Download PDF View Table of Contents

Fibromyalgia — Real or Imagined?

DUNCAN A. GORDON, MD,
Editor,
The Journal of Rheumatology

Address reprint requests to The Journal.

---

In this issue of The Journal we highlight 3 different editorial views of fibromyalgia (FM) based on the results of a study in an Amish community in rural Southwestern Ontario¹. The study was inspired by the possibility that FM could be symptomatic of a breakdown in societal values expressed by patients seeking disability compensation benefits².

Dr. Ehrlich, in his editorial, expresses the view that patients with chronic widespread musculoskeletal pain who encounter a rheumatologist and are labeled with the diagnosis of FM are poorly served³. In his opinion they become candidates for victimization by the "remunerative industry" of advocacy and medicolegal groups eager to certify them with "a hopeless prognosis." As such, he sees FM as an untenable diagnosis because "no one has FM until it is diagnosed." He calls for abandonment of the concept of FM because for patients, "pain may be real, but FM isn't."

In Dr. Hadler's view, persons who "have exhausted their wherewithal to cope" and enter the medical stream may become victims of the iatrogenic medical construct of FM⁴. The ineffective "circular treatment acts" that they subsequently receive only reinforce illness behaviors. For this reason, he too would dismantle the construct of FM and focus instead on the mind-body psychosocial confounders of this unexplained condition.

In recent years I have also observed that many physicians express frustration directed not only at the FM construct, but also at the patient. This hostility seems related to the fact that patients with FM display very much more psychological distress than other patients. All this is further compounded by the lack of effective treatment for it and the fact that many patients have a record of adversarial interactions within the healthcare system⁵. It is not so surprising that some rheumatologists will not see patients that are referred to them for FM and others will only see the patient for a one-time assessment to exclude other conditions, but not provide ongoing care⁶.

In his editorial, Dr. Wolfe examines why the American College of Rheumatology (ACR) criteria for the classification of FM have not met expectations⁷. For some, they only seemed to have served as a flashpoint to ignite and inflame controversy. In his analysis, Wolfe sees tender points as a distraction from the central psychosocial symptoms of patient distress. He worries that the ACR classification criteria are based on such an extreme degree of severity that they imply disability⁸. Moreover, in a comparison of patients with rheumatoid arthritis and FM he shows a bimodal distribution of FM features, in keeping with the view that FM-like illness can be identified in both conditions without a requirement for tender points. Thus, Wolfe presents original data to support his contention that ACR criteria should not be used in the clinic or in medical reports.

Finally, no matter where we put FM in our diagnostic lexicon, rheumatologists who care for patients continue to see chronic musculoskeletal pain unexplained by an identifiable organic disease⁴. If what some of us call FM is ever to be better managed, more research is required to identify the many factors that seem to cause and perpetuate this vexing medical problem^5,9.

REFERENCES

Search PubMed for:

1. White KP, Thompson J. Fibromyalgia syndrome in an Amish community: a controlled study to determine disease and symptom prevalence. J Rheumatol 2003;30:1835-40.

2. Shorter E. From paralysis to fatigue; a history of psychosomatic illness in the modern era. New York: The Free Press; 1992.

3. Ehrlich GE. Pain is real; fibromyalgia isn't [editorial]. J Rheumatol 2003;30:1666-7.

4. Hadler NM. "Fibromyalgia" and the medicalization of misery [editorial]. J Rheumatol 2003;30:1668-70.

5. Crofford LJ, Clauw DJ. Fibromyalgia; where are we a decade after the American College of Rheumatology classification criteria were developed? Arthritis Rheum 2002;46:1136-8. [MEDLINE]

6. Kraag G. Fibromyalgia. In: Mosher D, Stein H, Kraag G, editors. Living well with arthritis. Toronto: Viking Press; 2002:55-64.

7. Wolfe F. Stop using the ACR criteria in the clinic [editorial]. J Rheumatol 2003; 30:1671-2.

8. Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Arthritis Rheum 1990;33:160-72. [MEDLINE]

9. Gordon DA. Fibromyalgia — out of control? [comment]. J Rheumatol 1997;24:1247. [MEDLINE]