Abstract
Objective. Adolescents with juvenile-onset fibromyalgia (JFM) have increased rates of psychiatric disorders, but to our knowledge no studies have examined psychiatric disorders in adolescents with JFM when they enter young adulthood. This study examined the prevalence of psychiatric disorders in young adults diagnosed with JFM during adolescence and the relationship between mental health diagnoses and physical functioning.
Methods. Ninety-one young adults (mean age 21.60, SD 1.96) with a history of JFM being followed as part of a prospective longitudinal study and 30 matched healthy controls (mean age 21.57, SD 1.55) completed a structured interview of psychiatric diagnoses and a self-report measure of physical impairment.
Results. Young adults with a history of JFM were more likely to have current and lifetime histories of anxiety disorders (70.3% and 76.9%, respectively) compared with controls (33.3% for both, both p < 0.001). Individuals with JFM were also more likely to have current and lifetime histories of major mood disorders (29.7% and 76.9%, respectively) compared with controls (10% and 40%, p < 0.05). The presence of a current major mood disorder was significantly related to impairment in physical functioning [F (1, 89) = 8.30, p < 0.01] and role limitations attributable to a physical condition [F (1, 89) = 7.09, p < 0.01].
Conclusion. Psychiatric disorders are prevalent in young adulthood for individuals with a history of JFM, and a current major mood disorder is associated with greater physical impairment. Greater attention to early identification and treatment of mood disorders in patients with JFM is warranted.
Juvenile-onset fibromyalgia (JFM) is a chronic pain disorder that affects about 2–6% of school-aged children and adolescents, and is associated with chronic pain, significant impairment in physical functioning, fatigue, and psychological distress1. Psychiatric conditions, particularly anxiety and depressive disorders, are known to be highly prevalent in children and adolescents with JFM2 and in adults with fibromyalgia (FM)3,4,5. However, to our knowledge, there is no research examining current and lifetime prevalence of psychiatric disorders in young adults who were diagnosed with JFM in adolescence.
Mood and anxiety disorders are known to be more prevalent in adults with FM and adolescents with JFM than in the general population2,3,4,5,6. Specifically, in adults with FM, prevalence rates of anxiety and mood disorders are more than 3 times greater than those observed in the general population5, with major mood disorders being the most common (∼20–80%), followed by anxiety disorders (∼13–63.8%)3,4. In adolescents with JFM, high rates of depressive, internalizing, and externalizing symptoms have also been noted, with rates that exceed population norms6. To date, we have conducted the only clinical investigation examining the presence of psychiatric diagnoses in adolescent patients with JFM2. Similar to adults with FM, adolescents with JFM were found to have elevated rates of current and lifetime anxiety and depressive disorders. However, unlike adult samples, there were higher rates of current anxiety disorders (57.5%) than depressive disorders (22%) in adolescents with JFM. Thus, while psychological distress appears to be elevated across the lifespan for patients with JFM/FM, it remains unclear when or whether patterns of primarily anxiety problems in adolescence shift to mood problems in adulthood. It is plausible that depressive disorders become more common in patients with JFM as they continue to age, as is seen in the general population during young adulthood7.
Evidence suggests that psychological difficulties in patients with FM (JFM or FM) may correspond to increased impairment in daily functioning2,5,8. Epstein, et al found that current (but not lifetime) depression corresponded to increased physical impairment, but that neither depression nor anxiety was related to role limitations attributable to physical health in adults with FM8. On the other hand, Thieme, et al found that patients with FM with highest dysfunction (e.g., pain interference in daily tasks) were characterized by higher rates of anxiety disorders (> 60%) compared with those with better functioning5. In our previous investigation of adolescents with JFM, presence of an anxiety disorder corresponded to increased impairment through the physician’s global assessment of functioning, but not to self-reported pain intensity2. Thus, the effect of psychological symptoms on various aspects of daily functioning in patients with JFM are still not entirely understood and even less is known about these relationships in those transitioning from adolescence to young adulthood.
