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Scandinavian Journal of Psychology, 2021, 62, 328–338 DOI: 10.1111/sjop.12706

Cognition and Neurosciences

Memory complaints and cognitive performance in fibromyalgia and
chronic pain: The key role of depression
ANTONI CASTEL1,2

ROSALIA CASCON-PEREIRA2,3
and SERGI BOADA1
1
Pain Clinic, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain
2
Multidimentional Pain Research Group, Institut d’Investigaci
o Sanit
aria Pere Virgili, Reus, Spain
3
Business Management Unit, Universitat Rovira i Virgili, Reus, Spain

Castel, A., Casc
on-Pereira, R. & Boada, S. (2021). Memory complaints and cognitive performance in fibromyalgia and chronic pain: The key role of
depression. Scandinavian Journal of Psychology, 62, 328–338.

To explore the relationship between perceived cognitive problems and cognitive performance in three different samples, taking into account the possible
influence of depression, catastrophizing, pain intensity, or medication. Seventy individuals with fibromyalgia, 74 with non-malignant chronic pain and 40
pain-free controls, completed measures of verbal episodic memory, sustained attention, response inhibition, depression, catastrophizing, and pain intensity.
Fibromyalgia and chronic pain patients performed worse than controls in verbal memory and sustained attention, but these differences disappeared when
depressed participants were excluded from the analyses. Memory complaints were related with depression in all pain patients. However, in the case of
fibromyalgia, memory complaints were also related by pain intensity and inversely related by short-term episodic memory. This case-control study shows
the importance of jointly assessing cognitive performance and memory complaints and of controlling for variables such as depression, catastrophizing, pain
intensity and medication in the studied samples. Accordingly, this study highlights the differences in memory complaints, between the patients with
fibromyalgia and the patients with other chronic pain conditions. Finally, it has highlighted the important role played by depression in cognitive
performance and memory complaints considering the Neurocognitive Model of Attention to pain.
Key words: Fibromyalgia, chronic pain, memory complaints, verbal memory, attention, executive functions, medication.
Antoni Castel, Pain Clinic. Hospital Universitari de Tarragona Joan XXIII. Spain. Email: antonicastel.hj23.ics@gencat.cat

INTRODUCTION
In clinical settings, patients suffering from chronic pain often
reported difficulty in carrying out daily tasks involving cognitive
functions such as memory and attention. This has prompted a
variety of studies to examine the cognitive performance of patients
with chronic pain (Dick & Rashiq, 2007; Esteve, Ram
ırez &
L
opez-Mart
ınez, 2001; Landrø, Fors, V apenstad, Holthe, Stiles &
Borchgrevink 2013; Oosterman, Derksen, Van Wijck, Veldhuijzen,
& Kessels, 2011), and more specifically, with back pain (Jorge,
Gerard & Level, 2009; Ling, Campbell, Heffermnan & Greenough,
2007), musculoskeletal pain (S€oderfjell, Molander, Johansson,
Barnekow-Bergkvist & Nilsson, 2006), neuropathic pain
(Povedano, Gasc
on, G
alvez, Ruiz & Rejas, 2007), or fibromyalgia
(Bell et al., 2018; Dick, Verrier, Harker & Rashiq, 2008; Gelonch,
Garolera, Valls, Li & Pifarr
e, 2017; Gelonch, Garolera, Valls,
Rossell
o & Pifarr
e, 2016; Glass, 2006, 2008, 2009; Glass & Park,
2001; Kim et al., 2012; Pidal-Miranda, Gonz
alez-Villar, Carrillo-
de-la-Pe~na, Andrade & Rodr
ıguez-Salgado, 2018; Tesio, Torta,
Colonna et al., 2015; Wu, Huang, Fang, Ko & Tsai, 2018).
However, not all cognitive functions would be affected in the
same proportion. There is currently agreement on the existence of
deficits in working memory among patients with chronic pain and
fibromyalgia (Berryman, Stanton, Bowering, Tabor, McFarlane &
Moseley, 2013; Glass, 2009; Pidal-Miranda et al., 2018). In
response inhibition, a component of the executive functions
(Berryman, Stanton, Bowering, Tabor, McFarlane & Moseley,
2014), some authors found no differences between fibromyalgia
patients and healthy controls (Cuevas-Toro, L
opez-Torrecillas, D
ıaz-
Batanero & P
erez-Marf
ıl, 2014; Glass, Williams, Fernandez-
Sanchez et al., 2011), while others did (Bell et al., 2018; Correa, Mir

o,
Mart
ınez, S
anchez & Lupi
a~nez, 2011). The evidence from studies on
episodic memory remains controversial (Glass, 2009; Grace, Nielson,
Hopkins & Berg, 1999; Kim et al., 2012; Landrø, Stiles & Sletvold,
1997; Leavitt & Katz, 2006; McDermott & Ebmeier, 2009; Munguia-
Izquierdo & Legaz-Arrese, 2007; Oosterman et al., 2011; Park, Glass,
Minear & Crofford, 2001; Suhr, 2003; Walitt, Roebuck-Spencer,
Bleiberg, Foster & Weinstein, 2008).
Episodic memory can be understood as the ability to
remember specific events or episodes. In a laboratory setting,
episodic memory is considered as the ability to remember a
list of words. To the present, differences in episodic memory
have been reported between chronic whiplash patients and
control subjects (Antepohl, Kiviloog, Anderson & Gerdle,
2003; Schmand, Lindeboom, Schagen, Heijt, Koene &
Hamburger, 1998), or among patients with localized pain,
generalized pain, and neuropathic pain (Landrø et al., 2013),
but not between patients suffering from chronic pain of a
different aetiology and patients with fibromyalgia (Suhr, 2003;
Walitt et al., 2008).
With regard to attention, current data strongly suggest the
presence of attentional impairment in chronic pain and fibromyalgia
patients when the tasks require high attentional demand (Harker,
Klein, Dick, Verrier & Rashiq, 2011). Nevertheless, contradictory
results emerge when sustained attention is studied. Differences are
found between pain-free control subjects and rheumatoid arthritis
patients (Dick, Eccleston & Crombez, 2002), or between chronic
pain patients under different medication conditions and control
subjects (Sjøgren, Christrup, Petersen & Højsted, 2005), but not
among pain-free controls, and fibromyalgia and musculoskeletal

