Sleep and musculoskeletal pain

COVID-19 psychological factors associated with pain status, pain intensity, and pain-related interference

The 2019 novel SARS-CoV2 disease causing COVID-19 has had a devastating impact on the world, and those with pain conditions may be at heightened risk for these negative consequences. Given COVID-19 limitations, including social distancing and stay-at-home orders, pain is likely largely going untreated, leading to greater pain and associated consequences. Mental health symptoms, which have been found to be elevated due to COVID-19, may contribute to elevated pain experience, but little work has examined how COVID-19-specific mental health factors may be associated with pain. Therefore, the current study examined (1) how COVID-19-specific psychological factors and general mental health symptoms differ between those with pain and without, and (2) among those with pain, which psychological factors were most strongly associated with pain experience. Results from a national (U.S. based) online sample of 174 adults (42.5% female, M_age = 37.80 years, SD = 11.30, 88 with pain) collected between April and May 2020 indicated that, compared to those individuals reporting no pain, those with pain reported significantly higher values on all variables. Additionally, COVID-19 fear and sleep problems were associated with pain intensity, and for pain-related interference, fear, sleep problems, and depression were significantly associated. These results highlight the potential importance of COVID-19-specific psychological factors in pain experience.

Abnormal Activity of Neck Inspiratory Muscles during Sleep as a Prognostic Indicator in Chronic Obstructive Pulmonary Disease

Rationale: In patients with chronic obstructive pulmonary disease (COPD), increased activity of neck inspiratory muscles has been reported as a compensatory response to hyperinflation-related diaphragmatic dysfunction. The persistence of this activity during sleep could attenuate sleep-related hypoventilation and also negatively impact sleep and clinical outcomes.Objectives: To assess the persistence of neck-muscle activity during sleep in patients with COPD recovering from severe exacerbations (i.e., requiring hospitalization) and its impact on sleep quality and recurrence of exacerbations.Methods: Video polysomnography with neck-muscle EMG was performed in patients with COPD who were recovering from a severe exacerbation. The follow-up period lasted 6 months to record the next severe exacerbation.Measurements and Main Results: Twenty-nine patients were included in the study (median [25th-75th percentile] age, 71 [64-72] yr; 55% male; body mass index, 24 [21-29]; FEV₁% predicted, 37 [29-45]; and BODE [body mass index, airflow obstruction, dyspnea, and exercise] index, 6 [5-7]). Twenty-six of these patients exhibited sleep-related neck-muscle activity, which was intermittent (limited to stage 3 sleep) in 17 and permanent throughout sleep in 9. α-Delta EEG activity during stage 3 sleep was observed in 87% of the patients. Compared with patients with no or intermittent neck-muscle activity, those with permanent neck-muscle activity showed more disrupted sleep, had experienced more exacerbations in the previous year, and suffered their next severe exacerbation earlier.Conclusions: Sleep-related neck-muscle activity occurs frequently in patients with COPD who are recovering from a severe exacerbation and seems to negatively affect sleep quality and prognosis; therefore, identification of this activity might improve COPD management after a severe exacerbation.

Sleep problems in stroke patients: relationship with shoulder pain

This study was designed to document the occurrence and the type of sleep problems in stroke patients and to examine the importance of shoulder pain in stroke in relation to sleep disturbances. Forty-six stroke patients were evaluated for the presence of sleep disturbances, general health problems (Nottingham Health Profile) and anxiety-depression (Hospital Anxiety Depression Scale) and compared with 47 age- and sex-matched subjects who had not had strokes. A four-item sleep questionnaire was used to assess different components of insomnia disorders through the previous month. The results showed that stroke patients had significantly more problems in initiating sleep than controls (p < 0.01). Other components of insomnia, difficulty in maintaining sleep or nonrestorative sleep did not differ between the two groups (p < 0.05). Factors found to be associated with poor sleep such as pain (p < 0.01), anxiety (p < 0.01) and depression (p < 0.01) were more common in the patient group but these did not otherwise result in a significant increase in all components of insomnia, probably because of the high level of benzodiazepine and tricyclic antidepressant intake amongst patients. Stroke patients with shoulder pain showed significantly more sleep disturbances (p < 0.01 ) and less general well-being ( p < 0.05) than patients without shoulder pain. It is concluded that attention must be paid to shoulder pain and to ensuing sleep disturbances among stroke patients.

