**3.2.1 Emotion-focused coping strategies**

Essentially, there are conscious and intentional cognitive strategies that originate in an attempt to combat emotional distress, such as distraction, 'shutting down' and passive avoidance on one hand, looking for sympathy, turning to religious faith and positive reappraisal on the other. Endler and Parker (1990) describe emotion-orientated coping as comprising emotional reactions that are self-orientated but that may actually increase stress levels since they fail to actively reduce stress and may instead heighten the negative emotional component of the stress experience. Examples of such maladaptive reactions include blaming oneself for being too emotional, worrying about what one is going to do, or getting angry.

### **3.2.2 Problem-focused coping strategies or task-orientated coping**

There are the ways in which individuals consciously seek social support and elicit help from others: direct action, confrontation, planning and information seeking are all examples of this group. It involves using a problem-solving approach to eliminate stressors. For example, perceiving a demanding schedule as being stressful and deciding to use time management skills as a means to prioritise one's demands would be an example of taskorientated coping.

#### **3.2.3 Avoidance-orientated coping**

The coping strategies that are based on distraction and social diversion are characterised here. This coping style involves turning away from the stressors, possibly by ignoring it, psychologically distancing oneself from it, or engaging in another task. An avoidance coping style may not effectively eliminate stress since this style of coping does not actively reduce stress. However, engaging in substitute tasks may be beneficial as a means of temporarily removing oneself from stress until a patient is more able to actively face stress issues and implement a task-orientated coping style (Endler & Parker, 1990). Recent research findings have suggested that the use of an avoidance-orientated coping style may serve a protective function for individuals that are in situations in which they are not able to control the stressor that they are faced with (Simon-Thomas et al, 2001). For example, children that were exposed to the stressor of parental argument (stressor that they cannot control) were found to be protected/ buffered from the effects of inter-parental conflict on child internalising behaviours if they engaged in avoidance-orientated coping. Thus, depending upon the nature of the stressor, avoidance-orientated coping may be seen as either maladaptive or adaptive.

#### **3.2.4 Adaptive involuntary coping strategies**

Defence mechanisms reduce conflict and cognitive dissonance during sudden changes in reality caused by the illness. If such changes are not adjusted for they can result in disabling anxiety and depression. Adaptive defences operate in a hierarchical way: trough distortion or denial (immature defence level), repression, intellectualisation and reaction formation (intermediate defences), or at a higher adaptive level through self-assertion, affiliation, sublimation and humour.

#### **3.2.5 Coping hierarchy**

With the advent of measures that sought to investigate the nature, structure, and correlates of coping, theoreticians and researchers alike have begun to shift their views to focus more

Essentially, there are conscious and intentional cognitive strategies that originate in an attempt to combat emotional distress, such as distraction, 'shutting down' and passive avoidance on one hand, looking for sympathy, turning to religious faith and positive reappraisal on the other. Endler and Parker (1990) describe emotion-orientated coping as comprising emotional reactions that are self-orientated but that may actually increase stress levels since they fail to actively reduce stress and may instead heighten the negative emotional component of the stress experience. Examples of such maladaptive reactions include blaming oneself for being too emotional, worrying about what one is going to do, or

There are the ways in which individuals consciously seek social support and elicit help from others: direct action, confrontation, planning and information seeking are all examples of this group. It involves using a problem-solving approach to eliminate stressors. For example, perceiving a demanding schedule as being stressful and deciding to use time management skills as a means to prioritise one's demands would be an example of task-

The coping strategies that are based on distraction and social diversion are characterised here. This coping style involves turning away from the stressors, possibly by ignoring it, psychologically distancing oneself from it, or engaging in another task. An avoidance coping style may not effectively eliminate stress since this style of coping does not actively reduce stress. However, engaging in substitute tasks may be beneficial as a means of temporarily removing oneself from stress until a patient is more able to actively face stress issues and implement a task-orientated coping style (Endler & Parker, 1990). Recent research findings have suggested that the use of an avoidance-orientated coping style may serve a protective function for individuals that are in situations in which they are not able to control the stressor that they are faced with (Simon-Thomas et al, 2001). For example, children that were exposed to the stressor of parental argument (stressor that they cannot control) were found to be protected/ buffered from the effects of inter-parental conflict on child internalising behaviours if they engaged in avoidance-orientated coping. Thus, depending upon the nature of the

stressor, avoidance-orientated coping may be seen as either maladaptive or adaptive.

