WHAT ARE FIBROMYALGIA AND ITS SYMPTOMS?*

General Description of Fibromyalgia Symptoms
Fibromyalgia (also called fibrositis or fibromyositis) is a syndrome of unknown causes that results in chronic, sometimes debilitating muscle pain and fatigue.
Pain. The primary symptom of fibromyalgia is pain, both pain experienced in certain precise locations called tender points and generalized pain [ See Box Criteria for Classifying Fibromyalgia]. The pain of fibromyalgia is often is described as follows:

Fatigue and Sleep Disturbances. Another major complaint is fatigue, which some patients report as being more debilitating than the pain. Sleep disturbances, particularly restless leg syndrome, are also very common. Fatigue and sleep disturbances are, in fact, almost universal in patients with fibromyalgia, and if these symptoms are not present, then some experts believe that physicians should seek a diagnosis other than fibromyalgia.

Other Symptoms. Other symptoms that occur more often than average in fibromyalgia patients are the following:

Symptoms in Children. Although symptoms are similar in children, some experts suggest that they often have no set number of pain tender points. In one study, children had an average of 9.7 tender point locations compared to the minimum of 11 in adults. In general, children with fibromyalgia most often experience sleep disorders and diffuse pain, and less frequently headache, general fatigue, and morning stiffness.

WHAT CAUSES FIBROMYALGIA?
Fibromyalgia is sometimes categorized as primary or secondary; primary fibromyalgia is the more common form. The cause or causes of primary fibromyalgia (also called idiopathic fibromyalgia ) are not known. Many experts believe that fibromyalgia is not a disease but rather a dysfunctional disorder caused by a constellation of biologic responses to stress in individuals who are more susceptible to such stress because of negative personal histories, genetic factors, or both. Physical trauma, emotional trauma, or viral infections, such Epstein-Barr, may act as triggers for the onset of the disorder, but none have proven to be a cause of primary fibromyalgia.

Chronic Sleep Disturbance
Fibromyalgia patients have greater sleep disturbances than others. Specifically, both adult and young patients have a higher than average incidence of a sleep disorder called periodic limb movement disorder (PLMD), which is a form of restless legs syndrome. With PLMD (formerly known as nocturnal myoclonus) the leg muscles involuntarily contract every 20 to 40 seconds during sleep, occasionally arousing the patient, who, however, is usually unaware of the cause of the interruption.

Some experts believe that fibromyalgia does not cause disturbed sleeping patterns, but that sleep disturbances may be the precipitating factor for many cases of fibromyalgia pain. In one study, non-fibromyalgia volunteers reported fibromyalgia-like pain after they had been subjected to disrupted deep sleep. Disturbed sleep appears to trigger factors in the immune system that cause inflammation, pain, fatigue, and decreased pain threshold.

Hormonal Abnormalities
Studies of hormonal, metabolic, and brain chemical activity in fibromyalgia patients have shown a number of abnormalities. Alterations in hormonal levels appear to occur with serotonin and estrogen and stress, growth, and thyroid hormones. Some experts believe that such abnormal deviations are a result of the effects of pain and stress on the central nervous system and are not a cause of fibromyalgia.

Stress Hormones. Of particular interest to researchers are possible abnormalities in the brain system known as the hypothalamus-pituitary-adrenal gland (HPA) axis, which controls important functions, including sleep, response to stress, and depression. Alterations in the HPA axis appear to produce lower levels of cortisol, a stress hormone. (In depression, stress hormones are higher than normal.) Deficiencies produce impaired and weaker responses to psychologic or physical stresses (such infection or exercise).

Low Growth Hormone Levels. A third of patients have low insulin growth factor (IGF) levels. Low levels of growth hormone have been associated with impaired mental functioning, lack of energy, muscle weakness, and intolerance to cold.

