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. 2023 Mar 22;10(7):4797–4805. doi: 10.1002/nop2.1731

The frequency of psychiatric disorder co‐morbidities in patients with fibromyalgia: A cross‐sectional study in Iran

Sara Sadr 1, Maryam Mobini 2, Mohammad Tabarestani 3, Parisa Islami Parkoohi 4, Forouzan Elyasi 5,6,✉
PMCID: PMC10277415  PMID: 36947671

Abstract

Aim

This study aimed to investigate psychiatric disorders in Iranian female patients with fibromyalgia (FM).

Design

Female patients, newly diagnosed with FM, were interviewed by a psychiatrist for psychiatric assessments during a 2‐year period.

Methods

The diagnosis of the psychiatric disorders was based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM‐5), and sleep quality was evaluated using the Pittsburgh Sleep Quality Index (PSQI).

Results

In total, 159 patients with the mean age of 42.15 ± 9.89 were recruited in this study. Over 92% of the cases were also diagnosed with at least one type of psychiatric disorder. Sleep disorders (SDs, 90.57%), mood disorders (MDs, 52.83%), personality disorders (PDs, 40.25%) and anxiety disorders (ADs, 16.98%) were the most prevalent diagnoses among these patients. The logistic regression results correspondingly showed that suffering from Cluster‐B PDs was associated with a higher prevalence rate of somatic symptom disorders (SSDs), with a p‐value of 0.019 and an odds ratio (OR) of 2.7.

Keywords: depression, fibromyalgia, pain disorder, psychiatric co‐morbidities, somatic symptom

1. INTRODUCTION

Fibromyalgia (FM) is known as a rheumatologic disorder characterized by chronic widespread musculoskeletal pain and the stiffness of muscles and related soft tissues with a worldwide prevalence rate of 2%–8% (Cohen, 2017; Queiroz, 2013; Wolfe et al., 1990), and about 3.1% in Iran (Forqanizade et al., 1995). Patients affected with FM have an especially low pain threshold, although they typically feel the pain with a non‐painful stimulus the sensation of pain can be experienced even with no external stimuli (Clauw et al., 2011; Littlejohn, 2015). This disorder mostly affects middle‐age women, and it is seven times more frequent in women than men (Littlejohn, 2015), and is highly associated with a decrease in health‐related quality of life (Jafari et al., 2022; Samami et al., 2021).

The exact pathology of FM still remains unknown, since no evidence of inflammation or tissue injury is seen in the painful and affected areas of the body; this has led many clinicians to theorize that this disorder has a psychological and/or psychosomatic origin. Recent studies have proposed that an altered activation pattern for the CD4+ T‐cells can be observed in most cases of FM, which is accompanied by a higher incidence of other co‐morbid immune‐mediated diseases in patients and a higher rate of female involvement; furthermore, considering the data that suggest an association with viral infections, a dysfunction in the immune system can be theorized (Banfi et al., 2020). Another theory also advocates that a biological/biochemical abnormality leads to dysfunctional pain regulation and central nervous system (CNS) sensitization (Pomares et al., 2017). Furthermore, signs of neuropathy in small and big nerve fibres and the evident changes in the brain morphology suggest a neurological basis for this disorder (Cohen, 2017; Galvez‐Sánchez et al., 2019).

Personality disorders, traits and inclinations in patients with fibromyalgia have been widely studied using different psychological tests and methodologies, although there is no typical personality profile that is considerably common in patients with FM, some studies based on the 5‐factor model of personality (FFM) have reported that these individuals often have an introverted personality with high neuroticism, which can predispose them to exhibit altered behaviours and ruminations (Montoro et al., 2015; Torres et al., 2013). In another study, patients with FM were reported to present with higher scores of agreeableness and openness in addition to neuroticism (Bucourt et al., 2017); while others have reported agreeableness and conscientiousness to be the predominant personality traits in these patients (Bartkowska et al., 2018). Assessments of personality traits based on the Minnesota Multiphasic Personality Inventory (MMPI‐2) have repeatedly shown that there is a statistically significant elevation in the constituents of the neurotic triad (depression, hysteria and hypochondriasis) in patients with FM which can be expected since the neurotic triad is also known as a typical pain profile, seen in patients suffering from chronic painful disorders (Novo et al., 2017). Although, in addition to the neurotic triad, FM patients have been reported to present higher levels of social alienation, unusual beliefs, confusion and lack of adequacy (Bárbara Gonzalez et al., 2020). Emotional and cognitive elements can further affect the perceptions of painful stimuli, and dysregulation in the response system can eventually develop into symptoms that result in the diagnosis of FM or chronic fatigue syndrome (Malin & Littlejohn, 2012), and the identification of certain personality traits can help physicians exploit more individualized psychotherapeutic treatments for patients with FM (Seto et al., 2019). To encompass all the evidence regarding the aetiology of FM, the biopsychosocial model assumes that biological, psychological and social factors work together to predispose an individual to FM, and even maintain the symptoms in a patient (Eich et al., 2000).