Sodium oxybate for narcolepsy

Sodium oxybate (Xyrem), also known as gamma-hydroxybutyric acid, is the only therapeutic specifically approved in the USA for the treatment of cataplexy in narcolepsy. The US FDA has recently expanded its indication to include excessive daytime sleepiness associated with narcolepsy. In contrast to the antidepressants and stimulants commonly used to treat the disorder, sodium oxybate is the only compound that addresses both sets of symptoms and, when used properly, is less likely to lead to the development of tolerance and other undesirable side effects. In this review, the results of clinical trials and the place of sodium oxybate in narcolepsy treatment are discussed.

Gabapentin and pregabalin in the treatment of fibromyalgia: a systematic review and a meta-analysis

WHAT IS KNOWN AND OBJECTIVES

Fibromyalgia (FBM) is a common chronic pain disorder affecting up to 2% of the general population. Current treatment options are mostly symptom-based and limited both in efficacy and number. Two promising alternatives are gabapentin (GP) and pregabalin (PB). We aimed to estimate the efficacy and safety/tolerability of the two compounds in FBM through a systematic review and a meta-analysis of relevant randomized double-blind placebo-controlled (RCT) were performed.

DATA SOURCES, EXTRACTION AND ANALYSIS

A literature search was conducted through MEDLINE, EMBASE, Cochrane CENTRAL and the reference lists of relevant studies. Responders to treatment (>30% reduction in mean pain score) and dropouts due to lack of efficacy were used as primary outcome measures. Dropout rates and incidence of common adverse outcomes were also investigated. Four RCTs, reporting data on 2040 patients, were reviewed and three of them using PG were included in the meta-analysis.

RESULTS

Pregabalin at a dose of 600, 450 and 300 mg per day is effective in FBM compared to placebo (NNT: 7, upper 95% CI: 12, 450 mg). A number of adverse events (AE), such as dizziness, somnolence, dry mouth, weight gain, peripheral oedema, is consistently associated with treatment at any dose and could lead one out of four patients to quit treatment (NNH: 6, lower 95% CI: 4, 600 mg). Indirect comparison meta-analysis suggests that PB at a dose of 450 mg per day could result in more responders than at 300 mg, but this result needs to be interpreted with caution as there were no significant differences between 600 and 300 mg or between 600 and 450 mg. Data on GP is limited.

WHAT IS NEW AND CONCLUSIONS

The analysis indicates that PB at a dose of 450 mg per day is most likely effective in treating FBM, although AE are not negligible. Further evidence is necessary for more conclusive inferences.

A Feasibility Study of Valerian Extract for Sleep Disturbance in Person With Arthritis

Objectives: To present a pilot study of valerian to explore issues of feasibility and efficacy in studies of sedative herbs for arthritis-related sleep disturbance. Methods: Fifteen persons with arthritis and mild sleep disturbance were randomized to receive 600 mg valerian ( Valeriana officinalis, n = 7) or placebo ( n = 8) for five nights.

Results: Protocol adherence (dosing and data collection) was high. Allocation concealment was successful using a novel approach for matching the placebo on the distinctive odor of valerian. Nonsignificant differences between the groups were found on all sleep outcomes, measured by daily diaries and wrist actigraphy.

Conclusion: The study methods were feasible, except for recruitment issues (addressed in the discussion), and may guide the testing of other sedative herbs for persons with arthritis. Although efficacy outcomes were inconclusive due to the small sample size of this study, recent evidence from larger trials of valerian also does not support its efficacy.

Risk factors for excessive sleepiness in older adults

OBJECTIVE

To determine risk factors for excessive daytime sleepiness in older adults.

METHODS

This is a cross-sectional study assessing multiple risk factors for excessive daytime sleepiness in older subjects (mean age, 78 years; range 65-98 years) with (n=149) and without (n=144) complaints of frequent excessive daytime sleepiness. Assessment of risk factors included full in-laboratory sleep studies.

RESULTS

Excessive sleepiness among the elderly is multifactorial. Multivariable modeling identified the following as simultaneously significant risk factors for excessive sleepiness: severe sleep-disordered breathing (apnea-hypopnea index, >30 episodes/hr), self-report of poor sleep quality, increased percentage of time in rapid eye movement sleep, pain at night at least three times per week, wheezing or whistling from chest at night, and medications with sleepiness as a side effect. Male sex also was associated with increased risk, whereas alcohol use (more than seven beverages per week) reduced the risk for sleepiness. Multiple risk factors were more commonly present in those with complaints of sleepiness. The presence of periodic limb movements, which are common in older adults, was not associated with sleepiness.

