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Behavioral Psychology / Psicología Conductual, Vol. 21, Nº 2, 2013, pp. 381-392
ANXIETY, DEPRESSION AND FIBROMYALGIA PAIN AND
SEVERITY
Virginia A. Aparicio1, Francisco B. Ortega1, Ana Carbonell-Baeza2,
Ana María Cuevas1, Manuel Delgado-Fernández1, Jonatan R.1
1
University of Granada (Spain); 2University of Cadiz (Spain)
Abstract
We aimed to analyze the relationship of anxiety and depression with
fibromyalgia pain and severity. The study comprised 127 women aged 51.9±7
years. Anxiety and depression was assessed by means of the Hospital Anxiety and
Depression Scale (HADS) and fibromyalgia severity with the Fibromyalgia Impact
Questionnaire (FIQ). Pain was assessed by four indicators: tenderness (tender
points count [TPC] and algometer score) and the Short-Form-36 Health Survey
(SF36)-pain and FIQ-pain subscales. Perceived pain, as measured by SF36-pain,
was worse in the severe anxiety-group compared with the low and mild anxietygroups and in the severe compared with the low depression-group. Perceived
pain, as measured by FIQ, was higher for the severe compared to the low anxietygroup. Tenderness, as measured by algometer score and TPC, did not differ
among anxiety and depression categories. HADS-anxiety scores ≥8 were
associated with an increased odds ratio of severe fibromyalgia. HADS-depression
scores ≥ 8 were associated with severe fibromyalgia. Overall, women with higher
levels of anxiety and depression present increased pain perception and risk of
severe fibromyalgia. Consequently, anxiety and depression should be detected
and treated properly.
KEY WORDS: fibromyalgia, anxiety, depression, pain, severity.
Resumen
El presente estudio analiza la relación entre ansiedad y depresión con el
dolor y la gravedad de la fibromialgia en 127 mujeres de 51,9±7 años. Los niveles
de ansiedad y depresión fueron estimados mediante la “Escala hospitalaria de
ansiedad y depresión” (HADS) y la gravedad de la enfermedad a través del
“Cuestionario de impacto de la fibromialgia” (FIQ). El dolor se valoró mediante el
número de puntos de dolor, el umbral de sensibilidad al dolor por algómetro y las
dimensiones de dolor del FIQ y de la “Encuesta de salud, versión breve-36”
(SF36). La dimensión SF36-dolor fue mayor para ansiedad grave comparada con
ligera o moderada y para niveles de depresión grave frente a bajos. FIQ-dolor fue
mayor para ansiedad grave en comparación con ligera. Valores de HADS-ansiedad
o HADS-depresión superiores a 8 estuvieron asociados con un incremento del
riesgo de padecer fibromialgia grave. Altos niveles de depresión y ansiedad

Correspondence: Virginia Aparicio, School of Sport Sciences, University of Granada, Carretera de
Alfacar, s/n, 18011 Granada (Spain). E-mail: [email protected]
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APARICIO, ORTEGA, CARBONELL-BAEZA, CUEVAS, DELGADO-FERNÁNDEZ, RUIZ
incrementan la percepción del dolor en enfermas con fibromialgia y suponen un
mayor riesgo de padecer fibromialgia grave, por lo que deberían detectarse y
tratarse apropiadamente.
PALABRAS CLAVE: fibromialgia, ansiedad, depresión, dolor, gravedad.
Introduction
Chronic pain is often associated with comorbidities such as anxiety and
depression, resulting in a low health-related quality of life (Bennett, Jones, Turk,
Russell, & Matallana, 2007; Silverman, Harnett, Zlateva, & Mardekian, 2010;
Wilson, Robinson, & Turk, 2009; Wolfe et al., 1990) and poor daily functioning
(Ramirez y Valdivia, 2003). Fibromyalgia has been found to be strongly associated
with depressive and anxiety symptoms, a personal or family history of depression,
and accompanying antidepressant treatment (Arnold, 2008). Many individuals with
fibromyalgia also have comorbid psychiatric disorders, which can present
diagnostic dilemmas and require additional treatment considerations to optimize
patient outcomes (Silverman et al., 2010). Furthermore, Gormsen, Rosenberg,
Bach, & Jensen (2010), observed that patients with fibromyalgia have more
psychological symptoms such as depression and anxiety than patients with
neuropatic pain. Moreover, associations between pain intensity and mood
phenomena were only found in fibromyalgia patients. On the other hand, Jensen
et al. (2010), observed that negative mood in fibromyalgia patients can lead to a
poor perception of one’s physical health (and vice-versa) but do not influence the
performance in clinical and experimental pain assessments.