The prevalence of various psychiatric disorders, such as anxiety disorders (ADs), mood disorders (MDs), personality disorders (PDs) and obsessive compulsive disorder (OCD) have been shown to be higher in patients with FM in comparison to healthy individuals (Galvez‐Sánchez et al., 2019; Häuser et al., 2017; Uguz et al., 2010). These psychiatric co‐morbidities can also increase disability, decrease quality of life and be associated with considerably higher rates of suicide attempts (Bazzichi et al., 2005; Galvez‐Sánchez et al., 2019; Samami et al., 2021).

The psychological and psychosomatic aspects of FM have rarely been investigated in Iran, and the diagnosis of psychiatric disorders in previous studies has been mostly based on a questionnaire rather than a comprehensive unstructured interview by a psychiatrist (Bartkowska et al., 2018; de Souza Ramiro et al., 2014; do Nascimento et al., 2020; Seto et al., 2019). In this study, a comprehensive interview was performed by a psychiatrist, as a consultation‐liaison professional, to evaluate the psychological status of female patients with FM and the prevalence rate of various psychiatric disorders in this population.

2. MATERIALS AND METHODS

This cross‐sectional study was conducted on female patients, newly diagnosed with FM—based on the 1990 American College of Rheumatology (ACR) criteria (Wolfe et al., 1990)—who visited a private outpatient rheumatology clinic in Sari, Iran, during 2018–2019. Once the rheumatologist verified the diagnosis of FM, the study procedure and objectives were explained to each patient, and those who chose to participate in this study were visited and interviewed by a psychiatrist specialized in psychosomatic medicine. The patients who were included in the study were women, at the age range of 18–65, who were willing to participate in the study and completed the psychiatric interview. The rheumatologist also screened all patients for any concomitant rheumatologic and/or chronic pain disorders by physical examinations and/or laboratory studies, and patients who were positive for other disorders were excluded from the study.

The demographic characteristics data, including age, marital status, level of education, employment status, along with place of residence were documented during the interview by the psychiatrist. Psychiatric disorders were diagnosed based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM‐5) criteria, via an unstructured interview. The interview was unscripted and took approximately 45 min to complete. The quality of sleep was also evaluated at the end of the interview using the Persian version of the Pittsburgh Sleep Quality Index (PSQI‐P; Moghaddam et al., 2012).

The sample size for this study was calculated using the n=Z1−α22P1−Pd2 formula and the reported prevalence of psychiatric disorders in FM patients from similar studies conducted by Hosseini et al and Fu et al (Fu et al., 2015; Hosseini et al., 2015) were used to calculate the value of p (the prevalence of mood, anxiety and personality disorders were, respectively, 34.4%, 65.5% and 56.3%), and the value of d was set as 0.25 of p for each disorder group. With a 0.05 level of confidence, we calculated the sample size for mood, anxiety and personality disorders and the largest result: 118 was selected. During the study timeline, a total 159 patients met the inclusion criteria and entered the study.

The statistical analysis was performed using the SPSS software package (ver. 22). The Bonferroni correction for the Chi‐square analysis or, if necessary, the Fisher's exact test was used to evaluate the relationship between the psychiatric disorders and the demographic characteristics, including: age, marital status, level of education, employment status and place of residence. A logistic regression test was used to investigate the association between the Cluster‐B PDs and somatic symptom and related disorders (SSDs). Other psychiatric disorders were also included in the logistic regression model to determine the adjusted odds ratio. Of note, a p ˂ 0.05 was considered statistically significant.

