Vortex Questionnaire

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© Mark Doidge MD. All rights reserved.


These are questions about the possible interactions between pain, anxiety and poor sleep. It was designed by the author who has tested it out several hundred times on fibromyalgia patients. While it was conceived as an aid to diagnosis, it has become a tool for treatment. For example, if on completion and discussion of the results with the doctor, the patient crystallizes there understanding that the have a severe bad sleep—pain—bad sleep cycle, they might become more motivated than every before to begin to look seriously at how to improve their sleep as a means to try to improve their pains.

What is a vicious cycle?[edit]

By definition, a vicious cycle only occurs if A causes B and B causes A. The six questions in the vortex questionnaire are arranged in pairs with the first question corresponding to “A” and the second relating to “B”. If a patient answers “never” to either A or B or both, then they have no vicious cycle. Of greatest clinical interest to both the patient and the health care professional is if a patient answers “often” to both A and B. In this instance, both arms of the vicious cycle are “strong”. This means the cycle is a strong driver for their fibromyalgia symptoms, and is worthy of focus in the treatment on the part of both the patient and their health care worker.

Summary diagram showing the 6 possible relationships between pain, anxiety and bad sleep[edit]

Fibro vortex2.png
Two triangles summarizing the fibromyalgia vortex.
The above diagram depicts the relationship between pain, anxiety/agitation and bad sleep in patients with fibromyalgia. There are three lines on the left going clockwise and three more on the right going counter-clockwise. Each line means there is a presumed causal relationship that is clinical. For example, if a person consistently finds that a bad night of sleep is followed by a particularly bad day of fibromyalgia type muscle pains, then one presumes a causal relationship. Even though it is difficult to say that it proves to a certainty that the relationship is causal, it is still a reasonable and practical assumption which facilitates treatment. here is for example, on the left an arrow going from Anxiety to Pain. This relates to question 5 which states: “If you are agitated or nervous one day are you more likely to have more pain later that day?”

The six principal relationships of the fibromyalgia vortex[edit]

The three main factors mentioned in the previous subsection are the nucleus of what the author currently (as of 2020) believes to be the six principal relationships within the three vicious cycles of the fibromyalgia vortex. (There likely are other vicious cycles. Each person is unique, and so in a given case, other vicious cycles could be very important. For example, migraine is common in fibromyalgia patients, and the author has seen cases in which the migraine headache attacks interfere with sleep and possibly with the fibromyalgia pains.)

The three types of possible vicious cycles of the fibromyalgia vortex[edit]

Bad sleep-pain—bad sleep vicious cycle[edit]

(Author’s term.)

The first arm of this cycle is the well-established clinical complaint that occurs when patients say that after a bad night of sleep their fibromyalgia pains are worse. The reason for this pattern is not known, but need not be known in order to help the patient in many cases (often, they also say that their pains are better after a good night of sleep).

This cycle is based on questions 1 and 2.

Further research into this is urgently needed to determine if the reduction of pain is due to changes in the brain, spinal cord, muscles, peripheral nerves or some combination. At this time the most logical strategy is to try to repair every important sleep abnormality including insomnia, light sleep, sleep apnea, and any important cause of sleep interruption including on frequent nightmares, nocturia as in prostate problem in men or interstitial cystitis in women.

The author has seen this cycle frequently in his fibromyalgia patients. It is elicited with the fibromyalgia vortex questionnaire.

Considerable research has been done on the interaction between sleep and pain especially by Moldofsky in a string of papers dating back over 35 years to 1975. He refers to the bi-directionality of sleep and pain by which he means that the influence each other. The concept of a “bad sleep—pain—bad sleep cycle” crystallizes the research. It helps the patient to understand the interactions between pain and sleep in their body and therefore the urgency of trying to improve their sleep if they want to feel less pain.

The following quote is one of many in the scientific literature on the subject of how pain and sleep relate to each other: “Noxious stimuli and painful disorders interfere with sleep, but disturbances in sleep also contribute to the experience of pain...Noxious stimuli administered into muscles during slow-wave sleep (SWS) result in decreases in delta and sigma but an increase in alpha and beta EEG frequencies during sleep.” (Sleep and pain. Moldofsky H. Sleep Med Rev. 2001 Oct;5(5):385-396.)

For further perspective see the entry Pain Modulation by Bad Sleep.

Vortex Questionnaire (in pairs)[edit]

Vortex questionnaire (restricted).png
Vortex Questionnaire
© Mark Doidge, M.D. All rights reserved.
The vortex questionnaire is restricted. All rights reserved by Dr. Mark Doidge, M.D. To gain access to this questionnaire, you must attain the permissions. To view or utilize this questionnaire beyond restricted access, please email Dr. Mark Doidge at fibrowiki@gmail.com.

Descriptions of the three vicious cycles of fibromyalgia[edit]

“Bad sleep—pain—bad sleep cycle” vicious cycle[edit]

(Author’s term.)

This cycle is based on questions 1 and 2.

This cycle is based on the well established and common clinical fact that fibromyalgia patients frequently report having more pain after a night of poor sleep, and if they go to bed in pain or have pain during the night, their sleep will often be much worse.

The "anxiety/agitation—bad sleep—anxiety/agitation" cycle[edit]

This cycle is based on questions 3 and 4.

It is well established that worry while in bed when trying to go to sleep is a major and possibly the major cause of insomnia. It is a major focus in the leading treatment of insomnia which is called CBT-I. A chain of back-to-back worries while in bed is agitating and makes it hard to fall asleep. This problem is extremely common in fibromyalgia patients. (The patient is often left tired and agitated at the same time. This is called the “tired but wired” feeling. Many patients report that they are so “wired” from not sleeping the previous night that it is hard to get to sleep the next night. It is also well established and common knowledge that missing sleep can be agitating and anxiety promoting.

