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Vulnerability to Psychopathology and Dimensions of
Personality in Patients With Fibromyalgia
Alba Garcia-Fontanals, PhD,*Mariona Portell, PhD,
w
Susanna Garcı´a-Blanco, PhD,
z
Violant Poca-Dias, MD,
z
Ferran Garcı´a-Fructuoso, PhD, MD,
z
Marina Lo
´pez-Ruiz, MSc,
y
Teresa Gutie
´rrez-Rosado, PhD,*Montserrat Goma
`-i-Freixanet, PhD,*
and Joan Deus, PhD*
y
Objective: Fibromyalgia (FM) patients may present psychopa-
thology and some characteristic personality traits that may affect
their adaptation to the disease. The aim of this paper was to study
the relationship between personality dimensions according to
the psychobiological model of Cloninger and the presence of
psychopathology.
Materials and Methods: The study sample consisted of 42 patients
with FM and 38 pain-free controls. The assessment instruments
administered were the Temperament and Character Inventory-
Revised and the Millon Clinical Multiaxial Inventory.
Results: A higher proportion of clinical psychopathologic
syndromes (CPS) was observed in the FM group than in the con-
trol group, the most prevalent being anxiety disorder and dysthy-
mia. Patients with FM (with CPS or without CPS) presented higher
Harm Avoidance than the control group, and the presence of a
CPS also increased Harm Avoidance scores. FM patients with CPS
had low Self-directedness (SD) compared with both the control
group and with their FM peers without CPS. Purposefulness and
Anticipatory worry-Pessimism explained 38% of the variance of
dysthymia, and anticipatory worry-Pessimism explained 18% of
the variance of anxiety disorders.
Conclusions: Patients with FM have a high probability of anxious-
depressive-type psychopathologic alterations. Their vulnerability to
these conditions may be determined by personality traits. The SD
character dimension may have implications for therapy, as low SD
is associated with the presence of psychopathology and with a low
capacity to cope with the disease.
Key Words: personality, psychopathology, TCI-R, MCMI-III
(Clin J Pain 2017;33:991–997)
Fibromyalgia (FM) is a chronic condition characterized
by widespread muscoskeletal pain and hyperalgesia on
digital pressure in at least 11 of 18 tender points.1,2 Chronic
diseases associated with pain usually coexist with anxious-
depressive symptoms, and their effects are mutually rein-
forcing. In FM, a painful and chronic functional condition,
anxious-depressive psychopathology has been reported.3–11
However, recent studies have suggested that FM patients
are not a clinically homogenous group and that not all have
psychopathologic disorders.5,9,12 The presence of psycho-
pathology is seen as one of the factors that may influence
the impact of FM on daily functioning,4,13–15 health
status,3,4,16 and pain intensity.17,18 However, the variability
of the impact of FM, health status, and pain intensity
among different patients, and even within the same patient,
is evident5,8,12; therefore, the detection of predictors of this
variability and the distinguishing characteristics of patients
who endure the disease without developing psychopathol-
ogy may play a key role in limiting the distress caused.
Dersh et al19 state that patients with chronic pain may have
certain personality characteristics that make them more
vulnerable to the development of psychopathology and that
are exacerbated by the stressful experience of a chronic
disease. Indeed, in the literature a distinctive personality
profile of FM patients has been established20,21: studies
using the Temperament and Character Inventory (TCI)
have found high Harm Avoidance (HA) scores and low
Self-directedness (SD) scores in FM patients compared with
controls.21–25 According to the Cloninger theory,26 tem-
perament dimensions such as HA are inherited and stable,
and hence the fluctuations in these traits should be minimal.
In contrast, character dimensions such as SD are learned
and may fluctuate over time. Numerous studies, both in
general populations and in patients with chronic functional
pain, have reported that high HA and low SD are asso-
ciated with greater emotional distress,22,25,27–30 suggesting
that the combination of these 2 personality dimensions may
facilitate the manifestation of emotional disturbances.
