Psychiatric diagnoses in patients with fibromyalgia are related to health care-seeking behavior rather than to illness

Sex-Related Differences in Symptoms and Psychosocial Outcomes in Patients With Fibromyalgia: A Prospective Questionnaire Study

Objective

To investigate sex-related differences in patients with fibromyalgia (FM) in terms of demographic characteristics and clinical features, including tender point count (TPC), mood disorders, sleep problems, FM symptom severity, fatigue, cognitive dysfunction, and quality of life (QOL).

Patients and Methods

We studied 668 consecutive patients with FM (606 women) from May 1, 2012, to November 30, 2013. Validated questionnaires assessed outcomes of depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7), sleep problems (Medical Outcomes Study Sleep Scale), FM symptom severity (Revised Fibromyalgia Impact Questionnaire), fatigue (Multidimensional Fatigue Inventory), cognitive dysfunction (Multiple Ability Self-report Questionnaire), and QOL (36-Item Short Form Health Survey). Nonparametric Mann-Whitney U and Pearson χ² tests were used to compare continuous and categorical outcome measures, respectively, between men and women. Linear regression models were performed for all continuous dependent variables, adjusting for age, body mass index, ethnicity, marital status, and highest education level completed. P<.05 was considered statistically significant. The Benjamini-Hochberg procedure was used to adjust for multiple comparisons.

Results

Multiple linear regression analysis revealed a significant association of female sex and greater TPC (P<.001), lower overall FM symptom severity (lower overall Revised Fibromyalgia Impact Questionnaire score; P=.03), and higher QOL subscale score for vitality (36-Item Short Form Health Survey vitality subscale score; P=.02). After adjustment for multiple comparisons, only the association between female sex and greater TPC remained significant. There were no sex-related differences in demographic characteristics, depression, anxiety, sleep problems, FM symptom severity, cognitive dysfunction, and QOL.

Conclusion

A higher TPC may be associated with female sex in patients with FM. The assumption of other sex-based differences in the clinical presentation of FM was not supported in our study.

Clinical, psychological and quality of life differences in fibromyalgia patients from secondary and tertiary healthcare

BACKGROUND

The 'funnel effect' of Fibromyalgia (FM) assumes that as patients access healthcare services, they present greater severity and a more complex clinical situation than individuals with FM from the general population, but the studies comparing patients treated in different levels of healthcare are scarce. The aim of this study was to analyse the 'funnel effect' hypothesis by comparing patients from secondary and tertiary healthcare services.

METHODS

A cross-sectional sample of female patients was selected in secondary (rheumatology practices - RP) and in tertiary healthcare (chronic pain clinics - CPC). Information about sociodemographic, clinical and psychological characteristics was collected and health related quality of life (HRQL) was assessed.

RESULTS

In total, 55 patients from RP and 60 patients from CPC were included in the comparison. Patients from CPC revealed a worst clinical status (higher number of tender points, medical visits and comorbidity), more somatic symptoms (pain and daytime dysfunction levels) and worst emotional status (more anxiety) than patients from RP. Patients attending CPC also revealed a worst HRQL than RP patients although this difference was mediated by the differences in clinical and psychological variables.

CONCLUSIONS

Our study supports the 'funnel effect' hypothesis among patients of different healthcare levels, with patients from tertiary healthcare services revealing worst clinical status, more somatic and psychological symptoms, and worst HRQL than patients from secondary healthcare services.

SIGNIFICANCE

The worst clinical and psychological status and poorer quality of life in the patients from tertiary healthcare (chronic pain clinics) in relation to the patients from secondary healthcare (rheumatology practices) must be taken into account to design studies that assess any of these aspects, to a proper analysis and interpretation of the data, and to define the scope of its generalization, as data from different clinical settings are not directly comparable.

Adverse outcomes of chronic widespread pain and common mental disorders in individuals with sickness absence - a prospective study of Swedish twins

Background

Chronic widespread pain (CWP) and common mental disorders (CMDs) are common public health problems, but little is known about the role of CWP and CMDs on future adverse outcomes among work disabled individuals. The aims of the study were to investigate the associations between CWP and CMDs with subsequent disability pension (DP), long-term unemployment (> 90 days) and all-cause mortality in individuals with sickness absence (SA) and whether the associations were explained by familial factors.

Methods

In this prospective cohort study, 7884 Swedish twins born between 1933 and 1985 were included and baseline data were gathered from a questionnaire in 1998 to 2006. Register data were used for obtaining information regarding demographics, SA, DP, unemployment and mortality. Cox proportional hazards regressions were used to calculate Hazard Ratios (HR) with 95% Confidence Intervals (CI) for the associations between CWP and/or CMDs with DP, unemployment and mortality, while conditional Cox models for twin pairs provided control for familial confounding.

Results

Having either CWP or CMDs among those with a history of SA was associated with a higher risk of DP and all-cause mortality than individuals without CWP and CMDs after controlling for socio-demographic and health factors. Moreover, sick-listed individuals with both CWP and CMDs had a higher risk of DP while those who only had CMDs had a higher risk of long-term unemployment compared to those without CWP and CMDs. The association between CMDs with DP and long-term unemployment was no longer significant when controlling for familial factors.

Conclusions

CMDs was a risk factor for DP, unemployment and mortality among individuals with SA, while CWP seems to be important in relation to future DP and mortality. Familial factors played a role in the associations between CMDs and DP and CMDs and unemployment.

Central sensitization in knee osteoarthritis and fibromyalgia: Beyond depression and anxiety

Objectives

To determine the psychopathological profile of patients with central sensitization (CS) in a sample of knee osteoarthritis, with and without CS, and fibromyalgia, and to compare their psychopathological profiles.

