Attachment styles, pain intensity and emotional variables in women with fibromyalgia

The lived experience of mothers living with fibromyalgia syndrome: A phenomenological inquiry

INTRODUCTION

Fibromyalgia syndrome (FMS) is a complex chronic pain condition that negatively impacts women's daily lives, particularly their roles as mothers and wives. A phenomenological qualitative study was conducted to explore the lived experiences of motherhood and daily life among women diagnosed with fibromyalgia.

METHODS

A sample of 10 women affected by FMS was recruited between January and February 2020. Participants were interviewed in a face-to-face, in-depth interview using a semi-structured interview guide. Data were collected until saturation, and Colaizzi's method was used to analyse data.

RESULTS

This qualitative analysis identified five themes: A trauma preceding diagnosis, Pervasive feelings of misunderstanding, A struggle to maintain strength among limitations, Challenges in fulfilling maternal roles, and Persistent sexual discomfort. The latter two themes emerged as the most prominent.

CONCLUSION

These findings highlight the significant impact of fibromyalgia on women's family lives and suggest the need for a more comprehensive care programme.

Integrating intra- and interpersonal perspectives on chronic low back pain: the role of emotion regulation and attachment insecurity

Objective

Chronic low back pain (CLBP) is burdensome and interferes with psychological and physical functioning of those affected. Past research has examined interpersonal (e.g., attachment insecurity) or intrapersonal factors (e.g., emotion regulation [ER]) involved in chronic pain. However, to enhance our understanding of CLBP's biopsychosocial underpinnings, more empirical integration of both intra- and interpersonal factors involved in CLBP is needed. Thus, our study examined the independent and joint associations of insecure attachment dimensions and ER strategies with CLBP severity and interference.

Methods

We recruited 242 US adults with CLBP through Prolific Academic, an online participant pool. Participants from Prolific Academic were eligible for the study if they were at least 18 years of age, resided in the US, reported CLBP at least half the days over the past 6 months (>3 months), and used prescribed pain medication for their CLBP. Data collection was between November 2021 and February 2022. Eligible participants filled out a Qualtrics survey which consisted of measures assessing insecure attachment dimensions, ER strategies, as well as demographical information. Outcome variables in the present study were CLBP severity and interference. We ran multiple linear regression models to examine the associations between ER strategies and insecure attachment dimensions as predictors, and CLBP severity or interference as predicted variables, after controlling for sex as a covariate; we also conducted moderation analyses to investigate the interactions between ER strategies and insecure attachment dimensions when testing associations with CLBP severity or interference.

Results

Our results indicated that, after controlling for ER strategies, anxious attachment was positively associated with CLBP interference but not pain severity (CI: 0.101 to 0.569; CI: -0.149 to 0.186); avoidant attachment was not associated with CLBP interference or severity (CI: -0.047 to 0.511; CI: -0.143 to 0.256). After adjusting for anxious and avoidant attachment, emotional expression and expressive suppression were positively associated with CLBP severity (CI: 0.037 to 0.328; CI: 0.028 to 0.421) but not interference (CI: -0.003 to 0.403; CI: -0.406 to 0.143). Furthermore, emotional expression was associated with CLBP severity and interference at low and medium levels of avoidant attachment (CI: 0.165 to 0.682; CI: 0.098 to 0.455); expressive suppression and cognitive reappraisal did not interact with attachment dimensions when examining CLBP severity or interference (CIs: LLs ≤ -0.291 to ULs ≥ 0.030).

Conclusion

Our study shows that anxious attachment may be an interpersonal risk factor related to CLBP, above and beyond intrapersonal ERs, as anxious attachment was associated with higher levels of pain interference. Furthermore, emotional expression was associated with increased CLBP severity and interference, particularly among individuals at low and medium levels of avoidant attachment. Existing studies on chronic pain have mostly focused on examining intrapersonal or interpersonal correlates in isolation. The present study extends our understanding of CLBP by considering the role of interpersonal factors (i.e., insecure attachment dimensions), in combination with intrapersonal ER strategies. Given the correlational nature of the present study, longitudinal studies are needed to establish causality between psychosocial correlates and CLBP symptoms. Ultimately, we hope our integrated approach will facilitate the development of treatments and interventions tailored to address patients' attachment-related needs, enhancing the management and maintenance of CLBP among patients.

