Sunday, December 25, 2011

Fibromyalgia as Mind-Body Disorder

Note: The mind and body appear to interact in many diseases, however
some assumptions are tricky.

Misinterpretations of bodily symptoms as being depression or anxiety,
especially in diseases (and psychiatric disorders) lacking diagnostic
testing, may confound the results of studies and inflate estimates of
psychiatric co-morbidities. There is also always the danger of mixing
people without a disease in with people with a disease - which also
confounds study results.

As well, many doctors may assume psychiatric comorbidity instead of
asking the patient. Treatments are only efficacious if there is something to treat and assuming a psychiatric co-morbidity where none exist has the potential to create iatrogenic harm.

On the other hand, if a disease process involves the brain it may
create psychiatric problems such as in some seen in Lyme associated
disorders. There is much that remains unknown. Whether a virologist or
a psychiatrist if all you have is a hammer everything looks like a

Fibromyalgia: Mind-Body Disorder

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 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.2-7The 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

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

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
milnacipran24) 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.25-32This 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

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