Impact of fibromyalgia severity on patients mood, sleep quality, and quality of life

INTRODUCTION

Chronic and widespread pain in fibromyalgia syndrome (FMS) is not only associated with lowered pain threshold, increased touch sensitivity and fatigue but has shown significant impact on sleep as well as mood of the patients.^[1,2] Sleep disturbances informed as difficulty falling asleep, frequent night-time awakenings, and unrefreshing sleep have directly been associated with pain in FMS in several observational studies.^[3] More than 90% of patients with FMS suffer from sleep problems with non-restorative sleep being a common complaint.^[4]

Poor sleep not only leads to a reduction in pain threshold but even reduces cognitive skills and increases chances of depression, anxiety, and stress among affected individuals.^[5] Depression and anxiety are bi-directionally associated with sleep problems.^[6] Sleep disturbances along with chronic pain and depression further exacerbate somatic and psychological symptoms and impact the quality of life (QOL) of individuals.^[2,7] These symptoms lead to social isolation and reduction of interest in day-to-day activity, which further increases the disability with time, consequently leading to economic as well as social burden.^[8]

Although sleep disturbances and depression are included in the American College of Rheumatology (ACR) criteria, they are still underexplored and are given less attention in FMS patient care.^[9] The present study elucidated the association of sleep quality and mood with increasing symptom severity (SS) of fibromyalgia and its impact on the QOL of fibromyalgia patients.

MATERIALS AND METHODS

Setting

Individuals with fibromyalgia (screened using 2010 ACR criteria) attending outpatient department of a tertiary care institute in Central India from July 2021 to October 2022 were enrolled in the study [Figure 1].^[2] The ACR criteria use two clinician-rated measures: Widespread Pain Index (WPI) and SS scale. The WPI represents the number of areas in which the patient has had pain over the past week and ranges from 0 to 19 while the SS scale ranges from 0–12 and is the sum of the severity of three symptoms: Fatigue, unrefreshing sleep, and cognitive symptoms, plus the severity of somatic symptoms in general.

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Figure 1:

Study flow diagram. FIQR: Fibromyalgia impact questionnaire.

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All the patients, who met the following three criteria, were diagnosed to have FMS:^[2]

1. WPI ≥ 7 and SS ≥ 5 or WPI 3–6 and SS ≥ 9

2. Symptoms have been present at a similar level for at least three months.

3. The patient does not have a disorder that would otherwise explain the pain.

RESULTS

As evident, our study also showed sexual dimorphism among the patients of FMS enrolled in this study, with 88% of patients being female. Participants were relatively young with a mean age of 38.58 ± 10.37 years. The mean VAS and GPS were 6.80 ± 1.58 and 54.10 ± 14.33, respectively, and the mean FIQR score was 50.62 ± 13.68 [Table 1]. To assess the status of different modalities among patients of different SS, they were grouped into four, based on their FIQR scores. Results show an increasing trend of all the mood disturbances, that is, depression, anxiety, stress, somatization, and deteriorating sleep quality with FMS SS.

Maximum patients had moderately severe FMS (n = 49), 15 had very severe grade FMS, 24 had mild, and the rest were in the remission group (n = 12). It was not only pain that increased significantly with increasing grade of FIQR, but all the psychological symptoms, including somatization, depression, anxiety, and stress, increased significantly (P = 0.0001). Sleep quality deteriorated from 5.66 ± 1.92 in the remission group to 12.0 ± 3.41 in the highly severe FMS group (P = 0.0001) [Table 2]. A significant positive correlation was observed between FMS severity on FIQR with the pain (VAS and GPS) deteriorating sleep quality (PSQI), somatization (PHQ-15), and mood, that is, depression, anxiety, and stress (GAD-7, PHQ-9, and DASS-21) as shown in Table 3.

Health status measured by SF-36 showed that there was a significant difference in all the domains with poorer scores among the patients with higher FIQR grades [Figure 2]. The domain of emotional well-being did not reach statistical significance, and the scores were comparable among all four groups (FIQR1 = 48.33 ± 12.58; FIQR2 = 46.33 ± 11.55; FIQR3 = 43.75 ± 12.92), with the lowest among those with very severe FMS (FIQR4 = 37.60 ± 14.48). The domain of general health also registered poorer scores among all the four grades of FMS, with scores deteriorating with increasing severity (FIQR1 = 22.50 ± 9.65; FIQR2 = 18.95 ± 6.25; FIQR3 = 20.10 ± 11.79; and FIQR4 = 16.66 ± 17.99).