Personality systems interactions theory: an integrative framework complementing the study of the motivational and volitional dynamics underlying adjustment to chronic pain

In the endeavor to advance our understanding of interindividual differences in dealing with chronic pain, numerous motivational theories have been invoked in the past decade. As they focus on relevant, yet different aspects of the dynamic, multilevel processes involved in human voluntary action control, research findings seem fragmented and inconsistent. Here we present Personality Systems Interactions theory as an integrative meta-framework elucidating how different motivational and volitional processes work in concert under varying contextual conditions. PSI theory explains experience and behavior by the relative activation of four cognitive systems that take over different psychological functions during goal pursuit. In this way, it may complement existing content-related explanations of clinical phenomena by introducing a functional, third-person perspective on flexible goal management, pain acceptance and goal maintenance despite pain. In line with emerging evidence on the central role of emotion regulation in chronic pain, PSI theory delineates how the self-regulation of positive and negative affect impacts whether behavior is determined by rigid stimulus-response associations (i.e., habits) or by more abstract motives and values which afford more behavioral flexibility. Along with testable hypotheses, multimodal interventions expected to address intuitive emotion regulation as a central process mediating successful adaptation to chronic pain are discussed.

Measuring interpersonal trauma: Development and validation of the German version of the victimization experience schedule (VES)

OBJECTIVE

Interpersonal victimization experiences (VEs) significantly affect mental and physical health, particularly in disorders associated with life-time adversities, like fibromyalgia syndrome (FMS) and major depressive disorder (MDD). However, assessing VEs comprehensively remains challenging due to limited tools that encompass sub-traumatic events, such as bullying or discrimination, and contextual dimensions. We aimed to address this gap by validating the Victimization Experience Schedule (VES) in German, examining its reliability, and assessing VEs in clinical populations with FMS and MDD.

METHODS

We investigated the relationship between VEs and clinical symptoms in individuals with FMS, MDD and healthy controls (N = 105) in a case-control study. We also analyzed correlations between different types of VEs and categories of early childhood abuse and posttraumatic-stress-disorder instruments. Additionally, we validated our findings in an independent sample of individuals with FMS (N = 97) from a clinical study.

RESULTS

We observed excellent inter-rater reliability (Kw = 0.90-0.99), and VEs assessed using the VES were in alignment with subcategories of early childhood abuse. The prevalence of VEs extended beyond the categories covered by traditional survey instruments and was higher in individuals with MDD (4.0 ± 2.6) and FMS (5.9 ± 3.1) compared to controls (1.5 ± 1.7). We consistently identified a significant association between the number of VEs, the associated subjective distress, and clinical scores. Furthermore, distinct correlation patterns between VEs and clinical outcomes emerged across different cohorts.

CONCLUSION

Our study emphasizes the VES's value in understanding VEs within MDD and FMS. These experiences span from traumatic to sub-traumatic and correlate with posttraumatic-stress and clinical symptoms, underscoring the VES's importance as an assessment tool.

Are We Any Closer to Understanding How Chronic Pain Develops? A Systematic Search and Critical Narrative Review of Existing Chronic Pain Vulnerability Models

Identifying biopsychosocial factors underlying chronic pain vulnerability is essential for the design of preventative efforts. Multiple chronic pain vulnerability models exist, however, there is a lack of comprehensive evaluation of these models in the literature, potentially due to the lack of guidelines that specify the criteria by which these types of work should be assessed. In this work, we created evaluation criteria (based on the general goals of conceptual models), and we then used them to critically review the chronic pain vulnerability models available in the current peer-reviewed literature (identified through a systematic search). Particularly, we evaluated the models on the basis of conceptual clarity/specificity of measures, depth of description of aetiological and mechanistic factors, use of a whole system approach, and quality of the evidence associated with the models. We found nine conceptual models that have been explored in detail (eg, fear avoidance model, diathesis-stress model). These models excel at clarity and are supported mostly by self-report evidence of a psychological nature (anxiety sensitivity, pain catastrophizing, etc.), but provide little explanation of mechanistic and aetiological factors. In the future, models could be improved by complementing them with proposals from other models and exploring potential causal factors and mechanisms maintaining the condition. This task could be carried out through prospective cohort studies, and computational approaches, amongst others.

Neurophysiological and Psychosocial Mechanisms of Fibromyalgia: A Comprehensive Review and Call for An Integrative Model

Research into the neurobiological and psychosocial mechanisms involved in fibromyalgia has progressed remarkably in recent years. Despite this, current accounts of fibromyalgia fail to capture the complex, dynamic, and mutual crosstalk between neurophysiological and psychosocial domains. We conducted a comprehensive review of the existing literature in order to: a) synthesize current knowledge on fibromyalgia; b) explore and highlight multi-level links and pathways between different systems; and c) build bridges connecting disparate perspectives. An extensive panel of international experts in neurophysiological and psychosocial aspects of fibromyalgia discussed the collected evidence and progressively refined and conceptualized its interpretation. This work constitutes an essential step towards the development of a model capable of integrating the main factors implicated in fibromyalgia into a single, unified construct which appears indispensable to foster the understanding, assessment, and intervention for fibromyalgia.

