Psychiatric diagnoses in patients with fibromyalgia are related to health care–seeking behavior rather than to illness

Abstract

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 (' 'FMS nonpatients' '), and healthy controls. 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-

Perceived physical and emotional trauma as precipitating events in fibromyalgia. Associations with health care seeking and disability status but not pain severity

“…However, it is precisely the subjective perception of an event as emotionally stressful which has repeatedly been related to increased levels of health care utilization. Our findings are consistent with multiple sources of evidence indicating that perceived stressful life events and reports of emotional distress predict health care-seeking behavior in the general population as well as in patients with rheumatic diseases (10,15,23). Similarly, we have found that patients with FMS who are seen in tertiary care rheumatology practices exhibit a greater number of lifetime psychiatric diagnoses relative than did patients with no trauma (P = 0.0009).…”

“…Specifically, patients with emotional trauma reported significantly greater fatigue than did both patients with physical trauma and patients with no trauma ( P = 0.039 and P = 0.011, respectively). to nonpatients (15). Emotionally stressful events may enhance the perceived uncontrollability of symptoms, and thereby encourage persons to seek care from physicians as a means of modulating distress (2,25).…”

“…All subjects received $25.00 payment for their participation. We have described the method for recruiting our subjects in a previous report (15).…”

“…Pain threshold levels were obtained at 5 paired (left and right) tender points included in the ACR criteria for FMS and 5 paired control points (CPs) using a standard dolorimeter (Chatillon Instruments, Kew Gardens, NY) and a measurement procedure that we use in all studies performed in our laboratory (8,15,17). The dolorimeter pressures that evoked faint pain at each of the TPs were averaged to produce a mean pain threshold.…”

Abnormal pain perception in patients with fibromyalgia: comment on the article by Bendtsen et al

“…However, we believe that 3 critical methodologic procedures may have compromised the external (i.e., generalizability) and internal validity of the study. This is a crucial issue because we cannot easily reconcile Bendtsen et al's conclusion that abnormal central neurosensory processing among FMS patients occurs only at "tender" muscles but not at "normal" muscles, with the reliable finding of generalized low pain thresholds in FMS patients at both tender and control points, which has been reported by us and by others (2,3). Thus, Bendtsen et al's methodologic procedures should be carefully examined before the conclusion of their study is accepted.…”