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Psychosomatic Medicine 66:837-844 (2004)
© 2004 American Psychosomatic Society

ORIGINAL ARTICLES

Comorbid Depression and Anxiety in Fibromyalgia Syndrome: Relationship to Somatic and Psychosocial Variables

Kati Thieme, PhD, Dennis C. Turk, PhD and Herta Flor, PhD

From the Department of Anesthesiology, University of Washington, Seattle, Washington (K.T., D.C.T.); and the Department of Neuropsychology (K.T., H.F.), University of Heidelberg, Central Institute of Mental Health Mannheim, Mannheim, Germany.

Address correspondence and reprint requests to Kati Thieme, PhD, Department of Anesthesiology at the University of Washington, 1959 NE Pacific Street, Box 356540, Seattle, WA 98195-6540. E-mail: thiemek{at}u.washington.edu


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
OBJECTIVE: The prevalence as well as predictors of psychiatric disorders (Diagnostic and Statistical Manual of Mental Disorders, 4th edition [DSM-IV] axis I and II) in patients with fibromyalgia syndrome (FMS) was evaluated.

METHOD: One-hundred fifteen patients with FMS participated in the Structured Clinical Interview for DSM-IV to assess current mental disorders. In addition, patients completed standardized questionnaires regarding pain, pain impact, anxiety, depression, posttraumatic stress disorder-like symptoms, and sexual and physical abuse.

RESULTS: Patients were grouped into one of three psychosocial subgroups based on responses to the Multidimensional Pain Inventory (MPI)–Dysfunctional (DYS), Interpersonally Distressed (ID), and Adaptive Copers (AC). Axis I diagnoses were present in 74.8% of the participants overall with the DYS subgroup mainly reporting anxiety and the ID group mood disorders. The AC group showed little comorbidity. Axis II diagnoses were present in only 8.7% of the FMS sample.

CONCLUSION: These results suggest that FMS is not a homogeneous diagnosis, but shows varying proportions of comorbid anxiety and depression dependent on psychosocial characteristics of the patients. The results demonstrate the importance of not treating patients with FMS as a homogeneous group. Assessment should not only examine the presence of widespread pain and the number of tender points, but also the presence of affective distress. Treatment should focus both on physical and emotional dysfunction.

Key Words: fibromyalgia, • comorbidity, • DSM-IV, • SCID, • MPI subgroups.

Abbreviations: FMS = fibromyalgia syndrome;; MPI = Multidimensional Pain Inventory;; DYS = dysfunctional;; ID = interpersonally distressed;; AC = adaptive copers;; SCID = Structured Clinical Interview for DSM-IV;; CES-D = Center for Epidemiologic Studies Depression Scale;; STAI-T = State-Trait Anxiety Inventory–Trait scale;; PRSS = Pain-Related Self-Statements Scale.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Fibromyalgia syndrome (FMS) is characterized by widespread pain, hypersensitivity to palpation at specific body locations (tender points) (1), and a range of comorbid physical symptoms and functional limitations, including persistent fatigue, sleep disturbance, feelings of stiffness, headaches, and irritable bowel disorders (1). Patients also report cognitive impairment and general malaise sometimes referred to as "fibro fog" (2).

As is often the case in medicine, in the absence of specific physical findings that provide an adequate explanation for symptoms, a number of authors have suggested that FMS is primarily a psychogenic disorder (3–5). Depression is reported to be particularly prevalent in FMS, leading some to suggest that it is a depressive spectrum disorder (6–8). Examination of the prevalence of depression across studies reveals a wide diversity with current depressive disorders ranging from 28.6% to 70% across studies (9,10). The large differences in prevalence may be explained by the variation in methods for assessing depression, different definitions used for depression, and sampling bias (eg, patients referred to a psychiatrist for evaluation); reliance on treatment-seekers to establish prevalence (treatment seekers are likely to be the most distressed); or a combination of these factors. Less attention has been given to the prevalence of anxiety in FMS. However, Kurtze (11) found support for the hypothesis that depression and anxiety are independently associated with the severity of pain symptoms in FMS. Thus, not all patients diagnosed with FMS experience the same or necessarily any emotional disorders.

