Aspects of the psychology and epidemiology of rheumatoid disease

The Influence of Pain, Weakness and Rheumatoid Factor Status on Depression Incidence Among Iranian Patients With Rheumatoid Arthritis

BACKGROUND

Increased prevalence of depression among patients with Rheumatoid arthritis (RA) has been described previously. However, the impact of depression among Iranian patients has not yet been investigated.

OBJECTIVES

Here, the prevalence of depression was assessed and the effect of disease-related characteristics including pain, weakness and rheumatoid factor (RF) status on incidence of depression was evaluated.

MATERIALS AND METHODS

Patients with RA, who were referred to rheumatology clinics of Kermanshah University of Medical Sciences and healthy subjects from the general population of Kermanshah participated in this investigation. Depression was assessed using Beck's depression inventory II (BDI II). Pain and weakness were assessed subjectively by patients' self-report. Data was collected during a year between 2012 and 2013. Chi-square test and independent t-test were used.

RESULTS

One hundred and seventy-one patients with RA and 198 healthy individuals participated in this investigation. In the RA group, depressive mood was detected in 45.7% of patients, which was significantly higher than healthy subjects (P = 0.008). Depression was more common in elderly patients (> 50 years old) in comparison with healthy subjects at a similar age (P = 0.03). Pain and weakness had no influence on depression incidence (P = 0.14 and 0.19, respectively) whereas patients with negative RF status were significantly more susceptible to severe depression (P: 0.001).

CONCLUSIONS

Depression is more common among Iranian patients with RA (45%) than healthy subjects regardless of gender. Depression has a significant association with older age. Negative RF status may predict future risk of depression.

Rational/antiemotional behaviors in interpersonal relationships and the functional prognosis of patients with rheumatoid arthritis: a Japanese multicenter, longitudinal study

Background

The repression of negative emotions is a personality factor that received considerable attention in the 1950-60s as being relevant to the onset and course of rheumatoid arthritis (RA). Despite subsequent, repeated criticisms of the cross-sectional nature of the earlier studies, even to date few prospective studies have been reported on this issue. This multicenter study prospectively examined if “rational and antiemotional” behavior (antiemotionality), characterized by an extreme tendency to suppress emotional behaviors and to rationalize negative experiences in conflicting interpersonal situations, is associated with the functional prognosis of patients with RA.

Methods

532 patients with RA who regularly visited one of eight hospitals/clinics in Japan in 2000 were recruited for study. All completed a self-administered baseline questionnaire about lifestyle and psychosocial factors including antiemotionality. Two years after, 460 (mean age, 56.1 years; 54 men and 406 women) of 471 patients who continued to visit the clinics agreed to take the follow-up questionnaire. The functional status of the patients was evaluated by rheumatologists based on the ACR classification system.

Results

A multiple logistic regression model that included baseline demographic, disease activity/severity-related, therapeutic, and socioeconomic factors as covariates found a tendency toward higher antiemotionality to be related to poorer functional status at follow-up. This relationship was not explained by lifestyle factors.

Conclusions

Antiemotionality may be a prognostic factor for the functional status of patients with RA. This finding sheds light on a seemingly forgotten issue in the care of patients with RA.

Possible rheumatoid arthritis subtypes in terms of rheumatoid factor, depression, diagnostic delay and emotional expression: an exploratory case-control study

Introduction

Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis has been implicated in the pathology of rheumatoid arthritis (RA), particularly as vulnerable personality types are exposed to chronic stress. Emotions are powerful modulators of stress responses. However, little is known about whether patients with RA process emotions differently to matched controls. In this study we: 1) assessed whether the trait emotional intelligence (trait EI) scores of patients with RA differ from healthy controls at the facet level; 2) explored any subgroups in RA, in terms of trait EI and common risk factors.

Methods

A total of 637 patients with RA were compared to 496 controls on the trait EI Questionnaire (TEIQue). RA subgroups were explored in terms of trait EI, rheumatoid factor status (RF+/-), depression and time from onset of symptoms until diagnosis (diagnostic delay).

Results

The RA group rated themselves lower on Adaptability, Stress-management, Emotion management, Self-esteem, Sociability, Assertiveness, Impulsiveness and Well-being, and higher on Empathy and Relationships than healthy controls. The RF- subtype reported more time with depression (25.2 vs. 11.3 months), a longer diagnostic delay (3.0 vs. 1.7 years), and greater emotional expression (5.15 vs. 4.72), than the RF+ subtype. These differences were significant at the P <0.05 level, but not following strict Bonferroni corrections and should therefore be treated as indicative only. RF- patients with a longer diagnostic delay reported depression lasting three times longer (42.7 months), when compared to three other subtypes (11.0 to 12.7 months).

