fitzgerald and Robert Mayer Departments of Psychology, *Psychology, Anesthesiology & Urology and Urology, Queen s University, Kingston, Ontario, Canada, Department of Obstetrics, Gynecology, & Urology, Loyola University Medical Center, Maywood, IL, and Department of Urology, University of Rochester Medical Center, Rochester, NY, USA Accepted for publication 1 September 2010 Study Type Symptom prevalence (case series) Level of Evidence 4 OBJECTIVE To examine whether spousal responses to patient pain would alter the association between pain and patient health-related quality of life (HRQL), depression and disability. What s known on the subject? and What does the study add? Research has demonstrated that significant others influence the course of pain experienced by individuals with chronic pain. Generally, spousal responses to pain behaviour are associated with higher levels of pain, disability, and depression. The present research discusses novel findings regarding how spousal responses to patient pain behaviour influences the impact of pain on mental quality of life in women with IC/ PBS. These findings go beyond correlations, and begin to untangle the circumstances under which pain influences mental quality of life. Women with IC/PBS would benefit from spouse-led distraction as a way to help them cope with their pain. METHODS Ninety-six women with IC/PBlS (mean age = 50.6 (13.8); mean time since diagnosis = 6.2 years) completed questionnaires on demographics, depressive symptoms (Center for Epidemiological Studies-Depression Scale), disability (Pain Disability Index), HRQL (Medical Outcomes Study Short Form 12) and a measure of perceived spousal responses to their pain (Multidimensional Pain Inventory). A repeated measures multivariate analysis of variance examined association changes between pain and adjustment variables at high, moderate and low levels of negative, solicitous and distracting spousal responses. RESULTS The association between pain and all outcome variables did not vary as a function of levels of solicitous and negative spousal responses. However, the association between pain and mental HRQL was stronger at lower levels (β = 1.25) of distracting responses than it was at moderate (β = 0.66) and higher (β = 0.06) levels. CONCLUSION Distracting spousal responses act to buffer the deleterious effects of pain on mental HRQL for women suffering from IC/PBlS. Spousal support training may be a useful HRQL intervention. KEYWORDS IC/PBIS, spousal responses to pain, healthrelated quality of life, interstitial cystitis INTRODUCTION Interstitial cystitis/painful bladder syndrome (IC/PBlS) is characterized by suprapubic pain with or without voiding symptoms of urgency, frequency and nocturia [1]. Sufferers of IC/PBlS frequently report depressive symptoms [2] and diminished health-related quality of life (HRQL) [3]. Biopsychosocial factors are suggested to be relevant to poor IC/PBlS outcomes [4,5], but a wider consideration of social factors and patient outcomes is warranted, given the few biomedical treatments available for IC/PBlS and their limited effectiveness [6]. The transactional model of health [7] suggests that the manner in which couples react, or provide support within the couple, under stress can exacerbate or improve outcomes associated with that stressor. Indeed, individuals in physical or psychosocial distress with greater support report less depression and anxiety [8]. Some types of support, such as negative or punishing responses (e.g. they get angry with me), solicitous responses (e.g. they try to get me to rest) and distracting responses (e.g. they try to get me involved in some activity), from spouses of chronic pain patients are associated with patient , doi: /j x x 713

2 GINTING ET AL. depression [9,10], greater disability [11] and pain [12]. Although the spousal support findings are interesting, they predominantly offer bivariate investigations, when more complex analyses can be used to examine more deeply the interplay of relations amongst patient pain, spousal responses and patient outcomes (e.g. interaction models). Conclusions and insight into whether or not spousal responses to pain behaviour are beneficial or harmful to IC/PBlS patients would complement the general pain literature and would expand developing biopsychosocial models for IC/ PBlS [5]. Testing for interaction effects among variables allows the testing of how the relationship between two variables may change (or not) based on the function (or level) of a third variable. Thus, the aim of the present study was to determine if spousal support influences the association between pain and patient adjustment variables (i.e. HRQL, depressive symptoms and disability) in women suffering from IC/PBlS. Given the novel and exploratory nature of the present study, no specific predictions were made. METHODS Ninety-six women were recruited from three North American National Institutes of Health-funded centres (i.e. Queen s University, Canada; Loyola University, USA; University of Rochester, USA). 