European Journal of Pain 7 (2003) 113119 www.EuropeanJournalPain.

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Childhood adversities in patients with bromyalgia and somatoform pain disorder

Katrin Imbierowicza, Ulrich T. Egleb,*
b a Department of Psychotherapy and Psychosomatics, University Hospital Bonn, Bonn, Germany Department of Psychosomatic Medicine and Psychotherapy, University Hospital Mainz, Untere Zahlbacher Strae 8, Mainz 55131, Germany

Received 12 December 2001; accepted 8 July 2002

Abstract Primary bromyalgia is regarded as disorder with a complex symptomatology, and no morphological alterations. Findings increasingly point to a dysfunction of the central nervous pain processing. The study aims to discuss vulnerability for bromyalgia from a developmental psychopathological perspective. We investigated the presence of psychosocial adversities aecting the childhood of adult bromyalgia patients (FM) and compared them to those of patients with somatoform pain disorders (SOM) and a control group (CG) with medically explained chronic pain. Using the structured biographical interview for pain patients (SBI-P), 38 FM patients, 71 SOM patients, and 44 CG patients were compared on the basis of 14 childhood adversities veried as relevant regarding longterm eects for adult health by prospective studies. The FM patients show the highest score of childhood adversities. In addition to sexual and physical maltreatment, the FM patients more frequently reported a poor emotional relationship with both parents, a lack of physical aection, experiences of the parents physical quarrels, as well as alcohol or other problems of addiction in the mother, separation, and a poor nancial situation before the age of 7. These experiences were found to a similar extent in the SOM patients, but distinctly less frequently in the CG. The results point to early psychosocial adversities as holding a similar etiological meaning in bromyalgia as well as in somatoform pain disorders. The potential role of these factors as increasing the vulnerability for bromyalgia is discussed. 2002 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Science Ltd. All rights reserved.
Keywords: Fibromyalgia; Persistent somatoform pain disorder; Childhood adversities; Sexual abuse; Physical maltreatment

1. Introduction During the past few years, research into pathogenetic factors in bromyalgia has increasingly turned to the meaning of central nervous mechanisms, after the investigation of possible morphological or metabolic muscular alterations failed to bring any pathogenetical relevant ndings to light. The few peripheral morphological alterations described in the literature, such as reduced capillarization or abnormalities in certain mitochondrial enzymes, proved to be due to a poor physical condition resulting from the chronic multilocular pain symptomatology (Henriksson et al., 1996; Jacobson et al., 1992; Olsen and Park, 1998; Simms et al.,
*

Corresponding author. Fax: +49-6131-176688. E-mail address: ulrich_egle@web.de (U.T. Egle).

1994). The observed weakness in muscle tone and lack of relaxation between two consecutive muscle contractions, as well as the simultaneous activation of agonistic and antagonistic muscles were attributed to central functional disorders (Elert et al., 1993; Henriksson et al., 1996). Today, a dysregulation of the central stress response seems of decisive importance in the genesis of bromyalgia (Clauw and Chrousos, 1997), possibly resulting in a sensitization of central pain processing mechanisms (Kosek et al., 1996). Based on the ndings that bromyalgia patients have a higher level of daily stress (e.g., Dailey et al., 1990) and an altogether greater number of critical life events in their past (Anderberg et al., 2000), psychobiological studies assume a functional reduction in the release of cortocotropin-releasing-hormone (CRH) in the hypothalamus. This leads to a dysfunction of the hypothalamic-pituary-axis (HPA)

1090-3801/02/$30 2002 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Science Ltd. All rights reserved. PII: S 1 0 9 0 - 3 8 0 1 ( 0 2 ) 0 0 0 7 2 - 1

