The relationship of marital quality and psychosocial adjustment to heart disease Psychosocial adjustment to heart disease is variable, Some patients recover from a myocardial infarction or cardiac surgery quickly, return to work and leisure activities, and experience little ‘emotional distress. Othors sufor significant probloms in psychosocial adaptation. We proposed ‘and tested a theoretical model of adjustmont that included the quality of the marital relationship, dysphoria, chronologic ago, and time from the cardiac event (myocardial infarction or surgory) to identify the role that these variables play in adjustment. The study was conducted in 198 men. diagnosed with coronary heart diseaso using the following instruments: the Spanier Dyadic Adjustment Scale, the Multiple Affect Adjective Checklist, and the Psychosocial Adjustment to Mlness Scale, Data were collected on entry into the study and 3 months later to identify the stability of the relationships over time. The theorotical model was supported. Findings demonstrated that positive psychosocial adjustment to illness is influenced both by the quality of the patient's marriage and dysphoria, Tho spouse appoers to influence psychosocial adjustment in an indirect ‘manner by influencing the patient's experienco of emotional distress or dysphoria. Nurses can enhancs psychosocial adjustment to coronary heart disoaso by helping pationts and spouss focus on ways to improve the quality of their marriage and by suggesting stratogios to improve marital communication and decrease fear and misconceptions related to the illness. Key words: adjust- ment, coronary heart disease, emotional distress, marital quality Mary-Lynn Brecht, PhD Principal Statistician Kathleen Dracup, DNSc, RN Professor Debra K. Moser, DNSc, RN* Assistant Professor School of Nursing University of California, Los Angeles Los Angeles, California Barbara Riegel, DNSc, RN, CS Clinical Researcher Sharp Health Care Hospital San Diego, California ORONARY heart disease (CHD) is a chronic disease that currently affects more than 6 million people in the United States.! Although individuals may re- main asymptomatic for a relatively long period of time, the disease is characterized by acute exacerbations of myocardial ischemia. In addition, the specter of sud- 74 den death looms ominously for patients with diagnosed heart disease. Each year approximately 500,000 individuals die suddenly, usually as a result of ventricular fibrillation. Thus, the psychosocial ad- justment of cardiac patients is challenged by the unpredictable nature of the disease, the need forrehospitalizations and invasive treatments, and the threat of sudden death, Many CHD patients meet the challenge of lifestyle modification and altered health status with relative equanimity. Unfortunately, approximately one fourth of all patients suffer significant problems in psychosocial adjustment that are inde- pendent of their physiologic recovery. Investigators* have suggested that marital status exerts a strong positive influence on the ultimate adjustment of patients to car- This work was supported in part by grant no, RO1 HL92171 from the National Heart, Lung, and Blood Institute, National Institutes of Health. *Presently Assistant Professor, College of Nursing, Ohio State University, Columbus, Ohio. J Cardiovasc Nurs 1994;9(1}:74~85 © 1994 Aspen Publishers, Inc.Marital Quality and Psychosocial Adjustment 75 diac disease and positively affects mortal- ity, but the relationship between marital quality and psychosocial adjustment is complex, with the direction of causality notalways clear. It can be hypothesized, on the one hand, that patients’ poor adjust- ment to CHD creates marital strain and disharmony. If this hypothesis is true, ap- propriate interventions should focus on helping the patient deal with the losses associated with the disease; this would result in an improvement in the marriage as a consequence of improved adjustment to disease. On the other hand, a lack of marital intimacy may lead to inadequate social support for the patient from the spouse and, consequently, to poor adapta- tion on the part of the patient, In this scenario, appropriate nursing interventions should focus on improving the couple’s relationship. By helping the couple im- prove their marriage, the patient's psycho- social adjustmentto illness would improve. The relationship between the quality ofa patient’s marital relationship and his or her adaptation to CHD may be further con- fused by emotional states such as anxiety, depression, and hostility, Such emotions are commonly experienced in chronic ill- ness and may alter the patient's view of his or her marriage and adaptation to illness. Dysphoria, then, may serve as a significant confounding variable in the relationship between marital satisfaction and adapta- tion to illness. Therefore, we conducted a study to examine the relationships among marital quality, dysphoria, and psycho- social