Methods

The final sample consists of 19 patients with osteoarthritis and CS (mean 66.37 years ± 8.77), 41 osteoarthritis patients without CS (mean 66.8 ± 7.39 years), 47 fibromyalgia patients (mean 46.47 years ± 7.92) and 26 control subjects (mean 51.56 years ± 11.41). The psychopathological profile was evaluated with the Millon Multiaxial Clinical Inventory.

Results

The average score of MCMI-III reflect higher scores in the fibromyalgia and osteoarthritis-CS groups. Patients with osteoarthritis-CS are more likely to report larger scores in Borderline and Major Depression scales. Fibromyalgia patients are more likely to report more increased scores in Somatoform and Major Depression, versus osteoarthritis-CS group. Fibromyalgia patients versus osteoarthritis without CS are more likely to report higher scores in Schizoid, Depression, Histrionic, Sadistic, Borderline, Somatoform, Posttraumatic Stress Disorder and Major Depression scales.

Discussion

Patients with CS have less differences in their psychopathological profiles as well as in both osteoarthritis groups and greatest differences are obtained between the fibromyalgia and osteoarthritis without CS, so perhaps presence of CS is the key to differentiate those groups and not chronic pain. An exhaustive assessment brings more accurate psychopathological profiles, thus better psychological treatment could be applied.

The impact of fibromyalgia syndrome and the role of comorbidity with mood and post-traumatic stress disorder in worsening the quality of life

BACKGROUND:

The aim is to measure the association between fibromyalgia syndrome (FMS) and post-traumatic stress disorder (PTSD), mood and anxiety disorders using reliable psychiatric diagnoses according to Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) and with a case-control design.

METHODS:

Case-control study with cases (71 consecutive female patients with FMS) and controls (284 subjects without FMS), randomly drawn after a gender- and age-matching technique from the database of an epidemiological survey. Psychiatric diagnoses were conducted according to DSM-IV and carried out by clinical staff using a structured interview (Advanced Neuropsychiatric Tools and Assessment Schedule). QoL was measured by Short Form Health Survey (SF-12).

RESULTS:

The lifetime prevalence of major depressive disorder (MDD; 43.7% vs 8.1%, p < .0001), bipolar disorder (BD; 21.1% vs 0.7%, p  < .0001), PTSD (8.4% vs 1.4%, p < .0001) and panic disorder (28.2% vs 5.6%, p < .001) was higher in people with FMS than in controls. People with FMS showed a poorer QoL than controls on the SF-12 (26.43 ± 6.04 vs 37.45 ± 5.80, p < .0001). Those with comorbidity with MDD and BD showed a mean SF-12 score of 24.75 ± 6.31 versus 29.52 ± 4.84 ( N = 25) of people with FMS without any mood disorder ( p = .002). The attributable burden of FMS in worsening QoL was found comparable to that of serious chronic diseases such as multiple sclerosis.

CONCLUSION:

FMS is a disorder that 'in itself' can have a devastating impact on an individual's life. The frequency of the association with major depressive and bipolar disorders increases the impact on the QoL of people with FMS. One of the causes of this association appears to be the extreme vulnerability to chronic stress that this disorder involves. The findings have important clinical significance: the physician must interpret in the right dimension and with dignity the suffering of the people with FMS.

Personal relative deprivation associated with functional disorders via stress: An examination of fibromyalgia and gastrointestinal symptoms

BACKGROUND

Personal relative deprivation is a negative social comparison process typified by self-comparison, negative appraisal, and resultant negative emotionality. Personal relative deprivation has been associated with poorer physical and mental health in several domains. It has been hypothesized that the deprivation-health link operates through a stress pathway. Stress has been specifically implicated in the onset and maintenance of functional disorders, including fibromyalgia and functional gastrointestinal disorders. Despite the theoretical links between personal deprivation, stress, and functional disorders, researchers have not assessed relationships between these variables.

METHODS

We recruited community participants (n = 517; 54.9% female) to examine whether personal relative deprivation can account for variance in fibromyalgia and functional gastrointestinal symptoms beyond known demographic correlates of physical health. We also examined whether the relationships between personal relative deprivation and functional disorder symptoms are mediated by stress.

RESULTS

Consistent with our hypotheses, personal relative deprivation accounted for symptom variance in fibromyalgia and functional gastrointestinal disorders beyond that accounted for by demographic variables alone. Further, self-reported stress was found to mediate relationships between personal relative deprivation and fibromyalgia and gastrointestinal symptoms.

CONCLUSIONS

The current results support biopsychosocial models of physical health and suggest that, for patients presenting with functional disorders symptoms, a combination of biological and psychosocial interventions may be warranted.

Vulnerability to Psychopathology and Dimensions of Personality in Patients With Fibromyalgia

OBJECTIVE

Fibromyalgia (FM) patients may present psychopathology and some characteristic personality traits that may affect their adaptation to the disease. The aim of this paper was to study the relationship between personality dimensions according to the psychobiological model of Cloninger and the presence of psychopathology.

MATERIALS AND METHODS

The study sample consisted of 42 patients with FM and 38 pain-free controls. The assessment instruments administered were the Temperament and Character Inventory-Revised and the Millon Clinical Multiaxial Inventory.

RESULTS

A higher proportion of clinical psychopathologic syndromes (CPS) was observed in the FM group than in the control group, the most prevalent being anxiety disorder and dysthymia. Patients with FM (with CPS or without CPS) presented higher Harm Avoidance than the control group, and the presence of a CPS also increased Harm Avoidance scores. FM patients with CPS had low Self-directedness (SD) compared with both the control group and with their FM peers without CPS. Purposefulness and Anticipatory worry-Pessimism explained 38% of the variance of dysthymia, and anticipatory worry-Pessimism explained 18% of the variance of anxiety disorders.

CONCLUSIONS

Patients with FM have a high probability of anxious-depressive-type psychopathologic alterations. Their vulnerability to these conditions may be determined by personality traits. The SD character dimension may have implications for therapy, as low SD is associated with the presence of psychopathology and with a low capacity to cope with the disease.