Abnormal Pain Perception
Some studies have suggested that the lowered pain thresholds experienced by fibromyalgia patients may represent a central defect in the way fibromyalgia patients process pain. Brain scans of fibromyalgia patients have, in fact, suggested abnormalities in pain processing centers. Of particular interest is research that has detected up to three times the normal level of substance P (a neurotransmitter associated with increased pain perception) in the cerebrospinal fluid of fibromyalgia patients. Such abnormalities along with other factors (such as chronic sleep deprivation or physical injury) may produce a state called generalized hypervigilance , which is an amplification of sensation. People with this condition are oversensitive to external stimulation and are preoccupied with the sensation of pain. For example one study compared three groups of individuals:

They were given a questionnaire to assess their response to pain and noise. Of the three groups, the fibromyalgia patients were least tolerant and most attentive to such stimuli.

Immune Abnormalities
Fibromyalgia resembles a number of rheumatic disorders that are known as autoimmune disorders, including rheumatoid arthritis and systemic lupus erythematosus. These diseases occur when a defective immune system produces factors known as autoantibodies, which attack proteins in the body's own tissue, mistaking them as antigens (foreign proteins). Researchers have identified certain autoantibodies in many fibromyalgia patients that affect neurologic and hormonal systems. There is no strong evidence, however, that a faulty immune system is a primary cause of fibromyalgia.

Psychologic and Social Effects
Although not primary causes, psychologic and social factors may contribute to fibromyalgia in three ways:

Studies have reported a greater incidence of severe experiences of victimization from emotional and physical abuse in patients with fibromyalgia than in the general population. Most often the abuse originated from family or partners. This suggests that post-traumatic stress syndrome or chronic stress may play a strong role in the development of this disorder in some patients. Post-traumatic stress disorder (PTSD) is an anxiety disorder that is a reaction to a specific traumatic event. Symptoms of this condition, which can occur for years after the traumatic event, include emotional withdrawal, hopelessness, irritability, mood swings, sleep problems, inability to concentrate, and an excessive startle response to noise. There is some evidence that PTSD actually results in changes in the brain, possibly from long-term overexposure to stress hormones. [For more information, see Anxiety Disorders, Comprehensive Version. ]

Muscle Abnormalities
Some research has detected muscle defects in fibromyalgia patients, which can be classified as follows:

The observed biochemical and structural defects are usually related to the problem areas in the brain, for example in hypothalamus-pituitary-adrenal gland (HPA) axis, that have also been reported in fibromyalgia patients.

Causes of Secondary Fibromyalgia
Secondary fibromyalgias are conditions with fibromyalgia symptoms that are caused by specific disorders, including the following:

WHO GETS FIBROMYALGIA?

Prevalence
Studies report that between 1.3% and 2% of the general population meet the diagnostic criteria.

Specific Risk Factors
Some evidence suggests that a number of factors may predispose people to fibromyalgia, including being female, having had difficult experiences in childhood, having a psychological vulnerability to stress, and coming from a very stressful culture or environment.

Gender. The prevalence of fibromyalgia is higher in women (3.4%) than in men (0.5%). Women's symptoms are also more severe than men's are.

Age. The disorder usually occurs in people between 20 to 60 years of age and peaks at age 35. In one study, however, fibromyalgia increased with age and had a prevalence of over 7% in patients between 60 and 79 years of age.

A condition called juvenile primary fibromyalgia, which appears in children, is uncommon, but studies indicate that its incidence is increasing. One study found that 1.2% of school children, all girls, met the criteria for fibromyalgia. Other studies have found an even higher prevalence of fibromyalgia in children. A 2000 study reported that in one specialty center it typically developed in children after age 13 and was most commonly diagnosed at 15. Symptoms were similar but outcome appears to be better in young people than adults.

Family Factors. Studies report a higher incidence of fibromyalgia among family members. It is not clear if genetic or psychological factors or both are involved. Some studies reporting some relationship are as follows:

HOW IS FIBROMYALGIA DIAGNOSED?
Diagnostic Criteria
There is no unequivocal objective method for diagnosing the fibromyalgia. The criteria used for studying fibromyalgia are very helpful, particularly if the patient does not have any accompanying disorder, such as depression or arthritis, that could complicate the diagnosis. Failure to meet the criteria, however, does not rule out fibromyalgia. It should be suspected in any patients with muscle and joint pain when no identifiable cause has been found. [ See Box Criteria for Classifying Fibromyalgia.]

