Fibromyalgia and major affective disorder: a controlled phenomenology and family history study

Education programmes for fibromyalgia patients: description and evaluation

A firm theoretical basis for patient education in rheumatic disease care has been built up over the past 10 to 15 years. Education in self-management has enabled patients to control symptoms and become partners in care with their health providers. Education for fibromyalgia patients has come to the foreground during the last 5 years as health professionals have come to understand the syndrome better and recognize the role that stress plays in the exacerbation of symptoms. A few controlled trials of various strategies, such as aerobic conditioning and cognitive-behavioural techniques, have been reported recently. All have shown significant benefits to patients with fibromyalgia. Only one controlled trial has studied the effects of a self-management education programme alone. The results of this programme were positive. Self-efficacy and life quality were enhanced. This programme and an uncontrolled programme that integrated many strategies have shown some of the first positive long-term indications that patients who are treated intensively for even a short time can continue to improve as they practice self-management techniques. There is still a need for further documentation of non-drug treatment strategies and especially further research into who is helped by which strategies, the optimal length of time for a programme, and the need for ongoing treatment.

[Clinical features, pathophysiology and treatment of fibromyalgia.]

In rheumatology, all of the more than 400 specified syndromes are associated with pain. In the conceptual discussion on the multidimensional influences postulated to explain the development of chronic pain, fibromyalgia has gained increasing interest. Fibromyalgia (fibrositis) is an unspecific soft-tissue disorder with chronic wide-spread musculoskeletal pain and palpable hypersensitivity at fibrositic tender points. Fibromyalgia is often associated with fatigue, nonrestorative sleep and other symptoms. The syndrome has a high prevalence in women, but in most cases it has a long course with unsatisfactory attempts at therapy before the diagnosis is made. Though diagnostic criteria have been defined to describe it as a distinct clinical syndrome, speculations on its aetiology and pathogenetic mechanisms are still controversial. Histochemical investigations on muscle biopsy and biochemical tests have revealed unspecific changes but no characteristic muscle abnormality. It is supposed that the clinical features may result from central neurohumoral dysfunction combining with peripheral mechanisms to result in hyperalgesia. An integrated therapeutic concept with a reassuring and positive doctor-patient relationship can be helpful in achieving satisfactory treatment results.

A bio-psychosocial evaluation of ten adolescents with fibromyalgia

A comprehensive assessment of 10 adolescents (mean age 15.7 years) fulfilling the ACR criteria for fibromyalgia, disclosed that 3 patients also had juvenile chronic arthritis. Based on semi-structured psychiatric interviews, testing and family assessments, 6 of the patients had a psychiatric diagnosis (over anxious and/or depressive disorders). The pain scores for the group (mean 5.0, SD 1.5) were significantly higher than for a comparison group of patients with juvenile chronic arthritis (mean 2.5, SD 1.7), (p < 0.01). Average IQ was normal (mean 102.3, SD 13.9), but striving for achievement and high parental expectations were evident in 8 families. Seven of the mothers and 3 of the fathers had chronic diseases. The frequency of individual and family stress indicates a need for psychosocial assessment and counselling soon after onset of symptoms. This study also serves as a reminder that the diagnosis of juvenile chronic arthritis does not exclude fibromyalgia.

A blinded, controlled evaluation of anxiety and depressive symptoms in patients with fibromyalgia, as measured by standardized psychometric interview scales

The objective of the study was to evaluate the presence of psychopathology in fibromyalgia patients compared with a control group of other rheumatologic patients with pain. Forty-nine fibromyalgia patients and 33 control patients were interviewed blinded, using standardized psychometric scales. Pain was scored on a visual analogue scale. Fibromyalgia patients scored significantly higher than the controls on the Bech-Rafaelsen Melancholia Scale, the Atypical Depression Scale and the Hamilton Anxiety Rating Scale. On the Newcastle Depression Scale there was no difference. In both groups a correlation was found between pain score and psychometric scoring. The fibromyalgia patients scored significantly higher on pain than the controls. After correcting for this difference, the fibromyalgia patients still scored higher on anxiety and depression.