© 2021 Scandinavian Psychological Associations and John Wiley & Sons Ltd
Scand J Psychol 62 (2021) Memory complaints and cognitive performance 329

pain patients (Dick et al., 2002), or between chronic pain patients MATERIALS AND METHODS
and control subjects (Oosterman et al., 2011).
It is common for patients in a pain clinic to take various types Subjects
of medication, including opioids, non-steroidal analgesics, The sample used in this study consists of 70 patients with fibromyalgia
antidepressants or anticonvulsants that can interfere with cognitive (FM), diagnosed according to the American College of Rheumatology
performance. However, previous research shows not all drugs diagnostic criteria (Wolfe, Smythe, Yunus et al., 1990), 74 patients with
chronic pain without a diagnosis of fibromyalgia (CP) and 40 healthy
influence equally on cognitive functions. There is agreement on
controls (HC). As inclusive criteria, all participants were required to
the side effects of anticonvulsants in cognitive function (Loring, know reading and writing, be fluent in Spanish and be between 18 and
Marino & Meador, 2007; Mula, 2012), but as far as we know, 60 years old. The reason for the upper age limit set at 60 years old was
there are not conclusive results on the influence of antidepressants to minimize the possible interference of ageing on cognitive performance.
(Herrera-Guzm
an, Herrera-Abarca, Gudayol-Ferr
e et al., 2010; Exclusion criteria were severe psychopathology (e.g., psychosis), or
moderate to severe cognitive impairment secondary to a pathology with
Mohs, Mease, Arnold et al., 2012), non-steroidal analgesics
neuropsychological disorders. The free-pain controls were required not to
(Moriarti, McGuire & Finn, 2011) or long-term consumption of present any form of chronic disease and not to be taking regular
opioids (Chapman, Byass-Smith & Reed, 2002; Højsted et al., pharmacological treatment 188 out of the 289 subjects who were initially
2012; Jamison, Schein, Vallow, Ascher, Vorsanger, & Katz, contacted for the study (194 pain patients and 95 control subjects) were
2003; Tassian, Attal, Fletcher et al., 2003) on cognitive finally included. Regarding the pain patients, 12 out of them were
excluded for not meeting the inclusion criteria and 38 refused to
impairment. But cognitive performance in CP patients is not only
participate. With regard to the healthy controls, 37 were excluded for not
influenced by medication. Several studies evidence that pain meeting the inclusion criteria and 18 refused to participate. Therefore, the
intensity (Moriarty, McGuire, B.E. & Finn, 2011; S€oderfjell et al., initial sample consisted of 144 patients under treatment in our Pain Unit
2006) and catastrophizing (Crombez, Eccleston, Baeyens & and 44 control subjects recruited from civic centers and among hospital
Eelen, 1998; Crombez, Eccleston, Van den Broeck, Van volunteers. The pain patients were classified according to the primary
pain diagnosis recorded in their medical chart. Since the control group
Houdenhove & Goubert, 2002) can also interfere in cognitive
was younger and had a higher level of education than the pain group,
performance. four outliers from the HC group were excluded: two after considering
Memory complaints in chronic pain patients have also both age and educational level, and the other two only after considering
attracted considerable research attention (Castel, Casc
on, Salvat the age in order to make the three groups homogeneous in age and
et al., 2008; Dufton, 1989; Gelonch et al., 2017; Katz, Heard, educational level. Nonetheless, differences were maintained in the
distribution by sex, since the FM group contained a higher percentage of
Mills & Leavitt, 2004; Mu~noz & Esteve, 2005; Park et al.,
2001; Schnurr & McDonald, 1995; Suhr, 2003, Walitt et al.,
2016). In this regard, although some studies indicate depressive
Table 1. Demographic and clinical data
symptoms as the best single contributor to memory complaints
in chronic pain patients (McCracken & Iverson, 2001; Pidal- Groups
Miranda et al., 2018; Roth, Geisser, Theisen-Goodvich &
Dixon, 2005), more recent findings have also demonstrated the Chronic painChronic Healthy
Fibromyalgia pain control
relevance of some cognitive functions in the perception of
Variables (N = 70) (N = 74) (N = 40)
cognitive impairment (Gelonch et al., 2016, 2017; Landrø
et al., 2013; Tesio et al., 2015). Age 46.8 (S.D. 49.0 (S.D. 7.7) 45.1 (S.D.
Despite the growing interest in these issues, there are still 8.8) 9.3)
relatively few studies which have jointly focused on both Sex
Male 6 (8.6%) 31 (41.9%) 10 (25.0%)
cognitive performance and the perception of cognitive problems
Female 64 (91.4%) 43 (58.1%) 30 (75.0%)
in patients with fibromyalgia and chronic pain from different Marital Status
aetiologies (Castel et al., 2008; Gelonch et al., 2016, 2017; Grace Single 6 (8.6%) 4 (5.5%) 4 (10.0%)
et al., 1999; Landrø et al., 2013; Park et al., 2001; Pidal-Miranda Married 58 (82.9%) 58 (79.5%) 31 (77.5%)
et al., 2018; Suhr, 2003; Tesio et al., 2015; Walitt et al., 2016). Widow 5 (7.1%) 8 (10.8%) 5 (12.5%)
Separated 1 (1.4%) 3 (4.1%) 0 (0%)
Therefore, this study attempts to address the lack of
Formal Education
comprehensive studies in this regard, by jointly focusing on Low 52 (74.3%) 51 (68.9%) 23 (57.5%)
cognitive performance and memory complaints in different Mid 12 (17.1%) 17 (23.0%) 14 (35.0%)
samples of patients and control subjects, taking into account the High 6 (8.6%) 6 (8.1%) 3 (7.5%)
possible influence of variables such as depression, catastrophizing, Taking medication
NSAIDs, % 63% 60% 0%
pain intensity or medication. In particular, it aims to accomplish
Opioids, % 70% 47% 0%
the following objectives: (1) to compare the cognitive Anticonvulsants, 23% 47% 0%
performance in verbal episodic memory, sustained attention and %
response inhibition among patients with fibromyalgia, patients Antidepressants, 80% 36% 0%
with chronic pain but without fibromyalgia and healthy controls; %
(2) to compare the perception of memory problems among these
Note: Age (mean and standard deviation); qualitative variables (number of
three samples of subjects: and (3) to determine the relationship of subjects and percentage); low education = completed their primary
memory complaints with cognitive performance, and with clinical education; mid education = completed their secondary education; high
characteristics such as depression, catastrophizing or pain education = completed higher education; NSAIDs = non-steroidal anti-
intensity. inflammatory drugs

