Which stressors are responsible for the worsening in the clinical symptomatology of lupus?

doi:10.4236/health.2009.14051

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Vol.1, No.2, 313-319 (2009)

doi:10.4236/health.2009.14051

SciRes

Health

Which stressors are responsible for the worsening in

the clinical symptomatology of lupus?

M. I. Peralta-Ramírez1, J. Jiménez-Alonso2, M. Pérez-García1

1Department of Clinical Psychology, School of Psychology, University of Granada, Spain

2Systemic Autoimmune Disease Unit, University Hospital “Virgen de las Nieves”, Granada, Spain; mperalta@ugr.es

Received 26 October 2009; revised 9 November 2009; accepted 12 November 2009.

ABSTRACT

Objective: The purpose of this study was to test

which stressors worsen the symptoms perceived

by patients with lupus, thus broadening and

corroborating results obtained in a previous

study published in Psychosomatic Medicine.

Methods: In order to examine this question, we

selected 43 patients with lupus whose symp-

toms worsened due to the effects of daily stress.

These patients were divided into two groups:

patients whose increase in clinical lupus symp-

tomatology was predicted by an increase in

daily stressors on the same day (G1) and pa-

tients whose increase in clinical lupus symp-

tomatology was predicted by an increase in

daily stressors the day before and the same day

(G2). Later, three factorial analyses were con-

ducted with the items related to stressors and

the items related to lupic symptoms. Results:

The results showed that in G1 there were three

factors that made up a total of 35.08% of the

explained variance. The stressors associated

with certain symptoms of the illness in this

group are feeling ill or being worried about their

physical appearance, with the main stressor

being the illness itself. However, in G2, two

factors were found that made up a total of

40.37% of the explained variance for lag=0 and

38.67% for lag=1. The stressors associated with

the majority of the lupus symptoms are of an

interpersonal and work-related nature. This as-

sociation was maintained when we carried out

the factorial analyses with the items of the

symptoms from the following day. Conclusions:

The interpersonal and work-related stressors

are related to a worsening in the majority of the

lupic symptoms in the patients whose sympto-

matology worsens as a result of daily stress

experienced the day before.

Keywords: Daily Stress; Interpersonal Stressor;

Work-Related Stressors; Systemic Lupus Erythe-

matosus

1. INTRODUCTION

Various studies have shown the devastating effect psy-

chological stress has on certain rheumatic diseases [1].

Specifically, diverse studies have shown that stress is

one of the environmental factors that can cause a wors-

ening in lupus [2-8]. Although the role of stress in this

illness appears clear, at first, there was certain contro-

versy about the nature of the stressors, as some authors

supported the theory that daily stress (not organizing

time well, problems in social relationships...etc.) was

mainly responsible for the worsening in lupus [2-4,6-8],

while other authors defended a greater effect of the Ex-

traordinary Stressful Life Events (death of a family

member, car accident, etc.) on the lupus [5]. Although

there is currently a lot of evidence that daily stress is

primarily responsible for the worsening of this illness,

few studies have shown which specific stressors are

most related to this worsening. Specifically, three main

studies were carried out with this objective. The first was

conducted by Schubert et al. [4]. The authors studied a

woman suffering from SLE during a 63-day period. In

this patient, the concentration of neopterin (immunological

parameter closely related to lupic activity in patients

with SLE) in urine was measured daily, and her daily

stressors were evaluated weekly. The findings showed

that the moderately stressful incidents that led to a high

level of emotional irritation and had stressful interper-

sonal implications increased the concentration of neop-

terin approximately one day later, that is, with a lag=1.

Therefore, these stressors play a greater role in the in-

crease in neopterin than other stressors. One problem of

this study is that the sample studied is very small (only

one SLE patient was evaluated), so that it is impossible

to draw generalizable conclusions. Later, these authors

performed a new study [6] where they evaluated daily

(every 12 hours) the levels of stress, cortisol and neop-

terin in another lupus patient during a 56-day period.

