A community-based survey of fibromyalgia-like pain complaints following the World Trade Center terrorist attacks

Prevalence of Fibromyalgia Syndrome in Active-Duty Military Personnel

OBJECTIVE

Previous research with civilian populations has found strong associations between fibromyalgia (FM) and posttraumatic stress disorder (PTSD). We undertook this study to investigate the prevalence of FM in military service members with and without PTSD.

METHODS

Participants were active duty military personnel recruited into either an epidemiologic cohort study of service members before a military deployment or 1 of 3 PTSD treatment trials. Instruments used to document FM and PTSD included the PTSD Checklist-Stressor-Specific Version, the PTSD Symptom Scale-Interview, and the 2012 American College of Rheumatology FM questionnaire.

RESULTS

Across the 4 studies, 4,376 subjects completed surveys. The prevalence of FM was 2.9% in the predeployment cohort, and the prevalence was significantly higher in individuals with PTSD (10.8%) compared with those without PTSD (0.8%). In the treatment trials, all of the participants met criteria for PTSD before starting treatment, and the prevalence of FM was 39.7%.

CONCLUSION

The prevalence of FM in active duty service members preparing to deploy is similar to that reported for the general population of the US but is higher than expected for a predominantly male cohort. Furthermore, the prevalence of FM was significantly higher in service members with comorbid PTSD and was highest among those seeking treatment for PTSD. Further investigation is needed to determine the factors linking PTSD and FM.

Attention deficits in Brazilian health care workers with chronic pain

The impact of COVID-19 on chronic pain (CP) in non-infected vulnerable South American subjects is unknown. Healthcare workers (HCWs) are at increased risk for CP. During the pandemic, many HCWs with CP kept working. Knowing how cognition is affected by CP in these subjects is an important subject for work safety. The attention domain has a pivotal role in cognition. Previously, the Continuous Visual Attention Test (CVAT) was applied to detect specific attention deficits in fibromyalgia patients. The present investigation described CP prevalence in non-infected Brazilian HCWs during the pandemic and assessed HCWs' attentional performance with the aid of the CVAT. This study was carried out at a reference University Hospital in Rio de Janeiro, Brazil. HCWs of both sexes, aged 20 or older, were interviewed from August to December 2020. A 90-second version of the CVAT was performed. The average reaction time to correct responses and the respective intraindividual reaction time variability for correct responses to target (VRT) was determined. Omission and commission errors were also calculated. Then, for each participant we calculated the Z-scores of the CVAT variables based on the distribution of CVAT performance of 211 healthy subjects (reference-comparison group). HCWs with Z-scores > 1.64 were classified as significantly impaired. From the 154 selected HCWs, 72 reported CP during the pandemic (prevalence = 47%). Post hoc ANCOVAs showed that the average correct VRT was significantly higher in the CP group than in the non-CP group (F = 4.99, df = 1/150, p = 0.027, η2 = 0.032). The percentage of participants with impaired VRT performance was 30% (n = 21) in the CP group and 16% (n = 13) in the non-CP group. The difference between these two propositions reached significance (χ2 = 3.96, df = 1, p = 0.047). As VRT is associated with the sustained-attention subdomain, our data suggest that this subdomain is disrupted in the CP group.

Trajectories and Individual Differences in Pain, Emotional Distress, and Prescription Opioid Misuse During the COVID-19 Pandemic: A One-Year Longitudinal Study

Recent studies suggest that the COVID-19 pandemic can serve as a unique psychosocial stressor that can negatively impact individuals with chronic pain. Using a large online sample in the U.S., the present study sought to investigate the impact of the pandemic on the trajectories of pain severity and interference, emotional distress (ie, anxiety and depressive symptoms), and opioid misuse behaviors across one year. Potential moderating effects of socio-demographic factors and individual differences in pain catastrophizing, pain acceptance, and sleep disturbance on outcome trajectories were also examined. Adults with chronic pain were surveyed three times across 1 year (April/May 2020 [N = 1,453]; June/July 2020 [N = 878], and May 2021 [N = 813]) via Amazon's Mechanical Turk online crowdsourcing platform. Mixed-effects growth models revealed that pain severity and interference, emotional distress, and opioid misuse behaviors did not significantly deteriorate across one year during the pandemic. None of the socio-demographic factors, pain catastrophizing, or sleep disturbance moderated outcome trajectories. However, individuals with higher pain acceptance reported greater improvement in pain severity (P< .008, 95% CI: -.0002, -.00004) and depressive symptoms (P< .001, 95% CI: -.001, -.0004) over time. Our findings suggest that the negative impact of the pandemic on pain, emotional distress, and opioid misuse behaviors is quite small overall. The outcome trajectories were also stable across different socio-demographic factors, as well as individual differences in pain catastrophizing and sleep disturbance. Nevertheless, interventions that target improvement of pain acceptance may help individuals with chronic pain be resilient during the pandemic. PERSPECTIVE: Individuals with chronic pain overall did not experience significant exacerbation of pain, emotional distress, and opioid misuse across one year during the COVID-19 pandemic. Individuals with higher pain acceptance showed greater improvement in pain severity and depressive symptoms over time during the pandemic.

