LEARNED OPTIMISM AS AN INTERVENTION
FOR INDIVIDUALS DIAGNOSED WITH FIBROMYALGIA
CLINICAL RESEARCH PROJECT
Cynthia L. Wilson
Carl Davis, PhD
Chair
James Harlow, PsyD
Member
A Clinical Research Project submitted to the Faculty of the American School of Professional Psychology, Argosy University-Tampa in partial fulfillment of the requirements for the degree of Doctor of Psychology in Clinical Psychology.
Tampa, Florida
June, 2009
The Doctorate Program In Clinical Psychology
American School of Professional Psychology
Argosy University- Tampa
CERTIFICATE OF APPROVAL
Clinical Research Project
This is to certify that the Clinical Research Project of
Cynthia Leigh Wilson
with a major in Clinical Psychology has been approved by the
CRP Committee on June, 24, 2009 as satisfactory for the CRP
requirement for the Doctorate of Psychology degree
Examining Committee:
Committee Chair: Carl Davis, PhD
Member: James Harlow, PsyD
Abstract
Optimism and pessimism are known to affect health and illness. Clients with optimistic outlooks of the future who have organic-based illnesses recover faster and live longer than clients with a pessimist outlook. The reason for better outcomes is related to positive coping abilities, internal locus of control, and high self-efficacy. Functional disorders such as fibromyalgia have no known cause; however, research suggests that physical pain may be caused by psychological factors such as underlying depression, anxiety, and antecedents of trauma earlier in life. Currently, the primary interventions for fibromyalgia are medication, cognitive behavioral therapy, and learned coping skills. Since learned optimism is effective for depression, chronic medical conditions, and other psychological disorders, it is likely that learned optimism will be effective for clients with fibromyalgia.
TABLE OF CONTENTS
CHAPTER ONE: INTRODUCTION
Quality of Resilience
Positive Psychology and Coping
CHAPTER TWO: CONCEPT OF OPTIMISM
Optimism Versus Pessimism
Explanatory Styles
CHAPTER THREE: OPTIMISM AND PESSIMISM EFFECTS ON HEALTH
Depression and Anxiety
Learned Helplessness
Effects on Immune Systems
CHAPTER FOUR: FUNCTIONAL DISORDERS AND FIBROMYALGIA
Overview of Functional Disorders
What is Fibromyalgia?
Biological Components of Fibromyalgia
Psychological Components of Fibromyalgia
CHAPTER FIVE: FIBROMYALGIA VERSUS MAJOR DEPRESSION
Differential Diagnosis of Depression
Coping
Fibromyalgia and Treatment
CHAPTER SIX: CONCLUSION
Optimism as an Intervention
Limitations of Research
Further Clinical Implications
Recommendations for Future Research
List of References
Chapter One: Introduction
Quality of Resilience
The quality of resilience refers to patterns of dealing with adversity via positive adaptation. There are two fundamental findings. First is the level of functioning. Second is whether the individual is facing or has faced significant risk or adversity (Masten & Coatsworth, 1998). Factors that are known to positively affect patterns of resiliency are association with past and future experiences and adaptive resources, such as positive coping abilities, intellectual skills, effective parents, and socioeconomic advantages (Luthar, 2003). Of all the resources that contribute to resiliency, the one that seems to be most within the individual's control is adaptability. Resilient people successfully overcome adversity by bouncing back from setbacks and thriving under extreme on-going pressure without behaving in dysfunctional or harmful ways. The most resilient individuals tend to, as a result of overcoming traumatic events, become stronger, better, and wiser. It is believed that everyone is born with the potential to develop the ability to be resilient.
In the professional literature, five levels of resiliency have been identified: 1) the ability to maintain one's emotional stability, health, and well-being; 2) good problem-solving skills; 3) strong inner "self;" 4) well-developed level of resiliency; and 5) the talent for serendipity (Siebert, 1996). The first level, maintaining one's emotional stability, is essential to sustaining health and energy. The second level, good problem-solving skills, focuses outward on the challenges that must be handled. Research has found that problem-focused coping leads to resiliency better than emotion-focused coping. The third level, strong inner "self," focuses inward on the roots of resiliency, which include strong self-esteem, self-confidence, and a positive self-concept. The fourth level, well-developed level of resiliency, covers the attributes and skills found in highly resilient people. The fifth level, talent for serendipity, describes what is possible at the highest level of resiliency, and refers to the ability to convert misfortune into good fortune. Almost everyone encounters some type of adversity in his or her life, yet not all have the ability to bounce back and not give in to negativity. It appears as though people holding optimistic attitudes or outlooks on life tend to bounce back from adversity far better than those who have pessimistic attitudes or outlooks. Pessimism may lead to depression and the sense of helplessness (Siebert, 1996).
Research suggests that optimism and pessimism have effects on health and well-being. Clients with an organic-based illness who have optimistic outlooks recover faster and live longer than client who have a pessimist outlook. The reason for better outcomes is related to positive coping abilities, internal locus of control, and high self-efficacy. Functional disorders such as fibromyalgia have no known cause; however, researchers suggest that pain may be caused by psychological factors such as underlying depression, anxiety, and antecedents of trauma earlier in life. Currently, the primary interventions for fibromyalgia are medication, cognitive behavioral therapy, and learned coping skills. Since the intervention of learning to be optimistic has been effective in depression, chronic medical conditions, and other psychological disorders, it is likely that learned optimism will be an effective intervention for clients with fibromyalgia.
Positive Psychology and Coping
Positive psychology is a new branch of psychology that focuses on the empirical study of such things as positive emotions, strengths-based character, and healthy institutions. Martin Seligman (2000), the founder of positive psychology, has demonstrated that it is possible to be happier, feel more satisfied, be more engaged with life, find more meaning, have an increased level of hope, and probably even able to laugh and smile more, regardless of one's circumstances. Positive psychology interventions can decrease symptoms of depression. The main goal of positive psychology is to catalyze a change in the focus of psychology from preoccupation only with repairing the worst things in life to building positive qualities (Seligman & Csikszentmihalyi, 2000). Treatment using positive psychology is not just fixing what may be damaged; positive psychology is about nurturing the person's strengths. Human strengths act as buffers against mental illness, including courage, future-mindedness, optimism, interpersonal skill, faith, work ethic, hope, honesty, perseverance, and the capacity for insight (Seligman & Csikszentmihalyi, 2000). The science of positive psychology is focused on making normal people stronger and more productive. One dispositional trait that appears to mediate between external events and a person's interpretation of the events is optimism. Christopher Peterson (2000) considers optimism to be a quality that encompasses cognitive, emotional, and motivational components. He believes that people who have high levels of optimism tend to have better moods, to be more persevering and successful, and have better health overall.
In regard to health outcomes, research suggests that those who remain optimistic show less symptoms of illness later in life and survive longer than patients who confront reality objectively (Seligman, 2006). The positive effects of optimism are mediated primarily at the cognitive level (Seligman, 2006). Negative emotions tend to promote illness and discomfort, while positive emotions promote health. An optimistic patient is more likely to adhere to treatment that will enhance health outcomes and will have more social support. One of the most interesting studies discusses how persons high in optimism and hope are actually more likely to provide themselves with unfavorable information about their disease, thereby being better prepared to face realities even though their outcomes may be more positive (Seligman & Csikszentmihalyi, 2000). Because negative emotions often reflect immediate problems or objective dangers, it would seem likely that the negative emotions would be powerful enough to force people to stop and change direction, increase their vigilance, reflect on their behaviors, and change their actions; however, that is not always the case. Rather, positive psychology teaches how to buffer against and prevent mental illness, as well as some physical illnesses. Using positive psychology, a psychologist can learn how to build the qualities that help people, not just to survive, but to thrive.
