Stress-stimulated volitional coping competencies and depression in multiple sclerosis

Journal of Psychosomatic Research 74 (2013) 221–226

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Journal of Psychosomatic Research

Stress-stimulated volitional coping competencies and depression in multiple sclerosis J. Nielsen-Prohl ⁎, J. Saliger, V. Güldenberg, G. Breier, H. Karbe Department of Cognitive Rehabilitation, Neurological Rehabilitation Center “Godeshöhe”, University Hospital, Bonn, Waldstrasse 2-10, D-53117 Bonn, Germany

a r t i c l e

i n f o

Article history: Received 18 March 2012 Received in revised form 4 November 2012 Accepted 5 November 2012 Keywords: Coping Depression Self-control Self-regulation Stress Volitional inhibition

a b s t r a c t Objective: The present study examined the relationship between volitional modes of coping (self-regulation, volitional inhibition, and self-control) and depression in individuals with multiple sclerosis. Methods: A cross-sectional study of 121 participants aged 22–60 years with clinically defined MS who were consecutively admitted to a neurological rehabilitation center during a 23-month period. Correlation analyses and hierarchical regressions were conducted to evaluate the predictive value of volitional competencies (Volitional Components Questionnaire, short form, VCQ-S) on depression (Centre for Epidemiologic Studies Depression Scale, CES-D), while controlling for demographic (age, gender, and education) and certain clinical variables (Expanded Disability Status Scale, EDSS; disease duration; and Modified Fatigue Impact Scale, MFIS). Results: Hierarchical regression analyses of depression revealed a model in which 68% of the variance in the CES-D was explained by daily stress situations (VCQ-S), self-regulation (VCQ-S), fatigue (MFIS), and education. However, when the analysis included only participants who had scored above the cut-off of the CES-D (n = 42), the VCQ-S factor volitional inhibition seemed to play a more relevant part in depression. In particular, the VCQ-S scales stimulation of self-access, stimulation of volitional inhibition, self-motivation, and emotional perseverance/state orientation after failure appear to be valuable predictors on CES-D. Conclusions: The results suggest that personality-accentuated volitional coping competencies elicited by daily stressful situations could be a relevant factor for depressive mood states in individuals with MS. However, to clarify the exact relationships of this rather circular framework, longitudinal study designs with objective measurements and a stronger focus on MS-specific stressors are needed. © 2012 Elsevier Inc. All rights reserved.

Introduction Multiple sclerosis (MS) is a chronic (immune-mediated) disease. It is the most common cause of chronic neurological disability in young adults in North America and Europe, with onset commonly between 20 and 40 years of age, and two to three females are afflicted for every male [1]. The course of MS is uncertain, with some individuals showing a steady, often rapid, deterioration, and a small number having a benign course with few symptoms, but most have a relapsing– remitting course, marked by periodic attacks or exacerbations that remit partially or fully [2]. MS can produce a wide variety of symptoms, including, but not limited to, loss of function or feeling in limbs, loss of bowel or bladder control, sexual dysfunction, fatigue, blindness, loss of balance, pain, cognitive impairment, and emotional changes [3]. A sizable portion of the emotional impact of MS can be viewed in terms of affective disorders that may accompany the illness. Foremost among these is depression, with prevalence rates ranging from 14% to 57% in cross-sectional studies [4,5]. Evidence for an organic etiology of depression in MS has been

⁎ Corresponding author. Tel.: +49 228 381 323; fax: +49 228 381 350. E-mail address: [email protected] (J. Nielsen-Prohl). 0022-3999/$ – see front matter © 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpsychores.2012.11.003

mixed, with some studies reporting a depression and lesion load. It has also been suggested that depression may result from MS-specific medications (e.g., interferons) [6]. Other findings indicate that major depressive disorder (MDD) may occur as a prodrome to MS, and may delay diagnosis of the condition [7]. Given the broad spectrum of consequences of MS and its uncertain prognosis, depression may also be related to the stress of having such an illness, because MS can have widespread effects on individuals and on family life, ranging from mild interruption in daily routine to complete disruption of everyday life. By virtue of the disease pattern and its long-term nature, individuals must not only make an initial adjustment to disability, but are also required to undergo a continual process of coping and adaptation [1,8,9]. The vast majority of the literature on coping with MS has been guided by the well-known stress coping model of Lazarus and Folkmann [10]. In this model [11], and in many other traditional approaches, the central role of beliefs, appraisals and cognitive content in adapting to the physical, psychosocial, economic, and environmental needs of the individual is emphasized [12]. In comparison, the volitional coping model by Kuhl [13] shows how emotions and relevant personality traits affect cognition and behavior in adjusting to stress, sickness, or critical life events. “Volition” is conceptualized as the central control instance that coordinates

