(English) Fibromyalgia and overloading: an integrative hypothetical model

John L. Zant, Leo D. Roorda, Sharon Voet, Jos H.M. Dekker, Joost Dekker
All authors work at the Department of Rehabilitation Medicine and Psychology in the Jan van Breemen Institute, Amsterdam, The Netherlands; Professor Joost Dekker also works at the Department of Rehabilitation Medicine and the EMGO Institute, VU University Medical Centre, Amsterdam,

Jan van Breemen Institute, Amsterdam, The Netherlands

Summary

This study focuses on the concepts of over-activity, persistence, ergomania and endurance in relation to the etiology of fibromyalgia (FM). With respect to the etiology an integrative overloading model for FM is formulated on the basis of data from the few studies investigating this subject, and on the basis of clinical experience gained from a great number of well-documented psychological life-histories of patients with FM. Clinical implications are outlined. This model may serve as an agenda for further research on the etiologial relation between overloading and fibromyalgia.

Introduction

Fibromyalgia (FM) is one of the chronic non-specific or medically unexplained pain syndromes. The etiology of FM is still unknown (van Houdenhove, 2004). There is, however, growing evidence that psychological factors play an important role in the etiology of FM (Boissevain,1991; Clauw, 1995; Brosschot, 2001; Linton, 2002; 2005). FM has been described as a depressive disorder (Alfici, 1989; Raphael, 2004), as an affective disorder (Hudson, 2003), and as a stress-related disorder (van Houdenhove, 2004). In a study of dysfunctional psychological dimensions in FM-patients, factor analyses identified several psychological dimensions, including cognitive (catastrophizing, external control beliefs), emotional (alexithymia), behavioral (restless behavior) and social (need for support) dimensions (Colangelo, 2004). Van Houdenhove (1986; 1994; 1995; 2001ab; 2004) showed that action-proneness, or a pre-morbid overactive life-style, can be an etiological factor related to FM, an that it plays a role in 70% of chronic pain patients. Alfici (1989) reported that, among other factors, dependence, obsessive-compulsive personality and pre-pain ergomania were characteristic of FM-patients. Hasenbring (1994; 1996; 2001; 2006) demonstrated that avoidance behavior and endurance strategies were psychological predictors of pain persistence in lumbar disc patients. Vlaeyen (2004) hypothesizes that either disuse (fear-avoidance model) or overuse (persistence model) will lead to disability and chronic pain. There is growing evidence to support the fear-avoidance model (Vlaeyen, 2004; Leeuw, 2007)). However, studies on overuse and persistence have, until now, been relatively scarce (McCracken, 2007). According to these studies it seems that the concept of overloading plays an important role in the etiology of FM (and other non-specific pain- and fatigue-syndromes (van Houdenhove, 2004); this concept contains terms such as action-proneness, overactive life-style, ergomania, endurance strategies, overuse and persistence. A comprehensive theoretical model of overloading (overuse) has not yet been developed (Vlaeyen, 2004).