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K. Imbierowicz, U.T. Egle / European Journal of Pain 7 (2003) 113119

as well as of the locus-coeruleusnorepinephrin-axis (LCNE-axis) which in turn results in a dysfunction of the stress response system (Chrousos, 1998; Chrousos and Gold, 1992). This leads to the nding, that critical life events modulate the symtomatology of bromyalgia. Thus, traumatized bromyalgia patients demonstrate a heightened sensitivity to pain (Alexander et al., 1998; McBeth et al., 1999), more accessory symptoms (McBeth et al., 1999; Taylor et al., 1995), and a greater consumption of analgesics (Alexander et al., 1998; Boisset-Pioro et al., 1995). The primarily genetically determined stress-coping system, which determines the stress threshold, dampening, and reactivation (Lewis, 1992), is individually shaped in terms of its functional ability through psychosocial inuencing factors. Early inuencing psychosocial adversities, above all in the early relationship with important caregivers (see Bowlby, 1988; Hofer, 1994; Meaney et al., 1988) can lead to a long-term, impaired ability to react to stress in the sense of an early destabilisation of the stress system along the three dimensions mentioned above (Buskila, 1999; Gunnar, 1998; Schore, 1996). This increases the likelihood that both biological and psychosocial factors cause aective and psychovegetative complaints (somatizations) much more rapidly in adulthood. A series of prospective and retrospective studies (Baydar & Brooks-Gunn, 1991; Elder, 1974; Felitti sel et al., 1989; et al., 1998; Kessler et al., 1997; Lo Schepank, 1987; Werner & Smith, 1992) investigated the importance of psychosocial risk factors during childhood and adolescence, such as early separations, sexual abuse, physical maltreatment, and illnesses primarily of psychiatric origin. Above all, when there is an accumulation of events, we can assume an increased likelihood of psychiatric illness in later life (Kessler et al., 1997). Presumably, not only the vulnerability to mental illness but also to certain physical diseases is increased (Felitti et al., 1998). In bromyalgia patients these early stressors were found as well. The patients have a higher lifetime prevalence rate for psychosocial victimization during childhood and adolescence (Walker et al., 1997), even though the details about sexual abuse and physical maltreatment vary widely (Alexander et al., 1998; Boisset-Pioro et al., 1995; Goldberg et al., 1999; McBeth et al., 1999; Taylor et al., 1995; Walker et al., 1997). In contrast, van Houdenhove et al. (2001) found no increased frequency of sexual abuse in a European (Belgian) bromyalgia population sample. Yet, they did nd a higher frequency of emotional abuse and neglect and physical abuse during childhood as compared to an nociceptivly determined comparison group. Moreover, Goldberg et al. (1999) reported alcohol abuse in 41% of the families of origin in their bromyalgia patients.

Some authors regard bromyalgia, or at least a subgroup of these patients, as a form of persistent somatoform pain disorder (see Kellner, 1994; Wessely et al., 1999). The two disorders demonstrate common features regarding the occurrence of early biographical risk factors. Both retrospective (Adler et al., 1989; Drossman, 1995; Egle and Nickel, 1998; Linton, 1997; Schoerman et al., 1993) as well as prospective studies (Hotopf et al., 1998) describe a connection between multiple adverse childhood experiences and later somatoform disorders. Raphael et al. (2001) were able to establish a relation between a medically unexplainable pain syndrome and an early traumatization only through a retrospective approach, whereas they were unable to do so when using prospective data. Despite these common features of patients with bromyalgia and those with somatoform pain disorder, a corresponding, systematic comparison has not been carried out yet, nor has the meaning of early further stress events (in addition to sexual and physical abuse) and their accumulated eects been suciently investigated in bromyalgia patients. Against this background, the present study pursues the question of whether childhood risk factors veried in prospective studies occur with diering frequency in patients with bromyalgia, or with somatoform pain disorders, and in a control group with medically explained pain. Moreover, we examine which childhood risk factors are involved and whether the groups dier in terms of the accumulated occurrence of stress factors.

2. Sample and methods From an entire sample of 323 patients who consulted the interdisciplinary outpatient pain unit of a university hospital, n 38 patients were diagnosed with bromyalgia (FM) according to the American College of Rheumatology (ACR) criteria, and n 71 were diagnosed according to ICD-10 criteria as having a somatoform pain disorder (SOM), in particular nonmedically explained pain in the back, and in the arms and legs. The control group (CG) comprised n 44 patients with primarily medically explained, i.e., primarily nociceptively or neuropathically determined chronic pain syndrome. The sample description is presented in Table 1. The groups did not show any signicant dierences in age, allocation to social class (Rose and OReilly, 1997), education level and marital status. Dierences within the three samples emerged in the distribution of gender. For categorical variables dierences between the groups were tested for signicance by v2 tests. For interval-scaled data, tests of signicance were performed using ANCOVA. In ANCOVA the variable gender was calculated as a covariate. Results with p < 0:05 were

K. Imbierowicz, U.T. Egle / European Journal of Pain 7 (2003) 113119 Table 1 Random sample FM (n 38) Gender Female Male Age (years) Education (years) 69 613 P14 73.7% 26.3% 42.3 (SD 9.6) 50.0% 36.1% 13.9% SOM (n 71) 70.4% 29.6% 41.9 (SD 11) 62.0% 36.0% 2.0% CG (n 44) 36.4% 63.6% 41.6 (SD 12.1) 58.3% 38.9% 2.8% p

115

< 0:001 n.s.

n.s.