These results have also been confirmed in FM.21,22,25
Some studies have found that HA scores may be
higher in the presence of certain mental disorders such as
depression.24,31,32 They also note that patients who have
been depressed continue to score highly on HA than normative
groups even when the depression recedes.24 FM patients are
characterized by high HA scores and often present comorbidity
with anxiety and depression; hence, it is important to establish
whether high HA scores are a defining feature of FM inde-
pendent of the presence of anxious-depressive symptoms.22
In addition, low SD is also characteristic of FM patients,21
although not always to the same extent as high HA.22 As SD
Received for publication July 25, 2016; revised November 11,
2016; accepted April 8, 2017.
Fro m th e Departments of *Clinical and Health Psychology; wPsychobiology
and Methodology of Health Sciences, Autonomous University of
Barcelona; yMagnetic Resonance Imaging (MRI) MRI Research Unit,
CRC Mar, Hospital Mar; and zRheumatology Department, Hospital
CIMA Sanitas, Barcelona, Spain.
This work was supported in part by the Spanish Ministry of Science
and Innovation (Grant I + D PSI2014-53524-P) (Spain); the
Department of Clinical and Health Psychology at the Autonomous
University of Barcelona (Grant PIF 1927), (Barcelona, Spain) and
the Agency of University and Research Funding Management
of the Catalan Government (Research Group SGR 2014/1673)
(Barcelona, Spain). The authors declare no conflict of interest.
Reprints: Alba Garcia-Fontanals, PhD, Department of Clinical and
Health Psychology, Autonomous University of Barcelona, Campus
de la UAB, Bellaterra (Cerdanyola del Valle
`s), Barcelona 08193,
Spain (e-mail: agarciafontanals@gmail.com).
Copyright r2017 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/AJP.0000000000000506
ORIGINAL ARTICLE
Clin J Pain Volume 33, Number 11, November 2017 www.clinicalpain.com |991
Copyright r2017 Wolters Kluwer Health, Inc. All rights reserved.
is inversely related to the presence of mental disorders and
anxious-depressive symptoms,25,29,33 patients with FM who
present psychopathology are likely to have lower SD scores
than those who do not.
The aims of this study were as follows: (1) to determine
the predominant clinical psychopathology in patients with
FM and its relation to personality dimensions using the
Millon Clinical Multiaxial Inventory (MCMI-III), and (2) to
explore which of these personality dimensions account for
the presence of the predominant clinical psychopathology.
MATERIALS AND METHODS
Participants
The FM patients were selected by a senior rheuma-
tologist from an initial sample of 150 patients seen at the
Rheumatology Department of the Hospital CIMA Sanitas
in Barcelona, Spain. Strict selection criteria were applied:
patients with FM presenting comorbid rheumatological
diseases were excluded as were patients with chronic fatigue
syndrome, patients with a history of psychotic disorder or
substance abuse, patients with a history or diagnosis of
personality disorder, and patients with a history of neuro-
pathic pain. The final sample (Table 1) was made up of
42 women aged between 32 and 63 years (M= 47.1 y,
SD = 7.98). All FM patients met the diagnostic criteria of
the American College of Rheumatology. The participants
signed an informed consent before entering the study,
which was approved by the Local Ethics Committee and
was in compliance with the Helsinki Declaration.
The patients and pain-free participants were selected as
soon as they arrived at the health center. The pain-free female
volunteers were recruited in a health center while accompany-
ing an acquaintance. They were included only if they met the
inclusion criteria. The control group consisted of 38 pain-free
female volunteers aged 31 to 62 years (M= 44.37 y, SD = 6.3).
