Fibromyalgia and major affective disorder: a controlled phenomenology and family history study

A systematic review and meta-analysis of voxel-based morphometric studies of fibromyalgia

Objective

Although neuroimaging investigations have revealed significant changes in brain structure in fibromyalgia (FM) patients, these findings are inconsistent. The current study conducted a systematic review and meta-analysis of voxel-based morphometric studies in order to comprehend those alterations in brain structure in FM patients.

Methods

Voxel-based morphometric (VBM) studies published up to January 17, 2023 were searched in the Web of Science, PubMed, EMBASE, Cochrane Library (CENTRAL), China National Knowledge Infrastructure (CNKI), Chongqing VIP, Wanfang Database. Two independent researchers carried out study screening, quality assessment, clinical data and neuroimaging data extraction. The whole-brain voxel-based gray matter (GM) data of FM patients were collected from eligible studies, and meta-analyzed using anisotropic effect size-signed differential mapping (AES-SDM).

Results

Twelve researches were included in this study, including 289 FM patients (mean age: 47.36 years) and 272 HS (mean age: 47.34 years). According to the meta-analysis, FM patients had increased GM in the right postcentral gyrus and left angular gyrus, and decreased GM in the right cingulate gyrus, right paracingulate gyrus, left cerebellum, and left gyrus rectus.

Conclusion

Our study suggests that fibromyalgia patients have altered gray matter in several brain regions that are involved in affective, cognitive functions, and in motor adaptations to pain processing.

Reliability, Factor Structure and Predictive Validity of the Widespread Pain Index and Symptom Severity Scales of the 2010 American College of Rheumatology Criteria of Fibromyalgia

Fibromyalgia syndrome (FMS) is a chronic condition of widespread pain. In 2010, the American College of Rheumatology (ACR) proposed new diagnostic criteria for FMS based on two scales: the Widespread Pain Index (WPI) and Symptoms Severity (SS) scale. This study evaluated the reliability, factor structure and predictive validity of WPI and SS. In total, 102 women with FMS and 68 women with rheumatoid arthritis (RA) completed the WPI, SS, McGill Pain Questionnaire, Trait Anxiety Inventory, Fatigue Severity Scale, Oviedo Quality of Sleep Questionnaire, and Beck Depression Inventory. Pain threshold and tolerance and a measure of central sensitization to pain were obtained by pressure algometry. Values on WPI and SS showed negative-skewed frequency distributions in FMS patients, with most of the observations concentrated at the upper end of the scale. Factor analysis did not reveal single-factor models for either scale; instead, the WPI was composed of nine pain-localization factors and the SS of four factors. The Cronbach’s α (i.e., Internal consistency) was 0.34 for the WPI,0.83 for the SS and 0.82 for the combination of WPI and SS. Scores on both scales correlated positively with measures of clinical pain, fatigue, insomnia, depression, and anxiety but were unrelated to pain threshold and tolerance or central pain sensitization. The 2010 ACR criteria showed 100% sensitivity and 81% specificity in the discrimination between FMS and RA patients, where discrimination was better for WPI than SS. In conclusion, despite their limited reliability, both scales allow for highly accurate identification and differentiation of FMS patients. The inclusion of more painful areas in the WPI and of additional symptoms in the SS may reduce ceiling effects and improve the discrimination between patients differing in disease severity. In addition, the use of higher cut-off values on both scales may increase the diagnostic specificity in Spanish samples.

Evidence of new-onset depression among persons with migraine after discontinuing antidepressants

Antidepressants have been hypothesized to cause tardive dysphoria-the delayed development of negative emotional symptoms. We assessed the risk of tardive dysphoria in a cohort of persons with migraine taking anti-migraine antidepressants with no known diagnosis of any mood or anxiety disorder. We included all outpatient encounters in a university hospital system for migraine from January 2008 through October 2018, excluding subjects with prior psychiatric diagnoses. Kaplan-Meier survival curves and multivariable Cox proportional hazards analyses were conducted. 13,048 subjects were included; 1191 took an antidepressant; 402 discontinued an antidepressant. In multivariable analyses examining the first year after exposure, antidepressant use was not significantly associated with risk of a depression, any mood disorder (including depression, mania, and other mood disorders), or anxiety. Antidepressant discontinuation was significantly associated with increased risk of depression, but not any mood disorder or anxiety. Among persons with migraine with no known psychiatric diagnosis, antidepressants did not appear to be associated with indicators of tardive dysphoria. Antidepressant discontinuation, however, was associated with increased risk of a depression diagnosis.

