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Psychiatric diagnoses in patients with fibromyalgia are related to health careseeking behavior rather than to illness.

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ARTHRITIS & RHEUMATISM
Vol. 39, No. 3, March 1996, pp 4 3 W 5
0 1996, American College of Rheumatology
436
.
.. . .-
PSYCHIATRIC DIAGNOSES IN PATIENTS WITH FIBROMYALGIA
ARE RELATED TO HEALTH CARE-SEEKING BEHAVIOR
RATHER THAN TO ILLNESS
LESLIE A. AARON, LAURENCE A. BRADLEY, GRACIELA S. ALARC6N, RONALD W. ALEXANDER,
MIREYA TRIANA-ALEXANDER, MICHELLE Y. MARTIN, and KRISTIN R. ALBERTS
Objective. To compare the frequency of lifetime
psychiatric disorders among 3 groups of subjects: patients with fibromyalgia syndrome (FMS) from a tertiary care setting, community residents with FMS who
had not sought medical care for their FMS symptoms
(‘ ‘FMSnonpatients’’), and healthy controls.
Methods. We used the Computerized Diagnostic
Interview Schedule to assess lifetime psychiatric diagnoses, as well as the Center for Epidemiological Studies
Depression scale and the Trait Anxiety Inventory to
assess current psychological distress, among 64 patients
with FMS, 28 FMS nonpatients, and 23 healthy individuals.
Results. Patients with FMS, relative to F M S
nonpatients and healthy controls, were characterized by
a significantly greater number of lifetime psychiatric
diagnoses (P= 0.002). Nonpatients did not differ from
controls in psychiatric diagnoses. Patients also exhibited
higher psychological distress levels than nonpatients,
and nonpatients showed greater distress than controls.
Differences in psychological distress between patients
and nonpatients were eliminated after controlling for
pain threshold and fatigue ratings.
Conclusion. Psychiatric disorders are not intrinsically related to the FMS syndrome. Instead, multiple
lifetime psychiatric diagnoses may contribute to the
Supported by National Institute of Arthritis, Musculoskeletal and Skin Diseases grants 1 ROl-AR-43136-01 and P60-AR-20164,
and by National Center for Research Resources grant 5-MOI-00032.
Leslie A. Aaron, MA, Laurence A. Bradley, PhD, Graciela
S. Alarc6n, MD, MPH, Ronald W. Alexander, MA, Mireya TrianaAlexander, BA, Michelle Y. Martin, MA, Kristin R. Alberts, BA:
School of Medicine, The University of Alabama at Birmingham.
Address reprint requests to Leslie A. Aaron, MA, Division
of Clinical Immunology and Rheumatology, The University of
Alabama at Birmingham, 429 Tinsley Harrison Tower, 1900 University Boulevard, Birmingham, A L 35294-0006.
Submitted for publication June 15, 1995; accepted in revised form October 9, 1995.
decision to seek medical care for FMS in tertiary care
settings.
Fibromyalgia syndrome (FMS) is a relatively
common, chronic musculoskeletal pain disorder of
unknown cause that affects -15% of rheumatology
clinic patients (1). The etiopathogenesis of FMS is not
understood, but peripheral factors (e.g., muscle tissue
abnormalities) and central factors (e.g., ,neurohormonal changes, abnormal regional cerebral blood flow)
have been associated with symptom onset ( 2 4 ) .
Psychiatric disorders and psychological distress
represent one set of central factors that may influence
the behavior of patients with FMS. Some investigators
have suggested that psychiatric illness also may play a
role in the development of FMS. For example, Hudson and colleagues recently utilized a structured interview, the Diagnostic Interview Schedule, to assess
lifetime rates of psychiatric diagnoses in patients with
FMS or rheumatoid arthritis (RA) in a tertiary care
rheumatology clinic. Higher rates both of major mood
disorders (64% versus 22%) and of panic disorder or
agoraphobia (33% versus 11%) were found in FMS
versus RA patients. Moreover, for the majority of
diagnoses, initial symptoms predated the onset of pain
among the FMS patients (5,6). Although these observations were based on the interview responses of
patients who may not have been representative of
community residents with FMS, it was concluded that
FMS may share a common pathophysiology with
depressive and anxiety disorders.
Wolfe and colleagues recently examined psychological distress in FMS clinic patients and community residents with FMS (7). They found high levels of
psychological distress in both groups and therefore
suggested that psychological distress is intrinsically
related to the FMS syndrome. However, the cornmu-
PSYCHIATRIC DIAGNOSES, HEALTH CARE-SEEKING, AND FMS
nity residents were older than the clinic patients in
their study, and many of the community residents also
had other painful conditions for which they had consulted physicians during the 6 months prior to the
study assessment. Moreover, psychological distress
was assessed using questionnaires that tend to yield
inflated scores among individuals with chronic pain
conditions (8-10). Thus, the high levels of psychological distress reported by the community residents may
have been related to painful comorbid conditions that
often required medical treatment, and/or to extraneous
measurement factors, rather than to FMS per se.