adjustment in patients with chronic CHD. REVIEW OF THE LITERATURE Psychosocial adjustment in the context of chronic cardiac illness refers to the inte- gration of the physical and psychologic changes associated with thatillnessintoan individual's self-concept. The tasks to be completed for successful psychosocial ad- justment are complex, partly because ad- aptation is necessary in several areas, cluding work and leisure activities, social functioning, intimate relationships, emo- tional functioning, and attitudes toward health care, Many factors can influence psychosocial adjustment to chronic car- diac illness, but two prominent factors are the marital relationship» and patient dysphoria,2 ‘Several investigators have examined the effect of the marital relationship on patient dysphoria and psychosocial adjustment to cardiac disease, Waltz** demonstrated that postmyocardial infarction patients from marriages characterized by low levels of intimacy and high levels of conflict were more depressed and anxious than patients from supportive marital environments. In addition, these patients perceived the cir- cumstances surrounding their illness more negatively than did patients from intimate marriages with low levels of conflict. In many cases, the dysphoria continued for months and even years after the infarct, Cardiac patients who feel that they do not receive the support from their spouse that they need after their acute event often have a recovery period complicated by emotional distress and low self-esteem.? In fact, dissatisfaction with the marital rela- tionship is the strongest predictor of low self-esteem during the recovery period.” Moreover, patients who feel inadequately supported by their partner are less likely to relinquish the sick role, even when it is appropriate to do so."* Marital conflict can result in delayed recovery and serious im- pairment of psychosocial adjustment. Negative emotional states such as anger, anxiety, and depression are common reac- tions to an acute cardiac event and fre-76 Tue JOURNAL oF CARDIOVASCULAR NursiNc/Octoner 1994 quently continue long into the recovery period.**” In a significant minority of pa- tients, dysphoria becomesa long-term prob- lem inhibiting the adjustment process.* Dysphoriacan adversely affectmany realms of psychosocial adjustment. Cardiac pa- tients who experience undue emotional distress frequently do not return to work. even when physically capable of doing so, become more socially isolated, and are less compliant with medical and exercise regi- mens." They often have unrealistically negative health perceptions that hinder adaptation.” Such patients often fail to return to previous levels of sexual activity and feel incapable of engaging in former leisure time activities.” Finally, psycho- social adjustment may be impaired in dysphoric individuals secondary to nega- tive effects on the marital relationship. Although the studies just described are suggestive, the precise nature of the rela- tionship among dysphoria, marital qual- ity, and psychosocial adjustment has not been delineated, Does the quality of the marital relationship have a direct or indi- rect effect on psychosocial adjustment to chronic CHD? What role does patient dysphoria play in psychosocial adjustment? What is the relationship between the qual- ity of the marriage and dysphoria? Do these relationships change over time? To exam- ine the complex interactions among dysphoria, marital quality, and psycho- social adjustment, we used structural equa- We hypothesized that the indirect effects of the marital relationship on psychosocial adjustment are mediated through its effect on patient dysphoria and that patient dysphoria negatively affects the marital relationship. Fig 1. Cross-sectional theoretical model. tion modeling to analyze data from 198 patients with chronic CHD. Based on the literature, a theoretical model was devel- oped in which the quality of the marital relationship both directly and indirectly affects psychosocial adjustment (Fig 1). ‘We hypothesized that the indirect effects of the marital relationship on psychosocial adjustment are mediated through its effect on patient dysphoria and that patient dysphoria negatively affects the marital relationship. The proposed model allows consideration of these relationships across two points in time (at study entry and at 3- months’ follow-up). METHODS Sample The current study was part of a larger study conducted to identify the psycho- social consequences of teaching cardio- pulmonary resuscitation (CPR) to family members of patients at risk for sudden death. Patients did not participate in the intervention protocol of the larger study but did complete questionnaires at entry into the study and at 3 months’ follow-up. The study was approved by the University of California, Los Angeles, Institutional Review Board and the appropriate reviewMarital Quality and Psychosocial Adjustment 77 Table 1. Sociodemographic character- istics of sample (N=198 males) Characteristic Number Percent Raco/ethnicity Non-Hispanic white 188 95 Black 3 15 Asian 4 2 Other 3 18 Work status Unemployed 8 4 6 3 13 7 79 40 Retired/other 1 46 Mean S.D. Age (years) 636 (98 Years of education 49 33 Years married 315 13,7 Months since event. 