Despite relevant evidence of physical illness promoting fibromyalgia
syndrome, some authors claim that it is a psychological disorder, or due to
“psychological amplification”. More evidence for such views is lacking. The
physical distress of fibromyalgia syndrome can increase both anxiety and
depression. Current imaging studies support the view that central effects
connected with fibromyalgia syndrome relate to the processing of noxious
stimulation more than affective disorder (Merskey, 2008).
Although there are several studies investigating the relationship between
depressive disorders and symptoms of fibromyalgia, data regarding the impact of
anxiety and depression on perceived pain and tenderness in fibromyalgia patients
are still scarce and inconclusive. The aim of the present study was to analyze the
relationship of anxiety and depression with fibromyalgia perceived pain (as
measured by questionnaires) and tenderness (measured by tender points count
and algometer score) and fibromyalgia severity (global affectation) in women.
Moreover, the relationship between anxiety and depression and fibromyalgia pain
and severity has never been explored in Spanish population.
Anxiety, depression and fibromyalgia
383
Method
Participants
The study sample comprised 127 women aged 51.3±7.3 years diagnosed as
having fibromyalgia by a rheumatologist following the American College of
Rheumatology criteria (Wolfe et al., 1990). Women were recruited from different
fibromyalgia associations via e-mail, letter or telephone. 48% patients had been
diagnosed five or less years ago and 52% had been diagnosed of fibromyalgia
more than 5 years ago. 70% were postmenopausal, the majority of the
participants were married (73%). 8% of the sample had unfinished studies, 42%
finished primary school, 21% secondary school and 29% had a University degree.
The participants had varied levels of occupations: 60% were employed at home
(housewife), 25% working, 7% retired, 7% unemployed and 2% were students.
Measures


Stadiometer Seca 22 (Hamburg, Germany) and InBody 720 Biospace (Seoul,
Korea). Height (cm) was measured using a stadiometer (Seca 22, Hamburg,
Germany) and weight (kg) with a scale (InBody 720, Biospace, Seoul, Korea).
Body mass index (BMI) was calculated as weight (in kilograms) divided by
height squared (in meters) and categorized using the international criteria:
underweight (<18.5 kg/m2), normal weight (18.5-24.99 kg/m2), overweight
(25.0-29.99 kg/m2) and obese (≥300 kg/m2).
The Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983),
the Spanish version by Quintana et al. (2003). The HADS was developed to
identify caseness (possible and probable) of anxiety disorders and depression
among patients in non-psychiatric hospital clinics. It was divided into an
Anxiety subscale (HADS-Anxiety) and a Depression subscale (HADS-Depression)
both containing seven intermingled items. HADS has been found to perform
well in assessing the symptom severity and caseness of anxiety disorders and
depression in both somatic, psychiatric and primary care patients and in the
general population (Bjelland, Dahl, Haug, & Neckelmann, 2002). The HADS
contains 14 statements, ranging from 0 to 3 in which a higher score indicates
a higher degree of distress. The scores build 2 subscales: anxiety (0-21) and
depression (0-21) (Zigmond & Snaith, 1983). Interpretation of the HADS is
based primarily on the use of cut-off scores, although there is no generally
accepted cut-off to define anxiety or depression (Bjelland et al., 2002). Some
authors recommend that scores of between 8 and 10 identify mild cases, 1115 moderate cases, and 16 or above, severe cases (Snaith & Zigmond, 1994).
In most studies, an optimal balance between sensitivity and specificity was
achieved with a score of 8 or higher on both HADS-Anxiety and HADSDepression (Abiodun, 1994; Bjelland et al., 2002; Zigmond & Snaith, 1983). In
the present study we have used both types of cut-off scores as appropriated.
