Illness Perception Linked to Subjective Signs of RA Disease Activity

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A study presented at EULAR 2024 found tender joint count was linked to depression and illness perception but not anxiety.

Illness perception, anxiety, and depression are linked to subjective signs of disease activity in rheumatoid arthritis (RA), a study found. The data was presented as an abstract, led by Irina Gessl, MD, from the Medical University of Vienna, at the 2024 European Alliance of Association for Rheumatology (2024).1

Previous research indicates there is a bidirectional relationship between RA and mood and anxiety disorders. A 2022 study of 169 patients with RA and 85 healthy controls found 71% of patients with RA were diagnosed with psychiatry issues, but only 7.1% of healthy controls had either depression or anxiety (P < .0001).2

The connection between RA and psychiatric disorders could potentially affect outcomes in inflammatory arthritis. Additionally, studies suggest subjective illness perception is linked to worse patient-reported outcomes, as seen with patients with low back pain.3

Investigators aimed to assess the association of depression, anxiety, and illness perception with subjective and objective signs of inflammation in patients with RA.1 Investigators recruited 55 patients with RA, diagnosed according to the 2010 classification criteria, from an outpatient clinic. Patients completed several questionnaires evaluating symptoms of depression (9-question Patient Health Questionnaire, PHQ-9), anxiety (Beck Anxiety Inventory), and illness perception (Brief Illness Perception Questionnaire).

Along with questionnaires, patients underwent physical examination and musculoskeletal sonography of 22 hand and finger joints. Additionally, investigators assessed the clinical disease activity index (CDAI) and signs of sonographic inflammation with the EULAR-OMERACT grading system.

In their analysis, the team calculated Pearson correlations between the PHQ-9, Beck Anxiety Inventory, the Brief Illness Perception Questionnaire, Power Doppler score, the Gray Scale, and items on the CDAI. They also created clusters based on subjective and objective signs of disease activity, depression, anxiety, illness perception, and the visual analogue scale (VAS) pain through k-means clustering.

Participants had a mean CDAI of 17.0 ± 12.8. In the sample, 63% had at least mild depression symptoms and 23.1% had anxiety symptoms. The tender joint count was linked to depression and the Brief Illness Perception Questionnaire but not with anxiety. Neither depression, anxiety, nor illness perception were linked to swollen joint count.

Both the patient global assessment and evaluator global assessment were linked to depression (P < .001 and P < .001), anxiety, and illness perception. Furthermore, the Power Doppler and Gray Scale scores were linked to swollen joint count but not with depression, anxiety, or illness perception.

The cluster analyses revealed 3 clusters. No significant difference was found among the clusters regarding swollen joint count (1: 2.0 ± 1.4, 2: 2.8 ± 3.1, 3: 3.5 ± 4.5, P =.76).

Moreover, the mean CDAI of the patients correlated to moderate disease activity (1: 14.5 ± 6.3, 2: 12.1 ± 10.1) and high disease activity (3: 24.4 ± 14).

Investigators observed a small difference between objective (swollen joint count and evaluator global assessment) and subjective (tender joint count and patient global assessment) signs of disease activity in clusters 1 and 2 with a tender-swollen joint count difference of 1.0 ± 0.0 and 0.7 ± 4.8, respectively). However, they did see a difference between subjective and objective signs in cluster 3 (tender-swollen joint difference: 7.7 ± 6.1, patient global assessment 6.6±2.8 vs. evaluator global. Assessment 3.0 ± 2.1). Additionally, cluster 1 and cluster 2 have differences regarding anxiety (1: 51.0 ± 21.2, 2:5.4 ± 5.3), illness perception (1: 3.5 ± 0.7, 2: 40.7 ± 11.2) and pain (1: 8.0 ± 0.0 vs. 2: 3.8 ± 2.6).

Ultimately, illness perception, anxiety, and depression were linked with subjective signs of disease activity based on the tender joint count, patient global assessment, and evaluator global assessment.

“The identification of 3 clusters differing regarding the discrepancies in subjective and objective signs of disease activity as well as anxiety, depression and illness perception underscores the complexity to be taken into account in targeted patient care,” investigators wrote. “These results serve as the basis for future studies exploring the association of baseline psychiatric comorbidities and illness perception with treatment response rates and outcomes.”


  1. Gesselk, I, Watschinger, C, Monsheimer, A, et al. The Relationship of Psychiatric Comorbidities and Illness Perception with Signs of Subjective and Objective Signs of Inflammation in Rheumatoid Arthritis. Abstract presented at the 2024 European Alliance of Associations for Rheumatology (EULAR) from June 12 – 15, 2024 in Vienna, Austria
  2. Jones Amaowei EE, Anwar S, Kavanoor Sridhar K, et al. Correlation of Depression and Anxiety With Rheumatoid Arthritis. Cureus. 2022;14(3):e23137. Published 2022 Mar 14. doi:10.7759/cureus.23137
  3. Fors M, Öberg B, Enthoven P, Schröder K, Abbott A. The association between patients' illness perceptions and longitudinal clinical outcome in patients with low back pain. Pain Rep. 2022;7(3):e1004. Published 2022 Apr 27. doi:10.1097/PR9.0000000000001004