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A retrospective observational study comparing somatosensory amplification in fibromyalgia, chronic pain, psychiatric disorders and healthy subjects

Antonella Ciaramella, Simona Silvestri, Valentino Pozzolini, Martina Federici and Giancarlo Carli



Somatosensory amplification (SA) has been described as an important feature of somatoform disorders, and an “amplifying somatic style” has been reported as a negative connotation of body perception. As widespread pain (WSP) in fibromyalgia (FM) is due to a central sensitization (CS) rather than organic alterations, there has been discussion as to whether FM is equivalent to or distinct from somatization disorder (SD). Assuming SD and FM are two distinct entities, an increase in somatic amplification should be expected only in subjects who have SD, regardless of the type of pain they experience. Purpose of the study was to explore the magnitude of SA in FM, and whether this depends on the association with SD.


FM (n=159) other forms of chronic pain (OCP, n=582), psychiatric (Psy, n=53) and healthy (H, n=55) subjects were investigated using the Somatosensory Amplification Scale (SSAS), Illness Behavior Questionnaire, (IBQ), Italian Pain Questionnaire (IPQ), and Cold Pressor Test (CPT) in a retrospective observational study.


FM subjects displayed higher SSAS scores than the other groups. High SSAS score was associated with FM (OR=8.39; 95%CI: 5.43–12.46) but not OCP. Although FM has the highest prevalence of SD (x2=14.07; p=.007), high SSAS scores were associated with SD in OCP but not in FM.


Unlike in OCP, in FM high SSAS scores were independent of the presence of SD. From a biopsychosocial perspective, SSAS may be a factor associated with the onset of FM.

Corresponding author: Antonella Ciaramella, Aplysia onlus, Psychosomatic Center, GIFT Institute of Integrative Medicine, Cairoli, 12, Pisa, Italy, E-mail:

  1. Research funding: Authors state no funding involved.

  2. Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  3. Competing interests: Authors state no conflict of interest.

  4. Informed consent: Informed consent has been obtained from all individuals included in this study.

  5. Ethical approval: Being a retrospective study, no Ethics Committee approval was necessary [27]. The study adheres to the STROBE statement guidelines for observational research.

STROBE Appendix

  1. a.

    The title includes the study’s design.

  1. b.

    The abstract contains an informative and balanced summary of what was done and what was found.

2.The background explains the rationale behind the investigation.
3.The aim contains specific objectives formulated following the hypotheses mentioned in the background section.
4.The study is a retrospective observational case-controlled study.
5.In the methods, setting, location, period of recruitment and data collection have been described.
6.The eligibility criteria (inclusion and exclusion criteria) and rationale have been reported for each control and case group of subjects recruited.
7.Diagnostic criteria have been reported for each syndrome explored.
8.Method of assessment has been reported.
9.Bias has been described in a dedicated section.
10.Clinical but not statistical study size has been explained.
11.Each quantitative variable has been described.
12.All statistical methods and subgroup analyzed have been described.
13.Number of participants per each group has been reported.
14.Characteristics of participants have been described and corrected to avoid bias.
15.Description of variables has been reported in a Table.
16.Main results have been described in specific sections. Data have been reported in the tables and each described with the relative effect size. Odd’s ratio has been applied.
17.A section of the results of case and the variable differences from the controls have been shown.
18.The key results have been discussed, comparing them with the literature.
19.Limitations and potential bias have been reported.
20.Interpretation and comparison of results with other studies has been done.
21.At the end, the generalizability of the results has been discussed.
22.This study did not have any funding.


1. Barsky, AJ, Goodson, JD, Lane, RS, Cleary, PD. The amplification of somatic symptoms. Psychosom Med 1988;50:510–9. Search in Google Scholar

2. Köteles, F, Witthöft, M. Somatosensory amplification – an old construct from a new perspective. J Psychosom Res 2017;101:1–9. Search in Google Scholar

3. Jones, MP, Schettler, A, Olden, K, Crowell, MD. Alexithymia and somatosensory amplification in functional dyspepsia. Psychosomatics 2004;45:508–16. Search in Google Scholar

4. Nakao, M, Barsky, AJ, Kumano, H, Kuboki, T. Relationship between somatosensory amplification and alexithymia in a Japanese psychosomatic clinic. Psychosomatics 2002;43:55–60. Search in Google Scholar

5. Von Knorring, L, Monakhov, K, Perris, C. Augmenting/reducing: an adaptive switch mechanism to cope with incoming signals in healthy subjects and psychiatric patients. Neuropsychobiology 1978;4:150–79. Search in Google Scholar

