Psychiatric Disorders, Stress Reaction and Fibromyalgia Syndrome (FMS): Report of an Experience on 48 Patients

Abstract

Aim: The presence of psychiatric disorders and of alterations of stress reaction has been investigated in patients affected by Fibromyalgia Syndrome (FMS).

Methods: A number of 48 FMS patients and of 41 control subjects underwent a complete clinical evaluation, to psychometric tests (Zung test for Anxiety Disorder –Self Anxiety Scale, SAS- and Depressive Disorder –Self Depression Scale, SDS-, the Middlesex Hospital Questionnaire –MHQ-, Toronto Alexithymia Scale of Taylor -TAS-20- ) for psychiatric disorders and alexithymia and to psychophysiological evaluation of response to stress.

Results: Patients with FMS resulted to be significantly positive for depressive disorder, anxiety disorder, obsession and somatization and alexithymia as well. Furthermore, a relevant psycho physiological profile has been identified as an abnormal activation of the stress reaction.

Conclusion: FMF is a multifactorial disease in which the role of psychiatric disorders and of the altered reaction to stress seems to play a crucial role in the pathophysiological of the disease.

Keywords: Psychiatric disorder; Stress reaction; Fibromyalgia syndrome

Introduction

Fibromyalgia Syndrome (FMS) is a disease clinically characterized by the presence of a complex set of symptoms whose most frequent expressions are widespread musculoskeletal pain, with significant involvement of tendons and ligaments, presence of algogenic points or “tender points” localized in specific skeletal muscles and tendon sites, easy fatigability, weakness, functional impairment, sleep disorders [1-4].

FMS patients also commonly present a range of functional disturbances which may include nocturnal cramps, stiffness or encumbrance upon awakening, parenthesis, intolerance to cold and excessive heat, sensation of imbalance, concentrating difficulty, feelings of confusion, vision “floe”, absence of responsiveness of pain to analgesic therapy, sensitivity to changes in weather and seasons, “pain perceived as being different” than previous algic experiences, memory alterations, a specific chest pain, fluctuations in body weight.

These symptoms are combined with each other to varying degrees as well as with numerous diseases, often wrongly considered additional symptoms, such as primitive headache (migraine and tension headache), generalized anxiety disorder with panic attacks, Irritable Bowel Syndrome, the dyspeptic syndrome, Obesity, Depressive Disorder, Hepatitis HBV / HCV-related [5,6].

Its prevalence ranges between 0.72 and 5.3% with higher rates in the age groups between 25 to 35 years and 45 to 55 years, even if a juvenile form is reported in the age between 10 and 15 years [7,8].

The pathophysiological of the disorder is not yet fully known and several assumptions have been made: presence of psychological trauma in children [9], the conditions of life particularly stressful [10], the alteration of the hypothalamic-pituitary-adrenal axis, the impairment of neuro-modulation system of pain, the increased sympathetic tone with a reduction of parasympathetic tone and a possible deficiency of tryptophan and then serotonin [11- 13]. Moreover, the high recurrence of familiarity suggested the hypothesis of an important role of genetic factors, mainly of genetic polymorphisms related to the serotonergic system, dopamine system and catecholamine [14,15].

Because of uncertainty in pathophysiology, the FMS is nosographycally placed both within the Extra-particular rheumatism and in Dysfunctional syndromes or stress-related and affectivity disorders spectrum.

The diagnostic approach is based on the 1990 criteria of the American College of Rheumatology [13] recently underwent to a modification, which combines the results of a symptom severity scale and of the Widespread Pain Index (WPI), a measure of the number of painful body regions [16]. This clinical case definition of fibromyalgia correctly classifies 88.1% of cACR-1990 (pain in the 4 quadrants of the body and the axial skeleton since at least 3 months and pain in at least 11 of the 18 specific tender points).

The therapeutic approach has been characterized by the use of analgesic drugs (NSAIDs), muscle relaxants, anti-depressants, tricyclic and serotonin re-uptake inhibitors, benzodiazepines, antiepileptic (pregabalin), opiates, non-pharmacological approaches such as physiotherapy, massage therapy, aerobic physical activity, stretching, cognitive-behavioral approach and surgical procedures such as sympathetic blockade, with partial results or at least not entirely satisfactory [17-26].

