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Effects of Writing About Stressful Experiences on Symptom Reduction in Patients With Asthma or Rheumatoid Arthritis

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Nonpharmacological treatments with little patient cost or risk are useful supplements to pharmacotherapy in the treatment of patients with chronic illness. Research has demonstrated that writing about emotionally traumatic experiences has a surprisingly beneficial effect on symptom reports, well-being, and health care use in healthy individuals. To determine if writing about stressful life experiences affects disease status in patients with asthma or rheumatoid arthritis using standardized quantitative outcome measures. Randomized controlled trial conducted between October 1996 and December 1997. Outpatient community residents drawn from private and institutional practice. Volunteer sample of 112 patients with asthma (n = 61) or rheumatoid arthritis (n = 51) received the intervention; 107 completed the study, 58 in the asthma group and 49 in the rheumatoid arthritis group. Patients were assigned to write either about the most stressful event of their lives (n = 71; 39 asthma, 32 rheumatoid arthritis) or about emotionally neutral topics (n = 41; 22 asthma, 19 rheumatoid arthritis) (the control intervention). Asthma patients were evaluated with spirometry and rheumatoid arthritis patients were clinically examined by a rheumatologist. Assessments were conducted at baseline and at 2 weeks and 2 months and 4 months after writing and were done blind to experimental condition. Of evaluable patients 4 months after treatment, asthma patients in the experimental group showed improvements in lung function (the mean percentage of predicted forced expiratory volume in 1 second [FEV1] improved from 63.9% at baseline to 76.3% at the 4-month follow-up; P<.001), whereas control group patients showed no change. Rheumatoid arthritis patients in the experimental group showed improvements in overall disease activity (a mean reduction in disease severity from 1.65 to 1.19 [28%] on a scale of 0 [asymptomatic] to 4 [very severe] at the 4-month follow-up; P=.001), whereas control group patients did not change. Combining all completing patients, 33 (47.1%) of 70 experimental patients had clinically relevant improvement, whereas 9 (24.3%) of 37 control patients had improvement (P=.001). Patients with mild to moderately severe asthma or rheumatoid arthritis who wrote about stressful life experiences had clinically relevant changes in health status at 4 months compared with those in the control group. These gains were beyond those attributable to the standard medical care that all participants were receiving. It remains unknown whether these health improvements will persist beyond 4 months or whether this exercise will prove effective with other diseases.
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PRELIMINARY
COMMUNICATION
Effects of Writing About Stressful Experiences
on Symptom Reduction in Patients
With Asthma or Rheumatoid Arthritis
A Randomized Trial
Joshua M. Smyth, PhD
Arthur A. Stone, PhD
Adam Hurewitz, MD
Alan Kaell, MD
A
GROWING AMOUNT OF LITERA-
ture suggests that addressing
patients’ psychological needs
produces both psychological
and physical health benefits.
1-3
Expres-
sive writing is one such technique that
has been used successfully in several con-
trolled studies.
4-6
A brief written emo-
tional expression exercise developed by
Pennebaker and Beall
7
has been tested in
studies of health benefits in healthy per-
sons. It calls for participating subjects to
write an essay, typically during a 3-day
period, expressing their thoughts and
feelings about a traumatic experience.
Differences have been found between
control subjects (who write about in-
nocuous topics) and experimental sub-
jects in frequency of subsequent health
center visits, subjective well-being, and
immune function.
8-10
A recent meta-
analysis of this written emotional ex-
pression exercise concluded that the
procedure reliably improved health out-
comes.
11
Prior studies have not addressed the
clinical relevance of these findings, in
part because their samples were physi-
cally healthy people. It is not clear that
the effects extend to individuals with
medical conditions. Prior studies were
Author Affiliations are listed at the end of this ar-
ticle.
Corresponding Author and Reprints: Joshua M.
Smyth, PhD, Department of Psychology, Minard Hall,
North Dakota State University, Fargo, ND 58105-
5075 (e-mail: smyth@prairie.nodak.edu).
Context Nonpharmacological treatments with little patient cost or risk are useful supple-
ments to pharmacotherapy in the treatment of patients with chronic illness. Research has
demonstrated that writing about emotionally traumatic experiences has a surprisingly ben-
eficial effect on symptom reports, well-being, and health care use in healthy individuals.