The weights lay between 160 and 25; the degree of the score expresses the importance of the factor for longterm eects. The emotional relationship with the parents and feeling of security in the parental home were assessed using a visual analogue scale (VAS: min. 0, max. 100). The sum of the scores for the quality of the relationship with the mother and with the father results in the emotional relationship with both parents. This value was included in the calculation of the ACE score. The dierences in the three samples concerning gender distribution were taken into account in the calculation of the ACE score.

Social classa (Rose & OReilly, 1997) I/II 10.0% IIIa 60.0% IIIb 23.3% IV/V 6.7% Marital status Married Single 86.1% 13.9%

5.1% 74.4% 15.4% 5.1% 86.0% 14.0%

4.3% 65.2% 4.3% 26.1% 75.0% 25.0%

n.s.

3. Results 3.1. Relationship with the parents during childhood

n.s.

a I/II: Professional, managerial, and technical occupations; IIIa: nonmanual skilled occupations; IIIb: manual skilled occupations; IV/V: partly skilled and unskilled occupations.

interpreted as signicant. p-Values were corrected by Bonferroni procedure. A systematic survey of the childhood risk factors was carried out using a specially developed, structured interview for pain patients (SBI-P, Egle et al., 1993). The SBI-P is a structured interview with 144 questions in eight sections and is carried out by a trained interviewer. One of these sections with 67 questions investigates adverse childhood experiences. The interview needs about 6090 min for each patient. At the time, the interviewers are independent and have no knowledge of the results of the clinical classication. Following an ashrssen (1984), 14 risk factors sessment proposed by Du were weighted and combined into a global adverse childhood experience (ACE) score (see Table 4). The individual factors were weighted to take into account the dierent relevance of risk factors for the further development, e.g., the dierence in meaning between the loss of a parent during childhood, divorce of the parents, or a close dierence in age to the next sibling.

The FM group reported the relatively worst relationship with their parents. It was assessed that the higher the VAS value in describing the relationship with the parents, the better the relationship. Compared to the organic control group, the FM group had a poorer emotional relationship with the mother (VAS value: 64 vs. 86; p < 0:01), with the father (VAS value: 70 vs. 85; p < 0:01), with both parents (VAS value: 134 vs. 171; p < 0:001), and a lower-level feeling of security (VAS value: 59 vs. 81; p < 0:01), with their feeling of security even lower than that of the SOM group (p < 0:05) (see Table 2). 3.2. Violence and lack of physical care Physical violence between the parents was reported roughly seven times more frequently by patients in the FM group than by those of the organic control group (15.8% vs. 2.3%; p < 0:05). When dierences of opinion arose, it was less often possible for the patients of the FM group to talk about these dierences with their parents (39.5% vs. 61.9%; p < 0:05). In the FM group, sexual abuse (10.5% vs. 0%, p < 0:05) and frequent physical maltreatment (31.6% vs. 11.4%; p < 0:05) occurred several times more frequently than in the organic control group (see Table 3).

Table 2 Emotional relationship with parents during childhood FM (n 38) M Emotional relationship with mother Emotional relationship with father Emotional relationship with both parents Feeling secure
a

SOM (n 71) M 77 67 144 74 SD 25 32 42 25

CG (n 44) M 86 85 171 82 SD 18 20 28 24

FM vs. SOM F
a

FM vs. CG Fa 9.05 7.25 14.28 8.28 pa <0:01 <0:01 <0:001 <0:01

SD 28 30 38 32

64 70 134 59

2.10 0.07 0.46 5.71

n.s. n.s. n.s. < 0:05

ANCOVA.