2.1. Ethical considerations

Informed consent was obtained from all patients, and they were notified that they could withdraw from the study at any time, which would not hinder their potential future visits to the hospital or affect the quality of care they receive. This study was approved by the Mazandaran University of Medical Sciences (MAZUMS) Ethics board committee (approval code: IR. MAZUMS.REC.1398.5094) and adhered to the tenets of the 1975 declaration of Helsinki.

3. RESULTS

In this study, 159 women diagnosed with FM were evaluated. The patients had a mean age of 42.15 ± 9.89, ranging between 20 and 65 years, and the majority (62.12%) aged between 30 and 50 years. Further demographic characteristics data are presented in Table 1. As well, 147 patients (92.45%) were diagnosed with at least one psychiatric disorder. The most common psychiatric disorders among patients were MDs (52.83%) and sleep disorders (90.57%). The most frequent types of MDs were major depressive disorder (MDD) and persistent depressive disorder (PDD). The Cluster‐B PDs, and among them the histrionic PDs, were the most prevalent personality disorders. The prevalence of different psychiatric disorders is shown in Table 2.

TABLE 1.

Demographic characteristics of participants (N = 159).

No. (%)
Age (year)
20–29 20 (12.58)
30–39 44 (27.67)
40–49 55 (34.59)
50–59 31 (19.50)
>59 9 (5.66)
Marital status
Single 11 (6.92)
Married 139 (87.42)
Widowed 5 (3.14)
Divorced 4 (2.52)
Educational status
High school diploma or below 97 (61.01)
College education 51 (32.07)
Masters or higher degrees 11 (6.92)
Location of residence
Urban 122 (76.73)
Rural 37 (23.27)
Employment status
Part‐time 31 (19.50)
Full‐time 18 (11.32)
Unemployed 109 (68.55)
Retired 1 (0.63)
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TABLE 2.

Psychiatric disorders in participants (N = 159).

No. (%)
Personality disorders (n = 64, 40.25%)
Cluster A PD (n = 2, 1.26%)
Paranoid PD 1 (0.63)
Paranoid PT 1 (0.63)
Cluster B PD (n = 57, 35.85%)
Histrionic PD 24 (15.09)
Histrionic PT 19 (11.95)
Borderline PD 8 (5.03)
Borderline PT 6 (3.77)
Narcissistic PT 2 (1.26)
Narcissistic PD 1 (0.63)
Cluster C personality disorder (n = 6, 3.77%)
Dependent PT 3 (1.89)
Obsessive PT 3 (1.89)
Anxiety disorders (n = 27, 16.98%)
Generalized AD 12 (7.55)
Specific phobia 11 (6.92)
Separation AD 8 (5.03)
Unspecified AD 1 (0.63)
Mixed anxiety depressive disorder 1 (0.63)
Mood disorder (n = 84, 52.83%)
Major DD 34 (21.38)
Persistent DD 38 (23.90)
Unspecified DD 2 (1.26)
Post‐partum DD 3 (1.89)
Minor DD 7 (4.40)
Trauma and stressor‐related disorder (n = 5, 3.14%)
Adjustment disorder 4 (2.52)
Reactive attachment disorder 1 (0.63)
Somatic symptom and related disorders (n = 29, 18.24%)
Somatic symptom disorder 15 (9.43)
Illness AD 4 (2.52)
Conversion disorder 8 (5.03)
Psychological factors affecting other medical conditions 3 (1.89)
Obsessive–Compulsive Disorders 17 (10.69)
Sleep quality
Good 15 (9.43)
Weak 144 (90.57)
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Abbreviations: AD, anxiety disorder; DP, depressive disorder; PD, personality disorder; PT, personality trait.

Our data indicated that the prevalence of PDs is statistically significantly higher among the patients with FM in the 30–39 age group, compared to those in their 40s or 50s (p‐value = 0.011). The prevalence of psychiatric disorders according to each age group is shown in Table 3. The prevalence of OCD was statistically significantly higher in single versus married women (36.36% vs. 9.35%, p‐value = 0.030). Moreover, there was no significant relationship between the level of education, employment status and place of residence, and the prevalence of different psychiatric disorders (p‐value > 0.05).