Conclusions

RA patients and controls differ in their emotion-related personality traits, as operationalized by trait EI. These differences may make people with RA more susceptible to chronic stress and HPA-axis dysregulation. RA may be a highly heterogeneous illness where at least two subtypes may be characterized by personality, psychiatric and immunological differences. RF- status, as well as diagnostic delay and emotional expression, may predict future risk of depression. Research on the causes of RA could benefit from a systems science approach.

Temperament and satisfaction with health status among persons with rheumatoid arthritis

PURPOSE

Health-related quality of life is a subjective phenomenon shaped by personal attributes. Research has demonstrated links between temperament and health outcomes. Because temperament is relatively stable, it could function as a moderator of quality of life. This study examined relationships among temperament disposition and satisfaction with health status.

DESIGN

The model developed by Sprangers and Schwartz was used to develop a secondary analysis of data collected in a cross-sectional, correlational study with stepwise linear regression analysis. Instruments used were MPQ (dispositions) and AMIS2 (health satisfactions).

SETTING

Two rheumatology private practices and 3 rheumatology clinics.

SAMPLE

One hundred fifty-three persons diagnosed with rheumatoid arthritis (mean age = 55.4).

FINDINGS

Scores reflecting Negative Affectivity (intrapersonal orientation and perception) demonstrated significant positive correlation (r = .26-.58) with all health domain satisfaction scores (P < .001). Negative Affectivity and Positive Affectivity (interpersonal orientation) jointly predicted 8.2%-37.8% of score variance.

CONCLUSION

Temperament dispositions are associated with health-related satisfaction.

IMPLICATION

Assessment of temperament can facilitate early identification of potential problems in the 3 quality of life domains (meaningfulness, manageability), and comprehensibility, and is useful for selecting or designing tailored interventions.

Stress-vulnerability factors as long-term predictors of disease activity in early rheumatoid arthritis

OBJECTIVE

Stress-vulnerability factors were studied for their ability to predict long-term disease activity in early rheumatoid arthritis.

METHODS

In a prospective study involving 78 recently diagnosed rheumatoid arthritis (RA) patients, the role of personality characteristics (neuroticism, extraversion), physical and psychological stressors (chronic, disease-related stressors of functional disability, pain, disease impact on daily life, as well as major life events), coping and social support at the time of diagnosis was examined to predict changes in clinical indicators of disease activity 1, 3 and 5 years later.

RESULTS

While stress-vulnerability factors failed to predict disease activity at the 1-year follow-up, disease activity at the 3- and 5-year follow-ups was predicted by coping and social support at the time of diagnosis, after adjusting for disease activity at first assessment, other biomedical and psychosocial factors and use of medication. Low levels of social support predicted increased disease activity at the 3-year follow-up, and high avoidance coping predicted increased disease activity at the 3- and 5-year follow-ups.

CONCLUSION

Findings indicate the potential prognostic value of avoidance coping and social support for the long-term course of disease activity in early RA and suggest that the effects of these vulnerability factors predominantly operate in the long term.

Stress and rheumatic diseases

This study was done to review the literature concerning the influence of minor and major stress factors on onset and course of rheumatoid arthritis (RA), juvenile chronic arthritis (JCA), systemic lupus erythematosus (SLE), and fibromyalgia syndrome (FS). Major life events and chronic minor stress seem to be very important factors in JCA and are significantly associated with the onset of the disease. With respect to RA and FS, stress may be a provoking factor but the data in the literature are equivocal. However, during the course of the disease, minor stress aggravates SLE, FS, JCA, and RA. Patients with FS and RA may profit from psychological therapies. Optimistic and confronting coping strategies were found most frequently and perceived to be most effective. Very important for psychological function is the social background, especially the functioning of the family is of outstanding importance for clinical and psychological outcome.

Psychoneuroimmunology of autoimmune disorders

The interactions between the immune system and psychological states are both intricate and intriguing. Research at a molecular level has thrown considerable light on the previously ill-defined area of psychoneuroimmunology. In this report, we explore the psychoneuroimmunology of autoimmune disorders, particularly rheumatoid arthritis and lupus erythematosus. Animal models of these diseases have provided a particularly useful window on complex psychoneuroimmunological interactions. Observations about the effect of stress on the onset and course of autoimmune disorders has added to our understanding of psychoneuroimmunological interactions. These interactions are bi-directional, as reflected in the autoimmune-mediated neuropsychiatric manifestations of systemic lupus. Exploring the role of various neurotransmitters and neuromodulators in the stress response may have important therapeutic implications for autoimmune disorders.

Predictors of psychosocial adjustment in systemic sclerosis. The influence of formal education level, functional ability, hardiness, uncertainty, and social support

OBJECTIVE

To determine predictors of psychosocial adjustment in patients with systemic sclerosis (SSc).

