Hindawi Pain Research and Management Volume 2022, Article ID 2114451, 16 pages https://doi.org/10.1155/2022/2114451 Research Article Prevalence and Characterization of Psychological Trauma in Patients with Fibromyalgia: A Cross-Sectional Study Itxaso Gardoki-Souto ,1,2 Diego Redolar-Ripoll ,3,4 Marta Fontana ,1 Bridget Hogg ,1,2,5,6 Marı́a José Castro,7 Josep M. Blanch,7 Fabiola Ojeda,7 Aleix Solanes ,8 Joaquim Radua ,8,9,10 Alicia Valiente-Gómez ,1,5,6,11 Roser Cirici ,11 Vı́ctor Pérez ,5,6,11 Benedikt L. Amann ,1,5,6,11,12,13 and Ana Moreno-Alcázar 1,5,6,14 1 Forum Center Research Unit, Institute of Neuropsychiatry and Addictions (INAD), Parc de Salut Mar (PSMAR), Barcelona, Spain 2 Department of Psychiatry and Forensic Medicine, Autonomous Universtiy of Barcelona (UAB), Barcelona, Spain 3 Cognitive NeuroLab, Open University of Catalonia (UOC), Barcelona, Spain 4 Neuromodulation Unit, Brain 360 Institute, Barcelona, Spain 5 Hospital Del Mar Medical Research Institute (IMIM), Barcelona, Spain 6 Mental Health Networking Biomedical Research Centre (CIBERSAM), Institute of Health Carlos III, Madrid, Spain 7 Rheumatology Service, Parc de Salut Mar (PSMAR), Barcelona, Spain 8 August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain 9 Karolinska Institute (KI), Stockholm, Sweden 10 King’s College London, London, UK 11 Institute of Neuropsychiatry and Addictions (INAD), Parc de Salut Mar, Barcelona, Spain 12 Pompeu Fabra University (UPF), Barcelona, Spain 13 Department of Psychiatry and Psychotherapy, Ludwig Maximilian University Hospital, Munich, Germany 14 ISOMAE Institute of Neurosciences and Psychosomatic Psychology, Sant Cugat Del Vallés, Barcelona, Spain Correspondence should be addressed to Ana Moreno-Alcázar; amoreno.centreforum@gmail.com Received 1 March 2022; Revised 22 September 2022; Accepted 26 October 2022; Published 30 November 2022 Academic Editor: Massimiliano Valeriani Copyright © 2022 Itxaso Gardoki-Souto et al. Tis is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Preliminary evidence suggests that psychological trauma, especially childhood trauma, is a risk factor for the onset of fbromyalgia (FM). Objective. Te main objective of this study consisted of evaluating the prevalence and detailed characteristics of psychological trauma in a sample of patients with FM, the chronology of trauma across the lifespan, and its clinical symptoms. We also calculated whether childhood trauma could predict the relationship with diferent clinical variables. Method. Eighty-eight females underwent an interview to assess sociodemographic data, psychiatric comorbidities, level of pain, FM impact, clinical symptoms of anxiety, depression, insomnia, quality of life, and psychological trauma. Results. Te majority of participants (71.5%) met the diagnostic criteria for current post-traumatic stress disorder (PTSD). Participants reported having sufered traumatic events throughout their lifespan, especially in childhood and early adolescence, in the form of emotional abuse, emotional neglect, sexual abuse, and physical abuse. Traumatic events predict both poor quality of life and a level of pain in adulthood. All patients showed clinically relevant levels of anxiety, depression, insomnia, suicidal thoughts, and pain, as well as somatic comorbidities and poor quality of life. Pain levels predicted anxiety, depression, dissociation, and insomnia symptoms. 84% of the sample sufered one or more traumatic events prior to the onset of pain. Conclusions. Our data highlight the clinical complexity of patients with FM and the role of childhood trauma in the onset and maintenance of FM, as well as the high comorbidity between anxiety, depression, somatic symptoms, and FM. Our data also supports FM patients experiencing further retraumatization as they age, with an extremely high prevalence of current PTSD in our sample. Tese fndings underscore the need for multidisciplinary programs for FM patients to address their physical pain and their psychiatric and somatic conditions, pay special attention to the assessment of psychological trauma, and provide trauma-focused interventions. Trial registration: ClinicalTrials.gov NCT04476316. Registered on July 20th, 2020. 2 Pain Research and Management 1. Introduction development of unexplained physical pain [28, 29], espe- cially for FM. Fibromyalgia (FM) is considered the second most common Despite all the studies that highlight the relationship rheumatic disorder [1] and afects between 2% and 4% of the between childhood trauma and FM, few studies have col- population worldwide, in the majority of cases females [2]. lected in detail the chronology of the traumatic events to In addition, FM is often diagnosed alongside chronic fatigue which these patients are exposed throughout their lifespan, syndrome (CFS), due to the overlap between their symptoms from infancy to adulthood, as well as information on and their underlying biological mechanisms [3]. Although whether these events occurred mainly before or after the the etiology of FM remains unknown [4], several explana- onset of pain. Likewise, many studies have focused on tions have been proposed for the onset of FM, including studying the correlation between trauma and pain. However, genetic factors [5, 6], hormonal and immunological alter- there is a lack of studies on possible predictor variables that ations [7], nutritional aspects [4], and abnormalities in explain the relationship between childhood trauma, pain, central pain processing [4, 8] linked to the sensitization of and the presence of psychiatric comorbidities, which are the central nervous system (CNS) [4, 5, 9]. In fact, the highly prevalent in this population and signifcantly afect sensitization of the CNS has been suggested as one of the the functionality and quality of life of the patients. main pathophysiological changes involved in FM, involving Our study aimed to analyze the prevalence and clinical neurotransmitter imbalances, altered functional connectiv- characterization of traumatic events present in women with ity, and changes in the hypothalamic-pituitary-adrenal a principal diagnosis of FM and to what extent these events (HPA) axis, which infuence the autonomic nervous sys- can predict pain levels, the presence and intensity of afective tem [5, 10, 11]. Interestingly, exposure to diferent chronic symptoms, psychiatric comorbidity, insomnia, and quality or acute stressors, including psychological trauma, has of life. a signifcant impact on the dysregulation of the HPA axis [12]. Psychological trauma is defned as a stressful life event 2. Materials and Methods that causes distress and exceeds an individual’s ability to integrate the emotions and cognitions involved in the ex- 2.1. Participants of the Study. Te study sample consisted of perience [13]. Tese events happen in an unexpected and 90 female participants diagnosed with FM, who were con- uncontrollable manner, putting the individual’s physical and secutively derived from the rheumatology service (n � 42) psychological integrity at risk, exceeding their coping re- and from the adult mental health services (n � 30) of