Integrative hypothetical model

We have tried to formulate an integrative hypothetical model of overloading, based on the afore-mentioned studies and on our own clinical experience gained from some thousands of life-histories of FM-patients documented by our psychologists during the past fifteen years. According to van Houdenhove (2002) and Wentz (2004) the patient’s biography should be part of each diagnostic evaluation and considered an important focus of psychological/ psychiatric research in fibromyalgia and chronic fatigue syndrome; it illustrates the possible etiological role of adverse childhood experiences, premorbid overactivity and intense activity or hypomanic helpfulness. The model describes cognitive, emotional, behavioral and environmental conditions in the development of an overloading life-style, eventually leading to FM: Parental behavior and personality development In family situations in which the parents are not able to show warm and appreciative behavior towards their children, or when parents are overambitious or perfectionists, children may learn to disregard their own strivings and needs and to fulfill the needs of the parents in all respects. High demand, in combination with more negative than positive feedback, may lead to fear of failure, low self-esteem and a compulsory tendency to please the parents and avoid their criticism. It is also possible that a child has to take adult responsibilities when, for example, the mother is absent because of death, illness, divorce or a full-time job. When this pattern of disregarding one’s own strivings and needs and of hypomanic helpfulness has been learnt in childhood, adult relationships may develop into asymmetrical patterns in which one invests more energy in others than vice versa. This could lead to physical and mental overloading, and finally to chronic pain, exhaustion and inactivity. When a child learns that expressing his emotions elicits punishment he will suppress his emotions and will become alienated from his own feelings, which may lead to depression, especially when there is no positive feedback from relevant others. To avoid falling into a depression some people throw themselves into their work and other activities (in a compulsory way) which increases overloading until they are no longer able to work, due to increasing pain and fatigue, and yet depression will develop. There is growing evidence that adverse childhood experiences play an important role in the development of chronic pain- and fatigue-syndromes (McBeth, 1999; Wentz, 2004)). According to Zant (1997) and Fisher (2003), lack of affection and over-protection play an important role in the etiology of FM. Imbierowicz (2003) found a relationship between sexual and physical maltreatment in childhood and the development of FM. Waerden (2005) found that fearful and preoccupied attachment-styles are associated with symptom reporting via a negative model of the self and negative affectivity. Life-style and asymmetrical relationships In an asymmetrical relationship between a helpful person and a privileged person, the latter learns that he has to invest minimally in the relationship because the former is helpful under all circumstances (a-selective reinforcement). Because helpfulness is so easily gained, the privileged person does not learn to value the helpful behavior, and will experience it as a matter of course. If, later on, the helpful person wants to achieve a more symmetrical interaction, he will meet resistance because the other does not want to relinquish his privileges. And what is more, the helpful person has not learnt how to be assertive. This process will lead to continuously overloading behavior in the helpful person. It may be clear that for someone who has learnt to be more helpful to others than to satisfy his own needs, and who has developed a network of asymmetrical relationships, it requires a great deal of effort to reform most of his relationships with relevant others to achieve symmetrical and equivalent interactions. Even if the patient has learnt through psychotherapy to be more assertive, to express his feelings and to negotiate more effectively, it will take a lot of time and energy to implement the newly acquired abilities. The overloading person will receive little recognition of, and appreciation for, his helpful behavior because the privileged person has learnt to take it for granted. Moreover, the overloading person will receive little recognition of his pains and exhaustion from physicians, who are usually unaware of the pre-morbid overactive life of this momentarily very inactive patient with pain, but little or no physical defects. Therefore, physicians often see no valid reason for sick-leave or social security benefits. In our society, working hard and being helpful are valued positively, and can therefore not be unhealthy. Failing to protect one’s personal life is often regarded as a weakness, and as a sign of personal ineptitude. As mentioned above there is some evidence that FM is associated with concepts such as action-proneness and overactive life-style (van Houdenhove 1986, 1994, 1995, 2001ab, 2004), ergomania (Alfici, 1989), endurance strategies, overuse and persistence (Hasenbring, 1994, 1996, 2001; Vlaeyen, 2004). Complaints and somatization In contacts with the health services the patient often learns that diagnostic and therapeutic actions are primarily focused on his physical symptoms and the physical locus of pain, and much less and much later on underlying psychological aspects. Thus the patient learns to present his complex problem by communicating his (initially relatively innocent) physical pain problem. Perhaps as a child the patient learnt from his parents to communicate with physical complaints when he had emotional problems. At first, such a patient may receive attention and recognition, and there may even be temporary legitimacy to no longer be helpful and overloading. The result, however, for the patient is that the only way to continue to receive this beneficial environmental behavior is to suffer pain and other complaints. If the partner and other relevant people recognize the pain, fatigue and disability, and if they pay extra attention to the patient and recognize that the patient is discharged from his overloading duties, the complaints will be reinforced. The patient will be reinforced because of his complaints and not or much less because he is a valuable person (selective reinforcement). If these other people take care of the patient this even seems to result in “symmetrical” relationships. However, to continue this “equivalence” it is necessary that the pain or other complaints continue. There is substantial evidence that the environmental reinforcement of complaints (operant factors) leads to (further) somatization and inactivity ( e.g. Fordyce, 1978). Our hypothetical model of overloading in relation to the etiology of FM is summarized in Figure 1.

