John McBeth

Features of somatization predict the onset of chronic widespread pain: Results of a large population-based study

OBJECTIVE Chronic widespread pain, the clinical hallmark of the fibromyalgia syndrome, is associated with other physical and psychological symptoms both in patients studied in a clinical setting and in those identified in the community. The present study was undertaken to examine the hypothesis that psychological and physical indicators of the process of somatization predict the development of new chronic widespread pain. METHODS In this population-based prospective study, 1,658 adults ages 18-65 years completed a detailed pain questionnaire, which included a pain drawing. They also completed the following psychosocial instruments: General Health Questionnaire, Somatic Symptom Checklist, Fatigue Questionnaire, and Illness Attitude Scales. Individuals were followed up at 12 months, at which time 1,480 (93% of subjects still living at their baseline address) provided data on pain status, using the same instruments. RESULTS At baseline, 825 subjects were classified as pain free and 833 as having pain not satisfying criteria for chronic widespread pain. Of those, 18 (2%) and 63 (8%), respectively, were classified as having chronic widespread pain at followup. After adjustment for age and sex, there were strong relationships between baseline test scores and subsequent risk of chronic widespread pain (odds ratio for the Somatic Symptom Checklist 3.3; odds ratio for the Illness Behavior subscale of the Illness Attitude Scales 9.0). All 95% confidence intervals excluded unity. These associations were independent of baseline pain status. CONCLUSION Subjects who are free of chronic widespread pain are at increased future risk of its development if they display other aspects of the process of somatization. Data from this population-based prospective study lend powerful support to the hypothesis that chronic widespread pain can be one manifestation of the somatization of distress.

The association between chronic widespread pain and mental disorder: a population-based study.

OBJECTIVE Patients with chronic widespread pain (CWP) have been reported to have a greater prevalence of mental disorders and somatization than that found in the general population, but the true association between CWP and mental disorders is unknown. In this study, we investigated whether there is an increased prevalence of mental disorder in people with CWP from the general population. We also describe the psychiatric diagnoses associated with CWP. METHODS In a population-based case-control study, 1,953 subjects (75% of a random sample of individuals age 18-65 years) completed a questionnaire that included a pain assessment and the 12-item General Health Questionnaire (GHQ-12). Of 710 subjects scoring >1 on the GHQ-12, 301 were assessed further using a structured psychiatric interview and detailed assessment of medical records to identify cases of mental disorder, in accordance with criteria of the 10th edition of the International Classification of Diseases. The association between CWP and mental disorder was modeled using logistic regression, adjusting for possible confounders including age, sex, and nonresponders. RESULTS We estimated the overall population prevalence of mental illness to be 11.9%. The odds of having a mental disorder for subjects with versus those without CWP were 3.18 (95% confidence interval 1.97-5.11). Most subjects with mental disorders were diagnosed as having mood and anxiety disorders. Only 3 cases of somatoform disorders were identified, and all were associated with pain. CONCLUSION This study, although unable to demonstrate a cause-and-effect relationship, showed that 16.9% of those with CWP were estimated to have a psychiatric diagnosis, suggesting that these disorders should be identified and treated.

Widespread body pain and mortality: prospective population based study.

Abstract Objective: To determine whether there is excess mortality in groups of people who report widespread body pain, and if so to establish the nature and extent of any excess. Design: Prospective follow up study over eight years. Mortality rate ratios were adjusted for age group, sex, and study location. Setting: North west England. Participants: 6569 people who took part in two pain surveys during 1991-2. Main outcome measures: Pain status at baseline and subsequent mortality. Results: 1005 (15%) participants had widespread pain, 3176 (48%) had regional pain, and 2388 (36%) had no pain. During follow up mortality was higher in people with regional pain (mortality rate ratio 1.21, 95% confidence interval 1.01 to 1.44) and widespread pain (1.31, 1.05 to 1.65) than in those who reported no pain. The excess mortality among people with regional and widespread pain was almost entirely related to deaths from cancer (1.55 (1.09 to 2.19) for regional pain and 2.07 (1.37 to 3.13) for widespread pain). The excess cancer mortality remained after exclusion of people in whom cancer had been diagnosed before the original survey and after adjustment for potential confounding factors. There were also more deaths from causes other than disease (for example, accidents, suicide, violence) among people with widespread pain (5.21, 0.94 to 28.78). Conclusion: There is an intriguing association between the report of widespread pain and subsequent death from cancer in the medium and long term. This may have implications for the long term follow up of patients with “unexplained” widespread pain symptoms, such as those with fibromyalgia. What is already known on this topic Widespread body pain, the cardinal symptom of fibromyalgia, is common An organic basis for symptoms is found in only a small proportion of people Treatment is difficult, and studies with short term follow up have shown that symptoms commonly persist What this study adds This was the first study with long term follow up of people with widespread pain in the community These people experience an increased mortality and the excess is principally related to deaths from cancer

Poor sleep and depression are independently associated with a reduced pain threshold. Results of a population based study