The relationship of alexithymia to pain and other symptoms in fibromyalgia: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

People with fibromyalgia (FM) often report having difficulty with emotional identification and expression, and this "alexithymia" may contribute to their pain and other symptoms. Multiple studies have assessed alexithymia in FM, and we systematically reviewed and meta-analyzed this literature to: (a) describe the prevalence of alexithymia in people with FM; (b) compare the level of alexithymia in FM to both healthy controls and controls with other pain conditions; and (c) determine the association of alexithymia to pain intensity, depression, and anxiety in people with FM.

DATABASES AND DATA TREATMENT

Following PRISMA guidelines, we searched multiple databases (Scopus, PubMed/MEDLINE, Embase, Web of Science, PsycINFO and Google Scholar) from inception to May 31, 2022. Study quality was assessed with The Joanna Briggs Institute (JBI) tools for cross-sectional studies, and STATA:17 was used for meta-analysis. A total of 32 studies met eligibility criteria and were included in meta-analyses.

RESULTS

The prevalence of alexithymia in FM averaged 48%. People with FM had substantially higher alexithymia than healthy controls (SMD = 1.00; 95% CI: 0.79 to 1.22), as well people with other pain-related conditions (SMD = 0.35, 95% CI = 0.04 to 0.65), particularly rheumatoid arthritis (SMD = 0.49; 95% CI: 0.08-0.91). Alexithymia was positively associated with pain intensity (r = 0.24), anxiety (r = 0.50), and depression (r = 0.41) among people with FM.

CONCLUSIONS

Due to the high level of alexithymia in people with FM and the positive relationship of alexithymia with pain and psychological distress, interventions to improve emotional awareness, expression, and processing in FM are recommended.

Health-related quality of life of women with endometriosis: An Attachment-Diathesis Model of Chronic Pain perspective

Endometriosis is a common gynecological disorder that occurs in women of reproductive age, and negatively affects women's quality of life. We tested 'Attachment-Diathesis Model of Chronic Pain' in a sample of Turkish women with endometriosis by analyzing the paths among attachment styles, pain catastrophizing, coping strategies, and health-related quality of life (HRQoL). Attachment anxiety was related to using less problem-focused coping and seeking more social support, while attachment avoidance was associated with seeking less social support as a coping strategy. Moreover, attachment anxiety and higher pain catastrophizing were related to a worse HRQoL. Finally, problem-focused coping strategy mediated the relation between attachment anxiety and HRQoL, meaning that by employing less problem-focused coping strategies, anxiously attached women experienced a poorer HRQoL. In light of our findings, psychologists may develop intervention techniques that question attachment patterns, pain perception, and coping strategies in clients diagnosed with endometriosis.

A Link Between Inflammatory Mechanisms and Fibromyalgia

Fibromyalgia (FM) is a condition characterized by chronic widespread pain, which has traditionally been considered psychogenic in nature due to lack of known underlying organic pathophysiology. In more recent years, inflammation of the nervous system has become increasingly recognized as a sign of neuropsychiatric conditions, and this association may enhance our knowledge of conditions such as FM. Emerging evidence has suggested inflammation, particularly neuroinflammation, as a potential contributor underlying the etiology of FM. Studies have searched for linked biomarkers with mixed results, though the literature is beginning to point to increased systemic levels of pro-inflammatory cytokines such as IL-6 and IL-8 in patients with FM relative to healthy controls. A multicenter imaging study has also reported results suggestive of microglial activation related to the presence of FM. Given the consistency in neuroinflammatory effects implicated in "sickness behavior" characteristic of chronic systemic inflammatory conditions such as cancer or rheumatic diseases, therein springs the hypothesis for a connection between FM and neuroinflammation as discussed in this chapter.

Emotion regulation and the salience network: a hypothetical integrative model of fibromyalgia

Fibromyalgia is characterized by widespread pain, fatigue, sleep disturbances and other symptoms, and has a substantial socioeconomic impact. Current biomedical and psychosocial treatments are unsatisfactory for many patients, and treatment progress has been hindered by the lack of a clear understanding of the pathogenesis of fibromyalgia. We present here a model of fibromyalgia that integrates current psychosocial and neurophysiological observations. We propose that an imbalance in emotion regulation, reflected by an overactive 'threat' system and underactive 'soothing' system, might keep the 'salience network' (also known as the midcingulo-insular network) in continuous alert mode, and this hyperactivation, in conjunction with other mechanisms, contributes to fibromyalgia. This proposed integrative model, which we term the Fibromyalgia: Imbalance of Threat and Soothing Systems (FITSS) model, should be viewed as a working hypothesis with limited supporting evidence available. We hope, however, that this model will shed new light on existing psychosocial and biological observations, and inspire future research to address the many gaps in our knowledge about fibromyalgia, ultimately stimulating the development of novel therapeutic interventions.