116 Table 3 Violence and neglect

K. Imbierowicz, U.T. Egle / European Journal of Pain 7 (2003) 113119

FM (n 38) (%) Frequent physical violence between parents Talking about dierent opinions was possible Severe sexual abuse before age 15b Frequent physical maltreatment in childhood Lack of physical care
a 2 b

SOM (n 71) (%) 12.7 41.4 15.5 32.4 31.4 (9) (29) (11) (23) (22)

CG (n 44) (%) 2.3 61.9 0 11.4 19.0 (1) (26) (5) (8)

FM vs. SOM pa n.s. n.s. n.s. n.s. < 0:05

FM vs. CG pa < 0:05 < 0:05 < 0:05 < 0:05 < 0:001

15.8 39.5 10.5 31.6 57.9

(6) (15) (4) (12) (22)

v -Test. Attempted/committed sexual intercourse/manual manipulation.

Table 4 hrssen) Childhood adversities (following the assessment by Du Childhood adversities (before age 15) 1. Death of mother/father 2. Poor emotional relationship with both parents 3. Severe sexual abuse 4. Physical illness or handicap of mother 5. Physical illness or handicap of father 6. Mental illness of mother 7. Mental illness of father 8. Addiction (alcohol or other drugs) of mother 9. Addiction (alcohol or other drugs) of father 10. Frequent physical abuse 11. Separation/divorce of parents 12. Parents severely strained by job demands 13. Meagre nancial situation (before age 7) 14. Age-gap to next sibling < 18 months
a 2

Weight 160 160 160 135 130 130 130 130 130 130 130 50 50 25

FM vs. SOM pa n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. < 0:05 n.s. n.s. n.s.

FM vs. CG pa n.s. < 0:001 < 0:05 n.s. n.s. n.s. n.s. n.s. n.s. < 0:05 n.s. n.s. n.s. n.s.

v -Test, except item 2 (see Table 2).

Table 5 ACE-score FM (n 38) M ACE score

a

SOM (n 71) SD 245.7 M 342.7 SD 242.9

CG (n 44) M 202.8 SD 183.4

FM vs. SOM F
a

FM vs. CG
a

Fa 8.50

pa < 0:005

375.5

0.09

n.s.

ANCOVA.

Furthermore, the parents of the FM patients more frequently were not able to express aection through physical care than the CG parents (57.9% vs. 19%; p < 0:001) or the SOM parents (57.9% vs. 31.4%; p < 0:05). 3.3. Cumulative adverse childhood experience score Table 4 presents an overview of the risk factors that went into the calculation of the ACE-score, their weight, and the dierences between FM and CG as well as FM and SOM. Besides the factors already mentioned that occurred more frequently in the FM patients than in the CG, i.e., physical/sexual abuse and the poor emotional relationship with the parents. The FM group experienced separations before age 15 more frequently than the SOM group (< 0:05).

Subsequent to this, the sum score was formed folhrssen, and the groups were compared once lowing Du again (see Table 5). The ACE score was much higher among the FM patients than in the control group (M 375.5 vs. 202.8, p < 0:005). The dierent gender distribution of the three samples was taken into account by performing ANCOVA. The FM group had experienced more frequent and/or more severe adversities during childhood than the control group, but did not dier signicantly from the SOM group.

4. Discussion The present casecontrol study shows that childhood adversities have a relatively high frequency in bromyalgia patients. These experiences were found to a

