Introduction
Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease [
1]. The population prevalence of RA is relatively stable and ranges between .5 and 1 % with a higher incidence rate for women than for men [
2‐
5]. Pain is among the most serious and disabling symptoms reported by patients. It is also believed to be a crucial determinant of patients’ emotional state [
6] and overall quality of life [
7]. Nonetheless, empirical evidence has shown that coping strategies can qualify effects of pain on daily affect [
8], especially when pain intensity ranges between low to moderate. Effects of pain-related coping strategies can be distinguished depending on their problem- or emotion-focused character. Problem-focused coping strategies are mainly related to better adjustment, whereas emotion-focused strategies were shown to be associated with higher pain and worse well-being [
9‐
11].
However, a great majority of these studies have concentrated only on the negative side of affective well-being, and thus less is known about strategies that may create, maintain, or support positive affective states when coping with chronic pain. They can be analyzed within the scope of meaning-focused coping, which has been defined by Folkman and Park as appraisal-based efforts to derive meaning from the stressful experience in order to sustain well-being in spite of difficult times [
12‐
14]. Positive reappraisal is at the core of meaning-focused strategies, but their functions go beyond it, including also strategies that allow to actively control the situation, create positive sensory events, or fill daily routine with meaning [
12]. In addition to problem-focused and emotion-focused coping, meaning-focused coping is thus another major coping function [
15,
16]. This was also supported by findings from structural analyses of different coping questionnaires (see for instance [
17,
18] or [
19]).
As a driving force for positive emotions under stress, meaning-focused coping may be an important part of accommodative coping [
20], required when there are hardly any possibilities for major changes in objective characteristics of the situation. Growing empirical evidence has supported this assumption in the context of chronic health stressors [
21‐
24], which suggests that meaning-focused coping may also be beneficial when dealing with chronic pain. On the basis of this knowledge, it can be supposed that creation, maintenance, or support of positive affective states when facing chronic pain is achieved through different pathways [
25]. Among cognitive ones, positive reappraisal is best recognized and proved to be effective [
26], especially when perceived control is low [
27], which can be contrasted with the well-documented debilitating role of catastrophizing [
28]. Other meaning-focused strategies, being a mixture of cognitive processing and behavioral actions, just like intentionally creating and inducing positive sensory events with special meaning (e.g., having dinner with friends, see: [
12]), still require more systematic research as they are either poorly represented in existing coping questionnaires or classified within the same category as behavioral distraction. Also, meaning-focused coping with pain has not been studied yet in a day-to-day fashion.
Daily pain was shown to be associated with higher negative and lower positive affect [
29]. There is an ongoing debate in the literature whether positive and negative affects are two independent dimensions [
30] or two poles of one bipolar dimension [
31]. However, there is an agreement that even when analyzed in the chronic pain context [
32], distinct coping efforts are probably required for effective regulation of positive and negative emotional states [
33‐
35].
Thus, it is hypothesized that higher daily intensity of meaning-focused coping correlates with a higher level of daily positive affect, but not with a lower level of daily negative affect (hypothesis 1). If such relations are to illustrate functional specificity of meaning-focused coping, they should be observed even after control for pain level, emotion- and problem-focused coping strategies, and interindividual variability in coping.
When looking for a possible mechanism of the relation between pain, coping, and affect, a mediation model is theoretically justified. It is also in accordance with both Folkman’s [
12] and Park’s [
36] view on meaning-making processes under stress. Meaning-focused strategies are a response to distress, so they can be positively correlated with pain. In that light, on more painful days, higher intensity of meaning-focused coping should be observed, which would in turn be associated with increases in positive affect, but not necessarily with decreases in negative affect (
hypothesis 2). This way, meaning-focused coping can suppress the debilitating influence of pain on emotional state (for the detailed description of suppression see [
37]). To prove such a specific effect, it should be present in a multiple mediation model [
38], when adjusted for possible meditational effects of other coping strategies, i.e., problem- and emotion-focused ones.
Discussion
Although in previous studies the relationship between chronic pain and affect has been intensely explored, the current study is, to our knowledge, the first one that directly examines a role of meaning-focused coping and describes this relation during hospitalization on a day-to-day basis. It was hypothesized that among women hospitalized due to RA, higher values of MFC on a given day would be associated with higher PA, but not with lower NA, and that MFC would suppress the effect of pain on PA. Both these hypotheses were supported. The results can be also interpreted in terms of MFC incremental validity above and beyond PFC and EFC as all analyses were controlled for their possible interrelations. Thus, findings further support a theoretical distinction of MFC from PFC and EFC.
