174 Arthritis and Musculoskeletal Conditions
person•s beliefs in self-ef“cacy and control are major goals
in the treatment of an individual with a musculoskeletal
condition.
The bulk of the extant research literature on these vari-
ables is both consistent with and encouraging of future devel-
opments. Patients with higher self-ef“cacy beliefs report
less arthritis pain (Buckelew, Murray, Hewett, Johnson, &
Huyser, 1995; Keefe, Lefebvre, Maixner, Salley, & Caldwell,
1997) and show greater ”exibility and movement capacity
(Rejeski, Craven, Ettinger, McFarlane, & Shumaker, 1996).
While these results come from cross-sectional studies, simi-
lar results have been found in longitudinal studies. For in-
stance, Lefebvre et al. (1999) have shown that self-ef“cacy
beliefs predict outcome even after controlling for medical
status variables.
In spite of the consistency and reliability of results such
as these, questions remain. For instance, the mechanisms
whereby these effects hold true need further investigation.
Self-ef“cacy may in”uence an individual• s stress response
because feeling con“dent in his or her abilities to cope may
lead an individual to be less likely to appraise situations as
stressful than an individual who does not have beliefs in self-
competence. This would suggest an underlying cognitive
mechanism behind ef“cacy/control beliefs (Lazarus &
Folkman, 1984). In that sense, self-ef“cacy beliefs may not
only affect stress responses, but may also affect coping
responses themselves. More indirectly, low beliefs in self-
ef“cacy and control may be indicants of depression and help-
lessness, which themselves predict poorer health.
Like self-ef“cacy, locus of control has also been associ-
ated with health outcomes in individuals with arthritis-related
conditions. Whereas self-ef“cacy refers to an individual dif-
ference variable related to the achievement of speci“c goals,
the locus of control construct is thought of as a stable person-
ality disposition. Despite this difference, it is noteworthy that
the locus of control and health literature is nevertheless
relatively consistent with the self-ef“cacy literature. Greater
sense of control is associated with higher levels of health,
health behaviors, and health beliefs (Thompson & Spacapan,
1991). Although there are some differences between OA,
RA, and FM samples, there has been a relative lack of re-
search cross-comparing those illnesses on locus of control
scales. As might be expected, attributing causes of ill health
to external forces such as chance is associated with poorer
coping strategies, higher depression, and higher anxiety in
chronic pain patients (Crisson & Keefe, 1988). Similarly,
low internal control is correlated with high impairment in
performing activities of daily living (Nicassio, Wallston,
Callahan, Herbert, & Pincus, 1985). Some data indicate that
FM patients report more intense pain and are more external in
their sense of control than RA patients (Pastor et al., 1993);
however, Nicassio, Schuman, Radojevic, and Weisman
(1999) were not able to detect the same pattern in their sam-
ple of FM patients. Overall, these results suggest that those
patients who perceive themselves as having higher levels of
dispositional control report less pain and better adjustment to
their illness. Thus, having a high locus of control may serve
as a source of resilience to the effects of stress.DepressionAny discussion of chronic pain must necessarily include
elaboration of the role of depression. In fact, the clear and
consistent relationship between chronic pain and depression
serves to convincingly illustrate how pain consists not only
of biological, but also psychological and social factors (for
reviews, see Banks & Kerns, 1996; Romano & Turner, 1985).
There is a high prevalence of clinical depression in both
RA (Creed, Murphy, & Jayson, 1990) and FM patient popu-
lations (Aaron et al., 1996; Hudson, Hudson, Pliner, &
Goldenberg, 1985). Cross-sectional data gleaned from RA
patients show a signi“cant positive relationship between
clinical depression and pain (Parker & Wright, 1995), as
well as an association between depressive symptoms and
pain (Af”eck, Tennen, Urrows, & Higgins, 1991; Ferguson &
Cotton, 1996). A key question remains unanswered, how-
ever: Does the experience of chronic pain precede or follow
the development of depression? While not de“nitive, some
longitudinal data provide evidence that pain precedes clinical
depression (Morrow, Parker, & Russell, 1994) and depressive
symptoms (Brown, 1990) in individuals with RA.
Because chronic pain and depression are so strongly re-
lated, and because FM lacks any clear etiology or identi“able
biological markers, some investigators have proposed that
FM be considered an •af fective spectrum disorderŽ (Hudson
& Pope, 1989). Support for this hypothesis would include
demonstration of a higher prevalence of affective disorders
among FM patients and their relatives, compared with other
chronic pain patients. Some studies have demonstrated that
FM patients, in fact, do score higher on measures of psycho-
logical distress (Uveges et al., 1990) and depressive symp-
toms (Al“ci, Sigal, & Landau, 1989), report higher lifetime
prevalence of affective disorder (Walker et al., 1997), and
have a higher familial prevalence of major affective disorder
(Hudson et al., 1985) than their RA counterparts. FM patients
also experience signi“cantly more depressive symptoms than
patients with other forms of musculoskeletal pain, including
low back pain and lumbar herniation (Krag, Norregaard,
Larsen, & Danneskiold-Samsoe, 1994). In contrast, some
“ndings have indicated that there is no dif ference in current