More research has to be performed as to the interrelations between adverse childhood experiences, personality, an overloading life-style and FM (and other chronic pain- and fatigue-syndromes), cross-sectionnaly as well as longitudinally. This integrative hypothetical model could serve as an agenda for future research.

Clinical implications

From our overloading-model we formulated a multidimensional treatment program: If the behavior of the overloading patient has been directed more by external factors than by internal factors, then treatment has to result into a shift at cognitive, emotional, behavioral and relational (environmental) level from “what am I supposed to do” to “what can I do and what do I want to do myself”. In order to reach these results the patient needs to obtain insight into his present and his desired behavior (recognition) and to learn new skills to implement these insights into his life-pattern. Within this model treatment-results may be formulated as follows: Cognitive level: The patient now recognizes his cognitive patterns in which he strives at fulfilling demands of others and at pleasing others without taking into account what he can and what he wants. The patient now masters skills to decide when and how to draw a line and formulate his opinions, wishes and arguments in an assertive way, instead of trying to diminish his pain and fatigue symptomatically. Emotional level: The patient now recognizes he is suppressing his feelings and the fact that others restrict or even punish his expression of emotions. The patient now masters skills to admit and to express his feelings, especially anger when others place too great demands on him or ignore his opinions or feelings, in stead of going on and on in order not to experience his negative emotions. The patient feels no longer depressed or anxious. Behavioral level: The patient now recognizes overloading signals in his body and realizes that if he does not draw a line himself, his body will do it for him by pain and fatigue. The patient now masters skills to diminish his level of activity or to alternate activities or to take a rest in time. In case of resistance from other people the patient is able to stick to his guns and to negotiate or even think of or apply sanctions if necessary. Environmental (operant) level: The patient now recognizes that he mainly receives support and attention from others because of his complaints and that support and attention are/were hard to obtain in other ways. The patient now masters skills to secure support and attention from others not by complaining but by making others clear that it is their turn to be nice and supporting, not because the patient is ill but because he is a valuable person.

Acknowledgments

We thank the Jan van Breemen Institute for its financial and logistical support in setting up and conducting this study.

