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Comorbid Depression and Anxiety in

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Somatic and Psychosocial Variables

Article in Psychosomatic Medicine · November 2004

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Comorbid Depression and Anxiety in Fibromyalgia Syndrome: Relationship to
Somatic and Psychosocial Variables
KATI THIEME, PHD, DENNIS C. TURK, PHD, AND HERTA FLOR, PHD
Objective: The prevalence as well as predictors of psychiatric disorders (Diagnostic and Statistical Manual of Mental Disorders,
4th edition [DSM-IV] axis I and II) in patients with fibromyalgia syndrome (FMS) was evaluated. Method: One-hundred fifteen
patients with FMS participated in the Structured Clinical Interview for DSM-IV to assess current mental disorders. In addition,
patients completed standardized questionnaires regarding pain, pain impact, anxiety, depression, posttraumatic stress disorder-like
symptoms, and sexual and physical abuse. Results: Patients were grouped into one of three psychosocial subgroups based on
responses to the Multidimensional Pain Inventory (MPI)–Dysfunctional (DYS), Interpersonally Distressed (ID), and Adaptive
Copers (AC). Axis I diagnoses were present in 74.8% of the participants overall with the DYS subgroup mainly reporting anxiety
and the ID group mood disorders. The AC group showed little comorbidity. Axis II diagnoses were present in only 8.7% of the FMS
sample. Conclusion: These results suggest that FMS is not a homogeneous diagnosis, but shows varying proportions of comorbid
anxiety and depression dependent on psychosocial characteristics of the patients. The results demonstrate the importance of not
treating patients with FMS as a homogeneous group. Assessment should not only examine the presence of widespread pain and the
number of tender points, but also the presence of affective distress. Treatment should focus both on physical and emotional
dysfunction. Key words: fibromyalgia, comorbidity, DSM-IV, SCID, MPI subgroups.

FMS ⫽ fibromyalgia syndrome; MPI ⫽ Multidimensional Pain
Inventory; DYS ⫽ dysfunctional; ID ⫽ interpersonally distressed;
AC ⫽ adaptive copers; SCID ⫽ Structured Clinical Interview for
DSM-IV; CES-D ⫽ Center for Epidemiologic Studies Depression
Scale; STAI-T ⫽ State-Trait Anxiety Inventory–Trait scale;
PRSS ⫽ Pain-Related Self-Statements Scale.
INTRODUCTION
F ibromyalgia syndrome (FMS) is characterized by wide-
spread pain, hypersensitivity to palpation at specific body
locations (tender points) (1), and a range of comorbid physical
symptoms and functional limitations, including persistent fa-
tigue, sleep disturbance, feelings of stiffness, headaches, and
irritable bowel disorders (1). Patients also report cognitive
impairment and general malaise sometimes referred to as
“fibro fog” (2).
As is often the case in medicine, in the absence of specific
physical findings that provide an adequate explanation for
symptoms, a number of authors have suggested that FMS is
primarily a psychogenic disorder (3–5). Depression is reported
to be particularly prevalent in FMS, leading some to suggest
that it is a depressive spectrum disorder (6 – 8). Examination
of the prevalence of depression across studies reveals a wide
diversity with current depressive disorders ranging from
28.6% to 70% across studies (9,10). The large differences in
prevalence may be explained by the variation in methods for
assessing depression, different definitions used for depression,
and sampling bias (eg, patients referred to a psychiatrist for
evaluation); reliance on treatment-seekers to establish preva-
lence (treatment seekers are likely to be the most distressed);
or a combination of these factors. Less attention has been
given to the prevalence of anxiety in FMS. However, Kurtze
From the Department of Anesthesiology, University of Washington, Seat-
tle, Washington (K.T., D.C.T.); and the Department of Neuropsychology
(K.T., H.F.), University of Heidelberg, Central Institute of Mental Health
Mannheim, Mannheim, Germany.
Address correspondence and reprint requests to Kati Thieme, PhD, Department
of Anesthesiology at the University of Washington, 1959 NE Pacific Street, Box
356540, Seattle, WA 98195-6540. E-mail: thiemek@u.washington.edu
Received for publication March 10, 2004; revision received June 18, 2004.
DOI: 10.1097/01.psy.0000146329.63158.40
(11) found support for the hypothesis that depression and
anxiety are independently associated with the severity of pain
symptoms in FMS. Thus, not all patients diagnosed with FMS
experience the same or necessarily any emotional disorders.
Turk and Flor (12) suggested that FMS is likely comprised
of a heterogenous group of people who may differ on impor-
tant variables such as mood, adaptation to symptoms, as well
as presenting symptoms. Turk et al. (13,14) demonstrated that
patients with FMS could be classified into psychosocial sub-
groups based on the scores of the West Haven-Yale Multidi-
mensional Pain Inventory (MPI) (15). In a cluster analysis of
responses to the MPI, these investigators identified three psy-
chosocial subgroups that were characterized by different lev-
els of pain intensity, interference, and affective distress as well
as the reactions of significant others. One group, labeled
dysfunctional (DYS), exhibited the highest level of pain,
emotional distress, and disability. A second group, termed
interpersonally distressed (ID), reported significantly lower
levels of pain, disability, and marital satisfaction than the
other two subgroups. The significant others of ID patients
showed a higher level of negative responses to the patients’
expressions of pain. The third group, adaptive copers (AC),
showed low pain intensity, emotional distress, and interfer-
ence of pain with daily lives and activities. MPI-based sub-
groups have been replicated in several studies performed in
several Western countries (eg, The Netherlands (17), Ger-
many (18), Sweden (19)). These subgroups have been identi-
fied in diverse chronic pain syndromes (eg, headache, back
pain, temporomandibular disorders) (16). The percentages of
patients classified within each group do, however, vary across
diagnoses. These patterns appear to exist independent of med-
ical diagnosis. The subgroups identified are primarily descrip-
tive; there is no information available to clarify what factors,
if any, predispose people to respond to chronic pain in one of
the three patterns identified. Moreover, to date, there have
been no studies that we are aware of that have attempted to
clarify the extent and nature of psychiatric disorders in the
subgroups identified.
The MPI is a general screening instrument and, although it
contains a scale labeled “affective distress,” it does not di-