Assessing depression in fibromyalgia patients

PURPOSE

This study investigated the relationships among four methods of detecting depression in patients with fibromyalgia.

METHODS

Data were obtained from 100 women (mean age 43 years) who had been diagnosed with fibromyalgia. Instruments included a computerized Diagnostic Interview Schedule (C-DIS), Beck Depression Inventory (BDI), an adjusted "disease-free" BDI (BDI-A), and Minnesota Multiphasic Personality Inventory depression subscale (MMPI-D). Chance-corrected concordance, sensitivity, specificity, and accuracy among the four methods were calculated.

RESULTS

The C-DIS detected 22% and BDI-A 29% with current major depression. The BDI and MMPI-D yielded higher estimates of 55% of the 44%, respectively. Agreement on the diagnosis among the four methods was significantly greater than chance. When compared with the C-DIS, the BDI was the most sensitive instrument and the BDI-A most specific.

Clinical screening for narcolepsy/cataplexy in patients with fibromyalgia

We report two cases of fibromyalgia occurring during the course of a long-standing narcolepsy/cataplexy. This association is probably not fortuitous and we propose an easy clinical procedure to search for narcolepsy/cataplexy in these patients. Narcolepsy/cataplexy is a treatable condition requiring drugs that in turn may improve in the long-term symptoms of fibromyalgia.

A double-blind placebo controlled trial of fluoxetine in fibromyalgia

42 women were randomized to receive either placebo or fluoxetine at 20 mgs per day. Inter and intra group differences in clinical variables were evaluated after 3 and 6 weeks of treatment. Except for self rated anxiety which improved in the placebo treated group at 3 weeks, no differences between groups were noted. For those receiving fluoxetine both AIMS Anxiety (4.0 baseline vs. 3.3, p = 0.04) and Depression scores (2.6 baseline vs. 1.9, p = 0.03) improved at 3 weeks; however, improvement in the Beck Depression Scale did not reach significance (11.8 vs. 9.4, p = 0.34). At 6 weeks, both AIMS Depression (2.6 at baseline and 1.5 at 6 weeks, p = 0.03) and Beck Depression Scales (11.8 at baseline vs. 8.3 at 6 weeks, p = 0.04) showed improvement, as did sleep quality (9.6 vs. 7.6, p = 0.03). But no other variable had a significant change from baseline at either the 3 or 6 week point. Our data do not suggest that fluoxetine improves the signs and symptoms of fibromyalgia.

The impact of a meditation-based stress reduction program on fibromyalgia

Fibromyalgia is a chronic illness characterized by widespread pain, fatigue, sleep disturbance, and resistance to treatment. The purpose of this study was to evaluate the effectiveness of a meditation-based stress reduction program on fibromyalgia. Seventy-seven patients meeting the 1990 criteria of the American College of Rheumatology for fibromyalgia took part in a 10-week group outpatient program. Therapists followed a carefully defined treatment approach and met weekly to further promote uniformity. Patients were evaluated before and after the program. Initial evaluation included a psychiatric structured clinical interview (SCID). Outcome measures included visual analog scales to measure global well-being, pain, sleep, fatigue, and feeling refreshed in the morning. Patients also completed a medical symptom checklist, SCL-90-R, Coping Strategies Questionnaire, Fibromyalgia Impact Questionnaire, and the Fibromyalgia Attitude Index. Although the mean scores of all the patients completing the program showed improvement, 51% showed moderate to marked improvement and only they were counted as "responders." These preliminary findings suggest that a meditation-based stress reduction program is effective for patients with fibromyalgia.

Cluster arousal analysis in chronic pain-disturbed sleep

A new cluster arousal analysis system was developed to quantify microdisturbances in the sleep architecture. The system was evaluated in 10 healthy volunteers and the sleep of 23 outpatients with chronic low back pain was investigated before and after a special rehabilitative training. The comparison of sleep parameters before and after the treatment showed a significant reduction of the cluster disturbed sleep (CDS), whereas sleep efficiency and the number of stage shifts remained unchanged. The reduction of the CDS correlated with a reduction of depression scale. This cluster arousal analysis appears to be a sensitive tool for evaluating alterations in the sleep microstructure.

