How Does Rheumatoid Arthritis or Ankylosing Spondylitis Impact Mental Health | Mental Health Month

Hey there, everybody, and welcome to this video on rheumatoid arthritis, ankylosing spondylitis, and mental health. I'm your host, Dr. Donnellice Snipes. In this video, we're going to start out by defining rheumatoid arthritis and ankylosing spondylitis. Then we'll explore how the symptoms of these two disorders impact mental health and highlight general treatment strategies. Rheumatoid arthritis, a lot of us have heard of it. It's an autoimmune and inflammatory disease that occurs in adults that can lead to chronic pain, unsteadiness, and deformity. Now, rheumatoid arthritis is different than osteoarthritis, basically because of the mechanism of how it develops. Rheumatoid arthritis is autoimmune, so the immune system is actually attacking the body. Osteoarthritis is when the cartilage between the joints wears down. Rheumatoid arthritis tends to come on pretty quickly. Osteoarthritis comes on over time. Rheumatoid arthritis, there's pain, stiffness, and swelling. Osteoarthritis, there's pain and stiffness, but very rarely is there a lot of swelling. So we're dealing with arthritis, but we're dealing with arthritis that also has an inflammatory, inflammatory component. And if you remember from some of the other videos, systemic inflammation is significantly associated with mood issues, especially depression and anxiety. So when we start having systemic inflammation and having swelling in certain parts of our body, it may affect the neurotransmitter balance in our brain and promote, unfortunately, depression, which is kind of interesting. We'll talk about that more in a minute. Now, ankylosing spondylitis. Ankylosing means stiff, and spondyl means spine, and itis means inflammation. So a stiff, inflamed spine is basically what we're talking about. Ankylosing spondylitis is also an autoimmune inflammatory type of arthritis, which inflammation causes the creation of new bone, and the vertebra can actually start to fuse when we have an injury. And if you've ever had a bone spur, you may be familiar with what happens when you have an injury, and especially where a tendon meets a bone. The body may try to repair that injury by patching it with new bone. And, you know, again, that's grossly oversimplified, but I'm just kind of trying to give you a general idea about what's going on. People with ankylosing spondylitis have inflammation in their spine. And in order to try to fix itself, unfortunately, the body very hopefully adds new bone, which can sometimes fuse those vertebra and start to cause a lot of problems. Not only with posture, you know, the spine becomes less flexible, so people may develop a hunched posture. And generally just moving around can be a lot more difficult and more painful. An interesting additional complication, it's not really a side effect, it's a complication of ankylosing spondylitis is eye inflammation. So we know that ankylosing spondylitis is systemic inflammation, but there's also an associated condition called uveitis, which is inflammation of the eyes, which is very common to occur with ankylosing spondylitis. And this will cause very rapid onset eye pain, sensitivity to light and blurred vision. I want you to think about how that might impact your daily life. Just in and of itself, uveitis, let alone the ankylosing spondylitis or rheumatoid arthritis or any other itis we're throwing at it, how do these things impact mental health? Well, autoimmune conditions, because they promote systemic inflammation, can in and of themselves contribute to HPA axis activation, the stress response in the body, activation of that increased inflammation and mood issues. So we do know that there may be a biochemical aspect to it, but let's also look at some of the symptoms. Fatigue, both ankylosing spondylitis and rheumatoid arthritis may carry with them. Fatigue. Why? Well, number one, because the body's working overtime and fatigue is a common side effect. When the body is experiencing inflammation, it's saying, hey, something's wrong, I'm trying to fix it. I'm going to devote the energy to trying to fix whatever this is I'm attacking. So I'm not going to give you all this extra energy to run and play and do whatever you want. Fatigue is a common symptom. Well, let's think about this. When we experience fatigue and think about if you've had the flu and you've gotten over it, but then the next couple of months you felt really fatigued, or next few weeks you felt really fatigued and it was hard to do anything, think about how frustrating that was. Now multiply that times every day of your life, you can get a sense of how frustrating it might be to wake up in the morning and feel like, hey, everybody else is out playing and doing things and enjoying life, and I barely have the energy to take a shower today. Fatigue can contribute to depression, stiffness and what I call psychomotor slowing. But when people have arthritis or ankylosing spondylitis, they're stiff. It hurts, especially in the morning or after sitting or being still for long periods of time. But it hurts, which means it takes more effort to even do things that they want to do. For people who have whose condition has progressed, they may think back to what they used to be able to do. Some people have had this for as long as they can remember. Rheumatoid arthritis can have a juvenile onset. And ankylosing spondylitis is also largely genetic in nature, they're finding, and therefore its onset can be relatively