TABLE 3.

Psychiatric disorders according to each age group.

Age group p‐Value
20–29 (n = 20) 30–39 (n = 44) 40–49 (n = 55) 50–59 (n = 31) >59 (n = 9)
N (%) N (%) N (%) N (%) N (%)
Personality disorders a 9 (45%) 26 (59.09%) 16 (29.09%) 8 (25.81%) 5 (55.56%) 0.011
Anxiety disorders 2 (10%) 12 (27.27%) 7 (12.73%) 6 (19.35%) 0 (0%) 0.155
Mood disorder 9 (45%) 22 (50%) 35 (63.64%) 11 (35.48%) 7 (77.78%) 0.056
Somatic symptom and related disorders 4 (20%) 9 (20.45%) 7 (12.73%) 8 (25.81%) 1 (11.11%) 0.591
Obsessive–Compulsive and related disorders 3 (15%) 5 (11.36%) 5 (9.09%) 3 (9.68%) 1 (11.11%) 0.964
Sleep disorder b 20 (100%) 39 (88.64%) 46 (83.64%) 30 (96.77%) 9 (100%) 0.103
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a

All psychiatric disorders except sleep disorder were diagnosed based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

b

Sleep disorders were diagnosed based on the Pittsburgh Sleep Quality Index.

3.1. Concurrent psychiatric disorders

Most patients were diagnosed with two or more psychiatric disorders. Table 4 and Figure 1 show how often various psychiatric disorders were simultaneously diagnosed in the patients with FM. MDs and SDs were concurrently diagnosed in 32 patients (20.13%). As well, PDs, MDs and SDs were simultaneously diagnosed in 25 patients (15.72%), and 28 patients (17.61%) suffered from one type of Cluster‐B PD, a MD and a SSD (Figure 1).

TABLE 4.

Concurrent psychiatric disorders in participants.

Personality disorder Anxiety disorder Mood disorder Somatic symptoms and related disorders Obsessive–compulsive disorders Sleep disorder No. (%)
* * 32 (20.13)
* * * 25 (15.72)
* * 14 (8.81)
* * * 8 (5.03)
* * 8 (5.03)
* * * 6 (3.77)
* * 5 (3.14)
* * * * 4 (2.52)
* * * 4 (2.52)
* * * * 3 (1.89)
* * 3 (1.89)
* * * 3 (1.89)
* * * 2 (1.26)
* * 2 (1.26)
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The '*' symbol marks the diagnosis of the disorder(s) that the column(s) represents. The Number column shows how many patients are concurrently afflicted with the marked disorders in each respective row.

FIGURE 1.

FIGURE 1

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A Venn diagram of the most common psychiatric co‐morbidities in patients with FM.

Considering the high prevalence of Cluster‐B PDs in FM patients suffering from one form of SSDs, logistic regression analysis was performed to determine the possible relationship between these two conditions. The results showed that with a p‐value of 0.019 and an odds ratio of 2.7, suffering from a cluster B personality disorders is associated with a higher rate of SSD; and the odds ratio increases after adjustment for other psychiatric disorders (OR = 2.9, with upper and lower estimations of 7.26 and 1.19 within 95% confidence interval and p‐value of 0.019).

4. DISCUSSION

This study was the first attempt, to the best of the authors' knowledge, to assess the prevalence rate of psychiatric disorders in a population of Iranian women with FM via a comprehensive interview by a psychiatrist. The study results also showed that after poor sleep quality (90.57%), MDs (52.83%), PDs (40.25%) and SSDs (18.24%) were the most prevalent psychiatric disorders among the patients with FM.

4.1. Anxiety disorders

Generalized anxiety disorder (GAD, 7.55%), specific phobia (6.92%) and separation anxiety disorder (5.03%) were the most common ADs in this study; and ADs had an overall prevalence of 16.98%. Similar studies have reported an overall prevalence rate of 32% (Uguz et al., 2010) and 18% (Kayhan et al., 2016) for ADs in patients with FM, which were considerably higher than those in the control groups in both studies. Of note, GAD was the most common type of ADs in these studies. Another survey had further revealed that a woman with FM was five times more likely to experience one type of ADs during her lifetime in comparison to a healthy individual (Ablin et al., 2013), which is consistent with the results of this study and some other previous reports (Hosseini et al., 2015; Kayhan et al., 2016; Uguz et al., 2010).