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mental processes and subsystems (attention, motivation, emotion, activation, cognition, and behavior) in a way that optimizes implementation and maintenance of intentions. This interpretation of volition in terms of a central executive requires a modular concept of the mind: many cognitive, emotional, motivational, and temperamental (arousal) processes are simultaneously active, and each of them modulates a different behavioral tendency competing for access to an operating system that controls ongoing behavior [14]. Kuhl and Fuhrmann [14] postulated a variety of volitional competencies that are utilized by individuals to regulate and adapt to internal and external demands. They identified three main volitional coping modes that can be described as either consciously deployable strategies or unconsciously represented mechanisms: (1) a self-integrating, actionoriented mode of coping (self-regulation mode: e.g., emotional control or adaptation-calming); (2) a self-inhibiting, passive state-oriented mode of coping (volitional inhibition mode: e.g., initiating or energy control); and (3) a self-suppressive, but active and stimulus-sensitive, mode of coping (self-control mode: e.g., intention control or ruminative thinking). Example items of these volitional coping modes are provided in Table 1. Action and state orientation are two opposing poles in Kuhl's approach to volitional action management: action orientation is associated with efficient and context-sensitive self-regulation competencies, whereas state orientation describes the inability to regulate negative affective states and is related to volitional components promoting the conservation of stress [16]. According to Kuhl's affect-cognition modulation hypothesis, positive affect facilitates self-regulation strategies and reduces volitional inhibition while negative affect increases self-access inhibition and facilitates self-control. Thus, situations that reduce positive affect or enhance negative affect (e.g., frustration, exposure to uncontrollable events, and unpredictability of aversive events) can be regarded as antecedents of goal-oriented behavior or inhibition of access to integrated self-representations (e.g., people's needs, preferences, beliefs, attitudes, and positive mood states), respectively [13]. Some studies examining Kuhl's volitional coping modes suggest that self-regulation competencies are associated with better social relationships and interpersonal skills [15] and that they are particularly

necessary for patients with psychiatric or psychosomatic disorders because they promote recovery from stress and correlate with fewer reports of psychopathology [16–18]. The present study attempted to apply the concept of volitional coping competencies posed by Kuhl and Fuhrman [14] in individuals with MS. We expected to find meaningful associations between selfregulation and self-control competencies in relation to the degree of acute depressive symptoms. As the relationship between volitional competencies and depression in the MS population has been largely overlooked, we hoped that the present study could shed light on the heterogeneous concepts of depression in this chronic disease. Methods Participants During a 23-month period, 121 individuals with clinically defined MS [19], who were consecutively admitted to the Neurological Rehabilitation Center “Godeshöhe,” were invited to participate in this study, which took place from July 2009 to June 2011. All participants provided written informed consent, and the study protocol was approved by the Ethics Board of the Faculty of Medicine, University of Bonn, and conformed to institutional and federal guidelines for the protection of human subjects. The inclusion criteria were as follows: (1) an Expanded Disability Status Scale (EDSS) [20] score of between 0 and 8.0 (at admission), (2) no current or past life-threatening or severely-disabling physical disorder, (3) no history of psychotic disorders, (4) no history of substance abuse, (5) no evidence of severe cognitive impairment, as indicated by testing below the fifth percentile in at least three of five domains of neuropsychological functioning (i.e., visuo-spatial skills, attention, orientation, learning/memory, and executive function), (6) no current MS exacerbation, (7) no pregnancy, and (8) no inability to speak or read German. Of the 121 participants, 60 (49.59%) had relapsing–remitting (RRMS), 19 (15.70%) had secondary progressive (SPMS), and 27 (22.31%) exhibited a primary progressive (PPMS) disease course. Fifteen (12.40%) participants suffered from a first (mono-/multifocal) neurologic

Table 1 Factors, scales, volitional components, and sample items of the Volitional Components Questionnaire, short form (VCQ-S) Factor/scales Self-regulation mode (factor 1) Self-motivation Arousal control Self-determination

Volitional inhibition mode (factor 2) State orientation Volitional passivity Self-criticism/strength of concentration

Self-control mode (factor 3) Goal pursuit Alienation/conformity Emotional perseverance/state orientation after failure

Daily stress situations (factor 4) Burdens Threats

Components

Sample items

Motivation control Emotion control Adaptation-activating Adaptation-calming Self-congruence Optimism/self-efficacy beliefs

“Considering positive incentives concerning the matter” “Cheering myself up to make things work” “Being fit if matters get serious” “Being able to calm down if this will help” “Feeling at one with my decision” “Looking forward to overcoming unpleasant times”

Initiating Energy control Procrastination External control Susceptibility to intrusive thought Impulse control