Medical and Personal History
A physician should always take a careful personal and family medical history, which would include a psychological profile and a history of any factors that might be indicative of disorders other than fibromyalgia. Such factors might include recent weight change, physical injuries, infectious diseases, muscle weakness, rashes, and any instances of sexual, physical, or substance or alcohol abuse. The patient should report any drugs being taken, including vitamins and over-the-counter or herbal medications.

Physical Examination
Pressure on Tender Spots. Any physical examination for fibromyalgia requires that the physician press firmly on all potential tender spots. They must be painful when pressed, not simply tender. In addition, for a diagnosis of fibromyalgia, these tender sites are not typically accompanied by signs of inflammation, such as redness, swelling, or heat in the joints and soft tissue. The pressure points may also change in location and sensitivity over time. A physician, then, may re-check pressure points that do not respond the first time in patients who have other significant symptoms.
Detection of Other Causes of Symptoms. A physical examination also includes scrutiny of nails, skin, mucous membranes, joints, spine, muscles, and bones to help rule out arthritis, thyroid disease, and other disorders.

Other Tests
There are no blood, urine, or other laboratory tests that can provide a diagnosis of fibromyalgia. If such tests show abnormal results, then the physician should look for other disorders. Tests for specific diseases depend on family histories and other symptoms. They may include thyroid and liver function tests, blood count, tests of certain antibodies, and sedimentation rate. Follow-up psychological profile testing may be suggested if laboratory results do not indicate a specific disease.

WHAT CONDITIONS RESEMBLE FIBROMYALGIA?
Between 10% and 30% of all doctors' office visits are due to symptoms that resemble those of fibromyalgia, including fatigue, malaise, and general muscle pain [ see Table, below]. No laboratory test can confirm a diagnosis of fibromyalgia, and if tests for tender spots are ambiguous, physicians will rule out other conditions. It should be noted that a diagnosis of many of these disorders may not always rule out fibromyalgia, since it can accompany other common and similar conditions.

Other Diseases that Cause Joint Pain, Muscle Aches, or Both

Conditions That Do Not Rule Out Fibromyalgia
Chronic Fatigue Syndrome. About 75% of patients fit the diagnosis for both fibromyalgia and chronic fatigue syndrome (CFS). As with fibromyalgia, the cause of CFS is unknown and its course is chronic. Both disorders can be diagnosed by a physician only on the basis of symptoms reported by the patient and cannot be confirmed by laboratory tests or other objective measures. The two disorders share most of the same symptoms. They are even treated almost identically. The differences are primarily the following:

Some physicians believe that fibromyalgia is simply an extreme variant of chronic fatigue syndrome. There is some physical evidence, however, that the two disorders may be distinct, which offers the possibility for treatments that are specific to each. [For more information see Chronic Fatigue Syndrome, Comprehensive Version. ]

Myofascial Pain Syndrome. Myofascial pain syndrome can be confused with fibromyalgia and may also accompany it. Unlike fibromyalgia, myofascial pain tends to occur in trigger points , as opposed to tender points , and typically there is no generalized pain. Trigger-point pain occurs in taut muscles, and when the doctor presses on these points, the patients may experience a muscle twitch. Trigger points are also often small lumps, about the size of a pencil eraser.

Major Depression Disorder. The link between psychological disorders and fibromyalgia is very strong and problematic. Certain studies report that between 50% and 70% of fibromyalgia patients have a lifetime history of depression. Only between 18% and 36% of fibromyalgia patients, however, report current major depression disorder. It should be noted that some researchers have observed that people who have both psychologic disorders and fibromyalgia are more likely to seek medical help than patients who simply have symptoms of fibromyalgia. Such findings may bias study results and favor a higher-than-actual association between depression and fibromyalgia.