References

Alfici S, Sigal M, Landau M. Primary fibromyalgia syndrome-a variant of depressive disorder? Psychother Psychosom 1989; 51(3): 156-61. Boissevain MD, McCain GA. Toward an integrated understanding of fibromyalgia syndrome. II. Psychological and phenomenological aspects. Pain 1991; 45(3): 239-48. Brosschot JF, Aarsse HR. Restricted emotional processing and somatic attribution in fibromyalgia. Int J Psychiatry Med 2001; 31(2): 127-46. Clauw DJ. The pathogenesis of chronic pain and fatigue syndromes, with special reference to fibromyalgia. Med Hypotheses 1995; 44(5): 369-78. Colangelo N, Bertinotti L, Nacci F, Conforti ML, Beneforti E, Pignone A, Matucci-Cerinic M, Zoppi M. Dimensions of psychological dysfunction in patients with fibromyalgia: development of an Italian questionnaire. Clin Rheumatol 2004; 23(2): 102-8. Fisher L, Chalder T. Childhood experiences of illness and parenting in adults with chronic fatigue syndrome. J Psychosom Res 2003; 54(5): 439-43 Fordyce W. Learning processes in pain. In R.A.Sternbach: Psychology of Pain, New York, Raven Press, 1978. Hasenbring M, Plaas H, Fischbein B, Willburger R. The relationship between activity and pain in patients six months after lumbar disc surgery: do pain-related coping modes act as moderator variables. Eur J Pain 2006; 10: 701-9. Hasenbring M, Hallner D, Klasen B. Psychologische Mechanismen im Prozess der Schmerzchronifizierung, unter- oder überbewertet? Schmerz 2001; 15: 442-7. Hasenbring M. Kognitive Verhaltenstherapie chronische rund prächronischer Schmerzen. Psychotherapeut 1996; 41: 313-325. Hasenbring M, Marienfeld G, Kuhlendahl D, Soyka D. Risk factors of chronicity in lumbar disc patients. A prospective investigation of biologic, psychologic, and social predictors of therapy outcome. Spine 1994; 19(24): 2759-65. van Houdenhove B, Egle UT. Fibromyalgia: a stress disorder? Piecing the biopsychosocial puzzle together. Psychother Psychosom 2004; 73(5): 267-75. Van Houdenhove B. Why we should pay more attention to the story of the patient. J Psychosom Res 2002; 52(6): 495-9. van Houdenhove B, Neerinckx E, Lysens R, Vertommen H, van Houdenhove L, Onghena P, Westhovens R, D’Hooghe MB. Victimization in chronic fatigue syndrome and fibromyalgia in tertiary care: a controlled study on prevalence and characteristics. Psychosomatics 2001a; 42(1): 21-8. van Houdenhove B, Neerinckx E, Onghena P, Lysens R, Vertommen H. Premorbid “overactive” lifestyle in chronic fatigue syndrome and fibromyalgia. An etiological factor or proof of good citizenship? J Psychosom Res 2001b; 51(4): 571-6. van Houdenhove B, Onghena P, Neerinckx E, Hellin J. Does high ‘action-proneness’ make people more vulnerable to chronic fatigue syndrome? A controlled psychometric study. J. Psychosom Res 1995; 39(5): 633-40. van Houdenhove B. Prevalence and psychodynamic interpretation of premorbid hyperactivity in patients with chronic pain. Psychother Psychosom 1986; 45(4): 195-200. van Houdenhove B, Vasquez G, Neerinckx E. Tender points or tender patients? The value of the psychiatric in-depth interview for assessing and understanding psychopathological aspects of fibromyalgia. Clin Rheumatol 1994; 13(3): 470-4. Hudson JI, Mangweth B, Pope HG, De CC, Hausmann A, Gutweniger S, Laird NM, Tsuang MT. Family study of affective spectrum disorder. Arch Gen Psychiatry 2003; 60(2): 170-7. Imbierowicz K, Egle UT. Childhood adversities in patients with fibromyalgia and somatoform pain disorder. Eur J Pain. 2003; 7(2): 113-9. Leeuw M, Goossens ME, Linton SJ, Crombez G, Boersma K, Vlaeyen JW. The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med 2007; 30: 77-94. Linton SJ. Why does chronic pain develop? A behavioral a approach. New Avenues for the prevention of chronic musculoskeletal pain and disability. Pain Res Clin Manag. 2002; 12 (6): 67-80. Linton SJ. Do psychological factors increase the risk for back pain in the general population in both a cross-sectional and prospective analysis? Eur J Pain 2005; 9: 355-361. McBeth J. The association between tenderpoints, psychological distress and adverse childhood experiences. Arthritis & Rheumatism 1999; 42: 1397-1404. McCracken LM, Samuel VM. The role of avoidance, pacing and other activity patterns in chronic pain. Pain 2007; 130: 119-125. Raphael KG, Janal MN, Nayak S, Schwartz JE, Gallagher RM. Familial aggregation of depression in fibromyalgia: a community-based test of alternate hypotheses. Pain 2004; 110(1-2): 449-60. Vlaeyen JWS, Morley S. Active despite pain: the putative role of stop-rules and current mood. Pain 2004; 110: 512-516. Waerden AJ, Lamberton N, Crook N, Walsh V. Adult attachment, alexithymia and symptom reporting, an extension of the four category model of attachment. J Psychosom Res 2005; 58: 279-88. Wentz KA, Lindberg C, Hallberg R. Psychological functioning in women with fibromyalgia: a grounded theory study. Health Care for Women Int 2004; 25(8): 702-9. Zant JL, Mooij A, Griep EN, Boersma JW, de Kloet ER. Fibromyalgia in relation to the process of early attachment. Ned T Pijn Pijnbestrijding 1997; 2: 25-27. Note We searched systematically in PubMed and PsycINFO 1990-2008: Aetiol/childhood/determine/development/etiol/future/predict/premorbid/prognos/prospective/risk And Action-prone/endur/ergomania/hyperactive/persistence/overactive/overloading/overuse/surmenage And Chronic pain/fatigue/fibromyalgia/musculoskeletal pain/somatoform pain/ unexplained pain/ widespread pain And Attachment/catastrophiz/coping/emotional/life style/personal/psychologic/psychopath/reinforcement/self-efficacy/social/stress.