One way to build positive characteristics is through character development. "Character" refers to those aspects of personality that are morally valued. Good character is at the core of positive development. Baumrind (1998) stated that "it takes virtuous character to will the good and competence to do good well" (p. 13). Most schooling and youth programs today focus on helping youth acquire skills and abilities including reading, writing, mathematics, and critical thinking. In turn, these skills can help them to achieve their life goals. However, without good character, individuals may not desire to do the right thing.
Good character is central to psychological and social well-being. It is not simply the absence of problems, but rather a well-developed family of positive traits. The building and enhancing of character strengths not only reduce the possibility of negative outcomes (Botvin, Baker, Dusenbury, Botvin, & Diaz, 1995), the traits are important in their own right as indicators and causes of healthy positive lifelong development and thriving (Colby & Damon, 1992). Growing evidence shows that certain strengths of character, including hope, kindness, social intelligence, self-control, and perspective, can buffer the negative effects of stress and trauma, preventing or mitigating disorders in their wake (Park & Peterson, 2006). Good character is associated with desired outcomes such as school success, leadership, tolerance and the valuing of diversity, the ability to delay gratification, kindness, and altruism (Scales, Benson, Leffert, & Blyth, 2000). In addition, good character is associated with fewer problems such as substance use, alcohol abuse, smoking, violence, depression, and suicidal ideation (Park & Peterson, 2006).
Chapter Two: Concept of Optimism
Optimism Versus Pessimism
Within human nature, there are two ways in which individuals think about the world: Optimism and pessimism. Individuals can be described as optimists or pessimists based on their cognitive styles of future events. Such thought styles take place on two distinct levels, global and situational. Dispositional optimism or pessimism encompasses a global view of whether the individual sees future events as being positive or negative. Individuals also possess situation-specific expectations that are either positive or negative. Optimists can be confronted with the same difficult situation in the world, yet they think about misfortune in the opposite way compared with pessimists. Optimists tend to believe that negative events are just temporary setbacks, and the event is limited to just one aspect of their lives. Essentially, when optimists are faced with a difficult situation, they tend to perceive it as a challenge and try harder to defeat the situation. The defining characteristic of pessimists are that they tend to believe that bad events will last for a long time, and they undermine their actions and fault themselves for their shortcomings (Seligman, 2006). Martin Seligman (2006) believes that a pessimist can learn to be an optimist by learning a new set of cognitive skills. Chronic pessimism has been linked to several physiological and psychological problems. The four main areas that a pessimistic person may have difficulties with include depression, achieving less work than suggested by his or her talents, ineffective or improper function of the immune system, and life not being as pleasurable as it should be.
Optimists and pessimists tend to experience the same setbacks throughout life, but optimists cope better. A pessimist will give up and may even fall into depression. An optimist is more resilient and will achieve more professionally and within the home. Optimists tend to have better health, recover more quickly from illnesses, and live longer. Techniques and skills can be learned to become more optimistic. For example, one technique entails learning how to talk to yourself when you experience a personal defeat. Learning how to speak to yourself about your setbacks from a more encouraging viewpoint is a key component of optimism (Seligman, 2006). When a goal becomes impossible, the optimist will find another goal to work toward rather than over-focusing on an unattainable goal. Optimists tend to alternate between active coping and reappraisal. If active coping fails to fix the problem, they reappraise the situation, looking for hidden benefits, and ultimately write a new chapter in their lives (Neimark, 2007).
Optimism and pessimism have been related to physical and psychological outcomes. More and more research is being conducted to assess optimistic views of the future in individuals who have physical and psychological issues. However, conflict exists as to precise definitions of optimism and pessimism, as well as in the development and use of measures to determine the different viewpoints. Several studies have evaluated factors of optimism and the correlation between social support, parenting, perceived stress, depression, and anxiety (Seligman & Csikszentmihalyi, 2000). In common across studies is the idea that optimism plays an important role in an individual's psychological adjustment to adverse situations. In reviewing different studies, there are some critical points to be made on how to measure optimism and pessimism and the correlations to other individual factors within coping. In addition, research supports the notion that optimistic people influence other people, optimistic or pessimistic views may be a predictor of future coping abilities, and optimistic views facilitate other protective factors such as social support (Seligman & Csikszentmihalyi, 2000).
Explanatory Styles
As cited by Seligman, 2006 the concept of explanatory styles comes from Bernard Weiner's attribution theory. Attribution theory focuses on the ways an individual explains events to themselves (Seligman, 2006). The first component was the habits of a person's explanation. From the habits of the person came the style or explanation. The style of a person included how he or she saw causes for failure and imposing that style onto the world. The second component, explored from the attribution theory, involved the dimensions of explanation. Weiner described two dimensions, of permanence and personalization; Seligman included a third dimension of pervasiveness. Along with the differences in dimension of explanatory style there was one other major difference, area of focus. Weiner's interests were achievement of the person compared to, Seligman's interests in mental illness and therapy.
These three dimensions are important to understanding explanatory style: permanence, pervasiveness, and personalization. Permanence is related to the concept of time, in terms of viewing events or situations as permanent versus temporary. Individuals with a strong belief in permanence tend to give up easily, because the causes of their negative events are permanent and internal. They believe that the cause is also in their lives and will never go away. Conversely, people who tend to resist helplessness believe that the causes for the negative events are only temporary or external. Helplessness occurs when an individual or animal has learned to behave helplessly, even when the opportunity is restored for it to avoid an unpleasant or harmful circumstance (Peterson, Maier, & Seligman, 1993). When a person thinks about bad things in terms of "always" or "never" and as abiding traits, the person has a permanent pessimistic style of thinking. If a person thinks in terms of "sometimes" and "lately," uses qualifiers, and blames bad events on transient conditions, the person is likely to have an optimistic style of thinking (Seligman, 2006). The optimistic style of explaining good events is just the opposite of the optimistic style of explaining bad events. People who believe that positive events have a permanent cause are more optimistic than people who believe that they have temporary causes (Seligman, 2006). People who tend to believe good events have permanent causes try even harder after they succeed. People who see temporary reasons for a good event may give up even when they succeed, believing that their success was a fluke.
Pervasiveness is related to the concept of space, in terms of viewing events or situations as universal versus specific. People who make universal explanations of their failures give up on everything when failure strikes in one area. They allow one event to affect their entire lives, and they tend to catastrophize. In other words, when one thread breaks, their whole world unravels. People who make specific explanations may become helpless in that one part of their lives, but the person is able to continue to move forward in all other areas. The optimist believes bad events have specific causes, while good events will enhance everything he or she does. The pessimist believes bad events have universal causes, and good events are caused by specific factors (Seligman, 2006).
Both permanence and pervasiveness can determine if a person has hope or not. Finding a temporary and specific cause for misfortune is essential to the art of hope, while permanence and universal causes for misfortune are practices that engender despair or depression. Temporary causes limit helplessness in time, and specific causes limit helplessness to the origin of the situation (Seligman, 2006). On the other hand, permanent causes can produce helplessness far into the person's future, and universal causes spread helplessness in all aspects and endeavors of one's life. People who tend to make permanent and universal explanations for difficulties in their lives tend to break under pressure for longer periods of time and across many situations.
The final aspect of explanatory style is personalization. When bad things happen, we can blame ourselves, or we can blame other people or circumstances. People who blame themselves or internalize when they fail tend to have low self-esteem as a result. They believe that they are worthless, unlovable, and talentless. People who blame external events typically do not lose their self-esteem when difficult situations strike. Essentially, they like themselves better than those who blame themselves. The optimistic style of explaining good events is opposite of that used for bad events; it is internal rather than external (Seligman, 2006). People who believe that they cause good things tend to like themselves better than people who believe good things come from others or circumstances (Seligman, 2006).
Caution should be noted about personalization. Although it is good to have depressive episodes that are limited and to bounce back quickly, we also need to be careful in blaming others for our failures. We need to have personal responsibility. Questions have been raised about whether or not changing beliefs about failure from internal to external factors will undermine responsibility.
