Moderated Mediation Model Fibromyalgia Impact and Suicidal Behavior: Effects of Stress and Self-Compassion Morgan K. Treaster1, B.A., Jessica K. Rabon1, M.A., Kelley C. Pugh1, B.A., Annemarie Weber2, B.S., Niko Kohls2, Ph.D., Fuschia M. Sirois3, Ph.D., & Jameson K. Hirsch1, Ph.D. Department of Psychology, Laboratory of Resilience in Psychological and Physical Health, East Tennessee State University1 Division of Integrative Health Promotion, Coburg University of Applied Sciences2 Department of Psychology, University of Sheffield3 ABSTRACT Fibromyalgia is a chronic pain condition, affecting 3 – 6% of the world’s population. Many persons living with fibromyalgia experience high levels of stress and heightened risk for suicide, perhaps because symptoms of the condition limit one’s ability to complete daily activities (e.g., cooking, recreation). In a sample of persons with fibromyalgia, we assessed the mediating effect of perceived stress on the linkage between fibromyalgia impact and suicide risk, and the moderating effects of self-compassion. Our participants (N=508) completed the Fibromyalgia Impact Questionnaire – Revised, Depression Anxiety Stress Scales, Suicidal Behaviors Questionnaire – Revised, and Self-Compassion Scale – Short Form. In mediation analyses, stress significantly mediated the relation between fibromyalgia impact and suicide risk. Self-compassion moderated this mediation effect, weakening the relations between fibromyalgia impact and stress, stress and suicide risk, and fibromyalgia impact and suicide risk. Therapeutic interventions focused on alleviating stress (e.g., journaling) or promoting self-compassion (e.g., Mindful Self-Compassion Training) could ameliorate the perceived impact of fibromyalgia-related stressors and, thus, risk for suicide. ANALYSES Pearson product moment correlations Mediation & moderation analyses, consistent with Hayes (2013), covarying age, ethnicity, and sex. DISCUSSION Supporting bivariate hypotheses, fibromyalgia impact was positively related to stress and suicide risk, stress was positively related to suicide risk, and self-compassion was negatively related to all of these variables. In multivariate analyses, stress mediated the relation between fibromyalgia impact and suicide risk, and self-compassion weakened the link between fibromyalgia impact and stress, and between fibromyalgia impact and suicide risk. Our findings support past literature indicating the linkage between disease impact, illness-related stress (Houdenhove & Luyten, 2006) and suicide risk (Calandre et al., 2015) , and we extend this to a sample of persons with fibromyalgia. Fibromyalgia impact was related to both stress and suicide risk, suggesting that functional impairment may contribute to feelings of frustration or defeat (Arnold et al., 2008), and that suicide may be viewed as a viable alternative to daily suffering (Russell et al., 2009). Yet, self-compassion may help alleviate stress and reduce suicide risk, perhaps by promoting mindful acceptance of pain and limitations (Reibel et al., 2001) or through recognition of the shared experiences of fibromyalgia (i.e., common humanity of illness) (Gillanders et al., 2015). As well, in the face of limitations and impairment, the ability to be kind to the self, rather than self critical, is related to better mental and physical health (Sirois et al., 2015) and, per our findings, may help to reduce stress and suicidal behavior. RESULTS Bivariate Results Multivariate Results The total effect of fibromyalgia impact on suicide risk was significant, (b = .05[.019, .078], SE = .015, t = 3.21, p < .01. The direct effect reduced in significance when stress was added (b = .04[.004, .071], SE = .017, t = 2.21, p < .05), indicating mediation. Self-compassion significantly moderated the relation between fibromyalgia impact and stress (b = .00[-.007, -.001], SE = .001, t = -2.95, p < .01), stress and suicide risk (b = .01[.000, .023], SE = .006, t = 2.03, p < .05), and fibromyalgia impact and suicide risk (b = .00[-.009, -.002], SE = .002, t = -3.04, p < .01). Higher self-compassion was related to a weakening of the relation between fibromyalgia impact and stress, and between fibromyalgia impact and suicide risk. Stress Suicide Risk Self-Compassion Fibromyalgia Impact .46 .22 -.33 --- .26 -.60 -.24 * All correlations are significant at the p < .01 level. * INTRODUCTION Fibromyalgia is a chronic illness affecting 3 – 6% of the world’s population, and is characterized by widespread muscle pain, tenderness, joint stiffness, and fatigue (Theadom & Cropley, 2008). Persons with fibromyalgia are more likely to experience poor mental health (e.g., depression, heightened suicide risk), perhaps due to functional limitations associated with the disease (Jiminez-Rodriguez et al., 2014). For example, individuals may experience difficulties in the completion of daily activities such as cooking, cleaning, and employment (Bombardier & Buchwald, 1996; Da Silva Costa et al., 2017). Frustration related to the inability to complete daily routines may result in increased stress, and ending one’s life may be viewed as a viable alternative to daily physical suffering or overwhelming feelings of stress (Triñanes et al., 2014). However, not all persons with fibromyalgia experience overwhelming distress or engage in suicidal behaviors (Wolfe et al., 2011), perhaps due to individual-level protective factors. Self-compassion, which is composed of self-kindness, common humanity, and mindfulness, is one such protective factor (Neff, 2003), and it is inversely related to stress and risk for suicide (MacBeth & Gumley, 2012). Among persons living with fibromyalgia, stress and risk for suicide may be lessened to the extent that one can be kind to the self, acknowledge negative emotions, and recognize that suffering is a shared human experience. HYPOTHESES Bivariate: We hypothesized that fibromyalgia impact would be positively related to stress and suicide risk, that stress would be positively related to suicide risk, and that self-compassion would be negatively related to all of these variables. Multivariate: We hypothesized that stress would mediate the relation between fibromyalgia impact and suicide risk, and that self-compassion would moderate this mediation effect; greater self-compassion would weaken the relations between fibromyalgia impact, stress, and suicide risk. METHOD Participants Sample: N = 508 Recruitment: online invitations to state, regional, and national organizations and support groups Sex: 95.7% female (n = 401); 4.3% male (n = 18) Ethnicity: 91.8% White (n = 383) Mean Age: 47.72 (SD = 13.14) Measures Fibromyalgia Impact Questionnaire – Revised (Bennett et al., 2009) Depression Anxiety Stress Scales (Lovibond & Lovibond, 2009) Self-Compassion Scale – Short Form (Raes et al., 2011) Suicidal Behavioral Questionnaire – Revised (Osman et al., 2001) LIMITATIONS Cross-sectional data precludes examination of causality, and a predominately White, female sample may limit generalizability. Longitudinal research, with more diverse samples, is needed to substantiate our findings. Moderated Mediation Model IMPLICATIONS Interventions focused on promoting self-compassion (e.g., Mindful Self-Compassion Training) (Neff & Germer, 2013), or reducing stress (e.g., journaling) (Smyth et al., 1999), may ameliorate the impact of fibromyalgia-related stressors on suicide risk. Figure 1. Illustration of the conditional indirect effects model. FI = fibromyalgia impact; SC = self-compassion; SR = Suicide Risk. c = direct effect (FI related to SR); a = indirect effect (FI related to Stress); b = indirect effect (Stress related to SR); d1 = conditional effect of SC on the relation between FI and Stress; d2 = conditional effect of SC on relation between Stress and SR; d3 = conditional effect of SC on the relation between FI and SR. * p < .05; ** p < .01; *** p < .001