© 2021 Scandinavian Psychological Associations and John Wiley & Sons Ltd
330 A. Castel et al.
women. The final sample consisted of 184 participants. The mean age
was 47.3 years old (S.D. 8.6). The youngest participant was 21 years old
and the oldest was 60. A total of 25.5% were men and 74.5% were
women.
The FM group (70 patients) consisted of 33 patients with primary
fibromyalgia and 37 patients with fibromyalgia concomitant with other
pathologies of chronic pain. The CP group (74 patients) consisted of 18
patients with musculoskeletal pain, 43 patients with mixed neuropathic
pain, and 14 patients with neuropathic pain. Finally, the HC group
consisted of 40 participants. The demographic and clinical characteristics
of the various groups are shown in Table 1.
Measuring instruments
Memory Failures in Everyday Memory (MFE) (Garcia-Mart
ınez &
S

anchez-C
anovas, 1994; Sunderland, Harris & Cleave, 1984). It
evaluates the extent to which subjects perceive that their memory is
affected. It consists of 28 items which ask about the frequency with which
a particular memory failure has occurred in the three months prior to the
administration of the test. The test generates one total score, being the
higher the score, the higher the perceived memory impairment. The
questionnaire demonstrated good psychometric properties (Cornish, 2000;
Sunderland, Harris & Gleave, 1984).
Subscale of Depression from the Hospital Anxiety and Depression
Scale (HADS). (Tejero, Guimer
a, Farre & Peri, 1986; Zigmond &
Snaith, 1983). The complete scale was designed for detection and
assessment of anxiety and depression in the setting of Hospital and
Surgical Clinics. The subscale of depression consists of seven items with
four possible responses which are scored with values between 0 and 3.
Due to its optimal sensitivity and specificity, a cutoff of ≥ 9 inHADS
depression score was considered as indicator of depression (Bejland, Dahl,
Haug & Neckelmann, 2002).
Test de Aprendizaje Verbal Espa~na-Complutense (TAVEC):
Verbal Learning Test. (Benedet & Alejandre, 1998). This test is
based on the Rey Auditory Verbal Learning Test (RAVLT) and on the
California Verbal Learning Test (CVLT), and it measures verbal
memory and learning capacity. TAVEC consists of three lists of words
that are presented as “shopping lists”: a learning list that is repeated
five times (list A), an interference list (list B) and a recognition list.
Lists A and B have 16 words each classified in four semantic
categories. The recognition list consists of 44 words, among which the
words from list A are included.
From all the available indices that TAVEC provides, we selected: (1)
Level of Immediate Recall: Immediate Recall Total, Immediate Recall
Interference List; (2) Level of Delayed Recall: Short-Delay Free Recall,
Long-Delay Free Recall; (3) Recall Errors: Total Repetitions, Free Recall
Total Intrusions; and (4) Delayed Recognition Trials: Discriminability
Index, Total False Positives, Total Recognition. The selection of indices
was made considering their relevance in determining the cognitive
performance.
Toulouse–Pi
eron Perceptual and Attention Test (TP). (Toulouse &
Pi
eron, 1998). It measures sustained attention. The test has 1,600
graphic elements distributed in 40 rows and the task consists in
indicating the squares that are identical to the two models presented,
with a limited time of 10 minutes. Although the test provides a single
Total Score, a Number of Errors and Omissions score can also be
obtained.
Stroop Color-Word Test (SCWT). (Golden, 1978, 2001). This
instrument is a commonly used measure of executive functions (Berryman
et al., 2013). The test consists in performing three different tasks. The first
task consists in reading different color names (red, green, and blue)
printed in black ink. The second task requires naming the color (red,
green, and blue) in which different spots are printed. Finally, there is the
interference task. In this, the participant is required to name the color of
the ink in which the color words are printed. The color of the ink is never
© 2021 Scandinavian Psychological Associations and John Wiley & Sons Ltd
Scand J Psychol 62 (2021)
the same as the written color name. From these three different scores, a
final measure of interference is calculated.
Subscale of Catastrophizing from the Coping Strategies Questionnaire
(CSQ). (Rodr
ıguez-Franco, Cano-Garc
ıa & Blanco-Picabia, 2004;
Rosenstiel & Keefe, 1983). This subscale measures catastrophizing related
to pain, and is widely used in clinical settings and research contexts. The
questionnaire generates one score, and has demonstrated adequate validity
and reliability among different pain conditions (Rodr
ıguez-Franco et al.,
2004). The higher the score, then the higher the catastrophizing is.
Numerical Pain Intensity Rating Scale. The patient indicates the
maximum, minimum and usual intensities of pain suffered in the last week
using a numerical scale with values ranging from 0 to 10. A value of 0
indicates “no pain,” while a value of 10 indicates “the maximum pain
possible.” The average of these three scores was obtained and used as a
measure of retrospective pain intensity. This procedure has demonstrated a
high degree of reliability as a measure of the pain suffered during a
particular period of time (Dworkin & Siefried, 1994; Jensen, Turner,
Romano & Fisher, 1999).
Procedure
Before being included in the study, the medical chart of the patients was
assessed and participants were individually interviewed by a clinical
psychologist in order to determine the presence of possible
psychopathological exclusion criteria. After, they had signed the informed
consent form. Participants were tested individually. Tests were given in
the following order: (1) the Memory Failures in Everyday Memory
(MFE); (2) the subscale of Catastrophizing from the Coping Strategies
Questionnaire (CSQ); (3) the Hospital Anxiety and Depression Scale
(HADS); (4) the first part of the TAVEC (five learning trials for list A,
immediately followed by learning the interference list – list B – and then
free recall of list A); (5) the Toulouse – Pi
eron Perceptual and Attention
Test (TP); (6) the Stroop Color-Word Test (SCWT); and (7) exactly
20 minutes after the first part of the TAVEC test had ended, the second
part was applied, which consisted of long-delay free recall (list A) and the
subtest of long-delay recognition. The estimated time to complete all the
exploration was about 90 minutes.
Statistical analysis
To explore the homogeneity of the various groups of subjects in terms of
sex and educational level, chi-square analyses were carried out. The
homogeneity of the three groups in terms of age was also determined
using ANOVA. To achieve our first and second goals, that is, to compare
the cognitive performance in verbal episodic memory, response inhibition
and sustained attention, and to compare the memory complaints among the
three groups of participants, ANOVA analysis was carried out. Given the
unequal samples size, homogeneity of variances was tested and post hoc
analyses were adjusted with Tukey’s method whenever necessary. Also,
Cohen’s d effect size was determined by calculating the mean differences
between two groups and then dividing the difference by the pooled
standard deviation (Cohen, 1988). Later on, in order to control the
possible influence of depression on memory complaints and on cognitive
performance, given the different mean and distribution of the groups, we
followed the procedure of considering only participants without depression
(Miller & Chapman, 2001). In particular, we compared the performance of
the different groups in this new condition. Also, to control for the possible
influence of medication on cognitive performance, patients taking
anticonvulsants were excluded, and new analyses were carried out without
considering them.
Later on, to examine the association between memory complaints, and
pain intensity, catastrophizing, depression and cognitive performance,
bivariate correlations were calculated by separate in each group of
participants. Finally, multiple linear regression analyses were carried out
separately for each group of participants. Selected variables were depression,
catastrophizing, pain intensity, and the cognitive performance variables that
correlated with a significance ≤ 0.01 with memory complaints. Variables
were introduced according with the stepwise regression method.
 Table 2. Subjective variables and neuropsychological performance measures: Fibromyalgia, Chronic Pain and Healthy Controls (mean, standard deviation, signification). All participants, and participants with
HADS-D < 9