Psychosomatic Medicine 66:837– 844 (2004) 837

0033-3174/04/6606-0837
Copyright © 2004 by the American Psychosomatic Society

rectly assess psychiatric disorders. To better understand the
MPI-based subgroups, it would be useful to examine the
presence of specific comorbid mental disorders. In the present
study, we assessed the prevalence of psychiatric disorders in a
group of patients with FMS and sought predictors of mental
disorders from psychosocial variables. We examined the pres-
ence of specific psychiatric disorders associated with adapta-
tion to symptoms using the MPI psychosocial subgroups to
differentiate groups of patients with FMS.
METHODS
Participants
One hundred fifteen German-born, female patients with FMS were re-
cruited from rheumatologic outpatient departments as well as from a Hospital
for Rheumatic Disorders at Berlin-Buch. The rheumatologists referred the
patients to a Department of Neuropsychology to receive psychologic pain
treatment. Patients were informed about the study and were assured that
failure to agree would not interfere with their treatment. They were instructed
that they could withdraw from the study at any time without affecting the
treatment they received, and completed forms consenting to participate. All
patients had a diagnosis of FMS based on the ACR criteria (1). Exclusion
criteria were 1) inflammatory cause of the pain, 2) neurologic complications,
3) duration of pain less than 4 months, 4) pregnancy, 5) another severe disease
such as a tumor, liver, or renal disease, and 6) lack of fluency in the German
language.
The mean age of the sample was 48 years (standard deviation [SD] ⫽
10.32 years) and the average duration of symptoms was 9 years (SD ⫽ 9.23
years). The mean number of tender points was 16 (SD ⫽ 9.99), pain severity
provoked by palpation of tender points was 95 (SD ⫽ 36.56; scale range,
0 –180), and number of painful regions 7 (SD ⫽ 2.05). Forty-one percent of
the patients were employed, 26% were unemployed, and 32% were receiving
workers’ compensation (see Table 1 for a detailed description of the sample).
Assessment
The number of somatic complaints was obtained from medical records
that documented explicit information about all symptoms reported. These
symptoms were aggregated into a total symptom score. The number and
intensity of pain at tender points were assessed and added to obtain sum
intensity score (20).
The Structured Clinical Interview for DSM-IV (SCID I and II) (21,22) was
used to assess axis I and II disorders in accordance with the 4th-TR version
of the Diagnostic and Statistical Manual of Mental Disorders (APA, 1995).
SCID I and II show high validity and reliability in American and German
studies (21–23).
The abbreviated version of the Questionnaire of Sexual and Physical
Abuse (24) designed by the National Population Survey of Canada (25) and
translated into German was used to assess physical and sexual abuse. This
screening instrument provides information on the type and frequency of
sexual or physical abuse as well as on the age at the time of critical life events.
The German translation of the West Haven-Yale Multidimensional Pain
Inventory (MPI) (15,26) was used as a basis for classification of the patients
into one of the three subgroups identified by Turk and Rudy (16). The MPI is
a 61-item self-report inventory that generates 13 scale scores across three
sections (15). The first section addresses pain severity, perception of how pain
interferes with daily life activities, appraisals of the support received from
significant others, perceived life control, and affective distress. The second
section addresses the patients’ perception of how significant others respond to
their displays of pain: negative responses, solicitous responses, and distracting
responses. The third section is composed of a checklist of 18 common
activities to form a general activity scale.
The German version of the Center for Epidemiologic Studies Depression-
Scale (CES-D) was used to assess current symptoms of depression (27,28).
This 20-item measure is a reliable and valid indicator of depressed mood in
both clinical and research populations. The CES-D items are relatively free of
838
K. THIEME et al.
content related to pain and functional limitations associated with rheumato-
logic disorders; thus, depression scores are not spuriously inflated by pain.
State-Trait Anxiety Inventory–Trait Scale
The German version of trait version of the State-Trait-Anxiety Inventory
(29 –31) was used to measure a stable disposition characterized by tension and
apprehension across time and setting. The 20-item trait version is reliable and
valid, and it is the most commonly used measure of anxiety in psychologic
and behavioral medicine research.
Posttraumatic Stress Disorder-Like Symptoms
Posttraumatic stress disorder (PTSD)-like symptoms were determined
using the German version of Symptom Checklist-90 –Revised (32,33). Saun-
ders et al. (34) developed a posttraumatic stress disorder (CR-PTSD) scale for
women within the SCL-90-R. Using a criterion group classification approach,
a 28-item scale extracted from the SCL-90-R was developed that successfully
discriminated between CR-PTSD positive (PTSD⫹) and negative responders
(PTSD⫺). Participants were classified as having high levels of PTSD-like
symptoms (PTSD⫹) if they met or exceeded the recommended cutoff score
(0.89) as determined in the original validation study (34). Those below the
cutoff sore were classified as negative for PTSD-like symptoms (PTSD⫺).
Sherman et al. (35) demonstrated high levels of PTSD-like symptoms in
patients with FMS using the CR-PTSD.
The Pain-Related Self Statements Scale (PRSS) (36) with the subscales
“Coping” and “Catastrophizing” was used to assess the situation-specific
aspects of patients’ cognitive coping with pain. The PRSS has been shown to
have good reliability and validity (36).
Procedures
Each patient underwent a comprehensive evaluation, including medical
and physical assessments. A psychologic interview was conduced using the
SCID I and II. Patients completed the set of questionnaires described previ-
ously. Three behaviorally trained psychologists with more than 15 years
experience in psychosomatic and internal medicine, including experience
performing SCID interviews, conducted SCID I and II. Reliability data were
not obtained.
Statistical Analysis
Based on the SCID interviews, the frequency of axis I and II disorders was
determined and axis I disorders were grouped into 1) anxiety and 2) mood
disorders. SCID I diagnoses included the following anxiety diagnoses: panic
disorder without agoraphobia, generalized anxiety disorder, panic disorder
with agoraphobia, agoraphobia without panic disorder, social phobia, specific
phobia, obsessive-compulsive disorder, and acute stress disorder as well as
PTSD. The group of mood disorders included major depressive episode,
major depressive disorder, and dysthymic disorder as indicated in DSM-IV.
A multivariate analysis of variance (MANOVA) was conducted to deter-
mine whether there were differences among the groups with no axis I
disorders, anxiety disorders, and mood disorders. The STAI-T, CES-D Scale,
SCL-90, and number of symptoms associated with FMS, pain, and its con-
sequences (MPI), and sum pain at tender points were included in this analysis.
One-way ANOVAs were conducted following a significant MANOVA. Bon-
ferroni-corrected post hoc t tests were used for follow-up analyses of signif-
icant group effects. The prevalence of mental disorders was calculated for the
three psychosocial subgroups. As a result of their low prevalence, personality
disorders were not investigated in further detail. To assess predictors of
mental disorders, binary logistic regression analyses with a forward condi-
tioning method were used.
RESULTS
Current Mental Disorders
Axis I psychiatric disorders were found in 77.3% of the
sample: 32.2% of the patients with FMS reported symptoms
characteristics of anxiety disorders, 34.8% mood disorders,
1.75% met criteria of substance-related disorders, and another
Psychosomatic Medicine 66:837– 844 (2004)
ANXIETY AND DEPRESSION IN FIBROMYALGIA SYNDROME

