- 1 Definition
- 2 Precipitating traumatic events
- 3 Role of motor vehicle accidents and criteria for causality
- 4 Patients traumatized by surgery or scary illness
- 5 Trauma by torture cases that were successfully treated
- 6 War trauma
- 7 A traumatized artist who developed fibromyalgia
- 8 Additional comments on post-traumatic fibromyalgia based on the author’s clinical experience
- 9 A case history of fibromyalgia by Mailis et al.
- 10 Milstein et al.’s case history of post-traumatic fibromyalgia
- 11 The critical need for early diagnosis of post-traumatic fibromyalgia
- 12 Dissenting and supporting opinions to the existence of post-traumatic fibromyalgia
This is fibromyalgia that starts after a trauma or series of traumas. Examples include previously well soldiers who are traumatized in war and who then develop fibromyalgia as consequences of all the upheavals. Many cases come on after motor vehicle accidents or a series of them.
Precipitating traumatic events
A ten-year study of 176 people with post-traumatic fibromyalgia found that the onset of symptoms was preceded by:
- A motor vehicle accident in a 60.7%
- A work injury in 12.5%
- After surgery in 7.1%
- After a sports-related injury in 5.4%
- various traumatic events in 14.3%
(Post-traumatic fibromyalgia. A long-term follow-up. Waylonis GW1, Perkins RH. Am J Phys Med Rehabil. 1994 Nov-Dec;73(6):403-12.)
[Author’s comment: There are other ways to characterize the precipitating traumas. In the experience of the author it also occurs in some patients after a fall. It is well known to occur in others after a traumatic war experience. Other cases occur when there is a difficult pregnancy or when the infant is ill and there is an emotional and sleep strain on the mother.]
Role of motor vehicle accidents and criteria for causality
McLean et al. state”: “The evidence that MVC trauma may trigger FM meets established criteria for determining causality, and has a number of important implications, both for patient care, and for research into the pathophysiology and treatment of these disorders.” (Fibromyalgia after motor vehicle collision: evidence and implications. McLean SA1, Williams DA, Clauw DJ. Traffic Inj Prev. 2005 Jun;6(2):97-104.) They further explain: “MVC trauma appears capable of triggering FM, but generally not through direct biomechanical injury. Instead, the evidence suggests that MVC trauma can act as a "stressor," which in concert with other factors, such as an individual's biologic vulnerability, psychosocial factors, cultural factors, and so on, may result in the development of chronic widespread pain and other somatic symptoms. MVC trauma is only one of many stressors which can trigger such disorders, and the environment within which the stressor is experienced (biological and psychosocial) may largely determine whether there is an adverse physiologic result or not.” This statement is consistent with the author’s concept of the fibromyalgia vortex.
For further perspective see the entry Fibromyalgia, The Danger Hypothesis of.)
Patients traumatized by surgery or scary illness
Trauma is used here in its psychological meaning. Many cases come on after a car accident, even a minor car accident. Any sudden very disturbing event can be traumatic including such things as some divorces or other illnesses that scare the patient. For example, an attack of pneumonia with hospitalization and the attendant fears that go with weakness and shortness of breath can be traumatic. Railway spine is an old variation on this theme. The author has seen a number of cases of post-traumatic fibromyalgia developing after surgery including two separate cases coming on after thyroidectomy. Post-surgical fibromyalgia can be considered a variant of post-traumatic fibromyalgia. In one of the post-thyroidectomy cases it was found that for this patient the neck had a very special meaning because she said she had been traumatized as a five-year-old. Her memory of the event was of a male baby sitter tying her up around the neck. (For further perspective see the entries Railway Spine and Litigation as an Illness Trap.)
Trauma by torture cases that were successfully treated
A study by Danneskiold-Samsøe of 21 torture victims that had experienced “both physical and psychological torture, over nine months” stated that a “high percentage of the torture victims in our study suffered from fibromyalgia prior to treatment” Their multidisciplinary treatment has excellent results which may have wide implications for general treatment guidelines for fibromyalgia. What is not clear is exactly how the psychotherapy was conducted. We know it was in depth and that it lasted for months, but there could have easily been hundreds of messages, pieces of advice and opportunities for the patient to explain and confront their ideas and feelings in this period. Much could likely be learned from the therapists. They likely had special skills and intuitions that are not easy to described or teach.
The therapy was a combination of “individualised physiotherapy and psycho-therapy”. The physiotherapy “comprised elements such as massage, exercise on land, balance training and stimulation of proprioception, all aiming at regaining body awareness”. Results showed that there was a highly significant decrease in muscle pain.