Turk and Flor (12) suggested that FMS is likely comprised of a heterogenous group of people who may differ on important variables such as mood, adaptation to symptoms, as well as presenting symptoms. Turk et al. (13,14) demonstrated that patients with FMS could be classified into psychosocial subgroups based on the scores of the West Haven-Yale Multidimensional Pain Inventory (MPI) (15). In a cluster analysis of responses to the MPI, these investigators identified three psychosocial subgroups that were characterized by different levels of pain intensity, interference, and affective distress as well as the reactions of significant others. One group, labeled dysfunctional (DYS), exhibited the highest level of pain, emotional distress, and disability. A second group, termed interpersonally distressed (ID), reported significantly lower levels of pain, disability, and marital satisfaction than the other two subgroups. The significant others of ID patients showed a higher level of negative responses to the patients’ expressions of pain. The third group, adaptive copers (AC), showed low pain intensity, emotional distress, and interference of pain with daily lives and activities. MPI-based subgroups have been replicated in several studies performed in several Western countries (eg, The Netherlands (17), Germany (18), Sweden (19)). These subgroups have been identified in diverse chronic pain syndromes (eg, headache, back pain, temporomandibular disorders) (16). The percentages of patients classified within each group do, however, vary across diagnoses. These patterns appear to exist independent of medical diagnosis. The subgroups identified are primarily descriptive; there is no information available to clarify what factors, if any, predispose people to respond to chronic pain in one of the three patterns identified. Moreover, to date, there have been no studies that we are aware of that have attempted to clarify the extent and nature of psychiatric disorders in the subgroups identified.

The MPI is a general screening instrument and, although it contains a scale labeled "affective distress," it does not directly assess psychiatric disorders. To better understand the MPI-based subgroups, it would be useful to examine the presence of specific comorbid mental disorders. In the present study, we assessed the prevalence of psychiatric disorders in a group of patients with FMS and sought predictors of mental disorders from psychosocial variables. We examined the presence of specific psychiatric disorders associated with adaptation to symptoms using the MPI psychosocial subgroups to differentiate groups of patients with FMS.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Participants
One hundred fifteen German-born, female patients with FMS were recruited from rheumatologic outpatient departments as well as from a Hospital for Rheumatic Disorders at Berlin-Buch. The rheumatologists referred the patients to a Department of Neuropsychology to receive psychologic pain treatment. Patients were informed about the study and were assured that failure to agree would not interfere with their treatment. They were instructed that they could withdraw from the study at any time without affecting the treatment they received, and completed forms consenting to participate. All patients had a diagnosis of FMS based on the ACR criteria (1). Exclusion criteria were 1) inflammatory cause of the pain, 2) neurologic complications, 3) duration of pain less than 4 months, 4) pregnancy, 5) another severe disease such as a tumor, liver, or renal disease, and 6) lack of fluency in the German language.

The mean age of the sample was 48 years (standard deviation [SD] = 10.32 years) and the average duration of symptoms was 9 years (SD = 9.23 years). The mean number of tender points was 16 (SD = 9.99), pain severity provoked by palpation of tender points was 95 (SD = 36.56; scale range, 0–180), and number of painful regions 7 (SD = 2.05). Forty-one percent of the patients were employed, 26% were unemployed, and 32% were receiving workers’ compensation (see Table 1 for a detailed description of the sample).


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  		TABLE 1. Demographic and Clinical Characteristics of the Psychosocial Subgroups and the Entire Sample
 
Assessment
The number of somatic complaints was obtained from medical records that documented explicit information about all symptoms reported. These symptoms were aggregated into a total symptom score. The number and intensity of pain at tender points were assessed and added to obtain sum intensity score (20).

The Structured Clinical Interview for DSM-IV (SCID I and II) (21,22) was used to assess axis I and II disorders in accordance with the 4th-TR version of the Diagnostic and Statistical Manual of Mental Disorders (APA, 1995). SCID I and II show high validity and reliability in American and German studies (21–23).

The abbreviated version of the Questionnaire of Sexual and Physical Abuse (24) designed by the National Population Survey of Canada (25) and translated into German was used to assess physical and sexual abuse. This screening instrument provides information on the type and frequency of sexual or physical abuse as well as on the age at the time of critical life events.

