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Aims: Implicit gender biases (IGBs) are unconscious evaluations about a person based on gender. IGBs of healthcare providers may affect medical decision making. This study investigated whether IGBs and genders of patients and general practitioners (GPs) influence diagnostics and treatment decisions in the context of diabetes type 2. Methods: Ninety-nine GPs participated in this randomized online study. Implicit Associations Tasks were used to measure two IGBs, related to lifestyle (women have a healthier lifestyle than men) and communication (men are less communicative than women). Clinical decisions regarding type 2 diabetes were measured with vignettes that included a fictional male or female patient case. Results: Female GPs exhibited a significant lifestyle IGB (p < 0.001). GPs of both genders exhibited a significant communication IGB (p < 0.001). Several associations between IGBs and clinical decisions were found. The gender of the vignette character affected several outcomes, for example GPs were less certain in the diabetes diagnosis when the character was a woman (p < 0.001). Conclusion: We demonstrated that GPs have IGBs and these biases as well as patient's gender affect decisions of GP's when they are solving a diabetes vignette case. Future research is needed to understand the most important consequences of IGBs in the context of type 2 diabetes.

BackgroundAn unhealthy lifestyle increases the risk of developing rheumatoid arthritis (RA). Interventions including plant-based diets, physical activity, and stress management have shown benefits for RA patients but have not yet been evaluated in a program for patients at risk for RA.ObjectivesTo investigate preliminary effectiveness of a multidisciplinary lifestyle program on RA risk in patients at risk for RA, in comparison to usual care.MethodsIn the “Plants for Joints” (PFJ) pilot RCT, patients with anti-citrullinated protein antibody (ACPA) positive arthralgia were randomized to the PFJ or control group. Both groups received usual care while the PFJ group additionally followed a 16-week lifestyle program based on a whole food plant-based diet, physical activity, and stress management.1 The primary outcome was risk of developing RA as quantified by the RA risk score (including family history, symmetry, stiffness, pain level, RF/ACPA level).2 The maximum score (13 points) was given to participants who developed RA. Secondary outcomes included self-reported pain intensity, inflammatory, anthropometric, and metabolic markers, and serum levels of ACPA and rheumatoid factor (RF). A linear mixed model for between group analysis was used, adjusted for baseline values.Results14 out of 17 included patients completed the study (all female, mean age 47 years). Three patients (n = 2 PFJ group, n = 1 control group) were diagnosed with RA after mean 9.6 weeks and remained in the study. After 16 weeks there was no significant difference in RA risk score between PFJ and control groups (Figure 1). Compared to the control group, the PFJ group had significantly lower fat mass and LDL-cholesterol after 16 weeks (Table 1). After the intervention the PFJ group had an average weight loss of 4.9 kg, of which 2.7 kg was fat mass.Table 1.Results reported as mean (SD) when normally distributed and median [Q1 – Q3] when skewed. P-value Plants for Joints group (n = 7)Control group (n = 7)BaselineWeek 16BaselineWeek 16p-valueRA risk and related outcomesRA risk score6.1 (1.4)8.6 (3.4)7.1 (1.4)8.3 (2.3)0.56Pain intensity4.9 (2.6)3.8 (1.9)5.7 (2.6)4.0 (2.1)0.74ACPA, kU/l330 [94 - 530]225 [116 - 550]256 [79 - 462]202 [94 - 403]0.86RF, kU/l13 [3 - 68]11 [3 - 56]12 [3 - 21]5 [4 - 12]0.96RA diagnosis, N0201-InflammationESR, mmol/hour9 [6 - 15]7 [6 - 9]7 [6 - 12]12 [8 -17]0.79CRP, mg/l0.7 [0.6 - 2.5]0.6 [0.6 - 1.2]3.0 [1.1 - 3.6]3.3 [1.3 - 6.7]0.58AnthropometricWeight, kg78.4 (18.6)73.5 (16.4)77.4 (16.2)77.0 (16.3)0.28BMI, kgm-226.8 (5.3)25.1 (4.5)28.2 (6.2)28.0 (6.0)0.23Fat mass, kg30.6 (14.3)27.9 (12.3)31.2 (12.8)29.8 (13.0)Waist circumference, cm87.9 (13.3)86.6 (11.6)91.6 (15.5)90.6 (16.1)0.33MetabolicLDL-cholesterol, mmol/l3.1 (0.87)2.83 (0.75)3.07 (0.36)3.05 (0.36)HbA1C, mmol/mol34.9 (3.2)34.4 (3.1)35.1 (3.0)36.9 (3.6)0.97ConclusionThe results of this pilot study do not suggest the PFJ lifestyle program influenced RA risk score, pain, or autoantibody levels, although possible effects cannot be excluded due to the small sample size. However, metabolic health clearly improved in the PFJ group.References[1]Walrabenstein, Trials 2021[2]van de Stadt, Ann Rheum Dis 2013AcknowledgementsC. W. was funded by ZonMW (The Netherlands Organization for Health Research and Development) grant number 555003210.Disclosure of InterestsCarlijn Wagenaar: None declared, Wendy Walrabenstein: None declared, Marieke van der Leeden: None declared, Franktien Turkstra: None declared, Jos Twisk: None declared, Maarten Boers Consultant of: Consultant for Novartis, Henriët van Middendorp: None declared, Peter Weijs: None declared, Dirkjan van Schaardenburg: None declared

