More than half of patients in a large fibromyalgia study have a depressive trait style and report more severe symptom profiles

Karin B. Jensen

doi:10.1016/j.sjpain.2014.05.009

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More than half of patients in a large fibromyalgia study have a depressive trait style and report more severe symptom profiles

Karin B. Jensen

Veröffentlicht/Copyright: 1. Juli 2014

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Aus der Zeitschrift Scandinavian Journal of Pain Band 5 Heft 3

In this issue of the Scandinavian Journal of Pain, Toussaint and coworkers [1] report on the relationship between different affective trait styles and severity of fibromyalgia symptoms. Understanding the interaction between pain pathophysiology and dispositional affect has long been the holy grail of clinical pain research, especially since effective treatment for long-term pain is limited and the psychiatric comorbidity is high. In addition to enhanced management of chronic pain, increased knowledge about pain and affective trait styles could potentially lead to prevention of disease, as negative mood may not only be the consequence of long-term pain, but also a catalyst in the vicious circle that transforms acute pain into long-term pain and disability [2].

1 Fibromyalgia is a common pain disorder

Fibromyalgia is a common pain disorder, affecting 2–4% of the populations of industrialized countries [3]. Recent data suggests that fibromyalgia symptoms are caused by a generalized disturbance in central nervous system pain processing, leading to pain throughout the body in the absence of any tissue damage [4,5]. As for many pain syndromes, treatment options for fibromyalgia are scarce, and long-term follow-ups suggest small chances of recovery [6].

2 Depression and chronic pain manifest together but may represent segregated mechanisms. Forget the “chicken or the egg” discourse

The effect of psychological symptoms in fibromyalgia, and related pain disorders, is still an area of debate. There is a high frequency of comorbidity with major depressive disorder, and fibromyalgia is still regarded by some as “the grey area between medicine and psychiatry” [7]. For example, it has been speculated that emotional responses are exaggerated in fibromyalgia patients, and that the disorder is psychogenic [8]. Moreover, antidepressant drugs with combined serotonergic and noradrenergic action, and not traditional painkillers, are used to treat fibromyalgia symptoms, furthering the possibility that negative mood and fibromyalgia pain are etiologically related. Today, there is vast evidence rejecting such notion and a large review of published clinical data, investigating the causal relationship between long-term pain and depression [9], concluded that negative mood is more likely the consequence of pain than an antecedent. Moreover, two different antidepressant drugs are approved in the U.S. for the indication of fibromyalgia treatment, and large clinical trials have demonstrated that the antidepressant and analgesic effects are independent of each other [10,11]; thus discarding the assumption that the reduction in fibromyalgia symptoms are due to enhanced mood. A study from 2010, using functional magnetic resonance imaging (fMRI), added to the notion that pain and negative mood are largely independent in fibromyalgia; as pain-evoked brain activations in fibromyalgia patients were not different based on patients’ degrees of negative affect [12].

3 Four different affect-balance styles in fibromyalgia patients

The survey-based study by Toussaint and coworkers is one out of very few studies that combines positive and negative trait measures to address the relationship between pain and dispositional affect. In line with previous data, Toussaint and colleagues find that the majority of the total sample of 735 fibromyalgia patients had a depressive trait style, and patients who scored high on depressive traits also rated higher levels of fibromyalgia symptoms, including pain, fatigue and sleep problems. Yet, the group with high negative affect did not represent the most novel data, but patients with a combination of low positive and low negative affect scores did. As low levels of negative affect are usually expected to be beneficial for the patient, the present study demonstrates how a one-dimensional view of affect may bias the interpretation of data in fibromyalgia trials. Given the results by Toussaint and coauthors, patients with a generally low affective profile may be overlooked, as traditional instruments are sensitive to high scores of negative affect and clinical interventions often optimized for reducing pain or distress.

4 Symptom-associations are not causal associations in cross-sectional surveys

The study by Toussaint and coworkers points to important methodological considerations in clinical pain research. Firstly, cross-sectional studies of this kind can only address the association between different measures, and not the directionality of the relationship between affect balance style and fibromyalgia symptoms. Secondly, the lack of experimental measures of pain sensitivity to complement the subjective ratings of fibromyalgia symptoms, poses a potential risk that negative affect styles also influenced the rating of fibromyalgia symptoms in surveys. Hence, it is possible that depressive traits leads to a poor perception of one’s physical health, but not to poor performance on clinical and experimental pain assessments.

5 The study by Toussaint and coworkers [1] increases our understanding of fibromyalgia

Today, empirical studies have moved the discourse on fibromyalgia and negative mood from a debate of “virtual” or “real” disorders, to a scientific discussion where psychological instruments are seen as tools for enhancing clinical trials and developing new treatment strategies. In that regard, the study by Toussaint and colleagues is a valuable contribution to our understanding of the complex interplay between dispositional affect and subjective perception of health.

DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2014.05.001.

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References

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Published Online: 2014-07-01

Published in Print: 2014-07-01

Artikel in diesem Heft

https://doi.org/10.1016/j.sjpain.2014.05.009