M. I. Peralta-Ramírez et al. / HEALTH 1 (2009) 313-319

314

They found that when the patient anticipated a moderate

stressor (which in this case was the infidelity of her

partner), her cortisol increased 24 hours before the inci-

dent and lessened 12 hours after it had occurred. How-

ever, if the patient did not anticipate the incident, her

cortisol increased 24 hours after the incident and de-

creased 36 hours after it. With regard to the neopterin,

these authors found that after exposure to the stressor

there was a reduction in the amount of neopterin in the

following 36 hours, producing a new increase in the next

60 hours. In this way, the authors again showed the

modulation of the immune system due to stressful events

involving interpersonal relationships, and due to the an-

ticipation of these stressors, in the following 24-36 hours.

The latest study carried out with the objective of defin-

ing the type of stressor that can affect the worsening of

lupus is the one by Pawlak et al. [7]. These authors

studied the stressors in 41 women with lupus during a

six-month period and their physiological correlates

(complement activity, anti-dsDNA and ECLAM-European

Consensus Lupus Activity Measurement). The results

showed that the patients who had a larger number of

social obligations presented more outbreaks (92%) than

the patients who had fewer social obligations (39%).

Furthermore, these authors found an increase in the in-

terpersonal relationship conflicts in the month prior to

the lupic outbreak in the patients who experienced a wors-

ening in the disease.

As we can see, all of these studies seem to clearly

agree that the stressors most related to the worsening of

the disease are not only of a daily nature, but they also

have a clear component related to interpersonal relation-

ships. However, in addition to the different stressors

common to the general population, there have been no

studies on the effects that the perception itself of the

worsening of the disease (another stressor) has on this

worsening. Likewise, no studies been carried out to test

whether experiencing different stressors acts on some

target organ of the disease, thus produces its worsening

(joints, skin, etc.), or whether, on the contrary, it acts on

a general level by activating all the systems.

Therefore, the purposes of the present study were, on

one hand, to test what types of stressors are responsible

for the worsening in the clinical symptomatology of lupus

and, on the other, to find out what physical symptoms

are involved in this worsening. These were tested in a

group of patients that had already been evaluated and

classified according to the effect that the stress had on

their perception of the worsening of the disease [8].

2. PATIENTS AND METHODS

2.1. Study Population

64 patients originally participated in this study, of which

6 were later rejected because they had mixed connective

tissue disease rather than lupus. Therefore, 58 lupus pa-

tients participated in the study, of which 50 were women

and 8 men. 45 met at least 4 American College of Rheu-

matology (ACR) [9] criteria for classification as suffer-

ing from Systemic Lupus Erythematosus (SLE), and 12

were suffering from Chronic Lupus Discoid (CLD), di-

agnosed by their clinical history and an anatomopa-

thological study. The mean age was 39.37 years (SD=9.72),

and the mean educational level was 10.7 years (SD=3.44),

which is equivalent to a bachelor’s degree. The mean

duration of the illness was 9.1 years (SD=6.38), the

mean index of organ damage was 0.9 (SD=1.06), and the

mean on the index of lupus activity was 1.73 (SD=3.2).

All of the participants were patients at the Systemic

Autoimmune Disease Unit at the University Hospital

“Virgen de las Nieves” in Granada, Spain. They all had

at least a minimum cultural background (they could at

least read and write), and none of them presented any

associated mental illness at the time of the study, al-

though there were two patients with psychiatric histories.

All of these patients gave their signed informed consent

to participate in this study. Of these 58 patients, we only

included the 43 patients for whom stress predicted a

worsening in the clinical symptomatology of lupus. These

subjects were classified into two groups: G1 with 31 pa-

tients whose increase in the clinical symptomatology of

the lupus was predicted by an increase in daily stressors

on the same day; and G2 with 12 patients whose increase

in the clinical symptomatology was predicted by an in-

crease in daily stressors the day before and the same day.