BackgroundLifestyle factors have been associated with the development and progression of rheumatoid arthritis (RA). Interventions involving whole food plant-based diets (WFPDs), physical activity or stress management have shown promising results for people with RA but were not yet evaluated in an integrated program.ObjectivesTo determine the effect of a 16-week multidisciplinary lifestyle program on disease activity in patients with RA.MethodsIn the “Plants for Joints” (PFJ) parallel-arm, assessor-blind randomized clinical trial, patients with RA and a 28-joint Disease Activity Score [DAS28] score ≥ 2.6 and ≤ 5.1, were assigned to the PFJ group or the control group. The PFJ group followed a lifestyle program based on a WFPD, physical activity, and stress management in addition to usual care. The control group received usual care. Medication was kept stable three months before and during the trial. Secondary outcomes included anthropometric, and metabolic markers. An intention-to-treat analysis with a linear mixed model, adjusted for baseline values was used to analyze between-group differences of continuous outcomes.ResultsOf 115 people screened, 85 were randomized and 79 completed the study. Participants were 91% female with a mean (SD) age of 55 (12) and body mass index of 26 (4) kg/m2. After 16 weeks the PFJ group had a mean 0.85-point greater improvement of the DAS28 versus the control group (95% CI 0.40 to 1.30; p < 0.001) (Figure 1). Subgroup analyses showed significant improvements in the seropositive as well as the seronegative subgroup, although the effect was more profound in the seronegative group. Weight, fat mass, HbA1c, LDL and triglycerides also showed significant improvements in the PFJ versus control group, while blood glucose and HDL remained unchanged (Table 1). No serious adverse events occurred.ConclusionThe 16-week PFJ lifestyle program substantially decreased disease activity in people with RA with low-moderate disease activity.Disclosure of InterestsWendy Walrabenstein: None declared, Carlijn Wagenaar: None declared, Marike van der Leeden: None declared, Franktien Turkstra: None declared, Jos Twisk: None declared, Maarten Boers Consultant of: Consultant for Novartis, Henriët van Middendorp: None declared, Peter Weijs: None declared, Dirkjan van Schaardenburg: None declared

Chronic somatic conditions, such as psoriasis, arthritis psoriatica and rheumatoid arthritis, have a large impact on patients’ lives. Tailored therapist-guided internet-based cognitive-behavioural therapy (ICBT) has been shown to be effective in improving physical and psychological well-being in these patients. Two cases are presented here, in order to provide an in-depth illustration of the course and content of this novel treatment and to investigate the therapeutic alliance in an online treatment. After face-to-face intakes, both patients received therapist-guided ICBT tailored to their specific problems and treatment goals. The treatment resulted in improved physical and psychological well-being and these clinically significant improvements were maintained at 6-month follow-up. In addition, the therapeutic relationship was evaluated positively by both patients and increased further during treatment, indicating an adequate therapeutic working alliance in this online treatment. These case reports show that tailored ICBT may contribute to improved care for patients with chronic somatic conditions.

Contains fulltext : 190317.pdf (Publisher’s version ) (Open Access) Alopecia areata (AA) is an immune-mediated disease causing temporary or permanent hair loss. Up to 46% of patients with AA also have nail involvement. The aim of this study was to determine the presence, types, and clinical implications of nail changes in patients with AA. This questionnaire-based survey evaluated 256 patients with AA. General demographic variables, specific nail changes, nail-related quality of life (QoL), and treatment history and need were evaluated. Prevalence of nail involvement in AA was 64.1%. The specific nail signs reported most frequently were pitting (29.7%, p = 0.008) and trachyonychia (18.0%). Red spots on the lunula were less frequent (5.1%), but very specific for severe AA. Nail-related QoL was only minimally affected by nail changes. In conclusion, nail involvement is common in patients with AA and presents mostly with pitting and trachyonychia. The presence of these nail changes reflects the severity of the disease, with red spots on the lunula as a predictor for severe alopecia.

Contains fulltext : 169791.pdf (Publisher’s version ) (Open Access) BACKGROUND: The physical appearance of psoriasis can be cosmetically disfiguring, resulting in a substantial social burden for patients. An important aspect of this burden is the experience of stigmatization. While stigmatization is known to be disabling and stressful for patients, little is known about its correlates, and effective interventions are lacking. OBJECTIVES: To examine predictor variables for perceived stigmatization in psoriasis. METHODS: Questionnaires were administered to 514 patients with psoriasis in a cross-sectional study. Zero-order correlation and multiple-regression analyses were conducted including sociodemographic, disease-related, personality, illness cognitions and social support predictor variables. RESULTS: Stigmatization was experienced by 73+ACU- of patients to some degree, and correlated with all five categories of predictor variables. In multiple-regression analyses, stigmatization was associated with higher impact on daily life+ADs- lower education+ADs- higher disease visibility, severity and duration+ADs- higher levels of social inhibition+ADs- having a type D personality+ADs- and not having a partner. CONCLUSIONS: The results indicate that perceived stigmatization is common in psoriasis, and can be predicted by sociodemographic, disease-related and personality variables. These predictor variables provide indications of which patients are especially vulnerable regarding perceived stigmatization, which might be used in treatment.

Contains fulltext : 208355.pdf (Publisher’s version ) (Closed access)

Item does not contain fulltext OBJECTIVE: Health-related quality of life (HRQoL) is an important outcome in chronic disease. Generic HRQoL questionnaires may not adequately reflect disease-specific challenges in coeliac disease. We investigated whether disease-specific HRQoL questionnaires add relevant information to generic measures that will better help to identify patients experiencing problems. PATIENTS AND METHODS: We performed a cross-cultural validation of the Celiac Disease Quality Of Life-survey (CD-QOL), next we developed and validated a new disease-specific HRQoL questionnaire, and finally compared their predictive validity with the disease-generic RAND SF-36/SF-12 in 825 patients (mean age: 56.1+/-15.8 years) with (reported) biopsy-proven coeliac disease. Internal consistency and convergent, discriminative and predictive validity of the questionnaires was determined. RESULTS: Two Dutch versions of the CD-QOL were validated, consisting of 14 and six items, respectively (CD-QOL-14-NL, CD-QOL-6-NL). We developed and validated the CeliacQ-27, which has 27-items across three subscales (Limitations, Worries and Impact on daily life), and a short seven-item version, the CeliacQ-7. All questionnaires had excellent psychometric properties and differentiated well between active disease and clinical remission and strict versus poor dietary adherence. The added value of the disease-specific questionnaires to the generic HRQoL measure to the explained variance of symptom burden and dietary adherence was limited. CONCLUSION: HRQoL in patients with coeliac disease can easily be assessed by brief generic as well as disease-specific measures. Disease-specific questionnaires, however, provide more explicit information on disease-relevant areas of functioning.

