Fibromyalgia

[Psyclops]

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From the MD but mental health practioner perspective, is this a real thing? It seems to mean that it is like r = .92 with personality pathology.

And frankly, since we've been discussion many maligerers/frequent flyers on here lately, it seems to be the lifer psychiatric patient's dream illness. Non-specific pain throughout the body. Isn't that pretty much the only criteria?

It seems to offer ample oportunity for attention seeking complaints, and more imporntantly prescriptions for pain releavers.

Thoughts? Stories?

 

[Smilemaker100]

From the MD but mental health practioner perspective, is this a real thing? It seems to mean that it is like r = .92 with personality pathology.

And frankly, since we've been discussion many maligerers/frequent flyers on here lately, it seems to be the lifer psychiatric patient's dream illness. Non-specific pain throughout the body. Isn't that pretty much the only criteria?

It seems to offer ample oportunity for attention seeking complaints, and more imporntantly prescriptions for pain releavers.

Thoughts? Stories?

Believe it or not, I have had patients with dental pain blame it on their "fibromyalgia". While I don`t discount their dental pain, I am kind of skeptical of this whole " fibromyalgia" condition especially with regards to those alternative medicine organizations who promote all sorts of herbal remedies to " cure " it. I think the condition was probably invented by some charlatan belonging to the alternative health movement, as a sales pitch to sell their alternative therapies.

It sounds mostly psychopathological to me. Unfortunately, I find that an increasing number of members of my sex (women) are blaming ALL of their health problems on "fibromyalgia" . 🙄 I am not one of them Then again, maybe I need more scientifically valid evidence to be convinced that fibromyalgia is a genuine medical condition.

 

[TypeA]

Hi there...

A couple of things that may/may not be interesting to you. I was diagnosed with fibromyalgia in 2001 (by a rheumatologist) after I had had to walk with a cane and was unable in many cases to do anything without EXTREME pain. While there are many docs out there that do not believe it exists (and I can see why), there are many characteristics of the syndrome that unaware practioners have yet to notice. It is not merely widespread pain. FMS is also characterized by pain upon palpation at 11 of 18 tender points. These spots will literally double one over in pain if affected, but have no affect on a non-sufferer. TMJ is also an extremely common component of FMS...which would account for the dental pain. I deal with this and it is quite strange to realize the number of things that are affected. Dizziness, non-cardiac chest pain, migraines...I could go on. There was a documentary produced a few years ago called "Private Pain: understanding fibromyalgia"...it may shed some light on the subject for you.

While it may seem that FMS patients tend to blame the FMS for many seemingly ridiculous and unrelated symptoms, if you were to question a group of FMS patients about symptoms that they have experienced, you would be surprised at the commonality among them.

Much research is being conducted at the current time, but while not much is known...an interesting lead has been regarding HPV6 and the possible characterization of FMS as an auto-immune disorder.

Hope this sheds a little light on things...perhaps not as psychopathological as expected.

 

[whopper]

There are several conditions which are known to be real, but also known to be extremely overdiagnosed such as ADHD. Others which were once thought to be real are now highly suspected of being entirely BS such as multiple personality disorder.

I don't know if this is a "real" condition or not, is real, or is real but is overdiagnosed, and given my little experience with it, I will consider any patient I have diagnosed with fibromyalgia as real until I have reason to believe otherwise.

I would also seriously consider that perhaps the patient has another medical problem which may have been missed that could cause similar symptoms.

I did read an article on emedicine.com indicating that fibromyalgia has been associated with specific PTST like stressors such as the WTC collapse and the Gulf War, indicating there may be a psychological component to it.

Given that pain is proven to be subjective and various factors can influence the perception of pain, it makes it logical to believe that certain psychological outlooks--i.e. personality types could be more prone to pain.

There is evidence that FM does have some real physiological basis, but also that some patients with this dx may have been misdiagnosed by a frustrated doctor who might've just wanted to slap a label out of frustration, I also would follow the following reccomendation from emedicine.com

"limitations on activity, including work release, generally should be avoided. "

From studies, patients with FM respond well to elavil which is commonly known, but also apparently just as well to effexor & cymbalta. The supposed mechanism is that reuptake inhibition of norepinephrine does increase the threshold to pain. So if you do have a depressed patient with an FM diagnosis, why not try these medications, or even try them if they are not depressed (as an off label treatment, so treat responsibly and discuss the matter with the patient & document well).

Psychologically: give them encouragement, but also set limits. It is an unfortunate truth that some in our profession will slap any diagnosis they need to get managed care to put a label, and get that patient out of the office, and fibromyalgia is sometimes one of these diagnosis. I do sometimes see the diagnosis with suspicion, but I will not write off a patient as a malingerer until I have a solid reason to believe so.

