Friday, September 4, 2015

Is Fibromyalgia a Psychosomatic Illness? Med Student Asks Celeste Cooper

I received a request from a medical student taking an abnormal psychology class. He wanted to know if I thought fibromyalgia was a psychosomatic disorder.

The Psychology Dictionary defines psychosomatic disorder as:
Psychosomatic disorders are those in which psychological factors play a major role in the origin or course of the disorder.

Following is my response

[Medical student,]

You are offering others a great opportunity to learn by writing on this topic. I hope to give you the information you need [regarding whether fibromyalgia is a psychosomatic illness or not]… I will answer your questions bluntly.

"Fibromyalgia is NOT a psychosomatic illness."

While talk therapy, biofeedback, mindfulness for any chronic illness is important for coping, it will not cure or even eradicate symptoms from a physical underlying disorder. This is also true for fibromyalgia. There are many people, including myself, who have been through extensive therapy with the hopes that we could find something to help our pain. My co-author began as my therapist. He assured me that I do not have a psychosomatic illness, and encouraged me to validate that with a psychiatrist, which I did, and it was found that I do not. 

The Right Diagnostic Criteria is Critical to Understanding Fibromyalgia

Unfortunately, Dr. Frederick Wolfe has done a great deal of damage to the fibromyalgia patient. He has touted his criteria for diagnosing FM as the American College of Rheumatology criteria. I wrote to the ACR on this and they tell me they have NOT endorsed Dr. Wolfe’s or anyone else’s criteria. See my blog, [The ACR Responds to My Inquiry on the Fibromyalgia DiagnosticCriteria—Should I Scream or Cry?]  It is my understanding that the ACR is publishing an erratum on this matter in an issue of Arthritis Care and Research.

Dr. Wolfe resurrected the antiquated notion that fibromyalgia is a psychosomatic illness with his research on prevalence offibromyalgia in the German community (Wolfe, et. al., 2013).  What you don’t know is that he took a validated tool for assessing severity of somatic symptoms, the PHQ-15 (Kroenke, et. al., 2002) and tweaked it.

Dr. Wolfe’s “short form,” called the PHQ-8, regarded:

  1. stomach or problems going to the toilet
  2. pain in the back
  3. pain in the arms, legs, or joints
  4. headaches
  5. chest pain or getting out of breath
  6. dizziness
  7. feeling tired or having low energy
  8. trouble sleeping

First, why are stomach problems and problems going to the toilet lumped together? The PH-15 divides these somatic symptoms between 1) stomach pain 2) constipation, loose bowels or diarrhea and 3) nausea, gas, or indigestion. Secondly, is it 4) chest pain, or 4a) shortness of breath? These are divided in the PHQ-15. Where is the assessment for 5) fainting and 6) feeling your heart race? Patients with fibromyalgia do have 7) pain with intercourse, particularly if they have comorbid chronic pelvic pain. This “short form” could affect the outcome regarding severity of symptoms when compared to the validated PHQ-15 tool. Isn’t it possible that the validated tool is validated because of the way the questions are asked?

He even says, “The PHQ-15 is best characterized as a measure of somatic symptom severity.” So why didn’t he use it? That is the $100,000 question. Why did this escape a peer reviewed journal editor? 

The Role of Fibromyalgia Diagnostic Criteria

Roland Staud, MD et. al. (University of Florida, Gainesville, 2010) had this to say, in part, about the provisional diagnostic criteria which was later modified, but they bring up some good points to help with your questions.

