Fib Fib romyalgia - Balance Women's Health

 
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Fib Fib romyalgia - Balance Women's Health
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      Repeated pain
      signals in the
      periphery may
      sensitize spinal cord
      neurons, resulting
      in amplified and
      prolonged signals
      traveling to
      the brain

                      For mass reproduction, content licensing and permissions contact Dowden Health Media.

36_CPSY0309 36                                                                                                2/13/09 10:56:44 AM
Fib Fib romyalgia - Balance Women's Health
Web audio at CurrentPsychiatry.com                ONLINE
                                                                                              “Is it fibromyalgia or somatization disorder?”         ONLY

b romyalgia
                                                                Psychiatric drugs target
                                                                CNS-linked symptoms
                                                                                                        atients with fibromyalgia are a heterogeneous group, yet
                                                                                                        many describe a common experience: seeing multiple
                                                       Sharon B. (Shay)                                 physicians who seem unable or unwilling to provide a
                                                       Stanford, MD                        diagnosis or treat their symptoms. This situation may be changing
                                                       Assistant professor of psychiatry   with the recent FDA approval of an anticonvulsant and 2 antide-
                                                        and family medicine                pressants for managing fibromyalgia symptoms.
                                                       Assistant director, Women’s            These medications—pregabalin, duloxetine, and milnacipran—re-
                                                        Health Research Program
                                                                                           flect a revised understanding of fibromyalgia as a CNS condition,
                                                       University of Cincinnati
                                                        College of Medicine                rather than an inflammatory process in the muscles or connective tis-
                                                       Cincinnati, OH                      sue. As a result, psychiatrists—because of our experience with CNS
                                                                                           phenomena and managing antidepressant and anticonvulsant medi-
                                                                                           cations—are likely to play a larger role in treating fibromyalgia.

                                                                                           CASE REPORT
                                                                                           ‘Just too tired’
                                                                                           Ms. D, age 50, has a history of migraine headaches and is referred by her
                                                                                           primary physician for evaluation of depression and anxiety. She reports
                                                                                           deteriorating mood over 6 months, beginning when a minor car acci-
                                                                                           dent left her “very sore the next day.”
                  KEN ORVIDAS FOR CURRENT PSYCHIATRY

                                                                                              “Nothing helps” the persistent pain in her back, shoulders, and
                                                                                           thighs, which she rates as 7 to 8 on a 0-to-10 pain scale. She describes
                                                                                           an intense ache, “like having the flu,” that worsens with activity and in
                                                                                           stressful situations. She also experiences nausea and intermittent diar-
                                                                                           rhea, debilitating fatigue, and sleep disturbance.
                                                                                                                                                                   continued

                                                                                                                                             Current Psychiatry
                                                                                                                                                   Vol. 8, No. 3      37