Diagnostic Criteria for Fibromyalgia: Critical Review and Future Perspectives

Fibromyalgia syndrome (FMS) is a chronic illness characterized by widespread pain and other clinical and emotional symptoms. The lack of objective markers of the illness has been a persistent problem in FMS research, clinical management, and social recognition of the disease. A critical historical revision of diagnostic criteria for FMS, especially those formulated by the American College of Rheumatology (ACR), was performed. This narrative review has been structured as follows: Introduction; historical background of FMS, including studies proposing and revising the diagnostic criteria; the process of development of the ACR FMS diagnostic criteria (1990 and 2010 versions); revisions of the 2010 ACR FMS diagnostic criteria; the development of scales based on the 2010 and 2011 criteria, which could help with diagnosis and evaluation of the clinical severity of the disease, such as the Polysymptomatic Distress Scale and the FMS Survey Questionnaire; relationships of prevalence and sex ratio with the different diagnostic criteria; validity and diagnostic accuracy of the ACR FMS criteria; the issues of differential diagnosis and comorbidity; the strength and main limitations of the ACR FMS criteria; new perspectives regarding FMS diagnosis; and the impact of the novel findings in the diagnosis of FMS. It is concluded that despite the official 2010 FMS diagnostic criteria and the diagnostic proposal of 2011 and 2016, complaints from health professionals and patients continue.

Psychopathology measured by established self-rating scales and correlated to serotonin measures in patients with fibromyalgia

The objective of the study was to evaluate the presence of psychopathology in fibromyalgia patients compared to a control group of rheumatic patients with pain. Forty-nine fibromyalgia patients and 33 controls were evaluated using established self-rating scales. Serotonin was determined using a radioenzymatic method. Fibromyalgia patients scored significantly higher than the controls on the majority of the subscales on the SCL-90, the two subscales on the Spielberger State and Trait Anxiety Inventory, the GHQ 12 scale and on a visual analogue pain scale. In a multivariate analysis the somatization dimension followed by the state anxiety accounted for the highest difference. Platelet-poor plasma serotonin, platelet serotonin and platelet uptake index were not significantly different between the groups. In conclusion, fibromyalgia patients presented quantitatively more psychopathology than the control group on a wide range of psychopathologic axes, and this cannot solely be accounted for by their higher level of pain.

Alexithymia and attention deficit and their relationship with disease severity in fibromyalgia syndrome

Objectives

The aim of this study was to investigate the frequency of alexithymia and attention deficit and to evaluate their relationship with the severity of disease in patients with fibromyalgia syndrome (FMS).

Patients and methods

A total of 101 patients (6 males, 95 females; mean age 45.0 years; range, 33 to 56 years) who were admitted to Gaziantep University, Medical Faculty, Physical Medicine and Rehabilitation Department between January 2013 and December 2013 and were diagnosed with FMS and 40 healthy volunteers (4 males, 36 females; mean age 41.5 years; range, 31 to 51 years) were enrolled in this study. The Fibromyalgia Impact Questionnaire (FIQ), Hamilton Depression Scale (HAM-D), Toronto Alexithymia Scale-26 (TAS-26), and Jasper-Goldberg Attention Deficit Test (ADT) were applied.

Results

The rate of alexithymia and possible alexithymia was 56.4% and 20.8% in the patients with FMS and 2.5% and 5% in the control group, respectively. The mean TAS-26 score was 60.1±11.7 in the patients with FMS. According to the HAM-D, depressive symptoms were seen in 72.0% and 2.5% of the patients with FMS and healthy controls, respectively.

Conclusion

Our study results confirm the presence of psychiatric comorbidities in patients with FMS and clearly suggest that depression, alexithymia, and attention deficit are high and mutually correlated in FMS patients. Therefore, all patients should be meticulously evaluated for these conditions at the treatment stage.

Prevalence of depressive disorder among patients with fibromyalgia: Systematic review and meta-analysis

BACKGROUND

It is acknowledged that fibromyalgia (FM) as a medical (rheumatological) disorder and major depressive disorder (MDD) as a mental disorder often co-occurs, but the inconsistency is prevailing at study-level and no overall estimate of the co-occurrence exist.

