| Scientific Evaluation  Patients seek medical care because they are having symptoms. Symptoms are the
patient’s subjective experience of what is going on in the body. A
physician is able to help their patients because they are able to diagnose, or
name the disease, that explains those symptoms. A disease is an objective
pathological mechanism that is occurring in the body. The problem between
physician and patient occurs when the symptoms are not medically explainable.
There are many different syndromes that have been described for which there
seems to be no medical explanation:
Irritable bowel syndrome
Non-ulcer dyspepsia
Chronic pelvic pain
Fibromyalgia
Non-cardiac pain
Chronic fatigue syndrome
Tension headache
Temporomandibular joint dysfunction
Multiple chemical sensitivity
These syndromes describe a constellation of symptoms rather than an objective
disease. When people manifest physical symptoms that cannot be explained, one
possibility is that they are somatisizing. Somatically preoccupied people have
no genuine physical disorder but manifest psychological conflicts through bodily
symptoms. They are not consciously aware of creating physical symptoms, but
rather the physical pain or discomfort they experience is a ‘safe’ way of
communicating their internal problems or conflicts.
 According to Wessely, S et
al, there are several
characteristics that describe functional somatic syndromes:
1. There is overlap in the definition of the different syndromes.
2. Patients with one functional syndrome frequently meet diagnostic
criteria for other syndromes.
3. Patients with different functional syndromes share non-symptom
characteristics, such as similarities in sex, emotional disorders,
physiology, and a history of childhood maltreatment and abuse.
4. The different syndromes respond to the same therapies.
Fibromyalgia is a controversial diagnosis. There are indications that
fibromyalgia is a somatic manifestation of depression or other psychological
distress.
McBeth, J, et al discovered that
tender points, the physical foundation of a diagnosis of fibromyalgia, are
strongly associated with specific components of psychological distress as well
as characteristics of somatization and its antecedents. For this study, they
took subjects who demonstrated psychological distress and found that about
one-third had tender points. Additionally, a high tender point count was
associated with low levels of self care, a greater number of somatic complaints,
high levels of fatigue, and a pattern of illness behavior characterized by
increased medical care usage. They were also more likely to report adverse
childhood experiences. These results were not explained by the presence of
chronic pain.
Wolfe, F also studied tender points and their relationship to
symtpom severity. They found that tender points seem to indicate a low pain
threshold rather than an increase in severe symptoms. Therefore, the number and
severity of the tender points does not seem to correlate with disease. They felt
the use of tender points could be abandoned in assessing a diagnosis of
fibromyalgia.
Ford, CV states
that one variation of somatization can be the "fashionable" diagnosis,
for example fibromyalgia. Fashionable diagnoses represent a collection of
physical diseases, somatization, and anxiety or depression. They allow
psychosocial distress to be comfortably hidden from both the patient and the
physician. These disorders are related to environmental or occupational
syndromes and mass psychogenic illness. He says that they are characterized by:
Vague, subjective multisystem complaints
A lack of objective laboratory findings
Vague, subjective explanations
Overlap from one fashionable diagnosis to another
Symptoms consistent with depression or anxiety or both
Denial of psychosocial distress of attribution of it to the illness
Hausotter, W asserts that since scientific proof of an organic disorder cannot be
established for fibromyalgia, psychological causes should be considered
responsible. He suggests that is would be more useful to use the terms "somatization
disorder" or "pain disorder" to make the approach to early
psychotherapy more accessible and to also prevent the symptoms from becoming
chronic in nature.
Celiker, R et al evaluated the
relationship of fibromyalgia to the intensity of anxiety and depression and to
determine the correlation between psychological disturbances with disease
duration and pain severity. Significant differences between in the psychological
status between patients with fibromyalgia and control subjects were found. As
measured by the Beck depression inventory and trait anxiety inventory, 35.9% of
the patients scored higher than the cut-off score. Pain severity was found to be
correlated with anxiety inventory scores (the anxiety was not secondary to
pain.) These findings suggest that somatic expression of depression and anxiety
is found in fibromyalgia subjects and not in control groups.
Sorensen, J et al analyzed the
different mechanisms of processing pain in fibromyalgia patients by infusing
different analgesic drugs. They used morphine, lidocaine, ketamine, and saline.
They found:
2 patients responded to all infusions, including the placebo
(saline)
3 patients responded to none of the infusions
13 patients responded to one or several of the drugs, but not to
placebo.
Responders scored higher on personality inventory scales for somatic anxiety,
muscular tension, and psychasthenia compared with healthy controls. This seems
to indicate a somatic tendency in some people with fibromyalgia.
Hudson, J.I et al
at McLean hospital studied the relationship between fibromyalgia and depression.
They found that the majority of studies reveal an association between
fibromyalgia and major depressive disorder. They could not say that fibromyalgia
causes depression or vice versa, but it does appear likely that both disorders
share some unknown common etiologic factor.
On the opposite side of the coin, some studies have shown that the
relationship between fibromyalgia and depression is independent.
Okifuji, A
found that all fibromyalgia patients are not depressed. Living status, the
perception of functional limitations, maladaptive thoughts, and physical therapy
treatment identified diagnoses of depression rather than pain severity, number
of tender points, or intensity of tender points. Thus, depression in a patient
with fibromyalgia is independent of symptoms and is better correlated to the
effects of the symptoms on daily life.
Fassbender K;SamborskyW et al
compared the severity of tender point symptoms between patients with
fibromyalgia and major depression. Depressive symptoms were found in both
groups, but the patients with fibromyalgia had an increased sensitivity to
pressure when tender points were palpated.
Bonaccorso S
tried to establish a difference between fibromyalgia and depression by
studying immune markers. Fibromyalgia, unlike major depression, did not seem to
be accompanied by activation of cell-mediated immunity as measured by the
urinary excretion of neopterin. However, other immune markers should be measured
before any definite conclusions can be drawn.
Maes M found an
increased 24-hour urinary cortisol excretion in patients with PTSD and patients
with major depression, but not in patients with fibromyalgia.
Aaron LA compared
the frequency of lifetime psychiatric disorders and psychological distress
among:
- Patients
with fibromyalgia syndrome
- Those
with fibromyalgia (‘nonpatients’) who had not sought medical care
- Healthy
controls
Patients with fibromyalgia syndrome had a significantly
greater number of psychiatric diagnoses compared to nonpatients and healthy
controls. Nonpatients did not differ from controls. It was theorized that
psychiatric disorders are not intrinsically related to fibromyalgia but rather
these diagnoses are more related to their decision to seek medical care. Both
patients and nonpatients exhibited higher psychological distress levels.
However, differences in psychological distress were eliminated after controlling
for pain threshold and fatigue ratings. |
