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Psychosomatics 46:25-33, February 2005
© 2005 The Academy of Psychosomatic Medicine

Psychosocial Factors Associated With Perceived Disease Severity in Patients With Chronic Hepatitis C: Relationship With Information Sources and Attentional Coping Styles

Aymery Constant, Ph.D., Laurent Castera, M.D., Bruno Quintard, Ph.D., Pierre-Henri Bernard, M.D., Victor de Ledinghen, M.D., Ph.D., Patrice Couzigou, M.D., and Marilou Bruchon-Schweitzer, Ph.D.

Received Oct. 6, 2003; revision received Feb. 27, 2004; accepted April 1, 2004. From the Laboratoire de Psychologie de la Santé EA 3662, Université Victor Segalen Bordeaux-2; the Institut National de la Recherche Agronomique 1442, Centre National de la Recherche Scientifique Formation de Recherche en Évolution, Bordeaux Cedex, France; the Service d’Hépato-Gastroentérologie, Hôpital Haut Lévêque, Pessac, France; and the Service d’Hépato-Gastroentérologie, Hôpital St-André, Bordeaux, France. Address correspondence and reprint requests to Dr. Constant, Laboratoire de Psychologie de la Santé EA 3662, Université Victor Segalen Bordeaux-2, 33000 Bordeaux, France; aymery.constant{at}etud.u-bordeaux2.fr (e-mail).


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
The aim of this study was to investigate psychosocial factors associated with perceived disease severity, with emphasis on informational processing, in 185 consecutive patients with chronic hepatitis C. Medical data, information sources regarding chronic hepatitis C, and attentional coping styles were assessed. The patients considered their hepatitis C a severe disease and gave it a mean rating of 74 (SD=19) on a 100-mm visual analogue scale, but this perception was not related to liver histological severity. In multivariate analysis, age, coping styles (monitoring, blunting), and having a hepatologist as an information source accounted for 23% of the variance of perceived severity. These results suggest that information processing and psychological features play a key role in the way patients with chronic hepatitis C perceive their disease.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
Chronic hepatitis C is a major public health problem with over 170 million people infected worldwide. It is the leading cause of chronic liver disease and the main indication for liver transplantation in the western world.1 Approximately 80% of the patients with acute infection develop chronic hepatitis. Although chronic hepatitis C is usually an asymptomatic and slowly progressive disease, potentially life-threatening complications, such as cirrhosis and hepatocellular carcinoma, may occur in a subset of patients. Several studies have demonstrated that patients with chronic hepatitis C consistently have a significantly lower health-related quality of life than does the general population.2,3 This impairment of health-related quality of life has been documented even in the absence of significant liver disease.4 In addition, clinically significant emotional distress and depressive disorders have been widely reported in untreated patients with chronic hepatitis C5–7 as well as in interferon-treated patients.8 We have recently shown the considerable psychological and emotional burden of infection with the hepatitis C virus.9 In this study, the psychological impact of hepatitis C infection was assessed by using a visual analogue scale with scores from 0 to 100 mm, and these scores were compared with those for other stressful life events. Indeed, learning about hepatitis C infection was considered a stressful event (mean score=72, SD=25) rated lower than divorce (mean=78, SD=23) or the death of a loved one (mean=89, SD=13) but higher than job dismissal (mean=68, SD=30) or moving (mean=26, SD=24).

The manner in which patients perceive their illness is likely to influence many aspects of their experience, including the likelihood of seeking medical care,10 quality of life,11 and compliance with medical advice.12 A basic behavioral dimension in dealing with relevant medical information has been called "confrontation/distraction."13 These coping styles have been described in the "monitoring and blunting" hypothesis.14 This hypothesis posits that people can adopt two different cognitive attitudes toward relevant information to cope with a stressful situation: seeking information (monitoring) or distracting attention from any information (blunting). These concepts are applied mostly in medical settings and are of great relevance owing to their possible impact on the reporting of treatment side effects, on patient delay and preventive behavior, and on the effect of providing medical information.15–18 Effects of the interactions between attentional coping style and information delivery on patient’s stress have been reported.14,19 Moreover, important differences exist between men and women regarding the effect of coping styles on health issues.20,21 Previous studies involving individuals with chronic health problems suggest that pronounced monitoring of threat-relevant information is related to poorer behavioral and emotional adjustment19,22 and induces more concerns and pessimistic thoughts about the disease.17

Traditionally, physicians managing the treatment of patients with chronic hepatitis C have focused on medical outcomes, such as changes in liver enzyme levels or fibrosis progression on liver histology. However, it has become increasingly apparent that these traditional biological markers often do not parallel patients’ feelings or perceptions regarding their disease. Information exchange is a fundamental component of the doctor-patient relationship, and physicians are considered by patients to be the most reliable source of information.23,24 Indeed, patients who feel that their needs and concerns are being addressed are more likely to experience better health outcomes.25 We hypothesized that a monitoring attitude would be associated with greater perceived severity of chronic hepatitis C and that information regarding hepatitis C provided by physicians would have a reassuring effect on this perception.

