The dark psychosomatic history of rheumatoid arthritis

Rheumatoid arthritis, the autoimmune disease that causes pain and swelling in the joints, was once considered an emblematic psychosomatic affliction. According to Franz Alexander and his colleagues, the illness was characterized by repressed hostility, a domineering personality and a rejection of the feminine role in society. In this blog post, we delve into old textbooks, newspaper archives and the scientific literature to reconstruct the dark psychosomatic history of rheumatoid arthritis.

Auguste Renoir

Rheumatoid arthritis is an autoimmune disease that causes pain and swelling in the joints and affects approximately 1 in 200 people. The illness is three times more common in women and its prevalence increases with age.

Until recently, a diagnosis of rheumatoid arthritis had devastating consequences. The illness caused joint destruction, deformity, and reduced mobility. A case example is the French impressionist painter Auguste Renoir (1841-1919). Renoir’s rheumatoid arthritis began in his 50s and became progressively worse over time. Because of feet deformation, he could no longer walk and had to be carried around in a sedan chair. Severe pain and physical limitation became a constant in the last quarter of his life. He kept painting with bandages around his hands.

In the 20^th century, several effective treatments were discovered for rheumatoid arthritis from gold salts, nonsteroidal anti-inflammatory drugs (NSAIDs), to methotrexate, the first-line therapy today. In the 1990s additional treatments were found that target specific immune pathways involved in rheumatoid arthritis such as drugs that inhibit tumor necrosis factor (TNF). Because of these breakthroughs, the prognosis of rheumatoid arthritis has significantly improved. Nowadays, many patients can achieve remission if the disease is treated promptly.

The psychosomatic theory of rheumatoid arthritis

In the past, rheumatoid arthritis was sometimes described as a psychosomatic condition. This view was inspired by the periods of subsidence and recurrence seen in patients with the illness. Many thought that such fluctuations were due to psychosocial factors. As one author noted, “irrespective of any treatment applied, there exists the phenomenon of natural recovery brought about by forces within the patient.”

A conflict about expressing anger

The foremost proponent of this view was Franz Alexander. Working at the Chicago Institute for Psychoanalysis, the Hungarian-born Alexander was one of the leading figures in the American psychosomatic movement. In a 1947 paper, he and his colleagues laid the groundwork for a psychosomatic theory of rheumatoid arthritis.

It goes something like this. The main assumption is that people suffering from rheumatoid arthritis, have a lot of repressed hostility (a popular explanation in psychosomatic theory that was also used to explain other conditions such as hypertension). One author summarized that “The arthritic dramatizes in his or her body scheme a conflict about expressing anger.”

Rejection of the female role

Where does the hostility come from? According to Alexander, it has something to do with “a rejection of the feminine role, the so-called masculine protest reaction.” He describes female patients with rheumatoid arthritis as follows:

“They assume certain masculine attitudes, compete with men, and cannot submit to them. The husbands are for the most part compliant, and more passive than their wives.”

Others agreed and noted that “in the sexual sphere their masked dependence shows itself as a psychologic if not an actual rejection of the feminine role which in our culture is typically passive and submissive.” Alexander and colleagues also wrote that “some of the patients show their masculine identification in a predilection for the masculine posture in the sexual relationship.” Mclaughin and colleagues summarized it as follows: “The girls were tomboys, the boys sissies.”

Fearful of his own angers and resentments

The theory goes on to state that patients are fearful to express their anger and hostility. As one research group explained: “The rheumatoid arthritic seems to be tremendously fearful of his own angers and resentments and hostilities. He seems to fear that expressing his inner anger will have disastrous consequences for himself.”

Others wrote that “one could conceive of the arthritic as a person who has certain unacceptable impulses over which he is so fearful of losing control that he has found it necessary to convert his body into a containing vessel whose walls would prevent the outbreak of these impulses.”

A tendency toward bodily activity

Instead of being angry, persons with rheumatoid arthritis, the theory states, find other outlets for their inner tensions. Several authors noted a tendency toward bodily activity. Booth and colleagues, for example, highlighted that “these persons exhibit motor restlessness and hyperkinosia as instinctive outlets for the energies which cannot find employment in purposeful directions.” Alexander and colleagues made a comparison with hysteria that is worth quoting in full:

“The fact that these patients express and discharge unconscious emotional tendencies through the voluntary muscles puts their symptoms in the category of hysterical conversion. At least, the modus operandi is the same as in conversion hysteria—namely, the expression of an unconscious conflict by somatic changes in the voluntary muscles.”