These findings suggest that it is necessary to
examine the relationships between FMS,psychiatric
disorders, and psychological distress independently of
health careseeking for painful symptoms. It also is
necessary to attempt to confirm the finding by Hudson
et al that psychiatric disorders tend to predate the
onset of FMS symptoms in persons with FMS. We
therefore used the Diagnostic Interview Schedule and
standardized questionnaires to evaluate the frequency
of lifetime psychiatric disorders and current psychological distress among 3 groups that were comparable
in age, education level, and sex composition, i.e.,
patients with FMS from a university-based rheumatology practice, community residents with FMS who had
not seen a physician for their pain symptoms in the last
10 years (“FMSnonpatients”), and healthy controls.
We also examined the temporal relationship between
psychological diagnoses and onset of FMS among
patients and nonpatients, and we assessed the degree
to which psychological distress was associated with
severity of FMS symptoms.
We tested 2 hypotheses regarding the psychiatric diagnoses and 3 hypotheses concerning psychological distress. With respect to the diagnoses, we
hypothesized that patients with FMS would be characterized by a significantly greater number of lifetime
psychiatric diagnoses than either FMS nonpatients or
healthy controls. We also anticipated that the majority
of both patients and nonpatients would report that the
initial symptoms of their psychiatric disorders began
prior to the onset of their F M S pain. With regard to
psychological distress, we expected that FMS patients
and nonpatients would report higher levels of distress
than healthy controls, and, in addition, that patients
with FMS would show significantly higher levels of
psychological distress than FMS nonpatients. However, we also hypothesized that group differences in
psychological distress would be eliminated after controlling for pain threshold and level of fatigue.
437
PATIENTS AND METHODS
This investigation was approved by the Institutional
Review Board of The University of Alabama at Birmingham
(UAB) on March 1, 1991.
Subjects. Subjects were recruited as part of an ongoing study of factors related to health careseeking in persons
with FMS. All subjects received a $25.00 payment for their
participation.
Patients. A group of 64 patients with FMS (60
women, 4 men) was recruited from the 1992 UAB rheumatology clinic database and from consecutive patients referred
to the rheumatology clinic during 1993-1994. The sample
consisted of 57 white and 7 African-American subjects.
Inclusion criteria were (a) age 18-65 years and (b) a diagnosis
of FMS confirmed with a comprehensive clinical evaluation
by a board-certified rheumatologist using the American
College of Rheumatology (ACR) criteria (1 1). This evaluation included an examination of the 18 tender points identified in the ACR classification study of FMS (11). Other
rheumatologic disorders, as well as chronic fatigue syndrome, were ruled out. Thus, the psychiatric disorders
identified among these subjects could not be attributed to
the experience of painful musculoskeletal disorders other
than FMS.
There were 107 patients referred to the study, 105 of
whom were contacted by the project staff, met all entry
criteria, and were scheduled for assessment. The final group
of 64 patients with FMS reflects those who completed all
assessment procedures. This group did not differ in mean
age, sex composition, or mean education level from the
patients who failed to keep their assessment appointments.
Nonpatients. FMS nonpatients consisted of 28 volunteer residents of the Birmingham and Jefferson County
community (27 women, 1 man) who responded to newspaper
advertisements seeking persons with muscular aches and
pains who had not sought medical treatment for their symptoms during the last 10 years. AU subjects were white. The
advertisements directed these volunteers to telephone a
central number in the Division of Clinical Immunology and
Rheumatology at UAB. By telephone, the volunteers were
administered a valid screening interview for FMS (12) and
were asked several questions regarding their health care
history. If the volunteers met the interview criteria for FMS,
they were invited to the UAB rheumatology clinic to undergo a clinical evaluation and tender point examination by
one of the project rheumatologists (GSA).
The potential subjects again were questioned during
the clinical evaluation about their usage of health care
services, in order to screen out individuals who had sought
medical or chiropractic care for FMS-related symptoms.
Whenever possible, UAB medical records for persons who
received their primary health care at our institution were
reviewed, in order to verify the absence of past treatment for
FMS. Individuals who met the ACR criteria for FMS, did
not meet criteria for any other rheumatologic diagnosis, and
had not sought medical or chiropractic treatment for their
symptoms in the last 10 years were asked to participate in
the study.
