Common Clinical Sub-types of Fibromyalgia

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This section is based on the author’s clinical experience and not on formal prevalence studies of each sub-type. There are almost certainly other important sub-types.

Battered woman[edit]

Based on anecdotal experience by the author in his inner-city practice in Toronto from 1997—2010, I have the strong impression that battered women are a clinical sub-type of fibromyalgia involving cycles of violence. It is not hard to imagine how this could greatly agitate the fibromyalgia vortex.

“Intimate partner violence has been associated with fibromyalgia and many other disorders. (Intimate Partner Violence and Its Health Impact on Disproportionately Affected Populations, Including Minorities and Impoverished Groups, Jamila K. Stockman, PhD, MPH, 1 Hitomi Hayashi, MPH,2 and Jacquelyn C. Campbell, PhD, RN, FAAN3 J Women's Health (Larchmt). 2015 Jan 1; 24(1): 62–79, available in full online at:

A study by Ruiz-Perez et al found that “frequency of abuse was positively and significantly correlated with fibromyalgia.” (Risk factors for fibromyalgia: The role of violence against women, Isabel Ruiz-Pérez, Juncal Plazaola-Castaño, Rafael Cáliz-Cáliz, Isabel Rodríguez-Calvo, Antonio García-Sánchez, Miguel Ángel Ferrer-González, Manuel Guzmán-Úbeda, María del Río-Lozano &Isabel López-Chicheri García. Clinical Rheumatology 28(7):777-86, DOI: 10.1007/s10067-009-1147-6, available in full online at:

Imperilled offspring[edit]

This is the author’s term for the clinical situation in which fibromyalgia develops in a pregnant woman or a new mother in the context of worry over the fetus or baby. In the author’s experience, this is one of the most common precipitants of fibromyalgia. Also, in his experience the patient develops light or worsening of sleep due to worry. The author believes that the problem is driven material instincts to protect the offspring. The situation often involves medical problems during the pregnancy in which the mother comes to believe that her fetus in imperilled. Also common is a situation in which the newborn has a medical problem, such as a respiratory problem and the mother sleeps too lightly because her brain in on guard to detect if the breathing of the infant become s irregular so that she is ready to spring into immediate action to help the infant. There is overlap between Moldofsky’s concept of tired mothers and the concept of imperilled offspring. I prefer my characterization because in my opinion the fundamental issues are worry and what I call “danger mode”. In my experience this occurs in some women who are pregnant but not yet mothers.

Tired mothers[edit]

I have observed that a substantial percentage of my fibromyalgia patients started off as tired mothers. Dr. Harvey Moldofsky communicated to me that he had a thought to start a fibromyalgia prevention program called “Tired mothers”. He observed fibromyalgia in mothers, especially if there is a sickly child that the mother watches over in her sleep. He gives the example of a mother whose child had asthma, and the mother worried about the child’s breathing. I have met a number of mothers whose fibromyalgia could be traced to have started shortly after the birth a child.

Caregiver burnout[edit]

According to the Cleveland clinic caregiver burnout is a state that involves a combination of physical, emotional and mental exhaustion which can be accompanied by adopting ad negative or unconcerned attitude on the part of the caregiver along with fatigue, stress, anxiety and depression. (Jan 13, 2019,

Based on the author’s experience, some patients with fibromyalgia get flare ups in the process of demanding and stressful care of a loved one. One patient had an aged mother with Alzheimer’s which caused great strain on the caregiver rand she exhibited flareups under the strain. Management of such cases might call for some form of caregiver relief.

Difficult pregnancy or menopause[edit]

In the clinical experience of the author, many of the patients referred to him were women who developed fibromyalgia during a difficult pregnancy. Pregnancy can be a great strain especially if the woman is worried about her own health or the health of her fetus or both. In the experience of the author, this can throw the women into vicious cycles. For example, worrying can induce severe insomnia, and the muscle pains and fatigue can follow.

Furness et al. 2018, published a survey on what patients thought was causing their fibromyalgia. Their sample was mainly female. In it, “onset events” that were frequently identified by the patients included pregnancy, childbirth, hysterectomy, or menopause. They gave the example of a 32-year-old woman who developed extreme tiredness, brain fog and pain after a planned C-section. The authors went on to state: “Adjectives such as “difficult” (pregnancy, birth) and “traumatic” (labor) were used to reflect the psychological and physical impact of these events. In addition, there are broader impacts on a woman’s role and identity.”

They further explained that: “Pregnancy and birth represent transition to a new life stage and the onset of demands of motherhood. Menopause and hysterectomy represent the loss of reproductive capabilities, changes in hormonal function and their impact on health, alongside challenges to sexual identity, femininity, and youthful identity.”

To this, I would add that in my experience with pregnancy women and young mothers, the protective instincts are on heightened alert. Danger becomes a big theme in the mother’s mind and this seems to trigger what I call “danger mode”.

Post-traumatic fibromyalgia[edit]

See the separate entry in Fibro Wiki for Post-traumatic Fibromyalgia.

