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Results:Numerous studies indicate that patients with fibromyalgia experience psychological distress. Various instruments have been used to evaluate distress and related psychological domains, such as anxiety or depression, in fibromyalgia. In many cases, these same instruments have been used to study personality characteristics in fibromyalgia with a subsequent blurring of cause and effect between personality and psychological distress. In addition, the symptoms of fibromyalgia may change pre-illness personality characteristics themselves. These issues make it difficult to identify specific personality characteristics that might influence the fibromyalgia process. Despite this inherent problem with the methodologies used in the studies that make up this literature review, or perhaps because of it, we found no defined personality profile specific to fibromyalgia.

However, many patients with fibromyalgia do show personality characteristics that facilitate psychological responses to stressful situations, such as catastrophising or poor coping techniques, and these in turn associate with mechanisms contributing to fibromyalgia. INTRODUCTIONFibromyalgia (fibromyalgia syndrome) is a common musculoskeletal pain syndrome, more frequent in women than men (9:1 respectively) and occurring in up to 2-4% of the population within Western societies. It is characterized by widespread pain and abnormal tenderness, associated with variable stiffness, fatigue, poor quality sleep, cognitive disturbance and emotional distress ,.

Major quality of life issues result and these have high societal impact, including medical, psychological and financial.Clinicians typically recognize certain personality characteristics that they associate with fibromyalgia. For instance, patients with fibromyalgia have been described as perfectionist , introspective, demanding and at times exhausting to manage. While such personality traits may appear to contribute to the development and/or persistence of fibromyalgia symptoms, due to the complexities of both personality research and the pathophysiology of fibromyalgia, the links between the two remain unclear.Personality is generally considered to be an integration of affective, cognitive and behavioural patterns , at both a conscious and unconscious level that is unique to a person.

The study of personality is not straightforward. Numerous theories and perspectives have been proposed to account for the similarities and differences in human nature that typify personality, particularly how, when and why people adapt within certain environments. The breadth of theories is extensive with no single, unifying approach that captures all the elements of personality. Personality is multifaceted and therefore no simple assessment tool can account for all domains of personality.This review focuses on the “top-down” model of fibromyalgia mechanisms in order to explore associations between personality and fibromyalgia (Fig. Life predicaments represent events that may trigger psychological responses, including thoughts and emotions.

These in turn may modulate biological responses that include pain, tenderness, fatigue, sleep and cognitive changes, components of the fibromyalgia phenotype. Biological pain generators in the musculoskeletal system may provide the substrate for pain amplification in this setting, but this model places psychological factors, in the broad sense of that term, as the primary cause for fibromyalgia. Life events are filtered, or modulated, by factors such as core beliefs, coping skills and control. Personality is also seen as a filter between life events and psychological responses in this model. A number of pervading and variable factors, such as mood change, anger, and stress may contribute to background psychological distress and further amplify this process.

Finally, the psychological and biological responses in themselves will feedback and cause more psychological distress. Proposed model of fibromyalgia linking emotionaldistress, life events and physical responses. Personality is seen asone of a number of modulators or “filters” of psychologicalresponses that might link to the clinical features of fibromyalgia.Arrows on the left indicate the modulating effect of psychologicaldistress on down-stream responses and arrows on the right indicate“feed-back” effects on distress.This model fits with the biopsychosocial model of illness in fibromyalgia. Central psychological factors, acting under the influence of external social stressors, result in emotional distress that in turn may activate physiological stress responses if modifying “filters” allow. These filters include the individual’s personality, belief system, sleep pattern and other psychosocial influences – each possibly facilitating or impeding this outcome.

Change in function of pain-associated brain areas may then allow for pain and related sensory sensitization that in turn, depending on the body “substrate”-musculoskeletal, gastrointestinal, genitourinary, auditory or other- will result in characteristic symptoms and signs of the sensitization process in that organ system. These changes result in the clinical phenotype that is diagnosed as fibromyalgia.The relationship between psychological factors and fibromyalgia clinical features is more complex than this model suggests, as identifying cause and effect is difficult. Psychosocial factors, including personality, may contribute to the initiation of the fibromyalgia mechanism, as discussed above, but they may also modulate the process once established. The subsequent pain, sleep change and fatigue may be further aggravated by pain-associated maladaptive coping techniques and negative pain beliefs , each likely influenced by personality.