It seems the treatment was an extraordinary success as the authors stated: “Following nine months of treatment, only one torture victim in our study could be classified as suffering from fibromyalgia when applying the fibrositis index.” (Treatment of torture victims--a longitudinal clinical study. Danneskiold-Samsøe B1, Bartels EM, Genefke I. Torture. 2007;17(1):11-7, available in full online at: https://www.researchgate.net/publication/6372068_Treatment_of_torture_victims_-_A_longitudinal_clinical_study
These authors have provided us with a highly instructive explanation of their approach. They highlight their opinion that there is a critical need to establish an atmosphere of safety and trust. They wrote: The authors provided a number of details of their treatment which could be very useful when designing new, more formalized CBT treatment of fibromyalgia. Here are some of the highlights:
- They used a multidisciplinary treatment that was described by Bloch & Høhne
(See: Bloch I, Høhne L. Fysioterapi til torturofre. København: Munksgaard, 1989.)
- The treatment went for nine months (which is much longer than traditional CBT, but it seems reasonable for complex situations)
- All patients had psychotherapy treatment alongside the physiotherapy
- The physiotherapy focused on the torture victim’s main pain problems. The physiotherapist and the rheumatologist planned the treatment. The authors make a special note of saying that this aspect of the treatment took the particular torture that the victim has been exposed to into account.
- Creating a safe environment for the patient is critical. They stated: "The most important factor was to create a “safe” situation and to avoid creating a situation or position that might be felt as an imitation of the torture situation."
[Author’s comments: Creating a safe atmosphere is always a good idea but torture is all about evaluative processing and danger at the hands of tormentor. It seems the authors found through experience that the processing of safety by the mind is a big issue. This should not be a surprise to anyone. It probably involves a cognitive neurobiology that is poorly understood by modern medicine. The findings of these authors are highly compatible with the reflections of the author of this wiki on what is referred to as “danger mode”.]
- Creating a relationship of trust. As soon as a relationship of trust was created between the patient and the health professionals, heat treatment and massage became possible to carry out. This treatment was aimed at making the victim able to cope with being touched during treatment. Once the possibility for further physiotherapy was established, relaxation and breathing exercises as well as posture-awareness exercises were added to the programme. Following this, other more specific treatment methods became possible. The treatment programme was individualised according to the torture the victims had been exposed to. (See: Bloch I, Høhne L. Fysioterapi til torturofre. København: Munksgaard, 1989.) The final step in the treatment programme was further rehabilitation with the inclusion of fitness training with aerobic exercises like cycling and occupational therapy adjusted to each person’s need. The psychotherapy also was designed to suit each victim and was adjusted to meet the needs of each individual as the treatment progressed. All through the course, physiotherapist and psychotherapist cooperated closely on the treatment programme.”
(Italics added by the author of this wiki.)
These are any cases in which the main factor was psychological trauma due to warfare. A large number of cases occur in soldiers. Many cases of shell shock in WWI were likely fibromyalgia cases. (These cases were often mixed with post-traumatic hysteria, physical injuries and anxiety. Many cases occur in civilians that were traumatized by war. Note that physical trauma often brings associated psychological trauma.)
A study by Eisen of soldiers found: “Ten years after the Gulf War, the physical health of deployed and nondeployed veterans is similar. However, Gulf War deployment is associated with an increased risk for fibromyalgia, the chronic fatigue syndrome, skin conditions, dyspepsia, and a clinically insignificant decrease in the SF-36 physical component score.” (Gulf War veterans' health: medical evaluation of a U.S. cohort. Eisen SA1, Kang HK, Murphy FM, Blanchard MS, Reda DJ, Henderson WG, Toomey R, Jackson LW, Alpern R, Parks BJ, Klimas N, Hall C, Pak HS, Hunter J, Karlinsky J, Battistone MJ, Lyons MJ; Gulf War Study Participating Investigators. Ann Intern Med. 2005 Jun 7;142(11):881-90.)
Lewis et al. state: “The similarity between post-deployment syndrome and other medically unexplained conditions such as fibromyalgia [26,76], chronic fatigue syndrome [3,33,37], irritable bowel syndrome , post-concussion disorder [4,36], chronic headache , and post-traumatic stress disorder  has been previously noted . In all these conditions, CWP occurs together with memory difficulties, fatigue, sleep disturbances and, often, depressed mood .” (Central sensitization as a component of post-deployment syndrome. Jeffrey D. Lewis,a,b Eric M. Wassermann,a,∗ Wendy Chao,c Amy E. Ramage,dDonald A. Robin,e and Daniel J. Clauwf, NeuroRehabilitation. 2012; 31(4): 367–372. This is available in full online at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4880352/.)
