It's Not Just All in Your Head - The Impact of RA on Mental Functioning
A quick read of the experiences of RA patients will reveal not only a common set of physical symptoms but also an expression of changes in mental states and moods over time. These mental symptoms include mood swings, lack of interest in social interaction, depression, and what I like to call “brain fog” or more scientifically, cognitive dysfunction. The best way I’ve devised to describe this feeling for someone who doesn’t have RA is to think about how their brain feels while they have a bad case of influenza. Such dysfunction is associated with many autoimmune disorders.1
RA and changes in mood
The connection between mood and RA has been known for some time. In fact, as far back as 1970, scientists reported a correlation between joint symptoms and mood in RA patients.2 And these results were repeated numerous times in the scientific literature.3
For many with RA, mood changes associated with RA are more difficult to cope with than the physical symptoms. It’s quite frustrating when your brain just won’t “get up and work right.” Yet, the American College of Rheumatology (ACR) does not include mood/emotional changes in its diagnostic criteria for RA. This is the case in spite of the fact that the risk of depression in RA patients is much greater than general populations.4
Mood and RA: A hypothesis
Cognitive impairment of any sort is not “just in your head” as many friends, family members, and even doctors believe. I argue that there may be biochemical processes involved with RA that bring about these symptoms. A complex set of biochemical processes are involved with RA. Part of these processes includes the overproduction of inflammatory chemicals called cytokines. According to some researchers, cytokines play a role in the brain of sick patients in determining mood.5 RA related inflammatory cytokines include interleukin-1, interleukin-6, and tumor necrosis factor-alpha (TNF). These cytokines are the target of many biological medicines for RA such as Humira, Enbrel and others. These cytokines are also related to depression.67 One group of scientists demonstrated the connection between cytokines and mental changes in RA patients. They stated,
“The ‘cytokine hypothesis of depression’ implies that proinflammatory cytokines, acting as neuromodulators, represent the key factor in the (central) mediation of the behavioural, neuroendocrine and neurochemical features of depressive disorders. Several medical illnesses, which are characterised by chronic inflammatory responses, e.g. rheumatoid arthritis, have been reported to be accompanied by depression.” 8
For me, the link between RA and mental symptoms is clear. There are times when my brain shuts down, I can’t think clearly, I’m depressed, and I just don’t want to be around people. And those times tend to be when RA symptoms are at their greatest.
In addition to cognitive dysfunction caused by the biochemical processes of RA, the medications we take to control the disease may also contribute to mental well being. Almost all of the disease modifying (DMARD), biologicals, corticosteroids, and pain medications list side effects linked to mental functioning. These side effects include dizziness, drowsiness, headache, mood changes, anxiety, and a litany other related issues. Like with any side effect, one must consider the tradeoffs. If I don’t take the RA meds, I’m more prone to permanent tissue damage. If I take the meds, I have to learn to manage the brain fog. With most patients, getting the disease process under control takes priority over side effects.
Mood swings or RA?
RA patients must be careful to not blame every mental issue on RA or their treatments. I’ve learned to be able to tell when mood swings and brain fog are associated with RA. My general practitioner told me that my ongoing tiredness might point to something other than just depression. It was during that time that other symptoms of RA became apparent ultimately leading to a referral to a rheumatologist, diagnosis, and treatment. I wish that all doctors had this level of insight because I hate reading about RA patients being dismissed because their symptoms are only “in their head.”
I hope that scientists and doctors continue to investigate the connections between autoimmune diseases and cognitive functioning. Perhaps it will even be used as an indicator of disease activity someday. Most importantly, I wish that all those suffering from RA would not feel guilty about changes in their mental state. Get on a good RA treatment regimen, don’t be afraid to take medications for depression or anxiety, talk to others about how you’re feeling, and speak to your doctor about any noticeable changes mood that impacts daily functioning.
When was your last flare?