The Danger Mode Hypothesis of the Cause of Fibromyalgia

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(Author’s term.)

Definition[edit]

This is the author’s theory that the cause of fibromyalgia is that the patient’s mind goes into a defensive mode/posture and that the brain behaves as if the person is in great peril. According to this theory, the brain processes and reacts to innocuous stimuli as if they were dangerous. A metaphor to explain this is to think of the over-reactivity as “the paranoia of the body”.

This theory is an attempt to understand how and why people become centrally sensitized. (See the entry for central sensitization for further understanding of how the brain and body react to stimuli under conditions of central sensitization.) I believe that the defensive posture can occur in genuine peril as when the patient is soldier in a war zone and living under constant threat. This hypothesis is compatible with the cerebral sensitization theory of fibromyalgia and it accepts that the brain is oversensitive; but it goes an important step further to try to explain why. Also note that anecdotal evidence may be right or wrong, but it is not definitive.

Impetus for developing this theory[edit]

This theory was developed in the course of observing fibromyalgia patients. They universally, or almost universally, have mechanical allodynia whereby they over-react to mechanical pain stimuli not only with pain, but also, in severe cases with pain withdrawal reflexes (to pull the body part away from danger) and strong facial expression of pain and pain vocalizations (to signal others that they are in distress). Many also have nocturnal sound sensitivity during their light sleep such that their brain is monitoring the world for danger signs and waking to the slightest sound. To state the obvious, a withdrawal reflex is an unconscious process of pulling a body part away from danger. A facial expression of pain is an automatic unconscious reaction that serves to alert others that a person is suffering, and that they may be in danger. The fact that the pain occurring in mechanical allodynia is often accompanied by these reactions suggest that it may be wise to think of pain as part and parcel of the body’s reactions to physical danger.

Survival value[edit]

Animals, including man, that are passive in the face of danger run a high risk of being harmed, killed, and eaten by predators. It is entirely understandable that evolution would provide for brain systems that can recognize danger and respond to it during the day and while asleep. This includes the systems for vigilance and alerting.

One special case of survival value for a species is that in which a mother protects her infant from danger. Mother’s need to respond quickly, even during the night to any threat to the baby. For this they need to be analyzing sounds in their immediate vicinity unconsciously and sounds made by their baby for indicators of danger. Without this step, they would not wake to danger.

Aspect of over-reactivity to stimuli[edit]

It is a clinical and laboratory confirmed fact that the fibromyalgia brain is over-reactive to certain stimuli. This is most notable for pressure stimuli applied to tender points; but in many patients, there is also over-reaction to other types of stimuli including sounds, smells and emotional stimuli and light (as in photophobia). (For details see the medical literature on allodynia, hyperalgesia, pain thresholds, and other sensory thresholds.)

Clinical over-readiness to face danger[edit]

Hypervigilance can be thought of as a clinical over-readiness to react to danger.

Underpinnings[edit]

Some process must underlie this over-reactivity to evidence of imminent danger. Given that the current understanding is that these patients are not born with chronic pain; some process must have reset the brain.

Possible role for the reticular activating system[edit]

The RAS is believed to process alertness and aspects of sleep cycles. Perhaps when listen for sounds indicating danger during sleep, this system gets “turned on”. The RAS is known to be involved in the regulation of sleep cycles and in alertness.

There is evidence that a system in the brain known as the reticular activating system is involved in acoustic startle. (See: Giant neurons in the rat reticular formation: a sensorimotor interface in the elementary acoustic startle circuit? Lingenhöhl K & Friauf E (1994). J Neurosci 14, 1176–1194. [PMC free article] [PubMed] [Google Scholar]) Tazoe et al. site the work of others. Tazoe states: “Electrophysiological data in humans using transcranial magnetic stimulation (TMS) showed that an acoustic startle cue, a stimulus that engages the reticular system, modulates corticospinal responses at a cortical level (Furubayashi et al. 2000; Kühn et al. 2004)” Cortical and reticular contributions to human precision and power grip. Toshiki Tazoe 1 , 2 and Monica A. Perez 1 , 2 J Physiol, v.595(8); 2017 Apr 15, J Physiol. 2017 Apr 15; 595(8): 2715–2730, doi: 10.1113/JP273679)

The prevalence of over-active startle in fibromyalgia is unknown. It the danger mode hypothesis of fibromyalgia is correct, then one would expect it to be more common than in normal controls.

There are anecdotes that suggest that startle is more common and more pronounced in fibromyalgia. For example, a woman by the name of Sue Ingebretson made a posting on line on April 26, 2016. She said: "Do you jump out of your skin if someone unexpectedly taps you on the shoulder? Do you scream, shriek, or yelp like a banshee at sudden loud noises? If so, welcome to the club. You may have an exaggerated startle reflex. The question is, did fibromyalgia cause this problem?" (https://rebuildingwellness.com/startle-reflex-fibromyalgia/, also see another post at: https://www.prohealth.com/library/do-you-have-these-fibromyalgia-symptoms-of-systemic-dysfunction-37277.)

