Fibromyalgia versus Rheumatoid Arthritis: A Comparison of ...

Fibromyalgia versus Rheumatoid Arthritis: A Comparison of Psychological Disturbance and Life Satisfaction

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Reyhan Çeliker Pinar Borman

ABSTRACT. Objectives: The aim of this study was to compare the intensity of anxiety, depression, and hopelessness in fibromyalgia syndrome [FMS] and rheumatoid arthritis [RA] patients and to determine the differences of life satisfaction in these patient groups. Methods: Twenty patients with RA, 20 patients with FMS, and 20 healthy control subjects were included in this study. All the subjects were female. The Beck Depression Inventory [BDI], Spielberger State and Trait Anxiety Inventory [STAI], and Beck Hopelessness Scale [BHS] were used to evaluate psychological disturbance, and the life satisfaction index [LSI] was used to measure psychological well-being. Results: The mean BDI scores were higher in both the FMS and RA groups, trait anxiety scores in FMS and state anxiety scores in RA were significantly higher compared with the control group. The mean BHS score was higher in the RA group. The LSI results were similar in FMS and RA but significantly lower than the control group. The BDI was found to be correlated with functional status which was measured by health assessment questionnaire in the RA group. There was a negative correlation between LSI and STAI in both the FMS and RA groups but LSI was correlated with BDI only in the RA group. Reyhan Çeliker, MD, is Associate Professor in Hacettepe University, Medical School, Department of Physical Medicine and Rehabilitation, Ankara 06100, Turkey. Pinar Borman, MD, is Specialist in Physical Medicine and Rehabilitation, Ankara Numune Hospital, Ankara 06100, Turkey. Address correspondence to: Reyhan Çeliker, MD, Hacettepe University, Medical School, Department of Physical Medicine and Rehabilitation, 06100, Ankara, Turkey [E-mail: [email protected]]. Submitted: July 13, 1999. Revision Accepted: May 22, 2000. Journal of Musculoskeletal Pain, Vol. 9(1) 2001 E 2001 by The Haworth Press, Inc. All rights reserved.

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JOURNAL OF MUSCULOSKELETAL PAIN

Conclusion: In conclusion, life satisfaction was similar in RA and FMS patients although RA patients were more disabled because of the arthritic disease. Both depression and anxiety were predictors of low life satisfaction in RA, but in FMS only anxiety had a negative role on life satisfaction. [Article copies available for a fee from The Haworth Document

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KEYWORDS. Fibromyalgia, rheumatoid arthritis, depression, anxiety, life satisfaction


INTRODUCTION Fibromyalgia syndrome [FMS] is a common rheumatologic condition involving widespread musculoskeletal pain and multiple tender points. The etiology of this disorder is not definitely known but psychological disturbances have been noted frequently and also considered as etiological or modifying factors (1,2). Pain is the cardinal symptom in most of the rheumatic diseases including FMS and rheumatoid arthritis [RA] (3,4). Several studies have been done to examine the psychological disturbance in RA and FMS patients. Use of the Minnesota Multiphasic Personality Inventory [MMPI] assessment has shown psychological abnormalities in a subgroup of FMS patients compared with normal controls and with RA patients (3,4). Quality of life and life satisfaction are very important parameters especially in chronically ill patients. Although there are some studies on quality of life in FMS and RA, there are not any published articles about life satisfaction of the patients with these disorders and satisfaction with life must be evaluated independent of quality of life. The aim of this study was to compare the intensity of anxiety, depression, and hopelessness in FMS and RA patients and to determine the differences of life satisfaction in these patient groups. MATERIALS AND METHODS Twenty female patients with RA who fullfilled the diagnostic criteria of the American Rheumatism Association [1987] (5), 20 female