In a recently published study examining the longterm outcomes of adolescents with JFM, we reported that FM symptoms persisted for a majority (> 80%) of participants at about a 6-year followup9. We also found that 60% of participants reported moderate to severe anxiety symptoms and 26.6% reported moderate to severe depressive symptoms. However, the current/lifetime rates of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) psychiatric disorders were not examined in that study. The purpose of our investigation was to (1) examine current and lifetime prevalence of psychiatric disorders in a sample of 91 young adults who were diagnosed with JFM during adolescence, and (2) examine how current psychiatric disorders [anxiety and major mood disorders (i.e., major depressive disorder, bipolar disorder)] may relate to physical functioning in young adulthood. Consistent with prior research in pediatric and adult populations, we predicted that the rates of anxiety and major mood disorders would exceed rates found in age-matched healthy controls, with significantly higher rates expected for anxiety disorders (> 60%) and major mood disorders (> 60%). Further, we predicted that the presence of current anxiety disorders and major mood disorders would be associated with higher levels of physical impairment. As an exploratory aim, we also examined whether prevalence rates of current and lifetime psychiatric disorders differed in individuals with active FM versus those with subclinical FM symptoms in adulthood.
MATERIALS AND METHODS
Participants
Participants (mean age 21.60, SD 1.86) eligible for our study were young adults with JFM and healthy controls enrolled in a longitudinal study of physical and psychosocial functioning in patients with JFM9,10. Initial recruitment of patients with JFM (who were between the ages of 13–18 yrs at the time of recruitment) took place in a pediatric rheumatology clinic at a midwestern (USA) pediatric medical center. Patients were eligible if they met the criteria for JFM using the Yunus and Masi criteria1, i.e., generalized musculoskeletal aching at 3 or more sites for 3 or more months in the absence of another underlying condition, normal laboratory tests, pain in at least 5 tender points, and at least 3 of 10 associated features such as fatigue, irritable bowel syndrome, and poor sleep. At the time of the current followup, the age of the JFM group ranged from 19–27 years (mean 21.60, SD 1.96). Healthy controls (current ages 19–25 yrs, mean 21.57, SD 1.55) were originally recruited as part of a substudy of peer relationships in JFM11 and were selected from classroom rosters of patients with JFM; they were matched based on closest birth date, age, sex, and having no chronic illness. Our current study was based on data collected as part of the third wave of followup assessments that were conducted at about 2-year intervals with ∼84% retention of participants thus far. Of the original 144 participants (n = 100 with JFM and n = 44 healthy controls), 121 participants (84% retention rate) — 91 with JFM (91%) and 30 healthy controls (68.2%) — completed all required assessments for the current study.
Procedures
Participants were contacted by phone to obtain consent for their followup assessment (Kashikar-Zuck, et al9 for detailed procedures). After signed consent forms were received by mail, participants received a unique login name and password to access a secure Website to complete study questionnaires. For our current study, we used measures of demographic information, widespread pain, and physical functioning. Additionally, an in-person visit was scheduled at a convenient time for participants (at their homes or in the clinic) during which a trained examiner (psychology postdoctoral fellow or master’s level social worker) conducted a semistructured clinical interview to assess the presence of current and lifetime psychiatric disorders. Information on treatments in the past 2 years for medical or psychiatric conditions, and history of physical or sexual abuse in childhood were collected through patient self-report. A standard 18-site tender point examination based on the 1990 American College of Rheumatology (ACR) criteria for FM12 was also administered. Examiners were trained in the clinical assessment by a board-certified psychiatrist (LMA) and licensed clinical psychologist (SKZ), and in conducting standardized tender point assessments by a senior FM researcher (LMA), with confirmation of accuracy by reliability checks with the study rheumatologist (TT). This study was approved by the Children Hospital’s Institutional Review Board.
Background and demographic characteristics
Demographic information, including age, race, sex, marital status, and educational background, was obtained. For participants with JFM, information on current and past treatments for medical or psychiatric problems, including physical therapy, medication use, psychotherapy, and integrative treatments, was also obtained through self-report questionnaires.
Psychiatric diagnoses
The Structured Clinical Interview for DSM-IV-TR (SCID) is a semistructured psychiatric interview widely used to evaluate major DSM-IV Axis I disorders13. It uses a categorical rating system and provides a scoring algorithm that allows for the standardized assessment of current and lifetime psychiatric diagnoses. Studies have shown that the SCID is a reliable and valid measure of DSM-IV disorders14,15. For our study, a trained examiner assessed for current and past diagnoses of mood disorders, anxiety disorders, substance use disorders, somatoform disorders, eating disorders, and psychotic disorders.