The impact of COVID-19 stress on pain and fatigue in people with and without a central sensitivity syndrome

OBJECTIVES

Stress may augment somatic symptoms in central sensitivity syndromes (CSS) such as fibromyalgia, chronic fatigue syndrome, and irritable bowel syndrome. To test this hypothesis, we examined whether the association between COVID-19 stress and somatic symptom severity would be stronger in people with than without CSS and whether psychological flexibility would buffer the impact of this stress on symptom severity.

METHODS

In a 2-sample, repeated cross-sectional design, we analysed questionnaire data from Dutch people with and without CSS, collected in two independent surveys: before the COVID-19 pandemic (2018; CSS: n = 194, non-CSS: n = 337) and at the peak of the pandemic (2020; CSS: n = 428, non-CSS: n = 1101). Somatic symptom severity, worry and stress due to the pandemic, and psychological flexibility were examined in regression analyses. Two stress operationalisations were analysed: stress levels during the peak of the pandemic, and a comparison of measurements in 2020 and 2018 (assuming higher stress levels in 2020).

RESULTS

Higher worry and stress during the pandemic (standardized β = 0.14), the presence of a CSS (β = 0.40), and lower psychological flexibility (β = -0.33) were all (p < .0001) associated with more severe somatic symptoms, but the associations of each stress operationalisation with somatic symptoms was not particularly strong in people with CSS (β = -0.026, p = .27; β = -0.037, p = .22), and psychological flexibility (β = -0.025, p = .18; β = 0.076, p = .35) did not buffer this association.

CONCLUSIONS

Findings do not support the hypotheses that COVID-19 stress augments somatic symptoms, particularly in CSS, or that psychological flexibility buffers this impact. Rather, COVID-19-related stress appears to have an uncertain impact on somatic symptoms.

Loneliness, social isolation, and pain following the COVID-19 outbreak: data from a nationwide internet survey in Japan

The aim of cross-sectional study was to investigate the association between loneliness, increased social isolation, and pain following the COVID-19 outbreak. A total of 25,482 participants, aged 15–79 years, were assessed using an internet survey; the University of California, Los Angeles Loneliness Scale (Version 3), Short Form 3-item (UCLA-LS3-SF3) was used to assess loneliness, and a modified item of the UCLA-LS3-SF3 was used to measure the perception of increased social isolation during the pandemic. The outcome measures included the prevalence/incidence of pain (i.e., headache, neck or shoulder pain, upper limb pain, low back pain, and leg pain), pain intensity, and the prevalence of past/present chronic pain. Pain intensity was measured by the pain/discomfort item of the 5-level version of the EuroQol 5 Dimension scale. Odds ratios of pain prevalence/incidence and past/present chronic pain prevalence according to the UCLA-LS3-SF3 scoring groups (tertiles) and the frequency of the perceived increase in social isolation (categories 1–5) were calculated using multinomial logistic regression analysis. The mean pain intensity values among different loneliness and social isolation levels were tested using an analysis of covariance. Increased loneliness and the severity of the perceived social isolation were positively associated with the prevalence/incidence of pain, pain intensity, and the prevalence of past/present chronic pain.

Pain experience and social support of endometriosis patients during the COVID-19 pandemic in Germany - results of a web-based cross-sectional survey

BACKGROUND

Endometriosis is a chronic pain condition in premenopausal women. Pain is mainly characterized by pain intensity and may induce disability in all areas of daily life. Nevertheless, pain is influenced by emotional and social factors as well. Social distancing measures or quarantine, as reaction to rapidly rising infections with the COVID-19 virus due to the SARS-CoV-2 pandemic, were implemented across Europe to prevent the spread of the virus and social distancing measures were imposed by the German government by beginning of March 2020 with initiation of the lockdown by the end of March 2020. The objective of this study was to assess, how social distancing measures during the lockdown impacted the various aspects of pain perception in a group of chronic pain patients, such as women suffering from endometriosis.

METHODS

Between 6th to 27th April 2020, an online questionnaire was activated at internet platforms of endometriosis patients support groups. Participants were asked retrospectively at one time point about their visual pain intensity measured by the visual analogue scale (VAS) and pain disability via pain disability index (PDI) prior to initiation of social distancing measures in Germany (VASP, PDIP), as well as the pain intensity and pain disability since implementation of social distancing measures (VASI, PDII). Differences of VAS and PDI previous and after implementation of social distancing measures were displayed as ΔVAS and ΔPDI. Pain experience and social support were assessed by a 5-point Likert scale.