1 All participants were recruited by letter invitation after approval from the respective ethics boards. Adult women with a clinical diagnosis of IC/PBlS were identified as eligible for participation during their routine clinical care. All participants completed the following measures: demographic information (age, ethnicity, education, employment status, duration of symptoms, marital status), sensory and affective descriptors of pain (The Short-Form McGill Pain Questionnaire, SF-MPQ [13]), pain disability (The Pain Disability Index, PDI [14]), HRQL (Medical Outcomes Study Short Form 1 The present data set was drawn from a larger sample of women suffering from IC/PBlS. Only one other publication has been produced using the data set, and that focused almost exclusively on QoL and sexual functioning (Tripp et al., 2009 [5]). There is no overlap between that publication and the theoretical interpersonal (spousal) constructs examined in the current paper. Statistical correction across orthogonal studies is not necessary. 12, SF-12 [15]), depressive symptoms (The Center for Epidemiological Studies Depression Scale, CES-D [16]) and spousal support behaviours (The Multidimensional Pain Inventory [17]). The SF-MPQ is a reliable and valid measure, used in clinical urogenital pain research [5], that consists of 15 word descriptors of pain that assess sensory and affective qualities of pain and overall pain intensity. Eleven descriptors represent the sensory dimension of pain experience (e.g. throbbing, stabbing, gnawing) and four descriptors represent the affective dimension (e.g. tiring exhausting, fearful). Each descriptor is rated on a 4-point intensity scale ranging from 0 (none) to 3 (severe) and the descriptors are summed to provide the Pain Rating Index Total (PRIT). Higher scores on the PRIT indicate greater overall pain. The PDI is a valid and reliable measure that assesses the extent to which chronic pain interferes with a person s ability to engage in various life activities [14]. For each of seven categories of life activity (Family/Home Responsibility, Recreation, Social Activity, Occupation, Sexual Behaviour, Self-Care and Life Support Activity), patients are asked to rate their level of disability on a numeric rating scale ranging from 0 (no disability) to 10 (total disability) [18]. Higher scores on the PDI indicate higher pain-related disability. The SF-12 is a reliable and valid measure of patient HRQL, which asks patients to respond to 12 questions concerning HRQL [15]. Two SF-12 subscales can be computed, namely the Physical Component Summary (SF12-PCS) and the Mental Component Summary (SF12-MCS). The mean is set at 50 (range 0 100; higher scores indicate better QoL). The CES-D is a reliable and valid assessment tool for depressive symptoms, containing 20 items assessing symptoms within the last week [16]. The MPI is valid and reliable and is used to assess psychosocial variables associated with pain; it consists of 52 items distributed in three sections. For the current study, only the section assessing spousal responses to communications of pain as identified by the IC/PBlS patient was used. For each item, respondents are asked to indicate from 0 (never) to 6 (very often) how often their spouse responds to them when in pain. STATISTICAL ANALYSES Statistical analyses were conducted using SPSS 17 for Windows (Chicago, IL). Relationships between variables were examined using Pearson s correlation coefficients. To determine whether or not spousal responses influenced the relationship between pain and patient outcomes (i.e. interaction models), data were analysed using the repeated measures general linear model (GLM) procedure. The within-subjects factor (or repeated measure) was outcome and consisted of physical HRQL, mental HRQL, disability, and depressive symptoms. Pain (SF-MPQ), solicitous spousal responses, distracting spousal responses and negative spousal responses were included in the model as covariates. To determine whether or not spousal responses influenced the relationship between pain and the outcome variables, the model included two-way interaction terms involving pain and each of the spousal response variables. All covariates were centred to reduce collinearity with product terms [19]. Following repeated measures analyses, simple slopes analyses were conducted for each outcome variable significantly predicted by the pain interaction term(s). 2 RESULTS The mean age of women participating in the study was 50.6 (SD = 13.8), 46% were employed, 22% reported high school or less, and the average time since diagnosis was 6.2 years (SD = 5.9). Interestingly, bivariate correlations between outcome variables and solicitous responses or distracting responses 2 This procedure consists of two stages of analyses: repeated measures multivariate analysis of variance (MANOVA), followed by simple slopes analyses. For any moderation analysis in which the moderator (i.e. distracting spousal responses, in this case) is a continuous variable, participants are not divided into high, medium and low groups. Rather, the analysis is performed by conducting any number of simple slopes analyses sufficient to determine the levels at which the relationship exists. In the simple slopes analysis, mental QoL was the dependent variable, and the predictors were pain, solicitous responses, distracting responses, negative responses and interaction terms between pain and each of the spousal response variables. All predictor variables are centred (i.e. the distribution of each predictor variable is translated such that the mean becomes zero) prior to analysis to correct for the strength of associations between predictors and their product terms (i.e. interaction terms, Aiken & West, 1991 [19]) This analysis does not use a simple tertile cut score of the unadjusted original values