Widespread Pain Index (WPI) and Symptom Severity (SS)
The WPI and SS scale16 from the 2010 ACR criteria for FM diagnosis were adapted for self-report to gather comprehensive information about active FM symptoms at followup. On the WPI, participants indicated up to 19 body areas in which they experienced pain during the past week. Higher scores represent a greater number of pain locations (range 0–19). The SS scale assesses cardinal symptoms (e.g., fatigue, waking unrefreshed, cognitive symptoms) and other somatic symptoms (e.g., dizziness, numbness, irritable bowel, nausea) associated with FM. The severity of each cardinal FM symptom was rated by participants on a 4-point Likert scale. Participants then indicated (on a checklist) whether they experienced 40 somatic items within the previous week. Based on the number of somatic symptoms endorsed, the following ratings are assigned: 0 = no symptoms, 1 = few symptoms, 2 = moderate number of symptoms, or 3 = great deal of symptoms. The SS score consists of the sum of the 3 cardinal symptoms and the numeric rating of other somatic symptoms, with a final score between 0 and 12.
Physical functioning and perceived health status
The Medical Outcomes Study Short Form-36, version 217 is a self-report instrument designed for individuals ≥ 14 years of age that is frequently used to assess perceived health status in a variety of domains of physical and emotional health in adult patients with FM18. For our investigation, measures of impairment in physical functioning (physical function subscale) and role limitations attributable to a physical condition (role functioning subscale) were used as indicators of physical impairment in daily life. Impairment in physical functioning assesses the degree to which health limits participation in physical activities (i.e., vigorous activities such as running, lifting heavy objects, participating in strenuous sports, walking several hundred yards, bending/kneeling, climbing flight/s of stairs). Participants rate these items on a 3-point scale ranging from “Yes, limited a lot” to “No, not limited at all.” Role limitations were defined as problems with work or other daily activities as a result of physical health (i.e., cut down on the amount of time spent on work/school or other activities, accomplished less than would have liked). Raters indicate the degree of problems with these activities as a result of physical health, with responses ranging from “All of the time” to “None of the time”. Scores were transformed according to norm-based scoring (mean ± SD T score: 50 ± 10), with lower scores reflecting poorer functioning.
FM status
The ACR 2010 diagnostic criteria based on the WPI and SS scale described above, along with the ACR 1990 criteria12,16, were used to determine whether participants met the criteria for adult FM at followup. They were classified as having subclinical FM symptoms if they continued to experience pain and ≥ 1 of the cardinal symptoms (fatigue, sleep difficulty, and cognitive symptoms), but did not meet the full criteria for FM. Patients were considered “pain free” if they reported no pain and were not receiving any medications to manage FM pain.
Statistical analyses
Data were analyzed using SPSS 22.019. Descriptive data were computed for all demographic variables. Rates of current and lifetime psychiatric disorders were calculated for young adults previously diagnosed with JFM and controls. Differences in prevalence rates of current and lifetime psychiatric diagnoses between the JFM and control groups were assessed by Fisher’s exact tests. Exploratory analyses were also conducted to examine differences in current and lifetime psychiatric diagnoses prevalence rates within the JFM group based on clinical characteristics (clinical vs subclinical FM symptoms). Differences in the number of psychiatric diagnoses between groups were assessed by independent Student t tests. After ensuring that there were no violations of the assumptions of normality, linearity, and multicollinearity, 2 multivariate ANOVA were conducted to assess the effect of (1) a current anxiety disorder diagnosis, or (2) a current major mood disorder diagnosis on physical functioning and role limitations.
RESULTS
The final sample consisted of 91 young adults with JFM and 30 matched healthy controls. The retention rate for the JFM group was higher (91%) than healthy controls (68.2%). There were no significant differences between participants and dropouts based on age or baseline socioeconomic status, pain, or depressive symptoms. This sample has largely been described in a prior paper on the persistence of JFM (50% met full criteria for adult FM) and associated symptoms (85% continued to experience FM symptoms to some degree) into young adulthood9. In both the JFM and control groups, the majority of the sample was female, white, and single (Table 1). There were no significant differences between groups in age, sex, race, marital status, or education status.
Sample demographics. Values are n (%) unless otherwise specified.
Psychiatric diagnoses in patients with JFM and healthy controls
The current and lifetime prevalence of psychiatric disorders in patients previously diagnosed with JFM and the control group is shown in Table 2.
Current and lifetime prevalence of psychiatric disorders in young adults with and without JFM. Values are n (%) unless otherwise specified.