the Parc sources and leading to responses of helplessness and fear de Salut Mar in Barcelona, Spain. Further participants [14]. In some cases, exposure to one or more traumatic (n � 18) from the catchment area learnt about the study events can result in a diagnosis of PTSD [15, 16] or the through word of mouth or from local FM associations and presence of traumatic symptoms that cause discomfort contacted researchers to voluntarily enroll. Te study was without meeting the necessary criteria for a PTSD diagnosis conducted between January 2020 and January 2021. All [17]. Trauma exposure can happen throughout the entire women were evaluated through an individual clinical in- lifespan of a person, but if it occurs during childhood, its terview that lasted approximately 1.5 hours and was con- psychopathological and somatic consequences are severe ducted by two psychologists from the forum center research due to the vulnerability of the CNS during infancy and unit. In some cases, the assessments were carried out in adolescence [18,19]. In this sense, childhood trauma or person, but when participants were not able to attend the adverse childhood experiences (ACEs) encompasses various interviews because of COVID-19-related restrictions, clin- forms of physical and emotional abuse or neglect, sexual ical evaluations were carried out online. abuse, bullying, or household dysfunction experienced in Participants had to fulfll the following inclusion criteria: childhood. Along these lines, several studies have in- (1) women with an FM diagnosis based on a clinical in- vestigated the relationship between childhood trauma and terview aligned with the American college of rheumatology FM [5, 20–22], and have found a strong association. More criteria [30], and (2) aged between 18 and 70 years. Te specifcally, these studies have shown that women diagnosed exclusion criteria are as follows: (1) comorbid chronic in- with FM score higher on the childhood trauma question- fammatory or autoimmune disorders; (2) neurodegenera- naire (CTQ) as compared to controls [23, 24] or other tive disorders, which can interfere in the development of the medical conditions such as migraine, rheumatoid arthritis, clinical interviews; (3) severe mental disorders, namely bi- and myofascial pain syndrome [23, 25–27]. Further studies polar disorder, schizoafective disorder, or schizophrenia. Of showed a higher prevalence of emotional abuse [24, 25] and note, major depressive disorder and anxiety disorders were physical neglect [23] in patients with FM compared with not excluded as exclusion criteria due to the high prevalence controls, and higher scores in emotional abuse [25, 27], of these disorders in patients with FM; (4) present active emotional neglect [27], physical neglect [27], and physical suicidal ideation; and (5) dependence or substance abuse abuse [26], in comparison with patients afected by rheu- (except nicotine) in the previous month before the study matoid arthritis and migraine. All this data seems to indicate enrolment. Taking into account these criteria of the 90 that childhood trauma can be considered a risk factor for the participants, two women were excluded because of the Pain Research and Management 3 diagnosis of an infammatory or autoimmune disorder; according to their age when each occurred. Te table therefore, the fnal sample consisted of 88 women. is divided into fve-year segments spanning from 0–5 Te investigation was developed in accordance with the up to 65–70 years. For each segment, participants are latest version of the Helsinki Declaration and was approved asked, “Do you remember having any traumatic or by the ethics committee “Comité Ético de Investigación stressful experiences when you were in this age Clı́nica del Parc de Salut Mar” (reference number: 2020/ group?”. Answers are then coded using thematic 9158). All participants gave written informed consent fol- analysis. Traumatic events were then subsequently lowing a full explanation of the study before enrolling. categorized as one of the following: emotional abuse; physical abuse; sexual abuse; emotional neglect; physical neglect; parental violence; drug abuse by 2.2. Clinical Outcomes and Assessment. In the clinical in- a family member; parental mental disorder; parental terview, the evaluators gathered the data following a pre- mental disorder; accident; physical violence in viously designed case report form (CRF) for the study. Te adulthood; rape, abuse or sexual attack; harassment CRF collected sociodemographic variables such as age, race, or psychological maltreatment in adulthood; death educational level, marital status, employment status, psy- of a loved one; abortion; surgery; imprisonment, chiatric and somatic comorbidities, and pharmacological detention, or kidnapping; illness of a frst-degree treatment. A series of validated scales were also administered relative; personal illness; pregnancy itself or preg- for the evaluation of pain and FM impact, psychological nancy complications; personal separation or divorce; trauma and associated symptoms, comorbid psychiatric mobbing; economic problems; familiar conficts; disorders, clinical symptoms of depression and anxiety, others (such as bullying, natural disasters, eviction, insomnia, and quality of life. Te scales are detailed as or migration processes), or no traumatic event. follows: (2) Global assessment of post-traumatic stress ques- tionnaire (EGEP-5) [35]: Tis 55-item scale assess 2.2.1. Pain and FM Impact PTSD according to DSM-V criteria over the month (1) Visual analog scale (VAS) for pain [31]: Tis scale prior to the evaluation, based on the event from the consists of a straight horizontal line, ranging from chronology currently causing the greatest level of 0 (no pain) to 10 (maximum pain), which assesses distress. It evaluates symptoms of intrusion, avoid- the pain severity at the moment of the clinical in- ance, alterations in cognition, mood, arousal, and terview. Scores are interpreted as “no pain” (0–2), reactivity, as well as duration and impact on func- “mild pain” (2–4), “moderate pain” (4–6), “severe tioning, and determines the presence or absence of pain” (6–8), and “maximum pain” (8–10). PTSD, as well as specifying if depersonalization, (2) Pain disability index (PDI) [32]: Tis scale comprises derealization, and/or delayed expression are present. 