What is fibromyalgia?
Fibromyalgia is an alteration in the way the central nervous system perceives and processes pain.
In simple terms, the main problem is not necessarily located in every muscle or joint that hurts. It lies in the computer that receives, interprets and amplifies the signals.
The brain may interpret normal stimuli as painful and amplify signals that would cause much less discomfort in another person.
The pain is real even when tests are normal
A person may experience severe, widespread pain even when laboratory tests, X-rays and other studies are normal.
This does not mean that the pain is invented. It means that the problem is not necessarily a visible tissue lesion, but the way the nervous system processes information.
Fibromyalgia does not destroy the joints, but it can profoundly affect sleep, energy, concentration, activity and quality of life.
Diagnosis is not made with a single test
No blood test, X-ray or MRI can diagnose fibromyalgia by itself.
The diagnosis is clinical and requires listening to and examining the patient and determining whether another disease better explains the symptoms.
Previous studies and diagnoses can provide important information for reconstructing the history and excluding other causes.
Criteria classify; they do not diagnose
Questionnaires and lists of criteria are often used as though they were diagnostic tests.
They are primarily classification criteria. They were created to organize groups of patients, especially in research, not to replace clinical judgment.
A person should not automatically be diagnosed with fibromyalgia simply because a questionnaire or score reaches a threshold.
It can coexist with other diseases
Fibromyalgia can exist by itself or together with another disease.
A person may have fibromyalgia and, at the same time, lupus, rheumatoid arthritis or another rheumatic disease. This may be called an overlap.
This distinction is essential because not all pain in someone with lupus or rheumatoid arthritis is necessarily due to inflammation. Some symptoms may come from the inflammatory disease and others from altered pain perception.
If the source is not distinguished correctly, medicines for lupus or arthritis may be increased even though inflammation is already controlled and the remaining pain comes from fibromyalgia.
The opposite can also occur: attributing every symptom to fibromyalgia and missing a true inflammatory disease.
Diagnosis can be complex
Fibromyalgia is not always a simple diagnosis.
Before reaching that conclusion, we should assess whether an inflammatory, endocrine, neurological, muscular or other condition better explains the symptoms.
For me, the important thing is not to give pain a name quickly. It is to understand what the person truly has and find the best way to help.
If, after careful assessment, I believe it is not fibromyalgia, I must continue searching for the real cause of the symptoms.
A clinical observation about men and women
In my experience, fibromyalgia occurs almost exclusively in women.
Over many years of practice, I recall only three male patients in whom the diagnosis was considered: one was a child and the other two were adults with severe psychological problems. In those cases, there was always uncertainty about how much was truly fibromyalgia and how much could be related to somatization.
This is an observation from my clinical experience. I do not use it to dismiss a man's symptoms automatically, but it makes me especially careful before making the diagnosis.
If a man has widespread pain, I consider it essential to investigate other possible explanations thoroughly.
Usual age at onset
Fibromyalgia usually begins in young women.
When someone first develops similar symptoms after age 50, the diagnosis should be assessed with particular caution. Late onset is unusual, and at that age inflammatory diseases and other conditions can resemble fibromyalgia.
Widespread pain with initially normal tests should not automatically be assumed to be this disease.
Factors that can complicate the prognosis
Prognosis does not depend only on pain intensity.
In my experience, the course is often more difficult when major personality disorders, depression, anxiety or severe psychological problems are present.
It is also particularly difficult when the person cannot tolerate medicines. Some patients report adverse effects with virtually everything they receive, even at very small doses. This limits options and makes sustained improvement much harder.
Recognizing these factors does not mean blaming the patient. It means understanding why some people improve relatively easily while others require much more complex management.
Exercise and education are necessary, but may not be sufficient
Exercise is a fundamental part of treatment. So is understanding what is happening and abandoning the idea that every episode of pain represents a new injury.
However, in my experience, telling a person to exercise, sleep better and learn about the disease is often insufficient when used as the only strategy.
Many people also need medication to reduce pain amplification so that they can begin to sleep, move and function better.
Exercise is necessary, but a person in severe pain is unlikely to begin or maintain it unless some degree of symptom control is achieved first.
Treatment must be adapted to each person
Not every patient responds to the same medicine or requires the same management.
Treatment may require a combination of education, progressive exercise, better sleep, psychological or psychiatric support when appropriate, and medicines aimed at modifying pain perception.
The goal is not to eliminate every bodily sensation. It is to reduce pain to a level that allows recovery of activity, sleep and quality of life.
The role of Psychiatry
Referring someone to Psychiatry does not mean that their symptoms are false or that the physician wants to get rid of them.
If I identify a condition that would benefit entirely from psychiatric management, I make the referral and may discharge the person from my practice.
If the person needs rheumatologic and psychiatric care at the same time, we can work together.
The goal is not to hold onto patients or keep them indefinitely under a rheumatologist's care. It is to recognize which professional can help best at each point.
I am not concerned with whether the final diagnosis is fibromyalgia, lupus, arthritis, depression or another disease. I am concerned with identifying what is happening and finding the most appropriate way to help.