 

[Anasazi23]

It's not unreasonable to assume the condition is real, as it is recognized by both the AMA and WHO.

There is research that fibromyalgia patients have various lab and pathophysiological anomalies, such as increased levels of substance P, a dysfunctional hypothalamic-pituitary-adrenal axis, and increased nerve growth factor compared to normals.

However, there is an undenyable psychological component to the disease. More still, I must admit that I saw fibromyalgia cases on c/l where there was only minimal psychopathology.

Tender points and trigger points are established diagnostic indicators, and are evident in patients with this condition. I've seen patients who have excruciating pain on palpation of these points in marked disproportion to the stimuli.

As mentioned, TCAs work well in this condition, which either is due to the serotonergic dysregulation, or from its antidepressant properties, or both.

I try not to discount the diagnosis, since I've seen severe cases, but don't deny that in other cases, particularly those associated with moderate to severe psychopathology, there does appear to be a more psychological somatic component.

We're beginning to discover the great importance that cytokines play in what were previously thought to be psychiatrically-influenced conditions - fibromyalgia being one. Chronic pain disease and chronic fatigue syndrome being others. It may well be that our level of knowledge regarding these syndromes hasn't reached fruition quite yet.

 

[Psyclops]

Thanks for the replies. I've never seen it expressed without a comorbid psychiatric d/o. But, that is mainly because I have only worked in psychiatric hospitals. In doing research with non-psychiatric samples, I have encountered it from time to time, but again, it was generally comorbid with symptomology/treatment/diagnosis of psychiatric conditions. Even beyond that, there seemed to be certain personality characteristics associated.

If it did have a high comorbidity with certain PDs though, and it did return an abnormal lab profile, that would be something that interested me very much.

 

[PublicHealth]

http://www.ncbi.nlm.nih.gov/entrez/...uids=16698181&query_hl=32&itool=pubmed_docsum

http://www.ncbi.nlm.nih.gov/entrez/...uids=15745615&query_hl=32&itool=pubmed_DocSum

 

[whopper]

I hate saying it, but several of the attendings I work with, psychiatric or otherwise pretty much put their hand to their head whenever they see a patient with a fibromyalgia diagnosis in the patient's history, expecting the patient to be difficult.

And as we all know some patients can be difficult, but as Public Health mentioned, this is an accepted diagnostic disorder with hard evidence that there is some physiological component to it.

When it comes to patients like this, I try to get to know them & their intentions well. E.g. I had a patient with a fibromyaglia diagnosis and did everything she could, e.g. started a healthy diet, excercised, took her meds compliantly and refused to take off work. Her outpatient therapist motivated her to not see her disorder as an impairment, even reccomended that seeing it as an impairment and using it as an excuse to duck work could even possibly make it worse.

Then compare that to another patient-who shows no objective symptoms of the disorder, won't take the meds, even when you give the ones that have hard evidence such as elavil of improving the pain, then consistently asks you to sign for him/her to get disability, and when in therapy doesn't take it seriously. Now this doesn't necessarily prove the patient doesn't have fibromyalgia, but I think the 2 examples show the point of a pt who likely has it for real vs somone you're going to have to look at a little more closely.

 

[Psyclops]

I wanted to thank Type A for not being offended at my post. 👍

PH, so the first link suggested that there was 3.7% rate in the general (female) population. Does that sound high to anyone else? How were these ppts being recruited?

 

[TypeA]

I wanted to thank Type A for not being offended at my post. 👍

PH, so the first link suggested that there was 3.7% rate in the general (female) population. Does that sound high to anyone else? How were these ppts being recruited?

Not at all.

 

[asculapius]

My initial training was in PM&R, second in psychiatry. I've seen many fibromyalgia patients while at PM&R and tended to refer them to psych most of the time. The results were outstanding. Yet, I can't help to classify fibromyalgia as a psychiatric disorder. Of course, I have to admit that this is a personal opinion not based on evidence-based medicine. This area requires further research.

 

[whopper]

I'm looking at my old post from years ago and realizing how much more experience I have now.

I've seen a trend with several FM patients, and since my last post in this thread from 2006, there has been data verifying there actually is a real physiological process likely going on with the disorder....

That trend is that many of these patients had some type of prior or current immunological issue such as a prior Guillian Barre syndrome or Epstein Barr Virus. That has led me to suspect there may be some type of autoimmune connection with it. Despite that, whenever I read up on FM, I don't see much information on this other than speculation. So either I'm off and it's coincidence, or this may be something worth researching in the future.