Inclusion criteria for control group selection were as follows: no
history of rheumatic disorder, no history of functional pain (is a
state of chronic recurrent pain that is not due to structural,
organic, or metabolic diseases and it seems that the etiology
is emotionally based) or physical widespread pain, no known
or reported history of Diagnostic and Statistical Manual of
Mental Disorders-IV Axis I (eg, depressive disorders, anxiety
disorders) or/and Axis II (personality disorder) psychiatric
disorders, and no known or reported history of neurological
disease. There were no statistically significant differences of
either age (t
78
=1.69, P= 0.1) or educational level between
the 2 groups (t
78
=1.01, P=0.3).
Measures
Temperament and Character Inventory-Revised (TCI-R):
we administered the Spanish version of the TCI-R.34 The orig-
inal TCI-R is a 240-item personality self-report questionnaire,
based on the Cloninger multidimensional and psychobiological
model that accounts for both normal and abnormal variations
in 7 personality dimensions (4 temperament dimensions,
3 character dimensions) and 29 subscale categories. The tem-
perament dimensions are HA, Novelty Seeking (NS), Reward
Dependence, and Persistence. HA reflects a tendency to shyness
and worry in anticipation of possible danger. NS reflects a
tendency toward exploratory activity in response to novelty,
impulsive decision making, and active avoidance of monotony.
Reward Dependence reveals a tendency to sentimentality, social
attachment, and dependence on approval of others. Persistence
reflects a tendency to ambitious overachieving and perseveration
despite frustration. SD refers to the ability to control, regulate,
and adapt one’s behavior in accordance with chosen goals
and values. Cooperativeness reveals an inclination toward
social tolerance, empathy, helpfulness, and compassion. Self-
transcendence reflects a tendency toward spirituality. All these
temperament dimensions have 3 or 5 subscales with a more
specific content. HA includes 4 subscales (Worry and pessimism,
Fear of uncertainty, Shyness, Fatigability), whereas SD includes
5 subscales (Responsibility, Purposefulness, Resourcefulness,
Self-acceptance, Congruent Second Nature). This questionnaire
has proved to be reliable in its original version, with internal
consistency acoefficients ranging from 0.65 for Persistence to
0.89 for Cooperativeness.26 The Spanish version has shown
internal consistency acoefficients of over 0.77.
MCMI-III: we administered the Spanish version of the
MCMI-III,35 a 175-item self-report questionnaire based on
Millon model. The MCMI-III consists of 28 scales: 11 basic
clinical personality pattern scales (schizoid, avoidant,
depressive, dependent, histrionic, narcissistic, antisocial,
sadistic, compulsive, negativistic, masochistic), 3 severe
personality pathology scales (schizotypal, borderline,
paranoid), 7 clinical syndromes (anxiety, somatoform,
bipolar-maniac, dysthymia, alcohol dependence, drug
dependence, posttraumatic stress), 3 severe clinical syn-
dromes (thought disorder, major depression, delusional
disorder), 3 modifying indices (disclosure, desirability,
debasement), and a validity scale. This questionnaire has
proved to be reliable in its original version,36 with internal
consistency acoefficients ranging from 0.66 for the Com-
pulsive scale to 0.90 for the Major Depression scale. The
TABLE 1. Clinical Characteristics of Patients With FM (N = 42)
Clinical Characteristics n (%)
Tender points (mean [SD]) 15.90 (1.97)
Months from diagnostic (mean [SD]) 85.98 (55.39)
Months with widespread pain (mean [SD]) 60.57 (54.90)
Associated symptoms (0-14) 11.26 (2.49)
Morning tiredness 37 (88.1)
Unrefreshed sleep 36 (85.7)
Fragmented sleep 30 (71.4)
Fatigue 41 (97.6)
Morning stiffness 37 (88.1)
Stiffness after resting 29 (69)
Subjective swelling 36 (85.7)
Paresthesias 38 (90.5)
Headache 33 (78.6)
Symptoms of irritable bowel 21 (50)
Depression symptoms 30 (71.4)
Anxiety symptoms 34 (81)
Subjective difficulties of attention and
concentration (n [%])
35 (83.3)
Subjective memory complaints 37 (88.1)
Sick leave caused by FM (n [%]) 4.06 (7.13)
Longest period of sick leave caused by FM (mo) 22.40 (44.04)
Current pharmacotherapy 36 (85.7)
Antidepressants 32 (76.2)
Anxiolytics 21 (50)
Hypnotics 6 (14.3)
Anticonvulsants 10 (23.8)
Anti-inflammatory 29 (69)
Analgesic 23 (54.8)
Fibromyalgia Impact Questionnaire: Global score 66.50 (16.07)
FM indicates fibromyalgia.
