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Rheumatology Advance Access originally published online on November 4, 2006
Rheumatology 2007 46(4):666-671; doi:10.1093/rheumatology/kel363
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© The Author 2006. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

The role of psychosocial factors in predicting the onset of chronic widespread pain: results from a prospective population-based study

A. Gupta, A. J. Silman, D. Ray1, R. Morriss2, C. Dickens3, G. J. MacFarlane4, Y. H. Chiu, B. Nicholl and J. McBeth

Arthritis Research Campaign (ARC) Epidemiology Unit, School of Epidemiology and Health Sciences, 1Endocrine Sciences Research Group, Stopford Building, University of Manchester, Oxford Road, Manchester, M13 9PT, 2University Department of Psychiatry, Royal Liverpool University Hospital, Liverpool, L69 3GA, 3Department of Psychiatry, Rawnsley Building, The University of Manchester, M13 9WL and 4Epidemiology Group, Department of Public Health, University of Aberdeen, School of Medicine, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UK.

Correspondence to: Dr John McBeth, Arthritis Research Campaign (ARC) Epidemiology Unit, School of Epidemiology and Health Sciences, Stopford Building, University of Manchester, Oxford Road, Manchester, M13 9PT, UK. E-mail: john.mcbeth{at}manchester.ac.uk


   Abstract
Top
 Abstract
Introduction
 Subjects and methods
 Results
 Discussion
 Acknowledgements
 References
 
Objective. Chronic widespread pain (CWP) is strongly associated with psychosocial distress both in a clinical setting and in the community. The aim of this study was to determine the contribution of measures of psychosocial distress, health-seeking behaviour, sleep problems and traumatic life events to the development of new cases of CWP in the community.

Methods. In a population-based prospective study, 3171 adults aged 25–65 yrs free of CWP were followed-up 15 months later to identify those with new CWP. Baseline data were available on their scores from a number of psychological scales including Illness Attitude Scales (IAS), Somatic Symptom Checklist (SSC), Hospital Anxiety & Depression Scale, Sleep Problems Scale, and Life Events Inventory.

Results. 324 subjects [10%, 95% confidence interval (CI) 9.2, 11.3] developed new CWP at follow-up. After adjustment for age and sex, three factors independently predicted the development of CWP: scoring three or more on the SSC [odds ratio (OR) 1.8, 95% CI 1.1, 3.1], scoring eight or more on the Illness Behaviour subscale of the IAS (OR 3.3, 95% CI 2.3, 4.8), and nine or more on the Sleep Problem Scale (OR 2.7, 95% CI 1.6, 3.2). Subjects exposed to all three factors were at 12 times the odds of new CWP than those with low scores on all scales.

Conclusion. Subjects are at substantial increased odds of developing CWP if they display features of somatization, health-seeking behaviour and poor sleep. Psychosocial distress has a strong aetiological influence on CWP.

KEY WORDS: Pain, Psychosocial, Risk factors, Prospective


   Introduction
Top
 Abstract
 Introduction
Subjects and methods
 Results
 Discussion
 Acknowledgements
 References
 
The relationship between fibromyalgia and psychosocial distress is well-established. Studies show a high prevalence of current or lifetime depression [1], anxiety and somatization disorder [2, 3] in clinical patients. Psychosocial factors were also strongly related to chronic widespread pain (CWP), the cardinal symptom of fibromyalgia, in community-based subjects unselected for their consultation behaviour [4, 5]. However, these studies were cross-sectional and cannot determine the temporal relationship between psychosocial distress and the onset of CWP. Psychosocial distress may be a consequence of chronic pain, rather than the cause of it.

As far as we are aware, there has been only one prospective study examining the relationship between psychosocial distress and the onset of CWP. In 2001, we reported from the results of a population-based prospective study (The Altrincham Pain Study) of 1658 adult subjects free of CWP [6]. We observed an increased odds of developing new CWP 12 months later, among subjects who at baseline displayed aspects of the process of somatization, as measured by the Somatic Symptom Checklist (SSC), and health seeking behaviour, as measured by the Illness Behaviour subscale of the Illness Attitude Scales (IAS) [6]. Although robust predictors of symptom onset, the proportion of all new cases we were able to predict was relatively modest; among subjects in the highest odds groups, the prevalence of new CWP was 21%, while the majority of subjects did not develop CWP. Of all the new cases identified, only 6% were in the highest odds groups suggesting that other factors, psychosocial or otherwise, contribute to the development of CWP.