TABLE 1. Demographic and Clinical Characteristics of the Psychosocial Subgroups and the Entire Sample

Entire Sample DYS ID AC

(N ⫽ 115) (N ⫽ 35) (N ⫽ 38) (N ⫽ 42) Sign.
M M M M (between all
SD SD SD SD subgroups) p
(Range) (Range) (Range) (Range)

Age (in years) 48.17 47.31 47.77 49.42 .566

10.32 9.19 8.89 12.88
(21–68) (22–68) (21–66) (21–66)
Duration of the pain (in years) 9.29 11.18 7.34 9.36 .166
9.23 9.07 8.44 10.19
(0.5–45) (0.5–31) (1–45) (1–43)
Pain zones (number) 6.8 7.21 6.67 6.53 .399
2.05 1.93 1.99 2.24
(3–12) (3–10) (3–10) (3–12)
Tender points (number) 16.09 17.07 15.21 16.0 .098
9.99 2.92 4.04 3.03
(4–18) (7–18) (4–18) (7–18)
Pain severity of tender points 95 119.00 79.00 88.00 ⬍.001
(Scale from 0 to 180)
36.56 39.74 34.69 35.26
(14–180) (25–180) (18–157) (14–156)
Duration of occupational 25.41 24.73 23.47 28.03 .172
activity (in years)
32.8 11.43 11.16 10.21
(0–52) (0–46) (1–52) (2–46)
Intake of drugs (number) 3.0 3.61 2.80 2.59 .139
2.17 2.20 1.69 2.63
(0–10) (0–10) (0–7) (0–6)

N (%) N (%) N (%) N (%)

Occupational status
Working 48 (41.8) 7 (20.5) 22 (55.0) 19 (46.3)
Unemployed 26 (22.6) 12 (35.3) 5 (12.5) 9 (21.9)
Workers’ compensation 32 (27.8) 14 (41.2) 10 (25.0) 8 (19.5)
Retirement 9 (7.8) 1 (2.9) 3 (7.5) 5 (12.2) .034
Sexual abuse 47 40.9 22 64.7 15 37.5 10 24.4 .002
Physical abuse 24 20.9 13 38.2 5 12.5 6 14.6 .016

Dys ⫽ Dysfunctional; ID ⫽ Interpersonally Distressed; AC ⫽ Adaptive Copers.

1.75% met criteria for eating disorders. In this sample of
patients with FMS, 40.9% reported sexual abuse and 20.9%
physical abuse in childhood. Only 7.8% of the patients ap-
peared to have developed PTSD. Importantly, 11% of the
sample had more than two mental disorders such as anxiety
and substance-related disorder, mood and eating disorder,
mood disorder and various types of phobias. Only 22.7% of
the patients with FMS did not have evidence of any axis I
mental disorder. Personality disorders were found to be
present in only 8.7% of patients (N ⫽ 14), 5.25% borderline
personality disorder and 1.75% revealing either an avoidant
personality disorder, or dependent personality disorder.
Characterization of Axis I Comorbidity
The MANOVA identified significant differences between
the groups (F[18, 52] ⫽ 6.74, p ⬍.001, ⑀ ⫽ 7.0).
Psychologic Distress
As would be expected, patients with FMS who met criteria for
a diagnosis of anxiety disorder showed a significantly higher
level of anxiety (STAI-T: F[2, 112] ⫽ 75.85, p ⬍ .001) than
patients with mood disorders (t[67] ⫽ 7.69, p ⬍ .001) and
patients with FMS without mental disorders (t[80] ⫽ 11.98, p ⬍
.001). Similarly, as expected, patients who met criteria for mood
disorders demonstrated significantly more depressive symptoms
(CES-D-Scale: F[2, 112] ⫽ 48.90, p ⬍ .001) than patients with
anxiety disorders (t[67] ⫽ ⫺6.74, p ⬍.001) and patients with
FMS without an axis I disorder (t[77] ⫽ 10.25, p ⬍ .001). These
results of the self-report data provide additional support for the
validity of the SCID diagnoses.
PTSD-like symptoms were found in 40.9% of the sample.
The diagnostic subgroups were significantly different with
respect to PTSD-like symptoms (F[2, 112] ⫽ 15.98, p ⬍
.001). The patients with anxiety disorders exhibited signifi-
cantly more symptoms than depressed patients (t[67] ⫽ 4.20,
p ⬍ .001) and patients without axis I disorder (t[80] ⫽ 5.123,
p ⬍ .001).
The groups differed significantly in the prevalence of sex-
ual abuse (F[2, 112] ⫽ 14.43, p ⬍ .001). Patients with anxiety