Objective To determine if writing about stressful life experiences affects disease
status in patients with asthma or rheumatoid arthritis using standardized quantitative
outcome measures.
Design Randomized controlled trial conducted between October 1996 and Decem-
ber 1997.
Setting Outpatient community residents drawn from private and institutional practice.
Patients Volunteer sample of 112 patients with asthma (n = 61) or rheumatoid ar-
thritis (n = 51) received the intervention; 107 completed the study, 58 in the asthma
group and 49 in the rheumatoid arthritis group.
Intervention Patients were assigned to write either about the most stressful event
of their lives (n = 71; 39 asthma, 32 rheumatoid arthritis) or about emotionally neutral
topics (n = 41; 22 asthma, 19 rheumatoid arthritis) (the control intervention).
Main Outcome Measures Asthma patients were evaluated with spirometry and
rheumatoid arthritis patients were clinically examined by a rheumatologist. Assess-
ments were conducted at baseline and at 2 weeks and 2 months and 4 months after
writing and were done blind to experimental condition.
Results Of evaluable patients 4 months after treatment, asthma patients in the ex-
perimental group showed improvements in lung function (the mean percentage of
predicted forced expiratory volume in 1 second [FEV
1
] improved from 63.9% at base-
line to 76.3% at the 4-month follow-up; P,.001), whereas control group patients
showed no change. Rheumatoid arthritis patients in the experimental group showed
improvements in overall disease activity (a mean reduction in disease severity from
1.65 to 1.19 [28%] on a scale of 0 [asymptomatic] to 4 [very severe] at the 4-month
follow-up; P = .001), whereas control group patients did not change. Combining all
completing patients, 33 (47.1%) of 70 experimental patients had clinically relevant
improvement, whereas 9 (24.3%) of 37 control patients had improvement (P = .001).
Conclusion Patients with mild to moderately severe asthma or rheumatoid arthritis
who wrote about stressful life experiences had clinically relevant changes in health sta-
tus at 4 months compared with those in the control group. These gains were beyond
those attributable to the standard medical care that all participants were receiving. It
remains unknown whether these health improvements will persist beyond 4 months
or whether this exercise will prove effective with other diseases.
JAMA. 1999;281:1304-1309 www.jama.com
For editorial comment see p 1328.
1304 JAMA, April 14, 1999—Vol 281, No. 14 ©1999 American Medical Association. All rights reserved.
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also limited to indirect measures of dis-
ease (eg, liver enzyme function, health
center visits) or to self-reported assess-
ments.
11
While important outcomes in
their own right, self-reported symp-
toms are susceptible to many biases.
12
Therefore, we used outcomes more
closely related to disease status.
This study examined whether writ-
ing about stressful experiences affects
objective measures of disease status in
patients with chronic asthma or rheu-
matoid arthritis (RA). We chose these
2 diseases because they are common,
cause substantial personal and eco-
nomic burden, and are chronic condi-
tions affecting daily life. As writing pro-
duces health benefits in healthy people,
we hypothesized that patients as-
signed to the experimental group would
show improvements in outcomes 4
months after writing compared with a
control group. We also hypothesized
that health changes would be of clini-
cally significant magnitudes.
METHODS
Study Population
Participants were volunteers recruited
from local communities who had asthma
or RA. Diagnoses were confirmed in the
RA group by a board-certified rheuma-
tologist and all participants met Ameri-
can College of Rheumatology criteria.
Asthma was diagnosed by a history of
asthma confirmed by a physician; pa-
tients were also required to provide a
documented reduction in expiratory
function (either in physician records or
when evaluated by study staff). Adver-
tisements were posted in local newspa-
pers and at nearby hospitals and medi-
cal practices, seeking individuals with
asthma or RA to “participate in a study
of your daily experience of illness.” In-
terested participants were screened by
telephone to determine eligibility and to
collect demographic and other data used
to characterize participants vs nonpar-
ticipants. Exclusion criteria included the
following: (1) ongoing psychotherapy or
having a defined psychiatric disorder, (2)
using a medication that could interfere
with symptom report (eg, mood-
altering medications) or taking more
than 10 mg of prednisone daily, (3) be-
ing deemed unable to comply with the
protocol (either self-selected or by in-
dicating during screening that he or she
could not attend sessions or complete
all requested tasks), and (4) being un-
able to write for a duration of 20 min-
utes. Participants received $50 for com-
pleting the entire protocol, which was
conducted between October 1996 and
December 1997.
