Psychosocial functioning and physical symptoms in heart failure patients

Abstract

Objective

Heart failure (HF) markedly diminishes an individual's quality of life. However, little is known about how psychosocial functioning is related to heart failure physical symptom expression (e.g., chest pain or heaviness, shortness of breath) on a day-to-day basis.

Methods

Fifty-eight HF patients completed daily diaries that evaluated mood, social support, coping, and physical symptoms for 2 weeks.

Results

After being prewhitened for serial dependencies, the data were entered into regression analyses to determine the concurrent and lagged relationships among them. Significant concurrent relationships were obtained between physical symptoms and depression, social conflict, positive and negative mood, and symptom-focused coping. Furthermore, negative mood and distraction coping predicted greater physical symptoms the next day, while action/acceptance coping predicted fewer physical symptoms the next day.

Conclusion

Our data provide evidence for an association between daily psychosocial functioning and HF physical symptoms. Implications for research and clinical work with HF patients are discussed.

Introduction

Heart failure (HF) is debilitating, costly, and increasingly common [1], [2]. HF is increasing in incidence, prevalence, and overall mortality [1]. Approximately 5 million Americans currently suffer from HF and 550,000 new cases are identified each year [1], [2]. HF can significantly compromise quality of life by contributing to severe physical, role, and social functioning impairment, as well as increasing psychological distress [3], [4], [5], [6], [7], [8], [9], [10], [11], [12]. HF impairs quality of life more than any other common chronic medical condition [10]. When compared to a norm-referenced group of coronary artery disease patients, HF patients reported lower psychosocial adjustment [8] and a higher incidence of unremitting major depression [9]. The aim of this investigation is to examine the association between psychosocial functioning and HF physical symptom expression (e.g., chest pain or heaviness, shortness of breath) on a day-to-day basis.

Because physical and emotional functioning is compromised in HF patients, the accessibility and quality of social support is likely to contribute to physical symptom expression in many HF patients. Social support may buffer the adverse effects of stress and provide tangible opportunities for advice and assistance. Research on HF and social support suggests that a lack of adequate social support may contribute to perceptions of impaired health, rehospitalization, and HF-related mortality [4], [13], [14], [15], [16], [17].

Coping behaviors, which can be conceptualized as cognitive and behavioral efforts to manage the demands of HF, may be used to eliminate, ameliorate, or accept HF-related physical symptoms and psychological distress. Research has shown that coping with heart disease influences rehospitalization in ischemic heart-diseased patients [18] and impacts return to work in post-myocardial infarction (MI) patients [19]. To the extent that coping behaviors increase a sense of mastery, enhance feelings of acceptance, or help a HF patient to keep his or her mind off the illness, they are likely to be associated with HF physical symptoms [5], [20].

Despite the significant impact of HF on psychosocial adjustment, little is known about how day-to-day psychosocial functioning is associated with HF physical symptoms. Furthermore, detailed, within-individual examinations of psychosocial functioning in HF patients have not been published. This may reflect, in part, that the rigors of daily reporting may be difficult for this population given the instability of health and stamina that often accompany HF. Indeed, our own pilot research using daily diaries with HF patients revealed increased compliance and a strong patient preference for diary recording periods that did not exceed 2 weeks.

Research examining psychosocial factors in HF populations has traditionally used self-report instruments given to patients on one occasion. These instruments generally ask a respondent to summarize his or her physical and emotional functioning during the last several weeks or months [21], [22]. Research suggests these types of self-report measures, which require informants to recall events over several weeks or months are subject to distortion and bias from factors such as mood, past behaviors, preconceived notions, and self-image [23], [24], [25], [26]. Assessments from a single occasion also limit conclusions regarding the temporal relationship among psychosocial factors and physical symptoms. In general, daily diaries are less likely to be subject to cognitive distortion [27], less likely to rely on patients' limited ability to summarize and integrate information, and more able to begin to explicate the temporal relationships among constructs [28].

A number or research investigations have employed daily diaries to more closely examine the temporal relationships among psychological constructs or among psychological constructs and physical symptoms in other patient populations, such as chronic pain [29], [30], [31], [32], [33], [34], [35], fibromyalgia [36], irritable bowel syndrome [37], [38], diabetes [39], [40], and epilepsy [41]. In general, the conclusions from many of these investigations are that stress, mood, coping, and social support may influence and be influenced by disease-related physical symptoms on a day-to-day basis. For example, daily negative mood states may be associated with disease-related physical symptoms. Among women with irritable bowel syndrome, increases in psychological turmoil (i.e., anger, anxiety, depression, guilt, hostility, impatience, irritability, tearfulness, and tension) were associated with greater GI symptom distress [37]. In addition, in patients with reflex sympathetic dystrophy syndrome, depressed mood was associated with greater next-day pain, and greater pain was associated with increased next-day depression, anxiety, and anger [35].

Although social support has been shown to moderate the association between stressful events to next-day mood in rheumatoid arthritis (RA) patients [33], few studies have examined how daily changes in supportive or unsupportive interactions are associated with physical symptoms. In addition, comparatively few studies have examined coping as a daily process in managing physical symptoms [29], [42]. In several studies with RA patients, daily coping was associated with decreases in pain on the same and next day [29], while increased pain in recently depressed RA patients appeared to increase doubts in the effectiveness of their pain-coping strategies [42]. Finally, research suggests that an increase in pain from Days 1 to 2 is likely to influence the use of a different coping strategy from the previous day [42].

This investigation examines daily psychosocial factors and physical symptoms in patients with HF. The goal of this preliminary investigation was to better understand the temporal relationships among psychosocial functioning and physical symptoms that often accompany HF. The instability of health and stamina that often accompany HF necessitated a shorter reporting period than is typically performed with within-subjects data. Thus, a secondary goal of this project was to ascertain if meaningful relationships among these constructs could be derived from relatively brief time series (i.e., 2 weeks of daily reporting). A small number of previous investigations with short measurement duration supported the viability of this approach [43].