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Excerpt
FM appears to be an illness at present lacking a well-defined disease. This has much in common with many other chronic pain syndromes. The term chronic pain syndrome is not a diagnosis but a description of a constellation of symptoms including persistent pain, dysfunctional pain behaviors, self-limitations in functional activities, poor coping, and variable degrees of life disruption. The diagnosis of FM at the present time is legitimized by the ACR; therefore, until this changes, it is appropriate to use the term fibromyalgia for patients who meet the ACR criteria and whose symptoms cannot be better explained by an alternate medical or psychiatric diagnosis.
I concur with Dr. Hadler's assessment that the use of the term fibromyalgia often encourages illness behavior in a very vulnerable group of individuals for whom the attachment of a diagnostic label contributes more to their dysfunction than to their function and promotes a sense of learned helplessness. The concept of the medicalization of suffering is not new. FM may be one of the more recent examples.
In response to the critique by Dr. Thompson, I certainly agree with him that, in both MPS and FM, patients present to health care providers with variable degrees of distress. We must acknowledge that distress. Whether that distress represents soft tissue pathology or soft tissue complaints in the absence of pathology, these individuals deserve to be taken seriously, and their symptoms deserve clarification and explanation. However, I believe we do individuals a disservice when we promote their continuation in the role of pain patient or rheumatologic patient if the issue proves to be a process of somatization. For this very reason, I strongly suggest that, unless the clinician includes the concept of somatization in the differential diagnosis, it will never be found. Depending on the point at which the clinician intervenes in this symptom complex, now called fibromyalgia, will determine the extent to which interventions are needed. Certainly, if the process has already led to general deconditioning, debilitation, and depression, it may require interdisciplinary pain rehabilitation. However, if one is able to intervene early in the process, emphasizing reactivation, normalization of the life activities, and using a psychotherapeutic approach during office appointment, we may short circuit the process, which often leads to further debilitation and unnecessary disability. I have found that it is not what the clinician says to the patient but the manner in which it is said that often determines the degree to which patients will accept and follow treatment recommendations.
I concur with Dr. Valente's words of caution regarding being overly dogmatic about an illness whose etiology remains obscure. However, although we may not be totally cognizant of the pathophysiology, I remain firmly convinced that the biopsychosocial approach to therapeutic intervention remains the most likely to succeed. FM could be considered as a spectrum disorder in which some individuals may require more of a physical reconditioning and rehabilitative approach, others more of a psychotherapeutic approach, and still others more of a pharmacological approach.