Procedures
Approval was obtained from both the
State University of New York at Stony
Brook and the University Hospital hu-
man subjects review boards. Informed
consent was obtained from interested
and eligible patients for randomiza-
tion and for medical examinations at the
first visit to our laboratory. Consent-
ing patients completed baseline ques-
tionnaires, which included demo-
graphic information, measures of
disease severity and quality of life,
13,14
and a variety of psychological ques-
tionnaires to be used in future exami-
nations of individual differences in re-
sponse to this intervention.
15-23
Intervention
Participants were asked to write for 20
minutes on 3 consecutive days a week
after completing baseline assessments.
Writing took place in private rooms lo-
cated in our laboratory to ensure con-
fidentiality. All participants were given
a writing tablet containing an insert with
writing instructions. Participants in the
experimental group (39 asthma, 32 RA)
were assigned to write about the most
stressful experience that they had ever
undergone, while the participants in the
control group were asked to describe
their plans for the day. Expectancy dif-
ferences were minimized by informing
both groups that we were interested in
their experience of stress. Experimen-
tal participants were explicitly writing
about stressful life experiences, while
control group writing was framed as a
time-management exercise to reduce
stress. Participants were asked to write
continuously, without regard for spell-
ing or stylistic concerns, and were sig-
naled to stop after 20 minutes. Partici-
pants could write about a topic for 3
sessions, or move from one topic to an-
other (they were asked to repeat a pre-
vious topic, if necessary, rather than stop
early). All essays were anonymous and
were returned by dropping the writing
tablet into a sealed box. Participants did
not discuss their writing with project
staff, and participants were never in con-
tact with one another as part of the study
(eg, in a waiting room).
Sample-Size Determination
A recent meta-analysis
11
suggests that the
effect size of this exercise in healthy
samples is d = 0.47, although effect sizes
for the measures used in this study are
likely to be closer to d = 0.68. Power
computations for an unbalanced de-
sign indicate that an overall total of 120
should be sufficient to achieve 80%
power with 2-tailed tests and a = .05.
Outcome Measures
Disease activity outcomes were evalu-
ated at baseline, 2 weeks, 2 months,
and 4 months after writing. (Self-
assessments of the psychosocial envi-
ronment were also collected by partici-
pants for 1 week prior to and 2 weeks
following the writing exercise, but these
results are not presented herein.) The
pulmonary function of patients with
asthma was assessed in the laboratory
by spirometry (Renaissance, Nellcor Pu-
ritan Bennett, Mallinckrodt, St Louis,
Mo), following the guidelines put forth
by the American Thoracic Society. The
primary outcome measure was forced
expiratory volume in 1 second (FEV
1
).
Evaluations of RA patients were made
with a structured interview com-
pleted by the treating rheumatologist.
It is a modification of that used by Af-
fleck and colleagues,
24
and reflects the
recent shift away from entirely quali-
tative to more quantitative, standard-
ized methods.
25
The interview re-
quires the physician to rate diagnostic
symptoms, a global assessment of dis-
ease activity, symptom severity, distri-
bution of pain, tenderness, and swell-
ing throughout the affected joints,
presence and severity of deformities,
WRITING ABOUT STRESSFUL EXPERIENCES
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assessment of daily living capacity, and
general psychosocial functioning. The
primary outcome measure for this study
was the physician’s global assessment
of patients’ current clinical status, which
has been recommended for use in RA
clinical trials.
26,27
Each RA patient had
4 clinical examinations completed by
the same physician. Several physi-
cians conducted evaluations for the
study. These measures not only repre-
sent the core symptoms of the 2 dis-
eases but also represent contrasting
approaches to illness evaluation (1 bio-
mechanical, 1 clinical interview). All
raters were unaware of experimental
condition.
Statistical Analysis
In addition to overall intervention
group comparisons from baseline to fi-
nal follow-up, analyses examining the
clinical relevance of observed changes
and the time-course of changes were
planned in advance. Group differ-
ences were evaluated with analysis of
covariance, testing the effect of group
(control vs experimental) at 4 months
following writing, statistically control-
ling for baseline levels. Clinical rel-
evance was tested by examining the dis-
tribution of patients who met our
criteria for clinically relevant improve-
ment in each group, using x
2
analyses.