Garcia-Fontanals et al Clin J Pain Volume 33, Number 11, November 2017
992 |www.clinicalpain.com Copyright r2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r2017 Wolters Kluwer Health, Inc. All rights reserved.
Spanish version has shown internal consistency acoef-
ficients ranging from 0.65 for the Compulsive scale to 0.88
for the Major Depression scale. The validity of MCMI-III
is considered adequate.
Data Analysis
The proportion of cases with a clinical psychopatho-
logic syndrome (CPS) with base rate scores of Z75 on
the MCMI-III Anxiety and Dysthymia scales were estab-
lished in the FM and control groups. To determine the
presence of a clinical syndrome, the MCMI-III guidelines
were followed,36 according to which a Prevalence (PREV)
score of 75 on an Axis I scale indicates the presence of the
particular clinical syndrome, whereas a PREV score of 85
indicates its prominence. The PREV score is used as a
cut-off point for determining the presence of pathology.
Two members of the control group whose scores on the
MCMI-III indicated the presence of a CPS were excluded
as was 1 patient in the FM group whose scores indicated the
possible presence of bipolar disorder (Table 2).
The comparison groups (FM with CPS, FM without
CPS, and control) were created using the MCMI-III Axis I
scores reflecting the presence or absence of a CPS. The FM
group without CPS comprised participants who did not
show CPS according to the MCMI-III, with the exception of
somatoform disorder. Patients scoring Z75 only on the
somatoform disorders were categorized as non-CPS on the
grounds that the MCMI-III diagnosis of somatoform
disorders includes nonspecific symptoms of fatigue and
somatic complaints, which in this case were justified by the
presence of FM, a medical illness with chronic pain. The FM
group with CPS comprised patients with scores of 75 or
more on the MCMI-III clinical syndrome scales. The Fisher
exact test was used to compare the proportions of cases with
clinical syndromes and MCMI-III scale base rate scores
above 75 between the FM and control groups. Means of
the groups were compared with the scores obtained on the
TCI-R dimensions using either the Student ttest or the
Mann-Whitney test. The Bonferroni method was used to
control for the accumulated error risk due to the multiplicity
of comparisons. The 4 variables identified by the comparison
of means (Anticipatory worry-Pessimism, Purposefulness,
Resourcefulness, and Congruent second nature) were
introduced in the multiple regression model with backward
selection to explain the Dysthymia and Anxiety Disorder
scores assessed by the MCMI-III. An exit criterion of
P> 0.1 was used in the model building process.
RESULTS
MCMI-III
The FM group presented significantly more cases of
anxiety disorder (50%) (P< 0.0005), somatoform disorder
(71%) (P< 0.0005), dysthymic disorder (50%) (P< 0.0005),
and major depressive disorder (19%) (P= 0.006) than the
control group. All patients with major depressive disorder,
thought disorder (7%), or bipolar disorder (7%) presented
comorbidity with an anxiety disorder and dysthymia. Sixteen
patients presented comorbidity with an anxiety disorder and
dysthymia (Table 2).