The Spanish version of the HADS test-retest reliability presented correlation
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APARICIO, ORTEGA, CARBONELL-BAEZA, CUEVAS, DELGADO-FERNÁNDEZ, RUIZ
coefficients above 0.85. The internal consistency was high, with Cronbach's
alphas coefficients of 0.86 for anxiety and 0.86 for depression (Quintana et al.,
2003).
The Short-Form-36 Health Survey (SF36; Jenkinson, Coulter, & Wright (1993),
the Spanish version by Alonso, Prieto, & Antó (1995). The SF-36 was used to
assess health-related quality of life. The SF36 is composed of 36 items,
grouped into eight scales, which include both physical and mental health,
assessing eight dimensions: physical functioning, physical role, bodily pain,
general health, vitality, social functioning, emotional role, mental health and
general health. Each subscale score is standardized and ranges from 0 to 100,
where 0 indicates the worst possible health status and 100 the best possible.
The scores represent the percentage of the total possible score achieved (Ware
& Sherbourne, 1992). The test-retest reliability and internal consistency of the
Spanish version of this questionnaire has been studied (Alonso et al., 1995).
Correlation coefficients between the test and retest were between 0.58 for
SF36-emotional role subscale to 0.99 for SF36-physical role. Internal
consistency showed Cronbach's alpha coefficients between 0.78 for SF36vitality subscale to 0.96 for SF36-physical role subscale.
The Fibromyalgia Impact Questionnaire (FIQ; Burckhardt, Clark, & Bennett,
1991). We used the Spanish version (Rivera & Gonzalez, 2004) of FIQ to assess
fibromyalgia severity. The FIQ assesses the components of health status that
are believed to be most affected by fibromyalgia. It is composed of ten
subscales: physical impairment, overall well being, work missed and a seven
items of a visual analogy scale (VAS) marked in 1-cm increments on which the
patient rates the job difficulty, pain, fatigue, morning tiredness, stiffness,
anxiety and depression. The FIQ total score ranges from 0 to 100 and a higher
value indicates a greater impact of the disorder (Bennett, 2005). Correlation
coefficients between the test and retest were between 0.58 for VAS-anxiety to
0.83 for work missed days. Internal consistency showed Cronbach's alpha
coefficients of 0.82 for the total items of the FIQ; alpha=0.79 for the 8 items,
without the 2 items concerning work, and alpha=0.86 for the 9 sub-items of
the physical impairment (Rivera & Gonzalez, 2004). Patients were categorized
as having moderate or severe fibromyalgia according to the FIQ cut-off
proposed by Bennet, Bushmakin, Cappelleri, Zlateva, & Sadosky (2009): FIQ
<59 vs. ≥59 for moderate and severe fibromyalgia, respectively.
Algometer EFFEGI, FPK 20 (Alfonsine, Italy). We assessed 18 tender points
according to the American College of Rheumatology criteria for classification
of fibromyalgia (Wolfe et al., 1990). A standard pressure algometer (EFFEGI,
FPK 20, Alfonsine, Italy) was used to measure tender point count. The pain
threshold at each tender point was determined by applying increasing pressure
with the algometer perpendicular to the tissue, at a rate of ~1 kg/s. Patients
were asked to say ‘stop’ at the moment pressure became painful. The mean of
two successive measurements at each tender point was used for the analysis.
Tender point scored as positive when the patient noted pain at pressure of 4
kg/cm2 or less. The total of such positive tender points was recorded as the
individual’s tender point count. An algometer score was calculated as the sum
Anxiety, depression and fibromyalgia
385
of the pain-pressure values obtained for each tender point. This examination
was conducted by a trained physiotherapist.
Procedures
All patients were informed about the study and signed a written informed
consent to participate. Inclusion criteria for the data analysis were not to have
other rheumatic diseases and/or severe disorders such as cancer, severe coronary
disease, or schizophrenia, and to have valid data in the Hospital Anxiety and
Depression Scale (HADS) (Quintana et al., 2003). The study was reviewed and
approved by the Ethics Committee of the “Hospital Virgen de las Nieves” of
Granada.