groups

Fibromyalgia Chronic painChronic pain Healthy controls

Scand J Psychol 62 (2021)

All HADS-D < 9 All HADS-D < 9 All HADS-D < 9

Measures (N = 70) (N = 25) (N = 74) (N = 47) (N = 40) (N = 39)

Pain Intensity 6.1  1.8 5.2  1.8 5.8  1.9 (d2 = 0.162) 5.6  2.1 (d2 = 0.204) – –
MFE Test 99.1  43.2 ***,‡ (d1 = 1.514) 75.8  30.6*** (d1 = 1.058) 78.3  44.9††† (d2 = 0.472) 64.0  37.2 (d2 = 0.346) 49.3  17.2 (d3 = 0.852) 49.5  17.3 (d3 = 0.499)
HADS-D 9.4  4.8*** ‡‡ (d1 = 1.897) 4.0  2.5** (d1 = 0.964) 6.9  4.8††† (d2 = 0.520) 3.7  2.5††† (d2 = 0.120) 2.2  2.4 (d3 = 1.238) 1.9  1.8 (d3 = 0.826)
Catastrophizing (CSQ) 18.9  8.7 14.6  8.7 18.5  9.5 (d2 = 0.043) 14.6  9.1 (d2 = 0.0) – –
TAVEC Immediate Recall:
Total 48.7  10.4* (d1 = 0.500) 52.5  9.4 (d1 = 0.077) 47.6  10.4†† (d2 = 0.105) 48.4  10.9 (d2 = 0.488) 53.5  8.7 (d3 = 0.615) 53.2  8.6 (d3 = 0.488)
Interference list 5.7  2.1 (d1 = 0.0) 5.4  2.2 (d1 = 0.020) 5.3  2.0 (d2 = 0.195) 5.6  2.2 (d2 = 0.090) 5.7  2.1 (d3 = 0.195) 5.7  2.1 (d3 = 0.006)
TAVEC Delayed Recall:
Short-delay free- 10.3  2.9 (d1 = 0.315) 11.6  1.9 (d1 = 0.257) 10.2  3.1 (d2 = 0.033) 10.5  3.1 (d2 = 0.427) 11.2  2.8 (d3 = 0.338) 11.0  2.7 (d3 = 0.172)
recall
Long-delay free-recall 10.8  3.0 (d1 = 0.398) 12.0  2.1 (d1 = 0. = 0.086) 10.6  3.5 (d2 = 0.061) 10.8  3.2 (d2 = 0.443) 11.9  2.5 (d3 = 0.427) 11.8  2.5 (d3 = 0.348)
TAVEC Recall Errors:

© 2021 Scandinavian Psychological Associations and John Wiley & Sons Ltd
Total repetitions 6.4  4.8 (d1 = 0.140) 7.5  5.5 (d1 = 0.032) 6.0  5.6 (d2 = 0.197) 5.3  5.0 (d2 = 0.418) 7.2  6.5 (d3 = 0.076) 7.3  6.6 (d3 = 0.341)
Free recall total- 3.3  3.5* (d1 = 0.561) 2.2  3.1 (d1 = 0.153) 3.5  3.8†† (d2 = 0.054) 3.2  3.5 (d2 = 0.302) 1.7  2.0 (d3 = 0.592) 1.8  2.0 (d3 = 0.491)
intrusions
TAVEC Delayed Recognition Trials:
Discriminability 92.8  7.7 (d1 = 0.201) 96.7  3.1‡‡ (d1 = 0.467) 92.5  7.1 (d2 = 0.040) 93.4  5.7 (d2 = 0.719) 95.1  4.9 (d3 = 0.163) 95.0  4.1 (d3 = 0.322)
index
Total false positives 1.5  1.9 (d1 = 0.193) 0.96  1.1 (d1 = 0.218) 1.6  2.4 (d2 = 0.046) 1.4  1.3 (d2 = 0.365) 1.2  1.1 (d3 = 0.214) 1.2  1.1 (d3 = 0.166)
Total recognition 14.4  2.2 (d1 = 0.276) 15.5  0.8 (d1 = 0.555) 14.4  2.1 (d2 = 0.0) 14.5  1.8‡ (d2 = 0.717) 14.9  1.3 (d3 = 0.286) 14.9  1.3 (d3 = 0.254)
TP Test:
Total score 135.4  66.2** (d1 = 0.661) 151.7  68.3 (d1 = 0.406) 135.9  73.4†† (d2 = 0.007) 153.0  61.7 (d2 = 0.019) 184.6  81.8 (d3 = 0.620) 182.3  81.6 (d3 = 0.405)
Numbr of errors and 42.7  29.8 (d1 = 0.013) 41.3  30.1 (d1 = 0.015) 46.2  45.1 (d2 = 0.091) 38.8  30.8 (d2 = 0.082) 42.2  44.0 (d3 = 0.089) 40.8  35. (d3 = 0.059)
omissions
Stroop Color-Word Test:
Interference 0.37  9.8 (d1 = 0.082) 1.0  10.7 (d1 = 0.009) 0.1  9.6 (d2 = 0.027) 0.5  10.8 (d2 = 0.046) 1.2  10.4 (d3 = 0.109) 11  10.5 (d3 = 0.055)

