Fibromyalgia and Psychologic Status


Emotional distress is one of the core components of FMS. The search for a defined psychiatric disorder as a cause or trigger for FMS has been disappointing. Nevertheless, depression may follow chronic pain as a secondary phenomenon. Instruments designed to identify this treatable condition are important to the overall assessment of the FMS patient. On the other hand, there have been numerous abnormalities in a variety of other psychologic instruments that examine a wide range of patient characteristics. Although no one instrument seems useful in its own right, those that measure patients' beliefs, attitudes, and stress reactivity appear important in assembling information that might contribute to a management program or study of the pathogenesis of the disorder. Currently, no one single instrument appears to capture a global psychologic summary of FMS patients (Table 3).

General Psychopathology

A number of instruments may detect general psychologic distress in FMS patients. The Minnesota Multiphasic Personality Inventory (MMPI) .50. has been commonly used for assessing personality characteristics of chronic pain patients, including those with FMS. This is a 566-item true false questionnaire that describes the patient on their validity and 10 clinical scales. The MMPI was validated in medically healthy populations in persons over the age of 16 who could read English and were of at least low-average intelligence. It suffers from cultural biases for those not raised in the United States and does not differentiate organic from nonorganic pain-related symptoms. Interpretation of this instrument is based on scale elevations and profile patterns. Scale values are based on standardized T-scores derived from normative samples. In general, a standardized T-score over 70 is considered to be "elevated." T-scores are standardized to a mean of 50. It has been noted that this measure is time-consuming, tedious, and very psychologically orientated, but does have the advantage of providing an extensive database regarding personality characteristics.100.
Chronic pain patients, including those with FMS, are characterized by elevations of the hypochondriasis, depression, and hysteria scales,80,91,106. which suggests somatic preoccupation and concern, unhappiness, lack of psychologic insight, and tendency to develop somatic symptoms in response to stress and internal conflict. Further analysis of MMPI scores in FMS patients by multivariate analysis indicates that one third of subjects are psychologically disturbed; the others are normal or have typical chronic pain profiles.106 Smythe.93. pointed out that questions concerned with pain and somatic symptoms are positive in any person with a chronic pain condition. He felt that there was a 40% bias towards elevated scores on hypochondriasis, hysteria, and depression scales, based solely on the presence of chronic pain in FMS patients. Other studies.60. suggest a complex psychologic disturbance in FMS, as physical illness alone appears unlikely to drive MMPl profiles into the abnormal range.37 There have been few studies correlating MMPI results with other characteristics of FMS patients. Although the MMPl may be regarded as a "standard" measure of psychologic aspects of chronic pain, its routine use in the assessment of FMS patients, for the reasons just discussed, has not yet been established. Some would indicate that a skilled interpreter can eliminate the biases of the inventory in patients with FMS.37,100 .


Characteristic Instrument (examples)

General psychopathology Minnesota Multiphasic Personality Inventory (MMPI)

Symptom Check List-90 (SCL-90)

Brief Symptom Inventory (BSI)

Basic Personality Inventory

Diagnostic Interview Schedule (DIS)

Depression DIS

SCL-90 (BSI)

Profile of Mood States (POMS)

Visual Analog Scale (VAS)

Beck Depression Index

Zung Self-Rating Depression Scale

Hamilton Rating Scale

Centre for Epidemiology Studies Depression Scale

Face Scale

Arthritis Impact Measurement Scales (AIMS)

Anxiety POMS

SCL-90 (BSI)

Beck Anxiety Inventory



Speilberger State-Trait Anxiety Inventory


Stress Family Inventory of Life-Events

Holmes-Rahe Life Events Inventory

Daily Hassles Scale

Beliefs, Attitudes Multidimensional Health Locus of Control

Perceived Threat

Learned Helplessness

Fibromyalgia Attitudes Index

Pain Beliefs and Perceptions Inventory

Survey of Pain Attitudes

Social Skills,

Motivation Bakker Assertiveness Aggressive Scale

Self-Motivation Scale

Coping Strategies Questionnaire

In contrast to the MMPI, an empirically derived scale, the SCL-90 is a subjective face-validity constructed personality scale.33 This 90-item self-report symptom inventory is designed to measure psychologic symptom patterns of both psychiatric and medical patients. Each item is rated on a five-point scale of severity and nine symptom dimensions (including depression, anxiety, and hostility, for example), and three global indices of distress are scored. Scale scores are compared with normative samples and values expressed as T-scores and are graphed to yield a profile of symptom patterns. This questionnaire is considerably shorter than the MMPI and yields a numerical index of the degree of physiologic distress. Clark.29. found no significant difference between FMS patients and healthy controls using this methodology, although selection biases may have led to this result. The Brief Symptom Inventory (BSI) is a 53-item self-report screening instrument developed as a shortened version of the SCL-90." It also provides an index of psychologic distress in addition to multi-dimensional symptom measurement. Normative data using community nonpatient normal samples is available.

The Basic Personality ]Inventory (BPI) has shown FMS patients to have significantly higher scores in four of the scales (hypochondriasis, depression, anxiety, and social introversion). A high degree of classification accuracy is achieved with these scores compared to rheumatoid arthritis and normal controls.91.

It has been suggested that structured psychiatric interviews, such as the Diagnostic structured Interview (DIS)," are more likely to provide a valid psychiatric diagnosis according to standardized diagnostic criteria. These include the Diagnostic and Statistical Manual of Mental Disorders (DSM-Ill-R) .7.and the 10th Revision of the International Classification of Diseases (ICD-lO).9. The DSM-111-R criteria provide for definitions of a wide range of psychiatric disorders, including major affective disorders, anxiety disorders, substance abuse disorders, psychotic disorders, somatization disorders, and antisocial personality disorders. Using this technique, increased past and current diagnosis of major depression, anxiety, or somatization disorder, for instance, may be studied in patients with FMS. 5,42,52.

Next: Fibromyalgia Anxiety and Depression

Patient's Pain Communication Tool