There are a number of other psychosocial factors that may be important in identifying those at risk of new pain. Thus, anxiety and depression are well-known correlates of fibromyalgia and CWP [4, 7]. Disturbances of sleep pattern are very common in fibromyalgia [8, 9], with patients often complaining of unrefreshing sleep, repeated arousals at night and morning fatigue [10, 11]. Stressful life events have also been reported to precede fibromyalgia in various retrospective studies [12, 13].

The aim of the current study was to attempt a more robust evaluation of the contribution of psychological distress (anxiety, depression and somatization), health seeking behaviour, sleep disturbances and traumatic life events to the onset of CWP.


   Subjects and methods
Top
 Abstract
 Introduction
 Subjects and methods
Results
 Discussion
 Acknowledgements
 References
 
Study design
This was a population-based prospective study in which participants were contacted by postal survey. At baseline, the presence or absence of CWP was recorded in addition to the assessment of a large number of psychosocial factors. Fifteen months after the baseline survey, subjects free of CWP at baseline were followed-up, and new cases of CWP were ascertained.

Study subjects
A random sample of 11 000 subjects aged 25–65 yrs was selected from three population-based primary care registers covering a socio-demographically mixed urban area. Subjects were recruited from three disparate socio-demographic areas, with widely varying levels of employment and income, with the aim that the population would be broadly representative of a typical suburban population. The project had ethics committee approval from South Manchester Local Research Ethics Committee and South Cheshire Local Research Ethics Committee. All subjects gave written informed consent.

Baseline assessment of CWP
Subjects were sent a questionnaire by mail, which inquired whether they had experienced any pain during the last month that had persisted for at least 24 h, and, if so, whether the pain had been present for more than 3 months. Four manikin drawings of the body were included (front, back and sides), on which subjects were asked to indicate the sites of pain. These methods, which have been extensively studied [14, 15], were used to determine the location and duration of pain. On the basis of this information, a trained observer using standard manikin data capture forms for the presence or absence of CWP categorized subjects. CWP was defined using the American College of Rheumatology (ACR) criteria for fibromyalgia [16]. To satisfy these criteria, subjects must have pain present in two contralateral quadrants of the body, above and below the waist, and in the axial skeleton, and this pain must have been present for at least 3 months.

Baseline assessment of psychosocial factors
This comprised a number of different scales derived from subject-completed questionnaires.

The Somatic Symptom Checklist (SSC)
The SSC was devised as a screening test for somatization disorder [17]. The scale includes six basic items: trouble breathing, frequent vomiting (when not pregnant), loss of voice for more than 30 min, being unable to remember what you have been doing for hours or days (without the influence of alcohol or drugs), difficulty swallowing and frequent pain in the fingers or toes. A seventh item, frequent trouble with menstrual cramps, is included for female respondents. These symptoms are included in the American Psychiatric Association's criteria for somatization disorder [18]. In the study from which these criteria were derived, a threshold between three and four resulted in a sensitivity of 73% and specificity of 94% for identifying cases of somatization disorder. To avoid spurious associations with new cases of CWP, only the ‘non-pain’ somatic symptoms were examined (i.e. frequent trouble with menstrual cramps and frequent pain in the fingers or toes were excluded). The total score was, therefore, between zero and five for both males and females. The SSC modified in this way predicted the development of CWP in the community [6].

