Life changes as etiologic factors in juvenile rheumatoid arthritis

Abstract

JUVENILE Rheumatoid Arthritis (JRA or Still's Disease) is significant disease of children, annually affecting 175,000 (1 in 1,500) children in this country [1]. It cripples more children than any other musculo-skeletal disease and is major cause of childhood blindness [2]. Great strides have been made in diagnosis, treatment, and management of JRA, yet its etiology remains obscure. Immunopathy, allergy, infection, trauma, heredity, and psychosocial factors have all been postulated, but no conclusion has been reached. In focusing upon psychological factors involved, author agrees with Scotch and Geiger [3] who assume JRA may have a multiple, rather than unitary etiology .... The question is not whether social factors 'cause' disease, but rather whether they contribute to its causation. Although there was and is controversy, JRA is generally regarded as variant of Rheumatoid Arthritis (RA) [2-5], and despite significant differences in natural history of disease [2, 6], literature concerning both RA and JRA and their relationship to psychosocial factors will be reviewed briefly. A link between psyche and soma in RA has been hypothesized since 1920's [7-10]. However, no clear cut evidence such as Engel's [11] classic work with ulcerative colitis has emerged. Most investigations have concentrated on personality analysis and behavior patterns. King [7] described RA patient as shy and socially inadequate, self-sacrificing, overconscientious, depressed, and unable to show hostility. Later, he and Cobb [12] associated RA with men who made less money, had terminated marriages, worried more, and had fewer children; in women who had less education and more children; and in both sexes where there was incongruity of income and education. Cormier and Wittkower [13] say that RA patients have difficulty in usual methods of coping with environment and with other people, and severe blocking of external expression of emotion with internalization of feeling and autonomic activity. Solomon [14], comparing 16 RA patients with their unaffected siblings by means of psychodrama, noted that no RA showed more anger than sibling, and only 2 showed as much. He states that the clearest and most consistent finding related to masochism, self-sacrifice, and denial of hostility shown by arthritic patients. With Moos [15], he administered MMPI to patients and siblings and showed that RA's had higher scores on somatic reaction, female masochism, psychological rigidity and moralism, complianee/subserviance, reserve/introversion, and conservatism/security.