Psychosomatic Medicine 66:837– 844 (2004) 839


Figure 1. Frequency of axis I disorders for patients with fibromyalgia in the
psychosocial subgroups: dysfunctional, interpersonally distressed, and adap-
tive coper.
disorders reported significantly more frequent sexual abuse
than the depressed patients (␹2 [1] ⫽ 8.95, p ⬍ .003) and
patients without axis I disorder (␹2 [1] ⫽ 22.89, p ⬍ .001).
Similar results were found for physical abuse, with those with
anxiety disorders reporting significantly more physical abuse
in childhood (F[2, 112] ⫽ 5.64, p ⬍ .005) than the depressed
patients (␹2 [1] ⫽ 4.86, p ⬍.04) and patients without axis I
disorder (␹2 [1] ⫽ 8.91, p ⬍ .005).
Somatic Symptoms
Patients with anxiety disorders, mood disorders, and no
axis 1 diagnoses differed significantly in the number of so-
matic symptoms they reported (F[2, 112] ⫽ 8.45, p ⬍ .001).
Bonferroni corrected post hoc analyses found that the patients
with anxiety disorders reported significantly more somatic
symptoms than the patients with either mood disorders (t[67]
⫽ 3.49, p ⬍ .001) or the patients without any mental disorders
(t[80] ⫽ 3.59, p ⬍ .003). The patients with mood disorders,
however, were not significantly different from patients with-
out mental disorders in the number of symptoms reported
(t[77] ⫽ ⫺0.634, p ⫽ .53).
Pain and Its Consequences
Patients with anxiety disorders, mood disorders, and no
emotional disorders differed significantly in the pain tender
points sum score (F[2, 112] ⫽ 3.47, p ⬍ .04). Bonferroni-
corrected post hoc analyses indicated that the patients with
anxiety disorders reported significantly higher tender points
sum score than the patients with either mood disorders (t[67]
⫽ ⫺3.16, p ⬍ .02) or those without any mental disorders
(t[80] ⫽ ⫺2.33, p ⬍ .05). The patients with mood disorders,
however, did not significantly in the tender points sum score
reported from patients without mental disorders (t[77] ⫽
⫺0.634, p ⫽ .47).
The diagnostic subgroups were significantly different with
respect to many areas assessed on the MPI. They differed
840
K. THIEME et al.
significantly in pain intensity (F[2, 112] ⫽ 4.87, p ⬍ .009),
with patients with anxiety disorders reporting significantly
higher pain intensity compared with patients with mood dis-
orders (t[67] ⫽ 2.11, p ⬍ .04) and patients without axis I
diagnosis (t[80] ⫽ 3.19, p ⬍ .002). Patients who met criteria
for anxiety disorders also displayed significantly more inter-
ference related to pain (F[2, 112] ⫽ 7.16, p ⬍ .001) than
depressed patients (t[67] ⫽ 2.56, p ⫽ .01) and patients without
axis I disorder (t[80] ⫽ 3.80, p ⬍ .001), less life control (F[2,
112] ⫽ 3.88, p ⬍ .02) than patients without axis I disorder
(t[80] ⫽ ⫺2.72, p ⫽ .008), but not than depressed patients
(t[67] ⫽ ⫺1.35, p ⫽ .18). They reported receiving more social
support (F[2, 112] ⫽ 12.61, p ⬍ .001) than depressed patients
(t[67] ⫽ 4.39, p ⬍ .001), but not than patients without axis I
disorder (t[80] ⫽ 0.34, p ⫽ .69), and they indicated that their
significant others provided more solicitous behaviors (F[2,
112] ⫽ 18.43, p ⬍ .001) than those of depressed patients
(t[67] ⫽ 5.28, p ⬍ .001) but not those of patients without axis
I disorder (t[80] ⫽ 0.14, p ⫽ .89). The anxious patients also
showed the lowest general activity level (F[2, 112] ⫽ 5.61, p ⫽
.005) compared with depressed patients (t[67] ⫽ ⫺2.52, p ⫽ .01)
and patients without axis I disorder (t[80] ⫽ ⫺3.26, p ⫽ .002).
Patients with mood disorders exhibited the highest level of
affective distress (F[2, 112] ⫽ 12.33, p ⬍ .001) compared
with patients without axis I disorder (t[77] ⫽ 3.09, p ⫽ .003)
but did not differ significantly from the patients with anxiety
(t[67] ⫽ 1.61, p ⫽ .11). They did report more punishing
behaviors by significant others (F[2, 112] ⫽ 4.09, p ⫽ .02)
than the patients with anxiety (t[67] ⫽ 2.20, p ⬍.02) and
patients without axis I disorder (t[77] ⫽ 2.77, p ⬍.007) and
the lowest distracting spouse behaviors (F[2, 112] ⫽ 7.22, p ⫽
.001) compared with patients with anxiety (t[67] ⫽ 3.49, p
⬍.001) and patients without axis I disorder (t[77] ⫽ ⫺3.16,
p ⬍ .002) They showed higher general activities than patients
with anxiety (t[67] ⫽ ⫺2.52, p ⬍ .02) but were similar to
patients without axis I disorder (t[77] ⫽ ⫺0.08, p ⫽ .94).
Patients without axis I disorder reported significantly lower
levels of pain, interference, and affective distress but the
highest distracting behaviors by significant others (F[2, 112]
⫽ 7.22, p ⬍ .001) compared with depressed patients (t[77] ⫽
⫺3.16, p ⬍ .002), but not with patients with anxiety (t[80] ⫽
0.36, p ⫽ .72).
Prediction of Axis I Comorbidity
A stepwise logistic regression was performed to determine
the best predictors of axis I disorders. Pain-related, somatic,
cognitive, affective, behavioral, and spouse-related variables
were entered sequentially into the equation: pain intensity
(MPI) and pain at the tender points, somatic symptoms, active
coping and catastrophizing (PRSS), anxiety score (STAI),
depression score (CES-D), and PTSD-like-symptoms at SCL-
90, activity scores (MPI) and solicitous, punishing, and dis-
tracting spouse behavior (MPI).
The number of somatic symptoms associated with FMS (r2 ⫽
0.45, p ⬍ .02), the occurrence of PTSD-like-symptoms (r2 ⫽
0.31, p ⬍ .003), solicitous behaviors by significant others (r2 ⫽
Psychosomatic Medicine 66:837– 844 (2004)
ANXIETY AND DEPRESSION IN FIBROMYALGIA SYNDROME

TABLE 2. Clinical Characteristics of FMS Patients With and Without Axis I Diagnoses

Entire Sample Anxiety disorder Mood disorder Without Disorder

(N ⫽ 115) (N ⫽ 33) (N ⫽ 33) (N ⫽ 46) Sign.
Sign. Sign. Sign.
M M M M Entire
A B C
SD SD SD SD Sample
(Range) (Range) (Range) (Range)