“...After a series of analyses, Wolfe et al concluded that a widespread pain index was the best predictor of FM. When this index was excluded from the analysis, key predictors of FM were nonrefreshing sleep, fatigue, cognitive difficulties, and a host of somatic symptoms... there is a glaring omission of well-known mechanistic FM features, such as hyperalgesia, central sensitization, or dysfunctional pain modulation...Also, the somatic symptom list is extremely broad somatic symptoms, and the symptoms are ordered by neither relevance nor predictive value, etc., supposedly contributing equally to FM. In conclusion, whether or not these new criteria are easy to apply by practicing physicians will require empirical testing. Unfortunately, the new criteria are imprecise, ill-defined, lack mechanistic features, and are completely symptom focused…”

This has been my opinion as well. To simply list somatic complaints without further investigation is cause for alarm. The ACR suggests comorbid conditions, tension headache or migraine, digestive problems (i.e. irritable bowel syndrome, gastric reflux) irritable or overactive bladder, pelvic pain, and temporomandibular disorder, causing face or jaw pain, jaw clicking and ringing in the ears. And, they recognize depression or anxiety as a disorder that can accompany fibromyalgia, which can accompany any chronic illness. (Accessed 6-26-2015).  Other things may explain the somatic complaints, such as hypothyroidism, cancer, and much more.

Dr. Katsuhiro Toda (Japan) wrote a letter to the editor or Arthritis Care and Research on the provisional criteria, (Wolfe, 2010) which you can access here. And,  he wrote a letter  tothe editor of the Journal of Rheumatology, The Modification of the American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia Should Be Supplemented and Revised (Wolfe, 2011) of interest. “…In Japan, many physicians have ignored fibromyalgia. Therefore, patients with fibromyalgia are often diagnosed with psychogenic pain or somatoform disorder…”  

You might also be interested in seeing this editorial in the journal “Rheumatology.”  and Dr. Smythe’s article, which also outlines the lack of specificity in the Wolfe criteria.

Dr. Robert Bennett has contributed over 500 papers on fibromyalgia, he is considered an expert, and he led the research for theAlternative Diagnostic Criteria (Bennett, et al., 2014). You can read my blog regarding the criteria, and on my website.

I encourage you to visit my blog, look in the archives and you will see that I have written on MANY topics regarding fibromyalgia.   

Be sure to search PubMed. Connect the dots by searching fibromyalgia along with any one of the comorbid disorders. For instance, a study just published on fibromyalgia and migraine. You will find there has been more than one connection made between fibromyalgia and small fiber neuropathy and fibromyalgia too.

I have found that when one person has a question, someone else will too. Therefore, I will be sharing this information on my blog.

I am attaching a resource list for you and I will include reference to some recent studies that might help you. Good luck and please keep me updated. I would love to see what you come up with for your class.

Best regards, Celeste Cooper


Bennett R, Friend R, Marcus D, Bernstein C, Han BK, Yachoui R, Deodar A, Kaell A, Bonafede P, Chino A, Jones K. Criteria for the diagnosis of fibromyalgia: Validation of the modified 2010 preliminary ACR criteria and the development of alternative criteria. Arthritis Care Res (Hoboken). 2014 Feb 4. doi: 10.1002/acr.22301. [Epub ahead of print]

Kroenke K1, Spitzer RL, Williams JB. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med. 2002 Mar-Apr;64(2):258-66.

J Rheumatol. 2011 Jun;38(6):975-8. doi: 10.3899/jrheum.110142.

Staud R, Price DD, Robinson ME. The provisional diagnostic criteria for fibromyalgia: one step forward, two steps back: comment on the article by Wolfe et al. Arthritis Care Res (Hoboken). 2010 Nov;62(11):1675-6; author reply 1676-8. doi: 10.1002/acr.20290.

Toda K. Preliminary diagnostic criteria for fibromyalgiashould be partially revised: comment on the article by Wolfe et al. Arthritis Care Res (Hoboken). 2011 Feb;63(2):308-9; author reply 309-10. doi: 10.1002/acr.20358.  

Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Katz RS, Mease P, Russell AS, Russell IJ, Winfield JB, Yunus MB. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken). 2010 May;62(5):600-10. doi: 10.1002/acr.20140.

Wolfe F1, Clauw DJ, Fitzcharles MA, Goldenberg DL, Häuser W, Katz RS, Mease P, Russell AS, Russell IJ, Winfield JB. Fibromyalgia criteria and severity scales for clinical and epidemiological studies: a modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. J Rheumatol. 2011 Jun;38(6):1113-22. doi: 10.3899/jrheum.100594. Epub 2011 Feb 1.