Chapter Three: Optimism and Pessimism Effects on Health
Depression and Anxiety
To better understand depression and anxiety, it is useful to consider Beck's theory of depression and anxiety. Aaron Beck developed a cognitive theory that was based on people's thoughts. In his theory of psychopathology with depression and anxiety, a person's thoughts are unrealistic regarding issues within the person's life. Emotions are controlled by these thoughts, and when the person has an inappropriate or extreme reaction that causes distress or disability, the person may be diagnosed with an emotional disorder or neurosis. The thoughts frequently have characteristics that place them into one of three general categories: depression, anxiety, and phobias. The different categories of thought produce different misconstrued themes of thinking. The thoughts are internal and automatic. Most people are not aware that these automatic thoughts even occur. The person's thoughts follow general rules or themes that assist in the interpretation of events. These general rules are perceptions or views, which contribute to how the person receives and processes information. Thoughts occur when the person makes assumptions or predictions about an event or experience. Three specific types of thinking can cause misinterpretations or lead to distorted thoughts: selective abstraction, arbitrary reference, and overgeneralization. Selective abstraction occurs when a detail is taken out of context, and the significance of the total situation is misconstrued. Arbitrary reference occurs when a person jumps to a conclusion when the evidence is lacking or may contradict the conclusion. Overgeneralization occurs when a person refers to unjustified generalizations on the basis of a single experience. The cognitive theory also explores psychosomatic symptoms and their causes related to stressors and emotional reactions (Beck, 1976).
Depression focuses on significant loss. The depressive theme can be viewed in terms of the cognitive triad. The cognitive triad consists of three components: a negative conception of self, a negative interpretation of life experiences, and a nihilistic view of the future (Beck, 1976). Typical emotions associated with depression include sadness, disappointment, and apathy. Loss triggers depression, and the losses can be obvious or subtle. Once the person with depression experiences loss, he or she begins to perceive experiences in a negative way. He or she will overgeneralize or overinterpret experiences and likely views them as defective, deprived, or deficient. The sense of deprivation, pessimism, and self-criticism causes the person to experience sadness. The person then may experience the feeling of apathy and completely give up. The point at which a person gives up will either lead to avoidance of situations or suicidal thoughts.
Anxiety focuses on danger to a person's domain. He or she anticipates detrimental occurrences to himself, his family, property, status, or valued items (Beck, 1976). An anxious person perceives danger in events that cannot be avoided. The perception of danger may be psychological or physical. Cognitive distortion occurs with anxiety when a person has repetitive thoughts about danger; the ability to cope with fearful thoughts is reduced, and the person experiences stimulus generalization, which is the tendency for stimuli similar to an original stimulus to produce a response approximating that learnt under the original condition. The anxious person also has a tendency to catastrophize events, dwelling on the most extreme consequences imaginable regarding the threat of danger. A characteristic of catastrophizing is that the person will view the possibility of harm to be real, causing the event to seem more dangerous than it really may be. Anxiety can be referred to as an overactive alarm system that can be triggered at the slightest sign of danger. Phobias differ from anxiety in that the anticipation of danger, either psychological or physical, is specific to a given situation. If a phobic person is not in the specific situation, he or she does not experience anxiety.
Psychosomatic disorders may occur when a person experiences chronic stress or extreme emotional reactions. The stress causes emotional arousal such as anxiety, anger, or euphoria. This emotional arousal stimulates the autonomic nervous system. With autonomic arousal, one or more physiological systems are activated. The physiological systems affected by emotional arousal are different for each person; however, over time, the physiological system may be affected by somatic manifestations of lesions or disturbances. These physiological disturbances are not always ongoing. They are sometimes triggered by stressful events. For example, constant anxiety may cause a person to develop an ulcer. The ulcer may not affect the person until he experiences a stressful event. The kinds of psychosomatic disorders are dependent on the types of specific personality characteristics, discord, or thought processes.
Aaron Beck (1976) developed this cognitive theory on the basis of the thoughts of a person. The thoughts are mostly internal perceptions manifested by a person. If a person has irrational or illogical thinking, he or she may develop psychopathology. Psychopathology is categorized into three different types including depression, anxiety, and paranoid state. As discussed in the previous paragraphs, the difference between the types depends on the person's views or perceptions. The person tends to create a theme or rule by which he interprets events. Over time, if a person experiences distress, this in turn may cause physiological symptoms and illness. The goal of cognitive therapy is to assist a person in developing techniques to overcome irrational and unrealistic thoughts. If the person is open to exploring his thoughts and fantasies, he or she may be able to use the techniques to overcome blind spots, distorted perceptions, and self-deceptions. The person's thoughts can alleviate or alter inappropriate or excessive emotional reactions. These techniques can be used with future problems or situations, ultimately resulting in healthier psychological and physical outcomes.
Results of over 10 years of research conducted by Martin Seligman and his colleagues found that people who are depressed are also pessimistic (Seligman, 2006). This does not indicate that pessimism causes depression, but rather that depressed people happen to be pessimistic at the same time they are depressed. Rumination and pessimism can lead to depression by creating a threat in which one has no control, which leads the individual to believe that he or she is helpless. An additional consideration is the way one perceives the cause of the threat. For example, if you are a pessimist, you will arrive at a permanent, pervasive, and personal explanation. Consequently, you expect to be helpless in the future and in many situations, triggering depression (Seligman, 2006). Cognitive therapy and antidepressant medication are effective treatments for depression. Antidepressants are more of an activator to get the patient up and out into the world, but antidepressants do not make the world any brighter for the patient. Cognitive therapy changes the way a patient looks at things. One of the active steps in cognitive therapy for people with depression is a change in explanatory style from pessimistic to optimistic. The means by which cognitive therapy works is by making the patient more optimistic. This approach helps with relapse prevention because the patient acquires skills that he or she can use repeatedly without relying on other methods of treatment. Drugs alone fail to change the underlying pessimism, which is at the root of the problem.
Beck's cognitive therapy has five basic steps that are used to treat depression. The first step is learning to recognize the automatic thoughts that are flowing in a person's consciousness. The second step is learning how to dispute the automatic thoughts by exploring contrary evidence. The third step is learning how to consider alternative explanations for causes of the events, called reattribution, and using these alternatives to dispute the automatic thoughts. The fourth step is learning how to distract one's self from depressing thoughts. The fifth step is learning to recognize and question the depressing assumptions that govern a person's day-to-day actions (Beck, 1976).
Research suggests that there is relationship between depression and an individual's explanatory style. Beck (1983) interprets depressive vulnerability as two personality styles, which include sociotrophy and autonomy. Sociotrophy refers to an excessive reliance on social approval and support, such as placing the needs of others first and constantly trying to please others. Autonomy refers to the extreme need for independence and achievement, such as readily resenting any perceived violations to one's personal control and remaining highly reticent about personal issues (Beck, 1983). Optimism can be seen as resilience against depression. Optimism produces positive affect due to the expectations for a good outcome in any event. Empirical evidence indicates that optimists do indeed have better coping strategies and that well-adjusted people display more optimism than depressed people (Hawkins & Miller, 2003).
Learned Helplessness
Another important consideration when discussing optimism and pessimism is learned helplessness. Learned helplessness theory was originally proposed after the results of experiments in dogs demonstrated dramatic failures in a shuttle box avoidance task (Brennan & Charnetski, 2000). The central assertion of the theory was that "helpless" subjects learned that their actions were independent of shock termination in a task before the avoidance procedure, which translated into poor performance in the subsequent avoidance task (Maier & Seligman, 1976). It was later argued that exposure to inescapable shock produces a constellation of symptoms that resembles depression in humans (Maier & Seligman, 1976). According to Maier and Seligman (1976), there are three essential components to the learned helplessness theory including contingency, cognition, and behavior.