6. Byrne, D. Repression-sensitization as a dimension of personality. Prog Exp Pers Res 1964;72:169–220. Search in Google Scholar

7. Perez, DL, Barsky, AJ, Vago, DR, Baslet, G, Silbersweig, DA. A neural circuit framework for somatosensory amplification in somatoform disorders. J Neuropsychiatry Clin Neurosci 2015;27:e40–50. Search in Google Scholar

8. Craig, AD. How do you feel? Interoception: the sense of the physiological condition of the body. Nat Rev Neurosci. Review 2002;3:655–66. Search in Google Scholar

9. Larsen, JK, Brand, N, Bermond, B, Hijman, R. Cognitive and emotional characteristics of alexithymia: a review of neurobiological studies. J Psychosom Res. Review 2003;54:533–41. Search in Google Scholar

10. Gu, X, Hof, PR, Friston, KJ, Fan, J. Anterior insular cortex and emotional awareness. J Comp Neurol 2013;521:3371–88. Search in Google Scholar

11. Rossi, M, Bruno, G, Chiusalupi, M, Ciaramella, A. Relationship between Pain, Somatisation, and Emotional Awareness in Primary School Children. Pain Research and Treatment; 2018. Search in Google Scholar

12. Ercolani, M, Trombini, G, Chattat, R, Cervini, C, Piergiacomi, G, Salaffi, F, et al. Fibromyalgic syndrome: depression and abnormal illness behavior. Multicenter investigation. Psychother Psychosom 1994;61:178–86. Search in Google Scholar

13. Horta-Baas, G, Peláez-Ballestas, I, Queipo, G, Montero Hernández, U, Romero-Figueroa, MDS. Alexithymia is associated with mood disorders, impairment in quality of life and disability in women with fibromyalgia. Clin Exp Rheumatol 2020;38:17–24. Suppl 123. Search in Google Scholar

14. Petersel, DL, Dror, V, Cheung, R. Central amplification and fibromyalgia: disorder of pain processing. J Neurosci Res 2011;89:29–34. Search in Google Scholar

15. Fleming, KC, Volcheck, MM. Central sensitization syndrome and the initial evaluation of a patient with fibromyalgia: a review. Rambam Maimonides Med J 2015;6:e0020. Search in Google Scholar

16. Woolf, CJ. Pain amplification—a perspective on the how, why, when, and where of central sensitization. J Appl Biobehav Res 2018;23:e12124. Search in Google Scholar

17. McBeth, J, Macfarlane, GJ, Benjamin, S, Silman, AJ. Features of somatization predict the onset of chronic widespread pain: results of a large population‐based study. Arthritis Rheum 2001;44:940–6.;940::aid-anr151%3e;;2-s10.1016/j.bbabio.2015.05.007. Search in Google Scholar

18. Winfield, JB. Does pain in fibromyalgia reflect somatization? Arthritis Rheum 2001;44:751–3.;751::aid-anr130%3e;;2-z10.1146/annurev-arplant-043015-111949. Search in Google Scholar

19. Wolfe, F, Smythe, HA, Yunus, MB, Bennett, RM, Bombardier, C, Goldenberg, DL, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia, report of the multicenter criteria committee. Arthritis Rheum 1990;33:160–72. Search in Google Scholar

20. Bosma, RL, Mojarad, EA, Leung, L, Pukall, C, Staud, R, Stroman, PW. FMRI of spinal and supra-spinal correlates of temporal pain summation in fibromyalgia patients. Hum Brain Mapp 2016;37:1349–60. Search in Google Scholar

21. Latremoliere, A, Woolf, CJ. Central sensitization: a generator of pain hypersensitivity by central neural plasticity. J Pain 2009;10:895–926. Search in Google Scholar

22. Staud, R, Robinson, ME, Price, DD. Temporal summation of second pain and its maintenance are useful for characterizing widespread central sensitization of fibromyalgia patients. J Pain 2007;8:893–901. Search in Google Scholar

23. De Benedittis, G. Hypnosis and fibromyalgia. In: Elkins, G, editor Handbook of Medical and Psychological Hypnosis. New York: Springer Publishing Company; 2016:235–44 pp. Search in Google Scholar

24. Kosek, E, Cohen, M, Baron, R, Gebhart, GF, Mico, J-A, Rice, ASC, et al. Do we need a third mechanistic descriptor for chronic pain states? Pain 2016;157:1382–6. Search in Google Scholar

