Old and new theories of fibromyalgia

Fibromyalgia is commonly called a basket diagnosis - it doesn’t show up in almost all tests (except for functional MRI). Fibromyalgia is something we get labelled with when a doctor can’t find any explanation for our symptoms in our test results, it’s diagnosis by exclusion.

However, there are multiple components that contribute to fibromyalgia: genetic, neurobiological (brain chemicals), environmental (allergies), and psychological (especially long term trauma).

But first, the older theories of fibromyalgia, widely believed by both normal healthy people and, sadly, many doctors and specialists.

Fibromyalgia is psychosomatic (false)

If you have fibro, I’m positive you’ve heard very often that:

• “It’s all in your head.”
• “You are too stressed / too sensitive.”
• “Change your thinking and beliefs and you will be cured.”
• “It’s just depression.”
• “Just get over it.”

psychosomatic /ˌsʌɪkə(ʊ)səˈmatɪk/ adjective

1. (of a physical illness or other condition) caused or aggravated by a mental factor such as internal conflict or stress.
2. relating to the interaction of mind and body.

This is an old theory of fibromyalgia, and it came from the 1800s, although it wasn’t given the name fibromyalgia until the 1970s.

Unfortunately, many older doctors still consider fibromyalgia to be synonymous with hypochondria - there is nothing physically or chemically wrong with your body. That you are thinking yourself into pain, sometimes due to ‘too much stress’.

We are stigmatized as chronic complainers and attention seekers.

And they send fibro patients off to see a psychotherapist. Unfortunately, few are trained in strategies for managing chronic painful illnesses. Or we are prescribed anti-depressants without regard to which ones could actually help.

While there is no question that fibromyalgia has a strong psychosomatic component, as all chronic pain illnesses do, our understanding of fibromyalgia has moved on from a pure psychological root cause.

That doesn’t mean you shouldn’t see a psychotherapist - cognitive behavioural therapy (CBT) and other body feedback and stress management techniques like meditation do help you cope with and reduce the impact of fibromyalgia pain.

It is also interesting that several anti-depressants have a positive effect for many fibro patients. More on that later.

Fibromyalgia is genetic (likely)

Most recently, it was discovered there may be a genetic component to fibromyalgia, typically involving multiple genes that control the chemicals in our brains.

Fibromyalgia is rheumatological (false)

The next common diagnosis is of a musculoskeletal disorder that causes chronic pain, like arthritis.

Muscular rheumatism fibrositis, myositis, and fibromyositis are chronic inflammatory problems affecting the muscles, ligaments and tendons. These terms all used to be used interchangeably. Any condition that ends in -itis refers to inflammation. So, myositis means muscle inflammation, and it typically develops triggered something - lupus, the flu, covid, etc.

There is no inflammation in fibromyalgia. Fibromyalgia is not an inflammatory illness like rheumatism. Therefore, it is most definitely not an “-itis”.

“Myalgia” means muscle pain..

Having pointed out this difference, the actual pain symptoms of these inflammatory illnesses affecting the muscles and fibromyalgia are quite similar.

Most patients are still referred to rheumatologists for diagnosis and treatment, although the standard treatments for rheumatic and auto-immune diseases (anti-inflammatories, cortisone medications, biologics, chemotherapy) have no effect on fibromyalgia pain, unless the patient also has some kind of auto-immune disease. It’s this auto-immune disease that is likely causing their fibromyalgia symptoms - the fibromyalgia is a secondary symptom.

Wait - what about neuroinflammation?

Having repeatedly said that there is no inflammation in fibromyalgia unless it’s a symptom of another auto-immune disease or infection, brain or neuro-inflammation is fairly common in fibro patients, and is likely the cause of the brain chemical imbalances that sensitise fibro patients to pain. This type of inflammation, caused by malfunctioning microglial cells, is not regarded as a rheumatic disease, although medications that target the microglia-derived inflammation-inducing TNG-alpha genes are routinely used to treat various spondyloarthropathies.

So, maybe it is a form of rheumatism after all? Or there could just be a strong correlation between these co-morbid illnesses.

Fibromyalgia is neurological (highly likely)

Current fibromyalgia research is focusing on our brains and nerves, now that we can image the brain and it’s chemicals more accurately.

One study compared muscle fibers of healthy people and fibromyalgia. They found cellular damage consistent with known neuromuscular disorders, and impaired blood flow to the muscles which can lead the pain nerve cells around the muscle being sensitized - sending signals of increased pain, fatigue and muscle weakness.

A recent study that caused a stir in my pain support groups, found that fibromyalgia sufferers have many more nerve fibers in their hands than healthy people, similar to patients with small-fiber peripheral neuropathy. But others have argued that this could be the result of fibromyalgia, not the cause.

In fibromyalgia patients, the levels of neurochemicals in the brain that signal pain are not normal, leading to us feeling tha pain is more painful than it should be. Plus our brains’ pain receptors develop a memory of the pain, become more sensitised and don’t shut off correctly. So pain from any source lasts longer than it should, and feels stronger than it should.

The neurochemicals that are commonly out of balance in fibromyalgia patients include serotonin, dopamine, substance P, and noradrenaline.

These same neurochemicals affect our sleep, cognitive function, and mood.  This more accurately explains the other primary symptoms of fibromyalgia - from non-physical stimuli like noise or light, insomnia, exhaustion, anxiety, depression and the fibro-fog.

Fibromyalgia and trauma (definitely linked)

Years of trauma in childhood permanently damages the production and balancing functions of neurochemicals in our brains. Even if there was no childhood traume, the environment around us, our psychological and physical state all affect these same neurochemicals.

This would explain why people who have chronic illnesses of various types, and/or have gone through childhood trauma often develop fibromyalgia as a secondary symptom.

Neurochemical medications have an impact

The classes of medications that actually work for many (but not all) mess around with those particular neurochemical levels - antidepressants (SSRI, SNRI, tricyclic), anti-convulsant or anti-epileptic medications, and muscle relaxants work well for many fibromyalgia patients.

But as everyone has a different balance of these brain chemicals, this would explain why one medication works well for one fibromyalgia patient, and not for another.

Fibromyalgia is looking more convincingly to be neurochemical as more studies are done.

Treatment - multi-modal therapies

• Psychotherapists and cognitive behavioural therapy (CBT) is useful for reducing the poor mood, depressive symptoms, for teaching coping strategies for pain and fatigue, and of course for any history of trauma.
• Psychiatrists (or an experienced GP) can prescribe appropriate anti-depressants or anti-epileptic that may balance the neurochemicals. But it will be trial and error to see what works for your particular imbalance.
• Rheumatologists can help with any inflammatory problems that are commonly found alongside fibromyalgia.
• General physicians or pain medication specialists can help reduce the amount of, the sensitization to and perception of pain, as well as our reactions to painful stimuli.
• A neurologist or GP can help with sleep problems. A ear-nose-throat doctor may help if there are sinus or other airway/breathing difficulties in sleeping positions.
• Physical therapists can help reduce physical pain and mitigate the postural problems that can worsen fibro pain.

Beware - some doctors have outdated and dangerous beliefs

Most recently, an orthopedic surgeon who was standing in for my normal one, tried to convince me fibromyalgia was ‘just’ muscular rheumatism, and the cure was lots and lots of intense exercise.

While mild to moderate exercise certainly does help to reduce inflammation in rheumatism patients, and is most important for mobility, intense and sustained exercise would risk injury and worsening rheumatic inflammation.