Introduction
This research paper compares and contrasts the views of professionals with respect to fibromyalgia; whether it is of psychological or physical nature / origin. Having conducted the following research and studied the views of others, especially those who we would all hope should know – the medical professionals, the view of this researcher is that fibromyalgia is more psychological in nature, even though that opinion is changed considerably from the view that was almost universally held in less enlightened times, when referring to a condition as having psychological causes was interpreted as implying the person was suffering from a mental illness, which had clear negative connotations.
The Research
First we should perhaps define fibromyalgia; explain just what it is. According to the Centers for Disease Control and Prevention (CDC) article “Fibromyalgia” (updated Nov 2012), it is “a disorder of unknown etiology characterized by widespread pain, abnormal pain processing, sleep disturbance, fatigue and often psychological distress.” (Subsequent researched articles included in this paper will show that part of that definition “abnormal pain processing” is a key element of the definition.
According to the referenced article, sufferers may also experience additional symptoms including stiffness in the mornings, hands and/or feet tingling or numb, headache and migraine, disturbed sleep patterns, irritable bowel syndrome, painful menstrual cycles, and cognitive and memory issues. It affects about two percent of the population, mostly women, although men and children can also be affected, and tends to occur mostly from middle age onwards.
Now for the research into the question: “Is fibromyalgia a psychological or physical condition?”
Borigini (Jan 2011) considered there is a strong link between fibromyalgia and our emotions. Whilst not claiming the condition to be purely psychological in origin, he quoted research that had shown that fibromyalgia sufferers experienced much stronger emotions, especially emotions of a negative nature like sadness or anger. He claimed this is not a surprising finding, taking into account what he described as “a close anatomic relationship between the brain's pain and emotion circuitry.”
Seaton (n.d.) also viewed fibromyalgia as a condition having “physiological and psychological components.” In her article “How Can a Psychologist Help?” she reminded readers that a person’s mind and their body are “intimately related” and that one affects the other. For that reason, and because fibromyalgia sufferers experience psychological problems, Seaton stated that people with the condition can be helped by psychological treatment.
Gupta and Silman (2004) published a paper entitled: “Psychological stress and fibromyalgia: a review of the evidence suggesting a neuroendocrine link” in which the authors highlighted the current division of opinion that surrounds the nature of fibromyalgia – whether it is a response to stress of psychological origin or whether it is an “organically based” or physical syndrome. Their article explored the particular possibility that there is a link between fibromyalgia developing following a condition of chronic stress, due to abnormal neuroendocrine functions, which may possibly be the cause of the problems.
Gupta and Silman indicated that studies have supported the view that distress of a psychological nature (such as abuse in childhood or early loss of parents) can result in the later development of fybromyalgia. However, their review – in order to try to resolve the basic conflict between a psychological or physical cause – sought to confirm that there are “cogent neuroendocrine pathways” that could cause fibromyalgia to develop as a consequence of psychological stress.
Central to their review, Gupta and Silman separately looked at the possible roles of four systems: the HPA (hypothalamic–pituitary–adrenal) axis, the growth hormone axis, sex-related steroids, and neurotransmitters (serotonin and substance P.). For each of those four systems, the authors looked for abnormalities existing in the case of fibromyalgia sufferers. Summarizing the outcomes of the review, abnormalities in the case of the HPA axis indicate that in fibromyalgia sufferers it is underactive. Similarly, low growth hormone levels were present in people with fibromyalgia, although the reviewers noted that the reduced levels could have been a consequence of disrupted sleep, itself a feature common to fibromyalgia patients. In the case of the sex-related steroids (androgens and oestrogens) there were lower levels present in women with fibromyalgia, although the precise mechanism was unclear. There was a suggestion that low oestrogen caused reductions in production of substance P, thereby increasing pain. As far as the neurotransmitters were concerned, lower serotonin levels found in fibromyalgia sufferers were consistent with the symptoms of chronic stress, and with tests on patients with other psychiatric conditions including depression. Elevated substance P levels found are also consistent with other medical conditions featuring chronic pain.
Overall, the Gupta and Silman review found there were links between the various abnormalities found and the incidence of fibromyalgia, although they conceded that there were areas still needing further research and study, including further studies they are undertaking. In conclusion, they consider there are links between chronic stress and the condition, although the possibility exists that the pain experienced could cause the stress that in turn affects the hormones and neurotransmitters.