7 items referring to diferent aspects of life that can (3) Subjective unit of distress (SUD) [36]: this scale, be afected by chronic pain: home and family re- ranging from 0 (no distress) to 10 (maximum dis- sponsibilities, recreation, social activities, occupa- tress), evaluates the level of subjective perturbation tion, sexual activity, and life support activities. Each a person experiences when they bring to mind the item can be rated from 0 (no disability) to 10 (total traumatic event chosen in the EGEP-5 scale. disability), and the total score is obtained by sum- ming all the answers. Since there is currently no (4) Holmes and Rahe social readjustment scale [37], validated Spanish version, this scale was translated Spanish validation [38]: Tis scale lists 43 possible from the English version by a bilingual researcher. stressful events, and participants must mark the events that have happened to them in the previous 12 (3) Fibromyalgia impact questionnaire [33], Spanish months. Each event has a diferent score, and the validation (S-FIQ) [34]: Tis 10-item scale assesses global score is reached by summing all the scores of the impact of FM over the previous 7 days. Te frst the events selected. Scores under 150 indicate low item contains 11 questions, which are related to levels of stress, scores between 150 and 299 are physical functioning; items 2 and 3 ask the person to suggestive of a 50% risk of stress-related disorders, answer the number of days they have been unable to and scores above 300 mean an 80% risk of sufering work because of FM; and items from 4 to 10 are stress-related disorders. scaled items (0–10), in which the person rates work difculty, pain, fatigue, morning tiredness, rigidity, (5) Childhood trauma questionnaire (CTQ) [39], anxiety, and depression. Higher scores signify lower Spanish validation [40]: Tis self-applied scale levels of functioning. evaluates the presence of childhood trauma with 30 items (CTQ-T), which can be answered on a 5-point Likert scale. Te CTQ measures 5 types of childhood 2.2.2. Psychological Trauma and Associated Symptoms maltreatment: emotional (CTQ-EA), physical (CTQ- (1) Chronology of traumatic events: Tis tool consists of PA), sexual abuse (CTQ-SA), emotional (CTQ-EN), a table, which gathers all the traumatic events re- and physical neglect (CTQ-PN). Te numerical ported by the participants over their lifespan answers correspond with responses ranging from 4 Pain Research and Management “never true” to “very often true”, and the fnal score (HADS-A for anxiety and HADS-D for depression), of each factor indicates severity in terms of “none to which can be rated from 0 to 3. Te sum total of the minimal”, “low to moderate”, “moderate to severe” scores gives the overall score. Scores equal to or over and “severe to extreme”. 8 for each subscale can represent the presence of an (6) Dissociative experiences scale (DES) [41], Spanish anxiety or depressive disorder. validation [42]: Tis 28-item scale assesses the fre- (2) Athens insomnia scale (AIS) [49], Spanish validation quency of the presence of diferent dissociative expe- [50]: Tis scale evaluates the presence of insomnia riences, excluding acute intoxication by substances. according to ICD-10 criteria. It evaluates distur- Items are rated from 0% to 100%. Te total score is bances in sleep over the previous week and consists obtained by summing all item answers and dividing of 8 items. Te frst fve assess sleep induction, this result by 28. Tere are three diferent subscales, awakenings at night, fnal awakening, total sleep such as amnesia (DES-A), depersonalization/de- duration, and sleep quality, and the last three items realization (DES-DP), and dissociation (DES-D). A refer to well-being, functioning capacity, and total score (DES-T) equal to or higher than 30 is sleepiness during the day. All items can be rated from interpreted as a dissociative disorder. 0 to 3, providing a total score when summed between (7) Somatoform dissociation scale-20 (SDQ-20) [43], 0 and 24. Spanish validation [44]: Tis questionnaire evaluates (3) Satisfaction with life scale (SWLS) [51], Spanish the presence and intensity of 20 somatoform validation [52]: Tis self-applied scale consists of 5 symptoms or experiences that happened during the items evaluating the self-perception of satisfaction last year. Participants are asked to rate the intensity with one’s life. Each item can be rated from 1 (totally of each experience on a 5-point Likert scale and disagree) to 5 (totally agree). Higher scores represent whether there is a medical explanation for it. Te higher levels of satisfaction. total score is reached by summing the scores for each item, while the symptoms with no known cause are 3. Data Analysis summed to reach the total of symptoms with no known cause. 3.1. Sample Size Calculation. Given that the main objective of this study was to investigate the relationship between childhood trauma (CTQ) and FM pain (VAS pain), we 2.2.3. Diagnosis calculated the sample size needed to conduct a regression (1) FM diagnosis: FM diagnosis based on a clinical in- analysis between CTQ and VAS pain. According to the terview aligned with the American college of rheu- standard formula, the sample size required to detect matology criteria [30], which was carried out in all small correlations (R � 0.30) with 80% statistical power is participants. 84. However, researchers decided to include all candi- dates who were recruited between January 2020 and (2) Psychiatric comorbidities: MINI neuropsychiatric in- January 2021 who signed the informed consent and met ternational interview [45], Spanish validation [46]: Te inclusion criteria, even if the calculated number was MINI structured interview evaluates the presence of exceeded. psychiatric comorbidity according to DSM-IV criteria. In the present research project, only the following parts of the scale have been used for the assessment: major 3.2. Statistical Analysis. All analyses were performed using depressive episode, dysthymic episode, manic/hypo- STATA statistics/data analysis, version 16.1 (StataCorp LLC, manic episode, panic disorder, agoraphobia, social Texas, USA). Fitness to parametric assumptions was checked phobia, obsessive-compulsive disorder, and generalized for all variables. To assess the normality of data distribution, anxiety disorder. Te remaining MINI components the Shapiro–Wilk test was used. were not used because the data were covered by the First, regarding the descriptive analysis of the socio- inclusion and exclusion criteria (substance dependence, demographic, medical, and clinical data (Tables 1 and 2), the substance abuse, psychotic disorders, anorexia nervosa, arithmetic mean was used for quantitative variables and the and bulimia nervosa), were collected during the clinical proportion for categorical variables. In both cases, the interview (suicidality), or were assessed more exhaus- standard error and confdence interval (95%) were tively by other specifc psychometric scales (PTSD). calculated. Second, simple linear regression has been used to analyze whether diferent types of child maltreatment (CTQ mea- 2.2.4. Clinical Symptoms, Insomnia, and Quality of Life sures) could predict diferent clinical variables, namely Evaluation anxiety and depression. (1) Hospital anxiety and depression scale (HADS) [47], Tird, we also used the simple linear regression model to Spanish validation [48]: Tis self-administered scale analyze whether the scores obtained on the fbromyalgia measures the presence and intensity of anxious and pain and impact scales (VAS, PDI, and S-FIQ) could predict depressive symptoms in the previous 7 days. It the clinical variables discussed above (HADS and AIS) and contains 14 items, seven for each of the subscales the patients’ quality of life (SWLQ). Pain Research and Management 5 Table 1: Sociodemographic characteristics of the sample. Data are presented as the mean (SD) or number (%). (95% Conf. Variable Obs/Freq Mean/Percentage∗ Std. Err. Interval) Age 88 51.40 0.97 49.47 53.34 Education (years of studies) 88 14.05 0.41 13.23 14.87 Caucasian 74 84% 0.03 0.74 0.90 Race Latin 12 13.6% 0.03 0.07 0.22 Other 2 2.2% 0.01 0.005 0.08 Single 16 18.1% 0.04 0.11 0.27 Relationship status Married/in a couple 69 78.4% 0.04 0.68 0.85 Widowed 3 3.4% 0.01 0.01 0.10 Full-time employment 12 13.6% 0.03 0.07 0.22 Part-time employment 5 5.6% 0.02 0.02 0.13 Sick leave 31 35.2% 0.05 0.25 0.45 Unable to work due to mental health problems 6 6.8% 0.02 0.03 0.14 Employment status Unable to work due to other reasons 17 19.3% 0.04 0.12 0.29 Unemployed 31 14.7% 0.03 0.08 0.23 Others 3 3.4% 0.01 0.01 0.10 Student 1 1.1% 0.01 0.001 0.07 Obs/Freq, Number of cases observed/Frequency; Std. Error, Standard Error; Conf, Confdence ∗ Age and education data are presented as means. Te rest of the variables are presented as percentages. 