To investigate these hypotheses we studied illness perception (i.e., perceived disease severity) in patients with chronic hepatitis C and its relationship to actual severity, information sources, and coping styles.


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 REFERENCES
 
Recruitment of Participants
All patients chronically infected with the hepatitis C virus (defined as have detectable hepatitis C antibody and hepatitis C virus RNA) who attended the hepatology clinics at the University Hospital of Bordeaux between June and October 2002 were eligible. The exclusion criteria were previous or current malignancy, decompensated cirrhosis, co-infection with the hepatitis B virus or human deficiency virus (HIV), current psychotic or manic disorder, obvious intellectual impairment, and inability to communicate in French. The following data were collected: age, gender, marital status, educational level, route of hepatitis C virus transmission, and histological severity of liver disease (assessed by using the histological fibrosis score derived according to the METAVIR scoring system26). Patients were asked about their sources of information regarding hepatitis C, listed as follows: general practitioner, hepatologist, association of patients with hepatitis C, television, Internet, newspapers or magazines, health ministry booklet, and significant others.

Measures
Trait anxiety
Trait anxiety was assessed by using the Spielberger State-Trait Anxiety Inventory, form Y (STAI-Y),27 a 20-item standardized self-report scale, validated in French.28 On that scale, total scores range from 20 (low tendency to be anxious) to 80 (high tendency to be anxious).

Perceived severity of chronic hepatitis C
Immediately before or after an outpatient clinic appointment, each participant was asked to self-grade, using a 100-mm visual analogue scale, the perceived severity of the disease. On that scale, the left endpoint was 0, defined as not severe at all, and the right endpoint was 100, defined as very severe. There were no further marks on the line. Instructions were as follows: "Put a mark on the line at the point that best describes how severe you consider hepatitis C." The perceived severity was indicated by the distance in millimeters from the left endpoint.

Attentional coping styles
Levels of attentional coping styles were measured for each patient by using the Monitoring–Blunting Questionnaire.29 The Monitoring–Blunting Questionnaire was translated and back-translated between English and French by native English-speaking translators. The patients were provided with definitions of monitoring and blunting and asked to indicate on a 10-point scale (0=not at all, 10=very much) the extent to which they would rely on each strategy to cope with each of 10 potentially threatening situations. A subscore was calculated for each coping choice by summing up the scores for the 10 situations.29

Statistical Analysis
Scores for perceived severity from the visual analogue scale were expressed as means and standard deviations. The relationships between categorical variables (educational level, information sources, marital status, route of transmission, and histological severity of liver disease) and perceived severity of chronic hepatitis C (visual analogue scale score) were assessed by using one-way analyses of variance (ANOVAs). Bonferroni and least significant difference post hoc tests were performed to confirm levels of significance. In order to determine whether perceived hepatitis C severity was influenced by gender and coping styles, we performed a two-factor 2x3 ANOVA with the factors of gender (male or female) and coping style group (blunters, low monitors, or high monitors) and perceived severity as the dependent variable. The relationships between continuous variables (age, time since hepatitis C diagnosis, and scores for trait anxiety, monitoring, and blunting) and perceived severity of chronic hepatitis C were assessed by using Pearson’s correlations. Variables significantly associated with perceived hepatitis severity (p<0.05) were included in a hierarchical multiple regression in order to determine which combination of variables best accounted for the variance in perceived severity.


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
DISCUSSION
 REFERENCES
 
Participant Characteristics
During the 4-month study period, 220 patients with chronic hepatitis C were seen, and 185 fulfilled the criteria. None of the eligible patients refused to participate in the study. The mean time since their hepatitis C diagnosis was 2.9 years (SD=2.6). Other characteristics of the study group are shown in Table 1. There were 111 men and 74 women, with a mean age of 45 years (SD=11). The study group had a broad distribution of educational backgrounds. Seventy-four (40%) were infected through blood transfusions, and 48 (26%) were infected through intravenous drug use. Of the 169 patients with available liver biopsy data, 28 (17%) had evidence of cirrhosis. As expected, physicians (general practitioners and hepatologists) were the most common sources of information regarding chronic hepatitis C, much more common than the other sources.


