Is Fibromyalgia a Psychosomatic Illness? Med Student Asks Celeste Cooper

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Reprinted with the kind permission of Celeste Cooper.

I received a request from a medical student taking an abnormal psychology class. He wanted to know if I thought fibromyalgia was a psychosomatic disorder.

The Psychology Dictionary defines psychosomatic disorder as:

Psychosomatic disorders are those in which psychological factors play a major role in the origin or course of the disorder.

Following is my response.

[Medical student,]

You are offering others a great opportunity to learn by writing on this topic. I hope to give you the information you need [regarding whether fibromyalgia is a psychosomatic illness or not]… I will answer your question bluntly.

“Fibromyalgia is NOT a psychosomatic illness.”

While talk therapy, biofeedback, mindfulness for any chronic illness is important for coping, it will not cure or even eradicate symptoms from a physical underlying disorder. This is also true for fibromyalgia. There are many people, including myself, who have been through extensive therapy with the hopes that we could find something to help our pain. My co-author began as my therapist. He assured me that I do not have a psychosomatic illness, and encouraged me to validate that with a psychiatrist, which I did, and it was found that I do not.

The Right Diagnostic Criteria is Critical to Understanding Fibromyalgia

Unfortunately, Dr. Frederick Wolfe has done a great deal of damage to the fibromyalgia patient. He has touted his criteria for diagnosing FM as the American College of Rheumatology criteria. I wrote to the ACR on this, and they tell me they have NOT endorsed Dr. Wolfe’s or anyone else’s criteria. See my blog The ACR Responds to My Inquiry on the Fibromyalgia Diagnostic Criteria—Should I Scream or Cry? It is my understanding that the ACR is publishing an erratum on this matter in an issue of Arthritis Care and Research.

Dr. Wolfe resurrected the antiquated notion that fibromyalgia is a psychosomatic illness with his research on prevalence of fibromyalgia in the German community (Wolfe, et. al., 2013).  What you don’t know is that he took a validated tool for assessing severity of somatic symptoms, the PHQ-15 (Kroenke, et. al., 2002) and tweaked it.

Dr. Wolfe’s “short form,” called the PHQ-8, regarded:

  1. stomach or problems going to the toilet
  2. pain in the back
  3. pain in the arms, legs, or joints
  4. headaches
  5. chest pain or getting out of breath
  6. dizziness
  7. feeling tired or having low energy
  8. trouble sleeping

First, why are stomach problems and problems going to the toilet lumped together? The PH-15 divides these somatic symptoms between 1) stomach pain 2) constipation, loose bowels or diarrhea, and 3) nausea, gas, or indigestion. Secondly, is it 4) chest pain, or 4a) shortness of breath? These are divided in the PHQ-15. Where is the assessment for 5) fainting and 6) feeling your heart race? Patients with fibromyalgia do have 7) pain with intercourse, particularly if they have comorbid chronic pelvic pain. This “short form” could affect the outcome regarding severity of symptoms when compared to the validated PHQ-15 tool. Isn’t it possible that the validated tool is validated because of the way the questions are asked?

He even says, “The PHQ-15 is best characterized as a measure of somatic symptom severity.” So why didn’t he use it? That is the $100,000 question. Why did this escape a peer reviewed journal editor?

The Role of Fibromyalgia Diagnostic Criteria

Roland Staud, MD et. al. (University of Florida, Gainesville, 2010) had this to say, in part, about the provisional diagnostic criteria, which was later modified, but they bring up some good points to help with your question.

“…After a series of analyses, Wolfe et al concluded that a widespread pain index was the best predictor of FM. When this index was excluded from the analysis, key predictors of FM were non-refreshing sleep, fatigue, cognitive difficulties, and a host of somatic symptoms… there is a glaring omission of well-known mechanistic FM features, such as hyperalgesia, central sensitization, or dysfunctional pain modulation…Also, the somatic symptom list is extremely broad somatic symptoms, and the symptoms are ordered by neither relevance nor predictive value, etc., supposedly contributing equally to FM. In conclusion, whether or not these new criteria are easy to apply by practicing physicians will require empirical testing. Unfortunately, the new criteria are imprecise, ill-defined, lack mechanistic features, and are completely symptom focused…”

This has been my opinion as well. To simply list somatic complaints without further investigation is cause for alarm. The ACR suggests comorbid conditions, tension headache or migraine, digestive problems (i.e. irritable bowel syndrome, gastric reflux) irritable or overactive bladder, pelvic pain, and temporomandibular disorder, causing face or jaw pain, jaw clicking and ringing in the ears. And, they recognize depression or anxiety as a disorder that can accompany fibromyalgia, which can accompany any chronic illness. Other things may explain the somatic complaints, such as hypothyroidism, cancer, and much more.

Dr. Katsuhiro Toda (Japan) wrote a letter to the editor of Arthritis Care and Research on the provisional criteria, (Wolfe, 2010) which you can access here. And, he wrote a letter to the editor of the Journal of Rheumatology, The Modification of the American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia Should Be Supplemented and Revised (Wolfe, 2011) of interest. “…In Japan, many physicians have ignored fibromyalgia. Therefore, patients with fibromyalgia are often diagnosed with psychogenic pain or somatoform disorder…”

You might be interested in Dr. Smythe’s article, which also outlines the lack of specificity in the Wolfe criteria.