The German translation of the West Haven-Yale Multidimensional Pain Inventory (MPI) (15,26) was used as a basis for classification of the patients into one of the three subgroups identified by Turk and Rudy (16). The MPI is a 61-item self-report inventory that generates 13 scale scores across three sections (15). The first section addresses pain severity, perception of how pain interferes with daily life activities, appraisals of the support received from significant others, perceived life control, and affective distress. The second section addresses the patients’ perception of how significant others respond to their displays of pain: negative responses, solicitous responses, and distracting responses. The third section is composed of a checklist of 18 common activities to form a general activity scale.

The German version of the Center for Epidemiologic Studies Depression-Scale (CES-D) was used to assess current symptoms of depression (27,28). This 20-item measure is a reliable and valid indicator of depressed mood in both clinical and research populations. The CES-D items are relatively free of content related to pain and functional limitations associated with rheumatologic disorders; thus, depression scores are not spuriously inflated by pain.

State-Trait Anxiety Inventory–Trait Scale
The German version of trait version of the State-Trait-Anxiety Inventory (29–31) was used to measure a stable disposition characterized by tension and apprehension across time and setting. The 20-item trait version is reliable and valid, and it is the most commonly used measure of anxiety in psychologic and behavioral medicine research.

Posttraumatic Stress Disorder-Like Symptoms
Posttraumatic stress disorder (PTSD)-like symptoms were determined using the German version of Symptom Checklist-90–Revised (32,33). Saunders et al. (34) developed a posttraumatic stress disorder (CR-PTSD) scale for women within the SCL-90-R. Using a criterion group classification approach, a 28-item scale extracted from the SCL-90-R was developed that successfully discriminated between CR-PTSD positive (PTSD+) and negative responders (PTSD–). Participants were classified as having high levels of PTSD-like symptoms (PTSD+) if they met or exceeded the recommended cutoff score (0.89) as determined in the original validation study (34). Those below the cutoff sore were classified as negative for PTSD-like symptoms (PTSD–). Sherman et al. (35) demonstrated high levels of PTSD-like symptoms in patients with FMS using the CR-PTSD.

The Pain-Related Self Statements Scale (PRSS) (36) with the subscales "Coping" and "Catastrophizing" was used to assess the situation-specific aspects of patients’ cognitive coping with pain. The PRSS has been shown to have good reliability and validity (36).

Procedures
Each patient underwent a comprehensive evaluation, including medical and physical assessments. A psychologic interview was conduced using the SCID I and II. Patients completed the set of questionnaires described previously. Three behaviorally trained psychologists with more than 15 years experience in psychosomatic and internal medicine, including experience performing SCID interviews, conducted SCID I and II. Reliability data were not obtained.

Statistical Analysis
Based on the SCID interviews, the frequency of axis I and II disorders was determined and axis I disorders were grouped into 1) anxiety and 2) mood disorders. SCID I diagnoses included the following anxiety diagnoses: panic disorder without agoraphobia, generalized anxiety disorder, panic disorder with agoraphobia, agoraphobia without panic disorder, social phobia, specific phobia, obsessive-compulsive disorder, and acute stress disorder as well as PTSD. The group of mood disorders included major depressive episode, major depressive disorder, and dysthymic disorder as indicated in DSM-IV.

A multivariate analysis of variance (MANOVA) was conducted to determine whether there were differences among the groups with no axis I disorders, anxiety disorders, and mood disorders. The STAI-T, CES-D Scale, SCL-90, and number of symptoms associated with FMS, pain, and its consequences (MPI), and sum pain at tender points were included in this analysis. One-way ANOVAs were conducted following a significant MANOVA. Bonferroni-corrected post hoc t tests were used for follow-up analyses of significant group effects. The prevalence of mental disorders was calculated for the three psychosocial subgroups. As a result of their low prevalence, personality disorders were not investigated in further detail. To assess predictors of mental disorders, binary logistic regression analyses with a forward conditioning method were used.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Current Mental Disorders
Axis I psychiatric disorders were found in 77.3% of the sample: 32.2% of the patients with FMS reported symptoms characteristics of anxiety disorders, 34.8% mood disorders, 1.75% met criteria of substance-related disorders, and another 1.75% met criteria for eating disorders. In this sample of patients with FMS, 40.9% reported sexual abuse and 20.9% physical abuse in childhood. Only 7.8% of the patients appeared to have developed PTSD. Importantly, 11% of the sample had more than two mental disorders such as anxiety and substance-related disorder, mood and eating disorder, mood disorder and various types of phobias. Only 22.7% of the patients with FMS did not have evidence of any axis I mental disorder. Personality disorders were found to be present in only 8.7% of patients (N = 14), 5.25% borderline personality disorder and 1.75% revealing either an avoidant personality disorder, or dependent personality disorder.