Ceko, Bushnell and Gracely published an article (2011) entitled “Neurobiology Underlying Fibromyalgia Symptoms” in which the authors noted that the results of neuroimaging showed increased “sensory processing in pain-related areas” which together with other factors such as reduced gray matter and neurological changes in areas that control pain, added weight to the argument that changes in the perception of pain had psychological causes. Also, they felt that reduced levels of gray matter could mean that there were links between brain changes and disturbances of cognitive processes, and an association between neurochemical deviations and abnormal patterns of sleep. Summarizing these and other findings, the authors of the paper concluded that some of the symptoms of fibromyalgia are linked with brain changes or dysfunctions, giving credence to the view that fibromyalgia is a psychologically-related disorder.
Stahl, a well-known expert in the field of psychiatry and author of numerous books, published an article in 2001 entitled “Fibromyalgia: The Enigma and the Stigma.” He described how fibromyalgia has a long history of dubious diagnoses but in the current century is at last being recognized. In terms of an enigma, this label has been applied because its causes have long been a mystery. Although the obvious and evident symptoms are chronic pain, Stahl suggested that the origins may actually involve abnormal neurotransmission or poor regulation of HPA, although admitting that the actual causes remain uncertain.
The relevance of “Stigma” in Stahl’s title is that because a significant number of fibromyalgia sufferers have depression problems and some have anxiety issues, too. He poses the rhetorical question that if those mental disorders are removed from the equation, is what remains a “real” illness? In other words, fibromyalgia is perceived by some to be mental issues being manifested in the form of symptoms of a purely physical nature, the pain serving as an unconscious expression of an unhappy existence.
However, according to Stahl, that “rather unsympathetic and old-fashioned point of view” is giving way to regarding the condition as just as real as other disorders such as “obsessive-compulsive disorder, social anxiety disorder, and other previously ill-defined entities” that were equally thought to be imaginary until it was found they could be treated by antidepressant drugs. He also noted that disorders of a psychiatric nature often occur in tandem with other conditions, which lends credence to the view that fibromyalgia is similar to other psychiatric conditions that are recognized today.
Regarding typical sufferers, Stahl noted that over three quarters of all affected individuals are women, a fact that has been recognized and has resulted in targeted studies underway to design appropriate and effective treatments. One avenue that Stahl reported has been explored is the use of “tricyclic antidepressants and selective serotonin reuptake inhibitors”, although definitive success has not yet been achieved. He also noted that other approaches such as physical exercise training may be helpful.
Just as psychotherapy can improve the results with patients on antidepressants, Stahl believes that treating fibromyalgia on a multidisciplinary basis may be the most effective. Overall, he concluded that while there are still unresolved issues to deal with, fibromyalgia is being recognized in both the medical and psychiatric fields as a legitimate disorder.
Also supporting the argument that fibromyalgia has psychological roots, a New York Times article entitled “Fibromyalgia In-Depth Report” (n.d.), described the disorder as “a syndrome of unknown causes that results in lasting, sometimes debilitating, muscle pain and fatigue.” However, having given it that label, the article indicated that it is believed by many experts to be “not a disease, but is rather a chronic pain condition brought on by several abnormal body responses to stress.” It also noted that people with the condition have abnormalities in the areas of the brain that control moods and the emotional links with pain, which could also be the cause of their depressive state and why opioid painkilling medications often prove less effective for them.
As well as mentioning the abnormal levels of certain brain chemicals like serotonin, etc, also noted in the Gupta and Silman paper discussed earlier, the New York Times “Fibromyalgia In-Depth Report” article also reports the incidence of disrupted sleep patterns, although – like Gupta and Silman – it questions whether the sleeping disorder comes first. This article also discussed treatments recommended for fibromyalgia. Interestingly, bearing in mind that increasingly it is being considered as a psychological disorder, the article noted that the “American Pain Society Fibromyalgia Panel recommends a combined approach using cognitive-behavioral therapy, education, medication, and exercise.” It also noted that the treatments provided are aimed not only at relieving the symptoms, but at altering the patient’s ideas about the condition and in teaching them ways of behaving that assist them in coping with its effects. Those behaviors importantly include various techniques to reduce stress.
