Health anxiety and depression in patients with fibromyalgia syndrome

Abstract

Objectives

To investigate health anxiety and depressive symptoms in patients with fibromyalgia syndrome (FMS).

Methods

Patients with FMS and healthy control subjects were recruited. All participants completed the Health Anxiety Inventory Short Form (HAI-SF) and Beck Depression Inventory (BDI). Pain was assessed in patients with FMS using the Fibromyalgia Impact Questionnaire (FIQ) and Visual Analogue Scale (VAS).

Results

This study involved 95 patients with FMS (15 male) and 95 healthy controls (17 male). Mean ± SD HAI-SF and BDI scores were significantly higher in patients with FMS = than in controls=. HAI-SF scores were 23.50 ± 10.78 and 9.38 ± 4.24 respectively; BDI scores were 18.64 ± 10.11 and 6.21 ± 4.05 respectively. There were highly significant correlations between FIQ and HAI-SF, FIQ and BDI, and HAI-SF and BDI.

Conclusions

Patients with FMS had significantly higher HAI-SF and BDI scores than healthy controls. Psychiatric support is essential for patients with FMS. Treatment should include biological, psychological and social approaches.

Keywords

Health anxiety fibromyalgia syndrome depression chronic pain

Introduction

Fibromyalgia syndrome (FMS) is a chronic disease that is characterized by widespread musculoskeletal pain, tender points in the body, tiredness and sleep disorders.¹ In addition, FMS may be accompanied by irritable bowel syndrome, stress headache, premenstrual syndrome, urethral syndrome, Raynaud’s phenomenon and Sicca syndrome.²

The American College of Rheumatology (ACR)³ defines FMS as the presence of widespread pain lasting longer than 3 months (in the axial skeleton, on the left and right sides of the body, and above and below the waist) and tenderness to pressure in at least 11 out of 18 points in the body. Painkillers, antidepressants, myorelaxants and sleeping pills are used in the treatment of FMS, but these agents are not fully effective.⁴ FMS is a major cause of chronic pain, which is linked to psychiatric disorders. At least 30% of patients with chronic pain have major depression, and 30% are diagnosed with panic and diffuse anxiety disorder.^5,6

The global severity of FMS is assessed via the Fibromyalgia Impact Questionnaire (FIQ),⁷ whereas the Hospital Anxiety and Depression Scale (HADS)⁸ and Beck Depression Inventory (BDI)⁹ are used to evaluate anxiety and depression. These questionnaires provide limited information regarding the degree of health anxiety, however. Evaluation of health anxiety would help to focus on the cause of anxiety, and thus improve activities of daily living and health-related quality-of-life. The main disorder accompanying health anxiety is hypochondriasis, but this also commonly occurs in other somatic symptom disorders.¹⁰

The aim of the present study was to investigate health anxiety and depressive symptoms in patients with FMS, and also to explore whether any relationships exist among health anxiety and disease activity scores (FIQ), pain levels (VAS) and depression scales.

Patients and methods

Study population

Consecutive patients with FMS (diagnosed according to ACR criteria³) were recruited from the Outpatient Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Bozok University, Yozgat, Turkey, between December 2013 and December 2014. Healthy control subjects were recruited from among the staff of Faculty of Medicine, Bozok University, and healthy relatives of the patients. Exclusion criteria for patients and controls were illiteracy, neurological, psychiatric or systemic disease, alcohol and/or substance use disorders, or taking medication with a side-effect of anxiety.

The study was conducted in accordance with the tenets of the Declaration of Helsinki and was approved by the Ethics Committee of Bozok University Medical School, Yozgat, Turkey. Written informed consent was obtained from all study participants.

Data collection

Demographic data including age, sex, education level and marital status were collected from all participants. Health anxiety was assessed in all participants using the 18-item self-declaration Health Anxiety Inventory Short Form (HAI-SF):¹¹ this has been validated for the Turkish population.¹² The inventory includes questions that evaluate the state of mind of a patient, with and without the assumption of serious illness. A higher score indicates more severe health anxiety.

The BDI⁹ was used to evaluate depression in all participants. The validity and reliability of this scale for the Turkish population has been established.¹³ The questionnaire includes 21 questions, with a maximum possible score of 63 points. Scores were defined as: 0–13 points, no depression; 14–24 points, moderate depression; >25 points, severe depression.