AIMS

This systematic review and meta-analysis aimed to estimate the overall point- and life-time prevalence of MDD among FM patients based on structured clinical interviews (SCI); and to estimate the point-prevalence of MDD among FM patients based on screening symptom scales (SSS).

METHOD

The electronical databases MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and PsycINFO were searched for papers that reported on prevalence of MDD among FM patients. Eligible studies were included in a random effects meta-analysis pooling the prevalence of depression.

RESULTS

The literature search identified 11 eligible studies for the meta-analysis. For SCI, the overall pooled point-prevalence (PP) was 25% (95% CI 19 to 31%), and life-time prevalence (LP) was 65% (95% CI 59 to 71%). When estimating the PP with self-administered SSS the overall pooled PP was 45% (95% CI 32 to 59%), and a single clinician-administered SSS yielded a PP of 23% (95% CI 10 to 41%). There was low inconsistency for the SCI and high inconsistency for the SSS.

CONCLUSION

One fourth of all FM patients had MDD, and more than half experienced MDD during their life-time according to clinician-administered instruments. Prevalence of MDD was almost twice as high when using self-administered symptom scales and may be likely to overestimate the co-occurrence.

Factors Affecting Long-Term Postoperative Narcotic Use in Discectomy Patients

BACKGROUND

Long-term narcotic use has risks and potentially life-threatening opioid-related side effects. Extended narcotic use in patients undergoing discectomy raises concerns of other underlying causes of pain or overprescription and/or abuse. The goal of this study was to determine which factors have an effect on active narcotic prescription >3 months after discectomy.

METHODS

The PearlDiver Database was used in this study. Patients 30-55 years old undergoing discectomy without fusions were queried for active narcotic drug prescription occurring >30 days and >3 months after original surgery. Medical co-diagnoses were independently analyzed for effects on long-term active narcotic prescriptions. Prior narcotic use was defined by use within 4 months before surgery.

RESULTS

Of 1321 patients undergoing discectomy, 621 had actively prescribed narcotics >3 months after surgery. Preoperative narcotic use had the largest effect on odds of postoperative prescription (odds ratio [OR] = 3.4). Medical comorbidities increasing odds of long-term narcotic prescriptions included migraines (OR = 1.4), diabetes mellitus (OR = 1.4), depression (OR = 1.6), and smoking (OR = 1.9).

CONCLUSIONS

Narcotic abuse is a serious problem rooted in overprescription of these drugs, which has ultimately led to much more caution in prescribing among physicians. Because pain management and drug prescription must be balanced, identifying patients who may be susceptible to narcotic overprescription is important. Patients with co-diagnoses increasing odds of long-term narcotic prescriptions would benefit from early and continual postsurgical follow-up to ensure accurate pain management and to determine if narcotic prescriptions are justly warranted in the later postoperative period.

Features of mood associated with high body weight in females with fibromyalgia

BACKGROUND

Fibromyalgia (FM) is a common syndrome whose main characteristic is chronic widespread musculoskeletal pain, the severity of which is frequently worsened by concomitant obesity. Major depression (MD), particularly as part of a bipolar spectrum disorder (BSD), is associated with both obesity and FM.

OBJECTIVE

To evaluate the relationship between lifetime MD, hypomanic symptoms and the body mass index (BMI) in patients with FM.

METHOD

Of the 115 patients originally screened, 87 women with FM finally entered the study. Forty-nine patients (57%) had a lifetime diagnosis of MD, assessed by a structured clinical interview based on DSM-IV criteria, and four of them (4.6%) had a current MD episode. Lifetime hypomanic symptoms were measured by means of the self-rated Hypomania Checklist. According to the international criteria for BMI, FM patients were classified as under/normal-weight (61%), overweight (30%) and obese (9%).

RESULTS

62 patients (71.2%) with FM had a bipolar spectrum disorder (BSD). Thirty (48.3%) of them met criteria for bipolar II disorder, 32 (51,6%) for bipolar disorder NOS (18 FM patients with MD associated to sub-syndromal hypomanic syndrome and 14 with hypomanic syndrome without MD). No patient had a bipolar I disorder. Only one patient met the criteria for a major depressive disorder (MDD). There was no significant difference in mean BMI between the patients with and without a lifetime diagnosis of MD, but there was a positive association between the level of hypomanic symptoms and BMI values (p<0.009). When hypomania was considered categorically as hypomanic syndrome there was no significant effect on BMI.