In addition, these responses in themselves may also influence aspects of personality. With such interacting feedback influences on the fibromyalgia process it is therefore a challenge to identify how personality impacts on fibromyalgia ,. This review presents studies on the personality of fibromyalgia patients and discusses them in the context of current knowledge of the pathophysiology of this condition. METHODSThe databases Medline and PsychINFO were examined from 1967 to August 2011 to identify studies that investigated associations between fibromyalgia and personality.

Search terms included personality, traits, characteristics, individual differences and fibromyalgia. The terms were combined to elicit the relevant articles, refining the search to include only journal articles, those in English and those that defined personality on a validated scale (Fig. All references pertaining to elicited articles were also reviewed. General Personality-Related Descriptors Associated with FibromyalgiaCertain personality-related characteristics that may increase emotional distress are noted in individuals with fibromyalgia. These include perfectionism, having unrealistic expectations , and having Type A personality. There may be difficulty in relaxing, increased irritability, decreased social desirability, adoption of a sick role, increased anger and indirect aggression, poor coping techniques , pessimistic thinking, anxiety about the future , a tendency to somatize , pedantism, to be in need of order and planning , being overly clean and having difficulties in verbally expressing feelings and emotions.

Personality disorders are also noted but are not the subject of this review. Personality Scales in FibromyalgiaThere is inconsistency and potential confusion in the choice of scales used to identify aspects of personality in fibromyalgia.

Individual characteristics that technically are not personality traits, such as depression, anxiety, and psychological distress, are often classified as “personality”. These dimensions tend to ascribe styles that reflect constellations of characteristics rather than specific individual traits, but they do in turn have a significant influence on the underlying personality that may be fundamentally important to the fibromyalgia mechanism. For instance, a person with depressive characteristics will report cognitions, emotions and behaviors impeded by this state that in turn influences their choice of internal and external coping mechanisms.There are many limitations of the specific personality scales/tools to be discussed, ranging from length, biases, cross cultural issues, language considerations and questions surrounding causality. When applied to pain research, specific items on many scales tend to reflect the individual’s response to pain rather than to any specific psychopathology causing the problem. It is noted that the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders- TR indicates that to be diagnosed with a pain syndrome psychological factors need to be the cause of pain, rather than a consequence. This distinction is often not clearly defined in studies on fibromyalgia.

Most often results from personality tools in these settings reflect influences of non-organic clinical syndromes and/or outcomes from psychological or medical treatment rather than the intrinsic personality. Currently there are limited studies on personality in the pre-fibromyalgia population, including those that investigate the triggers associated with development of fibromyalgia. The Minnesota Multiphasic Personality Inventory (MMPI/MMPI 2)The MMPI/MMPI 2(shortened version) is the most widely used personality tool comprising 10 personality scales along with 3 validity scales. Developed initially to reflect the levels of psychopathology in a psychiatric population, the MMPI conceptually represents an individual’s conscious thought through identification of their psychological abnormalities, and their subsequent ability to adapt to the community. However, some items in the MMPI are intrinsically related to somatic symptoms. This means that within a fibromyalgia population, where somatic symptom reporting is high, there is a resultant artificial elevation of scores.

In this setting, in terms of personality influences , the MMPI highlights characteristics of the illness, such as living with pain, rather than the cause of the illness itself. Report profiles therefore often reflect the differences between groups rather than similarities.It is argued that when the MMPI is used in appropriate circumstances it does reflect the original purpose of the instrument through the identification of the underlying personality structure that can explain the development of the chronic pain condition. This instrument however has been used to investigate various clinical syndromes that lack clear “organic” cause, particularly in order to predict outcomes of medical or psychological interventions.

MMPI/MMPI-2 in FibromyalgiaWhen MMPI was first applied to fibromyalgia patients and compared to control groups a number of significant differences were noted ,. A profile based on the grouping of hysteria, hypochondriasis and depression , collectively labeled the “conversion V” profile, is present in fibromyalgia compared to controls. This profile is said to represent the psychological influence on physical symptoms whereby individuals transpose emotional problems into somatic conditions.