2.2. Information Collected

2.2.1. Daily Stress Inventory (DSI)

The translation and adaptation to the Spanish population

of the Brantley, Waggoner and Jones Daily Stress Inven-

tory (DSI) was carried out by Peralta-Ramírez [10]. For

this adaptation, they used the responses to a complete

version of the DSI given by a broad sample. They then

created a 20 item version comprised of some items that

remain identical (e.g., “I forgot something”), others that

are worded in a different way (e.g., “gave up an undesir-

able habit: eating too much, smoking, etc” for “gave up a

habit that was not good for him”), and others that grouped

various items from the DSI with related criteria (“Had

problems in his relationship with other people: was criti-

cized, ignored, interrupted when speaking…”). This in-

strument measures stressful daily events and the degree of

stress produced by each of them in the last 24 hours. It

contains 20 items that are categorized from 0 to 6, de-

pending on the degree of stress they have caused, keeping

in mind that 0 is no stress experienced and 6 means the

event caused panic. The instrument’s reliability coefficient

is 0.82, the Cronbach alpha coefficient is 0.88, and its

discriminated validity is 74.86% correct classification.

Therefore, the instrument presents high validity for

detecting change [10]. The items related to this instrument

are included in Table 1.

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315

Table 1. Items from the DSI and the SLI.

ITEMS FROM THE DSI

I1. Had problems at work, with a specific activity

I2. Did not organize his or her time well

I3. Had problems in his or her relationships with other people (was criticized, ignored, and interrupted when speaking...)

I4. Has not slept soundly

I5. Forgot something

I6. Felt or feared being ill

I7. Had some small accident

I8. Thought about the future

I9 Played a sport or game poorly

I10. Did something he or she did not want to do

I11. Lost something or couldn’t find something he or she was looking for

I12. Bad weather affected him or her

I13. Challenged someone in authority

I14. Heard bad news

I15. Something related to his or her personal appearance affected him or her

I16. Was faced with a feared situation or object

I17. Worried about other people’s problems

I18. Barely escaped something dangerous

I19. Gave up a habit that was not good for him or her

I20. Had economic problems

ITEMS FROM THE SLI

S1. Loss of appetite

S2. Joint pain

S3. General malaise

S4. Fatigue

S5. Skin rash

S6. Abdominal symptoms

S7. Difficulty breathing

2.2.2. SLE Symptoms Inventory (LSI)

This inventory was elaborated by the group of medical

specialists in the Systemic Autoimmune Disease Unit of

the Internal Medicine Service at the University Hospital

“Virgen de las Nieves” in Granada [11]. It refers to 8

symptoms suggestive of SLE activity, namely loss of appe-

tite, joint pain, general malaise, fever, tiredness or fatigue,

skin rash, difficulty breathing and abdominal symptoms.

These items are categorized from 1 to 10 according to the

degree of intensity of these symptoms on that day. This

inventory was designed to evaluate the subjective symp-

toms of large groups of SLE patients in clinical studies.

We tested its internal consistency, as well as its concor-

dance with physician reports and serological indicators

M. I. Peralta-Ramírez et al. / HEALTH 1 (2009) 313-319

316

Table 2. Factors that relate certain items of stress with lupus symptoms on the same day in G1 and G2 (lag=0)

and stress and symptoms the next day G2 (lag=1).

G1 (lag 0) G2 (lag 0) G2 (lag 1)