Current diagnoses
The most common current diagnoses for those previously diagnosed with JFM were generalized anxiety disorder (46.2%), major depressive disorder (18.7%), social and specific phobia (each 17.6%), panic disorder (14.3%), and posttraumatic stress disorder (14.3%). On average, the JFM group had 2.10 (SD 1.96) current psychiatric diagnoses compared with 1.03 (SD 1.65) diagnoses in controls [T (119) = 2.68, p < 0.01]. In the JFM group, 78% had at least 1 current psychiatric diagnosis compared with 40% of controls (Fisher’s exact test p < 0.001), and 51.6% had at least 2 psychiatric diagnoses compared with 26.7% of controls (Fisher’s exact test p < 0.05).
Lifetime diagnoses
The most common lifetime diagnoses in young adults previously diagnosed with JFM were major depressive disorder (63.7%), generalized anxiety disorder (47.3%), posttraumatic stress disorder (26.4%), and social phobia (22.0%). At least 1 lifetime psychiatric diagnosis was found in 89% of the JFM group (Fisher’s exact test p < 0.01), whereas the rate of at least 1 lifetime diagnosis in controls was 60%. On average, patients previously diagnosed with JFM had 2.87 (SD 1.90) lifetime diagnoses compared with 1.60 [SD 1.81, T (119) = 3.2, p < 0.01] in the control group. Two or more lifetime psychiatric diagnoses were found in 77% of patients who had JFM compared with 43% of the control group (Fisher’s exact test p < 0.001).
Prevalence rate comparison by group
Anxiety disorders were more common than mood disorders in both the JFM and healthy control groups. However, rates of anxiety and depressive disorders were significantly higher in patients who had been diagnosed with JFM compared with controls. For example, young adults with a past diagnosis of JFM were more than 3 times as likely to have a current major mood disorder, defined as major depressive disorder or bipolar disorder. There were significantly higher rates of both current (p < 0.05) and lifetime (p < 0.01) major depressive disorders in patients who had been diagnosed with JFM compared with controls. Similarly, young adults with a past JFM diagnosis were also more than twice as likely to have a current (p < 0.001) or lifetime (p < 0.001) anxiety disorder compared with controls. There were significantly higher rates of current (p < 0.05) and lifetime (p < 0.01) generalized anxiety disorders and higher rates of lifetime (p < 0.05) posttraumatic stress disorder in the JFM group compared with controls. Eating disorders, substance use disorders, psychotic disorders, and somatoform disorders (both current and lifetime) were relatively rare or absent in the JFM and control groups.
Psychiatric diagnoses in active FM versus subclinical FM
Of the 91 individuals with JFM, 47 (51.65%) continued to meet criteria for active FM and 44 (48.35%) had subclinical or minimal FM symptoms (with 14 of those 44 patients reporting no pain in the past 3 mos and no current use of pain medications). There were no statistical differences in the rates of anxiety and mood disorders in the clinical FM group compared with the subclinical FM group.
History of trauma (physical or sexual abuse)
There was no significant difference between individuals with and without JFM with regard to physical abuse during childhood [6.6% vs 0.0%, chi-square (1) = 2.08, Fisher’s exact test p > 0.05]; there was a significant difference regarding sexual abuse history in that those with JFM were more likely to have reported childhood sexual abuse than healthy control subjects [15.4% vs 0.0%, chi-square (1) = 5.22, Fisher’s exact test p < 0.05]. Patients with active FM had somewhat higher rates of physical abuse (10.6% vs 2.3%) and sexual abuse (19.1% vs 11.4%) during childhood compared with their subclinical FM counterparts. There were no significant differences between FM groups with regard to physical or sexual abuse reported during adulthood.
Other treatments in active FM versus subclinical FM
Overall, individuals with active FM reported similar treatments compared with those with subclinical FM, including use of antidepressant medication, integrative therapies, physical therapy, and psychotherapy (Table 3). The only difference in treatments between those who continued to meet criteria for FM and those who had subclinical symptoms was current serotonin norepinephrine reuptake inhibitor (SNRI) use, with those meeting FM criteria more likely to be treated with SNRI than those with subclinical symptoms [chi-square (1) = 8.21, Fisher’s exact test p < 0.01].
Treatments in young adults with JFM by clinical and subclinical FM. Values are n (%).
Anxiety and depressive disorders in relation to impairment in physical function
Mean differences in physical functioning based on the presence of major mood disorder and anxiety disorder are presented in Table 4. Multivariate ANOVA results indicated significantly higher levels of physical impairment for both physical functioning [F (1, 89) = 8.30, p < 0.01] and role limitations because of a physical condition [F (1, 89) = 7.09, p < 0.01] in the presence of current major mood disorder [F (2, 88) = 5.08, p < 0.01]. However, the model examining the relationship between the 2 measures of physical disability and presence of a current anxiety disorder was not significant.