STAI* 28.65 42.42 24.00 21.22

12.39 10.99 8.63 4.29
(20–78) (20–78) (20–60) (20–43) ⬍.001 ⬍.001 ⬍.001 ns.
CES-D† 20.60 18.44 32.48 13.76
11.46 9.34 7.82 8.14
(4–49) (5–42) (14–49) (4–40) ⬍.001 ⬍.001 ⬍.001 ns.
PTSD-like 1.27 1.84 1.04 0.99
symptoms‡ 0.82 0.87 0.89 0.64
(0.04–3.21) (0.43–3.21) (0.04–2.64) (0.09–2.75) ⬍.001 ⬍.001 ns. ⬍.001
Number of 24.39 30.86 20.53 19.16
complaints 9.87 9.23 9.73 8.29
(0–47) (8–47) (3–42) (0–38) .001 .001 .003 ns.
MPI§ Pain severity 4.08 4.49 3.99 3.83
1.01 .91 1.07 .96
(1–6) (2–6) (1–5) (1–6) .009 .038 .002 ns.
Interference 3.86 4.46 3.71 3.51
1.23 1.18 1.26 1.10
(0–6) (1–6) (0–6) (1–5) .001 .013 .001 ns.
Life Control 3.29 2.90 3.29 3.61
1.18 1.31 1.07 1.06
(0–6) (0–6) (1–5) (1–6) .024 ns. .008 ns.
Affective Distress 3.20 3.83 3.36 2.58
1.26 1.24 1.14 1.08
(0–6) (1–6) (1–6) (0–4) ⬍.001 ns. ⬍.001 .003
Social Support 3.72 4.26 2.55 4.13
1.74 1.27 1.93 1.54
(0–6) (0–6) (0–6) (0–6) ⬍.001 ⬍.001 ns. ⬍.001
Punishing Spouse 1.08 1.09 1.55 0.73
Behaviors 1.28 1.16 1.65 0.96
(0–6) (0–6) (0–6) (0–4) .019 .007 ns. .014
Solicitous Spouse 3.08 3.63 1.76 3.58
Behaviors 1.69 1.44 1.50 1.48
(0–6) (0–6) (0–6) (0–6) ⬍.001 ⬍.001 ns. ⬍.001
Distracting Spouse 2.68 3.07 1.87 2.95
Behaviors 1.53 1.34 1.51 1.50
(0–6) (0–6) (0–6) (0–6) .001 ns. ns. .002
General Activity 3.73 3.12 3.99 4.02
Level 1.36 1.37 1.49 1.10
(0–6) (0–6) (1–6) (1–6) .005 .014 .002 ns.

* State-Trait-Anxiety-Inventory-Trait, † Center for Epidemiologic Studies Depression-Scale, ‡ PTSD-like-Symptoms, § Multidimensional Pain Inventory. A:
Comparison between anxiety and mood disorders, B: Comparison between anxiety and without disorders, C: Comparison between mood disorders and without
disorders.

0.57, p ⬍ .05), and reduced general activity (r2 ⫽ 0.64, p ⬍ .002)
were the best predictors of anxiety disorders and accounted for
63.6% of the variance of anxiety disorders in FMS.
The occurrence of PTSD (r2 ⫽ 0.19, p ⬍ .02), less frequent
solicitous behaviors of significant others (r2 ⫽ 0.33, p ⬍
.003), high general activity (r2 ⫽ 0.43, p ⬍ .002), and lower
levels of coping (r2 ⫽ 0.53, p ⬍ .02) accounted for 69.6% of
the variance of depression in FMS. Interestingly, pain inten-
sity, interference, life control, and distracting responses by
significant others had no predictive value for either anxiety or
mood disorders in FMS.
Relationship of Comorbidity and Psychosocial
Subgroups
The entire sample was classified within one of the three
primary MPI subgroups. Thirty percent of the participants
were classified as DYS, 33.0% as ID, and 37% as AC.
Percentages are comparable to other samples of patients with
FMS (14). The subgroups were not significantly different with
respect to age, sex, number of distinct pain areas, or the
duration of the pain problem (see Table 1). The AC and the ID
groups had significantly lower rates if unemployment and less
workers’ compensation than the DYS group (␹2 [8] ⫽ 45.32,