The National Fibromyalgia Association (NFA) added further weight to the body of opinion that suggests the cause of the condition is psychological, describing the cause as “a disorder of central processing with neuroendocrine/neurotransmitter dysregulation.” This statement was contained in an article on the NFA website entitled simply “Causes” (n.d.). It explained that due to that brain processing disorder, the pain felt by a sufferer is amplified.
“Causes” continued on to report that studies have indicated that individuals may be more susceptible to fibromyalgia for genetic reasons, and can be either a slow-developing condition or can be triggered as a result of trauma. It is thought that the event(s) may activate what was an undetected but existing physiological condition. Although the article noted that the precise causes are still unknown, recent research in the fields of “brain imaging and neurosurgery” is being used to determine whether the root cause of fibromyalgia is an abnormal level of perceiving pain due to a central nervous system defect of an interpretative nature.
A fairly comprehensive source of information about fibromyalgia (including its possible causes) was provided by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), in an article entitled: “Questions and Answers about Fibromyalgia” (n.d.). Under the heading “What Causes Fibromyalgia?” the article echoed what has been published in most of the other sources researched; i.e. that the precise causes are not yet known, although traumatic or stressful events seem to trigger it in some individuals.
It also reported that researchers are considering possible causes including the way pain is processed by the central nervous system. Further, the article reported speculation by some experts that the cause may be gene-related; i.e. that those people with fibromyalgia more often possess certain genes that cause them to react in a more extreme way to certain stimuli that others would not classify as painful. Presumably because this is a promising line of research, the article indicated that NIAMS is supporting research into that and other possible causes.
Still supporting the belief that fibromyalgia is of psychological origin, but describing the nuts and bolts of the causes, is an article entitled “The Pain is in the Brain of Fibromyalgia Syndrome: Part 1” (October 2011). It stressed the need to understand two main concepts of “pain biology”, which it termed “central sensitization and descending inhibition.” It described both those terms as changes affecting a person’s central nervous system, which alter the way that individual feels painful sensations. The article reminded readers at this point that what feels painful to one person may not be so for someone else. It then stated that fibromyalgia pain results from “permanent neural plasticity changes creating a state of central sensitization maintained by peripheral painful input with impairment in descending pain modulation.” The article continued by explaining that rather technical statement in lay terms, as follows: “permanent neural plasticity” is referring to the central nervous system’s normally positive ability to change (to learn and to improve) in the case of fibromyalgia sufferers does not function in the correct way. As regards the remainder of that technical-sounding statement, “central sensitization” means the process in which all pain signals are processed centrally via the spinal cord to the brain. The part about “impairment in descending pain modulation” referred to the process in normal people (those without fibromyalgia) whereby the brain inhibits some of the pain signals coming from peripheral areas of the body before they reach the brain. In the case of fibromyalgia sufferers that descending system function is not there. The basic cause is associated with the fact that there are different types of nerves that detect and transmit pain signals, some types reacting to pain signals faster than others, for example. The type concerning us in the case of fibromyalgia is known as the C-fiber and is termed a “slow-conducting nerve.” As mentioned in the article by Gupta & Silman referenced in this paper, increased levels of a neurotransmitter called substance P may be the cause of these nerves malfunctioning, so that pain is felt when it really should have been inhibited if the system was functioning properly.
Even though the greater body of informed opinion is focused on psychological causes for fibromyalgia, most of the articles researched admitted that the precise causes are still unknown. That is also true of an article published by Gonzalez et al. in Psicothema (a Spanish journal) in 2011, entitled: “Sleep architecture in patients with fibromyalgia.” However, the authors did note under the sub-heading Discussion and conclusions (p. 371) that “There is evidence of the existence of anomalous psychophysiological processes in the origin of fibromyalgia.” So although the precise causes are as yet not determined, the weight of evidence among professionals is certainly in favour of psychological rather than organic origin.
Naturally, because the causes have not yet been pinned down, there are conflicting opinions on the matter. “Fibromyalgia is not a mental disorder” (2012), a piece published on a forum website by (presumably) a medical professional appears to take the opposite view. The author is presumed to be a medical professional because the piece begins: “I have seen over 5,000 fibromyalgia patients over the past 20 years.” and although the article claimed that treatment of “underlying psychological problems does not cure FM” it did also state that “fibromyalgia cannot be considered a primarily psychological disorder, but as in many chronic conditions, psychological factors may play a role”. So whilst the title appeared to conflict with the majority view, the content was not so definite, offered no substantive evidence to support the opposing view, and made room for at least the possibility that psychological factors have a causatory input.
