Treating Fibromyalgia in the Mental Health Setting

Content provided by the Faculty of the Harvard Medical School

Patients with this chronic pain syndrome often also suffer from anxiety or depression.

About 2% of Americans — more women than men — suffer from fibromyalgia. Primarily a chronic pain syndrome, fibromyalgia may also cause sleep disturbances, thinking difficulties, and fatigue. Although it is classified as an inflammatory disorder of the musculoskeletal system, evidence is growing that fibromyalgia may be a disorder of the central nervous system.

Bolstering this view is the fact that patients with fibromyalgia often suffer from anxiety or depression. And some patients who suffer only from a psychiatric disorder may develop somatic symptoms that mimic fibromyalgia — yet the primary challenge is a mental health problem, and symptoms will abate only when it is addressed. For all these reasons, the best treatment involves a team approach that includes mental health clinicians.

Making the diagnosis

The American College of Rheumatology developed the standard criteria for diagnosing fibromyalgia. A defining symptom is widespread pain, involving both the upper and lower parts of the body, which lasts at least three months. But a diagnosis of fibromyalgia also requires that a patient experience pain or soreness when pressure is applied to at least 11 of 18 specific sites where muscles join with tendons — known as "tender points" (see illustration).

Researchers at Harvard-affiliated McLean Hospital proposed alternative diagnostic criteria for use in the mental health setting, where clinicians may not know how to assess tender points. They suggest using a structured interview to assess the presence of at least four of the following six symptoms: fatigue, headaches, numbness or tingling, sleep disturbance, neuropsychiatric complaints, or irritable bowel syndrome (which causes abdominal pain and bloating).

Regardless of which criteria a clinician uses, it is also important to rule out disorders that can cause symptoms similar to fibromyalgia, such as chronic fatigue syndrome or irritable bowel syndrome, and to assess patients for co-occurring psychiatric disorders.

One large study reported that, during a one-year period, 5% of patients with fibromyalgia sought treatment for anxiety (compared with 1% of controls), and 12% sought treatment for depression (compared with 3% of controls). Lifetime prevalence of psychiatric disorders is even higher.

Tender points

Tender points

Behavioral therapies

The following strategies, alone or in combination, can reduce pain and fatigue and improve sleep, mood, stress management, and physical functioning.

Patient education. This basic element of patient care is sometimes neglected because of lack of time or insurance reimbursement. Yet several studies have reported that providing basic information about fibromyalgia not only helps alleviate symptoms but also prevents the development of catastrophic thinking. Two studies reported that basic patient education was as effective as cognitive behavioral therapy.

Physical activity. Two literature reviews by the Cochrane Collaboration concluded that moderate aerobic exercise (such as walking or riding a bike) not only improves overall physical functioning in patients with fibromyalgia, but also decreases pain and other symptoms. As an added bonus, aerobic exercise also helps moderate symptoms of depression.

The key, however, is to start slowly and build activity levels gradually, as patients with fibromyalgia are acutely pain-sensitive, and exercising too much early on may only worsen their symptoms. As a general guide, patients can start with low-intensity exercise (a slow walk) and then gradually increase the exertion level and time. Ultimately patients can aim for doing 30 to 40 minutes of moderate activity a day, at least three times a week.

Cognitive behavioral therapy (CBT). Patients with fibromyalgia (like others suffering from chronic pain) tend to develop counterproductive ways of thinking and acting, which only make their symptoms worse. CBT offers techniques and practice for recognizing and changing these often unconscious ways of thinking.

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