Depressive Disorder, Anxiety Disorder and Chronic Pain: Multiple Manifestations of a Common Clinical and Pathophysiological Core

INTRODUCTION

A high proportion of depressive disorders are accompanied by anxious manifestations, just as depression and anxiety often present with many painful manifestations, or conversely, painful manifestations cause or worsen depressive and anxious expressions. There is increasingly more evidence of the pathophysiological, and neurophysiological and technical imaging similarity of pain and depression.

METHODS

Narrative review of the pathophysiological and clinical aspects of depression and chronic pain comorbidity. Research articles are included that emphasise the most relevant elements related to understanding the pathophysiology of both manifestations.

RESULTS

The pathological origin, physiology and clinical approach to these disorders have been more clearly established with the latest advances in biochemical and cellular techniques, as well as the advent of imaging technologies. This information is systematised with comprehensive images and clinical pictures.

CONCLUSIONS

The recognition that the polymorphism of inflammation-related genes generates susceptibility to depressive manifestations and may modify the response to antidepressant treatments establishes that the inflammatory response is not only an aetiopathogenic component of pain, but also of stress and depression. Likewise, the similarity in approach with images corroborates not only the structural, but the functional and pathophysiological analogy between depression and chronic pain. Knowledge of depression-anxiety-chronic pain comorbidity is essential in the search for effective therapeutic interventions.

Personality, mental distress, and subjective health complaints among persons with environmental annoyance

The aim of this study was to assess possible early determinants of idiopathic environmental intolerance (IEI), contributing to an integrated model for the development of IEI. Questionnaires concerning personality traits, current mental distress, subjective health complaints, work load and satisfaction, and options for recovery, were given to 84 persons from the general population attributing annoyance to (i) chemicals/smells (smell-annoyed (SA) n= 29); (ii) electrical equipment (electrically annoyed (EA) n= 16); and (iii) both smells and electricity (generally annoyed (GA) n= 39), but otherwise healthy and in active work. Compared to referents ( n= 54), the EA and GA groups showed strongly elevated scores on 5/6 scales within the trait anxiety/neuroticism personality dimension, while the SA group had a slight elevation on only one anxiety scale. Current mental distress and subjective health complaints scores were generally elevated in the EA and GA groups, but only partially in the SA group. Higher proportions of the EA, GA, and SA groups reported low satisfaction with their work situation, including more frequent fatigue after work and a higher, and often unfulfilled, need for recovery. The findings suggest that trait anxiety is prominent already at prodromal stages of IEI, possibly indicating that trait anxiety facilitates the acquisition of attribution of health complaints to environmental factors.

Age Differences in the Correlates of Physical Functioning in Patients With Chronic Pain

OBJECTIVES

Pain-related disability in the elderly is a major contributor to poor quality of life. In this study, the author examined age-related differences in the factors associated with physical disability in the context of chronic pain.

METHOD

A large cohort of chronic pain patients was categorized into four age groups, and correlates of physical disability were evaluated within each age category.

RESULTS

Several important age differences in the predictors of physical disability were noted. Affective distress was unrelated to physical disability among the elderly, whereas this association was quite strong among younger patients. In contrast, pain severity was a weak predictor of disability within the younger group, but it accounted for more than one fourth of the variance in physical disability in those older than 65.

DISCUSSION

These data suggest that the determinants of functioning may vary across the life span, implying a potential for pain management programs tailored to a patient's age.

Prevalence of fibromyalgia and co-morbid bipolar disorder: A systematic review and meta-analysis

BACKGROUND

Fibromyalgia (FM) is a chronic disorder with high morbidity and significant health service utilization costs. Few studies have reported on the phenotypic overlap of FM and bipolar disorder (BD). The aim of this review is to qualitatively and quantitatively summarize the results and clinical implications of the extant literature on the co-occurrence of FM and BD.

METHODS

A systematic search of PubMed/Medline, Cochrane, PsycINFO, CINAHL and Embase was conducted to search for relevant articles. Articles were included if incidence and/or prevalence of BD was determined in the FM sample. Results of prevalence were pooled from all studies. Pooled odds ratio (OR) was calculated based on case-control studies using standard meta-analytic methods.

RESULTS

A total of nine studies were included. The pooled rate of BD comorbidity in samples of FM patients was 21% (n=678); however, results varied greatly as a function of study methodology. Case-controlled studies revealed a pooled OR of 7.55 of BD co-morbidity in samples of FM patients [95% Confidence Interval (CI)=3.9-14.62, FM n=268, controls n=413] with low heterogeneity (I(2)=0%).

LIMITATIONS

The current study was limited by the low number of available studies and heterogeneity of study methods and results.

CONCLUSIONS

These data strongly suggest an association between BD and FM. Future studies employing a validated diagnostic screen are needed in order to more accurately determine the prevalence of BD in FM. An adequate psychiatric assessment is recommended in FM patients with suspected symptoms consistent with BD prior to administration of antidepressants in the treatment of FM.

Is it necessary to strictly diagnose fibromyalgia syndrome in patients with chronic widespread pain?

The applicability of the American College of Rheumatology (ACR) 1990 and 2010 criteria for the diagnosis of fibromyalgia syndrome (FMS) was determined in 284 patients with chronic widespread pain (CWP) including those with regional and systemic painful disorders. On the basis of initial evaluation, patients were classified into three groups. Group 1, those without any comorbid disease (N = 105), group 2, those having regional non-inflammatory painful disorders (N = 104), and group 3, those with a diagnosis of an inflammatory rheumatic disease (N = 75). Overall, 65 % of the patients fulfilled the 1990 criteria, while 94 % of them fulfilled the 2010 criteria. Almost all of the patients (97 %) with CWP did meet at least one of the criteria set, regardless of whether they have accompanying painful disorders. Widespread pain index (WPI), symptom severity scale (SS), and fibromyalgia impact questionnaire (FIQ) scores were found to be significantly higher in the patients who satisfied the 1990 criteria than those who did not (P < 0.001). Tender point counts were found to be significantly correlated with WPI, SS, FIQ, and Beck depression inventory (BDI) scores (P < 0.001). The findings of the study support the suggestion that FMS is just a continuum of CWP, rather than a distinct diagnostic entity. As treatment of FMS is usually identical with that of CWP, strict diagnosis of FMS will provide little or no significance from the viewpoint of clinical practice. We suggest that future research should be directed toward classification of CWP to provide guidance to clinicians in selecting effective therapies.