“Beginning something without hesitation” “Feeling dispirited and exhausted/feeling dull” “Postponing the matter” “Keep going only if someone threatens to became angry” “Being unable to keep negative thoughts not related to a current activity from intruding into working memory” “Feeling defenseless when exposed to temptation”

Intention control Over control Informed introjection Negative self-motivation control Ruminative thinking Failure control

“Often rehearsing my decision” “Imposing discipline on myself” “Feeling obliged to meet the expectations of others” “Anticipating negative consequences of not acting” “Constantly asking myself how I could have done better” “Losing my drive after a failure”

Stimulation of volitional inhibition Stimulation of self-access

“I have to overcome a lot of trouble” “There are many changes in my life to which I must adapt” or “I have to cope with a lot of instability”

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episode (clinically isolated syndrome; CIS) caused by inflammatory/ demyelination in one or more sites in the CNS. At the time of investigation, 55 participants were not receiving MSspecific medication. Fifty-eight participants were being treated with interferon beta (n = 40), glatiramer acetate (n = 16), or azathioprine (n = 2), whereas eight participants were receiving escalating doses of natalizumab, mitoxantrone, or cyclophosphamide. Thirty-two participants were receiving antidepressants (primarily serotonin-specific reuptake inhibitors), most of whom were already receiving this before admission into the rehabilitation center. Measures The following questionnaires were applied to each participant on an individual basis on the second day after admission. All measurements were carried out by the same study investigator and were administered in a standardized format according to the manuals. Measures of volition The Volitional Components Questionnaire (VCQ) is a self-report instrument that measures a variety of volitional competencies conceptualized in the theory of volitional action management developed by Kuhl and Fuhrmann [14]. In the present study, we applied the short form of the VCQ (VCQ-S) consisting of 11 scales (56 items): nine scales measured volitional competencies and two scales assessed the stimulation of volitional inhibition or self-access because of “daily stress situations.” The short form comprised a three-factorial structure: (1) self-regulation contained three action-oriented self-regulation competencies (self-motivation, arousal control, and self-determination), (2) volitional inhibition assessed state-oriented self-inhibited behavior (prospective state orientation, volitional passivity, and self-criticism/ strength of concentration), and (3) self-control consisted of three selfdisciplining subsystems (goal pursuit, alienation/conformity, and emotional perseverance/state orientation after failure) (Table 1). Each participant rated the extent to which each item applied to him-/herself on a 4-point Likert scale (0, not applicable; 3, wholly applicable). The internal consistency of the scales was moderate to high (Cronbach's α: .62–.90), and the external validity of the VCQ(-S) was supported by a variety of studies [21]. Norm values (n= 365) were available separately for females and males. Measures of psychopathology, fatigue, and social support Depression was assessed with the Centre for Epidemiologic Studies Depression Scale (CES-D) (German adaptation: Allgemeine Depressionsskala, ADS [22]), a 20-item self-rating questionnaire of depressive symptoms [23]. In the German norm population (n = 1205) a score of ≥23 indicated clinically relevant depression. The severity of psychiatric illness was assessed using the Global Severity Index (GSI) of the German version [24] of the Brief Symptom Inventory (BSI). The BSI is a self-administered questionnaire with 53 items subdivided into nine sub-scales that cover a broad spectrum of psychopathological and somatic symptoms that have occurred in the last seven days. Participants answer using a five-point scale, ranging from 0 (never) to 5 (very strong). The Global Severity Index (GSI) is the best global indicator of current levels of psychological distress. Subjective physical well-being was assessed with a Questionnaire for assessing subjective Physical Well-Being (QPWB) composed of four scales, each containing four items: stress resistance, ability to enjoy, vitality, and inner peace [25]. Fatigue was measured with the Modified Fatigue Impact Scale (MFIS) [26]. The MFIS focused on physical, cognitive, and psychosocial fatigue and contained 21 items, which were scored from 0 (never) to 4 (almost always), with the total score ranging from 0 to 84. Those with a score of ≥38 were classified as suffering from clinically relevant fatigue. The assessment of social support was carried out with the 22-item short version of the Social Support Questionnaire (SocSQ)