Ítems Factor

Factor

Items Factor

Factor

Items Factor

Factor

S3 0.829 0.08 0.214 S1 0.876 -0.141 S4 0.853 0.159

S4 0.805 0.05 0.253 S4 0.843 0.225 S7 0.843 0.224

S2 0.687 0.02 0.242 S7 0.837 0.201 S3 0.841 0.156

S1 0.618 -0.02 0.123 S3 0.823 0.228 S1 0.838 -0.024

I6 0.591 0.131 -0.13 S2 0.809 0.259 S2 0.270 0.190

I3 0.127

0.711 0.08 I1 0.759 0.170 I2 0.691 0.133

I13 -0.07

0.671 0.03 I2 0.756 -0.003 I4 0.646 0.480

S6 0.336

0.505 0.173 I4 0.713 0.354 I1 0.629 0.362

I15 0.112 0.15

0.807 I6 0.661 0.267 S6 0.588 0.180

S5 0.311 -0.02

0.789 S6 0.555 0.233 I6 0.551 0.413

I12 0.298

0.695 I12 0.235

0.684

S5 0.527

0.662 I8 0.416

0.644

I8 0.486

0.606 I17 0.193

0.638

I17 0.272

0.532 S5 0.514

0.614

I15 0.407

0.559

Self-rating 5.973 2.102 1.396 9.313 1.588 8.861 1.581

% Variance 22.123 7.785 5.175 34.493 5.881 32.819 5.858

of disease activity. This instrument shows a high internal

consistency of the LSI, with a Cronbach alpha of 0.862.

Furthermore, a contingency analyses shows agreement

between the medical report and the patient self-report on

the same day for each of the lupus symptoms included

in the LSI (difficulty breathing (p<0.004), joint pain

(p<0.001), loss of appetite (p<0.003), general malaise

(p<0.005), fatigue (p<0.005) and skin rash (p<0.018)).

This agreement is not found on the abdominal symptoms

(LSI). On the other hand, we found differences between

the LSI scores of the patients with high serological ac-

tivity and those of the patients with low serological ac-

tivity (χ2(1)=5.302; p<0.021), with the former presenting

higher scores than the latter. The LSI is a highly reliable

and valid instrument for evaluating the subjective symp-

toms of the disease as well as their fluctuations. The

items related to this instrument are included in Table 1 too.

The SLE Disease Activity Index (SLEDAI) and Sys-

temic Lupus International Collaborating Clin-ics/American

College of Rheumatology (SLICC/ACR) Damage was

evaluated in the prior study but the data were not in-

cluded in this study [8].

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317

Table 3. Summary of the relationship between the different stressors and lupus symptom.

2.3. Procedure

During the first week, the patients were recruited by the

internist at the outpatient clinic for autoimmune diseases.

At the routine check-up, the patient was given informa-

tion about this study on the effects of stress and lupus

and invited to participate (90% agreed). If the patient

agreed, he or she was given an appointment for the first

session. In the first session, the study was explained in

detail, and subjects were asked to sign the consent form

(99% accepted). The subjects who accepted underwent

the following: 1) a clinical interview was carried out to

find out basic data like age, educational level and diverse

emotional problems occurring in his or her life; 2) the

SLEDAI and SLICC/ACR were evaluated; 3) they were

given 30 copies of the DSI and 30 copies of the LSI.

Furthermore, every 15 days they were contacted by tele-

phone in order to resolve any doubts about completing

the questionnaires, and they were encouraged to con-

tinue to fill them out. They were informed that they

would have to complete the DSI and LSI at the end of

the day every day for six months (This was done by all

the patients, except three who left the evaluation early).

Each month, they were provided with 31 IEC question-

naires and 31 LSI questionnaires, personally if they lived

in Granada or by mail if they lived outside of Granada.

Furthermore, every 15 days they were telephoned in order

to resolve any doubts about completing the questionnaires,

and they were encouraged to continue to fill them out.

2.4. Statistical Analyses

In a previous study published in the Journal

Psychosomatic Medicine [8], 3 groups were used: G1:

patients whose increase in the clinical symptomatology

of the lupus was predicted by an increase in daily

stressors on the same day (lag=0); G2: patients whose

increase in the clinical symptomatology was predicted

by an increase in daily stressors the day before and the

same day (lag=0,1); G3: patients for whom daily stress

did not predict any increase in the self-reported clinical

symptomatology of the lupus. In the present study, data

from two of the groups (G1, G2) were used for statistical

analyses.