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similar extent in patients with somatoform disorders, but less marked than in patients with medically explained chronic pain. Insuciently supportive relationships with the primary caregivers, a poor emotional relationship and a low-level feeling of security, poor physical care, as well as experiences of physical or sexual violence all characterise the biography of these patients. These patients might not only had to witness frequent episodes of physical violence between the parents, they also felt it on their own body (pain memory). One possible limitation of these results could be the distinctly larger share of male patients in the CG compared to the FM and SOM group. This could be an important inuence on the incidence of single adversities. In the calculation of the dierences in ACE score, this was taken into account, and wasdespite the different extent of adversitiesconrmed again. In previous studies, sexual abuse was repeatedly described as a relevant stress event in the lifes of the FM patients. This nding was conrmed. However, it is generally not an event occurring in isolation, but a part of a whole series of other psychosocial childhood adversities. One central result of our study is, furthermore, that traumatic experiences during childhood and adolescence tend to occur cumulatively and probably only through their summationin line with the results of van Houdenhove et al. (2001)lead to emotional and physical symptoms. Regarding such early biographical stress experiences as pathological factors, they may result in dysfunctions of central pain processing mechanisms or of the primarily genetically determined stress response system. These dysfunctions might be the pathogenetic mechanisms: pain, exhaustion, and psychovegetative symptomatology are the consequences of the dysregulation of this system (Buskila, 1999). Clinically and pathogenetically there is a broad overlap between SOM and FM, although the ocial denition and the diagnostic criteria are dierent. Somatoform pain can be generalized or localized but the occurrence of tender points is pathognomonic for bromyalgia. However, as our results show, adverse childhood experiences can be found in a distinctly larger proportion of the FM and SOM patients compared to the CG patients, yet they are not found in all patients of FM and SOM. In other words, they are not a necessary condition, but one potential factor for the development of the two disorders. It remains to be claried whether patients without adverse childhood experiences also have a disturbance of their stress response system, and which other factors, e.g., other forms of chronic stress, result in this case. Presumably, there is a large subgroup within the bromyalgia patients for whom psychosocial childhood adversities during childhood may have a pathogenetical meaning. The results of other studies indicate that such

victimizations are associated with a greater use of medical care (Aaron et al., 1996; Alexander et al., 1998), and therefore the traumatized patients might be overrepresented compared to bromyalgia in the general population. Furthermore, it was observed that in university treatment centres, i.e., facilities of tertiary care, patients with psychopathological abnormalities are more frequently found than in other medical care facilities or general population. Consequently, the subgroup of FM patients with childhood adversities is possibly smaller in primary care than described in our study. An additional factor to be discussed is the retrospective collection of data. The details about the occurrence of psychosocial risk factors depend on the subjective memory of the patients. Criticism of retrospective approaches refers directly to this point. An overestimation as well as an underestimation of the childhood risk factors inuenced by the patients mental state at the time of the interview has to be considered. The studies designed to take this into account (Coyne and Gotlib, 1983; Kendler et al., 1991; Lewinson et al., 1980; Parker, 1981; Robins et al., 1985) nevertheless veried that there is a tendency towards false negative results, that is towards underestimation. This was conrmed in a prospective study (Widom and Morris, 1997; Widom and Shepard, 1997; Widom et al., 1999). Only 73% of all individuals traumatized during childhood reported this 20 years later. This dierence can be explained by the general human inclination to repress stressful events which seems to be even more pronounced in patients with somatization. A further argument concerning bias by a selective recall of early psychosocial adversities is the present extent of depression or other aective states. However, a relation between mental state and selective recall could not be proved (Brewin et al., 1993; Gerlsma et al., 1993, 1994; Robins et al., 1985). A relevant bias was only found for the same disease or disorder of patients and their parents. For example, patients with headache report more headache of their parents as the parents themselves (Ottman et al., 1993). Because we did not look at the extent of pain reports and each of our three groups suers from chronic pain, we do not expect any bias by this phenomenon. Selective recall may inuence underreporting of childhood adversities (about 30%, Fergusson et al., 2000), but this applies to each of the three pain groups of our study. None of the three groups investigated by us, is convinced to have pain due to psychological reasons; all are convinced that their pain is due to a somatic process. The illness attribution of the three pain groups we investigated is quite similar. For this reason, an overreporting of childhood adversities cannot be assumed. Yet even prospective surveys of childhood adversities can make the interpretation of results dicult. If severe

