STRESS AND RHEUMATIC DISEASES

https://doi.org/10.1016/S0889-857X(05)70167-8Get rights and content

Rheumatic diseases are a group of painful and often disabling systemic diseases that usually become chronic. The most frequent problems reported by those affected are complaints connected with the musculoskeletal system. From the wide range of rheumatic diseases, rheumatoid arthritis (RA), ankylosing spondylitis, fibromyalgia syndrome (FS), and psoriatric arthritis have the highest prevalence, with almost 1% to 2% of the total population affected by each of them. Because of the fact that these illnesses are usually chronic and disabling, they represent a major social and economic burden. RA, ankylosing spondylitis, and psoriatric arthritis are especially known to be immune-related diseases. Their etiology still remains unclear. Most commonly, multiple factors are suspected to be responsible for the initiation of these illnesses. Lack of knowledge as to the causes of most rheumatic diseases meant that a wide range of different approaches evolved. One of them is the field of stress and personality research.

As early as 1909, the first article suggesting an association between factors in everyday life like anxiety and worry and the provocation of RA was published.63 Some years later, the personality of the RA patient was also taken into consideration as a possible risk factor for increased susceptibility to RA.18 In 1939, Cobb et al25 summarized speculations dating back to 1880 that there is a relation between environmental or emotional factors on the one hand and the onset and exacerbation of RA on the other hand. Alexander10 classified RA as one of the seven classic psychosomatic diseases. Since the beginning of this field of research, a large number of articles focusing on stress and personality traits as provoking, predisposing, or modulating factors have been published. The results were often equivocal and caused considerable controversy.

This article reviews the role of psychologic stress as a factor that may precipitate or exacerbate rheumatic diseases. The most common and effective strategies for coping employed by patients with rheumatic diseases and the value of stress-reducing therapies are discussed.

Section snippets

Measurement of Stress

Before illustrating the different diseases in greater detail, some general methodologic problems of research dealing with psychologic parameters should be mentioned. In most studies, measuring stress and other psychologic parameters and their significance for the affected person is based on information provided by the patient. The assessed person fills out a questionnaire or the physician does it, making use of the information given by the patient in an interview. As a result, the results are

STRESS AND SYSTEMIC LUPUS ERYTHEMATOSUS

Much less literature is available concerning stress and SLE or other rheumatic diseases. Most of the studies that were found were retrospective. A summary is provided in Table 4.

Only two articles indicate that emotional stress acts as a precipitating factor in SLE. Otto and Mackay94 compared 20 hospitalized SLE patients with other hospitalized seriously ill controls. The SLE group had significantly more stress before onset of the disease. All SLE patients believed that stress had provoked their

STRESS AND THE FIBROMYALGIA SYNDROME

FS is characterized by fatigue, stiffness, disturbed sleep, musculoskeletal aching, and multiple points of tenderness. Unlike the aforementioned inflammatory disorders, there are no histologic signs of inflammation in the affected tissue. Interestingly, 10% to 30% of patients with RA and SLE also fulfill the diagnostic criteria for FS.100, 138

With FS, numerous authors have focused on the relation between psychologic characteristics and disease (summarized in Table 5). Some of them looked for

RHEUMATIC DISEASES: THE MOST IMPORTANT PERCEIVED STRESSORS AND COPING STRATEGIES

Coping strategies are important for the daily routine and the psychologic well-being of persons with a chronic disease like RA. They enable the afflicted persons to adapt to the problems and stressors arising from the disease. The predominant perceived stressor in individuals with RA is pain, followed by limitation in mobility, difficulties in the activities of daily living, helplessness, dependency on others, threat to self-esteem, interference with social activities, problems in family

INTERACTION BETWEEN THE DISEASE AND PSYCHOSOCIAL FUNCTIONING

The relation between stress and rheumatic diseases is not unidirectional (stress influences the diseases) but rather bidirectional. Rheumatic diseases and their consequences cause a number of different stressors, which probably have effects on the psychologic and social functions of the afflicted individual.

