For bitter or worse. Embitterment in rheumatic diseases

Abstract

In clinical practice and in the context of work and disability pension examinations, clinical and vocational professionals regularly encounter patients with a rheumatic disease who are embittered. These patients view themselves as victims of external factors, experience a sense of resentment and injustice, show low motivation to improve their situation and have a misanthropic stance. The aim of this thesis was to improve insight into the phenomenon of embitterment in patients with a rheumatic disease. Using the cognitive appraisal theory of emotion as a framework, we hypothesized that appraisals that constitute embitterment will give rise to three emotions: (1) the undermining and flouting of one’s values and norms will be shown in the self-conscious affects of shame and guilt, (2) other-responsibility will be shown in anger and hostility, and (3) uncontrollability will be manifested in sadness. As hypothesized, embitterment was particularly associated to shame and guilt, hostility, and sadness. The question why some individuals are more prone than others to embitterment may partly be answered in terms of personality vulnerability factors. It was observed that the co-occurrence of high neuroticism (i.e., the tendency to react with negative emotions) and low agreeableness (i.e., the tendency to value getting along with others) was associated with embitterment. This might reflect that individuals with high neuroticism who lack agreeableness are impaired in the pro-social attenuation of hostile cognitive-emotional states in response to invalidation. This may clear the way for embitterment. An insecure attachment orientation may also be a vulnerability factor. Individuals may manage their attachment insecurity in two ways. Anxiously attached individuals hyperactivate their attachment system to avoid lack of acceptance and support, whereas avoidantly attached individuals deactivate their attachment system to avoid dependency and getting hurt. Especially the anxious attachment style was shown to be associated with embitterment. Besides personality vulnerability factors, embitterment appears to emerge as a psychological reaction to invalidation and helplessness. Invalidation is provoked by the invisibility of rheumatic symptoms. For example, employers may think that the patient could work if she or he had a tougher attitude. Helplessness is provoked by the uncontrollable nature of symptoms as detailed in learned helplessness theory. It was found that the joint experience of invalidation from the work environment and helplessness regarding one’s illness is associated with embitterment in patients. Whereas helplessness is a common therapeutic target, interventions to redress invalidation and embitterment are needed. Embitterment was frequent in patient groups. High levels were reported by16% of employed patients and 20% of patients after a disability pension examination, as compared to 8% in the general population. In patients after the disability pension examination, embitterment was associated with poorer levels of mental well-being, but not with physical functioning in a 15-month prospective study. As the results indicate that embitterment –besides fibromyalgia, having a comorbid disease and being young– threatens well-being, professional support needs to be directed especially at groups having these vulnerability variables.