Data collection was conducted for all the patients in the fibromyalgia
association in two different occasions separated by one day. The first day weight,
height and tender points were assessed and the questionnaires were administered
in the second appointment. All measurements were performed by the same
trained researchers group in order to reduce inter-examiners error.
Statistical analysis
One-way analysis of covariance (ANCOVA) with adjustment by age and BMI
was used to compare pain across HADS-anxiety and HADS-depression status
categories. Pairwise comparisons were performed with Bonferroni’s adjustment.
Standardized effect size statistics and its exact confidence interval were estimated
by Cohen’s d. Taking into account the cut-off established by Cohen, the effect size
(Cohen’d) can be small (~0.2), medium (~0.5) or large (~0.8). Binary logistic
regression after adjustment for age and BMI was used to further study the
relationship of high HADS-anxiety and high HADS-depression with fibromyalgia
severity (FIQ≥59 or FIQ≥70) and Type II fibromyalgia. We adjusted by BMI as
covariable because a high BMI has been associated with worse quality of life, pain
and symptomatology in fibromyalgia patients (Aparicio, Ortega, Carbonell-Baeza,
Camiletti et al., 2011; Aparicio, Ortega, Carbonell-Baeza, Femia et al., 2011;
Yunus, Arslan & Aldag, 2002). All analyses were conducted using SPSS version
16.0 for Windows (SPSS, Chicago, IL). The level of significance was set at p< .05.
Results
Physical and psychological characteristics of the study sample are shown in
table 1. We analyzed the differences in perceived pain, as measured by FIQ and
SF36 questionnaires and tenderness (algometer score and tender points count)
across the three categories of HADS-anxiety and HADS-depression status proposed
by Snaith & Zigmond (1994). We additionally included the cut-off of HADS-anxiety
and HADS-depression ≤8 proposed by several authors (Abiodun, 1994; Bjelland et
al., 2002; Zigmond & Snaith, 1983) (table 2). Perceived pain, as measured by SF36pain, differed across anxiety and depression categories (p< .01 and p< .05,
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APARICIO, ORTEGA, CARBONELL-BAEZA, CUEVAS, DELGADO-FERNÁNDEZ, RUIZ
respectively). SF36-pain scores were significantly worse in the severe anxiety group
compared to the low and mild-anxiety groups (12.1±3.4 vs. 27.0±2.9 and
27.9±3.1; respectively, both p< .05). Likewise, SF36-pain scores were lower in the
severe-depression group compared with the low and mild-depression groups
(7.5±5.4 vs. 26.4±2.2 and 24.4±2.2, respectively, p< .01 and p< .05). There were
also differences on perceived pain, as measured by FIQ, between the severe and
low-anxiety groups (8.1±0.4 vs. 6.6±0.3; respectively, p< .05). There were no
significant differences on FIQ-pain, algometer score and tender points count across
HADS-depression and HADS-anxiety categories.
Logistic binary regression analysis adjusted by age and BMI was used to
analyze the relationship between higher levels of anxiety and depression (HADS≥
8) and severe fibromyalgia (FIQ≥ 59). HADS-anxiety scores ≥8 were associated with
an increased odds ratio (OR) of severe fibromyalgia (OR= 4.98; 95% confidence
interval CI: 2.03-12.21). Likewise, HADS-depression scores ≥8 were associated
with severe fibromyalgia (OR= 4.95; 95% CI: 2.02-12.10).
Table 1
Physical and psychological characteristics of the study sample (n= 127)
Variable
Age (years)
Height (cm)
Weight (kg)
Body mass index (kg/m2)
Weight status (%) UW/NW/OW/OB
FIQ total score
Tender Points Count
Algometer Score
HADS-anxiety
HADS-depression
SF36
Mental Health
Bodily pain
Social functioning
Physical functioning
Vitality
Emotional Role
Physical role
General Health
Range
31-70
139-178
43-118
18-46
-14-92
4-18
24-87
0-20
1-20
M (SD)
51.9 (7.2)
157.3 (5.0)
70.3 (13.6)
28.4 (5.6)
1/32/35/32
66.8 (14.0)
16.6 (2.8)
48.4 (13.5)
10.6 (4.8)
8.6 (4.4)
4-96
0-68
0-100
0-90
0-80
0-100
0-100
0-85
47.1 (20.8)
22.7 (16.9)
42.9 (24.5)
36.6 (19.0)
21.5 (16.1)
34.9 (43.3)
5.5 (19.5)
30.5 (15.9)
Note: UW= underweight; NW= normal weight; OW= overweight; OB= obese; FIQ= Fibromyalgia Impact
Questionnaire; SF36= General Health Short-Form Survey; HADS= Hospital Anxiety and Depression
Scale.
