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

Key Points

  • Individuals with rheumatoid arthritis (RA) demonstrate an increased prevalence of mood disorders compared with the general population, but a decreased prevalence of schizophrenia, probably due to alterations in inflammatory processes

  • Several mechanisms underlie the relationship between RA and mental health comorbidities: cognitive, behavioural and affective responses, inflammatory processes, and fatigue

  • Social factors have important implications in psychological reactions to RA, and could also be involved in pain processing and RA disease activity

  • Neural reward-processing deficiencies are an emerging area of inquiry in understanding the relationship between pain and psychological states that warrants additional attention in patients with RA

  • Psychological treatments that increase active coping strategies, ameliorate affective distress, bolster self-efficacy, and increase supportive social relationships could improve treatment outcomes in patients with RA

Abstract

In addition to recurrent pain, fatigue, and increased rates of physical disability, individuals with rheumatoid arthritis (RA) have an increased prevalence of some mental health disorders, particularly those involving affective or 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 their psychological responses to the disease, and can also impair responses to treatment through disruption of patient-physician relationships 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.

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Figure 1: Mental health and disease activity are interconnected in rheumatoid arthritis.
Figure 2: Chronic inflammation and altered dopaminergic signalling are connected to coping responses through pain perception and decreased positive affect.
Figure 3: Social factors interact with psychological reactions to rheumatoid arthritis.

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Acknowledgements

Alex J. Zautra deceased June 2016. Dr Zautra was an accomplished researcher and academic, and a devoted mentor. This work was supported by grants from the NIH: NIDA 3T32DA035165-02S1 to J.A.S.; NIH K23 DA035915 and NIH P30 NR014131 to P.H.F.; and NIA R01 AG 026006 to A.J.Z.

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All authors researched the data for the article, provided substantial contributions to discussions of its content, wrote the article and undertook review and/or editing of the manuscript before submission.

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Cognitive styles

Relatively stable patterns of cognitive interpretation of events that have implications for behaviour and mood, such as an increased tendency towards catastrophic appraisal of pain or health, or optimistic views of oneself, health, or future function.

Insecure attachment

A stable cognitive and behavioural style of forming and maintaining meaningful social relationships, characterized by high levels of anxiety and hypervigilance to cues about whether an individual is loved by significant others to whom he or she is attached.

Therapeutic alliance

The relationship between a patient and his or her clinical provider (e.g. physician or psychologist), which has implications for treatment adherence and treatment outcomes, and might evolve over time.

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Sturgeon, J., Finan, P. & Zautra, A. Affective disturbance in rheumatoid arthritis: psychological and disease-related pathways. Nat Rev Rheumatol 12, 532–542 (2016). https://doi.org/10.1038/nrrheum.2016.112

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