Stress and sensitization are central concepts in chronic pain. Both can be a consequence and a contributor to the pain experience. This chapter describes the psychobiology of stress and sensitization within a multilevel perspective, indicating the impact of various forms of stress and sensitization on multiple psychoneurobiological processes (i.e., autonomic, endocrine, immune, and central processes) related to chronic pain. As a result of disordered stress regulation, sensitization may occur as a mechanism that explains how acute pain problems can become chronic and how acute pain problems can extend or generalize to other body parts or modalities. The evidence for stress and sensitization as consequences of or as contributors to chronic pain is reviewed, and possible underlying mechanisms are discussed. Next, strategies to reduce stress and sensitization and foster desensitization processes are described. The chapter concludes by introducing a motivational account of chronic pain informed by the stress and sensitization literature.

Background Within the field of rheumatoid arthritis (RA), patients report decreased health-related quality of life (HRQoL) as a result of living with physical factors such as pain and psychological factors such as negative mood. As these factors are associated with the disease trajectory, health care utilisation, and workplace disability of patients, these factors lead to significant societal health expenses. In a recent randomised controlled trial, improvements in especially psychological functioning (e.g., depressed mood) were found by offering tailored, therapist guided cognitive behavioural therapy online. 1 Although internet-based cognitive behavioural therapy holds promise for implementation and cost-reductions, scarce research is available on the cost-effectiveness of these treatments. Objectives A cost-effectiveness study from a societal perspective was conducted alongside a randomised controlled trial on a tailored and therapist-guided internet-based cognitive behavioural intervention (ICBT) for patients with elevated levels of distress, as an addition to usual care alone in order to inform stake-holders on implementation of this treatment. Methods Data were collected at baseline/pre-intervention, 6 months/post-intervention, and three-monthly thereafter during one year follow-up. Effects were measured in quality-adjusted life years (QALYs) and costs from a societal perspective including healthcare sector costs (including healthcare use, medication, and intervention costs), patient travel costs for healthcare use, and costs associated with loss of labour. Results The intervention improved quality of life compared to usual care alone (Δ QALYs=0.059), but also led to higher costs (Δ=€ 4.211,44), which reduced substantially when medication costs were left out of the equation (Δ=€ 1.862,72). Most (93%) of the simulated ICERS were in the north-east quadrant, suggesting a high probability that the intervention is effective in improving HRQoL, but at a greater monetary cost for society compared to usual care alone. Conclusions A positive effect on quality-adjusted life years is seen in the intervention group compared to the control group. However, cost-ratios show that this comes at a greater cost to society. The substantial costs in this population are generated by medication costs, for which no group differences could be found. The cost-benefit ratio improves when the costs for medication are not taken into account. Based on the effects for improvement of quality of life, implementation of the intervention is recommended, yet on the side of costs, further study is warranted. Reference [1] Ferwerda M, van Beugen S, van Middendorp H, Spillekom-van Koulil S, Donders ART, Visser H, Taal E, Creemers MCW, van Riel PCLM, Evers AWM. A tailored-guided internet-based cognitive-behavioural intervention for patients with rheumatoid arthritis as an adjunct to standard rheumatological care: Results of a randomized controlled trial. Pain2017;158(5):868–78. PMID: 28106666 Disclosure of Interest None declared

based cognitive behavioral therapy for patients with chronic somatic conditions Many patients with chronic somatic conditions regularly experience impairments in physical and psychological functioning in their daily life. A way to support these patients is to offer online programs based on cognitive behavioral therapy (Internet-based cognitive behavioral therapy; ICBT). Although a substantial evidence base already exists regarding the effectiveness of ICBT in treating, for example, depressive symptoms, research on ICBT for chronic somatic conditions is still upcoming. In recent years, a growing number of randomized controlled trials were published that examined the effectiveness of ICBT in various chronic somatic conditions. To systematically and quantitatively evaluate the results of these studies, a metaanalysis was conducted, the results of which are discussed in this article. Results indicated that ICBT is also overall effective for chronic somatic conditions, with small to moderate effect sizes. Larger effects were occasionally found for disease-specific outcomes such as disease symptoms and disease-specific quality of life. A longer treatment duration was found to be marginally related to a larger decrease in depressive symptoms. In addition to the results of the meta-analysis, this article provides an overview of the recent literature regarding several clinically relevant ICBT topics: cost-effectiveness, guided ICBT interventions versus self-help, the role of treatment duration, and optimal design and implementation of eHealth interventions.