Anxiety, depression and fibromyalgia
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APARICIO, ORTEGA, CARBONELL-BAEZA, CUEVAS, DELGADO-FERNÁNDEZ, RUIZ
Discussion
The present study shows that high levels of anxiety and depression are
associated with higher perceived pain (as measured by questionnaires) but not
with higher tenderness (measured by tender points count and algometer score) in
women with fibromyalgia. Furthermore, HADS-anxiety and HADS-depression
scores ≥8 were associated with increased risk of having severe fibromyalgia.
Fibromyalgia patients have more psychological distress, including depression
and anxiety, than healthy controls (Gormsen et al., 2010). In our study, mean
values of depression and anxiety were not pathological (HADS-anxiety and HADSdepression scores higher to 16), such as has also been reported in other similar
studies (Gormsen et al., 2010; Jensen et al., 2010). However, to note is that in
some studies, like the one performed by Aguglia, Salvi, Maina, Rossetto, & Aguglia
(2010), the 83% of the fibromyalgia patients had clinically significant depressive
symptoms.
We have observed a relationship between anxiety and perceived pain, as
measured by VAS and SF36-pain scores whereas in the study by Jensen et al.
(2010) anxiety symptoms did not correlate with clinical pain or experimental pain
ratings. Fibromyalgia patients tend to report more stressful life events than
controls (Stisi, Venditti, & Sarracco, 2008). Stisi et al. (2008) observed that this
phenomena was due to the tendency of fibromyalgia patients to rate more
severely mild stressful events. Therefore, they concluded that the particularly high
number of events in their patients might be due to increased perception of stress.
The relationship between depressive symptoms and pain in fibromyalgia
patients has been further explored in similar studies that have focused on the
influence of depressive symptoms on pain processing (Aguglia et al., 2010;
Giesecke et al., 2005; Jackson, O'Malley, & Kroenke, 2006; Jensen et al., 2010).
We have observed an association between depression and higher levels of
perceived pain, as measured by SF36-pain, but not with VAS scores (FIQ-pain). In
the study by Aguglia et al. (2010), patients with depressive symptoms displayed
significantly higher VAS scores, lower quality of life scores, and a higher Paykel
Scale scores, than those without depressive symptoms. The patients with
depressive symptoms from the study by Jackson et al. (2006), also displayed
significantly higher VAS scores. In contrast, in the study by Jensen et al. (2010),
depressive symptoms, anxiety and catastrophizing did not correlate with any
measure of pain sensitivity and the authors did not support pronounced affective
pain modulation in fibromyalgia. Instead, the significant correlation between
depression, anxiety and the subjective rating on one’s health (general health score
from SF36 and FIQ questionnaires) that they obtained suggests that negative
mood affects the perception of one’s health status. Negative mood in fibromyalgia
patients could thus lead to a poor perception of one’s physical health but not to
poor performance in clinical and experimental pain assessments as tenderness.
Gieseke et al. (2005) also observed that depressive symptoms had no influence on
the intensity of clinical pain or the sensory discriminative processing of induced
pressure pain. However, with increasing depressive symptoms, activity in two brain
regions pertaining to emotional processing, i.e. insula and amygdala, increased
Anxiety, depression and fibromyalgia
389
during sustained pain provocation (Giesecke et al. 2005). A similar study
performed in rheumatoid arthritis patients (Schweinhardt et al. 2008) showed no
relationship between depressive symptoms and cerebral pain processing in
rheumatoid arthritis patients during experimental pain (heat). However, there was
a positive correlation between ratings of depressive symptoms and activation of
the medial prefrontal cortex during provoked joint pain.