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Figure 2:

FMS: Fibromyalgia syndrome, PF: Physical functioning, Role limitation PH: Role limitation physical health. The status of quality of life in different domains of quality of life among the patients with different grades of severity of fibromyalgia is shown with the comparative bar graph. The p-value of the comparative status is mentioned at the top of each domain bar graph. ”*” signifies statistically significant differences among patients with different grades of FMS severity, especially between grade1, 2 with grade 3, 4.

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DISCUSSION

The present study explored the association of various physical as well as psychological symptoms with increasing fibromyalgia severity and assessed its impact on their QOL. This cross-sectional study enrolled 100 patients of FMS with different grades of severity, and it shows that it is not only pain that increases with the severity of the disease, but there is an overall deterioration in mood and quality of sleep, which further impacts their QOL.

Comorbidities such as sleep disturbances, depression, and anxiety have been suggested to facilitate the central nervous system in enhancing the sensitivity to pain.^[21,22] A few of the suggested etiological factors for central sensitivity of pain include a temporal summation of noxious stimuli labeled as “Wind up” and/or inflammatory response (glial cell activation).^[23,24] Studies have concluded that sleep deprivation causes alteration in descending pain inhibition, decreasing their effect, and thus leading to hyperalgesia.^[25] Although the exact mechanism between sleep and the descending pain inhibitory system is still unknown, the most common areas affected in nociception, sleep deprivation, and descending pain inhibition are periaqueductal gray matter and raphe nuclei.^[26,27] Repetitive stressful events and sleep deprivation may also cause glial cell overactivation. This inflammatory response affects brain function, increasing sensitivity to painful stimuli.^[24] In the present study also, we observed that all the mood parameters, somatization, as well as sleep deteriorated in a graded fashion along with the increasing severity of pain, further deteriorating the QOL of FMS patients. Although sleep and depression have been shown to have a bidirectional association, the origin of the vicious cycle of depression, deteriorated sleep, and enhanced pain sensitivity remains obscure. A study by Rodero et al. on 326 FMS individuals evaluated pain severity according to stages of chronicity of fibromyalgia (according to the duration of the condition).^[28] They concluded that psychological parameters change over time. They also suggested that these parameters are predictors for marking the stages of chronicity and change with respect to the duration of the condition. However, they too were unclear whether the duration of fibromyalgia enhances the comorbidities or it is the comorbidities that increase the severity of the disease.

Bigatti et al.^[29] reported that sleep is a core symptom of fibromyalgia and plays a crucial role in exacerbating symptoms such as pain, depression, and anxiety. However, Alok et al.^[30] have shown that the negative effects (depression, stress, and anxiety) are also associated with severity of FMS, and the magnitude of the results is correlated with the FIQR score. However, they did not comment on the association of sleep with FMS severity. Singh et al.^[31] also reported that patients of FMS have poorer sleep quality as well as QOL compared to healthy participants. However, they did not comment on the mood as well as its association with sleep in FMS.^[31] Although, they indicated that poorer sleep quality could be one of the predictors of FMS severity, the sample size in their study was quite small. The present study also correlated with OMERACT (Outcome Measures in Rheumatology Clinical Trials) FMS domain, that is, pain, sleep, cognitive dysfunction, and anxiety, but it concluded that the hierarchy of the core domains may be different in patients with high severity as compared to those with low severity.^[32]

Türkoğlu and Selvi^[33] and Theadom et al.^[34] have concluded that the standard forms of treatment approaches might not be effective enough if sleep and other psychological symptoms are not taken into consideration.^[33,34] Secondary analysis of four randomized control trials, including 1332 FMS patients by Marangell et al.^[35] showed that direct therapy for chronic pain rehabilitation was responsible for almost 70% of pain relief. However, the rest 30% relief in pain was due to improvement in mood due to indirect effect. Thus, the focus on domains other than pain is also important to enhance the recovery with the downstream severity of the disease.

With the present study, the status of comorbidities in FMS was recorded, and it showed that greater severity of FMS was associated with a higher grade of mood derangements, somatization, and sleep disturbances. The limitation of this study was that it was a cross-sectional study; thus, the direction of association of these comorbidities with pain in FMS could not be commented on.

CONCLUSION

With increasing FMS severity, not only pain increased but sleep, depression, anxiety, somatization, and QOL also deteriorated. Further, these symptoms correlated significantly with each other. Since FMS is associated with increased pain perception and worsened QOL, comorbid mood derangements too, must also be properly screened and addressed for the maximum benefit of the patients. As available treatments are mainly oriented toward pain, they can reach a limit of benefit to these FMS patients. The well-being of these patients could be maximized by additionally addressing these comorbidities as well. A holistic treatment approach addressing both physical as well as psychological improvement of FMS patients could be beneficial for FMS patients.