Benevolent tyranny

According to psychosomatic theory, patients with rheumatoid arthritis also experience guilt for their hostile feelings. To cope with this guilt, they feel a need to be a service to other people but they help out  in way that is controlling and dominating. One research group wrote that patients “attempted to control and dominate all persons and situations, usually in an open fashion, at times more subtly by binding others through self-sacrifice.” In an article in the New York Times, another research team explained:

“Rheumatoid arthritics tend to be people who handle aggressive hostile impulses by a life style of tight self-control and benevolent tyranny over others. (The ‘tyranny’ allows hostile impulses to be expressed: the benevolence allows them to be rationalized as good and socially defensible.)”

Patients are described as dominating the household: “being head of the house, controlling the environment and making the decisions.” While they care and do a great deal for their children, the theory stated, at the same time they dominate them.

When the equilibrium is disturbed

When these outlets are no longer available and the unconscious aggressive impulses and their means of control are no longer in balance, it was believed that patients may go on to develop rheumatoid arthritis. An example is a mother who has become too old for competitive sport and whose children have moved out of the house. Alexander explained: “Whenever this equilibrium is disturbed by specific events which interrupt their adaptive mode of discharging hostility and relieving guilt, the chronic inhibited aggression leads to increased muscle tonus and in some way to arthritis.”

The precise mechanism of how rheumatoid arthritis develops in this theory remains unclear. The main idea seems to be that hostility leads to increased muscle tonus and eventually pain and inflammation in the joints. Schiel for example highlights “arthritis patients believed to react to psychological stress with increased fusimotor frequency (i.e. muscle tension) which over-stretches the sensing tissue.”

Others simply ignore the question and highlight how rheumatoid arthritis helps patients to deal with their guilt and hostility. Alexander and colleagues for example write that “the diseased condition relieves the patient from guilt feelings and gives him the right to expect attention that was previously withheld or unacceptable.” Nissen & Spencer make a comparison between schizophrenia and rheumatoid arthritis and argue that both represent an escape from reality: 

“A striking similarity has been noted between a group of schizophrenic and arthritic patients. To date, genuine arthritis and schizophrenia have not been found present in the, same patient. The objective of each is to escape reality. The schizophrenic achieves this by the mechanism of fantasy or dream state in its variations, the arthritic by somatic or physical pathways through functional disability.”

Lowman and colleagues agreed by writing: “For several patients the arthritis provided a satisfactory excuse for his withdrawal from the environment and an adequate rationalization for his feelings of inadequacy.”

The psychic needs the disease is serving

Several authors have highlighted the “psychic needs” the disease is serving. When those needs disappear, patients can, apparently, make a sudden recovery. Alexander and colleagues write about “a woman with very severe arthritis [who] had to be carried about by her husband. When he died suddenly, she got out of bed, assumed charge of everything, travelled across the country for the funeral and made an immediate recovery which continued for many months.”

A rheumatoid arthritis personality

Several authors have also tried to define a rheumatoid arthritis personality, a personality type that predisposes people to the illness. According to Rimon for example, “rheumatoid arthritis patients have been described as possessing a strong reservoir of unconscious hostility, which is primitive in nature and is associated with sadistic and destructive fantasies.” Moos and colleagues summarizethe literature as follows:

“Several investigators agreed that rheumatoid arthritics, when compared to various control groups, tend to be self-sacrificing, masochistic, conforming, self-conscious, shy, inhibited, perfectionistic, and interested in sports and games. They also tend to over-react to their illness”

In the 1960s and 1970s, several skeptical papers came out with titles such as “The rheumatoid arthritic personality, a psychodiagnostic myth” that criticized the literature for its poor methodology. Most studies on the rheumatoid arthritis personality were retrospective in nature, lacked appropriate controls or used flawed measurements such as the Rorschach test. Eventually, Lerman concluded that “the existence of premorbid personality factors in RA [Rheumatoid Arthritis] patients has not received substantive support. Rather, the weight of the evidence suggest that psychological characteristicss observed in RA patients reflect problems in coping with the chronic disease process.”

