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Fibromyalgia (FM) is a syndrome of chronic widespread pain that is accompanied of nonrestorative sleep and fatigue, mood disturbances, cognitive difficulties, and numerous somatic complaints. This condition affects approximately 2-5% of the general population and carries enormous direct and indirect costs. While the etiology of FM is unclear, it is accepted that genetic vulnerability makes some persons susceptible to the development of FM after environmental triggers. Several studies have highlighted the relationship of FM with traumatic events that would act as triggers of this condition. However, there are few studies on this topic, many have methodological problems such as not including a control group, and practically it has not been investigated how the presence of trauma is related to the emergence of FM. 

This study explored the presence of trauma in an FM Spanish sample compared to a healthy control group and the relationships between number of several trauma types and post-traumatic stress disorder (PTSD) symptoms with the severity of clinical manifestations in FM, testing for potential mediators in the relationship between PTSD symptoms and FM status. The sample comprised 173 FM patients and 53 healthy controls of both sexes (aged 24 to 66 years). Traumatic events (physical trauma, physical and sexual abuse, psychological trauma), PTSD symptoms, pain intensity, sleep disturbance, anxiety, depression, coping style, and daily functioning were evaluated with semi-structured individual interviews and questionnaires.

FM patients reported a higher percentage of trauma (75.2%), mainly emotional and physical, a higher mean number of traumas (2.47) and higher scores in PTSD symptoms (8.91) than healthy participants (52.9%, 1.16 and 5.62, respectively). The presence of PTSD symptoms showed stronger relationships with clinical symptoms than the occurrence of trauma per se. This is logical because the frequency of trauma does not provide information about the extent to which the trauma was resolved. More PTSD symptoms were associated with higher scores of pain, sleep disturbances, anxiety and depression, worse coping style and poorer daily functioning. In FM patients with trauma, 64.4% reported that the most troublesome trauma occurred before pain onset, 13.48% stated that they already had some pain since childhood but the trauma aggravated it and that FM diagnosis occurred after the trauma, and 22.47% reported having FM before experiencing their worst trauma. In both group where trauma antedated pain, age of trauma occurrence was very variable (5-43 years) and the FM diagnosis occurred 2-14 years later. 

Given the correlation pattern found, sleep quality, anxiety, and emotional coping were examined as mediators of the effect of PTSD symptoms on daily functioning. Anxiety mediated the influence of PTSD symptoms on daily functioning but sleep quality and emotional coping did not. The mediating role of anxiety highlights that remaining in a state of hyperactivation in the long term could be key to the pathogenesis of FM after trauma. This hyperarousal is likely to lead to sleep problems and the use of ineffective coping styles that also worsen life stress situations leading to other symptoms. Future research should determine through which mechanisms to sustain a high level of anxiety over time connects PTSD with FM.  

FM remains a frustrating condition from a therapeutic point of view despite of improvements due to cognitive behavioral therapy (CBT) and exercise programs. Our results suggest the advisability of including the PTSD symptom detection in FM assessment protocols. The importance of considering the heterogeneity of patients when treating FM has been suggested by several researchers. Our findings suggest that one FM subgroup may need a more comprehensive therapeutic approach including some form of psychological therapy focused on the trauma. Complementing the current CBT in FM – which does not address trauma at all – with some form of therapy focused on the trauma in the FM patients with PTSD symptoms may help improve treatment effectiveness for FM patients and their quality of life. 

Reference Article

Miró, E., Martínez, M.P., Sánchez, A.I. and Cáliz, R. (2020), Clinical Manifestations of Trauma Exposure in Fibromyalgia: The Role of Anxiety in the Association Between Posttraumatic Stress Symptoms and Fibromyalgia Status. JOURNAL OF TRAUMATIC STRESS. doi:10.1002/jts.22550

Questions for Discussion

  • How to sustain a high level of anxiety or hyperarousal connects having symptoms of PTSD with the appearance of FM?
  • Can improve the effectiveness of current FM intervention programs by incorporating some form of trauma-centered therapy for the subgroup of patients showing symptoms of FM?

About the Authors

Elena Miró, Ph.D., is clinical psychologist, professor of psychological therapy at the University of Granada and Research Scientist at the Mind, Brain and Behavior Investigation Center (University of Granada). She has directed multiple research projects about the treatment of sleep disorders, various emotional problems and chronic pain syndromes such as fibromyalgia. She is the author of several books, book chapters and numerous scientific articles on these topics. She currently directs a program of assistance for fibromyalgia at the Psychology Clinic of the University of Granada.