Secondly, with the objective of testing what types of

G1 G2

Factors that relate certain items of stress with

lupus symptoms on the same day and

self-rating.

Factors that relate certain items of stress

with lupus symptoms on the same day

and self-rating.

Factors that relate certain items of

stress with lupus symptoms the next

day and self-rating.

Factor 1: 5.973

*Felt or feared being ill

General malaise

Fatigue

Joint pain

Loss of appetite

Factor 2: 2.102

*Had problems in his/her relationships

with other people.

*Challenged someone in authority

Abdominal symptoms

Factor 3: 1.396

*Something related to his/her personal

appearance affected him/her.

Skin rash

Factor 1: 9.313

*Did not organize his/her time well

*Has not slept soundly

*Had problems at work

*Felt or feared being ill

Loss of appetite

Fatigue

Difficulty breathing

General malaise

Joint pain

Abdominal symptoms

Factor 2: 1.588

*Bad weather affected him/her

*Thought about the future

*Worried about other people’s prob-

lems.

Skin rash

Factor 1: 8.61

* Did not organize his/her time

well

* Has not slept soundly

* Had problems at work

* Felt or feared being ill

Fatigue

Difficulty breathing

General malaise

Loss of appetite

Joint pain

Abdominal symptoms

Factor 2: 1.581

* Bad weather affected him/her

* Thought about the future

* Worried about other people’s

problems

* Something related to his/her

personal appearance affected

him/her..

Skin rash

M. I. Peralta-Ramírez et al. / HEALTH 1 (2009) 313-319

318

stressors are related to the worsening of the lupus symp-

tomatology itself, the two established groups were used,

and 3 factorial analyses were performed. Principal compo-

nent analysis was used as a factor extraction method. To

determine the number of factors to be extracted, a cut-off

point was established of specific values superior to one.

A factor rotation using the Varimax method was per-

formed to strengthen the grouping of the variables

around the associated factor. The registers noted in the

rotated factors matrix represent the weights of the vari-

ables in relation to each factor, and they receive the

name of factor charges. As this is an orthogonal rotation,

its interval oscillates between -1 and 1. The first two

factorial analyses were carried out with the scores on

each of the items from the DSI and the scores on each of

the items from the SLI for each of the groups, in other

words, one factorial analysis per group (G1, G2). Later,

based on results from the previous study [8], which

showed that in some patients a worsening occurs in the

clinical symptomatology of the lupus due to the effect of

the stress from the previous day (G2), we moved the

time series related to the items from the SLI question-

naire one square up with regard to the items on the DSI

questionnaire, so that the items on one day of stress

would be matched with the items on the lupus symptoms

the next day (SLI). After this shift, a factorial analysis

was performed using Varimax rotation with the scores on

the items from the DSI and the scores on the items from

the SLI; logically, this was only done for group G2.

3. RESULTS

3.1. Factorial Analyses of Daily Stressors

and Lupic Symptoms the Same Day

Two factorial analyses were performed, one for each

group’s “stressor-symptoms relationship” (see Tables 2

and 3). In the factorial analyses of G1, three factors were

found that related stressors with symptomatology, and

they explained 35.1% of the data variance. The main

factor related four of the seven most common symptoms

in lupus with the stressor “felt ill”. The second factor

seems to relate stressors that involve interpersonal rela-

tionships with stomach discomfort, and the third factor

relates skin rashes with the stressor “his or her personal

appearance affected him or her”.

In the factorial analyses of G2, two factors were found

that related stressors with symptomatology, and they

explained 40.4% of the variability of the data. The main

factor seems to relate 6 of the 7 lupic symptoms with

stressors closely related to work-related stress and per-

ception of the disease. In the second factor, stressors like

worry about others’ problems, thinking about the future

and bad weather are related to skin rashes.