Wolfe F1, Brähler E, Hinz A, Häuser W. Fibromyalgia prevalence, somatic symptom reporting, and the dimensionality of polysymptomatic distress: results from a survey of the general population. Arthritis Care Res (Hoboken). 2013 May;65(5):777-85. doi: 10.1002/acr.21931.


Antonio R Zamunér MSc, PT*, Meire Forti PT, Carolina P Andrade PT, Mariana Arias Avila PhD, PT andEster da Silva PhD, PT RespiratorySinus Arrhythmia and its Association with Pain in Women with FibromyalgiaSyndrome. Article first published online: 1 JUN 2015 DOI: 10.1111/papr.12321

Caro XJ, Winter EF. Evidence of abnormal epidermal nerve fiber density in fibromyalgia: Clinical and immunologic implications. Arthritis Rheumatol. 2014 Apr 9. doi: 10.1002/art.38662. [Epub ahead of print]

Flodin P1, Martinsen S, Löfgren M, Bileviciute-Ljungar I, Kosek E, Fransson P.
Fibromyalgia Is Associated with Decreased Connectivity Between Pain- and Sensorimotor Brain Areas. Brain Connect. 2014 Aug 7. [Epub ahead of print]

García JJ1, Cidoncha A2, Bote ME3, Hinchado MD3, Ortega E3. Altered profile of chemokines in fibromyalgia patients. Ann Clin Biochem. 2014 Sep;51(Pt 5):576-81. doi: 10.1177/0004563213506413. Epub 2013 Oct 8.

Giannoccaro MP, Donadio V, Incensi A, Avoni P, Liguori R. Small nerve fiber involvement in patients referred for fibromyalgia.  Muscle Nerve. 2014 May;49(5):757-9. doi: 10.1002/mus.24156. Epub 2014 Jan 28. 

Garcia JJ, Ortega E. Soluble fractalkine in the plasma of fibromyalgia patients.
An Acad Bras Cienc. 2014 Dec 9;0:0. [Epub ahead of print]

Inal S1, Inal EE, Okyay GU, Oztürk GT, Oneç K, Güz G. Fibromyalgia and nondipper circadian blood pressure variability. J Clin Rheumatol. 2014 Dec;20(8):422-6. doi: 10.1097/RHU.0000000000000189.

Jones GT1, Atzeni F, Beasley M, Flüß E, Sarzi-Puttini P, Macfarlane GJ. The prevalence of fibromyalgia in the general population - a comparison of the American College of Rheumatology 1990, 2010 and modified 2010 classification criteria. Arthritis Rheumatol. 2014 Oct 16. [Epub ahead of print]

Kosek E1, Altawil R2, Kadetoff D3, Finn A4, Westman M2, Le Maître E2, Andersson M5, Jensen-Urstad M6, Lampa J2. Evidence of different mediators of central inflammation in dysfunctional and inflammatory pain--interleukin-8 infibromyalgia and interleukin-1 β in rheumatoid arthritis. J Neuroimmunol. 2015 Mar 15;280:49-55. doi: 10.1016/j.jneuroim.2015.02.002. Epub 2015 Feb 19.

Kosmidis ML1, Koutsogeorgopoulou L1, Alexopoulos H1, Mamali I1, Vlachoyiannopoulos PG1, Voulgarelis M1, Moutsopoulos HM1, Tzioufas AG1, Dalakas MC2. Reduction of Intraepidermal Nerve Fiber Density (IENFD) in the skin biopsies of patients with fibromyalgia: A controlled study. J Neurol Sci. 2014 Sep 28. pii: S0022-510X(14)00633-9. doi: 10.1016/j.jns.2014.09.035. [Epub ahead of print]

Light AR, Bateman L, Jo D, Hughen RW, Vanhaitsma TA, White AT, Light KC. Gene expression alterations at baseline and following moderate exercise in patients with Chronic Fatigue Syndrome and Fibromyalgia Syndrome. J Intern Med. 2011 May 26. doi: 10.1111/j.1365-2796.2011.02405.x. [Epub ahead of print]

Napadow V1, Harris RE.What has functional connectivity and chemical neuroimaging in fibromyalgia taught us about the mechanismsand management of 'centralized' pain? Arthritis Res Ther. 2014;16(5):425.

