University of Groningen
Fibromyalgia
Blécourt, Alida Cornelia Ebelina de
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1995
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Blécourt, A. C. E. D. (1995). Fibromyalgia: towards an integration of somatic and psychological aspects
Groningen: s.n.
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Chapter 11
Psychological aspects of fibromyalgia compared
with chronic and non-chronic pain
A.A. KNIPPING, D.J. BIRNIE, A.C.E. DE BLÉCOURT, M.H. VAN RIJSWIJK, J.N. DE VOOGD.
Revised version of:
D.J. Birnie, A.A. Knipping, M.H. van Rijswijk, A.C.E. de Blécourt, J.N. de Voogd.
Psychological aspects of fibromyalgia compared with chronic and nonchronic pain.
J Rheumatol 1991;18:1845-1848.
207
Chapter 11
208
Chapter 11
Introduction
In spite of extensive research on fibromyalgia prompted by increasing interest in this
syndrome, many aspects remain poorly understood. At the clinical level much
research has been done to describe the clinical features of the syndrome (1). As a
result of these studies, making a correct diagnosis is no longer a great problem.
Many, but not all studies showed evidence for psychological abnormality in patients
with fibromyalgia (2-10).
Most of the aspects that are found are elevated scores on subscales of questionnaires.
Anxiety and depression are the most prominent aspects that are reported (see also
chapter 10). Anxiety and depression are also common features in other chronic pain
conditions.
Therefore we hypothesize that most of the psychological features of fibromyalgia
patients can be considered to be aspects of chronic pain, that is, pain existing for a
period longer than 6 months and which lacks an apparent somatic explanation. If so,
then this has implications for possible forms of treatment for fibromyalgia. As has
been proven useful in (multidisciplinary) treatment programs for chronic pain
patients, fibromyalgia patients have to learn coping with their complaints and
problems related to their complaints, such as professional status. In this treatment
programs the attention of the patients is shifted from things that are no longer possible
to activities that the patients still can perform, thus increasing the activity, and
possibly also the level of self esteem.
According to an advisory committee of the Dutch Ministry of Health (11) patients
with chronic pain share several characteristics. These are derived from the
International Association for the Study of Pain (12).
1. At onset of the chronic pain syndrome the patient with chronic pain cannot be
distinguished from other patients with pain.
2. The pain is present for a period of at least 6 months.
3. There is no clear causal relationship between the pain and somatic pathology.
4. The chronic pain patient has a history many contacts with medical and
paramedical specialists, often in addition to a fair number of contacts with nonallophatic healers. The chronic pain patient has undergone a variety of diagnostic
procedures, therapies (sometimes even surgery) without lasting beneficial effect,
and appears to be a regular visitor of the general practitioner for relatively
harmless physical complaints.
5. There is an important, partly iatrogenic reinforced fixation on the pattern of
complaining.
6. The pain complaints are incrementally accompanied by disturbed psychosocial
functioning and by some related features:
- medication abuse
- diminished physical functioning and ability of performance paired to the pain
and/or the fear of damaging the body due to physical activity (inadequate signal
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Chapter 11
-
function)
dependency on passive forms of physiotherapy
increased helplessness and hopelessness, highly resistant to therapy
emotional conflicts with persons in the direct social environment
withdrawal from psychosocial activities
lasting negative emotional and affective changes
receiving or attempting to receive money from a social security fund.
Many of these characteristics seem to describe the psychological problems of
fibromyalgia patients as well as those of other chronic pain patients. Therefore our
hypothesis is that fibromyalgia patients share many psychological and other aspects as
stated above with other chronic pain patients.
Materials and methods
Three groups of patients with pain:
1. a non-chronic pain group (n=34),
2. a chronic pain group (n=99),
3. and a fibromyalgia group (n=36)
were compared, using a standard interview technique and three self-administered
standardized psychologic tests (Dutch versions, translated and adapted from already
existing questionnaires):
- the Symptom CheckList (SCL-90R)(13),
- the Illness Behaviour Questionnaire (IBQ)(14),
- and the Chronic Illness Problem Inventory (CIPI)(14).
The subjects of chronic pain group and the fibromyalgia group were outpatients of the
Department of Rehabilitation of the University Hospital of Groningen (the
Netherlands) in the period january 1986 - may 1987. The patients in the non-chronic
pain group were selected in a period of 6 weeks in february-march 1987. Patients
visited the department because of musculoskeletal pain, and they were mainly referred
by family practitioners, neurologists or surgeons.