CONCLUSIONS

Our finding adds to previous evidence indicating that hypomanic symptoms are a central feature of FM. In the case of the early identification of high-level hypomanic symptoms, body weight should be closely monitored in order to prevent obesity and its detrimental impact on females with FM.

What we see when we digitize pain: The risk of valorizing image-based representations of fibromyalgia over body and bodily experience

Fibromyalgia is chronic pain of unknown etiology, attended by fatigue and affective dysfunction. Unapparent to the unpracticed eye or diagnostic image, it is denied the status of "real" suffering given to visually confirmable disorders. It is my customary mode of existence: a contingent landscape of swinging bridges that may or may not give way, everything a potential threat or deprivation. I don't express it within the framework of acute pain, but I am evaluated by traditional biomedical standards anyway. Ultimately, the diagnostic image of pain, and the medical and academic discourse used to interpret it, determines my functionality. Such a stance dismisses bodily senses and alternate ways of knowing in pursuit of the ocularcentric objectivity promised by digital health technologies, whose vision remains chained to the interpretive, discursive strategies of human operators and interpreters. A new poetics of pain is critical not only for rewriting the dominant metaphors that construct and delimit our imaginings of pain but also for rewiring the use and reading of digital technologies, wherein the digital image becomes the new site of the hermeneutic exercise, even when the suffering body lies in plain view. This facilitates a failure to listen and touch in patient care, and the imposition of a narrative based on visual evidence, translated into sanitized language, at the cost of intercorporeality. If pain strips sufferers of a voice, my body and its affects should be allowed to speak.

Fibromyalgia: A Critical and Comprehensive Review

Fibromyalgia is a disorder that is part of a spectrum of syndromes that lack precise classification. It is often considered as part of the global overview of functional somatic syndromes that are otherwise medically unexplained or part of a somatization disorder. Patients with fibromyalgia share symptoms with other functional somatic problems, including issues of myalgias, arthralgias, fatigue and sleep disturbances. Indeed, there is often diagnostic and classification overlap for the case definitions of a variety of somatization disorders. Fibromyalgia, however, is a critically important syndrome for physicians and scientists to be aware of. Patients should be taken very seriously and provided optimal care. Although inflammatory, infectious, and autoimmune disorders have all been ascribed to be etiological events in the development of fibromyalgia, there is very little data to support such a thesis. Many of these disorders are associated with depression and anxiety and may even be part of what has been sometimes called affected spectrum disorders. There is no evidence that physical trauma, i.e., automobile accidents, is associated with the development or exacerbation of fibromyalgia. Treatment should be placed on education, patient support, physical therapy, nutrition, and exercise, including the use of drugs that are approved for the treatment of fibromyalgia. Treatment should not include opiates and patients should not become poly pharmacies in which the treatment itself can lead to significant morbidities. Patients with fibromyalgia are living and not dying of this disorder and positive outlooks and family support are key elements in the management of patients.

Prevalence of fibromyalgia and co-morbid bipolar disorder: A systematic review and meta-analysis

BACKGROUND

Fibromyalgia (FM) is a chronic disorder with high morbidity and significant health service utilization costs. Few studies have reported on the phenotypic overlap of FM and bipolar disorder (BD). The aim of this review is to qualitatively and quantitatively summarize the results and clinical implications of the extant literature on the co-occurrence of FM and BD.

METHODS

A systematic search of PubMed/Medline, Cochrane, PsycINFO, CINAHL and Embase was conducted to search for relevant articles. Articles were included if incidence and/or prevalence of BD was determined in the FM sample. Results of prevalence were pooled from all studies. Pooled odds ratio (OR) was calculated based on case-control studies using standard meta-analytic methods.

RESULTS

A total of nine studies were included. The pooled rate of BD comorbidity in samples of FM patients was 21% (n=678); however, results varied greatly as a function of study methodology. Case-controlled studies revealed a pooled OR of 7.55 of BD co-morbidity in samples of FM patients [95% Confidence Interval (CI)=3.9-14.62, FM n=268, controls n=413] with low heterogeneity (I(2)=0%).

