Psychogenic Theories of Fibromyalgia/Psychological Theories of Fibromyalgia

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Definition[edit]

These are theories which ascribe the cause of fibromyalgia primarily to psychological factors. Numerous psychological factors have been described and researched in fibromyalgia. Those that precede the onset of the disorder deserve the most consideration as being possible causal factors.

The psychological conflict theory of fibromyalgia[edit]

Author’s definition[edit]

This is the theory that fibromyalgia is a psychosomatic illness and that psychological conflicts underlie it. There are a number of arguments and lines of evidence to support this theory. They stretch back over a century when the old names for it included: psychogenic rheumatism, neurasthenia, railway spine (which was probably post-traumatic fibromyalgia), battle fatigue and also shell shock (during WWI which often involved elements of chronic pain mixed with post-traumatic probably post-traumatic hysteria and sleep disorders).

Freud’s patients[edit]

Some of patients that Freud’s called hysterics in his late 1800s book, Studies in Hysteria, had chronic pain and were almost certainly fibromyalgics. He did a masterful job of engaging them, probing them and getting their detailed histories. In so doing he uncovered a number of psychological conflicts in them.

[Author’s comment: Few since him have probed these patients with his psychological interest and acumen and as a result, psychological elements are often overlooked especially when the clinician is mechanistic.]

Additional lines of evidence[edit]

Here are some additional lines of evidence in support of the conflict theory of fibromyalgia:

  • Goal conflict is a psychological conflict over goals. In many illnesses, the symptoms of the disease limit people’s ability to pursue many of their goals. This is true of fibromyalgia. A study by Hardy et al. found that: “On days with higher goal conflict, pain increased more from morning to evening. (Goal conflict, distress, and pain in women with fibromyalgia: a daily diary study. Hardy JK, Crofford LJ, Segerstrom SC. J Psychosom Res.2011 Jun;70(6):534-40.)
  • There have been a number of studies showing psychological differences between fibromyalgia patients and healthy controls. As an example, it has been shown that fibromyalgia patients have lower Sensitivity to Reward (SR) scores than normal controls, and these scores correlate “with musculoskeletal symptoms”. Based on regression analysis, these scores “significantly predicted musculoskeletal symptoms, after controlling for other variables measured in this study.” (Behavioral approach system activity and self-reported somatic symptoms in fibromyalgia: an exploratory study. Becerra-García JA1, Robles Jurado MJ. Int J Rheum Dis. 2014 Jan;17(1):89-92.)
  • Psychological treatments for fibromyalgia pain have been proven to be some- what useful. A literature review of randomized controlled trials found that cognitive-behavioural therapy and operant-behavioural therapy were the two most effective types of treatment to reduce pain in fibromyalgia.

There are no known controlled trials on the use of psychoanalysis to treat fibromyalgia. This is unfortunate because it is the most personalized and in-depth form of psychological treatment, and so in principle, in the right hands and with a cooperative patient, it could turn out to be the most effective.

A literature review of randomized controlled trials by Thieme et al. in 2009 looked at cognitive-behavioral therapy, operant-behavioral therapy relaxation, biofeedback, hypnotherapy and writing intervention. “The highest effect sizes (r = 0.53-2.14) for pain reduction are found after cognitive-behavioral therapy and operant-behavioral therapy treatments. Relaxation as a single treatment has not been proven useful. Hypnotherapy and writing intervention have demonstrated mild treatment effects, whereas psychological treatment is effective in fibromyalgia pain.” (Are psychological treatments effective for fibromyalgia pain? Thieme K, Gracely RH. Curr Rheumatol Rep. 2009 Dec;11-(6):443-50.)

It is not known why many people who have conflicts do not develop fibromyalgia. Many people in the context of conflict will develop fibromyalgia comorbidities such as PTSD, migraine or irritable bowel syndrome but not fibromyalgia.

There remains a great deal of latitude and opportunity to improve on existing psychological treatments. CBT for fibromyalgia could be improved through research and experimentation by adding new and more refined elements based on new discoveries about the psychology of the patient and the general psychology of fibromyalgia.

While the forms of biofeedback mentioned by Thieme have not proven effective, there remain a number of possibilities to create new types of biofeedback aimed at helping the patient take control of relevant aspects of their nervous system. For example, if any ongoing abnormal EEG frequency were to be discovered that is always or often present on the baseline EEG, then it may be possible to train it out.

Another possibility is that patients can be taught to use a hand-held algometer and press on a tenderpoint just up to the level of their paint threshold. This could be used as biofeedback. Perhaps a method could be discovered to help patients to use this information to gradually reduce their pain and to settle their pain system.

For further perspective see the entry Psychogenic Rheumatism.