I've also gotten into the habit of treating FM patients with a med with an NRI component (e.g. amitriptyline, Effexor, Cymbalta, Wellbutrin), or a seizure med known to reduce pain such as Lamictal, Gabapentin, or Trileptal.

I usually will not allow for disability for FM on the reasoning that a true evaluation for it needs to be done on a level I cannot do in a private office setting. The problem with this disorder as with several psychiatric (not saying FM is psychiatric, that's under debate), is that the disorder, while truly existing, in clinical practice can only be done so using methods easily faked and often times people want disability for FM. This is a problem because I do believe people are truly suffering but I have no easy method to distinguish them from malingerers.

 

[loveoforganic]

I know this doesn't take into account cause and effect, but how often do you see a fm pt without comorbid psychiatric issues? I've seen 0 (always depression), but my sample size is low to the point of being meaningless.

 

[nitemagi]

I'm looking at my old post from years ago and realizing how much more experience I have now.

I've seen a trend with several FM patients, and since my last post in this thread from 2006, there has been data verifying there actually is a real physiological process likely going on with the disorder....

That trend is that many of these patients had some type of prior or current immunological issue such as a prior Guillian Barre syndrome or Epstein Barr Virus. That has led me to suspect there may be some type of autoimmune connection with it. Despite that, whenever I read up on FM, I don't see much information on this other than speculation. So either I'm off and it's coincidence, or this may be something worth researching in the future.

I've also gotten into the habit of treating FM patients with a med with an NRI component (e.g. amitriptyline, Effexor, Cymbalta, Wellbutrin), or a seizure med known to reduce pain such as Lamictal, Gabapentin, or Trileptal.

I usually will not allow for disability for FM on the reasoning that a true evaluation for it needs to be done on a level I cannot do in a private office setting. The problem with this disorder as with several psychiatric (not saying FM is psychiatric, that's under debate), is that the disorder, while truly existing, in clinical practice can only be done so using methods easily faked and often times people want disability for FM. This is a problem because I do believe people are truly suffering but I have no easy method to distinguish them from malingerers.

I find the immunological data very interesting. If anyone attends meetings for the American Psychosomatic Society, often up to 1/2 the papers and studies presented include data showing that depression and a host of other psychiatric illnesses ALL have immunologic/inflammatory changes going on. All the more interesting is the use of NSAID's to treat refractory depression and psychosis, with research actually support it.

Regarding do FM pt's always have depression, my experience is the answer is Yes, though they may either not realize it, or state that they're "depressed because of my pain," which is a plausible account. I point to this study as an alternative take on somatizers, though. One of my faves. Essentially some pt's have high emotional and physical distress, which gets better during psychotherapy, as does their satisfaction with care. Those somatizers that stated they had low emotional distress but still physical distress got WORSE from their psychotherapy (at a surface level), in that they got more emotional distress. At the same time this group got more emotional distressed (including depressed), they felt more understood, and satisfied with care. So somatizers likely get worse as they get in touch with the emotions they've been expressing somatically only, and probably need time before their depression will get better as well.

 

[loveoforganic]

Very interesting study, thanks for sharing

 

[pysch4sure]

If anyone attends meetings for the American Psychosomatic Society, often up to 1/2 the papers and studies presented include data showing that depression and a host of other psychiatric illnesses ALL have immunologic/inflammatory changes going on.

👍👍👍👍👍

You're completely right, I'd say it was more than half last time. And there were plenty in Hawaii too

And what's wrong if those are effects, and not causes, of psychiatric illness?

I think Dr Wesseley from King's college said it best-
“Sadly some of the motivation seems to come from people who believe that any connection with psychiatry is tantamount to saying there is nothing wrong with you, go away, you're not really ill"

This, I think, is the reason why there's a rush to explain things like FM and CFS through biological models. A push for more research is usually a good thing, but in fact the environment is so toxic that entertaining a purely psychological explanation for said chronic conditions can result in death threats for researchers. It's gotten out of hand

Don't think I'm not for research of biomarkers in psychiatry, because I am. But FM seems like a pretty convincing case. With all due respect to Dr. Whopper, if you think this is autoimmune, why would TCAs be the best treatment? Using your example, the choice treatments for Gullian-Barre make sense knowing it's autoimmune; plasmapheresis, IvIg

And zemellachiro's example of the general retiring from the armed forces because of FM doesn't prove anything. Surely the social elite aren't exempt from mental health problems.

Fascinating stuff!

