It has long been suspected, of course, that the psyche is connected to rheumatic diseases. But this particular link may be more powerful than many psychiatrists realize.

So asserted Warren Katz, M.D., chief of rheumatology at Presbyterian Medical Center in Philadelphia and a clinical professor of medicine at the University of Pennsylvania, at APA’s Institute on Psychiatric Services in Philadelphia in October. He based his position mostly on anecdotal experiences from his own rheumatology practice. In other words, he appeared to be a "true believer" of the mind-body connection.

First off, Katz suggested, adverse early-life experiences can sometimes help set the stage for rheumatic diseases later in life. He implied, for instance, that this might occasionally be the case for persons with fibromyalgia. Some five million Americans, mostly middle-aged women, suffer from this syndrome, which is characterized by widespread local tenderness associated with disturbed sleep. A person experiencing

fibromyalgia might say, "I have this blasting sensation in my shoulder that seems to trickle down my elbow and fingers and seems to run around from the tip of my finger back and in this hot and searing fashion. . . ."

No organic cause for fibromyalgia has been determined. One study showed, however, that a large percentage of patients with fibromyalgia have some psychiatric history, including hospitalization for psychiatric illness, Katz pointed out. And several medical papers have reported that a number of fibromyalgia patients were sexually or physically abused as children, Katz added. He has also found this to be the case for many of his own fibromyalgia patients. Thus adverse early-life experiences such as sexual or physical abuse may sometimes help set the stage for fibromyalgia later in life, he suggested.

Psychological distress experienced as an adult can likewise set rheumatic diseases into motion, Katz contended. For instance, one of Katz’s patients swore that her rheumatoid arthritis started on the very day her husband underwent surgery for a brain tumor. A 74-year-old woman came to Katz recently with a florid case of rheumatoid arthritis. She told him that her symptoms had begun within days of her son’s committing suicide.

The same patient, Katz attested, also illustrates how psychological trauma can sometimes provoke flare-ups once rheumatic diseases have started. After he brought her rheumatoid arthritis under control with medications, she was fine for several years. Then she returned to him with a great deal of joint pain and swollen joints. Her rheumatoid arthritis had become active in the wake of another personal tragedy—this time her daughter had committed suicide.

Katz had another patient, he said, who also underscores how psychological upset can set rheumatic diseases into motion again. He had brought her rheumatoid arthritis under control with medication. She was happy caring for a grandchild. But then the son wanted the child back, and she was very upset over the loss. Shortly thereafter, her rheumatoid flared up again. It was so extreme, in fact, that Katz had trouble treating it.

"I can’t tell you how many patients I’ve seen like this," Katz declared. "Rheumatoid arthritis tends to get worse after some sort of meaningful loss to the individual, whether it be the death of a loved one, sickness, divorce, or so on." Actually, he stressed, there is hardly any rheumatic disease, such as osteoarthritis or gout, which does not get worse because of adverse psychological experiences.

And just as psychological inputs can influence rheumatic diseases, so can such diseases influence the psyche, Katz asserted. For instance, 66 million Americans are estimated to suffer from arthritic pains of one kind or another, and one study suggested that depression, along with fear and anger, are the results of recurrent or chronic pain, he pointed out. Studies have also implied that between 20 percent and 50 percent of rheumatoid arthritis patients experience depression as a result of their illness, he added. Considering the extreme pain and disability that rheumatoid arthritis can cause, he posited, it is surprising that the percentage of rheumatoid patients experiencing depression isn’t higher.

In fact, rheumatic diseases can sometimes even trigger psychosis, Katz stressed. For instance, lupus, which affects mostly young and middle-aged women, often leads to confusion, delirium, dementia, or other symptoms of psychosis. Also noteworthy, Katz added, is that lupus often starts with psychotic symptoms and only later leads to arthritis.

All in all, Katz emphasized, "Rheumatologic and psychiatric diseases not only affect each other, but. . . feed off each other." Thus, he said that he hoped that psychiatrists present at his talk would not be offended when he confessed, "Many times as a rheumatologist, I consider myself a psychiatrist in disguise."