4. Results consequences (e.g. hospitalization or physical lesions), and 18.18% nonsevere consequences (resolved without the need 4.1. Sample Characteristics. Te mean age of the 88 par- to go to health services) (see Table 2). ticipants in the sample was 51.41 years, with the majority As expected, subjective pain perception, measured being married or in a couple, and Caucasian. According to with the VAS, revealed high levels of pain (MD � 6.57; their employment status, a high number of them were on SD � 0.23). Furthermore, we also found a marked degree sick leave (n � 31, 35.2%), unemployed (n � 31, 15%), or of disability (PDI MD � 46.12; SD � 1.21) with a generally unable to work due to mental health problems or other large negative impact of FM on daily functioning and problems (n � 23, 26%) (see Table 1). quality of life (S-FIQ MD � 55.58; SD � 1.06). Te average Regarding the medical data of the sample, other number of years between the onset of pain and the di- comorbid axis III diagnoses were common, with the most agnosis of FM in the sample was 9.10 (onset of pain: prevalent being chronic fatigue syndrome (60.2%), followed M � 35.44, SD � 11.93; FM diagnosis: M � 44.55, by osteoarthritis (30.6%). Participants were prescribed SD � 8.50) (see Table 2). various pharmacological drugs, with the most frequent being Te EGEP-5 scores revealed that 71.5% of the par- anxiolytics/hypnotics (60.9%); then, serotonin- ticipants met the criteria for PTSD in the last month. In norepinephrine reuptake inhibitors (SNRIs) (49.4%), par- relation to the event chosen by each participant for the acetamol (36.7%), opioids (mainly tramadol and tapentadol, administration of this scale, 34 women selected an event 22.7% and 9.1%, respectively) and anti-infammatory drugs that occurred in their childhood, 47 an event that oc- (35.2%) (see Table 2). curred in adulthood, and this data was missing for 7 According to the MINI, anxiety disorders (87.5% for participants. Te average score of subjective distress, generalized anxiety disorder, 63.6% for panic disorder, and measured via SUD, was 8.23 (from 0 to 10, SD � 0.26), 29.5% for social phobia/agoraphobia) and mood disorders indicating great psychological distress in relation to that (76.1% for major depressive disorder and 11.3% for dys- event (see Table 3). Total DES scores revealed low-to- thymia) were the most frequent psychiatric comorbidities. moderate levels of dissociative symptoms in our sample Tese results were confrmed by higher current scores in the (MD � 24.72; SD � 1.34); however, the dissociation sub- HADS (anxiety MD � 14.34; SD � 0.39 versus depression scale of dissociative experiences obtained scores above MD � 12.04; SD � 0.46). Participants showed marked scores the cut-of point (MD � 36.26; SD � 1.86). Somatoform in the AIS (MD � 14.14; SD � 0.52) suggestive of sleep dis- dissociative symptoms, measured by the SDQ-20, con- turbances and an important degree of dissatisfaction with frmed the presence of a strong somatization tendency in their lives according to the SWLS scores (MD � 11.78; the sample (SD � 39.45; SD � 1.11), having an average of SD � 0.49). In terms of suicidal behavior, 82.9% of the 4.76 symptoms with no known cause (SD � 0.3) (see participants reported having had thoughts of suicide at some Table 3). point in their lives, and 32.9% had carried out at least one Our FM sample experienced low-to-moderate levels of suicide attempt in their lifetime, of which 4.5% used violent all types of child maltreatment in the CTQ, with both methods (e.g. physical self-harming) and 27.2% nonviolent emotional abuse (63.6%) and emotional neglect (62.5%) methods (e.g. drug over-ingest), 13.6% sufered severe being the most frequent maltreatment, followed by sexual 6 Table 2: Clinical characteristics of the sample. Data are presented as the mean (SD) and/or number (%). [95% Conf. Variable Obs/Freq Mean/Percentage∗ Std. Err. Interval] GAD 77 87.5% 0.03 0.78 0.92 MDD 67 76.13% 0.04 0.65 0.83 Panic disorder 56 63.6% 0.05 0.52 0.73 MINI Social phobia/Agoraphobia 26 29.5% 0.04 0.20 0.40 Dysthymia 10 11.3% 0.03 0.06 0.19 OCD 3 3.4% 0.01 0.01 0.10 HADS-D 88 12.04 0.46 11.12 12.96 HADS HADS-A 88 14.34 0.39 13.55 15.12 AIS 88 14.13 0.52 13.10 15.17 SWLS 87 11.78 0.49 10.79 12.76 VAS pain 88 6.57 0.23 6.11 7.03 PDI 88 46.12 1.21 43.71 48.53 Onset of pain 86 35.44 1.29 32.87 38.02 Diagnosis of fbromyalgia 87 44.55 0.92 42.73 46.37 S-FIQ 87 55.58 1.06 53.47 57.69 Suicidal thinking 73 82.9% 0.04 0.73 0.89 28 32.9% 0.05 0.23 0.43 Violent 4 4.5% 0.02 0.01 0.11 Suicide attempt No violent 24 27.2% 0.04 0.18 0.37 Severe 12 13.6% 0.03 0.078 0.22 Not severe 16 18.1% 0.04 0.11 0.27 CFS 53 60.2% 0.05 0.49 0.70 Osteoarthritis 27 30.6% 0.04 0.21 0.41 Spinal disc herniation 10 11.3% 0.03 0.06 0.19 Chronic migraine 9 10.2% 0.03 0.05 0.18 Diagnostics axis III Low back pain 9 10.2% 0.03 0.05 0.18 Tyroid diseases 8 9% 0.03 0.04 0.17 Rheumatoid arthritis 6 6.8% 0.02 0.03 0.14 Restless legs syndrome 5 5.6% 0.02 0.02 0.13 Chemical sensitivity syndrome 4 4.5% 0.02 0.01 0.11 Pain Research and Management Pain Research and Management Table 2: Continued. [95% Conf. Variable Obs/Freq Mean/Percentage∗ Std. Err. Interval] Anxiolytics/Hypnotics 53 60.9% 0.05 0.50 0.70 SNRI 43 49.4% 0.05 0.38 0.59 SSRI 18 20.6% 0.04 0.13 0.30 Other antidepressants 33 37.9% 0.05 0.28 0.48 32 36.7% 0.05 0.27 0.47 20 22.7% 0.04 0.14 0.32 1 1.1% 0.01 −0.01 0.03 Opioids+ Tramadol Codeine Morphine Fentanyl Oxycodone Buprenorphine 1 1.1% 0.01 −0.01 0.03 Pharmacological treatment Tapentadol 1 1.1% 0.01 −0.01 0.03 2 2.3% 0.01 −0.01 0.06 1 1.1% 0.01 −0.01 0.03 8 9.1% 0.03 0.03 0.16 Paracetamol 32 36.7% 0.05 0.27 0.47 Anti-infammatory drugs 31 35.6% 0.05 0.26 0.46 Anticonvulsants 18 20.6% 0.04 0.13 0.30 Antipsychotics 8 9.1% 0.03 0.04 0.17 Obs/Freq : Number of cases observed/Frequency; Std. Error, Standard Error; Conf., Confdence; MINI : MINI Neuropsychiatric International Interview; MDD : Major Depressive Disorder; GAD : Generalized Anxiety Disorder; OCD : Obsessive-Compulsive Disorder; HADS : Hospital Anxiety and Depression Scale; HADS-D : Hospital Anxiety and Depression Scale-Depression; HADS-A : Hospital Anxiety and Depression Scale-Anxiety; AIS : Athens Insomnia Scale; SWLQ : Satisfaction With Life Questionnaire; VAS pain, Visual Analogue Scale for pain; PDI : Pain Disability Index; S-FIQ : Fibromyalgia Impact Questionnaire-Spanish validation; CFS : Chronic Fatigue Syndrome; SSRI : Selective Serotonin Reuptake Inhibitor; SNRI : Serotonin-Norepinephrine Reuptake Inhibitor. ∗ Scales data are presented as means. Te rest of the variables are presented as percentages. + also in combination. 