Note: Mean differences were analyzed by ANOVA and post hoc analyses were corrected with Tukey’s method.
MFE: Memory Failures in Everyday Memory Test; CSQ: Coping Strategies Questionnaire; HADS-D: Subscale of Depression from the Hospital Anxiety and Depression Scale; TAVEC: Verbal Learning Test; TP:
Toulouse - Pi
eron Perceptual and Attention Test.
Significance between fibromyalgia and healthy controls: *p < 0.05; ** p < 0.01; *** p < 0.001.
Significance between chronic pain and healthy controls: † p <.05; †† p < 0.01; ††† p < 0.001.
Significance between fibromyalgia and chronic pain patients: ‡ p < 0.05; ‡‡ p < 0.01.
d = Cohen’s Standardized Difference: d = 0.2 – 0.5 small; d = 0.5 – 0.8 medium; d > 0.8 large.
d1 = Cohen’s d between FM and HC; d2 = Cohen’s d between CP and FM; d3 = Cohen’s d between HC and CP.
Memory complaints and cognitive performance 331
332 A. Castel et al.
RESULTS
Subjective symptoms: memory complaints, pain intensity,
catastrophizing and depression
ANOVA showed differences among the groups in terms of memory
complaints [F (2, 181) = 19.952; p < 0.001] and depression [F (2,
181) = 33.404; p < 0.001]. No differences were found between
FM and CP in pain intensity or catastrophizing. Post hoc analyses
showed that FM and CP patients evidenced more memory
complaints and more depression) than HC participants. When both
groups of patients (FM and CP) were compared, FM participants
presented more memory complaints and more depression than CP
(see Table 2). When looking in depth at the FM group, no
significant differences were found in any of these subjective
symptoms between patients with primary fibromyalgia and patients
with fibromyalgia concomitant with other chronic pain pathologies.
To correct the possible effect of depression on memory
complaints, a new analysis was carried out excluding the
participants with depression. In this case, only the 111
participants with a cutoff of < 9 in the HADS depression subscale
were considered. ANOVA showed differences in memory
complaints [F (2, 108) = 6.0699; p < 0.01] and depression [F (2,
108) = 8.731; p < 0.001] among the groups. Despite the
restriction limiting participants with depression, post hoc analyses
evidenced that FM and CP patients scored higher than HC in the
subscale of depression. Moreover, FM participants expressed
more memory complaints than HC participants (see Table 2).
Performance in neuropsychological tests
Post hoc analyses showed that the participants from the FM group
performed worse than the HC group participants in Immediate
Recall Total, Free Recall Total Intrusions, and TP Total Score.
Also, participants of the CP group performed worse than the HC
group participants in Immediate Recall Total, Free Recall Total
Intrusions, and TP Total Score (see Table 2). No differences were
found between FM and CP, or between patients with primary
fibromyalgia and patients with fibromyalgia concomitant with
other chronic pain pathologies. Furthermore, in the CP group, no
differences were found between patients with musculoskeletal
pain and patients with neuropathic pain.
In addition, when participants with depression (HADS
depression subscale ≥ 9) were removed from the analysis, the
differences described above disappeared. Nevertheless, new
differences appeared, in this case between FM and CP
participants. FM patients performed worse than CP patients in
Discriminability Index and better than CP patients in Total
Recognition (see Table 2).
The Pearson correlation indicated the lack of correlation of both
pain intensity and catastrophizing with cognitive performance, both
in FM and CP groups regardless of the level of depression.
Finally, to avoid the probability of insufficient effort with the
TAVEC, patients with a score ≤ 72 in the Discriminability Index
were excluded (Vilar-L
opez, Aparicio, G
omez-R
ıo & P
erez-
Garc
ıa, 2013). With this cutoff three patients were removed, two
from the FM group and one from the CP group. After eliminating
these participants from the analyses, no changes were observed in
the reported results.
© 2021 Scandinavian Psychological Associations and John Wiley & Sons Ltd
Scand J Psychol 62 (2021)
Medication and neuropsychological performance
Given the huge variety of medication that the patients took, we
decided to group the medicines into four categories (see Table 1),
without considering neither the dose nor the specific compounds. In
order to assess the differences among the groups taking into account
the interference of anticonvulsants in cognitive performance (Loring
et al., 2007; Mula, 2012), we performed a new comparative analysis
excluding the participants who took anticonvulsants.
After participants taking anticonvulsants were excluded,
ANOVA showed differences among the groups in terms of
memory complaints [F (2, 130) = 20,690; p <0.001], depression
[F (2, 130) = 31.276; p < 0.001] and TP Total Score [F (2,
130) = 5.513; p < 0.01]. Post hoc analyses showed that FM
patients evidenced more memory complaints, more depression,
and worse performance in TP Total Score than HC participants.
Also, FM patients exhibited more memory complaints and more
depression than CP patients. Overall, CP patients had more
memory complaints, more depression and worse performance in
TP Total Score than HC (for more details see Table 3).
Finally, when depressed participants were also excluded,
ANOVA analysis showed differences among the groups in terms of
memory complaints [F (2, 83) = 5,643; p < 0.01] and depression [F
(2, 83) = 7.281; p < 0.001]. Post hoc analyses showed that only FM
patients showed more memory complaints and more depression than
HC participants (for more details see Table 3).
Memory complaints and its relation with cognitive performance
and clinical characteristics
The Pearson correlation indicated that memory complaints
correlated significantly with depression and with catastrophizing
in both groups of pain patients, but not in the HC group (see
Table 4). Nonetheless, differences emerged in the variables
correlating with memory complaints when comparing both groups
of pain patients. In particular, while in FM patients the correlation
of memory complains was negatively related with recall and
recognition, in CP patients it was negatively related with
sustained attention (see Table 4).
When regression analyses were carried out, in the FM group
depression entered first (b = 0.522, D R2 = 0.273, F change [1,
62] = 23.282, p < 0.0001), followed respectively by Short-Delay
Free Recall (b = 0.338, D R2 = 0.104, F change [1, 61] = 10.149,
p < 0.01), and pain intensity (b = 0.362, D R2 = 0.106, F change
[1, 60] = 12.283, p < 0.01). In the CP group only depression
entered in the model (b = 0.483, D R2 = 0.236, F change [1,
69] = 21.341, p < 0.0001). Finally, in the HC group none of the
included predictor variables was significant.
When only the participants without depression were
considered, regression analysis showed that pain intensity was a
significant predictor of memory complaints in the FM group
(b = 0.562, D R2 = 0.316, F change [1, 23] = 10.640, p < 0.01).
In the other two groups, none variable was predictive.
DISCUSSION
This case-control study has explored the relationship between
perceived cognitive problems and cognitive performance (verbal
episodic memory, sustained attention, and response inhibition)
 Table 3. Subjective variables and neuropsychological performance measures: Fibromyalgia, Chronic Pain and Healthy Controls (mean, standard deviation, signification). All participants, and participants with
HADS-D < 9, excluded patients taking anticonvulsants

groups
Scand J Psychol 62 (2021)