Andrew11 estimates that organic psychiatric diseases occur in 22% to 29% of the patients with SLE and RA and that functional disorders occur in 18% to 35%. The most common mental change in

NEW STRATEGIES IN THERAPY

There is strong evidence that stress and psychologic factors play a role in the onset and course of rheumatic diseases. The common therapeutic regimens are mainly pharmacologic and combined with physiotherapeutic treatment. If one takes into account the role of stress as a provoking and modulating factor, psychologically orientated methods could also be of benefit and could possibly reduce the need for strong drugs.

Achterberg et al4 demonstrated the effectiveness of relaxation techniques and

SUMMARY: MAJOR AND MINOR STRESS INFLUENCES RHEUMATIC DISEASES

Despite difficulties in assessing the influence of minor or major stress on the onset or course of the chronic rheumatic diseases, it is likely that stress has an impact on the disease. Major life events and chronic minor stress seem to be important factors in JCA and are significantly associated with the onset and course of this disease (Fig. 1). With respect to RA and FS, stress may be a provoking factor, but the data in the literature are equivocal. During the course of the disease, minor

THE PSYCHE AND THE NEUROENDOCRINE-IMMUNE SYSTEM IN RHEUMATIC DISEASES

With the emergence of interdisciplinary research areas such as psychoneuroimmunology, new insights into the concept of stress as a stereotyped and relatively unspecific response (e.g., alarm, resistance, exhaustion) to aversive or noxious stimuli were obtained.6 Stress involves an array of regulatory mechanisms, including corticotropin-releasing hormone, adrenocorticotropic hormone, cortisol and other adrenal hormones, neurotransmitters of the sympathetic nervous system (e.g., norepinephrine,

ACKNOWLEDGMENT

We thank Niklas Beyersdorf, Kathrin Beyersdorf, and Dr Bunesh Agrawal for critical comments and manuscript corrections.

References (145)

  • H.C. Hendrie et al.

    Stress, immunoglobulin levels and early polyarthritis

    J Psychosom Res

    (1971)
  • M. Irwin

    Stress-induced immune suppression: Role of brain corticotropin releasing hormone and autonomic nervous system mechanisms

    Adv Neuroimmunol

    (1994)
  • K.H. Kaplan et al.

    The impact of a meditation-based stress reduction program on fibromyalgia

    Gen Hosp Psychiatry

    (1993)
  • N.S. Latman et al.

    Personality and stress: An exploratory comparison of rheumatoid arthritis and osteoarthritis

    Arch Phys Med Rehabil

    (1996)
  • A.R. Medsger et al.

    A comparative study of divorce in rheumatic arthritis and other rheumatic diseases

    J Chronic Disease

    (1972)
  • R. Melzack

    The McGill Questionnaire: Major properties and scoring methods

    Pain

    (1975)
  • R.H. Moos

    Personality factors associated with rheumatoid arthritis: A review

    J Chronic Disease

    (1964)
  • M. Pistiner et al.

    Lupus erythematosus in the 1980s: A survey of 570 patients

    Semin Arthritis Rheum

    (1991)
  • L.A. Aaron et al.

    Perceived physical and emotional trauma as precipitating events in fibromyalgia. Associations with health care seeking and disability status but not pain severity

    Arthritis Rheum

    (1997)
  • A. Aasland et al.

    Psychosocial factors in children with idiopathic musculoskeletal pain: A prospective, longitudinal study

    Acta Paediatr

    (1997)
  • A. Aasland et al.

    Psychosocial outcome in juvenile chronic arthritis: A nine-year follow-up

    Clin Exp Rheumatol

    (1997)
  • J. Achterberg et al.

    Rheumatoid arthritis: A study of relaxation and temperature biofeedback training as an adjunctive therapy

    Biofeedback and Self Recognition

    (1981)
  • S.G. Adams et al.

    Stress, depression, anxiety predict average symptom severity and daily symptom fluctuation in systemic lupus erythematosus

    J Behav Med

    (1994)
  • R. Ader et al.

