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Psychiatric Disorders in Patients With Fibromyalgia

A Multicenter Investigation

Received December 18, 1997; revised March 27, 1998; accepted April 2, 1998. From the Georgetown University Medical Center, Washington, D.C.; the University of California, San Diego; the State University of New York at Stonybrook, Long Island, New York; and the Medical University of South Carolina, Charleston. Address correspondence and reprint requests to Dr. Epstein, Department of Psychiatry, Georgetown University Medical Center, 3800 Reservoir Road, NW, Washington, DC 20007.

ABSTRACT

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The authors conducted an investigation in four tertiary-care centers to determine if psychiatric comorbidity and psychological variables were predictive of functional impairment in patients with fibromyalgia syndrome (FMS). Seventy-three individuals were administered the Structured Clinical Interview for DSM-III-R, the Rand 36-item Health Survey (SF-36), and multiple self-report measures. The patients with FMS were found to have a high lifetime and current prevalence of major depression and panic disorder. The most common disorders were major depression (lifetime [L]=68%, current [C]=22%); dysthymia (10% [C only]); panic disorder (L=16%, C=7%); and simple phobia (L=16%, C=12%). The self-report scales revealed significant elevations in depression, anxiety, neuroticism, and hypochondriasis. Functional impairment on all measures of the SF-36 was severe (e.g., physical functioning=45.5 and role limitations due to physical problems=20.0). Stepwise multiple-regression analysis revealed that current anxiety was the only variable that predicted a significant proportion of the variance (29%) in SF-36 physical functioning. Thus, in this multicenter study, the persons with FMS exhibited marked functional impairment, high levels of some lifetime and current psychiatric disorders, and significant current psychological distress. Current anxiety level appears to be an important correlate of functional impairment in individuals with FMS.

Key Words: Fibromyalgia • Psychiatric Disorders • Comorbidity

INTRODUCTION

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Fibromyalgia syndrome (FMS) is a common disorder that is estimated to affect 2%–4% of the population.¹ FMS is diagnosed when an individual complains of widespread musculoskeletal pain and has multiple tender points on examination. Persons with FMS also commonly suffer from severe fatigue, poor sleep, and numerous other physical complaints. There is considerable overlap of symptoms of this disorder with those of chronic fatigue syndrome² (CFS), and many clinicians use similar approaches to treat symptoms of both disorders.

In the past 15 years, there have been numerous investigations into psychiatric comorbidity in FMS. This research, which was prompted by clinical experience that many persons with FMS had psychiatric comorbidity such as depression and anxiety, has led to a number of general conclusions. First, there appear to be elevated rates of lifetime and current psychiatric disorders.^3–6 However, some researchers have not shown elevated rates of such disorders.⁷ Second, some studies have revealed elevations on psychological self-report measures assessing depression, anxiety, and hypochondriasis,^1,8–10 whereas others have not.⁷ Third, many but not all persons with FMS exhibit significant functional impairment.^3,11 Similar findings are present in persons with CFS.^2,12 Fourth, persons with FMS who seek health care may be more psychiatrically distressed than those who do not.¹³ Finally, psychological variables such as anxiety and depression may adversely affect perception of disease severity,¹¹ functional ability,⁹ and pain threshold and tolerance.¹⁴

In this report, we expand upon previous research by reporting on a multicenter investigation of persons with FMS, using established structured interviews to diagnose mental disorders. Because we have a sample of patients recruited from four sites across the United States, our findings should be more generalizable than those from studies in which patients were recruited at only one site. We specifically addressed the link between psychiatric variables and functional impairment, thereby allowing us to describe not only the extent of limitations but also which psychiatric factors may predict functional impairment in this population. Our principal hypothesis was that presence of psychiatric comorbidity would predict additional functional impairment among persons with FMS.