Depression most likely does not cause fibromyalgia, in any case, but it may increase susceptibility to it. Depressed feelings in people with fibromyalgia can certainly be normal responses to the pain and fatigue caused by this syndrome. Such emotions, however, are situational and temporary, and are not considered to be a depression disorder. Unlike ordinary periods of sadness, an episode of major depression disorder can last many months. Symptoms of major depression include the following:

Major depression is likely to be the responsible condition in the presence of several of these symptoms plus the absence of physical symptoms (particularly the tender points typical of fibromyalgia). [For more information, see Depression, Comprehensive Version. ]

Other Conditions that Do not Rule Out Fibromyalgia. In addition to chronic fatigue, myofascial pain syndrome, and depression certain stress-related disorders commonly occur with fibromyalgia and have overlapping symptoms. In fact some experts believe these disorders so commonly interact that they may all be part of one general condition. They include the following:

Other conditions may also occur that are similar to fibromyalgia but do not rule out a diagnosis of fibromyalgia. They include:

Conditions that Usually Rule out Fibromyalgia

Rheumatoid Arthritis and Other Autoimmune Diseases. Many autoimmune diseases, in which the person's immune system attacks the body's own tissues, resemble fibromyalgia. (Fibromyalgia, itself, may be an autoimmune disorder.) These diseases, like fibromyalgia, also occur more often in women than in men and early symptoms are often muscle and joint pain and fatigue. The following are some that may be confused with fibromyalgia:

Autoimmune diseases generally evolve slowly. Even if a physician determines that a patient is most likely to have fibromyalgia, he or she should keep track of any changes in symptoms over time in case one of these illnesses is actually present.

Lyme Disease. Early Lyme disease can usually be correctly diagnosed, but a delayed response or recurrence of this disorder may be mistaken for fibromyalgia. Some experts believe that between 15% and 50% of patients referred to clinics for Lyme disease actually have fibromyalgia. Late Lyme disease can usually (but not always) be ruled out using laboratory tests that identify the presence of the spirochete that causes this tick-borne disease. If fibromyalgia patients are incorrectly diagnosed and treated for Lyme disease with prolonged courses of antibiotics, they may contribute to the problem of antimicrobial resistance. [For more information, see Lyme Disease and Ehrlichiosis, Comprehensive Version. ]

Drugs and Alcohol. Fatigue is a side effect of many prescription and over-the-counter medications, such as antihistamines. In addition, dependency on or abuse of alcohol or illicit drugs may manifest as persistent fatigue. Medications should be considered as a possible cause of fatigue if an individual has recently started, stopped, or changed medications. Withdrawal from caffeine can produce depression, fatigue, and headache.

Polymyalgia Rheumatica. Polymyalgia rheumatica is a condition that causes pain and stiffness and generally occurs in older women. Tender points are also present with this disorder, although they almost always occur in the hip and shoulder area. Morning stiffness is common, and patients may also experience fever, weight loss, and fatigue. Elevated erythrocyte sedimentation rates (ESR or sed rates), detected from results of a blood test, can suggest polymyalgia rheumatica. (Elevated sed rates, however, also occur with other conditions as well.) The condition often resolves in about a year, but there is a risk of persistent disease. Worse, it is associated with a rare condition called temporal arteritis, which causes blindness if not healed, so an accurate diagnosis of polymyalgia rheumatica is important.

Other Diseases the Rule out Fibromyalgia. Many diseases and conditions, both benign and serious, can fully explain prolonged or chronic fatigue, including the following:

HOW SERIOUS IS FIBROMYALGIA?

Severity of Physical Symptoms
Fibromyalgia can be mild or disabling, and the emotional repercussions can be substantial. About half of all patients have difficulty with or are unable to perform routine daily activities. Estimates of patients who have had to stop work or change jobs range from 30% to 40%.

Risk of Substance Abuse
The pain, emotional repercussions, or sleep disturbances may lead to self-medication and overuse of sleeping pills, alcohol, drugs, or caffeine.

