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In a study conducted by Treharne et al., (2005), the relationship between RA since diagnosis and some psychological factors was explored. The study recruited a total of 154 participants, including: males (n=41) and females (113) with RA. The contributors were classified into three groups for different lengths of time of having experienced RA. The first group, early RA, included 55 people with less than six months since diagnosis. The second group, intermediate RA, included 52 members with one to seven years living with RA, and the final group included 47 people with over seven years established RA. All the group members filled in the same psychosocial questionnaires, for instance, the Illness Perception

Questionnaire (IPQ; Weinman, Petrie, Moss-morris, & Horne, 1996), to measure the perceptions of the RA illness, such as control or cure. The Life Orientation Test (LOT, Scheier & Carver, 1985) was also used to examine the levels of pessimism or optimism. Symptoms of anxiety and depression were assessed by means of the Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983) and social support was explored via the Social Support Survey (SSS; Funch, Marshall, & Gebhardt, 1986). The study identified psychosocial factors as being significant for the well-being of those diagnose with RA at different stages of their RA. For instance, the group with early onset presented more depression and lower life satisfaction. The members in group two, living with RA for one to seven years, showed more morning stiffness, and the third group, over seven years having established RA, illustrated social support in relation to levels of fatigue. However, the authors concluded that the type of social support might be important and require further attention, since emotional support may be beneficial in the early stages of RA, whereas functional support might be more appreciated in the later stages of the disease. Equally, the early RA and intermediate group reported more optimism in relation to experiencing lower levels of pain. While this study highlights the importance of psychosocial factors when exploring the impact of well-being in individuals with RA, the study focus is limited since the partakers were all Caucasian with an uneven gender ratio.

Treharne, Lyons, Booth, & Kitas, (2007) investigated whether using effective coping strategies is related to psychological well-being and perceived stress, in a longitudinal study design which assessed people with RA at the baseline, after six months and one year. It included 134 people with RA, and the majority were female (n=101) and married. The mean age was 55.5 years and they completed questionnaires that considered perceived stress, coping resources and psychological well-being, such as anxiety, depression and life satisfaction (see Treharne et al., 2007). The study findings show that perceived stress had the highest association with psychological well-being at the starting point, and also impacted on anxiety during the next six months (Treharne et al., 2007). Individuals with RA who were more pessimistic described higher levels of anxiety and depression at the baseline and at six months later; they also reported decreased levels of life satisfaction at six months. The findings from the Treharne et al. (2007) study support the unhelpful impact of negative thinking and the importance of positive thinking, as well as that they might have different effects over time. Furthermore, pessimism and stress were linked to lower psychological

well-being, whereas optimism, cognitive coping and social support were associated with stronger psychological well-being, even after one year, which suggests that pessimism and optimism might have differing effects over time. This study suggests that people with RA with larger levels of perceived stress, who avoid using active coping strategies, are more likely to be exposed to psychological problems. The study cited that people in the early stages of RA are more likely to be in denial about the illness compared to their counterparts who are established patients.

In a study conducted by Revenson, Schiaffino, Deborah Majerovitz, & Gibofsky, (1991) it was confirmed that those with RA with lower perceived support are more depressed in the first four years of the disease compared to those with greater support. Although the findings of these studies enhance the longitudinal evidence more, it is also possible that psychosocial status measured at one point in time does not have much of an impact on psychological well-being as time passes. It is also possible that more complex occurrences might take place that cannot be captured in a study with various time points.

Considering the impact of time post-diagnosis in individuals with RA, Newman & Revenson, (1993), argued that time can have two contradictory effects on RA. On the one hand, in the majority of people, accumulating time with the disease might lead to higher levels of disability; on the other hand, time might have a positive impact in terms of leading to a superior level of adaptation to the illness since people can learn to adjust to the long- term impact of the disease (Newman & Revenson, 1993). Correspondingly, this may confirm that, as people learn to cope with the symptoms, over a long period, they can potentially produce higher levels of RA adaptation, suggesting that people with RA familiarise themselves with the disease when given more time to develop successful strategies to overcome the hassles of RA. Therefore, time possibly will also lead to a greater level of psychological alteration as people with RA learn to adapt to the disease and possibly modify their anticipations and meaning of life and thus long- time sufferers are better adjusted (Newman & Revenson, 1993). Hence, it may be concluded that certain people with RA may display more PPC due to their personal resources, such as age and years post diagnosis. The present thesis predicted that:

a) There is a significant difference in PPC between RA duration groups (the RA duration groups are: 2-5; 6-10 and over 10 years since diagnosis)

b) That there is a significant positive correlation between PPC and RA duration groups (one-tailed).

Broadly speaking, experiencing RA is usually considered to go hand in hand with experiencing certain changes, for example, changes in bodily function, uncomfortable physical appearance, or changes in social and psychological status. It is also essential to recognise how persons with RA interpret their disease and how it interrupts their behaviour, interactions with others and consequently their adaptive coping strategies. The literature supports the proposal that individuals with RA might experience both positive and negative effects of disease (Tennen & Affleck, 2002). However, usually the negative side of the RA is focused upon neglecting the consideration of the potential benefits (Norekvål et al., 2008). Based upon, the experience of illness reported by people with RA, some previous studies found that people with chronic health conditions report improvement in their skills and confidence and in managing their health problems (Dures et al., 2013; Iversen et al., 2010). In addition, Sodergren et al., (2002) suggested that people with chronic health conditions experience positive consequences of illness more commonly than often realised. Hence, the next section aims to discuss the outcomes of some of the past research in support of PPC in people with RA.

1.4. Investigating Positive Psychological Change in people with Rheumatoid Arthritis