RESEARCH ARTICLEOpen Access
Depression in Dercum’s disease and in obesity:
A case control study
Emma Hansson*, Henry Svensson and Håkan Brorson
Background: Dercum’s disease is characterised by pronounced pain in the adipose tissue and a number of
associated symptoms. The condition is usually accompanied by generalised weight gain. Many of the associated
symptoms could also be signs of depression. Depression in Dercum’s disease has been reported in case reports but
has never been studied using an evidence-based methodology. The aim of this study was to examine the presence
of depression in patients with Dercum’s disease compared to obese controls that do not experience any pain.
Methods: A total of 111 women fulfilling the clinical criteria of Dercum’s disease were included. As controls, 40
obese healthy women were recruited. To measure depression, the Montgomery Åsberg Depression Rating Scale
(MADRS) was used.
Results: According to the total MADRS score, less than half of the patients were classified as having “no
depression” (44%), the majority had “light” or “moderate depression” (55%) and one individual had “severe
depression” in the Dercum group. In the control groups, the majority of the patients were classified as having
“no depression” (85%) and a small number had “light depression” (15%). There was a statistically significant
difference for the total MADRS score between the two groups (p=0.014).
Conclusion: The results indicate that the patients with Dercum’s disease are more likely to suffer from
depression than controls.
Keywords: Dercum’s disease, Adiposis dolorosa, Chronic pain, Obesity, Depression, MADRS
Dercum’s disease is characterised by pronounced pain in
the adipose tissue and a number of associated symp-
toms. The condition is usually accompanied by general-
ised weight gain. The pain is chronic (>3 months),
symmetrical, often disabling and therapy-resistant to
analgesics . The pathogenesis of Dercum’s disease is
unknown . In 1901, Roux and Vitaut  proposed
four cardinal symptoms of Dercum’s disease: (1) Mul-
tiple, painful, fatty masses (2) Generalised obesity (3)
Weakness and susceptibility to fatigue (asthenia) (4) Psy-
chiatric manifestations, including emotional instability,
depression, epilepsy, confusion and dementia. However,
it is still unclear which symptoms are cardinal and which
are associated. In fact, already in 1927, Labbé and Boulin
 questioned whether the weakness, susceptibility to
fatigue, and psychiatric manifestations should be classi-
fied as cardinal symptoms. They argued that obesity per
se can induce asthenia, and pointed out that psychiatric
symptoms have not been described in all cases of Der-
cum’s disease .
In addition, patients with depression are often diag-
nosed with chronic pain conditions and vice versa .
Both disorders activate common neurocircuitries, such
as the hypothalamic-pituitary-adrenal axis, limbic and
paralimbic structures, ascending and descending pain
pathways, and mutual neurotransmitters , and it is
therefore sometimes difficult to determine whether the
pain disorder or the psychiatric condition is the primary
diagnosis. However, symptoms that could be attributed
to depression have been described in patients in several
reports to date .
The aim of the present study was to examine the pres-
ence of depression in Dercum’s disease compared to
obese controls that do not experience any pain, thereby
investigating whether depression is truly a part of
* Correspondence: firstname.lastname@example.org
Department of Clinical Sciences Malmö, Lund University, Plastic and
Reconstructive Surgery, Skåne University Hospital, SE-205 02, Malmö, Sweden
© 2012 Hansson et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Hansson et al. BMC Psychiatry 2012, 12:74
Dercum’s disease. Depression was evaluated using The
Montgomery Åsberg Depression Rating Scale (MADRS).
It is thought that improving our knowledge about Der-
cum’s disease should improve patient care.
Patients and controls
A total of 111 patients fulfilling the clinical criteria of
Dercum’s disease were diagnosed and referred to the De-
partment of Plastic and Reconstructive Surgery in
Malmö by the same consultant in internal medicine.
Dercum’s disease was defined as adiposity and chronic
pain (>3 months) in the adipose tissue . Diagnosis
was based on the medical history evaluated from a stan-
dardised questionnaire and a systematic physical exam-
ination on three separate visits. The purpose of the
questionnaire and the examination was to exclude expla-
nations other than Dercum’s disease, such as other pain
conditions or endocrinological disorders, to the patients’
symptoms. All of the patients included in the study had
generalised Dercum’s disease, meaning that they did not
have any lipomas. The included subjects did not have
any disease involving inflammation or pain, other than
Dercum’s disease. The patients were referred to the De-
partment of Plastic Surgery to be included in a study on
the effect of liposuction on the pain experienced by the
consecutively-referred patients were later operated on
with liposuction and the following 58 women with Der-
cum’s disease were recruited as controls to compare the
effect of liposuction in the disease. The result of that
study has been reported elsewhere . All of the patients
that were referred to this study were female. Healthy
controls with a similar BMI, a similar age and the same
sex were selected from patients with no acute or chronic
pain, who were to undergo abdominoplasty surgery in
the same department. In total, 40 women with a similar
BMI and a similar age as the Dercum patients without
any chronic diseases were recruited for this study. The
patients’ profile is given in Table 1. During the first visit
at the Department of Plastic and Reconstructive Surgery
depression was evaluated in all of the patients and con-
trols. None of the patients or controls had a diagnosis of
depression and none of the patients or controls took
antidepressants. None of the patients or controls had
any disease that can give symptoms of depression.