3.2. Factorial Analyses Performed with the

Daily Stressors and the Lupic

Symptoms of the Next Day

The factorial analyses of G2 showed two factors that

related daily stressors with lupic symptomatology, and

they explained 38.7% of the variability of the data. Fac-

tor 1 related six of the seven lupic symptoms with stressors

of a work-related nature and perception of a worsening

of the disease. Furthermore, the second factor related

skin rashes with stressors like “bad weather affected him

or her”, “he or she thought about the future”, “he or she

worried about others’ problems” and “his or her personal

appearance affected him or her” (see Tables 2 and 3).

4. DISCUSSIONS

After performing the factorial analyses between the

items on the daily stress questionnaire and the items on

the inventory of clinical symptoms of lupus, the classi-

fication established of the different effects of stress on

the lupus symptoms (G1, G2) [8] is validated, as there is

a consistent correlation between the different stressors

and the lupic symptoms. Specifically, we can see how

the patients’ clinical symptomatology worsens on the

same day, the majority of the lupic symptoms are related

to the stressor “he or she felt ill”, just as in another factor

personal appearance (as a stressor) and skin rashes (as a

symptom) were related. On the other hand, the results

found with the patients whose symptomatology wors-

ened the same day and the day after the stressful situa-

tion (G2) show that the same factors are found at two

moments in time when the factorials were performed

(stress and symptoms the same day, and stress and

symptoms the next day). Here we found two factors.

One factor relates six of the seven symptoms most char-

acteristic of lupus with stressors of a work-related nature,

such as “does not organize time well”, “problems at

work”, etc., and health stressors like “feeling ill”. The

second factor relates stressors of a psychosocial nature,

like worrying about others’ problems or the future, etc.,

with the symptom of skin rashes.

As we can see, in the patients from G1, it seems more

likely that the stressor “he or she felt ill” would be

caused by the perceived symptoms than that this would

be the causal agent of these symptoms. The same thing

occurs with factor 3 for this group where the skin rashes

are related to the stressor “his or her personal appearance

bothered him or her”. Finally, in the other factor we found

different stressors are related to only one isolated item

from the lupus symptom inventory (stomach discomfort),

so that we can rule this out as being representative of the

lupic symptoms. Instead, we would consider it more as a

physical consequence of the stress in general.

The data found in G2 were very interesting, as they

M. I. Peralta-Ramírez et al. / HEALTH 1 (2009) 313-319

319

[2] Adams, S.J., Dammers, P.M., Saia, T.L., et al. (1994)

Stress, depression and anxiety predict average symptom

severity and daily symptom fluctuation in systemic lupus

erythematosus. J Behav. Med., 17, 459-477.

show a clear relationship between the different work and

health stressors and six of the seven symptoms associ-

ated with lupus. Likewise, the skin rashes are not related,

as they were in the former group, with personal appear-

ance, but rather with stressors regarding interpersonal

relationships and worry about the future. It is noteworthy

that in the group in which the worsening of the symp-

toms of the disease is predicted by the stress the day

before, when we performed the factorial analyses with

the stress data and the symptoms of the following day,

the same factors remained and with similar self-ratings.

These data do make it possible to state that certain

stressors of a work and interpersonal nature produce

worsening in the lupic symptomatology perceived the

same day and the day after experiencing the stress.

[3] Wekking, E.M., Vingerhoets, A.J., Van Dam, A.P., et al.

(1991) Daily stressors and systemic lupus erythematosus:

A longitudinal analyses-first findings. Psychother Psy-

chosom, 55,108-113.

[4] Schubert, C., Lampe, A., Rumpold, G., et al. (1999) Daily

psychosocial stressors interfere with the dynamics of

urine neopterin in a patient with systemic lupus erythe-

matosus: An integrative single-case study. Pychosom

Med, 61, 876-882.

[5] Da costa, D., Dobkin, P., Pinard, L., et al. (1999) The role

of stress in functional disability among women with sys-

temic lupus erythematosus: A prospective study. Arthritis

Care and Research, 12, 112-119.