MCMI-III and TCI-R
The results show that patients with FM who do not
present CPS had significantly lower NS scores than the
control group (U= 132; P= 0.004), and significantly
higher scores for overall HA (t
49
= 4.58, P= < 0.0005)
and for the HA Fear of uncertainty (t
49
= 2.99, P= 0.004)
and Fatigability subscales (U= 18.5, P< 0.0005)
(Tables 3, 4). Compared with the control group, FM
patients with a CPS scored significantly higher on overall
HA (t
60
= 7.60, P< 0.0005) and on the HA subscales
Anticipatory worry-Pessimism (t
60
= 6.45, P< 0.0005),
Fear of uncertainty (U= 168.5, P< 0.0005), and Fatig-
ability (U= 20.5, P< 0.0005), and lower on overall SD
(t
60
=4.60, P= < 0.0005) and on the SD subscales
Responsibility (U= 222, P= < 0.0005), Purposefulness
(U= 221, P= < 0.0005), Resourcefulness (t
60
=3.46,
P= 0.001), and Congruent second nature (t
60
=3.49,
P= 0.001) (Tables 2, 3). Compared with the FM group
without CPS, FM patients with a CPS had higher overall
scores for HA (t
39
=2.86, P= 0.007) and for the HA
subscales Anticipatory worry-Pessimism (t
39
=3.19,
P=0.003), and lower scores for SD (t
39
= 4.59,
P= < 0.0005), specifically on the SD subscales Purpose-
fulness (U= 92.5, P= 0.005), Resourcefulness (t
39
= 2.73,
P= 0.004), and Congruent second nature (t
39
= 3.31,
P= 0.002) (Tables 3, 4).
In the regression analysis, the model that best described
dysthymia comprised Anticipatory worry-Pessimism and
Purposefulness, accounting for 38% of its variance. The only
variable that made a statistically significant contribution after
controlling for the effect of the 4 variables included in the
analysis (Anticipatory worry-Pessimism, Purposefulness,
Resourcefulness, and Congruent second nature) was Pur-
posefulness. The model that best described anxiety disorder
included only Anticipatory worry-Pessimism and explained
19% of its variance. The only variable that made a significant
contribution after controlling for the effect of the 4 variables
included in the regression model (Anticipatory worry-Pessi-
mism, Purposefulness, Resourcefulness, and Congruent
second nature) was Anticipatory worry-Pessimism (Table 5).
DISCUSSION
Compared with the control group, patients with FM
presented a higher proportion of cases with CPS (63.41%)
characterized by anxiety (50%), and dysthymia (50%). Other
studies have shown that psychopathology in FM patients
TABLE 2. Fisher Exact Test Between the FM and Control Groups
on the Presence of Clinical Syndromes
FM (N = 42) Control (N = 38)
PREVZ75
(n [%])
PREVZ75
(n [%]) P*
Anxiety disorder 21 (50) 2 (5) < 0.0005
Somatoform
disorder
30 (71) 0 < 0.0005
Bipolar disorder 3 (7) 0 0.242
Dysthymia disorder 21 (50) 0 < 0.0005
Thought disorder 3 (7) 0 0.242
Major depression
disorder
8 (19) 0 0.006
Clinical syndrome scales: Alcohol Dependence, Drug Dependence,
Posttraumatic Stress Disorder, and Delusional Disorder had a frequency of
0 cases in both groups.
Significant at Bonferroni-adjusted P-value of (P< 0.05/6 = 0.008).
*Degree of significance obtained with the Fisher exact test.
FM indicates fibromyalgia; PREV, prevalence.
Bold values indicates Significant data.
Clin J Pain Volume 33, Number 11, November 2017 Vulnerability to Psychopathology in Fibromyalgia
Copyright r2017 Wolters Kluwer Health, Inc. All rights reserved. www.clinicalpain.com |993
Copyright r2017 Wolters Kluwer Health, Inc. All rights reserved.
tends to comprise anxiety with avoidance behaviors and
somatization.4,7,10,11,18 This explains why FM was historically
classified as a somatoform disorder, although today a clear
neurobiological etiology is supported.37–39 However, in our
study a significant proportion of FM patients did not present
CPS (36.6%), a finding which confirms that they represent a
heterogenous group.5With regard to personality profile, FM
patients (with or without CPS) generally had higher HA
scores than controls, and thosewithCPShadsignificantly
higher scores than their peers without CPS. As for SD, FM
patients with a comorbid CPS scored lower than both
the control group and the FM group without CPS. In the
multiple regression model, the best predictors of Dysthymia
were Purposefulness and Anticipatory worry-Pessimism
together, and the best predictor of Anxiety Disorder was
Anticipatory worry-Pessimism.