Authors: John L. Zant, Leo D. Roorda, Sharon Voet, Jos H.M. Dekker All authors work at the Department of Rehabilitation Medicine and Psychology in the Jan van Breemen Institute, Amsterdam, The Netherlands Correspondence to: Dr. J.L. Zant, psychologist, Department of Rehabilitation Medicine and Psychology, Jan van Breemen Institute, Dr. Jan van Breemenstraat 2, 1056 AB Amsterdam, The Netherlands Tel. 0031205896337 Fax 0031204896704 E-mail j.zant@janvanbreemen.nl

Abstract

This study focuses on the concepts of over-activity, persistence, ergomania and endurance in relation to the etiology of fibromyalgia (FM). With respect to the etiology an integrative overloading model for FM is formulated on the basis of data from the few studies investigating this subject, and on the basis of clinical experience gained from a great number of well-documented psychological life-histories of patients with FM. Clinical implications are outlined. This model may serve as an agenda for further research on the etiologial relation between overloading and fibromyalgia.

Introduction

Fibromyalgia (FM) is one of the chronic non-specific or medically unexplained pain syndromes. The etiology of FM is still unknown [1]. There is, however, growing evidence that psychological factors play an important role in the etiology of FM [2, 3, 4, 5, 6]. FM has been described as a depressive disorder [7, 8], as an affective disorder [9], and as a stress-related disorder [1]. In a study of dysfunctional psychological dimensions in FM-patients, factor analyses identified several psychological dimensions, including cognitive (catastrophizing, external control beliefs), emotional (alexithymia), behavioral (restless behavior) and social (need for support) dimensions [10]. Van Houdenhove [1, 11, 12, 13, 14, 15] showed that action-proneness, or a pre-morbid overactive life-style, can be an etiological factor related to FM, an that it plays a role in 70% of chronic pain patients. Alfici [7] reported that, among other factors, dependence, obsessive-compulsive personality and pre-pain ergomania were characteristic of FM-patients. Hasenbring [16, 17, 18, 19] demonstrated that avoidance behavior and endurance strategies were psychological predictors of pain persistence in lumbar disc patients. Vlaeyen [20] hypothesizes that either disuse (fear-avoidance model) or overuse (persistence model) will lead to disability and chronic pain. There is growing evidence to support the fear-avoidance model [20, 21]. However, studies on overuse and persistence have, until now, been relatively scarce [22]. According to these studies it seems that the concept of overloading plays an important role in the etiology of FM (and other non-specific pain- and fatigue-syndromes [1]; this concept contains terms such as action-proneness, overactive life-style, ergomania, endurance strategies, overuse and persistence. A comprehensive theoretical model of overloading (overuse) has not yet been developed [20].