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(German: Fragebogen zur sozialen Unterstützung, F-SozU), a widely used German self-report questionnaire [27]. Statistical analyses Descriptive sample statistics were computed for demographic characteristics (age, gender, and education), clinical data (EDSS and disease duration), and psychometric data (VCQ-S, CES-D, GSI, QPBW, MFIS, and SocSQ). The results are depicted as mean (SD) (in the case of parametric distributions), and as median (Md), minimum (Min), and maximum (Max) (in the case of non-parametric distributions). As in preliminary analyses, no differences were revealed between either the different medication groups or the different MS disease courses with respect to the psychometric variables; therefore, they were excluded from further calculations. The relationships between volitional competencies and psychopathological measures were assessed by linear correlation analyses. The degree of association was calculated using a Pearson correlation coefficient (two-tailed). Coefficients were interpreted as follows: .1 ≤ r ≤ .3 as small, ≤.5 as moderate, and >.5 as large correlations. Hierarchical multiple regressions were conducted to evaluate the predictive value of volitional competencies on depression (CES-D), while controlling for specific demographic and clinical variables. At each step in hierarchical modeling the method of stepwise entering was performed. Statistical evaluations were performed with the SPSS 15.0 software package. Due to the exploratory nature of this investigation, the level of significance was set to .05 for all statistical evaluations. Results Relevant sample statistics concerning demographic, clinical, and psychometric characteristics are presented in Table 2. The study sample consisted of 80 women (66.9%) and 41 men (33.1%), which is in line with the gender ratio of a typical MS-population. The mean (standard deviation) age of the participants was 42.03 years (SD=8.90; range: 22–60 years). The duration of education (years of education according to the

Table 2 Demographic, clinical, and psychometric characteristics of the total sample (n = 121) Variables

Mean

Md

SD

Min

Max

Age (years) Educationa (years) EDSS Disease duration (years)a VCQ-S self-regulation Self-motivationa Arousal control Self-determinationa VCQ-S volitional inhibition State orientationa Volitional passivitya Self-criticism/concentration a VCQ-S self-control Goal pursuit Alienation/conformity Emotional perseverance/state orientation after failure VCQ-S daily stress situations Stimulation of volitional inhibitiona Stimulation of self-accessa CES-D GSI (BSI) QPWBa MFIS SocSQa

42.03 10.36 3.65 7.03 16.18 50.36 48.04 51.50 14.08 58.92 48.18 36.13 15.39 52.00 48.58 49.74

43.00 10.00 3.50 5.00 16.00 50.00 47.00 53.00 13.00 62.00 48.00 31.00 15.00 52.00 48.00 48.00

8.90 1.52 1.66 6.79 6.33 10.67 10.47 14.69 6.92 12.86 10.20 13.72 6.86 10.31 10.64 14.90

22 8 0 0 2 28 31 5 0 0 0 0 1 24 27 11

60 13 8 26 35 80 80 80 35 80 80 73 34 80 80 80

25.13 75.69 70.13 19.38 60.04 18.86 49.77 66.49

24.00 80.00 80.00 18.00 58.50 9.20 49.00 75.00

11.51 8.49 12.55 11.53 13.25 22.29 18.66 29.01

2 49 33 0 30 0.5 2 1

52 80 80 47 80 90.6 84 99

Note. EDSS=Expanded Disability Status Scale. VCQ-S=Volitional Competencies Questionnaire (VCQ, short form) [VCQ-S factors 1–4=raw scores, VCQ-S scales=t values (gender-adjusted)]; CES-D=Centre for Epidemiologic Studies Depression Scale (German norms, cut-off: ≥23); GSI=Global Severity Index of Brief Symptom Inventory [t values]; QPWB=Questionnaire of subjective Physical Well-Being [PR=percentile rank]; MFIS= Modified Fatigue Impact Scale (sum score, cut-off: ≥38); SocSQ=Social Support Questionnaire [PR]. a No normal distribution.