The results found coincide, on one hand, with those

obtained by other researchers [4,6,7], where the psycho-

social stressors were related to the worsening in lupus

activity. However, we were able to relate different types

of stressors with certain specific symptoms of lupus,

finding a great effect of the stressors related to work

overload and to the perception of the illness itself. Fur-

thermore, we went one step further in which we can de-

fine what types of stressors are related to a certain sym-

ptomatology. One piece of data which stands out is that

skin rashes are not associated with other lupic symptoms

in their relationship with the stressors. Instead, they are

related to interpersonal relationship stressors.

[6] Schubert, C., Lampe, A., Geser, W., et al. (2003) Daily

psychosocial stressors and cyclic response patterns in

urine cortisol and neopterin in a patient with systemic

lupus erythematosus. Psyc ho neuroendocrinolog y , 28,

459-473.

[7] Pawlak, C., Witte, T., Heiken, H., et al. (2003) Flares in

patients with systemic lupus erythematosus is associated

with daily psychological stress. Psychother Psychosom,

72, 159-165.

[8] Peralta-Ramirez, M.I., Jimenez-Alonso, J., Godoy-Garcia,

J.F., and Perez-Garcia, M. (2004) The effects of daily

stress and stressful life events on the clinical symptoma-

tology of patients with lupus erythematosus. Psychosom

Med., 66, 788-94.

In conclusion, this study highlights the importance of

certain stressors in approaching stress in patients with

lupus. Knowing which stressors are most related to the

worsening of the symptoms provides us with guidelines

for action and intervention in the diverse psychological

therapies that are being conducted with the objective of

providing lupus patients with psychological strategies

for controlling stress and other related emotional vari-

ables [12-14]. Furthermore, the results obtained are an

important tool for the medical specialist who works with

these patients, as he or she can provide information of a

preventative nature to patients, emphasizing the impor-

tance of avoiding work overload and controlling any

possible interpersonal conflicts. Finally, the results found

in this study corroborate the results found in the previous

study published in Psychosomatic Medicine [8].

[9] Tan, E.M., Cohen, A.S., Fries, J.F., Masi, A.T., McShane,

D.J., Rothfield, N.F., Schaller, J.G., Talal, N., and Win-

chester, R.J. (1982) The revised criteria for the classifica-

tion of systemic lupus erythematosus. Arthritis Rheum,

25, 1271-7.

[10] Peralta, M.I., López, F., Godoy, J.F., Godoy, D., Sánchez,

M.B., and Pérez, M. (2002) Validación de la detección de

cambio del inventario de estrés cotidiano. Psicología

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[11] Peralta-Ramírez, M.I., Verdejo García, A., Muñoz, M.A.,

Sabio Sánchez, J.M., Jiménez-Alonso, J., and Pérez García,

M. (2007) Lupus symptoms inventory (LSI): Develop-

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344-350.

[12] Greco, C.M., Rudy, T.E., and Manzi, S. (2004) Effects of

a stress-reduction program on psychological function,

pain, and physical function of systemic lupus erythema-

tosus patients: A randomized controlled trial. Arthritis

Rheum, 15, 625-34.

5. ACKNOWLEDGMENTS

[13] Haupt, M., Millen, S., Janner, M., et al. (2005) Improve-

ment of coping abilities in patients with systemic lupus

erythematosus: A prospective study. Ann Rheum Dis., 64,

1618-1623.

To the patients with lupus who participated in this study. Financial

support is gratefully acknowledged from the National Spanish ‘‘I+D’’

Projects SEJ2007-61857.

[14] Peralta-Ramírez, M.I., Robles-Ortega, H., Navarrete-

Navarrete, N., and Jiménez-Alonso, J.F. (2009) Aplicación

de la terapia de afrontamiento del estrés en dos poblaciones

con alto estrés: Pacientes crónicos y personas sanas.

REFERENCES

[1] Herrmann, M., Scholmerich, J., and Straub, R.H. (2000)

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Am., 26, 737-63.

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