A study was done by Drummond et al. to determine if the clinical pain associated with fibromyalgia “would increase during standard laboratory tasks and, if so, whether these increases were linked with individual differences in psychological distress.” (Painful effects of auditory startle, forehead cooling and psychological stress in patients with fibromyalgia or rheumatoid arthritis. Peter D Drummond, Margot Willox, Journal of Psychosomatic Research 74(5):378-383 May 2013, DOI: 10.1016/j.jpsychores.2013.01.011, abstract available online at: https://www.researchgate.net/publication/236226542_Painful_effects_of_auditory_startle_forehead_cooling_and_psychological_stress_in_patients_with_fibromyalgia_or_rheumatoid_arthritis. Available in full online at: https://researchrepository.murdoch.edu.au/id/eprint/14489/1/Painful_effects_of_auditory_startle%2C_forehead_cooling_and_psychological_stress_in_patients_with_fibromyalgia_or_rheumatoid_arthritis.pdf.) Among other things, they looked at acoustic startle. Results showed that “clinical pain increased after the acoustic startle stimulus and painful forehead cooling, and increased during stressful mental arithmetic.”

Possible theoretical role for evaluative processors in making assessment of situations as being dangerous[edit]

When a person enters an environment, they may come to believe that it is threatening. Studies are needed to determine if fibromyalgia patients are more likely to feel physically threatened. If this is the case, it likely would involve evaluative processors in the brain.

Clinical light sleep as a type of danger mode processing[edit]

Here, the term "light sleep" refers to the commonplace description of a certain types of sleep by patients who describe it as being half asleep and sleeping with one eye open They often complain of waking unrefreshed. In the experience of the author it is common in insomnia and fibromyalgia, as well as in new mothers, and people who have recently moved into a neighbourhood that they consider to be dangerous.

Possibility that danger mode is belief-based in reaction to ideas about “badness” or evil[edit]

In principle, the underlying problem could be belief-based (i.e., based on a set on the patient’s beliefs that they are in danger). This helps explain cases of fibromyalgia developing after child physical or sexual abuse or cases starting after adult physical traumas such as motor vehicle accidents or mental traumas such as divorce.

Beliefs are ideas combined with conviction. The most important beliefs are probably evaluative beliefs. They are a product of evaluative belief processing mechanisms of the brain. Example of strong evaluative beliefs include religious and political beliefs as well as belief about being victimized.

In the author’s clinical experience danger mode can be heightened in a wide variety of potentially dangerous circumstances. Sometimes this involves a focal conflict with a principle enemy.

Here is a list of examples of the enemies mentioned by patients which had a clinical tie-in to their symptoms from my fibromyalgia practice:

  • The insurance company.

(Typically, this occurs in accidents and it is their insurer. The patient believes that they are in a fight over their claim for disability after car accident. Patient resentment and struggle can be very intense.)

  • The medical system.

An example is one young lady who blamed her regional medical system as being unfeeling. She voiced frustration over the failed treatments that doctors had advised for her.

  • The vindictive boss.

One patient blamed her boss as tormenting her and her fibromyalgia symptoms and bad dreams echoed the bad relationship.

  • The devil.

In another case the patient was superstitious. She came from a culture where beliefs in the devil were prominent and she believed the devil was oppressing her thus putting her “under the gun”. She had a feeling that she was in jeopardy.

  • A brother.

One woman had a brother that sexually abused her when she was young. She hat¬ed him. She lived under continual tension worrying she would not meet his expectations of her. Other cases involve people who were sexually abused as children and who reported to me that they lived on guard against their tormentor. (An ex¬ample is a woman who wore her clothes to bed.)

  • The pains.

Some people appear to make their own pains and disease into the enemy. The author calls this “evilization of pain”. (By treating their own pains as an enemy they anthropomorphize them i.e. they treat them as if they were human.)

  • The evil driver that caused their accident and their injuries.

This is self-explanatory.

I suspect that in cases of military post-traumatic fibromyalgia the enemy is the re¬al enemy that they were fighting during the war.

In my experience, not all patients have a clear perceived enemy (based on a series of interviews lasting an average of about 4 hours, and on many forms filled out by my patients.) However, the situation is not always clear. For example, one patient was a struggling immigrant. She had gone through a divorce but it was not possible to say if she had taken her x-husband as evil. Many people are restrained and private when discussing such matters, especially with strangers.

Implications for therapy[edit]

If a deep root cause for a patient having fibromyalgia is a fundamental belief that they are in danger, then it is hard to imagine how they could improve unless they can alter this core belief and reposition their mind to feel safer.

