Publications
APS Bulletin • Volume 7, Number 6, November/December 1997
Research Update
Robert J. Gatchel, PhD, Department Editor
Fibromyalgia: Pain and Confusion
Kate McGraw, PhD; Peter Lipsky, MD; Ann Matt Maddrey, PhD
Etiology and symptoms
Fibromyalgia syndrome (FMS) is a painful condition predominantly involving muscles and soft tissues rather than joints. It is one of the most frequent causes of widespread musculoskeletal pain and disability in patients seen in rheumatology clinics (Quijada-Carrera et al., 1996; Wallace, 1997; Wolfe & Potter, 1996). However, physicians and patients alike commonly misunderstand FMS. It is a source of much controversy because the underlying pathophysiology remains a mystery. Moreover, considerable debate continues about whether fibromyalgia is even a distinct syndrome or is instead a collection of painful conditions with overlapping features. Associated features of fibromyalgia include migraine, memory loss, word-finding difficulties, irritable bowel, widespread pain, morning stiffness, and sleep disturbance (Tuncer, Butun, Arman, Akyokus, & Doseyen, 1997). Women are more often affected by fibromyalgia than men. The prevalence rate is 2.0% in both genders: 3.4% in women but only 0.5% in men. FMS is most often found in patients aged 20 to 60 years (Branco, 1995; Wolfe, 1989; Wolfe, Ross, Anderson, Russell, & Hebert, 1995).
The etiology of FMS eludes researchers. However, investigators are exploring the following as possible causes of this painful condition: serotonin deficiency (Nicolodi & Sicuteri, 1996); emotional trauma precipitants (Aaron et al., 1997); lymphocyte phenotype and IgE levels, which may have an impact on allergen sensitivity (Samborski, Stratz, Lacki, Klama, Mennet, & Muller, 1996; Tuncer et al., 1997); generalized hypervigilance and perceptual amplification of pain (McDermid, Rollman, & McCain, 1996); genetic and familial factors (Buskila, Neumann, Hazanov, & Carmi, 1996); and abnormal blood flow to muscles (Simms, 1996).
Diagnostic criteria
Accurate and timely diagnosis of fibromyalgia is essential in order for patients to obtain both psychological support and relief from the pain. However, a correct differential diagnosis can be difficult even for the most skilled clinician, because the presenting symptoms include weakness as well as pain. Thus, an accurate diagnosis can become a lengthy process that may heighten both the patient's and the clinician's frustration in finding a cause for symptoms and appropriate treatment options. Well-defined criteria developed by the American College of Rheumatology, in a multicenter trial, use both objective and subjective symptoms to correctly diagnosis FMS (McCain, 1996; Wolfe et al., 1995; Wolfe et al., 1990). The proposed criteria for diagnosis and classification of this syndrome include widespread pain and the presence of 11 out of 18 possible fibromyalgia tender points (FTP; i.e., areas of tenderness occurring in muscle, muscle-tendon junctions, or fat pads). These criteria have become essential for diagnostic reliability and validity in both clinical and research arenas. The FTP method, when used with a calibrated dolorimeter, is highly reliable and valid, as demonstrated by numerous studies showing high intrarater and interrater agreement (Borg-Stein & Stein, 1996; Okifuji, Turk, Sinclair, Starz, & Marcus, 1997).
Treatment
At this time, there is no known cure for fibromyalgia. Treatment is palliative and is primarily focused on restoration of sleep and pain relief via the use of psychopharmacological agents such as zolpidem (Moldofsky, Lue, Mously, Roth-Schechter, & Reynolds, 1996), tenoxicam, bromazepan (Quijada-Carrera et al., 1996), and tropisetron (Samborski et al., 1996). Currently, however, treatments have led to only moderate success. Often a team of specialists, including a rheumatologist, psychologist, internist, pain specialist, and physical therapist, provide treatment. Therapy emphasizes exercise and good sleep hygiene, and it often involves relaxation training. Recently, one study of 11 patients who received 15 sessions of biofeedback training showed significant decreases in both the number of tender points reported and the pain threshold of patients (Minhoto, Roizenblatt, & Tufik, 1997).
Most recent studies indicate that although FMS patients are a heterogeneous group, in general FMS does not appear to be a physical manifestation of psychological disturbance (Aaron et al., 1996; Buskila et al., 1996; Reid, Lang, & McGrath, 1997; Turk, Okifuji, Starz, & Sinclair, 1996). However, a recent study of 23 patients newly diagnosed with fibromyalgia revealed that these patients often experience depression and anxiety and report a poorer quality of life associated with their physical condition (McGraw, Gatchel, Cullum, & Lipsky, 1997). It is not clear whether this psychological state precedes the syndrome (endogenous FMS, symptomatic of depression), or whether it is a result of the physical condition (reactive FMS, or depression symptomatic of FMS). In either case, individual supportive psychotherapy, in conjunction with antianxiety or antidepressant agents when indicated, may provide some relief. Support groups may prove helpful as well.
Another recent study evaluated a 6-month group-therapy program that involved lectures, group sessions emphasizing behavior modification and stress reduction, and support sessions for spouses and significant others. The group met weekly for a 90-minute session. Outcome measures (i.e., tender points) indicated significant improvement in 70% of the 104 subjects who completed the program, as compared to a control group of 29 who showed no significant improvement (Bennett et al., 1996).
Conclusions
Although not fatal or disfiguring, fibromyalgia is a syndrome of unknown etiology that is often disabling and can cause significant impairment in all areas of patient functioning. Patients with undiagnosed FMS may feel isolated, misunderstood by others, and alone in their search for a correct diagnosis, which may take years and numerous visits to different specialists. During this time, their relationships with others may suffer, and their ability to work productively and enjoy a high quality of life may decrease. Current treatment methods employ pharmacological agents to aid in pain management, improve sleep quality, and stabilize mood. Education, biofeedback, individual and group psychotherapy, and stress management can be valuable interventions. Future research efforts will increase understanding of this syndrome, thereby helping practitioners and patients identify the syndrome more rapidly and intervene effectively.
References
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The proposed criteria for diagnosis and classification of fibromyalgia syndrome include widespread pain and the presence of 11 out of 18 possible fibromyalgia tender points.
Kate McGraw is a staff psychologist at Sheppard AFB in Wichita Falls, TX; Peter Lipsky is professor and chair of rheumatology at the University of Texas Southwestern Medical Center at Dallas; Ann Matt Maddrey is clinical assistant professor of psychiatry at the University of Texas Southwestern Medical Center at Dallas.