Physical functioning and role limitations in participants with JFM based on current anxiety and mood disorder status. Values are mean (SD).
DISCUSSION
Our investigation examined the prevalence of psychiatric disorders in young adults who were previously diagnosed with JFM. JFM is a persistent and enduring condition in most patients, and is commonly associated with anxiety and depressive symptoms9. The findings from our followup study suggest that rates of DSM-IV anxiety and depressive disorders are also highly prevalent in young adult patients who had JFM compared with healthy controls. The rates of anxiety and depression in individuals with JFM exceeds the prevalence rates seen in individuals with other chronic disease conditions, including diabetes20, inflammatory bowel disease21, and rheumatoid arthritis3. The rates of psychiatric disorders in this sample also exceed the rates seen in certain functional pain conditions, such as irritable bowel syndrome, although individuals with other conditions such as chronic fatigue syndrome may have comparable or higher rates of psychiatric comorbidities22. The prevalence rates of major depressive disorder and anxiety in our healthy controls were generally consistent with population norms23,24,25. Our current study also found that the presence of a current major mood disorder is associated with increased impairment in physical functioning.
Previous investigations have documented high levels of anxiety disorders in children and adolescents diagnosed with JFM2. Our current findings indicate that patients with JFM who grow into young adults with persistent FM may be at risk for progressing toward developing a clinically complicated profile categorized by increased physical impairment and comorbid anxiety and depressive disorders26. These findings are interesting in light of work theorizing that FM in the presence of comorbid depression may be categorically distinct from FM in the absence of depression, with the former constituting an affective spectrum disorder and the latter possibly considered a functional pain condition27. Although there were no statistically significant differences in psychiatric comorbidity between the clinical FM group and the subclinical FM group, both groups showed more psychiatric comorbidities than in the healthy control group. Overall, the exploratory findings support the notion of categorically distinct FM profiles based on symptom severity and presence of psychiatric comorbidities.
Patients previously diagnosed with JFM who have a current depressive disorder may be at increased risk for greater physical function impairment and increased limitations in day-to-day activities, though this does not appear to be the case for a current anxiety disorder diagnosis. These findings are consistent with a prior investigation of adults with FM in which a current diagnosis of depression but not anxiety was associated with increased physical impairment8. These findings have important clinical implications for medical providers who treat young adults who were diagnosed with JFM. The identification and treatment of mood disorders, in particular, among young adults previously diagnosed with JFM and those with persistent FM symptoms were critical because of the link between depression and increased physical impairment found in our current investigation.
Several limitations of our study should be noted, including generalizability. Our study is based on a clinical population of patients with JFM (i.e., initially recruited from a pediatric rheumatology subspecialty clinic) and so these patients may have had more severe disease or greater impairment compared with individuals with JFM from community-based studies. Moreover, our sample was predominantly female and white. Although this demographic is generally characteristic of patients with JFM and FM, it limits generalizability to other groups of people with JFM, such as males or those from other ethnic backgrounds. Many participants in our longitudinal study were recruited from a clinical trial in which severe psychopathology (e.g., schizophrenia) was an exclusionary criterion9. Although very few patients were excluded on these grounds, the original selection criteria for our study may further discriminate this clinical sample from the general population. Finally, we did not systematically assess for family history of psychiatric disorders, current/past life stressors (other than abuse history), or daily hassles, which may have also affected psychosocial functioning and physical impairment.
The findings of our study allow for enhanced understanding of the psychiatric comorbidity and physical function of patients diagnosed with JFM during a critical transitional period to young adulthood. It is possible that if children and adolescents are screened regularly and treated for psychiatric symptoms at the time of initial JFM diagnosis, this may prevent the maintenance and onset of additional psycho-pathology, such as major mood disorders and deterioration in physical functioning. Future research aimed at following patients with JFM over a longer period of time would be beneficial to understanding how longterm functioning is affected after the transition from adolescence to young adulthood. Future work may identify the longterm trajectories of anxiety and depression in patients with JFM and more clearly identify risk profiles for the progression of anxiety to more complex presentations that include depressive disorders and impairment in function over time. The developmental psychopathology of patients with JFM remains a relatively poorly understood area, and more research is needed to improve clinical care and to prevent the emotional impairment associated with this chronic pain condition.
Footnotes
Funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the US National Institutes of Health, grants R01AR054842 and K24AR056687 to the last author (Kashikar-Zuck).
- Accepted for publication July 14, 2015.
