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Identifier 000457809
Title Διαχρονική μελέτη γνωστικών και ψυχιατρικών συμπτωμάτων σε αυτοάνοσα νοσήματα : συστηματικός ερυθηματώδης λύκος (ΣΕΛ) και ρευματοειδής αρθρίτιδα (ΡΑ)
Alternative Title Longitudinal study of cognitive and psychiatric symptoms in autoimmune diseases : systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA)
Author Παπαστεφανάκης, Εμμανουήλ Σ.
Thesis advisor Σίμος Παναγιώτης - Γαβριήλ
Reviewer Καραδήμας Ευάγγελος
Γιακουμάκη Στυλιανή
Κούτρα Αικατερίνη
Μπάστα Μαρία
Φανουριάκης Αντώνης
Abstract OBJECTIVES AND RESEARCH AIMS: Systemic lupus erythematosus (SLE) often has neuropsychiatric manifestations (NPSLE), including cognitive impairment (CI), depression and anxiety, which can adversely affect mental and physical health as well as illness adaptation. The Montreal Cognitive Assessment (MoCA) has been proved sensitive for detecting CI in several medical conditions but only four studies have tested its properties in SLE patients. The First Research Aim (1) of this study was to evaluate the Greek version of MoCA as a screening tool for CI in SLE. The Second Research Aim (2) was to assess the CI prevalence in non-NPSLE, NPSLE and clinical controls with Rheumatoid Arthritis (RA) as determined through neuropsychological testing (NPT). The Third Research Aim (3) was to identify the most prominent differences among the three patient groups on specific cognitive domains, mental (depression and anxiety) and physical health indices (pain, physical health quality of life and fatigue). Only a few studies have examined the course of CI in SLE patients over time, with most of them reporting stability or improvement. The Fourth Research Aim (4) was to examine changes in CI, mental and physical health indices over a 1-year period. The Fifth (5) & Sixth (6) Research Aims derived from the Common Sense-Self Regulation Model (CS-SRM) describing the interplay between illness representations (IR) and coping strategies (CS) as they impact physical and mental health. Specifically, we examined if the change of IR and CS over a 1-year period mediates the concurrent changes in mental (depression & anxiety) and physical health variables (health quality status, physical well-being & pain) in the entire sample of Inflammatory Rheumatic Disease (IRD) patients. In view of previous reports that IRD patients’ mental health can influence their physical functioning, the Seventh Research Aim (7) examined whether the change of Depression & Anxiety symptoms mediates the concurrent one-year changes in physical health variables in the total sample of IRD patients. Finally, the Eighth Research Aim (8) addressed the role of cognitive functioning in the illness adaptation process by testing the mediating effect of the one-year changes in CI on the concurrent changes in mental health variables and physical health variables in IRD patients. PATIENTS AND METHODS: Study 1 examined the First Research Aim: Seventy-one SLE patients were evaluated using MoCA and an extensive NPT, incorporating the cognitive domains suggested by the ACR. The criterion validity of MoCA was assessed through receiver operating characteristic (ROC) analyses using three different case definitions: i) against normative population data, ii) & iii) against average performance of a comparison group of RA patients, to adjust for possible confounding effects of chronic illness and inflammatory processes on cognitive performance. The effect of patient- and disease-related parameters on the MoCA was examined. The remaining research aims (2-8) were examined within the context of Study 2: Eighty-two non-NPSLE, 36 NPSLE and 99 RA patients were evaluated at baseline using extensive NPT while 64, 26 and 61 of the patients, respectively, returned at the one-year follow-up. Cognitive indices were computed from the NPT while patients were, also, administered questionnaires assessing mental- and physical health, IR and CS. The Second Research Aim (2) was based on two different CI definitions (CI1 and C12) against normative data. Chi-square tests were used to compare patient groups on proportions. For the Third Research Aim (3), group differences on age- and education- adjusted z cognitive scores as well as on mental- and physical- health scores were tested with one-way ANOVAs. For the Fourth Research Aim (4), non-NPSLE, NPSLE and RA patients were retested at one-year follow-up in all the aforementioned cognitive, mental and physical health measures. Composite scores were computed to index verbal memory indices, verbal fluency, and visuomotor coordination speed and along with self-rated mental and physical scores were submitted to 2 (time points) by 3 (groups) mixed-design ANOVA controlling for disease duration. Change in CI classifications over time was assessed using the McNemar’s test. For the remaining Research Aims (5-8), we applied repeated measures mediated