However living with a chronic painful condition in itself will result in an emotional impact from the pain and that could include depression , due to the severity or length of suffering , thus casting doubt on this “personality’ profile as measuring a causal factor in fibromyalgia. Furthermore, as previously mentioned, items within the scale intrinsically relate to clinical characteristics of many similar chronic “non-organic” conditions, particularly disturbed sleep, fatigue, distress and pain and so encompass conditions that overlap with fibromyalgia. In short, studies of MMPI in the context of chronic pain suggest that the MMPI result is independent of psychological status.The non-specificity of this profile was also highlighted in a study that found the conversion V profile both in fibromyalgia and chronic pain patients but not in rheumatoid arthritis or healthy controls, with no significant difference between chronic pain or fibromyalgia groups ,. The conversion “V” profile is not stable over time. A study utilizing a “mini-MMPI”, the MMPI-2, reported that psychological disturbance in fibromyalgia changed with pain intensity and found neurotic symptoms common in all groups. Against this background, a study of 31 fibromyalgia patients compared to 31 controls found that the responses on the MMPI lacked any significant psychopathology, with many scales recording “normal levels” indicating that the MMPI showed “no psychological disturbance of any serious nature”. A further study reported correlation between previous psychiatric treatment and higher levels of somatic complaints in fibromyalgia, however all individuals in this study were involved in litigation which may skew the degree of psychopathology reported.In an attempt to improve the usefulness of the scale contemporary normative data, derived from the original norms, has been defined.

Groups were statistically recalculated to separate a normal (healthy) group, a chronic pain group and a psychologically disturbed group ,. These studies reported that less than one-third of fibromyalgia patients could be categorized into the psychologically disturbed group with 41% normal and 47% having the chronic pain profile. The lack of correlation between the key triad features of pain, sleep, and fatigue and the MMPI scales was the explanation for these findings.At best, using the MMPI/2, psychological issues are implied in many fibromyalgia patients but at worst the nature and exact placement of the psychological change in the top-down fibromyalgia cascade is not possible (Fig.

Cesarec Marke Personality Schedule (CMPS)This Swedish scale, derived by factor analysis, is based on Murray’s theory of needs. This theory identifies the motives an individual requires to drive their desired outcomes. The “needs” reflect aggression, extraversion and neuroticism. Underlying this theory of personality is the existence of two main needs: primary needs of hunger, thirst and sexuality and secondary needs of wishes and pursuits.

The motivation for the need reflects the individuals’ push to achieve certain outcomes. Traits are seen as either stable or unstable with personality reflected as maturity due to historical, cultural and social components.

CMPS in FibromyalgiaA study, aimed to validate a computer based version of the CMPS in 110 fibromyalgia patients in comparison to a pen – paper version in 45 separate fibromyalgia patients and compared to a normative group, found that this scale indicated a greater need for order in the fibromyalgia groups. This identified the fibromyalgia patient to be pedantic, perfectionist, or in need of order and/or planning, in response to everyday stressors. These are all attributes that are evident in clinical practice. Karolinska Scales of Personality (KSP)The KSP scale is hypothesized to reflect temperament dimensions that underlie the biological disposition and as such the relationship that temperament plays on the development of personality. KSP is said to be a measure of stable traits contributing to personality rather than a level of psychopathology.

It is not designed to assess the “whole personality” but rather to explore dimensions that contribute to the person, specifically that of anxiety proneness, impulsivity and aggression. The scale is argued to “handle different types of pain easier” and is a closer fit to the proposed fibromyalgia top down model with the scale delineating an individual’s response to psychological stressors. These dimensions of the KSP are said to explain the individual’s vulnerability towards certain forms of psychopathology but not the psychopathology itself. Psychometrically, the scale shows validity and it is less time consuming, easier to apply and interpret than the MMPI/2. Factor studies compared the KSP to both the 3 factor and 4 factor Eysenck Personality Inventory (EPI) (see later) and found consistency amongst a number of traits of the KSP to EPQ such as neuroticism to negative emotionality. Limited studies compare the KSP to the MMPI-2. KSP in FibromyalgiaThis instrument shows that fibromyalgia individuals who rate high on muscle tension are influenced by their personality traits ,.

