9 de agosto de 2014
Fibromyalgia Syndrome and Psychiatry
Mention the words psychiatry or psychiatrist to an individual with Fibromyalgia syndrome (FMS) and you’re bound to get some raised neck hairs. However, even though some people may refuse to even mention the “P” word, psychiatrists and the field of psychiatry have made notable contributions to the study of FMS. This short report will review the psychiatric findings, the accompanying psychological conditions, and their relationship to FMS.
Hopefully, it may finally answer some longstanding issues and questions you may have and “set the record straight” about how the fascinating and complex field of psychiatry meshes with FMS. Remember, emotions and feelings are far different than actual diagnoses so it may be time to really understand what the psychiatric medical field has come to understand about FMS.
In order to speak about psychiatry we have to learn a little about the language of psychiatry. Psychiatrists are very ordered people – they like to categorize things. They have the ultimate catalog. It’s called the DSM-IV. That stands for the Diagnostic and Statistical Manual, fourth edition. The fifth edition will be coming out about 2015. Right now, there are groups of psychiatrists meeting to decide on changes. The DSM-IV lists all the possible psychiatric and psychological diagnoses that could possibly be given to people and assigns them a set of numbers, e.g. 203.5. The larger number is the main diagnosis and the number after the decimal point is a subcategory within the main diagnosis. Here is an interesting aside. Internet addiction will most likely be added to the new DSM-V.
Part of the categorization that psychiatrists use is the “Axis” system, of which there are five. Axis I includes the major mental disorders, learning disorders, and substance use disorders. It also includes the eating disorders such as anorexia nervosa and bulimia nervosa. Axis II includes personality disorders and intellectual disabilities. Axis III includes medical conditions and physical disorders. Axis IV are psychosocial and environmental factors that may play a role in the individual’s primary disorder. Axis V concerns what is called the “global assessment of functioning” which can be thought of as a general survey of just how well someone is doing in life. With these five methods of assessments a psychiatrist, or any physician, can gain a pretty complete picture of someone’s overall physical and mental health.
Now that you have a basic overview, time to look at FMS.
Early studies in FMS were strongly influenced by an emphasis placed on the accompanying psychiatric and psychological disorders because FMS was originally considered to be more in the realms of psychiatry than pain management. In 1982 Dr. Payne’s group published the first report on “psychologic disturbances” in fibrositis. Remember, fibrositis was the first medical term applied to FMS. Using what has become the “gold standard” in psychological assessments, a tool called the Minnesota Multiphasic Personality Inventory, they found fibrositis patients were more “psychologically disturbed” than patients with rheumatoid arthritis or other types of arthritis. They wrote in their paper, “We might be dealing with a number of different psychologic disturbances that have stiffness and musculoskeletal pain as principal and common symptoms.”
Hmm… not a very good start you’re probably thinking – but remember, this was 1982. Everyone in FMS has heard of Dr. Frederick Wolfe, probably one of the most famous researchers in FMS. Dr. Wolfe in 1995 concluded from a study in Wichita, Kansas, that psychological distress seemed to naturally be a part of FMS syndrome.
In 1992 Dr. Hudson and his group published a study that found major mood disorders (the most important disorder in this category is major depression) and panic disorder to be present, respectfully, in 64% and 33% of FMS patients sampled from a specialized rheumatologic treatment center. Remember, studying patients from a specialized treatment center samples a different group of FMS patients, specifically, those who were more severely affected. If you do not have a severe case of FMS chances are you will not be referred to a university or specialized center, you will be managed by a community based physician. This is such a significant issue in statistics that it even has its own name – Berkson’s Bias. It means that findings from more specialized centers may not be applicable to all patients as the patients from these centers represent a distinct subset of patients – those that may be more ill.
In 1996 the findings of the above research were re-examined by a different study that controls for the differences between people, a study called a case-control study. When reviewed in this manner it seemed that the FMS patients referred to the university or specialized treatment centers had an average of three lifetime psychiatric diagnoses, primarily anxiety and major depressive disorder. However, the community FMS patients were not any different from the general population in regards to their psychiatric status.
So, bearing in mind the caveat that FMS patients from specialized referral centers may have more psychiatric diagnoses and referring back to the distinction between Axis I and Axis II categories, let’s look at some numbers. We’ll even consider countries from around the world.
Axis II disorders have only been investigated in three studies. A 2010 report of 128 consecutive patients referred to a Turkish rheumatology clinic found 47.6% with Axis I disorders: major depression (14.6%) and generalized anxiety (9.7%); and 31.1% with Axis II disorders: 23.3% obsessive-compulsive disorder, and 10.7% each of avoidant and passive aggressive personalities. In a 2009 study from France approximately 63.3% of 30 FMS patients had Axis I disorders, primarily depression and anxiety, and 46.7% had Axis II: 30% obsessive-compulsive, and 16.7% each of borderline personality disorder and depressive disorder. Finally, back in the US: a study from Seattle found 87.1% Axis I and only 8.7% Axis II disorders in 115 FMS patients in a 2004 report.