Characterization of Axis I Comorbidity
The MANOVA identified significant differences between the groups (F[18, 52] = 6.74, p <.001, {epsilon} = 7.0).

Psychologic Distress
As would be expected, patients with FMS who met criteria for a diagnosis of anxiety disorder showed a significantly higher level of anxiety (STAI-T: F[2, 112] = 75.85, p < .001) than patients with mood disorders (t[67] = 7.69, p < .001) and patients with FMS without mental disorders (t[80] = 11.98, p < .001). Similarly, as expected, patients who met criteria for mood disorders demonstrated significantly more depressive symptoms (CES-D-Scale: F[2, 112] = 48.90, p < .001) than patients with anxiety disorders (t[67] = –6.74, p <.001) and patients with FMS without an axis I disorder (t[77] = 10.25, p < .001). These results of the self-report data provide additional support for the validity of the SCID diagnoses.

PTSD-like symptoms were found in 40.9% of the sample. The diagnostic subgroups were significantly different with respect to PTSD-like symptoms (F[2, 112] = 15.98, p < .001). The patients with anxiety disorders exhibited significantly more symptoms than depressed patients (t[67] = 4.20, p < .001) and patients without axis I disorder (t[80] = 5.123, p < .001).

The groups differed significantly in the prevalence of sexual abuse (F[2, 112] = 14.43, p < .001). Patients with anxiety disorders reported significantly more frequent sexual abuse than the depressed patients ({chi}2 [1] = 8.95, p < .003) and patients without axis I disorder ({chi}2 [1] = 22.89, p < .001). Similar results were found for physical abuse, with those with anxiety disorders reporting significantly more physical abuse in childhood (F[2, 112] = 5.64, p < .005) than the depressed patients ({chi}2 [1] = 4.86, p <.04) and patients without axis I disorder ({chi}2 [1] = 8.91, p < .005).

Somatic Symptoms
Patients with anxiety disorders, mood disorders, and no axis 1 diagnoses differed significantly in the number of somatic symptoms they reported (F[2, 112] = 8.45, p < .001). Bonferroni corrected post hoc analyses found that the patients with anxiety disorders reported significantly more somatic symptoms than the patients with either mood disorders (t[67] = 3.49, p < .001) or the patients without any mental disorders (t[80] = 3.59, p < .003). The patients with mood disorders, however, were not significantly different from patients without mental disorders in the number of symptoms reported (t[77] = –0.634, p = .53).

Pain and Its Consequences
Patients with anxiety disorders, mood disorders, and no emotional disorders differed significantly in the pain tender points sum score (F[2, 112] = 3.47, p < .04). Bonferroni-corrected post hoc analyses indicated that the patients with anxiety disorders reported significantly higher tender points sum score than the patients with either mood disorders (t[67] = –3.16, p < .02) or those without any mental disorders (t[80] = –2.33, p < .05). The patients with mood disorders, however, did not significantly in the tender points sum score reported from patients without mental disorders (t[77] = –0.634, p = .47).