LIMITATIONS

The current study was limited by the low number of available studies and heterogeneity of study methods and results.

CONCLUSIONS

These data strongly suggest an association between BD and FM. Future studies employing a validated diagnostic screen are needed in order to more accurately determine the prevalence of BD in FM. An adequate psychiatric assessment is recommended in FM patients with suspected symptoms consistent with BD prior to administration of antidepressants in the treatment of FM.

Fibromyalgia comorbid with anxiety disorders and depression: combined medical and psychological treatment

Fibromyalgia is associated with high level of pain and suffering. Lack of diagnosis leads to onerous indirect economic costs. Recent data indicate that fibromyalgia; anxiety disorders, and depression tend to occur as comorbid conditions. They also share some common neurochemical dysfunctions and central nervous system alterations such as hypofunctional serotonergic system and altered reactivity of the hypothalamic-pituitary-adrenal axis. Conversely, functional neuroimaging findings point to different patterns of altered pain processing mechanisms between fibromyalgia and depression. There is no cure for fibromyalgia, and treatment response effect size is usually small to moderate. Treatment should be based on drugs that also target the comorbid psychiatric condition. Combined pharmacotherapy and cognitive-behavior therapy should ideally be offered to all patients. Lifestyle changes, such as physical exercise should be encouraged. The message to patients should be that all forms of pain are true medical conditions and deserve proper care.

Bone mass and vitamin D levels in women with a diagnosis of fibromyalgia

No differences in either bone mineral density or serum 25OHD levels have been found between 205 women with fibromyalgia (both pre- and postmenopausal) and their controls. However, a lack of the expected 25OHD summer rise was observed in patients.

INTRODUCTION

Contradictory data have been published regarding a possible association between fibromyalgia and osteoporosis or hypovitaminosis D. Most studies, however, have been performed in small size samples and have excluded postmenopausal women. We decided to study this association in a larger sample of fibromyalgia patients including both pre- and postmenopausal women.

METHODS

Two hundred five patients were recruited from a clinic specializing in fibromyalgia and 205 healthy controls were enrolled from the census of a Primary Care Center. Controls were matched with patients by age and the time of the year they were included in the study. Bone mineral density (BMD) was measured by DXA. Serum 25OHD, iPTH, P1NP, and CTX were also determined.

RESULTS

BMD was similar in both groups (lumbar spine, 0.971 ± 0.146 g/cm(2) in patients and 0.970 ± 0.132 g/cm(2) in controls; femoral neck, 0.780 ± 0.122 g/cm(2) and 0.785 ± 0.117 g/cm(2), respectively). 25OHD levels were also similar: 23.0 ± 9.5 ng/ml and 24.1 ± 9.6 ng/ml. However, while controls showed the usual summer rise in 25OHD, fibromyalgia patients did not. PTH did not show seasonal changes, but on average was higher in patients (51 pg/ml vs. 48 pg/ml; p = 0.034). P1NP or CTX were similar in both groups.

CONCLUSIONS

No differences in BMD were found between patients and controls. As for 25OHD, a lack of its expected summer rise was observed. It is doubtful whether this has any homeostatic consequence. We consider that the association reported in other studies is merely circumstantial, and not due to the intrinsic characteristics of these disorders.

Chronic pain treatment: the influence of tricyclic antidepressants on serotonin release and uptake in mast cells

The involvement of serotonin (5-HT) in chronic pain mechanisms is established. 5-HT inhibits central painful stimuli, but recent data suggests that 5-HT could also enhance pain stimulus from the periphery, where mast cells play an important role. We aimed in our study to clarify the influence of selected tricyclic antidepressants (TCAs) on mast cell function: secretion, uptake, and reuptake of 5-HT, that could interfere with 5-HT levels and in this way contribute to the generation of pain. As an experimental model, we used isolated rat peritoneal mast cells and incubated them with selected TCAs (clomipramine, amitriptyline, doxepin, and imipramine) under different experimental conditions. 5-HT release, uptake, and reuptake were determined spectrofluorometrically. We showed that TCAs were able to inhibit 5-HT secretion from mast cells, as well as uptake of exogenous 5-HT and reuptake of secreted 5-HT back into mast cells. The effects of TCAs were concentration dependent; higher concentrations of TCAs inhibited the secretion of 5-HT induced by compound 48/80, whereas lower concentrations of TCAs inhibited 5-HT uptake. The most effective TCA was halogenated clomipramine. As TCAs are well introduced in chronic pain treatment, the insight into mechanisms of action is important for an understanding of their effect in various pain conditions.