INTERPRETATION

There is a distinct differential diagnosis of excessive daytime sleepiness in older adults. Many of the risk factors that we identified are treatable.

Sleep quality and psychological adjustment in chronic fatigue syndrome

Without specific etiology or effective treatment, chronic fatigue syndrome (CFS) remains a contentious diagnosis. Individuals with CFS complain of fatigue and poor sleep--symptoms that are often attributed to psychological disturbance. To assess the nature and prevalence of sleep disturbance in CFS and to investigate the widely presumed presence of psychological maladjustment we examined sleep quality, sleep disorders, physical health, daytime sleepiness, fatigue, and psychological adjustment in three samples. individuals with CFS; a healthy control group; and individuals with a definite medical diagnosis: narcolepsy. Outcome measures included physiological evaluation (polysomnography), medical diagnosis, structured interview, and self-report measures. Results indicate that the CFS sample had a very high incidence (58%) of previously undiagnosed primary sleep disorder such as sleep apnea/hypopnea syndrome and restless legs/periodic limb movement disorder. They also had very high rates of self-reported insomnia and nonrestorative sleep. Narcolepsy and CFS participants were very similar on psychological adjustment: both these groups had more psychological maladjustment than did control group participants. Our data suggest that primary sleep disorders in individuals with CFS are underdiagnosed in primary care settings and that the psychological disturbances seen in CFS may well be the result of living with a chronic illness that is poorly recognized or understood.

Sleep and headache

The relationship between sleep and headache has been known for over a century. Headache and sleeping problems are both some of the most commonly reported problems in clinical practice, and cause considerable social and family problems, as well as socio-economic impact and costs. There is a clear association between headache and sleep disturbances, especially headaches occurring during the night or early morning. The mechanism and causes are complex, multifactorial and poorly understood. Headache disorders like migraine, tension-type headache, cluster headache and hypnic headache all affect or are directly related to sleep disturbances and daytime functioning. Sleep fragmentation, insomnia and hypersomnia all show relations to headache. Primary sleep disorders like insomnia, hypersomnias including sleep disordered breathing are all associated with and may cause headache. Furthermore medical, psychiatric and rheumatic diseases are associated with sleep disturbances and headache. The current knowledge about headache and sleep is still sparse and further research is advocated.

Sleep disturbance in cancer patients

Sleep difficulty is a prominent concern of cancer patients, yet there has been no large study of the prevalence and nature of sleep disturbance in cancer patients. This cross-sectional survey study examined: (a) the prevalence of reported sleep problems in patients attending six clinics at a regional cancer centre; (b) sleep problem prevalence in relation to cancer treatment; and (c) the nature of reported insomnia (type, duration, and associated factors). For three months, all patients attending clinics for breast, gastrointestinal, genitourinary, gynecologic, lung, and non-melanoma skin cancers were offered a brief sleep questionnaire. Response rate was 87%; the final sample size was 982. Mean age of respondents was 64.9 years (SD 12.5). The most prevalent problems were excessive fatigue (44% of patients), leg restlessness (41%). insomnia (31%), and excessive sleepiness (28%). Chi square tests showed significant variation among clinics in the prevalence of most sleep problems. The lung clinic had the highest or second-highest prevalence of problems. The breast clinic had a high prevalence of insomnia and fatigue. Recent cancer treatment was associated with excessive fatigue and hypersomnolence. Insomnia commonly involved multiple awakenings (76% of cases) and duration > or = 6 months (75% of cases). In 48% of cases, insomnia onset was reported to occur around the time of cancer diagnosis (falling within the period 6 months pre-diagnosis to 18 months post-diagnosis). The most frequently identified contributors to insomnia were thoughts, concerns, and pain/discomfort. In a multivariate logistic regression analysis, variables associated with increased odds of insomnia were fatigue, age (inverse relationship), leg restlessness, sedative/hypnotic use, low or variable mood, dreams, concerns, and recent cancer surgery. This study provides new information about sleep-related phenomena in cancer patients, information which will be useful in planning supportive care services for cancer patients.

Rational and targeted pharmacologic treatment of fibromyalgia

Despite disappointing results when subjected to randomized clinical trials, pharmacologic agents remain an important component of FM management. Addressing the main symptoms of pain, disturbed sleep, mood disturbances, fatigue, and associated conditions is essential to improve patient functioning and enhanced quality of life. However, much work remains to design clinical trials which address the complexity of FM, while satisfying evidence based medicine paradigms.

