Fibromyalgia (FM) is an especially difficult syndrome to evaluate because there is such controversy about what it is. Although the American College of Rheumatology (ACR) criteria for fibromylagia has been generally accepted (see below), it has yet to be recognized as a distinct disease entity by any major medical body. Whether FM is one entity or a syndrome with several different causes has also been debated.

How a physician evaluates FM depends to some extent on what he or she believes FM is. Theories about the etiology of FM include rheumatological explanations involving inflammation, psychophysiological explanations (e.g. muscular bracing or stress related pains), allergic processes, comparisons to somatization (which also tends to have a strong psychophysiological component), genetic predispositions, and central sensitization to pain secondary to depression, trauma, the so-called "substance P" (a chemical affecting pain perception), or something else. Research has found a number of biochemical differences in FM patients, one of which is low levels of serotonin, which would also seem to associate FM with affective/stress factors. A helpful links about FM can be found below.

In general, I try to evaluate both psychological and psychophysiological aspects of FM. I begin by talking to the patient's physician. To the extent that the physician feels that there are medical inconsistencies, overuse of opioids (another controversial issue!) or excessive disability present, I look at psychological factors more closely. However, FM is such a controversial condition that I try to factor in extreme physician attitudes about this.

To evaluate psychophysiological contributions, I do a standardized biofeedback evaluation taking readings on muscle tension, hand temperature, skin resistance, heart rate, heart rate variability, and respiration rate. I track these across alternating stress and rest periods as follows:

1. Baseline relaxed
2. Cognitive challenge (Stroop test)
3. Rest
4. Cognitive challenge (math)
5. Rest
6. Physical challenge (cold pressor)
7. Rest
8. Final Levels

If there are any prominent psychophysiological responses I treat them. If not, I look more at psychological processes.

Psychological assessment for me involves looking at a number of factors. I have used the MMPI 2 a lot in the past and I have seen a lot of FM patients with 1-3 profiles, but that doesn't really help me diagnostically. I suspect that the physical symptoms of FM may inflate these scales, as it is known to do with chronic pain and a variety of other conditions. As the MMPI 2 lacks patient norms, it is hard to know what a high score is here. The MMPI 2 subscales are often more helpful for me clinically, however, and if the validity scales suggest a strong biasing of reports, I think a more conservative course of care is indicated.

I tend to focus on affective distress - both recognized and especially unrecognized depression anxiety and anger. I use the BHI 2 for this as it has scales for all 3, rehab patient norms, separately assesses psychological and physical aspects of affective distress, and has bidirectional scales that looks at both high and low scores. Any high levels of affective distress reported are indications for treatment.

I have found one significant profile on the BHI 2 to be one that includes a Functional Complaints scale that is high (indicating more perceptions of disability than the average patient), a high level of physical symptoms associated with anxiety and depression, but a low level of depressed/anxious/angry affective thoughts and feelings. If a patient perceives his or her physical symptoms as being unusually disabling, yet reports levels of affective distress that are 1-2 standard deviations BELOW what is seen in the average healthy person in the community, this is worth a closer look. It is kind of like a "la belle indifference" syndrome. This could indicate a patient with an unusually severe condition and who is remarkably well adjusted. However, in my experience more likely interpretation is that dissociated/repressed affect or alexithymia may be contributing to the symptom picture. This is more likely to be true if there are issues with compliance or motivation in treatment, a lack of response to any treatment, or if excessive disability is judged to be present by the medical professionals. If have often found these patients to have more unrecognized psych involvement.

With regard to affective distress, the direction of the arrow of causality can be debated. Some feel that depression causes FM, while others feel that FM may lead to depression. Although in particular cases I find myself inclined to lean in one direction or the other, pragmatically it make little difference - the depression needs to be treated.

I also try to evaluate the psychosocial context in which the symptoms occur. I also use the BHI 2 here to assess high levels stress at home or in the workplace that may be exacerbating factors. A really LOW score on Family Dysfunction can indicate a solicitous family, though, and high levels of attention by family have been shown to increase pain perception and reinforce pain reports. High levels of BHI 2 Doctor Dissatisfaction may indicate MDs who are dismissive of the patient's condition, and that might need to be addressed as well. A high score on the Survivor of Violence scale must be explored as well, as FM has been associated by some researchers with trauma.

FM patients are sometimes the recipients of a great deal of passive treatment modalities. Especially when the patient is receiving a lot of hands on treatment (massage, etc) but failing to progress, I explore the possibility that the patient is to some extent using the massage or other treatments as a means to soothe underlying and unexpressed needs for nurturance or dependency. I think of the BHI 2 symptom dependency scale here.

If there is any indication of characterological disturbance, I will also give the patient an MCMI III. I think the MCMI III does the best job of assessing all of the various combinations of Axis II conditions that may play a complicating roles. The combinations here are too numerous to go into, but I find that the presence of any Axis II condition is generally bad news for the prognosis, as is the presence of litigation or secondary gain.

If the patient is on opioids, I take a substance abuse history and use various scales on the above mentioned tests to assess for any risks for Rx abuse.

Finally, given the uncertain etiology of FM, I tend to take a rather pragmatic, trial and error approach. I work with the MD, and try the usual stuff with medications and pain management. If the psych evaluation shows up something significant, I treat that. If there appears to be minimal psych involvement, I support the patient through the medical treatment process if needed. I know my approach involves casting a rather large net, but for me the challenge of treating FM is first of all trying to figure out what factors may be affecting a particular patient sitting in front of me, and getting a handle on what to do.

Links:

The ACR definition of FM can be found at:

http://www.rheumatology.org/research/classification/fibro.html

• (Note that this definition has been criticized by some, as identifying trigger points by the point application of a 4 kg force would involve over 40 pounds per square inch with a 1/2 inch square point of application (such as a thumb) - Skeptics say many people WITHOUT FM would find this painful, and that this could lead to a high false positive rate with this criteria)

http://www.upcmd.com/dot/diseases/01174/rule-out.html#common3

http://www.ampainsoc.org/pub/bulletin/nov97/resupdate.htm

http://www.ampainsoc.org

• There are a lot of good research abstracts on the American Pain Society site
• These are longer than most abstracts and often quite helpful

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