4.2. Obsessive compulsive and related disorders

OCD was diagnosed in over 10% of the patients in this study. Other researchers have reported 3.9% (Uguz et al., 2010) and 2.1% (Kayhan et al., 2016) prevalence rates for OCDs in patients with FM that were not significantly high as compared to the control group (Kayhan et al., 2016) and the expected prevalence rate of OCDs in the general population which is 2%–3% (Sadock et al., 2017). However, 8.5% of the patients with FM were diagnosed with OCDs in another study, which was significantly more than the rate in the control group (Hadlandsmyth et al., 2020). The prevalence rate of OCDs among healthy individuals in Mazandaran Province, Iran, has not been investigated, so it is plausible to attribute the relatively high prevalence rate of OCDs in this study to a generally higher rate of OCDs among women in the region. As well, a controlled study could better clarify and cancel the impact of regional and cultural differences regarding the co‐morbidity of OCDs and FM.

4.3. Sleep disorders

SDs have been one of the most common complaints among patients with FM (Cohen, 2017). Using the PSQI, one study has reported that about 93% of the cases with FM experienced a poor quality of sleep, which was strongly associated with the severity of FM symptoms (Andrade et al., 2020). This high prevalence of poor sleep quality (~90%) has been also shown in previous studies (Bennett et al., 2007; Jacobson et al., 2015; Mork & Nilsen, 2012; Pimentel et al., 2015). With the prevalence rate of 90.57%, the results of this study supports the previous outcomes. Notably, a meta‐analysis of the studies that has evaluated subjective and objective quality of sleep by means of questionnaires and polysomnography further indicates that even though the objective assessments (viz., polysomnography) of the quality of sleep shows a considerable decrease in sleep quality, the perceived quality of sleep in the patients with FM is substantially lower than the results of objective evaluations (Wu et al., 2017); implying that questionnaires, interviews and other forms of subjective evaluations of sleep are probably not the most reliable methods for assessing the quality of sleep in patients with FM.

4.4. Mood disorders

With a prevalence rate of 52.83%, MDs were the most commonly diagnosed psychiatric disorders during the interviews; as was expected considering other similar Iranian and regional studies where MDs were diagnosed in 22%–86% of FM patients using structured interviews and questionnaires (Hosseini et al., 2015; Kayhan et al., 2016; Uguz et al., 2010). Other studies have shown that up to 30% of patients are also diagnosed with a MD at the time of FM diagnosis, and up to 74% of FM patients experience depression at some point in their life (Arnold et al., 2004; Giesecke et al., 2003). A recent meta‐analysis has shown that depression/MDD are the most prevalent psychiatric co‐morbidities among patients with FM, with the prevalence rate of 52%–63% (Kleykamp et al., 2021), although there is considerable discrepancy in the prevalence rate of MDs in patients with FM in different studies, which can highlight the impact of environmental and social aspects of predisposition to depression in these individuals rather than similar genetic susceptibilities and biological pathways for both conditions.

