Title


CME Background Information


Part 1: Fibromyalgia and Comorbid Disorders

Nature of Fibromyalgia

Fibromyalgia and Psychiatric Comorbidity

Role of Psychiatrists in Treating Fibromyalgia

Abbreviations

Part 1 CME Posttest


Part 2: Diagnosis and Evaluation of Fibromyalgia

Initial Evaluation

Psychiatric Evaluation

Other Evaluative Testing

Conclusion

Abbreviations

Part 2 CME Posttest

Narrator: Fibromyalgia is a common syndrome that causes considerable pain and impairment. It is strongly associated with other pain syndromes and psychiatric disorders. A group of experts gathered to discuss the evaluation and diagnosis of fibromyalgia and its comorbid disorders.

Narrator: The faculty first talked about the key symptoms of fibromyalgia, including widespread pain over the whole body, pain at specific tender points on the body, fatigue, cognitive problems, sleep disturbances, mood disturbances, reduced quality of life, and impaired functioning.

  1. Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 1990;33:160–172
  2. Mease PJ, Clauw DJ, Arnold LM, et al. Fibromyalgia syndrome. J Rheumatol 2005;32:2270–2277

Narrator: Next, the faculty addressed the abnormal sensory processing mechanism behind fibromyalgia and its comorbid pain disorders.
Goldenberg: Dan, let me ask you to take the lead on discussing central sensitization and your current thoughts on fibromyalgia and the spectrum of illnesses in that regard.
Clauw: There are a lot of data both in fibromyalgia as well as in allied conditions that suggest that one of the primary abnormalities in this entire spectrum of illness is a problem with pain processing or sensory processing. Central sensitization might be one of many ways that people can have this sort of amplified pain processing or amplified sensory processing. Also, the treatments that work in all of these illnesses are treatments that we would expect would work in a setting of central augmentation.

  1. Carli G, Suman AL, Biasi G, et al. Reactivity to superficial and deep stimuli in patients with chronic musculoskeletal pain. Pain 2002;100:259–269

Goldenberg: This is a good lead-in to questions about comorbid disorders and the spectrum of these chronic illnesses. Larry, let me ask you how these common illnesses overlap.
Bradley: There is a good deal of data indicating tremendous overlap among the various kinds of chronic pain syndromes, such as irritable bowel syndrome, temporomandibular disorder, fibromyalgia, chronic fatigue syndrome, and others, and there is a large prevalence of major depressive disorders.

  1. Aaron LA, Buchwald D. Chronic diffuse musculoskeletal pain, fibromyalgia and co-morbid unexplained clinical conditions. Best Pract Res Clin Rheumatol 2003;17:563–574
  2. Hudson JI, Hudson MS, Pliner LF, et al. Fibromyalgia and major affective disorder: a controlled phenomenology and family history study. Am J Psychiatry 1985;142:441–446
  3. Walker EA, Keegan D, Gardner G, et al. Psychosocial factors in fibromyalgia compared with rheumatoid arthritis, 1: psychiatric diagnoses and functional disability. Psychsom Med 1997;59:565–571
  4. Arnold LM, Hudson JI, Keck PE Jr, et al. Comorbidity of fibromyalgia and psychiatric disorders. J Clin Psychiatry 2006;67:1219–1225

Arnold: If you look at the studies of patients who are identified with fibromyalgia, depressive and anxiety symptoms were common, as was a current and past depression, a history of treatment for depression, and a history of depression in the family.

  1. Hudson JI, Hudson MS, Pliner LF, et al. Fibromyalgia and major affective disorder: a controlled phenomenology and family history study. Am J Psychiatry 1985;142:441–446
  2. Walker EA, Keegan D, Gardner G, et al. Psychosocial factors in fibromyalgia compared with rheumatoid arthritis, 1: psychiatric diagnoses and functional disability. Psychsom Med 1997;59:565–571
  3. Arnold LM, Hudson JI, Keck PE Jr, et al. Comorbidity of fibromyalgia and psychiatric disorders. J Clin Psychiatry 2006;67:1219–1225

Arnold: I think that mental health professionals have an important role to play in the management of patients with fibromyalgia, and I say that for several reasons, with the first being that psychiatrists can be involved in the management of comorbid mood and anxiety disorders.

Arnold: Also, psychiatrists are very familiar with the kinds of treatments that are now being recommended for the treatment of fibromyalgia, including medications like antidepressants and anticonvulsants. Additionally, psychiatrists and psychologists are familiar with many of the types of therapies that are recommended for the management of pain associated with fibromyalgia and other symptoms, including therapies like cognitive-behavioral therapy.
Bradley: I think there are a lot of opportunities for psychiatrists and psychologists who are examining the same sorts of treatment questions that we are examining in fibromyalgia to share knowledge and share techniques and produce better and more cost-effective treatments for fibromyalgia patients in the future.

Goldenberg: Why wouldn’t psychiatrists be the lead physicians in the care of people with fibromyalgia?
Arnold: In order for psychiatrists to be more involved, they need to be better educated about fibromyalgia and the treatment options that people have. Whether or not a patient with fibromyalgia would go to a psychiatrist first—I don’t know if that is going to occur any time soon. It may be best for patients to be seen by primary care physicians, but I think the psychiatrist or the mental health professional should be a very important collaborator.
Clauw: I find that patients are quite resistant to being sent to psychiatrists because that implies that this is a psychiatric rather than a physical disorder. Because this is such a common condition, it would be better for us to focus on this primarily being managed by primary care physicians and then secondarily being co-managed by other people, including psychiatrists.

  1. Goldenberg DL. Office management of fibromyalgia. Rheum Dis Clin North Am 2002;28:437–446, xi

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Abbreviations

ACR = American College of Rheumatology

CBT = cognitive-behavioral therapy

GAD = generalized anxiety disorder

MDD = major depressive disorder

NA = not assessed

OCD = obsessive-compulsive disorder

PTSD = posttraumatic stress disorder