FACT: Individuals Suffering From Fibromyalgia Are More Likely to Suffer From Irritable Bowel Syndrome (IBS) 

Fibromyalgia and irritable bowel syndrome (IBS) frequently occur together, indicating a strong link between the two. Both are functional somatic syndromes marked by chronic pain, increased sensitivity, and functional issues without obvious structural causes. Studies show that 30-70% of people with fibromyalgia also have IBS, and the reverse is also true. This overlap likely arises from common underlying mechanisms like abnormalities in pain processing, neurotransmitter imbalances, and autonomic nervous system dysregulation. Psychological factors such as stress and anxiety, which can worsen symptoms, are also expected for both conditions. Having IBS often leads to more severe symptoms and a reduced quality of life in fibromyalgia patients, making diagnosis and management more challenging. Recognizing this connection is essential for healthcare providers to create thorough, multidisciplinary treatment plans that address gastrointestinal and musculoskeletal issues, ultimately improving patient outcomes.

FACT: Chronic Widespread Pain Remains the Defining Feature of Fibromyalgia

The International Association for the Study of Pain (IASP) established a task force for the classification of chronic pain. The goal is to create a classification system applicable in primary care and specialised pain management settings. One such category is chronic primary pain, defined as pain in one or more anatomic regions persisting or recurring for longer than three months, associated with significant emotional distress or functional disability, and not better explained by another chronic pain condition. This new definition was created due to the unknown aetiology of many forms of chronic pain. The term “primary pain” was widely accepted, especially from a non-specialist perspective. Dysfunction in pain modulation, demonstrated by allodynia and spontaneous pain, suggests that fibromyalgia could be a pain disease due to increased pain sensitivity and decreased pain inhibitory controls.

Whether fibromyalgia is solely a pain disorder remains debated. As early as 1989, Turk and Flor argued that fibromyalgia is more than chronic widespread pain and tender points. Tender points can be seen as indicators of somatic and psychological distress. The new diagnostic criteria for fibromyalgia give nearly equal weight to unrefreshed sleep and fatigue for diagnosis and even include depression as a minor symptom. The composite of symptoms in fibromyalgia patients raises the question of whether these other symptoms are merely consequences of chronic pain or critical components of the disorder. Individual patients may attribute varying importance to these comorbid symptoms, but chronic widespread pain remains the defining feature of fibromyalgia.

MYTH: Fibromyalgia is an Unhelpful Diagnosis for Both The Patient and The Doctor

It is a myth that diagnosing fibromyalgia has negative implications for both patients and doctors. Critics, particularly from psychiatry and pediatrics, argue that the “fibromyalgia” label neglects psychosocial factors, disempowers patients, and promotes unnecessary medicalization. However, proponents of the “central sensitization” theory argue that fibromyalgia can be medically explained as a neurological disorder, minimising the relevance of psychological factors like somatization or catastrophizing. The approval of pregabalin by the FDA for fibromyalgia, supported by pharmaceutical companies and patient advocacy groups, marked a significant step in legitimising fibromyalgia as an actual disease. This validation is comparable to how fluoxetine brought depression into mainstream acceptance. 

Whether fibromyalgia is a helpful diagnosis depends on the information provided to patients about the disorder, treatment strategies, and expected outcomes. Recent guidelines recommend communicating the diagnosis to reduce anxiety avoid unnecessary diagnostic procedures, and inappropriate treatments. Educating patients on the biopsychosocial model of fibromyalgia, which includes biological and psychosocial factors, is crucial. Acknowledging the legitimacy of symptoms, improving quality of life, and encouraging self-management strategies are essential components of effective treatment.

MYTH: Fibromyalgia Only Impacts Middle-Aged Women

It is a myth that fibromyalgia only impacts middle-aged women. In reality, fibromyalgia affects all populations across the world and can occur at any age. Symptom prevalence ranges from 2% to 4% in the general population. While clinical studies often show a higher prevalence among women aged 40 to 60, with a female-to-male ratio of 8-10:1, epidemiological studies using the 2011 criteria without tender point examination show a ratio closer to 1-2:1. Several hypotheses explain these gender differences. The 1990 ACR classification criteria are inherently biassed towards women due to the tender point examination, as women generally report more positive tender points than men, possibly due to a lower pain threshold.

Additionally, women in Western countries tend to seek healthcare more frequently for somatic and psychological symptoms. The perception of fibromyalgia as a “women’s disease” can lead to underdiagnosis in men and avoidance of the stigma associated with a predominantly female condition. Notably, fibromyalgia can also affect children and adolescents, meeting the criteria for juvenile fibromyalgia. However, epidemiological data on this is conflicting.

MYTH: Mental Health Medication is Effective At Treating Fibromyalgia

The belief that all psychopharmacological agents are effective for mental disorders and also alleviate fibromyalgia symptoms like pain, sleep problems, and fatigue is not supported by evidence. Among tricyclic antidepressants, only amitriptyline shows sufficient proof of efficacy. Monoamine oxidase inhibitors have limited effectiveness based on two small, biassed studies. The serotonin reuptake inhibitors such as citalopram, fluoxetine, and paroxetine lack robust evidence due to small sample sizes and other biases. While the SNRIs duloxetine and milnacipran are FDA-approved for fibromyalgia, their efficacy wasn’t confirmed in European studies. Desvenlafaxine also failed to show superiority over placebo. Pregabalin, another FDA-approved drug, did not meet primary endpoints in European trials. Gabapentin’s results were compromised by bias, and studies on eslicarbazepine, lacosamide, and levetiracetam did not demonstrate effectiveness. Although some antipsychotics are used for refractory major depression, only quetiapine has shown efficacy for fibromyalgia-related pain and sleep issues. Thus, the class effect of many agents used for mental health disorders is unproven for fibromyalgia treatment.

