Psychosocial interventions in rheumatoid arthritis: A patient centred approach using imagery and hypnotherapy

This thesis is written as a collection of research papers through which the therapeutic effects of imagery and hypnotherapy in rheumatoid arthritis (RA) are investigated using a patient-centred approach. The first section of this thesis explores the biomedical model of disease in RA, highlighting the limitations of this model which led to the development of a biopsychosocial model. Specifically, the biopsychosocial model of disease in RA identifies factors other than pathology which influence the symptoms associated with the disease, e. g. , self-efficacy and social support. With a view that psychosocial variables can have an impact for the outcome in RA, a variety of psychosocial interventions have been utilised. Consequently, chapter two reviews the literature on psychosocial interventions and provides the rationale for further investigation of imagery and hypnotherapy. The second section of this thesis examines the application of these two psychosocial interventions using a patient-centred approach in RA patients. Patient-centredness was achieved by allowing participants to identify areas for therapeutic intervention using a patient generated outcome measure (PGOM). Specifically, chapter three identified that both imagery and hypnotherapy significantly increase health related quality of life (HRQOL) when measured with a PGOM of HRQOL in the short-term. However, only hypnotherapy maintained this significant increase in the long-term. Furthermore, a discrepancy between the most commonly used HRQOL measure (the SF-36) and a PGOM was identified, indicating that the SF-36 may not be measuring what is perceived to be HRQOL in individuals with RA. Using the same participants, chapter four identifies that both imagery and hypnotherapy significantly reduce pain in RA in the short-term. Additionally, hypnotherapy significantly increased self-efficacy for controlling pain, and significantly reduced functional disability. Given these results it was concluded that hypnotherapy was statistically superior to imagery. Consequently, as these psychosocial interventions provided some benefit to patients with stable RA, chapter five explored their use in active RA patients. Specifically, the biopsychosocial model assumes a reciprocal relationship between the three systems in the model. Using a case study approach several areas of improvement in clinical assessment were identified, with the disease activity score (DAS28) of two patients receiving hypnotherapy and four receiving imagery, showing a moderate response to the intervention in accordance with the European League Against Rheumatism (EULAR) response criteria. Additionally, participants reported improvement in psychosocial function with clinically significant reductions in pain and fatigue in some cases, and clinically significant reductions in functional disability in all ten participants. As the imagery group reported more clinically significant change it was concluded that this intervention was clinically more superior to hypnotherapy. The final section addresses methodological issues, the strengths and weakness of the research programme, future research directions and the clinical implications from the results of this thesis.