The diagnostic subgroups were significantly different with respect to many areas assessed on the MPI. They differed significantly in pain intensity (F[2, 112] = 4.87, p < .009), with patients with anxiety disorders reporting significantly higher pain intensity compared with patients with mood disorders (t[67] = 2.11, p < .04) and patients without axis I diagnosis (t[80] = 3.19, p < .002). Patients who met criteria for anxiety disorders also displayed significantly more interference related to pain (F[2, 112] = 7.16, p < .001) than depressed patients (t[67] = 2.56, p = .01) and patients without axis I disorder (t[80] = 3.80, p < .001), less life control (F[2, 112] = 3.88, p < .02) than patients without axis I disorder (t[80] = –2.72, p = .008), but not than depressed patients (t[67] = –1.35, p = .18). They reported receiving more social support (F[2, 112] = 12.61, p < .001) than depressed patients (t[67] = 4.39, p < .001), but not than patients without axis I disorder (t[80] = 0.34, p = .69), and they indicated that their significant others provided more solicitous behaviors (F[2, 112] = 18.43, p < .001) than those of depressed patients (t[67] = 5.28, p < .001) but not those of patients without axis I disorder (t[80] = 0.14, p = .89). The anxious patients also showed the lowest general activity level (F[2, 112] = 5.61, p = .005) compared with depressed patients (t[67] = –2.52, p = .01) and patients without axis I disorder (t[80] = –3.26, p = .002).

Patients with mood disorders exhibited the highest level of affective distress (F[2, 112] = 12.33, p < .001) compared with patients without axis I disorder (t[77] = 3.09, p = .003) but did not differ significantly from the patients with anxiety (t[67] = 1.61, p = .11). They did report more punishing behaviors by significant others (F[2, 112] = 4.09, p = .02) than the patients with anxiety (t[67] = 2.20, p <.02) and patients without axis I disorder (t[77] = 2.77, p <.007) and the lowest distracting spouse behaviors (F[2, 112] = 7.22, p = .001) compared with patients with anxiety (t[67] = 3.49, p <.001) and patients without axis I disorder (t[77] = –3.16, p < .002) They showed higher general activities than patients with anxiety (t[67] = –2.52, p < .02) but were similar to patients without axis I disorder (t[77] = –0.08, p = .94). Patients without axis I disorder reported significantly lower levels of pain, interference, and affective distress but the highest distracting behaviors by significant others (F[2, 112] = 7.22, p < .001) compared with depressed patients (t[77] = –3.16, p < .002), but not with patients with anxiety (t[80] = 0.36, p = .72).

Prediction of Axis I Comorbidity
A stepwise logistic regression was performed to determine the best predictors of axis I disorders. Pain-related, somatic, cognitive, affective, behavioral, and spouse-related variables were entered sequentially into the equation: pain intensity (MPI) and pain at the tender points, somatic symptoms, active coping and catastrophizing (PRSS), anxiety score (STAI), depression score (CES-D), and PTSD-like-symptoms at SCL-90, activity scores (MPI) and solicitous, punishing, and distracting spouse behavior (MPI).

The number of somatic symptoms associated with FMS (r2 = 0.45, p < .02), the occurrence of PTSD-like-symptoms (r2 = 0.31, p < .003), solicitous behaviors by significant others (r2 = 0.57, p < .05), and reduced general activity (r2 = 0.64, p < .002) were the best predictors of anxiety disorders and accounted for 63.6% of the variance of anxiety disorders in FMS.

The occurrence of PTSD (r2 = 0.19, p < .02), less frequent solicitous behaviors of significant others (r2 = 0.33, p < .003), high general activity (r2 = 0.43, p < .002), and lower levels of coping (r2 = 0.53, p < .02) accounted for 69.6% of the variance of depression in FMS. Interestingly, pain intensity, interference, life control, and distracting responses by significant others had no predictive value for either anxiety or mood disorders in FMS.

Relationship of Comorbidity and Psychosocial Subgroups
The entire sample was classified within one of the three primary MPI subgroups. Thirty percent of the participants were classified as DYS, 33.0% as ID, and 37% as AC. Percentages are comparable to other samples of patients with FMS (14). The subgroups were not significantly different with respect to age, sex, number of distinct pain areas, or the duration of the pain problem (see Table 1). The AC and the ID groups had significantly lower rates if unemployment and less workers’ compensation than the DYS group ({chi}2 [8] = 45.32, p < .04). The subgroups also differed significantly in the pain severity of tender points, with the group of ID patients exhibiting lower pain severity than the DYS patients and the AC (F[2, 112] = 8.26, p < .001).

The psychosocial subgroups were significantly different in the prevalence of axis I mental disorders ({chi}2 [4] = 95.94, p < .001). 67.6% of the DYS patients reported anxiety disorders in comparison to 15% in the ID group and 19.5% in the AC group. Furthermore, 80% of ID patients were clinically depressed in contrast to only 20.6% of the DYS patients and 2.4% of the AC (see Figure 1).



