Is Fibromyalgia Real?

[Guest guest]

What Is Fibromyalgia? found on www.medscape.com (free registration

required)

* Kay, MD:* " Fibromyalgia " is a label that has been given to a large

number of patients who experience chronic pain. A small subset of these

patients have characteristic tender points, but the vast majority of

patients who carry this label describe diffuse pain that is not more

pronounced when specific areas are palpated. The vast majority of these

patients also describe migraine headaches, shooting pains in their

extremities, chronic fatigue, and sleep disturbances. Some report

alternating constipation and diarrhea, which usually is labeled as being

" irritable bowel, " but others do not experience these gastrointestinal

symptoms.

Also, patients with inflammatory arthritis or early fibrosing syndromes may

experience pain in multiple areas without manifesting detectable signs of

joint inflammation or tissue fibrosis. Some of these patients may be labeled

as " fibromyalgia, " but display signs of more typical disease as time passes.

Other conditions, such as certain endocrinopathies, may also present with

fatigue, generalized aching, and other symptoms that prompt giving these

patients the label of " fibromyalgia. "

Although a few patients may present with increased tenderness over

characteristic tender points, fatigue, migraine headaches, shooting pains in

the extremities, fatigue, and irritable bowel syndrome symptoms, without

another obvious diagnosis, it is clear that " fibromyalgia " is not by itself

a distinct condition with a single pathophysiologic mechanism. Rather, it is

a common symptom complex that is characteristic of the heightened perception

of pain associated with a number of different precipitating factors.

* Argoff, MD:* Clinicians should be accustomed to being faced with

managing conditions for which absolute knowledge regarding the conditions

and their etiology and pathophysiology are not known. In fact, this is true

for most medical conditions we encounter including many nonpain-related

conditions such as hypertension, various cancers and diabetes. Even the

wisest among us cannot state with absolute certainty the exact cause(s) of

fibromyalgia syndrome and/or its mechanisms(s). Fibromyalgia syndrome is not

a label to be applied to another human being. It is a common chronic medical

condition associated with widespread pain, lowered pain thresholds, and

augmented sensory perception. Recent efforts by the American College of

Rheumatology have focused attention as well on the nonpainful aspects of

fibromyalgia syndrome such as fatigue and sleep disturbances as important

diagnostic features.

*Dr. Kay:* I agree with Dr. Argoff that clinicians often face and manage

conditions for which the etiology is unknown. In rheumatology, we do not

know the etiology of most rheumatic diseases. However, the pathophysiology

of most diseases that we treat is understood, at least to the extent that

there is some understanding of the mechanism by which therapies interfere

with the disease process.

I disagree with Dr. Argoff that the pathophysiology of " fibromyalgia "

syndrome is not known. No specific pathophysiology is ascribed to the label

of " fibromyalgia " ; however, patients develop the symptoms of this syndrome

in association with various underlying disorders. Applying the label of

" fibromyalgia " syndrome to the syndrome of widespread pain, lowered pain

thresholds, and augmented sensory perception without attempting to identify

an underlying pathophysiologic process makes treatment of patients with this

symptom complex more difficult than necessary. Considering sleep

disturbances, for example, to be " aspects " of the syndrome rather than

predisposing factors is " chicken and egg " logic. It is important to

acknowledge which comes first, so that the predisposing factor may be

treated to prevent the resulting symptoms.

*Dr. Argoff:* Given that all patients currently diagnosed with fibromyalgia

do not have completely identical symptoms including the fact that not all

patients share the same sleep disturbances, Dr. Kay's comments actually

underscore the complexity of managing the person with fibromyalgia as well

as the urgent need to learn more about its pathophysiology, which is

currently incompletely understood.

What Causes Fibromyalgia?

*Dr. Kay:* The fibromyalgia symptom complex can result from a number of

different etiologies. The vast majority of patients labeled as having

" fibromyalgia " describe a disturbed sleep pattern, either as a primary

process or resulting from their underlying pain syndrome. Many obese

patients who experience a heightened perception of pain have obstructive

sleep apnea that either has not been diagnosed or is inadequately treated. A

number of patients, many of whom have normal body mass indices, describe

symptoms of restless legs syndrome. Those patients may have associated iron

deficiency and often report family members who also have restless leg

syndrome.