For further perspective see the entry Shell Shock.
A traumatized artist who developed fibromyalgia
An instructive case history of probable post-traumatic fibromyalgia was reported by a group of Mexican doctors led by Dr. Martinez-Lavin. They reviewed the case of the famous female artist from Mexico named Frida Kahlo (1907-1954). (Fibromyalgia in Frida Kahlo's life and art. Martinez-Lavin, Manuel ; Amigo, Mary-Carmen ; Coindreau, Javier ; Canoso, Juan. Arthritis Rheum. 2000 Mar;43(3):708-9 available online at: www.myalgia.com/Frida_Kahlo.htm) Their review included gaining access to and studying her old medica records.
Kahlo was involved in a terrible accident when she was 18 when the streetcar impacted the bus she was riding. She suffered multiple fractures including to “the third and fourth lumbar vertebrae, and had a deep abdominal wound inflicted by a metal rod.” “She was confined for several months in a plaster corset. From that time on, Frida suffered severe, widespread pain and profound fatigue. Generalized pain and exhaustion lingered with her for the remainder of her life.” (Martinez-Lavin et al. 2000)
She is of special interest because she depicted aspects of her injury and her chronic pain in a famous painting.
The severity of her injuries could have easily misled her many doctors to assuming that her many pains were due to her many injuries. This remains a problem in clinical medicine even today. There is a fairly simple fix which is to train doctors and the public to be on the lookout for chronic widespread muscular pain after accidents including in muscles that were not impacted in the accident. Furthermore, in spite of the recent reduction of emphasis on having primary care physicians testing the 18 fibromyalgia tender points, they should be reintroduced and tested more often because they often reveal the widespread tenderness pattern which is indicative of fibromyalgia. This can help alter doctor and patient alike to the possibility of the diagnosis, especially in cases of lingering pain, months or years after an accident.
The authors of the article on Kahlo went on to say: “Through the years, a variety of diagnoses were offered to explain her chronic illness, such as tuberculosis and syphilis, that were later ruled out. She received diverse types of treatments, including medications and long periods of confinement in a metal or plaster corset. In efforts to relieve her pain, she underwent several orthopedic operations on her spine, both in Mexico and in the United States, without improvement in her symptoms.” (Martinez-Lavin et al. 2000) This pattern of misdiagnosis of fibromyalgia leading to years of confusion, inappropriate treatments, needless operations and wasting money, happens all too often. It underscores the need for proactive screening of pains for fibromyalgia after accidents. Dr. Harvey Moldofsky once told me that he felt there should be early intervention medical services to intercept emerging fibromyalgia patients right after their accidents. This was always a good idea. If patients reported high levels of insomnia, nightmares about the accident or other early symptoms, then they could be given intensive therapy, education and advice to try to prevent them from developing full blown fibromyalgia or chronic fatigue syndrome.
The authors of the Kahlo article believe that she “suffered posttraumatic fibromyalgia”. (They were probably correct but it is not a certainty because of the lack of formal scoring according to diagnostic guidelines.) The authors argued: “Our diagnosis explains her chronic, severe, widespread pain accompanied by profound fatigue. It also explains the lack of response to diverse forms of treatment. The onset of fibromyalgia after physical trauma is well-recognized.” (Buskila D, Neumann L, Vaisberg G, Alkalay D, Wolfe F. Increased rate of fibromyalgia following cervical spine injury: a controlled study of 161 cases of traumatic injury. Arthritis Rheum. 1997; 40:446-52.)
It can occur after just about any type of accident including a boating accident in which there is a near drowning.
Some cases involve a dramatic sudden event. There is a suspicion that the suddenness of the trauma may take the person off guard and increase the likelihood that they will be traumatized, but this idea may never have been scientifically verified.
Some cases involve serious physical injury combined with psychological trauma.
The traumatic event may be followed immediately by daily nightmares.
The post-traumatic fibromyalgia pains are often accompanied by typical PTSD symptoms with nightmares that relive the trauma as well as daytime hallucinatory flashbacks to the trauma.
In the few weeks right after the trauma the patient may feel they are “stir crazy”. In some cases the delay in the occurrence of the fibromyalgia pains is lengthy, even a few years. However, in such cases the patient may admit that there was an unbroken sequence of such dreams in the entire intervening period after the accident up until the fibromyalgic symptoms occurred.
The nightmares may include hallucinations in which terrifying somatosensory sensations, feelings and ideas which were part of her near-death experience are repeated. An example would be a person who was in a boating accident during which they were pulled under the boat, and in their nightmares, they relive the feeling of being dragged under the water and the feeling they had in real life of the water rushing over their face. The post traumatic nightmare can keep occurring for a very long time, even twenty years.