Reyhan Çeliker and Pinar Borman

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patients with FMS who satisfied the diagnostic criteria designed by the American College of Rheumatology [1990] (2), and 20 heathy female control subjects were included in this study. All the patients were from the Hacettepe University out-patient clinics and the control group consisted of volunteers from the personnel at the University. The mean age was 46.6  9.7 years in the RA group, 31.4  9.1 years in the FMS group and 33.8  8.0 years in the control group and the mean age of the RA group was higher than the other two groups [P < 0.05]. The mean duration of the symptoms was 3.1  2.3 years in the FMS group and 8.1  5.2 years in the RA group. Complete blood count, erythrocyte sedimentation rate, serum chemistry profile including liver and renal function tests, C reactive protein, and rheumatoid factor titers were measured in both groups. Duration of morning stiffness was recorded and hand grip strength was measured in the RA patients. Articular involvement was evaluated with the Ritchie Articular Index [RAI] and functional status was assessed by the Stanford Health Assessment Questionnaire [HAQ]. The Beck Depression Inventory [BDI], Spielberger State and Trait Anxiety Inventory [STAI], and Beck Hopelessness Scale [BHS] were used to evaluate the psychological disturbance, and the Life Satisfaction Index [LSI] was used to measure the psychological well being. The Beck Depression Inventory is a 21-item instrument designed to measure the severity of a broad spectrum of depressive symptoms. Each item consists of four self-evaluative statements, which are assigned a numerical value that represents the symptoms severity. Item responses are summed to yield a total score with a range from 0 to 63. A score of 14-24 is indicative of moderate depressive symptoms and a score of 25 or greater is strongly associated with clinically significant major depression (6,7). The Beck Hopelessness Scale is a 20 item true-false questionnaire assessing negative expectations and pessimism about one’s future. One-half of the items are reverse scored. The total scores can range from 0 to 20 and are obtained by summing the individual items. A score of 13 or greater is indicative of significant hopelessness (8). The Spielberger State and Trait Anxiety Inventory contains two scales that measure current [A-State] and long-standing [A-Trait] anxiety. A-State is composed of 20 items that assess the intensity of current anxiety symptoms. A-Trait consists of 20 items and measure the level and symptoms of anxiety across situations. Scale scores are

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obtained by summing the ratings for scale items. Scores range from 20 to 80 for both with higher scores indicating higher levels of anxiety (7). The Life Satisfaction Index-A consisted of 20 attitude items for which participants indicated whether they agreed, disagreed or were uncertain. Scores could range from 0 to 20, with the greater value indicating maximum life satisfaction (9). The LSI is multidimensional in character and three factors are relish for life, mood tone, and congruence between desired and achieved goals (10). All statistical evaluations were done using the Statistical Package for Social Sciences for Windows. Student’s t test [for unpaired observations], Pearson’s correlation matrix, chi square test, and analysis of variance was used to test the differences between groups. For the analysis of pairwise differences Tukey’s test was used as a post-hoc analysis. In the statistical results P < 0.05 was regarded as significant. RESULTS The mean scores of BDI, BHS, and STAI were significantly different between groups and the results are given in Table 1. The results of post-hoc analysis of pairwise differences are summarized in Table 2. The mean BDI scores were significantly higher in both patient groups than the control group [P = 0.000]. Eight patients with RA and six patients with FMS had moderate depressive symptoms, one with RA and one with FMS had clinically significant depressive symptoms. All control subjects were in the normal range and the frequency of depression in both groups were significantly higher than the control group [P < 0.05]. TABLE 1. Psychological Tests and Life Satisfaction Index Results of the Patient and Control Groups [Analysis of Variance] RA N = 20

FMS N = 20

Control N = 20

F

P value

Beck Depression Inventory

13.2  7.1

12.4  7.8

3.8  3.6

12.909

0.000

Beck Hopelessness Scale

6.8  3.1

4.6  3.3

4.3  4.4

3.608

0.034

Trait Anxiety Inventory

38.2  8.3

47.5  8.3

41.7  4.5

8.121

0.001

State Anxiety Inventory

46.9  7.0

41.0  8.8

35.7  10.8

7.517

0.001

Life Satisfaction Index

8.8  3.5

8.0  4.4

13.1  3.1

9.078

0.000

RA = Rheumatoid arthritis FMS = Fibromyalgia syndrome


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TABLE 2. The Results of Post-Hoc Analysis of Pairwise Differences of RA, FMS and Control Groups [Tukey’s Test] Variable

