Rheumatic Disease Disfigurement Linked to Depression

SYDNEY, Australia, March 12 -- Unhappiness with the appearance of swollen and twisted joints in the hands and feet of rheumatoid arthritis patients can predict depression, researchers here said.

The same holds true for the skin rashes and lesions characteristic of systemic lupus erythematosus, said Louise Sharpe, M.D., of the University of Sydney here.

Nearly one-third of RA patients reported concerns about their physical appearance, as did more than half of those with SLE, Dr. Sharpe and colleagues reported in the March 15 issue of Arthritis & Rheumatism.

Concern about physical appearance was a significant predictor of depression in both patient groups, the researchers found. Patients should be routinely screened for such concern and receive psychological treatment for it, they added.

"Although RA and SLE are associated with perceptible changes in physical appearance, body image concerns have received little empirical investigation," the researchers said.

The study included 53 patients with recent-onset RA, 44 with chronic RA, and 60 with SLE. Patients underwent psychological assessments as well as clinical exams and health assessments to identify the extent of any disability.

In the recent RA group, 34% reported being unhappy with their physical appearance, compared with 30% of the chronic RA group and 53% of the SLE group. "This finding suggests that appearance concerns are frequently associated with rheumatic diseases," the researchers said.

"However, the fact that a similar proportion of patients with recent-onset RA and chronic RA reported concerns regarding their physical appearance implies that objective disfigurement is not the sole cause," they added. "Participants in the recently diagnosed group were still in the early stages of disease and had few, if any, objectively observable disfigurements."

In the combined RA group (recent and chronic), dissatisfaction with physical appearance was an independent and significant predictor of depression (P=0.006), accounting for about 6% of the variance in depression, the study found.

But the extent of disability was an even stronger predictor of depression in this group (P=0.001), accounting for 24% of the variance in depression.

The results were similar in the SLE group. Appearance concern was a significant independent predictor of depression (P=0.001), accounting for 18% of the variance. The same was true of disability (P=0.004), which accounted for 32% of variance.

Interestingly for the SLE group, when appearance concerns were factored into the calculation of the relationship between disability and depression, disability was no longer a significant predictor (P>0.1).

This finding suggests that "appearance concerns in patients with SLE are largely related to individuals' ability to perform their physical role functions," the researchers said. "This is consistent with theories of depression in the context of illness, which suggests that it is the way in which illness affects the view of the self that determines the degree of mood disturbance."

In other words, if SLE patients functioned well physically, they tended not to perceive their rashes or lesions as marring their physical appearance, the study suggested.

But self-perception of one's appearance was not tied to functional ability in the RA group. "Therefore, in patients with RA, not all appearance concerns are likely to be manifestations of physical disability and damage associated with illness," the researchers said.

The study did not investigate the reason behind the different findings in the two patient groups, and the researchers did not speculate as to the cause.

Finally, appearance concerns were not linked with anxiety in either patient group, suggesting that "although anxiety may be common in rheumatic diseases, appearance concerns are not associated with increased anxiety," the researchers said.

"Our results clearly establish that appearance concerns are associated with depression in patients with rheumatic diseases," the researchers said.

"Although body image dissatisfaction is predictive of depression, this does not establish a causal relationship," they added. "It is possible that depression causes body image dissatisfaction, rather than dissatisfaction causing depression. To date, there is no prospective research to confirm the direction of causality."

The study suggests that "the assessment of concerns regarding appearance should form part of the routine treatment of patients with rheumatic diseases, even in the absence of objective disfigurement," the researchers concluded.

Cognitive behavioral therapy is a proven method to address body image concerns, the researchers said. "By expanding cognitive behavioral therapy to focus on positive perception of appearance, appearance concerns should decrease. This, in turn, may enhance the effectiveness of cognitive behavioral therapy in reducing depression," they said.