Alexander’s theory and the search for a rheumatoid arthritis personality became unpopular. Afterward, researchers interested in mind-body interaction and preferred to focus on the role of stress in the progression of rheumatoid arthritis. This coincided with a change from a psychosomatic to a biopsychosocial view on the illness.

How influential were those psychosomatic papers?

Now that we have provided a brief summary of the psychosomatic literature on rheumatoid arthritis, the next question is: did it have any influence? After all, the scientific literature is quite large. It’s not difficult to find a marginal, old paper that focuses on a ridicuslously weird idea. We would like to know if the psychosomatic literature was respected and had any influence on doctors and patients.  

The size of the literature

A first indication is the size of the literature: these are not just a couple of papers on this subject, there are dozens of them spanning several decades and published by multiple research groups. The fact that this theory was proposed by influential people such as Franz Alexander in the United States and James Halliday in the United Kingdom, suggests that it was a central element in the psychosomatic movement. Rheumatoid arthritis was often seen as a case example of a psychosomatic condition.

Publications in prestigious journals

A couple of these papers ended up in prestigious scientific journals. Halliday for example wrote down his theories in The Lancet and The BMJ. He listed rheumatoid arthritis as a possible psychosomatic affection and associated it with a “self-restricting, self-sacrificing” personality type, similar to those seen in patients with hypertension. He wrote that “persons who develop rheumatoid arthritis show definite emotional self-limitation and self-restriction. They tend to be independent and self-sufficient, keeping themselves to themselves. They are self-sacrificing and show obsessional trends : for example they may be over-tidy, over-cleanly, overconscientious, a slave to routine and with a heavily developed sense of duty.”

In a 1930 article in the New England Journal of Medicine, Smith lists various examples of emotional trauma preceding the onset of atrophic arthritis  (at the time an alternative name for rheumatoid arthritis). After giving two case examples, she concluded “these two patients, and occasional others of a similar type, are strong evidence for the hypothesis that emotional and physical trauma can be the cause of atrophic arthritis.”

A letter in the Lancet from 1963 described a case where rheumatoid arthritis developed in a young girl while nursing her bedridden mother. The author explains: “The old lady became progressively more difficult to live with, and had her daughter running about most of the day. Not surprisingly, the joints chiefly affected were the knees and ankles. There was a striking improvement in symptoms after her mother’s eventual demise. She has never actually got round to admitting that her mother was a cause of resentment to her, and the truth is , that it may not have occurred to her that this was so.” The Guardian ran an article on this report titled “Family discord causes illness.”  

JAMA published a book review on “The Psychosomatic Approach to Primary Chronic Rheumatoid Arthritis” where psychosocial factors of rheumatoid arthritis are highlighted.

Old textbooks

Thirdly we looked at what old textbooks said about rheumatoid arthritis. Unfortunately, we weren’t able to find many online, only classics that were published several decades before Franz Alexander worked out his theory. It’s nonetheless notable how many of these highlighted psychosomatic elements. Llewellyn Jones, for example, wrote in 1909

“That mental shocks, continuous anxiety, and worry may determine the onset or provoke an exacerbation of rheumatoid arthritis, is, I think beyond question. Nearly all writers from Charcot onwards have remarked the frequency with which some such depressing influence has been at work”

In the first edition of his textbook, the great Canadian physician William Osler highlighted “the association of the disease with shock, worry, and grief.”  In his book ‘Rheumatoid arthritis : its pathology, morbid anatomy, and treatment’ (1896) Gilbert Bannatyne wrote:

“Emotional causes – The influence of these is not confined to the period immediately preceding the onset of the disease, but it also to a certain extent influences the progress of the disorder. Over and over again do we find patients who say they are worse after any anxiety or worry. The disease has been known even to arise after prolonged worry; but in such cases worry probably only acts by lowering the tone of the constitution.”

Baring Garrod, the person who introduced the name ‘rheumatoid arthritis’ wrote that “Prolonged mental anxiety likewise powerfully predisposes to the disease, especially if, as is often the case, it is combined with night watching. I have known many instances where rheumatoid arthritis has followed, in daughters, the nursing of parents during a long illness.”

One important caveat is that these older texts were written at a time when doctors often could not accurately differentiate rheumatoid arthritis from osteoarthritis, a more prevalent joint disease that results from breakdown of joint cartilage and underlying bone.