In the patient group, pain was assessed using a 0–100 mm visual analogue scale (VAS), and the number of tender points was evaluated according to ACR criteria.³ A total of 18 anatomical points and four symmetrical control points were assessed using ∼4.0 kg of pressure. The severity of FMS was evaluated via the Fibromyalgia Impact Questionnaire (FIQ).⁷

Statistical analyses

Power calculations were based on data from a pilot study evaluating HAI-SF scores and morphine consumption in 20 patients with FMS and 20 control subjects (unpublished). In this pilot study, morphine consumption was 18.5 ± 8.42 vs 13.2 ± 5.8 mg in patient and control groups, respectively. Assuming a two-tailed α-value of 0.05 (sensitivity 95%) and a β-value of 0.20 (study power: 80%), it was determined that the present study required at least 95 patients in each group. Power analysis was performed using G*Power version 3.0.10 (Dusseldorf University, Dusseldorf, Germany).

Data were presented as mean ± SD or n (%) of patients. Between-group comparisons were made using Student’s t-test. Spearman’s correlation coefficient analysis was used to evaluate the relationships between VAS, FIQ, HAI-SF, BDI scores, disease duration, number of tender points and mean age of patients. Statistical analyses were performed with SPSS® version 17.0 (SPSS Inc. Chicago, IL, USA) for Windows®. P-values < 0.05 were considered statistically significant.

Results

The study recruited 95 patients with FMS (15 male/80 female; mean age 38.11 ± 11.73 years; age range 26–54 years) and 95 healthy control subjects (17 male/78 female; mean age 42.86 ± 9.52 years; age range 27–56 years). There were no statistically significant between-group differences in any sociodemographic characteristic (Table 1).

Table 1.

Sociodemographic characteristics of patients with fibromyalgia syndrome (FMS) and healthy control subjects included in a study investigating health anxiety and depression in patients with FMS.

Characteristic	FMS group n = 95	Control group n = 95
Age, years	38.11 ± 11.73	42.86 ± 9.52
Sex, male/female	15/80 (15.8/84.2)	17/78 (17.9/82.1)
Weight, kg	69.13 ± 12.96	71.65 ± 14.11
Height, cm	161.31 ± 7.16	162.41 ± 8.51
Body mass index, kg/m²	26.6 ± 1.8	27.1 ± 1.9
Duration of disease, years	4.3 ± 3.47	–
Marital status, single/married	27/68 (28.4/71.6)	31/64 (32.6/67.4)
Education level
Literate	15 (15.7)	12 (12.6)
Primary School	38 (40.1)	45 (47.3)
High School	17 (17.8)	13 (13.7)
University	25 (26.4)	25 (26.4)
Employment Status
Working	30 (31.6)	36 (38.3)
Housewife	44 (46.4)	42 (44.2)
Retired	6 (6.3)	5 (5.2)
Unemployed	15 (15.7)	12 (12.6)

Data presented as mean ± SD or n of subjects (%).

No statistically significant between-group differences observed (P ≥ 0.05; Student’s t-test).

Data regarding clinical characteristics of patients and controls are shown in Table 2. Mean HAI-SF and BDI scores were significantly higher in the patient group than in the control group (P < 0.001 for each comparison).

Table 2.

Clinical characteristics of patients with fibromyalgia syndrome (FMS) and healthy control subjects.

Parameter	FMS group n = 95	Control group n = 95	Statistical significance^a
VAS 100, mm	55.34 ± 16.45	–	–
Tender points, n	14.72 ± 2.34	–	–
FIQ	56.01 ± 15.32	–	–
HAI-SF	23.50 ± 10.78	9.38 ± 4.24	P < 0.001
BDI	18.64 ± 10.11	6.21 ± 4.05	P < 0.001

Data presented as mean ± SD.

Student’s t test.

VAS, visual analogue scale; FIQ, Fibromyalgia Impact Questionnaire;⁷ HAI-SF, Health Anxiety Inventory Short Form;¹¹ BDI, Beck Depression Inventory.⁹

Results of correlation analysis in the patient group are given in Table 3. Of note, there were highly significant (P < 0.001) positive correlations between FIQ and HAI-SF, FIQ and BDI, HAI-SF and BDI, and number of tender points and FIQ, HAI-SF and BDI. VAS was significantly positively correlated with FIQ, HAI-SF, BDI and number of tender points (P < 0.05 for each correlation; Table 3).

