Uncategorized

Fibromyalgia: Mind-Body Disorder

Fibromyalgia: Mind-Body Disorder

August 11, 2011

Question:”I am seeing more and more patients come to my office saying they have fibromyalgia. How should I conceptualize them? Do they have a body disease, or a mind disease?”

Fibromyalgia: Mind-Body Disorder

August 11, 2011

Question:”I am seeing more and more patients come to my office saying they have fibromyalgia. How should I conceptualize them? Do they have a body disease, or a mind disease?”

Rakesh Jain, MD, MPH:  The answer to your excellent question is – yes, you guessed it, both! To consider many disorders as Mind-Body Disorders is not just “politically correct,” it is actually scientifically highly accurate to do so, and it also helps shape, for the better, our therapeutic offerings.

Mind-Body Disorders have been the focus of our work for many years, and the four of us—Drs. Draud, Maletic, Raison, and myself—who participate in this Community Forum on a rotating basis have been deeply and positively affected by this changing paradigm. We have become firmly convinced, based on both our experiences and the huge amount of literature out there, that this Mind-Body approach is both accurate and highly therapeutically beneficial to our patients. Nothing exemplifies this crucial point better than the example of fibromyalgia.

Fibromyalgia is a disorder that until recently was described as a disorder with widespread, unexplained pain only, and therefore thought only to be a “body” disorder. You can easily see why this mistake was made, right? The thinking was, “The patient’s body hurts – well then, of course it’s a body disorder! Why drag the poor innocent brain and mind into it?”

This mistake was so widespread that the 1990 American College of Rheumatology criteria for fibromyalgia did indeed entirely focus on the body and its pain.1 And that’s it. It completely ignored several facts, including the shockingly high rates of depression, anxiety, insomnia, obesity, and cognitive difficulties that these unfortunate patients suffered right alongside the pain.2-7 The simplistic explanation was, “They have all these problems, wouldn’t you too be depressed, anxious, etc if you had chronic pain?”

Well, the only problem with this simplistic explanation is that it’s not accurate. Don’t you hate it when hard data and cold facts kill all of our previous theories?! Multiple epidemiological studies show that poor physical health, anxiety, depression, and insomnia can actually precede the development of fibromyalgia.8-12 This, along with recent neurobiological findings (we will discuss these shortly) then forces you and me to confront a more complex, but ultimately more integrative view of fibromyalgia – that it is actually a true Mind-Body Disorder.

The evidence to support this new Mind-Body paradigm is so striking that the American College of Rheumatology’s proposed revised criteria for fibromyalgia actually now incorporates “mind” symptoms such as depression and unrefreshing sleep into the diagnostic criteria. Such true progress in a relatively short time is to be celebrated by clinicians all over!2,13,14 True progress in conceptualizing this disorder as a Mind-Body Disorder has been made.

At this point, I sincerely hope I have whetted your appetite to examine some seriously impressive research studies. I will say, and stand by it too, that the evidence for Mind-Body disruption in fibromyalgia is so strong that no other explanation for this disorder will work. For example, we know that even though it is body pain these patients report, the clearest evidence for malfunction appears to be at the level of the dorsal column of the spinal cord.15,16 Here, evidence points to poor pain modulation being a key disruption, thereby leading to the excessive pain perception.17,18 But the story does not end here. We also have striking evidence pointing to cerebral cortex disruption (both anatomic and functional) in fibromyalgia afflicted patients, with high quality evidence from volumetric MRIs and functional MRIs all suggesting one thing: the pathology is as much in the brain as it is in the body.19-21

Let’s look at the smoking gun evidence that now implicates and explains the enormously high psychiatric burden these patients endure. The brain areas I discussed above (anterior cingulate cortex, medical prefrontal cortex, to name just a few) are also involved with stress, mood, anxiety, and sleep regulation. Now you can see why we conceptualize many disorders, including fibromyalgia, as Mind-Body Disorders.19

What clinical implications arise from this emerging Mind-Body view? This question deserves attention from us as well. Let’s first examine the errors that have been made because we initially did not use a Mind-Body approach with fibromyalgia. By solely focusing on pain alone, we used to treat this condition solely with analgesics, and that led to suboptimum outcomes. Now that the field utilizes a Mind-Body treatment approach, things are improving. We now have 3 FDA-approved medications (pregabalin,22 duloxetine,?23 and milnacipran24) that have the ability to modulate neurotransmitters in both the spinal column and the brain. We also have integrated non-pharmacological treatment modalities (such as yoga, physical exercise, cognitive-behavioral therapies) that are all genuinely Mind-Body in their approach to helping the patient.25-32 This progress has come about truly as a result of the emergence of the Mind-Body approach to understanding and treating the condition. (By the way, using this Mind-Body paradigm in explaining disorders to patients and their families has been a very successful psycho-educational technique in my practice.)

I suspect this change to the Mind-Body paradigm will become standard for more and more disorders with the passage of time. I truly believe that we, the forward-looking clinicians, should rush to embrace this model as it appears to offer both the best explanation, as well as the best outcomes for our patients.

