Arthritis




Arthritis literally means “joint inflammation.” The terms arthritis and rheumatic disease are usually used interchangeably. These chronic diseases and conditions, of which there are over 100 different types, involve pain and stiffness in or around the joints. Arthritis symptoms can affect nearly every activity of daily living. Arthritis is a leading cause of disability in the United States and a major public health concern. Costs from arthritis-related medical care and lost wages due to disability amount to billions of dollars each year.

Approximately one of every six Americans has arthritis. This number is expected to increase as the population ages. Although age is a risk factor for some types of arthritis, people of all ages, including young children, can be diagnosed with arthritis. Women are more likely to have arthritis than are men; reasons for this gender difference are not well understood.

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The most common type of arthritis among adults is osteoarthritis. It is characterized by degeneration of joint cartilage, often in the knee, hip, back, or fingers. Although osteoarthritis is common among the elderly, it is not an inevitable part of aging. Half of all people in their 70s and 80s have osteoarthritis.

The type of arthritis that has been studied most by health psychologists is rheumatoid arthritis. It is a systemic disease that involves inflammation of the joint lining. The cause is unknown but thought to be autoimmune. Although it most often affects the hands and feet, it may also involve organ systems. Its course is unpredictable, with symptoms that tend to flare and remit. Juvenile rheumatoid arthritis is the most common type of arthritis among children. As with other types of arthritis, juvenile rheumatoid arthritis may be mild or severe. Some of the other types of arthritis are fibromyalgia, systemic lupus erythematosus, gout, ankylosing spondylitis, bursitis, and Lyme disease.

Effects of Arthritis on Functioning

For some people arthritis may be barely noticeable, whereas for others it may erode their quality of life profoundly. Symptoms of arthritis can limit ability to perform basic motions such as bending, walking, grasping, and lifting. Consequently, arthritis may interfere with functioning at work, home, and school; participation in social, leisure, and recreational activities; and personal care activities such as bathing, dressing, and eating. People with arthritis are less likely to be employed than those without arthritis. If they are employed, then on average they earn less.

Disruption in important life activities and roles, reductions in independence, and uncertainly about the future may result in a variety of negative psychological and social consequences. Nonetheless, research also shows that as with other chronic diseases, most people with arthritis report finding positive meaning or benefit in their experience, such as improved relationships, increased empathy, and spiritual growth.

Despite the numerous potential stressors caused by arthritis, most people with arthritis do not experience clinical depression. However, compared to people who do not have a chronic disease, people with arthritis are more likely to experience depression. Depression, which can worsen the pain and disability associated with arthritis, must be recognized and treated. Unfortunately, depression in individuals with arthritis may be difficult to assess. Some types of arthritis manifest symptoms (e.g., fatigue, sleep problems) that may overlap with symptoms of depression, so the diagnosis of one might mask the other. Complicating the clinical picture, medications such as corticosteroids that are used to treat some types of arthritis may induce depressive symptoms.

Coping and Control

Research on the different ways that individuals cope with arthritis has shown that some coping strategies may be more effective than others. Coping strategies such as actively seeking information and trying to view one s situation in a more positive light have been associated with better psychological functioning. In contrast, wishful thinking and self-blame have been associated with poorer psychological functioning. Experimental research suggests that disclosing emotions through writing or talking also may be an effective coping tool.

The extent to which patients believe that they have control over their symptoms appears to have a significant impact on their adjustment to arthritis. Numerous studies have found that self-efficacy, or patients’ confidence in their ability to cope with arthritis, predicts decreased pain, disability, and psychological distress. In contrast, perceived helplessness has been associated with increased pain, disability, and psychological distress. Among people with rheumatoid arthritis, perceived helplessness has also been linked to early mortality.

Interpersonal Factors

Family and friends play an important role in patients’ adjustment to arthritis. Numerous studies have linked social support to well-being among patients with arthritis. The type and amount of social support that is most helpful may vary during different points in the disease course. Some studies of people with arthritis have also revealed a potential downside of social support. For example, arthritis patients report being negatively affected by critical or well-intended but unwelcome comments from others. Among women with rheumatoid arthritis, interpersonal stress (i.e., conflicts with others) has been shown to affect immune system activity.

Research also has addressed the impact of arthritis on patients’ spouses. Partners of individuals with arthritis report feeling distressed and helpless in response to seeing their partner in pain. They also may experience a reduction in pleasurable activities previously shared with their partner, as well as fear and uncertainly regarding the future. Partners may feel reluctant to burden the person with arthritis with their own needs. At the same time, patients may fear burdening their partners. It is important that patients and their partners develop strong support networks to bolster their own mental health as well as the health of their relationship.