We found HA to be characteristic of the defining
personality profile in FM, consistent with the results found
TABLE 3. Comparison of Means Between FM With CPS, Without CPS, and Control Groups in Temperament and Character
Inventory-Revised Scales
Mean (SD) 1 vs. 2 1 vs. 3 2 vs. 3
FM With CPS
(N = 26)
1
FM Without
CPS (N = 15)
2
Control
(N = 36)
3
PCI PCI PCI
Novelty Seeking 90.38 (11.68) 87.33 (9.91) 97.67 (12.41) 0.432 10.32 to
4.22
0.023 13.52 to
1.05
0.004 17.59 to
3.08
Harm
Avoidance
124.88 (15.73) 113.93 (8.76) 93.08 (16.61) 0.007 18.69 to
3.21
< 0.0005 23.44-
40.17
< 0.0005 13.65-
28.05
Reward
Dependence
111.73 (14.50) 110.07 (16.27) 108.44 (12.26) 0.737 11.61 to
8.28
0.339 3.53 to
10.10
0.698 6.73 to
9.98
Persistence 101.31 (18.36) 107.33 (17.06) 112.03 (15.36) 0.306 5.71 to
17.77
0.015 19.31 to
2.14
0.340 14.49 to
5.10
Self-
Directedness
139.62 (14.92) 162.47 (16.12) 158.08 (16.05) < 0.0005 12.77-
32.93
< 0.0005 26.49 to
10.44
0.379 5.54 to
14.31
Cooperativeness 144.08 (15.57) 147.47 (10.88) 147.61 (9.62) 0.462 5.84 to
12.61
0.312 10.51 to
3.44
0.963 6.32 to
6.03
Self-
Transcendence
65.12 (15.23) 62.60 (11.04) 65.17 (15.50) 0.579 11.61 to
6.58
0.737 7.97 to
7.87
0.780 11.44 to
6.31
Significant at Bonferroni-adjusted P-value of (P< 0.05/7r0.007).
CI indicates confidence interval; CPS, clinical psychopathologic syndromes; FM, Fibromyalgia.
Bold values indicates Significant data.
TABLE 4. Comparison of Means Between FM With CPS, Without CPS, and Control Groups in Temperament and Character
Inventory-Revised Subscales
Mean (SD) 1 vs. 2 1 vs. 3 2 vs. 3
FM With CPS
(N = 26)
1
FM Without CPS
(N = 15)
2
Control
(N = 36)
3
PCI PCI PCI
Harm Avoidance
Anticipatory
Worry-
Pessimism
37.96 (5.92) 32.47 (4.02) 27.47 (6.59) 0.003 8.98 to
2.01
< 0.0005 7.24-13.74 0.009 1.31-8.68
Fear of
uncertainty
29.65 (4.34) 27.73 (2.82) 23.97 (4.49) 0.089 4.18 to
34
< 0.0005 3.40-7.96 0.004 1.24-6.28
Shyness 22.19 (6.13) 21.60 (5.18) 20.17 (5.68) 0.755 4.40 to
3.21
0.185 0.99 to
5.05
0.404 1.98 to
4.85
Fatigability 35.08 (4.19) 32.13 (2.85) 21.47 (5.28) 0.020 5.18 to
0.71
< 0.0005 11.11-
16.11
< 0.0005 7.75-
13.58
Self-Directedness
Responsibility 29.27 (4.45) 33 (3.61) 33.67 (4.22) 0.009 1.0-6.46 < 0.0005 6.62 to
2.17
0.449 3.17 to
1.84
Purposefulness 19.58 (5.12) 24.27 (2.89) 24.08 (3.16) 0.005 2.16 to
7.22
< 0.0005 6.80 to
2.21
0.847 1.72 to
2.08
Resourcefulness 16.73 (4.17) 20 (2.65) 19.97 (3.21) 0.004 1.11-5.43 0.001 5.12 to
1.37
0.977 1.86 to
1.92
Self-Acceptance 36.04 (5.79) 41.47 (5.89) 37.81 (7.61) 0.007 1.61 to
9.25
0.325 5.33,1.79 0.103 0.76 to
8.08
Congruent Second
Nature
38 (5.64) 43.73 (4.77) 42.56 (4.63) 0.002 2.23-9.24 0.001 7.17 to
1.95
0.416 1.71 to
4.06
Significant at Bonferroni-adjusted P-value of (P< 0.05/9 = P< 0.0055).