It should be noted that, of the 204 persons who
responded to the advertisements, 90 met the interview
AARON ET AL
438
criteria for FMS and were examined by the rheumatologist.
Of these 90 individuals, 44 were diagnosed as having FMS,
met all other entry criteria, and were scheduled for study
assessment. The final group of 28 FMS nonpatients consisted of those individuals who completed all assessment
procedures. This nonpatient group did not differ in age, sex
composition, or education level from the nonpatients who
failed to keep their assessment appointments.
Healthy controls. The healthy control group consisted of 23 volunteer residents of the Birmingham and
Jefferson County community (21 women, 2 men) who responded to newspaper advertisements seeking persons who
did not have muscular aches and pains and who considered
themselves to be healthy. This sample consisted of 22 white
subjects and 1 African-American. A telephone screening
procedure similar to that used for the nonpatients was
utilized with the control subjects, and potential subjects
were invited to attend the clinic for a clinical evaluation and
tender point examination. The volunteers were asked to
participate in the study only after successful completion of
the evaluation.
Given the need to ensure that subject groups were
comparable in terms of age, sex, and education level, 137
healthy persons were excluded from the initial pool of 232
advertisement respondents. The major reason for exclusion
was failure to match on the sex variable. Of the 95 remaining
subjects, 61 met all entry criteria and were scheduled for
study assessment. A group of 23 healthy persons completed
all assessment procedures. This group did not differ in age or
education level from the healthy persons who failed to keep
their assessment appointments.
Demographic and clinical symptom interview. An
initial interview was administered at the start of each assessment. Information on demographic variables including age,
sex, and education was obtained for all subjects. FMS
patients and nonpatients also were asked to report time since
the onset of pain (pain duration) and to record present pain
intensity on a 10-cm visual analog scale (VAS).
Pain threshold stimulus. Pain threshold levels were
obtained from 5 paired (left, right) tender points included in
the ACR criteria for FMS, using a standard dolorimeter
(Chatillon Instruments, Kew Gardens, NY). The tender
points included the following: the knee at the medial fat pad,
the second rib at the second costochondral junctions, the
gluteal at the upper outer quadrant of the buttocks, the
trapezius at the midpoint of the upper border, and the lower
cervical at the anterior aspect of the intertransverse spaces
at C K 7 . The use of these tender points is standard procedure in our laboratory (4). A mean pain threshold level was
obtained by summing the thresholds at each tender point and
dividing by 10. We have reported a high level of interrater
reliability among the 4 trained research associates who
administered the pain threshold assessment in this study
(93.5%; K = 0.87) (4).
Self-report questionnaires. Fatigue. Current levels of
fatigue were assessed with the Fatigue Severity Scale (FSS),
a 9-item scale designed to assess the extent to which fatigue
interferes with activities of daily living (13). Krupp and
colleagues have demonstrated the internal reliability and
validity of this instrument (13).
Table 1.
Selected psychiatric disorders by diagnostic category*
Anxiety
Simple phobia
Social phobia
Generalized anxiety disorder
Panic disorder
Agoraphobia
Post-traumatic stress
disorder
Obsessive compulsive
disorder
Mood
Major depression
Major depression-recurrent
episode
Bipolar disorder
Dysthymia
Behaviodcharacter
Alcohol abuse/dependence
Other substance abuse/
dependence
Prescription drug abuse/
dependence
Pathological gambling
Antisocial personality
disorder
Body image
Anorexia nervosa
Bulimia nervosa
Somatization disorder
* Diagnoses derived from the Computerized Diagnostic Interview
Schedule, a computerizedinterview that generates psychiatric diagnoses from criteria in the Diagnostic and Statistical Manual of
Mental Disorders, third edition, revised.
Depression. Current symptoms of depression were
assessed using the Center for Epidemiological Studies Depression scale (CES-D) (14). This 20-item measure is a
reliable and valid indicator of depression in both clinical and
research populations (14). The CES-D items are relatively
free of content related to pain and functional limitations
associated with rheumatologic disorders (15); thus, depression scores are not spuriously inflated by pain.
Anxiery. The Trait Anxiety Inventory (TAI) was
used to measure a stable disposition characterized by tension and apprehension across time and setting (16). The
20-item TAI is reliable and valid and is the most commonly
used measure of trait anxiety in psychological and behavioral medicine research (16).
