Investigating the Mediating Role of Cognitive Emotion Regulation Strategies in the Relationship Between Attachment Styles and Ego Strength With Pain Adjustment in Patients With Rheumatoid Arthritis

Rheumatoid arthritis is the most common inflammatory rheumatic disease. Due to its chronic course, this disease is debilitating and its chronic pain brings a lot of emotional and psychological stress that produces or aggravate disability resulting from this disease. Pain causes a serious disturbance and challenge to a person's balance at different levels, especially in cognitive functions. Medical, pharmacological, and surgical treatments are insufficient to cure rheumatoid arthritis and other chronic pain situations and have limited effect at best. Therefore, the study of related psychological variables can help improve the treatment processes and ultimately improve the quality of life of these patients. This study aimed to investigate the mediating role of cognitive emotion regulation strategies in the relationship between attachment styles and ego strength with pain adjustment in patients with rheumatoid arthritis.

This research was a correlational study based on structural equation modeling. The statistical population was all the patients with rheumatoid arthritis, referred to Imam Hossein Hospital in Tehran City, Iran. Of them, 285 people were selected using the available sampling method based on the physician's diagnosis. The inclusion criteria were as follows: diagnosis of rheumatoid arthritis by a specialist doctor based on medical records, ability to read and write, willingness to participate in research and respond to questionnaires, pain rate above 3 on the Pain Scoring Scale (von Baeyer, 2009). The inability to answer the questionnaires was considered as the exclusion criterion. Participants responded to the Attachment Styles Questionnaire (Hazan & Shaver, 1987), Psychosocial Inventory of Ego Strength (Markstrom & Marshall, 2007), Cognitive Emotion Regulation Questionnaire (Garnefski et al., 2001), and Multidimensional Pain Inventory (Kerns et al., 1985). The data were analyzed using Pearson correlation coefficient and structural equation modeling at a significant level 0.05 in SPSS–23 and AMOS–22 software.

The direct effect of the attachment styles variable on pain adjustment was significant (p<0.001, β=0.61). Also, the direct effect of attachment styles on cognitive emotion regulation was significant (p<0.001, β=0.89). Regression weights of the path of the ego strength on pain adjustment were at the level of significance (p<0.001, β=0.93) and also the path of the ego strength on cognitive emotion regulation was at the level of significance (p<0.001, β=0.76). Indirect effect of attachment styles mediated by cognitive emotion regulation on pain adjustment was significant (p<0.001, β=0.89). The indirect effect of ego strength on cognitive emotion regulation mediation on pain adjustment was significant (p<0.001, β=0.76). The fit indices' results indicated the model's confirmation (p=0.415, CMIN/df=3.821, GFI=0.907, RMR=0.610, TLI=0.902, CFI=0.911, NFI=0.937, and RMSEA=0.076).

Since cognitive emotion regulation strategies have both a direct and mediating effect on pain adjustment, they can be used as an important factor in providing psychological services to patients with rheumatoid arthritis.