Degrees of Psychological Distress in RA, Chronic Pain Compared

Researchers assessed average pain intensity in relation to levels of depression, anxiety, and stress in patients with chronic pain and rheumatoid arthritis.

Although a number of psychological variables can add to depression and anxiety among patients with chronic pain and rheumatoid arthritis (RA), patients with chronic pain are more likely to have more severe symptoms, according to research published in Pain Research and Management.

Robert W. Teasell, MD, from the Lawson health Research Institute in Ontario, Canada, and colleagues conducted a cross-sectional study of 2 patient populations—a chronic pain group and a rheumatoid arthritis (RA) group—over a period of 20 months to compare their relative levels of psychological distress.The researchers recruited the chronic pain group from an academic specialist chronic pain clinic while the RA group was recruited from an academic specialty rheumatology clinic.

High Yield Data Summary

  • Study participants with chronic pain generally displayed more severe symptoms of depression, anxiety, and stress as compared with participants with RA

Primary outcome measures were patient scores on the Depression Anxiety Stress Scales-Short Form (DASS-SF) questionnaire, the Acceptance and Action Questionnaire (AAQ), the Pain Anxiety Symptom Scale (PASS-20), the Pain Catastrophizing Scale (PCS), and an Average Pain Intensity Rating.

The study included 330 participants (167 with chronic pain; 163 with RA; 70% female; mean age 49.9 ±13.3 years). Overall, patients in the chronic pain group presented with nearly double the average pain intensity of the RA patients, and a significant difference was noted between groups (t(328)=11.21, P <.001).

After adjustments were made for age, gender, and pain intensity, Dr Teasell and colleagues found significant differences between the 2 groups for AAQ, DASS-SF, PASS, and PCS scores (P <.001).

Across all primary outcome measures, participants in the chronic pain group scored significantly higher than participants in the RA group. Subscale scores on the DASS, PASS, and PCS questionnaires were also significantly higher among participants with chronic pain (P <.001).

After categorization based on DASS severity, the researchers found that chronic pain participants generally displayed more severe symptoms of depression and anxiety (Table).

Table. Comparative Severity of Depression, Anxiety, and Stress in Study Participants With Chronic Pain and RA

Chronic Pain Group (%) RA Group (%)
Mild 16.2% 12.3%
Moderate 28.1% 7.4%
Severe 13.8% 2.5%
Extremely Severe 14.4% 1.8%
Mild 13.2% 19.6%
Moderate 11.4% 16%
Severe 19.2% 4.2%
Extremely Severe 38.3% 9.8%
Mild 12.6% 3.7%
Moderate 18.6% 4.3%
Severe 13.8% 1.8%
Extremely Severe 6% 0.6%

Summary and Clinical Applicability

“Based on our 2 study populations, individuals with chronic pain experienced more severe depressive, anxiety, and stress symptoms compared to those with chronic RA,” Dr Teasell and colleagues concluded. “Average pain intensity was significantly greater than among chronic pain participants than RA…[with] chronic pain patients experiencing significantly more psychological distress.”

Dr Teasell and colleagues note that the causative relationship between pain and psychological distress in the 2 populations is unclear, but suggest that that some differences may be due to referral bias. Chronic pain patients may be “less likely to be referred to a tertiary care clinic until pain becomes more intense and psychological distress more problematic.”

These study results have several clinical implications; primarily, they emphasize the need for multidisciplinary pain management—including psychological counseling and support—within the chronic pain patient population. 

“An analysis of the current resources available for the 2 populations with regard to information and counseling support may…potentially lead to differences in psychological distress.”

Limitations and Disclosures

  • Because the chronic pain patient population came from tertiary care clinics, they may not be representative of patients with chronic pain in general
  • The RA population may have included patients with RA that could have been either active or in remission when the patients entered the study
  • A number of factors, including duration of pain, disability, employment, litigation, or workers compensation status, are all variables that could account for score differences between both patient populations
  • Participants were cross-sectionally studied just prior to and during their clinic appointment, meaning that cause and effect cannot be determined

Disclosures: The authors declare no conflict of interests. 


Rice D, Mehta S, Shapiro A, et al. Psychological distress in out-patients assessed for chronic pain compared to those with rheumatoid arthritis. Pain Res Manag. 2016; doi: 10.1155.2016.7071907

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