How to Conceptualize Fibromyalgia

Question:

"I am seeing more and more patients come to my office saying they have fibromyalgia. How should I conceptualize them? Do they have a body disease, or a mind disease?"

Rakesh Jain MD MPH:

The answer to your excellent question is - yes, you guessed it, both! To consider many disorders as Mind-Body Disorders is not just “politically correct,” it is actually scientifically highly accurate to do so, and it also helps shape, for the better, our therapeutic offerings.

Mind-Body Disorders have been the focus of our work for many years, and the four of us—Drs. Draud, Maletic, Raison, and myself—who participate in this Community Forum on a rotating basis have been deeply and positively affected by this changing paradigm. We have become firmly convinced, based on both our experiences and the huge amount of literature out there, that this Mind-Body approach is both accurate and highly therapeutically beneficial to our patients. Nothing exemplifies this crucial point better than the example of fibromyalgia.

Fibromyalgia is a disorder that until recently was described as a disorder with widespread, unexplained pain only, and therefore thought only to be a “body” disorder. You can easily see why this mistake was made, right? The thinking was, “The patient’s body hurts – well then, of course it's a body disorder! Why drag the poor innocent brain and mind into it?”

This mistake was so widespread that the 1990 American College of Rheumatology criteria for fibromyalgia did indeed entirely focus on the body and its pain. ¹ And that’s it. It completely ignored several facts, including the shockingly high rates of depression, anxiety, insomnia, obesity, and cognitive difficulties that these unfortunate patients suffered right alongside the pain. ^2-7 The simplistic explanation was, “They have all these problems, wouldn’t you too be depressed, anxious, etc if you had chronic pain?”

Well, the only problem with this simplistic explanation is that it’s not accurate. Don’t you hate it when hard data and cold facts kill all of our previous theories?! Multiple epidemiological studies show that poor physical health, anxiety, depression, and insomnia can actually precede the development of fibromyalgia. ^8-12 This, along with recent neurobiological findings (we will discuss these shortly) then forces you and me to confront a more complex, but ultimately more integrative view of fibromyalgia – that it is actually a true Mind-Body Disorder.

The evidence to support this new Mind-Body paradigm is so striking that the American College of Rheumatology’s proposed revised criteria for fibromyalgia actually now incorporates “mind” symptoms such as depression and unrefreshing sleep into the diagnostic criteria. Such true progress in a relatively short time is to be celebrated by clinicians all over! ^2,13,14 True progress in conceptualizing this disorder as a Mind-Body Disorder has been made.

At this point, I sincerely hope I have whetted your appetite to examine some seriously impressive research studies. I will say, and stand by it too, that the evidence for Mind-Body disruption in fibromyalgia is so strong that no other explanation for this disorder will work. For example, we know that even though it is body pain these patients report, the clearest evidence for malfunction appears to be at the level of the dorsal column of the spinal cord. ^15,16 Here, evidence points to poor pain modulation being a key disruption, thereby leading to the excessive pain perception. ^17,18 But the story does not end here. We also have striking evidence pointing to cerebral cortex disruption (both anatomic and functional) in fibromyalgia afflicted patients, with high quality evidence from volumetric MRIs and functional MRIs all suggesting one thing: the pathology is as much in the brain as it is in the body. ^19-21

Let’s look at the smoking gun evidence that now implicates and explains the enormously high psychiatric burden these patients endure. The brain areas I discussed above (anterior cingulate cortex, medical prefrontal cortex, to name just a few) are also involved with stress, mood, anxiety, and sleep regulation. Now you can see why we conceptualize many disorders, including fibromyalgia, as Mind-Body Disorders. ¹⁹

What clinical implications arise from this emerging Mind-Body view? This question deserves attention from us as well. Let’s first examine the errors that have been made because we initially did not use a Mind-Body approach with fibromyalgia. By solely focusing on pain alone, we used to treat this condition solely with analgesics, and that led to suboptimum outcomes. Now that the field utilizes a Mind-Body treatment approach, things are improving. We now have 3 FDA-approved medications (pregabalin, ²² duloxetine, ²³ and milnacipran ²⁴ ) that have the ability to modulate neurotransmitters in both the spinal column and the brain. We also have integrated non-pharmacological treatment modalities (such as yoga, physical exercise, cognitive-behavioral therapies) that are all genuinely Mind-Body in their approach to helping the patient. ^25-32 This progress has come about truly as a result of the emergence of the Mind-Body approach to understanding and treating the condition. ( By the way, using this Mind-Body paradigm in explaining disorders to patients and their families has been a very successful psycho-educational technique in my practice. )

I suspect this change to the Mind-Body paradigm will become standard for more and more disorders with the passage of time. I truly believe that we, the forward-looking clinicians, should rush to embrace this model as it appears to offer both the best explanation, as well as the best outcomes for our patients.

—Rakesh Jain, MD, MPH

References

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