S. Newman¹, K. Mulligan¹, M. Shipley^2
1Centre for Behavioural and Social Sciences in Medicine, University College London, ²Centre for Behavioural and Social Sciences in Medicine, University College London Hospitals, London, United Kingdom

Abstract: Although rheumatoid arthritis (RA) has been viewed by some as a psychosomatic problem and possibly the result of a particular personality type, it is now accepted that this is not correct. Many people have drawn the Cartesian distinction between mental and physical events such that the psychological state of patients is not considered to have any bearing on their RA. This is questionable and also it is clear that RA itself can lead to a variety of psychological responses or consequences.

The difficulty with suggesting that psychological factors cannot influence the outcome of RA can be seen at a variety of levels:

A: OUTCOME CRITERIA
The WHO/EULAR response criteria and a general evaluation of the impact of RA in patients involves their reports of pain as well as an assessment of their perception or the physician’s perception of global disease activity.
1. There is much data to indicate that a patient’s own ratings of symptoms (and by inference their reports) are influenced by a range of factors, such as their mood and coping style. This means that any evaluation of disease outcome is intrinsically influenced by psychological factors.
2. The possibility that patient’s self reports influence the doctor’s global rating is less well researched.

B: INDIRECT EFFECTS ON OUTCOMES
Psychological factors may also influence outcomes in RA through their impact on adherence to medication regimes. Adherence is important both for drugs which directly affect pain and stiffness (analgesics and non steroidal anti-inflammatory drugs) and in the long term benefit gained from disease modifying agents by controlling inflammation and reducing irreversible joint damage. The extent to which psychological and social factors influence medication adherence has been demonstrated in a variety of conditions including RA.

C. DIRECT EFFECTS
The direct influence of psychological factors on outcomes in RA varies according to the way the outcome is assessed. The increased early mortality seen in patients with RA has been associated with a number of factors including infection, attributable either to treatment or to a direct effect of poorly controlled disease. There is good evidence that psychological factors, including illness cognitions (what a patient thinks and believes about their disease), influence the speed with which patients seek help. Given that early intervention is associated with better outcomes, it is possible that delay in seeking help may have an effect on mortality in RA.

There is also much evidence to demonstrate the direct effects psychological factors have on assessments of disability and whether patients return to work. Essentially measures that enquire whether an individual engages in some form of activity include both their capacity to perform that activity as well as whether they choose to engage in it or not. As a consequence, disability has been demonstrated to be influenced by a range of psychological factors.