The impact of mental health is not insignificant. In two separate studies using a measure that provides general health assessments FMS patients with significantly higher mental health scores showed significant impairment in their physical scores. The FMS patients were compared to rheumatoid arthritis patients whose lives are unquestionably affected. Using the same measuring instrument an investigation was conducted at four specialty care centers to determine if having a psychiatric condition was predictive of how much impairment would be present in FMS. Functional impairment on all measures used to assess FMS was found to be more severe if people also had a psychiatric condition. The most common psychiatric disorders were found to be major depression (lifetime = 68%, current = 22%), panic disorder (lifetime = 16%, current = 7%) and simple phobias (lifetime = 16%, current = 12%). The strongest predictor of functional impairment in this group of FMS patients was their current anxiety level.
The relationship between FMS and psychiatric comorbidities is a perpetual chicken and egg conundrum – what came first, the FMS or the psychiatric condition? The 1992 study mentioned above indicated that 45% to 57% of psychiatric diagnoses occurred more than one year before the onset of FMS symptoms and 24% to 45% occurred within the same year; only 9% to 19% occurred after one year. In another study 50% to 100% of patients reported their psychiatric symptoms began before the onset of FMS pain. Dr. Fishbain and his colleagues reviewed 191 studies to ascertain whether depression precedes or follows different types of chronic pain and found that depression is more commonly a consequence of having chronic pain, which makes sense to most people – but it’s nice to have a study to convince the skeptics.
However, there is something called the “scar hypothesis.” This is based on family studies of relatives with depressive disorders. It means if there is a predisposition to depression in families this increases the likelihood that if someone develops chronic pain they have an increased chance of developing depression. This also makes sense – a genetic predisposition to depression tends to run in families. Depression has both genetic and environmental factors. If there is a genetic predisposition something in the environment may be more likely to trigger its development.
It is clear that depressive disorders occur with the greatest frequency in FMS. The impact of depression is also greater in FMS patients than in patients suffering from other chronic pain conditions (rheumatoid arthritis, diabetic neuropathic pain). This has led many researchers contemplating whether there is a biologic connection between the two. Depending on the study, up to 40% of FMS patients have depression at the time of diagnosis and the lifetime prevalence of depressive disorders can exceed 70% to 80%. The greatest percentage of clinically significant depressive symptoms, 83.3%, was reported in a 2011 study of 30 FMS patients between 18 and 75 years of age that were consecutively referred to an Italian university rheumatology outpatient clinic.
The Europeans are very good at keeping track of disease in their populations. A group of researchers using the Swedish Twin Registry (a registry that follows all of the twins born in Sweden) screened 44,897 individuals for chronic widespread pain using the American College of Rheumatology’s 1990 written criteria for FMS, (they didn’t perform a clinical examination) and found that 40% of FMS patients also fulfilled criteria for depression.
Two studies have looked at the family patterns of FMS and depression. In a 2004 community based study it was found that FMS ran in families along with major mood disorders (92% of which were major depressive disorder). Another 2004 study also found a family clustering of depression and FMS. Both groups of researchers concluded their findings support the possibility that FMS and depressive syndromes share an underlying biologic connection.
Everybody, patients and physicians, is concerned about the effects of psychiatric disorders on aspects of FMS, especially pain. FMS patients may experience something called “emotional allodynia,” which is a fancy way of saying there is an increase in pain as a result of negative emotions. Conversely, the term, alexithymia, which means a lack of emotional awareness, while common in chronic pain patients, is an especially prominent feature of FMS. Alexithymia tends to be more correlated with the affective, or emotional, rather than the sensory, or painful components of pain. In a comparative study of rheumatoid arthritis, FMS, and normal people it was found that 57% of FMS patients had alexithymia. Another study showed FMS patients with the highest levels of alexithymia reported the highest levels of pain and disability two years later, independent of their original pain and disability levels. If you remember from reading the short reports on cytokines and the hypothalamic pituitary axis FMS patients have a dysfunctional sympathetic nervous system, coincidentally, the etymological meaning of the word sympathetic is “sharing emotions.” Do you catch the analogy – a dysfunction in sharing emotions?
If you have read the short reports on the radiologic studies on FMS you will have read how some of the new advanced devices have provided some fascinating results on how FMS changes the brain. Even though depression seems to accompany FMS it has been found that neither the presence of major depression nor the extent of depression modified the sensory-discriminative aspects of pain processing as assessed by functional MRI imaging. However, there are differences. The amygdala, which is an important brain region involved in emotional processing is much different in FMS patients who are depressed.