4.5. Personality disorders

With a prevalence of 40.25%, personality disorders (including personality traits) were the second most common psychiatric diagnoses in our study. In similar studies, PDs have been reported to affect as high as 56% (Fu et al., 2015), 65% (Gumà‐Uriel et al., 2016) and 96% (Muñoz et al., 2010) of female patients with FM, while in some other studies only 13.5% (Kayhan et al., 2016) and 8.7% (Thieme et al., 2004) of such patients had been reported to suffer from a PD. Previous studies have largely pointed to cluster C personality disorders (e.g. avoidant and obsessive compulsive disorders) as the most common PDs among female FM patients (Fernández, 2011; Fu et al., 2015; Garcia‐Fontanals et al., 2016; Gumà‐Uriel et al., 2016; Uguz et al., 2010), but in a few other studies, cluster B personality disorders (most commonly histrionic) were reported to be the most common PDs among these patients (Kayhan et al., 2016; Muñoz et al., 2010), which is in line with the results of this study, which indicated that Cluster‐B PDs were diagnosed in 35.85% of the patients (histrionic PD, 15.09%). In previous studies, personality disorders and FM have both been linked to higher rates of traumatic childhood experiences (Bayram & Almıla, 2014; Gonzalez et al., 2013; Grover et al., 2007; Schilling et al., 2007), as such we can potentially see these events as a possible explanation for the greater presence of personality disorders in FM. The high prevalence of histrionic PD could be expected since histrionic PD has been associated with higher rates of somatization, or it can also be attributed to a higher inclination for help and attention‐seeking behaviour in these patients that could result in more doctor visits and a higher rate of successful diagnoses of both FM and histrionic PD (Sadock et al., 2017). Therefore, we cannot confidently concluded that there is a relationship between histrionic PD and FM. Furthermore, compared to similar studies, cluster‐C PDs had a relatively low prevalence among patients in this study (3.77%); and for lack of a control group, we cannot dismiss the possibility that this discrepancy may extend to the general population of the region. Larger studies with a control group can better clarify the possible cause for this disparity, and the incredibly high prevalence of histrionic PD in Iranian FM patients.

4.6. Somatic symptom and related disorders

Somatic symptom disorders, defined as distressing or disruptive psychological responses to physical symptoms, have an expected rate of 5%–7% in the general population (Sadock et al., 2017), and were diagnosed in just over 18% of the participants in this study. Similar surveys have reported a prevalence of 37.5% (Häuser et al., 2020) and 75% (Fu et al., 2015) for these conditions in patients with FM. The co‐morbidity of SSDs and FM is especially observed in younger patients with FM that also suffer from other psychiatric disorders (Wolfe et al., 2014). It has been further speculated that the majority of patients diagnosed with FM also meet the criteria for SSDs, and the diagnosis of such disorders signals a pathological psychological process that maintains and exacerbates pain (Axelsson et al., 2020; Wolfe et al., 2014). One theory accordingly suggests that the association between FM and SSDs stems from a common biological pathology in the neurotransmitter system (Penacoba Puente et al., 2013); but, another theory states that since patients with FM exhibit a high degree of health‐related anxiety, as an attribute that drives them to seek more medical attention, they are more likely to be correctly diagnosed with FM, compared to those who would not visit multiple physicians and specialists (Thieme et al., 2004). This means that there is an inherent bias when researchers estimate the prevalence rate of health‐related anxiety, and to some extent, SSDs in patients with FM (Penacoba Puente et al., 2013). Based on this theory, the population of patients with FM is underestimated because there are a number of cases with FM who do not have concurrent health‐related anxiety, and are not diagnosed; whereas, the prevalence rate of SSDs and health‐related anxiety in patients with FM is overestimated.

4.7. Psychiatric co‐morbidities, possible associations, existing theories and a vicious cycle

As shown in Table 3, many patients in this study suffered from more than one type of psychiatric disorders, to the extent that co‐morbid MDs and SDs were diagnosed in over 20% of the participants. On the one hand, chronic pain is a known cause and exacerbating factor for depression and anxiety (Galvez‐Sánchez et al., 2020; Perrot et al., 2011), on the other hand, depression could also amplify the effects of anxiety, increase fatigue and impair sleep. This chain of negative conditions could thus show why depression was often accompanied by impaired sleep in patients with FM (Hadlandsmyth et al., 2020). On the other hand, it has been hypothesized that the connection between FM, depression and SDs is caused by a common biological pathology in the central nervous system (CNS), which leads to a hypersensitization or inflammation of the CNS. Based on this theory, it has been proposed that a chronic, systemic inflammation is the common pathology behind both FM and depression (Hadlandsmyth et al., 2020).