The study was approved by the Ethics of Human Investi-
gation Committee at Lund University (LU 236–89). All
participants gave their written informed consent to par-
ticipate. The procedures followed were in accordance
with the Declaration of Helsinki of 1964, as revised.
Montgomery Åsberg Depression Rating Scale (MADRS)
The MADRS is a self-rating scale that comprises nine
different items, evaluating: (1) mood, (2) feelings of un-
ease, (3) sleep, (4) appetite, (5) ability to concentrate, (6)
initiative, (7) emotional involvement, (8) pessimism, and
(9) zest for life. There is an apparent overlap between
the MADRS items and the DSM-IV criteria for depres-
sion, although the MADRS does not directly evaluate
the nine DSM-IV criteria. For instance, fatigue or loss of
energy and psychomotor agitation or retardation are not
directly assessed. The occurrence of suicidal thoughts
was not included in the MADRS used in this study.
The use of items allows rating of individual symptoms
and mood dimensions. Each item was given a score of
0–6, resulting in a total of 0–54 points. According to the
interpretation guidelines, a total score of 0–12 points
equalled “no depression”, 13–19 points implied a “light
depression”, 20–34 points was “moderate depression”,
and ≥35 points indicated “severe depression” .
A Swedish version of the MADRS has been validated
and scores on the scale have been shown to correlate
with scores on the Hamilton Rating Scale (HRS)  and
the Beck Depression Inventory (BDI) . The MADRS
has previously been used to make the diagnosis of de-
pression in patients with chronic pain conditions .
Histograms were drawn to examine the distribution of
the measured factors. The histograms indicated that the
measured factors were not normally distributed. Because
of this, and the ordinal nature of the MADRS scale,
values were given as median, ranges and percentages and
the non-parametric Mann–Whitney U-test was used to
compare MADRS scores between patients and controls.
According to the total MADRS scores, less than half of
the patients were classified as having “no depression”
(44%), the majority had light or moderate depression
(55%), and one individual was suffering from “severe de-
pression” in the Dercum group (Figure 1). In the control
group, the majority of the patients were classified as hav-
ing “no depression” (85%) and a small number had “light
depression” (15%) (Figure 1). A statistical difference for
the total score could be seen between the two groups
(p=0.014). For the items tested, a statistically significant
difference was detectedfor
Table 1 Patient profile (median, range)
Age (years) 53 (22–73)50 (26–69)
94 (55–147) 91 (55–129)
34 (22–58)34 (28–46)
Hansson et al. BMC Psychiatry 2012, 12:74
Page 2 of 5
“pessimism” (p=0.022) and “zest for life” (p=0.009). No
statistically significant differences were seen for the rest
of the items (Table 2).
Dercum’s disease is characterised by obesity, chronic
pain and other associated symptoms. Some of the asso-
ciated symptoms, previously described in case reports
on Dercum’s disease , include depression and symp-
toms associated with depression, such as asthenia, weak-
ness, fatigue, emotional instability, mental confusion,
dementia, poor sleep quality and changes in appetite.
Several studies have demonstrated that there is a signifi-
cant association between depression and pain , as well
as between depression and obesity . Patients with de-
pression are often diagnosed with chronic pain condi-
demonstrated that depression predicts obesity later in
life , and other studies support that obese subjects
develop depression to a greater extent than subjects with
lower, “normal” body weights . Nonetheless, it is un-
clear whether there is a causal relationship between the
three entities. The possible co-morbidity could be
explained by Berkson’s bias , that is, patients with an
illness might seek care more often. Thus co-morbidity
could be overrepresented in a group of subjects that are,
as in this study, recruited from a care setting. In sum-
mary, it is difficult to separate chronic pain from
The elevated MADRS scores in the Dercum patients
in this study cannot be explained by obesity alone, as the
distribution of the Dercum subjects’ scores was different
to that of the weight-matched control patients (Figure 1),
and there was a statistical difference for the total score
between the two groups (Table 2). The lack of statistical
difference for a number of the items could be explained
by low power, that is, by the small number of subjects in
the control group (n=40). The results suggested that
the obese Dercum patients experience worse depression
than obese healthy controls. As all of the Dercum
patients had chronic pain whilst none of the controls
had any history of chronic or present acute pain, it is
.Some studies have
Figure 1 Per cent of patients in the groups that received total scores in each interval. According to the interpretation guidelines, a total
score of 0–12 points equals “no depression”, 13–19 points a “light depression”, 20-34 points a “moderate depression”, and ≥35 points a “severe
Table 2 MADRS scores (median, range) and comparison
MADRS Dercum ControlDercum patients vs.