*Dr. Argoff:* Fibromyalgia is a medical condition whose diagnosis can be

made based upon established diagnostic criteria. It may coexist and, in

fact, often interrelates with other medical conditions including rheumatoid

arthritis and others. Mental health comorbidities are common but are not the

cause of fibromyalgia.

*Dr. Kay:* Certainly, patients with symptoms that are labeled as

" fibromyalgia " syndrome may have other medical conditions, including

rheumatoid arthritis and other forms of inflammatory joint disease. I also

agree with Dr. Argoff that mental health comorbidities are common among

patients with " fibromyalgia " syndrome. However, having stated that the

" etiology and pathophysiology " of " fibromyalgia syndrome are not known, " how

can he then assert that mental health comorbidities are not the cause of

" fibromyalgia, " if " even the wisest among us cannot state with absolute

certainty the exact cause(s) of fibromyalgia syndrome? " My esteemed

colleague seems to be engaging here in a circular argument.

*Dr. Argoff:* Given that all patients currently diagnosed with fibromyalgia

do not meet current diagnostic criteria for major depressive disorder or any

other mental health disorder per se, and given that it is well documented

that treatment benefit from serotonin*-*norepinephrine reuptake inhibitor

(SNRI) agents is independent of whether or not an individual is depressed or

not, it is clear that mental health comorbidities are not the cause of

fibromylagia since they don't occur in all patients

Is Abuse To Blame?

*Dr. Kay:* A disturbingly high number of patients with chronic pain that has

been labeled as " fibromyalgia, " upon direct questioning, report having been

victims of preadolescent sexual abuse, often at the hands of close relatives

or of others who abuse their position of authority and responsibility.

Others report having been in an abusive relationship.

Unfortunately, many patients who are victims of spousal abuse are

accompanied to their medical visit by the abusive spouse who is trying to

prevent them from disclosing the nature of this relationship. Thus, a large

number of patients who are labeled as having " fibromyalgia " actually have a

posttraumatic syndrome that manifests with a heightened perception of pain

and associated symptoms. Interestingly, these patients typically report

migraine headaches, shooting pains in their extremities, and fatigue, but no

alternating constipation and diarrhea.

*Dr. Argoff:* Victims of preadolescent sexual abuse are noted to experience

autoimmune diseases, chronic migraine and other headache syndromes, and

hypertension, to name just a few medical conditions. In other words, those

individuals who are unfortunate victims of such horrifically traumatic

experiences are at risk of developing many medical consequences, including

but not restricted to fibromyalgia syndrome.[1-3] Being aware of a person's

history of preadolescent sexual abuse does not diminish the legitimacy of

the medical condition that has emerged in any way whatsoever.

*Dr. Kay:* I am unaware of any evidence that demonstrates an autoimmune

disease to result from preadolescent sexual abuse. Certainly, victims of

such abuse develop chronic migraine headaches and other features of

" fibromyalgia " syndrome as part of a posttraumatic syndrome. It is important

for medical professionals to be aware of physical and sexual abuse to which

patients have been subjected and to make certain that individuals are

removed from the setting in which they are subject to such abuse. In no way

does a history of physical or sexual abuse diminish the legitimacy of any

objective medical condition.

*Dr. Argoff:* There are numerous peer-reviewed articles that have examined

this relationship.[1-3]