In order to present a more balanced argument, this researcher aimed to refer to other sources claiming that fibromyalgia is not of (at least in part) psychological origin, but extensive searches failed to uncover any such opinion. That in itself bears testimony to the almost complete strength of the view that psychological factors are at the root of the fibromyalgia syndrome.
Conclusions
Although practically all of the information obtained through researching this topic conceded that the precise causes of fibromyalgia are as yet not determined, the vast preponderance of informed opinion is that the causes are psychologically rather than organically related. Much of the detailed research studies have focused on imperfect processing of pain stimuli by the central nervous system and/or the brain, although the reasons for such malfunctions are attributed to various causes such as physical or emotional trauma or even genetic factors.
Whilst the research to date has not yet pinpointed the cause(s) of the condition, the recent developments in brain imaging and neurosurgery as reported in the “Causes” article published on the NFA website offer hope that further research will identify the cause of this debilitating syndrome, that will then facilitate more effective treatment for fibromyalgia sufferers.
References
Borigini, M. (Jan 2011). “Fibromyalgia: The Choice Between Swimming and Drowning in Emotion Is Not Unique?” Psychology Today. Retrieved from http://www.psychologytoday.com/blog/overcoming-pain/201101/fibromyalgia-the-choice-between-swimming-and-drowning-in-emotion-is-not-
“Causes.” (n.d.). The National Fibromyalgia Association (NFA). Retrieved from http://fmaware.org/site/PageServer06af.html?pagename=fibromyalgia_causes
Ceko, M., Bushnell, M., C., & Gracely, R., H. (2011). “Neurobiology Underlying Fibromyalgia Symptoms.” Hindawi Publishing Corporation, Pain Research and Treatment Volume 2012, Article ID 585419, 8 pages, doi:10.1155/2012/585419. Retrieved from http://hindawi.com/journals/prt/2012/585419/ref/
“Fibromyalgia.” (updated Nov 2012). Centers for Disease Control and Prevention (CDC). Retrieved from http://www.cdc.gov/arthritis/basics/fibromyalgia.htm
“Fibromyalgia In-Depth Report.” (n.d.). New York Times Health. Retrieved from http://health.nytimes.com/health/guides/disease/fibromyalgia/print.html
“Fibromyalgia is not a mental disorder.” (2012). Phoenix Rising. Retrieved from http://forums.phoenixrising.me/index.php?threads/fibromyalgia-is-not-a-mental-disorder.18347/
Gonzalez, J., L., B., Fernandez, T., V., S., Rodriguez, L., A., Muniz, J., Giraldez, S., L., & Fernandez, A., A. (2011). “Sleep architecture in patients with fibromyalgia.” Psicothema 2011. Vol 23, No. 3. Pp 368-373. Retrieved from http://www.psicothema.com/pdf/3896.pdf
Gupta, A., & Silman, A., J. (2004). “Psychological stress and fibromyalgia: a review of the evidence suggesting a neuroendocrine link.” Arthritis Research & Therapy, v.6(3); 2004; U.S. National Library of Medicine. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC416451/
“Questions and Answers about Fibromyalgia.” (n.d.). National Institute of Arthritis and Musculoskeletal and Skin Diseases. Retrieved from http://www.niams.nih.gov/Health_Info/fibromyalgia/#h
Seaton, Dr. P. (n.d.). “How Can a Psychologist Help?” Dr Pamela Seaton & Associates. Retrieved from http://www.drpamelaseaton.com.au/infofibromyalgia.htm
Stahl, S., M. (2001). “Fibromyalgia: The Enigma and the Stigma.” The Journal of Clinical Psychiatry, 2001 Jul;62(7):501-2. Retrieved from http://www.psychiatrist.com/pcc/brainstorm/br6207.htm
“The Pain is in the Brain of Fibromyalgia Syndrome: Part 1.” (October 2011). Fibromyalgia.com. Retrieved from http://www.fibromyalgia.com/symptom-control/item/46-the-pain-is-in-the-brain-of-fibromyalgia-syndrome-part-1