A case history of fibromyalgia by Mailis et al.
Mailis et al. described the case of a family of six consisting of two parents and four children. (Chronic pain in a family of 6 in the context of litigation. Mailis A1, Furlong W, Taylor A. J Rheumatol. 2000 May;27(5):1315-7.) They were evaluated six and eight years after a minor care accident for chronic pain. The authors pointed out: “A near identical complex of multiple physical, constitutional, and psychological symptoms were shared by all family members, all of whom bore the diagnosis of fibromyalgia.” It goes without saying that this is highly unusual and calls for an explanation. After nearly 10 years of symptoms the case when to court. The patient had made extensive use of the health care system. They receive minor compensation and this money was mostly consumed by legal fees. The paper discusses what the authors called “psychosocial/personality issue and “iatrogenic and medico-legal contributions to the evolution and resolution of the legal claim…”
[Author’s comments: This case raises many questions: Were the family members prone to fibromyalgia? Were they influencing each other in a negative manner? Did they all have the fibromyalgia vortex? Did motivation for compensation contribute to the problem?]
Milstein et al.’s case history of post-traumatic fibromyalgia
This is a compelling case history which clearly connects fibromyalgia to stressors. Milstein et al. described the case of a 35-year-old divorced professional artist with three children. She had not completed high school. She was not abused as a child. She had been content with her personal life and family. “She described a positive, full lifestyle until her third pregnancy. Due to complications, she underwent a pregnancy termination and curettage during the sixth week of gestation. During the procedure a small uterine perforation occurred and a laparoscopic repair was performed. The patient was discharged with no postoperative complications.
She got pregnant again a year later, then “for the first time in her life” she had “severe anxiety with delusions and false ideations regarding a recurrent uterine rupture and its possible consequences. At the same time, she noticed the emergence of diffuse pain, arthralgias, migraines, depressed mood, and tiredness, fatigue, and a disturbed sleep pattern. She became more sensitive to stimulation and experienced symptoms of irritable bowel syndrome.”
She had developed a full-blown case of post-traumatic fibromyalgia syndrome along with several known fibromyalgia comorbidities i.e. migraine and irritable bowel syndrome. The whole chain of events seems to have been triggered by the emotional upheaval. These can be viewed, like so many other conflicts, as being evaluative in nature because they involve ideas about good and evil. This is especially true of her paranoid ideas; but also looming large in the background is the “evil” of a loss of a baby and the idea of being physically harmed by past surgery. It seems these conflicts caused her to become physically unhinged i.e. to develop her various psychosomatic disorders.
The authors commented: “The uniqueness of this reported case lies in the unusual evolution of fibromyalgia in this patient. Prior to her third pregnancy, she led an active life and fulfilled multiple familial, vocational social and even altruistic roles. Despite the described operative results, she coped successfully with an unpleasant stressful event (a miscarriage and a uterine perforation) and resumed her normal daily life activities. However, re-experiencing a similar event a year later in the form of a subsequent pregnancy triggered retraumatization that resulted in classic fibromyalgia manifestations. The awareness of a significant threat to her body and to the integrity of her pregnancy generated numerous somatic, emotional and cognitive symptoms, which probably reflected decompensation of her personal resilience and defense mechanisms. As time passed, her symptoms become fixed .and more incapacitating. Reexperiencing a traumatic event, at a specific time and in a personal setting in this case, triggered a cascade that led to the onset of fibromyalgia syndrome.” (For the details of her case the full article, Retraumatization is the process of reexperiencing a traumatic event or circumstances that elicit stressful conceptions Renana Milstein et al. IMAJ VOL 15, February 2013 available in complete form online at: http://www.ima.org.il/FilesUpload/IMAJ/0/50/25000.pdf.)
[Author’s comment: It is very surprising to find just how few published cases histories of fibromyalgia there are especially in view of the many articles relating fibromyalgia to psychological problems such as anxiety, depression and PTSD. This case history is important because it supports the view that the stress over a conflict was causal. The onset of her pain was concomitant with the conflict.]