17.0 29.0 committees of the participating hospitals. Patients were selected from the cardiac outpatient clinics, cardiac rehabilitation programs, and cardiac inpatient units of six hospitals in a large metropolitan area on the West Coast. Patients were included in the study if they were 25 to 80 years of age, had been diagnosed with chronic CHD (ie, history of documented myocardial infarction and/or coronary artery revascularization), and were married and residing in the same household with their spouse, Patients were excluded if they were not fluentin English, were not mentally competent, had a his- tory of mental illness or were taking a mood-altering medication, had a serious co-morbid illness, had been diagnosed with heart disease within the previous 3 months, orifthe private physician refused to permit participation. Patients also were excluded if they did not have complete data for all variables in the model for the two time periods, ‘The sample for the current analysis con- sisted of 198 male cardiac patients diag- nosed with chronic CHD. These patients were predominantly white, well educated, and upper middle class (Table 1). This study focused on male patients because gender differences in psychosocial adjust- ment have been demonstrated in patients with chronic cardiac disease, and previous research on the relationship of marital sta- tus and marital intimacy to patient out- comes has been conducted almost exclu- sively in men. We limited the study to men because the aim was to identify the mechanisms operating forthe relationships previously identified by other investiga- tors. Procedure Patients were approached in the hospital orclinic or were telephoned after discharge to elicit their participation. The purpose of the study and the procedures were ox- plained. After obtaining informed consent, patients were asked to complete the ques- tionnaires; this was designated as Time 1. Patients were asked to complete the same written questionnaires 3 months later, which was designated as Time 2, The ques- tionnaires took approximately 40 minutes to finish and, in most cases, were mailed to the patient’s home and returned by mail. If they were not received within 7 days, a follow-up telephone call was made to see if they had been received and to request that they be completed and returned. Research instruments Psychosocial adjustment Tho primary dependent variable of psychosocial adjustment was measured using the total score on the Psychosocial78 — Tue Journat or Carpiovascutar Nursinc/Ocrossr 1994 Adjustment to Illness Scale (PAIS)? A total of 46 self-report items were com- pleted, with each item rated ona four-point scale of adjustment, with higher scores indicating poorer adjustment. The PAIS reflects the multidimensional nature of adjustment by measuring seven domain: health care orientation, vocational em ronment, domestic environment, sexual relationships, extended family relation- ships, social environment, and psychologic distress. A raw total adjustment score was computed and converted to standardized area T-scores based on cardiac patient nor- mative scores established by Derogatis and Lopez.?* Internal consistency reliability cooffi- cients for the PAIS have been calculated based on three samples of patients. In a cardiac patient cohort, the coefficient al- pha was .92.” The content validity of the instrument was established in the process of item development, based as it was on clinical observations of psychosocial ad- justment. Construct validity of the tool was established by means of factor analysis, while convergent validity was supported by a series of significant correlations with external criteria.™** Predictive and dis- ctiminant validity of the PAIS was docu- mented by Kaplan-DeNour,® who found that PAIS scores predicted which renal dialysis patients would be classified as good or poor adjusters by their physicians. Quality of the marital relationship Marital quality was assessed using the Spanier Dyadic Adjustment Scale.** The 32-item scaleis divided into foursubscales: satisfaction, dyadic cohesion, consensus, and affectional expression. Affectional ex- pressionis specificto the physical orsexual relationship of the couple, and approxi- mately one fourth of the patients left some orall of the items in this subscale blank. To maximize the number of subjects included for the current analyses, this subscale was excluded as an indicator variable in the model. Higher scores indicate higher satis- faction with the quality of the marital rela- tionship, ‘The instrument has established criterion- related validity and concurrent validity based on a comparison with the Locke- ‘Wallace Marital Adjustment Scale (0.86 for married respondents and 0.88 for divorced respondents).?