Day hospital Mentalization-based treatment versus intensive outpatient Mentalization-based treatment for patients with severe borderline personality disorder: protocol of a multicentre randomized clinical trial

BACKGROUND

Borderline personality disorder (BPD) is associated with a high socioeconomic burden. Although a number of evidence-based treatments for BPD are currently available, they are not widely disseminated; furthermore, there is a need for more research concerning their efficacy and cost-effectiveness. Such knowledge promises to lead to more efficient use of resources, which will facilitate the effective dissemination of these costly treatments. This study focuses on the efficacy and cost-effectiveness of Mentalization-Based Treatment (MBT), a manualized treatment for patients with BPD. Studies to date have either investigated MBT in a day hospitalization setting (MBT-DH) or MBT offered in an intensive outpatient setting (MBT-IOP). No trial has compared the efficacy and cost-effectiveness of these MBT programmes. As both interventions differ considerably in terms of intensity of treatment, and thus potentially in terms of efficacy and cost-effectiveness, there is a need for comparative trials. This study therefore sets out to investigate the efficacy and cost-effectiveness of MBT-DH versus MBT-IOP in patients with BPD. A secondary aim is to investigate the association between baseline measures and outcome, which might improve treatment selection and thus optimize efficacy and cost-effectiveness.

METHODS/DESIGN

A multicentre randomized controlled trial comparing MBT-DH versus MBT-IOP in severe BPD patients. Patients are screened for BPD using the Structured Clinical Interview for DSM-IV Axis II Personality Disorders, and are assessed before randomization, at the start of treatment and 6, 12, 18, 24, 30 and 36 months after the start of treatment. Patients who refuse to participate will be offered care as usual in the same treatment centre. The primary outcome measure is symptom severity as measured by the Brief Symptom Inventory. Secondary outcome measures include parasuicidal behaviour, depression, substance use, social, interpersonal, and personality functioning, attachment, mentalizing capacities, and quality of life. All analyses will be conducted based on the intention-to-treat principle. Cost-effectiveness will be calculated based on costs per quality-adjusted life-year.

DISCUSSION

This multisite randomized trial will provide data to refine criteria for treatment selection for severe BPD patients and promises to optimize (cost-)effectiveness of the treatment of BPD patients.

TRIAL REGISTRATION

NTR2292 . Registered 16 April 2010.

A systematic review of the comorbidity between PTSD and alcohol misuse

PURPOSE

This systematic review aimed to assess (1) the level of comorbidity of post-traumatic stress disorder (PTSD) and alcohol misuse reported in research studies since 2007 and (2) any associations found between specific PTSD symptom clusters and alcohol misuse.

METHODS

A literature search was carried out to capture any papers published from 2007 to the end of July 2012. Six hundred and twenty abstracts were identified and reviewed, and 42 papers were included in the final review after applying inclusion and exclusion criteria.

RESULTS

The prevalence of comorbid alcohol misuse in those with PTSD ranged from 9.8 to 61.3 %. The prevalence of comorbid PTSD in those with alcohol misuse ranged from 2.0 to 63.0 %, and the majority of prevalence rates were over 10.0 %. Almost all of the odds ratios representing the strength of association between the conditions across a variety of populations were significant, and those ranged from 1.1 to 4.87. Of the different PTSD symptom clusters, this review found most evidence for associations between alcohol misuse and both avoidance/numbing symptoms and hyperarousal symptoms.

CONCLUSIONS

Given that comorbidity appears to be common, the evidence from this systematic review supports the use of routine screening for comorbidity in populations who are known to have PTSD or alcohol misuse.

Do comorbid fibromyalgia diagnoses change after a functional restoration program in patients with chronic disabling occupational musculoskeletal disorders?

STUDY DESIGN

A retrospective study of prospectively collected data.

OBJECTIVE

To determine whether comorbid fibromyalgia, identified in patients with chronic disabling occupational musculoskeletal disorders (CDOMDs), resolves with a functional restoration program (FRP).

SUMMARY OF BACKGROUND DATA

Fibromyalgia involves widespread bodily pain and tenderness to palpation. In recent studies, 23% to 41% of patients with CDOMDs entering an FRP had comorbid fibromyalgia, compared with population averages of 2% to 5%. Few studies have examined whether fibromyalgia diagnoses resolve with any treatment, and none have investigated diagnosis responsiveness to an FRP.

METHODS

A consecutive cohort of patients with CDOMDs (82% with spinal disorders and all reporting chronic spinal pain) and comorbid fibromyalgia (N = 117) completed an FRP, which included quantitatively directed exercise progression and multimodal disability management. Diagnosis responsiveness, evaluated at discharge, created 2 groups: those who retained fibromyalgia and those who did not. These groups were compared with chronic regional lumbar pain only patients (LO group, n = 87), lacking widespread pain and fibromyalgia.

RESULTS

Of the patients with comorbid fibromyalgia, 59% (n = 69) retained the fibromyalgia diagnosis (RFM group) and 41% (n = 48) lost the fibromyalgia diagnosis (LFM group) at discharge. Although all 3 groups reported decreased pain intensity, disability, and depressive symptoms from admission to discharge, RFM patients reported higher symptom levels than the LFM and LO groups at discharge. The LFM and LO groups were statistically similar. At 1-year follow-up, LO patients demonstrated higher work retention than both fibromyalgia groups (P < 0.03).