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German schooling system) was 10.36 years (1.52; range: 8–13 years). Of the 121 participants, 22, 56, and 43 individuals had >12 years, 10–12 years, and b10 years of school education, respectively. The mean EDSS score was 3.65 (1.66; range: 0–8.0). The mean disease duration (years since diagnosis) was 7.03 years (6.79; range: 0–26 years). Compared to the published norms, or cut-off values, the study sample scored markedly higher on MFIS (sum score) and slightly higher on severity of psychiatric illness (GSI), whereas the CES-D, QPWB, and SocSQ scores fell within the norms, or below the clinically relevant cut-off values. With regard to VCQ-S, nearly all scales (factors 1–3) were in the normal range, with the exception of factor 4, which pointed to a greater amount of daily stress on the study sample. Correlation analyses were initially performed to determine the relationship between volitional competencies and psychopathological parameters, fatigue, and social support. The results are presented in Table 3. Significant negative correlations between self-regulation competencies and depression (CES-D), severity of psychiatric illness (GSI), and fatigue measures (MFIS) were found, whereas positive correlations between the variables of volitional inhibition, self-control, and daily stress situations, with depression, severity of psychiatric illness, and fatigue were demonstrated. QPWB and SocSQ exhibited the opposite pattern, yet there were modest, or no, correlations between the VCQ-S scales and SocSQ. Considering the strength of the correlations, the relationship between the CES-D score and VCQ-S yielded the highest correlation coefficient (r ≤ .75). In addition, Table 3 shows the partial correlation coefficients between CES-D and VCQ-S factors when controlling for MFIS. The comparison of the bivariate (2nd column) and partial coefficients (3rd column) suggested a potential influence of the fatigue measure on this relationship. Using hierarchical multiple regressions, the extent to which the VCQ-S factors predicted depression (CES-D) was examined while controlling for certain demographic and clinical variables. Theoretical and practical implications, other study results, as well as the correlation coefficients in Table 4 had led to the focus on these specific covariates. In hierarchical multiple regressions the F-change statistics are of particular interest since they show the significance of the addition of the entered variables as predictors, whereas the standardized regression coefficient (beta-coefficient) indicates the contribution (= estimation of the variance explained) of each entered variable in predicting depression, along with the usual tests of significance. To control for potential confounding with age, gender, and education, these variables were included in the initial regression model (the first step in hierarchical modeling). The method of stepwise entering was performed with backward elimination to remove terms with p >.05. The result was a model that accounted for only 10% of the variance in CES-D, and this model contained the predictor of gender only: F (df1, df2) = 12.87 (1/119), pb .001; R2 = .10; adj. R2 = .09. The second model (the second step in hierarchical modeling) considered demographic predictors with the MSrelated variables of EDSS, disease duration, and fatigue (MFIS). The variables of MFIS and gender remained in the model: F (df1,df2) = 32.21 (2/118), p b .001; R2 = .35; adj. R2 = .34. Thus, the addition of MFIS significantly changed the model fit for depression from R2 = .10 to .35. The final model considered the demographic variables (age, gender, and education), the clinical variables (EDSS, disease duration, and MFIS), and all four VCQ-S factors. Again, stepwise regressions were calculated, and the final model explained 68% of the variance in CES-D. The addition of VCQ-S factors significantly changed the model fit for depression from R2 = .35 to .68. This final model initially included the variables daily stress situations (R2change = .57, Fchange [df1,df2] = 153.27 [1/119], p b .001; β = .57, p b .001), self-regulation (R2change = .08, Fchange [df1,df2] = 26.31 [1/118], p b .001; β = −.24, p b .001), followed by MFIS (R2change = .02, Fchange

[df1,df2]=6.40 [1/117], p=.013; β=.16, p=.013), and education (R2change =.02, Fchange [df1,df2]=6.31 [1/116], p=.013; β=−.13, p=.013) (Table 5). A number of techniques were employed to test whether the assumptions of a linear regression model were met: (1) visual inspection of residual plots did not reveal systematic patterns or violations of the normality assumption, (2) the Durbin–Watson test indicated no influencing autocorrelation (2.03 [1.5–2.5]), and variance inflation factors (VIF) to test for predictor collinearity were between 1.01 and 1.51 (b10). Final regressions were computed to identify the specific VCQ-S scales (raw scores) that provided valuable information on depression. The calculated stepwise regressions significantly explained approximately 70% of the variance in CES-D in the total sample (n=121): F (df1,df2)=91.21 (3/117), pb .001; R2 =.70; adj. R2 =.69. The model included the following predictors: stimulation of self-access (β=.50, pb .001), self-motivation (β=−.26, pb .001), and emotional perseverance/state orientation after failure (β=.29, pb .001). Stepwise regressions accounted for 50% of the variance in CES-D in the subgroup (n = 42) that scored above the CES-D cut-off value: F (df1,df2) = 19.45 (2/39), p b .001; R2 = .50; adj. R2 = .47. The model included the following predictors: stimulation of volitional inhibition (β = .57, p b .001) and emotional perseverance/state orientation after failure (β = .31, p b .05).

Discussion In a study population of 121 individuals with MS, a coping concept that emphasized the role of volitional competencies was investigated in relation to the degree of acute depressive symptoms. The sample statistics showed typical demographic and clinical data for MS cohorts admitted to a neurological rehabilitation center. The total sample demonstrated high fatigue scores, whereas the depression (CES-D), the subjective well-being scores (QPBW), and the social support scores (SocSQ) were within normal limits. However, the severity of psychiatric illness (GSI), and the VCQ-S factor 4 (daily stress situations) in particular, indicated that the study sample experienced a high level of stress. The examination of the beta-coefficients indicated that daily stress situations made the greatest contribution towards predicting depression, thus it was wise to include this factor in the regression model, as suggested by the VCQ-S authors. Stressful and demanding conditions elicit maladaptive volitional behavior more than do friendly and safe environments. As expected from the correlation analyses, the factor of self-regulation was also included in the final regression models of depression. The negative beta-coefficients show that low self-regulation competencies correlate with higher levels of depression. With respect to the total sample self-regulation was indicated as being the best volitional coping mode in predicting depression, better than either volitional inhibition or self-control. The scale of self-motivation, in particular, appears to be a