° Internal consistency by Cronbach's coefficient « has been estab- lished at 0.96.5 Dysphoria Dysphoria was represented by state anxi- ety, depression, and hostility scores from the Multiple Affect Adjective Checklist (MAACL).”’ A respondent indicates which of 132 adjectives describe his or her feel- ings, and scores are obtained by adding the number of positive items checked for a particular affect and the number of nega- tive items not checked, Higher scores on each scale indicate higher levels of anxiety, depression, or hostility. Estab- lished norms are 7 or less for anxiety and hostility and 11 or less for depression.” The MAACL has shown sensitivity to changes in anxiety, depression, and hostil- ity associated with stressful or stress-alle- viating conditions.” Concurrent validity has been established using a variety of self reportinstruments and clinical interviews. Internal reliability has been established at r= 0.73 for the anxiety scale, r= 0.65 for depression, and r = 0.90 for the hostility scale,” Test-retest reliability is low, as it should be for a measure of mood state. Covariates Patient age and time since cardiac event were included as covariates in the model. Age has been included as a covariate inMarital Quality and Psychosocial Adjustment 79 most studies of psychosocial adjustment and heart disease, with researchers hy- pothesizing a positiverelationship between age and psychosocial adjustment.?* As men age, they are likely to reduce their physical activity and work fewer hours. ‘Thus, the loss in physical stamina and time at work that accompanies cardiac surgery or myocardial infarction may be less im- portant to the older individual. Time from eventand psychosocial adjustment are also positively related.?*"In general, the longer the time elapsed from a cardiac event (ie, myocardial infarction or cardiac surgery), the better the psychosocial adjustment. Analysis Structural equation modeling procedures ‘were used to estimate measurement and structural parameters.” In describing the analytic methods and results, the authors use the following terms: * latent variables: the theoretical con- cepts in the model (represented by circles in all figures); * measured variables; the observed vari- ables or measurements made (repre- sented by boxes in all figures); * empirical indicators (orindicatorvari- ables): measured variables that repre- sent the latent variables in the model; * themeasurement model: the relation- ships between the latent variables and their empirical indicators; © the structural model: the “causal” re- lationships among the variables; and * error: the portion of an indicator vari- able not accounted for by a latent construct or the portion of a variable not predicted by other variables in the structural model.** A two-wave, longitudinal, latent vari- able model was constructed including the relationships hypothesized in Figure 1 Subscales scores for all study variables are presented in Table 2. Subscale scores of satisfaction, cohesion, and consensus from the Spanier tool were used as empirical indicators of quality of the marital relati ship; anxiety, depression, and hostility subscale scores from the MAACL were used as indicators of dysphoria. The total PAIS score was used to represent psycho- social adjustment; because only one em- pirical variable was used for this construct, psychosocial adjustment does not appear in the measurement portion of the model but appears in the structural model as a measured variable without an explicit measurement structure, Covariates of time since event and patient age were included inthe structural model as potentially influ- encing psychosocial adjustment, The same structure was proposed at each time pe- riod. The model also included stability pa- rameters for each construct (ie, the influence that a variable from an earlier period has on that same variable measured at a later pe- riod) and selected cross-lagged parameters (ie, the influence of variables from the first period on other variables at the later period). Table 2. Mean and standard deviation of study variables at baseline (Time 1) and 3 months’ follow-up (Time 2) for 198 males with CHD Time1 Time 2 Marital quality Cohesion 15.8 4.2 18.9 4.2 Consensus 494 8.1 50.0 89 Satisfaction 399 5.8 994 5.8 Dysphoria Anxiety 63 45 64 44 Depression 12.0 64 12.3 6.6 Hostility B1 44 80 48 Psychosocial «48.8 10.9 «4.8 11.1 adjustment to illness80 Tue Journat or Carpiovascutar Nursinc/Ocroser 1994 The model was tested using the EQS structural equation software." Maximum likelihood estimates were used. The mea- surement aspects of the model were tested first (confirmatory factor analysis) to evalu- ate whether the indicator variables ad- equately represented the latent constructs of marital quality and dysphoria at each of the two time periods. In the measurement