CI indicates confidence interval; CPS, clinical psychopathologic syndromes; FM, Fibromyalgia.
Bold values indicates Significant data.
Garcia-Fontanals et al Clin J Pain Volume 33, Number 11, November 2017
994 |www.clinicalpain.com Copyright r2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r2017 Wolters Kluwer Health, Inc. All rights reserved.
in other studies of FM patients21–25 and patients with other
types of chronic pain.27,30 However, our results allow us to
make some additional comments in relation to this
temperament dimension. The FM group, both with and
without CPS, had significantly higher HA scores than
controls. Comparing FM groups with and without CPS in
our rigorously selected sample, the group with CPS
presented significantly higher HA scores, although the
difference was not as great as with regard to the control
group. That is, patients with FM showed high HA
regardless of the presence or absence of CPS, but the
presence of CPS pushed HA scores up; or, in other words,
patients with high HA were more likely to present a CPS.
Analyzing the subscales reveals that the FM group
with CPS had higher scores on Anticipatory worry-Pessi-
mism, Fear of uncertainty, and Fatigability than the con-
trol group, in agreement with previous studies,21 whereas
the FM group without CPS only presented higher scores on
Fear of uncertainty and Fatigability compared with con-
trols. That is, the subscales most closely linked to the
anxiety component of HA, specifically Anticipatory worry-
Pessimism and Fear of uncertainty, were the ones that
increased the likelihood of presenting psychopathology.
The Fatigability subscale seems to be a characteristic
feature of FM, as it increased regardless of the presence of
CPS. Comparison of the 2 FM groups (with and without
CPS) shows that the subscale Anticipatory worry-
Pessimism was responsible for the difference between
them and therefore seems to be the dimension that deter-
mines the presence of clinical psychopathology.
As for SD, the group with CPS scored significantly
lower than the control group and the group without CPS.
Analyzing the subscales, the group with CPS scored lower
on Responsibility, Purposefulness, Resourcefulness, and on
Congruent second nature than the control group. Com-
paring both groups with FM, it is important to note that
both groups differed on the SD character dimension and
specifically on the Purposefulness, Resourcefulness, and
Congruent second nature subscales. However, the FM
group without CPS did not differ significantly from the
control group. Previous studies of the defining personality
profile of FM have also highlighted the low scores obtained
on the SD character dimension.21,23,24 However, our anal-
ysis shows that only FM patients with CPS score low on
SD, confirming that FM patients are not a homogenous
group.5,9 These results are consistent with those of previous
studies that observed an association between low SD and
the presence of anxious-depressive symptomatology.21,24,29
This is important because the SD dimension reflects the
ability to focus one’s behavior to one’s goals and values
and, according to the Cloninger theory,26 this is indicative
of the capacity of the individual to cope and adapt. This
approach may have important therapeutic implications.
