Skip to main content

Advertisement

SpringerLink
Log in

Delineating psychological and biomedical profiles in a heterogeneous fibromyalgia population using cluster analysis

  • Original Article
  • Published:
Clinical Rheumatology Aims and scope Submit manuscript

Abstract

The heterogeneity of patients meeting American College of Rheumatology (ACR) criteria for a diagnosis of fibromyalgia (FM) challenges our ability to understand the underlying pathogenesis and to optimize treatment of this enigmatic disorder. Our goal was to discern clinically relevant subgroups across multiple psychological and biomedical domains to better characterize the phenomenology of FM. Women meeting 1990 ACR criteria for FM (N = 107) underwent psychological (childhood trauma, mood, anxiety, and stress) and biomedical (neuroendocrine, immune, and metabolic) testing. Cluster analysis identified four distinct subgroups. Subgroups I, II, and III exhibited profiles that included high psychological distress. Subgroup I was further distinguished by a history of childhood maltreatment and hypocortisolism, and these women reported the most pain and disability. Subgroup II evinced more physiological dysregulation and also reported high levels of pain, fatigue, and disability. Subgroup III was characterized by normal biomarkers and reported intermediate pain severity with higher global functioning. Subgroup IV was distinguished by their psychological well-being, reporting less disability and pain. Our findings underscore the heterogeneity of both psychological and physiological features among FM patients presenting with nearly identical tender point counts. This subgroup categorization is compatible with hypothesized pathogenetic mechanisms of early trauma, stress system dysregulation, and pro-inflammatory bias, each prominent in some but not all FM patients. Appreciation of distinct FM subgroup features is invaluable for selecting the most appropriate treatment modalities.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, Tugwell P, Campbell SM, Abeles M, Clark P (1990) The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the Multicenter Criteria Committee [see comment]. Arthritis Rheum 33(2):160–172

    Article  PubMed  CAS  Google Scholar 

  2. Bernatsky S, Dobkin PL, De Civita M, Penrod JR (2005) Co-morbidity and physician use in fibromyalgia. Swiss Med Wkly 135(5–6):76–81

    PubMed  CAS  Google Scholar 

  3. Wolfe F (1997) The relation between tender points and fibromyalgia symptom variables: evidence that fibromyalgia is not a discrete disorder in the clinic. Ann Rheum Dis 56(4):268–271

    Article  PubMed  CAS  Google Scholar 

  4. Van Houdenhove B, Egle U, Luyten P (2005) The role of life stress in fibromyalgia. Curr Rheumatol Rep 7(5):365–370

    Article  PubMed  Google Scholar 

  5. Vierck CJ Jr (2006) Mechanisms underlying development of spatially distributed chronic pain (fibromyalgia). Pain 124(3):242–263

    Article  PubMed  Google Scholar 

  6. Geenen R, Jacobs JW, Bijlsma JW (2002) Evaluation and management of endocrine dysfunction in fibromyalgia. Rheum Dis Clin N Am 28(2):389–404

    Article  Google Scholar 

  7. Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Katz RS, Mease P, Russell AS, Russell IJ, Winfield JB, Yunus MB (2010) The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken) 62(5):600–610. doi:10.1002/acr.20140

    Article  Google Scholar 

  8. Flor H, Turk DC (1989) Psychophysiology of chronic pain: do chronic pain patients exhibit symptom-specific psychophysiological responses? Psychol Bull 105(2):215–259

    Article  PubMed  CAS  Google Scholar 

  9. Spertus IL, Burns J, Glenn B, Lofland K, McCracken L (1999) Gender differences in associations between trauma history and adjustment among chronic pain patients. Pain 82(1):97–102

    Article  PubMed  CAS  Google Scholar 

  10. Hauser W, Thieme K, Turk DC (2010) Guidelines on the management of fibromyalgia syndrome—a systematic review. Eur J Pain 14(1):5–10. doi:10.1016/j.ejpain.2009.01.006

    Article  PubMed  Google Scholar 

  11. Oral R, Can D, Hanci H, Miral S, Ersahin Y, Tepeli N, Bulguc AG, Tiras B (1998) A multicenter child maltreatment study: twenty-eight cases followed-up on a multidisciplinary basis. Turk J Pediatr 40(4):515–523

    PubMed  CAS  Google Scholar 

  12. Giesecke T, Williams DA, Harris RE, Cupps TR, Tian X, Tian TX, Gracely RH, Clauw DJ (2003) Subgrouping of fibromyalgia patients on the basis of pressure-pain thresholds and psychological factors. Arthritis Rheum 48(10):2916–2922

    Article  PubMed  Google Scholar 

  13. de Souza JB, Goffaux P, Julien N, Potvin S, Charest J, Marchand S (2009) Fibromyalgia subgroups: profiling distinct subgroups using the Fibromyalgia Impact Questionnaire. A preliminary study. Rheumatol Int 29(5):509–515. doi:10.1007/s00296-008-0722-5