Long-term Outlook in Adults
Some studies indicate that fibromyalgia symptoms remain stable over the long term, while others report a better outlook, with 25% of patients in remission two years after diagnosis. Although the disease is chronic, it is neither progressive nor fatal, and remission can occur in many patients who participate in disease management programs. Patients with secondary fibromyalgia, particularly when it is caused by injury, tend to have a more severe and less easily treated condition than those with primary fibromyalgia.

Outlook in Children
Children with fibromyalgia tend to have better outlooks than adults do. In adult patients who were studied for four and a half years, those who had adequate exercise had the most promising outcome; those with a significant life crisis or who were on disability had a poorer outcome than others. Outcome was determined by improvements in the patients' capacity to work, their own feelings about their condition, pain sensation, disturbed sleep, fatigue, and depression.

WHAT ARE THE GENERAL GUIDELINES FOR TREATING FIBROMYALGIA

Combination Treatments
The specific tender points and generalized pain suffered by fibromyalgia patients are most likely the end-points of a disease process that starts in the brain. Therefore, treatments should involve not just dealing with the pain centers but must be a multi-faceted approach. An example is the following sequence:

One study found that interdisciplinary treatment programs were effective in significantly improving pain in 42% of patients. After treatment stopped, improvements in pain and other symptoms, including depression and sense of physical capability, persisted for at least six months, although patients tended to become fatigued again. The effectiveness of the treatments tended to depend on how depressed the patients were, the sense of their own disability, personal support networks, and whether the cause was known. The severity of the pain at the start of treatment had little to do with outcome.

Studies vary over which combinations are most helpful and individuals will probably need to try many different variations to find one that fits their needs. Examples of results from different programs include the following:

Preparation for Treatment
Patients must have realistic expectations about the long-term outlook and their own individual capabilities. It is important to understand that the condition can be managed and patients can live a full life. The following tips may be helpful in embarking on a treatment program for fibromyalgia:

WHAT ARE LIFESTYLE METHODS FOR MANAGING FIBROMYALGIA?

Physical Therapy and Exercise

Many studies have indicated that exercise is the most effective component in managing fibromyalgia, and patients must expect to undergo a long-term exercise program. Physical activity prevents muscle atrophy, increases a sense of well being, and, over time, reduces fatigue and pain itself.

Some patients with fibromyalgia avoid exercise for fear it will exacerbate their pain. However, according to studies, any pain caused by exercising subsides within 30 minutes. Some tips may be helpful:

Physical Therapy. The use of physical therapy may be very helpful. One study suggests that such therapy may reduce muscle overload, reduce fatigue from poor posture and positioning, and help condition weak muscles.

Aerobic and Strength Training Exercise. Strength training and regular low-impact aerobic exercise are very helpful for raising the pain threshold, although it may take months to perceive benefits. Desirable exercises are walking, swimming, and using stationary bikes. Swimming and water therapy, which eliminate weight-bearing, appear to be excellent choices for getting started.

Training Index. Some experts recommend the use of a training index for gauging progress and establishing a goal. This index is the product of three calculations:

People just beginning an exercise program should start with an index of 10 to 25 and aim over time for at least 42. The following are some examples for determining these indexes using exercise goals.

Stretching exercises should be performed for about 10 minutes before aerobic exercise, but they are not considered part of the total exercise time that the patient uses in calculating the index goal.

Establish Regular Sleep Routines
Sleep is essential, particularly since pain is aggravated by disturbed sleep. Improvement is low in those who are unable to sleep consistently and at night. Swing shift work, for example, is extremely hard on fibromyalgia patients. [For tips on improving sleep, see Insomnia, Comprehensive Version and Leg Disorders (Restless Legs Syndrome and Nocturnal Leg Cramps). ]

Diet
Fibromyalgia patients should maintain a healthy diet low in animal fat and high in fiber, with plenty of fresh fruits and vegetables. A small 2000 study in Finland suggested that a vegan diet (no meat, dairy, or eggs plus uncooked fruits, vegetables, nuts, and germinated seeds) had beneficial effects on fibromyalgia symptoms including pain, stiffness, and quality of sleep. In addition, the diet was associated with lower weight and cholesterol levels. There is no evidence, however, that any specific dietary factor is effective in managing fibromyalgia. Nevertheless, it is always wise to avoid saturated fats (found in animal products) and place emphasis on whole grains, fruits, and vegetables. Although everyone should be careful about calories in fats, some are healthy. Oils containing omega-3 fatty acids are of particular interest for arthritic pain. Such oils are found in cold water fish and can be purchased as supplements called EPA-DHA or omega 3.

