Affective disturbance in rheumatoid arthritis: psychological and disease-related pathways

Abstract

In addition to recurrent pain, fatigue, and increased rates of physical disability, individuals with rheumatoid arthritis (RA) show an increased prevalence of some mental health disorders, particularly those involving mood disturbances. This narrative Review provides an overview of mental health comorbidities in RA, and discusses how these comorbidities interact with disease processes, including dysregulation of inflammatory responses, prolonged difficulties with pain and fatigue, and the development of cognitive and behavioural responses that could exacerbate the physical and psychological difficulties associated with RA. This article describes how the social context of individuals with RA affects both their coping strategies and psychological responses to the disease, and can also impair responses to treatment through disruption of therapeutic alliance and treatment adherence. Evidence from the literature on chronic pain suggests that the resulting alterations in neural pathways of reward processing could yield new insights into the connections between disease processes in RA and psychological distress. Finally, the role of psychological interventions in the effective and comprehensive treatment of RA is discussed.

The role of psychological factors in inflammatory rheumatic diseases: From burden to tailored treatment

“…Some evidence in rheumatic diseases, which corresponds with evidence from other chronic illnesses, has also indicated that specific ways of regulating emotions, including difficulty in identifying and describing emotions (alexithymia) and emotional suppression, are predictive of impaired quality of life and increased self-reported disease activity, whereas other strategies, such as emotional expression, could be associated with improved functioning under specific circumstances [41,50e52]. Acceptance and self-efficacy have been shown to generally protect against psychological distress and increase in physical symptoms [2,8,23]. More recently, the role of expectancies has become a research topic of particular interest in the area of placebo effects, in which expectancies, for example, with regard to treatment effectiveness, have been shown to be a strong predictor of subsequent outcomes including pain.…”

“…Regarding the social aspects within the healthcare context, a satisfactory relationship between the care provider and patient, which, for example, consists of mutual trust and active participation of the patient in treatment and decision making, has been shown to be an important predictor of high patient engagement and well-being in inflammatory rheumatic diseases. High patient engagement or empowerment has been shown to be related to improved treatment adherence, treatment satisfaction, and health-related quality of life [2].…”

“…For patients with mild adjustment problems or who are recently diagnosed, patient education will probably suffice [88]. In case of moderate adjustment problems, self-management interventions could sufficiently improve functioning by combining education with some cognitive-behavioral principles such as relaxation, problem solving, and goal setting [2]. For more severe adjustment problems, different evidence-based personalized therapist-guided treatments have become available for diverse patient groups and also include disease-generic approaches that encompass a broad variety of treatment modules of the most relevant areas of functioning across diseases and different cognitive-behavioral techniques and assignments that can be flexibly applied [68,89,90].…”

“…Good quality social support has shown to protect against psychological distress and increase in physical symptoms [2,8,23]. It has, however, also been shown that problematic, unwanted, or stressful relationships lead to increased distress, higher symptom levels, and increased inflammatory activity in rheumatic diseases, thus indicating that the quality of social support is particularly important [2, 11,23,34].…”

“…Similarly, it has been well-documented that the manner in which patients deal with this chronic stressor affects their long-term physical and psychological functioning, indicating a number of biopsychosocial risk and resilience factors in these patient groups [1e7]. Tackling these biopsychosocial risk and resilience factors through psychological interventions has shown to have possible benefits for patients with inflammatory rheumatic diseases, with recent advances concerning screening, stepped care, tailoring, and eHealth providing new opportunities for optimizing patient care [2,3,8].…”