Fibromyalgia syndrome in patients infected with human immunodeficiency virus. The Boston City Hospital Clinical AIDS Team

PURPOSE

To prospectively assess rheumatic manifestations of human immunodeficiency virus (HIV) disease in a municipal hospital clinic population in which intravenous drug use was the most common risk factor for HIV infection.

PATIENTS AND METHODS

Patients with documented HIV infection were evaluated for rheumatic disease using a standardized questionnaire and examination. Patients with fibromyalgia were compared with HIV-infected patients without fibromyalgia and with fibromyalgia patients without known risk factors for HIV infection.

RESULTS

Thirty-seven of 140 patients with HIV infection had muskuloskeletal symptoms. Three of these 37 patients had arthritis, but none had Reiter's syndrome or psoriatic arthritis. Thirty (81%) of 37 patients had chronic musculoskeletal symptoms (for 3 months or longer). Twenty of 30 patients with chronic musculoskeletal symptoms had polyarthralgia, and of those, 15 (75%) were found to have either definite or probable fibromyalgia syndrome. Therefore, fibromyalgia syndrome was found in 41% of HIV-infected patients with musculoskeletal symptoms and in approximately 11% of all HIV-infected patients. Fibromyalgia patients with HIV infection had a longer duration of HIV infection (p = 0.01) and more frequently reported past depressed mood (p = 0.001) than HIV-infected patients without fibromyalgia. Compared with 301 patients with fibromyalgia syndrome and no known risk behavior for HIV, known HIV-infected patients with fibromyalgia were more commonly male (p = 0.001) and reported current depressed mood more frequently (p = 0.0001).

CONCLUSION

Few patients with arthritis were noted among HIV-infected patients who had intravenous drug use as risk behavior. By comparison, fibromyalgia syndrome appeared to be a common cause of musculoskeletal symptoms in this patient population.

Comorbidity of fibromyalgia with medical and psychiatric disorders

PURPOSE

Patients with fibromyalgia have been reported to display high rates of several concomitant medical and psychiatric disorders, including migraine, irritable bowel syndrome, chronic fatigue syndrome, major depression, and panic disorder. To test further these and other possible associations, we assessed the personal and family histories of a broad range of medical and psychiatric disorders in patients with fibromyalgia.

PATIENTS AND METHODS

Subjects were 33 women (mean age 42.1 years) who each met American College of Rheumatology criteria for fibromyalgia and presented to a rheumatologist at a tertiary referral center. They received the Structured Clinical Interview for DSM-III-R (SCID); a supplemental interview, in SCID format, for other medical and psychiatric disorders, including migraine, irritable bowel syndrome, and chronic fatigue syndrome; and an interview for family history of medical and psychiatric disorders.

RESULTS

Patients with fibromyalgia displayed high lifetime rates of migraine, irritable bowel syndrome, chronic fatigue syndrome, major depression, and panic disorder. They also exhibited high rates of familial major mood disorder.

CONCLUSIONS

The finding that migraine, irritable bowel syndrome, chronic fatigue syndrome, major depression, and panic disorder are frequently comorbid with fibromyalgia is consistent with the hypothesis that these various disorders may share a common physiologic abnormality.

Polysomnography in idiopathic muscle pain syndrome (fibrositis)

Muscle pain occurs in various neuromuscular disorders with characteristic physiological or biochemical abnormalities. There is, however, a group of patients in whom there is no clear physiological or structural basis for their pains. This syndrome has been called fibrositis or fibromyalgia. Sleep abnormalities have been reported in some of these patients, but have not been confirmed by others. We studied 8 patients with this disorder and found sleep abnormalities that were characterized by nocturnal myoclonus, alpha-delta sleep, and abnormalities compatible with depression. Polysomnography was, therefore, instrumental in helping direct the treatment of these patients. Therapeutic approaches aimed to correct the specific disorders were effective in improving the pain symptoms.

Psychiatric disorders in patients with esophageal disease

Psychiatric disorders have potentially important roles in the manifestations of esophageal disease. A primary causative role for psychiatric factors in the common motility disorders associated with chest pain (esophageal spasm and the nonspecific motor disorders) remains unproven, but psychiatric disorders appear particularly prevalent in this group. In most other esophageal diseases, psychiatric factors interact through recognized psychophysiologic or behavioral mechanisms to affect the clinical presentation. Recognizing the possible levels of interaction has significant therapeutic implications.

