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Facts and myths pertaining to fibromyalgia

Fibromyalgia (FM) is characterized by chronic widespread pain, unrefreshing sleep, physical exhaustion, and cognitive difficulties. It occurs in all populations throughout the world, with prevalence between 2% and 4% in general populations. Definition, pathogenesis, diagnosis, and treatment of FM remain points of contention, with some even contesting its existence. The various classification systems according to pain medicine, psychiatry, and neurology (pain disease; persistent somatoform pain disorder; masked depression; somatic symptom disorder; small fiber neuropathy; brain disease) mostly capture only some components of this complex and heterogeneous disorder. The diagnosis can be established in most cases by a general practitioner when the symptoms meet recognized criteria and a somatic disease sufficiently explaining the symptoms is excluded. Evidence-based interdisciplinary guidelines give a strong recommendation for aerobic exercise and cognitive behavioral therapies. Drug therapy is not mandatory. Only a minority of patients experience substantial symptom relief with duloxetine, milnacipran, and pregabalin.

Many physicians—particularly rheumatologists, pain specialists, and general practitioners, but also mental health care specialists—have experience of patients who describe chronic widespread pain (pain all over the body), which is associated with a range of other symptoms including poor sleep, fatigue, and depression. This complex set of symptoms is now recognized as fibromyalgia (FM), but remains a challenging concept for numerous reasons.

FM is “a bitterly controversial condition.” FM “wars” are fought on the legitimacy and clinical usefulness of the diagnostic label “FM,” the nosological classification, suggested etiology and pathophysiology, “ownership,” and the preferred treatment options.

In the past 30 years, the scientific publications on FM have increased considerably. This surge might be explained by an increased awareness and shared interest of a number of stakeholders, including the patients who are suffering, patient self-help organizations, clinicians, researchers, and the pharmaceutical industry. This recognition of FM will serve to promote research to understand the underlying pathophysiology and thereby improve therapy. Beyond the altruistic goals of understanding and treating an illness, other factors may play a role in the attention given to FM, including the legitimization of symptoms and sickness for patients, influence for academics, economic gain for pharmaceutical companies, and legal interests.

It is our opinion that some FM “wars” are fought because of the belief systems of medical and psychological specialties, the interests of patient self-help organizations, financial advantages for the pharmaceutical industry, and personal academic advancement, rather than the objective of valid scientific and clinical progress. Within these disputes, we may observe strong opinions about the nature of FM and treatment recommendations that are contrary to mainstream medicine and the current scientific knowledge. These we identify as the myths of FM.

In this paper, we discuss some of the myths concerning FM, with a special focus on those extolled by mental health specialists (psychiatry, psychosomatic medicine, and clinical psychology) and neurologists. We have based our facts on the interdisciplinary evidence-based clinical guidelines on FM of Canada, Germany, and the European League Against Rheumatism (EULAR). High-quality guidelines, based upon the best available scientific evidence and the clinical experience and consensus of patients with all specialties involved in the management of a disease, are designed to overcome dogmatic belief systems and to give patients, their families, and clinicians a guide to navigate the diagnostic and therapeutic challenges of FM, while respecting the societal context of fiscal responsibility within health care systems.

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