    Article  PubMed  Google Scholar 

  14. Maes M, Lin A, Bonaccorso S, van Hunsel F, Van Gastel A, Delmeire L, Biondi M, Bosmans E, Kenis G, Scharpe S (1998) Increased 24-hour urinary cortisol excretion in patients with post-traumatic stress disorder and patients with major depression, but not in patients with fibromyalgia. Acta Psychiatr Scand 98(4):328–335

    Article  PubMed  CAS  Google Scholar 

  15. Catley D, Kaell AT, Kirschbaum C, Stone AA (2000) A naturalistic evaluation of cortisol secretion in persons with fibromyalgia and rheumatoid arthritis. Arthritis Care Res 13(1):51–61

    Article  PubMed  CAS  Google Scholar 

  16. Goldberg RT, Pachas WN, Keith D (1999) Relationship between traumatic events in childhood and chronic pain. Disabil Rehabil 21(1):23–30

    Article  PubMed  CAS  Google Scholar 

  17. Weissbecker I, Floyd A, Dedert E, Salmon P, Sephton S (2006) Childhood trauma and diurnal cortisol disruption in fibromyalgia syndrome. Psychoneuroendocrinology 31(3):312–324

    Article  PubMed  CAS  Google Scholar 

  18. Dinser R, Halama T, Hoffmann A (2000) Stringent endocrinological testing reveals subnormal growth hormone secretion in some patients with fibromyalgia syndrome but rarely severe growth hormone deficiency. J Rheumatol 27(10):2482–2488

    PubMed  CAS  Google Scholar 

  19. Dessein PH, Shipton EA, Joffe BI, Hadebe DP, Stanwix AE, Van der Merwe BA (1999) Hyposecretion of adrenal androgens and the relation of serum adrenal steroids, serotonin and insulin-like growth factor-1 to clinical features in women with fibromyalgia. Pain 83(2):313–319

    Article  PubMed  CAS  Google Scholar 

  20. Loevinger BL, Muller D, Alonso C, Coe CL (2007) Metabolic syndrome in women with chronic pain. Metabolism 56(1):87–93. doi:10.1016/j.metabol.2006.09.001

    Article  PubMed  CAS  Google Scholar 

  21. Hernanz W, Valenzuela A, Quijada J, Garcia A, de la Iglesia JL, Gutierrez A, Povedano J, Moreno I, Sanchez B (1994) Lymphocyte subpopulations in patients with primary fibromyalgia. J Rheumatol 21(11):2122–2124

    PubMed  CAS  Google Scholar 

  22. Smart PA, Waylonis GW, Hackshaw KV (1997) Immunologic profile of patients with fibromyalgia. Am J Phys Med Rehabil 76(3):231–234

    Article  PubMed  CAS  Google Scholar 

  23. Alonso C, Loevinger BL, Muller D, Coe CL (2004) Menstrual cycle influences on pain and emotion in women with fibromyalgia. J Psychosom Res 57(5):451–458

    Article  PubMed  Google Scholar 

  24. Yunus MB, Inanici F, Aldag JC, Mangold RF (2000) Fibromyalgia in men: comparison of clinical features with women. J Rheumatol 27(2):485–490

    PubMed  CAS  Google Scholar 

  25. Bernstein DP, Stein JA, Newcomb MD, Walker E, Pogge D, Ahluvalia T, Stokes J, Handelsman L, Medrano M, Desmond D, Zule W (2003) Development and validation of a brief screening version of the Childhood Trauma Questionnaire. Child Abuse Negl 27(2):169–190

    Article  PubMed  Google Scholar 

  26. Bernstein DP, Fink L, Handelsman L, Foote J, Lovejoy M, Wenzel K, Sapareto E, Ruggiero J (1994) Initial reliability and validity of a new retrospective measure of child abuse and neglect. Am J Psychiatry 151(8):1132–1136

    PubMed  CAS  Google Scholar 

  27. Scher CD, Stein MB, Asmundson GJ, McCreary DR, Forde DR (2001) The childhood trauma questionnaire in a community sample: psychometric properties and normative data. J Trauma Stress 14(4):843–857

    Article  PubMed  CAS  Google Scholar 

  28. Cohen S, Kamarck T, Mermelstein R (1983) A global measure of perceived stress. J Health Soc Behav 24(4):385–396

    Article  PubMed  CAS  Google Scholar 

  29. Watson D, Clark LA, Weber K, Assenheimer JS, Strauss ME, McCormick RA (1995) Testing a tripartite model: II. Exploring the symptom structure of anxiety and depression in student, adult, and patient samples. J Abnorm Psychol 104(1):15–25

    Article  PubMed  CAS  Google Scholar 

  30. Huskisson EC (1983) Visual analogue scales. In: Melzack R (ed) Pain measurement and assessment. Raven, New York, pp 33–37

    Google Scholar 

  31. Piper BF, Dibble SL, Dodd MJ, Weiss MC, Slaughter RE, Paul SM (1998) The revised Piper Fatigue Scale: psychometric evaluation in women with breast cancer. Oncol Nurs Forum 25(4):677–684