Mood 1 (0–5) 0 (0–3)0.018
2 (0–5) 0 (0–2)0.40
Sleep4 (0–6) 0 (0–4)0.19
Appetite 0 (0–5)0 (0–4) 0.60
2 (0–5) 0 (0–2)0.051
Initiative2 (0–6)0 (0–4)0.092
2 (0–5)0 (0–2)0.074
Pessimism 1 (0–4)0 (0–4)0.022
Zest for life 1 (0–6) 0 (0–3) 0.009
Total score 14 (0–38)4 (0–18)0.014
Hansson et al. BMC Psychiatry 2012, 12:74
Page 3 of 5
unclear whether the depression is due to the Dercum’s
disease per se or due to the experience of pain. Further-
more, it is unclear whether the depression or the Der-
cum’s disease came first. Previous research has shown
that antidepressants have an effect on pain and the qual-
ity of life in patients with chronic pain  and that
obese patients could benefit from the treatment of any
co-existing features of depression [14,15].
An example of an associated symptom in Dercum’s dis-
ease that can also be explained by depression is poor
sleep quality. Poor sleep quality can diminish an indivi-
dual’s ability to cope with pain and stress and can influ-
ence the onset and course of disease . In fact, a study
on patients with chronic pain conditions demonstrated
that sleeping less than 8 hours per 24 hours, especially in
combination with poor sleep quality, might generate
stronger reactions to pain . In addition, Affleck et al.
concluded that there is a correlation between sleep qual-
ity and experienced pain intensity, as well as the ability
to cope with pain, among patients with fibromyalgia .
It can be speculated, therefore, that poor sleep can con-
tribute to the onset of Dercum’s disease and the mainten-
ance of pain. Conversely, obesity can also affect sleep
quality . Obstructive sleep apnoea (OSA) and Pick-
wick syndrome , both of which have been previously
described in Dercum’s disease, can be explained by obes-
ity, as 50% of otherwise healthy obese women with BMI
>40 have OSA and more than 29% of severely obese
patients have nocturnal hypoventilation . This could
explain why no difference can be seen between the Der-
cum patients and the control subjects in this study, as all
of the subjects have similar BMIs.
One advantage of the present study is that the same
consultant made the diagnosis of Dercum’s disease in all
of the cases and that a control group of healthy obese
subjects was included. Furthermore, an instrument was
used to measure depression that has been previously
validated and extensively used in research studies focus-
ing on depression and patients with chronic pain . A
disadvantage is the fact that a normal weight control
group was not included. However, there was an oppor-
tunity to include a control group of healthy obese sub-
jects, which means that the hypothesis that signs of
depression in Dercum’s disease could be explained by
obesity alone can be excluded. Another weakness is the
low number of patients included in this study, which is
as a result of the rarity of the condition. Furthermore, it
should be noted that the results are only valid for
women as all of the subjects included were female.
The relationship between Dercum’s disease, chronic pain,
depression, and obesity is complex and it is not possible
to separate depression and chronic pain completely.
However, the results of this study indicate that patients
with Dercum’s disease could suffer from worse depres-
sion than equally obese controls with no history of Der-
cum’s disease. This fact should be kept in mind when a
treatment strategy for Dercum’s disease is selected.
The authors declare that they have no competing interests.
The work was supported by grants from The Swedish Rheumatism
Association, the insurance company Förenade Liv, the Department of Clinical
Research and Development at Malmö University Hospital, Helge Wulff’s Trust,
and the Faculty of Medicine at the Lund University. We thank Birger Fagher
MD (deceased on 21 April 2011), for kindly letting our group conduct
research on patients in his care. We are indebted to Associate Professor
Jonas Manjer for statistical advice.
EH participated in the design of the study, performed the statistical analysis
and wrote the manuscript. HS participated in the choice of statistical
methods and in the writing of the manuscript. HB initiated and designed the
study and contributed to the writing of the manuscript. All authors have
read and approved the final manuscript.
Received: 11 November 2011 Accepted: 3 July 2012
Published: 3 July 2012
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Cite this article as: Hansson et al.: Depression in Dercum’s disease and
in obesity: A case control study. BMC Psychiatry 2012 12:74.
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