Central pain mechanisms in chronic pain states--maybe it is all in their head

Mechanisms underlying chronic pain differ from those underlying acute pain. In chronic pain states, central nervous system (CNS) factors appear to play particularly prominent roles. In the absence of anatomical causes of persistent pain, medical sub-specialities have historically applied wide-ranging labels (e.g., fibromyalgia (FM), irritable bowel syndrome, interstitial cystitis and somatisation) for what now is emerging as a single common set of CNS processes. The hallmark of these 'centrally driven' pain conditions is a diffuse hyperalgesic state identifiable using experimental sensory testing, and corroborated by functional neuroimaging. The characteristic symptoms of these central pain conditions include multifocal pain, fatigue, insomnia, memory difficulties and a higher rate of co-morbid mood disorders. In contrast to acute and peripheral pain states that are responsive to non-steroidal anti-inflammatory drugs (NSAIDs) and opioids, central pain conditions respond best to CNS neuromodulating agents, such as serotonin-norepinephrine reuptake inhibitors (SNRIs) and anticonvulsants.

Electroconvulsive therapy in patients with depression and fibromyalgia

The effect of electroconvulsive therapy (ECT) on depression and other symptoms of fibromyalgia was studied in a prospective 3-month trial in 13 patients with fibromyalgia and concomitant depression. All the patients met the DSM-IV diagnostic criteria for Major Depressive Disorder and fulfilled the American College of Rheumatology diagnostic criteria for fibromyalgia. The Montgomery and Asberg Depression Rating Scale (MADRS) and the clinical global impression scale (CGI) were used to assess the severity of depression and the clinical change of the patients. The fibromyalgia impact questionnaire (FIQ) was used to evaluate the severity of the fibromyalgia symptoms. The intensity of pain was evaluated using a 6-point scale (0=no pain, 5=very severe pain), and tender point palpation. All assessments were performed at baseline and at follow-up visits, which took place one week, one month and three months after ECT. There was a significant improvement in depression after ECT according to MADRS. Using CGI, six patients were much or very much improved, while four patients were minimally improved and three patients had no change. There was significant improvement in four out of ten FIQ item scores, "feel good", "fatigue", "anxiety" and "depression". No significant change was found in the FIQ item scores "physical function", "pain", "stiffness" and "morning tiredness" or number of tender points and self-reported pain. We conclude that ECT is a safe and effective treatment for depression in fibromyalgia patients, but has no effect on the pain or other physical symptoms of these patients.

Newer treatments for fibromyalgia syndrome

Fibromyalgia syndrome is a common chronic pain disorder of unknown etiology. The lack of understanding of the pathophysiology of fibromyalgia has made this condition frustrating for patients and clinicians alike. The most common symptoms of this disorder are chronic widespread pain, fatigue, sleep disturbances, difficulty with memory, and morning stiffness. Emerging evidence points towards augmented pain processing within the central nervous system (CNS) as having a primary role in the pathophysiology of this disorder. Currently the two drugs that are approved by the United States Food and Drug Administration (FDA) for the management of fibromyalgia are pregabalin and duloxetine. Newer data suggests that milnacipran, a dual norepinephrine and serotonin reuptake inhibitor, may be promising for the treatment of fibromyalgia. A double-blind, placebo-controlled trial of milnacipran in 125 fibromyalgia patients showed significant improvements relative to placebo. Milnacipran given either once or twice daily at doses up to 200 mg/day was generally well tolerated and yielded significant improvements relative to placebo on measures of pain, patient's global impression of change in their disease state, physical function, and fatigue. Future studies are needed to validate the efficacy of milnacipran in fibromyalgia.

