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For starters, this is not a medical text, but a psychological one, published as it is by the British Psychological Society. The first chapter is an introduction, setting out how the book will largely deal with the psychological aspects of the illnesses (four main subtypes) and their treatment. These are osteo- and rheumatoid, ankylosing spondylitis and juvenile idiopathic.
Chapter two begins by discussing the characteristics of the four subtypes, covering the lifespan as it is, certainly, a disease that does not spare children. Strangely, the immediate discussion of aspects of the disease lends itself to the metaphysical and alternative treatments. The former really refers to insufficient management of emotions such as anger or bitterness, with stiffness of joints perhaps indicating rigid thinking, self critical or low self worth attitudes, anger being expressed perhaps as inflammation. Fatigue could indicate weariness of life, or a loss of purpose or direction. Overall, meanings applied include lack of support, insecurity, inflexibility, and other attributions made depending on body part affected. Whether you support this kind of approach or not, there is nevertheless a complex interaction between perception and pain and stressors, and of course mood and anxiety outcomes, no matter to what extent one delves into the attributions above. In the same way, placebo effects being what they are, alternative treatments, and complementary treatments, are also worthy of some consideration. For instance, EMG biofeedback may improve cognitive and behavioral measures, but not pain measures. Relaxation may reduce pain measures, as might direct heat application or similar, and clearly the results are pretty much for any other self guided intervention, namely, an improvement in self-efficacy as a sense of self or self capacity, will lead to a better outcome for pain and learned helplessness. The preferred treatments here are no different to other conditions, eg massage, acupuncture and so on.
The following chapters however focus on the psychosocial. Barlow embarks on a historical look at how personality first began to be viewed in the context of arthritis, particularly its onset. There are of course considerable difficulties with doing this, given the poorly defined nature of personality anyway, as well as the difficulty in establishing causal links between these entities. Perhaps easier, who responds better to their symptoms is easier to establish. While there may be little link with personality, obviously, but as with other conditions, negativity or neuroticism is going to be correlated with poor adjustment and mood states once the condition has set in. Response to medication is thus going to fluctuate with mood and daily stress measures, even in children. Early diagnosis may also suffer, with symptoms reported often being considered as psychological intolerance for normal pain and stiffness, rather than a normal response to a pathological state. Strangely, there are few studies which observe psychological functioning over time, despite the persistence of the condition across some lifetimes.
Chapter 4 follows a client centered view, namely how patients and carers bring meaning to their experiences of the conditions reported on here. This is done to facilitate the context of self help and intervention later, from the client’s perspective. There is an impact on roles and conceptions of health, illness, pain, fatigue, loss of vitality and physical attractiveness, and the qualitative summaries by victims are posted here. The illness fluctuates, sometimes diurnally, with not only good days and bad days, but good and bad periods ultradian as well.
Chapters five and six then discuss the psychological and social impact separately, with a quantitative view now taken on the qualitative accounts of chapter four. Again, as expected, the focus is on the complex interrelationship between depression and pain, and again, self efficacy, a sense of control, that what the patient does, makes a difference to them, and how there is then a sense of control. There is less focus on anxiety and self esteem, predictably. Medical science has focused on rheumatoid more than the other variants, and following on this lead, the psychosocial studies have also neglected the other conditions. As has been the fashion, more studies on positive psychology versus pathology have begun to emerge. As expected, the lifespan approach shows impact along all spectra of social life, with home, family, work, leisure, relationships, all affected, and with lesser studies on collateral damage to the carers, family and friends. Support, as with any disability, may be a mixed blessing, or rather a double edged sword for both carers and patient, depending on the relationship. Facilities to support sufferers at work are still problematic, although some aspects of limiting work may have positive spinoffs, such as more engagement with family or social aspects of life.
Given the complexity and endurance of the condition, various perspectives from both carers, health care providers and sufferers may clash, or not follow the same trajectories. This can create difficulties, and chapter seven addresses this, and the role of a more inclusive response to the condition. Different foci may appear in any player in the drama, and converging these is important. Not just treatment compliance, but compliance with healthy lifestyles and exercise and other issues may need support. Different formats for patient education and motivation are also canvassed, as they may not guarantee positive outcomes in health behavior. The intercession of the internet may not have been entirely positive, as of course the internet is not a peer reviewed space. Nevertheless, the value of these interventions in supporting self guided solutions is emphasized.
Chapter eight then takes this further, psychosocial interventions, with support provided for self guided solutions and self efficacy by more complex psychological interventions, mostly drawing on social cognition theory, as do most interventions with attempt to alter health behavior in other conditions which are, in part, preventable or mediated by lifestyle changes or interventions. Other interventions include the supposed value of emotional disclosure, and the evidence supporting this, and social support interventions, including those that support exercise as an intervention, eg the sidewalkers walking program. Given that most sufferers spend a lot of time at home, self guided and directed interventions are dominant, as the sufferer is the most engaged carer, given these facts. The promotion of health behavior, positive mood, fostering confidence in self management, namely, self efficacy again.
Chapter nine addresses the future agendas, or what she refers to as a research wish list. Psychosocial domains, especially in children, positive dimensions, health care and interventions, and as mentioned above, longitudinal studies on the psychology of living with the illness, and finally, as an appendix, a study on a single sufferer from an interview conducted by a Dr Turner, complete the book, with the last 90pages devoted to references and the index.
I am not sure there are any "wow!" moments in the book, and for most psychologists, the forty or so pages of chapter eight will pretty much suffice to scaffold their knowledge, but as many books must, this work highlights what a Health Psychologist would most like to know about, and about which there appears to be not much known, hence her wish list. It’s certainly not an adequate guide as to what to do about your condition and how to live with it if you have arthritis, but more about the experience of living with the illness in a more abstract way, and how it impacts on other areas of life, this is its strength, and hence, it is more for academics than patients or treatment specialists.
© 2010 Roy Sugarman
Roy Sugarman, PhD, Human Performance Institute, Sydney, Australia