CONCLUSION

Despite a significant comorbid fibromyalgia prevalence in a cohort of patients with CDOMDs entering an FRP, 41% of patients with an initial fibromyalgia diagnosis no longer met diagnostic criteria for fibromyalgia at discharge and were indistinguishable from LO patients on pain, disability, and depression symptoms. However, both fibromyalgia groups (LFM and RFM) had lower work retention than LO patients 1 year later, suggesting that an FRP may suppress symptoms of fibromyalgia in a subset of patients, but prolonged fibromyalgia-related disability may be more difficult to overcome.

LEVEL OF EVIDENCE

2.

Multiple somatic symptoms predict impaired health status in functional somatic syndromes

BACKGROUND

The relationship between functional somatic syndromes and multiple somatic symptoms is unclear.

PURPOSE

We assessed whether the number of somatic symptoms is a predictor of health status in three functional somatic syndromes (FSS).

METHODS

In a population-based study of 990 UK adults we assessed chronic widespread pain (CWP), chronic fatigue (CF) and irritable bowel syndrome (IBS) by questionnaire and medical record data. We assessed health status (Short Form 12 and EQ-5D), number of somatic symptoms (Somatic Symptom Inventory) and anxiety/depression (Hospital Anxiety and Depression Scale) both at baseline and at follow-up 1 year later.

RESULTS

The proportion of people with an FSS who also have multiple somatic symptoms (52-55 %) was similar in the three functional syndromes. The presence of multiple somatic symptoms was associated with more impaired health status both at baseline and at follow-up. This finding was not explained by severity of FSS. In the absence of multiple somatic symptoms, the health status of the FSS was fair or good. In multiple regression analysis, the number of somatic symptoms, the presence of a functional syndrome (CWP or CF) and anxiety/depression were predictors of EQ-5D thermometer at follow-up after adjustment for confounders.

CONCLUSIONS

Multiple somatic symptoms in people with an FSS are associated with impaired health status and this cannot be explained by more severe functional syndrome or the presence of anxiety and depression.

Living with the unexplained: coping, distress, and depression among women with chronic fatigue syndrome and/or fibromyalgia compared to an autoimmune disorder

Chronic fatigue syndrome (CFS) and fibromyalgia are disabling conditions without objective diagnostic tests, clear-cut treatments, or established etiologies. Those with the disorders are viewed suspiciously, and claims of malingering are common, thus promoting further distress. It was hypothesized in the current study that levels of unsupportive social interactions and the coping styles used among those with CFS/fibromyalgia would be associated with perceived distress and depressive symptoms. Women with CFS/fibromyalgia (n=39), in fact, reported higher depression scores, greater perceived distress and more frequent unsupportive relationships than healthy women (n=55), whereas those with a chronic, but medically accepted illness comprising an autoimmune disorder (lupus erythematosus, multiple sclerosis, rheumatoid arthritis; n=28), displayed intermediate scores. High problem-focused coping was associated with low levels of depression and perceived distress in those with an autoimmune condition. In contrast, although CFS/fibromyalgia was also accompanied by higher depression scores and higher perceived distress, this occurred irrespective of problem-focused coping. It is suggested that because the veracity of ambiguous illnesses is often questioned, this might represent a potent stressor in women with such illnesses, and even coping methods typically thought to be useful in other conditions, are not associated with diminished distress among those with CFS/fibromyalgia.

A psychoeducational intervention (SWEEP) for depressed women with diabetes

BACKGROUND

Clinically significant depression is present in 25 % of individuals with type 2 diabetes, its risk being doubled in women.

PURPOSE

To examine the effectiveness of the Study of Women's Emotions and Evaluation of a Psychoeducational (SWEEP), a group therapy for depression treatment based on cognitive behavioral therapy principles that was developed for women with type 2 diabetes was conducted.

METHODS

Women with significantly elevated depression symptoms (Center for Epidemiologic Studies Depression Scale ≥16) were randomized to SWEEP (n = 38) or usual care (UC, n = 36).

RESULTS

Multilevel modeling indicated that SWEEP was more effective than UC in reducing depression (mean difference of -15 vs. -7, p < .01), decreasing trait anxiety (mean difference of -15 vs. -5, p < .01), and improving anger expression (mean difference of -12 vs. -5, p < .05). Although SWEEP and UC had improvements in fasting glucose (mean difference of -24 vs. -1 mg/dl) and HbA1c (mean difference of -0.4 vs. -0.1 %), there were no statistically significant differences between groups.

CONCLUSIONS

SWEEP was more effective than UC for treating depressed women with type 2 diabetes. Addition of group therapy for depression meaningfully expands the armamentarium of evidence-based treatment options for women with diabetes.

Chemical intolerance in primary care settings: prevalence, comorbidity, and outcomes

PURPOSE

This study extends previous community-based studies on the prevalence and clinical characteristics of chemical intolerance in a sample of primary care clinic patients. We evaluated comorbid medical and psychiatric disorders, functional status, and rates of health care use.

METHODS

A total of 400 patients were recruited from 2 family medicine clinic waiting rooms in San Antonio, Texas. Patients completed the validated Quick Environmental Exposure and Sensitivity Inventory (QEESI) to assess chemical intolerance; the Primary Care Evaluation of Mental Disorders (PRIME-MD) screen for possible psychiatric disorders; the Dartmouth-Northern New England Primary Care Cooperative Information Project (Dartmouth COOP) charts for functional status; and the Healthcare Utilization Questionnaire.