Finally, the time course of changes was
examined using repeated measures
analysis of covariance including terms
representing the effect of group, time,
and the interaction of group and time.
Random Assignment and Masking
An unbalanced design with greater
numbers of participants assigned to the
experimental than the control condi-
tion (35:21 for RA, 48:22 for asthma,
respectively) was used to enhance later
exploration of the experimental group
(14 patients dropped out of the study
before receiving the intervention). After
entering the study and completing base-
line assessments, participants were ran-
domized into the control or experimen-
tal group using a computer-generated
random assignment scheme, which
assigned 2 of every 3 patients (within
disease group) to the experimental con-
dition. This strategy also provided com-
parable seasonal effects for control and
experimental groups. Assignments were
kept in sealed opaque envelopes until
participants were scheduled to com-
plete the writing intervention, at which
point the research coordinator pre-
pared intervention instructions spe-
cific to group assignment. These instruc-
tions were then handed to patients who
were instructed to open them in pri-
vacy. Neither patients nor physicians
were informed of the assignment. There
was no indication that either patients
or physicians attempted to compro-
mise blinding procedures. Statistical
analyses were conducted primarily by
the first author, who was aware of group
assignment.
RESULTS
Participants
We received 465 telephone calls ex-
pressing interest in the study, 222 from
asthma patients and 243 from RA pa-
tients. Among the asthma patients, 31
callers (14.0%) were interested but not
eligible, 73 (32.9%) were eligible but said
they were not interested in participat-
ing because of the time commitment, 32
(14.4%) were not interested and did not
provide eligibility information, and
project staff were not able to contact the
remaining 16 (7.2%). Among the RA pa-
tients, 35 callers (14.4%) were inter-
ested but not eligible, 49 (20.2%) were
eligible but not interested because of the
time commitment, 87 (35.8%) were not
interested and did not provide eligibil-
ity information, and project staff were
not able to contact the remaining 16
(6.6%). This resulted in 126 eligible and
Figure 1. Trial Profile
Left Study: 2
Control
Intervention: 41
Followed Up:
2 wk: 39
2 mo: 39
4 mo: 37
Withdrawn: 4
Lost to Follow-up: 4
Completed Trial: 37
Left Study: 12
Experimental
Intervention: 71
Followed Up:
2 wk: 71
2 mo: 70
4 mo: 70
Withdrawn: 1
Lost to Follow-up: 1
Completed Trial: 70
Eligible Patients: 126
Not Randomized: 0
Randomized:126
Table 1. Sample Characteristics by Disease Group
*
Characteristics
Arthritis
(n = 49)
Asthma
(n = 58)
Age, mean (SD), y 51.1 (11.8) 41.2 (17.4)
Female 71.4 73.3
Ethnicity
White 95.9 73.3
Black 0.0 5.0
Asian 0.0 1.7
Hispanic 0.0 11.7
Native American 0.0 0.0
Other 4.1 8.3
No. of children, mean (SD) 2.53 (1.7) 1.25 (1.6)
Education, mean (SD), grade 14.1 (1.8) 14.7 (1.7)
Working full-time 41.0 31.7
Working part-time 30.0 27.4
Part-time, mean (SD), h 20.3 (5.8) 18.8 (9.9)
Family income, mean (SD), in thousands 65.6 (37.0) 50.4 (33.6)
Regular medication use 97.9 89.8
Regular exercise 49.1 49.2
Smokers 9.8 8.5
*
Data are presented as percentages except where noted otherwise.
WRITING ABOUT STRESSFUL EXPERIENCES
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interested callers who initiated partici-
pation in the study. These subjects did
not differ on any demographic mea-
sures (age, sex, number of children, edu-
cation, employment status, income; all
P values ..10) from individuals ineli-
gible or not interested. After beginning
the study, 14 participants (11%) dropped
out before completing the written dis-
closure exercise—9 from the asthma
group and 5 from the RA group. All par-
ticipants exiting the study were de-
briefed. Four participants cited current
life events (divorce, the development of
a neurological disorder, death of a close
friend, and being recently unemployed
and constantly interviewing for new
jobs). One participant was unable to par-
ticipate due to work constraints. The re-
maining 9 participants indicated that
they were too busy with personal is-
sues. This information is summarized in
a trial profile (F
IGURE 1).