METHODS

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Subjects
We conducted our study from 1994 to 1995. The subjects were 73 individuals with FMS who were recruited through advertisements in local newspapers and by calling existing patients with FMS. Patient demographic data are in Table 1. There were four study sites, each of which tested about the same number of subjects (Washington, D.C. 18; Long Island, New York 20; Charleston, South Carolina 16; San Diego, California 19). Persons with FMS were required to meet the 1990 American College of Rheumatology criteria for diagnosis.¹⁵ These criteria include widespread muscle pain of greater than 3 months' duration and complaints of pain under 4 kg of pressure in 11 of 18 specified tender points. Subjects were recruited as part of a large study that also examined psychiatric and neurocognitive variables in individuals with eosinophilia-myalgia syndrome and individuals who had previously ingested L-tryptophan but had not developed eosinophilia-myalgia syndrome.

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TABLE 1.

Instruments
The subjects completed a battery of self-report scales and a structured clinical interview. Components of the assessment are as follows.

Structured Clinical Interview for DSM-III-R (SCID).¹⁶
The SCID, which has been extensively used for clinical research, was administered to all subjects by interviewers specifically trained in its use. It is designed to assess for the presence of DSM-III-R Axis I disorders on a current and lifetime basis. The somatoform-disorder module was not administered because the investigators did not believe that a distinction between FMS with somatization and FMS without somatization could be made reliably.¹⁷

Because this was a multicenter study, an interrater reliability study was performed by having the raters at each site rate one audiotape of an FMS interview performed at each of the other three sites. For the diagnosis of mood disorders, agreement was 100% (with missing data, i.e., inability to rate a specific diagnosis, 4.5%). For all other disorders, agreement was 100% (with 4.2% missing data).

Beck Depression Inventory (BDI).¹⁸
The BDI is a 21-item measure of current depressive symptoms. The cognitive subscale consists of 14 items, and the neurovegetative subscale consists of 7 items.

Beck Anxiety Inventory (BAI).¹⁹
The BAI is a 21-item measure of state anxiety.

The Rand 36-item Health Survey (SF-36).²⁰
The SF-36 is a self-report measure of functional impairment and well-being. Eight domains are assessed: physical functioning, bodily pain, role limitations due to physical health problems, role limitations due to emotional problems, emotional well-being, social functioning, energy/fatigue, and general health perception. Higher scores indicate better health and less pain.

NEO Personality Inventory-Revised (NEO PI-R).²¹
The NEO PI-R is a 240-item self-report inventory for assessment of personality traits based on the five-factor model of personality. The domains are neuroticism, extroversion, openness to experience, agreeableness, and conscientiousness.

Barsky Amplification Scale.²²
This test is a 10-item scale measuring somatosensory amplification, the tendency to experience somatic sensations as unusually intense or disturbing.

Whitely Index of Hypochondriasis.²³
This test is a 14-item scale that measures hypochondriasis, the tendency to be convinced one has a serious disease.

Dolorimetry Threshold.
The score on this test represents the average amount of pressure (kg) necessary to elicit pain at 18 different "tender points" throughout the body.

Data Analysis
Two-tailed t-tests were used to compare SF-36 means between the patients with and without psychiatric disorders. Stepwise regression was used to predict variance in SF-36 physical functioning.

RESULTS

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Demographic data are in Table 1. Virtually all patients were women, and many were married. Most were white, and the mean years of education indicate that ours was a well-educated sample. Mean age was 46.5, and mean age of diagnosis of FMS was 40.5.