Toward an integrated understanding of fibromyalgia syndrome. II. Psychological and phenomenological aspects

The present paper is the second of a 2-part series in which extant empirical literature concerning fibromyalgia syndrome (FS) is reviewed in order to provide a preliminary approach to forming an integrated understanding of the syndrome. Research on psychological disturbance in FS is reviewed with particular emphasis on affective dysfunction among FS patients. The phenomenology of FS is then described. We attempt to suggest that FS represents a quantitatively and qualitatively experience distinct from similar chronic pain syndromes. Substantive findings in FS research are summarized in the final section and potential ways in which these findings might be integrated to provide a more cohesive model for future research are suggested.

Treatment of primary fibrositis/fibromyalgia syndrome with ibuprofen and alprazolam. A double-blind, placebo-controlled study

A multidimensional evaluation of 78 patients with primary fibrositis/fibromyalgia syndrome (PFS) revealed no significant relationship between clinical measures of physical discomfort and psychological measures. This observation provided evidence against the notion that the pain of PFS has a psychological etiology. The same patients were randomized into 4 groups for treatment with ibuprofen and/or alprazolam in a randomized, double-blind, double-dummy, placebo-controlled pilot trial. Clinical improvement in patient rating of disease severity and in the severity of tenderness upon palpation was most apparent in the subgroup of patients who were receiving both ibuprofen and alprazolam. An 8-week, open-label study in which 52 patients received both drugs further documented improvement in outcome measures. These data indicate that treatment with a combination of ibuprofen and alprazolam can be beneficial for some patients with PFS.

Fibrositis (fibromyalgia syndrome) and the dental clinician

The purpose of this article is to inform the general dentist treating the temporomandibular joint complex about fibrositis (fibromyalgia syndrome). Patients may present with spasms in the muscles of mastication, which may mimic joint pain or cause joint dysfunction. Tooth pain, which may mimic endodontic pain, may also be referred from a trigger pain in a muscle.

A systems model of chronic musculo-skeletal pain

A comprehensive systems model of chronic musculo-skeletal pain is presented. Physical and mechanical events may impinge directly upon the organism to produce pain. In addition life experience, as interpreted by each individual, may result in unpleasant affect which may lead through three psychosomatic pathways to musculo-skeletal pain. The suggested pathways are conversion, dysponesis and neurotransmitter disturbance. It is suggested that the construing of the self as being "ill", "an invalid" or a "pain person" is a crucial step in the development of the chronic pain syndrome and that therapies which fail to change this self-construct are unlikely to meet with long-term success.

Psychological disorders in rheumatoid arthritis: a growing consensus?

Previous reviews of psychological factors in arthritis have emphasised the methodological weaknesses of many studies, especially those attempting to measure personality after years of disabling disease. To make sense of the published reports three factors need to be considered separately: previous personality, social stresses, and current mental state. Each can now be measured reliably and independently of symptoms which might be directly attributable to the arthritis. There is a growing consensus that the normal range of personality is represented among patients with early arthritis, that the prevalence of depression is similar to that of patients with other medical conditions, and that social stress is more closely related to depression than activity and the disabling effect of arthritis. Longitudinal studies are now required to examine which social stresses can be attributed to the disabling effect of arthritis. Depression and social stress often manifest themselves to the rheumatologist as excessive complaints of pain and frequent clinic attendances so appropriate psychosocial treatments may reduce this behaviour.

Is emotional disturbance a precipitator or a consequence of chronic pain?

The present study examined the relationship between psychological factors and pain in order to assess the contribution of emotional disturbance to the perpetuation of pain. A group of 163 chronic pain suffers in multiple settings was compared with 81 control subjects on measures of personal history antecedent to pain onset, as well as on measures of current emotional disturbance. In addition, these psychological variables were examined for their associations with subjectively rated pain intensity. Overall, pain was found to be related to more current depression and less current life satisfaction, but was not associated with most of the personal history variables examined. These results suggests that emotional disturbance in pain patients is more likely to be a consequence than a cause of chronic pain. The dangers of routinely ascribing intractable pain to psychological causation are discussed in the light of these findings.