model, latent constructs were allowed to intercorrelate (with no proposed causal- ity), and errors were allowed to correlate for each indicator variable across time. Then the structural or path model was tested using an iterative process, beginning with a more complex (saturated) model than that proposed. Errors for each indica- tor variable and for the primary dependent variables were allowed to correlate across time. Based on initial steps in the model- testing process, statistically nonsignificant paths were eliminated, as suggested by the ‘Wald test for dropping parameters." A weak suppressor effect (of marital quality at Time 1 on psychosocial adjustment at Time 2) was dropped, since the first-order correla tion suggested a theoretically supportable relationship in the opposite direction. The goodness-of-fit of the model to the data was evaluated using 7? and Bentler- Bonett normed fit index. A nonsignificant xf and a fit index greater than approxi- mately 0.90 indicate that a model ad- equately represents the data empirically, RESULTS Descriptive results forthe measured vari- ables appear in Table 2. In general, pationts did not report feeling particularly anxious or dopressed (ie, values were similar to published norms for other clinical popula- tions) and had good psychosocial adjust- ment to their illness. (A score of 80 is the norm for cardiac patients, and scores lower than 50 represent better adjustment.) Factor loadings from the confirmatory factor analysis appear in Table 3. The pro- posed measurement structure fit the data adequately (y?,, = 48.0, P=0.24; normed fit index = 0.97), Factor loadings were statis- tically significant (0: < 0.001), and errors wore correlated across time (0.35~0.66). Factorloadings were almost identical across the two time periods. Tho final structural model representing relationships among latent constructs and the outcome variables is presented in Figure 2with statistically significant structural co- efficients shown. The resulting model is supported empirically, with a nonsignifi- cant ?statistic (x2, = 109.41), anda Bentler- Bonet normed fit index of 0.95, Each construct shows stability over time. For example, psychosocial adjustment to illness at Time 2 is predicted directly by earlier psychosocial adjustment to illness. Table 3, Measurement model param- eter estimates (factor loadings)" Standardized coofficionts* Latent —“Indicator._‘Time1 Time 2 construct Marital quality Cohesion 0650.68 Consensus 0.75 0.80 Satisfaction 0.81 0.78 Dysphoria Anxiety 0,950.04 Depression 0,880.91 Hostility 0.73 0.84 “The model included intercorrolations among latent constructs and correlated errors for each indicator across time, ‘All cooffcionts significant at -<0.001,Marital Quality and Psychosocial Adjustment These stability relationships are the stron- gestdirectinfluencesintheestimated model. ‘The hypothesized theoretical model is supported at Time 1, with marital quality and dysphoria intercorrelated and both directly predicting psychosocial adjust- menttoillness, Although a somewhat simi- lar structure holds at Time 2, marital qual- ity at that later period no longer directly affects concurrent psychosocial adjustment to illness. At both times, higher levels of marital quality (higher scores) are related to lower concurrent levels of dysphoria (lower scores), Better psychosocial adjust- ment to illness (lower scores) is predicted by higher levels of marital quality (higher scores) and lower levels of dysphoria (lower scores) at Time 1 and by lower levels of 81 dysphoria at Time 2. Marital quality at ‘Time 1 also affects later dysphoria, with higher levels of marital quality leading later to lower dysphoria. Additional patient characteristics of time since event and patient age have spe- cific effects on indicator variables at the earlier time period, but not more general effects on factors of marital quality, dysphoria, or psychosocial adjustment to illness at either time period. Greater age is related to higher levels of satisfaction with marital quality and to less hostility at Time 1. Longer time since event is related to less consensus on marital quality at Time 1, ‘These variables exhibit their direct effects at Time 1 only and show no significant direct effects by the later time period, Fig 2. Longitudinal model—structural parameters. Latent varisbles are shown in circles, and empirical indicators are shown in boxes. The strength of the relationship among variables is shown by standardized path coefficients, *, Coefficients significant at P=0.05; **, coefficients significant at P=0.01; ***, coefficients significant at P=0.001.82 Tae JouRNAL of Carpiovascuar Nuzsinc/Ocroper 1994 DISCUSSION Professionals working with patients who are either chronically ill or in chronically stressful circumstances have long been in- terested in identifying theroleofthe spouse and the marital relationship in offsetting the potential negative effects of a chronic