Contingency refers to the objective relationship between a person's actions and the outcome. The most important contingency is uncontrollability, that is, a random relationship between an individual's actions and outcomes (Maier & Seligman, 1976). The opposite of contingency, controllability, occurs when the individual's actions reliably produce the outcomes desired. Cognition refers to the way in which the person perceives, explains, and extrapolates the contingency (Maier & Seligman, 1976). Behavior refers to the observable consequence of (non)contingency and the person's cognitions about the observable consequence. Helplessness studies measure a person's passivity versus activity in a situation different from the one in which uncontrollability was first encountered (Maier & Seligman, 1976). The learned helplessness theory indicated that other symptoms might follow from the individual's expectation of future helplessness such as low self-esteem, sadness, loss of aggression, cognitive retardation, immune changes, and physical illnesses.
In addition to the mentioned research, later research discovered that the original theory of learned helplessness failed to account for people's varying reactions to situations that can cause learned helplessness (Peterson & Park, 1998). Although learned helplessness sometimes remains specific to one situation (Cole & Coyne, 1977), at other times, it generalizes across situations (Hiroto & Seligman, 1975). An individual's attribution style or explanatory style was the key to understanding why people responded differently to adverse events (Peterson & Seligman, 1984). Although a group of people may experience the same or similar negative events, it is how each person privately interprets or explains the event that will affect the likelihood of acquiring learned helplessness and subsequent depression (Abrahamson, Seligman, & Teasdale, 1978). People with a pessimistic explanatory style, which views negative events as permanent ("it will never change"), personal ("it's my fault"), and pervasive ("I can't do anything correctly") are most likely to suffer from learned helplessness and depression (Peterson, Maier, & Seligman 1993). Cognitive behavioral therapy, heavily endorsed by Seligman, can help people to learn more realistic explanatory styles and can help ease depression.
Effects on Immune Systems
The immune system is the body's cellular defense against illness. It contains different kinds of cells whose job is to identify and kill foreign invaders, such as viruses, bacteria, and tumor cells. Research has indicated that learned helplessness does not just affect behavior, it also reaches to the cellular level and makes the immune system passive and weak (Brennan & Charnetski, 2000). An optimistic person will have fewer episodes of helplessness than a pessimistic person. Since the optimist has less helplessness, the immune system of the optimistic person might be better. Optimistic people also tend to adhere to health regimens and medical advice because they believe their actions will cause the health problem to decrease. The more negative events a person encounters in any given time period, the more illness he or she will experience (Seligman, 2006). Pessimistic people tend to be more passive when it comes to illness. They are less likely to take steps to avoid bad events and less likely to do anything to stop them once they start. Overall, pessimists have more frequent bad events (Seligman, 2006). If more bad events lead to more illnesses, pessimists might have more illness. There is another reason optimist have better health, which is social support. Optimists tend to be able to develop relationships with others, and social contact and support is a buffer against health concerns. People who tend to isolate themselves when they are sick tend to get sicker.
The immune system is connected to the brain, and states of mind such as hope have corresponding brain states that reflect the psychology of the person (Seligman, 2006). These brain states have an effect on the rest of the body, so emotion and thought can affect illness. The brain and immune system are connected through hormones, the chemical messengers that drift through the blood and can transmit emotional states from one part of the body to another. When a person is depressed, the brain changes as well (Seligman, 2006). Neurotransmitters, which are hormones that relay messages from one nerve to another, can become depleted. One set of transmitters, called catecholamines, becomes depleted during depression (Seligman, 2006). When catecholamines become depleted, other chemicals called endorphins, the body's own morphine, and increases activity. Cells of the immune system have receptors that sense the endorphin levels. When catecholamines are low, as in depression, endorphins go up. As a result, the immune system detects this and turns itself down (Seligman, 2006). Over time, both the immune system and the endorphin levels become depleted. Pessimism itself seems to lower immune activity (Seligman, 2006).
The first systematic study of pessimism's role in causing sickness was carried out by Chris Peterson and Martin Seligman (1984). They had his class of 150 students complete an optimism questionnaire and a report on their health. They then followed the health of the students for the next year. They found that pessimists had twice as many infectious illnesses and made twice as many visits to the doctor than optimists did. In another study, 69 women with breast cancer were followed for 5 years (Scheier & Carver, 1987). Women who did not experience recurrence tended to be those who responded to the cancer with a "fighting spirit." Conversely, those who died or who experienced recurrence tended to respond to their initial diagnosis with helplessness and stoic acceptance (Peterson & Seligman, 1984).
In addition to better overall health and better survival of breast cancer, optimists have more stable cardiovascular systems, more responsive immune systems, and less hormonal responses to stress compared to pessimists (Neimark, 2007). They tend to have a stronger sense of self-efficacy, resulting in behaviors that make them more likely to follow through with healthy behaviors because they actually think they can make a difference. Being an optimist means you are actively engaging with the world and taking concrete steps to make yourself healthier. Of note, there is a caveat to becoming an optimist. If a person starts working harder, stress hormones may go up, which decreases the effectiveness of the immune system for a period of time (Neimark, 2007). However, it is like working out at the gym. For example, after the first few times, a person may have discomfort over a short period of time. Yet in the long term, the person gets the payback of health and fitness. Optimism may also predict whether people remain actively involved with life after falling ill (Segerstrom, 2001).
Optimism, or the expectation of positive outcomes, has been tied to better physical health and more successful coping when faced with health challenges (Segerstrom et al, 1998). Optimists tend to cope differently with stressors, experience less negative mood, and may have more adaptive health behaviors. All of these factors could lead to a better immune system. Dispositional optimists are people who hold generalized positive outcome expectancies, have less mood disturbance in response to a number of different stressors compared to pessimist (Scheier & Carver, 1987). These finding may be attributed to optimists' belief that discrepancies between their goals and their current attainment will be resolved, minimizing self-defeating moods such as shame, depression, and anger (Carver & Scheier, 1985). Because optimism is reliably associated with less negative mood, mood is a plausible first pathway by which optimism can be associated with immune changes under stress. In relation to specific psychiatric disorders, major depression, generalized anxiety, and posttraumatic stress disorders have been associated with fewer circulating lymphocytes and worse lymphocyte function (Segerstrom et al., 1998). Having fewer circulating and functioning lymphocytes makes it difficult to fight off diseases and heal already present health problems (Segerstrom et al., 1998).
Chapter Four: Functional Disorders and Fibromyalgia
Overview of Functional Disorders
Functional disorders are defined as disorders of physiological function with no organic cause. However, there is some controversy between the medical and psychiatric fields regarding the etiology of functional disorders. Medical practitioners state that these disorders may be biological. Psychiatric practitioners believe that somatic symptoms are caused by common mental disorders such as depression and anxiety. Somatic symptoms are physical symptoms with no biological or organic cause that are attributed to a mental health disorder. Somatic symptoms account for over 50% of all outpatient visits in the United States alone (Schappert, 1992). Approximately 75% of patients report resolution or improvement of their somatic symptoms within a few weeks of health care treatment. The other 25% of patients report no change or even worsening of their symptoms (Kroenke, 2003). Overall, somatic symptoms persist in 20% to 25%; however, some symptoms such as back pain, headaches, and musculoskeletal complaints have higher levels of persistence, between 35% and 45% (Kroenke, 2003).
Functional disorders are characterized by groups of somatic symptoms; such disorders include irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, temporomandibular disorder, and the controversial multiple chemical sensitivity. Irritable bowel syndrome is a chronic gastrointestinal disorder of unknown cause. Common symptoms include abdominal cramping or pain, bloating and gassiness, and altered bowel habits. Irritable bowel syndrome has been called spastic colon, functional bowel disease, and mucous colitis. Fibromyalgia is a disorder characterized by muscle pain and fatigue. Chronic fatigue syndrome is a disorder of extreme fatigue. The fatigue of chronic fatigue syndrome is not the kind of tired feeling that resolves after rest. Instead, it lasts a long time and limits a person's ability to do ordinary daily activities. Temporomandibular disorders occur as a result of problems with the jaw, jaw joint, and surrounding facial muscles that control chewing and moving the jaw. Multiple chemical sensitivity syndrome is a disorder that seems to be triggered by exposure to low levels of multiple identifiable or unidentifiable chemical substances commonly present in the environment.