Abused as a child: sexually, non-sexually or both[edit]

Sexual or physical abuse in childhood are known risk factors for fibromyalgia (and some other central sensitization syndromes including migraine.)

It has long been the clinical impression of the author that this group was over-represented amongst patients with severe fibromyalgia syndrome such as those that have unusually strong pain or those with an inordinate number of fibromyalgia co-morbidities. This impression is based partly on several decades of work in the inner city of Toronto and partly by a long list of referrals for assessment and treatment of fibromyalgia from other doctors.) This clinical impression was confirmed by researchers at the Cleveland Clinic. They enrolled 593 fibromyalgia patients and they surveyed their symptoms and their history of abuse. Almost 38 percent of said that they had been physically and/or sexually abused at some point. Results also showed that fibromyalgia patients with a history of abuse were more likely to report severe fibromyalgia than those patients without a history of being abused.

The issue of causality[edit]

It is not unusual for doctors to point out to their sexually and physical abused fibromyalgia patients that these factors mean they were high risk to get the disorder. It is probably equally common for these health care workers to shy off from saying they believe it was an important cause of them getting ill. This sheepishness is understandable given the difficulties in proving such a theory especially since it relates to events that may have happened many years ago.

It is the clinical impression of this author based on many interviews that in many cases it is causal. This impression is based partly on timelines and partly on the views of some patients including one middle aged-women who was badly abused mentally by her mother as a child and to some degree physically abused by her. As an adult in the patient spoke about the mother with great resentment, and in an animated way almost as if the psychological wounds were fresh. The patient stated emphatically that she was sure her abuse was the cause of her fibromyalgia.

There could be legal ramifications if one could prove that another person was the direct cause of chronic pain. Few people would be willing to say they have irrefutable proof of such a thing. However, the therapist who is responsible for trying to release their patient from chronic pain, would be fool hearty to ignore this possibility as it would defeat any chance at emotional healing. In the experience of the author, some patients go into an animated lengthy recollection of all the many injustices done to them by the abuser. It is clear that filling one’s mind with negative thoughts about these injustices, which in many cases are terrible, I is counter-productive. Fortunately, modern psychology as done a lot to research ways of overcoming negative thoughts. One well known contributor is the father of CVT, Adam Beck who had a lot to say about what he called “automatic negative thoughts”. Another lesson learned is that such patients may have suffered decades of negative thoughts before they arrive at a fibromyalgia clinic. There is a great need to identify such thinking pattern much earlier in life and to begin addressing them before they become too entrenched. It is not always clear how to approach them, but one approach that his been tried is to encourage the person to forgive their abusers, not because they deserve it, but because it might give the victim some emotional peace.

One plausible explanation which deserves formal study is that during abuse the child is angry and frustrated and resentful of the treatment. This involves evaluative processing as when the child comes to belie they are victims of unfair or cruel treatment. This then has, according the theory, a spill over effect on the pain centers of the brain. This might include central sensitization and the chronic brain state referred to in this Encyclopedia as “danger mode”.

Ulysses syndrome/Strained immigration[edit]

It is the clinical impression of the author that fibromyalgia is more common in patients undergoing a difficult integration into the new society after their immigration from their original third or second world country to their new first world country, Further study is needed to verify this impression. Common themes seen by the author is the person who considered themselves a “somebody” in their country of origin, but upon arrival in the new country they face a host of problems including language issues, being unable to compete in a new work place, self-respect issues, anxiety and associated sleep problems.

Wikipedia describes Ulysses syndrome as follows: “Ulysses syndrome (Immigrant Syndrome of Chronic and Multiple Stress) is an atypical set of depressive, anxious, dissociative, and somatoform symptoms that results from being exposed to extreme levels of stress unique to the process of modern migration.[1] Rather than a mental disorder, this syndrome is a natural reaction to toxic levels of stress seen in migrants who are otherwise in normal mental health.[1]

The Ulysses syndrome has both physical and psychological symptoms.[2] These include migraines, insomnia, recurrent worrying, tension, nervousness, irritability, disorientation, fear, fatigue, sadness, gastric pain, bone pain, low self-esteem, increased tobacco and alcohol consumption, and decreased productivity.[1][3][4] A lack of social support or access to appropriate medical care may aggravate these symptoms.[4] In some occasions, patients with Ulysses syndrome are mistakenly diagnosed with another medical condition which can further impede recovery.[4]” (

Empty nest[edit]

This is based on some limited experience and needs further verification. Sometimes the patient does not volunteer that this is their main issue and it only become clear when one of their relatives, such as a child brings it to the doctor’s attention.

This is the situation in which a parent spent much of their adult life dedicating themselves to the love and care of their children. When the children grow up and leave the home, there is an emotional hole. It can create would could be called a “meaning gap”. For example, a mother with four children sees that her last child is about to leave the home. Her role as cook, protector and caregiver is disappearing. If she does not have enough hobbies and other sources of deep emotional reward. The obvious treatment is to try to find ways to fill the gap and enrich one’s hobbies and other relationships.