Furthermore, a separation of more stable interindividual characteristics (level 2, between-person) from daily fluctuations (level 1, within-person) revealed limitations to a beneficial role of daily MFC. It seemed to suppress the negative effect of daily pain on PA only when the general level of pain was below sample average, and when this strategy was implemented more in response to the situation than as a general preference. The higher pain intensity is, the more difficult it is to control it through cognitive processes. First, the cognitive functioning itself gets impaired due to pain-related load of limited neuronal resources which in turn impedes self-regulation [
54]. Secondly, such pain can be caused by active inflammation, disease progression, or structural changes in joints, all of which are not subject to volitional control [
55]. Thus, an implementation of MFC strategies may not be sufficient to sustain daily PA in face of intense pain. Also, using MFC seems to be more beneficial to patients who use it more occasionally than habitually. Keeping in mind that only very few measurements were available, probably too few to comment on the possible patterns, it could be hypothesized that occasional use of MFC may be a more deliberate response to demands of a given day and as such may have been more effective [
56]. On the other side, habitual use of MFC may merely reflect personal preferences, independent from situational context. Therefore, some mismatch between more frequent implementation of such strategies and changes in day-by-day pain level may occur.
However, it must be noted that patients who used MFC with an overall higher intensity had a generally higher level of PA (controlled for pain), independent of these coping strategies’ daily variations. Thus, both kinds of use (habitual vs contextual) may be beneficial, but for different persons and probably through different mechanisms. Taken together, it shows an interesting interplay between stable (level-2 "style") and contextual (level-1 "strategy") aspects of coping behavior. Clinically, these findings may contribute to better fit interventions to patients’ needs which are of special importance when effective coping with chronic pain is fundamental for health-related quality of life [
57]. More traditional data analyses do not allow for the separation of such effects.
Additionally, there was no relation between NA and pain at any level after control for coping strategies. It may suggest the effectiveness of coping, even if only level-2 MFC appeared to be significant. On the other hand, co-occurrence of negative affect and pain is probably not so obvious as assumed on the basis of findings from cross-sectional studies, where between- and within-person variance is not systematically separated [
58]. In studies that take into account a hierarchical data structure, the aforementioned relationship has already been noted as insignificant, especially when a moderate or lower pain level was considered. This was also the case here as the sample pain mean was below five on the ten-point pain scale. For instance, Hamilton et al. [
59] did not obtain the prospective effect of pain on NA for women with rheumatoid arthritis assessed in weekly intervals. The level of pain as well as a baseline zero-order correlation between pain and NA in that group was similar to the one reported in the current study. Using a within-day perspective, such lack of significant relationships between pain and NA was noted by Newth and Delongis [
60], as well. This was also the case in the prototypical study differentiating individual and contextual influences in relations between daily hassles, mood, and chronic pain by Affleck et al. [
61]. Nonetheless, these null findings can be misleading [
59] because plenty of level-2 moderators of the pain and NA relationship have already been reported, including a history of depressive episodes, vulnerability or pain acceptance [
62‐
64]. Still, this may indicate that a debilitating effect of pain on state affect is not necessarily true for every RA patient (see also [
65] for comparison).
However, the current study has limitations that should be kept in mind when discussing the results. Although a diary approach was implemented, the present design consisted only of few measurements, which was determined mainly by an expected short duration of the participants’ hospitalization, but may result in insufficient statistical power. Alternatively, such an approach is more reliable than a cross-sectional study. Still, the question arises how this might influence the findings. When the raw correlations were inspected carefully, we noticed that all coefficients were generally weaker for the third day of the study, compared to relations noted for the previous days. Two explanations are possible. First, this may be an artifact due to the testing procedure, an effect already observed in other dairy studies [
66]. However, quite interestingly, this effect would address only correlations among indicators of different constructs as this drop was not noted for autocorrelations among indicators of the same construct over time. Also, stable mean and SD values would not support this methodological argument. Thus, another explanation should be considered: Weakening of correlations can be a sign of an adaptation process and because of it results should be interpreted mainly in the context of the first days of hospitalization. Moreover, the correlative character of the study design makes all the interferences only probabilistic. Data collection was also restricted to women. Accordingly, findings may also be valid only for women with RA, as in previous research significant gender differences are systematically noted with regard to pain intensity and affect [
67,
68]. It must be noted, however, that the first days after admission are probably the most challenging for patients, and that a majority of those diagnosed with RA are women, so the clinical value of the obtained results seems promising.
Finally, a wide range of patients’ age can be perceived as both a weakness and a strength of the study. Older age among RA patients is connected with higher comorbidity [
69], which was not sufficiently included in the study, also due to the fact that at the time of the study, RA was the patients’ only major health concern. On the other hand, age appeared to be normally distributed and unrelated to pain, affect, and coping so there is no evidence that older patients in our sample provided any substantially different data on these variables. Thus, as older adults (≥65 years) have rarely participated in the studies regarding coping with RA, our findings may suggest that age itself is not a determining factor underlying patient’s actual functioning (see also [
70,
71]), which should stimulate further research in this area.
To sum up, daily meaning-focused coping was found to suppress the negative effect of daily pain on positive affect. Advanced methodological and statistical approaches allow to separate within- from between-person sources of variance and to determine the limits of the aforementioned effect. Also, as far as we know, it is the only diary study of RA patients during hospitalization. As such, it has a strong clinical relevance regarding the high hospitalization rate among this group of patients, who cite pain as one of the leading causes of lowered quality of life [
7].