Co-occurrence of functional disorders occurs commonly. The co-occurrence was 35% to 70% for fibromyalgia and chronic fatigue syndrome, 32% to 80% for fibromyalgia and irritable bowel syndrome, 58% to 92% for irritable bowel syndrome and chronic fatigue syndrome, 33% to 55% for fibromyalgia and multiple chemical sensitivity, and 30% to 67% for chronic fatigue syndrome and multiple chemical sensitivity (Kroenke, 2003). The high levels of co-occurrence are not surprising considering how these functional syndromes are diagnosed, which are predominately or exclusively on the basis of somatic symptoms.
The majority (70%-90%) of patients with depression or anxiety who present in primary care complain of somatic symptoms rather than volunteering psychological symptoms such as "I'm depressed" or "I've been feeling anxious" (Simon et al., 1999). However, most patients will disclose psychological symptoms if asked specifically about them (Gur et al., 2006). This being said, even though somatic symptoms present as the opening in a primary care setting, the treating practitioner will need to inquire about coexisting psychological disturbance(s). Several aspects should lead to suspicion of depressive or anxiety disorders. First, symptoms that remain medically unexplained after the initial evaluation carry a higher risk of psychiatric comorbidity. To note, it does not matter what the type of somatic symptom is. Approximately 50% to 75% of patients with medically unexplained symptoms have a depressive disorder, and 40% to 50% have an anxiety disorder (Kroenke, 2003). Second, the number of somatic symptoms is a powerful marker of psychological comorbidity. The other predictors are recent stress, low self-rated health, high utilization of health care services, and high severity of the patient's presenting symptoms. Functional disorders such as fibromyalgia have no known cause; however, researchers suggest that pain may be caused by psychological factors such as underlying depression, anxiety, and antecedents of trauma earlier in life (Hughes, 2006). Currently, the primary interventions for fibromyalgia are medication management, cognitive behavioral therapy, and learned coping skills. If learning to be optimistic has been effective in the treatment of depression, chronic medical conditions, and other psychological disorders (Seligman, 2006), it is likely that learned optimism will be an effective intervention for clients with fibromyalgia.
What is Fibromyalgia?
Fibromyalgia is a chronic pain syndrome characterized by diffuse musculoskeletal aches, stiffness, and exaggerated tenderness at 18 specified tender points. It is found in approximately 2% of the U.S. population, in 3.4% of women and 0.5% of men (Abeles et al., 2007). The modern concept of fibromyalgia as a pain syndrome in the absence of otherwise apparent organic disease was established in the 1950s; however, it was not until the 1990s that the American College of Rheumatology committee established the following criteria for the diagnosis of fibromyalgia: A history of widespread pain involving all four limbs and the trunk of the body and mild or greater tenderness to digital palpitation of at least 11 of 18 specified tender points (Abeles et al., 2007). The precipitants of chronic widespread pain are unknown, but fibromyalgia seems to be a final common pathway for a myriad of conditions or combinations thereof, ranging from the psychosocial to the mechanical to the biological. Patients with anxiety, depression, or somatizing personality traits may be predisposed to develop fibromyalgia, or once developed, to maintain the syndrome. In other patients, physical or psychological trauma or certain viruses including hepatitis B, hepatitis C, and human immunodeficiency virus (HIV) may be partly responsible for initiating the events that lead to fibromyalgia (Abeles et al., 2007).
Although fibromyalgia patients have a greater number of comorbid physical and psychological conditions than patients with other chronic pain conditions, they also have more difficulty coping because this syndrome is difficult to treat and is characterized by multiple symptoms with no known organic basis (Johnson, Zautra, & Davis, 2006). Progression towards illness occurs when distrusting and negative validating patterns dominate the interaction between health care professionals and significant others. An example of a negative interaction is the health care professional who views the patient in a stressful life situation dominated by pain and despair. Rather than viewing pain as the main problem, the pain is looked upon as a consequence of psychological need or desire for secondary gains (Hughes, 2006). One important factor that appears to characterize the condition of fibromyalgia is illness uncertainty. Illness uncertainty has been found to be significantly higher in fibromyalgia compared to osteoarthritis patients. Illness uncertainty has been described as cognitive stressors, a sense of loss of control, and a perception about one's illness that changes over time. Researchers define illness uncertainty as "the inability to determine the meaning of illness-related events in situations where the decision maker is unable to assign definite values to objects and events and/or is unable to accurately predict outcomes because sufficient cues are lacking" (p. 696) (Johnson et al., 2006). Research has indicated that high levels of uncertainty were most often associated with more perceived stress-related hospital events, less hope, more illness intrusiveness, and greater emotional distress and mood disturbance, specifically more anxiety, tension, anger, and depression (Johnson et al., 2006).
Biological components of fibromyalgia. Over time, a number of hypotheses have been investigated for a broad range of etiological and biological causes for fibromyalgia. Accruing evidence shows those patients with fibromyalgia experience pain differently from the general population because of dysfunctional pain and how it is processed in the central nervous system. Aberrant pain processing, which can result in chronic pain and associated symptoms, may be the result of several interplaying mechanisms, including central sensitization, blunting of inhibitory pain pathways, alterations of neurotransmitters, and psychiatric comorbid conditions (Abeles et al., 2007). Many clinical studies have found differences in pain processing between patients with fibromyalgia and healthy persons (Gur et al., 2006). Although patients with fibromyalgia have similar thresholds for sensing normal stimuli, such as pressure, heat, and cold, the threshold at which stimuli become painful is lower in patients with fibromyalgia than in healthy persons. Investigators have objectively documented a lower pain threshold in patients with fibromyalgia by using a pain measure known as the nociceptive flexion reflex, a validated tool for studying central and chronic pain states and the effects of centrally acting analgesic drugs (Fan, 2004). Patients with fibromyalgia had a statistically significantly lower nociceptive flexion reflex threshold compared with control participants (Abeles et al., 2007).
An earlier study suggested that metabolites such as adenosine triphosphate and adenosine diphosphate were lower in tender points of the muscles than in the same anatomical locations in control participants (Fan, 2004). However, muscle detraining results in decreased levels of these compounds, and patients with fibromyalgia are typically deconditioned. Because these studies did not match the levels of aerobic fitness of healthy control participants with those of patients with fibromyalgia, their results must be viewed with skepticism. Earlier studies attributing the cause of fibromyalgia to peripheral tissue pathology were methodologically flawed, and none have been validated (Fan, 2004). Despite the accumulating evidence against the notion that fibromyalgia is caused by peripheral lesions, groups are still searching for and publishing information on such abnormalities (Abeles et al., 2007).
In studying levels of pressure causing pain in patients with fibromyalgia but not in control participants, two areas of the brain were active only in the control group, suggesting that patients with fibromyalgia may demonstrate blunting of descending inhibitory pathways. Results of functional magnetic resonance imaging have shown that, compared with healthy control participants, patients with fibromyalgia experience increased brain activity in pain-relevant areas not only while receiving painful and nonpainful tactile stimuli, but also while at rest (Abeles et al., 2007). Results of positron emission tomography (PET) scans of the brain in patients with fibromyalgia demonstrate tonic reduction in baseline thalamic metabolic activity, even in the absence of painful stimuli, suggesting intrinsic abnormalities of initial pain signal processing (Fan, 2004). However, researchers have also demonstrated decreased thalamic activity in chronic neuropathic pain, suggesting that abnormalities of thalamic function may be a signature of chronic pain in general and may not be unique to fibromyalgia (Abeles et al., 2007). Moreover, the abnormalities found in functional imaging of patients with fibromyalgia have not been consistent across studies (Abeles et al., 2007).