Psychosomatic Medicine 66:837– 844 (2004) 841


p ⬍ .04). The subgroups also differed significantly in the pain
severity of tender points, with the group of ID patients exhib-
iting lower pain severity than the DYS patients and the AC
(F[2, 112] ⫽ 8.26, p ⬍ .001).
The psychosocial subgroups were significantly different in
the prevalence of axis I mental disorders (␹2 [4] ⫽ 95.94, p ⬍
.001). 67.6% of the DYS patients reported anxiety disorders in
comparison to 15% in the ID group and 19.5% in the AC
group. Furthermore, 80% of ID patients were clinically de-
pressed in contrast to only 20.6% of the DYS patients and
2.4% of the AC (see Figure 1).
The psychosocial subgroups were also significantly differ-
ent with respect to current psychologic distress such as anxiety
(STAI-T: F[2, 112] ⫽ 14.46, p ⬍ .001), depressed mood
(CES-D Scale: F[2, 112] ⫽ 23.92, p ⬍ .001), and PTSD-like
symptoms (SCL-90-R: F[2, 112] ⫽ 6.44, p ⬍ .002). Specif-
ically, DYS patients reported significantly higher levels of
current anxiety than ID patients (t[72] ⫽ 3.54, p ⬍ .001) and
AC (t[76] ⫽ 5.048, p ⬍ .001). In addition, ID patients re-
ported comparable levels of anxiety as the AC (t[79] ⫽ 1.47,
p ⫽ .62). ID patients reported significantly greater levels of
depressed mood than dysfunctional patients (t[72] ⫽ ⫺4.69, p
⬍.001) and AC (t[79] ⫽ 7.38, p ⬍ .001). DYS patients
reported the same levels of depressed mood as AC (t[76] ⫽
1.60, p ⫽ .11). The self-report data are consistent with the
results for the axis 1 diagnoses determined from the SCID
interviews.
Using the cutoff score criterion of 0.89 (35), 40.9% of the
subjects were classified as PTSD⫹ and 59.1% as PTSDⴚ.
DYS patients endorsed the highest proportion of PTSD-like
symptoms (61.8%) in comparison to the ID patients (15%,
t[72] ⫽ 2.60, p ⬍ .02) and the AC (11%, t[76] ⫽ 3.30, p ⬍
.001). No significant differences were found between the ID
patients and the AC (t[79] ⫽ 0.76, p ⫽ .45).
Sexual and Physical Abuse
The chi-squared analysis revealed that the MPI subgroup
distribution of the two groups (sexual abuse was vs. no sexual
abuse/physical abuse was vs. no physical abuse) was signifi-
cantly different for sexual abuse (␹2 ⫽ 12.58, p ⬍ .002) as
well as physical abuse (␹2 ⫽ 8.28, p ⬍ .02). The DYS patients
reported experiencing significantly more sexual (64.7%) and
physical abuse (38.2%) than the ID patients (37.5% sexual and
12.5% physical abuse) and the AC (24.4% sexual and 14.6%
physical abuse).
DISCUSSION
This study examined its relationship with somatic and
psychosocial variables in subgroups of patients sought to
determine axis I and II comorbidity in patients with FMS. We
found that overall 32.3% of the patients revealed an anxiety
disorder and 34.8% a mood disorder. These results are more
than three times higher than the prevalence of these psychi-
atric disorders in the general population in which 9% were
found to have an anxiety and 10% a mood disorder (37). These
data, however, match prevalence rates of other pain disorders
842
K. THIEME et al.
such as rheumatoid arthritis (RA) with 31% mood disorders
(9,38 – 40) and chronic back pain with 35% anxiety and 60%
mood disorders (41). PTSD, substance-related, eating and
personality disorders were rarely diagnosed in our sample
(⬍10%). The mean frequency of personality disorders in FMS
was 8.7%, slightly lower than that observed in the general
population in which 10% has been reported (42). Thus, al-
though the prevalence of psychiatric disorders in high com-
pared with the general population, the rates for FMS are
comparable to other chronic pain syndromes.
Patients with anxiety and mood disorders were character-
ized by specific psychologic distress. Patients with anxiety
disorders exhibited high dispositional anxiety, greater PTSD-
like symptoms (61.8%), as well as more sexual (64.7%) and
physical (38.2%) abuse, but relatively low levels of depres-
sion. These results replicate the studies of PTSD-like-symp-
toms in FMS (13,35) in which patients with posttraumatic
symptoms reported significantly higher degrees of pain, dis-
ability, interference, and a lower level of activity than patients
with FMS without PTSD-like symptoms (13,35). These data
are also in accordance with Taylor et al. (43) who found 65%
sexual abuse in FMS. Sexual abuse was associated with sig-
nificantly more physical symptoms.
In the present study, patients with FMS with anxiety dis-
orders reported the greatest number of physical symptoms
associated with FMS and the highest pain intensity and inter-
ference. In addition, this group had a high level of solicitous
behaviors by significant others as well as more avoidance
behaviors.
Patients with mood disorders exhibited the highest level of
affective distress. However, they reported lower anxiety levels
as well as a smaller number of physical symptoms, lower pain
intensity, more negative and low distracting behaviors from
significant others, and the highest reported levels of general
activities compared with patients with anxiety or patients
without any axis I diagnoses. These results suggest that sig-
nificant others’ behaviors influence anxiety as well as mood
disorders. The reduced solicitous behaviors explained a sig-
nificant amount of variance (33%) in mood disorders, sug-
gesting that reduced solicitous behaviors might impede coping
(44). Okifuji et al. (45) found that the living circumstances of
patients with FMS (ie, living alone) predicted depression.
Also, for inflammatory rheumatic diseases such as rheumatoid
arthritis, patients with a highly critical spouse engaged in more
maladaptive coping behaviors and reported poorer psycho-
logic adjustment (46). Reduced social support or marital dis-
satisfaction has been shown to have an important influence on
physical and mental health in general (47). The results of our
study are consistent with the hypothesis that significant oth-
ers’ responses can affect the coping and adjustment of people
with chronic pain.
Consistent with Kurtze et al. (11), pain intensity and inter-
ference were not significantly related to psychiatric comor-
bidity. Our results indicate that anxiety and depression are
independent of levels of pain in FMS.
The cluster analysis replicated the three primary MPI pro-
Psychosomatic Medicine 66:837– 844 (2004)
ANXIETY AND DEPRESSION IN FIBROMYALGIA SYNDROME
files of psychosocial subgroups (16), and the results are sim-
ilar to several studies in the United States (16,48), Finland
(49), and The Netherlands (17) with diverse populations,
including FMS. FMS appears to be a heterogeneous diagnosis
comprised of subgroups of patients (12,14). FMS is charac-
terized by significant levels of pain and fatigue along with a
host of distressing co-morbid symptoms. One of the most
interesting questions is why not all people with FMS are
significantly distressed or anxious. Premorbid personality