Stress Reduction Techniques

Relaxation and stress-reduction techniques are proving to be helpful in managing chronic pain. There is certainly evidence that people with fibromyalgia have a more stressful response to daily conflicts and encounters than those without the disorder. A number of relaxation and stress-reduction techniques have proven to be helpful in managing chronic pain:

[For more information, see Stress, Comprehensive Version. ]

Biofeedback.
Evidence suggests that biofeedback techniques may be helpful for fibromyalgia patients. During biofeedback, electric leads are taped to a subject's head. The person is encouraged to relax using methods such as those described above. Brain waves are measured and an auditory signal is emitted when alpha waves are detected, a frequency that coincides with a state of deep relaxation. By repeating the process, subjects associate the sound with the relaxed state and learn to achieve relaxation by themselves.

Meditation
Meditation, used for many years in eastern cultures, is now widely accepted in this country as an effective relaxation technique. For example, one recent study reported that patients who performed qigong, an Oriental technique, reported reduced pain, fatigue, and sleeplessness and improved function, mood, and general health after eight weeks. The practiced meditator can achieve a reduction in heart rate, blood pressure, adrenaline levels, and skin temperature while meditating. A number of organizations, both religious and non-religious, teach meditation; the names of these organizations along with instructional books can be found at public libraries.

An important goal for both religious and therapeutic meditative practices is to quiet the mind, essentially to relax thought. This redirection of brain activity from thoughts and worries to the senses disrupts the stress response and prompts relaxation and renewed energy. Eventually many develop a sense of calmness and peace that can have a significant impact on the stress that can intensify physical pain. A number of meditation techniques are available; some may be more or less useful for fibromyalgia.

New practitioners should understand that it can be difficult to quiet the mind and should not be discouraged by lack of immediate results. Some recommend meditating for no longer than 20 minutes in the morning after awakening and then again in early evening before dinner. Even once a day is helpful. (One should probably not meditate before going to bed, which causes some people to wake up in the middle of the night, alert and unable to return to sleep.)

Hypnosis.
In one controlled study, hypnosis was more effective than physical therapy in improving function and reducing pain.

Massage Therapy.
Massage therapy is thought to stimulate the parasympathetic nervous system, which slows down the heart and relaxes the body. Rather than causing drowsiness, massage actually increases alertness; the reduction of stress and anxiety levels and the resulting relaxation, however, do contribute to better sleep.

Alternative Treatments

Because of the difficulties in treating fibromyalgia, many patients seek alternative treatments. Everyone should be wary of those who promise a cure or urge the purchase of expensive but useless and potentially dangerous treatments. Major analyses have indicated that mind-body therapies, such as biofeedback or hypnosis, are more effective than no treatment at all, but less effective than moderate to intense exercise. In one analysis, evidence was weakest on advantages of manipulative approaches (massage and chiropractic treatments).

Acupuncture
Acupuncture may be effective for some patients. It should be noted, however, that there is some concern that it may actually intensify symptoms in certain patients.

Chiropractic Manipulation
Chiropractic care may also improve symptoms for some patients. In one study 21 patients improved after four weeks of spinal manipulation compared to those receiving only medications. It may be less effective, however, in older patients with severe symptoms. (It should be noted that in rare cases manipulation of the neck has been known to cause stroke or damage to the arteries.)

Magnet Therapy
Magnet therapy has received some attention. One study using magnets that were only slightly more powerful than refrigerator magnets showed some benefits, although there is no strong evidence to confirm their benefits.