Abnormal temporal summation, or "wind-up," is the phenomenon whereby, after an initial painful stimulus, subsequent equal stimuli are perceived to be more intensely painful. This magnified "second pain," which occurs in everyone, is exaggerated in patients with fibromyalgia. In patients with fibromyalgia, as N-methyl d-aspartate receptor (NMDA-receptor) antagonist ketamine attenuates wind-up; muscular hyperalgesia, referred pain, and muscle pain are at rest. The NMDA-receptor antagonist dextromethorphan, a common ingredient in cough medicine, was also recently shown to reduce experimentally induced wind-up in patients with fibromyalgia and control participants (Abeles et al., 2007). Mounting evidence indicates that patients with fibromyalgia experience abnormal pain amplification at the level of the spine, although the specific abnormalities leading to amplification have not been completely elucidated (Abeles et al., 2007).
Glial cells, long thought to be metabolically inactive support cells in the nervous system, are now recognized as playing a substantial role in the modulation of pain signals. Glial cells and astrocytes, which are star shaped glial cells, are activated by stimuli that induce pain, such as nerve trauma, subcutaneous irritation, and intraperitoneal inflammation, and by neurotransmitters involved in pain signaling (Abeles et al., 2007). In addition to being receptors for neurotransmitters, glial cells express receptors for bacteria and viruses, which may explain why infection with neurotropic organisms, such as HIV, is frequently associated with fibromyalgia or other chronic pain syndromes. Glial cells release many neuroactive substances on activation by painful stimuli, including nitric oxide, prostaglandins, leukotrienes, nerve growth factors, excitatory amino acids, and reactive oxygen species. Activated glial cells have unregulated release of substance P and other excitatory amino acids from primary afferent neurons in the spinal cord and enhance the excitability of pain transmission neurons (Abeles et al., 2007). In addition, microglia, which are a type of glial cells that are the resident macrophages of the brain, and astrocytes release proinflammatory cytokines. Blocking these actions of the cytokines prevents or reverses exaggerated pain states. Because connections exist between groups of glial cells and the types of transmitters they release, activation of glial cells may cause expansion of the pain field or extraterritorial pain. Glial cells surrounding pain neurons can alter and enhance the signaling and perception of pain. Inhibition of glial cell activation prevents exaggerated pain states. Although a role for glial cells in fibromyalgia pathogenesis is attractive, studies of glial cell responses in fibromyalgia remain to be conducted (Abeles et al., 2007).
Serotonin, a neurotransmitter derived from tryptophan, is produced by neurons in the brainstem. Serotonin is widely distributed and has inhibitory effects on several pain pathways. Increased serotonin in the brain leads to blunted pain signaling via decreased release of substance P in the spinal cord. Measurements of serotonin levels in patients with fibromyalgia have yielded conflicting data. Although some small studies showed decreased serotonin levels in patients with fibromyalgia, decreased levels were also found in patients with osteoarthritis. Larger studies found no statistically significant difference between patients with fibromyalgia and pain-free persons (Abeles et al., 2007). A different study was conducted in which researchers compared serotonin levels in the cerebrospinal fluid in patients with fibromyalgia with those in patients with lower back pain and pain-free persons. Patients with fibromyalgia had statistically significantly lower levels of serotonin in cerebrospinal fluid than did persons in either control group (Abeles et al., 2007). Because these studies were small, and their results were not concordant, no definite conclusions can be drawn (Abeles et al., 2007).
The S allele, an alternative form of a gene, is found with greater frequency in patients with anxiety traits, affective disorders, and obsessive-compulsive disorder (OCD). Offenbaecher et al (1999) observed an increased frequency of the S/S genotype, a gene found in depression, in patients with fibromyalgia compared to healthy control participants. Of note, the S/S subgroup showed higher levels of psychological distress and depression. A study conducted in the early 1990s genotyped the 5-HTT, the serotonin transporter gene, in patients with fibromyalgia and healthy control participants and found a statistically significantly higher expression of the S/S genotype in patients with fibromyalgia (Abeles et al., 2007). In contrast, a different study compared 5-HTT polymorphisms in patients with fibromyalgia who had normal psychological profiles and with those of healthy control participants and observed no statistically significant differences (Abeles et al., 2007). Taken together, these studies identified no differences between mentally healthy patients with fibromyalgia and healthy control subjects. However, they suggest differences between control participants and the subset of patients with fibromyalgia with anxiety traits. Thus, aberrant serotonin signaling may link anxiety and chronic pain, which indicates that anxiety, may be linked to pain. Altered levels of serotonin alone are probably insufficient to explain the pain state in fibromyalgia (Abeles et al., 2007).
In animal models, acute stress states activate mesolimbic dopamine neurons and induce analgesia. Prolonged stress, however, decreases mesolimbic dopaminergic output and, in turn, creates a hyperalgesic state. Results of a recent study comparing the response of female patients with fibromyalgia and healthy control participants to buspirone showed an augmented prolactin response in the fibromyalgia group (Jeffrey & Clauw, 2005). Researchers attributed this to altered dopamine sensitivity in the patients with fibromyalgia. Of note, the study was small and suggests further work is needed before any conclusions can be drawn about the role dopamine may play in fibromyalgia (Abeles et al., 2007).
Psychological components of fibromyalgia. The hypothalamic-pituitary-adrenal axis plays a central role in the physiologic response to stress. Studies have shown that the hypothalamic-pituitary-adrenal axis in patients with fibromyalgia is disturbed, including elevated cortisol levels lacking diurnal fluctuation and increased corticotrophin-releasing hormone stimulation (Abeles et al., 2007). However, these findings were not specific to patients with fibromyalgia. Elevated cortisol levels were also seen in patients with depression and patients with a history of child abuse who do not have fibromyalgia (Abeles et al., 2007). In primary care practices, more than one-half of patients with depression present with purely somatic symptoms, and most of these symptoms are pain (Abeles et al., 2007). The presence of depression worsens pain outcomes and vice versa; their common pathways and neurotransmitters probably explain the reciprocal relationship between depression and pain (Abeles et al., 2007). Patients with fibromyalgia have increased rates of depression compared to patients without fibromyalgia, which have been thoroughly detailed in several previous reviews (Abeles el al., 2007). Antidepressants, which help normalize norepinephrine and serotonin responses, are mainstays of fibromyalgia therapy. Despite substantial overlap between depression and fibromyalgia, most patients with fibromyalgia are not clinically depressed, and fibromyalgia is therefore an independent but overlapping entity (Abeles et al., 2007). Patients with nonorganic somatic symptoms have elevated rates of psychological distress, anxiety, depression, and functional impairment, compared to patients with organic symptoms. The more unexplained somatic symptoms a patient presents with, the more psychiatric comorbid conditions he or she is likely to have. Cross-sectional studies of patients with fibromyalgia have shown elevated rates of anxiety and somatization, compared to patients not diagnosed with fibromyalgia. However, because these studies examined the psychiatric profiles of patients with known fibromyalgia, it is not possible to determine whether these patients had a psychiatric comorbid condition causing fibromyalgia or whether the pain state led to psychiatric distress (Abeles et al., 2007).
The presence of tender points in patients with fibromyalgia is closely associated with their current level of anxiety. Additionally, patients with a history of psychological trauma associated with anxiety, for example childhood trauma or sexual abuse, have a higher number of tender points. The results of several studies have documented that patients with fibromyalgia are more likely to have experienced abuse. Moreover, patients with fibromyalgia have increased rates of posttraumatic stress disorder. Two recent studies surveying for posttraumatic stress symptoms in consecutively presenting patients with fibromyalgia found a high percentage of these symptoms, 57% and 56%, respectively (Abeles et al., 2007). Traumatic events in the lives of patients with fibromyalgia should therefore be explored, because they may be contributing to current pain and distress (Abeles et al., 2007).