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K. Imbierowicz, U.T. Egle / European Journal of Pain 7 (2003) 113119 Boisset-Pioro MH, Esdaile JM, Fitzcharles MA. Sexual and physical abuse in women with bromyalgia syndrome. Arthritis Rheum 1995;38(2):23541. Buskila D. Fibromyalgia, chronic fatigue syndrome, and myofascial pain syndrome. Curr Opin Rheumatol 1999;11:11926. Bowlby J. The secure base. Clinical applications of attachment theory. London: Tavistock/Routledge; 1988. Brewin CR, Andrews B, Gotlib ICH. Psychopathology and early experience: a reappraisal of retrospective reports. Psychol Bull 1993;113:8298. Chrousos GP. Stressors, stress, and neuroendocrine integration of the adaptive response. The 1997 Hans Selye Memorial Lecture. Ann NY Acad Sci 1998;85:131135. Chrousos GP, Gold PW. The concepts of stress and stress system disorders. Overview of physical and behavioral homeostasis. JAMA 1992;267:124452. Clauw DJ, Chrousos GP. Chronic pain and fatigue syndromes: overlapping clinical and neuroendocrine features and potential pathogenic mechanisms. Neuroimmunomodul 1997;4:13453. Coyne J, Gotlib IM. The role of cognition in depression: a critical appraisal. Psychol Bull 1983;94:472505. Dailey PA, Bishop GD, Russell AL, Fletcher EM. Psychological stress and the brositis/bromyalgia syndrome. J Rheumatol 1990;17: 13805. Drossman DA. Sexual and physical abuse and gastrointestinal illness. Scand J Gastroenterol 1995;30(Suppl 208):906. hrssen A. Risikofaktoren fu r die neurotische Kindheitsentwicklung. Du Ein Beitrag zur psychoanalytischen Geneseforschung. Z Psychosom Med 1984;30:1842. Egle UT, Schwab R, Holle R, Homann SO. Dierentialdiagnostische herkennung somatoformer Schmerzpatienten. Parameter zur Fru Der Schmerz 1993;7(Suppl 1):4. Egle UT, Nickel R. Childhood risk factors of somatoform pain patients. Z Psychosom Med 1998;44:2136. Elder GH. Children of the great depression. Chicago: University of Chicago Press; 1974. Elert J, Dahlqvist SR, Almay B, Eisemann M. Muscle endurance, muscle tension and personality traits in patients with muscle or joint paina pilot study. J Rheumatol 1993;20(9):15506. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 1998;14:24558. Fergusson DM, Horwood LJ, Woodward LJ. The stability of child abuse reports: a longitudinal study of the reporting behaviour of young adults. Psychol Med 2000;30:52944. Gerlsma C, Das J, Emmelkamp PM. Depressed patients parental representations: stability accross changes in depressed mood and specity across diagnoses. J Aect Dis 1993;27:17381. Gerlsma C, Kramer JJ, Scholing A, Emmelkamp PM. The inuence of mood on memories of parental rearing practices. Br J Clin Psychol 1994;33:15972. Goldberg RT, Pachas WN, Keith D. Relationship between traumatic events in childhood and chronic pain. Disabil Rehabil 1999;21(1):2330. Gunnar M. Quality of early care and buering of neuroendocrine stress reactions: potential eects on the developing human brain. Prev Med 1998;27:20811. Henriksson KG, Backman E, Henriksson C, de Laval JH. Chronic regional muscular pain in women with precise manipulation work. A study of pain characteristics, muscle function, and impact on daily activities. Scand J Rheumatol 1996;25(4):21323. Hofer MA. Early relationships as regulators of infant physiology and behavior. Acta Peadiatr 1994;397(Suppl Jun):918. Hotopf M, Mayou R, Wadsworth M, Wessely S. Childhood risk factors for adults with medically unexplained symptoms: results from a national birth cohort study. Am J Psychiat 1998;156:1796800.

childhood experiences are observed in children during an interview or documented by court, appropriate supportive intervention may not be excluded for ethical and moral reasons. The children have thus related their troubles and received help. The further course of these children is presumably dicult to compare with that of children who have not experienced similar relief. The conclusion that a lack of predictive value of childhood adversities for physically unexplainable pain is an expression of the low meaning of early childhood risk factors (Raphael et al., 2001) appears to be a rash conclusion in light of these circumstances. In this study the emphasis lays on surveying adverse life experiences that predispose patients to pain. In doing so, we left out of consideration protective factors in the childhood development. Statements about the vulnerability can be put into concrete terms through studies that explore the interaction of risk factors with protective factors. We are already involved in realizing studies dealing with this subject. Nevertheless adversities seem to have an important inuence on vulnerability to mental but also to some physical disorders (Felitti et al., 1998), and they require appropriate treatment strategies. In the subgroup of the FM patients with early childhood adversities, psychotherapeutic interventions are likely to be quite an essential part of the treatment. Besides symptom-oriented treatment approaches, corrective, new relationship experiences might be necessary to increase self-esteem while reducing anxiety and depression. In summary, a detailed survey of pathogenetic factors in bromyalgia serves the clinical understanding of this complex disorder, while making a dierentiation of subgroups possible and, in this way makes the development of more specic therapeutic approaches than previously achievable.

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