 

[zenman]

My wife was diagnosed with it years ago...after a difficult to treat staph infection if that means anything. She went to a few FM support groups but quit due to all the whining. She went on and earned a 3rd degree black belt in Hapkido. I'd say she does relatively well and has no psych problems.

 

[st2205]

My wife was diagnosed with it years ago...after a difficult to treat staph infection if that means anything. She went to a few FM support groups but quit due to all the whining. She went on and earned a 3rd degree black belt in Hapkido. I'd say she does relatively well and has no psych problems.

Ah, yes, but does she have the boots to match?

http://m.youtube.com/index?desktop_uri=/&gl=US#/watch?v=d4reL9AmhVg

 

[zenman]

Ah, yes, but does she have the boots to match?

http://m.youtube.com/index?desktop_uri=/&gl=US#/watch?v=d4reL9AmhVg

I have no idea what you're trying to convey.

 

[ghost dog]

I find the immunological data very interesting. If anyone attends meetings for the American Psychosomatic Society, often up to 1/2 the papers and studies presented include data showing that depression and a host of other psychiatric illnesses ALL have immunologic/inflammatory changes going on. All the more interesting is the use of NSAID's to treat refractory depression and psychosis, with research actually support it.

Regarding do FM pt's always have depression, my experience is the answer is Yes, though they may either not realize it, or state that they're "depressed because of my pain," which is a plausible account. I point to this study as an alternative take on somatizers, though. One of my faves. Essentially some pt's have high emotional and physical distress, which gets better during psychotherapy, as does their satisfaction with care. Those somatizers that stated they had low emotional distress but still physical distress got WORSE from their psychotherapy (at a surface level), in that they got more emotional distress. At the same time this group got more emotional distressed (including depressed), they felt more understood, and satisfied with care. So somatizers likely get worse as they get in touch with the emotions they've been expressing somatically only, and probably need time before their depression will get better as well.

FM doesn't seem to have an inflammatory component to it, as witnessed by the fact that the vast majority of FM pts obtain minimal benefit from NSAIDs. This could almost be a diagnostic criteria for FM.

The current thinking is that it is a centrally modulated / neuropathic pain disorder - which is why meds like Cymbalta and Lyrica are helpful. As to the psych component - absolutely / 100 % some pts do have that aspect. Do all pts have this ? No.

This type of syndrome is an excellent argument for a multidisciplinary approach to chronic pain. And also an outstanding argument, generally, for avoiding strong opioids.

The large number of FM pts I have seen and treated over the years just don't respond to narcs - particularly when they have a lot of psychopathology. I can count on one hand the number who have responded in a meaningful way to opioids (i.e. increased function , not just "it makes me feel great doc! ").

 

[ghost dog]

My wife was diagnosed with it years ago...after a difficult to treat staph infection if that means anything. She went to a few FM support groups but quit due to all the whining. She went on and earned a 3rd degree black belt in Hapkido. I'd say she does relatively well and has no psych problems.

I think this goes to show that there is a significant spectrum of disability associated with FM - a lot of people can work / hold down a job. Some just can't - or don't want to ( likely more important).

 

[whopper]

All the more interesting is the use of NSAID's to treat refractory depression and psychosis, with research actually support it.

Very reasonable, especially considering in depression that the iflammatory pathways are supposed to become hyperactive in depression.

Someone else (Nightmagi? Billy Pilgrim) recommended that patients should go on an antiinflammatory diet. I generally recommend this with fish oil. Of course several have no intention of trying it but it's worth at least mentioning to patients.

I've seen patients with FM but without psychiatric issues. I remember them during my IM rotation. This disorder, however, is highly associated with psychiatric comorbidity.

And of course, I have a relative (on my wife's side), a right-wing Limbot, basically spewing his comments verbatim within hours of a broadcast, and she's got FM, is on disability, plays the victim role, and I wonder if she really has it, but like Limbaugh ridicules those with restless leg syndrome (like him arguing it's not real), is against social-assistance, and pointing fingers to the unemployed as lazy.

She's certainly a poster-girl for neurosis.

 

[Apollyon]

You're completely right, I'd say it was more than half last time. And there were plenty in Hawaii too

In almost 3 years living in HI, I have never seen a Polynesian with FM. Exclusively, the only FM patients I've seen are white mainlanders visiting or having moved to HI (as one does not freeze to death sleeping on the beach while homeless).

 

[nitemagi]

In almost 3 years living in HI, I have never seen a Polynesian with FM. Exclusively, the only FM patients I've seen are white mainlanders visiting or having moved to HI (as one does not freeze to death sleeping on the beach while homeless).

Interesting. FYI though I think the post you're replying to was referencing the APA conference in Hawaii.