Defensive aspects of danger mode in fibromyalgia[edit]

All or almost all patients have mechanical tender points which are a form of mechanical allodynia in reaction to non-threatening stimuli. This is proof of over-reactivity as if they were in danger.

Some even have exaggerated protective pain withdrawal reflexes.

In my experience, post-traumatic fibromyalgia is common, perhaps even the most common form at this time (2016).

Patients are “on guard” and many freely admit to this. Their fibromyalgia is essentially a defensive posture of their cognitive and sensory systems, especially the somatosensory system. Their body literally acts as if it were in a war zone. (Fibromyalgia is rampant amongst previously well soldiers who are grossly traumatized in the field of battle. For example, during WWI there were massive numbers of cases of what the military doctors at the time called “battle fatigue”. The Veterans Administration in the US, which is charge with caring for soldiers after wartime exposures, is now recognizes Gulf War Syndrome as being a form of fibromyalgia.

Many sensory systems are affected including reactions to mechanical touch, but also to heat touch, and in some cases light and sound.

Defensive reflex motor reactions to pain are also exaggerated in many patients.

Grimacing to modest mechanical touch to tender points is a social-communication reaction to pain. We have seen it many times in severe fibromyalgia patients. Grimacing serves to notify other people that a person is in distress. It is reflex in nature in the sense that it is automatic. It may serve to motivate others to try to help, and in this sense, it is protective.

Some patients seem jumpy.

There are cognitive aspects to the disorder as well. An example is catastrophizing.

Some patients develop memory and dream changes if they develop a concomitant PTSD.

There may be a reduced light touch threshold.

Evidence for the theory[edit]

Risk-factor related evidence[edit]

  • Trauma of any kind, including a minor car accident of any major upsetting loss is a risk factor for fibromyalgia.
  • Childhood adversity is a risk factor

Precipitating factor evidence[edit]

  • Many cases are post-traumatic. Traumas often involve danger as in motor vehicle accidents with danger of bodily injury and after a fall.

Danger-related physical reactions[edit]

  • When pressed on tenderpoints, severe fibromyalgia patients exhibit several danger-related protective reactions. This include withdrawal reflexes, facial expression of pain and vocalization of pain.

Cognitive-related evidence[edit]

  • Fibromyalgia patients tend to catastrophize. This is an evaluative process whereby they evaluate situations as being more dangerous than is justified.

Defensive activity and social reflexes that alert others to danger[edit]

  • Reduced pressure pain thresholds which are considered by many as a hallmark of fibromyalgia, serve to alert conscious awareness to touch and the result is that levels of force which are not threatening are experienced by the patient as painful and offensive as expressed by facial grimacing and by withdrawal reactions which serve to move the body part away from the site of applied force.

Anecdotal evidence from the author’s practice[edit]

  • Anecdotally, a number of my patients said they feel they are “on guard” more than other people. One even said she was hyper-vigilant. One says she has two dogs that help her feel safe.
  • Anecdotally, many of my patients told me they live under a feeling of constant tension.
  • Some of my patients had a turning point in their care in which they openly admitted that feeling unsafe was a major issue, and they began to focus their effort on reorganizing their mind. We agreed they needed to “get to safety”.
  • Many cases in my practice erupted at times of danger including difficult pregnancy sin which the mother felt herself and her fetus to be in danger: imperilled offspring situations such as in a mother whose baby had breathing problems and she sleeps with on eye open watching out for danger to her newborn

Epidemiological evidence[edit]

  • Fibromyalgia has bene shown to be more common is soldiers during wars including WWI and the Gulf War
  • There was an epidemic after Chernobyl which exposed large number of people to the danger and fear of radiation.

Protective sensory awareness patterns[edit]

  • Fibromyalgia features several critical sensory awareness patterns that are protective in nature: including, in many cases, heightened reactivity to light, smell and sound of which can help protect people and facilitate their immediate reaction to danger.
  • Light sleep which serves to allow the person to awaken to the slightest sensory stimulus or indicator of danger. (I call this “sentry sleeping”.)

PTSD co-morbidity[edit]

  • There is a proven association between post-traumatic stress disorder and fibromyalgia. Moreover, I have seen cases of PTSD starting at the same time as fibromyalgia right after physically minor car accident. In PTSD the patient hallucinates the situation of danger in their flashbacks and nightmares.

Focal conflict evidence[edit]

Social dangers can be precipitating factors. These include the danger of losing one’s marriage or one’s job, or remaining disabled or becoming poor.