Self-report data are presented in Table 2 and Table 3. The patients had elevations on most self-report psychiatric scales. BDI and BAI scores are in the mildly distressed range. BAI mean of 14.5 is comparable to a range of 18–29 for anxiety disorders and 8–11 for nonclinical samples.¹⁹ The BDI mean of 14 may be compared with research findings that show that cutoffs of 12–14 have high sensitivity and specificity for the diagnosis of depression in medical patients.²⁴ In this sample, the Barsky score revealed a level of amplification of 2.9. (For reference, prior studies with this instrument showed that hypochondriacal persons had a mean ± standard deviation [SD] of 3.05 ± 0.79 and the nonhypochondriacal medical outpatients had a mean ± SD of 2.11 ± 0.60; [Barsky, personal communication, 1993]). The hypochondriasis score of 6.5 is also in the elevated range. The score of this group may be compared with 6.2 in women with CFS²⁵ and with the mean of 2.9 for psychiatric (nonhypochondriacal) inpatients, 2.3 for nonpsychiatric (malignant disease) patients, and 8.9 for hypochondriacal psychiatric inpatients.²³ NEO scores are not elevated (presented as t-scores), with the exception of the neuroticism factor score, a measure of emotional instability or psychological maladjustment, which is nearly three-quarters of an SD greater than the mean for a nonclinical population. The dolorimetry threshold score of 3.3 kg is comparable to other cohorts of fibromyalgia patients and may be compared with a mean ± SD score of 8.1 ± 2.1 found in 114 consecutive female patients from a general medicine clinic (D. Clauw, unpublished data).

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TABLE 2.

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TABLE 3.

As can be seen in Table 3, SF-36 scores are in the severely impaired range across most measures. FMS patients in our study are significantly more impaired than the Medical Outcome Study patients with depression, arthritis, and heart disease.

SCID interviews revealed a high level of lifetime and current major depression and panic disorder, compared with the general population data from the National Comorbidity Survey, in which the Diagnostic Interview Schedule was used (Table 4).²⁷ Lifetime rate of mood disorders was 69% and for anxiety disorders was 35%. Eighty-one percent of the sample had a lifetime history of any psychiatric disorder. Current rate of mood disorders was 29% and for anxiety disorders was 27%. Forty-eight percent of the sample had a current psychiatric disorder.

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TABLE 4.

Among the FMS sample, the patients with current anxiety disorder or current mood disorder showed worse physical functioning and well-being, but differences were significant only for physical functioning for the patients with depression. No significant differences were found when comparing the patients with and without lifetime anxiety and depression (Table 5, Table 6, Table 7, and Table 8).

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TABLE 5.

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TABLE 6.

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TABLE 7.

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TABLE 8.

To test the hypothesis that psychiatric variables would be associated with poorer physical functioning, we performed stepwise regression. Age did not correlate with SF-36 physical functioning (F=-0.19, P=0.87), so it was not entered into the model. We chose variables that would reflect a range of factors that might be expected to contribute to current physical functioning, including scores on the BAI, BDI, Barsky Amplification Scale, Whitely Index of Hypochondriasis, and the dolorimetry threshold. Stepwise regression revealed that BAI score was the only variable that predicted a significant proportion of the variance (29%) in SF-36 physical functioning (beta=-1.33; standard error of beta=0.27, T=-4.9, P<0.000). BDI score approached significance (P=0.09).

DISCUSSION AND CONCLUSIONS

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In this multicenter study, the patients with FMS were found to have high levels of lifetime and current major depression and panic disorder. The prevalence rates are comparable to those of earlier studies that were based on data from a single site. Thus, our data support the view that there is a high prevalence of psychiatric disorders, including major depression and panic disorder, among tertiary-care FMS patients across the country.

What could be responsible for the high prevalence of psychiatric disorders among patients with fibromyalgia? Psychiatric disorders could be a reaction to having a debilitating chronic illness, but rates of psychopathology are higher than those seen in other debilitating illnesses such as cancer²⁸ and human immunodeficiency virus infection.²⁹ Life stressors could predispose one to both FMS and mood/anxiety disorders. This explanation is supported by studies demonstrating a blunted "stress response" in FMS (including decreased production of cortisol in response to corticotropin-releasing hormone or adrenocorticotropic hormone and low 24-hour urine free cortisol), although this is opposite to the changes seen in melancholic depression.³⁰ This hypothesis is also supported by the fact that lifetime rates of panic disorder and depression are quite high in our sample. However, we cannot determine which came first, because it is often difficult to accurately determine when symptoms of fibromyalgia first started. Alternatively, depression/anxiety symptoms could be seen as "symptoms" of fibromyalgia. In this model, FMS is conceptualized as a central nervous system disorder with multiple manifestations, including widespread pain, fatigue, depression, and anxiety.³¹