Case histories are becoming something of a lost art. In many respects, Freud’s case histories of his chronic pain patients in Studies in Hysteria surpass modern case histories in terms of their attention to detail and general insight into the patients. In retrospect in now appears that some were fibromyalgia patients with a concomitant conversion disorder. For further perspective see the entry on “fibromyalgia, Hysteria as a comorbidity:” Note for example the case of Elisabeth von R.:”] Also see the entry Fibromyalgia, Focal Conflicts in
For the Freud material see Studies in Hysteria, Sigmund Freud, Sigmund Freud and Joseph Breuer, Translated by AA Brill, Beacon Press, Beacon Hill, Boston, 1937 Edition of the original 1895 book, available online at: https://archive.org/details/studiesinhysteri002062mbp or see the full text version at: https://archive.org/stream/studiesinhysteri002062mbp/studiesinhysteri002062mbp_djvu.txt.)
The critical need for early diagnosis of post-traumatic fibromyalgia
A basis heuristic of critical medicine which has stood the test of time is that early diagnosis is critical. The author recommends that the insurance industry make it a stand practice to encourage fibromyalgia screening after all moderate to severe accidents, and possibly after even fairly minor ones. One currently available short convenient tool is called the "FiRST", which stands for "Fibromyalgia Rapid Screening Tool". Anyone screening as positive should go for further testing using the ACR-2016. People testing positive to this should, in the opinion of the author, proceeded to in-depth questioning using tools such as the Fibromyalgia Registration and Patient History/Assessment Form, which is available in Fibro Wiki.
If there are associated post-traumatic nightmares, current level A evidence is that they should be treated with prazosin or imagery rehearsal therapy or both. Intuitively it seems wise to start with imagery rehearsal therapy because it is safer and more directed to reversing the underlying problem of the scary ideas in the nightmares.
Dissenting and supporting opinions to the existence of post-traumatic fibromyalgia
Some leading fibromyalgia experts accept the idea that fibromyalgia can be caused by physical trauma. Others disagree. For a paper by prominent dissenters see: Fibromyalgia and Physical Trauma: The Concepts We Invent. Frederick Wolfe, Winfried Häuser, Brian T. Walitt, Robert S. Katz, Johannes J. Rasker and Anthony S. Russell J Rheumatol 2014 Sep;41(9):1737-45, available in full online at: http://www.jrheum.org/content/41/9/1737.full.pdf+html.
For papers by leading supporters see: McLean SA, Williams DA, Clauw DJ. Fibromyalgia after motor vehicle collision: evidence and implications. Traffic Inj Prev. 2005;6:97-104. Or see: The Development of Persistent Pain and Psychological Morbidity After Motor Vehicle Collision: Integrating the Potential Role of Stress Response Systems into a Biopsychosocial Model. SA. Mclean, Daniel J. Clauw, James L. Abelson, Israel Liberzon. Psychosom Med. 2005 Sep-Oct;67(5):783-90.
For a letter to the editor about this debate see: Comment on “Fibromyalgia and Physical Trauma: The Concepts We Invent” To the Editor by Reuven Mader, Dan Buskila and Michael Ehrehfeld: available in full online at: http://www.jrheum.org/content/42/2/351.long The debate is potentially resolvable. Part of the problem is the inadequate number of published cases histories. There is also a need for more psychologically-minded clinicians who are attuned to psychological issues when they take the histories.
Direct causality is different than indirect causality. When a billiard ball strikes a second ball which immediately moves, then there is direct causality. In fibromyalgia, the situation is much more complicated because it involves the brain and interactions between factors. For example, after an injury, many people are scared and in pain. This affects their sleep and sleep often affect pain. Unless there is an inquiry by the health care professional into these interactions, the connection between new one set fibromyalgia or exacerbation of preexisting fibromyalgia may be overlooked.
Consider this situation: There is a person with a complex web of risk factors for fibromyalgia. They also have a number of psychological vulnerabilities. Then they have a trauma. This is followed by very complex reaction to it involving emotions such as fear, anger and guilt, sleep problems, acute pain from the injury and various other mental reactions such as uncertainty about their future employability. All this unfolds as a multi-layered chain reaction that is different in each person. Because of the many individual differences, it is difficult to study in controlled clinical trials.
In the experience of the author (who has taken several hundred in-depth case histories of fibromyalgia patients), there are cases in which there is very compelling evidence in favour of the idea that an accident was the major inciting incident. They are especially compelling if the patient was a pain free and a relatively good sleeper prior to a serious accident, and then immediately after the accident they experienced direct pain from their damaged tissues. Experience shows that this situation then triggers a chain reaction of worry, trouble sleeping because of the pain and then widespread extension of the pain into non-injured areas. (This is sometimes referred to as “pain amplification”. In other words, they fall into what is referred to here as the “fibromyalgia vortex”. Once caught in this vortex their problems often become compounded, self-amplifying and self-sustaining due to multiple vicious cycles.
For further clarity, see the entry Fibromyalgia Vortex Theory, The.