Fibromyalgia diagnosis and diagnostic criteria

Abstract Criteria for fibromyalgia developed from the conceptualization and hypotheses of Smythe and Moldofsky in 1977 and gradually evolved to a set of classification criteria endorsed by the American College of Rheumatology that emphasized tender points and widespread pain, measures of decreased pain threshold. In 2010, American College of Rheumatology fibromyalgia diagnostic criteria were published that abandoned the tender point count and placed increased emphasis of patient symptoms. The 2010 criteria also contained severity scales and offered physicians the opportunity to assess polysymptomatic distress on a continuous scale. This enabled physicians who were opposed to the idea of fibromyalgia to also assess and diagnose patients using an alternative nomenclature.

Subgroups of older adults with osteoarthritis based upon differing comorbid symptom presentations and potential underlying pain mechanisms

Introduction

Although people with knee and hip osteoarthritis (OA) seek treatment because of pain, many of these individuals have commonly co-occurring symptoms (for example, fatigue, sleep problems, mood disorders). The purpose of this study was to characterize adults with OA by identifying subgroups with the above comorbid symptoms along with illness burden (a composite measure of somatic symptoms) to begin to examine whether subsets may have differing underlying pain mechanisms.

Methods

Community-living older adults with symptomatic knee and hip OA (n = 129) participated (68% with knee OA, 38% with hip OA). Hierarchical agglomerative cluster analysis was used. To determine the relative contribution of each variable in a cluster, multivariate analysis of variance was used.

Results

We found three clusters. Cluster 1 (n = 45) had high levels of pain, fatigue, sleep problems, and mood disturbances. Cluster 2 (n = 38) had intermediate degrees of depression and fatigue, but low pain and good sleep. Cluster 3 (n = 42) had the lowest levels of pain, fatigue, and depression, but worse sleep quality than Cluster 2.

Conclusions

In adults with symptomatic OA, three distinct subgroups were identified. Although replication is needed, many individuals with OA had symptoms other than joint pain and some (such as those in Cluster 1) may have relatively stronger central nervous system (CNS) contributions to their symptoms. For such individuals, therapies may need to include centrally-acting components in addition to traditional peripheral approaches.

Fibromyalgia: from pathophysiology to therapy

Individuals with fibromyalgia generally experience chronic widespread pain, which can be accompanied by further symptoms including fatigue, sleep disturbances, cognitive dysfunction, anxiety and depressive episodes. As the recognition and diagnosis of fibromyalgia has improved, the availability of therapeutic options for patients has increased. Furthermore, research into the neurobiological mechanisms that contribute to the chronic pain and concomitant symptoms experienced by patients with fibromyalgia has advanced our understanding of this debilitating disorder. In this Review, we aim to provide an overview of existing pathophysiological concepts. The roles of biological and psychological stress, genetic factors, and pain and sensory processing in the pathophysiology of fibromyalgia and related conditions are discussed. In addition, pharmacological treatments, including monoamine modulators, calcium channel modulators and γ-aminobutyric acid modulators, as well as nonpharmacological treatment options are considered.

Fibromyalgia syndrome and depressive symptoms: comorbidity and clinical correlates

OBJECTIVE

Fibromyalgia is characterized by chronic widespread musculoskeletal pain and higher pain perception in specific anatomic sites called tender points. Fibromyalgia is frequently associated with psychiatric symptoms, like depression and anxiety; indeed some authors have argued about the possibility to classify this syndrome into affective spectrum disorder. Few studies have analyzed the impact of depressive symptoms on pain threshold. This research is aimed at evaluating the prevalence and the clinical correlates of depressive symptoms in fibromyalgic patients, and investigating their impact on pain perception and quality of life.

METHODS

Outpatients between 18 and 75 years with diagnosis of fibromyalgia according to the criteria of the American College of Rheumatology have been included. All subjects have been evaluated with the following rating scales: HAM-D; VAS (to quantify pain); a visual analogical scale to evaluate quality of life; and Paykel's List of Recent Life Events.

RESULTS

Thirty subjects have been recruited. Most patients (83.3%) had clinically significant depressive symptoms as indicated by a HAM-D score >7. Depressive symptoms are associated with higher pain perception, worse quality of life and more severe life events.

CONCLUSION

The presence of depressive symptoms is associated with a great impairment in patients with fibromyalgia syndrome: indeed the psychiatric comorbidity lowers pain threshold and worsens the quality of life of our patients. Future studies should be conducted in order to identify the individual factors, e.g. stress or inflammatory processes, which drive the association between depression and higher severity of fibromyalgia syndrome.