early. But this stiffness can be very frustrating is for lack of a better word, it can be infuriating. Sometimes when you wake up in the morning, I know for myself I've got osteoarthritis. However, when I go out in the garden and if which I love doing, y' all know I love my gardening and I'm pruning trees and I'm pulling weeds and I'm doing all kinds of grabbing and gripping. Literally in the morning when I wake up, I cannot hold my coffee because I can't clench my fists. I can't make clench my fist tight enough to hold a cup of coffee. So I'm, you know, I'm using what I call paddle hands. In the morning when I first wake up, I can't type, I can't do anything, which is exasperating to me because I really like to be the master of my body and let instead of having my boss body master me. But it is something that people have to deal with pain and inflammation. Well, there you go. Inflammation is your body's signal that something is wrong. And generally you don't separate the two. You don't have inflammation without pain. Now, you may have pain without inflammation, but when you have inflammation, there's usually some level of pain. And this can be exhausting. And sometimes it will promote and we're going to talk about the mood stuff in a minute. But sometimes it can promote anxiety because you wonder, is this going to get worse? What are the consequences going to be sleep disruption? Well, when you're in pain, it's hard to sleep when you're stiff, when you can't get comfortable, it's hard to sleep sleep. When somebody is sleep deprived, not because they weren't in bed, but because they just couldn't get quality sleep, they couldn't get comfortable, it triggers that HPA axis, that threat response. System, it can exacerbate or worsen inflammation. So it's a problem that feeds on itself. Sleep, Sleep disruption worsens inflammation, inflammation worsens sleep disruption. And we really need to break this cycle here. Physical deformations and, or deformities, whatever you want to call it. With people with rheumatoid arthritis, I think a lot of us can think back to a person that we've known that's had rheumatoid arthritis and their fingers have started to get somewhat deformed because they couldn't completely extend their fingers anymore. Their toes may have two. We don't usually see people's toes as much as. And in people with ankylosing spondylitis, as I mentioned before, they may start developing a hunch in their back or leaning to one side or the other, depending on how the vertebra have fused. And that can make people very self conscious. Not only is it limiting the activities that they can do sometimes, like with rheumatoid arthritis, some of the big things include buttoning your shirts. If you can't make your fingers work that way anymore, then something we take for granted, like getting dressed, can be very difficult. Something we take for granted, like blow drying our hair, holding a brush or brushing our teeth, we may take for granted. And that might be something that is very difficult for somebody with rheumatoid arthritis in their hands. Now obviously that's more rheumatoid arthritis. The physical deformities for ankylosing spondylitis tend to make people more self conscious because they are sort of front and center. A lot of times because it does involve their posture and the way they carry themselves and a loss of function or independence. Thinking about what is more difficult for you to do as a result of your body's injuries, if you will. So how does this impact mental health? The first thing I'll say is grief and I could list anger and depression separately. But anger and depression, when we're talking about people with chronic illness is often related to the grief process. They're angry that they are not healthy. They're angry that they can't do things that other people can do. They're angry that they're in pain. You see where I'm going with this? Anger is a normal response. When something is not going the way you want it to. Anger is a normal response. Now, holding on to that anger just contributes to inflammation and sleep problems and everything else. But anger is one of the first parts of the grieving process. You get angry because you don't want it to be this way. Depression comes a little bit later, and that's when you've been angry for a while and you finally realize that, hey, I can't change this. It is what it is. And some people enter into a phase of helplessness and hopelessness, depression, because they recognize that certain things they can't change. Now, in counseling, working through the grief process at the person's pace can be really helpful. My job as a clinician is not to take away your grief. My job is not to tell you how to take away your pain, whether it's physical or. Or emotional. My job is to walk with you as you process this. So some people stay in anger for longer, some people stay in depression for longer. But when people are ready, and that is so key to effective treatment, when somebody is ready, then we can start looking at acceptance. All right, you've recognized it is what it is. You can't change it now. How can you have a rich and meaningful life and, and have this diagnosis? But that is down the road. Most of the time, after people have a diagnosis or after people have a severe flare up, they may go through a grieving process. And it's important to allow them to grieve before you start trying to look at, okay, what next? Anxiety is another side effect of either of these disorders and many other autoimmune issues. Because of their