Fibromyalgia diagnosis and biased assessment: Sex, prevalence and bias
Open accessAbstract
PURPOSE: Multiple clinical and epidemiological studies have provided estimates of fibromyalgia prevalence and sex ratio, but different criteria sets and methodology, as well as bias, have led to widely varying (0.4%->11%) estimates of prevalence and female predominance (>90% to <61%). In general, studies have failed to distinguish Criteria based fibromyalgia (CritFM) from Clinical fibromyalgia (ClinFM). In the current study we compare CritFM with ClinFM to investigate gender and other biases in the diagnosis of fibromyalgia. METHODS: We used a rheumatic disease databank and 2016 fibromyalgia criteria to study prevalence and sex ratios in a selection biased sample of 1761 referred and diagnosed fibromyalgia patients and in an unbiased sample of 4342 patients with no diagnosis with respect to fibromyalgia. We compared diagnostic and clinical variables according to gender, and we reanalyzed a German population study (GPS) (n = 2435) using revised 2016 criteria for fibromyalgia. RESULTS: In the selection-biased sample of referred patients with fibromyalgia, more than 90% were women. However, when an unselected sample of rheumatoid arthritis (RA) patients was studied for the presence of fibromyalgia, women represented 58.7% of fibromyalgia cases. Women had slightly more symptoms than men, including generalized pain (36.8% vs. 32.4%), count of 37 symptoms (4.7 vs. 3.7) and mean polysymptomatic distress scores (10.2 vs. 8.2). We also found a linear relation between the probability of being females and fibromyalgia and fibromyalgia severity. Women in the GPS represented 59.2% of cases. DISCUSSION: The perception of fibromyalgia as almost exclusively (≥90%) a women's disorder is not supported by data in unbiased studies. Using validated self-report criteria and unbiased selection, the female proportion of fibromyalgia cases was ≤60% in the unbiased studies, and the observed CritFM prevalence of fibromyalgia in the GPS was ~2%. ClinFM is the public face of fibromyalgia, but is severely affected by selection and confirmation bias in the clinic and publications, underestimating men with fibromyalgia and overestimating women. We recommend the use of 2016 fibromyalgia criteria for clinical diagnosis and epidemiology because of its updated scoring and generalized pain requirement. Fibromyalgia and generalized pain positivity, widespread pain (WPI), symptom severity scale (SSS) and polysymptomatic distress (PSD) scale should always be reported.
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The authors showed a greater impact of pain on male patients with fibromyalgia syndrome in terms of stronger experience and more catastrophizing thoughts about pain than in women with fibromyalgia syndrome.
“Notably, the authors showed a greater impact of pain on male patients with FMS in terms of stronger experience and more catastrophizing thoughts about pain than in women with FMS.”
From Pain and small fiber pathology in men with fibromyalgia syndrome (2024) · cites this paper as [55]
The Discussion reports slightly higher pain and symptom severity in women than in men, the opposite of the claimed direction. The Results for the unbiased rheumatoid arthritis sample likewise report higher pain scores in women; those figures are not a comparison restricted to patients with fibromyalgia. Our copy does not report a comparison of pain-catastrophizing thoughts. (LLM, conf=0.86)
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measuredIn a few studies, characteristics of fibromyalgia syndrome pain were investigated in both sexes, and a higher symptom load including more cases with generalized pain was reported in women than in men.
“In a few studies, characteristics of FMS pain were investigated in both sexes, and a higher symptom load including more cases with generalized pain was reported in women than in men.38,55”
From Pain and small fiber pathology in men with fibromyalgia syndrome (2024) · cites this paper as [55]
Earlier studies also showed high FIQ scores in male FMS patients, indicating a great impact on pain, in line with the authors' results.
“Earlier studies38,55 also showed high FIQ scores in male patients with FMS indicating a great impact on pain, which is in line with our results.”
From Pain and small fiber pathology in men with fibromyalgia syndrome (2024) · cites this paper as [55]
The NDB clinical-variables table reports VAS pain and other scores by sex, and the Discussion says women had slightly higher pain and symptom severity than men. Neither passage reports Fibromyalgia Impact Questionnaire (FIQ) scores for male patients or interprets such scores as showing a great impact on pain. Searches for “FIQ” and “Fibromyalgia Impact Questionnaire” found no supporting passage in our copy. (LLM, conf=0.74)
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The hand grip force test as a measure of physical function in women with fibromyalgia
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- Authors
- Wolfe, F., Walitt, B., Perrot, S., Rasker, J. J., & Häuser, W.
- Affiliations
- University of Kansas (US)
- Georgetown University (US)
- Hôpital Cochin (FR)
- University of Twente (NL)
- Klinikum Saarbrücken (DE)
- Corresponding author
- Wolfe, Frederick
- Venue
- PLOS ONE
- Publisher
- Public Library of Science (PLoS)
- Published
- 2018-09-13
- Volume
- 13
- Issue
- 9
- Pages
- e0203755
- ISSN
- 1932-6203 (ISSN-L)
- PMC
- PMC6136749
- OpenAlex
- W2890457018
- Cited by
- 346
- References
- 51
- Citations by year
- 2026: 45 · 2025: 43 · 2024: 51 · 2023: 58 · 2022: 47 · 2021: 45 · 2020: 39 · 2019: 17 · 2018: 1
- FWCI
- 20.26
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- public-domain
- creativecommons.org/publicdomain/zero/1.0/ (vor)
- Locations
- PLoS ONE (publishedVersion, public-domain)
- Europe PMC (PubMed Central) (publishedVersion, public-domain)
- PubMed Central (publishedVersion, public-domain)
- PubMed (publishedVersion)
- RePEc: Research Papers in Economics (submittedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Figshare (submittedVersion, cc-by)
- mediaTUM – the media and publications repository of the Technical University Munich (Technical University Munich) (submittedVersion)
- University of Twente Research Information (submittedVersion, cc-by)
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Fibromyalgia and Chronic Fatigue Syndrome Research
- Health Sciences › Medicine › Psychiatry and Mental health › Psychosomatic Disorders and Their Treatments
- Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
- Keywords
- fibromyalgia, sex bias, prevalence, sex ratio, diagnostic criteria, selection bias, confirmation bias, gender differences, rheumatoid arthritis, pain symptoms
- MeSH terms
- Aged, Arthritis, Rheumatoid, Female, Fibromyalgia, Germany, Humans, Longitudinal Studies, Male, Middle Aged, Pain, Severity of Illness Index, Sex Factors, Prevalence, Databases, Factual, Self Report, Sexism
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