Illness Attitude Scales (IAS)
The IAS [19] assesses attitudes and concerns about illness and health. Each scale includes three items, each scored from zero to four, providing a total score between 0 and 12. Individual scales assess worry about health, concern about pain, health habits, hypochondriacal beliefs, thanatophobia (fear of death), disease phobia, bodily preoccupation, treatment experience and effect of symptoms. A study based on a principal components analysis demonstrated that of the 27 items which make up the IAS, 17 measure two dimensions reflecting ‘health anxiety’ and ‘illness behaviour’ [20]. The ‘health anxiety’ subscale consists of 11 items (such as ‘Are you worried that you may get a serious illness in the future?’) and has a total score between 0 and 44, with a general population mean score of 9.1 (S.D. 6.9). The ‘illness behaviour’ subscale consists of six items (such as ‘Do your bodily symptoms stop you from working?’) and has a total score between 0 and 24, with a general population mean score of 4.7 (S.D. = 4.2).

Hospital Anxiety and Depression Scale (HAD)
The HAD was developed to identify ‘caseness’ (possible and probable) of anxiety disorders and depression among patients with physical health complaints in non-psychiatric hospital units [21]. The scale was divided into an Anxiety subscale (HAD-A) and a Depression subscale (HAD-D), both containing seven intermingled items. Each of the 14 items asks about symptoms of anxiety or depression in the last week on a 0–3 scale. Scores on each subscale of 10–11 gives a high probability of an anxiety or a depressive episode being present.

Sleep Problem Scale
This validated four-item Sleep Problem Scale [22] asks about problems with sleep within the past month. Responses are scored in the range of 0–5, giving a total score of between 0 and 20. The scale has been used extensively in previous studies on fibromyalgia and CWP [15, 23, 24].

Life Events Inventory
Information on adverse life events associated with a significant marked or moderate long-term threat in the previous 6 months was obtained using the 12-item ‘List of Threatening Experiences’ [25], modified from a 67-item life events inventory [26]. The categories cover personal relationships, employment, illness and financial and legal problems.

Follow-up
Subjects free of CWP at baseline were mailed an identical questionnaire after 15 months. Methods for categorizing pain were identical to those used in the baseline survey. The observer, categorizing pain status from the follow-up pain manikins, was blinded to subjects’ baseline status, measures of psychosocial distress, and all other information included in the baseline questionnaire. New CWP at follow-up was defined using the ACR definition as aforediscussed.

Statistical analysis
Those subjects who provided complete data at baseline and follow-up were included in the analysis. The distributions of baseline psychosocial scale scores were not Gaussian. The Illness Behaviour & Somatic Symptom Checklist scales were categorized in the same way as our previous prospective community study of CWP [6]. For the other scales, subjects’ scores were divided by thirds. The association between new CWP and the scale scores of subjects who scored in the middle and highest thirds were compared with those in the lowest third by logistic regression analysis, adjusted for age and gender. The results are presented as odds ratios with 95% CI that under the rare disease assumption provide a valid estimate of the relative risk [27]. Risk factors found to be associated with CWP were entered into a multiple logistic regression model to examine their relative contribution to the presence of new CWP. All analyses were conducted using the STATA statistical software package (STATACorp, 1993).


   Results
Top
 Abstract
 Introduction
 Subjects and methods
 Results
Discussion
 Acknowledgements
 References
 
At baseline, 10 987 persons were mailed a questionnaire (13 subjects were deemed not able to participate by their general practitioner and were removed from the study). A total of 6792 responses were received (68.2% response rate after adjusting for persons not resident at their listed address and subjects who had died, n = 1032). Of the subjects who responded, 5190 were free of CWP, of whom 4201 were eligible to be followed-up and comprised the cohort for the present study (Fig. 1).


Figure 1
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  		FIG. 1. Flow chart showing participation of subjects from baseline to follow-up phase.

 
Figure 1 shows that at the 15-month follow-up, 3185 subjects returned the questionnaire (82% after adjustment for subjects who had moved to another address or died), of whom 3001 returned a full questionnaire, 139 a short questionnaire, and 45 subjects completed a telephone questionnaire. Of these, pain status could be determined in 3171 subjects. We compared the baseline characteristics of participants at follow-up with those subjects who were lost to follow-up due to various reasons (Table 1). Participants were older, more likely to be female, and had higher scores on Illness Behaviour and Sleep Problem scales than those who were lost to follow-up.