Baseline sample characteristics for
each disease group are shown in
T
ABLE 1. The sample represents the
typical distribution of these diseases and
is representative of the geographic area
from which it was drawn.
Baseline Equivalence
Control and experimental groups did
not differ (using an a of P,.20) at base-
line on demographic measures (age,
sex, number of children, education, em-
ployment status, income), health be-
haviors (regular medication use, exer-
cise, smoking), or psychological
measures (alexithymia, intrusive and
avoidant thoughts, coping strategies, or
anxiety). Baseline disease severity did
not differ between control and experi-
mental groups for asthma outcomes
(FEV
1
, FEV
1
/forced vital capacity
[FVC], quality of life) or RA out-
comes (overall disease activity, RA
symptoms, joint pain, joint swelling).
Outcomes
The first hypothesis was that the ex-
perimental group, relative to the con-
trol group and controlling for baseline
levels of disease, would show improve-
ments in objective health indicators 4
months after writing. In patients with
asthmas, writing about emotionally
traumatic events was related to signifi-
cantly greater improvement in FEV
1
,
compared with controls (F
1,55
= 15.11,
P,.001; F
IGURE 2). The same effect was
found for overall rheumatic disease ac-
tivity, for which writing was related to
significant reductions in disease activ-
ity (F
1,46
= 11.48, P = .001; Figure 2).
These results confirm the hypothesis
that writing about emotionally trau-
matic experiences reduced symptoms
in individuals with chronic illness.
These primary analyses were repli-
cated using nonparametric statistics,
which require many fewer assump-
tions about the distribution of the data,
to ensure that the findings were ro-
bust. For both RA and asthma groups,
no control vs experimental difference
was observed at baseline (Wilcoxon
matched-pairs signed-rank test z = 0.07,
P..20; z = −0.61, P..20, respec-
tively), but a strong difference was
found at the 4-month follow-up (Wil-
coxon matched-pairs signed-rank test
z = 3.41, P,.001; z = −2.42, P = .016).
The second hypothesis concerned the
clinical significance of observed differ-
ences. To quantify patient change over
4 months, we defined 3 categories of
change, which include the following: im-
provement, no significant change, and
worsening (defined by baseline to 4-
month follow-up change). For patients
with asthma, improvements of 15% or
greater in FEV
1
over pretreatment val-
ues were defined as improvement,
whereas worsening was 15% or greater
decline from pretreatment values. The
overall rating of disease activity used for
RA patients was categorical (asymptom-
atic, mild, moderate, severe, very se-
vere), so we followed published guide-
lines that a shift in 1 category to another
is a clinically significant change.
28
A shift
of 1 or more categories toward asymp-
tomatic defined improvement, and a
worsening condition was by moving 1
or more categories toward very severe.
(No participants shifted more than 2 cat-
egories in either direction over the
course of the study.)
Experimental group participants
showed greater rates of improvement
and lesser rates of worsening than the
control group across both diseases
Figure 2. Effect of Structured Writing by
Disease: Asthma or Rheumatoid Arthritis
90
85
65
75
55
4-mo Follow-upBaseline
Forced Expiratory Volume
in 1 s, % Predicted
80
70
60
Control Experimental
Asymptomatic
Moderate
Severe
4-mo Follow-upBaseline
Time
Overall Disease Activity
Mild
Asthma
Rheumatoid Arthritis
Table 2. Percentage of Patients With Clinically Relevant Changes From Baseline to 4-Month
Follow-up by Experimental Group Assignment
*
No. (%) of Patients With Change in Disease Status
Worse No Change Improve
Patients completing study
Control (n = 37) 8 (21.6) 20 (54.1) 9 (24.3)
Experimental (n = 70) 3 (4.3) 34 (48.6) 33 (47.1)
Intent to treat†
Control (n = 43) 8 (18.6) 26 (60.5) 9 (20.9)
Experimental (n = 83) 3 (3.6) 47 (56.6) 33 (39.8)
*
Clinical significance for asthma patients is determined by a 15% or greater change in forced expiratory volume in 1
second (percentage of predicted); for patients with rheumatoid arthritis by a 1-category or greater change in overall
disease activity (0, asymptomatic; 1, mild; 2, moderate; 3, severe; and 4, very severe).