Functional impairment is severe among this sample of persons with FMS and greater than that found for persons with other chronic medical conditions. The extent of impairment is comparable to that seen in other studies of FMS³ and CFS.^2,12 In the present study, multiple-regression analysis revealed that the best psychological predictor of functional impairment was current anxiety symptoms, and current BDI score approached a significant correlation in the regression model. Thus, it appears that current emotional states correlate with current physical functioning in this population. In addition, on physical functional health-status measures, those with current major depression and those with current anxiety disorders functioned worse than those without these disorders. However, these differences reached statistical significance only for current major depression (vs. not) on the measure of physical functioning. These findings are consistent with those of Komaroff et al.,¹² who found that patients with CFS and depression histories did not differ from those without depression on SF-36 physical health measures, and run contrary to those found in the MOS, in which patients with major depression plus a chronic medical illness had additive functional impairment.³² The reason why this effect was not seen in the patients with FMS is unclear, but may be due to the fact that nondepressed FMS patients have many symptoms of depression that are intrinsic to the illness (thus making it less likely to find a difference between them and the depression group). Alternatively, our sample size may have been too small for significant differences to be detected.

The study addressed not only psychiatric diagnoses and symptoms of anxiety and depression but also psychological measures purported to be associated with somatization, such as neuroticism and hypochondriasis. This cohort of FMS patients had high levels of hypochondriasis and neuroticism. One interpretation of these findings is that some FMS patients are neurotic and hypochondriacal. Alternatively, as discussed by Schweitzer et al.,²⁵ such "trait" features may be more state measures as a reaction to having FMS.

The limitations of this study include the selection scheme. Whereas most of the patients answered an advertisement, some were recruited through patient practice. Thus, it is best to conceptualize our sample as being a patient-based one as opposed to a community-based sample. Since community samples may be less likely to be impaired than tertiary-care samples,¹³ these data cannot be used to estimate the prevalence of psychiatric comorbidity among the general population of individuals with FMS. Nonetheless, we believe our findings are generalizable to patients seen in tertiary-care centers throughout the country. In addition, we relied on self-report data for functional impairment (the SF-36) and not actual measures of physical impairment. Reports of functional ability might not correlate with true functional impairment in FMS.³³ However, reports of impairment are important to understanding a patient's perception of impairment. In addition, it is difficult to assess true levels of impairment in this population.¹² Future studies could examine the correlation between functional impairment reports and measures of performance abilities. Finally, our study reports cross-sectional data only.

This population has both high levels of psychiatric comorbidity and significant functional impairment. The high lifetime comorbidity of the frequently recurring syndromes of panic disorder and major depression suggests that even for the patient who does not present with a current psychiatric disorder, careful psychiatric assessment should be made periodically in the future. When treating a person with FMS, it is important to evaluate carefully and treat all current mood and anxiety disorders, since failure to do so may result in significant physical impairment as well as emotional distress. Treatments such as cognitive–behavioral therapy,³⁴ aerobic exercise,³⁵ and brief consultation management programs³⁶ have been shown to be helpful for patients with FMS and CFS. Medical treatments that may not directly affect depression or anxiety (e.g., low-dose tricyclics or cyclobenzaprine) also benefit many individuals with FMS.

Psychopharmacologic interventions such as amitriptyline, fluoxetine, and venlafaxine have been shown to be helpful for fibromyalgia symptoms,^4,37–39 and these drugs may be helpful for the treatment of psychiatric symptoms, even in the absence of a clinical psychiatric disorder. The present study underscores the importance of including treatment of psychiatric problems such as depression and anxiety in a comprehensive approach to patients with FMS.