25. De Benedittis, G. Hypnotherapy for fibromyalgia. In: Jensen, M.P., editor Hypnotic Techniques for Chronic Pain Management. Favorite Methods of Master Clinicians. Kirkland, WA: Denny Creek Press; 2018:54–75 pp. Search in Google Scholar

26. Häuser, W, Kosseva, M, Üceyler, N, Klose, P, Sommer, C. Emotional, physical, and sexual abuse in fibromyalgia syndrome: a systematic review with meta-analysis. Arthritis Care Res 2011;63:808–20. Search in Google Scholar

27. Häuser, W, Galek, A, Erbslöh-Möller, B, Köllner, V, Kühn-Becker, H, Langhorst, J, et al. Posttraumatic stress disorder in fibromyalgia syndrome: prevalence, temporal relationship between posttraumatic stress and fibromyalgia symptoms, and impact on clinical outcome. Pain 2013;154:1216–23. Search in Google Scholar

28. Ciaramella, A. The influence of trauma on autobiographical memory in the assessment of somatoform disorders according to DSM IV criteria. Psychiatr Q 2018;89:991–1005. Search in Google Scholar

29. Nakao, M, Takeuchi, T. Alexithymia and somatosensory amplification link perceived psychosocial stress and somatic symptoms in outpatients with psychosomatic illness. J Clin Med 2018;7:112. Search in Google Scholar

30. Kumar, V, Avasthi, A, Grover, S. Somatosensory amplification, health anxiety, and alexithymia in generalized anxiety disorder. Ind Psychiatr J 2018;27:47–52. Search in Google Scholar

31. Spinhoven, P, van der Does, AJ. Somatization and somatosensory amplification in psychiatric outpatients: an explorative study. Compr Psychiatr 1997;38:93–7. Search in Google Scholar

32. Barsky, AJ, Wyshack, G, Klerman, G. The somatosensory amplification scale and its relationship to hypochondriasis. J Psychiatr Res 1990;24:323–34. Search in Google Scholar

33. Wolfe, F, Clauw, DJ, Fitzcharles, MA, Goldenberg, DL, Katz, RS, Mease, P, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res 2010;62:600–10. Search in Google Scholar

34. Häuser, W, Henningsen, P. Fibromyalgia syndrome: a somatoform disorder? Eur J Pain 2014;18:1052–9. Search in Google Scholar

35. American Psychiatric Association. Diagnostic and statistical manual of mental disorders., 5th ed. Washington, DC: Author; 2013. Search in Google Scholar

36. Kıraç, FS. Is Ethics approval necessary for all trials? A clear but not certain process. Mol Imaging Radionucl Ther 2013;22:73–5. Search in Google Scholar

37. Wolfe, F, Clauw, DJ, Fitzcharles, MA, Goldenberg, DL, Katz, RS, Mease, P, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res 2010;62:600–10. PMID: 20461783. Search in Google Scholar

38. Wolfe, F, Clauw, DJ, Fitzcharles, MA, Goldenberg, DL, Häuser, W, Katz, RL, et al. Revisions to the 2010/2011 fibromyalgia diagnostic criteria. 2016. Semin Arthritis Rheum 2016;46:319–29. Epub 2016 Aug 30. PMID: 27916278. Search in Google Scholar

39. Yunus, MB. A comprehensive medical evaluation of patients with fibromyalgia syndrome. Rheum Dis Clin N Am 2002;28:201–17. Search in Google Scholar

40. Fitzcharles, MA, Yunus, MB. The clinical concept of fibromyalgia as a changing paradigm in the past 20 years. Pain Res Treat 2012. Search in Google Scholar

41. Staud, R. Biology and therapy of fibromyalgia: pain in fibromyalgia syndrome. Arthritis Res Ther 2006;8:208. Search in Google Scholar

42. Roelofs, J, Peters, ML, McCracken, L, Vlaeyen, JWS. The pain vigilance and awareness questionnaire (PVAQ): further psychometric evaluation in fibromyalgia and other chronic pain Syndromes. Pain 2003;101:299–306. Search in Google Scholar

43. Ciaramella, A. Person-centred management of chronic intractable pain: an observational study comparing conventional treatment with hypnosis and treatment of psychiatric comorbidity. J Pain Mana 2018;11:369–79. Search in Google Scholar