In a 2010 study of FMS patients, there was no relationship between experimentally induced pain and levels of depressive symptoms or anxiety even though both of these were inversely related to the patients overall general sense of health. The more depressed or anxious the patient the less their sense of their overall quality of health. This also makes sense. At this point you may be wondering why studies have to be done to prove what may be obvious points but, that’s medicine. The main take-away from this study is that neither depression nor anxiety affected pain perception. At this point, there is still a need for additional studies to address the neurobiological basis for the co-existence of pain and depression.
Studies have suggested that anxiety and depressive disorders tend to coexist in FMS. One study found that current anxiety symptoms were the best psychological predictor of functional impairment in a group of 73 FMS patients recruited from four specialty care centers. In other words, anxiety may be more important than depression. A recent 2006 trial for the FMS drug pregabalin noted significantly more patients reporting anxiety (71%) than depressive symptoms (56%).
Emotions not specifically examined in FMS patients are anger and sadness. Anger (an externalizing emotion) or sadness (an internalizing emotion) are general risk factors for pain amplification in all women, regardless of whether FMS is present. Both anger and sadness can result in greater subjective pain that can be brought about at less levels of stimulation. In other chronic pain populations, e.g. low back pain, anger, possibly by increasing muscle tension, also has significant effects on pain symptoms.
Another psychological component important to FMS is something the psychologists have termed “catastrophizing.” Catastrophizing means many things – people will magnify their pain symptoms. They also have feelings of helplessness and a general sense of pessimism about their future. Catastrophizing can be assessed with the Pain Catastrophizing Scale (PCS), a 13 item scale divided into three subscales, rumination, magnification, and helplessness that records feelings or thoughts regarding pain experiences. When compared to other conditions of chronic pain, e.g., rheumatoid arthritis, individuals with FMS will score significantly higher on measures of catastrophizing.
Catastrophizing in the context of FMS patients is not an insignificant issue; catastrophizing can explain between 7% and 31% of the different types of clinical pain and can account for up to 47% of the reason people develop chronic pain from acute pain. From a mind-body perspective, catastrophizing has been shown to disrupt the endogenous opioid pain systems – the natural endorphins the body makes to “feel good.” It also increases inflammatory compounds in the body.
The three types of catastrophic thinking have been found to be predictive of the severity of limitations that FMS pain imposes when considered by the length of time an individual has been diagnosed with FMS. Rumination predicted FMS impact for individuals with a diagnosis of two years or less, helplessness predicted FMS impact for those with FMS for more than four years and, both magnification and helplessness predicted impact for a diagnosis between two to four years; findings which all make sense clinically. In one study catastrophizing was a stronger predictor of activity limitations due to FMS than pain. What this means is that how you think and feel about your FMS pain has a very strong influence on the limitations you feel are imposed upon your body.
It is interesting to consider these issues from an armchair and talk about them. However, they have relevance to the clinical practice of medicine. A challenge to the physician in trying to obtain a history from a FMS patient can be ascertained from a comparative study of FMS, rheumatoid arthritis, and healthy people; 57% of FMS patients had an “inability to express” themselves, compared to 10% of arthritis patients, and 36% of the normal folks. This is an extremely important point as a 2000 survey of FMS patients found that “simply wanting the support of their health providers” was the most desired item (51%) of patients. Other issues paled in comparison – producing better medications (15%), conducting additional research (14%), and developing better diagnostic tools (8%).
One of the most frequent situations that FMS doctors face will be patients with anxiety often with depression. Anxiety and depression in a medical setting in FMS patients have been linked to concerns about new symptoms, the impact of ongoing illness on family members, and fears of disability or work status. Anger may reflect the patient’s self-anger regarding their limitations and inability to find resolve with their medical condition or towards individuals in the past who have not provided support, including health care providers.
Conversely, many FMS patients suffer from alexithymia and have difficulty expressing anger towards those who have doubted the reality of their illness and instead manifest self-anger, which has been found to be of greater magnitude compared to arthritis patients with a disease that has a distinct cause. Another reason for alexithymia may be that FMS patients see anger expression as inherently against their nature of being caregivers. Sometimes FMS sufferers even believe that expressing any personal feeling is viewed as self-centered. These are things you need to think about in yourself if you have FMS.
Dr. Raphael conducted a 2006 study of 2,033 women in the New York / New Jersey metropolitan area that has provided some additional interesting information. Over 90% of the 158 women who ultimately met the ACR criteria for FMS had sought medical care for their pain. Among the women with FMS only 14.3% felt they knew the cause of their pain even though 75.5% had seen a physician within the last six months, specifically for pain; 90.4% were taking medication for pain. Of the women who met ACR criteria for FMS as a result of their study only 11.9% indicated that a physician or health care provider had ever informed them they had FMS. All the more reason you need to find a physician who is experienced in treating FMS.
This wraps up the summary on the psychiatric and psychologic perspective of FMS. It’s certainly a complex and fascinating area. Hopefully, you’ve gleaned some new information and perspectives on the impact that these issues may have on FMS and you’re no longer hesitant to mention the “P” word around your friends with FMS.