MYTH: Fibromyalgia Requires Tender Point Examination by a Rheumatologist for a Diagnosis

The myth that fibromyalgia is a diagnosis of exclusion requiring a tender point examination by a rheumatologist is outdated. Primary care physicians can and should diagnose fibromyalgia through a complete history and physical examination. Although the tender point examination was once common practice, it is no longer considered reliable. It is not part of the current diagnostic criteria. Despite challenges in diagnosing fibromyalgia, especially among general practitioners and psychiatrists, recent guidelines emphasise that the diagnosis is clinical. No specific lab test or biomarker exists for fibromyalgia, and the physical examination, along with limited lab tests, serves to rule out other conditions that might explain the symptoms. While various medical conditions can mimic fibromyalgia, a thorough clinical evaluation can usually differentiate them. Primary care physicians can typically establish the diagnosis, reserving specialist referrals for cases where another condition might be present. The American College of Rheumatology’s criteria focus on widespread pain and symptom severity, eliminating the need for tender point palpation.

FACT: Fibromyalgia Impacts The Brain’s Processes Surrounding Pain

The best-established pathophysiological features of fibromyalgia are those of central sensitization, meaning the brain processes pain and sensory input more intensely. This involves increased functional connectivity to brain regions that amplify pain signals, decreased connectivity to areas that inhibit pain, and changes in neurotransmitter levels and brain structure. When targeted with therapies affecting CNS function, some individuals with fibromyalgia report symptom improvement, supporting the concept that fibromyalgia is a brain disease. However, these CNS changes are not unique to fibromyalgia. Similar alterations are observed in other conditions, suggesting broader CNS-based hypotheses. These include the impact of personality traits like pain catastrophizing, dysfunction in the sympathetic nervous system, the evolutionary stress response, and activation of homeostatic neural programs. Thus, while CNS involvement is evident in fibromyalgia, it overlaps with other factors and conditions, complicating the idea that fibromyalgia is solely a brain disease.

MYTH: Fibromyalgia is a Masked Depression

Another myth is that fibromyalgia is masked depression or an affective spectrum disorder. While the lifetime prevalence of depressive disorders among fibromyalgia patients ranges from 40% to 80%, depending on the diagnostic criteria used, not every fibromyalgia patient is depressed, and not every person with depression experiences widespread chronic pain. The overlap in symptoms, such as sleep problems and fatigue, and shared biological and psychological factors, like genetic predispositions and childhood adversities, explain the frequent co-occurrence of these conditions. German guidelines clearly state that fibromyalgia and depression are distinct entities and should not be used interchangeably. This distinction is crucial for accurate diagnosis and effective treatment, ensuring that both conditions receive the appropriate attention and care.

MYTH: Fibromyalgia “Does Not Exist”

Many patients diagnosed with fibromyalgia by a rheumatologist or pain specialist often hear that “fibromyalgia doesn’t exist” from other healthcare professionals. This raises the question of what truly defines the existence of a disease. Defining a disease is complex and evolves due to advances in diagnostics and shifts in social and economic perspectives. For example, osteoporosis was once considered a normal part of ageing until the World Health Organization (WHO) officially recognized it as a disease in 1994. Suppose official recognition by the WHO is the criterion, fibromyalgia qualifies, as it has been listed under “diseases of the musculoskeletal system and connective tissue” since the ICD-10 in 1994. However, without a defined aetiology and pathophysiology, some argue that fibromyalgia is not a disease. The WHO’s term “disorder” implies a set of clinically recognizable symptoms causing distress and functional interference, fitting fibromyalgia well.

The reluctance to diagnose fibromyalgia also stems from the biomedical model’s focus on objective findings like lab tests or imaging, which fibromyalgia lacks. Diagnosis relies on a history of symptoms defined by expert consensus and clinical studies, similar to mental disorders. Fibromyalgia can be viewed as a continuum disorder, much like diabetes or depression, rather than a binary condition. Its prevalence varies with diagnostic criteria, and symptoms may fluctuate over time. People with fibromyalgia are not a distinct group but part of a spectrum of polysymptomatic distress within the population.

MYTH: Psychodynamic Therapy Can Cure Fibromyalgia

There’s a myth that psychodynamic therapy can cure fibromyalgia. Cognitive behavioural therapies are designed to help patients manage their symptoms and enhance their quality of life. However, some advocates of psychodynamic treatment argue that it can cure fibromyalgia in certain patients. This claim has been tested in only one randomized controlled trial involving fibromyalgia patients with major depression. In this study, brief psychodynamic therapy (25 weekly sessions) was compared to supportive treatment, which included antidepressant and analgesic medication (four sessions over six months). The results showed no significant difference between the two treatments regarding somatic and psychological symptoms or health-related quality of life. Therefore, there is no substantial evidence supporting psychodynamic therapy as a cure for fibromyalgia.