METHODS

We surveyed 94 patients with SSc. Age, sex, education level, marital status, work status, income, support group attendance, length of time since diagnosis, functional status, social support, illness-related uncertainty, and hardiness were examined as potential predictors of psychosocial adjustment. The reliability and validity of the instruments used to measure these variables have been established.

RESULTS

Only education level, functional ability, illness-related uncertainty, hardiness, and social support were predictive of psychosocial adjustment. Education level and functional ability explained 14% of the variance in psychosocial adjustment, while illness-related uncertainty, hardiness, and social support increased the explained variance to 38%.

CONCLUSION

Although patients with relatively poorer psychosocial adjustment to illness have lower formal education levels and more functional disability, the majority of the explained variance in psychosocial adjustment is ascribable to illness-related uncertainty, low level of hardiness, and less satisfaction with social support.

The experience and management of pain in rheumatological disorders

A case for studying the psychological aspects of pain is made through a discussion of the problems resulting from investigations of the so-called rheumatoid personality. Following a review of the current theory about pain mechanisms, proposals are made about the best ways of measuring pain in the rheumatological disorders. Later sections tackle issues about the many meanings of pain. Discussion particularly focuses on expectations about pain, on lay beliefs about the rheumatic diseases and on beliefs about pain control. Recommendations are made about the ways in which some of these psychological features might profitably be incorporated into the management of clinical pain.

Psychological reactions in patients with early rheumatoid arthritis

We report the interaction of RA and psychological factors over 2 years in a group of 89 patients with newly established disease. Short-time outcome regarding physical features was fairly good. Disease activity decreased, and disability evaluated by HAQ remained at a low level. Psychological distress as measured by the depression and anxiety subscales of SCL 90 (Symptom Check List) was not very pronounced and not related to disease state factors. A slight decrease of anxiety was recorded after 2 years. A new adjustment test was applied. It contained 13 items focused mainly on negative illness effects such as loss of independence, feelings of guilt, and change of social and leisure time activities. Three factors (regret of lost life values, dysphoric mood, and acceptance) explained 48% of the variance of the 13 items. The validity of the test was acceptable. The patients' degree of adjustment changed slowly or not at all during the 2 years.

Psychological factors affecting pulmonary and rheumatologic diseases. A review

This review examines some of the questions and current literature regarding psychological factors as they affect pulmonary and rheumatologic diseases. Recommendations are made concerning directions for future research in these areas.

Psychological disorders in rheumatoid arthritis: a growing consensus?

Previous reviews of psychological factors in arthritis have emphasised the methodological weaknesses of many studies, especially those attempting to measure personality after years of disabling disease. To make sense of the published reports three factors need to be considered separately: previous personality, social stresses, and current mental state. Each can now be measured reliably and independently of symptoms which might be directly attributable to the arthritis. There is a growing consensus that the normal range of personality is represented among patients with early arthritis, that the prevalence of depression is similar to that of patients with other medical conditions, and that social stress is more closely related to depression than activity and the disabling effect of arthritis. Longitudinal studies are now required to examine which social stresses can be attributed to the disabling effect of arthritis. Depression and social stress often manifest themselves to the rheumatologist as excessive complaints of pain and frequent clinic attendances so appropriate psychosocial treatments may reduce this behaviour.

Methodological issues in the study of personality and psychiatric state in rheumatoid arthritis

Many studies of personality and psychiatric state among patients with rheumatoid arthritis (RA) suffer from methodological weaknesses. This review considers these weaknesses, and suggests criteria that should be met for the sound design of studies that are intended to demonstrate a role for personality traits and psychiatric states in the aetiology and course of the disease. These criteria include the method used to diagnose RA, sample size, the appropriateness of the tests of personality and psychiatric state for use with RA, and the matching of RA subjects with controls.

Measurement of psychiatric disorder in rheumatoid arthritis

In a detailed physical and psychiatric assessment of 80 patients with definite or classical rheumatoid arthritis (RA) different instruments were used to measure psychiatric disorder. The prevalence of psychiatric disorder was 21% when assessed by the PSE/CATEGO programme and 24% according to RDC criteria, but these figures were nearly doubled if a lower threshold was used to define psychiatric disorder. This study demonstrates how symptoms directly attributable to arthritis may inflate the estimated prevalence of psychiatric disorder in RA and erroneously indicate a direct relationship between severity if RA and psychiatric disorder. In fact, the best prediction of psychiatric disorder resulted from using a combination of measures of social stress and severity of RA.