RESULTS

Overall, 20.3% of the sample met criteria for chemical intolerance. The chemically intolerant group reported significantly higher rates of comorbid allergies and more often met screening criteria for possible major depressive disorder, panic disorder, generalized anxiety disorder, and alcohol abuse disorder, as well as somatization disorder. The total number of possible mental disorders was correlated with chemical intolerance scores (P <.001). Controlling for demographics, patients with chemical intolerance were significantly more likely to have poorer functional status, with trends toward increased medical service use when compared with non-chemically intolerant patients. After controlling for comorbid psychiatric conditions, the groups differed significantly only regarding limitations of social activities.

CONCLUSIONS

Chemical intolerance occurs in 1 of 5 primary care patients yet is rarely diagnosed by busy practitioners. Psychiatric comorbidities contribute to functional limitations and increased health care use. Chemical intolerance offers an etiologic explanation. Symptoms may resolve or improve with the avoidance of salient chemical, dietary (including caffeine and alcohol), and drug triggers. Given greater medication intolerances in chemical intolerance, primary care clinicians could use the QEESI to identify patients for appropriate triage to comprehensive nonpharmacologic care.

Central pain mechanisms in chronic pain states--maybe it is all in their head

Mechanisms underlying chronic pain differ from those underlying acute pain. In chronic pain states, central nervous system (CNS) factors appear to play particularly prominent roles. In the absence of anatomical causes of persistent pain, medical sub-specialities have historically applied wide-ranging labels (e.g., fibromyalgia (FM), irritable bowel syndrome, interstitial cystitis and somatisation) for what now is emerging as a single common set of CNS processes. The hallmark of these 'centrally driven' pain conditions is a diffuse hyperalgesic state identifiable using experimental sensory testing, and corroborated by functional neuroimaging. The characteristic symptoms of these central pain conditions include multifocal pain, fatigue, insomnia, memory difficulties and a higher rate of co-morbid mood disorders. In contrast to acute and peripheral pain states that are responsive to non-steroidal anti-inflammatory drugs (NSAIDs) and opioids, central pain conditions respond best to CNS neuromodulating agents, such as serotonin-norepinephrine reuptake inhibitors (SNRIs) and anticonvulsants.

Peripheral pain mechanisms in chronic widespread pain

Clinical symptoms of chronic widespread pain (CWP) conditions like fibromyalgia (FM), include pain, stiffness, subjective weakness, and muscle fatigue. Muscle pain in CWP is usually described as fluctuating and often associated with local or generalised tenderness (hyperalgesia and/or allodynia). This tenderness related to muscle pain depends on increased peripheral and/or central nervous system responsiveness to peripheral stimuli, which can be either noxious (hyperalgesia) or non-noxious (allodynia). For example, patients with muscle hyperalgesia will rate painful muscle stimuli higher than normal controls, whereas patients with allodynia may perceive light touch as painful, something that a 'normal' individual will never describe as painful. The pathogenesis of such peripheral and/or central nervous system changes in CWP is unclear, but peripheral soft tissue changes have been implicated. Indirect evidence from interventions that attenuate tonic peripheral nociceptive impulses in patients with CWP syndromes like FM suggest that overall FM pain is dependent on peripheral input. More importantly, allodynia and hyperalgesia can be improved or abolished by removal of peripheral impulse input. Another potential mechanism for CWP pain is central disinhibition. However, this pain mechanism also depends on tonic impulse input, even if only inadequately inhibited. Thus, a promising approach to understanding CWP is to determine whether abnormal activity of receptors in deep tissues is fundamental to the development and maintenance of this chronic pain disorder.

CONCLUSIONS

Most CWP patients present with focal tissue abnormalities including myofascial trigger points, ligamentous trigger points or osteoarthritis of the joints and spine. While not predictive for the development of CWP, these changes nevertheless represent important pain generators that may initiate or perpetuate chronic pain. Local chemical mediators, including lactic acid, adenosine triphosphate (ATP) and cytokines, seem to play an important role in sensitising deep tissue nociceptors of CWP patients. Thus, the combination of peripheral impulse input and increased central pain sensitivity may be responsible for widespread chronic pain disorders including FM.

Glutamate-based depression GBD

We describe a new term: glutamate-based depression (GBD). GBD is defined as a chronic depressive illness associated with environmental stress and diseases associated with altered glutamate neurotransmission. We hypothesize that glutamate-induced over-activation of extrasynaptic NMDA receptors in the subgenual cingulate area called Brodmann's 25 plays an important role in the etiology of depression and may be responsible for the high incidence of co-morbid depression associated in diseases with glutamate etiology. While depression is a syndrome with multiple possible etiologies, we propose that a disruption in glutamatergic neurotransmission may underline a substantial proportion of clinically observed depression. The high rates of depressive symptoms associated with various disorders in which altered glutamatergic functions have been identified, may suggest a common pathophysiological mechanism is underlying the diverse clinical presentations.

EEG biofeedback treatment improves certain attention and somatic symptoms in fibromyalgia: a pilot study

Fibromyalgia (FMS) is a chronic, painful disorder often associated with measurable deficiencies in attention. Since EEG biofeedback (EEG-BF) has been used successfully to treat attention problems, we reasoned that this modality might be helpful in the treatment of attention problems in FMS. We also speculated that improvement in central nervous system (CNS) function might be accompanied by improvement in FMS somatic symptoms. We studied fifteen FMS patients with attention problems, demonstrated by visual and auditory continuous performance testing (CPT), while completing 40 or more EEG-BF sessions. Training consisted of a "SMR protocol" that augmented 12-15 Hz brainwaves (sensory motor rhythm; SMR), while simultaneously inhibiting 4-7 Hz brainwaves (theta) and 22-30 Hz brainwaves (high beta). Serial measurements of pain, fatigue, psychological distress, morning stiffness, and tenderness were also obtained. Sixty-three FMS patients who received standard medical care, but who did not receive EEG-BF, served as controls. Visual, but not auditory, attention improved significantly (P < 0.008). EEG-BF treated subjects also showed improvement in tenderness, pain and fatigue. Somatic symptoms did not change significantly in controls. Visual attention parameters and certain somatic features of FMS appear to improve with an EEG-BF SMR protocol. EEG-BF training in FMS deserves further study.

