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Anxiety and Arthritis 

 

            One of the main problems in dealing with any chronic illness is the comorbid diseases that present along with the diagnosis. Like any chronic condition, arthritis can be disabilitating to those afflicted, whether due to rheumatoid arthritis, osteoarthritis, or juvenile rheumatoid arthritis. The pain associated with arthritis can severely limit mobility and level of participation in activities creating increased social stress.   People may find themselves unable to function normally in everyday situations or are unable to maintain the level of functioning that they had previously been used to. The chronic stress and pain may affect one’s mind and body manifesting itself psychologically as depression, generalized anxiety disorder, panic attacks, and decreased overall well being.

            A recent study regarding anxiety in rheumatoid arthritis (RA) found that people with arthritis exhibit higher levels of anxiety than the general population.  Furthermore, the relationship between RA and anxiety is stronger with individuals also diagnosed with depression(1).  In an extensive study conducted by representatives from the University of Manitoba and Columbia University, investigators found a significant correlation between arthritis and psychiatric disorders; not only did those with arthritis have increased comorbidity of  depression, but also panic disorder and generalized anxiety disorder (GAD).   Specifically, the correlation found between arthritis and panic disorder or GAD, both were much greater than between arthritis and depression.  Similarly, studies examining other chronic conditions associated with pain such as back pain and migraine headache also reveal similar findings related to psychiatric disorders as seen in arthritis.  Chronic illnesses such as arthritis leading to long term pain and disability warrant increased efforts in the medical community and their families to look for signs and symptoms suggesting development of a mood or anxiety disorder.

In light of the apparent association between arthritis and anxiety disorders, one must consider whether current treatments for arthritis have an effect on the development of depression, panic disorder, and GAD.  It has been theorized that an emotional stress reaction is a means by which arthritis patients use to cope with the pain: individuals focused on worrying or being anxious about one’s condition use this worry in order to distract themselves from the pain associated with arthritis.  However, arthritis sufferers often must cope with frustrating pain and disability.  This frustration can certainly lead to anxiety and other psychological problems.  Regardless of the underlying cause of the anxiety (fear of the unknown, unconscious means of distraction from the pain, anxiety of uncertain function, anxiety of future debilitation, etc), both the physical as well as the psychological needs of the patient must be addressed by the physician. Likewise, if you or a loved one has arthritis, it is important to recognize and appreciate signs and symptoms of anxiety as well as other psychological disturbances, and to address those psychological concerns head on.

            Anxiety and mood disorders both can be successfully treated pharmacologically with many classes of medications, such as tricyclic antidepressants (TCAs) and selective serotonin uptake inhibitors (SSRIs).   A recent clinical trial examining TCAs effectiveness in treating major depression in RA patients with dothiepin hydrochloride (dopress) was tested. The 25 individuals in the trial were administered 75mg/day over the course of 6 weeks, and results were gathered in 2-week intervals. At each of the 2-week intervals there appeared to be a statistically significant reduction in anxiety levels among participants, all of whom were diagnosed with comorbid major depressive disorder. Few side effects were reported (only two individuals reported dry mouth), and marked improvement was shown in 80% of individuals. All individuals in the trial experienced some improvement with dothiepin hydrochloride with a good degree of toleration of the medication which appears to be better tolerated than other traditional TCAs (2).  On the whole, however, SSRIs tend to have fewer potential side effects and also have been used with great efficacy in the treatment of anxiety and depression symptoms.

            While medications are one alternative that should be considered, an additional alternative, and perhaps one that should be used first or at least in conjunction with medications, is psychological intervention.  Studies have also shown effectiveness in treating RA with psychological interventions, such as relaxation methods, biofeedback, and cognitive-behavioral therapy. These methods allow arthritis patients to make themselves aware of their anxiety and specifically dispel it using these psychological techniques rather than only taking medications. While studies do not show whether one treatment is more effective than another (relaxation versus drug-therapy), psychological interventions may provide treatment to those reluctant to take medications and the combination of both drug and psychological treatments may provide a better chance of long-term success (3).

            The duration of time one has lived with the diagnosis of arthritis may be an important factor in determining those at risk for anxiety-related symptoms.   Patients who have been recently diagnosed with RA are much more likely to be optimistic regarding their treatment and symptoms, and less likely to endorse pain as a complaint whereas patients with long established RA are less likely to exhibit optimism, more likely fatigued and have less social support (4).   The clinical diagnosis for an anxiety disorder, GAD or panic disorder, however, has shown to be unrelated to duration of RA, although it has been shown to be related to the development of depression.  Overall, individuals with both arthritis and depression exhibited significantly higher levels anxiety in general (1)

            In summary, this information leads us to believe that many arthritis sufferers have a higher risk of developing anxiety and/or depression.  “Several studies have shown that 20 to 66.2% of patients with rheumatoid arthritis have associated psychiatric comorbidity especially depression (1).”  The onset of these comorbidities has been suggested to be due to increased pain associated with daily activities using the same range of motion that had once been possible without pain free.   The loss of independence and ability to function in routine social situations can also exacerbate feelings of anxiety and depression as well as chronic pain.   Lastly, some have suggested that worry may play a part in lessening the effects of self perceived arthritic pain, contributing to the onset of psychopathology in arthritis sufferers.  In terms of treating anxiety, a combination of medication and psychological support may be necessary.  You should have a full and open discussion about your feelings and all of the treatment options available you’re your physician.  Anxiety in arthritis patients is shown overwhelmingly to be a real and significant problem.  With increased patient and physician awareness, there are increasingly more options for treatment through a combination of counseling, drug therapy and more nontraditional methods such as biofeedback that will improve the quality of life for those living with arthritis and brings new hope for those suffering silently in the future.

 

Authors: Melissa S. Deutsch, Princeton University, Princeton, NJ

  Victoria Chan Harrison M.D., New York-Presbyterian Hospital, The University Hospital of Columbia and Cornell, New York, NY

 

 

References:

 

(1)    VanDyke MM, Parker JC, Smarr KL, Hewett JE, Johnson GE, Slaughter JR, Walker SE. “Anxiety in rheumatoid arthritis”. Arthritis and Rheumatism (2004 Jun 15), pp. 408-412.

(2)    HS, Gawande S, Bhagat V, Durge V, Londhe V, Kini S, Nadkar MY, Borges NE. “Evaluation of efficacy and tolerability of dothiepin hydrochloride in the management of major depression in patients suffering from rheumatoid arthritis”. Journal of the Indian Medical Association (2005 May), pp. 291-294.

(3)    Astin JA, Beckner W, Soeken K, Hochberg MC, Berman B. “Psychological interventions for rheumatoid arthritis: A meta-analysis of randomized controlled trials”. Arthritis Care & Research (2002 Jun 5), pp.291-302.

(4)    Treharne GJ, Kitas GD, Lyons AC, Booth DA. “Well-being in rheumatoid arthritis: the effects of disease duration and psychosocial factors”. Journal of Health Psychology (2005 May), pp. 457-474.

 

 

 

 

 

 Arthritis MD. © 2005