chronicity, because of the fact that they're chronic in nature, because they do limit some of the things that you are able to do. Some people have anxiety when they have a flare up. They have anxiety, oh my gosh, is this getting worse? They may worry that they're getting a secondary condition. They may worry that they're not going to be able to do the things they want to do. They may worry that they're going to be rejected or abandoned by those that they love because they can't do those things. They can't go rock climbing. They can't. Whatever it is that you do, rock climbing has a lot of hand motions to it. So that's the one I'm most familiar with. But it is important to address those issues of anxiety and look at the facts. What is it that you can and cannot do? And how likely is it? Do you have any facts to support your belief that you will be rejected if you can't do these things? And what can you do instead? What's a compromise? Maybe you can't do the same things that you used to do with your family. What can you do instead? So you're still spending time with them, I believe. Well, without calling names because I may be wrong. There was at least one golfer who developed rheumatoid arthritis. And think about playing golf with rheumatoid arthritis, having to grip that little teeny tiny club and the amount of strength when you're trying to hit the ball hundreds of yards down the fairway, that can be really painful. That can be terrifying when your entire livelihood rests on your ability to use your hands. So there is a lot of anxiety that can come with either the diagnosis or as I said, people may have mood episodes as their condition gets worse or when they have a particularly bad flare up. What are some interventions? Obviously you're going to be working with a rheumatologist if you've got a, or an endocrinologist if you, if you've got an autoimmune sort of issue going on. One of the main treatment strategies is to reduce the inflammatory response. Now doctors have their own way of handling that, whether it's medicine or physical therapy. From a mental health standpoint, HPA axis regulation is really, really important. If that threat response system, your HPA axis stays activated, then it's going to contribute to higher levels of cortisol constantly which is going to impair your sleep and increase inflammation. We work a lot on HPA axis regulation and helping people learn to trigger or manually override the stress response to trigger that relaxation response. Three of the best ways to do this, my opinion, or most straightforward ways to do this, in my opinion, are breathwork, where people focus on slow controlled breathing. Remember, breathe in for four, hold for four, exhale for four, hold for four. We call it square breathing for that reason and repeat that a few times. When you slow your breathing, it tells your brain, hey, there's nothing that we need oxygen for, there's excessive oxygen for. We don't need to fight or flee right now. So it helps trigger the relaxation response. Activities that improve what they call vagal tone are also important. Yoga is a good one because in yoga you are actually moving through different postures, you're holding positions which can trigger a physical stress response. Not a huge one always, but a physical stress response. But you're also pairing that with that slow controlled breathing, telling your body, hey, you know, turn off the autopilot, I've got this. And as you become more able to turn off the autopilot, turn off that stress response when it's unnecessary, then you're reducing cortisol levels and potentially improving inflammatory levels levels. Anti inflammatory nutrition is also Important as a mental health clinician, that's outside of my lane. So I would refer somebody to a dietitian, a nutritionist, or their physician. However, we do know that eating foods that are high in flavonoids, high in antioxidants, are very helpful at reducing inflammation. And, and reducing some foods like highly processed sugars, nitrates, nitrites, and unfortunately for some, red meat can also help. It's important to talk with your doctor about how to explore which foods may be triggering for you and which foods may be helpful for you and sleep improvement. There is a direct correlation between the functioning of your immune system and, and the quality and quantity of your sleep. If you are not sufficiently rested, then it negatively impacts your immune system. As a mental health clinician, helping people with sleep hygiene is something that is within my lane, helping them figure out what can I do to get better quality sleep. Another target is reduction of pain. Duh. If people are in pain, then their HPA axis, that threat response system is going to be triggered. That's just, that's our body's response. It feels pain. It says, hey, warning, warning, something's wrong. So reduction of pain, not only to reduce the HPA axis over activation, but also just to improve quality of life. Physical therapy can be helpful at reducing pain. A lot of people with, especially with ankylosing spondylitis, when they've been still for a long period of time, their symptoms can get worse. One of the things they found during the lockdowns was that people's mental health and their perception of their physical condition significantly deteriorated during the lockdowns because they weren't moving around as much. They had more stiffness, more pain. But there's also speculation that the associated anxiety that came with the lockdowns contributed to worsening of the autoimmune