characteristics and prior learning history may predispose pa-
tients to the development of FMS as well as the mode of
responding following symptom onset. The different preva-
lence of mental disorders in the psychosocial subgroups sup-
ports the hypothesis that mental disorders are not directly
associated with FMS per se, but that previous experience,
coping, social support in general, and spouse behaviors in
particularly could mediate the association between FMS
symptoms and emotional distress and thereby contribute to
comorbidity in FMS. Additional research is required to clarify
the variables that contribute to the evolution of FMS, mode of
responding to the presence of symptoms, the maintenance of
symptoms, and the accompanying disability observed in a
subset of patients who receive this diagnosis.
The results of this study have several implications for
treatment planning. An important problem with current studies
of treatment of patients with FMS is high degrees of attrition
from treatment and nonadherence (50). The presence of either
anxiety or mood disorders might be associated with nonad-
herence with treatment, but for different reasons. High pain-
related fear and avoidance behaviors may be associated with
anxiety disorder. Cognitive and emotional factors should be
considered when treatment programs are developed for FMS
and FMS-related disability. The only indirect association of
pain and mental disorders suggests that both symptoms and
emotional disorders should be targeted by treatment. Because
different emotional disorders are associated with the different
subgroups of patients identified by the MPI, it might also be
worthwhile to target the different characteristics of the psy-
chosocial subgroups (51). For example, solicitous responses
by significant others appears to be an important feature of
DYS patients; this group might benefit from an operant be-
havioral treatment component that focuses on modification of
behaviors of significant others (52) and because they have
high levels of anxiety disorders and thus a treatment compo-
nent that targets fears may be appropriate (53). ID patients
might benefit from a treatment component that focuses on
interpersonal problem-solving and communication skills be-
cause these patients are characterized by inadequate social
support. A treatment component targeting depression might
also be appropriate (54). The group of AC might profit most
from an exercise approach and support and may not require
additional psychologic interventions.
In summary, the results of this study showed high levels of
comorbid anxiety and depression in patients with FMS that
were associated with different sets of psychosocial variables.
The results support the suggestion that FMS is a multidimen-
Psychosomatic Medicine 66:837– 844 (2004)
sional disorder that requires a differential indication of various
treatment modalities.
This study was supported by a grant from the Deutsche Forschungs-
gemeinschaft (DFG) to Dr. Thieme (Th 899/2–1), a grant from the
National Institutes of Arthritis and Musculoskeletal and Skin Dis-
eases to Dr. Turk (AR 44724), and a grant of the DFG to Dr. Flor (Fl
156/26), as well as the MAX Planck Research Award for Interna-
tional Cooperation (Clinical research unit “Learning, Plasticity and
Pain”).
REFERENCES
1. Wolfe F, Smythe HA, Yunus MB, Benett RM, Bombardier C, Golden-
berg DL, Tugwell P, Campell SM, Abeles M, Clark P. The American
College of Rheumatology 1990 criteria for the classification of fibromy-
algia. Report of the Multicenter Criteria Committee. Arthritis Rheum
1990;33:160 –72.
2. Baumstark KE, Buckelew SP, Sher KJ, Beck N, Buescher KL, Hewett J,
Crews TM. Pain behavior predictors among fibromyalgia patients. Pain
1993;55:339 – 46.
3. Shapiro B. Building bridges between body and mind: the analysis of an
adolescent with paralyzing chronic pain. Int J Psychoanal 2003;84:
547– 61.
4. Netter P, Hennig J. The fibromyalgia syndrome as a manifestation of
neuroticism? Z Rheumatol. 1998;57(suppl 2):105– 8.
5. Egle UT, Heucher K, Hoffmann SO, Porsch U. Psychoanalytically ori-
ented group therapy with psychogenic pain patients. A contribution to the
treatment method. Psychother Psychosom Med Psychol 1992;42:79 –90.
6. Ford CV. Somatization and fashionable diagnoses: illness as a way of
life. Scand J Work Environ Health 1997;23(suppl 3):7–16.
7. Robbins JM, Kirmayer LJ, Hemami S. Latent variable models of func-
tional somatic distress. J Nerv Ment Dis 1997;185:606 –15.
8. Meyer-Lindenberg A, Gallhofer B. Somatized depression as a subgroup
of fibromyalgia syndrome. Z Rheumatol 1998;57(suppl 2):92–3.
9. Ahles TA, Yunus MB, Masi AT. Is chronic pain a variant of depressive
disease? The case of primary fibromyalgia syndrome. Pain 1987;29:
105–11.
10. Epstein SA, Kay G, Clauw D, Heaton R, Klein D, Krupp L, Kuck J,
Leslie V, Masur D, Wagner M, Waid R, Zisook S. Psychiatric disorders
in patients with fibromyalgia. Psychosomatics 1999;40:57– 63.
11. Kurtze N, Gundersen KT, Svebak S. The role of anxiety and depression
in fatigue and patterns of pain among subgroups of fibromyalgia patients.
Br J Med Psychol 1998;71:185–94.
12. Turk DC, Flor H. Primary fibromyalgia ⬎ tender points: toward a
multiaxial taxonomy. J Rheumatol 1989;16:80 – 6.
13. Turk DC, Okifuji A, Starz TW, Sinclair JD. Effects of type of symptom
onset on psychological distress and disability in fibromyalgia syndrome
patients. Pain 1996a;68:423–30.
14. Turk DC, Okifuji A, Sinclair JD, Starz TW. Pain, disability and physical
functioning in subgroups of patients with fibromyalgia. J Rheumatol
1996b;23:1255– 62.
15. Kerns RD, Turk DC, Rudy TE. The West-Haven Multidimensional Pain
Inventory (WHYMPI). Pain 1985;23:345–56.
16. Turk DC, Rudy TE. Towards a comprehensive assessment of chronic
pain patients. Behav Res Ther 1987;25:237– 49.
17. Lousberg R, Schmidt AJM, Groenman NH. The relationship between
spouse solicitousness and pain behavior: searching for more experimental
evidence. Pain 1992;51:75–9.
18. Flor H, Rudy TE, Birbaumer N, Streit B, Schugens MM. Zur Anwend-
barkeit des West Haven-Yale Multidimensional Pain Inventory im deut-
schen Sprachraum: Daten zur Reliabilität und Validität des MPI-D. Der
Schmerz 1990;4:82–7.
19. Dalhstrom L, Widmark G, Carlsson SG. Cognitive-behavioral profiles
among different categories of orofacial pain patients: diagnostic and
treatment implications. Eur J Oral Sci 1997;105:377– 83.
20. Okifuji A, Turk DC, Sinclair JD, Starz TW, Marcus DA. A standardized
manual tender point survey. I. Development and determination of a
threshold point for the identification of positive tender points in fibro-
myalgia syndrome. J Rheumatol 1997;24:377– 83.
21. First MB, Spitzer RL, Gibbon M, Williams JBW. User’s Guide for the
Structured Clinical Interview for DSM-IV Personality Disorders (SCID
II). Washington, DC: American Psychiatric Press, Inc; 1996.
843