Alterations in central processing of sensory input may also contribute to the
cardinal symptoms of fibromyalgia, persistent widespread pain and enhanced pain
sensitivity (Bradley, 2008). Exposure to psychosocial and environmental stressors,
as well as altered autonomic nervous system and neuroendocrine responses, can
induce to alterations in pain perception or pain inhibition. Understanding the
pathophysiology of fibromyalgia and co-occurring disorders may help clinicians to
provide the most appropriate treatment for each patient (Bradley, 2008).
There have been speculations about a generally exaggerated emotional
response among fibromyalgia patients, suggesting that fibromyalgia was a virtual
disease, caused by psychological vulnerability (Ehrlich, 2003). However, the effects
of antidepressants on pain seem to be independent of mood, since the
antidepressant and analgesic effects are independent of each other in clinical trials
(Arnold et al., 2005; Russell et al., 2008). On the other hand, the role of
psychological factors in the pathogenesis of fibromyalgia is controversial.
Depressive symptoms are often present, but it has been difficult to determine if
depressive disorders are a primary cause of fibromyalgia, or a reaction to the
debilitating symptoms of this disease (Jackson et al., 2006).
Another explanation for the higher perception of pain in fibromyalgia patients
with depressive symptoms is the tendency of depressed patients to adopt coping
strategies defined as “catastrophizing” (Aguglia et al., 2010; Roth, Geisser,
Theisen-Goodvich, & Dixon, 2005). Catastrophizing increases the perception of
pain through the modification of attention and the anticipation of the pain itself,
emphasizing emotional responses. Depression and catastrophizing are critically
important variables in understanding the experience of pain in patients with
rheumatologic disorders (Edwards, Calahan, Mensing, Smith, & Haythornthwaite,
2011). Pain, depression, and catastrophizing might all be uniquely important
therapeutic targets in the multimodal management of fibromyalgia (Edwards et al.
2011). Another factor that influences pain perception and pain coping strategies
are personality traits. It has been observed that some personality traits, such as
harm avoidance (characterized by pessimism, fear, shyness and fatigability),
influence the adoption of maladaptive strategies to cope with pain and pain
perception (Cuevas, López, García & Díaz, 2008; Cuevas & Torrecillas, 2008).
Therefore, high harm avoidance scores are associated with higher scores on
depression (Mazza et al., 2009) and may negatively influence both adaptive coping
pain strategies and a greater perception of pain.
Psychological interventions, and particularly cognitive behavioral therapy, can
reduce catastrophizing, harm avoidance, anxiety and depression (Glombiewski et
al., 2010). Intervention studies will confirm or contrast the potential long-term
benefits of reducing such aspects in fibromyalgia patients, focusing particularly on
studies of tailored early intervention (Evers, Kraaimaat, van Riel, & de Jong, 2002)
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APARICIO, ORTEGA, CARBONELL-BAEZA, CUEVAS, DELGADO-FERNÁNDEZ, RUIZ
that may help to move patients from a ‘high-risk’ to a relatively lower-risk profile in
order to improve long-term pain outcomes.
Some limitations of the present study need to be mentioned. First, the study
was developed just in women and thus, research on depression and anxiety
presence and its relationship with pain in male fibromyalgia patients are needed.
Second, individually tailored medication such as analgesics, antidepressants and
anxiolytics, usually employed by patients to manage fibromyalgia symptoms, might
have had some influence on pain, anxiety and depression levels. On the other
hand, one of the strengths of the present study is that we have analyzed pain
across low, mild, moderate and severe depression and anxiety subgroups, which
allows us to compare between different anxiety and depression intensities.
Overall, high levels of anxiety and depression were associated with higher
perceived pain but not with higher tenderness. Furthermore, patients with higher
levels of anxiety and depression presented increased risk of severe fibromyalgia.
Since these anxiety and depressive symptoms are associated with increased pain
perception, anxiety and depression should be diagnosed and properly treated in
order to improve fibromyalgia symptoms.
Future studies will confirm or contrast the present findings. Taking into
account the present results, it would be of interest to analyze if psychological
interventions focus on anxiety and depression could reduce fibromyalgia pain and
severity.
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RECEIVED: Mai 6, 2012
ACCEPTED: October 10, 2012