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  		Figure 1. Frequency of axis I disorders for patients with fibromyalgia in the psychosocial subgroups: dysfunctional, interpersonally distressed, and adaptive coper.

 
The psychosocial subgroups were also significantly different with respect to current psychologic distress such as anxiety (STAI-T: F[2, 112] = 14.46, p < .001), depressed mood (CES-D Scale: F[2, 112] = 23.92, p < .001), and PTSD-like symptoms (SCL-90-R: F[2, 112] = 6.44, p < .002). Specifically, DYS patients reported significantly higher levels of current anxiety than ID patients (t[72] = 3.54, p < .001) and AC (t[76] = 5.048, p < .001). In addition, ID patients reported comparable levels of anxiety as the AC (t[79] = 1.47, p = .62). ID patients reported significantly greater levels of depressed mood than dysfunctional patients (t[72] = –4.69, p <.001) and AC (t[79] = 7.38, p < .001). DYS patients reported the same levels of depressed mood as AC (t[76] = 1.60, p = .11). The self-report data are consistent with the results for the axis 1 diagnoses determined from the SCID interviews.

Using the cutoff score criterion of 0.89 (35), 40.9% of the subjects were classified as PTSD+ and 59.1% as PTSD–. DYS patients endorsed the highest proportion of PTSD-like symptoms (61.8%) in comparison to the ID patients (15%, t[72] = 2.60, p < .02) and the AC (11%, t[76] = 3.30, p < .001). No significant differences were found between the ID patients and the AC (t[79] = 0.76, p = .45).

Sexual and Physical Abuse
The chi-squared analysis revealed that the MPI subgroup distribution of the two groups (sexual abuse was vs. no sexual abuse/physical abuse was vs. no physical abuse) was significantly different for sexual abuse ({chi}2 = 12.58, p < .002) as well as physical abuse ({chi}2 = 8.28, p < .02). The DYS patients reported experiencing significantly more sexual (64.7%) and physical abuse (38.2%) than the ID patients (37.5% sexual and 12.5% physical abuse) and the AC (24.4% sexual and 14.6% physical abuse).


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
ACKNOWLEDGMENTS
 REFERENCES
 
This study examined its relationship with somatic and psychosocial variables in subgroups of patients sought to determine axis I and II comorbidity in patients with FMS. We found that overall 32.3% of the patients revealed an anxiety disorder and 34.8% a mood disorder. These results are more than three times higher than the prevalence of these psychiatric disorders in the general population in which 9% were found to have an anxiety and 10% a mood disorder (37). These data, however, match prevalence rates of other pain disorders such as rheumatoid arthritis (RA) with 31% mood disorders (9,38–40) and chronic back pain with 35% anxiety and 60% mood disorders (41). PTSD, substance-related, eating and personality disorders were rarely diagnosed in our sample (<10%). The mean frequency of personality disorders in FMS was 8.7%, slightly lower than that observed in the general population in which 10% has been reported (42). Thus, although the prevalence of psychiatric disorders in high compared with the general population, the rates for FMS are comparable to other chronic pain syndromes.

Patients with anxiety and mood disorders were characterized by specific psychologic distress. Patients with anxiety disorders exhibited high dispositional anxiety, greater PTSD-like symptoms (61.8%), as well as more sexual (64.7%) and physical (38.2%) abuse, but relatively low levels of depression. These results replicate the studies of PTSD-like-symptoms in FMS (13,35) in which patients with posttraumatic symptoms reported significantly higher degrees of pain, disability, interference, and a lower level of activity than patients with FMS without PTSD-like symptoms (13,35). These data are also in accordance with Taylor et al. (43) who found 65% sexual abuse in FMS. Sexual abuse was associated with significantly more physical symptoms.

In the present study, patients with FMS with anxiety disorders reported the greatest number of physical symptoms associated with FMS and the highest pain intensity and interference. In addition, this group had a high level of solicitous behaviors by significant others as well as more avoidance behaviors.

