Documenting the presence of generalised anxiety disorder and its maintaining factors in patients in work rehabilitation program for persistent musculoskeletal pain Coutu MF, Durand MJ, Marchand A, Labrecque ME, Berbiche D
Financial Disclosure Information Financial support associated with the research: Grants/Research support Joint grant from the Québec rehabilitation research network (REPAR/FRSQ) and the Institut de Recherche Robert-Sauvé en Santé et Sécurité du Travail (IRSST). Salary award Fonds de la recherche en santé du Québec (FRSQ)
Introduction Musculoskeletal disorders (MSDs) are a frequent cause of work absence (Coyte, Asche, Croxford, & Chan, 1998). Long-term work absence undermines workers mental health.
Introduction Generalised anxiety disorder (GAD) Population survey: Patient with somatoform disorder 6.9 times greater risk of having a GAD after controlling for age, gender, depression, substance abuse and physical comorbidities (Beesdo et al., 2009).
Problem Factors associated with GAD Excessive worries Intolerance of uncertainty (Dugas et al. 1998) Beliefs about the usefulness of worrying Negative attitude toward problems may lead to a perception that all problem situations are threatening Explicit or voluntary cognitive avoidance
Aim Documenting the presence of generalised anxiety disorder (GAD) and the intensity and change in time of its maintaining factors during rehabilitation, in a sample of disabled workers on sick leave due to musculoskeletal disorder (MSDs).
Methods Design Observational/correlational, prospective repeated-measures design Participants Convenience sample 39 workers starting their rehabilitation program Recruited from 3 work rehabilitation centres in the Montreal and Estrie regions.
Methods Inclusion criteria: Having an accepted MSD compensated by Quebec s workers compensation board and causing a work absence of over 3 months; Ages between 18 and 64; Speaking French speaker, Having work exposure as a component of their treatment plan. Exclusion criteria MSD related to a specific pathology Severe mental disorder identified in their medical file.
Methods The interdisciplinary evidence-based rehabilitation program Aim at reducing the work disability Based on the Sherbrooke model (Loisel et al., 1997) Program activities based on Fear Avoidance Model (Vlaeyen et al, 1995) Psycho-education Pain/stress management Problem solving on the main hindering factors of return to work Early gradual and supervised return to work Concerted action among stakeholders
Methods Measurement instruments Worry and Anxiety Questionnaire (WAQ; Dugas & Freeston, 2001) Intolerance of Uncertainty Scale (IUS; Freeston, et al. 1994) Negative Problem Orientation Questionnaire (NPOQ; Gosselin, et al., 2002; 2005; 2000) Cognitive Avoidance Questionnaire (CAQ; Gosselin, et al., 2002) Why Worry-II questionnaire (WW-II; Gosselin et al., 2003) Beck Depression Inventory II (BDI-II; A. T. Beck, et al., 1997)
Methods Data collection procedure Beginning of the program RTW was announced Resumed working 50% of their regular work hours End of the program.