Pharmacologic treatment of fibromyalgia

Fibromyalgia is a chronic syndrome characterized by widespread pain, unrefreshed sleep, disturbed mood, and fatigue. Until such time as we have a clearer understanding of the trigger and/or pathophysiologic mechanisms producing these symptoms, pharmacologic treatment should be aimed at individual symptoms. Such treatment should ideally be offered as part of a multidisciplinary treatment program using both pharmacologic and nonpharmacologic treatment modalities. Critical components of any successful fibromyalgia treatment program include addressing physical fitness, work and other functional activities, and mental health, in addition to symptom-specific therapies. The main symptoms that should be addressed include pain, sleep disturbances including restless leg syndrome, mood disturbances, and fatigue. Pharmacologic therapy should also be considered for syndromes commonly associated with fibromyalgia including irritable bowel syndrome, interstitial cystitis, migraine headaches, temporomandibular joint dysfunction, dysequilibrium including neurally mediated hypotension, sicca syndrome, and growth hormone deficiency. This article provides general guidelines in initiating a successful pharmacologic treatment program for fibromyalgia.

Trauma and fibromyalgia: is there an association and what does it mean?

OBJECTIVES

The primary objective is to review current research with respect to the role of trauma in fibromyalgia (FM). A secondary objective is to hypothesize which steps need to be taken, first to determine whether such an association truly exists, and second to clarify what such an association might mean.

METHODS

An extensive literature review was undertaken, including Medline from 1979 to the present.

RESULTS

The strongest evidence supporting an association between trauma and FM is a recently published Israeli study in which adults with neck injuries had greater than a 10-fold increased risk of developing FM within 1 year of their injury, compared with adults with lower extremity fractures (P= .001). Several other studies provide a hypothetical construct for such an association. These include studies on (1) postinjury sleep abnormalities; (2) local injury sites as a source of chronic distant regional pain; and (3) the concept of neuroplasticity. There are, however, several primary arguments against such an association: (1) FM may not be a distinct clinical entity; (2) FM may be a psychological, rather than physical, disease; (3) the evidence supporting any association is limited and not definitive; (4) the Israeli study, itself, has some methodological limitations; and (5) other factors may be more important than the injurious event in determining chronic symptoms after an acute injury.

CONCLUSIONS

Although there is some evidence supporting an association between trauma and FM, the evidence is not definitive. Further prospective studies are needed to confirm this association and to identify whether trauma has a causal role.

Psychological and behavioral approaches to pain management for patients with rheumatic disease

This article reviews the efficacy of the psychological and behavioral pain management interventions that have been evaluated among adult patients with rheumatoid arthritis (RA), osteoarthritis (OA), and fibromyalgia (FM). Using published criteria for empirically validated interventions, it is concluded that cognitive-behavioral therapies and the Arthritis Self-Management Program represent well-established treatments for pain among patients with RA and OA. These interventions involve education, training in relaxation and other coping skills, and rehearsal of these skills in patients' home and work environments. There currently are no psychological or behavioral interventions for pain among FM patients that can be considered as well-established treatments. Future intervention research should use clinically meaningful change measures in addition to conventional tests of statistical significance, attend to the pain management needs of children, and assess whether outcomes produced in university-based treatment centers generalize to those in local treatment settings.

Popular press diagnoses and psychiatric diagnoses

The symptom spectra of several 'popular press' diagnoses are examined and compared to Diagnostic and Statistical Manual of Mental Disorders-IIIR criteria for somatization disorder, depression, and generalized anxiety disorder. While there is much overlap, there are clear distinctions, and these psychiatric terms do not adequately coincide with the symptom spectra of these disorders. These conditions may represent 'neuroendocrine dysrhythmias' - abnormal/normal physiological dysfunctions with psychodynamic roots and/or influences. They currently often fall between the established domains claimed by Medicine and Psychiatry, with resultant poor evaluation and management with this spectrum of problems.

Work disability evaluation and the fibromyalgia syndrome

Fibromyalgia syndrome (FMS) is a common and costly cause of work disability. Patients with FMS, nevertheless, encounter considerable difficulties in their assessment of claims for disability payments. Factors that contribute to FMS as an important cause of disability are its high prevalence, the patients' perception of severe discomfort, and poor function. Disability evaluation in FMS is controversial for several reasons including lack of acceptance of the diagnosis, concurrent psychological abnormalities, difficulties in objectifying disability, deficiencies in instruments of evaluation, the uncertain efficacy of treatment, and physician attitudes. Third parties appear to have inappropriate expectations of the physician's role in determining disability. We suggest that the process of disability evaluation be improved by more objective assessments and by the inclusion of other health professionals in assessing disability and necessary retraining. Further research is needed to develop better instruments for measuring disability, to assess the long-term effects of various treatments, and to clarify the contributions of the work place and of compensation in causing or aggravating FMS.