In a study, comparing 73 fibromyalgia patients and 200 controls, fibromyalgia patients reported significantly higher somatic anxiety (autonomic disturbance, distress and panic attacks), muscular tension and psychasthenia (fatigue). However it has been suggested that this was due to reduced energy due to pain, fatigue and sleep deprivation, all common components of fibromyalgia. The KSP instrument does identify personality traits that may contribute to the process of central sensitization, such as heightened anxiety, pronounced preoccupation with somatic complaints, consequent inability to relax and constant levels of fatigue. Temperament and Character Inventory The TCI reviews different dimensions of temperament and character constructed from biological, social, psychological and cultural factors.

Temperament (likely an inherited quality) is sub-classified into novelty seeking, harm avoidance, reward dependence, and persistence. Character (a more transient quality), produces a sense of self directedness (will power and determination), cooperativeness (tolerance and empathy) and self transcendence (spirituality) ,. The temperament and character dimensions are said to be mutually exclusive with the inventory measuring both normal and abnormal behaviour ,.

From a psychobiological perspective the hypothesis argues that neurochemical transmitters determine the stimulus response patterns and, it is these patterns that shape personality. Underlying temperament are the neurochemical transmitters, serotonin (the inhibition system), dopamine (the activation system) and noradrenalin (the behavioural maintenance system). These factors affect the modulating pain pathways i.e. The inhibitory modulation of the descending pathways that are important in chronic pain. TCI in FibromyalgiaUsing this instrument, 40 fibromyalgia patients, when compared to 38 healthy controls, were found to have a significantly high level of harm avoidance.

It was speculated that fibromyalgia individuals present with a personality style that reflects being easily worried, pessimistic about their future, having heightened fear and avoidance of situations with which they cannot cope. Interestingly, harm avoidance also corresponds to the KSP findings of heightened levels of anxiety, tension and fatigue , giving further support to this personality style in fibromyalgia. In another study, fibromyalgia individuals were found to struggle with self-directedness , which raises questions around their ability to take control in regards to the self.

However other studies were inconclusive regarding the findings in fibromyalgia. Using this instrument personality traits do associate with the development of fibromyalgia, but whether this is cause or effect cannot be answered by these studies. For example, the development of harm avoidance may be a result of long-term exposure to fibromyalgia and not a precursor of the condition. TPQ in FibromyalgiaIn a study using the TPQ, 81 fibromyalgia patients compared to 458 controls showed a linkage between the serotonin transporter gene and anxiety-prone personality traits (high harm, low novelty profile) ,. An exclusive fibromyalgia profile that significantly differed from the controls was identified.

Additionally, the frequency of the dopamine receptor D4 (DRD4) was decreased significantly in the fibromyalgia group compared to controls, with the DRD4 also correlating with low novelty seeking on the TPQ. This suggests that both serotonin and dopaminergic neurotransmission are involved in fibromyalgia pain mechanisms and personality characteristics may be involved in this association. The NEO Five-Factor Personality Inventory (NEO PI-R, Big 5)The NEO PI-R inventory measures 5 broad dimensions of personality, namely neuroticism, extraversion, agreeableness, conscientiousness and introversion. The scale is said to identify “differences among normal individuals” by identifying how a person may feel, think and act. The traits are said to stable throughout adult life, unless there is a conscious decision or major life event that produces major change. Neuroticism has been extensively investigated in relation to survival needs coping and, optimism , health practices and number of physical symptoms ,. It has received extensive notoriety with the predominant focus being on the relationship between neuroticism and symptom perception and report bias.Neuroticism is the most explored personality trait in pain research and has been suggested to associate with the unpleasantness of the pain, and pain threshold rather than with the pain intensity.

The degree of neuroticism will impact on psychological factors such as perceived stress and social support. Extroversion characteristics denote an individual who actively interacts with a stimulus, has an outgoing nature and associates with better health outcomes. In contrast, introversion characteristics include increased cortical arousal, lower threshold for sensory stimulus and more physiological reactivity to stressors. NEO PI-R in FibromyalgiaThere are few studies using the NEO PI-R questionnaire in fibromyalgia. In one study, there were inconsistent findings in regards to the influence of neuroticism on pain sensitivity between a fibromyalgia group, who sort medical treatment, compared to another fibromyalgia group, who sort no medical treatment. In another study, neuroticism was examined in terms of being a possible underling trigger to the development of fibromyalgia.