Fibromyalgia Chronic pain

Excluded: Patients taking anticonvulsants Excluded: Patients taking anticonvulsants Healthy controls

All HADS-D < 9 All HADS-D < 9 All HADS-D < 9

Measures (N = 54) (N = 20) (N = 39) (N = 27) (N = 40) (N = 39)

Pain Intensity
MFE Test
HADS-D
Catastrophizing (CSQ)
TAVEC Immediate Recall:
Total
Interference list
TAVEC Delayed Recall:
Short-delay free recall
Long-delay free recall
TAVEC Recall Errors:
6.0  1.9 5.1  2.0 5.5  2.1 (d2 = 0.249) 5.4  2.3 (d2 = 0.139) – –
96.8  40.7*** ‡ (d1 = 1.520) 76.2  31.0** (d1 = 2.148) 71.0  41.6† (d2 = 2.179) 62.1  39.9 (d2 = 0.498) 49.3  17.2 (d3 = 1.325) 49.5  17.3 (d3 = 0.409)
9.0  4.6*** ‡‡ (d1 = 1.853) 4.1  2.6** (d1 = 0.983) 5.8  4.7††† (d2 = 0.688) 3.0  2.1 (d2 = 0.465) 2.2  2.4 (d3 = 0.964) 1.9  1.8 (d3 = 0.562)
17.9  8.8 14.1  8.9 16.7  10.5 (d2 = 0.123) 12.0  8.3 (d2 = 0.244) – –
50.3  9.9 (d1 = 0.343) 52.7  10.2 (d1 = 0.053) 49.5  9.9 (d2 = 0.080) 48.9  11.0 (d2 = 0.523) 53.5  8.7 (d3 = 0.429) 53.2  8.6 (d3 = 0.701)
6.0  2.2 (d1 = 0.139) 5.5  2.3 (d1 = 0.090) 5.5  2.1 (d2 = 0.232) 5.9  2.1 (d2 = 0.181) 5.7  2.1 (d3 = 0.095) 5.7  2.1 (d3 = 0.095)
10.7  2.8 (d1 = 0.178) 11.8  1.9 (d1 = 0.342) 10.9  2.8 (d2 = 0.071) 10.7  3.1 (d2 = 0.427) 11.2  2.8 (d3 = 0.107) 11.0  2.7 (d3 = 0.103)
11.2  2.7 (d1 = 0.269) 12.2  2.2 (d1 = 0.169) 10.9  3.2 (d2 = 0.101) 11.0  3.3 (d2 = 0.427) 11.9  2.5 (d3 = 0.348) 11.8  2.5 (d3 = 0.273)

© 2021 Scandinavian Psychological Associations and John Wiley & Sons Ltd
Total repetitions
Free recall total intrusions
TAVEC Delayed Recognition Trials:
Discriminability index
Total false positives
Total recognition
TP Test:
Total score 144.4
Number of errors and
omissions
Stroop Color-Word Test
Interference
6.7  5 (d1 = 0.086) 8.3  5.6 (d1 = 0.163) 6.3  4.9 (d2 = 0.114) 5.2  3.6 (d2 = 0.658) 7.2  6.5 (d3 = 0.156) 7.3  6.6 (d3 = 0.395)
3.0  3.5 (d1 = 0.456) 1.8  3.1 (d1 = 0) 3.5  3.7† (d2 = 0.138) 2.8  3.5 (d2 = 0.302) 1.7  2.0 (d3 = 0.605) 1.8  2.0 (d3 = 0.350)
93.8  5.7 (d1 = 0.259) 96.8  3.4 (d1 = 0.477) 94.0  5.6 (d2 = 0.035) 94.0  6 (d2 = 0.574) 95.1  4.2 (d3 = 0.222) 95.0  4.1 (d3 = 0.194)
1.4  1.7 (d1 = 0.139) 1.0  1.2 (d1 = 0.173) 1.3  1.1 (d2 = 0.069) 1.3  1.3 (d2 = 0.239) 1.2  1.1 (d3 = 0.090) 1.2  1.1 (d3 = 0.083)
14.7  1.7 (d1 = 0.132) 15.5  0.8 (d1 = 0.555) 14.7  2.1 (d2 = 0) 14.6  2.0 (d2 = 0.590) 14.9  1.3 (d3 = 0.114) 14.9  1.3 (d3 = 0.177)
= 0.548)
 63.6* (d1 155.8  69.2 (d1 = 0.350) 130.3  85†† (d2 = 0.187) 151.0  61.9 (d2 = 0.073) 184.6  81.8 182.3  81.6 (d3 = 0.432)
(d3 = 0.650)
37.7  25.2 (d1 = 0.125) 36.4  28 (d1 = 0.138) 53.2  57.3 (d2 = 0.350) 39.8  33.6 (d2 = 0.109) 42.2  44.0 (d3 = 0.215) 40.8  35.0 (d3 = 0.029)
1.2  8.9 (d1 = 0) 1.0  8.7 (d1 = 0.090) 0.8  9.3 (d2 = 0.101) 0.3  10.6 (d2 = 0.020) 1.2  10.4 (d3 = 0.139) 1.1  10.5 (d3 = 0.018)

Notes: Mean differences were analyzed by ANOVA and post hoc analyses were corrected with Tukey’s method.
MFE: Memory Failures in Everyday Memory Test; CSQ: Coping Strategies Questionnaire; HADS-D: Subscale of Depression from the Hospital Anxiety and Depression Scale; TAVEC: Verbal Learning Test; TP:
Toulouse - Pi
eron Perceptual and Attention Test.
Significance between fibromyalgia and healthy controls: * p < 0.05; ** p < 0.01; *** p < 0.001.
Significance between chronic pain and healthy controls: † p <.05; †† p < 0.01; ††† p < 0.001.
Significance between fibromyalgia and chronic pain patients: ‡ p < 0.05; ‡‡ p < 0.01.
d = Cohen’s Standardized Difference: d = 0.2 – 0.5 small; d = 0.5 – 0.8 medium; d > 0.8 large.
d1 = Cohen’s d between FM and HC; d2 = Cohen’s d between CP and FM; d3 = Cohen’s d between HC and CP.
Memory complaints and cognitive performance 333
334 A. Castel et al. Scand J Psychol 62 (2021)