The association of major depressive episode and personality traits in patients with fibromyalgia

INTRODUCTION

Personality traits have been associated with primary depression. However, it is not known whether this association takes place in the case of depression comorbid with fibromyalgia.

OBJECTIVE

The authors investigated the association between a current major depressive episode and temperament traits (e.g., harm avoidance).

METHOD

A sample of 69 adult female patients with fibromyalgia was assessed with the Temperament and Character Inventory. Psychiatric diagnoses were assessed with the Mini-International Neuropsychiatric Interview severity of depressive symptomatology with the Beck Depression Inventory, and anxiety symptomatology with the IDATE-state and pain intensity with a visual analog scale.

RESULTS

A current major depressive episode was diagnosed in 28 (40.5%) of the patients. They presented higher levels of harm avoidance and lower levels of cooperativeness and self-directedness compared with non-depressed patients, which is consistent with the Temperament and Character Inventory profile of subjects with primary depression. However, in contrast to previous results in primary depression, no association between a major depressive episode and self-transcendence was found.

CONCLUSIONS

The results highlight specific features of depression in fibromyalgia subjects and may prove important for enhancing the diagnosis and prognosis of depression in fibromyalgia patients.

Comparative pain and mood effects in patients with comorbid fibromyalgia and major depressive disorder: secondary analyses of four pooled randomized controlled trials of duloxetine

The objective of this paper is to better understand the relationship of pain and mood in patients with fibromyalgia and comorbid major depressive disorder (MDD). Pooled data from 4 double-blind, placebo-controlled, randomized trials of duloxetine hydrochloride 60-120mg/day in patients with fibromyalgia were included (N=1332). Of these, 350 (26% [147 placebo, 203 duloxetine]) had comorbid MDD (per Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision criteria) and were included in these analyses. Primary measures included Brief Pain Inventory average pain; Hamilton Depression Rating Scale or Beck Depression Inventory. Logistic regression was used to evaluate the consistency of treatment effect across various subgroups. Path analysis was used to assess the effect of duloxetine on improvement in pain in the presence of improvement in mood and vice versa. Results indicated that 69% of improvement in pain was a direct effect of treatment, with improvement in mood accounting for 31% of pain response. In conclusion, consistent with our hypothesis, duloxetine produced a substantial direct effect on pain improvement and change in mood exerted a modest indirect effect on pain improvements in patients with fibromyalgia and MDD. Hence, both direct and indirect analgesic and antidepressant properties appear to be relevant for the treatment of these comorbid patients with duloxetine.

The pathophysiology, diagnosis and treatment of fibromyalgia

Research in fibromyalgia has increased understanding of the possible genetic and environmental factors that could be involved in the etiology of fibromyalgia. There is now substantial evidence for augmentation of central pain processing in fibromyalgia. Because the clinical presentation of fibromyalgia is heterogeneous, treatment recommendations must be individualized for each patient. The rapid growth of trials in fibromyalgia in recent years has resulted in new evidence-based approaches to pharmacological and nonpharmacological treatment.

Perspectives on fatigue from the study of chronic fatigue syndrome and related conditions

Fatigue is a symptom whose causes are protean and whose phenotype includes physical, mood, and behavioral components. Chronic fatigue syndrome (CFS) is an illness that has strong biological underpinnings and no definite etiology. Diagnostic criteria established by the Centers for Disease Control and Prevention have helped classify CFS as an overlap of mood, behavioral, and biological components. These include the presence of fatigue for more than 6 months associated with a diminution of functional activity and somatic symptoms, and pain not attributable to a specific diagnosis or disease. Four of the following criteria need to be present: sore throat, impaired memory or cognition, unrefreshing sleep, postexertional fatigue, tender glands, aching stiff muscles, joint pain, and headaches. Many researchers have observed that CFS shares features in common with other somatic syndromes, including irritable bowel syndrome, fibromyalgia, and temporomandibular joint dysfunction. Correlations between inflammation and infection, augmented sensory processing, abnormalities of neurotransmitters, nerve growth factors, low levels of serotonin and norepinephrine, abnormalities of homeostasis of the stress system, and autonomic dysfunction may be hallmarks of CFS. The relative contributions of each of these abnormalities to the profound fatigue associated with CFS need to be explored further to better evaluate and treat the syndrome.