Group

Group

P

Beck Depression Inventory

Contol

RA FMS

0.000 0.000

Beck Hopelessness Scale

Control

RA FMS

0.041 0.856

Trait Anxiety Inventory

FMS

RA Control

0.001 0.035

State Anxiety Inventory

Control

RA FMS

0.001 0.171

Life Satisfaction Index

Control

RA FMS

0.005 0.001


RA = Rheumatoid arthritis FMS = Fibromyalgia syndrome

The mean trait anxiety inventory score in FMS was higher than the RA [P = 0.001] and control groups [P = 0.035]. State anxiety inventory scores in RA patients were significantly higher compared with the control group [P = 0.001]. In the RA group the mean BHS score was higher than the control group [P = 0.041] but not different from the FMS patients [P = 0.101]. The LSI results were similar in FMS and RA but significantly lower than the control group [P = 0.005 and P = 0.001, respectively]. The BDI was found to be correlated with the HAQ [R = 0.5592, P = 0.010] and the HAQ was correlated with the RAI [R = 0.5165, P = 0.024] in the RA group. There was a negative correlation between the LSI and A-State and A-Trait anxiety in both the FMS [R = −0.6960, P = 0.001 and R = −0.5036, P = 0.024] and RA groups [R = −0.5005, P = 0.041 and R = −0.5103, P = 0.052]. The LSI was correlated with the BDI only in the RA group [R = −0.5605, P = 0.019]. None of the psychological test results and life satisfaction scores were correlated with age, duration of disease, laboratory tests, and clinical parameters like duration of morning stiffness and hand grip strength [P > 0.05]. DISCUSSION The role of psychological factors in FMS has been controversial. Several authors have shown that FMS patients had more psychologi-


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cal distress than RA patients or healthy controls. Payne et al. (4) compared FMS and RA and found that MMPI profiles were higher in the FMS patients. Ahles et al. (3) reported that one third of FMS patients were psychologically disturbed, one-third had profiles which are typically seen in patients with other pain-related disorders, including those with a definite organic etiology, and the rest were normal. Hudson et al. (11) suggested that FMS and major affective disorder might share certain features, raising the possibility of common etiologic factors. They found significantly higher occurrence of a history of major depression in FMS patients than in arthritis patients. Wolfe et al. (12) compared the MMPI profiles in FMS, RA, and patients with FMS associated with RA. The hypochondriasis and hysteria scales were highest in the FMS patients. The MMPI classification seems to provide useful information on psychological status (13), however interpretations of abnormal MMPI results, especially on such pain-filled scales as hypochondriasis, depression, and hysteria must be viewed with caution because the elevated scales may reflect organic disease activity rather than psychopathology (14). Clark et al. (15) found no significant difference in BDI, STAI, and Symptom Check List [SCL-90-R] between FMS patients and controls. In our study the mean BDI scores were significantly higher in both the RA and FMS groups compared with the healthy control group, but the results of the RA and FMS groups were not different from each other and the frequency of moderate and clinically significant depressive symptoms were similar in both groups. The BDI includes several somatic items and this suggests that somatic expression of depression is similar in RA and FMS. Ahles et al. (16) compared the frequency of the occurrence of DSM-III diagnoses [Diagnostic and Statistical Manual of Mental Disorders criteria] in patients with FMS, patients with RA, and subjects without pain. Their data revealed no group differences in terms of lifetime history of any psychiatric disorder but only patients with FMS and psychiatric history endorsed significantly more somatic symptoms than did patients with RA and subjects without pain. In another study they reported that FMS and RA groups differ significantly from the normal control group but do not differ from each other on the self-rating Zung depression scale (17). Kirmayer et al. (18) found no significant differences in the occurrence of depression between FMS patients [20%] and arthritis patients [8.7%]. There have been other studies that have found higher rates of major depression in patients with FMS