Item does not contain fulltext BACKGROUND: Generic instruments measuring health-related quality of life (HRQoL), like EQ5D, enable comparison of skin diseases with healthy populations and nondermatological medical conditions, as well as calculation of utility data. OBJECTIVES: To measure HRQoL in patients with common skin diseases and healthy controls across Europe using the EQ5D. METHODS: This multicentre observational cross-sectional study was conducted in 13 European countries. Each dermatology clinic recruited at least 250 consecutive adult outpatients to complete questionnaires, including the EQ5D. RESULTS: There were 5369 participants (4010 patients and 1359 controls). Mean +/- SD self-rated health state reported by patients was 69.9 +/- 19.7; for controls it was 82.2 +/- 15.5. When adjusted for confounding factors, including comorbidity, mean patient EQ visual analogue scores were 10.5 points lower than for controls (standardized beta = -0.23). Odds ratio with 95% confidence interval for impairment in all five dimensions of EQ5D adjusted for confounders was doubled for patients compared with controls. Patients with hidradenitis suppurativa (HS), blistering conditions, leg ulcers, psoriasis and eczemas had the highest risk for reduction in HRQoL in most dimensions (2-10-fold). Data on differences of impairment by dimensions offer new insights. CONCLUSIONS: This study confirms the large impact skin conditions have on patients' well-being, differentiating between aspects of HRQoL. Patients with HS, blistering diseases, leg ulcers, infections and most chronic skin diseases reported reduced HRQoL compared with patients with chronic obstructive lung disease, diabetes mellitus, cardiovascular disease and cancers. These findings are important in the prioritization of resource allocation between medical fields and within dermatological subspecialities.

BackgroundPatients with rheumatic diseases may face ‘discounting’ (denying and patronising) or ‘lack of understanding’ because of having symptoms without external clinical signs, but instruments to assess such invalidation experiences are lacking.ObjectivesTo develop and evaluate the Illness Invalidation Inventory (3*I), to compare invalidation experiences of two groups of patients who differ in visual signs and laboratory findings—rheumatoid arthritis (RA) and fibromyalgia—and to examine the association of invalidation with health status.MethodsA questionnaire (eight items with respect to five sources: spouse, family, medical professionals, work environment and social services) was constructed. It was completed by 142 patients with RA and 167 patients with fibromyalgia.ResultsPrincipal axis factoring with oblimin rotation yielded two factors with high internal consistency (α>0.70): ‘discounting’ (five items) and ‘lack of understanding’ (three items). Patients with fibromyalgia experienced significantly more discounting and lack of understanding from their family, medical professionals, colleagues and social services than did patients with RA. Both patient groups experienced more invalidation from social services, colleagues and family than from medical professionals and spouses. More discounting and lack of understanding correlated with poorer mental well-being and social functioning in both patient groups. Discounting correlated with more physical disability and pain in patients with RA.ConclusionsThe 3*I is a brief, reliable instrument for assessing patients' perceptions of invalidation from different sources, which differ between patient groups and are associated with health status. Future validation research should clarify the clinical impact of invalidation on treatment adherence and outcome.

Contains fulltext : 151820.pdf (Publisher’s version ) (Open Access) A certain level of attention to bodily signals may be adaptive in the management of chronic skin conditions, as a lack of attention may lead to inadequate self-care behaviour and, consequently, may affect functioning and treatment outcomes. The purpose of this study was to develop a body awareness questionnaire and to investigate its psychometric properties and physical and psychological correlates in a cross-sectional study in patients with psoriasis (n = 475). The 16-item Body Attention, Ignorance and Awareness Scale demonstrated a 3-factor structure that could be interpreted as body ignorance, body attention, and body awareness (Cronbach's alpha of 0.73, 0.74, and 0.68, respectively). Higher body ignorance was significantly related to more physical symptoms and worse psychological functioning. Body attention and body awareness showed small significant correlations with coping and personality. Given the negative influence of impaired psychological functioning on treatment outcomes, it may be clinically important to screen for theses constructs of body awareness in chronic skin conditions.

Item does not contain fulltext A better understanding of the course and risk factors for impaired long-term health-related quality of life (HRQoL; ie, physical, psychological, and social-relational functioning) after kidney donation might help clinicians improve the care of live kidney donors. This systematic review and meta-analysis summarizes prospective studies about the course and predictors of HRQoL in living kidney donors. Studies indicate that shortly after donation, donors have lower HRQoL, with minor to moderate changes in psychological and social-relational functioning and major changes in physical functioning. At 3-12 months after donation, HRQoL returned to baseline or was slightly reduced, particularly for fatigue, but scores were still comparable to general population norms. Results were mainly robust across surgery techniques. A limited number of studies examined risk factors for impaired HRQoL, with low psychological functioning before donation as the most consistent predictor. Based on these results, clinicians can inform potential donors that, on average, kidney donors have high long-term HRQoL; however, donors with low psychological functioning at baseline are those most at risk of impaired long-term HRQoL. Future studies should focus on other potentially relevant predictors of postdonation HRQoL, including donor eligibility criteria and donor-recipient relationships, to optimize screening and interventions for donors at risk.

Item does not contain fulltext BACKGROUND: Psychosocial stress can be a risk factor for the maintenance and exacerbation of chronic inflammatory diseases, such as psoriasis and rheumatoid arthritis (RA). OBJECTIVES: To gain insight into the specificity of the psychophysiological stress response during chronic inflammation, we assessed autonomic and neuroendocrine responses to stress in different chronic inflammatory diseases. METHODS: Thirty patients with psoriasis (nine women, mean age 58.5 years +/- 12.4), 34 patients with RA (16 women, mean age 60.8 years +/- 9.2) and 25 healthy controls (16 women, mean age 55.6 years +/- 8.7) underwent a standardized psychosocial stress task (Trier Social Stress Test). Salivary levels of alpha-amylase and cortisol and self-reported tension levels were measured before and after the stress test. RESULTS: The cortisol response to stress was heightened in patients with psoriasis compared with patients with RA and healthy controls, whereas there were no differences in the autonomic and self-reported measures. CONCLUSIONS: The altered neuroendocrine stress response in patients with psoriasis suggests that stressful events might have different physiological consequences for specific patient groups with chronic inflammatory conditions, possibly adversely affecting disease status.