Overall, 9.4% of the participants in this study were diagnosed with both SSDs and one type of co‐morbid PDs, which was Cluster‐B PDs in all cases. This group also constituted over 50% of all patients with SSDs. Moreover, the logistic regression results showed that the patients with FM and underlying Cluster‐B PDs, which was almost exclusively the histrionic PDs, were 2.9 times more likely to suffer from one type of SSDs (p‐value = 0.022). A close relationship between SSDs and histrionic PDs was thus expected because SSD presentations are often enhanced in the presence of traits that characterize hysteria, and patients with SSDs repeatedly assume the sick role in order to avoid responsibilities and challenges (Sadock et al., 2017). On the other hand, other studies had shown that the prevalence rate of depression and GAD was higher in patients with FM and diagnosed with SSDs (Axelsson et al., 2020). Considering that patients with histrionic PDs are more prone to MDD (Sadock et al., 2017), it was concluded that the high prevalence rate of histrionic PDs and SSDs in the patients with FM could be among the triggering factors for their depression.

4.8. Limitations

Failure to conduct standardized semi‐structure diagnostic interview of the DSM‐5 is one of the limitations of this study. Also, there was no control group to compare the frequency of such conditions in healthy individuals and the patients with FM. Another limitation was that some psychiatric disorders may only be diagnosed after multiple interview sessions, but the investigations here were limited only to one interview, and not all disorders might have been diagnosed. Furthermore, it was not possible to collect reliable data concerning the duration of the symptoms in the participants with FM, whereas the length of time the patients had been suffering from this disorder could have a direct effect on the prevalence rate of psychiatric disorders in these patients, which is recommended be addressed in future studies. We also did not collect data on childhood traumatic events or the duration and intensity of the pain experienced by our participants, both of which are elements that can potentially directly and negatively affect patients' psychiatric profile. The high prevalence rate and co‐morbidity of psychiatric disorders among the patients with FM accordingly call for further research in this area, recruiting controlled and/or longitudinal studies.

5. CONCLUSION

The study results combined with the reports in previous research showed that patients with FM were potentially suffering from a variety of psychiatric disorders that could exacerbate one another in a vicious cycle. In this respect, depression could lead to SDs, the pain arising from FM could cause SDs, chronic pain could also induce depression, PDs, especially histrionic PDs associated with SSDs, histrionic PDs were attributed to a higher prevalence rate of depression, FM could be associated with SSDs and SSDs were correlated with depression. It was thus argued that each type of disorder needed to be addressed, which meant the FM treatment in most cases was obliged to include thorough psychiatric assessments and multidisciplinary treatments.

AUTHOR CONTRIBUTIONS

SS did the literature search, contributed to drafting the article and editing the article, MM contributed to selection of patients according to rheumatologic criteria and referring to psychosomatic clinic and editing the article, MT analysed the data, PEP contributed to data curation and editing the article and FE contributed in the conception of the work, study design, collected the data and editing the article.

CONFLICT OF INTEREST STATEMENT

The authors have no conflicts of interest relevant to this article. All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare that they have no competing interests.

CODE AVAILABILITY

Not applicable.

ETHICAL APPROVAL

The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. Informed Consent: Written informed consent on the first page of questionnaires was obtained from all participants to be included in this study The research proposal was approved by the Ethics Committee affiliated with Mazandaran University of Medical Sciences (ethics code: IR.MAZUMS.REC.1398.512).

CONSENT TO PARTICIPATE

Informed consent was obtained from all participants included in the study.

CONSENT FOR PUBLICATION

The authors hereby affirmed that human research participants provided informed consent for the publication of their medical data in an anonymous format.

ACKNOWLEDGEMENTS

This article has been extracted from M.D. Thesis. (Sara Sadr). The project was financially supported by the Mazandaran University of Medical Sciences, Sari, Iran (Grant number: 5094). We thank all the patients who co‐operated in this study, and also the staff of the Mostafavian Multi‐Specialty Clinic of the Imam Khomeini Hospital.

Sadr, S. , Mobini, M. , Tabarestani, M. , Islami Parkoohi, P. , & Elyasi, F. (2023). The frequency of psychiatric disorder co‐morbidities in patients with fibromyalgia: A cross‐sectional study in Iran. Nursing Open, 10, 4797–4805. 10.1002/nop2.1731

DATA AVAILABILITY STATEMENT

The data sets generated and/or analysed during this study are available from the corresponding author upon reasonable requests.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data sets generated and/or analysed during this study are available from the corresponding author upon reasonable requests.

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