The inclusion and exclusion criteria of the three groups are representedtable
in 1 .
Among patients in the non-chronic group, 38% had pain complaints in the lower
extremities, and 32% in the neck-shoulder region. The pain complaints in this group
were mainly caused by distortion, rupture or fracture. In the chronic group 39% had
low back pain, 48% had pain complaints in the lower extremities, and 35% in the
neck-shoulder region which could not be explained by underlying somatic pathology
in the vision of the physiatrist. In this group the physiatrist discovered no dysfunctions
in strength, mobility, coordination, sensibility, tonus, balance, condition, or posture. In
the fibromyalgia group 94% had pain complaints in the lower extremities, 81% in the
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neck-shoulder region and 75% in the lower back region.
Table 1
INCLUSION AND EXCLUSION CRITERIA FOR THE NON CHRONIC PAIN, CHRONIC PAIN AND
FIBROMYALGIA GROUP
inclusion criteria
exclusion
criteria
non chronic
chronic
fibromyalgia
* musculoskeletal pain
* musculoskeletal pain
* fibromyalgia
according to
criteria of Yunus
(15)
* duration < 6 months
* duration $ 6 months
* clear relation between
pain and somatic
pathology
* no (clear) relation
between pain and
somatic pathology
* fibromyalgia diagnosis
* fibromyalgia diagnosis
The variables that characterize chronic pain as described in the report of the Dutch
advisory committee are shown intable 2 .
Duration of complaints was determined on the interview question: "How long have
you had these complaints?". If the patient could not give a clear, reliable answer, the
first time that he visited a doctor with the complaints was taken as the measuring
point.
The groups were compared with each other using the Oneway analysis of variance,
where a parametric test was allowed (16). Multiple comparisons were made with the
modified least-significant difference test. Applying the Bonferroni procedure (17)
(with type-I error for each comparison set to 0.05) significance was set to 0.005.
For the analysis of nominal variables a chi-square test was used to determine
statistical dependency between groups and variables.
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Table 2
CONCEPTS THAT CHARACTERIZE CHRONIC PAIN
Concept:
Mode of measurement:
Duration of the pain complaint:
Duration (in months) according to the interview
data.
Progress of the complaints since onset:
Answer on interview question.
(better, no change, worse)
Number of other physical
complaints:
Answer on interview question:
the subjects were asked to check off a list.
Medication use:
Answer on interview question.
(yes or no)
Number of painful localizations:
Subjects had to mark the spots in a drawing of a
human body. Considered as a localization were: a)
head and neck b) upper back c) low back d)
gluteal/genital region e) chest f) abdomen g) arms
h) legs.
Extent of somatization:
Somatization-scale SCL-90R
Fixation on complaining:
Preoccupation-scale IBQ
Diminished physical functioning:
Body Deterioration-scale CIPI
Emotional conflicts with others:
Hostility-scale SCL-90R
Negative emotional and affective
changes:
Anxiety- and Depression-scale SCL-90R
Results
The mean age and standard deviation in the three groups were: 43.7±17.1 in the nonchronic pain group, 36.0±11.3 in the chronic pain group and 39.0±10.4 in the
fibromyalgia group. There was a difference between the three groups on age (Oneway
F=5.11 p=0.0070). The least significance procedure reveals that the mean age in nonchronic group is significant (p<0.05) higher than in the chronic pain group. The
percentages female subjects were 56 in the non-chronic pain group, 74 in the chronic
pain group and 64 in the fibromyalgia group.
No significant differences (p<0.05) between the three groups were found for sex,
using the chi-square-test.
We found no satisfactory explanation for the relatively low percentage of female
subjects in the fibromyalgia group when compared with other researcher reports (1).
The comparison of the three groups involved in this study is displayed table
in 3 . To
keep the focus on the variables related to our hypothesis, other subscales of the
questionnaires were not included in this table (e.g. the sensitivity-scale SCL-90R).
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Chapter 11
Table 3
COMPARISON OF MEAN SCORES IN THE THREE GROUPS.
* = SIGNIFICANT DIFFERENCE BETWEEN CHRONIC AND NON CHRONIC GROUP
@ = SIGNIFICANT DIFFERENCE BETWEEN CHRONIC AND FIBROMYALGIA GROUP
# = SIGNIFICANT DIFFERENCE BETWEEN NON CHRONIC AND FIBROMYALGIA GROUP
NS = NO DIFFERENCES BETWEEN GROUPS (ONEWAY, P <0.005)
variable
chronic group
(mean ± SD)
non-chronic
group (mean ±
SD)
fibromyalgia
(mean ± SD)
sign. diff.