&NA; To determine the relative contributions of psychological factors and sleep disturbance to reduced pain threshold we conducted a cross‐sectional two‐phase population‐based study. A total of 424 subjects were recruited, stratified by pain and distress status. Subjects completed a postal questionnaire that asked about current pain and covered aspects of psychological status and sleep disturbance. Samples of subjects stratified by the extent of bodily pain they reported and psychological status were invited to participate in an examination of pain threshold. The association between psychological status, sleep disturbance and a low pain threshold was examined using ordinal regression. High levels of psychological distress (OR=1.6, 95% CI (1.02, 2.5)), disturbed sleep (OR=2.2, 95% CI (1.4, 3.5)) and high scores on the HAD depression scale (OR=2.1, 95% CI (1.3, 3.2)) were all associated with having a low pain threshold. In multivariate analysis disturbed sleep and depression remained independently associated with a low pain threshold. These relationships persisted after adjustment for pain status. This study had demonstrated that depression and poor sleep are associated with a reduced pain threshold.

The association between tender points, psychological distress, and adverse childhood experiences: A community-based study

OBJECTIVE To examine the hypothesis that characteristics of somatization and illness behavior, and their childhood antecedents, are associated with the presence of multiple tender points. METHODS Two hundred eighty-nine subjects who had demonstrated psychological distress (General Health Questionnaire score > or =2) had a tender point examination and in-depth psychological evaluation. In addition, subjects were interviewed about a number of adverse childhood experiences. The 99 subjects with 5 or more tender points were compared with the remaining 190 subjects. RESULTS A high tender point count (> or =5) was associated with low levels of self-care (odds ratio [OR] 2.4, 95% confidence interval [95% CI] 1.1-5.0), reports of a greater number of somatic symptoms (OR 2.2, 95% CI 1.0-4.9), high levels of fatigue (OR 3.3, 95% CI 1.7-6.3), and a pattern of illness behavior characterized by increased medical care usage (OR 4.2, 95% CI 2.1-8.4). Those with high tender point counts were substantially more likely to report adverse childhood experiences, including loss of parents (OR 2.1, 95% CI 1.1-3.9) and abuse (OR 6.9, 95% CI 2.0-24.6). These results were not explained by the presence of chronic pain. CONCLUSION These data add further weight to the hypothesis that tender points, as part of the fibromyalgia syndrome, are strongly associated with specific components of psychological distress as well as characteristics of somatization and its antecedents. It is possible that these features contribute to the development of the syndrome of fibromyalgia.

Psychosocial risk markers for new onset irritable bowel syndrome – Results of a large prospective population-based study

&NA; Irritable bowel syndrome (IBS) affects up to 22% of the general population. Its aetiology remains unclear. Previously reported cross‐sectional associations with psychological distress and depression are not fully understood. We hypothesised that psychosocial factors, particularly those associated with somatisation, would act as risk markers for the onset of IBS. We conducted a community‐based prospective study of subjects, aged 25–65 years, randomly selected from the registers of three primary care practices. Responses to a detailed questionnaire allowed subjects’ IBS status to be classified using a modified version of the Rome II criteria. The questionnaire also included validated psychosocial instruments. Subjects free of IBS at baseline and eligible for follow‐up 15 months later formed the cohort for this analysis (n = 3732). An adjusted participation rate of 71% (n = 2456) was achieved at follow‐up. 3.5% (n = 86) of subjects developed IBS. After adjustment for age, gender and baseline abdominal pain status, high levels of illness behaviour (odds ratio (OR) = 5.2; 95% confidence interval (95% CI) 2.5–11.0), anxiety (OR = 2.0; 95% CI 0.98–4.1), sleep problems (OR = 1.6; 95% CI 0.8–3.2), and somatic symptoms (OR = 1.6; 95% CI 0.8–2.9) were found to be independent predictors of IBS onset. This study has demonstrated that psychosocial factors indicative of the process of somatisation are independent risk markers for the development of IBS in a group of subjects previously free of IBS. Similar relationships are observed in other “functional” disorders, further supporting the hypothesis that they have similar aetiologies.

Mechanical and psychosocial factors predict new onset shoulder pain: a prospective cohort study of newly employed workers

Aim: To test the hypothesis that work related mechanical and psychosocial factors predict new onset shoulder pain in newly employed workers. Methods: Two year prospective study of newly employed workers from 12 diverse occupational settings. At baseline, 1081 subjects provided information on work related mechanical and psychosocial risk factors, and current pain status. Results: In all, 803 (74%) subjects were free from shoulder pain at baseline. Of those, 638 (79%) responded at 12 months and 476 (88%) at 24 months. New onset shoulder pain was reported by 93 (15%) and 73 (15%) subjects respectively. An increased risk of symptom onset was found in subjects reporting mechanical exposures involving heavy weights including lifting with one or two hands, carrying on one shoulder, lifting at or above shoulder level, and pushing or pulling. Working with hands above shoulder level was also predictive of new onset shoulder pain. Of the psychosocial factors examined, the strongest predictor was monotonous work. Those individuals with any other previous pain also had an increased risk of new onset shoulder pain at follow up. In multivariate analysis, lifting heavy weights with one or two hands, pushing or pulling heavy weights, working with hands above shoulder level, and monotonous work were independently associated with new onset shoulder pain. Conclusions: This study supports the hypothesised relation between mechanical risk factors and shoulder pain. In general, work related psychosocial factors were modestly associated with new onset shoulder pain. However, monotonous work was a strong risk factor for new onset shoulder pain.