Mud Pack Treatments
One 1999 Italian study suggested that taking an antidepressant and undergoing mud-pack treatment may release natural steroids that reduce inflammation and relieve pain. Further research is needed to confirm any benefits.

Herbal or Natural Remedies
Some alternative agents are being investigated for fibromyalgia:

It is extremely important for patients to realize that any herbal remedy or natural medicine that has positive effects most likely has negative side effects and toxic reactions, just as any conventional drug does. [See Warning Box.] Everyone is strongly advised to consult a physician before using any untested products or dietary supplements, and to discuss potential interactions with any medications being taken.

WHAT ARE THE PSYCHOLOGICAL THERAPIES AVAILABLE FOR FIBROMYALGIA?

Cognitive-Behavioral Therapy

Studies continue to show that when fibromyalgia patients increase their psychological capacity to deal with the specific conditions of their disorder and their lives, they are more apt to experience physical improvement. Cognitive-behavioral therapy is an effective method for enhancing patients' belief in their own abilities and to develop methods for dealing with stressful situations.

The Goals of Cognitive-Behavioral Therapy. The primary goals of cognitive-behavioral therapy are to change any distorted perceptions that individuals have of the world and of themselves and to change their behavior accordingly. Using specific tasks and self-observation, patients gradually shift their fixed ideas that they are helpless against the pain that dominates their lives to the perception that pain is only one negative factor and, to a degree, a manageable experience among many positive ones.

Cognitive therapy is particularly helpful in defining and setting limits, behavior that is extremely important for these patients. Many fibromyalgia patients live their lives in extremes. They first become heroes or martyrs, doggedly pushing themselves past the point of endurance until they collapse and withdraw. This inevitable backlash reverses their self-perception, and they then view themselves as complete failures, unable to cope with the simplest task. One important aim of cognitive therapy is to help such patients discover a middle route, whereby they can prioritize their responsibilities and drop some of the less important tasks or delegate them to others. Such behavior will eventually lead to a more manageable life and to less of an absolutist perspective on themselves and others.

The Procedure . Cognitive therapy may be expensive and not covered by insurance, although it is usually of short duration, typically six to 20 one-hour sessions. Patients are also given homework, which usually includes keeping a diary and attempting tasks that they have avoided because of negative thinking.

A typical cognitive therapy program may involve the following measures:

Support Organizations

Cognitive therapy may be expensive and not covered by insurance. An alternative that may be as beneficial for some patients are strong, intelligently managed support groups. In one center, educational discussion groups were as effective, or even more so, than a cognitive therapy program. Such results cannot necessarily be applied to all centers, of course. Therapeutic success varies widely depending on the skill of the therapist. [ See Where Else Can Help Be Found for Fibromyalgia?, below.]

WHAT ARE THE MEDICAL TREATMENTS FOR FIBROMYALGIA?
The primary goal of drug therapy is to improve sleep, but many of the medications may relieve other symptoms of fibromyalgia, including depression and low energy.

Targeting Pressure Points and Stretching Techniques
Much of the pain experienced by patients occurs where muscles join tendons or bones, particularly when the muscles are stretched. Stretching, or flexibility exercises, are part of the warm-up and cool-down routines of any regular program. Stretching technique used for muscle relaxation and pain reduction in fibromyalgia, however, are different and employ injections or cooling agents to inactivate the pressure points so that muscles can be stretched. These techniques must be performed by a person other than the patient, usually a family member or close friend. With use of either injections or the spray, the benefits may last from a few days to weeks. Neither the spray nor the injection is useful without muscle stretching.

Spray and Stretch. One such technique is known as "spray and stretch." This method uses the following approach:

After the procedure, the muscle should feel looser, and the patient should have a greater range of motion with that muscle.

Trigger-Point Injections. In some cases, "trigger-point injections" of an anesthetic may be used for particularly painful tender points as an aid to stretching.

It should be noted that the benefits of this treatment may not be apparent immediately.