Defence mechanisms reduce conflict and cognitive dissonance during sudden changes in reality caused by the illness. If such changes are not adjusted for they can result in disabling anxiety and depression. Adaptive defences operate in a hierarchical way: trough distortion or denial (immature defence level), repression, intellectualisation and reaction formation (intermediate defences), or at a higher adaptive level through self-assertion, affiliation,

With the advent of measures that sought to investigate the nature, structure, and correlates of coping, theoreticians and researchers alike have begun to shift their views to focus more

**3.2.2 Problem-focused coping strategies or task-orientated coping** 

**3.2.1 Emotion-focused coping strategies** 

getting angry.

orientated coping.

**3.2.3 Avoidance-orientated coping** 

**3.2.4 Adaptive involuntary coping strategies** 

sublimation and humour.

**3.2.5 Coping hierarchy** 

on the hierarchical nature of coping. Three broad levels have been implicated: (a) coping styles that reflect global, dispositional, macroanalytic tendencies (e.g., monitoring-blunting, vigilance-avoidance, approach-avoidance); (b) coping strategies or modes that reflect an intermediate level in this hierarchy, and are typically indicated by summative scores on coping scales (e.g., confrontation, seeking social support, planful problem solving); and (c) coping acts or behaviors that reflect specific, situation-determined, microanalytic responses that are often indicated by individual item endorsement on a coping scale (Endler & Parker, 1990; Krohne, 1996; Schwarzer & Schwarzer, 1996).

The literature on coping with chronic illnesses and disabilities has, likewise, generated much insight into the nature and structure of coping efforts directed at diffusing or removing the stress engendered by the associated trauma, loss, and pain. Results from these and other studies strongly suggest that coping plays a significant role during the process of psychosocial adaptation to both sudden and gradual onset of chronic illnesses and disabilities. More specifically, these results indicate that: (a) a wide range of coping efforts has been employed by persons with disabilities to deal with the stresses engendered by their conditions; (b) these numerous efforts, both problem-solving and emotional-focused coping, as well as engagement- and disengagement- type coping have been found to be adaptive; (c) different coping efforts assume different roles and are, therefore, differentially employed to regulate stressful emotions and solve problems during the adaptation process; (d) coping efforts have played both a direct role (i.e., are directly linked to measures of psychosocial adaptation to disability) and a mediator role (i.e., act as mediators between sociodemographic variables, personality attributes, disability-related factors, environmental conditions, and outcomes of psychosocial adaptation); and (e) different disabling conditions imply different functional (e.g., mobility, manipulation, fatigue, cognitive) limitations, medical courses and prognostic indicators (e.g., deteriorating, unpredictable, stable), related health problems, treatment modalities, and psychosocial reactions. Individuals cognitively appraise the situation in terms of its personal significance, and then look at the resources and options they have available. This notion helps to appreciate the variability in individual coping reactions. The coping strategies adopted by an individual are quite unique; they include the way one perceives threatening experiences and reacts to stressful events, how one manages ones emotions and how one attempt to solve problems.

#### **3.2.6 Age and gender differences**

The effectiveness of coping strategies across the lifespan has been another area of clinical interest. Contrary to suggested belief that individuals become less efficient at coping with the demands of life as they get older, research into success of coping revealed immunity to the age process. Thus, in a recent study investigating age variance in coping across a broad range of stressors in a sample of more than 2,000 men ranging in age from the late 40s to over 90, there were no significant age differences in the reporting of negative emotional states in response to stressors, nor perceived efficacy in coping (Dunkin & Amano, 2005). In relation to gender differences, women appear to report positive and negative affects more vividly than men. In one study (Diener et al, 1999), gender accounted for 13 percent of the variance of the intensity of reported emotional experiences. There is also considerable evidence that women are more likely to use formal helping systems than are other groups, especially men and people of colour. One recent study addressed the natural coping systems of male and female students in largely young, Euro-American sample (Slattery et al, 2002).