RESULTS

285 participants completed at least one question regarding pain intensity, disability, pain experience or social support. Dysmenorrhea, the symptom with the highest level of pain assessed by VAS, decreased significantly during the SARS-CoV-2 pandemic compared to the time period prior to social isolation (45.30% respondents experienced improvemenet vs 40.50% who experienced worsening; p = 0.025). The global physical impairment improved significantly (improvement of pain induced disability in 48.20% vs 40.90% with worsening of pain symptoms; p = 0.032) after the implementation of social distancing measures. Pain experience was negatively affected by social distancing measures, since frequency of pain awareness increased in 43.6% (p<0.001) of participants and 30.0% (p<0.001) more participants experienced pain as a threat. Verbalization of pain experience was reduced in 36.6% (p = 0.001) of participants and 14.6% (p = 0.91), 21.9% (p<0.001) and 31.5% (p<0.001) of participants reported less social support from their partner, family and friends.

CONCLUSIONS

Physical pain and disability on one hand and emotional and social pain experience on the other were differentially affected by the emerged emotional, social and health care constraints related to the SARS-CoV-2 pandemic.

Short-term impact of the COVID-19 pandemic on patients with a chronic pain disorder

The current Covid-19 pandemic has already had a definite impact on the daily life of many people worldwide. It has been proposed that people with preexisting medical conditions will be harder hit by the pandemic and the subsequent measures to contain the spread of the disease. In this questionnaire-based, observational study, we aimed to assess the impact of the pandemic on patients with a chronic pain disorder, who are treated at a tertiary multidisciplinary pain center.Participants rated the impact of the pandemic on their chronic pain disorder using a self-designed questionnaire. Also, participants filled out the regular follow-up questionnaire to assess a chronic pain disorder measuring among other parameters pain intensity, symptoms of depression, anxiety, stress, and pain-related quality of life.Of 136 eligible patients who presented to our pain center between May 5th and July 17th, 112 agreed to participate in the study (82.4%). Eighty two participants (73.2%) reported a deterioration of the pain disorder using the self-designed questionnaire. The more robust parameters of the regular follow-up questionnaire showed no relevant changes compared to data collected before the pandemic. We were not able to detect any demographic and medical parameters that were clinically relevantly associated with a higher impact of the pandemic.We conclude that a chronic pain disorder is a relatively stable disease that does not change significantly due to external factors, like the Covid-19 pandemic, even if the subjective impact is perceived to be high.

Prevalence of Chronic Pain, Treatments, Perception, and Interference on Life Activities: Brazilian Population-Based Survey

Background and Objectives

Chronic pain affects between 30% and 50% of the world population. Our objective was to estimate the prevalence of chronic pain in Brazil, describe and compare differences between pain types and characteristics, and identify the types of therapies adopted and the impact of pain on daily life.

Methods

Cross-sectional study of a population-based survey with randomized sample from a private database. The interviews were conducted by phone. 78% of the respondents aged 18 years or more agreed to be interviewed, for a total of 723 respondents distributed throughout the country. Independent variables were demographic data, pain and treatment characteristics, and impact of pain on daily life. Comparative and associative statistical analyses were conducted to select variables for nonhierarchical logistic regression.

Results

Chronic pain prevalence was 39% and mean age was 41 years with predominance of females (56%). We found higher prevalence of chronic pain in the Southern and Southeastern regions. Pain treatment was not specific to gender. Dissatisfaction with chronic pain management was reported by 49% of participants.

Conclusion

39% of interviewed participants reported chronic pain, with prevalence of females. Gender-associated differences were found in intensity perception and interference of pain on daily life activities.

Prevalence of Posttraumatic Stress Disorder in Persons with Chronic Pain: A Meta-analysis

OBJECTIVE

To summarize evidence for the prevalence of posttraumatic stress disorder (PTSD) among persons with chronic pain (CP).

METHODS

We searched databases for studies published between January 1995 and December 2016, reporting the prevalence of PTSD in persons with CP. Two reviewers independently extracted data and assessed the risk of bias. We calculated the pooled prevalence using a random-effects model and performed subgroup analyses according to pain location, the population and assessment method.

RESULTS

Twenty-one studies were included and the PTSD prevalence varied from 0-57%, with a pooled mean prevalence of 9.7%, 95% CI (5.2-17.1). In subgroup analysis, the PTSD prevalence was 20.5%, 95% CI (9.5-39.0) among persons with chronic widespread pain, 11.2%, 95% CI (5.7-22.8) among persons with headache, and 0.3%, 95% CI (0.0-2.4) among persons with back pain. The prevalence in clinical populations was 11.7%, 95% CI (6.0-21.5) and in non-clinical populations 5.1%, 95% CI (0.01-17.2). In studies of self-reported PTSD symptoms, PTSD prevalence was 20.4%, 95% CI (10.6-35.5), and in studies where structured clinical interviews had been used to assess PTSD its prevalence was 4.5%, 95% (CI 2.1-9.3). The risk of bias was medium for most studies and the heterogeneity was high (I2 = 98.6).