7 8 Pain Research and Management Table 3: Clinical variables of psychological trauma. Data are presented as the mean (SD). Variable Obs/Freq Mean/Proportion Std. Err. (95% Conf. Interval) Total 88 49.97 2.11 45.78 54.17 Emotional A 88 12.10 0.64 10.81 13.39 Physical A 88 8.19 0.54 7.11 9.27 CTQ Sexual A 88 8.76 0.60 7.55 9.96 Emotional N 88 12.72 0.63 11.47 13.97 Physical N 88 7.51 0.30 6.89 8.12 PTSD 63 0.71 0.04 0.61 0.80 EGEP-5 No PTSD 24 0.27 0.04 0.18 0.37 NA 1 0.01 0.01 0.001 0.07 SUD 87 8.23 0.26 7.71 8.75 Total 86 24.72 1.34 22.05 27.39 Amnesia 86 11 1.20 8.61 13.38 DES Depersonalization 86 19.47 1.63 16.22 22.72 Derealization Dissociation 86 36.26 1.86 32.55 39.97 Number of symptoms 86 4.76 0.30 4.16 5.37 SDQ-20 Total score 86 39.45 1.11 37.22 41.67 Number of events 88 7.64 0.42 6.80 8.49 Holmes and Rahe Total scores 88 224.52 13.16 198.34 250.69 Obs/Freq : Number of cases observed/Frequency; Std. Error, Standard Error; Conf., Confdence; CTQ : Childhood Trauma Questionnaire; Emotional A : Emotional Abuse; Physical A : Physical Abuse; Sexual A : Sexual Abuse; Emotional N : Emotional Neglect; Physical N : Physical Neglect; EGEP-5 : Global Assessment of Post-traumatic Stress Questionnaire-5; PTSD : Post-traumatic Stress Disorder; NA : Not Applicable; SUD : Subjective Unit of Disturbance; DES : Dissociative Experiences Scale; SDQ-20 : Somatoform Dissociation Questinnaire-20; Number of symptoms: Number of symptoms with unknown cause; Holmes and Rahe : Holmes and Rahe Social Readjustment Scale. abuse (48.8%), physical neglect (40.9%), and physical p � 0.0140), emotional neglect (CTQ-EN : F (1, 86) = 12.94; abuse (31.8%). Of note, minimization and denial in the p � 0.0005), and physical neglect (CTQ-PN : F (1, 85) = 6.10; CTQ were controlled for. Furthermore, patients showed p � 0.0155) predicted low quality of life (high scores on the an average of 7.64 (SD = 0.42) stressful events that hap- SWLS) in our sample. Te same was true for the total score pened during the last year and a high total score on the obtained on the CTQ (CTQ-T; F (1, 85) = 8.27; p � 0.0051) Holmes and Rahe scale (MD = 224.52; SD = 13.16), which and two measures of pain, the PDI and S-FIQ (F (1, 85) is suggestive of a 50% risk of developing stress-related = 8.69; p � 0.0041 and F (1, 85) = 8.08; p � 0.0056), disorders (see Table 3). respectively. Regarding the chronology of traumatic events, the In addition, linear regression analysis also showed that highest number of these events occurred in the stages of higher scores in physical neglect signifcantly predicted second childhood and early adolescence. However, a high higher levels of pain in the VAS (CTQ-PN: F (1, 86) = 4.12; number of traumatic events were also reported during the p � 0.0455). frst year of life (see Figure 1(a)). From Figure, it can also On the other hand, linear regression showed that be gathered that traumatic events in this population begin higher scores in the pain measures and FM impact on to occur at very early ages and continue throughout all quality of life (VAS, PDI, and S-FIQ) signifcantly pre- lifespans, well into late adulthood or older age, changing dicted the presence and intensity of depressive and the typology of the exposed traumatic event (see anxious symptomatology. More specifcally, the VAS Figure 1(b)). Te most prevalent traumatic events to occur signifcantly predicted both depressive (HADS-D: F (1, between 0 and 15 years were physical abuse (n � 39), 86) = 3.99; p � 0.0489) and anxious (HADS-A: F (1, 86) sexual abuse (n � 32), and emotional abuse (n � 29) (see = 10.08; p � 0.0021) symptomatology, which was also true Figure 2(a)), while the most prevalent type of traumatic for the PDI (HADS-D: F (1, 86) = 31.14; p � 0.0000); event in the sample after childhood and adolescence was HADS-A: F (1, 86) = 22.58; p � 0.0000) and S-FIQ scales the death of a loved one (n � 71), followed by harassment (HADS-D: F (1, 85) = 12.39; p � 0.0007); HADS-A: F (1, or psychological abuse in adulthood (n � 57), and other 85) = 27.16; p � 0.0000). experiences grouped in the category “other traumatic Likewise, the scores in the pain and in the FM impact events” (n � 39) (see Figure 2(b)). Interestingly, 84% of the (VAS, PDI, and S-FIQ) also signifcantly predicted the sample sufered from one or more types of traumatic degree of dissociative experiences (DES). VAS signif- events prior to the onset of pain. cantly predicted both the total score (DES-T: F (1, 86) = 4.31; p � 0, 0410) and the scores obtained in dissociation 4.2. Simple Linear Regression. All linear regression results (DES-D: F (1, 84) = 4.30; p � 0.0412). Te PDI signif- can be gathered from Table 4. Hereby, 3 types of child cantly predicted the total score (DES-T: F (1, 84) = 10.50; maltreatment (emotional abuse (CTQ-EA : F (1, 85) = 6.30; p � 0.0017) and the scores obtained in amnesia (DES-A: F Pain Research and Management 9 15 years 56 70 20 years 40 60 Number of events 25 years 47 50 30 years 46 40 35 years 49 30 40 years 50 20 45 years 41 10 50 years 38 0 55 years 22 Imprisonment/detention/kindnapping Pregnancies/delivery complications Family conflicts Personal illness Physical violence in adulthood Abortion Mobbing Family drug abuse Parental violence Accidents Economic issues Sepration/Own Divorce First-degree family illness Parental Mental disorders Rape/Abuse/Sexual Assault Others Death of a loved one Harassment/Psychological abuse Surgery 60 years 13 65 years 4 70 years 3 (a) (b) Figure 1: (a) Number of traumatic events per age (n � 77), and (b) typology of traumatic events throughout lifespans (n � 77). 