Left-right spatial agnosia and other mental defects that characterize clinical researchers

There are mathematical rules for determining the logical significance of data, just as there are such rules for determining the statistical significance of data. Logical significance reflects the question a study is asking, whereas statistical significance reflects how well it has been answered. Clinical researchers routinely make an incorrect determination as to their study's logical significance because of a spatial (left-right) agnosia. More diffuse cognitive dysfunctions are encouraged by journals that expect clinicians to report on a study as a prerequisite for communicating their pre-existing opinions. The unwillingness or inability of the clinical community to acknowledge this problem reflects a related anosagnosia.

Illness worry and disability in fibromyalgia syndrome

Fibromyalgia (FM) is a common syndrome of functional somatic symptoms. This article examines whether an amplifying somatic style (increased body awareness and illness worry) might explain the distress and disability expressed by FM patients. Twenty FM patients were compared to twenty-three rheumatoid arthritis (RA) patients on measures of depressive and somatic symptomatology, pain, disability, and amplifying somatic style. FM patients reported greater somatic symptomatology, equivalent levels of pain, and less physical disability than did RA patients. No differences were observed between groups on body awareness or illness worry. Illness worry correlated highly with symptomatology for both groups but with physical disability only among FM patients. Results suggest that disability in functional somatic syndromes may be determined by patients' worry about having a serious disease. Feelings of vulnerability and apprehension about having an illness of unknown origin may contribute to FM sufferers' activity limitations, inability to sustain a work effort, and varied somatic distress.

DSM-III diagnoses of patients with myofascial pain syndrome (fibrositis)

Rheumatology centers report that chronic pain patients with myofascial pain (fibrositis) are prone to psychiatric pathology. However, the distribution of DSM-III diagnoses in this population is unknown. This distribution is reported for 238 chronic pain patients with fibrositis. Statistical comparisons of men and women were also made with regard to the prevalence of each diagnosis, and the results were compared to published DSM-III diagnoses prevalence data for mixed chronic pain patients and rheumatology fibrositis patients. In our sample, women with fibrositis were equally as likely as men with fibrositis to have current depression. Within the general chronic pain population, women are more likely to have current depression. The incidence of current major depression and current and past major depression was much lower in our fibrositis sample than that reported by rheumatology programs. These results indicate that there may be psychiatric differences between chronic pain patients with and without fibrositis. Fibrositis patients in rheumatology programs may also be psychiatrically different from chronic pain program patients with fibrositis.

Is RA27/3 rubella immunization a cause of chronic fatigue?

Patients with chronic fatigue syndromes (primary fibrositis syndrome, major affective disorder, etc.) have elevated IgG serum antibodies to multiple common viruses. Only IgG rubella antibodies are positively correlated with the intensity of symptoms and have a height that is clearly significant compared to healthy controls. The lymphotropic properties of the rubella virus could account for the multiple elevated antibodies. Adult women are over-represented in the population of patients with chronic fatigue, and are especially susceptible to developing such symptoms following exposure to attenuated rubella virus. A new more potent strain of live rubella vaccine (strain RA27/3) was introduced in 1979. Within three years reports of patients with chronic fatigue began surfacing in the literature. Considering all this, the possible role of rubella immunization in the etiology of chronic fatigue syndromes deserves further study.

The concept of primary fibromyalgia (fibrositis): clinical value, relation and significance to other chronic musculoskeletal pain syndromes

PFS, MPS and TMPDS can be identified using positive diagnostic criteria among patients presenting with chronic pain. A directed rather than exhaustive search for organic diseases known to coexist with these syndromes is usually all that is necessary. Criteria are presently empirical but do identify homogeneous populations of patients for study and treatment. Some patients, however, provide examples of overlap and it may be useful to think of CMPS in terms of the Venn diagram depicted in Fig. 2. In this report we have attempted an initial classification for a group of common and perplexing chronic pain disorders of the musculoskeletal system which at present have no identifiable cause. Previous investigations have been hampered by erroneous pathological concepts, heterogeneous patient populations and poor study design particularly with respect to treatment modalities. We hope that this classification, while empirical, will lead to needed epidemiological studies outlining the similarities and differences between these clinically observable and different musculoskeletal syndromes. We hope, further, that it will foster cooperation between different medical disciplines so that clinical biases might be tested in light of current concepts of the scientific method.

