Dennis C. Turk, PhD
Dr Turk is John and Emma Bonica Professor of Anesthesiology and Pain Research in the department of anesthesiology and pain medicine of the University of Washington in Seattle. He reports that he is a member of the Advisory Board for Eli Lilly.
Acknowledgment—Support for the preparation of this manuscript was provided in part by the National Institutes of Health, NIAMS grant #AR44724.
Anxiety
A large, multicenter study reported that between 44% and 51% of patients with FM acknowledged that they were anxious.22 A recent epidemiological study found that patients with FM were 4 times more likely to have an anxiety-related claim than health care users who did not have FM.23
Depression
The prevalence of depression among patients with FM has been reported to be as high as 70% in clinic samples.2,24 In community samples, the prevalence exceeds 30%.25 Whether depression causes pain or the converse has been of some theoretical interest. However, practically, once a person receives a diagnosis of FM, it no longer matters which is the cause and which is the consequence—pain or depression. Both need to be treated.
Anger
Chronic angry emotional reactions are maladaptive because they lead to pervasive interpersonal disruption and conflict with significant others, including health care providers. Such reactions also alter descending and central pain modulation systems and can lead to chronic sympathetic activation that may exacerbate symptoms.26 Furthermore, anger has been associated with more severe pain in patients with FM.27,28 In an anonymous Internet survey, more than 85% of people with FM acknowledged some degree of anger.10
Be aware of the significant role that negative mood plays in patients with FM because it is likely to influence a patient’s motivation and willingness to adhere to treatment recommendations. Clinicians who treat patients with FM must focus on mood states, as well as physical pathology and somatic factors. Patients with FM cannot be treated successfully without attention to their emotional state along with behavioral, cognitive, and physical contributors.
BEHAVIORAL FACTORS
Operant conditioning is an important principle of behavioral learning that helps us understand acquisition of adaptive as well as dysfunctional behaviors associated with symptoms. Its cardinal premise is that if the consequence of the given behavior is rewarding, the likelihood of its occurrence increases; if the consequence is aversive, the likelihood of its occurrence decreases (Table 1).
Behaviors associated with symptoms, such as distorted ambulation and rubbing painful body parts, are labeled “pain or symptom behaviors.” When a person is exposed to a stimulus that causes tissue damage, the immediate behavior is withdrawal in an attempt to escape from noxious sensations. Such symptom behaviors are adaptive and appropriate. However, Fordyce29 reported that these these behaviors are subjected to the principles of operant conditioning and may not be adaptive in the long term. For example, such symptom behaviors as avoidance of activity effectively prevent or withdraw aversive results (eg, pain, fatigue); these effects increase the likelihood that the behaviors will be repeated and that they may evolve into a chronic problem.
