RA Naiveté

An illusory correlation is a logical fallacy that denotes assigning a causal relationship to two events when in fact they are unrelated. For instance, the rising of the sun does not cause traffic on the freeway, though the two often occur together. The gambler's fallacy is similar to an illusory correlation and is an assumption that unrelated previous events impact future events. The gambler's belief in "a hot hand," for instance, or that "the game catches up," or that "a win is due," belies the fact that the statistical odds of certain outcomes remain the same between subsequent pulls of the slot lever or rolls of the dice.

Humans have a tendency to anthropomorphically imbue probability events with motivations: "Fate was against me that day." We also have a tendency to see causes where no relationship exists. Superstition is an excellent example.

Over dinner last week my wife and I reflected on the last few years and how difficult the struggle with RA has been on top of the birth of our son, my graduate training, and both of us working. Yet our mood was one of merriment, and we spent the evening celebrating her birthday. As I sipped on a glass of red wine, something I have largely abandoned since my diagnosis, I wondered if my belief that alcohol precipitated flares was in fact correct. How many drinks have I had that were not followed by a flare up, versus how many that did? What does the scientific literature say?*** My wife spotted my signature withdrawal into my thoughts and inquired as to my current muse. "I'm just trying to figure out what causes these flares and whether or not they are truly random or precipitated by something I can control," I replied. I then had a moment of startling clarity of how much time I have spent contemplating what caused RA, and what precedes flares. Laughing out loud, I saw myself as a farcical character in a tragic story, a dark humor that carries me through some of the hardest facts of life. In hindsight, the reasons I came up with for my massive hands, bloated feet, constant pain, and mind-numbing fatigue at the onset of the disease, were the true absurdities.

I blamed the first night that I awoke in pain about two years ago, with my wrist more than double its regular size, on the dishwasher. We had been moving, and I had recently replaced many appliances with awkward movements I was unaccustomed to. The swelling went down a few days later, leaving me with the belief that I had a minor injury or strain.

My feet began a gargantuan swelling a few weeks later while riding my road bike. Forty miles into the ride and the pain became unbearable. Taking my feet out of my shoes, I pedaled on the tops of them to give room for the swelling. Arriving home and limping off my bike, I inspected the shoes, and thought that perhaps I needed new insoles. Never mind that something like this had never occurred in the past sixteen years of riding on average 12-14 hours a week in the stiffest carbon soled shoes available, I went out and bought new insoles anyway. The swelling dissipated shortly thereafter.

Weeks later came a morning that I awoke with an immobile shoulder, and my wedding ring contracting on a finger that resembled a strangled sausage. I blamed this on our new memory foam mattress that I found uncomfortable. Perhaps I was not moving enough in my sleep, I thought. After acquiring a new mattress, I felt better for a while.

I could barely hold the screaming bundle of joy that was my first born when he announced his miraculous presence in my life later that year. My shoulders had been howling in pain for days. I limped around the hospital, wondering if I were experiencing the vague phenomenon people refer to as sympathy pains. Seeing my wife suffer inspired endless appreciation for what women go through during pregnancy, labor, and delivery. Yet, the idea of psychosomatic vicarious suffering seemed a stretch, and was only entertained for a few hours. "It must be the lack of sleep," I thought later that week, "or the heightened stress of being on twenty-four seven."

That all of these events of swelling were separated by weeks without inflammation made the underlying cause indiscernible. I truly felt at a loss. Healthy, young, and athletic, I did not think something could go seriously awry. Yet, when my wrists took to swelling again in the night, I scheduled an appointment with a hand and wrist doctor. By the time I sat in his office, however, all swelling had disappeared. Trying to explain a pain that had no visible causes on x-ray and clinical assessment left me feeling like a doltish fool. Thankfully the doctor exercised precaution, ordering a blood test. Shortly thereafter he referred me to rheumatology. An appointment was a three-month wait, during which time my denial ended. In the interim, the swelling set up permanent residence. Agony pervaded every minute of every day.

"You have the signature distribution of swelling characteristic of rheumatoid arthritis,” my doctor said the first time I saw her. "You have the blood markers of systemic inflammation as well." When she left the room, I looked at my wife. Both of us had tears streaming down our faces. The illusory correlations that the swelling was due to some benign strain or sprain, a fleeting soreness, a symptom of stress and lack of sleep, or some other unknown cause, now appear naive. I had been making a critical error in correlating unrelated events when in fact a single variable, RA, explained everything.

I continue to monitor my activities, especially after flare-ups. I am nearly certain they are less frequent when I exercise, avoid alcohol, get sufficient rest, and keep the stress low. Biologics have been a boon of tremendous value, as has prednisone. Yet, the flares still occur on occasion, knocking me flat and leaving me searching.

The gambler's fallacy still lingers. I often think things like, "I haven't had a flare in a few weeks, and I’m probably due." Or, "This month has been terrible. Next month will be better." There is a randomness to the flares, however, that undermines my attempts to predict them. That I had many bad days this week does not predict the next.

If you are undiagnosed and experiencing symptoms please see a doctor as soon as possible. It can be frightening to confront the possibility that one has a serious illness. The risks of avoiding that possibility, however, far outweigh any benefits. Illusory correlations that maintain denial are dangerous and must be seen for what they are. Early intervention can be crucial in preventing long-term damage.

*** According to a systematic review and meta-analysis published in 2013 in the Oxford University Press Journal of Rheumatology, moderate alcohol consumption can have a protective effect on the development of RA.1 Further, in a study of 2,800 adult RA patients in Sweden from 1992-2005, female patients with non-hazardous alcohol use had lower self-reported disease activity and higher reported quality of life.2 This was not reported in men. Arthritis.org reports that, "red wine has a compound in it called resveratrol, which has well-established anti-inflammatory effects," and notes current findings that moderate drinking has potential protective effects for RA.3 However, something to seriously consider before popping the cork is that, "many experts question the strength of these studies and argue it’s hard to distinguish confounding factors in this research. Other research shows alcohol’s detrimental effects on arthritis."4 Everyone seems to agree that starting alcohol use to help with RA does not convey significant health benefits, and that current drinkers should moderate, as excess use always comes with health hazards. Discuss any changes in diet or alcohol consumption with your doctor.

Something else to consider is the interaction of alcohol with RA medications. Methotrexate and liver damage are associated, and combining alcohol with methotrexate will increase this risk.5 Alcohol use during treatment is something that should be discussed with your doctor as medications vary from patient to patient.

My personal reduction in alcohol intake from 3-5 drinks per week to 1-2 drinks a month is due to many anecdotal observations. The drugs are hard enough on me as is. Alcohol seems to compound this. Further, exercise with RA requires daily determination, and I notice motivational changes with alcohol consumption. Managing a healthy weight is also more difficult with RA and alcohol consumption. Though I love a good glass of beer, whiskey, or wine, only imbibing on special occasions has left me feeling better and happier.

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