A controlled family history study of bulimia

Using the family history method, we assessed the morbid risk for psychiatric disorders in the first-degree relatives of 69 probands with bulimia, 24 probands with major depression, and 28 nonpsychiatric control probands. The morbid risk for major affective disorder among the first-degree relatives of the bulimic probands was 32%, significantly greater than that found in the nonpsychiatric control probands. The rate of familial major affective disorder was significantly greater in bulimic probands who had a history of major affective disorder themselves than in bulimic probands without such a history - but the latter group, in turn, displayed significantly higher rates than the nonpsychiatric control probands. Eating disorders were slightly, but not significantly, more prevalent in the families of bulimic probands than nonpsychiatric control probands. We present two alternative hypotheses which might explain these findings.

Double-blind study of dothiepin versus placebo in the treatment of primary fibromyalgia syndrome

A double-blind study comparing the efficacy and tolerability of dothiepin with that of placebo in the treatment of primary fibromyalgia syndrome was carried out. Dothiepin was shown to improve significantly the condition of patients with primary fibromyalgia syndrome and there was a significant difference between dothiepin and placebo in all the clinical variables measured. Only mild and transient side-effects were reported. Further controlled studies are required to define the effects of dothiepin on fibromyalgia.

Is chronic pain a variant of depressive disease? The case of primary fibromyalgia syndrome

The responses of 45 primary fibromyalgia syndrome (PFS) patients, 29 rheumatoid arthritis (RA) patients and 31 healthy non-pain controls (NC) on the Zung Self-Rating Depression scale were compared. No difference between the PFS and RA groups was found, although the former has no known organic pathology, unlike the latter. Therefore, the hypothesis that the presentation of chronic pain in the absence of a known organic pathology is a variant of 'depressive disease' was not supported in the case of PFS. However, a subgroup of PFS (28.6%) and RA (31.0%) patients appeared to be experiencing significant depressive symptomatology.

A randomized, controlled trial of amitriptyline and naproxen in the treatment of patients with fibromyalgia

Sixty-two patients with fibromyalgia were randomly assigned to receive 25 mg of amitriptyline at night, 500 mg of naproxen twice daily, both amitriptyline and naproxen, or placebo in a 6-week, double-blind trial. Amitriptyline was associated with significant improvement in all outcome parameters, including patient and physician global assessments, patient pain, sleep difficulties, fatigue on awakening, and tender point score. Patients taking the combined naproxen-amitriptyline regimen experienced minor, but not significant, improvement in pain when compared with patients who took amitriptyline alone. Amitriptyline, or amitriptyline and naproxen, is an effective therapeutic regimen for patients with fibromyalgia.

Dysthymic disorder and rheumatic pain modulation disorder (fibrositis syndrome): a comparison of symptoms and sleep physiology

It has been suggested that "fibrositis" or rheumatic pain modulation disorder (RPMD) is a variant of depressive illness. Both disorders are associated with abnormalities in sleep physiology. Since the clinical features of RPMD do not meet all the criteria for a major depressive disorder, the symptoms and sleep physiology in subjects with dysthmic disorder (DSM III criteria) (N = 6), and RMPD (N = 6) were compared, in order to determine the similarity between the two groups. The sleep physiology in dysthymic disorder was first examined over three consecutive nights since a systematic evaluation of the sleep physiology in this group of disorders has not yet been reported. All dysthymic patients showed episodic bursts of high-amplitude (75-150 microvolts) theta (3-5 Hz) bursts in stage 2 sleep, and REM onset latency was abbreviated only on night 2. The theta bursts have not been previously reported, and may be an early marker of disorganization of non-REM sleep in the dysthymic subjects. The comparison of the two groups revealed that RPMD subjects reported more pre- and post-sleep pain (p less than 0.01), lighter sleep (p less than 0.01), and more physical ailments during sleep (p less than 0.01), and had more alpha (7-11.5 Hz) in non-REM sleep (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Sleep and musculoskeletal pain