Table 4. Person’s correlation coefficients between memory complaints and clinical characteristics, and between memory complaints and cognitive
performance, separately for each group of participants (Fibromyalgia, Chronic Pain and Healthy Controls). All participants, and participants with HADS-
D<9

groups

Fibromyalgia Chronic pain Healthy controls

All HADS-D < 9 All HADS-D < 9 All HADS-D < 9

Measures (N = 70) (N = 25) (N = 74) (N = 47) (N = 40) (N = 39)

Pain Intensity r = 0.545*** r = 0.562*** r = 0.180 r = 0.114 – –

HADS-D r = 0.517*** r = 0.312 r = 0.493*** r = 0.095 r= 0.066 r= 0.026
Catastrophizing (CSQ) r = 0.386** r = 0.398* r = 0.442*** r = 0.257 – –
TAVEC Immediate Recall
Total r= 0.436*** r = 0.064 r= 0.073 r = 0.036 r= 0.179 r = 0.180
Interference list r= 0.252* r = 0.167 r= 0.074 r = 0.082 r= 0.179 r = 0.183
TAVEC Delayed Recall
Short-delay free recall r= 0.454*** r = 0.082 r= 0.074 r = 0.089 r= 0.254 r= 0.283
Long-delay free recall r= 0.449*** r = 0.124 r= 0.046 r = 0.091 r= 0.309 r= 0.263
TAVEC Recall Errors:
Total repetitions r = 0.184 r= 0.083 r= 0.084 r = 0.004 r = 0.131 r = 0.114
Free recall total intrusions r = 0.123 r= 0.347 r= 0.084 r = 0.061 r = 0.187 r = 0.270
TAVEC Delayed Recognition Trials:
Discriminability index r = 0.468*** r = 0.210 r = 0.153 r = 0.088 r = 0.459** r = 0.296
Total false positivesTotal r = 0.196 r = 0.014 r = 0.181 r = 0.093 r = 0.277 r = 0.324*
Total recognition r = 0.483*** r = 0.306 r = 0.051 r = 0.016 r = 0.112 r = 0.130
TP Test:
Total score r = 0.130 r = 0.082 r = 0.326** r = 0.177 r = 0.236 r= 0.232
Number of errors and omissions r = 0.113 r = 0.155 r = 0.240* r = 0.049 r = 0.027 r= 0.012
Stroop Color-Word Test:
Interference r= 0.006 r= 0.143 r = 0.081 r = 0.055 r= 0.292 r= 0.290

Notes: HADS-D: Subscale of Depression from the Hospital Anxiety and Depression Scale; CSQ: Coping Strategies Questionnaire; TAVEC: Verbal
Learning Test; TP: Toulouse - Pi
eron Perceptual and Attention Test.
Significance of the correlation: * p < 0.05; ** p < 0.01; *** p < 0.001.

among patients with fibromyalgia, patients with chronic pain
without fibromyalgia and healthy controls, taking into account the
possible influence of variables such as depression, catastrophizing,
pain intensity, or medication.
The most important findings from this study are that: (1) FM
and CP patients performed worse than controls in immediate
recall, free recall intrusions and sustained attention. However,
when participants with depression were removed from the
analysis, these differences disappeared. (2) When participants
taking anticonvulsants were removed from the analysis, FM and
CP patients still performed worse than HC in sustained attention.
Nevertheless, when participants with depression were also
removed from the analysis, these differences disappeared. (3)
Patients with FM expressed more memory complaints than CP
and HC participants. Even after eliminating the participants taking
anticonvulsants and with depression from the analysis, the FM
patients continued expressing more memory complaints than HC.
(4) Memory complaints were directly predicted by depression in
FM and CP. Moreover, memory complaints of FM patients were
also directly predicted by pain intensity and inversely by verbal
episodic memory.
We have structured our discussion regarding the above-
mentioned main findings. Firstly, in relation to the performance in
verbal episodic memory our findings indicate that fibromyalgia
and chronic pain patients were impaired in comparison to healthy
controls, although these differences disappeared after eliminating
participants with depression. This result is in line with the
findings of Kim and colleagues (2012) in FM patients that used
the RAVLT as a measure instrument of verbal episodic memory.
However, our findings are opposed to other studies that found
differences between patients with FM and healthy controls
(Munguia-Izquierdo & Legaz-Arrese 2007; Tesio et al., 2015).
Nonetheless, in these latter studies the effect of depression was
not controlled.
We obtained a similar result in sustained attention. In
particular, we found differences between patients and healthy
controls when depression was not considered but these differences
disappeared once depression was considered. These results
support those of Dick, Eccleston and Crombez (2002), who found
no differences in sustained attention between pain-free controls
and fibromyalgia patients with the Test of Everyday Attention
(TEA), and are also consistent with the study of Oosterman and
colleagues (2011), who assessed sustained attention with the
Bourdon–Vos test after controlling for depression. Our work also
adds to the evidence provided by other studies (C^ ote &
Moldofsky, 1997) on the lack of differences between patients and
healthy controls with regard to the precision with which they
carry out attentional tasks. Also, our study adds evidence about
the lack of differences between pain patients and controls in
response inhibition measured with the Stroop Color-Word Test
(Cuevas-Toro et al., 2014; Oosterman, Derksen, Van Wijck,
Kessels & Veldhuijzen, 2012; Suhr, 2003).
All in all, and in line with the Neurocognitive Model of
Attention to pain (Legrain et al., 2009), our results suggest that,