22. Wittchen HU, Fydrich T. Strukturiertes Klinisches Interview für DSM-
IV. Manual zum SKID-I und SKID-II. [Structured clinical interview for
DSM-IV. Manual for SCID-I and SCID-II.] Göttingen: Hogrefe; 1997.
23. Strakowski SM, Keck PE, McElroy SL, Lonczak HS, West SA. Chro-
nology of comorbid and principal syndromes in first-episode psychosis.
Compr Psychiatry 1995;2:134 – 8.
24. Drossman DA, Leserman J, Nachman G, Li Z, Gluck H, Toomey TC,
Mitchell CM. Sexual and physical abuse in women with functional or
organic gastrointestinal disorders. Ann Intern Med 1990;113:828 –33.
25. Bagdley R, Allard HA, Proudfoot M, Ogilvie D, Gelinas P, Sutherland S,
McCormick N, Fortin D, Rae-Grant Q, Pepin L. Occurrence in the
Population, Sexual Offences Against Children, vol 1. Ottawa: Canadian
Government Publishing Centre; 1984.
26. Flor H, Rudy TE, Birbaumer N, Striet B, Schugens MM. Zur Anwend-
barkeit des West Haven-Yale Multidimensional Pain Inventory im deut-
schen Sprachraum: Daten zur Reliabilität und Validität des MPI-D. [The
applicability of the West Haven-Yale Multidimensional Pain Inventory in
German-speaking countries: data on reliability and validity of the MPI-
D.] Der Schmerz 1990;4:82–7.
27. Weissman MM, Sholomskas D, Pottenger M, Prusoff BA, Locke BZ.
Assessing depressive symptoms in five psychiatric populations: a vali-
dation study. Am J Epidemiol 1977;106:203–14.
28. Hautzinger M, Bailer M. Allgemeine Depressionsskala. [The German
version of Center for Epidemiologic Studies Depression Scale.]
Göttingen: Hogrefe; 1993.
29. Laux L, Glanzmann P, Schaffner P, Spielberger CD. Das State-Trait-
Angstinventar (STAI). [The State-Trait-Anxiety-Inventory.] Göttingen,
Bern Hogrefe; 1981.
30. Spielberger CD, Gosuch RL, Lushene RE. STAI Manual. Palo Alto, CA:
Consulting Psychologists Press; 1975.
31. Bieling PJ, Antony MM, Swinson RP. The State-Trait Anxiety Inventory,
Trait version: structure and content re-examined. Behav Res Ther 1998;
36:777– 88.
32. Derogatis LR SCL-90-R: Administration, Scoring and Procedures Man-
ual. Minneapolis: National Computer Systems; 1994.
33. Franke GH, Jager H, Stacker KH, Beyer B. Zwischen Isolation und
Hoffnung: Der psychosoziale Status HIV-infizierter Frauen. [Between
isolation and hope: the psychosocial status of HIV-infected women.]
Psychother Psychosom Med Psychol 1995;45:310 –20.
34. Saunders BE, Arata CM, Kilpatrick DG. Development of a crime-related
post-traumatic stress disorder scale for women within the symptom
Checklist-90-revised. J Trauma Stress 1989;3:439 – 48.
35. Sherman JJ, Turk DC, Okifuji A. Prevalence and impact of posttraumatic
stress disorder-like symptoms on patients with fibromyalgia syndrome.
Clin J Pain 2000;16:127–34.
36. Flor H, Behle DJ, Birbaumer N. Assessment of chronic pain-related
cognitions in chronic pain patients. Behav Res Ther 1993;31:63–73.
37. Wittchen HU, Müller N, Pfister H, Winter S, Schmidtkunz B. Affektive,
somatoforme und Angststörungen in Deutschland—Erste Ergebnisse des
bundesweiten Zusatzsurveys ’Psychische Störungen. [Affective, somato-
844
K. THIEME et al.
form and anxiety disorders in Germany—first results of the nation wide
additional survey ’mental disorders.’] Gesundheitswesen 1999;61:
216 –22.
38. Kirmayer LJ, Robbins JM, Kapusta MA. Somatization and depression in
fibromyalgia syndrome. Am J Psychiatry 1988;145:950 – 4.
39. Ahles TA, Kahn AS, Yunus MB, Spiegel DA, Masi AT. Psychiatric
status of patients with primary fibromyalgia, patients with rheumatoid
arthritis, and subjects without pain: a blind comparison of DSM-III
Diagnoses. Am J Psychiatry 1991;148:1721– 6.
40. Hawley DJ, Wolfe F. Depression is not more common in rheumatoid
arthritis: a 10-year longitudinal study of 6,153 patients with rheumatic
disease. J Rheumatol 1993;20:2025–31.
41. Dickens C, Jayson M, Sutton C, Creed F. The relationship between pain
and depression in a trial using paroxetine in sufferers of chronic low back
pain. Psychosomatics 2000;41:490.
42. Mayer HU, Baltes PB. Die Berliner Altersstudie. [The Berlin Aging
Study.] 1992.
43. Taylor ML, Trotter DR, Csuka ME. The prevalence of sexual abuse in
women with fibromyalgia. Arthritis Rheum 1995;38:229 –34.
44. Evers AW, Kraaimaat FW, Geenen R, Jacobs JW, Bijlsma JW. Pain
coping and social support as predictors of long-term functional disability
and pain in early rheumatoid arthritis. Behav Res Ther 2003;41:
1295–310.
45. Okifuji A, Turk DC, Sherman JJ. Evaluation of the relationship between
depression and fibromyalgia syndrome: why aren’t all patients de-
pressed? J Rheumatol 2000;27:212–9.
46. Manne SL, Zautra AJ. Spouse criticism and support: their association
with coping and psychological adjustment among women with rheuma-
toid arthritis. J Pers Soc Psychol 1989;56:608 –17.
47. Kiecolt-Glaser J, Newton TL. Marriage and health: his and hers. Psych
Bull 2001;127:472–503.
48. Jamison RN, Rudy TE, Penzien DB, Mosley TH. Cognitive– behavioral
classifications of chronic pain: replication and extension of empirically
derived patient profiles. Pain 1994;57:277–92.
49. Talo S, Rytokoski U, Puukka P. Patient classification, a key to evaluate
pain treatment: a psychological study in chronic low back pain patients.
Spine 1992;17:998 –1011.
50. Turk DC. Cognitive– behavioral approach to the treatment of chronic pain
patients. Reg Anesth Pain Med 2003;28:573–9.
51. Turk DC. Customizing treatment for chronic pain patients: who, what,
and why. Clin J Pain 1990;6:255–70.
52. Thieme K, Gromnica-Ihle E, Flor H. Operant behavioral treatment of
fibromyalgia: a controlled study. Arthritis Rheum Arthritis Care Res
2003;49:314 –20.
53. Vlaeyen JW, De Jong JR, Onghena P, Kerckhoffs-Hanssen M, Kole-
Snijders AM. Can pain-related fear be reduced? The application of
cognitive-behavioural exposure in vivo. Pain Res Manag 2002;7:144 –53.
54. Turk DC, Okifuji A, Sinclair JD, Starz TW. Differential responses by
psychosocial subgroups of fibromyalgia syndrome patients to an inter-
disciplinary treatment. Arthritis Care Res 1998;11:397– 404.
Psychosomatic Medicine 66:837– 844 (2004)