Social and emotional problems in early rheumatoid arthritis. 75 patients followed up for two years

Seventy-five patients with an early RA (disease duration between 2 and 12 months; 79% female; average age 49 years; 72% with "definite" RA) were followed in a prospective study over a period of 2 years. Within this 24 month observation period there was a drop in the average diagnostic ARA count from 5.0 to 4.2, in the ESR from 48 to 31 mm within the first hour and also in the number of affected joints from 13 to 9. Pain intensity and functional capacity showed a slight decrease in the average score. Despite a consistent antirheumatic therapy (72% on RID's after one year) there was a noticeable increase from 23 to 58% in the prevalence of patients with any erosive changes in the X-ray. Within the two years of this study one third of the patients employed at the onset had to quit their job. The number of patients retired due to RA rose from 0 to 23%. A comparison of two groups of patients (employed versus retired) revealed no significant differences in the initial examination with one exception: The patients eventually retired by the end of the study were significantly older with an average age of 51 versus 39 in the group of still employed patients. On the other hand, by the end of the study the patients remaining employed for the duration of the 2 years were significantly less active and also less severely diseased and handicapped. The number of patients with clinically relevant depression (BDI) or anxiety (STAI) did not change significantly over the 24 month period.(ABSTRACT TRUNCATED AT 250 WORDS)

Psychological predictors of disease course in rheumatoid arthritis

A three year prospective study of 30 patients with established rheumatoid arthritis demonstrated that symptoms of depression and anxiety predicted a good outcome whilst externalized hostility predicted a poorer outcome. A multiple regression analysis further showed that patients who denied the emotional significance of their illness faired worse. Psychological variables accounted for 32% of the variance of outcome.

The role of psychological influences in rheumatoid arthritis

Patients with rheumatoid arthritis were tested on a number of psychological variables, including locus of control, cognitive style, general psychopathology and problem solving. Demographic data were also noted, including social supports and life events. Those people whose serum was positive for rheumatoid factor showed a negative style of thinking, particularly in relation to their illness, and they were more likely to believe in powerful external forces. There were no differences between these patients and those who did not have rheumatoid factor on the general measure of psychopathology, except that the positive group experience more phobias. This latter result is in contradiction to previous findings, and a number of possible reasons are discussed.

Verbal expression of affect in rheumatoid arthritis patients. A blind, controlled test for alexithymia

The claim that alexithymia is associated with specific disease categories is subjected to empirical testing. We report results from a controlled, single blind study in which Thematic Aperception Test (TAT) protocols from 64 arthritis patients attending an outpatient clinic were examined for operationally defined characteristics of alexithymia. We studied two groups of rheumatoid arthritis patients, one with the combination of rheumatoid factor and erosive joint changes and the other without and a third group with other forms of arthritis. Controlling for all variables that may confound alexithymia, we were unable to find any relationship between alexithymia and diagnostic subgroup, duration of illness or functional impairment.

Psychological aspects of pain in rheumatoid arthritis: a review

Pain in rheumatoid arthritis (RA) is reviewed from a socio-cognitive perspective. Questions are raised about the usefulness of the distinction between organic vs non-organic pain patients, and alternative explanations for the behaviour of seronegatives is presented. A case based on physiology and behaviour is made for more studies of the acute and prechronic stages of RA. Four major areas of methodology are considered: studies of lay explanations about RA show that people hold relatively accurate views about the nature of pain in RA, and where causal explanations are given for pain and illness, this is conducive to good mental health. A section on the measurement of pain addresses issues about the applicability and standardisation of scales, and welcomes the move from the exclusive use of quantitative to qualitative multidimensional measures. The pain language of RA is described. Experimental studies of pain in RA appear to be of limited use. A review of activities and functional disability indicates that cognitive and behaviour modification techniques appear to have most promise in motivating chronic patients to be more active, and to comply with medication, as well as improving mental health. In a discussion of successful therapies, the principles of reducing uncertainty and increasing perceptions of control are the underlying features. However the reliability of cognitive therapies in the treatment of RA so far remains unproven.

Psychological aspects of rheumatoid arthritis

This study had 3 aims: to determine whether rheumatoid arthritics had certain personality traits; to examine the relationship between psychological factors and the presence of rheumatoid factor in blood serum; and to explore the prognostic significance of psychological factors in the management of rheumatoid arthritis. Within a few days of discharge, 129 in-patient rheumatoid arthritics were clinically and psychologically assessed and allocated at random to 1 of 3 forms of follow-up care. The psychological assessment included measures of personality, non-psychotic psychiatric disturbance, and attitudes and beliefs. A year later all patients were reassessed. It was found that rheumatoid arthritics were more neurotic in personality, more likely to give socially desirable responses, and more prone to psychiatric disturbance, than the general population. Seropositive patients were less susceptible to psychiatric disturbance than seronegative patients. None of the psychological variables predicted disease activity, but those patients who rated themselves as 'slow, dependent, and weak' lost more time off work in the subsequent year.

Personality in frozen shoulder

Fifty-six patients with frozen shoulder have had their personality profiles investigated by means of the Middlesex Hospital Questionnaire. Females showed significantly increased somatic anxiety compared with controls. It is suggested that this may be important both to aetiology and treatment. Males and females should be assessed separately in future studies of frozen shoulder.