Oaklander AL, Herzog ZD, Downs H, Klein MM. Objective evidence that small-fiber polyneuropathy underlies some illnesses currently labeled as fibromyalgia. Pain. 2013 Jun 5. pii: S0304-3959(13)00294-7. doi: 10.1016/j.pain.2013.06.001. [Epub ahead of print]

Olivan-Blázquez B1, Herrera-Mercadal P2, Puebla-Guedea M2, Pérez-Yus MC2, Andrés E3, Fayed N4, Hoyo YL5, Magallon R6, Roca M7, Garcia-Campayo J8. Efficacy of memantine in the treatment of fibromyalgia: a double-blind randomised controlled trial with 6-month follow-up. Pain. 2014 Sep 10. pii: S0304-3959(14)00424-2. doi: 10.1016/j.pain.2014.09.004. [Epub ahead of print]

Riva R1, Mork PJ, Westgaard RH, Okkenhaug Johansen T, Lundberg U.Catecholamines and heart rate in female fibromyalgia patients. .J Psychosom Res. 2012 Jan;72(1):51-7. doi: 10.1016/j.jpsychores.2011.09.010. Epub 2011 Oct 24.

Shmygalev S, Dagtekin O, Gerbershagen HJ, Marcus H, Jübner M, Sabatowski R, Petzke F. Assessing Cognitive and Psychomotor Performance in Patients with Fibromyalgia Syndrome. Pain Ther. 2014 Oct 25. [Epub ahead of print]

Sugimoto C1, Konno T2, Wakao R3, Fujita H1, Fujita H1, Wakao H1. Mucosal-associated invariant T cell is a potential marker to distinguish fibromyalgia syndrome from arthritis.
PLoS One. 2015 Apr 8;10(4):e0121124. doi: 10.1371/journal.pone.0121124. eCollection 2015.

Tsai PS1, Fan YC, Huang CJ. Fibromyalgia Is Associated With Coronary Heart Disease: A Population-Based Cohort Study. Reg Anesth Pain Med. 2014 Nov 26. [Epub ahead of print]

Nurcan Üçeyler, Susanne Kewenig, Waldemar Kafke, Sarah Kittel-Schneider and Claudia Sommer. Skin cytokine expression in patients with fibromyalgia syndrome is not different from controls. BMC Neurology 2014, 14:185  doi:10.1186/s12883-014-0185-0

Veldhuijzen DS, Sondaal SF, Oosterman JM. Intact cognitive inhibition in patients with fibromyalgia but evidence of declined processing speed.J Pain. 2012 May;13(5):507-15. doi: 10.1016/j.jpain.2012.02.011.

Vij B1, Whipple MO2, Tepper SJ1, Mohabbat AB2, Stillman M1, Vincent A2. Frequency of Migraine Headaches in Patients With Fibromyalgia. Headache. 2015 May 21. doi: 10.1111/head.12590. [Epub ahead of print]

Wallace DJ1, Gavin IM, Karpenko O, Barkhordar F, Gillis BS. Cytokine and chemokine profiles in fibromyalgia, rheumatoid arthritis andsystemic lupus erythematosus: a potentially useful tool in differentialdiagnosis. Rheumatol Int. 2014 Nov 7. [Epub ahead of print] 

 ~ • ~ • ~ • ~ • ~ • ~

"Adversity is only an obstacle if we fail to see opportunity."  
Celeste Cooper, RN
Author—Patient—Health Central Chronic Pain ProAdvocate

Learn more about what you can do to help your body function to its potential in the books you can find here on Celeste's  blog

All answers and blogs are based on the author's opinions and writing and are not meant to replace medical advice.  

No comments:

Celeste's Website

Celeste's Website
Click on the picture