“She Doesn’t Look Disabled. Some Doctors Believe Her Condition Isn’t Real. But for the Author, Fibromyalgia Makes Every Day a Struggle.” —Washington Post As a psychiatrist who has long had an interest in controversial syndromes on the boundary of mental health and other fields of medicine, I have written on, taught about and treated fibromyalgia and “fibromyalgia” since it first came on the radar screens. There is a “real” syndrome but I believe it is also necessary to put the diagnosis of some, perhaps most, sufferers in quotes; the central triad of symptoms — debilitating chronic muscle pain, fatigue, and sleep disorder — can represent either a physical ailment or somatization, i.e. the physicalization of essentially mental distress.
The credibility of the diagnosis in a particular cse is established by the story and also the examination, in that the pain can be reproduced by palpation by a knowledgable examiner (usually a rheumatologist) of several dozen ‘trigger points’ in the muscle of whose existence or location the patient was unaware. While this is a controversial finding, I believe the research showing chemical and microscopic structural changes in biopsied muscle fibers in affected areas. Given the strong emotional component to the disorder, one way to think about its etiology is that people who are prone to experience stress as muscle tension are somehow chronically damaging their muscles, perhaps because the blood flow to chronically tense muscles is altered. I have also been impressed by the evidence that an added mechanism is in play. Impairment of the normal nighttime phased secretion of growth hormone from the pituitary gland given the altered sleep pattern in emotional distress, especially depression, may be important. GH is crucial to the repair of normal daily wear and tear in muscle fibers throughout the body; sleep deprivation causes muscle aches even in people who do not have fibromyalgia.
But, because I believe this syndrome has its origins in emotional distress and is a condition in which the physical manifestations come to predominate, it is attractive to many other emotionally distressed individuals who prefer to see their problems in physical rather than psychological terms, who are invested in an outmoded dichotomy and not open to a mind-body interactional perspective. Now granted, I work in a psychiatric setting and so my sample is skewed. But, for every legitimate fibromyalgia case I have seen, two or three young women come my way with chronic depression, complications of a trauma history, and/or borderline personality disorder (a triad of overlapping but not synonymous concerns) who are hell-bent on having fibromyalgia as the explanation of their social and occupational dysfunction instead.
Why am I making such an issue of this? Physicians and other clinicians who jump on the bandwagon of a sexy and faddish novel diagnosis ‘enable’ the dysfunction of such patients in a number of ways in which their patients are unconsciously invested, including suppporting disability claims and maintaining these patients (who may be prone to substance abuse as part of their psychiatric disturbance) on narcotic painkillers and addictive muscle relaxants for their supposed “fibromyalgia”. Many physicians are not open to examining their own “enabling”, since patients are uniformly appreciative of this kind of service, and we all like to please our patients. Legitimizing the disorder in such cases is a disservice to such patients, pandering to their unconscious maneuvering to look everywhere but at their own responsibility for their behavior patterns. By displacing them from a focus on their real concerns, such treatment prevents such patients from developing effective coping strategies that would alleviate or control distress in a lasting way and perpetuates their maladaptive way of doing business with the world instead.
Furthermore, fibromyalgia illustrates a more general phenomenon seen with controversial and murkily-defined syndromes. It remains a ‘wastebasket’ diagnosis, a syndrome diagnosed by clinical impression rather than diagnostic tests. If we lump together a heterogeneous cast of characters only a subset of whom have the “true” disorder, research efforts to characterize the processes behind it and clinical efforts to find effective treatments are compromised by the dilution of any relevant results in the mixed sample. In a vicious circle, the harder the condition is to characterize correctly, the harder it will be to characterize correctly. The more it attracts people for maladaptive reasons, the more it will continue to do so.