FOOTNOTES

 
This study was presented at the 44th Annual Meeting of the Academy of Psychosomatic Medicine, San Diego, CA, November 1997. This work was supported by Showa-Denko Corporation of America.

REFERENCES

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1. Wolfe F, Ross K, Anderson J, et al: The prevalence and characteristics of fibromyalgia in the general population. Arthritis Rheum 1995; 38:19–28[Medline]
2. Buchwald D, Pearlman T, Umali J, et al: Functional status in patients with chronic fatigue syndrome, other fatiguing illnesses, and healthy individuals. Am J Med 1996; 171:364–370
3. Walker EA, Keegan D, Gardner G, et al: Psychosocial factors in fibromyalgia compared with rheumatoid arthritis: I. Psychiatric diagnoses and functional disability. Psychosom Med 1997; 59:565–571[Abstract/Free Full Text]
4. Goldenberg D, Mayskiy M, Mossey C, et al: A randomized, double-blind crossover trial of fluoxetine and amitriptyline in the treatment of fibromyalgia. Arthritis Rheum1996; 39:1852–1859
5. Hudson JI, Hudson MS, Pliner LF, et al: Fibromyalgia and major affective disorder: a controlled phenomenology and family history study. Am J Psychiatry 1985; 142:441–446[Abstract/Free Full Text]
6. Kirmayer LJ, Robbins JM, Kapusta MA: Somatization and depression in fibromyalgia syndrome. Am J Psychiatry 1988; 145:950–954[Abstract/Free Full Text]
7. Ahles TA, Khan SA, Yunus MB, et al: Psychiatric status of patients with primary fibromyalgia, patients with rheumatoid arthritis, and subjects without pain: a blind comparison of DSM-III diagnoses. Am J Psychiatry 1991; 148:1721–1726[Abstract/Free Full Text]
8. Krag NJ, Norregaard J, Larsen JK, et al: A blinded, controlled evaluation of anxiety and depressive symptoms in patients with fibromyalgia, as measured by standardized psychometric interview scales. Acta Psychiatr Scand 1994; 89:370–375[Medline]
9. Ledingham J, Doherty S, Doherty M: Primary fibromyalgia syndrome—an outcome study. Br J Rheumatol 1993; 32:139–142[Abstract/Free Full Text]
10. Wolfe F, Cathey MA, Kleinheksel SM: Fibrositis in rheumatoid arthritis. J Rheumatol 1984; 11:814–818[Medline]
11. Hawley DJ, Wolfe F, Cathey MA: Pain, functional disability, and psychological status: a 12-month study of severity in fibromyalgia. J Rheumatol 1988; 15:1551–1556[Medline]
12. Komaroff AL, Fagioli LR, Doolittle TH, et al: Health status in patients with chronic fatigue syndrome and in general population and disease comparison groups. Am J Med 1996; 101:281–290[Medline]
13. Aaron LA, Bradley LA, Alarcon GS, et al: Psychiatric diagnoses in patients with fibromyalgia are related to health care–seeking behavior rather than to illness. Arthritis Rheum 1996; 39:436–445[Medline]
14. Epstein SA, Williams DA, Osbeck L, et al: Effect of psychological factors on pain perception in fibromyalgia (abstract). Psychosomatics 1995; 36:192
15. Wolfe F, Smythe HA, Yunus MB, et al: The American College of Rheumatology 1990 criteria for the classification of fibromyalgia: report of the multicenter criteria committee. Arthritis Rheum 1990; 33:160–172[Medline]
16. Spitzer RL, Williams JBW, Gibbon M, et al: Structured Clinical Interview for DSM-III-R. Washington, DC, American Psychiatric Press, Inc., 1990
17. Johnson SK, DeLuca J, Natelson BH: Assessing somatization disorder in the chronic fatigue syndrome. Psychosom Med 1996; 58:50–57[Abstract/Free Full Text]
