I read this article today in Current Psychiatry online magazine. It is a peer-reviewed magazine, meaning the articles are written for and to other psychiatrists. So reading it was kind of like listening in on their private conversation about Fibromyalgia – I didn’t understand some of the technical terms used, but it was enlightening to read how the psychiatric world views Fibromyalgia and patients diagnosed with it. I have to say, I think they get it! At the very least the doctor who wrote the article does.
Sharon B. Stanford, MD is the Assistant Professor of Psychiatry and Family Medicine, Assistant Director, Women’s Health Research Program, University of Cincinnati College of Medicine. The article is partly an examination of the current drugs approved and used in the treatment of Fibromyalgia, and Dr. Stanford discloses that she receives grant/research support from several drug companies, but beyond the drug exploration, Dr. Stanford has written a very accurate and empathetic report on Fibromyalgia. She even touches on a recent conversation we had here on FibroHaven – which came first, the pain or the emotion.
Stanford offers Ms. D as a cases study:
Ms. D, age 50, has a history of migraine headaches and is referred by her primary physician for evaluation of depression and anxiety. She reports deteriorating mood over 6 months, beginning when a minor car accident left her “very sore the next day.”
“Nothing helps” the persistent pain in her back, shoulders, and thighs, which she rates as 7 to 8 on a 0-to-10 pain scale. She describes an intense ache, “like having the flu,” that worsens with activity and in stressful situations. She also experiences nausea and intermittent diarrhea, debilitating fatigue, and sleep disturbance.
Ms. D reports she is depressed because she feels “just too tired” after work to keep up with social activities or housework. Her physician’s referral notes a normal physical exam except for tenderness over her upper back and hips. Laboratory testing is negative.
As you elicit more details about Ms. D’s mood, she continues to focus on her physical symptoms. She states that some days she wishes to die because her pain gets so bad, but she denies any plan or intent to harm herself. She worries that her symptoms will worsen and that she will become completely disabled.
Her primary physician attempted to relieve Ms. D’s pain with multiple trials of nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclobenzaprine. She says she gained no benefit from the NSAIDs and discontinued the muscle relaxant because it made her too sleepy.
Sound familiar? We all understand the horrible cycle of pain Ms. D is in and the frustration she is experiencing just hoping and looking for some relief. Dr. Stanford is frustrated too and here is the treatment she proposes for Fibromyalgia patients.
TREATING THE WHOLE PATIENT
As a clinician who specializes in fibromyalgia, I counteract my patients’ and my own frustration with this condition by structuring office visits, determining realistic treatment goals, and treating all symptoms as part of a common syndrome rather than individual illnesses.
Structure office visits. Before every visit, have patients rate each symptom domain and write their top 2 or 3 concerns for that day (Click here for a sample form). Focusing on the patient’s most troublesome symptoms can help both of you feel greater satisfaction with treatment.
Educate patients. Ask them to discuss their beliefs about fibromyalgia; many know others with this condition or have researched diagnosis and treatment. Before developing a treatment plan, explain that their symptoms are chronic and all part of the same syndrome. Describe their pain as a complex phenomenon with possible peripheral and CNS components. Guide them to reputable Web sites and resources (see Related Resources).
Set realistic expectations. Many patients expect to resume an energetic and pain-free life, which usually is not the case with fibromyalgia (Box). Most medications are considered successful if they reduce pain by 30% to 50%, and side effects can be problematic. Discuss side effects before treatment begins to reduce patients’ anxiety and improve compliance in the first weeks.
Cognitive-behavioral therapy (CBT) for fibromyalgia incorporates relaxation techniques, helping patients view symptoms as manageable, reinforcing adaptive coping skills, and teaching them how to monitor thoughts, feelings, and behavior to change the view that they are helpless victims. A modest course of 6 weekly group CBT sessions significantly improved physical functioning in 25% of fibromyalgia patients (n=76) compared with 12% in a standard-care group (n=69), even though patients’ pain severity did not improve.16
Recommend exercise, lifestyle changes. Aerobic exercise can significantly improve well-being and physical functioning in fibromyalgia patients.17 Low-impact aerobics, such as done in warm water, usually are well tolerated, although any low-impact exercise can help. Because fibromyalgia symptoms often increase with physical activity, counsel patients to begin with a few minutes daily and increase very slowly each week.
Lifestyle changes are as important as medications in controlling fibromyalgia symptoms. In addition to exercise, recommend that patients:
- follow a daily routine
- pace activity to avoid exacerbating symptoms
- reduce stress.
Sometimes, I use the analogy of diabetes: treating fibromyalgia with medication but without changing lifestyle is like prescribing medication for a diabetic patient without changing diet. Follow up on this “homework” at each visit to reinforce that patients helping themselves is an important part of treatment.
There is nothing “murky” about Dr. Stanford’s approach to Fibromyalgia. I appreciate that her approach is to treat the WHOLE patient, not just individual symptoms, and she provides resources to help the patient and the doctor. Click on the sample form above. I think it is a great tool to use before any doctors visit. How often do we forget or feel too rushed to cover everything we intended at an appointment? This sheet will help improve communication between patient and doctor. The link to the box is also a useful summary on managing unrealistic expectations of Fibromyalgia patients. It is worth the read.
Even though I chose drug-free management for my Fibromyalgia, I was able to appreciate Dr. Stanford’s article very much. She clearly cares and is invested in helping her Fibromyalgia patients. Her article will help countless other psychiatrists treat their FM patients as well. And it is another step forward in promoting Fibromyalgia Awareness and Visibility.