Stress and Worry Affect RA

Research suggests emotional distress may trigger or worsen RA, but many questions remain.


Can trauma or stress trigger the development of rheumatoid arthritis? Can worrying make the disease worse?

Research examining the role of trauma and emotional distress in rheumatic diseases suggests the answers to both questions may be yes.

For example, a 2009 study by researchers at the Centers for Disease Control and Prevention found that people who reported two or more traumatic childhood events – including physical, emotional, or sexual abuse -- had twice the risk of rheumatic disease compared with those who reported no childhood trauma.

Psychological Stress May Affect Disease Outcomes

Further, many studies have described relationships between psychological stress and poor outcomes in RA, including disease flares, says Daniel Clauw, MD, professor of anesthesiology, rheumatology and psychiatry at the University of Michigan in Ann Arbor.

In one of those studies, researchers at the University of Nebraska analyzed the records of 1,522 U.S. veterans with RA. They found that those who also had a diagnosis of post-traumatic stress disorder (PTSD) had higher scores of self-reported pain, physical impairment and tender joint count, and worse global well-being than those with RA but no PTSD. Results of the study were published in 2013 in the journal Arthritis Care & Research.

Worry May Worsen Symptoms

In a Dutch study published the same year in Annals of the Rheumatic Diseases, researchers found a correlation between worry, RA symptoms and disease activity.

Trying to understand how daily stressors and worrying impact symptoms and disease activity in RA, researchers gathered data from 80 RA patients once a month for six months. Patients answered questions about daily stressors (for example, long appointment wait times or losing something valuable); level of worry; and symptoms of pain, fatigue and disease activity.

Researchers also took blood samples to measure levels of the stress hormone cortisol as well as inflammatory cytokines -- including TNF-alpha and interleukin-1 beta (IL-1β) -- believed to play a key role in RA severity. (Some biologics, including etanercept (Enbrel) and adalimumab (Humira) are TNF inhibitors, and anakinra (Kineret) is an IL-1 inhibitor.)

Their findings showed that “patients who have a tendency for more worrying reported slightly more disease activity, more swollen joints and more pain one month later,” explains lead author Andrea W. M. Evers, PhD, a clinical psychologist and coordinator at Radboud University Nijmegen Medical Centre in the Netherlands.

Understanding the Role of Emotions

Researchers say such findings point to the need for more studies about exactly how stress and worrying impacts the disease process. Dr. Clauw says one presumption is that stress leads to changes in the functioning of the autonomic, neuroendocrine and/or immune systems.

Authors of the Dutch study offer another possible explanation: because worrying affects emotional well-being and behavior, it could lead to less treatment adherence.

Despite the growing evidence that emotional stress can affect the immune system, quantifying or explaining the effect can be difficult due to the subjectivity of stress and people’s response to different stressors, experts say.

Terry L. Moore, MD, director of the division of rheumatology at St. Louis University School of Medicine in Missouri, questions the findings of the Dutch study in particular, because he says it had too many difficult-to-measure variables at play.

“Self-reported disease activity, pain and fatigue – some of the things they were monitoring -- are very subjective,” Dr. Moore says. “You are relying on patients to tell you what went on during the day. Fatigue varies – what one says is fatigue another might not view that way.”

While the medical community continues to search for answers, Evers says there is no question patients with the tendency to worry extensively can be helped with psychological interventions like cognitive-behavioral therapy.


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