The “anxiety/agitation—pain—anxiety/agitation” cycle[edit]

(Author’s term.)

This is based on the well-known pattern whereby many patients with fibromyalgia admit that shortly after becoming emotional they often experience more fibromyalgic pains. An example is an elderly woman with longstanding fibromyalgia who had more pains after getting emotional when she felt insulted by her daughter.

Note that this has not been studied systematically for each of the main negative emotions of man. These include anger and guilt. With more study, it may become appropriate to rename this as the “intense negative emotion—pain—intense negative emotion vicious cycle”

It is based on questions 5 and 6.


Use in fibromyalgia care[edit]

The vortex questionnaire was invented with the intention of helping the patient and their doctor to understand main factors that are driving the disorder in the individual.

The references to pain in it were intended to refer to fibromyalgia pains (which are typically, but not always muscular and typically worse with stress and or bad sleep.) In the course of his clinical practice with migraine patients it became clear that they too can have similar vicious cycles. Furthermore, it is well recognized that some migraine paints develop headaches during sleep. Some severe insomniacs with migraine were found to have periods of great frustration when they were trying to get to sleep, and at least one of them had a clear pattern of headache being brought on by these episodes of frustration and tossing and turning in bed.

Range of use possible future versions of vortex questionnaires[edit]

The range of clinical applications for the vortex questionnaires is not fully known, but it seems reasonable to start evaluating versions of this vortex question its use in many chronic pain situations including the pain of irritable bowel syndrome and migraine. (However, the vortex questionnaire as it stands relates only to fibromyalgia pains, and so for example, if a version were to be studied for irritable bowels syndrome, the pain would have to relate to abdominal pains.)

Its main value is in guiding patients to understand what things they need to correct in order to improve their fibromyalgia symptoms. For example, if it shows that poor sleep is driving their pain, then they now know that in order to improve their pains they should try to repair their sleep.

These are questions about the possible interactions between pain, worry/anxiety and bad sleep. They relate to what is referred to in this Encyclopedia as “The fibromyalgia vortex”.

It is possible that after research, the fibromyalgia vortex questionnaire will turn out to be a useful screening test for fibromyalgia. Furthermore, it may be discovered moderately high scores will turn out to provide moderately good evidence for having the diagnosis, and that high scores will be even more reliable.


Who should score?[edit]

Scoring is normally done by the health care provider. The document refers to two types of scores. The first is called the “raw score”. The second one is called the “cycle strengths score”.

Goals of scoring[edit]

The goals of this exercise are:

  • to inform the patient if they have vicious cycles;
  • to prioritize the vicious cycles in terms of clinical importance; and
  • to inform the patient which are the “strongest” so that the patient can start organizing their mind to try to improve and so that the doctor can focus their treatment efforts on the cycles that are most important for driving the patient’s symptom.

Vicious cycle raw scores[edit]

Score patients on the raw scale out of 12. Score zero points for each answer of “never”, one point for “sometimes” and two points for “often”. In other words, the highest possible raw score is 12. It means that the patient is severely affected by all three vicious cycles.

Patient’s Raw Score:___ /12

Vicious cycle strength scores[edit]

It is impossible to have a vicious cycle if one arm of the cycle does not exist i.e. if the patient answered “never” to at least one arm of a cycle. If the patient answers “never” to the first pair of questions in a cycle, or to the second pair, or both, then there is no vicious cycle, and the strength score for it is zero.

A cycle can be weak (sometimes and sometimes); medium (sometimes and often); or strong (often and often).

Score each cycle strength pairs as follows:

If “never”, “sometimes” or “often” for one member of a pair, but “never” for the other member, then score zero for that pair.

If “sometimes” for both members of a pair, then score one cycle point. (This represents a mild strength vicious cycle.)

If one member is “sometimes” and one is “often”, score two points. (This represents a moderate strength vicious cycle.)

If both members are “often” score the cycle strength as three points. (This represents a severe or strong vicious cycle.)

This means that the highest possible total cycle strength score is 9.

Patient’s Cycle Strength Score:_/9

Summarizing the results to the patient[edit]

It is helpful at the end of the exercise to summarize by pointing out to the patient which of their vicious cycles were the most serious. This can help motivate them to take action and allow them to prioritize their efforts.

Author’s comments on the possible used vicious cycle strength scores as a screening tool[edit]

The author suspects that that if research was to be conducted on this topic in which vicious cycle strength scores were studied in comparison to the ACR1990 and the ACR016, then it would be possible to discover a threshold or cut off score that could serve as a rapid screening test for fibromyalgia. (A rough estimate is that the threshold will be about 5 or 6. However, even if this turns out to be untrue, the vortex scoring process described above is still a valuable teaching tool to help the patient understand what is driving their symptoms. This can be a good motivator to encourage the patient to try to make psychological and behavioural adjustments in their life to reduce their anxiety/ agitation issues or sleep treatments and adjustments aimed at correcting any sleep related issues such as insomnia due to worry.

Suggested follow-up steps based on findings from the vortex questionnaire[edit]

The doctor can see from the questionnaires the degree to which pain, poor sleep an anxiety are driving each other. If anxiety is a major issue, then it is logical to conduct a more detailed assessment using interview and psychological assessment tools.

If sleep is a big driver for symptoms including pain, then the next step suggested by the author is to do an in-depth sleep questionnaire.