Abstract
PurposeTo describe and evaluate somatic symptoms in patients with rheumatoid arthritis (RA) and fibromyalgia, determine the relation between somatization syndromes and fibromyalgia, and evaluate symptom data in light of the Diagnostic and Statistical Manual-5 (DSM-5) criteria for somatic symptom disorder.MethodsWe administered the Patient Health Questionnaire-15 (PHQ-15), a measure of somatic symptom severity to 6,233 persons with fibromyalgia, RA, and osteoarthritis. PHQ-15 scores of 5, 10, and 15 represent low, medium, and high somatic symptom severity cut-points. A likely somatization syndrome was diagnosed when PHQ-15 score was ≥10. The intensity of fibromyalgia diagnostic symptoms was measured by the polysymptomatic distress (PSD) scale.Results26.4% of RA patients and 88.9% with fibromyalgia had PHQ-15 scores ≥10 compared with 9.3% in the general population. With each step-wise increase in PHQ-15 category, more abnormal mental and physical health status scores were observed. RA patients satisfying fibromyalgia criteria increased from 1.2% in the PHQ-15 low category to 88.9% in the high category. The sensitivity and specificity of PHQ-15≥10 for fibromyalgia diagnosis was 80.9% and 80.0% (correctly classified = 80.3%) compared with 84.3% and 93.7% (correctly classified = 91.7%) for the PSD scale. 51.4% of fibromyalgia patients and 14.8% with RA had fatigue, sleep or cognitive problems that were severe, continuous, and life-disturbing; and almost all fibromyalgia patients had severe impairments of function and quality of life.ConclusionsAll patients with fibromyalgia will satisfy the DSM-5 “A” criterion for distressing somatic symptoms, and most would seem to satisfy DSM-5 “B” criterion because symptom impact is life-disturbing or associated with substantial impairment of function and quality of life. But the “B” designation requires special knowledge that symptoms are “disproportionate” or “excessive,” something that is uncertain and controversial. The reliability and validity of DSM-5 criteria in this population is likely to be low.
Highlights
Fibromyalgia is defined by criteria that depend upon the range and severity of symptoms
With respect to the Diagnostic and Statistical Manual-5 (DSM-5) criteria [9], we considered any of the Patient Health Questionnaire-15 (PHQ-15) items that was scored as ‘‘bothered a lot’’ to satisfy the DSM-5 ‘‘A’’ criterion: ‘‘ One or more somatic symptoms that are distressing ...’’ As noted above, we investigated ‘‘3 or more severe somatic symptoms’’ in the PHQ-15 as a more rigorous measure of somatic symptom severity
To investigate the DSM-5 ‘‘B’’ criteria items of ‘‘1) Disproportionate and persistent thoughts about the seriousness of one’s symptoms; 2) Persistently high level of anxiety about health or symptoms; and 3) Excessive time and energy devoted to these symptoms or health concerns–we used as a surrogate the reporting of 1, 2 or 3 American College of Rheumatology (ACR) criteria symptoms that were ‘‘3 Severe: continuous, life-disturbing problems.’’ As there are no precise instructions about how to evaluate the DSM-5 ‘‘B’’ criterion, we examined mean levels of clinical severity variables described below
Summary
Fibromyalgia is defined by criteria that depend upon the range and severity of symptoms. A tendency to experience and communicate somatic distress and symptoms unaccounted for by pathological findings, to attribute them to physical illness, and to seek medical help for them,’’ adding that ‘‘it is usually assumed that this tendency becomes manifest in response to psychosocial stress brought about by life events and situations that are personally stressful to the individual’’ [4]. In his comprehensive review he warned, that ‘‘... DSM-IV, DSM-IVTR), [6,7,8] but was abandoned in 2013 in DSM-5 [9] and replaced by ‘‘Somatic Symptom Disorder’’ (DSM SSD) (See Table S1)
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