Newer treatments for fibromyalgia syndrome

Fibromyalgia syndrome is a common chronic pain disorder of unknown etiology. The lack of understanding of the pathophysiology of fibromyalgia has made this condition frustrating for patients and clinicians alike. The most common symptoms of this disorder are chronic widespread pain, fatigue, sleep disturbances, difficulty with memory, and morning stiffness. Emerging evidence points towards augmented pain processing within the central nervous system (CNS) as having a primary role in the pathophysiology of this disorder. Currently the two drugs that are approved by the United States Food and Drug Administration (FDA) for the management of fibromyalgia are pregabalin and duloxetine. Newer data suggests that milnacipran, a dual norepinephrine and serotonin reuptake inhibitor, may be promising for the treatment of fibromyalgia. A double-blind, placebo-controlled trial of milnacipran in 125 fibromyalgia patients showed significant improvements relative to placebo. Milnacipran given either once or twice daily at doses up to 200 mg/day was generally well tolerated and yielded significant improvements relative to placebo on measures of pain, patient's global impression of change in their disease state, physical function, and fatigue. Future studies are needed to validate the efficacy of milnacipran in fibromyalgia.

Fibromyalgia: from pathophysiology to therapy

Individuals with fibromyalgia generally experience chronic widespread pain, which can be accompanied by further symptoms including fatigue, sleep disturbances, cognitive dysfunction, anxiety and depressive episodes. As the recognition and diagnosis of fibromyalgia has improved, the availability of therapeutic options for patients has increased. Furthermore, research into the neurobiological mechanisms that contribute to the chronic pain and concomitant symptoms experienced by patients with fibromyalgia has advanced our understanding of this debilitating disorder. In this Review, we aim to provide an overview of existing pathophysiological concepts. The roles of biological and psychological stress, genetic factors, and pain and sensory processing in the pathophysiology of fibromyalgia and related conditions are discussed. In addition, pharmacological treatments, including monoamine modulators, calcium channel modulators and γ-aminobutyric acid modulators, as well as nonpharmacological treatment options are considered.

The longitudinal outcome of fibromyalgia: a study of 1555 patients

OBJECTIVE

To describe the diagnosis status and outcome of patients diagnosed with fibromyalgia (FM) by US rheumatologists.

METHODS

We assessed 1555 patients with FM with detailed outcome questionnaires during 11,006 semiannual observations for up to 11 years. At entry, all patients satisfied American College of Rheumatology preliminary 2010 FM criteria modified for survey research. We determined diagnosis status, rates of improvement, responder subgroups, and standardized mean differences (effect sizes) between start and study completion scores of global well-being, pain, sleep problems, and health related quality of life. (QOL) RESULTS: The 5-year improvement rates were pain 0.4 (95% CI 0.2, 0.5), fatigue 0.4 (95% CI 0.2, 0.05), and global 0.0 (95% CI -0.1, 0.1). The standardized mean differences were patient global 0.03 (95% CI -0.02, 0.08), pain 0.22 (95% CI 0.16, 0.28), sleep problems 0.20 (95% CI 0.14, 0.25), physical component summary of the Short-form 36 (SF-36) 0.11 (95% CI -0.14, -0.07), and SF-36 mental component summary 0.03 (95% CI -0.07, 0.02). Patients switched between criteria-positive and criteria-negative states, with 716 patients (44.0%) failing to meet criteria at least once during 4228.5 patient-years (7448 observations). About 10% of patients had substantial improvement and about 15% had moderate improvement of pain. Overall, FM severity worsened in 35.9% and pain in 38.6%.

CONCLUSION

Although we found no average clinically meaningful improvement in symptom severity overall, 25% had at least moderate improvement of pain over time. The result that emerged from this longitudinal study was one of generally continuing high levels of self-reported symptoms and distress for most patients, but a slight trend toward improvement.

Influence of craniosacral therapy on anxiety, depression and quality of life in patients with fibromyalgia

Fibromyalgia is considered as a combination of physical, psychological and social disabilities. The causes of pathologic mechanism underlying fibromyalgia are unknown, but fibromyalgia may lead to reduced quality of life. The objective of this study was to analyze the repercussions of craniosacral therapy on depression, anxiety and quality of life in fibromyalgia patients with painful symptoms. An experimental, double-blind longitudinal clinical trial design was undertaken. Eighty-four patients diagnosed with fibromyalgia were randomly assigned to an intervention group (craniosacral therapy) or placebo group (simulated treatment with disconnected ultrasound). The treatment period was 25 weeks. Anxiety, pain, sleep quality, depression and quality of life were determined at baseline and at 10 minutes, 6 months and 1-year post-treatment. State anxiety and trait anxiety, pain, quality of life and Pittsburgh sleep quality index were significantly higher in the intervention versus placebo group after the treatment period and at the 6-month follow-up. However, at the 1-year follow-up, the groups only differed in the Pittsburgh sleep quality index. Approaching fibromyalgia by means of craniosacral therapy contributes to improving anxiety and quality of life levels in these patients.

Further validation of a model of fibromyalgia syndrome in the rat

We have recently developed an animal model of fibromyalgia syndrome in the rat. In this model, rats exposed to unpredictable sound stress develop a delayed onset enhancement and prolongation of cytokine-induced mechanical hyperalgesia in muscle and skin. In this study, we tested the hypothesis that our model also manifests symptoms of common comorbid diagnoses: irritable bowel syndrome, temporomandibular disorder, and anxiety. Both visceral sensitivity and cytokine hyperalgesia in masseter muscle were present in the stressed rats. Furthermore, in an established model of irritable bowel syndrome-water avoidance-we observed significant muscle hyperalgesia. Finally, using the elevated plus maze to assess for anxiety level, we observed a significantly higher anxiety level in sound stress-exposed rats. Thus, unpredictable sound stress produces a condition in the rat with several features-delayed onset visceral and temporomandibular hyperalgesia and increased anxiety, as well as cutaneous and muscle hyperalgesia-commonly found in patients with fibromyalgia syndrome.