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compared to RA (19). Some authors have reported a high lifetime prevalence of major depression in patients with FMS (19-21). Wolfe et al. (2) found a higher prevalence of current depression, lifetime depression, hospitalization for depression, drug therapy for depression, and family history of depression in individuals with FMS compared with individuals without FMS in a community sample. In this study we have not performed interviews to assess lifetime prevalence of psychiatric disorder, but have obtained data only on current psychological symptomatology. So we have failed to find differences in lifetime psychopathology. Depression seems to be an important problem among patients with RA and was found to be more prevalent compared with the control subjects. Katz and Yelin (22) have found that, among a group of RA patients those with depressive symptoms had poorer function, were likely to have a major physical limitation, spent more days in bed, and reported more joints with pain. They also reported that functional decline that leads to development of depressive symptoms is the loss of valued activities (23). The BDI scores were found to be correlated with the HAQ and the HAQ was correlated with RAI in our study and it seems likely that the presence of depressive symptoms was related with the severity of physical disability. In this study RA patients were significantly older than the FMS and control subjects. The RA patients also had a significantly longer duration of symptoms. For this reason, the RA patients might have had greater disability and psychological disturbance on the basis of having a longer period of time with a chronic illness, but psychological test results and life satisfaction were not found to be correlated with age and duration of disease. Crotty et al. (24) evaluated early RA patients using the BDI and the HAQ in a longitudinal study and found that psychological variables were as important as disease and pain in determining function. Pincus et al. (25) used the Hospital Anxiety and Depression Scale and their results indicated that RA patients were more depressed and anxious than controls and the prevalence of depression above the cut-point was 15%. Abdel-Nasser et al. (26) compared RA and osteoarthritis [OA] patients and reported that RA patients showed significantly higher depression scores than OA patients and found that HAQ disability was a significant predictor of clinical depression in RA patients. Van der Heide et al. (27) suggested that patients with recent onset RA appeared not to be different with respect to the strong association between


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physical disability and psychological well being from patients with RA of longer duration. The BHS results which reflects the global, pessimistic beliefs about oneself and future were significantly higher in the RA group compared with the control group. The state anxiety scores were high in RA and trait anxiety scores were high in the FMS group. These results suggest that symptoms of anxiety across situations are more evident in FMS but intensity of current anxiety symptoms are evident in RA patients. There was a negative correlation between the LSI and the STAI in both groups and this suggests that life satisfaction is strongly related with anxiety in RA and FMS. The interaction of subjective well-being with impairment and disability was investigated generally in neurologic disorders. The mean LSI was found to be lower in spinal cord injury patients compared with the general population and it was influenced by selective aspects of their social role performance, but not by their degree of impairment or disability (28). Ahles et al. (3) examined the role of stressful life events and social skills in FMS and found an association of FMS with stressful life events, especially within the psychologically disturbed subgroup. Dailey et al. (29) also investigated the relationship of stress and social support to the FMS, RA, and control groups. They found that FMS patients showed higher levels of stress than did RA or control groups but no differences were found between groups with regard to social support. Yunus et al. (13) reported that central features of FMS like number of pain sites, number of tender points, fatigue, and poor sleep were independent of psychological status, but pain severity might be influenced by psychological factors. Some studies have demonstrated correlation between pain and psychometric scoring in RA and FMS patients (30,31). In the study of Viitanen et al. (32) the patients with FMS were more depressed than the RA patients but a positive correlation between depression score and pain intensity was found only in the RA patients, depression was not able to explain the high pain intensity in the FMS patients. Functional disability and work disability have been recognized as important factors in FMS severity and should be assessed as an outcome measure (33,34). Our previous study demonstrated that individuals with increasing functional disability had a reduced quality of life in both RA and FMS patients (35). Our results suggest that the features of psychological disturbance in RA and FMS show some differences except the similarity of the


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intensity and frequency of depression. The intensity of hopelessness and current anxiety were significant in RA but anxiety across situations were evident in FMS. Although RA patients are more disabled because of arthritic disease, life satisfaction was not lower than the FMS group. Both depression and anxiety were predictors of low life satisfaction in RA, but in FMS only anxiety had a negative effect on life satisfaction.


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