conditions. So that was kind of interesting. But physical therapy can help people start to figure out what they can do to move and not overdo it. Physical therapy can be really important for something called reconditioning. A lot of times when people are on bed rest or when they've had chronic pain for a while, they may not engage in a lot of activities because it hurts or they do it and they're sore afterwards because they overdo it. And physical therapy can help people gradually work up to the point where they can do something without it hurting. Massage is another technique that's been shown for many people to help reduce pain. Now, the type of massage varies from person to person, but it does promote the release of oxytocin and endorphins, which just generally can help reduce HPA axis activation. It promotes relaxation and can reduce just general pain. Heat and cold. Hot relaxes more. Cold can numb more. Many physicians that I've worked with have really said it depends on the person, what feels best for them. As long as it's not an acute injury. If it's a new injury, then a lot of times they recommend ice, rest, ice, compression and elevation. That's the Rice theory. But after the injury is old or when they've got a chronic condition like this, a lot of times the physician will say, whatever works best for you. For me, I use ice. I prefer ice to heat most of the time. But again, it depends on the person. Compression. Compression is something that I've just started learning more about as my osteoarthritis has gotten worse. But after I work in the garden, there is a lot of inflammation in my hands. And my doctor pointed out that, you know, think about pitchers and athletes. They tried, they put compression sleeves on. They try to keep that area warm. After working it out in order to reduce the, the swelling. I was like, oh, okay. So sometimes compression can help. Now, if you've got ankylosing spondylitis, compression can be a little bit harder to come by because you're trying to compress on the spine. Rheumatoid arthritis gloves can be somewhat easier. TENS unit Transcutaneous electronic nerve stimulation. You can get TENS units online now, which is beautiful. Back when I first started using them, they were by prescription only. This was back in the 80s. But tens units actually stimulate the nerve endings in order to block the nerves ability to send the pain signal to the, to the brain. Another thing they found is after a TENS treatment, a lot of times the levels of endorphins and in the body remain higher for a little while, which I thought was really interesting. So TENS units can actually be helpful for a variety of things, from rheumatoid arthritis to osteoarthritis to muscle pulls, spasming, carpal tunnel syndrome. There are a lot of things that can be used for. Talk to your doctor, ask them, would this help? Now with ankylosing spondylitis, you know, it's a little bit different because sometimes it is on your, on your back. And if you've got a pacemaker or other conditions, your doctor may not want you using a TENS unit that close to your heart. But most of the time it's not a big deal, especially if you're not using it. You can't Use it on your neck, but ask your doctor. Most doctors are really happy to talk about non pharmacological pain management. Acupuncture has been found to be helpful for a lot of things. And when we've got pain in our joints, in wherever, a lot of times we do something called guarding and we'll guard that area. We may not even realize we're doing it, but we're tensing up muscles around that area and in order to prevent it from being injured anymore. And that can cause muscle spasming. Acupuncture, a technique called dry needling has been found to be very helpful for slowing or reducing those muscle spasms. And I'm sure there's a lot of other uses for acupuncture. I'll be honest, I have not studied it in depth. I know it is an evidence based practice for a lot of things. And then finally, guided imagery and meditation. This can be helpful for improving sleep as well as for pain management. And I have a variety of videos on the YouTube channel on non pharmacological interventions for pain and case management for chronic pain that talk about different types of meditation scripts or guided imagery that can be used for. For pain. Two main types are what I call the focused and the altered focus. The focus imagines the pain. Say the pain's in your hand. You imagine the pain there and imagine it being this really deep red color. And then you slowly envision turning a dial and the intensity of that color turns down. The intensity of the pain is turning down. There are a lot of other techniques that you can use for focusing on the pain area. Then altered focus is when you focus on somewhere else. If you've got pain in your, in your neck, then you focus on your feet, your knees, your breathing. You focus on some other body parts, some other sensation. So you're intentionally telling your body, hey, we're not going to pay attention to that right now and we're going to focus over here and it can give you a something of a break. I'm not going to say it does everything, by all means it does not. However, it can be very helpful in terms of mental health. I already mentioned grief resolution is a huge issue. As long as people are bouncing around between anxiety or anger and depression because of their situation, their stress response is going to be active. Their quality of life is not going to be great. I mean, if you're either angry or depressed, that's