 

[Apollyon]

Interesting. FYI though I think the post you're replying to was referencing the APA conference in Hawaii.

Well, if you put it THAT way, it certainly makes sense. (The "THAT" is strictly comedic.)

For vague reasons, we get a lot of CMEs and conferences out in HI. A few years ago, a dentist got assaulted and murdered while on O'ahu for a conference. ("Vague reasons" is irony.)

 

[whopper]

There's a theory that multiple sclerosis may be caused by a inflammation set off by a virus evidenced by the fact that it happens more in people of a certain race and less (edit--meant more!) the further away they are from the equator.

This could be the case with FM. Like I said, all my patients with it or chronic fatigue syndrome all have had strange immunological issues. When I saw my 4th one straight, I started asking every single one--"Did you every have a problem with your immune system or have Epstein Barr Virus?" with the overwhelming majority saying yes. I really think I'm onto something here but I don't see myself doing any research on it in the near future.

I friend of mine has FM, and she was the final straw in my theory...at least for me. We were part of the same D&D group (and oddly enough, she was a D&D player but very very hot!, not too many of those around) andwere hanging out, I asked,, "As a kid did you ever have any immune problems?" She told me she was misdiagnosed as having lupus, turned out she had Epstein Barr Virus, and ever since she had FM and chronic fatigue syndrome.

The bad thing is, and this is another thing that I found with several patients, those with Epstein Barr virus, then later developing chronic fatigue syndrome all have incredibly high sensitivity to side effects from virtually all meds. I've had 4 patients so far that fit this profile and my friend. Whenever any med was tried at anything higher than a miniscule dosage (e.g. Cymbalta at 30 mg) they'd get very bad side effects a feeling of nausea.

My friend ended up joining a message forum with people with similar problems and they all have strange phenomenon going on with them that are all similar but are not printed in the medical journals.

 

[nitemagi]

FM is an interesting entity, and is believed to have an overlap with other similar syndromes like chronic fatigue, epstein-barr and the like. It's controversial as to whether it should be classified as a "somatoform disorder or not"

Quick review--
http://www.ncbi.nlm.nih.gov/pubmed/21878603

This is a large issue as to how to classify somatoform disorders -- typically the old criteria included a requirement of "Not d/t a medical cause," but then all the inflammatory literature seems to legitimize a "medical cause" through some objective measures. This is confounded though by most anxiety and depressive disorders ALSO showing elevated inflammatory markers. Research literature is further troubled by often using the inclusion criteria of MUS (Medically unexplained symptoms) or the diagnosis of "multisomatoform disorder" which involves X # of unexplained sx's. We all know how fallible the unexplained concept is, and how clinically useless that is since physicians are loathe to ever want to be wrong by missing a zebra.

This is what has led to the revision for DSM-5 of creating the CSSD diagnosis. The point being the issue is one of distress out of proportion to cause. Some people weather cancer just fine. Others show up in your office every day needing reassurance. It's the former that would be diagnosed, regardless of presence/absence of a medical condition.

I did a review article last year exploring expanding diagnostic criteria for somatoform disorders and touched on a lot of this. It's complex and needs a lot better research studies that're actually prospective.

 

[InBoston]

FM is an interesting entity, and is believed to have an overlap with other similar syndromes like chronic fatigue, epstein-barr and the like. It's controversial as to whether it should be classified as a "somatoform disorder or not"

Quick review--
http://www.ncbi.nlm.nih.gov/pubmed/21878603

This is a large issue as to how to classify somatoform disorders -- typically the old criteria included a requirement of "Not d/t a medical cause," but then all the inflammatory literature seems to legitimize a "medical cause" through some objective measures. This is confounded though by most anxiety and depressive disorders ALSO showing elevated inflammatory markers. Research literature is further troubled by often using the inclusion criteria of MUS (Medically unexplained symptoms) or the diagnosis of "multisomatoform disorder" which involves X # of unexplained sx's. We all know how fallible the unexplained concept is, and how clinically useless that is since physicians are loathe to ever want to be wrong by missing a zebra.

This is what has led to the revision for DSM-5 of creating the CSSD diagnosis. The point being the issue is one of distress out of proportion to cause. Some people weather cancer just fine. Others show up in your office every day needing reassurance. It's the former that would be diagnosed, regardless of presence/absence of a medical condition.

I did a review article last year exploring expanding diagnostic criteria for somatoform disorders and touched on a lot of this. It's complex and needs a lot better research studies that're actually prospective.

oh come on, it's a bunch of bull****

 

[nitemagi]

oh come on, it's a bunch of bull****

:troll: