Original Articles
Mental adjustment, coping strategies, and psychological distress among end-stage renal disease patients

https://doi.org/10.1016/j.jpsychores.2005.01.004Get rights and content

Abstract

Objective

The study examines the association between mental adjustment, coping strategies [emotion (EF) and problem focused (PF)], and psychological distress.

Method

Sixty end-stage renal disease (ESRD) patients were interviewed a year or more after they began dialysis, measured by the COPE, Mental Adjustment to Cancer (MAC), and Brief Symptom Inventory (BSI) scales.

Results

The main findings indicate that patients with a strong fighting spirit are in less psychological distress. Moreover, patients who tend to use PF strategies rely on a fighting spirit as an adjustment coping style.

Conclusion

ESRD patients in the adjustment phase (patients diagnosed at least 1 year previously) tend to struggle to lead as normal a life as possible despite the dependency caused by the illness.

Introduction

End-stage renal disease (ESRD) is a chronic, life-threatening condition. Inevitably, psychological distress is highly prevalent among ESRD patients and, moreover, has been found to contribute to greater morbidity, and even to earlier mortality, in this population [1], [2]. Evidence suggests that psychological distress accompanying ESRD is alleviated when the patients' style of coping is consistent with the demands of the renal treatment they are undergoing [3].

Although mental adjustment as a style of coping has been found to be an important factor affecting psychological distress in most chronic illness—e.g., in the case of breast cancer [4], immunodeficiency virus infection [5], muscular dystrophy [6], leukemia and lymphoma [7], and cervical cancer [8]—no research in this area has been devoted to ESRD patients. In light of this gap, the present study has a twofold aim: (1) to assess the association between mental adjustment style and coping strategies, on the one hand, and psychological distress on the other—a relationship that has not been examined explicitly so far, although several conjectures have been made; and (2) to explore whether the mental adjustment (fighting spirit) style of coping and the use of problem-focused (PF) coping strategies predict less psychological distress.

ESRD is defined as engendering a state of prolonged stress. The dialysis patient must cope with the constant threat of death, reduced life expectancy, decreasing physical strength, and an intrusive medical regime [9] that necessitates dependency as a result of dialytic therapy sessions typically scheduled three times weekly for an average of 4–6 hours per session, usually in a hospital. Other burdensome aspects are weight gain and continuous monitoring of blood pressure and serum electrolytes to evaluate patient adherence to dietary limitations and a complex pharmacological regimen [19]. How ESRD patients adjust to the alteration in their lives caused by these ongoing stressful experiences depends on their coping process [10], namely, how they evaluate the stress (appraisal) and what coping resources they have.

Research shows that coping strategies represent behavioral and cognitive efforts to deal with stressful encounters (e.g., Refs. [11], [12]). Such strategies have been classified by Lazarus and Folkman as either problem or emotion focused (EF), thereby delineating the functions of coping as dealing directly with the problem or with its emotional and physiological outcomes, respectively. In subsequent studies [13], [14], coping strategies were classified by outcome as having either functional or adaptive value, while effectiveness was assessed in terms of stressor/distress elimination and the preservation of social functioning and a sense of well-being [15]. Other research has shown PF coping to be more effective than EF coping in terms of emotional reactions and performance levels in a stressful situation [16], [17]. The model of mental adjustment of Moorey and Greer [18] focuses on the appraisal, interpretation, and evaluation of the illness made by patients, which determines their emotional and behavioral reactions. A cognitive triad is involved in this process, consisting of a negative view of the diagnosis, control of the disease, and prognosis. Five common adjustment styles emerge from the process, each representing a slightly different way of viewing the threat to survival: fighting spirit, denial, fatalism, helplessness/hopelessness, and anxious preoccupation. The patient with a helplessness/hopelessness response, for example, sees the diagnosis as a death sentence, believes there is nothing anyone can do about it, and feels hopeless about the future.

Based on the two coping-with-stress models (cognitive and mental), an important question arises related to the way renal patients cope with the illness: Is there an association between coping strategies (PF and EF), mental adjustment and psychological distress?

Extant research on the psychological distress of ESRD patients focuses mainly on the characteristics and the prevalence of depression among them [2], [20], [21], [22]. Only a few studies deal with coping strategies and psychological distress in the ESRD context. One of the earliest [23] reported that active coping strategies adopted by patients with ESRD who were undergoing dialysis diminished over time. Baldree et al. [24] and, later, Gurklis and Menke [25] found that such patients experience psychological and physiological stressors equally and use PF coping strategies more often than EF coping. Moreover, they found no significant association between stressors and coping strategies. Murdaugh [26] examined the coping responses of dialysis patients by having them rank the order of the coping responses cited in the Jalowiee Coping Scale. The top 11 of 20 coping responses chosen were problem focused. In the realm of an association between personal resources and coping strategies, Blake and Courts [27] reported that patients aged 50–60 who were on dialysis for less than 8 years had an educational level of less than 12 years, showed no differences related to gender, and used more EF coping strategies. A study by Lindqvist et al. [28] found that men regarded themselves as better able to cope with the physical aspect of the illness.

Several studies using the Mental Adjustment to Cancer (MAC) scale to measure adjustment to chronic illness have shown that mental adjustment characterized as a fighting spirit is associated with better psychological adjustment; mental adjustment representative of helplessness/hopelessness, anxious preoccupation, and fatalism is associated with high psychological distress; and denial is not associated with psychological distress (e.g., Refs. [4], [5], [6], [29], [30]. Naetterlund et al. [6], for example, found significant correlations between (MAC) mental adjustment and quality of life among 45 muscular dystrophy patients, although the correlations were weak to moderate and according to data from two separate points in time (1991 and 1996). Hirabayashi et al. [5], in a study of HIV patients, indicated that emotional controls, including lack of a fighting spirit, helplessness/hopelessness, and anxious preoccupation, are key determinants of quality of life (physical and psychological states). Similarly, Montgomery et al. [7] showed that leukemia and lymphoma patients most likely to be suffering from severe psychological distress were those with a worse coping style, as measured by the MAC scale. Grassi et al. [31] indicated that psychological distress (BSI) was associated with poor coping (MAC coping factor) among Hepatitis C and HIV patients and the same finding was present in the study of Nair [8] of cervical cancer patients.

Furthermore, studies that used coping measurements other than MAC have generally found parallel relationships. For example, Carver et al. [32] found that the acceptance and the use of humor predicted lower psychological distress, while denial and behavioral disengagement predicted more psychological distress. Stanton and Snider [33] showed that better psychological adjustment by breast cancer patients was associated with “maintaining a positive focus”, while patients who used cognitive and behavioral avoidance strategies experienced high levels of emotional distress.

Based on theory and extant research in coping with stress [13], [18], [34], on studies on the contribution of mental adjustment to the coping process in chronic illness, and the physical characteristics of ESRD, the following four hypotheses were posited:

  • (1)

    A correlation exists between mental adjustment and coping strategies: ESRD patients who have a stronger fighting spirit as an adjustment style will tend to use a more PF strategy, while those who display anxious preoccupation, helplessness/hopelessness, or fatalism will tend to use an EF strategy.

  • (2)

    A correlation exists between mental adjustment and psychological distress: ESRD patients who tend to have a fighting spirit will be in less psychological distress, while patients who tend to use an anxious preoccupation, fatalism, or helplessness/hopelessness adjustment style will be in greater psychological distress.

  • (3)

    A correlation exists between denial as an adjustment style and psychological distress: ESRD patients who adopt denial as an adjustment style will have less psychological distress.

  • (4)

    A correlation exists between denial as an adjustment style and EF strategies: ESRD patients who show less denial tend to use more PF strategies, while patients who use more denial tend to use EF strategies.

Section snippets

Sample

The research sample was drawn from Hebrew-speaking ESRD patients under treatment in two hospitals in northern Israel during October 2001–October 2002, a year or more after they began treatment. The sample included patients aged 30–65 who are not failure transplantation and who were Hebrew speaking. Arab patients and new immigrants were not included in the sample, both because of linguistic inability to reply to the questionnaires and because they constituted a small group of the patient

Results

The first step in the analysis was to ascertain whether a correlation exists between mental adjustment subscales, coping strategies (EF and PF), and GSI (psychological distress). Table 2 presents the means, S.D., and correlation (Pearson) between mental adjustment subscales, coping strategies (PF and EF), and GSI. A significant negative correlation was found between helplessness/hopelessness, anxious preoccupation, and fighting spirit, while a positive correlation was found between denial and

Summary and discussion

ESRD is a life-threatening condition that evokes psychological distress. The present study was designed to examine the association between coping strategies (PF and EF), mental adjustment style of coping (fighting spirit, denial, helplessness/hopelessness, anxious preoccupation, and fatalism), and psychological distress among 60 ESRD patients.

The findings partly confirm the first hypothesis, namely, that a positive correlation exists between mental adjustment and coping strategies: ESRD

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