16 70 14 60 12 Number of events 50 10 40 8 30 6 4 20 2 10 0 0 Emotional neglect Physical neglect Physical violencein adulthood Parental violence Parental Mental disorders Accidents Death of a loved one Abortion First-degree family illness Imprisonment/detention/kindnapping Pregnancies/delivery complications Abortion Emotional abuse Mobbing Parental violence Parental Mental disorders Accidents Economic issues Sepration/Own Divorce Personal illness Others Family conflicts Personal illness Rape/Abuse/Sexual Assault Physical violence in adulthood First-degree family illness Others Death of a loved one Physical abuse Sexual abuse Family drug abuse Harassment/Psychological abuse Family drug abuse Harassment/Psychological abuse Surgery Surgery 0-5 years 6-10 years 11-15 years (a) (b) Figure 2: Number and typology of traumatic events (a) between 0 and 15 years (n � 77), and (b) between 16 and 70 years (n � 77). (1, 85) = 6.27; p � 0.0142), depersonalization (DES-DP: F characterization of psychological trauma across their life- (1, 85) = 6.29; p � 0.0140), and dissociation (DES-D: F (1, span and how it can predict the relationship with diferent 85) = 7.56; p � 0.0073) subscales. Te same was true for clinical variables. the S-FIQ (DES-T: F (1, 83) = 11.83; p � 0.0000), DES-A: F To the best of our knowledge, this is one of the few (1, 83) = 8.61; p � 0.0043), DES-DP: F (1, 83) = 5.08; studies that has assessed the characteristics of the traumatic p � 0.0268), DES-D: F (1, 83) = 10.25; p � 0.0019). events sufered by a sample of women with FM in a sys- Furthermore, linear regression analysis was also sug- tematic and chronological way. Te results have shown that gestive that patient scores on pain and FM impact (VAS, the most prevalent traumatic events categorized by age PDI, and S-FIQ) also signifcantly predicted sleep distur- occurred during childhood and adolescence, especially in the bance (AIS: F (1, 86) = 19.18; p � 0.0000; F (1, 86) = 8.94; form of physical abuse, sexual abuse, and emotional abuse, p � 0.0036; and F (1, 85) = 7.69; p � 0.0068, respectively). but have continued into adulthood, modifying their typol- ogy and presenting themselves mainly in the form of deaths 5. Discussion of loved ones, harassment and physical abuse, rape, abuse, or sexual assault. Tese data are clinically relevant as they Te present study evaluated 88 patients with FM in detail suggest that female FM patients are chronically and re- with regard to their sociodemographic and clinical data and currently exposed to diferent types of stressful or vital biographical history, focusing on the prevalence and events throughout their lives, favoring the appearance of 10 Pain Research and Management Table 4: Linear regression results. F and R-squared and Linear regression t and (95% Conf. Variables∗ Obs prob > F Adj R-squared equation P > (t) Interval) SWLS (Y) R 2 � 0.0887 87 F (1, 85) � 8.27; p � 0.0051 ^Y � −0.069 × 15.25 t � −2.88; p � 0.005 −0.117 −0.021 CTQ-T (X) Adj R2 � 0.0780 SWLS (Y) R 2 � 0.0690 87 F (1, 85) � 6.30; p � 0.0140 ^Y � −0.198 × 14.18 t � −2.51; p � 0.014 −0.355 −0.411 CTQ-EA (X) Adj R2 � 0.0580 SWLS (Y) R 2 � 0.1321 87 F (1, 86) � 12.94; p � 0.0005 ^Y � −0.283 × 15.40 t � −3.60; p � 0.014 −0.440 −0.126 CTQ-EN (X) Adj R2 � 0.1219 SWLS (Y) R 2 � 0.0669 87 F (1, 85) � 6.10; p � 0.0155 ^Y � −0.410 × 14.87 t � −2.47; p � 0.016 −0.741 −0.080 CTQ-PN (X) Adj R2 � 0.0560 HAD-D (Y) R 2 � 0.0443 88 F (1, 86) � 3.99; p � 0.0489 ^Y � 0.419 × 9.28 t � 2.00; p � 0.049 0.001 0.837 VAS (X) Adj R2 � 0.0332 HAD-A (Y) R 2 � 0.1049 88 F (1, 86) � 10.08; p � 0.0021 ^Y � 0.547 × 10.74 t � 3.18; p � 0.002 0.204 0.889 AS (X) Adj R2 � 0.0945 AIS (Y) R 2 � 0.1823 88 F (1, 86) � 19.18; p � 0.000 ^Y � 0.952 × 7.87 t � 4.38; p � 0.000 0.520 1.385 VAS (X) Adj R2 � 0.1728 DES-T (Y) R 2 � 0.0488 86 F (1, 86) � 4.31; p � 0.0410 ^Y � 1.262 × 16.46 t � 2.08; p � 0.041 0.053 2.47 VAS (X) Adj R2 � 0.0375 DES-D (Y) R 2 � 0.0487 86 F (1, 84) � 4.30; p � 0.0412 ^Y � 1.750 × 24.81 t � 2.07; p � 0.041 0.071 3.43 VAS (X) Adj R2 � 0.0374 HAD-D (Y) R 2 � 0.2658 88 F (1, 86) � 31.14; p � 0.0000 ^Y � 0.197 × 2.94 t � 5.58; p � 0.000 0.127 0.267 PDI (X) Adj R2 � 0.2573 HAD-A (Y) R 2 � 0.2079 88 F (1, 86) � 22.58; p � 0.0000 ^Y � 0.147 × 7.52 t � 4.75; p � 0.000 0.086 0.209 PDI (X) Adj R2 � 0.1987 AIS (Y) R 2 � 0.0941 88 F (1, 86) � 8.94; p � 0.0036 ^Y � 0,131 × 8,07 t � 2.99; p � 0.004 0.044 0.218 PDI (X) Adj R2 � 0.0836 SWLS (Y) R 2 � 0.0927 87 F (1, 85) � 8.69; p � 0.0041 ^Y � -0.122 × 17.44 t � −2.95; p � 0.004 −0.205 −0.039 PDI (X) Adj R2 � 0.0821 DES-T (Y) R 2 � 0.1111 86 F (1, 84) � 10.50; p � 0.0017 ^Y � 0.361 × 8.10 t � 3.24; p � 0.002 0.139 0.582 PDI (X) Adj R2 � 0.1005 DES-A (Y) R 2 � 0.0695 86 F (1, 85) � 6.27; p � 0.0142 ^Y � 0.2551 × -0.74 t � 2.50; p � 0.014 0.052 0.457 PDI (X) Adj R2 � 0.0584 DES-DP (Y) R 2 � 0.0697 86 F (1, 85) � 6.29; p � 0.0140 ^Y � 0.3481 × 3.45 t � 2.501 p � 0.014 0.072 0.624 PDI (X) Adj R2 � 0.0586 DES-D (Y) R 2 � 0.0826 86 F (1, 85) � 7.56; p � 0.0073 ^Y � 0.4331 × 16.37 t � 2.75 p � 0.007 0.119 0.744 PDI (X) Adj R2 � 0.0716 HAD-D (Y) R 2 � 0.1272 87 F (1, 85) � 12.39; p � 0.0007 ^Y � 0.1531 × 3.60 t � 3.52 p � 0.001 0.066 0.240 S-FIQ (X) Adj R2 � 0.1170 HAD-A (Y) R 2 � 0.2422 87 F (1, 85) � 27.16; p � 0.0000 ^Y � 0.1741 × 4.79 t � 5.21 p � 0.000 0.107 0.240 S-FIQ (X) Adj R2 � 0.2333 AIS (Y) R 2 � 0.0830 87 F (1, 85) � 7.69; p � 0.0068 ^Y � 0.137 × 6.64 t � 2.77 p � 0.007 0.038 0.235 S-FIQ (X) Adj R2 � 0.722 SWLS (Y) R 2 � 0.0877 86 F (1, 85) � 8.08; p � 0.0056 ^Y � −0.136 × 19.24 t � −2.84 p � 0.006 −0.231 −0.040 S-FIQ (X) Adj R2 � 0.769 DES-T (Y) R 2 � 0.1247 85 F (1, 83) � 11.83; p � 0.0000 ^Y � 0.440 × 0.488 t � −3.44 p � 0.001 0.185 0.695 S-FIQ (X) Adj R2 � 0.114 DES-A (Y) R 2 � 0.0940 t � 2.93 85 F (1, 83) � 8.61; p � 0.0043 ^Y � 0.342 × −7.860 0.110 0.574 S-FIQ (X) Adj R2 � 0.831 p � 0.004 DES-D (Y) R 2 � 0.0577 t � 2.25 85 F (1, 83) � 5.08; p � 0.0268 ^Y � 0.367 × −0.792 0.043 0.691 S-FIQ (X) Adj R2 � 0.046 p � 0.027 DES-D (Y) R 2 � 0.1099 t � 3.20 85 F (1, 83) � 10.25; p � 0.0019 ^Y � 0.575 × 4.56 0.217 0.933 S-FIQ (X) Adj R2 � 0.099 p � 0.002 VAS (Y) R 2 � 0.0457 t � -2.03 88 F (1, 86) � 4.12; p � 0.0455 ^Y � −0.161 × 7.78 −0.003 9.058 CTQ-PN (X) Adj R2 � 0.0346 p � 0.046 ∗ Linear regression equation for predicting Y from X in two ways. CTQ-EA : CTQ Emotional Abuse; CTQ-EN : CTQ Emotional Neglect; CTQ-Physical Neglect; DES-T : DES Total; DES-D : DES Dissociation; DES-A : DES Amnesia; DES-D : DES Depersonalization; HADS-DP : Hospital Anxiety and De- pression Scale-Depression; HADS-A : Hospital Anxiety and Depression Scale-Anxiety; VAS : Visual Analogue Scale for pain; AIS : Athens Insomnia Scale; PDI : Pain Disability Index; S-FIQ : Fibromyalgia Impact Questionnaire-Spanish validation; SWLS : Satisfaction With Life Scale. Pain Research and Management 11 a process of continuous retraumatization that would explain maltreatment occurred, all these results underline the high the very high percentage of PTSD diagnoses in our sample. prevalence of childhood maltreatment in patients afected by In fact, 100% of the participants reported having sufered at FM, supporting previous research that found childhood least one major traumatic event at some point in their lives, trauma is not only a risk factor for developing several mental and 84% had sufered one or more types of these traumatic disorders in adulthood, such as depression [66], but also for events prior to the onset of pain. Likewise, 71.5% of the the onset and maintenance of several chronic pain condi- whole sample met the criteria for current PTSD, adding tions [61, 67]. Our data also showed that only physical a further comorbidity in this complex population. Tese data neglect could explain the pain reported by patients. A are far higher than the prevalence data found in the general possible explanation for these results could be that early population, which range from 0.2% to 3.8% [53], and also exposure to traumatic events may have long-term efects on higher than in mental disorders such as depression the developing nociceptive system. More specifcally, (48–49%) [54], bipolar disorder (4% to 40%) [55], or