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British Journal of Clinical Psychology (2006), 45, 585590 q 2006 The British Psychological Society

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Brief report

Social support and psychological outcome in people with Parkinsons disease: Evidence for a specic pattern of associations
Jane Simpson1*, Katrina Haines1, Godwin Lekwuwa2, John Wardle2 and Trevor Crawford1
1 2

Lancaster University, UK Lancashire Teaching Hospitals NHS Trust, UK

Objective. The aim of this study was to explore the relationship between social support and psychological functioning in people with Parkinsons disease. Method. 34 participants with idiopathic Parkinsons disease completed a comprehensive range of social support assessments and measures of depression, anxiety, stress, general psychological distress and positive affect. Results. A clear pattern of relationships emerged, with the less satisfaction with social support, the higher the depression, anxiety and stress scores. Conversely, positive affect was related to more quantitative assessments of social support, such as the number of close relationships. Conclusion. The relationship between social support and psychological outcome in people with PD is complex. Furthermore, the complexity of this relationship should be addressed in any therapeutic attempts to relieve psychological distress and promote happiness.

Parkinsons disease (PD) is a chronic degenerative condition primarily affecting motor control but which can also lead to cognitive decline and dementia (Stern, 1988). A frequent accompaniment to the motor symptoms are psychological problems, with high levels of both depression and anxiety consistently reported (e.g. Cummings, 1992; Richard, Schiffer, & Kurlan, 1996). Positive outcomes and also other psychological reactions such as frustration, anger or regret remain relatively unresearched. In line with the medico-biological dominance of research in, and treatment of, this disease (Dakof & Mendelsohn, 1986), many studies (see Slaughter, Slaughter, Nichols, Homes, & Martens, 2001 for a review) have used disease-related variables to predict psychological functioning. However, this approach cannot fully explain the variance in psychological

* Correspondence should be addressed to Jane Simpson, Institute of Health Research, Lancaster University, Lancaster, LA1 4YT, UK (e-mail: J.Simpson2@lancaster.ac.uk).
DOI:10.1348/014466506X96490

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586 Jane Simpson et al.

outcome (Brown & Jahanshahi, 1995) and psychosocial factors have, to a lesser degree, also been investigated (McCarthy & Brown, 1989). Although a number of possible predictors exist, this study focuses on social support given its established role as a buffer against maladaptive psychological outcome (Cohen & Wills, 1985). Early conceptualizations of social support emphasized the amount of social support as important. However, more recently, it has been argued (e.g. Burg & Seeman, 1994) that, in times of stress, extensive family ties can bring costs as well as benets and more family support does not necessarily predict less psychological distress. Indeed, satisfaction with the level of support provided may have the real predictive power. For example, Lazarus and Folkmans transactional stress model (1984) emphasizes that the appraisal of support as sufcient is crucial to the avoidance of distress. In keeping with this distinction, in studies on the relationship between social support and psychological outcome in people with Parkinsons disease, Ehmann, Beninger, Gawel, and Riopelle (1990), using a measure of social support that included a considerable degree of quantication, found no association between social support and depression. However, Brod, Mendelsohn, and Roberts (1998) and Fleminger (1991) found that more satisfaction with social support was associated with less psychological distress, reinforcing the idea that satisfaction with social support might be the more important predictor. Conversely, MacCarthy and Brown (1989) found a relationship between one of their quantied measures of social support instrumental support and positive well-being, suggesting that happiness (as opposed to distress) could well be inuenced by the amount of support available. This study aims to explore the relationship of social support with measures of psychological functioning. Based on previous literature, it is hypothesized that less satisfaction with social support will be associated with more negative psychological functioning. However, positive affect is hypothesized to correlate with more quantiable measures of support.