PERSPECTIVE

A stress model-unpredictable sound-in the rat exhibits several features (cutaneous, musculoskeletal, and visceral hyperalgesia, as well as anxiety) that are found in patients with fibromyalgia syndrome. Thus, this model may be used to test hypotheses about the underlying mechanisms and response to therapy in patients with fibromyalgia.

Catastrophic appraisal of acute and chronic pain in a population sample of new jersey national guard troops

OBJECTIVES

Catastrophic appraisal has been implicated as a possible cause of psychiatric morbidity, psychological distress, and physical impairment in individuals with chronic pain. At issue in this study was whether catastrophizing was associated with psychiatric morbidity in a population sample of National Guard members. In addition, we sought to determine whether it could account for individual differences in psychological distress and impaired physical function in the presence of acute and chronic pain.

METHODS

We performed a secondary analysis of an existing survey database. The original survey was designed to assess combat readiness in a population sample of 2995 National Guard troops about to deploy overseas. The database included screening instruments for psychiatric illness as well as continuous measures of psychological distress, pain perception, pain catastrophizing, and perceived physical function.

RESULTS

Among Guard members reporting a problem with pain, frequent catastrophizing was associated with higher rates of depression, posttraumatic stress, alcohol dependence, and somatization-like illness. Higher rates were also associated with chronic as opposed to acute pain (except for alcohol dependence). Pain-related catastrophizing accounted for substantial variance in measures of psychological distress and physical impairment regardless of pain duration.

DISCUSSION

Although catastrophizing beliefs are common in clinical settings, this study suggests that the phenomenon may be prevalent in the population at large and likely to influence the outcome of acute as well as chronic pain.

Fibromyalgia and bipolar disorder: a potential problem?

OBJECTIVE

To screen patients with fibromyalgia for bipolar disorder and to determine if there were any clinical clues, other than the Mood Disorders Questionnaire (MDQ), which might suggest a diagnosis of comorbid bipolar disorder.

METHODS

A total of 128 consecutive new fibromyalgia patients referred to a tertiary care center rheumatology practice were enrolled and assessed using a standard clinical protocol that included the completion of four screening questionnaires: (i) MDQ for bipolar disorder, (ii) Beck Depression Inventory (BDI) for depression, (iii) Epworth Sleepiness Scale (ESS) for daytime sleepiness, and (iv) Fibromyalgia Impact Questionnaire Disability Index (FIQ-DI) to assess for functional capacity.

RESULTS

A quarter of the fibromyalgia subjects, 25.19%, had a positive screen for bipolar disorder (MDQ >or= 7); 78.12% were clinically depressed (BDI >or= 10); and 52.13% reported daytime sleepiness (ESS >or= 10). Fibromyalgia subjects who screened positive for bipolar disorder had more severe depression than those with a negative screen [median BDI: 26.0 (19.0, 32.0) versus 15.0 (9.0, 24.0), p < 0.001].

CONCLUSIONS

We report a high prevalence of positive testing for bipolar disorder in this fibromyalgia cohort. Clinical data and questionnaire instruments other than nonspecific high depression severity failed to identify these patients. Since the norepinephrine serotonin reuptake inhibitors duloxetine and milnacipran have been recently approved by the U.S. Food and Drug Administration for the treatment of fibromyalgia, and because patients with bipolar disorder may experience destabilization of mood when treated with such agents, patients with fibromyalgia should be systematically screened for bipolar disorder prior to treatment.

Perspectives on fatigue from the study of chronic fatigue syndrome and related conditions

Fatigue is a symptom whose causes are protean and whose phenotype includes physical, mood, and behavioral components. Chronic fatigue syndrome (CFS) is an illness that has strong biological underpinnings and no definite etiology. Diagnostic criteria established by the Centers for Disease Control and Prevention have helped classify CFS as an overlap of mood, behavioral, and biological components. These include the presence of fatigue for more than 6 months associated with a diminution of functional activity and somatic symptoms, and pain not attributable to a specific diagnosis or disease. Four of the following criteria need to be present: sore throat, impaired memory or cognition, unrefreshing sleep, postexertional fatigue, tender glands, aching stiff muscles, joint pain, and headaches. Many researchers have observed that CFS shares features in common with other somatic syndromes, including irritable bowel syndrome, fibromyalgia, and temporomandibular joint dysfunction. Correlations between inflammation and infection, augmented sensory processing, abnormalities of neurotransmitters, nerve growth factors, low levels of serotonin and norepinephrine, abnormalities of homeostasis of the stress system, and autonomic dysfunction may be hallmarks of CFS. The relative contributions of each of these abnormalities to the profound fatigue associated with CFS need to be explored further to better evaluate and treat the syndrome.

Chronic widespread pain and fibromyalgia: two sides of the same coin?

Chronic widespread pain (CWP) is very prevalent in the general population (5%-10%) and is characterized by pain in all four body quadrants, the neck, and back. CWP differs from localized pain not only in its distribution but also in the way it affects lives. Multiple pain sites are associated with higher pain intensity, longer pain duration, and greater disability. Anxiety and depression are more common in CWP patients than among those with localized pain and pain-free controls. Fibromyalgia (FM) has been classified as CWP of more than a 3-month duration, with mechanical hyperalgesia at > or = 11 tender-point sites. FM has been found in 2% to 4% of community subjects and represents the extreme of CWP. This article compares pain characteristics, quality of life, consequences for daily living, and psychosocial status between FM patients and individuals with CWP. Available evidence shows that FM is associated with more severe symptoms and consequences for daily life and higher pain-severity compared with CWP.