August 1, 2008
Psychiatric Times.
No. 9
Special Report
Psychiatry and Medical Illness
Behavioral Comorbidities in Rheumatoid Arthritis
A Psychoneuroimmunological Perspective
Michael R. Irwin, MD, Mary Davis, PhD, and Alex Zautra, PhD
Dr Irwin is Norman Cousins Professor in the department of psychiatry and biobehavioral sciences in the David Geffen School of Medicine, University of California, Los Angeles (UCLA), and director and senior research scientist at the Cousins Center for Psychoneuroimmunology UCLA Semel Institute for Neuroscience and Human Behavior. Dr Davis is professor and Dr Zautra is foundation professor in the department of psychology at Arizona State University, Tempe. The authors report no conflicts of interest concerning the subject matter of this article.
Clinical Impact of Treatment
Pharmacological treatments for RA have been effective in controlling pain, inflammation, and swelling, but they may not address key psychosocial vulnerabilities that contribute to adaptation. The gold standard of behavioral approaches, cognitive-behavioral therapy (CBT), attempts to change maladaptive ways of thinking and feeling in response to illness. The specific techniques have encompassed an extensive range of strategies, including biofeedback and relaxation training, cognitive restructuring and distraction, and activity pacing. The majority of studies have focused on the management of pain, but some CBT trials have also emphasized the management of stress and the development of more general life management skills.
A recent review of 25 randomized clinical trials that tested psychosocial treatments for RA underscores the effectiveness of these approaches in increasing patients’ ability to cope with pain and reduce pain, physical disability, and depressive symptoms.40 Yet the findings show substantial variability across outcome measures. The effects were strongest for active coping outcomes and relatively more modest for pain and affective disturbance, a pattern that was also evident in a review of behavioral treatments for RA and osteoarthritis.41 The findings invite speculation about the general effectiveness of behavioral interventions for RA and the role of individual differences in the response to treatment based on patients’ history and clinical needs.
Recent evidence highlights the adaptive value of positive emotional resources, particularly in those who are vulnerable because of social stressors and/or a history of depression. More attention to this and other potential “resilience” factors may provide greater specificity about the nature of the relationship between depression and pain and offer new targets for therapeutic and preventive treatments for those with chronic pain.
A study by Matsuzaki and colleagues42 revealed that mirthful laughter lowered circulating levels of plasma IL-6, which suggests the potential treatment effectiveness of mood change for disease severity. Unique difficulties in patients with RA also may point the way to successful interventions tailored to address problems in affective regulation that underlie inflammatory processes in RA and other illnesses.
We have found that interventions that focus on mindfulness and emotional regulation generally are more successful in reducing pain and elevating well-being among patients with RA with recurrent depression than standard treatment, such as CBT.43 Thus, vulnerabilities due to depression history may be offset for those who learn ways to weather the storms of negative emotions that accompany pain and distress and sustain positive affect in spite of their chronic difficulties.
There is qualified support for mindfulness meditation in addition to the pain management skills training in standard CBT for the treatment of pain in patients with RA. In addition, data highlight the importance of recognizing and managing depression in patients with RA because those with a history of depression appear to have a differential response to intervention approaches that emphasize self-management strategies compared with those that do not.
Drugs Mentioned in This Article
Adalimumab (Humira)
Etanercept (Enbrel)
Infliximab (Remicade)
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Evidence-Based References
Motivala SJ, Khanna D, FitzGerald J, Irwin MR. Stress activation of cellular markers of inflammation in rheumatoid arthritis: protective effects of tumor necrosis factor alpha antagonists. Arthritis Rheum. 2008;58:376-383.
Zautra AJ, Davis MC, Reich JW, et al. Comparison of cognitive behavioral and mindfulness meditation interventions on adaptation to rheumatoid arthritis for patients with and without history of recurrent depression. J Consult Clin Psychol. 2008;76:408-421.
Acknowledgments—This work is supported by NIH grants AG026364, HL079955, T32-MH19925, CA 0014152, M01-RR00865, the General Clinical Research Centers Program; and the Cousins Center for Psychoneuroimmunology (to Dr Irwin).
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