Implications for Treatment 183example, Zautra et al. (1999) found that FM patients used
more avoidant strategies than their OA counterparts. Despite
the evidence for an association between active coping and
favorable outcomes in individuals with RA and OA, studies
focusing on individuals with FM have yielded con”icting
results. In individuals with FM, increases in both passive
and active coping have been associated with depression
(Nicassio, Schoenfeld-Smith, Radojevic, & Schuman, 1995),
and more coping effort was associated with increased physi-
cal disability, although less psychological disability (Martin
et al., 1996). These results suggest that coping responses
which may be adaptive in some conditions (RA and OA) may
actually be maladaptive in another (FM). For instance, in
conditions such as OA, where pain is somewhat predictable
and controllable, active coping processes may reduce pain
symptoms. As a result, an individual may experience in-
creased feelings of self-esteem and self-ef“cacy, and subse-
quently less depression. In contrast, when pain is experienced
in spite of active coping responses, as in FM, these coping re-
sponses may be interpreted as failures to affect pain, resulting
in decreased self-ef“cacy and increased feelings of helpless-
ness and depression. Thus, the adaptiveness of speci“c cop-
ing responses may be in”uenced by symptom characteristics
unique to each disorder.
Social Stress Factors
In addition to the data highlighting the psychological aspects
of stress, there is mounting evidence that social stressors
are particularly stressful for patients coping with chronic ill-
nesses. Family con”ict has been associated with poor
psychological adjustment to RA (Manne & Zautra, 1989).
Indeed, patients with chronic illness may be more sensitive
than their healthy counterparts to interpersonal con”ict with
individuals who are major sources of support, such as family
and close friends (Revenson, Schiaf“no, Majerovitz, &
Gibofsky, 1991). Since chronic illness often leads to severe
limitation in the capacity to function independently, a distur-
bance in supportive relationships threatens to further isolate
the patients and thus may increase anxiety and depression.
IMPLICATIONS FOR TREATMENT
The goals of controlling disease activity and reducing disease
symptoms have been the typical targets for conventional
biomedical treatment of arthritis and musculoskeletal
conditions. Within pharmacological interventions, a disease-
speci“c methodology has prevailed, so that drugs used to
treat RA, OA, or FM disease activity are not always identical.
In contrast to the speci“c nature of conventional biomedical
treatment, psychosocial interventions have typically been
based on the idea that one general strategy is adequate to treat
all of the diseases, thus ignoring speci“c needs or issues
unique to each disease. Although some interventions have
included a more holistic combination of biological and psy-
chological factors, the two components have not always been
utilized in a coordinated fashion.Biological TreatmentTraditional pharamacological approaches to treating RA have
followed a •pyramidal strategyŽ of aiming to minimize harm
by prescribing steroid and nonsteroidal anti-in”ammatory
drugs (NSAIDS) in attempts to control in”ammation and
other disease symptoms (McCracken, 1991). Unfortunately,
the progressive nature of RA, left unchecked, often causes
signi“cant disability and mortality (Harris, 1993). As a result,
physicians changed their strategy, attempting to •turn the
pyramid upside downŽ by prescribing an aggressive arsenal
of pharmaceutical treatments in the earlier stages of the
disease (Fries, 1990; Harris, 1993). This included disease-
modifying drugs and biologic response modi“ers, as well as
the more traditional medications that reduce symptom and
physical impairment, such as NSAIDS, salicylates, and pred-
nisone (Harris, 1993).
Given that OA has no known cure, symptom relief is tar-
geted as the primary goal of treatment. Such treatment in-
cludes pharmacological agents such as NSAIDS, analgesics,
and topical ointments (Brandt, 1993). Surgical replacement
of joints, although usually viewed as a last-resort option, is
often utilized for severe OA and RA (Brandt, 1993).
As in OA, treatment for FM focuses on symptom manage-
ment. Thus, far, optimal treatment strategies are far from clear,
as both pharmacological and psychological interventions
have yielded con”icting results. In contrast to RA and OA, FM
does not involve an in”ammatory process, so treatment with
NSAIDs and corticosteroids is usually ineffective (Bennett,
1993). Tricyclic antidepressants, taken at lower doses than re-
quired for the treatment of depression, are one common form
of pharmacological treatment. In addition, the newer class of
selective serotonin-reuptake inhibitors (SSRIs) is used widely
in the treatment of FM pain. In addition to pain relief, these
substances also promote slow-wave sleep, something that has
often been demonstrated to be de“cient in patients with FM
(Moldofsky et al., 1975). Unfortunately, because of the fear of
dependence and addiction, medications such as narcotic anal-
gesics have been avoided, even when their use may have been
greatly bene“cial. While effective pharmacological treatment
of the pain associated with FM remains elusive, a recent