Structured psychiatric interview: the Diagnostic Interview Schedule. The Diagnostic Interview Schedule (DIS) is a
structured psychiatric interview that generates current and
lifetime diagnoses based on the Diagnostic and Statistical
Manual of Mental Disorders, thud edition, revised (17). The
DIS is a reliable and valid interview (18,19) that has been
used in several studies of psychological status in patients
with FMS (20,21). Our subjects used a self-administered
computerized version of the DIS (CDIS-R) with assistance
from one of the research associates. This computerized
interview, developed in cooperation with the original developers of the DIS, is highly correlated with the original
version (the C-DIS Group, Ottawa Civic Hospital, Ottawa,
Ontario, Canada) (22). In addition to determining the psychiatric diagnoses for the subject, the CDIS-R assesses the
exact age at which symptoms of each diagnosis first began.
Thus, we calculated the time of symptom onset for all
psychiatric diagnoses relative to the time of onset of the
subject’s FMS pain. In order to facilitate analyses, each of
the 40 psychiatric diagnoses generated by the CDIS-R was
assigned to 1 of 4 categories: anxiety, mood, body image,
and behavioral disorders (Table 1). The total number of
PSYCHIATRIC DIAGNOSES, HEALTH CARE-SEEKING, AND FMS
lifetime psychiatric diagnoses (i.e., both past and current
diagnoses) then was calculated for every subject.
Procedure. Informed consent was obtained at the
time of the clinical evaluation. Subjects who met all entry
criteria were asked by the rheumatologist, and reminded
later by telephone, to discontinue all analgesic, antiinflammatory, and psychotropic medication 4 days prior to assessment in the UAB General Clinical Research Center (GCRC).
Subjects who were taking psychotropic medication were
instructed to gradually taper and then discontinue these
medications. Approximately 1 week before assessment, all
subjects received the CES-D, TAI, and FSS instruments by
mail, along with written instructions to complete the questionnaires and bring them to the GCRC.
Each subject’s assessment began at 8:OO AM. First, 1
of 4 research associates administered the demographic and
clinical symptom interview. The research associate then
measured the subject’s pain threshold levels using a procedure that is standard in our laboratory (4,23). After marking
the specified tender points with a colored pen, the research
associate gave the subject a card (21.5 x 28 cm) displaying a
7-category scale in which 0 = no pressure, 1 = faint
pressure, 2 = moderate pressure, 3 = severe pressure, 4 =
faint pain, 5 = moderate pain, and 6 = severe pain. The
subject was instructed to view the card throughout the
procedure and to say the word “now” when shelhe experienced “faint pain” (i.e., the equivalent of 4 on the scale or
pain threshold). Next, the research associate used the dolorimeter at each tender point to deliver pressure levels of
increasing intensity at a rate of 1 kdl.54 cmz per second until
the subject reported “faint pain.” The research associate
then withdrew the dolorimeter and recorded the pressure
intensity. After all pain assessment procedures were completed, the subject had a 1-hour rest.
Following the rest, the research associate instructed
the subject to self-administer the CDIS-R. The research
associate remained with the subject during the interview to
answer any questions the subject may have had concerning
specific items.
Statistical analyses. Three sets of statistical analyses
were performed. First, a series of one-way analyses of
variance (ANOVA) with the between-subject variable of
group (patient, nonpatient, healthy control) were used to test
for daerences in age and education levels. The F-tests were
not significant; thus, no pairwise comparisons were evaluated for these variables. A chi-square test of independence
was used to determine whether there were differences
among groups in the distribution of white and AfricanAmerican subjects. In addition, ?-tests were performed to
assess differences between patients and nonpatients in pain
duration and pain intensity levels. Alpha levels of 0.05 were
used for all analyses.
Next, number of lifetime psychiatric diagnoses was
entered as the dependent variable in a one-way ANOVA,
with the between-subject variable of group and an alpha
level of 0.05. To test hypotheses concerning total number of
diagnoses, t-tests for non-orthogonal comparisons were performed. Group differences in frequency of diagnoses within
each of the 4 diagnostic categories (anxiety, mood, body
image, behavioral) were evaluated by chi-square tests of
independence, with alpha levels of 0.05. When significant
439
group effects were found, a 2-tailed Fisher’s exact test was
performed to compare both patients and nonpatients with
controls, using an alpha level of 0.01 (24).
Finally, a series of one-way ANOVAs was performed with the between-subject variable of group, to evaluate dserences in total number of tender points, pain
thresholds at the tender points, and scores on the FSS,
CES-D, and TAI. To test hypotheses regarding these variables, t-tests for non-orthogonal comparisons were then
used. A series of analyses of covariance (ANCOVA) also
was performed, to test whether group differences on the
CES-D and TAI were maintained after controlling for FSS
and tender point pain threshold scores. An alpha level of
0.05 was used to evaluate the significance for each of the
ANOVA and ANCOVA analyses, because each tested a
pre-specified hypothesis.