© 2021 Scandinavian Psychological Associations and John Wiley & Sons Ltd
Scand J Psychol 62 (2021)
depression has a role in explaining cognitive performance in CP
and FM patients. According to this model, the cognitive and
emotional response to pain may impair top-down attentional
control mechanisms which filter out task-irrelevant stimuli
resulting in impaired task performance. In this regard and
according to our results, depression might have interfered top-
down attentional control mechanisms and in consequence,
cognitive performance in CP and FM patients. Accordingly, we
suggest that previous treatment of depression might improve
cognitive performance as the studies of Herrera-Guzm
an et al.
(2010) with antidepressants in patients with depression evidence.
The Neurocognitive Model of Attention to pain (Legrain et al.,
2009, p. 231) also “predicts that when we try to discard attention
from pain, a nociceptive stimulus can still capture attention in two
ways: (1) when it is salient enough and (2) when it shares one of
the perceptual features defined by the attentional set” in a bottom-
up capture process of attention by pain. In relation to this, our
results have not evidenced that pain intensity is related with lower
performance of attentional processes as other studies have done
(see Moriarty et al., 2011; S€oderfjell et al., 2006). This
discrepancy might be explained when considering the
characteristics of our study. The Neurocognitive Model of
attention to pain considers that attention is unintentionally
captured by pain when it is intense, novel and threatening. These
pain features are not present in our CP and FM patients as we
further explain. First, the pain experienced by our patients was
not novel as it uses to be in the case of experimental or acute
pain. Secondly, the intensity of pain was assessed in a
retrospective way in our study (a numerical scale of the pain
suffered in the last week). And finally, the task to perform was
highly demanding which might diminish the possibility of
attentional capture by task-irrelevant stimuli. All in all, we can
conclude that the characteristics of pain did not act as a bottom-
up capture process of attention by pain in our study. By contrast,
depression interfered top-down attentional control mechanisms.
Nevertheless, given the amount of medication that clinic pain
patients usually take, our study also tried to avoid the possible
confusion effect of medication in cognitive performance, and in
doing so, to contribute to extant research. Therefore, we decided
to compare cognitive performance among the groups excluding
participants who took anticonvulsants, given their recognized
effects on cognitive functions (Loring et al., 2007; Mula, 2012).
After doing this, differences in memory performance disappeared,
but differences in sustained attention did not. However, these
differences disappeared after excluding depressed patients. This
finding suggests that although medication can influence
differently on cognitive performance, its influence is probably
lower than the influence of depression itself.
Secondly, as far as memory complaints are concerned, interesting
findings emerged about the level of memory complaints and about
the variables related with them. Our results confirm the existing
findings in the literature; that is to say, patients with fibromyalgia
express more memory complaints than healthy controls (Grace et al.,
1999; Park et al., 2001; Suhr, 2003), even after the participants with
depression were removed from the analysis, or when the effect of
medication was considered.
Our data also indicated that in both groups of patients, memory
complaints were significantly related with depression, in agreement
© 2021 Scandinavian Psychological Associations and John Wiley & Sons Ltd
Memory complaints and cognitive performance 335
with other studies (Gelonch et al. 2016, 2017; McCracken &
Iverson, 2001; Roth et al., 2005). However, depression was not the
only subjective symptom related with memory complaints. In fact,
catastrophizing in FM and CP (Mu~ noz & Esteve, 2005) and pain
intensity in FM (Grace et al., 1999; Suhr, 2003) proved to be
significant in our work as in the mentioned. With regard to the
relationship between memory complaints and cognitive
performance, our study showed interesting findings. According to
previous research in FM, there is an inverse relationship with verbal
episodic memory (Glass, Park, Minear & Crofford, 2005; Tesio
et al., 2015). In CP, the inverse relationship has been found with
sustained attention (Landrø et al., 2013). When multiple linear
regression analysis was performed interesting results appeared.
Depression explained about 30% of the variance of memory
complaints in both groups of patients, although differences appeared
between them. In particular, in FM, verbal episodic memory and
pain intensity emerged as predictors of memory complaints,
explaining each one about 10% of the variance. On the contrary, in
CP, neither of the commented variables appeared as predictors.
Nonetheless, if memory complaints in daily tasks of FM patients are
also related with verbal episodic memory and pain intensity, an
explanation of this fact can be due to the bottom-up attentional
control mechanisms suggested by Legrain et al.’s (2009) model and
the interference of pain in attentional processes. If we consider that
daily tasks are less cognitive demanding than laboratory tasks,
attention would be more likely captured by non-task related stimuli
such as pain. From this perspective, FM patients are more sensitive
to this interference that CP patients, and this interference cannot be
clearly detected by laboratory tests.
In conclusion, our results support the existing evidence about the
influence of depression on memory complaints, but they also alert
about the possible differences depending on the chronic pain
diagnosis. Specifically in FM, although the performance in Short-
Delay Free Recall was not lower than in the other groups, their
memory complaints did have a significant inverse relationship with
the performance in this cognitive function. This finding suggests a
possible attentional bias in which difficulties or errors are
emphasized. In this regard, it would be important for future research
to determine the significance of variables such as generalized
hypervigilance (Grisard, Van der Linden & Masquelier, 2002;
McDermid, Rollman & McCain, 1996) or self-efficacy (Glass et al.,
2005) in this finding.
Last but not least, this study has some limitations that should
be pointed out. Although the samples were homogeneous as far as
age and level of education were concerned, there were gender
differences. In particular, the FM group had a higher percentage
of women. Nevertheless, we do not believe this to be a
determining factor since gender did not prove to be a predictive
variable of the cognitive performance of our sample. Other factors
we have not considered in our study are: the heterogeneity of the
diagnoses of the CP group; malingering (Bar-On-Kalfon, Gal,
Shorer & Ablin, 2016; Etherton, Bianchini, Ciota, Heinly &
Greve, 2006; Gervais et al., 2001; Suhr, 2003) and sleep quality
(Grace et al., 1999; Oosterman et al., 2013). Although the
heterogeneity of the CP group might be considered as a limitation
of this study, it is not determinant since there were not significant
differences among the CP subgroups once factors of correction
were introduced. As for malingering, it does not seem to have
336 A. Castel et al.
been a relevant factor in this study because only three patients
showed insufficient effort according to Vilar-L
opez and
colleagues (2013) criteria and after having removed them, our
results did not change. As for the latter, although sleep quality is a
variable that can affect episodic memory, contradictory findings
have been found (Grace et al., 1999; Oosterman et al., 2013). One
final limitation is that no assessment was made about the occasional
consumption of medication, or of the influence of such variables as
fatigue (Suhr, 2003), or the hour of the day in which the assessments
were done considering the circadian typology of the subjects
(Bennett, Petros, Jonhson & Ferraro, 2008; Cavallera, Boari, Giudici
& Ortolano, 2012), which were subsequently proved to be
significant for the cognitive performance of individuals.
Notwithstanding the above limitations, the results of this case-
control study are interesting for a variety of reasons. In the first
place, the study control for important confounds, as depression
and medication. Also, the study shows the importance of jointly
assessing cognitive performance and memory complaints in
various clinical samples. Further, this study highlights the subtle
differences, specifically those related with perceived memory
complaints, between the patients with fibromyalgia and the
patients with other chronic pain conditions. Finally, the results of
this study have given rise to new unknowns that should be
cleared up by future research. In particular, further studies should
examine how the diagnosis of chronic pain can affect differently
various cognitive functions, and the relation between cognitive
performance and the perception of memory problems.
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Received 8 April 2020, accepted 27 November 2020