Neuroendocrine dysrhythmias

Neuroendocrine rhythms play a major role in the regulation of physiological function. Stress can disrupt these rhythms and produce neuroendocrine dysrhythmias. A paradigm of classification of these dysrhythmias is presented and includes diurnal (phase and amplitude), autonomic (adrenergic or cholinergic excess or imbalance), and muscle tension (skeletal or smooth). By placing common psychosomatic conditions in this paradigm, one can model these conditions as exaggerations of normal responses producing disruption in normal neuroendocrine rhythms. This can also lead to a focus of therapy on restoring neuroendocrine balance and rhythm.

Fibromyalgia: A Review of Current Knowledge

Muscular pain in the presence of a normal ESR has laboured under a variety of names and supposed causes, often being dismissed as psychogenic in origin. It is now clear that there are two specific disorders of body musculature, each with its own defined pattern of symptoms. Fibromyalgia is a disease of unknown aetiology, predominantly affecting women, that gives generalised muscular pain, a disturbed sleep pattern, morning stiffness and fatigue. Tender spots are found at certain charecteristic sites. The Myofascial Pain Syndromes, on the other hand, can usually be related to some form of trauma and are normally localised to particular muscles with readily palpable myofascial trigger points at specific spots according to the pattern of pain referral.

Acupuncture may be a rapid and effective treatment for both disorders, often giving long lasting relief in Myofascial Pain Syndromes, but offering only repeated short term responses to Fibromyalgia sufferers.

Lack of association between fibromyalgia and sleep apnoea syndrome

To determine whether sleep disorders can cause a fibromyalgia syndrome, 30 patients with sleep apnoea syndrome were studied. All presented an important reduction in deep sleep stages (-93.1 (SD 17.9)% of stage IV and -77.2 (45.7)% of stage III) and frequent episodes of wakening ('arousals'), factors which are involved in fibromyalgia. One patient (3%) met the criteria for fibromyalgia; the estimated prevalence of fibromyalgia for patients attending a general medical clinic is 6%. No significant correlation was found between the number of points which were tender upon pressure and the various sleep parameters studied. It is concluded that sleep disorders alone are not able to produce a fibromyalgia syndrome.

Polysomnography in idiopathic muscle pain syndrome (fibrositis)

Muscle pain occurs in various neuromuscular disorders with characteristic physiological or biochemical abnormalities. There is, however, a group of patients in whom there is no clear physiological or structural basis for their pains. This syndrome has been called fibrositis or fibromyalgia. Sleep abnormalities have been reported in some of these patients, but have not been confirmed by others. We studied 8 patients with this disorder and found sleep abnormalities that were characterized by nocturnal myoclonus, alpha-delta sleep, and abnormalities compatible with depression. Polysomnography was, therefore, instrumental in helping direct the treatment of these patients. Therapeutic approaches aimed to correct the specific disorders were effective in improving the pain symptoms.

Fibromyalgia and parvovirus infection

An infectious cause of fibromyalgia (FM) has been hypothesized based upon the observed similarity of this entity and chronic fatigue syndrome. Three patients developed symptoms of FM after documented episodes of acute parvovirus B19 infections. B19 antibody determinations were obtained approximately 1 month after the symptoms began; both IgM and IgG titers were positive at that time. All 3 patients met criteria for FM. Polysomnography performed on 2 of the patients revealed profound alpha-wave intrusion throughout nonrapid eye movement sleep. A more careful search for viral infections in FM patients whose symptoms appear following a "flu-like" illness appears warranted.

Toward an integrated understanding of fibromyalgia syndrome. I. Medical and pathophysiological aspects

Fibromyalgia syndrome (FS) is a chronic pain disorder characterized by diffuse musculoskeletal soreness, stiffness, non-restorative sleep and psychological disturbance. At present, much about the etiology, pathological mechanisms and course of FS are unknown. Indeed, standardized diagnostic criteria have only been recently agreed upon. The present paper is the first of a two-part series which reviews the extant empirical literature concerning FS, with a view to arriving at an integrated understanding of the syndrome. The present paper describes the clinical presentation of FS and historical conceptualizations of the disorder. Available research on pathophysiological mechanisms in FS is then presented. In this section we have included literature concerning histology of muscle, sleep architecture, neurotransmitter anomalies and neuropeptide involvement in FS symptomatology.