sub- physical and emotional stress could provoke alterations not stance use disorder (20.67%) [56]. It is important to note that only in the proper functioning of the HPA axis, favoring almost half of the sample (n � 34) was selected for the ad- a hyperactivation of it, but also in the pain processing ministration of the EGEP-5, an event that occurred in system, favoring a lack of inhibition of nociceptive stimuli by childhood that was the most signifcant traumatic event in descending pain control mechanisms [68]. their lives. Tese data, therefore, once again highlight the According to the Holmes and Rahe social readjustment strong and enduring impact that childhood trauma can have scale, we found a high prevalence of major stressors that on health in adulthood. Our data not only reafrm the happened over the last year, compounding the prior pres- existence of high comorbidity between PTSD and FM but ence of trauma-related stress and increasing its negative also confrm that individuals with comorbid pain and PTSD impact on participants’ well-being. In fact, people with FM report greater pain, PTSD symptoms, depression, anxiety, sufer from more major life stressors than patients with disability, and opioid use than people who only have one of migraine [26], rheumatoid arthritis, and healthy controls these conditions [57]. [69], which can be explained by the increased sensitivity to Regarding the results of the CTQ, our participants stressful conditions and the high risk of retraumatization presented low to moderate levels of all types of childhood they are exposed to. A recent study has found that cumu- maltreatment, especially emotional abuse and emotional lative trauma and somatoform disorders increase the impact neglect, followed by sexual abuse, physical neglect, and of FM [70], which is in line with our work. Taking into physical abuse. Tese results are in line with other studies account the devastating efects of chronic stress on physical, which compared FM patients to controls or patients with cognitive, and mental health [71], continued exposure to other pain conditions, where they found higher CTQ scores trauma would increase the vulnerability of these women to in the FM group, with emotional abuse and neglect rep- the development of diferent pathologies, including the resenting the most frequent subtypes [24–27, 29, 58–60]. appearance of pain and, consequently, psychological/psy- Other studies reported physical abuse and physical neglect as chiatric comorbidities. being the frst [23] or the second most prevalent types of Although our results showed that scores on pain scales maltreatment in patients with FM [24, 25, 27, 58]. Tese predicted the occurrence of dissociation, participants were less frequent in our sample’s CTQ scores. Interestingly, showed generally low dissociation scores on the DES scale, despite this, physical abuse and neglect were the most fre- with the exception of the dissociation subscale, where our quently reported types of maltreatment in the chronological patients scored highly. Te general low scores in dissociation evaluation of traumatic events in our participants. One are surprising, taking into account the aforementioned possible explanation for this phenomenon is that, although trauma load and high prevalence of PTSD in our sample, and physical maltreatment has been more present in the lives of also considering that dissociation is a very common phe- these women, emotional abuse and neglect have had nomenon in people sufering from PTSD. A possible ex- a greater impact from a psychological point of view. Tis planation for this could be that psychotropic medication hypothesis would corroborate previous research that has improves dissociative symptoms by exerting an inhibitory found not only that a lack of emotional warmth from pri- efect on the central nervous system. However, this hy- mary caregivers is one of the greatest risk factors for the pothesis needs further data because pharmacological studies development of both physical and mental disorders in both available in this feld are scarce and inconclusive [72]. adolescence and adulthood [61, 62], but that parental Another explanation could be that patients with FM tend to support is the most signifcant predictor of individual express physically traumatic memories. Te appearance of resilience [63], quality of life in adulthood [64], and mental medically unexplained symptoms could occur due to the health stability in any stage of life [65]. In fact, our results disconnection between mind and body because of the im- show how the presence of child abuse, in particular emo- pact of traumatic experiences, followed by an amplifcation tional abuse and emotional and physical neglect, predicts of subthreshold body sensations [70]. Hereby, it is in- a poorer quality of life in the women of our sample. In teresting that our FM patients scored high on the SDQ-20, addition, our results also emphasize that childhood trauma which represents somatoform dissociative disorders. Other is associated with greater severity of anxious and depressive studies has demonstrated that FM is associated with high symptoms and sleep disturbances in adulthood. Terefore, levels of somatoform dissociation [58], in comparison with regardless of the order in which the diferent types of controls [70] and other functional somatic syndromes (FSSs) 12 Pain Research and Management [73]. Furthermore, previous results suggested a direct as- estimating that almost 80% of patients with FM present poor sociation between childhood trauma and somatoform dis- sleep [85]. Interestingly, poor sleep is strongly and dose- orders [58, 70, 73, 74], showing childhood trauma can dependently associated with pain symptom severity in FM predict the impact and the severity of FM. patients [86], at the same time as interfering with the ability Additionally, we detected a very high prevalence of to cope with pain [87], resulting in tiredness and poor psychiatric comorbidities such as generalized anxiety dis- quality of life [82, 88]. order (87.5%), major depressive disorder (76.13%), and Finally, our sociodemographic characteristics provide panic disorder (63.6%), and a lower but still important insight into the high co-occurrence of various axis III di- prevalence of social phobia/agoraphobia (29.5%), followed agnoses, including CFS (60.2%), confrming the overlap by dysthymia (11.3%), and fnally obsessive-compulsive between both diagnoses [3,89], osteoarthritis (30.6%), spinal disorder (3.4%). Tis underlines the complexity and mul- disc herniation (11.3%), low back pain (10.2%), and chronic tidiagnostic nature of FM patients and is in line with pre- migraine (10.2%). In addition, we also detected thyroid vious literature, which reports that psychiatric comorbidity diseases (9%) and restless leg syndrome, rheumatoid ar- among FM, anxiety, and mood disorders is common and is thritis, and chemical sensitivity syndrome (all of them be- a factor that can complicate medical prognosis [23,75]. Of tween 5% and 6%) as somatic comorbidity. Tis confrms the note here, we excluded bipolar disorder, schizoafective high