Chronic musculoskeletal pain and fatigue of "fibrositis syndrome" are associated with a physiologic arousal disorder within sleep, the alpha (7.5 to 11 Hz) electroencephalographic, non-rapid-eye-movement sleep anomaly. In this nonrestorative sleep disorder, pain and mood symptoms may be mediated by psychologic distress (e.g., following a nonphysically injurious industrial or automobile accident), noxious environmental stimuli (e.g., noise), physiologic disturbance (e.g., sleep-related myoclonus, painful inflamed joints, i.e., rheumatoid arthritis), and altered central nervous system metabolism (e.g., disordered brain serotoninergic functions). Because such heterogeneous agents influence this hitherto poorly understood nonarticular rheumatic syndrome, the descriptive term "rheumatic pain modulation disorder" is suggested.

Concepts of illness in populations as applied to fibromyalgia syndromes

Fibromyalgia syndromes are common noninflammatory, painful musculoskeletal disorders that vary in the extent and intensity of involvement. The biologic gradient of musculoskeletal pain varies from no or few symptoms and tender points in the majority of persons to generalized fibromyalgia with multiple tender points. Standardized criteria are needed in order to categorize different strata of the biologic gradient of fibromyalgia syndromes and differentiate them from other conditions. Both the sensitivity and specificity of criteria should be high. The course and prognosis of fibromyalgia syndromes are not yet known. Limited clinical data suggest three basic patterns: remitting-intermittent; fluctuating-continuing; and progressive. However, course patterns need to be derived scientifically. Multiple host and environmental factors seem to contribute to the onset and course of fibromyalgia syndromes, and these require definition. Generalized fibromyalgia syndromes share many constitutional manifestations with other common functional disorders, e.g., irritable bowel syndrome and tension headache syndrome, which suggest common underlying psychoneurophysiologic mechanisms in a subset of patients. Progress made in fibromyalgia research will find application in many dysfunctional syndromes without obvious organ pathology.

Is there a metabolic basis for the fibrositis syndrome?

Patients with the fibrositis syndrome experience moderately severe musculoskeletal discomfort, mood changes associated with nonrestorative sleep, and tenderness to palpation at specific body sites. There is no characteristic abnormal laboratory finding in these patients to help identify the population. A report by Moldofsky and Warsh (Pain 1978; 5: 65-71) of low serum levels of free tryptophan in patients with severe fibrositis syndrome is intriguing but remains unexplained. Those data plus the observation by Hudson et al (Am J Psychiatry 1985; 142: 441-446; Biol Psychiatry 1984; 19: 1489-1493) that patients with fibrositis syndrome exhibit an increased prevalence of anxiety and depression suggest a number of possible avenues for further study. They include potential alterations in the homeostasis of catecholamines, corticosteroids, serotonin, aromatic amino acids, platelet membrane receptor levels, and the activity of platelet membrane monoamine oxidase. Among these possibilities, evidence is now available that suggests an increased production of catecholamines in fibrositis syndrome.

The clinical syndrome of fibrositis

Fibrositis is a disorder of musculoskeletal pain and aching with at least a five to one female-to-male ratio. It is most commonly seen between the ages of 40 and 60, and has a prevalence in the clinic of 6 to 15 percent. Its most common mode of presentation involves generalized musculoskeletal pain and aching, but articular pain, axial skeletal pain, myalgias, and neurovascular complaints sometimes predominate. All patients have multiple areas of local tenderness called "tender points" that are easily identified during physical examination, and are diagnostic. Essential symptoms of fibrositis are disturbed sleep, morning stiffness, and fatigue. Additional rheumatic symptoms include subjective swelling, paresthesias, and numbness. Headaches and irritable bowel syndrome are common nonrheumatic complaints. Modest improvement follows treatment by tricyclic agents such as low-dose cyclobenzaprine and amitriptyline, by physical measures, and by reduction in stress. Remission occurs in 20 percent of patients, but is generally short-lived.