Self-reported childhood maltreatment, lifelong traumatic events and mental disorders in fibromyalgia syndrome: a comparison of US and German outpatients.

OBJECTIVES: The robustness of findings on retrospective self-reports of childhood maltreatment and lifetime traumatic experiences of adults with fibromyalgia syndrome (FMS) has not been demonstrated by transcultural studies. This is the first transcultural study to focus on the associations between FMS, childhood maltreatment, lifetime psychological traumas, and potential differences between countries adjusting for psychological distress. METHODS: 71 age-and sex-matched US and German FMS outpatients were compared. Childhood maltreatment were assessed by the Childhood Trauma Questionnaire and potential, traumatic experiences by the trauma list of the Munich Composite International Diagnostic Interview. Potential posttraumatic stress disorder (PTSD) was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders IV-TR symptom criteria by the Posttraumatic Diagnostic Scale. Potential depressive and anxiety disorder were assessed by the Patient Health Questionnaire PHQ 4. RESULTS: US and German patients did not significantly differ in the amount of self-reported childhood maltreatment (emotional, physical and sexual abuse or neglect) or in the frequency of lifetime traumatic experiences. No differences in the frequency of potential anxiety, depression, and PTSD were seen. Psychological distress fully accounted for group differences in emotional and sexual abuse and emotional and physical neglect. CONCLUSIONS: The study demonstrated the transcultural robustness of findings on the association of adult FMS with self-reports of childhood maltreatment and lifelong traumatic experiences. These associations are mainly explained by current psychological distress.

Section 3: The nature of pain: pathophysiology.

An understanding of the pathophysiology of pain involves the concepts of neuronal plasticity at the levels of the nociceptor neurons, spinal cord, and brain. Neuroplasticity allows the neurons in the brain to compensate for injury and adjust their activity in response to new situations or changes in their environment. This is an important physiologic event in the development of central sensitization. Other concepts include modulatory effects at the nociceptor, sympathetically mediated pain, the "wind-up" phenomenon, central sensitization, and descending and ascending central modulatory mechanisms for the perception of pain, as well as the related pain motivations and behaviors. Numerous modulatory mechanisms for pain have been postulated that control the degree of pain perceived and the emotional and behavioral phenomena associated with a patient's pain experience. These numerous mechanisms take place at all levels of the nervous system: peripheral nerves, spinal cord, and brain. Despite great advances in unraveling the complexities of the pathophysiology of pain, much remains to be discovered. It is hoped that further research into this critical area will lead to better therapies.

Section 4: treating the patient in pain.

Physicians may choose from a variety of pharmacologic and nonpharmacologic options to treat patients with painful rheumatic diseases. Osteoarthritis (OA) is the most common type of arthritis requiring pain management. New disease-modifying antirheumatic drugs and biologic response modifiers can improve disease states in patients with rheumatoid arthritis (RA). After the inflammatory component of RA is minimized with such agents, treatment goals shift to those similar to secondary OA and other degenerative joint diseases. Relief of pain and improvement in functional status are essential components of effective therapy. A pure analgesic such as acetaminophen and nonsteroidal antiinflammatory drugs, including the cyclooxygenase-2-selective inhibitors for those at risk for gastrointestinal side effects, may be used at the lowest effective doses. Combination therapy for acetaminophen and an opioid may maximize pain relief and provide greater speed and duration of action than the separate components. Use of the atypical opioid tramadol with acetaminophen often results in an improved side-effect profile compared with stronger opioids, with similar levels of pain relief. Adjunctive therapy with agents such as topical analgesics, intraarticular hyaluron, tricyclic antidepressants, anticonvulsants, muscle relaxants, and anxiolytics may also be helpful. Nonpharmacologic therapies such as exercise, physical therapy, and psychologic counseling may also diminish pain and improve outcome in patients with rheumatic diseases. One may also consider yoga, acupuncture, biofeedback, massage, relaxation techniques, and other alternative therapies.

Section 2: The importance of improving function in patients with pain.

When evaluating pain in the rheumatic diseases, assessment of adequate therapy has expanded from purely biochemical measures and joint counts to determining the degree of function. Because pain is an important predictor of function, instruments have been developed that attempt to measure how disease and pain affect parameters such as activities of daily living, quality of life, ability to work, and emotional well-being. Some measures, such as visual analogue scales, measure only the intensity of pain; multidimensional scales assess a variety of factors related to the patient's overall ability to function. The Short Form-36 measures the impact of disease on overall quality of life; adaptations have been made to some specific diseases. The Health Assessment Questionnaire was one of the first multidimensional questionnaires developed for rheumatic diseases, and this has been further refined for rheumatoid arthritis with the Multidimensional Health Assessment Questionnaire.