Biomedical Interventions

The medications used to treat most types of arthritis control symptoms, and in some cases slow disease progression, but do not cure it. As with other chronic diseases, the effectiveness of treatment is related to the degree to which patients adhere to the prescribed medical regimen. Depending on the type of arthritis, treatment may include nonsteroidal anti-inflammatory drugs, analgesics, biologic response modifiers, corticosteroids, or disease-modifying antirheumatic drugs. Assistive devices such as splints or braces also may be used. Surgical intervention such as joint replacement may benefit some patients. Physical and occupational therapy are also important components of a comprehensive treatment plan.

Psychological Interventions

In some cases arthritis can be prevented. For example, maintaining a healthy body weight and taking precautions to avoid occupational or sports-related injuries can contribute to the prevention of osteoarthritis, and learning how to reduce the risk of tick bites can contribute to the prevention of arthritis related to Lyme disease. However, these types of primary prevention strategies are not applicable to most cases of arthritis. Therefore health psychologists interested in arthritis have focused their efforts on helping individuals who are living with the disease.

Cognitive-behavioral interventions have been shown to improve physical and psychological functioning among people with arthritis. The cognitive component of these interventions focuses on goals such as understanding pain, gaining an increased sense of control, and developing coping skills. The behavioral component focuses on mastering techniques such as relaxation, goal setting, and activity pacing. Cognitive-behavioral therapy, whether administered in a group or individual setting, also involves home practice.

Randomized, controlled studies of arthritis patients who participate in cognitive-behavioral interventions generally result in positive effects following treatment. Although findings vary across studies, these effects include reductions in pain, disability, psychological distress, and health care utilization. Unfortunately these gains are not always sustained through long-term follow-up assessments. Incorporating strategies for preventing relapse and coping with setbacks into cognitive-behavioral interventions may help patients maintain treatment gains over time.

Cognitive-behavioral techniques are part of the Arthritis Self-Help Course, a widely used educational program sponsored by the Arthritis Foundation. The Arthritis Self-Help Course uses a structured group format and is led by trained volunteers. The course provides disease-related information and teaches self-management skills such as relaxation and problem solving. Research indicates that benefits of the course include increased knowledge, self-care behaviors, and self-efficacy and decreased pain, depression, and number of physician visits.

The Arthritis Foundation also offers an exercise program called People with Arthritis Can Exercise, as well as programs focused specifically on aquatic exercise and walking. In the past arthritis patients were discouraged from exercising, but since the 1970s research findings have consistently shown that moderate-intensity exercise is safe for people with arthritis. Not only does regular exercise improve overall health and fitness, but it also has been shown to relieve symptoms such as joint pain and stiffness. Reported benefits of the People with Arthritis Can Exercise program include increased functional ability and self-care behaviors, decreased pain and depression, and increased self-efficacy.

Arthritis can pose a multitude of daily challenges. The symptoms and stressors associated with arthritis can lead to physical, occupational, social, and psychological impairment. Although most people with arthritis find ways to manage or cope with their disease, depression is not an uncommon response. Arthritis also has an impact on family members, who may play important roles in patients’ adaptation to the disease. Interventions such as cognitive-behavioral therapy can positively affect psychological (e.g., self-efficacy, mood) and physical (e.g., pain, disability, health care utilization) outcomes.

References:

  1. American College of Rheumatology. Available at http://www.rheumatology.org
  2. Arthritis Foundation. Available at http://www.arthritis.org
  3. DeVellis, B. M., Revenson, T. A., & Blalock, S. J. (1997). Rheumatic disease and women’s health. In S. J. Gallant, G. P. Keita, & R. Royak-Schaler (Eds.), Health care for women: Psychological, social, and behavioral influences (pp. 333-347). Washington, DC: American Psychological Association.
  4. Fries, J. F. (1999). Arthritis: A take care of yourself health guide for understanding your arthritis (5th ed.) Cambridge, MA: Perseus.
  5. Keefe, F. J., Smith, S. J., Buffington, A. L. H., Gibson, J., Studts, J. L., & Caldwell, D. S. (2002). Recent advances and future directions in the biopsychosocial assessment and treatment of arthritis. JournalofConsulting and Clinical Psychology, 70, 640-655.
  6. Lorig, J. F. (1999). Arthritis: A take care of yourself health guide for understanding your arthritis (5th ed.). Cambridge, MA: Perseus.
  7. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Available at http://www.niams.nih.gov

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