Original articleExploring the role of sleep and coping in quality of life in fibromyalgia☆
Introduction
Fibromyalgia syndrome (FMS) has been estimated to occur in 3.5–5% of the population. It is characterized by chronic widespread pain, tender points, and fatigue [1]. There is currently no recognized effective treatment for FMS patients [2], which has large implications for quality of life, well-being, ability to work, physical functioning, and health care utilization. Poor sleep quality is a prominent feature of FMS, with 70–90% of patients experiencing some form of sleep disturbance [2], [3]. Poor sleep has also been found to take on primary significance in the course of FMS [4], with strong links between sleep and the experience of pain [5], [6], [7], [8]. These links appear to be bidirectional, with poor sleep linked to increased pain and with pain linked to poor sleep [6], although little is known about the effect of sleep on other health outcomes such as fatigue, emotional well-being, and physical functioning in FMS.
There is emerging evidence of abnormalities in the sleep architecture in patients with FMS. For example, patients with FMS have been found to have increased Stage 1 nonrapid eye movement (NREM) sleep [9], [10] and less slow-wave sleep [11], [12]. Higher α-wave intrusions during NREM sleep have also been found in patients with FMS in comparison to healthy controls [13]. These high α-wave intrusions have been associated with higher levels of pain and tender points [14], although findings have not been consistent [15], [16].
In order to establish a comprehensive understanding of the role of sleep and its effect on quality of life in FMS, it is important to fully explore patients' perceptions and experiences of sleep quality. Previous studies of sleep and FMS have revealed a high prevalence of sleep disturbances and the effect of poor sleep on pain in patients with this condition. However, perceptions of sleep quality have not been based on standardized assessment measures. For example, Nicassio et al. [8] measured subjective sleep quality based on a rating of 1–10 on a visual analogue scale. There are several components of sleep that can affect sleep quality, such as sleep latency, sleep efficiency, and frequency of disturbances during the night, which need to be taken into account in measures of sleep quality [17]. One study used the Pittsburgh Sleep Quality Index (PSQI) as a measure of subjective sleep quality, although the findings of this study were limited by its small sample size [7].
Coping strategies can be effective in helping patients manage chronic conditions and other difficulties experienced, such as poor sleep quality. Coping strategies are often classified as either problem-focused (the person confronts the problem directly, such as coming up with a strategy to resolve the problem) or emotion-focused (the person focuses on controlling their emotional reactions, such as talking to family and friends) [18]. Some researchers in the chronic pain literature classify coping in terms of active coping (such as planning and pacing activities) and passive coping (such as resting and taking medications) strategies. Research on coping and chronic pain has revealed that active coping strategies are associated with improved health outcomes. In contrast, research focusing on coping and FMS, specifically, has revealed that active coping is associated with increased disability, pain, and poor physical functioning [19], [20]. However, these studies only explored the use of coping strategies specifically in response to pain [19], [20]. As FMS is a complex syndrome, it may be necessary to explore the use of more generic coping strategies on a range of outcomes in addition to pain to understand the effect of coping on FMS.
Sleep may also be associated with coping, as poor sleep may reduce patients' ability to successfully use cognitive coping strategies in response to pain [21]. It is likely that mechanisms regulating attention to pain may be disrupted by poor sleep [6]. Sadeh and Grober [22] suggest that a passive coping approach, such as using disengagement, may be related to increased sleep as a way of escaping the stressor. They also suggest that some strategies (such as cognitive rumination) may lead to increased arousal, preventing sleep onset; therefore, poor sleep may be indicative of the use of less effective coping strategies [23]. For example, although information seeking may be a useful strategy to reduce stress, its use has also been associated with insomnia [24]. In addition, compared to good sleepers, patients with insomnia have been found to perceive minor stressors as having a higher negative impact [25].
Sleep and mood are highly correlated [26], [27], and mood has been related to a wide range of physical and psychological problems in FMS [28], [29]. Negative affect is thought to influence the relationship between self-reports of stressors and strain [30], [31], [32], and one study revealed that patients with FMS found it more difficult to sustain positive affect in response to stressful situations [33] and, therefore, both positive affect and negative affect need to be controlled for when exploring coping in patients with FMS. The present study aims to explore the links between sleep and coping in health-related quality of life in FMS.
Section snippets
Participants
Participants were recruited through community-based FMS support groups in southeast England. This was performed to ensure that patients managed by their general practitioners (GPs) in primary care (who may not attend a rheumatology clinic) were not excluded. General inclusion criteria were as follows: (a) diagnosis of FMS by a GP or a consultant, based on the 1990 American College of Rheumatology criteria [34]; (b) FMS as the primary medical diagnosis; and (c) age of ≥18 years. Participants
Participant characteristics
Of the 200 questionnaires that were distributed, 111 (56%) were returned. Ten questionnaires were omitted from the analysis as they did not meet the inclusion criteria (e.g., one participant reported a diagnosis of sleep apnea that had not been previously identified, or more than 20% of a questionnaire was missing). Of the 101 participants included in the analysis, 94 were female (93%) and 7 were male (7%). All participants were aged between 26 and 80 years, with a mean age of 55 years
Discussion
This exploratory study aimed to investigate the effect of self-reported sleep and coping in participants with FMS. A high percentage of the sample (99%) experienced some form of sleep difficulties [2], [3], with poor sleep quality being significantly predictive of pain, fatigue, and social functioning. In support of previous findings, negative affect was significantly predictive of poorer health outcomes, and positive affect was significantly associated with better health outcomes, excluding
Acknowledgments
We would like to thank the Fibromyalgia Association UK support groups for supporting the study.
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There were no competing interests.