44. Treede, RD, Rief, W, Barke, A, Aziz, Q, Bennett, MI, Benoliel, R, et al. Chronic pain as a symptom or a disease: the IASP classification of chronic pain for the international classification of diseases (ICD-11). Pain 2019;160:19–27. Search in Google Scholar

45. Merskey, H, Bogduk, N. Classification of Chronic Pain, 2nd ed. Seattle: IASP Press; 1994. Search in Google Scholar

46. Noyes, RJr, Stuart, SP, Watson, DB. A reconceptualization of the somatoform disorders. Psychosomatics 2008;49:14–22. PMID: 18212171 Review. Search in Google Scholar

47. American Psychiatric AssociationDiagnostic and statistical manual of mental disorders, 4th ed. (Text Revision). Washington, DC: Author; 2000. Search in Google Scholar

48. Sheehan, DV, Lecrubier, Y, Sheehan, KH, Amorim, P, Janavs, J, Weiller, E, et al. The mini-international neuropsychiatric interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatr 1998;59:22–33. Search in Google Scholar

49. Wolff, BB. Methods of testing pain mechanisms in normal man. In: Wall, P.D., Melzack, R., editors Textbook of Pain, 2nd ed. Edinburgh: Churchill Livingstone; 1984:186–94 pp. Search in Google Scholar

50. Rossi, A, Alberio, R, Porta, A, Sandri, M, Tansella, M, Amaddeo, F. The reliability of the mini-international neuropsychiatric interview- Italian version. J Clin Psychopharmacol 2004;24:561–3. Search in Google Scholar

51. Bernini, O, Berrocal Montiel, C, Ciaramella, A, Poli, P, Guazzelli, M. Reliability and validity of the Italian version of the somatosensory amplification scale. Psychol Health 2008;23:65–65. Search in Google Scholar

52. Ciaramella, A. A retrospective observational study investigating the relationship between somatisation and pain perception in subjects with intractable pain. Eur J Integr Med 2016;8:394–401. Search in Google Scholar

53. De Benedittis, G, Massel, R, Nobili, R, Pieri, A. The Italian pain questionnaire. Pain 1988;33:53–62. Search in Google Scholar

54. Pilowsky, I, Bassett, D, Barrett, R, Petrovic, L, Minniti, R. The illness behavior assessment schedule: reliability and validity. Int J Psychiatr Med 1983-1984;13:11–28. Search in Google Scholar

55. Sheskin, DJ. Handbook of parametric and nonparametric statistical procedures., 3rd ed. Boca Raton: Chapman & Hall; 2004. Search in Google Scholar

56. Sarzi-Puttini, P, Atzeni, F, Mease, PJ. Chronic widespread pain: from peripheral to central evolution. Best Pract Res Clin Rheumatol 2011;25:133–9. Search in Google Scholar

57. Kim, J, Loggia, ML, Cahalan, CM, Harris, RE, Beissner, F, Nat, Dr Phil, et al. The somatosensory link in fibromyalgia: functional connectivity of the primary somatosenssory cortex is altered by sustained pain and is associated with clinical/autonomic dysfunction. Arthritis Rheum 2015;67:1395–405. Search in Google Scholar

58. McTeague, LM, Huemer, J, Carreon, DM, Jiang, Y, Eickhoff, SB, Etkin, A. Identification of common neural circuit disruptions in cognitive control across psychiatric disorders. Am J Psychiatr 2017;174:676–85. Search in Google Scholar

59. Fink, P, Schröder, A. One single diagnosis, bodily distress syndrome, succeeded to capture 10 diagnostic categories of functional somatic syndromes and somatoform disorders. J Psychosom Res 2010;68:415–26. Search in Google Scholar

60. Lipowski, ZJ. Somatization: a borderland between medicine and psychiatry. CMAJ (Can Med Assoc J) 1986;135:609–14. Search in Google Scholar

61. Häuser, W, Bialas, P, Katja Welsch, K, Wolfe, F. Construct validity and clinical utility of current research criteria of DSM-5 somatic symptom disorder diagnosis in patients with fibromyalgia syndrome. J Psychosom Res 2015;78:546–52 [Epub 2015 Mar 30]. Search in Google Scholar

62. Sayar, K, Barsky, AJ, Gulec, H. Does somatosensory amplification decreases with antidepressant treatment ? Psychosomatics 2005;46:340–4. Search in Google Scholar

Supplementary Material

The online version of this article offers supplementary material (

Received: 2020-06-23
Accepted: 2020-09-14
Published Online: 2020-11-02
Published in Print: 2021-04-27

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