Psychological therapies for rheumatoid arthritis
Rheumatoid arthritis is a chronic condition which has unpredictable flares and relapses. This can make it difficult to cope with the symptoms and plan daily activities.Around 50% of people with RA feel depressed, helpless or anxious because of pain, loss of function or lack of social networks. You may also be afraid of worsening your arthritis by exercising. This is called pain avoidance behavior.
Psychological therapies aim to deal with this as best as possible and can reduce pain and discomfort.
The role of stress
Stress can make RA symptoms worse and sometimes trigger flare-ups. One study categorised people into two groups: those with ‘major conflict group’ (MCG) arthritis, and those with ‘non-conflict group’ (NCG) arthritis. The patients with MCG arthritis were more influenced by stressful live events, whereas NCG arthritis was more closely related to genetic factors and family history.
One study looked at the role of emotional disclosure and whether it helped in managing stress. The participants wrote their feelings in a diary or recorded them onto tape. Interestingly, those who spoke them on tape had faster walking speeds, reduced pain and swelling and lower disease activity rated by their doctor. Those who used the diary also had greater walking speeds and improved pain scores on touch. Both effects were mild to moderate in size.
Feelings of ‘control’
If you feel in control of your RA, you are likely to have better mood and adjustment to your symptoms, as well as more predictable courses of the condition. In contrast, patients who felt less in control in a recent study had more negative moods, particularly if their symptoms were severe. Feelings of control are related to personality traits such as neuroticism and may also be affected by learned behavior.
Culture can also affect your perception of symptoms and how they affect you. For instance, patients from Poland were more likely to feel excluded than social situations (95%) than those from Germany (66%) despite the fact their states of health were similar. In Poland, poorer physical function, lower levels of education and being male were risk factors, whereas in Germany living in a small town had a greater effect.
Measuring the psychological impact of RA
Psychologists and psychiatrists have developed standardized assessments to record the consequences of RA for psychological health. These include the Hospital Anxiety and Depression Scale, Patient Health Questionnaire, Disease Acitivity Score 28 and Clinical Disease Activity Index.
Duration of RA
A meta-analysis (group) of 25 studies looked at the effects of psychological therapies on pain, coping ability, self-efficacy, function and emotional health. At the end of the studies (which lasted on average for 8.5 months), the first three effects had improved significantly. Patients who have had the illness for a shorter time benefited most from these treatments.
Coping with symptoms
There are many psychological techniques available to deal with the symptoms of RA. These include:
Cognitive behavioral therapy
Cognitive behavioural therapy, or CBT, can help people to deal with the pain, stiffness and reduced functionality associated with RA. It looks at how you respond to problems and how to manage stress, pain and other problems, and proposes better ways to react to these.
Clinical psychologists can help people with RA cope with their symptoms
For instance, people with musculoskeletal pain often have problems with the overactivity-rest cycle, where they overdo things and then find they have to rest afterwards. A paced cycle of activity can be a better way to manage symptoms throughout the day.
One study in 30 women found improvements in self-efficacy (perceived ability to carry out tasks) and reductions in loneliness, stress and depression scores which were directly related to self-efficacy ratings in the CBT group compared with those who received a self-help book only.
Another trial of 32 patients found that early CBT reduced pain, negative mood, social isolation, helplessness, depression and fatigue in patients with RA at 6 months in addition to standard treatment from a specialist rheumatology team.
Another clinical trial in 53 patients who received psychological interventions and social support or a placebo led to major reductions in pain behavior and disease activity in the intervention group. The most significant part of the treatment was thought to be relaxation techniques, while social support acted mainly to reduce anxiety following treatment.
Therapies in children
Psychological treatments can also be effective in children. For instance, one study educated children in biofeedback, relaxation training and electromyography, and mothers in physical therapy and advice on encouraging school attendance. The children reported significant pain reductions of at 25%, which lasted for 6 months or longer. This was also noticed by the mothers although the physical therapists reported no difference.
Mindfulness is a form of meditation. It includes “non-doing”, non-judgmental thinking that allows thoughts to pass through without hindrance, and focusing on the present. In this video lecture, Jon Kabat-Zinn explains the theories behind mindfulness:
Also, see http://www.youtube.com/watch?v=qgK3eVE3TK0 for treatment specific to rheumatoid arthritis.
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Written by Dr Anne Parfitt-Rogers, Medical Writer, UK