According to Cloninger, temperament dimensions are quite
stable, whereas character dimensions such as SD are
potentially modifiable. Returning to the diathesis-stress
model19 mentioned above, SD, conceptualized as an indi-
vidual’s capacity to adapt, may have been weakened by the
exposure to the stress caused by chronic pain, thus facili-
tating the emergence of psychopathology. However, there
may also be a subgroup of patients with FM who present
low SD before the onset of the illness, and this could
prompt the emergence of psychopathology, which in turn
could hinder the adaptation to the disease. Only a longi-
tudinal study would clarify these issues.
The regression model shows that the Purposefulness
character subscale and the Anticipatory worry-Pessimism
temperament subscale together explained 38% of the variance
of Dysthymia. This finding is consistent with the negative
relationship observed between scores on the Purposefulness
subscale and self-reports such as the Hospital Anxiety and
Depression Scale-Despression Scale and the State Trait Anxiety
Scale-Trait Scale.21 It is worth stressing that the Anticipatory
worry-Pessimism is a temperament dimension, which may
predispose the patient to the development of dysthymia.
Purposefulness, which reflects the extent to which individuals
have valued goals or the meaning or significance they
attribute to their lives, is a character dimension and is
therefore potentially modifiable; acting upon it might help to
reduce the likelihood of developing dysthymia or might at
least modify its severity, which would undoubtedly be of
great therapeutic value.
The regression model also reported that the Anticipatory
worry-Pessimism temperament subscale explained 19% of the
variance of Anxiety Disorder. Hence, the subscale most closely
related to anticipating harm or failure, excessive worrying, and
being pessimistic is the one that contributes most to explaining
thepresenceofnonspecificanxiety disorder as assessed by the
MCMI-III. Anticipatory worry-Pessimism is a temperament
variable, theoretically not amenable to modification. Therefore,
from the therapeutic point of view, high scores on this subscale
suggest vulnerability to the development of anxiety disorders.
These results underline the importance of assessing the presence
of comorbid anxiety disorders in FM to prevent them
from compounding the suffering caused by this chronic
disease.3,4,15,16
The present study has several limitations: (1) the
sample size is relatively small, though highly selective, and
TABLE 5. Standardized Regression Coefficients and Estimates of Variance in “DIS”and “ANS”Explained by the Subset of “HA”and
“SD”Variables
95% CI for B
Variables B SE B Lower Bound Upper Bound bP
Dysthymia Disorder
Anticipatory Worry-Pessimism
1.316 0.726 0.155 2.786 0.266 0.078
Purposeful Adjusted R
2
= 0.38 2.599 0.864 4.348 0.850 0.442 0.005
Anxiety Disorder
Anticipatory Worry-Pessimism Adjusted R
2
= 0.18
2.227 0.740 0.730 3.724 0.434 0.005
Associations of independent variables with dependent variables were analyzed using backward elimination procedure (the exit criterion was P> 0.1).
ANS indicates anxiety disorder; CI, confidence interval; DIS, dysthymia disorder; HA, Harm Avoidance; SD, Self-Directedness.
Bold values indicates Significant data.
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patients were regularly receiving hospital care, which may
reduce the statistical power and limit the generalizability of
the results5; (2) FM patients with comorbid rheumatologic
disease and chronic fatigue syndrome were excluded; (3) the
study design is cross-sectional and hence the possible fluc-
tuation in scores of HA and SD in the same participant
after remission of depressive symptoms was not assessed;
(4) correction of scores using the Bonferroni method may
lead to overcorrection40; and (5) moreover, there is still
some controversy1,2 about the use of the American College
of Rheumatology criteria in making a differential diagnosis
of FM; however, these criteria are widely used.
In conclusion, patients with FM have a high proba-
bility of developing anxious-depressive-type psychopatho-
logic alterations. Their vulnerability to these conditions
may be due to high HA, in the form of high Anticipatory
worry-Pessimism, and low SD, in the form of lower
Purposefulness, Resourcefulness, and Congruent second
nature. HA is a moderately stable dimension, whereas SD
may be modifiable. These findings may have significant
therapeutic implications for the design of future research
and applied purposes.
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