Newspaper articles

Next, we looked at articles that appeared in prestigious newspapers. We subscribed to the New York Times (NYT) in the US and The Guardian/The Observer in the UK and dived into their impressive archive.  We found several articles that highlight the psychosomatic view of rheumatoid arthritis.

A 1957 article in the NYT titled “Personality link in arthritis seen”, quotes the work of  Sanford Gifford (psychiatrist) and Theodore Bales, (rheumatologist) from Harvard Medical School. They stated: “Attitudes of stern self-righteousness are prominent among persons with rheumatoid arthritis. So are attitudes of long-suffering stoicism, a devotion to serving others and a rigid preoccupation with cleanliness and high moral principles.”

A 1963 piece in the NYT titled “Psychological stress is linked to arthritis in studies of twins” reports on the work of Sanford Meyerowitz and colleagues. The article writes: “The physicians concluded that the cases supported their continuing observation on more than 100 rheumatoid arthritis patients: that there are characteristic personality patterns and stress experiences in patients that precede the onset of the illness.”

The most remarkable article in the NYT was published in 1968 and titled ‘Psychoanalysts do well in blind diagnoses’. It begins with the following line: “Seven of eight psychoanalysts correctly diagnosed MR. A.O’s ailment as rheumatoid arthritis even though they had never met him or read his medical record. They made the diagnosis on the basis of a psychological case study as part of a series of experiments designed to prove that certain personality types develop particular diseases.”

A 1973 article in The Observer titled ‘Moved to anger’ informs readers about the work of Dr. Mohammed Shafii of the Children’s Psychiatric Hospital in Ann Arbor, Michigan: “He observes that the typical sufferer from rheumatoid arthritis is an individual who represses anger and rage and in a masochistic fashion turns his aggression against himself. He attempts to control his environment by adopting a martyr’s role. Thus while aggression is suppressed and makes the sufferer virtually immobile, the illness enables the patient to manipulate those who have to care for him.”

There’s also a book review about the life of Auguste Renoir, where the author argues that Renoir’s illness was psychosomatic. It reads: “…The third change was brought about by the advent of the rheumatoid arthritis which was finally to cripple him. Most doctors today would, I think, agree that the disease is very usually psychosomatic in origin. (Always allowing for the fact that some patients have an arthritic tendency, and others none at all.) The suggestion that Renoir was first physically paralysed by a psychological conflict is borne out by a later story…”

Patients beliefs

Finally, we also searched for interviews with patients and how they experienced rheumatoid arthritis.  Unfortunately back in the days, there was little interest in the patient perspective (which probably explains why doctors could write such horrible things about patients without being reprimanded). We did found a couple of papers that looked into what patients see as the cause of their rheumatoid arthritis.

Affleck and colleagues report that personal behaviors and psychological stress were among the most frequently cited causes for the illness while psychological stress was the most frequently cited cause for symptom flares.

In another study “One-third agreed worry was a decisive factor, and others named marriage problems, death of close friends, and other personal stress situations as contributory agents.” In this particular study, conducted in the 1960s, the authors interviewed patients and also briefly talked to their healthcare providers. In the introduction, they note that “Physicians and social workers consulted during the study frequently stated that rheumatoid arthritics were ‘difficult’ people with personality problems. Even the least psychiatrically oriented physician expressed a conviction that rheumatoid arthritis in some way is a psychosomatic disease.”

Williams and colleagues studied combinations of causes and concluded: “An example of what was more common was a belief in arthritis as stress-linked, overlapping with and including identification of the role of personality in determining the degree to which the particular individual was vulnerable to the effects of stressful circumstances “

Conclusion

Our overview indicates that psychosomatic theories were once popular even in a disease like rheumatoid arthritis that has clear signs of inflammation and where the biomedical pathology was partly understood.

We feel, however, a need to caution for overstatements about the evidence presented here. It does not demonstrate that rheumatoid arthritis was once considered to be psychosomatic. The articles and quotes we have summarized clearly presented a minority view.

We do, however, believe that this theory isn’t negligible. It was popular for several decades, was promoted by influential people such as Franz Alexander and James Halliday and occasionally appeared in prestigious newspapers and scientific journals. It might have influenced patients and doctors and how they looked at rheumatoid arthritis.

Click here to read more chapters in our series on the dark history of psychosomatic medicine.