Restorative sleep predicts the resolution of chronic widespread pain: results from the EPIFUND study

Objectives. Poor sleep is associated with chronic widespread pain (CWP). Conversely, good-quality sleep may play a role in the resolution of pain symptoms. Sleep is a multidimensional construct, comprising a number of diverse components. The aims of the current study were to examine the hypotheses that: (i) good sleep quality would predict the resolution of CWP, (ii) restorative sleep would predict the resolution of CWP and (iii) that these relationships would be independent of confounding psychological factors. Methods. Subjects in a population-based prospective study completed a pain questionnaire at baseline from which subjects with CWP were identified. Baseline sleep was measured using the Estimation of Sleep Problems Scale which measures sleep onset, maintenance, early wakening and restorative sleep. The questionnaire also contained scales examining psychosocial status. Subjects were followed up 15 months later and pain status was assessed. Results. A total of 1061 subjects reported CWP at baseline of whom 679 (75% of eligible subjects) responded at follow-up. Of those, a total of 300 (44%) no longer satisfied criteria for CWP. Univariate analysis revealed that three of the four sleep components were associated with the resolution of CWP: rapid sleep onset, odds ratio (OR) = 1.7, 95% CI 1.2, 2.5; absence of early wakening, OR = 1.6, 95% CI 1.1, 2.4; and restorative sleep, OR = 2.7, 95% CI 1.5, 4.8. After adjusting for the effect of psychosocial factors, which may have confounded the relationship, only restorative sleep (OR = 2.0, 95% CI 1.02, 3.8) was associated. Conclusions. Self-reported restorative sleep was independently associated with the resolution of CWP and return to musculoskeletal health.

The prevalence and management of low back pain across adulthood: results from a population-based cross-sectional study (the MUSICIAN study)

Summary Amongst the oldest old, severe back pain (but not back pain overall) is most common, and primary care consultation is more likely to result in pharmacological‐only management. ABSTRACT The aim of the current study was to determine: the prevalence of low back pain (LBP) and associated disability; the frequency of consultation to general practice; whether there were differences in management by age. We conducted a cross‐sectional population study in Aberdeen city and Cheshire County, UK. Participants were 15,272 persons aged 25 years and older. The 1‐month period prevalence of LBP was 28.5%. It peaked at age 41–50 years, but at ages over 80 years was reported by 1 in 4 persons. Older persons were more likely to consult, and the prevalence of severe LBP continued to increase with age. Management by general practitioners differed by age of the patient. Older persons (>70 vs ⩽40 years) were more likely to only have been prescribed painkillers (odds ratio [OR] 1.74, 95% confidence interval [CI] 1.28–2.35) or only pain killers with other medications (OR 1.45, 95% CI 1.07–1.98). They were less likely to be prescribed physiotherapy or exercise (OR 0.63, 95% CI 0.46–0.85) or to be referred to a specialist (OR 0.77, 95% CI 0.57–1.04). Older persons were more likely to have previously received exercise therapy for pain, were less likely to be enthusiastic about receiving it now (P < 0.0001), and were less likely to think it would result in improved symptoms (P < 0.0001). It is important that older persons, who have the highest prevalence of LBP with disability and are most likely to consult, are receiving optimal pharmacological and nonpharmacological management.

Insecure attachment style is associated with chronic widespread pain

ABSTRACT Individuals with “insecure” adult attachment styles have been shown to experience more pain than people with secure attachment, though results of previous studies have been inconsistent. We performed a cross‐sectional study on a large population‐based sample to investigate whether, compared to pain free individuals, subjects with chronic widespread pain were more likely to report insecure adult attachment style. Subjects in a population‐based cross‐sectional study completed a self‐rated assessment of adult attachment style. Attachment style was categorised as secure (i.e., normal attachment style); or preoccupied, dismissing or fearful (insecure attachment styles). Subjects completed a pain questionnaire from which three groups were identified: pain free; chronic widespread pain; and other pain. Subjects rated their pain intensity and pain‐related disability on an 11 point Likert scale. Subjects (2509) returned a completed questionnaire (median age 49.9 years (IQR 41.2–50.0); 59.2% female). Subjects with CWP were more likely to report a preoccupied (RRR 2.6; 95%CI 1.8–3.7), dismissing (RRR 1.9; 95%CI 1.2–3.1) or fearful attachment style (RRR 1.4; 95%CI 1.1–1.8) than those free of pain. Among CWP subjects, insecure attachment style was associated with number of pain sites (Dismissing: RRR 2.8; 95%CI 1.2–2.3, Preoccupied: RRR = 1.8, 95%CI 0.98–3.5) and degree of pain‐related disability (Preoccupied: RRR = 2.1, 95%CI 1.0–4.1), but not pain intensity. These findings suggest that treatment strategies based on knowledge of attachment style, possibly using support and education, may alleviate distress and disability in people at risk of, or affected by, chronic widespread pain.