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  		TABLE 1. Distribution of age, gender and psychological scale scores of participants and non-participants in the follow-up questionnaire

 
As shown in Table 2, of the 3171 subjects who did not have CWP at baseline, 324 (10.2%) reported new CWP at follow-up. Older female subjects were slightly more likely to report symptoms. Table 3 shows the age- and sex-adjusted univariate associations of all the baseline psychosocial scores with the presence of new CWP. Subjects in the highest third based on their scores for the psychosocial factors were at the greatest odds for reporting new CWP. For all scales there was evidence of a ‘dose-response’ effect across the thirds of the distributions. The strongest effects were in the illness behaviour score and the Sleep Problem Scale. In a multivariate analysis (Table 3), three factors made independent contributions to the odds of new CWP, namely illness behaviour, somatic symptoms and sleep problems.


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  		TABLE 2. Prevalence of new CWP by age and sex

 

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  		TABLE 3. Psychological predictors of new CWP on univariate logistic regression, adjusted for age and gender

 
Of the subjects who were free of CWP at baseline, a substantial proportion reported some pain at baseline: while 1326 (41.8%) reported no pain, 1771 (55.6%) reported pain that was not widespread, while 74 (2.3%) had widespread pain that was not chronic. We expected that individuals with pain would be at greater odds of new CWP at follow-up. This was indeed the case: 38 (2.9%) of subjects with no pain developed CWP, 270 (15.3%) of those with some pain and 16 (21.2%) of those with widespread but not chronic pain at baseline developed new CWP. Indeed, compared with those reporting no pain, those with some pain [OR = 6.1, 95% CI (4.3, 8.6)] and those with widespread pain [OR = 9.4, 95% CI (5.0, 17.9)] had an increased odds of developing CWP after adjusting for the effects of age and gender. These relationships were not simply a reflection of increased rates of somatization among those with some pain at baseline: no differences were observed in scores on the somatic symptom, illness behaviour and sleep scales. After adjusting for the presence of pain at baseline the somatic symptom checklist [OR = 2.2, 95% CI (1.4, 3.6)], illness behaviour scale [highest third OR = 5.2, 95% CI (3.8, 7.2)] and sleep scale [OR = 2.5, 95% CI (1.8, 3.4)] remained independent, albeit attenuated, predictors of symptom onset.

Finally, we examined the point prevalence of new CWP by the combination of those three factors significantly associated in the multivariate analysis with prevalent cases at follow-up, i.e. somatic symptoms, illness behaviour and sleep problems. As shown in Table 4, there was evidence of an additive effect. Subjects who scored in the highest range of all three factors had 27.4% odds of new CWP, while those who scored in the lowest categories of all four factors had only 3.2% odds. Subjects scoring highly on all three scales were at 12 times higher odds of developing new prevalent CWP than those who had the lowest scores.


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  		TABLE 4. Prevalence and odds of new CWP according to exposure to psychological factors

 

   Discussion
Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
Acknowledgements
 References
 
We have demonstrated that psychosocial factors including multiple physical symptoms, help-seeking for health problems, sleep problems and adverse life events increase the likelihood of the onset of CWP in the next 15 months 20-fold in a community sample. The presence of one or more of these four factors, present in 78.6% of the study sample, predicted 93% of new cases of CWP. In a previous cohort, we demonstrated that the best predictors of CWP at 12 months were the Somatic Symptom Checklist and Illness Behaviour Scale [6]. Table 5 shows that in our current cohort, of those subjects scoring in the highest categories of both scales, 28.0% developed new CWP, while among those subjects who scored in the lower ranges of both these scales, 4.6% developed new CWP. These proportions compare with 20.8% and 1.4%, respectively, in the original study [6].


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  		TABLE 5. Prevalence of new CWP at follow-up, by baseline Somatic Symptom and Illness Behaviour scores

 
The strengths of the study are the prospective follow-up design, the community sample drawn from three disparate socio-demographic areas, with widely varying levels of employment and income, the use of a broad range of standardized measures and the use of blinding to establish outcome independent of baseline pain status, demographic data or psychosocial data. The study is an improvement on our first cohort study which was conducted in a smaller sample drawn from a relatively prosperous area and considered a smaller range of psychosocial factors (illness attitudes and somatization) [6].