—Rakesh Jain, MD, MPH

References

Wolfe F. New American College of Rheumatology criteria for fibromyalgia: a twenty-year journey. Arthritis Care Res. 2010;62(5):583-584.
Wolfe F, Hauser W. Fibromyalgia diagnosis and diagnostic criteria. Ann Med. 2011;[Epub ahead of print].
Aguglia A, Salvi V, Maina G, Rossetto I, Aguglia E. Fibromyalgia syndrome and depressive symptoms: comorbidity and clinical correlates. J Affect Disord. 2011;128(3):262-266.
Sivertsen B, Krokstad S, Overland S, Mykletun A. The epidemiology of insomnia: associations with physical and mental health. The HUNT-2 study. J Psychosom Res. 2009;67(2):109-116.
Lee DM, Pendleton N, Tajar A, et al. Chronic widespread pain is associated with slower cognitive processing speed in middle-aged and older European men. Pain. 2010;151(1):30-36.
Hajj-Ali RA, Wilke WS, Calabrese LH, et al. Pilot study to assess the frequency of fibromyalgia, depression, and sleep disorders in patients with granulomatosis with polyangiitis (Wegener’s). Arthritis Care Res. 2011;63(6):827-833.
Ursini FS, Naty S, Grembiale RD. Fibromyalgia and obesity: the hidden link. Rheumatol Int. 2011;[Epub ahead of print].
Rehm SE, Koroschetz J, Gockel U, et al. A cross-sectional survey of 3035 patients with fibromyalgia: subgroups of patients with typical comorbidities and sensory symptom profiles. Rheumatology. 2010;49(6):1146-1152.
Mease PJ, Arnold LM, Crofford LJ, et al. Identifying the clinical domains of fibromyalgia: contributions from clinician and patient Delphi exercises. Arthritis Rheum. 2008;59(7):952-960.
McBeth J, Jones K. Epidemiology of chronic musculoskeletal pain. Best Pract Res Clin Rheumatol. 2007;21(3):403-425.
Nicholl BI, Macfarlane GJ, Davies KA, et al. Premorbid psychosocial factors are associated with poor health-related quality of life in subjects with new onset of chronic widespread pain – results from the EPIFUND study. Pain. 2009;141(1-2):119-126.
Spaeth M. Epidemiology, costs, and the economic burden of fibromyalgia. Arthritis Res Ther. 2009;11(3):117.
Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res. 2010;62(5):600-610.
Wolfe F, Clauw DJ, Fitzcharles MA, et al. Fibromyalgia criteria and severity scales for clinical and epidemiological studies: a modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. J Rheumatol. 2011;38(6):1113-1122.
Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011;152(3 Suppl):S2-S15.
DeSantana JM, Sluka KA. Central mechanisms in the maintenance of chronic widespread noninflammatory muscle pain. Curr Pain Headache Rep. 2008;12(5):338-343.
Maletic V, Raison CL. Neurobiology of depression, fibromyalgia and neuropathic pain. Front Biosci. 2009;14:5291-5338.
Smith HS, Harris R, Clauw D. Fibromyalgia: an afferent processing disorder leading to a complex pain generalized syndrome. Pain Physician. 2011;14(2):E217-E245.
Robinson ME, Craggs JG, Price DD, Perlstein WM, Staud R. Gray matter volumes of pain-related brain areas are decreased in fibromyalgia syndrome. J Pain. 2011;12(4):436-443.
Petersel DL, Dror V, Cheung R. Central amplification and fibromyalgia: disorder of pain processing. J Neurosci Res. 2011;89(1):29-34.
Jensen KB, Kosek E, Petzke, et al. Evidence of dysfunctional pain inhibition in Fibromyalgia reflected in rACC during provoked pain. Pain. 2009;144(1-2):95-100.
Siler AC, Gardner H, Yanit K, Cushman T, McDonagh M. Systematic review of the comparative effectiveness of antiepileptic drugs for fibromyalgia. J Pain. 2011;12(4):407-415.
Marangell LB, Claud DJ, Choy E, et al. Comparative pain and mood effects in patients with comorbid fibromyalgia and major depressive disorder: secondary analyses of four pooled randomized controlled trials of duloxetine. Pain. 2011;152(1):31-37.
Owen RT. Milnacipran hydrochloride: its efficacy, safety and tolerability profile in fibromyalgia syndrome. Drugs Today. 2008;44(9):653-660.
Schmidt S, Grossman P, Schwarzer B, et al. Treating fibromyalgia with mindfulness-based stress reduction: results from a 3-armed randomized controlled trial. Pain. 2011;152(2):361-369.
Terry R, Perry R, Ernst E. An overview of systematic reviews of complementary and alternative medicine for fibromyalgia. Clin Rheumatol. 2011;[Epub ahead of print].
Rodero B, Casanueva B, Luciano JV, et al. Relationship between behavioural coping strategies and acceptance in patients with fibromyalgia syndrome: Elucidating targets of interventions. BMC Musculoskelet Disord. 2011;12:143.
Ozkurt S, Donmez A, Zeki Karagulle M, et al. Balneotherapy in fibromyalgia: a single blind randomized controlled clinical study. Rheumatol Int. 2011;[Epub ahead of print].
Morris LD, Grimmer-Somers KA, Spottiswoode B, Louw QA. Virtual reality exposure therapy as treatment for pain catastrophizing in fibromyalgia patients: proof-of-concept study (Study Protocol). BMC Musculoskelet Disord. 2011;12(1):85.
Miro E, Lupianez J, Martinez MP, et al. Cognitive-behavioral therapy for insomnia improves attentional function in fibromyalgia syndrome: a pilot, randomized controlled trial. J Health Psychol. 2011;16(5):770-782.
Kesiktas N, Karagulle Z, Erodogan N, et al. The efficacy of balneotherapy and physical modalities on the pulmonary system of patients with fibromyalgia. J Back Musculoskelet Rehabil. 2011;24(1):57-65.
Jones KD. Nordic walking in fibromyalgia: a means of promoting fitness that is easy for busy clinicians to recommend. Arthritis Res Ther. 2011;13(1):103.
 


© 1996 – 2011 CME LLC

 

 

Leave a Reply