CONCLUSION

PTSD is overall more prevalent in clinical cohorts of persons with CP and particularly in those with widespread pain, but may not always be more prevalent in non-clinical samples of persons with CP, compared to the general population. There is a large heterogeneity in prevalence across studies. Future research should identify sources of heterogeneity and the mechanisms underlying the comorbidity of the two conditions.

Fibromyalgia: A Critical and Comprehensive Review

Fibromyalgia is a disorder that is part of a spectrum of syndromes that lack precise classification. It is often considered as part of the global overview of functional somatic syndromes that are otherwise medically unexplained or part of a somatization disorder. Patients with fibromyalgia share symptoms with other functional somatic problems, including issues of myalgias, arthralgias, fatigue and sleep disturbances. Indeed, there is often diagnostic and classification overlap for the case definitions of a variety of somatization disorders. Fibromyalgia, however, is a critically important syndrome for physicians and scientists to be aware of. Patients should be taken very seriously and provided optimal care. Although inflammatory, infectious, and autoimmune disorders have all been ascribed to be etiological events in the development of fibromyalgia, there is very little data to support such a thesis. Many of these disorders are associated with depression and anxiety and may even be part of what has been sometimes called affected spectrum disorders. There is no evidence that physical trauma, i.e., automobile accidents, is associated with the development or exacerbation of fibromyalgia. Treatment should be placed on education, patient support, physical therapy, nutrition, and exercise, including the use of drugs that are approved for the treatment of fibromyalgia. Treatment should not include opiates and patients should not become poly pharmacies in which the treatment itself can lead to significant morbidities. Patients with fibromyalgia are living and not dying of this disorder and positive outlooks and family support are key elements in the management of patients.

Neurobiology of fibromyalgia and chronic widespread pain

Fibromyalgia is the current term for chronic widespread musculoskeletal pain for which no alternative cause can be identified. The underlying mechanisms, in both human and animal studies, for the continued pain in individuals with fibromyalgia will be explored in this review. There is a substantial amount of support for alterations of central nervous system nociceptive processing in people with fibromyalgia, and that psychological factors such as stress can enhance the pain experience. Emerging evidence has begun exploring other potential mechanisms including a peripheral nervous system component to the generation of pain and the role of systemic inflammation. We will explore the data and neurobiology related to the role of the CNS in nociceptive processing, followed by a short review of studies examining potential peripheral nervous system changes and cytokine involvement. We will not only explore the data from human subjects with fibromyalgia but will relate this to findings from animal models of fibromyalgia. We conclude that fibromyalgia and related disorders are heterogenous conditions with a complicated pathobiology with patients falling along a continuum with one end a purely peripherally driven painful condition and the other end of the continuum is when pain is purely centrally driven.

Vulnerability to traumatic stress in fibromyalgia patients: 19 month follow-up after the great East Japan disaster

Introduction

The aim of this study was to investigate vulnerability and long-term influence of traumatic stress caused by the Great East Japan Disaster which occurred on March 11, 2011, in patients with fibromyalgia, which is a chronic pain syndrome probably involving central sensitization.

Methods

A total of 60 female patients with fibromyalgia were compared with female patients with rheumatoid arthritis (RA, n = 23) as another chronic pain disease, and with female healthy controls (HC, n = 26) in the observational study. To evaluate responses to traumatic stress, the scores of Impact of Event Scale-Revised (IES-R) were assessed one month after the disaster and every six months until 19 months after the disaster. We also evaluated levels of depression during the study period. To know the score of IES-R of patients with fibromyalgia during usual living, we assessed IES-R in another population of fibromyalgia patients without exposure to a great disaster.

Results

The mean score of IES-R one month after the disaster in the fibromyalgia group (24.6 [SD 18.9]) was significantly higher than that of RA group (13.4 [SD 14.5]) or HC group (9.1 [9.2]) (F = 9.96, p < 0.0001). However, the mean score of IES-R in fibromyalgia patients without exposure to a great disaster was (20.3 [SD 18.7]), which was almost the same value as the fibromyalgia group seven months after the disaster (20.2 [SD 19.5]). Repeated measures analysis of variance showed significant effect of time course in the depression-related symptoms (F = 6.68, P = 0.001), and a post-hoc test revealed that the number of depression-related symptoms one month before the disaster was significantly different from other time points until 19 months after the disaster, respectively.

Conclusions

Although response to acute stress induced by the great earthquake was likely to be settled within seven months after the disaster, depression-related symptoms have been increasing for more than one year after the disaster, despite exclusion of patients with major depression at baseline. This long-lasting worsening of depression-related symptoms may have been in response to chronic stress induced by the fear of radiation due to the nuclear power disaster. These findings suggest that patients with fibromyalgia are vulnerable to chronic stress rather than acute stress.

Central sensitization as a component of post-deployment syndrome

Many service members and veterans report chronic unexplained symptoms such as pain, fatigue and memory complaints, which have most recently been characterized as post-deployment syndrome (PDS). Chronic widespread pain is a component of this syndrome, producing significant disability and considerable health care costs. The similarity between the nature of these complaints and other medically unexplained illnesses such as fibromyalgia, irritable bowel syndrome, and chronic fatigue syndrome suggest that they may share a common mechanism. Here, we provide support for PDS as a consequence of pain and sensory amplification secondary to neuroplastic changes within the central nervous system, a phenomenon often termed central sensitization. We also discuss how factors such as stress and genetics may promote chronic widespread pain in veterans and service members who develop PDS.

Personality and fibromyalgia syndrome

Objectives:

We aimed to review how personality characteristics contribute to the onset, maintenance or modulation of fibromyalgia.

Method:

The databases Medline and PsychINFO were examined from 1967 to 2012 to identify studies that investigated associations between fibromyalgia and personality. Search terms included fibromyalgia and personality, trait psychology, characteristics and individual differences.

Results:

Numerous studies indicate that patients with fibromyalgia experience psychological distress. Various instruments have been used to evaluate distress and related psychological domains, such as anxiety or depression, in fibromyalgia. In many cases, these same instruments have been used to study personality characteristics in fibromyalgia with a subsequent blurring of cause and effect between personality and psychological distress. In addition, the symptoms of fibromyalgia may change pre-illness personality characteristics themselves. These issues make it difficult to identify specific personality characteristics that might influence the fibromyalgia process. Despite this inherent problem with the methodologies used in the studies that make up this literature review, or perhaps because of it, we found no defined personality profile specific to fibromyalgia. However, many patients with fibromyalgia do show personality characteristics that facilitate psychological responses to stressful situations, such as catastrophising or poor coping techniques, and these in turn associate with mechanisms contributing to fibromyalgia.

Conclusion:

No specific fibromyalgia personality is defined but it is proposed that personality is an important filter that modulates a person’s response to psychological stressors. Certain personalities may facilitate translation of these stressors to physiological responses driving the fibromyalgia mechanism.

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.

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.

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.

Understanding fibromyalgia: lessons from the broader pain research community

Fibromyalgia (FM) is a chronic pain condition marked by centrally mediated augmentation of pain and sensory processes. Skepticism has marked the history of this condition, but more recent study has identified neurobiological underpinnings supporting many of the symptoms associated with this condition. Early research in FM had unprecedented latitude within the rheumatology community to borrow heavily from theory and methods being applied in chronic pain research more generally. These insights facilitated rapid advances in FM research, not the least of which was the abandonment of a peripheral focus in favor of studying central mechanisms associated with central augmentation. Currently, rapid-paced discovery is taking place in FM genetics, patient assessment, new therapeutic targets, and novel methods of treatment delivery. Such insights are not likely to be limited in application just to FM and could have relevance to the broader field of pain research as well.

PERSPECTIVE

This manuscript reviews the history of FM and its diagnosis, evidence supporting central augmentation of pain in FM, potential mechanisms of central augmentation, current approaches to integrated care of FM, and areas of active collaboration between FM research and other chronic pain conditions.

[Etiology and pathophysiology of fibromyalgia syndrome and chronic widespread pain]

OBJECTIVE

To write a systematic review on the etiology and pathophysiology of the fibromyalgia syndrome (FMS) and of chronic widespread pain (CWP).

METHODS

An interdisciplinary level-3 guideline (i.e. systematic literature search and assessment, logic analysis, formal consensus procedure) for the diagnosis and therapy of FMS was created in cooperation with 10 medical and psychological societies and 2 patient self-help organizations. A literature search was performed covering all available review articles on the etiology and pathophysiology of FMS and CWP using the Cochrane Collaboration Reviews (1993-12/2006), Medline (1980-2006), PsychInfo (1966-12/2006), and Scopus (1980-12/2006). For the assignment of evidence classes the system of the Oxford Centre for Evidence-Based Medicine was applied. Consensus was achieved by a multi-step nominal group procedure.

RESULTS

FMS aggregates in families (evidence level 2c). Physical and psychological stress at the workplace are risk factors for the development of CWP and FMS. Affective disorders are risk factors for the development and maintenance of FMS. Operant learning mechanisms and sensitization are risk factors for the chronification of FMS (evidence levels 2b). Several factors are associated with the pathophysiology of FMS, but the causal relationship is unclear. This includes alterations of central pain pathways, hyporeactivity of the hypothalamus-pituitary-adrenal axis, increased systemic pro-inflammatory and reduced anti-inflammatory cytokine profiles and disturbances in the dopaminergic and serotonergic systems.

CONCLUSIONS

FMS is the common final product of various etiological factors and pathophysiological mechanisms.

Social influences on the concept of fibromyalgia

Despite relevant evidence of physical illness promoting fibromyalgia syndrome (FMS), some authors claim that it is a psychological illness, or due to "psychological amplification." Good evidence for such views is lacking. Selection processes lead to increased rates of psychological illness in general practice and in specialist practice. The physical distress of FMS can increase both anxiety and depression. Questionable research supported by the insurance industry has tended to provide negative and disparaging views of pain. Current imaging studies support the view that central effects connected with FMS relate to the processing of noxious stimulation more than affective disorder.

Fibromyalgia syndrome: presentation, diagnosis, differential diagnosis, and vulnerability

Fibromyalgia syndrome (FMS) presents with widespread soft tissue pain. Common comorbidities include severe insomnia, body stiffness, affective symptoms, irritable bowels, and urethral syndrome. A 1990 research classification depends on a history of widespread pain and prominent tenderness to palpation at 11 or more of 18 specific tender points. It is a criteria-based diagnosis rather than one by exclusion and can accompany other medical conditions. FMS occurs worldwide, and can present any age, but is most common in adult females. Although numerous studies and reviews contend that FMS may be caused by psychological stress such as sexual abuse, critical epidemiological review fails to support that concept. Existing data suggest that some individuals with FMS may have a dysregulated physiological stress response system that predates the onset of symptoms.

PTSD and stress sensitisation: a tale of brain and body Part 1: human studies

Post-traumatic stress disorder (PTSD) is a chronic, debilitating psychiatric disorder that can follow exposure to extreme stressful experiences. It is characterised by hyperarousal and increased startle responses, re-experiencing of the traumatic event, withdrawal or avoidance behaviour and emotional numbing. The focus of this review is on aspects that have received less attention. PTSD develops only in a substantial minority of people exposed to traumatic stress, and possible individual traits that increase vulnerability are discussed. An overview is given of the wide variety of physiological disturbances that accompany PTSD and may contribute to disability, including neuroendocrine, cardiovascular, gastrointestinal and immune function and pain sensitivity. Brain imaging and pharmacological studies have generated some insight into the circuitry that may be involved in the generation of PTSD symptoms. Major limitations of human studies so far are the issue of causality and our lack of understanding of the underlying molecular substrates in the brain, which are easier to address in relevant animal models and will be discussed in a companion paper.

Predictors of Incident Chronic Widespread Pain Among Veterans Following the First Gulf War

OBJECTIVE

We sought to determine the predictors of incident chronic widespread pain (CWP), specifically, the effect of preexisting symptoms, stress, and psychosocial factors in the subsequent development of CWP among veterans from the first Gulf War (GW).

METHODS

We conducted a structured telephone survey (baseline) of military personnel originally from Iowa who were either eligible for or deployed to Operation Desert Shield/Desert Storm, approximately 5 years postconflict. We conducted a follow-up, clinical, in-person study of those who met a priori-defined outcomes of symptoms of cognitive dysfunction, depression, or CWP, and also a sample of those who did not meet any of the outcomes of interest.

RESULTS

A total of 370 of 602 evaluated GW veterans were free of CWP 5 years postconflict. At follow-up, 69 (19%) of these had developed CWP. A positive family history of medically unexplained persistent symptoms [odds ratio (OR)=4.8 (2.3, 13.2)] was strongly associated with CWP. At baseline, individuals who reported preexisting symptoms of bronchitis [OR=4.9 (1.9, 12.3)] and cognitive dysfunction [OR=2.1 (1.1, 4.2)] were more likely to develop CWP. Alcohol use [OR=0.2 (0.1, 0.7)] was protective against CWP. Rather than combat-related exposure per se, the perception of stress at the time of the GW [OR=1.6 (1.1, 2.3)] correlated with CWP.

DISCUSSION

Among the GW veterans evaluated longitudinally in this study, family history, predeployment symptoms, and the level of perceived stress during the GW were associated with subsequent development of CWP.

Localization of Pain and Self-Reported Rape in a Female Community Sample

OBJECTIVE

Studies suggest that rape increases risk of medically unexplained pain in women. At present it is not clear whether rape is associated with pain at specific locations or at multiple locations. In this study we tested the hypothesis that rape was associated with a preferential increase in risk of pelvic pain that was not explained by pain at other sites.

DESIGN

We relied on an existing community study that oversampled women with fibromyalgia and major depression. Localization was assessed by asking about pain at four sites: pelvic region; jaw/face; headache; and lower back. Three groups were identified using a structured telephone interview: Abuse Only (sexual/physical abuse excluding rape); Rape+Abuse (rape in addition to other sexual/physical abuse); and No Abuse.

RESULTS

Compared with the No Abuse group, the Rape+Abuse group was eight times more likely to have pelvic pain and 3.7 times more likely to have jaw/face pain after we controlled for the effect of widespread pain. Rape was not associated with lower back pain or headache. The Abuse Only group did not show a preferential increase in risk of pain at any of the four locations that were assessed. After controlling for pain at other locations, we found that the Rape + Abuse group was 10 times more likely to report pelvic pain than the No Abuse group (P<0.005).

DISCUSSION

In accord with the localization hypothesis, self-reported rape was uniquely associated with pelvic pain. Future efforts to account for pain in the aftermath of rape must specify a mechanism that can simultaneously cause widespread pain as well as increase risk of localized pain.

The role of life stress in fibromyalgia

This paper focuses on recent evidence of etiopathogenetic links between fibromyalgia and life stress. From an etiologic point of view, studies concerning the role of adverse life events, personality and lifestyle factors, post-traumatic stress, and negative childhood experiences are reviewed. From a pathogenetic point of view, neurobiologic links between stress and fibromyalgia symptoms, notably chronic pain and fatigue are highlighted. Finally, several methodologic issues with regard to stress research on fibromyalgia, as well as the clinical relevance of the stress concept for fibromyalgia are discussed.

Correlation of C-reactive protein with clinical, endoscopic, histologic, and radiographic activity in inflammatory bowel disease

INTRODUCTION

We sought to examine the relationship between C-reactive protein (CRP) and clinical, endoscopic, histologic, and radiographic activity in inflammatory bowel disease (IBD).

METHODS

All IBD patients at our institution between January 2002 and August 2003 who had a CRP, colonoscopy, and either small bowel follow-through (SBFT) or CT enterography (CTE) performed within 14 days were identified. Clinical activity was assessed retrospectively through review of the medical record. Logistic regression was used in Crohn's disease (CD) patients to estimate the odds ratio (OR) with 95% confidence intervals for an elevated CRP. Associations were assessed using Fisher exact test in ulcerative colitis (UC) patients due to small sample size.

RESULTS

One-hundred four CD patients (46% males) and 43 UC and indeterminate colitis patients (44% males) were identified. In CD patients, moderate-severe clinical activity (OR, 4.5; 95% CI, 1.1-18.3), active disease at colonoscopy (OR, 3.5; 95% CI, 1.4-8.9), and histologically severe inflammation (OR, 10.6; 95% CI; 1.1-104) were all significantly associated with CRP elevation. Abnormal small bowel radiographic imaging was not significantly associated with CRP elevation. In UC patients, CRP elevation was significantly associated with severe clinical activity, elevation in sedimentation rate, anemia, hypoalbuminemia, and active disease at ileocolonoscopy, but not with histologic inflammation.

CONCLUSIONS

CRP elevation in IBD patients is associated with clinical disease activity, endoscopic inflammation, severely active histologic inflammation (in CD patients), and several other biomarkers of inflammation, but not with radiographic activity.

Psychiatric comorbidity in fibromyalgia

This review examines the current literature regarding psychiatric comorbidities associated with fibromyalgia. The aim of this review is to enhance understanding of psychiatric disorders that, alone or in combination with other physiologic (eg, neuroendocrine dysfunction) and psychosocial factors (eg, poor coping skills), may contribute to abnormal pain sensitivity and other illness behaviors of individuals with fibromyalgia. The review first identifies the psychiatric comorbidities that are associated most often with fibromyalgia and tend to aggregate within families of individuals with this disorder. It then examines the literature regarding the extent to which psychiatric illness, environmental stressors, or other psychosocial factors may contribute to the development of fibromyalgia. The review also presents recent findings concerning the extent to which psychosocial factors may contribute to treatment-related outcomes in pain and other health status variables among patients with fibromyalgia.

Fibromyalgia: a stress disorder? Piecing the biopsychosocial puzzle together

Fibromyalgia (FM) is a controversial syndrome, characterised by persistent widespread pain, abnormal pain sensitivity and additional symptoms such as fatigue and sleep disturbance. The syndrome largely overlaps with other functional somatic disorders, particularly chronic fatigue syndrome (CFS). Although the exact aetiology and pathogenesis of FM are still unknown, it has been suggested that stress may play a key role in the syndrome. This article first reviews the function of the stress response system, placing special emphasis on the relationships between adverse life experiences, stress regulation and pain-processing mechanisms, and summarising the evidence for a possible aetiopathogenetic role of stress in FM. Finally, an integrative biopsychosocial model that conceptualizes FM as a stress disorder is proposed, and the clinical and research implications of the model are discussed.

Regional prevalence of fatiguing illnesses in the United States before and after the terrorist attacks of September 11, 2001

OBJECTIVE

Stress or emotional traumas are considered risk factors for unexplained fatiguing illnesses. From July to December 2001, the Centers for Disease Control and Prevention conducted a multigeographical pilot study to test the feasibility of a survey to estimate the prevalence of fatiguing illnesses in the United States. We used data obtained during this survey to estimate the effect of the coincidentally occurring terrorist attacks of September 11, 2001, on the regional prevalence of fatiguing illnesses.

METHODS

Identified by random-digit dialing, 2,728 households in eight regional strata were interviewed, and 7,317 respondents were screened for severe fatigue of at least 1 month duration. Identified fatigued people of age 18 to 69 years (N = 440) and a sample of nonfatigued people of the same age range (N = 444) were interviewed in detail concerning fatigue, other symptoms, and medical and psychiatric histories.

RESULTS

Weighted prevalence estimates based on interviews performed after the attacks were significantly lower compared with estimates based on interviews performed before the attacks (prolonged fatigue: 5,450 vs. 1,530/100,000, p =.010; chronic fatigue: 18,510 vs. 10,070/100,000, p =.002; chronic fatigue syndrome-like illness: 2,510 vs. 960/100,000, p =.014).

CONCLUSION

Our findings suggest decreased regional prevalence of fatiguing illnesses in the aftermath of the terrorist attacks. The causes of this effect are unknown but might involve acute psychological and physiological adaptations that modify the perception or manifestation of fatigue. Future studies should be specifically designed to scrutinize the relationship between stress and fatiguing illnesses and the mediating mechanisms of such a relationship.

Familial aggregation of depression in fibromyalgia: a community-based test of alternate hypotheses

Numerous studies report that fibromyalgia (FM), a syndrome characterized by widespread pain and generalized tender points, is comorbid with major depressive disorder (MDD). The current study tests two alternate explanations for their comorbidity using a family study methodology. The first is that FM is a depression spectrum disorder. The second is that depression is a consequence of living with FM. We recruited potential probands by initially screening by telephone for FM and MDD among women in the NY/NJ metropolitan area, randomly selecting telephone numbers from a list of households with women. Eligible women were invited for second stage physical examinations for FM diagnosis and psychiatric interviews for MDD diagnosis. All available adult, first-degree relatives received psychiatric interviews. Relatives of probands were divided into four groups on the basis of the probands' FM and MDD diagnoses (FM+/MDD+ (n = 156), FM+/MDD- (n = 51), FM-/MDD+ (n = 351) and FM-/MDD- (n = 101)). Results indicated that rates of MDD in the relatives of probands with FM but without personal histories of MDD were virtually identical to rates of MDD in relatives of probands with MDD themselves. This outcome is consistent with the hypothesis that FM is a depression spectrum disorder, in which FM and MDD are characterized by shared, familially mediated risk factors. The implications of these findings for a stress-vulnerability model of FM are discussed.

Comorbidity of Fibromyalgia and Posttraumatic Stress Disorder Symptoms in a Community Sample of Women

OBJECTIVE

To test alternative explanations for the comorbidity between fibromyalgia (FM), a medically unexplained syndrome involving widespread pain, and posttraumatic stress disorder (PTSD). In contrast to a default "risk factor" hypothesis, tested hypotheses were that: A) The association is due to a sampling bias introduced by the study of care-seeking individuals; B) FM is an additive burden that strains coping resources when confronting life stress; and C) Arousal symptoms of PTSD and FM are confounded.

DESIGN

Community-dwelling women in the New York/New Jersey metropolitan area (N=1,312) completed a telephone survey regarding FM-like symptoms prior to September 11, 2001. Approximately 6 months after the World Trade Center terrorist attacks, they again completed the survey, to which questions regarding PTSD symptoms were added.

RESULTS

The odds of probable PTSD were more than three times greater in women with FM-like symptoms, both assessed after 9/11. The odds ratio was not reduced by controlling for FM-like symptoms before 9/11 or for the potentially confounded symptoms of PTSD specifically related to arousal.

CONCLUSIONS

These findings lead us to reject alternate explanations for the comorbidity between FM and PTSD. Speculations that FM and PTSD share psychobiological risk factors remain plausible.

Chronic widespread pain and fibromyalgia: what we know, and what we need to know

Fibromyalgia (FM) is currently defined as the presence of both chronic widespread pain (CWP) and the finding of 11/18 tender points on examination. Only about 20% of individuals in the population with CWP also have 11/18 tender points; these individuals are considerably more likely to be female, and have higher levels of psychological distress. There is no clear clinical diagnosis for the other 80% of individuals with less than 11/18 tender points, but it is likely that these persons, like FM patients, also have pain that is 'central' (i.e. not due to inflammation or damage of structures) rather than peripheral in nature. Research into FM has taught us a great deal about the confluence of neurobiological, psychological and behavioural factors that can cause chronic central pain. These conditions respond best to a combination of symptom-based pharmacological therapies, and non-pharmacological therapies such as exercise and cognitive behavioural therapy. In contrast to drugs that work for peripheral pain due to damage or inflammation (e.g. NSAIDs, corticosteroids), neuroactive compounds [especially those that raise central levels of noradrenaline (norepinephrine) or serotonin] are most effective for treating central pain.