regressions using MEMORE. RESULTS: Research Aim 1: the MoCA score was affected by education level, but not by other demographic or clinical variables. The optimal cutoff for detecting CI, as defined on the basis of normative data, was 23/30 points, demonstrating 73% sensitivity and 75% specificity. A cutoff of 22/30 points, using NPT profiles of the RA group, exhibited higher sensitivity (100%, based on both definitions) and specificity (87% and 90%, depending on the definition). The standard cutoff of 26/30 points displayed excellent sensitivity (91–100%) with significant expenses in specificity (43–45%). Research Aim 2: according to the first CI definition, the frequency of impairment was higher in the NPSLE group (91.4%) as compared to the non-NPSLE group (73.2%), but not significantly different than the RA group (80.8%). Based on the second CI definition, rates were comparable among groups (31.7% in non-NPSLE, 48.6% in NPSLE and 36.4% in RA patients). Research Aim 3: pairwise Bonferroni-adjusted tests indicated worse performance of the NPSLE patients in verbal short-term and working memory, abstract reasoning, lexical knowledge and immediate episodic recall compared to the RA group, and in immediate and delayed episodic recall compared to the non-NPSLE patients who performed higher than the RA group in a visuomotor coordination efficiency test. Group effects on abstract reasoning, lexical knowledge, visuomotor coordination efficiency as well as immediate recall and retention persisted after controlling for depression, anxiety and pain severity. The three groups displayed similar rates for presence of significant mental health symptoms (ranging between 29.5% and 55.6%). Additionally, NPSLE patients scored higher than non-NPSLE patients on the physical impact subscale, even after controlling for disease duration. Research Aim 4: longitudinal performance improved at similar rates on the verbal memory indices, verbal fluency, and visuomotor coordination speed across groups, although CI classification remained stable across time points. Anxiety symptom severity (but not depression) was significantly reduced across groups, although anxiety prevalence rates remained stable across time. Longitudinal mediation models (LMM) addressing the Research Aims 5 and 6, demonstrated significant direct & total effects but nonsignificant indirect effects on Depression & Anxiety through IR & CS. Regarding physical health outcomes, only significant direct effects on Health Quality Status were detected through timeline, personal & treatment control IR. Research Aim 7 revealed a significant indirect effect with anxiety mediating physical well-being change. Research Aim 8 demonstrated significant direct & total effects on Depression & Anxiety through each of the mediating cognitive indices tested. Moreover, the Immediate Memory Recall (IMR) and the Semantic Verbal Fluency (SVF) displayed significant indirect effects on Depression while the Delayed Memory Recall (DMR) exhibited a significant indirect effect on Anxiety. Regarding the physical health indices only the direct effect on Health Quality Status through SVF was revealed. CONCLUSIONS: This study highlights the significant burden incurred by CI, mental and physical health symptoms which varies significantly between non-NPSLE, NPSLE and RA patients. Longitudinally, improvement and stability were detected in specific cognitive indices with a few differences among groups while CI prevalence remained stable in all groups. Anxiety burden was relieved in time while depression and physical burden resisted. Cognition was revealed to have specific mediating effects on the change of mental adjustment overtime. Mental adjustment was, also, influenced by IR and CS without generating robust evidence. Anxiety was the only factor that mediated the change of physical well-being over time. Although, further research is needed to establish the interplay of these factors, the current findings can possibly have clinical applications that can further assist in the management of IRD patients.
Language English
Subject Anxiety
Autoimmune diseases
Cognitive impairment
Coping strategies
Illness representations
Longitudinal study
Neuropsychiatric systemic lupus erythematosus
Neuropsychological deficits
Neuropsychological disorders
Neuropsychological tools
Physical well being
Rheumatoid arthritis
Systemic lupus erythematosus ( SLE)
Αναπαραστάσεις νόσου
Αυτοάνοσα νοσήματα
Γνωστική δυσλειτουργία
Διαχρονική μελέτη
Νευροψυχιατρικός συστηματικός ερυθηματώδης λύκος
Νευροψυχολογικά ελλείματα
Νευροψυχολογικές διαταραχές
Νευροψυχολογική έκβαση
Ρευματοειδής αρθρίτιδα
Στρατηγικές διαχείρισης
Συστηματικός ερυθηματώδης λύκος (ΣΕΛ)
Σωματική ποιότητα ζωής
Issue date 2023
Collection   School/Department--School of Social Sciences--Department of Psychology--Doctoral theses
  Type of Work--Doctoral theses
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