 37_CPSY0309 37                                                                                                                                             2/17/09 11:21:25 AM
Table 1                                          Ms. D reports she is depressed because
                                                                                she feels “just too tired” after work to keep up
                                Medical and cognitive
                                                                                with social activities or housework. Her phy-
                                symptoms related to                             sician’s referral notes a normal physical exam
                                fibromyalgia                                    except for tenderness over her upper back
                                Neurologic                                      and hips. Laboratory testing is negative.
                                Tension/migraine headache
      Fibromyalgia              Psychiatric
                                Memory and cognitive difficulties               Making the diagnosis
                                Mood disturbance                                American College of Rheumatology (ACR)
                                Anxiety disorders
                                                                                criteria for fibromyalgia require wide-
                                Ear, nose, throat                               spread pain for at least 3 months. “Wide-
                                Sicca symptoms
                                                                                spread” is defined as pain in the axial
                                Vasomotor rhinitis
                                Vestibular complaints                           skeleton, left and right sides of the body,
                                                                                and above and below the waist. Pain must
                                Cardiovascular
                                Neurally mediated hypotension                   be found in at least 11 of 18 tender point
     Clinical Point             Mitral valve prolapse                           sites on digital palpation using a force of
                                Noncardiac chest pain                           approximately 4 kg/cm2.1 For many fibro-
     Musculoskeletal
                                Gastrointestinal                                myalgia patients, however, musculosk-
     pain is not the            Esophageal dysmotility                          eletal pain is not their most problematic
     most problematic           Irritable bowel syndrome                        symptom (Table 1). They may suffer:
     symptom for many           Urological                                         • migraine and tension headaches (10%
                                Interstitial cystitis                                 to 80% of patients)
     patients with
                                Gynecological                                      • irritable bowel syndrome (32% to
     fibromyalgia                Vulvodynia                                            80%)2
                                Chronic pelvic pain                                • mood disorders (major depressive dis-
                                Oral/dental                                           order [62%], bipolar disorder [11%])
                                Temporomandibular joint syndrome                   • anxiety disorders (panic disorder
                                Other (general)                                       [29%], posttraumatic stress disorder
                                Chronic fatigue syndrome                              [21%], social phobia [19%]).3
                                Sleep disturbances
                                                                                   ACR criteria are useful in research but
                                Idiopathic low back pain
                                Multiple chemical sensitivity                   lack many common symptoms and comor-
                                                                                bidities. A structured interview that follows
                                                                                the DSM-IV-TR format incorporates other
                                  Table 2
                                                                                symptoms into the diagnosis (Table 2).4
                                Fibromyalgia: Structured                           Because patients with fibromyalgia
                                interview for diagnosis                         often meet criteria for somatization or
                                                                                somatoform disorders, how to classify
                                A. Generalized pain affecting the axial, plus
                                   upper and lower segments, plus left and
                                                                                them—as medically or psychiatrically
                                   rights sides of the body                     ill—is controversial. Some patients believe
                                                                                their mood or anxiety problem stems from
                                Either B or C:
                                                                                the difficulty they experience dealing with
                                B. At least 11 of 18 reproducible tender
                                                                                their physical symptoms, and if they could
      ONLINE                       points
      ONLY                                                                      feel better physically they would not be
                                C. At least 4 of the following symptoms:        depressed or anxious. Others believe their
     Download a form               • Generalized fatigue
                                   • Headaches
                                                                                psychiatric symptoms impede their ability
     for patients to report
                                   • Sleep disturbance                          to help themselves feel better.
     fibromyalgia symptoms.
     Saves time, structures        • Neuropsychiatric complaints                   Consider fibromyalgia in any patient
                                   • Numbness, tingling sensations              with widespread pain of unknown cause.
     office visits.
                                   • Irritable bowel symptoms
     CurrentPsychiatry.com                                                      Before making the diagnosis, rule out oth-
                                D. It cannot be established that disturbance    er illnesses that present with similar symp-
                                   was due to another systematic condition
                                                                                toms (Table 3). Because many patients
           Current Psychiatry
                                Source: Reference 4
     38    March 2009                                                           newly diagnosed with fibromyalgia worry

38_CPSY0309 38                                                                                                               2/17/09 11:21:35 AM
Table 3

             Differentiating fibromyalgia from illnesses with similar symptoms
             Illness                                             Tests to differentiate from primary fibromyalgia
             Rheumatic diseases
             Osteoarthritis                                      Radiographs
             Spondyloarthropathies,                              Rheumatic markers (antinuclear antibody,
             rheumatoid arthritis                                rheumatoid factor, antibodies)
             Systemic lupus erythematosus,                       Inflammatory markers (ESR, C-reactive protein)
             polymyalgia rheumatica
             Osteomalacia                                        Vitamin D level
             Myopathy                                            CPK
             Neurologic
             Multiple sclerosis, Chiari’s                        MRI
             malformation, spinal stenosis,
             radiculopathy
                                                                                                                                                  Clinical Point
             Neuropathy                                          EMG
             Endocrine
                                                                                                                                                  Fibromyalgia
             Hypothyroidism                                      TSH                                                                              patients show lower
             Diabetes                                            Basic chemistry panel with fasting glucose                                       levels of serotonin,
             Other                                                                                                                                norepinephrine,
             Infectious                                          CBC                                                                              and dopamine
              Lyme disease                                       Lyme titer
                                                                                                                                                  metabolites in
                 Hepatitis                                       Hepatitis antibody panel, liver function tests
                                                                                                                                                  cerebrospinal fluid
             Anemia                                              Hemoglobin/hematocrit
             Cancers                                             Routine cancer screening tests, bone scan, blood
                                                                 chemistries specific for suspected primary cancer
             ESR: erythrocyte sedimentation rate; CPK: creatine phosphokinase; EMG: electromyography; TSH: thyroid-stimulating hormone;
             CBC: complete blood count

