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Ask the Mental Health Expert Archives 2001-2004

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Fibromyalgia and Psychiatry

Q. I developed chronic pain from a work-related injury. It took one year before an orthopedist diagnosed it. She is going to refer me to a pain management program at a nearby medical school.

About half-way through the year while continuing to work with increasing pain, I developed fibromyalgia. My care was transferred back to my family physician for this. This has resulted in my family physician distancing himself from me since fibromyalgia is supposed to stem from depression which requires psychiatric treatment. Also, fibromyalgia pain is a chronic pain disorder, and requires the possible use of opiods which may result in addiction because nothing really works for the pain of fibromyalgia. Therefore, I should see a psychiatrist.

This would be fine, except I have already been under treatment for dysthymia for the past two years quite successfully prior to all of this with the exception of lifelong fatigue which has never been touched by any medication. Should I ask my psychiatrist to try to treat my fibromyalgia also? Are they qualified? I currently take Celexa and was quite pleased with the results until the injury and the increasing chronic pain. Who should I consider for treatment of this condition if not a psychiatrist?

A. I can appreciate your frustration and confusion regarding fibromyalgia. Despite a good deal of research, the jury is still out on precisely what causes this condition, as well as how (and by whom) it should be treated. Indeed, the existence of a single condition called fibromyalgia is still a matter of some debate. Some clinicians regard fibromyalgia as a rheumatological (inflammatory) condition with both physical and psychological symptoms.

Others see it as an atypical form of depression. I personally am not convinced that fibromyalgia can be considered a psychiatric disorder, or that it simply stems from depression. There is growing evidence that fibromyalgia is associated with (if not caused by) a variety of hormonal (endocrine) and sleep abnormalities, including a peculiar sleep disorder called alpha-delta sleep. This amounts to the intrusion of the waking state brain rhythm into deep (delta) sleep.

I have seen patients go many years without this sleep pattern being recognized, since it requires an overnight sleep study called a polysomnogram. Usually, small doses of a tricyclic antidepressant (rarely used nowadays) can be helpful with this sleep disorder, and may also help with the pain of fibromyalgia. A variety of approaches may be helpful in fibromyalgia, including not only antidepressants, but special exercise programs, supportive counseling, and even acupuncture. (For a review of these issues, you might want to read the article by Millea & Holloway in the American Family Physician, Oct. 2000, pp. 1575-82).

I personally would recommend seeing a rheumatologist for a complete evaluation of chronic pain/chronic fatigue. He or she may then have further recommendations regarding other specialists (or family practitioners, etc.) who may be helpful, including possibly a sleep disorders specialist. Another approach would be to enroll in a comprehensive pain treatment center that could draw on a variety of specialists, and provide an integrated treatment regimen for you to follow. This would not preclude your continuing to see your psychiatrist, or your family physician, but ideally, both should be comfortable with whatever approach you take. Furthermore, though this rarely seems to happen, your doctors should be consulting with each other on the best plan of action. I hope you are able to get some help with this frustrating situation.

March 2002

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