†All patients who failed to complete the study were placed in the no-change group.
WRITING ABOUT STRESSFUL EXPERIENCES
©1999 American Medical Association. All rights reserved. JAMA, April 14, 1999—Vol 281, No. 14 1307
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(x
2
2
= 10.42, P = .005; Fisher exact
P,.006; T
ABLE 2). Across all groups, 33
experimental patients (47.1%) im-
proved according to these criteria,
whereas 9 of control patients (24.3%)
improved. Adopting a more conserva-
tive intent-to-treat approach, we repli-
cated these results by including all pa-
tients who had not completed the study
in the “no change” group (x
2
2
= 10.38,
P = .006; Fisher exact P,.007; Table 2).
These results support our second hy-
pothesis, that observed changes in health
status are clinically significant.
We were also interested in understand-
ing how outcomes changed over time,
and added the 2-week and 2-month data
to the analysis. For asthma patients, the
effect of group remained significant
(F
1,55
= 31.37, P = .003), indicating im-
provement in the experimental group
across all 3 follow-up evaluations. The
effects of time (F
2,110
= 1.54, P..20) and
group 3 time (F
2,110
= 2.20, P = .13) were
not significant, indicating that the ob-
served improvement was consistent over
time (T
ABLE 3). For RA patients, 1 of
whom did not have data at time 2, the
main effects of group (F
1,45
= 0.13, P..70)
and time (F
2,90
= 2.17, P = .12) were not
significant. The effect of group 3 time
(F
2,90
= 6.13, P,.01) was significant. We
examined this interaction by testing the
effect of group at each point for RA pa-
tients. It was not significant at time 2 or
3(Pvalues ..30), but was significant at
time 4 (F
1,45
= 9.32, P = .004), indicating
the RA experimental and control groups
did not differ until the 4-month fol-
low-up (Table 3). Means (and SEs) for
each time point, by group assignment,
are shown in Table 3.
COMMENT
This is the first study to demonstrate that
writing about stressful life experiences
improves physician ratings of disease se-
verity and objective indices of disease se-
verity in chronically ill patients. These
findings extend our knowledge about
this writing exercise from self-reported
symptom and health use outcomes ob-
served in healthy individuals. Not only
were these effects reliably observed 4
months following the structured writ-
ing, they appear clinically meaningful.
Approximately 47% of experimental pa-
tients vs 24% of control patients met cri-
teria for clinically relevant improve-
ment. Thus, both of the study’s primary
hypotheses were confirmed. Although
it may be difficult to believe that a brief
writing exercise can meaningfully af-
fect health, this study replicates in a
chronically ill sample what a burgeon-
ing literature indicates in healthy indi-
viduals. Mechanisms underlying these
effects have not been established, al-
though several have been proposed.
Observation of participants in simi-
lar writing conditions show that they re-
port considerable emotional upset dur-
ing the writing sessions; concomitant
alterations in psychophysiological mea-
sures (eg, heart rate, blood pressure) are
also observed.
29
Additionally, several
studies have shown alterations in func-
tional immune measures following the
writing exercise.
10,30,31
It is possible that
such affective or physiological re-
sponses can explain our results. Alter-
natively, participants’ cognitive and
memory representation of past traumas
may be altered by this writing exercise,
perhaps facilitating improvements in
coping with stressful events.
11,32
The most
common topics patients wrote about
were the death of a loved one, serious
problems of a close other, problems in
relationships, and, on rare occasions, see-
ing or being in a major disaster such as
a train or car wreck. Alterations of health
behaviors (eg, medication compliance,
smoking, and alcohol consumption) in
response to the exercise could also im-
prove health, although there is cur-
rently little support for this explana-
tion.
11
These speculations require
examination in the context of studies in
which physiological and behavioral fac-
tors are explicitly tested as mediators of
illness outcomes.
The time course of change in the pri-
mary outcomes (a secondary analysis)
showed that asthmatic patients in the
experimental group improved within
2 weeks, whereas change for the RA
patients was not evident until the
4-month assessment. We did not pre-
dict this pattern of response and there-
fore view it cautiously. Nevertheless, the
finding implies that mechanisms under-
lying improvements, possibly immune
response, may differ in the 2 diseases.
