Editorial

Fibromyalgia: Beyond the Rhetoric

WARREN R. NIELSON, PhD, CPsych,
Associate Professor of Medicine;

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MANFRED HARTH, MD, FRCPC,
Professor of Medicine,
University of Western Ontario,
London, Ontario, Canada.
Address reprint requests to Dr. W.R. Nielson, Monsignor Roney Building, Room K368, St. Joseph's Health Care London, 268 Grosvenor Street, London, ON N6A 4V2. E-mail: warren.nielson@sjhc.london.on.ca

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Although it is true that fibromyalgia syndrome (FM) has become a political and social issue^1,2, Dr. Wolfe's assumption³ that Drs. White and Thompson⁴ conducted their study to make a "political point" (p. 1672) is both disparaging and incorrect. In our view, it is admirable that these careful researchers have gone beyond the political rhetoric related to FM and conducted a well designed study to test the commonly stated hypothesis that FM is an iatrogenic disorder driven by overly generous compensation and insurance systems^1,2,5. Indeed, the results of the study provide strong evidence against the iatrogenic assumption. In our view, White and Thompson should be given credit for adopting a scientific approach to this question rather than engaging in the type of armchair philosophizing that has become all too common in discussions of FM. The literature is replete with commentaries such as those by Hadler, Ehrlich, and Wolfe; they do nothing to advance our understanding of FM or resolve issues that can, without research, be debated ad nauseam.

FM as a diagnostic entity is not without problems. Other than providing an indication of hyperalgesia, there is probably nothing special about the 18 tender points. As with many other illnesses, such as hypertension, a "cutoff point," although necessarily arbitrary, is needed to differentiate "normal" from "abnormal." Broadening the definition by elimination of the tender points would create an alternative diagnosis that would affect a larger portion of the population and increase the social and economic impact. Whether, in the final analysis, the construct continues to be used should be determined not by polemical editorials about "chronic complainers" who can't get on with their lives¹, but by research. If we are to move towards a better understanding of FM, it will be important to recognize that, at this point, there is abundant evidence that FM is not a purely psychogenic disorder and that there are, in fact, neurophysiological and neuroendocrine abnormalities underlying FM⁶. This does not mean that psychological factors do not play a significant role in FM. Like other chronic pain conditions — from cancers to migraine to low back pain — FM is a complex, biopsychosocial disorder. Psychological and social factors play important roles in pain intensity, pain expression, suffering, and disability. However, there is no evidence that if psychological and social factors could be eliminated from the equation, FM would cease to exist. Chronic widespread pain warrants our clinical and research interest not only because as health care professionals we have an obligation to reduce pain and suffering, but also because persistent pain appears to be associated with other health consequences such as cancer risk and cancer survival⁷.

REFERENCES

Search PubMed for:

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

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

3. Wolfe F. Stop using the American College of Rheumatology criteria in the clinic [editorial]. J Rheumatol 2003;30:1671-2. [MEDLINE]

4. 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. [MEDLINE]

5. Bohr T. Fibromyalgia and myofascial pain syndrome: Do they exist? Neurol Clin 1995;13:365-84. [MEDLINE]

6. Clauw DJ, Crofford LJ. Chronic widespread pain and fibromyalgia: what we know, and what we need to know. Best Prac Res Clin Rheumatol 2003;17:685-701. [MEDLINE]

7. McBeth J, Silman AJ, Macfarlane GJ. Association of widespread body pain with an increased risk of cancer and reduced cancer survival: a prospective, population-based study. Arthritis Rheum 2003;48:1686-92. [MEDLINE]