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TABLE 1. Characteristics of 185 Patients With Chronic Hepatitis C



Descriptive Analyses
Chronic hepatitis C was perceived as a severe disease; the mean score on the visual analogue scale was 74 (SD=19). The mean STAI-Y score for trait anxiety was 45 (SD=11, range=22–80). This score did not differ from that obtained in a community sample.28 Scores on the Monitoring–Blunting Questionnaire subscales showed a preference for a monitoring attitude toward threatening information (mean score=67, SD=16) over blunting (mean=41, SD=20). Only 33 patients had higher scores for blunting than for monitoring. Since no normative data regarding attentional coping styles in a French community were available, a summary score was calculated by subtracting the blunting score from the monitoring score. Three groups were derived from this difference score: patients with a blunting score that was equal to or higher than the monitoring score were classified as "blunters" (N=33), those with a monitoring score that was higher than the blunting score by 1–49 points were classified as "low monitors" (N=118), and patients with a monitoring score more than 50 points above the blunting score were classified as "high monitors" (N=34). A multivariate analysis of variance (MANOVA) was used to compare the blunters, low monitors, and high monitors on the two Monitoring–Blunting Questionnaire subscales. The MANOVA was significant (Wilks’s lambda=0.22, Rao’s R=102.9, df=4, 362, p<0.001), showing that the scores on both the monitoring and blunting subscales discriminated all groups. Post hoc tests confirmed these results: all differences were significant (p<0.05).

Factors Associated With Perceived Severity
Table 2 shows the relationship between the categorical variables and the perceived severity of hepatitis C. Only educational level had an influence on perceived severity. A least significant difference post hoc test revealed that patients who had graduated from college had significantly lower scores on the visual analogue scale than did other patients (p<0.02). The scores for perceived severity were significantly lower for patients who reported hepatologists as a source of information about hepatitis C than for patients who did not, and scores were also lower for those who cited the Internet as an information source than for those who did not. Bonferroni post hoc tests confirmed these results (p<0.002 for hepatologists and p<0.02 for the Internet). As shown in Figure 1, perceived severity was significantly influenced by gender (F=5.91, df=1, 179, p<0.02) and coping style (F=5.50, df=2, 179, p<0.01). Indeed, women considered their hepatitis C to be more severe than men did; the mean scores were 79 (SD=18) and 71 (SD=20), respectively. High monitors had the highest perceived severity scores (mean=85, (SD=14), followed by the low monitors (mean=74, SD=19) and the blunters (mean=67, SD=22). The interaction effect was significant (F=3.99, df=2, 179, p<0.04). Least significant difference post hoc tests revealed that coping style had a significant influence on perceived severity for men (p<0.05) but not for women.


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TABLE 2. Relationship Between Categorical Variables and Perceived Illness Severity Among 185 Patients With Chronic Hepatitis C





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FIGURE 1.  Relationship of Gender and Attentional Coping Stylea to Perceived Illness Severity Among 185 Patients With Chronic Hepatitis C

aCoping style was assessed with the Monitoring–Blunting Questionnaire.29 Patients with a blunting score that was equal to or higher than the monitoring score were classified as "blunters," those with a monitoring score that was higher than the blunting score by 1–49 points were classified as "low monitors," and patients with a monitoring score more than 50 points above the blunting score were classified as "high monitors."


Table 3 shows the relationship between continuous variables and perceived severity of chronic hepatitis C. Age, monitoring, and blunting significantly correlated with perceived severity. In addition, monitoring and trait anxiety were significantly correlated, a finding consistent with previous results on this topic.


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TABLE 3. Correlations Between Continuous Variables and Perceived Illness Severity Among 185 Patients With Chronic Hepatitis C



Factors Associated With Perceived Severity in Multivariate Analysis
To identify a "best" set of independent predictors of perceived hepatitis C severity, we performed a hierarchical multiple regression (Table 4). The predictors were grouped in three domains: 1) demographic characteristics (gender, age, educational level), 2) information sources (hepatologist, Internet), and 3) attentional coping styles (monitoring, blunting). Gender, age, and educational level together accounted for 12% of the variance in perceived severity (step 1). It is interesting that educational level was negatively related to perceived severity. When information sources were entered in the equation, they added 4% to the explanation of perceived severity (step 2), but only "hepatologist" was significantly related to perceived severity. When monitoring and blunting scores were entered, both were significantly related to severity and explained an additional 10% of the variance (step 3). As expected, monitoring was positively correlated with perceived severity, whereas blunting had a smaller but significant negative correlation. After we controlled for the direct effect of the predictors, the interactions between information sources ("hepatologist" and "Internet") and coping styles ("monitoring" and "blunting") were tested, but all combinations failed to explain any additional percentage of variance of the dependent variable (p>0.05) and were removed from the model. When all selected variables were entered in the equation, they accounted for 23% of the variance of the dependent variable. In the final model, the best predictors were age and monitoring, which were positively correlated with perceived severity, and hepatologist as information source and blunting, which were negatively correlated with perceived severity.