prevalence of physical comorbidity in FM patients and disorder, and schizophrenia, whereas we cannot provide the challenges of fnding adequate treatment for two or more prevalence data accordingly. Furthermore, we observed that somatic disorders [75]. Similar to previous studies, partic- FM patients received a number of psychotropic drugs, most ipants reported severe levels of both pain and disability [24, frequently anxiolytics/hypnotics (60.9%), antidepressants 27, 90, 91], which was entirely expected given that FM is (SNRI: 49.4%; SSRI: 20.6%; others: 37.9%), followed by characterized by severe widespread musculoskeletal pain various analgesics (paracetamol: 36.7%; anti-in- throughout the body that ends up having repercussions in fammatories: 35.6%), opioids (mainly tramadol and diferent areas of the person’s life and, consequently, afects tapentadol, 22.7% and 9.1%, respectively) and antipsychotic their quality of life. Moreover, the delay between the onset of medication (9.1%), indicating again the high comorbidity pain and the clinical diagnosis of FM of the participants was, between FM and mental sufering. Some of the medications on average, almost 10 years, which may have afected their used, such as duloxetine, have the ofcial indication to be functioning and recovery processes. In fact, FM patients prescribed for FM patients. consider the lack of a clear explanation of the etiology and Our results not only confrm the high anxiety and de- their doubts about the authenticity of the illness to be key pression scores in our sample but also that the scores ob- factors in the delay in receiving a diagnosis. Both aspects are tained by the participants in the pain and fbromyalgia scales related to the lack of understanding and support from family (VAS, PDI, and S-FIQ) signifcantly predict the presence and and friends due to a lack of understanding of the nature of intensity of depressive and anxious symptomatology. Tis the illness and stigma [9], something that frequently occurs bidirectionality has been reported in previous literature in mental disorders [92]. showing that mental disorders, such as depression or anx- Several limitations have to be considered when translating iety, can be a consequence of living with chronic pain [76], as our results into clinical reality. Te frst limitation is that we did well as a history of a mental disorder being considered a risk not include a matched control group to compare our results factor for developing chronic pain [77]. with those of the FM group, which needs to be taken into Of note, 82.9% of the participants in the present study account when interpreting and generalizing our results. Sec- reported suicidal ideation in their history, while 32.9% re- ond, we did not control for possible psychiatric drug efects that ported suicide attempts. Tese data confrm the high could be interfering with the clinical manifestations reported by prevalence of suicidal behaviors in patients sufering from the participants. Tird, the sample comprised solely female chronic pain compared to the general population [9]. participants, so we do not know whether these results can be According to previous literature, there is a whole set of risk extrapolated to the male population. However, previous data factors that could favor suicidal behaviors, such as psy- shows that mainly female patients are afected by FM [30]. chological stress, sleep disturbances, the experience of fa- Fourth, the participants were recruited mainly from two ser- tigue, dizziness, and weakness, depression, female gender, vices of our hospital, with the constraints that this entails: we and physical comorbidities like headaches and gastric dis- might have missed FM patients who are attended by their eases [9, 78–81]. Terefore, as suicidal behavior is highly general practitioner with lower levels of pain, clinical severity, prevalent due to clinical manifestations of FM and its and disability. Fifth, the method for assessing trauma varied psychiatric comorbidities, it needs to be assessed routinely in between trauma-specifc scales and an individual’s chrono- patients with FM. Te same is true for sleep alteration in FM logical interview by self-report, meaning it can be afected by patients. Our results are in agreement with other studies, recall bias and an individual’s subjective interpretation [93]. which have shown a high prevalence of sleep disturbances [6, However, a prior study emphasizes the importance and clinical 23, 82], which can be explained not only by pain and the relevance of subjective memories in a recent natural human direct impact of FM, but also by the presence of other axis III behaviour publication [94]. Te authors compared in a cohort diagnoses, and mood and anxiety comorbidities [83, 84]. of 1196 children both objective, court-documented evidence of Our data revealed that 93.2% of our sample sufered from maltreatment and subjective reports of their childhood mal- sleep alterations, which is higher than in previous studies, treatment histories, and found psychopathology in adulthood Pain Research and Management 13 to be associated with subjective rather than objective measures Acknowledgments of experience of childhood maltreatment. Furthermore, amnestic dissociation might alter the recall process; in- Ana Moreno-Alcázar wants to thank to the “Ministry of terestingly, we detected very low scores in amnestic dissocia- Universities and Research of the Department of Economics tion, which further underlines the consistency of subjective and Knowledge (2017 SGR 46 to “Centre Forum Research recalls. Finally, we did not evaluate nonpharmacological in- Unit”), Government of Catalonia” for its recognition as an terventions in FM, such as physical exercise or others, which emerging research group. B. Hogg is supported by the In- can exert a positive efect on anxiety and depression. stitute of Health Carlos III with a PFIS grant (FI10/00017). Te strengths of our work included the exhaustive A. Valiente-Gómez is supported by the Institute of Health evaluation of psychosocial and clinical data; a detailed Carlos III with a Juan Rodés grant (JR19/00001). B. L. evaluation of psychological trauma and its impact on par- Amann received a project grant (PI18/00009) and a mobility ticipants by using validated psychometric tools; and a de- grant (BA21/00002) from the Institute of Health Carlos III - tailed knowledge of the chronology of traumatic events, General Sub-Directorate for Research Evaluation and Pro- allowing us to sequence the appearance of pain in their lives. motion - National Plan 2008-2011 and 2013-2016. Furthermore, the homogeneity between raters has helped to obtain data, reducing observational bias. References [1] D. J. Clauw, “Fibromyalgia: a clinical review,” JAMA, the 6. Conclusions Journal of the American Medical Association, vol. 311, no. 15, Our data highlight the complex comorbidity of FM patients pp. 1547–1555, 2014. [2] G. T. Jones, F. Atzeni, M. Beasley, E. Flüß, P. Sarzi-Puttini, with somatic disorders, psychiatric disorders, such as anxiety, and G. J. 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