Evidence for the theory based on the role of psychological triggers for fibromyalgia symptoms and pain[edit]

Psychological factors have been repeatedly cited as triggers for a new flare up and as aggravating factors. According to a survey done by Bennett et al. the most common aggravating factor for fibromyalgia was “emotional distress” occurring in 83 percent of subjects in a large survey. (An internet survey of 2,596 people with fibromyalgia. Robert M Bennett, 1 Jessie Jones,2 Dennis C Turk,3 I Jon Russell,4 and Lynne Matallana5, BMC Musculoskelet Disord. 2007; 8: 27, available in full online at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/table/T4/. Copyright © 2007.

Arguments favouring psychogenic theories of fibromyalgia[edit]

Here are a number of arguments in favour of them:

  • The most common precipitating factor for fibromyalgia is a trauma such as a mo¬tor vehicle accident. However, emotionally traumatic events of many kinds can also precipitate a first attack. (For a compelling case history, see the entry Milstein et al.’s Case of Fibromyalgia.)
  • There are known documented psychological risk factors for fibromyalgia related to distant past histories of sexual and physical abuse.
  • The symptom complex we now call fibromyalgia is similar in a number of respects to the symptom complex that used to be called neurasthenia. (Unfortunately, there was so many different definitions for neurasthenia and subtypes, the concept lost the precision needed to be scientifically useful. One of the greatest doctors of his generation, the great William Osler, considered neurasthenia to be largely due to psychological factors. He said that it was “the expression of a morbid, unhealthy reaction to stimuli acting on the nervous centers which preside over the functions of organic life”. He felt it was caused by both heredity and strain, particularly those “cares and anxieties” of living that lead to distress and “worry”. Arguments from authority and his statements do not constitute scientific proof, but in view or his tried and true judgment, it suggests that one take psycho¬logical theories of the cause of fibromyalgia seriously.
  • It is well established that psychological stressors often aggravate and existing case of fibromyalgia.

[Author’s comments: While it is true that research supports the theory that many cases start with stress, probably even the majority if we consider motor vehicle accidents as stressful, the author has seen a few cases in which the best evidence is that the problem started with either a major sleep problem or a localized physical organic pain. These exceptions are one of the reasons why the author created his “Vortex theory of fibromyalgia”. (See entry under that heading.) The vortex theory embraces the psychological theory of fibromyalgia while at the same time stating that it is the mutual exacerbation of anxiety, poor sleep and pain all combining to augment and exacerbate each other which best explains the clinical course of a given case of fibromyalgia.]

“It is common clinical experience that anxiety about pain can exacerbate the pain sensation.” (Exacerbation of pain by anxiety is associated with activity in a hippocampal network. Ploghaus A1, Narain C, Beckmann CF, Clare S, Bantick S, Wise R, Matthews PM, Rawlins JN, Tracey I. J Neurosci. 2001 Dec 15;21(24):9896-903.)

  • One line of evidence favouring the psychogenic theory is the rising levels of evidence that a psychological treatment known as CBT is using in treating the disorder.
  • The fact that there are a large number of proven psychological risk factors for fibromyalgia is a form of evidence in favor of the psychogenic theory. These factors include:
    • traumatic experiences
    • abused as a child (sexual, physical, unusual verbal)
    • parent who was alcoholic
    • severe neglect in childhood by your parents
    • raised by a depressed person
    • mother drug addicted during your childhood
    • low income/low social level/low socio-economic status
    • grew up in poverty before age 7 (certain populations
    • divorced
    • disabled
    • lower household income
    • lower education
    • middle age
    • previous history of depression
    • poor family financial situation before the age of 7
    • exposure to addicted mother during one’s childhood
    • poor emotional relationship with both parents during childhood
    • physical maltreatment in childhood
    • family history of alcohol abuse
    • family history of drug abuse
    • after a mass disaster or mass scare (epidemic fibromyalgia, e.g. as in Chernobyl)

Further information[edit]

Victimization in chronic fatigue syndrome and fibromyalgia in tertiary care: a controlled study on prevalence and characteristics. Van Houdenhove B, Neerinckx E, Lysens R, Vertommen H, Van Houdenhove L, Onghena P, et al. Psychosoma-tics. (2001) 42:21–8. 10.1176/appi.psy.42.1.21, available in full online at: https://www.academia.edu/10309572/Victimization_in_Chronic_Fatigue_Syndrome_and_Fibromyalgia_in_Tertiary_Care_A_Controlled_Study_on_Prevalence_and_Characteristics.

For an article about the debate over the degree to which psychological factors contribute to fibromyalgia see: The psychological mislabelling of fibromyalgia. Howard Pikoff, 2010, http://www.theacpa.org/uploads/fibro%20preprint.pdf.