Handbook of Psychology

176 Arthritis and Musculoskeletal Conditions

are related to positive health outcomes via at least two possi-
ble paths. One path involves a direct link between support
and positive health outcomes, such that the bene“ts of sup-
port are experienced under all circumstances. The second
path is a moderated one, such that the bene“ts of support are
experienced only during times of high stress. The second
path may be particularly important for individuals with
musculoskeletal conditions, because individuals with chronic
pain and disability may be especially vulnerable to the effects
of stress. Thus, social support may be a key factor in”uencing
adaptation to chronic pain. In fact, there is evidence to sug-
gest that social support exerts a stress-buffering effect in
individuals with arthritis and musculoskeletal conditions
(Af”eck, Pfeif fer, Tennen, & Fi“eld, 1988; for review, see
Manne & Zautra, 1992). Moreover, the quality of close rela-
tionships has also been associated with greater pain medica-
tion effectiveness (Radanov, Frost, Schwarz, & Augustiny,
1996), less disability (Weinberger et al., 1990), and lower
levels of depression (Nicassio, Radojevic, Schoenfeld-Smith,
& Dwyer, 1995) among arthritis pain patients.
The detrimental health effects of a lack of supportive
social ties during stress in individuals with chronic illness is
also apparent and may be compounded by depression, poor
coping responses, and other psychological factors. For in-
stance, the tendency of individuals with FM to cope with
pain by withdrawing from personal relationships may make
them more vulnerable to the negative effects of stress (Zautra
et al., 1999).

Stigma

Along with the bene“ts of social relationships, some individ-
uals with chronic pain may also experience stresses and
strains from their social ties through stigmatization. Individ-
uals with chronic pain of unknown etiology are particularly
likely to feel stigmatized and think that others are attribut-
ing their symptoms to personality problems, compared to
people with pain from an identi“able cause (Lennon, Link,
Marback, & Dohrenwend, 1989). Moreover, a brief perusal
of recent research suggests that the perception of pain pa-
tients that they are stigmatized is warranted. For example,
both the early investigations of RA and more recent studies of
FM have focused on identifying personality attributes that
distinguish pain patients from healthy individuals, in part to
identify a psychological explanation for the experience of
these pain conditions. Although it may be an accurate per-
ception, perceived stigmatization is problematic because it
appears to promote use of maladaptive coping strategies.
For instance, common responses to perceived stigma among
those with chronic pain include withdrawal from personal

relationships (Osborn & Smith, 1998) and increasing fre-

quency of medical consultations (Lennon et al., 1989).

Although no data are yet available for FM, some evidence

suggests that stigma may be a common source of social stress

in FM patients: They have a condition of unknown etiology,

tend to withdraw from social relationships (Zautra et al.,

1999), and have high medical utilization rates (Kirmayer

et al., 1988). Furthermore, the perception of being stigmatized

is quite likely to extend beyond those with FM. As one exam-

ple, RA patients may feel stigmatized by the physical dis“g-

urement that typically marks the later stages of RA. Given the

pronounced effect of the experience of stigmatization on

adaptation, greater attention to vulnerability to stigmatization

in arthritis and musculoskeletal conditions is warranted.

STRESS

According to the diathesis-stress model, stressors in life are

seen as provoking agents that challenge adaptation for all, but

only harm those who are vulnerable (Banks & Kerns, 1996;

Monroe & Simons, 1991). Before discussing the biopsy-

chosocial aspects of stress in RA, OA, and FM, it is important

to “rst describe how stress is de“ned in this chapter. Stress

may be de“ned as a physiological, emotional, or behavioral

response to an event, or stressor, that is perceived as threat-

ening or beyond one•s ability to cope (Lazarus & Folkman,

1984). Individual differences in appraisal of a stressor may

determine the degree of perceived stress experienced and

how an individual copes with this perceived stress. Thus,

biopsychosocial in”uences may af fect exposure to, appraisal

of, and reaction to stressful events. In this section, we discuss

the biological, psychological, and social contributions to

stress in RA, OA, and FM.

Biological Stress Systems

Since the pioneering work of Cannon (1932) and Seyle

(1956), the most extensively studied physiological stress

systems have been the hypothalamic-pituitary-adrenal axis

(HPA) and the sympathetic-adrenal-medullary axis (SAM).

In addition, other aspects of the CNS, hypothalamic-

pituitary-gonadal axis (HPG; i.e., reproductive system), and

immune systems appear to be activated under stressful condi-

tions. We brie”y describe each of these stress systems, and

then present evidence for the intrinsic involvement of these

systems in musculoskeletal conditions.

The interrelationships between the endocrine and nervous

systems have evolved to maintain biological equilibrium, or

homeostasis, in the face of an ever-changing environment.