Method
Participants There were 34 participants (24 men and 10 women) in the study, all with a conrmed diagnosis of idiopathic Parkinsons disease. The mean age of participants was 64.29 (SD 8:28; range 3976), with the mean number of years since formal diagnosis being 6.06 (SD 4:14; range 117). In terms of Hoehn and Yahr (Hoehn & Yahr, 1967) scores (a 7-point clinical assessment of symptom severity), 18 were mildly impaired, 12 were moderately impaired and 4 were severely impaired. The sample size was sufcient to detect a medium to large effect size (.4) using a two-tailed test of association (Pearsons) at power of .80 and with alpha at p :05. Procedure Patients were referred to the study by consultant neurologists who conrmed diagnosis and clinical details. Participants were interviewed individually, usually at home. Interviews generally lasted around an hour although for some participants this was signicantly extended. Materials A comprehensive approach was taken to the measurement of social support. Assessments of social support which were of a more quantiable nature were current

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marital status (married or not), number of children, work status (currently in employment or not) and number of close relationships. On the other hand, to provide an estimate of satisfaction, the social support subscale of the Parkinsons Disease Questionnaire (PDQ-39: Jenkinson, Fitzpatrick, Peto, Greenhall, & Hyman, 1997) was also administered. This is a 3-item scale which asks for indications of problems on a 5-point scale with (a) close relationships, (b) spouse or partner or (c) friends or family. Scores are converted to range from 0 to 100, with higher scores indicating less satisfaction. Cronbach alpha, an estimate of internal reliability, for this subscale has been reported at a :69 (Jenkinson et al., 1997). A number of psychological outcome measures were taken including: (1) The Positive and Negative Affect Schedule (PANAS: Watson, Clark, & Tellegen, 1988); a self-rated scale in which 20 mood descriptive words are rated on a 5point scale of degree experienced over the past few weeks. The scale comprises two subscales, positive and negative, with scores ranging from 10 to 50 with higher scores indicating more intensity of that particular affect. Only the positive scale is reported in this study. Internal consistency has been reported for the positive scale as a :89 (Crawford & Henry, 2004). The Depression Anxiety and Stress Scales (DASS: Lovibond & Lovibond, 1995); a 42-item self-rated scale with three specic subscales. Each of the three 14-item subscales has a possible range of 042, with higher scores indicating more severe symptoms. The scale has been extensively validated (Crawford & Henry, 2003) and is suitable for use with a non-clinical sample. Internal consistencies for the three subscales have been reported as: depression, a :95; anxiety, a :90; and stress, a :93 (Crawford & Henry, 2003). The emotional well-being subscale of the PDQ-39 (Jenkinson et al., 1997); this 6-item subscale, rated on a 5-point scale, provides a general summary of emotional functioning. Although the subscale is described as emotional wellbeing, the scale assesses a wide range of negative emotions. It is converted to a 0100 range, with higher scores indicating more problems in this domain. Its reported internal consistency is a :83.

(2)

(3)

Results
The mean scores for the social support and psychological outcome variables are shown in Table 1. It should be noted that the score for the satisfaction with social support subscale is low relative to published norms (Jenkinson et al., 1997), indicating few problems. The psychological scales show considerable variation in terms of current levels of adjustment. Using the norms supplied by Crawford and Henry (2003), the sample is fairly high on anxiety (79th percentile) but lower on depression (around 50th percentile) and stress (40th percentile). Using the cut-off scores from the DASS (Crawford & Henry, 2003), 16 participants (47%) could be classied as having clinically signicant (though mild) levels of depression, 5 participants (15%) of anxiety and 3 (9%) of stress. Furthermore, positive affect was also relatively low, at the 21st percentile (Crawford & Henry, 2004). All scales were checked for normality of distribution and outliers before a correlation matrix was computed on the ve measures of social support and the ve outcome measures.