Patients with mood disorders exhibited the highest level of affective distress. However, they reported lower anxiety levels as well as a smaller number of physical symptoms, lower pain intensity, more negative and low distracting behaviors from significant others, and the highest reported levels of general activities compared with patients with anxiety or patients without any axis I diagnoses. These results suggest that significant others’ behaviors influence anxiety as well as mood disorders. The reduced solicitous behaviors explained a significant amount of variance (33%) in mood disorders, suggesting that reduced solicitous behaviors might impede coping (44). Okifuji et al. (45) found that the living circumstances of patients with FMS (ie, living alone) predicted depression. Also, for inflammatory rheumatic diseases such as rheumatoid arthritis, patients with a highly critical spouse engaged in more maladaptive coping behaviors and reported poorer psychologic adjustment (46). Reduced social support or marital dissatisfaction has been shown to have an important influence on physical and mental health in general (47). The results of our study are consistent with the hypothesis that significant others’ responses can affect the coping and adjustment of people with chronic pain.

Consistent with Kurtze et al. (11), pain intensity and interference were not significantly related to psychiatric comorbidity. Our results indicate that anxiety and depression are independent of levels of pain in FMS.

The cluster analysis replicated the three primary MPI profiles of psychosocial subgroups (16), and the results are similar to several studies in the United States (16,48), Finland (49), and The Netherlands (17) with diverse populations, including FMS. FMS appears to be a heterogeneous diagnosis comprised of subgroups of patients (12,14). FMS is characterized by significant levels of pain and fatigue along with a host of distressing co-morbid symptoms. One of the most interesting questions is why not all people with FMS are significantly distressed or anxious. Premorbid personality characteristics and prior learning history may predispose patients to the development of FMS as well as the mode of responding following symptom onset. The different prevalence of mental disorders in the psychosocial subgroups supports the hypothesis that mental disorders are not directly associated with FMS per se, but that previous experience, coping, social support in general, and spouse behaviors in particularly could mediate the association between FMS symptoms and emotional distress and thereby contribute to comorbidity in FMS. Additional research is required to clarify the variables that contribute to the evolution of FMS, mode of responding to the presence of symptoms, the maintenance of symptoms, and the accompanying disability observed in a subset of patients who receive this diagnosis.

The results of this study have several implications for treatment planning. An important problem with current studies of treatment of patients with FMS is high degrees of attrition from treatment and nonadherence (50). The presence of either anxiety or mood disorders might be associated with nonadherence with treatment, but for different reasons. High pain-related fear and avoidance behaviors may be associated with anxiety disorder. Cognitive and emotional factors should be considered when treatment programs are developed for FMS and FMS-related disability. The only indirect association of pain and mental disorders suggests that both symptoms and emotional disorders should be targeted by treatment. Because different emotional disorders are associated with the different subgroups of patients identified by the MPI, it might also be worthwhile to target the different characteristics of the psychosocial subgroups (51). For example, solicitous responses by significant others appears to be an important feature of DYS patients; this group might benefit from an operant behavioral treatment component that focuses on modification of behaviors of significant others (52) and because they have high levels of anxiety disorders and thus a treatment component that targets fears may be appropriate (53). ID patients might benefit from a treatment component that focuses on interpersonal problem-solving and communication skills because these patients are characterized by inadequate social support. A treatment component targeting depression might also be appropriate (54). The group of AC might profit most from an exercise approach and support and may not require additional psychologic interventions.

In summary, the results of this study showed high levels of comorbid anxiety and depression in patients with FMS that were associated with different sets of psychosocial variables. The results support the suggestion that FMS is a multidimensional disorder that requires a differential indication of various treatment modalities. Go


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  		TABLE 2. Clinical Characteristics of FMS Patients With and Without Axis I Diagnoses
 

   ACKNOWLEDGMENTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
REFERENCES
 
This study was supported by a grant from the Deutsche Forschungsgemeinschaft (DFG) to Dr. Thieme (Th 899/2–1), a grant from the National Institutes of Arthritis and Musculoskeletal and Skin Diseases to Dr. Turk (AR 44724), and a grant of the DFG to Dr. Flor (Fl 156/26), as well as the MAX Planck Research Award for International Cooperation (Clinical research unit "Learning, Plasticity and Pain").

Received for publication March 10, 2004.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 

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