Indian Journal of Rheumatology

: 2018  |  Volume : 13  |  Issue : 3  |  Page : 150--151

Anxiety and depression in fibromyalgia: Are we putting the cart before the horse?

Sakir Ahmed, Able Lawrence 
 Department of Clinical Immunology and Rheumatology, SGPGIMS, Lucknow, Uttar Pradesh, India

Correspondence Address:
Dr. Able Lawrence
Department of Clinical Immunology and Rheumatology, SGPGIMS, Raebareli Road, Lucknow - 226 014, Uttar Pradesh

How to cite this article:
Ahmed S, Lawrence A. Anxiety and depression in fibromyalgia: Are we putting the cart before the horse?.Indian J Rheumatol 2018;13:150-151

How to cite this URL:
Ahmed S, Lawrence A. Anxiety and depression in fibromyalgia: Are we putting the cart before the horse?. Indian J Rheumatol [serial online] 2018 [cited 2019 Aug 17 ];13:150-151
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Full Text

Fibromyalgia (FM) is a widespread disorder. So are anxiety and depression. The symptoms of FM are sometimes attributed to anxiety and depression. In this issue, Singh and Kaul have demonstrated a high prevalence of both these entities in an FM cohort in Jammu. They have also quoted various papers showing similar results.[1]

FM has a central sensitization component similar to that in anxiety or depression. Our understanding of the human psyche or driving mechanisms is still not adequate to differentiate whether this implies a common pathophysiology or is just an association! Neuroinflammation, or inflammation triggered through neuronal pathways, has been implicated in all three.[2] However, there may be a subgroup of FM patients that have pain predominantly due to small fiber neuropathy.[3] This is an exciting new area of research.

A widely proposed hypothesis is that FM is the common phenotype of widespread pain due to certain different pathophysiological processes. One subset may have a predominant central component that could have related to posttraumatic stress disorder say child abuse in their past.[4] The second subset may have neuroinflammation due to some trauma, say a whiplash injury.[5] The third subset may be predominantly due to small fiber neuropathy, and so on and so forth. The prevalence of anxiety and depression maybe be different in each. In some it may be reactive while in some it may arise (the central sensitization predominant subgroup) due to common aetiology. It is a disease with a myriad of overlapping comorbidities beyond anxiety and depression: chronic fatigue syndrome, posttraumatic stress disorder, restless leg syndrome, and temporomandibular pain disorder.[6]

Studies from referral centers show much higher prevalence of depression and anxiety in FM than do the community studies. Two hypotheses may be put forward to explain this phenomenon. First, patients at referral centers will have more severe and more refractory disease. This itself will predispose to higher levels of anxiety and of depression. Second, they may share common genetic or environmental susceptibilities including psychosocial stress and biological responses that predispose them to all of these three entities.[7] The presence of these comorbidities in FM patients leads to more severe pain perception and poorer function of life.[1] Thus, they are more likely to come to a referral center. A nationwide longitudinal study has shown a bidirectional temporal association between FM and depression – occurrence of one may predispose to the other.[8]

A third viewpoint may be argued that most of the community-based studies are questionnaire-based, and not physician diagnoses. This implies they may not be representing a true picture. However, for all practical purposes, the inferiority of questionnaires at the community level has not be shown, and instruments like the proposed 2011 ACR FM criteria for screening [9] have been widely validated across populations. While the original 2010/2011 proposed FM criteria over-diagnosed patients with psychiatric diseases due to the absence of a persistent widespread pain criterion, this has been rectified in the ACR 2016 final version.[10] Inclusion of mandatory persistent pain (for at least 3 months) and a definition for widespread pain improves the specificity of the latter. Singh and Kaul have used the original ACR 1990 criteria for FM.[1],[11] Thus, the possibility of misdiagnosing pure anxiety or depression as FM is minimal thereby retaining construct validity.

In conclusion, there is a need to assess all patients of FM for additional comorbidities. There is an unmet need of developing core sets of FM for clinical research.[12] This will provide a platform to delve further into the basic pathophysiology of FM and its connections with comorbidities such as anxiety and depression – whether these are cause, effect or mere associations!


1Singh G, Kaul S. Anxiety and depression are common in fibromyalgia patients and correlate with symptom severity score. Indian J Rheumatol 2018;13:167-71.
2Skaper SD, Facci L, Zusso M, Giusti P. An inflammation-centric view of neurological disease: Beyond the neuron. Front Cell Neurosci 2018;12:72.
3Üçeyler N, Zeller D, Kahn AK, Kewenig S, Kittel-Schneider S, Schmid A, et al. Small fibre pathology in patients with fibromyalgia syndrome. Brain 2013;136:1857-67.
4Häuser W, Hoffmann EM, Wolfe F, Worthing AB, Stahl N, Rothenberg R, et al. Self-reported childhood maltreatment, lifelong traumatic events and mental disorders in fibromyalgia syndrome: A comparison of US and German outpatients. Clin Exp Rheumatol 2015;33:S86-92.
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10Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Häuser W, Katz RL, et al. 2016 revisions to the 2010/2011 fibromyalgia diagnostic criteria. Semin Arthritis Rheum 2016;46:319-29.
11Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Katz RS, Mease P, et al. The American college of rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken) 2010;62:600-10.
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