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588 Jane Simpson et al. Table 1. Social support and psychological outcome measures (N 34) Variable Number of children Work status No Yes Number of active social contacts Marital status Single Married Social support subscale of PDQ-39 Psychological outcome measures Positive affect Emotion subscale of PDQ-39 Depression subscale of DASS Anxiety subscale of DASS Stress subscale of DASS Mean (SD) or Number (%) 1.76 (1.52) 28 (79%) 6 (21%) 18.29 (18.23) 4 (13%) 30 (87%) 4.66 (8.75) 25.15 (8.77) 14.34 (13.65) 3.73 (3.76) 5.38 (2.96) 6.38 (4.71)

As can be seen in Table 2, a striking and specic pattern of correlations can be seen. Positive affect is associated with more children, current employment and a greater number of close relationships. On the other hand, higher levels of depression, anxiety and stress were only signicantly associated with greater reported problems in social support. The only correlation to approach signicance on the emotional subscale of the PDQ-39 was problems with social support.
Table 2. Correlations between measures of social support and psychological functioning No. of children Positive affect .462** Depression 2 .059 Anxiety .155 Stress .296 Emotional subscale .125 of PDQ-39
a

No. of close relationships .369* 2 .218 .122 .261 2 .127

Social support subscale of PDQ-39 .060 .533*** .740*** .488** .322

Marital statusa .091 .097 .173 .246 .106

Work statusb .429* 2 .154 2 .272 2 .188 2 .039

*p , .05; **p , .01; ***p , .001; p , .07. Dichotomous variable entered where 0 single and 1 married. b Dichotomous variable entered where 0 not in work and 1 in work.

Discussion
The results conrm the studys hypotheses of a relationship between satisfaction with social support and negative psychological states, and positive affect and variables which could be argued to indicate a more quantitative assessment of support. The disassociation between the predictors of emotional distress compared with positive affect requires some theoretical integration. As has already been noted, Lazarus and Folkmans (1984) model, in its translation to chronic illness, emphasizes the importance of the subjective appraisal of the adequacy of social support to cope with current stress. If that appraisal suggests that current levels of support are not appropriate, psychological distress

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can follow. However, this theory is about the avoidance of distress and not the generation of well-being. Consequently, Lazarus and Folkmans theoretical framework is consistent with the following pattern of relationships seen in the current study: (1) (2) (3) positive correlations between psychological distress and dissatisfaction with social support; the lack of a correlation between the more quantiable predictors of social support and satisfaction with social support; the lack of a relationship between satisfaction with social support and positive affect.

However, it cannot explain the relationship between positive affect and quantiable measures of social support. To explain this, it is rst necessary to emphasize the relative independence of the constructs of distress and happiness and their predictors (e.g. Curtis, Groarke, Coughlan, & Gsel, 2004). Second, the theoretical framework of Cohen and Wills (1985) might also be useful. They argued that the type of support which could only have positive implications is emotional esteem support. It could be argued that the number of close relationships, current work status and greater number of children greatly facilitates the prospect of this type of support. Interestingly, MacCarthy and Brown (1989) also demonstrated a strong relationship between self-esteem and positive affect in people with Parkinsons disease, which is consistent with the possibility that the relationship between at least some of the quantiable social support variables in this study and positive affect is mediated through self-esteem. The studys design does limit the strength of the conclusions. Cross-sectional designs cannot imply causation. It is probable that negative mood in itself can cause problems both in accessing and maintaining social support (Hammen, 1991) and in the perception of the level of support. Consequently, the relationships between these two sets of variables are likely to be complex and bidirectional. The signicance levels of the correlations have also not been statistically corrected to allow for multiple testing. In this respect, it is accepted that this is an exploratory study. However, the observed pattern is consistent and so is unlikely to be the result of a statistical confound. Finally, self-report data can be inuenced by a number of biases, including social desirability bias. However, in this particular dataset, it is difcult to envisage how, again, such a bias might result in this very specic pattern of associations. This study concludes by emphasizing the importance of using these ndings in developing psychological approaches for people with Parkinsons disease (see also Cole & Vaughan, 2005). Given the importance of appraisal in the perception of social support, this could be usefully included as a cognitive restructuring component of a cognitive-behavioural programme aimed at reducing distress. Similarly, in order to promote well-being, the development and encouragement of activities to improve social network size and quality, and possibly also self-esteem, should also be emphasized.

References
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