There are features of JIA that suggest that young people may be at high risk of psychological complications, these include: pain, disability and physical deformity. A number of studies have shown that psychological problems, particularly depression, are higher in adults with inflammatory arthritis compared to the general population (45,46). The major psychological difference between adult-onset inflammatory arthritis and JIA is that coping strategies are not fully developed in childhood and that adolescence has to be negotiated with a chronic disease. This may affect the long-term psychological health of the individual and the ability to cope with disability in adulthood (see Chapter 2).
David et al. (2) reported clinical depression in 21% of 43 adults with polyarticular JIA, the rate increasing with the degree of disability. Anxious and helpless responses were seen more commonly in patients whose arthritis started in adolescence, possibly because adolescents have less time to adapt and develop alternative coping strategies compared to those with arthritis from early childhood. Aasland et al. (47) found that 17% of 52 adult JIA patients had a psychiatric diagnosis, often anxiety, but none had a depressive disorder. Peterson et al. (5) studying a cohort with predominantly oligo-articular JIA, suggested they " were not emotionally impaired and were able to perform social activities similar to controls."
Packham et al. (48) reported a 32% anxiety and 5% depression incidence in 246 adult JIA patients. Patients with systemic onset JIA had significantly higher levels of anxiety 41.7% and depression 10.7%, and those with oligoarticular JIA had lower levels of anxiety 7.7% compared to patients in the other JIA subsets. Depression was most commonly seen when the age at onset of JIA was between 6 and 12 years (11.1%) compared to early (2.7%) or late (0%) onset JIA. Those patients in the late onset group over 12 years of age had the highest risk of developing anxiety-related problems (41.5%, p<0.05), compared to the mid (29.6%) and early (28.7%) groups. The age at onset of disease may have a later effect on the effectiveness of learned coping strategies to avoid anxiety or depression. The apparent benefit to psychological health in the early onset group may be related to a lack of sufficient cognitive development (49) to comprehend the potential effects of arthritis. In the mid and late onset groups there may be a more pronounced effect on the development of self-identity and self-confidence.
Previous depression is common (21%) (48), often occurring first in the late teens or early twenties. At this age individuals tend to leave home and seek independence, consequently this is the time when coping techniques are being finalized and also put under the most strain. Depressive episodes become less common in later life, suggesting that experience enables patients to learn to cope with their disease more effectively. This supports the hypothesis suggested by Timko et al. (50) that psychosocial adjustments continue with time as an individual adapts to the disease. There is an important role for transitional care from pediatric to adult care at this time to ensure that at a time of change in care and an increase in patients' responsibility for their own care, they have acquired sufficient personal tools and strategies to cope with the demands of their situation. Transition is discussed further in Chapter 16.
There is little influence from physical disease-related factors on mood. Two important causes of anxiety and depression are a lack of satisfaction with social support and poor body image. In both anxiety and depression, the most important predictive factor is self-efficacy, patients' belief that they can achieve a specific behavior or control a specific symptom. This measure may indicate either less predictability of symptoms in those patients or difficulty coping with similar levels of symptoms experienced by other patients. Self-management courses, with specific techniques being learned and practiced, not only improve self-efficacy but also benefit adult patients' health outcomes (51). Similar studies have yet to be conducted in adolescent populations.
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With all the stresses and strains of modern living, panic attacks are become a common problem for many people. Panic attacks occur when the pressure we are living under starts to creep up and overwhelm us. Often it's a result of running on the treadmill of life and forgetting to watch the signs and symptoms of the effects of excessive stress on our bodies. Thankfully panic attacks are very treatable. Often it is just a matter of learning to recognize the symptoms and learn simple but effective techniques that help you release yourself from the crippling effects a panic attack can bring.