  • Some patients develop fibromyalgia, in the course of what is often called a focal conflict which is generally a disturbing interpersonal conflict such as a big fight with a boss, competitor, spouse or family member. I have seen quite a number of such cases. They all differ, but the common thread seems to be the psychology of good and evil. This may come through in bad dreams about an enemy. Examples include: the patients who became conflicted over a car accident and who do battle with the insurance companies; a lady who had a major family feud with her daughter’s in-laws; a woman who had tension with a boss that she felt was vindictive; a woman who was sexually abused by her brothers and who had lifelong resentments of them all of her life to date; a woman who had an abusive father when she was a little girl and who seems to have developed fibromyalgia in childhood.

Brain imaging evidence for defensive activation in fibromyalgia[edit]

  • A study by Bartley et al. of fibromyalgia patient was conducted in which subjects were presented “unpleasant (attack related) pictures” (abrupt white noises were delivered during two-thirds of the pictures to evoke startle eyeblinks). Results suggested that fibromyalgia syndrome is “associated with greater defensive activation (displeasure, subjective arousal, corrugator EMG) to the unpleasant, threat-related pictures….: Results also suggested that in fibromyalgia syndrome, there is “enhanced defensive activation to nonpainful threat-related stimuli…” (Experimental assessment of affective processing in fibromyalgia. Bartley EJ, Rhudy JL, Williams AE. J Pain. 2009 Nov;10(11):1151-60, available in full online at: https://www.jpain.org/article/S1526-5900(09)00499-4/fulltext.

Evidence from psychological studies[edit]

  • Hypervigilance study: A study by Mcdermid et al. found that fibromyalgia patients were hypervigilant. (Generalized hypervigilance in fibromyalgia: Evidence of perceptual amplification. Mcdermid AJ, Rollman GB, Mccain GA. Pain. 1996;66(23):133–144.)
  • Harm avoidance trait study: A study by et al. found that fibromyalgia patients had high scores for “harm avoidance”. (Differences in the personality profile of fibromyalgia patients and their relatives with and without fibromyalgia. Glazer Y1, Buskila D, Cohen H, Ebstein RP, Neumann L. Clin Exp Rheumatol. 2010 Nov-Dec;28(6 Suppl 63):S27-32. Epub 2010 Dec 22.)
  • Catastrophization studies show an issue of pain catastrophizing in fibromyalgia. (Brain. 2004 Apr;127(Pt 4):835-43. doi: 10.1093/brain/awh098. Epub 2004 Feb 11. Pain catastrophizing and neural responses to pain among persons with fibromyalgia. R H Gracely 1, M E Geisser, T Giesecke, M A B Grant, F Petzke, D A Williams, D J Clauw, DOI: 10.1093/brain/awh098. Also see: J Clin Psychol Med Settings. 2018 Mar;25(1):80-92. doi: 10.1007/s10880-018-9543-1. Catastrophizing, Acceptance, and Coping as Mediators Between Pain and Emotional Distress and Disability in Fibromyalgia. María J Lami 1, M Pilar Martínez 2, Elena Miró 2, Ana I Sánchez 2, Manuel A Guzmán 3 DOI: 10.1007/s10880-018-9543-1.)

In the clinical opinion of the author, the issue is not catastrophizing about one’s pain, but rather it is a matter that some fibromyalgia patients seem to have a general tenancy to catastrophize. This hypothesis could be tested in a future study using the Catastrophizing questionnaire in the Fibro Wiki, as opposed to other questionnaires that just focus on the catastrophizing of pain.

Implications of the danger-mode theory of fibromyalgia[edit]

If the theory is true then there are important implications for counselling and therapy. The treating health care professional can try to enlist the support of the patient to curtail their defensive posture gradually over time.

Some fibromyalgia patients are very aware of feeling endangered. For example, I am aware of a female patient whose “X” was getting out of jail and the woman feared being attacked again.

In other patients there was no conscious realization that they are in danger, but there is still evidence based on the presence of withdrawal hyperreflexia, lowered pressure pain thresh¬olds, light sleep, and heightened grimace reactions to application of modest force to a fibromyalgia tender point. In my experience patients are taken by surprised and perplexed by their reactions, but they can easily see that the reflexes are protective because they automatically move the body part away. From this they learn that their body is behaving as if it is in danger. This gives the doctor the opportunity to broach the whole subject of the psychology of danger.

An essential element of my theory is that processing of ideas about danger and enemies is critical to many cases. According to the theory if a patient gets into an intense conflict over time with a person they consider to be an enemy, it starts a cascade of reactions: lower pressure pain thresholds, light sleep etc. If the theory is true then the logical approach is to help the patient deal more affectively with the underlying issues related to the psychology of evil. This could take the form of seeing a psychologist or psychiatrist for help with their interpersonal issues. Essentially the patient must “bury the hatchet” and retool their whole psychology being in a safer place mentally.

For further perspective see the entry Danger Mode Hypothesis, The.