Fibromyalgia Anxiety and Depression

Depression

As a mood, depression is an expression of distress or unhappiness including feelings of worthlessness, self-depreciation, listlessness, apathy, and guilt.35. Because depression is treatable and may follow or be associated with FMS, it is important to identify this problem. A number of instruments may be used. The DIS has produced validated diagnoses of depression according to standardized diagnostic criteria,42. but there needs to be better standardization in medically ill patients. Quantified scales have been suggested whereby certain "somatic" symptoms have been deleted and substituted with affective and cognitive symptoms. 20,38. The SCL-90 and the BSI contain depression subscales that comprise descriptors of dysphoric moods, including "crying easily," "feeling no interest in things," and "thoughts of ending your life." Responses range from "not at all" to "extremely." Both cognitive and somatic correlates of depression are included in addition to the affective symptoms described.

The Profile of Mood State (POMS) consists of 65 adjectives describing mood status.66. Responses are constrained to 1 of 5 possibilities ranging from "not at all" to "extremely." The questionnaire is administered and scored by a technician and can be completed in 5 to 10 minutes. This is a reliable and valid instrument describing transient feelings rather than personality traits occurring "during the past week, including today" with different time specifications. Fifteen descriptors are included in the depression-dejection scale including "desperate," "hopeless," "unworthy," and "gloomy." The Beck Depression Inventory (BID) is a 21- item self-report yielding a numerical estimate of depression severity.11.

Patients select one of four or five statements ranked in order of severity in each item. Scores range from O to 63, with high scores indicating greater depression. The statements deal with sadness, sense of failure, self-hate, and easy fatigue, each of which can be rated according to severity. Each statement is intended to describe the specific behavior or manifestation of depression. The inventory can be read to the patient or presented in written form. This measure is widely used for research and clinical purposes because it only takes a few minutes to administer and score and is quite practical. The Zung Self-Rating Scale is a 20-item self-report, 114. that yields a numerical estimate of depression severity. Each item is ranked on a four-point scale, indicating frequency of occurrence of that symptom. There is no weighting of this scale, which makes it more biased towards a score indicating depression. Patients with fibromyalgia have been shown to have higher scores than normal controls, R but retest reliability and its validity in nonpsychiatric settings and with different age groups is lacking. The Hamilton Rating Scale is a 21 item scale, 52. that gives higher scores in patients with FMS than in controls. 52 The Centre for Epidemiological Studies Depression Scale is a 20-item self-report measure,86. that relates to frequency of depression symptoms in the past week. It was developed for a community rather than a psychiatric population. FMS patients score higher on this scale than do controls.81.

The Face Scale is a nonverbal assessment method 62. that depends on responses to a series of 20 line drawings of faces that change progressively from "very happy" in appearance at one end to "very sad" at the other. Patients are instructed to select the face that best reflects their feelings. This test is particularly useful for illiterate persons or those who do not speak English. This scale has shown differences between FMS patients who have improved following rheumatologic intervention compared to those who have not. 46. The pain subscale of the AIMS may be used to evaluate depression in FMS patients. This is incorporated in the CLINHAQ.106.

A 10-cm VAS labeled with end points such as "extremely depressed" and "not at all depressed" shows good test-retest reliability and correlations with established methods of assessment of active symptoms. 2, 53. There may be problems with patients' interpretation of the words on the scale, and it is best used over the short term (e.g., 1 week or 1 month). Using this method, similar levels of depression have been noted in patients with FMS and regional pain syndromes. 91.

Anxiety

This represents extreme uneasiness of mind or unfocused fear characterized by restlessness, nervousness, and tension. 35. In severe situations, avoidance behavior, fear of social situations, or panic attacks may occur. Anxiety may also be a manifestation of depression. It is essential to identify this mood disorder as it is over-represented in patients with FMS, and management strategies may need to be particularly tailored to address this issue in affected patients. Nine of the 65 adjectives of the POMS describing mood status comprise the tension-anxiety subscale, including "tense," "uneasy," and "panicky." Responses relate to experiences within the past week and are constrained to one of five possibilities ranging from "not at all" to "extremely." Ten of the 90 items on the SCL-90 reflect anxiety, including trembling and feelings of dread and terror. The DIS allows for DSM-III-R classifications, which include anxiety-associated psychiatric diagnoses.

Of particular relevance to FMS patients are the diagnosis of post traumatic stress disorders and phobic anxiety. The former may be an essential component of post-injury fibromyalgia situations, and the latter may impinge on appropriate rehabilitation programs.

The (Speilburg State-Trait Anxiety Inventory (STAl) is a self-evaluation questionnaire, 96. that includes 40 short sentences about how the subject feels; for example, "at ease" or "jittery." The current "state" of anxiety represents how the subject feels at that moment and is measured by the first 20 statements, which are answered from "not at all" to "very much so." Anxiety as a "trait" represents how the subject generally feels and is measured with the other 20 statements, with responses ranging from "almost never" to "almost always." The "state" component of this inventory has high criterion validity and excellent internal consistency. 75.

There was no difference between FMS subjects and controls, although controls included a high percentage of patients with chronic musculo-skeletal pain and sleep disturbance in one study," whereas another showed significantly higher levels of anxiety in patients with FMS. 111.

The Beck Anxiety Inventory can also be used in FMS patients, 13. and the anxiety subscale of the AIMS instrument may be used to provide information on anxiety in patients with FMS. This has been incorporated in multidimensional instruments such as CLINHAQ. Finally, a VAS with a 10-cm line is bounded by "not at all nervous" and "most nervous I have ever felt" at the other extreme" can allow a subject to be directed to consider feelings within a recent time interval such as 1 day, 1 week, or longer. Once again, there is often difficulty in the exact meaning of the word for each patient, and responses may differ because of this. The scales are most effective over short periods. Similar findings have been found in patients with FMS and regional pain syndromes.91

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