not how we want to live our entire life. So working through the grief resolution process and arriving at a narrative for life with Rheumatoid arthritis or ankylosing spondylitis is going to be a treatment goal. Stress management, not just as it relates to the physical condition, but in general. It's so important for everybody, but especially for people with autoimmune diseases to, to recognize the significant impact stress has on triggering those autoimmune conditions and feeling empowered to make a decision when they start to get stressed. Body sets off that smoke alarm, says, threat, threat, threat. The person either feels angry or anxious, but then responding to that by, by saying, yes, this is worth my energy and I'm going to focus on it and do something about it. Or you know what? This is not worth me getting upset about and triggering all those neurochemicals and potentially triggering a flare up. It's just not. This person, this situation, this whatever is just not worth triggering a flare up. And hardiness and resiliency kind of goes along with stress management and grief resolution. But hardiness is recognizing all of those things in your rich and meaningful life to which you are committed and recognizing all of those things that are currently going well in your rich and meaningful life. A lot of times when things are going poorly, we focus on the thing that's going poorly. We almost don't even notice the rest of the stuff. So hardiness encourages us to look at a. Get a broader perspective. We're acknowledging the crappy things, but we're also acknowledging, hey, I've got some other things going for me right now. Identifying aspects of your life that you can control in order to continue to move toward that goal of a rich and meaningful life and perceiving the pain, perceiving the diagnosis, perceiving anything that gets in your way as an obstacle. Something to get over, under, through, around. Not a barrier, not something that stops you in your tracks, but something that presents a challenge to you. Sorry, they're blasting two lots down and I don't know if that picked up on audio or not, but it scares the everliving daylights out of me every time they do it. Anyhow, environmentally feeling safe, that's ironic. Feeling safe in your environment so you can relax, you can get good sleep, but that also means safe in your own head. So that inner critic is not continually telling you, well, you're a lazy lump of whatever. You can silence that inner critic. You can feel safe in your own body, that you are lovable, that you are valuable to other people. Accommodations. One of the best places, in my opinion, to go to find accommodations is the Jan Network. It's the job accommodation network. Website. And when you go to that website, it obviously it's talking about job accommodations. However, a lot of those things can be translated into your home life, your private life, what things can you do in order to make life easier for yourself? And sometimes they have some suggestions that you may not have come up with on your own. And finally, relationships. Improve the health literacy surrounding your diagnosis for yourself so you understand that hey, this is real, this is happening, this is the potential course that it could take. These are the things that I can do to manage my condition. All of those things will help you feel more validated, more empowered, and also improve health literacy in your significant others. So they understand what triggers flare ups, what a flare up is, what it means. And they can understand why some days are better than others. And they can understand how best to support you on the bad days as well as the good days. Sometimes when we have a chronic condition, our significant others don't understand and they invalidate it or dismiss it. On the other end of the spectrum, sometimes our significant others are so concerned about us that they are overwhelming and will not let us do what we want to do, what we can do, what we feel we need to do. And that is them just fawning. They're trying to address the problem. They're trying to keep us safe in their own way because they don't know how better to help we which is where improving their understanding of the condition and improving their understanding of how you best, how they can best help you is so important. And address your self esteem. It's not only your relationships with others, but it's your relationship with yourself. You may not have anticipated developing one of these conditions, therefore your vision may have been for your life may have been somewhat different. And it's important to address your self esteem as a person. Not just someone who can do something, someone who can be an Olympic athlete, someone who can play golf, but also just as a person, regardless of what you do. That way when you're having those flare ups, you recognize that you are still a very valuable important person, even if you can't do the things that you normally want to or would do. Rheumatoid arthritis and ankylosing spondylitis are both inflammatory autoimmune conditions. While there currently is no cure, treatment aims to reduce inflammation triggers like lack of sleep, too much stress and certain foods. Manage pain and improve people's quality of life by helping them re engage in activities that are meaningful to them. Create environments that are supportive and conducive to their current abilities and enhancing their relationships. So they do feel like they've got support and they're not fearful of abandonment or rejection.