Integrative hypothetical model

We have tried to formulate an integrative hypothetical model of overloading, based on the afore-mentioned studies and on our own clinical experience gained from some thousands of life-histories of FM-patients documented by our psychologists during the past fifteen years. According to van Houdenhove [23] and Wentz [24] the patient’s biography should be part of each diagnostic evaluation and considered an important focus of psychological/ psychiatric research in fibromyalgia and chronic fatigue syndrome; it illustrates the possible etiological role of adverse childhood experiences, premorbid overactivity and intense activity or hypomanic helpfulness. The model describes cognitive, emotional, behavioral and environmental conditions in the development of an overloading life-style, eventually leading to FM: Parental behavior and personality development In family situations in which the parents are not able to show warm and appreciative behavior towards their children, or when parents are overambitious or perfectionists, children may learn to disregard their own strivings and needs and to fulfill the needs of the parents in all respects. High demand, in combination with more negative than positive feedback, may lead to fear of failure, low self-esteem and a compulsory tendency to please the parents and avoid their criticism. It is also possible that a child has to take adult responsibilities when, for example, the mother is absent because of death, illness, divorce or a full-time job. When this pattern of disregarding one’s own strivings and needs and of hypomanic helpfulness has been learnt in childhood, adult relationships may develop into asymmetrical patterns in which one invests more energy in others than vice versa. This could lead to physical and mental overloading, and finally to chronic pain, exhaustion and inactivity. When a child learns that expressing his emotions elicits punishment he will suppress his emotions and will become alienated from his own feelings, which may lead to depression, especially when there is no positive feedback from relevant others. To avoid falling into a depression some people throw themselves into their work and other activities (in a compulsory way) which increases overloading until they are no longer able to work, due to increasing pain and fatigue, and yet depression will develop. There is growing evidence that adverse childhood experiences play an important role in the development of chronic pain- and fatigue-syndromes [25, 24]. According to Zant [26] and Fisher [27], lack of affection and over-protection play an important role in the etiology of FM. Imbierowicz [28] found a relationship between sexual and physical maltreatment in childhood and the development of FM. Waerden [29] found that fearful and preoccupied attachment-styles are associated with symptom reporting via a negative model of the self and negative affectivity. Life-style and asymmetrical relationships In an asymmetrical relationship between a helpful person and a privileged person, the latter learns that he has to invest minimally in the relationship because the former is helpful under all circumstances (a-selective reinforcement). Because helpfulness is so easily gained, the privileged person does not learn to value the helpful behavior, and will experience it as a matter of course. If, later on, the helpful person wants to achieve a more symmetrical interaction, he will meet resistance because the other does not want to relinquish his privileges. And what is more, the helpful person has not learnt how to be assertive. This process will lead to continuously overloading behavior in the helpful person. It may be clear that for someone who has learnt to be more helpful to others than to satisfy his own needs, and who has developed a network of asymmetrical relationships, it requires a great deal of effort to reform most of his relationships with relevant others to achieve symmetrical and equivalent interactions. Even if the patient has learnt through psychotherapy to be more assertive, to express his feelings and to negotiate more effectively, it will take a lot of time and energy to implement the newly acquired abilities. The overloading person will receive little recognition of, and appreciation for, his helpful behavior because the privileged person has learnt to take it for granted. Moreover, the overloading person will receive little recognition of his pains and exhaustion from physicians, who are usually unaware of the pre-morbid overactive life of this momentarily very inactive patient with pain, but little or no physical defects. Therefore, physicians often see no valid reason for sick-leave or social security benefits. In our society, working hard and being helpful are valued positively, and can therefore not be unhealthy. Failing to protect one’s personal life is often regarded as a weakness, and as a sign of personal ineptitude. As mentioned above there is some evidence that FM is associated with concepts such as action-proneness and overactive life-style [11, 12, 13, 14, 15, 1], ergomania [7], endurance strategies, overuse and persistence [16, 17, 18, 19, 20]. Complaints and somatization In contacts with the health services the patient often learns that diagnostic and therapeutic actions are primarily focused on his physical symptoms and the physical locus of pain, and much less and much later on underlying psychological aspects. Thus the patient learns to present his complex problem by communicating his (initially relatively innocent) physical pain problem. Perhaps as a child the patient learnt from his parents to communicate with physical complaints when he had emotional problems. At first, such a patient may receive attention and recognition, and there may even be temporary legitimacy to no longer be helpful and overloading. The result, however, for the patient is that the only way to continue to receive this beneficial environmental behavior is to suffer pain and other complaints. If the partner and other relevant people recognize the pain, fatigue and disability, and if they pay extra attention to the patient and recognize that the patient is discharged from his overloading duties, the complaints will be reinforced. The patient will be reinforced because of his complaints and not or much less because he is a valuable person (selective reinforcement). If these other people take care of the patient this even seems to result in “symmetrical” relationships. However, to continue this “equivalence” it is necessary that the pain or other complaints continue. There is substantial evidence that the environmental reinforcement of complaints (operant factors) leads to (further) somatization and inactivity [30]. Our hypothetical model of overloading in relation to the etiology of FM is summarized in Figure 1.