RESULTS
Demographic and clinical variables. Table 2
shows the demographic and clinical characteristics of
the 3 subject groups. There were no differences in age,
education, or the distribution of white and AfricanAmerican subjects among the groups. Furthermore,
F M S patients and nonpatients did not differ in the
amount of time since the onset of symptoms (i.e., pain
duration). However, there were significant group differences in number of tender points, pain threshold,
pain intensity, and fatigue. First, a significant main
effect of group was found for total number of tender
points (F = 220.87, P <.0001). Patients with FMS
exhibited a significantly greater number of tender
points than nonpatients and controls (P 5 0.01).
Nonpatients also exhibited a significantly greater number of tender points than healthy controls ( P <
0.0001). Next, a significant main effect of subject
group on pain threshold was found (F = 125.61, P <
O.OOOl), in which patients with F M S had a significantly
lower pain threshold level than those in both the
nonpatient and the healthy control groups ( P < 0.001).
In addition, nonpatients displayed a significantly lower
pain threshold level compared with healthy controls
(P< 0.001).
Similar results were obtained with regard to
subjects’ reports of fatigue and pain intensity. A
significant main effect of group on FSS scores was
found (F = 65.61, P < 0.OOOl). Patients with FMS
reported significantly higher levels of fatigue than
nonpatients and controls (P < 0.001). In addition,
nonpatients reported a significantly higher fatigue level
than did healthy controls (P < 0.001). Finally, it was
found that patients with FMS reported significantly
AARON ET AL
440
Table 2. Demographic and clinical characteristics by subject group*
FMS patients
(n = 64)
FMS nonpatients
Variable
Age, yearst
Education, yearst
Pain duration, monthst
No. of tender points$
Pain threshold (at tender points)§
Fatigue severity4
FMS pain intensity, 10-cm VASt
45.0 f 1.4
12.9 f 0.3
87.7 2 10.7
16.4 f 0.3
1.9 f 0.1
6.1 f 0.1
6.8 2 0.3
50.9 f 2.1
13.3 f 0.4
110.3 f 22.8
14.9 0.7
2.6 f 0.1
4.5 f 0.3
4.3 f 0.4
(n = 28)
*
Controls
(n = 23)
43.7 f 3.3
13.9 2 0.4
-
2.5 2 0.6
5.4 f 0.3
2.7 ? 0.2
-
* Values are the mean f SEM. FMS = fibromyalgia syndrome; VAS = visual analog scale.
t There were no significant differences among subject groups in these variables or in the distribution
of white and African-American subjects (patients 51 white, 7 African-American; nonpatients 28 white,
0 African-American; controls 22 white, 1 African-American).
$ P < 0.01, patients versus nonpatients and controls, and nonpatients versus controls.
8 P < 0.001, patients versus nonpatients and controls, and nonpatients versus controls.
IT P < 0.001, patients versus nonpatients.
higher levels of pain intensity on the VAS than did the
nonpatients (P < 0.001).
Lifetime psychiatric diagnoses. Figure 1 shows
the mean ? SEM number of lifetime psychiatric
diagnoses for the 3 subject groups. A significant main
effect of group on total number of lifetime psychiatric
diagnoses was found (F = 8.01, P = 0.0006). Patients
with FMS met criteria for a significantly greater number of diagnoses than did FMS nonpatients and controls (P = 0.002). Remarkably, there was no significant
s
3'53
8
1
T
FM Patients
FM Non-patients
2 2.5
0Controls
-4
0
-
0
2
*
2
1.5
a
z
c 1
I
I
0.5
0
N = 64
N = 28
N = 23
Figure 1. Mean 2 SEM number of lifetime psychiatric diagnoses
for patients with fibromyalgia (FM),FM nonpatients, and healthy
controls. Patients with FM met criteria for a significantly greater
number of lifetime psychiatric diagnoses than nonpatients and
controls (P= 0.002). However, there was no significant difference
between nonpatients and controls in the number of psychiatric
diagnoses.
difference in number of diagnoses between FMS nonpatients and healthy control subjects.
Table 3 shows the percentage of individuals
who met criteria for the psychiatric diagnoses that
reliably differentiated the subject groups within the 4
diagnostic categories. In all subject groups, anxiety
and mood disorders were found most frequently. Patients were significantly more likely than healthy controls to meet criteria for at least 1 psychiatric diagnosis
in the anxiety, mood, and body image diagnostic
categories (P < 0.01). In contrast, nonpatients did not
differ from control subjects in the frequency of psychiatric diagnoses within any category.