The greatest potential threat to the validity of the current findings was in the attrition of the cohort at the various stages of investigation. Of those subjects free of CWP who sent in completed questionnaires at baseline, a substantial number was lost to follow-up because of moving house, death, non-response and refusals. We were concerned about any effect of such non-participation, and therefore undertook an analysis comparing those who participated with those who did not. As is usual in epidemiological surveys, those who participated were more likely to be older and female, two factors associated with the reporting of CWP. It is possible that we have therefore over-estimated the rate of CWP in our population. Assuming that all subjects who did not respond were likely to be free of CWP, we have calculated the minimum prevalence rate of CWP at follow-up to be 6.2% [95% CI (5.6%, 6.9%)]. Non-responders also had higher scores on Illness Behaviour and Sleep Problem Scales. These differences would only affect the internal comparisons in the present study if the relationship between the illness behaviour and sleep problem scores and the prevalence of new CWP were different in those subjects who participated in the study compared with those who did not. It is possible that people who seek help from doctors for their health problems are also more likely to participate in research on those health complaints. The external validity of the study is likely to be influenced by the fact that the follow-up sample was restricted to 58% of the subjects who had sent in completed baseline questionnaires, although this would not have affected the internal validity of the study. Given that help seeking for health problems was related to the development of CWP and if help seeking for health problems is related to participation in research on those health problems, then the prevalence rate of new CWP in the community may not be as high as 10%.

Another potential confound in the study is that some of these patients presenting with CWP may have an underlying physical pathology causing their symptoms. The sample was restricted to an <65 yr age group, and the prevalence of new CWP was little influenced by age or gender. A substantial effect of underlying physical pathology would probably be reflected in a strong age effect on the prevalence of new CWP so it is unlikely that underlying physical pathology would bias the association between psychosocial factors and the development of new CWP.

Our follow-up period was 15 months. This is a relatively short follow-up period in the context of a chronic disorder such as CWP, which has a ‘low turnover’. We realize that by making the follow-up period short, we may have missed some subjects who may have gone on to develop CWP in the future. Conversely, given the chronicity of the outcome, we are unlikely to have missed many subjects who developed CWP during the follow-up period, but were not ‘in-state’ at the time of the follow-up survey.

There are a number of psychosocial factors we have not considered that have been previously reported in clinical samples with fibromyalgia. Psychosocial factors include previous sexual, physical and emotional abuse and neglect experiences as a child or an adult [12, 28], positive affect and information processing disposition [29], previous lifetime pain experience [30], and lifetime illicit drug abuse and eating disorders [28]. All of these are difficult to establish in a valid way in a large-scale community study. It is unclear whether these factors would explain more new cases of CWP, or whether they would contribute to the psychosocial predictors of CWP that we have established. For instance, sexual assault is related to somatization, illness attitudes and help seeking for health problems in primary care samples [31].

In summary, we have shown that in a group of persons free of CWP, psychosocial factors are important predictors of the future development of CWP. These data lend further support to the hypothesis that psychological factors precede the onset of CWP and may relate to its origin. The low rate of symptom onset among the minority of subjects not exposed to these factors is notable.


   Acknowledgements
Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 Acknowledgements
References
 
The authors are grateful for the participation and help of the doctors, staff and patients of the three general practices in Greater Manchester, and Joanne Bradley and Karen Schafheutle for survey administration. This study was supported by the Arthritis Research Campaign, Chesterfield, United Kingdom.

The authors have declared no conflicts of interest.


   References
Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 Acknowledgements
 References
 

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Submitted 29 March 2006; revised version accepted 21 September 2006.
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K. L. Limer, B. I. Nicholl, W. Thomson, and J. McBeth
Exploring the genetic susceptibility of chronic widespread pain: the tender points in genetic association studies
Rheumatology, May 1, 2008; 47(5): 572 - 577.
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