In summation, fibromyalgia is frequently associated with psychiatric comorbid conditions, which may contribute to the development or persistence of symptoms or both. Although it was previously unclear whether fibromyalgia led to psychiatric illness or vice versa, evidence is accruing that psychiatric illness predisposes to the development of the syndrome (Abeles et al., 2007). What is most clear is that patients with fibromyalgia experience pain differently than the general population, and they do so in the absence of an organic cause. On the basis of the known precipitants, emotional or psychiatric disturbance or both may modulate pain processing to produce fibromyalgia in many patients (Abeles et al., 2007). The prevalence of depression in patients with fibromyalgia is estimated to be between 20% and 80%, and this is higher than those in healthy controls and in patients with other chronic pain syndromes (Hudson & Pope, 1989). Depression scores have been related to symptom severity including pain, fatigue, and illness behavior (Kurtze, Gundersen, & Svebak, 1998). Coping strategies have also been related to poor health outcomes in patients with fibromyalgia.
Chapter Five: Fibromyalgia versus Major Depression
Differential Diagnosis of Depression
Depression profoundly impairs the ability to function in everyday situations by affecting mood, thoughts, behaviors, and physical well-being. Study after study suggests biochemical and genetic links to depression (Pinel, 2008). A considerable amount of evidence also supports the view that depressed people have imbalances in the brain's neurotransmitters, the chemicals that allow communication between nerve cells (Pinel, 2008). Serotonin and norepinephrine are two neurotransmitters whose low levels are thought to play an especially important role (Pinel, 2008). The fact that women have naturally lower serotonin levels than men may contribute to women's greater tendency toward depression. Environmental factors may also play a role in depression (Pinel, 2008). When combined with a biochemical or genetic predisposition, life stressors, such as relationship problems, financial difficulties, death of a loved one, or medical illness may cause depression to manifest.
To qualify for the diagnosis of a major depressive episode, a person must have experienced at least five of the nine symptoms below for the same 2 weeks or more, for most of the time almost every day, and this is a change from the person's prior level of functioning. One of the symptoms must be either (a) depressed mood or (b) loss of interest (American Psychiatric Association, 2000).
- Depressed mood. For children and adolescents, this may be irritable mood.
- A significantly reduced level of interest or pleasure in most or all activities.
- A considerable loss or gain of weight (e.g., 5% or more change of weight in a month when not dieting). This may also be an increase or decrease in appetite. For children, they may not gain an expected amount of weight.
- Difficulty falling or staying asleep (insomnia) or sleeping more than usual (hypersomnia).
- Behavior that is agitated or slowed down. Others should be able to observe this.
- Feeling fatigued, or diminished energy.
- Thoughts of worthlessness or extreme guilt (not about being ill).
- Ability to think, concentrate, or make decisions is reduced.
- Frequent thoughts of death or suicide (with or without a specific plan), or an attempt at suicide.
Results of an extensive literature review demonstrate that depression predicts morbidity, mortality, and health service utilization (Tennen, Eberhardt, & Affleck, 1999). Although the high rate of depression among individuals with chronic pain is well-documented, there remains considerable debate regarding the causal relationship between pain and depression (Wolfe & Hawley, 1993). The results of recent investigations have found that pain predicts subsequent depression, depression influences pain, and that reciprocal influence processes characterize the association between pain and depression (Tennen & Affleck, 2006). Individuals with fibromyalgia have a high prevalence of lifetime depressive disorder and a family history of depression (Johnson et al., 2006). Although the individual may be predisposed to depression, one theory suggests that the depression is latent until it is triggered or primed by a stated of elevated distress (Tennen & Affleck, 2006). Instead of attempting to alleviate their pain, interpret pain sensations, or distract themselves from pain, these individuals may catastrophize in their response to pain. Studies of coping with chronic pain have been able to conclude only that individuals who report more severe pain also experience more unpleasant mood and less effective coping skills when dealing with pain (Tennen & Affleck, 2006). Results of studies have found those individuals with fibromyalgia and a history of depression demonstrated increase in venting emotions and reductions in perceived coping efficacy on days with increased pain, compared to patients with fibromyalgia without depression (Tennen & Affleck, 2006). This finding suggests that when dealing with patients with fibromyalgia, lifetime depression should expand beyond examining personality traits, attitudes, and explanatory styles.
Coping
Coping strategies and the effectiveness of the used strategies have been an important part of dealing with pain. A study conducted in 1989 found significant differences in coping related to gender. The study suggested that when confronted with stressors, women more than men sought social support and focused on venting emotions, and men more than women reported alcohol use (Tennen & Affleck, 2006). The results of studies also indicated that better-adjusted and physically active patients with pain were more inclined to use adaptive coping strategies such as ignoring the pain and coping self-statements. These patients were less likely to engage in catastrophizing responses that involve negative cognitions and ruminations (Novy et al, 1998).
Coping is a dynamic process that shifts in nature across stages of a stressful situation. People who view their stressors as changeable report engaging in more active coping, planning, suppression, competing activities, and seeking of social support then those who view their stressors as something that that they have gotten used to (Novy et al., 1998). The practices of diverting attention, ignoring pain, and using coping self-statements were related to improved adjustment for people reporting relatively low levels of pain severity. Optimistic active coping and a higher perceived ability to both control and decrease pain in association with a variety of active coping strategies, such as diverting attention, engaging in positive self-talk, and increasing overall activity level, have also been very effective in decreasing pain levels.
Fibromyalgia and Treatment
Although it is unknown whether pain causes depression or depression contributes to pain, when looking at fibromyalgia, there are no clear criteria to differentiate between the two. The type of treatment the patient receives depends on whether the patient goes to a physician or a mental health professional. If a patient presented for psychological treatment, he or she would likely be diagnosed with a major depression disorder and a pain disorder. If the same patient sought medical treatment, he or she may be diagnosed with fibromyalgia. Some of the current treatments for fibromyalgia include medications, psychological interventions, and homeopathic treatments. One type of psychological intervention is cognitive behavioral therapy, which provides education, training in relaxation, coping skills, rehearsal of skills learned, and relapse prevention. Additional coping skills including activity pacing, visual imagery, and distraction strategies are also used to decrease distress. Other psychological factors that should be addressed include aggressive treatment of depression, treatment of anxiety, assistance in dealing with stress, and treatment for sleep disturbance. Exploring the patient's beliefs about pain and assessing self-efficacy are central to the pain experience and frequently determine outcomes.
Other treatments include physical therapy, which can include massage, low-grade aerobic exercises, and trigger point injections. Attention to diet is also encouraged to promote general nutrition, with the use of appropriate vitamin supplements as needed, bone health, and weight reduction. Several types of medications can be prescribed to patients with fibromyalgia to address symptoms of anxiety and insomnia. These medications include benzodiazepines such as alprazolam, temazepam, and clonazapam; the anxiolytic buspirone; the antidepressant trazodone; and the hypnotics zolpidem, zalephon, and eszopiclone. Opiates are prescribed for general pain, and skeletal muscle relaxants, such as cyclobensaprine are prescribed for muscle pain. Selective serotonin reuptake inhibitor (SSRI) antidepressants such as fluoxetine, citalopram, escitalopram, paroxetine, and sertraline or dual serotonin/norepinephrine reuptake inhibitors such as venlafaxine and duloxetine are prescribed to treat depression. Anticonvulsants such as gabapentin, topiramate, tiagabine, and pregabalin serve as adjunctive medication for disturbed sleep and depression. Topiramate may also be prescribed for migraine headaches associated with fibromyalgia. As some of these medications may cause weight gain or weight loss treatment compliance may become an issue. At times, antihypertensive agents , such as clonidine, are helpful in controlling withdrawal symptoms during tapering of opioids. Recently, the first Food and Drug Administration (FDA)-approved medication for treatment of fibromyalgia was released. This medication is the anticonvulsant pregabilin. Pregabalin is an oral medication that is chemically similar to gabapentin. It was initially used for treating pain caused by neurologic diseases, such as postherpetic neuralgia, as well as seizures, and now it is also used for treating fibromyalgia. The mechanism of action of pregabalin is unknown. Pregabalin binds to calcium channels on nerves and may modify the release of neurotransmitters (Ogbru, 2006). Reducing communication between nerves may contribute to pregabalin's effect on pain and seizures. The FDA approved pregabalin in December 2004. There are other areas of concerns related to complications in patients with fibromyalgia other than prescribed medications. These concerns include allodynia, opioid or alcohol dependence, functional impairment, severe depression and anxiety, and obesity and physical deconditioning. Allodynia is pain from stimuli that are not normally painful. The pain may occur in areas other than in the area stimulated.