Table 3 also reveals that within the category of
anxiety diagnoses, only simple phobia (P = 0.001)
reliably distinguished the subject groups. Panic disorder with agoraphobia also tended to differentiate the
groups (P = 0.05), but did not meet our stringent
criterion for significance. Patients with FMS were
more likely than nonpatients and controls to meet
criteria for 2 of the mood disorders: major depressive
episode (P = 0.001) and dysthymia (P = 0.004).
However, major depression-recurrent episode and
bipolar disorder also tended to distinguish the groups
(P = 0.014 and P = 0.043, respectively). Finally, the
only diagnosis within the body image category that
differentiated patients with FMS from the other subject groups was somatization disorder (P = 0.004).
There were no significant differences among subject
groups in the overall frequency of the behavior/
character diagnoses; thus, no further analyses of individual diagnoses in that category were performed.
PSYCHIATRIC DIAGNOSES, HEALTH CARE-SEEKING, AND FMS
441
Table 3. Percentage of individuals with psychiatric diagnoses by subject group
FMS patients
Diagnosis
(n = 64)
Anxiety
Simple phobia
Panic disorder with agoraphobia
Mood
Major depressive episode
Major depression-recurrent episode
Dysthymic disorder
Bipolar disorder
Body image
Somatization disorder
Behaviork haracter
60
38
II
52
39
25
22
13
34
23
21
FMS nonpatients
(n = 28)
Controls
(n = 23)
36
18
0
18
26
4
0
22
9
4
0
0.008*
0.001
0.050t
0.002*
0.001
0.014t
0
0.043t
0.002*
11
1
I
4
14
10
14
P
0.004
4
0
13
0.004
0.23
* Probability of meeting criteria for at least I diagnosis in this category: P < 0.01. fibromyalgia
syndrome (FMS) patients versus controls; P not significant, FMS nonpatients versus controls.
t Group differences did not reach the stringent significance level of P 5 0.01 established by the
Bonferroni correction procedure.
Table 4 illustrates the time of onset of psychiatric symptoms relative to the onset of FMS pain
among patients with FMS and FMS nonpatients. Both
patients and nonpatients consistently reported that the
symptoms associated with anxiety and body image
diagnoses predated the onset of FMS pain. In contrast,
nearly half of all patients reported that symptoms of
the mood-related diagnoses followed the onset of pain.
Nonpatients, however, reported that symptoms of all
mood-related diagnoses first occurred prior to FMS
pain onset.
Current psychological distress. Figure 2 shows
the mean k SEM scores for each subject group on the
measures of anxiety and depression, the TAI and
CES-D. There were significant group effects on both
the TAI (F = 17.30, P = 0.OOOl) and the CES-D (F =
23.44, P = 0.OOOl). Specifically, patients with FMS
reported significantly higher levels of current anxiety
than nonpatients and healthy controls (P = 0.001). In
addition, nonpatients reported significantly higher levels of anxiety than the controls (P= 0.016). A similar
pattern of results was found on CES-D scores. Patients with FMS reported significantly greater levels of
depression than FMS nonpatients ( P = 0.001) and
controls (P = 0.026); FMS nonpatients reported significantly higher depression levels than controls ( P =
0.026). However, the group differences were eliminated when pain threshold and fatigue levels were
Table 4. Onset of psychiatric symptoms relative to fibromyalgia-syndrome (FMS) pain in FMS
patients and nonpatients
Subject group
Anxiety disorder symptoms
Patients
Nonpatients
Mood disorder symptoms
Patients
Nonpatients
Body image disorder symptoms
Patients
Nonpatients
Symptoms
pre-FMS pain*
Symptoms
post-FMS paint
Symptoms both
pre- and post-FMS pain$
I5
5
20
80
20
0
50
40
0
10
0
15
10
0
0
100
15
100
* Percentage of FMS patients (n = 64)and nonpatients (n = 28) who reported that symptoms for all
psychiatric diagnoses in each diagnostic category began before onset of FMS pain.
t Percentage of FMS patients and nonpatients who reported that symptoms for all psychiatric
diagnoses in each diagnostic category began after onset of FMS pain.
$ Percentage of FMS patients and nonpatients who reported that symptoms of psychiatric diagnoses
in each diagnostic category began both prior to and after onset of FMS pain.
AARON ET AL
442
80 FM Patients
70 -
FM Non-patients
0Controls
60-
2
8
S
50.
40.
Q
Q)
30.
20.
10
0
TAI
CES-D
Figure 2. Mean f SEM scores on the Trait Anxiety Inventory
(TAI) and the Center for Epidemiological Studies Depression scale
(CES-D) among patients with fibrornyalgia (FM), FM nonpatients,
and healthy controls. Patients had significantly higher scores than
nonpatients and controls on the TAI (P = 0.001) and the CES-D
(P 5 0.026). Nonpatients also had significantly higher scores than
the controls on both of these measures (P5 0.026). However, the
group differences were eliminated when pain threshold and fatigue
levels were statistically controlled for in reanalyses of the TAI and
CES-D scores.
statistically controlled for in analyses of TAI (F =
0.82, P = 0.445) and CES-D scores (F = 2.34, P =
0.101).