Dr. Robert Bennett has contributed over 500 papers on fibromyalgia, he is considered an expert, and he led the research for the Alternative Diagnostic Criteria (Bennett, et al., 2014). You can read my blog regarding the criteria.

I encourage you to visit my blog; look in the archives and you will see that I have written on MANY topics regarding fibromyalgia.

Be sure to search PubMed. Connect the dots by searching fibromyalgia along with any one of the comorbid disorders. For instance, a study was just published on fibromyalgia and migraine. You will find there has been more than one connection made between fibromyalgia and small fiber neuropathy.

I have found that when one person has a question, someone else will too. Therefore, I will be sharing this information on my blog.

I am attaching a resource list for you and I will include reference to some recent studies that might help you. Good luck and please keep me updated. I would love to see what you come up with for your class.

Best regards, Celeste Cooper

Resources:

Abeles, M* and Abeles, AM. The New Criteria for Fibromyalgia: Evolution or Devolution?

Bennett R, Friend R, Marcus D, Bernstein C, Han BK, Yachoui R, Deodar A, Kaell A, Bonafede P, Chino A, Jones K. Criteria for the diagnosis of fibromyalgia: Validation of the modified 2010 preliminary ACR criteria and the development of alternative criteria. Arthritis Care Res (Hoboken). 2014 Feb 4. doi: 10.1002/acr.22301. [Epub ahead of print]

Kroenke K1, Spitzer RL, Williams JB. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med. 2002 Mar-Apr;64(2):258-66.

Smythe HA. Unhelpful criteria sets for “diagnosis”and “assessment of severity” of fibromyalgia. J Rheumatol. 2011 Jun;38(6):975-8. doi: 10.3899/jrheum.110142.

Staud R, Price DD, Robinson ME. The provisional diagnostic criteria for fibromyalgia: one step forward, two steps back: comment on the article by Wolfe et al. Arthritis Care Res (Hoboken). 2010 Nov;62(11):1675-6; author reply 1676-8. doi: 10.1002/acr.20290.

Toda K. Preliminary diagnostic criteria for fibromyalgia should be partially revised: comment on the article by Wolfe et al. Arthritis Care Res (Hoboken). 2011 Feb;63(2):308-9; author reply 309-10. doi: 10.1002/acr.20358.

Toda K. The Modification of the American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia Should Be Supplemented and Revised. J Rheumatol 2011;38;2075

Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Katz RS, Mease P, Russell AS, Russell IJ, Winfield JB, Yunus MB. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken). 2010 May;62(5):600-10. doi: 10.1002/acr.20140.

Wolfe F1, Clauw DJ, Fitzcharles MA, Goldenberg DL, Häuser W, Katz RS, Mease P, Russell AS, Russell IJ, Winfield JB. Fibromyalgia criteria and severity scales for clinical and epidemiological studies: a modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. J Rheumatol. 2011 Jun;38(6):1113-22. doi: 10.3899/jrheum.100594. Epub 2011 Feb 1.

Wolfe F1, Brähler E, Hinz A, Häuser W. Fibromyalgia prevalence, somatic symptom reporting, and the dimensionality of polysymptomatic distress: results from a survey of the general population. Arthritis Care Res (Hoboken). 2013 May;65(5):777-85. doi: 10.1002/acr.21931.


Celeste Cooper, RN is an advocate, writer and published author, and she is a person living with chronic pain. She is lead author of Integrative Therapies for Fibromyalgia, Chronic Fatigue Syndrome, and Myofascial Pain and Broken Body, Wounded Spirit, Balancing the See Saw of Chronic Pain (a four book series). She spends her time enjoying her family and the rewards she receives from interacting with nature through her writing and photography. You can learn more about Celeste’s writing, advocacy work, helpful tips, and social network connections at http://CelesteCooper.com.

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3 thoughts on “Is Fibromyalgia a Psychosomatic Illness? Med Student Asks Celeste Cooper”

  1. Spurky says:

    I’m so glad to hear that a med student asked if Fibromyalgia is real or not. I’m also glad you responded and gave additional resources, however I personally would have liked to see more of a focus on the scientific evidence underlining the many abnormal physiological issues present in FM. There’s a book that was written a few years ago that specifically debunked the notion that FM is not real using scientific clinical trials that prove FM is real. I think it was written by Dr. White. Unfortunately I’m not sure and can’t remember the title, but it was an excellent book. Basically I think using scientific evidence is the best way to persuade unbelievers or those who are unsure like this medical student.

  2. Matariki says:

    Thank you so much, Celeste, for a fantastic article. I have been plagued by the Psychosomatic label for the 40 years, positively diagnosed in 2002 and endured all that stuff. Do I detect that attitudes are changing? I hope so.

  3. 5chickens says:

    I read, on this site, that the Social Security Disablilty acknowledges fibromylgia as a real disease and has real symptoms they use to diagnose it. I myself was diagnosed with fibromylgia in 1999. Years before that I had 2 different doctors (that I respected) tell me they would not diagnose me with fibro because there was no treatment for it. What?! I was relieved when I finally got a diagnosis, I wasn’t crazy. Now I get mad when a physician isn’t interested in my problems. Change your doctor. Education is happening. I do want to add that I sent a copy of the SSD requirements for fibro disability with my papers and info for disability and was granted permanent disability from Social Security Disability and early disability retirement from my union. Thanks for the right info. Knowledge is power.

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