Table 3.

Spearman’s correlation coefficient analysis of clinical characteristics of patients with fibromyalgia syndrome (n = 95).

Parameter	VAS	FIQ	HAI-SF	BDI	Duration of disease, years	Tender points, n	Age, years
VAS	1
FIQ	r = 0.402 P = 0.017	1
HAI-SF	r = 0.247 P = 0.025	r = 0.622 P <0.001	1
BDI	r = 0.279 P = 0.011	r = 0.431 P = 0.001	r = 0.502 P < 0.001	1
Duration of disease, years	r = 0.142 NS	r = 0.264 P = 0.016	r = 0.271 P = 0.014	r = 0.271 P = 0.014	1
No. of tender points	r = 0.285 P = 0.009	r = 0.762 P < 0.001	r = 0.664 P < 0.001	r = 0.633 P < 0.001	r = 0.231 NS	1
Age, years	r = 0.263 NS	r = 0.209 NS	r = 0.406 P = 0.034	r = 0.443 P = 0.028	r = 0.306 NS	r = 0.450 NS	1

VAS, Visual analogue scale; FIQ, Fibromyalgia Impact Questionnaire;⁷ HAI-SF, Health Anxiety Inventory Short Form;¹¹ BDI, Beck Depression Inventory.⁹

NS, not statistically significant (P ≥ 0.05).

Discussion

Patients with FMS had significantly higher HAI-SF and BDI scores than controls in the present study. Both FIQ and VAS were positively correlated with BDI and HAI-SF scores in patients with FMS. Mild forms of health anxiety are common and are not considered a disorder; more severe forms are less common but can be very distressing for the patient, causing physical symptoms of serious illnesses and leading to hypochondriasis.¹⁴

The attitudes of patients with FMS have been found to be associated with psychological factors such as depression and anxiety, rather than tissue damage.¹⁵ Widespread pain is common in FMS, and such pain can lead to psychological problems (as both a component of the physical disorder and as a psychiatric disorders in its own right).¹⁶ Better understanding of health anxiety will allow fuller comprehension of somatic symptom disorders, depression and anxiety. Anxiety has been shown to be associated with oxidative stress in the absence of clinical disorders, however.^17,18

In accordance with the present findings, anxiety and depression levels were higher in a group of patients with low back, neck and knee pain when compared with controls;¹⁹ these symptoms of pain and depression significantly impaired the health-related quality-of-life and functioning of patients. The increased levels of health anxiety in patients with FMS compared with healthy controls in the present study may have been due to the patients’ increased perception of pain and resulting somatization of symptoms.

There was no association between pain score and disease duration or patient age in the present study. Our finding that the number of tender points was correlated with HAI-SF, BDI and FIQ is in contrast to an earlier study, which identified an association between the number of points and the pain score, but not between depression and anxiety.²⁰

Health anxiety scores have been shown to be higher in patients with both clinical insomnia and chronic pain compared with patients with chronic pain alone.²¹ A large-scale study of patients (n = 28 991) admitted to hospitals or medical clinics determined that the prevalence of health anxiety was highest in those attending neurology clinics (24.7%), followed by respiratory medicine (20.9%), gastroenterology (19.5%), cardiology (19.1%) and endocrinology clinics (17.5%).²²

The prevalence of clinical hypochondriasis has been reported to be ∼1%,²³ increasing to 14% when subclinical forms are included.²² Health anxiety therefore results in reduced health-related quality-of-life as well as increased costs relating to the health care system.²⁴ Our study provides valuable data regarding the prevalence and severity of both depression and health anxiety in patients with FMS.

Our study has several limitations. First, the sample size was relatively small. Secondly, HAI-SF was the only health anxiety assessment measure used; the use of additional assessment tools may have strengthened our results. To the best of our knowledge, however, this is the first study investigating mild forms of health anxiety in patients with FMS.

In conclusion, psychiatric support is essential for patients with FMS. Treatment should include biological, psychological and social approaches.

Footnotes

Declaration of conflicting interest

The authors declare that there are no conflicts of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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