DISCUSSION
This is the first reported study of the relationship between psychiatric disorders and health careseeking behavior in persons with FMS. We compared
the frequency of lifetime psychiatric disorders in
healthy controls and 2 groups of persons with FMS
and no other rheumatologic or musculoskeletal disorders: patients recruited from a university-based rheumatology practice and community residents who had
not sought medical care for their pain (i.e., FMS
nonpatients). We found that FMS patients were characterized by a significantly greater number of lifetime
psychiatric diagnoses than nonpatients and healthy
controls. The patients met criteria for a mean of -3
lifetime psychiatric diagnoses, whereas both the nonpatients and the controls met criteria for a mean of -1
diagnosis. Hudson et al (6) have suggested that the
high rates of affective and anxiety-based psychiatric
disorders among patients with FMS indicate that these
disorders share a common pathophysiologic mechanism with FMS. If this were the case, one would
expect to find few differences in psychiatric morbidity
between patients and nonpatients with FMS. However, the low frequencies of psychiatric diagnoses
among our FMS nonpatients strongly suggest that
psychiatric illness is not intrinsically associated with
the FMS syndrome.
We also examined psychological distress and
symptom levels in our subject groups and found that
patients reported significantly higher levels of anxiety,
depression, and fatigue than nonpatients and healthy
controls. In addition, the patients displayed significantly lower pain threshold levels than the other
subject groups. However, the differences in psychological distress between patients and nonpatients were
eliminated after controlling for pain threshold and
fatigue. These findings suggest that psychological distress in persons with FMS is strongly associated with
symptom severity. These observations differ from
those of Wolfe et a1 (7),who reported that both FMS
clinic patients and community residents were characterized by high but comparable levels of psychological
distress.
It should be noted that the investigation by
Wolfe and colleagues was a population-based epidemiologic study that did not control for covarying
factors such as age or health care usage for FMS or
comorbid painful conditions that tend to be associated
with psychological distress. Thus, the investigators
could not examine the relationship between FMS and
psychological distress independently of these covarying factors. In contrast, we performed a case-control
study in which both patients and nonpatients experienced pain due solely to FMS and in which the patient
and nonpatient groups did not differ from one another
or from healthy controls in any background variables
including age. Therefore, differences among our subject groups in symptom levels, psychological distress,
and frequency of psychiatric disorders suggest that,
although psychiatric disorders are not intrinsically
related to FMS, multiple psychiatric illnesses and high
levels of psychological distress and FMS-related
symptoms may be important factors that impel persons with FMS to seek medical care for their pain.
This conclusion is consistent with previous
studies of persons with irritable bowel syndrome,
which indicate that high levels of symptom severity
(e.g., pain, diarrhea) and psychological distress differ-
PSYCHIATRIC DIAGNOSES, HEALTH CARE-SEEKING, AND FMS
entiate tertiary care patients from community residents with initable bowel syndrome who do not seek
treatment (25,26).Indeed, these reliable relationships
among symptom severity, psychological factors, and
health care-seeking behavior across syndromes support Wolfe et al’s contention that community residents
with FMS and comorbid painful conditions who frequently have sought health care are characterized by
high levels of psychological distress.
It is important to note that our findings regarding rates of psychiatric illnesses in persons with FMS
cannot be attributed to sources of error in our measurement procedures or to unique psychological features of our subject groups. With regard to measurement, we assessed psychiatric illness using a reliable,
computerized version of the same structured interview, the DIS, used in previous studies of patients
with FMS (6) and persons in the general population
(27,28).With regard to psychological features, the
frequency of psychiatric diagnoses in our groups was
very similar to that found in independent studies of
FMS patients and the general population. For example, our patient group is comparable in psychiatric
morbidity with other samples of patients with FMS
from tertiary care clinics, including those studied by
Hudson et a1 (6). Both our FMS patient group and the
FMS patient group described in the report by Hudson
and colleagues exhibited very high rates of major
mood disorders, such as major depressive episode
(39% and 58%, respectively) and anxiety disorders,
such as panic disorder with agoraphobia (11% and
33%, respectively). These frequencies greatly exceed
the prevalence rates found in 3 population-based studies for major depressive episode (47%) and panic
disorder ( 1 . 4 1 3%) (27).
