 |
|
|
 |
Editorial
Pain Is Real; Fibromyalgia Isn't
GEORGE E. EHRLICH, MD, MACR,
and Adjunct Professor of Clinical Medicine, New York University, 241 South Sixth Street, #1101, Philadelphia, Pennsylvania 19106-3731, USA
Address reprint requests to Dr. Ehrlich. E-mail: g2e@mindspring.com When one has tuberculosis, one has tuberculosis, whether or not it is diagnosed. The same is true for cancer, rheumatoid arthritis, hookworm infestation -- really, of the gamut of diseases. But not for fibromyalgia (FM). No one has FM until it is diagnosed. Chronic pain? Surely. The proportion of people who have chronic pain tends to be similar in all climes and cultures. But chronic pain isn't FM. The London, Canada, group has found a proportion of Amish who have chronic pain1. They were never diagnosed as having FM until these investigators labeled them. In the context of the Amish culture, the diagnosis is meaningless. Even when psychological factors, social and vocational dissatisfaction, and urban stresses are taken into account, chronic pain remains chronic pain, without physical or organic signs or specific laboratory or imaging abnormalities. Until a doctor diagnoses FM. Then support and advocacy groups aggravate the problem, disability is certified, a hopeless prognosis is offered; and in sophisticated societies, some antecedent event is blamed and the tort lawyers and their experts for hire spring into action. Thus have we turned a common symptom into a remunerative industry. Everybody has pain sometimes, and even chronic pain during a lifetime. In Western cities, FM tends to be diagnosed when no other reason is found for the pain. The same pains in rural areas or developing countries go unmarked, and people get on with their lives. But not in Europe or North America. The illogic of the "I am the evidence" cry suggests innumeracy and an ignorance of science and logic. The Austrian sociologist Ferdinand Toennies in another context identified 2 major social distinctions: Gemeinschaft, or community, for the nonurban population, and Gesellschaft, or society, for those in urban environments2. These distinctions apply well to the FM conundrum. In rural areas, chronic complainers aren't well tolerated. In cities, one can round a corner and become anonymous. Chronic pain becomes involved in a lifestyle mix, and all manner of associated symptoms or nonsymptoms become prominent when the individual focuses on herself and her discomfort (and it is mostly women who fall into this category). There are no objective findings and not even one acceptable definition. If one consults the Wallaces' book3, written for the public, anything goes. The 1990 classification criteria were meant for grouping cases for reporting purposes4. Unfortunately, the FM proponents have often used these as diagnostic criteria, and then added other irrelevant common manifestations, mostly self-reported and unverifiable. They have also reported purported laboratory or other data that are neither specific nor sensitive and are shared with other chronic pain sufferers not diagnosed as having FM, and even pain-free individuals. Journals, books, and audiovisual materials proliferate, and even some of our authoritative textbooks and seminars attempt to legitimize this untenable diagnosis. In this instance, giving a name to the pains has spawned the very symptom amplification and imitative behavior the rheumatologic profession should be combating. This is not a semantic quarrel. The sooner we abandon the diagnosis, fibromyalgia, disband the patient advocacy organizations, and stop the irresponsible publications, the better we serve the public. Is it any wonder that most treatments, at least the drugs and the obscene neurosurgical interventions, don't really work? One cannot really treat non-diseases. Sympathetic listening, physical activity, maybe cognitive therapy can help, but there are no statistically significant studies to confirm this (although clinical impressions generally agree that these help). Without the dollar poultice, would these patients be separated from the rest of humanity and threaten to bankrupt disability compensation systems in the Western world? Some have argued that other syndromes besides FM exist without verifiable physical features5. Included in that list are migraine headache and dyslexia, among others. But, pace Crofford and Clauw, these are well defined conditions with exacting criteria, which FM (and the closely related chronic fatigue syndrome) lacks. Sensible antagonism to FM and its cognates now graces several books6-10 and innumerable papers and editorials (too many to be cited here, but referenced in11). Eschew the diagnosis and help us prevent "turn[ing] diseases into commodities" or turning common chronic pain in people getting on with their lives into diseases and syndromes. FM is an iatrogenic syndrome because it has to be named by a doctor to exist. More's the pity that 10 years after Sidney Block's wise essay, this lesson has not yet been learned12. 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. Toennies F. Community and civil society. [Translated by M. Hollis] Gemeinschaft und Gesellschaft; 1887. Cambridge: Cambridge University Press; 2001. 3. Wallace DJ, Wallace JB. All about fibromyalgia. A guide for patients and their families. Oxford, UK: Oxford University Press; 2002. 4. 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;33:160-72. [MEDLINE] 5. Ehrlich GE. Fibromyalgia is not a diagnosis; comment on the editorial by Crofford and Clauw [letter]. Crofford LJ, Clauw DJ. Reply. Arthritis Rheum 2003;48:277. [MEDLINE] 6. Showalter E. Hystories. Hysterical epidemics and modern media. New York: Columbia University Press; 1997. 7. Wessely S, Hotopf M, Sharpe M. Chronic fatigue and its syndromes. Oxford, UK: Oxford University Press; 1998. 8. Ferrari R. The whiplash encyclopedia. The facts and myths of whiplash. Gaithersburg, MD: Aspen Publishers; 1999. 9. Hadler NM. Occupational musculoskeletal disorders. 2nd ed. Philadelphia: Lippincott Williams and Wilkins; 1999. 10. Malleson A. Whiplash and other useful illnesses. Montreal: McGill-Queens University Press; 2002. 11. Ehrlich GE. Fibromyalgia: a virtual disease. Clin Rheum 2003;22:8-11. [MEDLINE] 12. Block S. Fibromyalgia and the rheumatisms. Common sense and sensibility. Rheum Dis Clin North Am 1993;19:61-78.[MEDLINE] |