The health problems of patients with rheumatoid arthritis and fibromyalgia are mostly invisible to others, which can lead to a discrepancy between patients' and spouses' appraisals of the severity of the health problems. As a consequence, some patients may feel 'invalidation' from their spouse, such as not being understood and believed. Aim of this study was to compare patients' and spouses' appraisals of the health status of patients with rheumatoid arthritis and patients with fibromyalgia, and to examine whether discrepancies in these appraisals are associated with invalidation experiences of the patient.Eighty-four patients with rheumatoid arthritis and 95 patients with fibromyalgia filled out a health status questionnaire (MOS short-form general health survey, SF-20) and a questionnaire on invalidation by the spouse (Illness Invalidation Inventory, 3*I). The spouses appraised the patients' health status independently from the patients using a spouse version of the SF-20.Patients with fibromyalgia and their spouses appraised the patients' health status significantly worse than patients with rheumatoid arthritis and their spouses. The agreement between patients and spouses was generally fair with somewhat more agreement in rheumatoid arthritis than in fibromyalgia. Patient-spouse discrepancies in health status appraisals were not associated with invalidation experiences.The invisibility of health problems in fibromyalgia and rheumatoid arthritis is not accompanied by large patient-spouse discrepancies of health status appraisals, which suggests that invalidation by spouses is not dependent on observable evidence such as clinical signs of damage or pathology.

Emotion regulation has been associated with perceived health in rheumatoid arthritis, which is diagnosed three times more often in women than men. Our aim was to examine gender differences in styles of emotion regulation (ambiguity, control, orientation, and expression) and gender-specificity of the associations between emotion regulation and perceived health (psychological well-being, social functioning, physical functioning, and disease activity) in 244 female and 91 male patients with rheumatoid arthritis. Women reported more emotional orientation than men, but did not differ from men with regard to ambiguity, control, and expression. Structural equation modelling showed that relationships between emotion regulation and perceived health were more frequent and stronger for women than men. This held especially for the affective dimension of health, while associations were similar for both women and men with regard to social and physical functioning. Only for women, the association between ambiguity and disease activity was significant, which appeared to be mediated by affective functioning. The observations that women are more emotionally oriented than men and that emotion regulation is more interwoven with psychological health in women than men, support the usefulness of a gender-sensitive approach in research and health care of patients with rheumatoid arthritis.

Objectives: To examine whether emotion regulation predicts change of perceived health in patients with rheumatoid arthritis ( RA).Methods: Sixty six patients ( 44 female, 22 male; mean (SD) age 57.7 (11.6) years) participated in a prospective study. Hierarchical regression analysis was used to predict change of perceived health between study entry and follow up (1 1/2 years later) from the emotion regulation styles ambiguity, control, orientation, and expression at study entry.Results: Valuing and intensely experiencing emotions ( emotional orientation) predicted a decrease of positive affect. Difficulty recognising and expressing emotions ( ambiguity) predicted an increase of perceived disease activity. Emotion regulation showed no associations with change of negative affect and social and physical functioning.Conclusions: Two styles of emotion regulation were shown to have a significant though modest role in the prediction of perceived health change in patients with RA. This suggests that the monitoring of emotion regulation may help to identify patients who are at risk for a reduction of perceived health. If our findings were confirmed by experimental research, improving emotion regulation skills might favourably affect perceived health.

Objectives. Emotion regulation is hypothesized to be related to health through neuroendocrine–immune changes. This study examined the role of the neuroendocrine variables 24-h urinary cortisol and noradrenaline, and the immune variable serum interleukin 6 as mediators between emotion regulation styles and health (perceived health and disease activity: erythrocyte sedimentation rate (ESR) and Thompson joint score). Methods. Sixty patients with rheumatoid arthritis (mean age 59.0±11.2 yr; 38 female) participated. Results. Emotion regulation was not associated with immune functioning or disease activity, but it was somewhat related to neuroendocrine functioning: one of the emotion regulation styles, ambiguity, was related to noradrenaline in women (r ¼ 0.39) but not in men. The indicators of neuroendocrine functioning (cortisol and noradrenaline) were correlated (r ¼ 0.40), as were indicators of immune functioning (interleukin 6) and inflammatory activity (ESR; r ¼ 0.53), but analyses did not indicate a role of these physiological variables in mediating between emotion regulation and health: neuroendocrine variables were not related to interleukin 6 or ESR, and none of the physiological parameters was correlated with joint score or perceived health. Conclusions. To examine whether the proposed mediational processes apply to individual patients, a longitudinal withinsubjects design is needed. In our cross-sectional study, emotion regulation was somewhat related to neuroendocrine functioning, but our study did not uncover a potential mediational role of cortisol, noradrenaline or interleukin 6 in the relationship between emotion regulation and health in rheumatoid arthritis.

In previous articles, the technical specifications, validation and clinical applicability of a new metabolic calibrator for stress test apparatuses were described. However no indication was given of a basic protocol for the current clinical practice. Here we present an organised check system to satisfy this aim. A method for the exhaustive evaluation of the technical reliability of the metabolic instruments is presented together with the proposal of a uniform simulation approach to organise checks on-line of the apparatuses' ability to follow correctly the various test phases (protocol). Examples of recordings of checks using the standardised approach are shown. The method seems to be very effective. Every operation is computer directed.

Objective.To examine psychosocial problems and adaptation of adolescent girls with chronic fatigue syndrome (CFS).Methodology.Thirty-six adolescent girls with CFS (mean age: 15.2 years; mean syndrome duration: 19.7 months) who fulfilled the criteria of the Centers for Disease Control and Prevention were examined by interviews regarding premorbid problems and by questionnaires regarding psychosocial functioning and distress, psychological attitudes, and coping resources. Data were compared with normative data.Results.Of the adolescents, 86.1% reported 1 or more premorbid problems (58.3% physical, 38.9% psychological, and 52.8% familial). Normal adjustment was reported for psychosocial self-esteem, social abilities, and attentional abilities. High adjustment to adult social standards of behavior was found, but low perceived competence in specific adolescent domains, such as athletic ability, romance, and participation in recreational activities. The girls reported predominantly internalizing problems. Normal achievement motivation, no debilitating fear of failure, and high internal locus of control were observed. Palliative reaction patterns and optimism were predominantly used as coping strategies.Conclusions.The large number of premorbid problems suggests a possible contributing factor to the onset of the syndrome, although there were no reference data of healthy adolescents. In distinct domains of psychosocial adjustment, the adolescent girls with CFS showed strengths such as adequate self-esteem and scholastic and social abilities, and weaknesses such as low competence in adolescent-specific tasks and internalizing distress, which may partly be explained by syndrome-specific somatic complaints. The use of optimistic and palliative reaction patterns as coping strategies in this patient group indicates that the patients with CFS seem to retain an active and positive outlook on life, which may result in a rather adequate psychological adaptation to the syndrome, but also in maintenance of the syndrome by exceeding the physical limits brought about by the CFS. Our results on adjustment and coping strategies may be helpful to implement (individual) rehabilitation programs.

Background The popularity of E-health is rising and research has shown that E-health interventions can be effective [1]. However, they also offer new challenges and questions in clinical practice and research, for example about the role of the patient-therapist relationship [2,3]. In face-to-face treatments, a better patient-therapist relationship has often been reported as a predictor for improved treatment outcome. Objectives In an E-health cognitive-behavioral treatment for patients with rheumatoid arthritis and psoriasis, the patient-therapist relationship was assessed and related to patient-reported outcomes. Methods After a face-to-face intake, all patient-therapist contact was through e-mail. Patients rated the patient-therapist relationship pre and post treatment using the Working Alliance Inventory and internet-specific relationship questions. After treatment, patients were asked to rate improvement in symptoms and coping with these symptoms. Paired samples t-tests (patient-therapist relationship change during treatment) and regression analyses (association patient-therapist relationship and patient-reported outcome) were performed in a subsample of patients who had finished treatment. Results The patient-therapist relationship was rated positively and increased during treatment (p Conclusions These preliminary results indicate that the patient-therapist relationship is a possible predictor for self-reported improvements in E-health treatments, similar to the role of this patient-therapist relationship in face-to-face treatments. Future results need to demonstrate whether the patient-therapist relationship also contributes to the cost-effectiveness of this E-health treatment in the randomized controlled trial. References Cuijpers, P., Straten, A., & Andersson, G. Internet-administered cognitive behavior therapy for health problems: A systematic review. Journal of Behavioral Medicine 2008;31:169-77. Martin, D.J., Garske, J.P., & Davis, M.K. Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Counseling and Clinical Psychology 2000;68:438-50. Preschl, B., Maercker, A., & Wagner, B. The working alliance in a randomized control trial comparing online with face-to-face cognitive behavioral therapy for depression. BMC Psychiatry 2011;11:189. Acknowledgements We would like to thank the patient representatives Henk van Duijn, Mariette Tomas, and Hen Ros for their contributions to the study, and ZonMw (The Netherlands Organisation for Health Research and Development) and Pfizer Inc. for their financial contribution to this research project. Disclosure of Interest M. Ferwerda Grant/research support from: Pfizer Inc., S. Spillekom: None Declared, H. van Middendorp: None Declared, S. van Beugen Grant/research support from: Pfizer Inc., W. Kievit: None Declared, J. Fransen: None Declared, H. Visser: None Declared, P. van Oijen: None Declared, E. Taal: None Declared, P. van Riel Consultant for: Roche, Abbott, Pfizer, E. de Jong: None Declared, P. van de Kerkhof: None Declared, M. van der Laar: None Declared, A. Evers Grant/research support from: Pfizer Inc., Consultant for: Roche

Background Results from early E-health research for patients with several chronic somatic conditions including rheumatoid arthritis are promising [1]. Despite obvious advantages of E-health interventions for patients, research also shows high drop-out rates and low adherence, and sometimes only part of a patient population is willing to use the interventions. Patient involvement in E-health innovation projects could make the projects more attuned to the needs and wishes of patients. Although patient involvement in research and intervention development is stimulated in general [2] and also specifically for rheumatoid arthritis [3], little is known about the value of involving patients in E-health projects and is mainly based on experiential descriptions. Objectives In different E-health innovation projects for somatic conditions, including rheumatoid arthritis, patient involvement as well as patient satisfaction and user friendliness of the resulting intervention were assessed using questionnaires and interviews with different stakeholders, including patient representatives, researchers, and intervention participants. Methods A questionnaire was developed in cooperation between patients and researchers, which was filled out by all stakeholders. Patient representatives and researchers took part in (group) interviews to gain more insight into advantages and disadvantages of patient involvement in E-health research and intervention development. Descriptive and t-test analyses were performed. Results Patients are currently involved in E-health innovation projects. This involvement varies widely in both content and degree. Usually, involvement is more prominent in the development of the intervention than in research. Patient representatives and researchers have similar views on the potential benefits and difficulties of patient participation in E-health innovation projects, and are positive about patient involvement. Researchers do however report more concerns about time constraints and tend to be more critical about the resulting interventions. Results from the interviews show that patient involvement is seen as a necessity to develop useful E-health interventions. Preliminary results indicate how to resolve problems and ensure effective involvement of patients in E-health innovation projects. Conclusions Although patient involvement in E-health developments becomes more common practice, patient involvement in research is less prominent. Researchers and patient representatives are satisfied with the involvement of patients and the resulting interventions. Future results could demonstrate which degree of involvement is needed to obtain effective and patient-friendly interventions and research. References Cuijpers, P., Van Straten, A., & Andersson, G. (2008). Internet-administered cognitive behavior therapy for health problems: A systematic review. Journal of Behavioral Medicine, 31 (2), 169-177. Boote, J., Baird, W., & Sutton, A. (2011). Public involvement in the design and conduct of clinical trials: A review. International Journal of Interdisciplinary Social Sciences, 5 , 91-111. Hewlett, S., Wit, M. d., Richards, P., Quest, E., Hughes, R., Heiberg, T., & Kirwan, J. (2006). Patients and professionals as research partners: Challenges, practicalities, and benefits. Arthritis Care & Research, 55 (4), 676-680. Acknowledgements We would like to thank ZonMw (The Netherlands Organisation for Health Research and Development) and the VSBfonds for their financial contribution to this project, and would like to thank prof.dr. Jan Kremer, prof.dr. Judith Prins, prof.dr. Marjolijn Sorbi, dr. Jan Vercoulen, and dr. Chris Verhaak, and their junior researchers for cooperating in this study. Disclosure of Interest H. van Duijn: None Declared, M. Ferwerda Grant/research support from: Pfizer Inc., M. Tomas: None Declared, H. van Middendorp: None Declared, H. Ros: None Declared, A. Evers Grant/research support from: Pfizer Inc., Consultant for: Roche