*Dr. Kay:* The papers cited by Dr. Argoff support my assertion that many

patients who are labeled as having " fibromyalgia " actually have a

posttraumatic syndrome that manifests with a heightened perception of pain

and associated symptoms. This is exactly the point made by Dr. and

his colleagues and Dr. . [2,3] In the abstract of her review article,

Dr. defines " autoimmune disorders " as irritable bowel syndrome,

asthma, and fibromyalgia. Most rheumatologists would disagree with her

classifying these 3 conditions as " autoimmune " and would instead classify

them as belonging to the spectrum of " central sensitivity syndromes. " [4] The

study by Drs. Goodwin and Stein used a self-report checklist form to query

participants in the National Comorbidity Survey as to the presence of

" physical illnesses " within the past 12 months. One of the categories asked

about " thyroid disease, or other autoimmune disorders. " Although the

adjusted odds ratio for an association between self-reported physical abuse

and self-reported " autoimmune disease " ranged from 1.7 to 3.1, this

self-diagnosis of " autoimmune disease " is of questionable legitimacy given

that the patients' self-diagnoses were not validated and the absence of a

definition for " autoimmune disease " on the checklist.[1] Thus, there remains

no convincing evidence to demonstrate that an autoimmune disease results

from preadolescent sexual abuse.

So Is It Depression?

*Dr. Kay:* A very small number of patients who carry the label of

" fibromyalgia " actually have inadequately treated depression. With

appropriate adjustment of their psychopharmacologic regimen, the somatic

symptoms that are labeled as " fibromyalgia " come under better control.

*Dr. Argoff:* Mental health comorbidities are common but are not the cause

of fibromyalgia. It is well established in the medical literature that many

antidepressants have analgesic properties that have been conclusively

demonstrated to be independent of their antidepressant properties. Two such

agents are currently US Food and Drug Administration (FDA)-approved for the

treatment of fibromyalgia syndrome.

*Dr. Kay:* I do not assert that depression or other mental health conditions

are the cause of " fibromyalgia " syndrome. Dr. Argoff is correct in his

statement that antidepressant medications have analgesic properties that are

independent of their antidepressant properties. The FDA has approved both

pregabalin and milnacipran for the treatment of patients with " fibromyalgia "

syndrome. Although milnacipran is also approved for the treatment of major

depressive disorder, pregabalin is not an antidepressant medication.

*Dr. Argoff:* There are 3 FDA-approved medications for the treatment of

fibromyalgia. Two of them, duloxetine and milnacipran, are considered SNRI

agents but only 1 of these, duloxetine, is also approved by the FDA for

major depressive disorder and/or generalized anxiety disorder. Minalcipran

is not approved by the FDA for any mental health indication. The European

Medicines Agency (EMEA) however has approved milnacipran for the treatment

of major depression, and it has been used in Europe for many years for this

purpose. Pregabalin is an example of an alpha(2)-delta agonist medication,

and it is not an antidepressant nor did any of my prior comments suggest

otherwise!

Where Does This Leave Us?

*Dr. Kay: *Dr. Argoff and I agree that " fibromyalgia " syndrome is a

condition in which patients experience chronic diffuse pain, typically

accompanied by migraine headaches, shooting pains in their extremities, and

chronic fatigue. It is frustrating to both the patient and the physician

that this constellation of symptoms does not have a single cause and that

its pathophysiology remains incompletely understood. Many patients with this

condition do not have mental health comorbidities, yet they may respond to

treatment with SNRIs.

We disagree about the relationship between preadolescent sexual abuse and

the subsequent development of autoimmune disease. Although Dr. Argoff states

that " numerous peer-reviewed articles... have examined this relationship, "

the " autoimmune disorders " included were " irritable bowel syndrome, asthma,

and fibromyalgia. " [3] None of these conditions is associated with

autoantibody production and none is typically considered to be an autoimmune

disease.

Regardless of how one categorizes its pathophysiology, individuals with

chronic diffuse pain suffer with their symptom complex. As physicians, we

must try our best to relieve their distress. Understanding the specific

pathophysiologic basis for a patient's chronic pain helps to direct

treatment: therapies that address underlying causes of heightened pain

perception are more likely to be successful than those which merely lessen

symptoms. However, the questions raised by our dialogue highlight some of

the unanswered questions about " fibromyalgia " syndrome that warrant

clarification by well-designed research studies.

*Dr. Argoff: *It has been an honor to participate in this virtual debate and

I agree with Dr. Kay that only with continued quality research efforts can

we hope to clarify so many of the details of fibromyalgia and its care.

--

Ortiz, MS, RD

*The FRUGAL Dietitian* <http://www.thefrugaldietitian.com>

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