    Psychoneuroimmunology

  • G. Affleck et al.

    A dual pathway model of daily stressor effects on rheumatoid arthritis

    Ann Behav Med

    (1997)
  • G. Affleck et al.

    Person and contextual features of daily stress reactivity: Individual differences in relations of undesirable daily events with mood disturbance and chronic pain intensity

    J Pers Soc Psychol

    (1994)
  • T.A. Ahles et al.

    Psychological factors associated with primary fibromyalgia syndrome

    Arthritis Rheum

    (1984)
  • F. Alexander

    Psychosomatic Medicine

  • W.F.J. Andrew

    Psychiatric illness associated with systemic lupus erythematosus

    South Med J

    (1975)
  • G.H. Baker

    Life events before the onset of rheumatoid arthritis

    Psychother Psychosom

    (1982)
  • M. Barrera et al.

    Preliminary development of a scale of social support: Studies on college students

    Am J Community Psychol

    (1981)
  • P. Bendtsen et al.

    Rheumatoid arthritis, coping and well-being. Cross-sectional sub-group comparisons and correlational analyses

    Scand J Soc Med

    (1994)
  • BesedovskyH.O. et al.

    Immune-neuro-endocrine interactions

    Endocr Rev

    (1996)
  • G. Blom et al.

    Emotional factors in children with rheumatoid arthritis

    Orthopsychiatry

    (1954)
  • G.C. Booth

    Personality and chronic arthritis

    J Nerv Ment Dis

    (1937)
  • R. Brons et al.

    Type of stressor and depressive mood in patients with rheumatoid arthritis

    Percept Mot Skills

    (1993)
  • S. Buchi et al.

    Sense of coherence–a protective factor for depression in rheumatoid arthritis

    J Rheumatol

    (1998)
  • J. Cassel

    The contribution of the social environment to host resistance: the Fourth Wade Hampton Frost Lecture

    Am J Epidemiol

    (1976)
  • B.R. Cassileth et al.

    Psychological status in chronic illness: A comparative analysis of six diagnostic groups

    N Engl J Med

    (1984)
  • S. Clark et al.

    Clinical characteristics of fibrositis. II. A “blinded, ” controlled study using standard psychological tests

    Arthritis Rheum

    (1985)
  • S. Cobb et al.

    Environmental factors in rheumatoid arthritis, study of relationship between onset and exacerbations of arthritis and emotional and environmental factors

    JAMA

    (1939)
  • F. Creed

    Psychological disorders in rheumatoid arthritis: A growing consensus?

    Ann Rheum Dis

    (1990)
  • L.J. Crosby

    Stress factors, emotional stress and rheumatoid arthritis disease activity

    J Adv Nurs

    (1988)
  • S. Crown et al.

    Aspects of the psychology and epidemiology of rheumatoid disease

    Psychol Med

    (1975)
  • P.A. Dailey et al.

    Psychological stress and the fibrositis/fibromyalgia syndrome

    J Rheumatol

    (1990)
  • D. Daniels et al.

    Psychosocial risk and resistance factors among children with chronic illness, healthy siblings, and healthy controls

    J Abnorm Child Psychol

    (1987)
  • A. DeLongis et al.

    Relationship of daily hassles, uplifts and major live events to health status

    Health Psychol

    (1982)
  • F.S. Dhabhar et al.

    Effects of stress on immune cell distribution. Dynamics and hormonal mechanisms

    J Immunol

    (1995)
  • B.L. Downe-Wamboldt et al.

    Emotions, coping, and psychological well-being in elderly people with arthritis

    West J Nurs Res

    (1995)
  • E. Duboise

    Lupus Erythematodes

  • Cited by (156)

    View all citing articles on Scopus

    Address reprint requests to Rainer H. Straub, MD, Department of Internal Medicine I, University Medical Center, D-93042 Regensburg, Germany, [email protected]

    *

    Department of Internal Medicine, University Medical Center, Regensburg, Regensburg, Bavaria, Germany

    View full text