Table 3 Pearson coefficients (r) between VCQ-S factors/scales and measures of psychopathology, fatigue and social support (raw scores) VCQ-S factors/scales

CES-D

CES-Da (MFIS)

CES-Db (n = 42)

GSI

QPWB

MFIS

MFIS phy

MFIS cog

MFIS psy

SocSQ

VCQ-S self-regulation Self-motivation Arousal control Self-determination VCQ-S volitional inhibition State orientation Volitional passivity Self-criticism/concentration VCQ-S self-control Goal pursuit Alienation/conformity Emot. perseverance/state orient. VCQ-S daily stress situations Stimulation of volit. inhibition Stimulation of self-access

−.57⁎⁎⁎ −.53⁎⁎⁎ −.45⁎⁎⁎ −.47⁎⁎⁎ .61⁎⁎⁎ .25⁎⁎ .22⁎ .35⁎⁎⁎ .67⁎⁎⁎ .42⁎⁎⁎ .48⁎⁎⁎ .69⁎⁎⁎ .75⁎⁎⁎ .70⁎⁎⁎ .72⁎⁎⁎

−.41⁎⁎⁎ −.35⁎⁎⁎ −.29⁎⁎ −.34⁎⁎⁎ .43⁎⁎⁎ n.s. n.s. .22⁎ .53⁎⁎⁎ .29⁎⁎ .39⁎⁎⁎ .55⁎⁎⁎ .66⁎⁎⁎ .57⁎⁎⁎ .66⁎⁎⁎

n.s. n.s. n.s. n.s. .39⁎⁎ .39⁎⁎ .31⁎ .34⁎ .33⁎

−.44⁎⁎⁎ −.34⁎⁎⁎ −.37⁎⁎⁎ −.42⁎⁎⁎ .48⁎⁎⁎ .39⁎⁎⁎ .37⁎⁎⁎ .52⁎⁎⁎ .62⁎⁎⁎ .44⁎⁎⁎ .47⁎⁎⁎ .56⁎⁎⁎ .65⁎⁎⁎ .58⁎⁎⁎ .65⁎⁎⁎

.53⁎⁎⁎ .52⁎⁎⁎ .44⁎⁎⁎ .38⁎⁎⁎ −.50⁎⁎⁎ −.29⁎⁎⁎ −.20⁎ −.30⁎⁎⁎ −.54⁎⁎⁎ −.33⁎⁎⁎ −.40⁎⁎⁎ −.57⁎⁎⁎ −.58⁎⁎⁎ −.57⁎⁎⁎ −.53⁎⁎⁎

−.49⁎⁎⁎ −.48⁎⁎⁎ −.41⁎⁎⁎ −.36⁎⁎⁎ .57⁎⁎⁎ .27⁎⁎

−.40⁎⁎⁎ −.38⁎⁎⁎ −.34⁎⁎⁎ −.29⁎⁎ .45⁎⁎⁎ .29⁎⁎ .19⁎ .23⁎ .43⁎⁎⁎ .33⁎⁎⁎ .23⁎ .46⁎⁎⁎ .45⁎⁎⁎ .48⁎⁎⁎ .37⁎⁎⁎

−.50⁎⁎⁎ −.49⁎⁎⁎ −.40⁎⁎⁎ −.37⁎⁎⁎ .56⁎⁎⁎ .23⁎

−.39⁎⁎⁎ −.34⁎⁎⁎ −.36⁎⁎⁎ −.29⁎⁎ .42⁎⁎⁎ .21⁎

.25⁎⁎ .32⁎⁎⁎

n.s. .33⁎⁎⁎ .50⁎⁎⁎ .33⁎⁎⁎ .30⁎⁎ .55⁎⁎⁎ .44⁎⁎⁎ .50⁎⁎⁎ .35⁎⁎⁎

n.s. .21⁎ .43⁎⁎⁎ .26⁎⁎ .31⁎⁎ .45⁎⁎⁎ .40⁎⁎⁎ .43⁎⁎⁎ .33⁎⁎⁎

n.s. n.s. .44⁎⁎ .65⁎⁎⁎ .64⁎⁎⁎ .56⁎⁎⁎

n.s. .31⁎⁎ .52⁎⁎⁎ .35⁎⁎⁎ .31⁎⁎ .56⁎⁎⁎ .48⁎⁎⁎ .53⁎⁎⁎ .39⁎⁎⁎

n.s. = no significance. Note. MFIS phy = physical score of MFIS, MFIS cog = cognitive score of MFIS; MFIS psy = psychosocial score of MFIS. See Table 2 for key to abbreviations. ⁎⁎⁎ p b .001. ⁎⁎ p b .01. ⁎ p b .05. a Partial correlation (controlling for MFIS). b Participants scoring above the cut-off value of CES-D (n = 42).

