Depression in Dercum’s disease and in obesity
A case control study
Emma Hansson, Henry Svensson and Håkan Brorson
Dercum’s disease is characterised by pronounced pain in the adipose tissue and a number of associated symptoms. The condition is usually accompanied by generalised weight gain. Many of the associated symptoms could also be signs of depression. Depression in Dercum’s disease has been reported in case reports but has never been studied using an evidence-based methodology. The aim of this study was to examine the presence of depression in patients with Dercum’s disease compared to obese controls that do not experience any pain.
Patients with depression are often diagnosed with chronic pain conditions and vice versa. Both disorders activate common neurocircuitries, such as the hypothalamicpituitary-adrenal axis, limbic and paralimbic structures, ascending and descending pain
pathways, and mutual neurotransmitters, and it is therefore sometimes difficult to determine whether the pain disorder or the psychiatric condition is the primary diagnosis. Symptoms that could be attributed to depression have been described in patients in several reports to date.
A total of 111 women fulfilling the clinical criteria of Dercum’s disease were included. As controls, 40 obese healthy women were recruited. To measure depression, the Montgomery Asberg Depression Rating Scale (MADRS) was used.
According to the total MADRS score, less than half of the patients were classified as having “no depression” (44%), the majority had “light” or “moderate depression” (55%) and one individual had “severe depression” in the Dercum group. In the control groups, the majority of the patients were classified as having “no depression” (85%) and a small number had “light depression” (15%). There was a statistically significant difference for the total MADRS score between the two groups (p=0.014).
Dercum’s disease is characterised by obesity, chronic pain and other associated symptoms. Some of the associated symptoms, previously described in case reports on Dercum’s disease, include depression and symptoms associated with depression, such as asthenia, weakness, fatigue, emotional instability, mental confusion, dementia, poor sleep quality and changes in appetite. Several studies have demonstrated that there is a significant association between depression and pain, as well as between depression and obesity. Patients with depression are often diagnosed with chronic pain conditions and vice versa. Some studies have demonstrated that depression predicts obesity later in life, and other studies support that obese subjects develop depression to a greater extent than subjects with lower, “normal” body weights. Nonetheless, it is unclear whether there is a causal relationship between the three entities. The possible co-morbidity could be explained by Berkson’s bias, that is, patients with an illness might seek care more often. Thus co-morbidity could be overrepresented in a group of subjects that are, as in this study, recruited from a care setting.
In summary, it is difficult to separate chronic pain from depression. The elevated MADRS scores in the Dercum patients in this study cannot be explained by obesity alone, as the distribution of the Dercum subjects’ scores was different to that of the weight-matched control patients, and there was a statistical difference for the total score between the two groups. The lack of statistical difference for a number of the items could be explained by low power, that is, by the small number of subjects in the control group. The results suggested that the obese Dercum patients experience worse depression than obese healthy controls. As all of the Dercum patients had chronic pain whilst none of the controls had any history of chronic or present acute pain, it is unclear whether the depression is due to the Dercum’s disease per se or due to the experience of pain. Furthermore, it is unclear whether the depression or the Dercum’s disease came first. Previous research has shown that antidepressants have an effect on pain and the quality of life in patients with chronic pain and that obese patients could benefit from the treatment of
any co-existing features of depression.
An example of an associated symptom in Dercum’s disease that can also be explained by depression is poor sleep quality. Poor sleep quality can diminish an individual’s ability to cope with pain and stress and can influence the onset and course of disease. In fact, a
study on patients with chronic pain conditions demonstrated that sleeping less than 8 hours per 24 hours, especially in combination with poor sleep quality, might generate stronger reactions to pain. In addition, Affleck et al. concluded that there is a correlation between sleep quality and experienced pain intensity, as well as the ability to cope with pain, among patients with fibromyalgia. It can be speculated, therefore, that poor sleep can contribute to the onset of Dercum’s disease and the maintenance of pain. Conversely, obesity can also affect sleep quality. Obstructive sleep apnoea (OSA) and Pickwick syndrome, both of which have been previously described in Dercum’s disease, can be explained by obesity, as 50% of otherwise healthy obese women with BMI >40 have OSA and more than 29% of severely obese patients have nocturnal hypoventilation. This could explain why no difference can be seen between the Dercum patients and the control subjects in this study, as all of the subjects have similar BMIs.
The results indicate that the patients with Dercum’s disease are more likely to suffer from depression than controls. The relationship between Dercum’s disease, chronic pain, depression, and obesity is complex and it is not possible to separate depression and chronic pain completely. However, the results of this study indicate that patients with Dercum’s disease could suffer from worse depression than equally obese controls with no history of Dercum’s disease. This fact should be kept in mind when a treatment strategy for Dercum’s disease is selected.
Provisional PDF: http://www.biomedcentral.com/content/pdf/1471-244X-12-74.pdf