Adult attachment styles, self-esteem, and quality of life in women with fibromyalgia

Recently, the research on pain-related disability has increasingly paid attention to the psychological and social factors that may influence the biological condition. In the current study, we aimed to explore attachment styles, self-esteem, and quality of life in individuals with a diagnosis of fibromyalgia. Participants were 371 diagnosed women, with a mean age of 42.7 years (standard deviation = 10.6). The average number of years since diagnosis was 7.4 years (standard deviation = 2.4) years. To assess attachment, quality of life, and self-esteem, women responded, respectively, to the Relationship Questionnaire, the World Health Organization Quality of Life Questionnaire, and the Rosenberg Self-Esteem Inventory. Our results showed that secure attachment relationships and high self-esteem represent protective factors for quality of life of women with fibromyalgia, while the contrary emerged for insecure attachments and low self-esteem. The understanding of the psychological components that contribute to fibromyalgia may improve the effectiveness of interventions.

Attachment style and parental bonding: Relationships with fibromyalgia and alexithymia

Objectives

Fibromyalgia (FM) is a chronic pain syndrome, and alexithymia, which is a condition that is characterised by deficits in emotional self-awareness, is highly prevalent among individuals with FM. Insecure attachment styles and inadequate parental care appear to play an important role in the onset and maintenance of both alexithymia and chronic pain. Therefore, the present study aimed to examine the associations between attachment styles, parental bonding, and alexithymia among patients with FM and healthy controls (HC).

Methods

All participants completed a battery of tests that assessed alexithymia, attachment styles, and parental bonding. Two logistic regression models were tested to examine whether these variables predict (a) group membership (i.e. patients with FM vs. HC) and (b) the likelihood of having alexithymia (i.e. among patients with FM and HC).

Results

Alexithymia (i.e. difficulty identifying and describing feelings subscales of the 20-item Toronto Alexithymia Scale) significantly predicted group membership (i.e. the likelihood of having FM). On the other hand, educational level and dismissive attachment (i.e. the discomfort with closeness and relationships as secondary subscales of the Attachment Style Questionnaire) were the only significant predictors of the likelihood of having alexithymia.

Conclusions

These findings highlight both the relevance of alexithymic traits to the definition of FM and centrality of an insecure attachment style to the manifestation of alexithymia.

Cost-Utility of Attachment-Based Compassion Therapy (ABCT) for Fibromyalgia Compared to Relaxation: A Pilot Randomized Controlled Trial

A recent study has supported the efficacy of Attachment-Based Compassion Therapy (ABCT) compared to relaxation (REL) for the management of fibromyalgia (FM). The main objective of this paper is to examine the cost-utility of ABCT compared to REL in terms of effects on quality-adjusted life years (QALYs) as well as healthcare costs. Forty-two Spanish patients with FM received 8 weekly group sessions of ABCT or REL. Data collection took place at pre- and 3-month follow-up. Cost-utility of the two treatment groups (ABCT vs. REL) was compared by examining treatment outcomes in terms of QALYs (obtained with the EQ-5D-3L) and healthcare costs (data about service use obtained with the Client Service Receipt Inventory). Data analyses were computed from a completers, ITT, and per protocol approach. Data analysis from the healthcare perspective revealed that those patients receiving ABCT exhibited larger improvements in quality of life than those doing relaxation, while being less costly 3 months after their 8-week treatment program had ended (completers: incremental cost M, 95% CI = €−194.1 (−450.3 to 356.1); incremental effect M, 95% CI = 0.023 QALYs (0.010 to 0.141)). Results were similar using an ITT approach (incremental cost M, 95% CI = €−256.3 (−447.4 to −65.3); incremental effect M, 95% CI = 0.021 QALYs (0.009 to 0.033)). A similar pattern of results were obtained from the per protocol approach. This RCT has contributed to the evidence base of compassion-based interventions and provided useful information about the cost-utility of ABCT for FM patients when compared to relaxation. However, the small sample size and short follow-up period limited the generalizability of the findings.

Fibromyalgia and its New Lessons for Neuropsychiatry

Background

Fibromyalgia (FM) is a centralized pain state that until recently has been shrouded in mystery and questionable as a disease entity in the eyes of many physicians, who considered it purely psychogenic. Fibromyalgia is now thought of as a discrete diagnosis with a clustering of symptoms characterized by central nervous system pain amplification along with anergia, memory loss, disturbances of mood, and sleep disruption. The condition is present in approximately 2% to 8% of the population.

Material/Methods

We review the link between inflammatory mechanisms and FM from a neuropsychiatric perspective.

Results

Recent studies are pointing to a neuroinflammatory etiology that may open up more effective treatment strategies in the future.

Conclusions

Better conceptualization of FM may also elucidate a neuropsychiatric understanding of how nociception, dysthymia, and suicidality co-develop and feed off one another.