n.s. n.s. −.19⁎ n.s. n.s. n.s. −.23⁎ n.s. n.s. −.29⁎⁎ −.21⁎ −.21⁎ −.20⁎

J. Nielsen-Prohl et al. / Journal of Psychosomatic Research 74 (2013) 221–226

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Table 4 Inter-correlation coefficients for the study variables entered in the hierarchical regression analyses

(1) Age (2) Sexa (3) Education (4) EDSS (5) Disease duration (6) MFIS (7) VCQ-S self-regulation (8) VCQ-S volitional inhibition (9) VCQ-S self-control (10) VCQ-S daily stress situations (11) CES-D

2

3

4

5

6

7

8

9

10

11

.11

−.24⁎⁎ .11

.22⁎ −.02 .02

.22⁎ −.11 −.03 .26⁎⁎

.02 −.23⁎ −.05 .12 −.01

.19⁎ .31⁎⁎ .10 .05 −.08 −.49⁎⁎⁎

−.22⁎ −.25⁎* .06 −.03 .08 .57⁎⁎⁎ −.59⁎⁎⁎

−.13 −.36⁎⁎⁎ −.07 .09 −.03 .52⁎⁎⁎ −.53⁎⁎⁎ .69⁎⁎⁎

.05 −.28⁎⁎ .02 .12 −.01 .48⁎⁎⁎ −.42⁎⁎⁎ .60⁎⁎⁎ .67⁎⁎⁎

.04 −.32⁎⁎⁎ −.16 .04 −.00 .56⁎⁎⁎ −.57⁎⁎⁎ .61⁎⁎⁎ .67⁎⁎⁎ .75⁎⁎⁎

Note. See Table 2 for key to abbreviations. ⁎⁎⁎ p b .001. ⁎⁎ p b .01. ⁎ p b .05. a = Spearman-rho coefficient.

valuable predictor on depression. Volitional inhibition was positively correlated with depression, severity of psychiatric illness, and fatigue, and negatively correlated with the subjective well-being scores (QPBW), but exerted no influence in the predictor set of the final regression model of depression. However, when the analysis included only participants who had scored above the cut-off value of the CES-D (n=42), the VCQ-S factor volitional inhibition and its associated scales seemed to play a more relevant part in depression than other VCQ-S components did. The factor self-control showed a meaningful significant correlation with subjective reports of depressive symptoms (especially emotional perseverance/state orientation after failure), however, the factor became less important in the context of all predictors. The MS-related variables of EDSS and disease duration did not in any way appear to be meaningful covariates in these regressions. The variable education was included in the final regression model on depression as a demographic variable. This relationship is supported by findings from other studies (e.g., [28]), yet there is no evidence for a substantial relationship between VCQ scales and general intelligence [14]. We think that the data from the present study suggest, it would be useful to associate the volitional coping competencies developed by Kuhl and Fuhrmann [14] with depression in MS populations, although it is important to note that the reasons for depression in individuals with MS are multifaceted. With respect to the macro-components of the VCQ-S, the associations revealed suggest that volitional selfregulatory processes play a role in emotional and motivational stress-balancing. However, an inspection of the subgroup analysis indicated that aspects of volitional inhibition and self-control (especially emotional perseveration/state orientation after failure) contribute to depressive mood states as well. Therefore, various aspects of Kuhl's affect-cognition modulation hypothesis could explain the manifestation of depressive symptoms in some MS patients through the following hypothesized pathway: individuals with MS are faced with the unpredictability and uncontrollability of symptom burdens and

exacerbations, and they may face physical and psychological limits when overcoming daily stress situations. They may thus experience feelings of instability, anxiety, or frustration when encountering these threats and burdens. Some individuals tend to minimize selfregulation strategies (e.g., to motivate oneself for social participation), which may lead to low rates of positive reinforcement. They may intensify self-control at the same time by suppressing internal signals (e.g., emotional needs) or neglecting somatic signs due to a desire to preserve their daily routines. These mechanisms result from unrealistic goal setting. Negative mood subsequently arises and this can lead to a period of state orientation with emotional perseverance, rumination, and cognitive distortions with regard to their selfesteem. Similar mechanisms have been corroborated by Shnek et al. [28], who found positive correlations between depression and learned helplessness and cognitive distortions, and a negative correlation between depression and perceived self-efficacy. According to Kuhl [13], permanently preventing self-regulatory coping strategies may reduce access to “vital” aspects of the integrated self (e.g., participation of needs, preferences, and positive mood states). Therefore, individuals with MS may suffer from physical and psychological exhaustion in the long-term, which partially overlaps with the concept of MS-related fatigue. A relationship between volitional coping modes and fatigue is supported by the moderate correlation coefficients in the present study and may help interpret the results obtained by Penner et al. [29]; they found a tendency towards a state-oriented behavior among MS-fatigued individuals, indicated by a negative correlation between fatigue scales and the HAKEMP-90 subscales [30] pre-occupation, hesitation and volatility. Kuhl's volitional approach to coping, which incorporates the functional account of the self and its role in action management control, can be placed in the “third generation of coping theories,” which is characterized by new efforts to better understand the role of personality in generating, maintaining, and directing coping strategies [31]. Deficits in volitional competences are discussed as a vulnerability factor for