Background Theories suggest that the social environment, especially one’s spouse or partner, affects one’s pain as well as emotions, which is confirmed by both cross-sectional and experimental studies. For instance, the operant conditioning model postulates that spouses may serve as a discriminant cue and selective reinforcer for the behavioral expression and experience of pain [[1][1]]. This has been confirmed in studies showing a positive correlation between a solicitous spouse response style and more severe everyday pain in people with fibromyalgia [[2][2]]. Moreover, a punishing spouse response style will more easily trigger negative emotions than a solicitous response spouse style. This can be due to classical conditioning processes such as previous associations between punishment and negative affect [[3][3]]. Finally, the coupling of pain and emotions may have become stronger in patients having a spouse with a high solicitous or punishing response style. Objectives To examine whether solicitous or punishing spouse responses predict pain, negative emotions, emotion-induced pain, and pain-induced emotions in the everyday life of female patients with fibromyalgia. Methods A diary study was conducted. At the end of each of 28 consecutive days, 229 participants with a steady relationship (age 47.5±11.1) reported a significant emotional event during the day and rated their pain as well as sadness and anger. Patient perceptions of solicitous or punishing responses from their spouses were assessed prior to the daily assessment. Multilevel regression analyses were conducted. Results Solicitous spouse responses predicted greater daily pain ( p

Background Patients with fibromyalgia vary widely in their physical and psychological functioning, and in how they perceive their disease. It has been reported that only one-third of patient benefits from treatment [1]. Multidimensional classification might help to tailor psychological treatment to the characteristics of patients [2]. Objectives 1) To replicate and describe the Multidimensional Pain Inventory (MPI) classification [3] in women with fibromyalgia and to examine whether the three MPI-classified subgroups differ in emotions, emotion processing styles, and emotion regulation strategies. 2) To study the association of emotion processing styles and emotion regulation strategies with fibromyalgia impact and positive and negative affect in MPI-classified subgroups. Methods Participants were 291 women with fibromyalgia. Cluster procedures, analyses of covariance, and moderator and simple slope regression analyses were conducted. Results Dysfunctional patients (DYS, 35% of the sample) presented the worst heath status and the highest levels of negative emotions, followed by the interpersonally distressed (ID, 26%) and the adaptive copers (AC, 38%) (all p p Conclusions This study confirms the importance of subdividing patients into subgroups and it highlights the possible differential impact of emotion processing styles and emotion regulation strategies on affect in each subgroup. Clinicians should take this into account when tailoring interventions to patients with fibromyalgia. References Turk DC. Fibromyalgia: A patient-oriented perspective. In: Dworkin RH, Breitbart WS, eds. Psychosocial and psychiatric aspects of pain: A handbook for health care providers . Seattle, WA: IASP Press 2004:309–338. Turk DC. The potential of treatment matching for subgroups of patients with chronic pain: Lumping versus splitting. Clin J Pain 2005;21:44–55. Turk DC, Rudy TE. Toward an empirically derived taxonomy of chronic pain patients: Integration of psychological assessment data. J Consult Clin Psychol 1988;56:233–238. Disclosure of Interest None Declared