Chapter Six: Conclusion
Optimism as an Intervention
If depression is either a major contributor or the cause of fibromyalgia, then the concept of learned optimism could be a very effective treatment for any functional disorder and specifically for fibromyalgia. Several steps would need to be taken to determine if this hypothesis is true. First, a study would need to be conducted to determine if patients with fibromyalgia are in fact pessimistic and to determine the explanatory style of individuals with fibromyalgia. Pessimists can learn to be optimists by learning a new set of cognitive skills. Second, a treatment plan would need to be developed; for example, group therapy, individual therapy, or a combination of both would need to be developed to provide treatment for patients with fibromyalgia. Third, open communication would be needed with other health professionals to provide continuity of care and to monitor any additional factors such as medications.
If learned optimism were used as a primary mode of psychological intervention, the outcomes may include a decrease in symptoms of depression and anxiety, an increase in locus of control, decreased helplessness, and improved quality of life. Although the patient's pain may not completely resolve, by decreasing depression and anxiety, the patient would be less susceptible to pain and discomfort. The patient may also be more compliant with treatment if efforts to comply were seen as beneficial and likely to have a positive outcome to decrease pain. It is likely that the patient would be less susceptible to future illness and may even be healthier than the average person.
Previous studies on optimism used only nonclinical populations. In the future, research involving optimism or pessimism should evaluate clinical populations with psychiatric disorders. Most clinical populations have more psychological distress compared to nonclinical populations, and optimism is considered an important part of coping. If individuals could be taught to be more optimistic with treatment, it is then possible to enhance coping skills and protective factors so the individual has a better chance of being successful in life. This area of psychology has potential and should be explored for better treatment approaches in both physical illnesses and psychological disorders such as depression and anxiety.
Limitations of Research
There are several noted limitations of the literature reviewed on fibromyalgia. First, the study samples consist primarily of White females. The samples are typically volunteers from internet Web sites or pain management centers, and very little of the literature includes other racial or ethnic populations or male subjects. Second, there are limitations on differential diagnoses of psychological disorders including depression, anxiety, or possible personality disorders. Although some studies explored the patient's psychological history with instruments such as questionnaires, none used professional interviews or psychological assessments to explore personality profiles of patients with fibromyalgia.
Although the literature identifies the comorbidity of fibromyalgia and depression, it gives very little understanding to the possibility of other disorders and how they manifest. Additionally, the nature of the association between fibromyalgia and depression is controversial. Patients with fibromyalgia may become depressed because of pain and disability, or controversially, as a classic psychosomatic theory, depression may cause fibromyalgia. Future research in this area needs to provide a better understanding of the clients and psychological factors. Some of the studies that should be conducted may include full psychological batteries to determine any patterns that may present themselves and can be used for treatment purposes. Psychological patterns that may emerge could be personality characteristics such as, histrionic personality, hypochondriasis, dependency issues, somatization, and possibly substance abuse issues.
Furthermore, there are limited studies that support empirical psychological treatments with patients with fibromyalgia. The results of a review of 31 controlled trials of cognitive behavioral therapy for somatic symptoms and functional syndromes documented the efficacy of cognitive behavioral therapy in the treatment of back pain, chest pain, irritable bowel syndrome, chronic fatigue syndrome, somatization, and other selected somatic symptoms (Kroenke & Swindle, 2000). As few as five sessions of group therapy provided efficacious results and, in some, benefits were sustained for up to 12 months. If more studies were conducted, psychological treatment may be indicated as the first line of treatment of any functional disorder. If there were more empirical studies, it may give the mental health provider a starting point to provide effective treatment.
Further Clinical Implications
By providing mental health professionals with a better understanding of the diagnosis of fibromyalgia and other functional disorders, they will have a better understanding of what type of treatment is needed for this population. Up until the last few years, there was little literature for the mental health professional as a source of information for functional disorders. In the upcoming Diagnostic Manual, functional disorders will receive greater emphasis in relation to psychiatric disorders.
Formulating treatment recommendations for a client presenting with fibromyalgia include several steps. The first step is a psychological evaluation to determine if a mental health diagnosis is present. It is also important to understand if the client has a history of substance abuse, due to the number of medications that may be prescribed for fibromyalgia. Because some medications often prescribed for fibromyalgia are addictive, the mental health provider should take into consideration clients with a substance abuse history and the likelihood that they may develop cross addictions. Assessing personality characteristics is an essential component in determining the limitations and types of treatment that may be appropriate for the client. For example, personality dysfunctions such as dependent and histrionic personality may decrease or complicate treatment effectiveness. The second step would be to determine what, if any, secondary gain the client may be receiving from their disorder. Secondary gain is any covert advantage that is not directly related to the professed desired outcome. Secondary gain is not consciously known by the person, but it motivates their behavior all the same, often in a self-destructive way. This may give an understanding as to why the client is endorsing symptoms and displaying behaviors. The third step would be to determine the type of treatment to recommend to the client. The client may benefit more from group therapy, individual therapy, or even a combination of therapies. The therapy should focus on coping skills and changing explanatory styles. The fourth step involves ensuring open communication between all parties to assess progress and to monitor if the client is adhering to treatment.
Like cognitive therapy, the appropriate selection of individuals for different interventions should be taken into account. Cognitive therapy is considered effective for a variety of psychological disorders, including anxiety disorders, depressive disorders, phobias, sexual abuse, pain management, behavioral disorders, posttraumatic stress disorder, eating disorders, substance abuse disorders, and obsessive compulsive disorders (Stallard, 2002). Cognitive therapy is not effective for active psychosis and mental retardation (Stallard, 2002). There are also developmental components to be considered regarding social and cognitive development when using cognitive therapies, such as learned optimism. With this in mind, the therapist should assess the client to determine if cognitive therapy is an appropriate intervention to use as treatment for the client.
Recommendations for Future Research
There are many areas for recommendations for future research regarding learned optimism and fibromyalgia. At this time, the literature is limited regarding the psychological aspects of an individual diagnosed with fibromyalgia. The literature would benefit from additional research that includes a more diverse population to include both genders and different ethnic backgrounds. The research could also improve on sample selection and recruit from areas other than the internet. If the populations of individuals diagnosed with fibromyalgia are truly somatic the individuals are not likely going to be seeking psychological treatment and may need to be referred by their treating medical physician. Another area that could be expanded is providing a full psychological assessment for individuals with fibromyalgia to determine any other psychological disorders that may be associated with fibromyalgia.
Other recommendation includes conducting studies on learned optimism as an intervention for individuals with a fibromyalgia diagnosis. Initially, there would need to be an intervention designed specifically for fibromyalgia clients. This design would likely include a series of groups to provide psychoeducation to the group about learned optimism and how to develop the skills needed to change their thought processes. The groups should also provide information about how to self-monitor thoughts and affect. An additional psychotherapy process group or individual therapy may also be beneficial to assist in treatment. Once the learned optimism intervention is designed, it would be beneficial for studies to be conducted to collect outcome data on groups with a fibromyalgia diagnosis and overall treatment outcomes for each individual. Additional, if information is provided from a full psychological evaluation of the individual, revealing other psychological issues, individual therapy and psychotropic medications may also need to be considered as part of treatment. If the individual is prescribed psychotropic or any other medications it would be beneficial to have open communication with all treating practitioners. If the intervention of learned optimism is successful in the treatment of individuals with fibromyalgia it could decrease the need for additional medical treatment, therefore decreasing the financial overall cost of long term treatment for each individual. Other benefits of the learned optimism intervention may be to apply the intervention to other functional disorders such as, irritable bowel syndrome and chronic fatigue.
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