Table 5 Summary of hierarchical regression analyses (stepwise entering), predicting depression (CES-D), total sample (n = 121) CES-S

Variable

R2 change

F change

p value

B

SE B

β

p value

Model 1 Model 2

Gender MFIS Gender Daily stress situations Self-regulation MFIS Education

.10 .32 .94 .56 .08 .02 .02

12.87 55.43 6.45 153.27 26.31 6.40 6.31

.000 .000 .012 .000 .000 .013 .013

−7.63 .32 −4.72 .58 −.43 .10 −1.01

2.13 .05 1.86 .06 .11 .04 .40

−.31 .52 −.19 .57 −.24 .16 −.13

.000 .000 .012 .000 .000 .013 .013

Model 3

FModel 3 (age, gender, education, EDSS, disease duration, MFIS, VCQ-S factors) (df1,df2) = 61.24 (4/116), pb .001; R2 = .68; adj. R2 = .67. Note. CES-D=Centre for Epidemiologic Studies Depression Scale, MFIS=Modified Fatigue Impact Scale; B=unstandardized coefficient; SE B=standard error of B, Beta=standardized coefficient.

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depression in this framework [32]. Kuhl [14] proposed that a chronic disposition toward a dominance role of self-control or volitional inhibition in life-span can seriously impair the development of an integrated self and may increase the probability of a manifestation of depressive symptoms in the long run. Nevertheless, the individual can learn to balance volitional facility modes after taking into account personal, situational, and contextual conditions. However, when considering the mechanisms of the affect-cognition modulation hypothesis, the relationship between volitional coping competencies, depression and daily stress situations may be better understood as a dynamic circular process: depressive mood states could predict a person's ability to cope with daily stress situations or be a response to maladaptive volitional coping, which in turn leads to difficulty in coping with the next stressful life event. There is good reason to believe that stressors specific to MS, such as fear of disease progression [33] or patients' illness representations [34], may play a significant role in these framework, which is the focus of our future research. A number of limitations in the present study should be acknowledged. First, the study results are based solely on self-report measures and the findings can only be generalized to a non-random, consecutive-recruited sample admitted to a neurological rehabilitation center; the EDSS range indicates that the results should be applied primarily to such individuals with MS. Second, to measure the reliability of volitional coping mode over time, a longitudinal design (including objective assessments of depression, stressful life events, and MS-specific stressors) would have greater validity in distinguishing depressive symptoms from certain volitional micro-components than the cross-sectional study design used here. Third, it is important to emphasize that although the participants were administered the CES-D, which enabled the investigator to assess subjective reports of acute depressive symptoms, this instrument does not provide diagnostic classifications. Nevertheless these findings could advance research in the field of MS because they provide evidence of a partial influence of volitional aspects in coping with daily stress situations in an individual with MS. The greater the understanding of volitional coping mechanisms in relation to the macro system of personality on the one hand and disease-related conditions gained from future research on the other, the better the individual success in developing therapy motivation as a function of the self and as an improved realization of intended behavioral change. These findings may also be useful in achieving greater acceptance for self-management trainings. This is important, because the episodic nature of many chronic illnesses (including MS) poses a problem for self-management such that patients will volunteer to learn these skills when they are symptomatic, but lose interest once they are asymptomatic [35]. Several studies have shown that negative health outcomes are associated with deficits in self-regulation, and the results of some studies suggest that rehabilitation outcomes are better in individuals who exhibit improvements in volitional competencies [36,37]. However, further research should demonstrate that a systematic training of volitional self-regulatory skills can be empirically supported, especially with respect to reducing depressive episodes. Conflict of interest statement The authors have no conflicts of interest to declare and the research received no specific grant from any funding agency in the public, commercial, or non-profit sectors. References [1] McNulty K. Coping with multiple sclerosis: considerations and interventions. In: Martz E, Livneh H, editors. Coping with chronic illness and disability. New York: Springer Science; 2007. p. 289-311. [2] Lublin FD, Reingold SC. Defining the clinical course of multiple sclerosis: results of an international survey. Neurology 1996;46:907-11.

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