In order to gain further insights into the relation among symptoms of FMS and affective and stress disorders, we have evaluated in patients with FMS the presence of psychiatric disorders and the way of stress reaction in response to stressful events.

Patients and Methods

We studied 48 patients, including 45 females and 3 males (age range 39 to 58 years), affected by FMS on the basis of the ACR- 1990 criteria (that at the moment still represent the international standard for the diagnosis of the disease), and consecutively admitted to our internal medicine unit in the late three years. All patients underwent to a complete assessment including clinical evaluation, biological (blood count with formula, glucose, blood urea nitrogen, total cholesterol, HDL, ESR, CRP, ANA, CPK, transaminases, TSH, FT4, anti-HBV and anti-HCV) and instrumental exams (ECG, chest X-ray, ultrasound examination of upper abdomen).

Each patient underwent a psychological study by means of Zung test for Anxiety Disorder (Self-rating Anxiety Scale, SAS) and Depressive Disorder (Self-rating Depression Scale, SDS), the Middlesex Hospital Questionnaire (MHQ) for the evaluation of different psychiatric disorders, the Toronto Alexithymia Scale of Taylor (TAS-20) for the assessment of alexithymia.

The stress reaction was evaluated by SATEM-Biolab PT104 SC with use of 4 stressors, 2 physical and 2 psychics, monitoring of variables EMG- contraction of the frontal muscle, SCL-conductivity of skin, THP-peripheral temperature, HR-heart rate for assessing the reaction of Stress and the Visual Analogue Scale (VAS) for the assessment of intensity of pain. This device is currently used for the evaluation of psychophisiological response to different stimuli as expression of the condition of patient stress.

A psychosomatic interview was proposed in all cases and was aimed to the identification of possible etiopathological factors.

41 subjects, including 35 females and 6 males, aged between 35 and 60 years old, free from disease, constituted the control-group.

Count and percentages for qualitative variables, were used to characterize the study cases. Differences between proportions were tested by z-test comparison of proportions and Fisher correction for small numbers. The power of the test and the size of the sample were calculated considering a difference in the expected values of proportions ranging among 0,40 and 0,50 and a desired alpha level equal to 0,05. Results were considered significant when P was <0.05.

Calculations were performed with the NCSS 2009 statistical software (Kaysville, UT, USA).

An informed consent has been obtained from each patient enclosed in the study for the utilization for scientific purposes of relative clinical data. Each procedure followed in the study was in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 and 2008. For this purpose, the approval of the local Ethical Committee was purchased.

Results

Our data showed the epidemiological prevalence of females (94.77%) compared to that of males (5.23%).

The use of the ACR-1990 for the diagnosis of SFP showed positivity from 13 to 18 of the tender points considered.

The blood-chemical and instrumental examinations were normal and no significant difference was evident from the comparison with the control group.

Psychometric evaluation revealed (Table 1) that SAS and SDS test were significantly more positive in the FMS group as well as each section of the MHQ test (depressive disorder, anxiety disorder, obsession and somatization). Alexithymia as well was higher in the FMS group.

  

    
 
    
Patients    with Fibromyalgia Syndrome (n=48)
    
Control    subjects (n=41)
    
p
  
  

    
SAS    test (anxiety)
    
57,1
    
12,4
    
.00001
  
  

    
SDS    test (depression)
    
39,3
    
7,3
    
.0004
  
  

    
MHQ    test
    
 
    
 
    
 
  
  

    
-    anxiety disorder
    
63
    
16,5
    
.00001
  
  

    
-    depressive disorder
    
37,5
    
9,6
    
.005
  
  

    
-    obsession
    
55,3
    
7,3
    
.00001
  
  

    
-    somatization
    
71,4
    
15,6
    
.00001
  
  

    
TAS    20 (Alexithymia)
    
31,5
    
4,8
    
.003
  

Table 1:  Psychometric evaluation results in Fibromyalgia Syndrome and in control subjects: comparison among proportions of positive results (%) on the basis of the score of each test.