illness, Several investigators” have dem- onstrated that just the presence of a marital relationship directly affects the patient’s physical adaptation after a cardiac event. However, the role of the quality of the marital relationship in the psychologic adaptation to chronic heart disease is less well understood. A limitation of the current study was its exclusion of female cardiac patients. Fu- ture researchers should test the relation- ships among marital quality, dysphoria, and psychosocial adjustment in females to see whether the relationships identified in the current study hold true or differences by gender exist. Collection of data over longer time would also strengthen attribu- tions of causality. Focusing on men witha history ofchronic heart disease, findings from the current study were that positive psychosocial ad- justment to illness was predicted both by the quality of the patients’ marriages and the amount of emotional distress or dysphoria they experienced. Examining the process overtime, marital quality seems to affect psychosocial adjustment prima- rily through its relationship with dysphoria. That is, the quality of the marriage affects the degree of emotional distress experi- enced by the patient, which in turn affects psychosocial adjustment. Previous investigators**** have docu- mented a strong inverse relationship be- tween social support and dysphoria in a chronic cardiac population, but the rela- tionship among social support (as provided inthe marital relationship), dysphoria, and psychosocial adjustment has been lessclear. The important link between the marital relationship and emotional states was hy- pothesized by Waltzand associates," who suggested that emotionally close and grati- fying marriages provide a strong sense of coherence and security in the presence ofa serious illness, positively affecting both cognitive and affective responses. Alterna tively, they proposed that a lack of coher- ence and security, social stress in marriage, and the nonprovision ofemotional support hinder effective coping at the cognitive and affective levels, In their view, a major pathway of marital contextual influence on psychosocial adjustment may be the cognitive coping behavior associated with the assessment of threat or loss, a view based on the coping theory of Lazarus and Folkman.* Patients with a supportive spouse probably view their resources as adequate to theillness and respond with less depression, anxiety, and anger than patients who feel themselves unsupported by their spouse. Long-standing marital strain may cause patients to feel bereft of support when confronted with the double burden of a stressed maritalzelationship and poorhealth, ‘The finding that patients in long-term marriages were more likely to express sat- isfaction with their marriage sheds light on the classic work ofRosen and Bibring about the effect of age on psychosocial adjust- ment after a myocardial infarction.” These investigators found that older patients (ie, those over 65 years of age) experienced Examining the process over time, marital quality seems to affect psychosocial adjustment primarily through its relationship with dysphoria.Marital Quality and Psychosocial Adjustment 83 better psychosocial adjustment than younger patients. They explained theirfind- ings by suggesting that patients who are older have less to lose with the transition into a chronic sick role; however, the find- ings of the current study suggest that such patients are more likely to have strong partnerships in their marriage. The combi- nation of effective social support and a history of crises that have been experi- enced and successfully resolved may ex- plain the relationship between age and adjustment. Empirical evidence has been accumulat- ing to support the notion that husbands and wives who have an intimate relation- ship become closer as a result of one of them suffering a chronic illness.'*%° In- vestigators** have hypothesized that these couples have the communication skills and sense of commitment to help them adapt to the difficult challenges posed by an illness. In contrast, couples in strained marriages become further estranged. This phenom- enon of “the rich getting richer and the poor getting poorer” is explained by the finding in the current study that causality between marital quality and dysphoria flows in both directions, A lack of marital intimacy appears to lead to anxiety, hostil- ity, and depression, which in turn puts REFERENCES additional strain on the marital relation- ship. The reciprocal nature of dysphoria and marital quality is an important finding in that it suggests interventions need to address both constructs. Based on these findings, nurses must focus on supporting the marital relation- ships of male cardiac patients and their wives and providing these wives the strat- egies they need to support their husbands appropriately. 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