More research has to be performed as to the interrelations between adverse childhood experiences, personality, an overloading life-style and FM (and other chronic pain- and fatigue-syndromes), cross-sectionnaly as well as longitudinally. This integrative hypothetical model could serve as an agenda for future research.

Clinical implications

From our overloading-model we formulated a multidimensional treatment program: If the behavior of the overloading patient has been directed more by external factors than by internal factors, then treatment has to result into a shift at cognitive, emotional, behavioral and relational (environmental) level from “what am I supposed to do” to “what can I do and what do I want to do myself”. The aim of this treatment program is not to diminish the pain or how to cope with the pain, but to change the overloading life-pattern in a structural way. In order to reach these results the patient needs to obtain insight into his present and his desired behavior (recognition) and to learn new skills to implement these insights into his life-pattern. Within this model treatment-results may be formulated as follows: Cognitive level: The patient now recognizes his cognitive patterns in which he strives at fulfilling demands of others and at pleasing others without taking into account what he can and what he wants. The patient now masters skills to decide when and how to draw a line and formulate his opinions, wishes and arguments in an assertive way, instead of trying to diminish his pain and fatigue symptomatically. Emotional level: The patient now recognizes he is suppressing his feelings and the fact that others restrict or even punish his expression of emotions. The patient now masters skills to admit and to express his feelings, especially anger when others place too great demands on him or ignore his opinions or feelings, in stead of going on and on in order not to experience his negative emotions. The patient feels no longer depressed or anxious. Behavioral level: The patient now recognizes overloading signals in his body and realizes that if he does not draw a line himself, his body will do it for him by pain and fatigue. The patient now masters skills to diminish his level of activity or to alternate activities or to take a rest in time. In case of resistance from other people the patient is able to stick to his guns and to negotiate or even think of or apply sanctions if necessary. Environmental (operant) level: The patient now recognizes that he mainly receives support and attention from others because of his complaints and that support and attention are/were hard to obtain in other ways. The patient now masters skills to secure support and attention from others not by complaining but by making others clear that it is their turn to be nice and supporting, not because the patient is ill but because he is a valuable person.

Acknowledgments

We thank the Jan van Breemen Institute for its financial and logistical support in setting up and conducting this study. We thank Prof. Joost Dekker for his valuable advice.