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TABLE 4. Hierarchical Regression Analysis of Possible Predictors of Perceived Illness Severity Among 185 Patients With Chronic Hepatitis Ca




  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
REFERENCES
 
The influence of illness perception on patients’ psychological well-being and physical functioning has been shown for many chronic diseases with potential complications, such as diabetes mellitus,30 rheumatoid arthritis,31 chronic obstructive pulmonary disease,31 and heart disease.32 So far, very few data regarding illness perception in patients with chronic hepatitis C are available. The results of the present study, conducted in a large cohort of consecutive patients with chronic hepatitis C, provide insights into the processing by which patients infected with the hepatitis C virus formulate a judgment about their disease. We found that the perceived severity of chronic hepatitis C was considerable, with a mean score of 74 (SD=19) on a 100-mm visual analogue scale. In comparison, in a previous study9 in which we used the same method to assess perceived severity of chronic hepatitis C relative to the severity of four other common chronic diseases carrying a risk of life-threatening complications, hepatitis C was considered less severe than AIDS and cancer but more severe than diabetes mellitus and hypertension. As the natural history of chronic hepatitis C virus infection remains poorly defined,33 it is not surprising that chronic hepatitis C, a disease with an uncertain outcome, raises significant concerns about future health status. However, an interesting finding of the present study is the lack of correlation between the perceived severity of hepatitis C and the actual severity of liver disease, as assessed by the histological fibrosis score, or any other medical variable. This finding is in keeping with the results of Foster et al.,4 who showed that the substantial impairment of health-related quality of life experienced by patients with chronic hepatitis C could not be attributed to the histological severity of liver disease. It is also consistent with previous findings34–36 that the perception of a disease usually correlates poorly with its medically defined characteristics.

Another major finding of the present study is that disease severity perception was mainly influenced by patients’ psychological features and behavior. Indeed, in our multivariate model, psychosocial factors, such as attentional coping styles and information sources regarding chronic hepatitis C, together with age were strong predictors of perceived illness severity and explained 23% of the total variance.

Attentional coping styles have already been reported to induce cognitive distortions in patients’ symptom reports and illness burden appraisal.37 In the present study, actively searching for information (monitoring) was positively correlated with perceived severity and was the strongest predictor of the model, whereas distracting (blunting) had a weaker, but significant, reassuring influence. These results are consistent with those of Miller and Mangan14 and Miller et al.19 showing that monitoring is associated with higher stress levels and a pessimistic view about the future. According to another study by Miller et al.,38 monitors confronted with an aversive situation are more inclined to endure intrusive ideation and tend to interpret neutral or ambiguous information in a threatening way. Therefore, it is not that surprising that a lack of information for high monitors with chronic hepatitis C, an asymptomatic and silent disease potentially carrying life-threatening complications, may lead to an overrated evaluation of the medical threat. Indeed, being informed by a specialist had a significant reassuring effect in our multivariate model, suggesting a differential qualitative effect among information sources regarding chronic hepatitis C. We cannot exclude the fact that educational level, by influencing the choice of information sources, may be a confounding factor. However, this seems unlikely as a low educational level, although associated with higher perceived severity in the univariate analysis, did not influence illness perception in our final multivariate model. Altogether, these results highlight the crucial role of the specialist in providing accurate information and emphasize the need for improving patient education regarding the natural history and potential complications of chronic hepatitis C.

Age and gender were strongly related to perceived chronic hepatitis C severity in our initial model (step 1 and step 2), but age remained the only demographic predictor in the final model (step 3). Age and gender have been shown in several longitudinal studies39,40 to have a significant influence on illness burden and the number of symptoms reported by patients. Surprisingly, perceived disease severity did not differ according to the route of transmission: patients infected through intravenous drug use had scores that were similar to those of patients infected through blood transfusions. Although our study group did not represent a random sampling of patients with chronic hepatitis C, its demographic and clinical characteristics, including routes of transmission, are similar to those reported in large surveys of patients with chronic hepatitis C in France.41

The fact that we did not assess affective state and symptoms of depression in our patients may be a limitation of this study. However, patients with psychiatric disorders (clinical depression, psychotic or manic disorders) were excluded. In addition, although we did not systematically measure anxiety and depressive symptoms, trait anxiety was not a predictor of perceived disease severity.

The results of the present study may have important implications for clinicians taking care of patients with chronic hepatitis C. They highlight the importance of communication between patients and their physicians and the crucial role of the hepatologist in providing adequate and accessible information for patients coping with their condition. We have shown the key role that psychological factors play in the disease evaluation process in patients with chronic hepatitis C, suggesting that it is a complex and multifactorial process that cannot be reduced to the biological characteristics of the disease. Information sources and attentional coping style should be taken into account in taking care of patients with chronic hepatitis C. Their influence on health-related quality of life, emotional states, and observance of antiviral therapy warrants further investigation.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 

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