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health perception and more physical limitations, while women have greater life
interference due to pain [ 31 , 32 ]. In addition, women’s pain threshold is signifi -
cantly lower, and they suffer more diffuse pain, increased fatigue, and irritable
bowel syndrome than men [ 22 , 32 , 33 ]. In addition, women with FMS feel fatigue
more sharply than men with FMS [ 22 , 33 ]. Prados et al. found that in FMS men,
lower quality of sleep, with negative effects of somnolence, fatigue, decreased vigi-
lance, etc. were the main predictors of pain [ 34 ]. Subsequent studies by this group
showed that women tend to catastrophize and to consume more painkillers than men
[ 35 ]. On the other hand, Racine et al. observed no gender differences in the extent
(i.e., number of painful areas) and operation of pain (i.e., depressive symptoms, pain
severity, and interference); however, they found differences in pain-related beliefs,
as men were more likely to view pain as refl ecting harm, and they were also more
likely than women to use activity avoidance as a pain-coping strategy [ 36 ]. It was
also reported that psychosocial distress impacts differently on men and women and
thus produces different FMS pictures [ 11 , 37 ].
Cultural Issues
In addition to the gender factor—in particular pain behavior that is usually more
acceptable in women than in men—some of the symptoms in FMS, or their effect
on daily life, may have a different expression in different cultures.
Illness perception, for instance , varies between Spanish and Dutch women with
FMS, with the Spanish perceiving more symptoms and showing greater emotional
representation than the Dutch; these latter presenting more positive beliefs about the
controllability of the illness [ 38 ]. Fatigue has different impact and daily-living con-
sequences in different countries and clearly affects work differently—depending
mainly on availability of work adaptations or fl exibility among countries—as well
as care-seeking behavior [ 39 – 41 ].
Pain is perhaps the symptom with more clear cultural implications. Some cul-
tures, for example, do not accept pain as desirable or acceptable [ 42 , 43 ], and this
may have an infl uence on reporting levels of pain; pain-coping strategies; activities
of daily living that can be accomplished; or behaviors, such as victimizing or sup-
port seeking [ 43 – 46 ]. Very interestingly, linguistic reports and classifi cations of
pain differ between cultures, with dozens of specifi c pain terms in some languages
and a single inclusive term in others [ 47 ]. This must be taken into account when
developing PROMs that include description of “pains.”
Evidence on commonalities among cultures also exists. A comparative study
between German and US patients with FMS showed that the reporting of childhood
abuse was overlapping in the two countries, thus highlighting the importance of
psychological distress in FMS [ 15 ].
L. Carmona et al.