Rheumatoid Arthritis: A Historical and Biopsychosocial Perspective 209

psychological wellbeing. Much of this work has focused on the health and wellbeing of chronically ill patients with musculoskeletal illnesses such as rheumatoid arthritis. Scharloo and colleagues (Scharloo et al, 1998) presented data showing that patients with rheumatoid arthritis, chronic obstructive pulmonary disease and psoriasis achieve significantly better functioning when cope by seeking social support and believe in controllability and curability of the disease. Support from family and close companions can help to increase individual's sense of control of their symptoms, as this kind of empowerment helps people

While today we celebrate the advances in clinical science and in therapeutics, the enigmatic nature of RA still gives way to conceptualisation disparity. Indeed, despite some significant gains in the areas of immunopathology and genetics, Landré Beauvais' first clinical description of rheumatoid arthritis in 1800 encompasses most of what we know about this disease today. Where no single factor can provide a satisfactory explanation of a disorder in question, the biopsychosocial approach helps to position the multiple layers of existing knowledge in relation to it. Laboratory studies of inflammation and genetics provide the scientific basis of mainstream treatments, although the speciality still lacks good clinical and

In conclusion, our predecessors are to be congratulated for providing a platform for future developments. There are compelling data to suggest that the combination of earlier use of disease modifying treatments, attention to coexisting conditions and patient's coping and illness perception, that are considered to be important contributing factors in the relationship between physical and psychological factors in RA. The evolution and refinement of the newer therapies will allow more patients to realistically strive for disease remission and return of function in the near future. Rheumatologists of tomorrow are to be encouraged to carefully sift through the complex information generated during assessment process and to focus clinical and therapeutic developments where they can best be

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act on their own behalf in relation to their dealings with RA (Delzell, 2011).

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**4. Conclusion** 

**5. References** 

They found significant gender-specific pattern in the use of coping strategies and their perceived effectiveness. The authors reported that females were significantly more likely than males to seek appropriate help and try to solve the problem, but also to use eating, cleaning, shopping, crying and praying. Interestingly enough, males were more likely to report using sex and masturbation in their attempt to cope than females. Both sexes described avoiding others, doing nothing, and ignoring the problem as least helpful.

#### **3.2.7 Cultural aspects of coping**

Cultural aspects of coping emerge as a new dimension in the ethnically diverse world today. Native Americans, for example, tend to turn to spiritual leaders and extended family (informal helping system) rather than to formal helping systems such as therapists (LaFramboisie, 2000). Similar findings have been reported for African Americans and Hispanic cultures (Sue & Sue, 1997); in England the Government's race equality strategy (Department of Health UK, 2003) have illustrated how local African community avoid statutory care systems and try to contain problems in their homes long beyond the expected point of seeking outside help. This could be a result of natural difficulty with disclosing problems or sharing emotions in this group or inadequacy of existing services to address their psychological needs. In his timely review Brendan Kelly (Kelly, 2003) highlighted that globalisation and large-scale social changes could induce a wave of 'anomie'in migrants, that is in essance a breakdown of social values (Durkheim, 1947). For Durkheim, in 1897 anomie arised more generally from a mismatch between personal or group standards and wider social standards, or from the lack of a social ethic, which produced moral deregulation and an absence of legitimate aspirations. For migrants living in a state where societal standing is compromised and social ties are broken, anomie becomes a nurtured condition that has detrimental effects on their coping capacity.

#### **3.3 Illness perception**

Patients do not respond to treatment in a predictable manner and show a wide variation in perception of causation. Individual preconceptions determine help seeking, compliance and treatment outcome, yet clinicians rarely explore these issues. Early exploration of illness perceptions may enhance health behaviour and maximise the impact of intervention.

Lay illness representations often diverge from the clinician's understanding of the presenting problem and strongly influence treatment behaviour. Perception of the significance of decline in social functioning, including some losses in valued activities, which an individual regards as being important, e.g. visiting the family, going away on holiday is an important factor that only recently has been emphasised by Katz & Yelin (1995). In their 4-yr longitudinal study they found that patients' perception of a decline in valued activities by 10% was followed by a seven-fold increase in depression over the subsequent year. The self-regulation model (Leventhal et al, 1980) suggests that the cognitive and emotional aspects of illness perception guide the response to illness and determine the effectiveness of coping. Furthermore, five components of illness perception have been recognised: the identity of the illness (i.e., the symptoms and their labels); the perceived consequences of the illness; the illness's causation; its likely time line and the potential for control and cure (Lau et al, 1989).

Studies investigating the relationship between illness perceptions and coping show that the way affected people deal with their illness has great influence on their physical and psychological wellbeing. Much of this work has focused on the health and wellbeing of chronically ill patients with musculoskeletal illnesses such as rheumatoid arthritis. Scharloo and colleagues (Scharloo et al, 1998) presented data showing that patients with rheumatoid arthritis, chronic obstructive pulmonary disease and psoriasis achieve significantly better functioning when cope by seeking social support and believe in controllability and curability of the disease. Support from family and close companions can help to increase individual's sense of control of their symptoms, as this kind of empowerment helps people act on their own behalf in relation to their dealings with RA (Delzell, 2011).