References

1. van Houdenhove B, Egle UT: Fibromyalgia: a stress disorder? Piecing the biopsychosocial puzzle together. Psychother Psychosom 2004; 73(5): 267-75. 2. Boissevain MD, McCain GA: Toward an integrated understanding of fibromyalgia syndrome. II. Psychological and phenomenological aspects. Pain 1991; 45(3): 239-48. 3. Clauw D: The pathogenesis of chronic pain and fatigue syndromes, with special reference to fibromyalgia. Med Hypotheses 1995; 44(5): 369-78. 4. Brosschot JF, Aarsse HR: Restricted emotional processing and somatic attribution in fibromyalgia. Int J Psychiatry Med 2001; 31(2): 127-46. 5. Linton SJ: Why does chronic pain develop? A behavioral a approach. New Avenues for the prevention of chronic musculoskeletal pain and disability. Pain Res Clin Manag. 2002; 12 (6): 67-80. 6. Linton SJ: Do psychological factors increase the risk for back pain in the general population in both a cross-sectional and prospective analysis? Eur J Pain 2005; 9: 355-361. 7. Alfici S, Sigal M, Landau M: Primary fibromyalgia syndrome-a variant of depressive disorder? Psychother Psychosom 1989; 51(3): 156-61. 8. Raphael KG, Janal MN, Nayak S, Schwartz JE, Gallagher RM: Familial aggregation of depression in fibromyalgia: a community-based test of alternate hypotheses. Pain 2004; 110(1-2): 449-60. 9. Hudson JI, Mangweth B, Pope HG, De CC, Hausmann A, Gutweniger S, Laird NM, Tsuang MT: Family study of affective spectrum disorder. Arch Gen Psychiatry 2003; 60(2): 170-7. 10. Colangelo N, Bertinotti L, Nacci F, Conforti ML, Beneforti E, Pignone A, Matucci-Cerinic M, Zoppi M: Dimensions of psychological dysfunction in patients with fibromyalgia: development of an Italian questionnaire. Clin Rheumatol 2004; 23(2): 102-8. 11. van Houdenhove B: Prevalence and psychodynamic interpretation of premorbid hyperactivity in patients with chronic pain. Psychother Psychosom 1986; 45(4): 195-200. 12. van Houdenhove B, Vasquez G, Neerinckx E: Tender points or tender patients? The value of the psychiatric in-depth interview for assessing and understanding psychopathological aspects of fibromyalgia. Clin Rheumatol 1994; 13(3): 470-4. 13. van Houdenhove B, Onghena P, Neerinckx E, Hellin J: Does high ‘action-proneness’ make people more vulnerable to chronic fatigue syndrome? A controlled psychometric study. J. Psychosom Res 1995; 39(5): 633-40. 14. van Houdenhove B, Neerinckx E, Lysens R, Vertommen H, van Houdenhove L, Onghena P, Westhovens R, D’Hooghe MB: Victimization in chronic fatigue syndrome and fibromyalgia in tertiary care: a controlled study on prevalence and characteristics. Psychosomatics 2001a; 42(1): 21-8. 15. van Houdenhove B, Neerinckx E, Onghena P, Lysens R, Vertommen H: Premorbid “overactive” lifestyle in chronic fatigue syndrome and fibromyalgia. An etiological factor or proof of good citizenship? J Psychosom Res 2001b; 51(4): 571-6. 16. Hasenbring M, Marienfeld G, Kuhlendahl D, Soyka D: Risk factors of chronicity in lumbar disc patients. A prospective investigation of biologic, psychologic, and social predictors of therapy outcome. Spine 1994; 19(24): 2759-65. 17. Hasenbring M: Kognitive Verhaltenstherapie chronische rund prächronischer Schmerzen. Psychotherapeut 1996; 41: 313-325. 18. Hasenbring M, Hallner D, Klasen B: Psychologische Mechanismen im Prozess der Schmerzchronifizierung, unter- oder überbewertet? Schmerz 2001; 15: 442-7. 19. Hasenbring M, Plaas H, Fischbein B, Willburger R: The relationship between activity and pain in patients six months after lumbar disc surgery: do pain-related coping modes act as moderator variables. Eur J Pain 2006; 10: 701-9. 20. Vlaeyen JWS, Morley S: Active despite pain: the putative role of stop-rules and current mood. Pain 2004; 110: 512-516. 21. Leeuw M, Goossens ME, Linton SJ, Crombez G, Boersma K, Vlaeyen JW: The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med 2007; 30: 77-94. 22. 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