3 SPOUSAL SUPPORT DECREASES THE IMPACT OF PAIN IN WOMEN WITH IC/PBLS TABLE 1 Bivariate correlations of spousal responses to pain behaviour and pain with patient outcome variables Physical HRQL Mental HRQL PDI CES-D SR DR NR ** 0.25* 0.32** SF-MPQ 0.37** 0.28** 0.53** 0.41** *P < 0.05; **P < SR, solicitous spousal responses to pain behaviour; DR, distracting spousal responses to pain behaviour; NR, negative spousal responses to pain behaviour; SF-MPQ, Short-Form McGill Pain Questionnaire; HRQL, health-related quality of life; PDI, Pain Disability Index; CES-D, Centre for Epidemiological Studies Depression Scale. were not significant (Table 1). Negative responses to pain behaviour, however, were associated with poorer mental HRQL (r = 0.30, P < 0.01), greater disability (r = 0.25, P < 0.05) and higher levels of depressive symptoms (r = 0.32, P < 0.01), but were not significantly associated with physical HRQL. Similar to in previous research, pain was associated with poorer physical (r = 0.37, P < 0.01) and mental (r = 0.28, P < 0.01) HRQL, and with greater disability (r = 0.53, P < 0.01) and depressive symptoms (r = 0.41, P < 0.01). The repeated measures GLM procedure indicated that there was a significant interaction between outcome, pain and distracting spousal responses (F(3, 264) = 2.82, P < 0.05). The interactions between outcome, pain and negative spousal responses (F(3, 264) = 0.28, ns) or solicitous spousal responses (F(3, 264) = 1.04, ns) were not significant. Therefore, neither negative spousal responses nor solicitous spousal responses influenced the association between pain and outcome. Parameter estimates indicated that the interaction between pain and distracting spousal responses was significant only for mental HRQL (t(88) = 2.30, P < 0.05), and not physical HRQL (t(88) = 0.21, ns), depressive symptoms (t(88) = 1.59, ns), nor disability (t(88) = 0.86, ns). Simple slopes analyses then indicated that, at high levels of distracting spousal responses, the relationship between pain and mental HRQL was not significant (β = 0.06, ns). Furthermore, at moderate (β = 0.66, P < 0.05) levels of distracting spousal responses, the relationship between pain and mental HRQL was weaker than at low (β = 1.25, P < 0.05) levels of distracting spousal responses (Fig. 1). Therefore, the results suggest that distracting spousal responses may reduce or buffer the impact of pain on mental HRQL. Note that tertiles were not used to conduct the simple slopes analyses; see Footnote 1 for further reading. DISCUSSION The purpose of the current study was to determine whether or not spousal support (i.e. spousal responses to pain behaviour) altered the relationship between pain and patient outcomes such as disability, depressive symptoms or mental and physical HRQL. Social support protects individuals from the negative stress impact [8], and the current results show that support in the form of distracting spousal responses to pain behaviour is one such type of social support that diminishes the impact of pain (a stressor) on mental HRQL in women with IC/PBlS. Bivariate correlations indicated that higher pain was associated with poorer mental HRQL. Using moderation analyses, we examined how different levels of distracting spousal responses (i.e. low, moderate, high) differentially influenced the strength of the association between pain and mental HRQL. For example, the results showed that at higher levels of distracting responses, the correlation between pain and mental HRQL was not significant. By contrast, the correlation between pain and mental HRQL was significant at moderate and lower levels of distracting spousal responses. These findings are similar to research showing that distraction results in reports of reduced pain intensity [20]. Although negative spousal responses are correlated with poorer mental HRQL, greater FIG. 1. Relationship between pain and mental quality of life at different levels of distracting spousal responses to pain behaviour. Note: This figure consists of three superimposed graphs to enable comparison of the differences in regression slopes. Mental QoL (SF-12) Low DR Med DR High DR Min Max Pain (SF-MPQ) disability and depressive symptoms, different levels of negative spousal responses (i.e. low, moderate, high) did not differentially influence the strength of the correlation between pain and patient adjustment (i.e. disability, mental HRQL, and depressive symptoms). Similarly, solicitous responses to pain behaviour did not influence the relationship between pain and patient adjustment. Contrary to previous findings in the chronic pain literature [9 12], solicitous responses and distracting spousal responses were not significantly associated with measures of physical and mental HRQL, disability and depressive symptoms. This difference may be the result of random sampling differences (e.g. in pain duration, pain severity and chronicity) between patients