Moreover, the pattern of psychiatric diagnoses
found in our patients is consistent with the psychological profile of women in the general population who
seek health care. The National Institute of Mental
Health has reported that both simple phobias and
major mood disorders occur more often in women who
frequently use medical services relative to those who
do not (28).Accordingly, the members of our patient
sample were characterized by substantially higher
frequencies of simple phobia (38%) and major mood
disorders (52%) compared with the nonpatients (18%
and 18%, respectively) and healthy controls (4%
and 22%).
In contrast to the high rates of psychiatric
disorders in our patient sample, both our FMS nonpatient group and our healthy control group were char-
443
acterized by low levels of psychiatric morbidity that
were similar to those in the general population. For
example, the frequencies of major depressive episode
in the nonpatients (1 1%) and healthy controls (Wo)
do not differ substantially from the 47% found in
population-based studies (27).The rates of panic disorder with agoraphobia in our nonpatients (0%) and
controls (0%) are also comparable with the I-2%
frequencies found in the general population (27). Finally, the frequencies of simple phobia in our nonpatients (18%) and controls (4%) are consistent with the
population-based prevalence rates for this disorder
(8-23%) (27).Thus, the difference in lifetime psychiatric diagnoses between patients and nonpatients with
FMS cannot be attributed to measurement error or to
unusual patterns of psychiatric illness that deviate
from those found in other studies of patients or the
general population.
In addition to examining the frequencies of
psychiatric disorders, we assessed the time of onset of
psychiatric symptoms relative to the onset of FMS
pain. The majority of patients and nonpatients reported that the symptoms of their anxiety-based and
body image disorders first occurred prior to the onset
of pain. This is consistent with the findings that
phobias and eating disorders tend to first appear in
childhood or adolescence (17).The nonpatients also
exhibited this temporal pattern in the symptoms of
their mood disorders. However, similar to findings by
Hudson et al (6),approximately one-half of the patients reported that their mood disorder symptoms
followed the onset of FMS pain. The observation that
depression may both precede and follow the onset of
chronic pain is consistent with the results of prospective epidemiologic investigations in the general population (29).
The onset of mood disorders after the development of FMS may be related to poor coping strategies
among some patients in response to development of a
chronic pain syndrome (30).However, it is also possible that a subset of persons who seek health care for
FMS do not recognize their symptoms of affective
illness until after they develop FMS symptoms. The
pain itself may serve as a cue for the recognition of
affective distress. For example, it is well known that
women who have been sexually or physically abused
often obtain multiple medical treatments but infrequently seek mental health services immediately following the abusive event (3I). However, when abused
women seek treatment at tertiary care specialty clinics
for chronic painful disorders, they tend to report high
444
levels of depression (31). It may be, then, that the large
numbers of abused women found in FMS patient
groups (5345%) account for a substantial number of
reports of mood disorder onset following the development of pain (32-34).
It may seem surprising that psychological distress levels among our patients and nonpatients were
highly associated with pain threshold and fatigue levels, given that the onset of psychiatric disorders
among these subjects frequently tended to predate the
development of FMS. It must be remembered, however, that psychological distress represents a set of
observable behaviors that is influenced by multiple
factors in addition to psychiatric history. These factors
may include pain, fatigue, use of coping strategies, and
social support. Thus, the correspondence between
lifetime psychiatric disorders and current levels of
psychological distress may not always be strong. One
example of this imperfect correspondence may be seen
in our finding that although both patients and nonpatients reported high levels of psychological distress
compared with controls, only the patients were characterized by greater psychiatric morbidity than the
controls.
In conclusion, our results are consistent with
the observations of health care professionals and other
investigators (6) that persons with FMS who come to
tertiary care centers for treatment frequently exhibit
multiple psychiatric disorders and high levels of pain
and fatigue. We do not dispute the finding by Wolfe et
a1 that community residents with FMS and comorbid
painful conditions who seek medical treatment also
show high levels of psychological distress (7). However, our data indicate that community residents with
FMS who do not have other rheumatologic or painful
musculoskeletal disorders and who do not seek treatment for pain are characterized by less severe symptoms and by psychiatric histories that are comparable
with those of healthy persons in the community. Thus,
it is unlikely that psychiatric disorders share a common pathophysiology with FMS.
Nonetheless, rheumatologists must respond to
the psychiatric problems that appear to impel a large
number of persons with FMS to seek treatment at
tertiary care centers. These patients especially may
benefit from consultations with health professionals
who are skilled in the use of psychotropic medications
and behavioral treatments for chronic pain syndromes
and associated psychiatric problems (35). Maximizing
the patient’s ability to cope effectively with symptoms
and psychological distress requires good communica-
AARON ET AL
tion between rheumatologists and their consultants as
part of an ongoing coordinated treatment care team.
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