Fibromyalgia: Treating this "True Biopsychosocial Disorder" Requires a Multidisciplinary, Multifaceted Approach

Rakesh Jain, MD, MPH wants mental health professionals to rethink fibromyalgia. Though the disease has historically been characterized only as a pain disorder—and its treatment has focused on relieving only pain symptoms, resulting in mixed outcome results—Dr. Jain says that recent research has shown fibromyalgia to be a “true biopyschosocial disorder,” and that psychiatric disorders such as depression, anxiety and sleep problems are often precursors for the disease. He shared his views on the subject with other mental health professionals during a Meet the Experts session entitled “The Interrelationship of Fibromyalgia with Psychiatric Disorders ” held during the 24^th Annual U.S. Psychiatric and Mental Health Congress (2011 Psych Congress) on November 8, 2011.

“Fibromyalgia is a real entity, but it is not just a pain disorder,” said Dr. Jain, Director of Psychiatric Drug Research, R/D Clinical Research Center in Lake Jackson, TX, Associate Clinical Professor, Department of Psychiatry and Behavioral Sciences, University of Texas Medical School at Houston, and a member of the Steering Committee for the 2011 Psych Congress. “Pain is one manifestation of this disease. In the past, fibromyalgia treatment was limited to rheumatologists because we saw it as an inflammatory disorder. But now, with improved understanding, it belongs to primary care and to psychiatry. Everybody’s pulled in because the disorder is multifaceted and requires the talents and expertise of multiple specialties.”

According to Dr. Jain, studies attempting to identify the root cause or causes of fibromyalgia have focused on many of the same biologic and neurologic pathways involved in depression and anxiety, including disruption of neurotransmitters and limbic system dysfunction. “Pain amplification” is associated with fibromyalgia and is thought to occur in the spinal column – more specifically, in the doral column of the spinal column. In fact, he told the audience, recent research has indicated that fibromyalgia can be effectively treated, and even potentially prevented, by proper management of patients’ comorbid depression and anxiety. Guidelines from American Pain Society (APS)¹ and European League Against Rheumatism (EULAR)² both recommend a multidisciplinary approach to the treatment of fibromyalgia that includes cognitive behavioral therapy (CBT) and regular exercise.

“We may be good at preventing fibromyalgia. We just don’t know it yet,” Dr. Jain noted. “In our practices, we encounter patients with depression, anxiety or sleep problems. If you’re able to change trajectory of those conditions, their odds of developing fibromyalgia are vastly diminished. Depression, anxiety and sleep problems are really the gasoline for the fire that is fibromyalgia.”

In addition to CBT, the APS and EULAR guidelines also emphasize the importance of what Dr. Jain described as “intentional, purposeful” exercise (he recommends at least 15 minutes per day, seven days per week). In his practice, Dr. Jain told the audience that he recommends biking and water-based exercise over walking, because the latter is harder on the joints, and that he advocates group exercise because the defined schedule and social aspects are helpful for fibromyalgia patients.

“The guidelines emphasize that we should not reach for medications immediately,” he said. “Even though I’m a physician and I’m supposed to prescribe meds, if you want to be a good fibromyalgia clinician, you should prescribe non-pharmacological treatments, such as exercise or stress management, and consider the addition of medication if appropriate.”

References

1. Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA. 2004;292(19):2388-2395.
2. Carville SF, Arendt-Nielsen S, Bliddal H, et al. EULAR evidence-based recommendations for the management of fibromyalgia syndrome. Ann Rheum Dis. 2008;67(4):536-541.