Statistical analyses Presence, intensity and variation over time Descriptive analyses Variation in time Generalized Estimating Equations (GEE) with the SAS PROC GENMOD program (Stokes, Davis, & Koch, 1995) (for TAG) Mixed linear models (Verbeke & Molenberghs, 1999) using the SAS PROC MIXED program
Results Participants characteristics Sociodemographic variables N = 36 Average age 40.39 (10.49) Injury site Back 25 (69.4%) Upper extremity 6 (16.7%) Lower extremity 1 (2.8%) Multi-sites 4 (11.1%) Unionized (yes) 16 (44.4%) Medico-legal disputes (yes) 7 (19.4%) RTW attempted before starting program (yes) 16 (44.4%) Number of days between accident and program start-up Average (S.E.) 305.11 (21.23)
Results Participants characteristics Average duration of the rehabilitation program 10 weeks Return to work status at the end RTW: 18 N-RTW: 15
60% GAD participants 50% 50% 40% 30% 20% 22% 27% 21% 10% 0% T1: Baseline (N=36) T2: Work exposition (N=18) T3: 50% of regular work hours (N=11) T4: End of program (N=19)
Worry themes Main themes identified concerned health illness well-being Future Finances Other people s judgements Family and friends Rehabilitation process Work Leisure and other activities Workers compensation board
Intolerance of Uncertainty 77 67 Severe GAD MFC1 57 47 62,78 (S.E. 4,11) 53,59 (S.E. 4,61) 48,64 (S.E. 5,19) 48,15 (S.E. 4,60) Moderate GAD PDA Mild GAD Arthritis, Dyspepsia & Ataxie Undergraduate 37 27 T1: Baseline (N=36) T2: Work exposition (N=18) T3: 50% of regular work hours (N=11) T4: End of program (N=19)
Slide 17 MFC1 Changer et mettre les niveaux de gravités de dugas 2007 Marie-France Coutu, 2/7/2011
Why Worry? 55 50 47,92 (S.E. 3,23) 45 41,24 (S..E 3,50) 40 39,57 35 38,47 (S.E. 3,81) (S.E. 3,49) Severe GAD Moderate GAD 30 Mild GAD 25 T1: Baseline (N=36) T2: Work exposition (N=18) T3: 50% of regular work hours (N=11) T4: End of program (N=19)
Cognitive Avoidance 100 90 80 70 PDA GAD Multiple Slerosis Undergraduate 60 59,22 (S.E. 3,75) 50 40 52,69 (S.E. 4,13) 49,71 (S.E. 4,57) T1: Baseline (N=36) T2: Work exposition (N=18) T3: 50% of regular work hours (N=11) 46,43 (S.E. 4,13) T4: End of program (N=19)
Problem orientation 37 32 GAD 27 25,61 (E.S. 1,70) Undergraduate 22 21,18 (E.S. 1,94) 17 21,36 (E.S. 2,22) 17,79 (E.S. 1,94) 12 T1: Baseline (N=36) T2: Work exposition (N=18) T3: 50% of regular work hours (N=11) T4: End of program (N=19)
Depression 25 20 16,81 (E.S. 1,84) 15 15,44 (E.S. 2,19) 12,97 (E.S. 2,59) Severe Depression 10 10,02 (E.S. 2,19) Mild Depression 5 0 T1: Baseline (N=36) T2: Work exposition (N=18) T3: 50% of regular work hours (N=11) T4: End of program (N=19)
Discussion Elevated percentage of participant meeting GAD diagnostic criteria Different form study population 6.2% (Von Korff et al. 2005).
Discussion GAD usefulness of worrying Anx. Dis. Intolerance of uncertainty ½ SD Undergraduate Cognitive avoidance Negative problem orientation
Discussion How can we explain these results? Misdirected problem-solving model (Eccleston & Crombez, 200&) Worries are not pathological Problem solving strategy adopted by patient having a biomedical perspective and seeking eradication of pain.
Discussion How can we explain these results? Misdirected problem-solving model (Eccleston & Crombez, 200&) Solution: reconceptualisation of the problem The treatment offered in our study focussed on work disability rather than pain treatment
Discussion How can we explain these results? Workplace phobia (Muschalla & Linden, 2009) 1. Intense fear when approaching the workplace; 2. Inability to enter the workplace due to severe anxiety symptoms; 3. Reduction in symptoms upon leaving the workplace Distinguished from simple phobia by the complexity of the stimuli that can trigger and maintain it.
Strengths and limitations Theory-based study A comparison with empirical or normative data provided an interpretation and better understanding of the range of the difficulties experienced by workers with a work disability. The type of statistical analysis performed allowed the sample size to be maximized, using 85 observations.
Strengths and limitations Self-administered questionnaire Vs standardised clinical interview Participants representative: Workers compensated for their injuries and on sick leave for an average of nearly one year. Referred to an interdisciplinary work rehabilitation program.
Perspectives New version of the Intolerance of Uncertainty Scale (Gosselin et al., 2008). Documents the need for reassurance Further exploration of the association between work exposition and none work exposition and intolerance of uncertainty and usefulness of worrying