Objective Illness perceptions are key determinants of behavior directed at managing disease. Although suboptimal disease management has been reported in patients with gout, patients' perceptions of illness have not been systematically studied. The aim of this study was to examine illness perceptions in patients with gout. Methods A total of 142 patients with gout for <10 years were recruited from primary and secondary care settings. Participants completed a gout‐specific Brief Illness Perception Questionnaire, questionnaires about medication beliefs and adherence to urate‐lowering therapy (ULT), and had a comprehensive assessment of gout disease activity. Serum urate, flare frequency, and Health Assessment Questionnaire (HAQ‐II) scores were recorded at baseline and after 1 year. Results Patients viewed gout as a chronic condition that was responsive to treatment but not strongly influenced by personal actions. Overall, gout was seen as having a moderate impact on their life. Most patients believed that gout was caused by dietary factors. Adherence to ULT was positively associated with a greater perceived understanding of gout and inversely associated with perceived severity and consequences of disease. Of the clinical factors assessed, pain scores were most strongly associated with negative illness perception scores at baseline. Baseline illness perception scores (perceived severity of symptoms and consequences, lower personal and treatment control) predicted worsening musculoskeletal disability at 1 year as determined by the HAQ‐II. This relationship was independent of baseline disability scores. Conclusion Negative or pessimistic views about gout are associated with poorly controlled disease, lower adherence to ULT, and progression of musculoskeletal disability in patients with gout.