It was suggested that the fibromyalgia individual’s inability to adapt due to their high pain sensitivity and low pain threshold resulting in maintenance of pain. The influence of neuroticism on pain recall did not show that interference with recall was impaired through recall bias of memory, retrieval and interpretation of painful events. However, studies in fibromyalgia are more limited and conflicting and they have tended to focus on neuroticism and extraversion. These traits have been used based on associations between them and outcomes associated with illness behaviour. It is also suggested that neuroticism has the potential to predict physical health outcomes. Some studies have suggested that fibromyalgia is a substrate of neuroticism , while others have reported a lack of reliability in the predictive power of neuroticism over external psychosocial factors and then while neuroticism was found to influence pain recall, there were no associations to the accuracy of recall nor pain intensity or ratings of unpleasantness of pain. EPI in FibromyalgiaThe EPI shows high scores in the fibromyalgia population.

The fibromyalgia individual is said to be anxious, worried, depressed, and a poor sleeper. A study, using a biopsychosocial approach explored how best to explain the pain variances found within a fibromyalgia population allowed for numerous factors that might shape and maintain fibromyalgia symptoms. Neuroticism, along with stress, was reported as having good predictive power in a sample that compared 22 fibromyalgia patients to 17 controls.

Forty-one percent of the variance was explained by personality (neuroticism) and stress, along with factors associated with the hypothalamic-pituitary-adrenal axis and to the autonomic nervous system. Perfectionism and Type A in FibromyalgiaIn defining the personality characteristics of an individual with fibromyalgia there are other elements, which are not truly defined as personality traits yet depict important descriptors of their behaviour, that also need to be mentioned. Clinical observations have noted the person with fibromyalgia be perfectionist, pedantic, an over achiever, and a “go getter”. As such perfectionism and type A behaviour are potential characteristics that may contribute to fibromyalgia. Both elements have been associated with poor health. While studies are limited, a few have shown an overactive lifestyle, along with negative perfectionism and Type A behaviour, are potential elements in developing and maintaining fibromyalgia. It was suggested that these individuals would “burn out” due to self-perpetual behaviors that included exhaustion from exacerbating distress, leading on to greater fatigue.

This in turn meant that their higher expectations were not achieved, triggering further stress and in turn producing negative self-beliefs, reinforcing a sense of helplessness. There is a significant positive relationship between perfectionism and Type A, particularly in regard to impatience, competitiveness and socially perceived and imposed standards.Another study into Type A characteristics and perfectionism within the fibromyalgia population found that those high in sense of coherence reported less Type A behaviour. However, as Type A was used as a constant for both the fibromyalgia and control groups, limited explanations can be extrapolated.Table summarizes selected studies that relate to aspects of personality in patients with fibromyalgia. AuthorDatePopulationPersonality ScaleConstruct InvestigatedCommentMMPI: Minnesota Multiphasic Personality InventoryPayne T, Leavitt F, Garron D et al. 1982FM 30RA 30OA 30MMPIPersonality differences and levels of psychopathologyConcluded that FM individual’s psychological state is not directly due to pain or their disability; that their psychological status is variable and contributes significantly to the symptoms that they experience.Wolfe F, Cathey MA, Kleinheksel SM et al.

1984FM 46RA 32RA no FM 43MMPIPsychological factors that contribute to psychopathologyJust over 25% of FM patients had “normal profile” compared to over 50% of controls; FM patients report significant psychopathic, psychasthenia and paranoia scales along with significant anxiety and depression scalesAhles T, Yunus M, Gaulier B, Riley S, Masi A 1986FM 45RA 30NC 32MMPIPsychological factors that contribute to psychopathologyLow psychopathology found in FM, even though similar patterns were obtained when recalculating groups based on new contemporary norms. DISCUSSIONChronic pain incorporates a complex mix of nociception, peripheral neural processing, cognitive processing, and affective and behavioural responses. Early studies investigating the relationship between personality and pain (not identified as fibromyalgia-related) recognized various factors, both physiological and psychological, that made an individual more vulnerable to pain. More recent work has also focused on how personality might influence the way individuals with certain characteristics adjust to pain. For instance, there may be resultant negative attitudes and expectations that inhibit improvement.