Duration (months)
53.9±58.8
3.3±2.7
82.0±60.0
*#@
N other complaints
5.0±4.0
1.8±2.3
6.5±3.3
*#@
N painful localizations
2.3±1.4
1.4±0.6
4.8±1.8
*#@
Somatization SCL-90R
23.1±8.0
17.8±4.8
28.2±5.7
*#@
Preoccupation IBQ
1.8±1.4
1.0±1.5
1.6±1.1
NS
Body Deterioration CIPI
7.3±3.7
5.6±2.5
8.5±4.4
*#
Hostility SC-90R
8.0±3.0
6.9±1.1
7.7±2.7
NS
Anxiety SCL-90R
15.7±7.0
13.2±3.3
16.0±4.7
NS
Depression SCL-90R
25.3±10.5
21.0 ±5.4
26.1±9.7
NS
As expected, the chronic group had higher scores on most of the variables when
compared to the non-chronic group. Difference in the variable "duration" was caused
by the selection criteria of the groups.
When compared to the non-chronic group, the chronic group has more "other
complaints", not directly related to the complaint for which they visited the physician,
more painful localizations and they show more somatization. Differences on the
variables preoccupation IBQ, body deterioration CIPI, hostility, anxiety, and
depression SCL-90R did not reach significance. Almost the same pattern of
differences occurs when fibromyalgia patients are compared with non-chronic pain
patients. Fibromyalgia patients report also more body deterioration than non-chronic
pain patients.
Fibromyalgia patients report more painful localizations than chronic pain patients and
have a higher score on the somatization scale. Other variables show no differences
between these two groups.
On the variable "progress of complaints" 44% of the non-chronic group stated that
they were getting better, 29% reported no change and 27% a worsening of their
complaints. In the chronic group only 3% reported that they were getting better, 17%
reported no change and 80% a worsening of their complaints. In the fibromyalgia
group no subject stated that he or she was getting better, 6% reported no change and
94% reported that the complaints were getting worse (chi-square = 61.6, p<0.00001).
In the non-chronic group 18% used medication, in the chronic group 46%, and in the
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fibromyalgia group 50% used medication (chi-square = 9.3,
p<0.009).
Discussion
We started our research in 1986, using the criteria for fibromyalgia diagnosis from
Yunus et al. (15) In the meantime, in 1990, the American College of Rheumatology
adopted new criteria for the classification of fibromyalgia (18): widespread pain in
combination with 11 or more of the 18 specific tender point sites. In their report the
authors also provide the sensitivity, specificity and accuracy of previous criteria sets
in their study population. It appeared that the criteria described by Yunus et al.
performed fairly well in their study sample, with a sensitivity of 83.6% and a
specificity of 76.6%. Therefore we don not expect very much problems with the
generalizability of our data.
The hypothesis that fibromyalgia patients are very similar to other chronic pain
patients when compared on psychological variables is supported by the results above.
The fibromyalgia group shows many characteristics of chronic pain and even more
painful localizations and a higher extent of somatization. The fact that fibromyalgia
patients report more painful localizations is not very surprising, because one of the
clinical characteristics of fibromyalgia is having "pain all over". The fact that
fibromyalgia patients have higher scores on the somatization scale of the SCL-90R
seems to be related to this aspect of fibromyalgia, since this scale contains items such
as: headaches, low back pain, painful muscles, etc. When the items that are related to
the physical complaints of fibromyalgia patients are removed, there is no longer a
significant difference between the two groups (chronic group: m=8.9 SD=3.8,
fibromyalgia group: m=10.0 SD=2.7; t-value=-1.79, p<0.078).
An important aspect is the duration of the pain complaint. All but one of the
fibromyalgia patients had pain complaints for over one year. Many researchers in the
field of chronic pain state that having pain complaints for a period between 2 and 6
months can be sufficient to develop chronic pain (19,20).
The finding that our fibromyalgia group is characterized by a long duration of the pain
complaint is probably not exceptional. The recognition and acknowledgement of the
diagnosis "fibromyalgia" is complex and time-consuming.
Considering fibromyalgia patients as chronic pain patients has important implications
for treatment. A strictly somatic approach of the complaints in treating chronic pain
patients may lead to a strong fixation on the somatic aspects of these complaints (2123).
A multidisciplinary approach seems to be the best way to deal with complexity of the
patient's situation in the treatment of chronic pain (24,25). Further research must point
out if this is also a good option in the treatment of fibromyalgia.
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