    PubMed  CAS  Google Scholar 

  32. First MB, Spitzer RL, Gibbon M, Miriam JBW, Williams, Janet BW (1998) Structured Clinical Interview for DSM-IV Axis I Disorders—non-patient edition (SCID-I/NP, Version 2.0—8/98 revision). Biometrics Research Department, New York State Psychiatric Institute, New York, p 10032

    Google Scholar 

  33. Bennett R (2005) The Fibromyalgia Impact Questionnaire (FIQ): a review of its development, current version, operating characteristics and uses. Clin Exp Rheumatol 23(5 Suppl 39):S154–S162

    PubMed  CAS  Google Scholar 

  34. Cairns RB, Bergman LR, Kagan J (eds) (1998) Methods and models for studying the individual. Sage Publications, Thousand Oaks

    Google Scholar 

  35. Kotter I, Neuscheler D, Gunaydin I, Wernet D, Klein R (2007) Is there a predisposition for the development of autoimmune diseases in patients with fibromyalgia? Retrospective analysis with long term follow-up. Rheumatol Int 27(11):1031–1039

    Article  PubMed  Google Scholar 

  36. Meeus M, Nijs J (2007) Central sensitization: a biopsychosocial explanation for chronic widespread pain in patients with fibromyalgia and chronic fatigue syndrome. Clin Rheumatol 26(4):465–473. doi:10.1007/s10067-006-0433-9

    Article  PubMed  Google Scholar 

  37. Hsu MC, Schubiner H, Lumley MA, Stracks JS, Clauw DJ, Williams DA (2010) Sustained pain reduction through affective self-awareness in fibromyalgia: a randomized controlled trial. J Gen Intern Med 25 (10):1064-1070. doi:10.1007/s11606-010-1418-6

    Google Scholar 

  38. van Koulil S, Effting M, Kraaimaat FW, van Lankveld W, van Helmond T, Cats H, van Riel PL, de Jong AJ, Haverman JF, Evers AW (2007) Cognitive-behavioural therapies and exercise programmes for patients with fibromyalgia: state of the art and future directions. Ann Rheum Dis 66(5):571–581

    Article  PubMed  Google Scholar 

  39. Zautra AJ, Fasman R, Reich JW, Harakas P, Johnson LM, Olmsted ME, Davis MC (2005) Fibromyalgia: evidence for deficits in positive affect regulation. Psychosom Med 67(1):147–155

    Article  PubMed  Google Scholar 

  40. Schleicher H, Alonso C, Shirtcliff EA, Muller D, Loevinger BL, Coe CL (2005) In the face of pain: the relationship between psychological well-being and disability in women with fibromyalgia. Psychother Psychosom 74(4):231–239

    Article  PubMed  Google Scholar 

  41. Staud R, Vierck CJ, Robinson ME, Price DD (2006) Overall fibromyalgia pain is predicted by ratings of local pain and pain-related negative affect—possible role of peripheral tissues. Rheumatol (Oxford) 45(11):1409–1415

    Article  CAS  Google Scholar 

  42. Burckhardt CS (2006) Multidisciplinary approaches for management of fibromyalgia. Curr Pharm Des 12(1):59–66

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgments

This study was supported by a grant from the National Institute of Mental Health (MH61083). Dr. Coe receives partial salary support from the NIA, NIAID, and NICHD (AG20166, AI067518, HD38386). During the conduct of the study, Dr. Loevinger was supported by a National Institute of Health training grant (T32AG00265). Support for Dr. Shirtcliff was provided by a Career Development Award, K01-MH077687. This project benefited from the support and staff of our General Clinical Research Center (currently a CTSA 1UL1RR025011). We thank Holly Schleicher, PhD, for her invaluable assistance in data acquisition. We also express our gratitude to Jeff Jefferson, M.D., and Molly Carnes, M.D., M.S., for their editorial comments on early versions of this paper.

Disclosures

None.

Author information

Authors and Affiliations

  1. Department of Psychiatry, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA

    Barbara L. Loevinger, Daniel Muller & Carmen Alonso

  2. Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA

    Daniel Muller

  3. Department of Psychology, University of New Orleans, New Orleans, USA

    Elizabeth A. Shirtcliff

  4. Department of Psychology, University of Wisconsin, Madison, WI, USA

    Christopher L. Coe

  5. Harlow Center for Biological Psychology, University of Wisconsin School of Medicine and Public Health, 22 N. Charter Street, Madison, WI, 53715, USA

    Barbara L. Loevinger

Authors
  1. Barbara L. Loevinger
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Elizabeth A. Shirtcliff
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Daniel Muller
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Carmen Alonso
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Christopher L. Coe
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Barbara L. Loevinger.

Additional information

This study is from the University of Wisconsin Mind/Body Center, Departments of Psychology, Psychiatry, and Rheumatology.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Loevinger, B.L., Shirtcliff, E.A., Muller, D. et al. Delineating psychological and biomedical profiles in a heterogeneous fibromyalgia population using cluster analysis. Clin Rheumatol 31, 677–685 (2012). https://doi.org/10.1007/s10067-011-1912-1

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10067-011-1912-1

Keywords

Search

Navigation