Despite the study’s experimental de-
sign and the robust results, we have sev-
eral concerns about translating these re-
sults into supplemental treatments for
chronic diseases. First, although our 4-
month follow-up data demonstrate the
importance of the effects, it is unclear
if effects will persist beyond this period.
Second, patients with only 2 diseases,
asthma and RA, were examined in this
study, and the results may not general-
ize to other acute or chronic conditions.
Third, it is clear from the clinical im-
provement analyses that approximately
half of the patients in both control and
experimental groups did not respond to
the exercise, and additional research
should explore the characteristics of re-
sponders. Fourth, until the mechanism
Table 3. Outcomes for Each Time Point for Patients With Asthma or Rheumatoid Arthritis
by Experimental Group Assignment
Time After Writing
Baseline 2 Weeks 8 Weeks 16 Weeks
Patients With Asthma
Forced expiratory volume in
1 second, % predicted, mean (SE)
Control group (n = 19) 64.0 (3.0) 58.8 (3.9) 65.8 (3.2) 65.3 (3.2)
Experimental group (n = 39) 63.9 (3.6) 74.1 (3.3) 74.7 (3.4) 76.3 (3.2)
Patients With Rheumatoid Arthritis
*
Overall disease activity, mean (SE)
Control group (n = 17) 1.71 (0.23) 1.76 (0.23) 1.65 (0.20) 1.71 (0.17)
Experimental group (n = 31) 1.65 (0.13) 1.90 (0.16) 1.81 (0.09) 1.19 (0.09)
*
For patients with rheumatoid arthritis, 0 indicates asymptomatic; 1, mild; 2, moderate; 3, severe; and 4, very severe.
One patient with rheumatoid arthritis did not have data at time 2.
WRITING ABOUT STRESSFUL EXPERIENCES
1308 JAMA, April 14, 1999—Vol 281, No. 14 ©1999 American Medical Association. All rights reserved.
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underlying the findings is identified, we
cannot say how the exercise will inter-
act with other treatments for the diseases.
Since Engel’s classic article introduc-
ing the biopsychosocial model,
33
the
medical community has come to recog-
nize the importance ofpsychological and
social factors in preventing and treating
illness. This research shows that a psy-
chological exercise—writing about emo-
tionally stressful experiences—can re-
duce symptoms of 2 chronic diseases.
These provocative yet preliminary results
lead us to endorse further research on
structured writing and illness.
Author Affiliations: Department of Psychiatry (Drs
Smyth and Stone) and Divisions of Pulmonary Medi-
cine (Dr Hurewitz) and Rheumatology (Dr Kaell), State
University of New York at Stony Brook School of Medi-
cine, Stony Brook. Dr Smyth is now at the Depart-
ment of Psychology, North Dakota State University,
Fargo.
Author Contributions: Dr Smyth was responsible for
the study design, supervision of the study, analysis,
and article preparation. Dr Stone was also respon-
sible for the study design and was cowriter of the ar-
ticle. Dr Hurewitz was responsible for the develop-
ment of the asthma-specific aspects of the study,
asthma patient recruitment, and training for spirom-
etry technician. Dr Kaell was responsible for the
development of the RA-specific aspects of the study,
RA patient recruitment and the clinical examination
of the majority of patients. Dr Hurewitz and Dr Kaell
also contributed to the article.
Funding/Support: This work was funded by the Fetzer
Institute, Kalamazoo, Mich.
Previous Presentation: Portions of this work were pre-
sented at the 1998 Annual Meeting of the American
Psychosomatic Society, March 11-14, Clearwater
Beach, Fla, and the 1999 Annual Meeting of the Ameri-
can Psychosomatic Society, March 17-20, 1999, Van-
couver, British Columbia.
Acknowledgment: We thank the Rheumatology
Associates of Long Island, NY, for assistance with
clinical examinations for patients with RA; Erica
Shertzer for her work and dedication to the study;
Steven Grossman, MS, and Joe Schwartz, PhD, for
statistical advice.
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Supplementary resource (1)

... The current evidence suggests that the experience of both, anger and/or sadness amplify pain in women with and without FMS [44], which is congruent with the suggested presence of an overlap of neural circuits that are involved not only in pain but also in the regulation of anger [73]. As anger expression usually predicts less pain [29], the use of therapeutic emotional expression techniques in the treatment of clinical population including FMS may be beneficial [74][75][76]. ...
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Thesis
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