Background Type D personality combines 2 stable traits: negative affectivity and social inhibition. It has been linked to poor health status and disease course and outcome in cardiovascular and other chronic conditions [1]. Patients with fibromyalgia experience high negative affect associated with symptoms such as pain and fatigue [2] and may be socially inhibited, e.g., due to earlier victimization or lack of understanding for their medically unexplained symptoms [3]. Therefore, we hypothesized that Type D personality would be prevalent in fibromyalgia and potentially relevant for functioning. Objectives The aim of the current study was to examine the prevalence and correlates of Type D personality in fibromyalgia. Methods As part of an online cross-sectional questionnaire study, 559 English-speaking patients with fibromyalgia (94% women, 21 to 77 (M=47, SD=11) years), filled out measures of Type D personality (DS14), illness invalidation from the social environment (3*I), physical and mental health (RAND SF-36), and pain, loneliness, and quality of life (visual analogue scales). Results The internal consistency of the Type D questionnaire was high (α>.90). Using the standard cut-score, Type D personality was present in 56% of patients, which exceeds the prevalence estimates in the general (13-24%), cardiovascular (27-31%), and diverse chronic pain (43%) populations [1,4]. Compared to the general population, negative affectivity was high (Cohen’s d=1.28) and social inhibition was above average (Cohen’s d=0.35). Having Type D personality was associated with worse mental health (d=1.02), more loneliness (d=0.72), more role limitations due to emotional functioning (d=0.54), lower quality of life (d=0.52), less vitality (d=0.36), poorer social functioning (d=0.27), and a higher perceived lack of understanding (d=0.23) and more discounting (d=0.20) from the social environment. Regarding physical health, only associations between type D personality and a worse general health were found (d=0.48). Conclusions Type D personality is highly prevalent in fibromyalgia and a potential risk factor for emotional and social adjustment in fibromyalgia. In contrast to the evidence in cardiovascular diseases, Type D is not associated with poorer physical health. References Mols F, Denollet J. Type D personality among noncardiovascular patient populations: A systematic review. Gen Hosp Psychiatry 2010;32:66-72. Van Middendorp H, Lumley MA, Jacobs JW, et al. Emotions and emotional approach and avoidance strategies in fibromyalgia. J Psychosom Res 2008;64:159-67. Kool MB, Van Middendorp H, Lumley MA et al. Lack of understanding in fibromyalgia and rheumatoid arthritis: The Illness Invalidation Inventory (3*I). Ann Rheum Dis 2010;69:1990-5. Barnett MD, Ledoux T, Garcini LM et al. Type D personality and chronic pain: Construct and concurrent validity of the DS14. J Clin Psychol Med Settings 2009;16:194-9. Acknowledgements This study was funded by the Dutch Arthritis Association. Disclosure of Interest None Declared

Background Patients with fibromyalgia often report that the weather aggravates their symptoms, but research so far did not conclusively demonstrate such a relation. Objectives To examine the association between weather conditions and daily symptoms of pain and fatigue in female patients with fibromyalgia, and to identify patient characteristics explaining individual differences in these associations. Methods Female patients with fibromyalgia ( n =333, mean age 47.0 years, mean time since diagnosis 3.5 years) completed diaries, including questions on immediate pain and fatigue during 28 consecutive days. The daily weather conditions that were obtained from the Royal Netherlands Meteorological Institute (KNMI) in “De Bilt99, the Netherlands, included air temperature, sunshine duration, rainfall, atmospheric pressure, relative humidity, and wind speed. Multilevel regression analysis was applied. Considering that six weather conditions were included, the p -value was set to 0.008. Results Few significant, but small associations were found between weather conditions and symptoms of pain and fatigue. Pain was associated with an increase in relative humidity on the previous day ( p =0.004) and with rain on the same day ( p =0.003); fatigue was associated with a higher air temperature on the previous day ( p =0.001).Patients differed from each other with respect to associations of weather conditions with pain and fatigue (see Figure). However, no demographic, functional or mental patient characteristic was found to explain these differences in weather sensitivity. Conclusions This study provides few indications for at best a small overall influence of weather conditions on daily pain and fatigue in female patients with fibromyalgia. Associations between weather and symptoms differ between patients, but it is unclear which patient characteristics play a role in this. Disclosure of Interest None Declared

Background About 5% of the Dutch patients with rheumatoid arthritis and 20% of the patients with fibromyalgia experience invalidation by medical professionals sometimes or often. Invalidation is defined as responses of others that are perceived as lack of understanding (not supporting and not acknowledging) and discounting (patronizing and denying) with respect to the condition of the patient [1]. It is unknown to what extent medical professionals, such as rheumatologists, may have a tendency to invalidate patients with rheumatoid arthritis and patients with fibromyalgia. Objectives The aim of this study was to examine whether rheumatologists have more feelings of lack of understanding and discounting, together defined as ‘invalidation’, towards patients with fibromyalgia than towards patients with rheumatoid arthritis. Methods The patient version of the Illness Invalidation Inventory (3*I) was adjusted to the perspective of the rheumatologist. Online, 84 rheumatologists filled out the rheumatologist version of the 3*I to indicate how often during the past year they experienced the described statements (e.g., ‘I think they are exaggerators’ and ‘I take them seriously’) towards their regular patients with rheumatoid arthritis or fibromyalgia. Results The rheumatologist version of the 3*I showed the two expected factors present in the patient version, discounting and lack of understanding. Internal consistency was acceptable (α RA:.71 and FM:.70) for the discounting factor, and questionable to poor (α RA:.69 and FM:.57) for the lack of understanding factor. Rheumatologists reported significantly more feelings of discounting (F=119.9, p d = 0.98) and lack of understanding (F=27.3, p d = 0.55) towards patients with fibromyalgia than towards patients with rheumatoid arthritis. Seventy percent of the rheumatologists experienced discounting towards patients with fibromyalgia sometimes or often, while this percentage was 27 with regard to patients with rheumatoid arthritis. Lack of understanding towards both patients groups was higher in younger than in older rheumatologists ( r = -.26, p =.02). Conclusions In accordance with the perception of patients, rheumatologists report more feelings of invalidation towards patients with fibromyalgia than towards patients with rheumatoid arthritis. Future research can examine whether rheumatologists verbally or non-verbally communicate their feelings of invalidation towards patients. In educational programs, it seems important to include attention to invalidation experiences; especially in education of young rheumatologists. References Kool MB, van Middendorp H, Lumley MA, Schenk Y, Jacobs JWG, Bijlsma JWJ, Geenen R. Lack of understanding in fibromyalgia and rheumatoid arthritis: the Illness Invalidation Inventory (3*I). Ann Rheum Dis 2010;69:1990-5. Acknowledgements This study was funded by the Dutch Arthritis Association. Disclosure of Interest None Declared