18. Beck AT, Rush AJ, Shaw BF, et al: Cognitive Therapy of Depression. New York, Guilford, 1979
19. Beck AT, Steer RA: Beck Anxiety Inventory Manual. San Antonio, TX, Harcourt Brace, 1990
20. Stewart AL, Hays RD, Ware JE: The MOS Short-Form General Health Survey: reliability and validity in a patient population. Med Care 1991; 26:724–735
21. Costa PT, McCrae RR: NEO Personality Inventory-Revised Professional Manual. Odessa, FL, 1992
22. Barsky AJ, Wyshak G, Klerman GL: The somatosensory amplification scale and its relationship to hypochondriasis. J Psychiatr Res 1990; 24:323–334[Medline]
23. Pilowsky I, Spence ND. Manual for the Illness Behavior Questionnaire, 2nd Edition, 1983. Department of Psychiatry, Royal Adelaide Hospital, University of Adelaide, Adelaide, South Australia
24. Rodin G, Craven J, Littlefield C: Depression in the Medically Ill. New York, Bruner/Mazel, 1991, p. 83
25. Schweitzer R, Robertson DL, Kelly B, et al: Illness behaviour of patients with chronic fatigue syndrome. J Psychosom Res 1993; 38:41–49
26. Sherbourne CD, Wells KB, Judd LL: Functioning and well-being of patients with panic disorder. Am J Psychiatry 1996; 153:213–218[Abstract/Free Full Text]
27. Kessler RC, McGonagle KA, Zhao S, et al: Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry 1994; 51:8–19[Abstract]
28. Massie MJ, Holland JC: Overview of normal reactions and prevalence of psychiatric disorders, in Handbook of Psychooncology, edited by Holland JC, Rowland, JH. New York, Oxford University Press, 1989, pp. 273–282
29. Perkins DO, Stern RA, Golden RN, et al: Mood disorders in HIV infection: prevalence and risk factors in a nonepicenter of the AIDS epidemic. Am J Psychiatry 1994; 151:233–236[Abstract/Free Full Text]
30. Clauw DJ, Chrousos GP: Chronic pain and fatigue syndromes: overlapping clinical and neuroendocrine features and potential pathogenic mechanisms. Neuroimmunomodulation 1997; 4:134–153[Medline]
31. Clauw DJ: Fibromyalgia: more than just a musculoskeletal disease. Am Fam Physician 1995; 52:843–851[Medline]
32. Wells KB, Stewart A, Hays RD, et al: The functioning and well-being of depressed patients: results from the Medical Outcomes Study. JAMA 1989; 262:914–919[Abstract]
33. Turk DC, Okifuji A, Sinclair JD, et al: Pain, disability, and physical functioning in subgroups of patients with fibromyalgia. J Rheumatol 1996; 23:1255–1262[Medline]
34. Sharpe M, Hawton K, Simkin S, et al: Cognitive behaviour therapy for the chronic fatigue syndrome: a randomised controlled trial. BMJ 1996; 312: 22–26
35. Wigers SH: Effects of aerobic exercise versus stress management treatment in fibromyalgia: a 4.5-year prospective study. Scand J Rheumatol 1996; 25:77–86[Medline]
36. Granges G, Zilko P, Littlejohn GO: Fibromyalgia syndrome: assessment of the severity of the condition 2 years after diagnosis. J Rheumatol 1994; 21:523–529[Medline]
37. Dwight MM, Arnold LM, O'Brien H, et al: An open clinical trial of venlafaxine treatment of fibromyalgia. Psychosomatics 1998; 39:14–17[Abstract/Free Full Text]
38. Goldenberg DL, Felson DT, Dinerman H: A randomized controlled trial of amitriptyline and naproxen in the treatment of patients with fibromyalgia. Arthritis Rheum 1986; 29:1371–1377[Medline]
39. Carette S, McCain GA, Bell DA, et al: Evaluation of amitriptyline in primary fibrositis: a double-blind, placebo-controlled study. Arthritis Rheum 1986; 29:655–659[Medline]

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