Review of oral skeletal muscle relaxants for the craniomandibular disorder (CMD) practitioner

The presence of acute or chronic muscle pain and muscle spasm is a common finding in the treatment of craniomandibular disorders. A review of the literature on the centrally acting oral skeletal muscle relaxants is presented to assist the practitioner in treating CMD. The pharmacology, pharmacokinetics, metabolism, adverse reactions and available dosage forms of the skeletal muscle relaxants are discussed. The agents reviewed are carisoprodol, methocarbamol, chlorphenesin carbamate, metaxalone, chloroxazone, orphenadrine citrate, diazepam, and cyclobenzaprine. Their mechanisms are not well defined. Most act via selective inhibition of polysynaptic pathways in the central nervous system. Most evidence for their efficacy is based on subjective responses and there is question as to the adequacy of the clinical studies to date. Based on the data all of the relaxants (possibly excepting diazepam) are better than placebo based on subjective analyses. Although combinations with analgesics provide better symptom relief, no superiority over analgesics exists. No skeletal relaxant has been shown to be superior over any other oral relaxant. Based on recent clinical suspicions, further study of multiple pharmacologic effects of newer agents is indicated.

High bone turnover in fibromyalgia

This paper seeks to determine if patients with a fibromyalgic syndrome have specific abnormalities of skeletal homeostasis. Radioisotopic evaluation of skeletal remodeling showed higher Fogelman index and increased 24-hour pyrophosphate retention in the group of fibromyalgics (n = 28) when compared to the control group (n = 16). Bone density (lumbar vertebrae and femoral neck) was not significantly different from control subjects. These data might suggest an accelerated bone metabolism in these patients.

Fibromyalgia syndrome

Fibromyalgia is a chronic rheumatologic disorder. The primary symptoms include musculoskeletal pain and aching, disturbed sleep, fatigue, morning stiffness, and local tenderness. It is frequently misdiagnosed, despite being a fairly common, chronic disorder in most primary care clinics. Failure to make this diagnosis often leads to unnecessary medical and surgical treatment. The treatment of fibromyalgia syndrome is multifaceted. Goals include reassurance, education about pain management and modification, and symptom reduction. Exercise may be beneficial. Amitriptyline is effective in reducing certain symptoms of fibromyalgia, such as pain and lack of restful sleep. Narcotics, steroids, and nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided.

Sleep patterns in congenital dopamine beta-hydroxylase deficiency

Sleep patterns of two young female patients with congenital dopamine beta-hydroxylase deficiency are described. In this orthostatic syndrome central and peripheral noradrenergic failure occurs as a result of impaired beta-hydroxylation of dopamine. Consequently, the levels of dopamine and its metabolites are elevated. The relative importance of noradrenaline deficit in the face of dopamine excess for sleep-regulatory mechanisms can be inferred from the sleep pattern of these patients. No subjective sleep complaints were reported. The sleep patterns showed a high percentage of slow-wave sleep in both patients (29% and 34% of sleep period time) and a relatively low to normal percentage of REM sleep (18% and 21%). A normal cyclic REM sleep pattern was observed. Alpha-delta sleep occurred during light sleep (15% and 8%); consequently, the amount of stage 2 sleep was reduced. These results indicate that functional insufficiency of the noradrenergic system in two patients with dopamine beta-hydroxylase deficiency is not associated with profound changes in the (REM) sleep pattern. This supports a modulatory or permissive role for noradrenaline in REM sleep mechanisms.

Illness worry and disability in fibromyalgia syndrome

Fibromyalgia (FM) is a common syndrome of functional somatic symptoms. This article examines whether an amplifying somatic style (increased body awareness and illness worry) might explain the distress and disability expressed by FM patients. Twenty FM patients were compared to twenty-three rheumatoid arthritis (RA) patients on measures of depressive and somatic symptomatology, pain, disability, and amplifying somatic style. FM patients reported greater somatic symptomatology, equivalent levels of pain, and less physical disability than did RA patients. No differences were observed between groups on body awareness or illness worry. Illness worry correlated highly with symptomatology for both groups but with physical disability only among FM patients. Results suggest that disability in functional somatic syndromes may be determined by patients' worry about having a serious disease. Feelings of vulnerability and apprehension about having an illness of unknown origin may contribute to FM sufferers' activity limitations, inability to sustain a work effort, and varied somatic distress.