examined in the current study and other published studies. Most importantly, however, this study is the first to examine this association in women with IC/PBlS, so replication is required to establish the solicitous and distracting spousal response finding. The findings of this study have important clinical implications for couples suffering from IC/PBlS. Psychosocial interventions are very much needed for women with IC/PBlS, given the chronicity of the condition, and the few effective biomedical treatments. It may be beneficial to provide a brief psychoeducational intervention for spouses of women with IC/PBlS on their response to expressions of spousal pain, which could be delivered by an attending nurse or from within a support group setting. This type of couple psychotherapy has been

4 GINTING ET AL. examined in arthritis patients and has shown positive effects [21,22]. However, future research is needed to identify any differences between arthritis and IC/PBlS samples that may create the need for a different therapeutic approach from this earlier model. In particular, distracting responses have not been empirically examined for utility. Distracting someone expressing pain may diminish the psychological distress experienced by that person simply by preventing them from ruminating on their pain. Cognitive models of pain suggest that distress is a result of attending to sensory information and processing such information emotionally [23]. Assuming that we have limited attentional capacity (i.e. we can only attend to a finite number of stimuli), distraction is thought to interrupt the emotional processing of pain. Furthermore, neuroimaging studies have shown neurophysiological changes associated with reduction in pain ratings during distraction [20]. Therefore, not only can distraction prevent cognitive processes involved with the emotional processing of pain, but it is also associated with physiological changes that may affect pain perception. A particular limitation of the current study is that reports of spousal responses were provided from the patient, not from selfreports from their spouses. However, patients perceptions of their spouses behaviour account for a larger proportion of the variance in pain and activity measures when compared with spouses self-reports [24]. Thus, although corroborating information from the non-identified spouse may be optimal, it is not necessary. The patients from these three centres, all well-respected tertiary IC/PBlS centres, may not represent the general IC/PBlS population and, more importantly, their spouses may not represent the general population of IC/PBlS spouses. Another limitation concerns generalizability, especially as this sample concerned only women with IC/PBlS. It is uncertain whether results are generalizable to males with IC/PBlS, but future research could seek to replicate the present findings in a male IC/PBlS sample. Importantly, gender is suggested to have an important impact on the provision and reception of social support [25]; it has been suggested that women are more likely to seek social support than men [26]. Replication in males with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is suggested, as CP/ CPPS and IC/PBlS share common syndromeassociated outcomes (i.e. diminished HRQL, increased marital distress, disability and psychological distress) and overlapping symptom profiles [27]. In conclusion, this study is the first to examine and report on the influence of spousal responses to pain behaviour on the association between pain and patient adjustment in women with IC/PBlS. Distracting spousal responses act to buffer the deleterious effects of pain on mental HRQL for women suffering from IC/PBlS. 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5 SPOUSAL SUPPORT DECREASES THE IMPACT OF PAIN IN WOMEN WITH IC/PBLS 21 Keefe FJ, Caldwell DS, Baucom D et al. Spouse-assisted coping skills training in the management of osteoarthritic knee pain. Arthritis Care Res 1996; 9: Martire LM, Schulz R, Keefe FJ et al. Feasibility of a dyadic intervention for management of osteoarthritis: a pilot study with older patients and their spousal caregivers. Aging Ment Health 2003; 7: McCaul KD, Malott JM. Distraction and coping with pain. Psychol Bull 1984; 95: Flor H, Kerns RD, Turk DC. The role of spouse reinforcement, perceived pain, and activity levels of chronic pain patients. J Psychosom Res 1987; 31: Turner RJ, Marino F. Social support and social structure: a descriptive epidemiology. J Health Soc Behav 1994; 35: Edwards AC, Nazroo JY, Brown GW. Gender differences in marital support following a shared life event. Soc Sci Med 1998; 46: Moldwin RM. Similarities between interstitial cystitis and male chronic pelvic pain syndrome. Curr Urol Rep 2002; 3: Correspondence: Jessica Ginting, Humphrey Hall, 62 Arch Street, Queen s University, Kingston, ON, K7L 3N6, Canada. jessica.ginting@queensu.ca Abbreviations: IC/PBlS, interstitial cystitis/ painful bladder syndrome; HRQL, healthrelated quality of life; SF-MPQ, The Short- Form McGill Pain Questionnaire; PDI, The Pain Disability Index, SF-12, Medical Outcomes Study Short Form 12; CES-D, The Center for Epidemiological Studies Depression Scale; PRIT, Pain Rating Index Total; GLM, general linear model