Antidepressants
Studies suggest that antidepressants help between a third and a half of patients. Doses used for fibromyalgia are generally lower than for depression, so combinations may be an option. Benefits may be strongest with a combination of drugs from two classes, the tricyclics and SSRIs. None have been well researched for fibromyalgia, however. It should be noted that some patients report worse symptoms with antidepressants.

Tricyclics. Tricyclics not only help relieve depression but they also have properties that reduce sleeplessness and muscle pain. The tricyclic drug most commonly used for fibromyalgia is amitriptyline (Elavil, Endep), which produces modest benefits with pain, but which can lose effectiveness over time. Other tricyclics include desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), amoxapine (Asendin), trazodone (Desyrel), and nortriptyline (Pamelor, Aventyl). Generally only small doses are necessary for relief of fibromyalgia, so, although tricyclics have a number of side effects, they may occur less frequently in fibromyalgia patients than in those taking tricyclics for depression. Side effects most often reported include dry mouth, blurred vision, sexual dysfunction, weight gain, difficulty in urinating, disturbances in heart rhythm, drowsiness, and dizziness. Like all medications, tricyclics must be taken as directed; overdose can be life threatening.

Selective Serotonin-Reuptake Inhibitors (SSRIs). Selective serotonin-reuptake inhibitors (SSRIs) increase serotonin levels in the brain. Serotonin is a chemical messenger important for feelings of well being. Commonly prescribed SSRIs include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and fluvoxamine (Luvox). In some patients, they may improve sleep, fatigue, pain, and well-being. SSRIs should be taken in the morning, since they may cause insomnia. Common side effects are agitation, nausea, and sexual dysfunction, including delayed or loss of orgasm and low sexual drive.

Newer Antidepressants. Trazodone (Desyrel) is an antidepressant that might be specifically helpful for fibromyalgia suffers.

Cyclobenzaprine
Cyclobenzaprine (Flexeril) relaxes muscle spasms in specific locations without affecting overall muscle function. It is related to the tricyclic antidepressants and has similar side effects, the most common being dry mouth, drowsiness, and dizziness.

Sleep Medications
Zolpidem (Ambien) or other newer sleep medications may improve sleep with a lower risk for dependence than older sleeping drugs.

Estrogen Therapy
Because fibromyalgia often develops when a woman reaches menopause, some experts believe that estrogen replacement therapy may have special benefits for fibromyalgia patients. Women who take estrogen therapy seem to fall asleep faster, have longer periods of REM sleep, have fewer wakeful periods, and sleep longer than those not taking estrogen. Taking estrogen shortly before going to bed is most helpful. Postmenopausal women with fibromyalgia should discuss all risks and benefits of hormone replacement therapies. [For more information, see Menopause, Estrogen Loss, and Their Treatments. ]

Pain Relievers
Pain relief is of major concern for patients with fibromyalgia.

Other Drugs
Some treatments being tried for fibromyalgia are experimental and have potentially toxic side effects and interactions with other drugs. Patients should be sure to inform their physicians of any other drugs, including so-called natural remedies, that they are taking.

Tropisetron
Tropisetron (Navoban) is an agent used to reduce vomiting during chemotherapy. European studies are suggesting it may also help patients with fibromyalgia, including reducing pain, dizziness, and depression and improving sleep. Gastrointestinal symptoms and headaches were the most common side effects.

Interferon
Preliminary studies are reporting some improvement in morning stiffness and physical function when fibromyalgia patients take small doses of oral interferon-alpha, an agent used for chronic hepatitis.

Growth Hormone
Some studies have suggested that growth hormones may benefit some patients with fibromyalgia who show evidence of deficiencies.

Gabapentin
Gabapentin (Neurontin) is an antiseizure medication that is helpful for some neuralgias. Some experts believe it may prove to help patients fibromyalgia, but no studies have been conducted yet.

Guaifenesin
One researcher reported improvement with guaifenesin, an agent that loosens mucus and is used in some common cough medications, but a well controlled study confirmed that its benefits were only due to placebo effects.