           that something “more serious” may be go-                             Fibromyalgia affects 3.5% of women and
           ing on, confirm the diagnosis with appro-                            0.5% of men.5 It runs in families with his-
           priate testing and physical examination,                             tories of fibromyalgia and major mood
           usually by a rheumatologist or primary                               and anxiety disorders, suggesting ge-
           care physician.                                                      netic links.6 Defects in genes controlling
                                                                                serotonin and norepinephrine have been
            CASE CONTINUED                                                      implicated.7-9
           Central pain sensitization                                              Fibromyalgia patients show lower lev-
           As you elicit more details about Ms. D’s mood,                       els of serotonin, norepinephrine, and do-
           she continues to focus on her physical symp-                         pamine metabolites in cerebrospinal fluid
           toms. She states that some days she wishes                           (CSF), compared with controls.10 These
           to die because her pain gets so bad, but she                         neurotransmitters may inhibit descending
           denies any plan or intent to harm herself. She                       pain pathways in the CNS, and low levels
           worries that her symptoms will worsen and                            in the brain and spinal cord may inhibit
           that she will become completely disabled.                            CNS regulation of pain impulses from the
              Her primary physician attempted to relieve                        periphery.11
           Ms. D’s pain with multiple trials of nonsteroidal                       Although many patients describe mus-
           anti-inflammatory drugs (NSAIDs) and cyclo-                           cle pain, evidence suggests central pain
           benzaprine. She says she gained no benefit                            augmentation rather than an abnormality
           from the NSAIDs and discontinued the muscle                          of muscle or connective tissue.12 Some stud-
                                                                                                                                                    Current Psychiatry
           relaxant because it made her too sleepy.                             ies have found evidence of “windup,” in                                   Vol. 8, No. 3   39
                                                                                                                           continued on page 46

39_CPSY0309 39                                                                                                                                                     2/13/09 10:56:59 AM
continued from page 39
                                     Box

                                 Managing unrealistic expectations of fibromyalgia patients
                                 BELIEF: ‘A magic pill exists that will resolve     BELIEF: ‘You (the psychiatrist) can make
                                 all my symptoms and have no side effects’          me feel better’
                                     Clinical evidence: Most medications that           Clinical evidence: Psychiatrists can
                                 have been studied were effective in 30% to         help by prescribing appropriate medications,
                                 50% of patients and reduced pain scores by         but much of the burden falls on the patient
      Fibromyalgia               30% to 50%.                                        to maintain a healthy, active lifestyle and to
                                     Patient education: Explain to the patient      manage stressors in an adaptive manner.
                                 with a pain rating of 7 at the first visit that        Patient education: A fibromyalgia
                                 achieving a pain level of 3 to 4 may be            patient may find relief with a medication, but
                                 possible with treatment. Even with successful      symptoms may flare if they ‘overdo’ and take
                                 treatment, symptoms may flare intermittently.      on too many physical or emotional stressors.
                                 As with any treatment, adverse effects may         A consistent, healthy routine is ideal.
                                 occur. Discuss these, so the patient is not
                                                                                    BELIEF: ‘I will eventually become disabled
                                 surprised.
                                                                                    by fibromyalgia’
     Clinical Point              BELIEF: ‘I can’t exercise’                             Clinical evidence: Despite little long-
                                     Clinical evidence: Most patients               term research on fibromyalgia patients, most
     Many patients               experience more fatigue and pain with              evidence points to a chronic, fluctuating
     expect to resume an         physical activity, but exercise is important to    syndrome that does not worsen with age.
                                 maintain physical function.                        Factors that may worsen symptoms include
     energetic, pain-free            Patient education: When discussing an          uncontrolled comorbid conditions, chronic
     life, which usually         exercise program, focus on what the patient        opiate use, inactivity, and deconditioning.
                                 can do. Most patients attempt too much, too            Patient education: Discourage long-term
     is not the case             soon; advise them to start at a tolerable level    physical disability; exercise and maintaining
     with fibromyalgia            (such as 2 to 3 minutes of aerobic activity        an active daily routine helps patients avoid
                                 daily for the first week) and gradually increase   focusing in a nonadaptive manner on their
                                 as tolerated.                                      dysfunction and symptoms.

                                 Source: Sharon B. (Shay) Stanford, MD

                                which second-order neurons in the spinal            degree of overlap was seen in brain ar-
                                cord become sensitized by repeated signals          eas responsible for pain processing. This
                                from first-order neurons in the periphery,          indicates that fibromyalgia patients and
                                resulting in amplified and prolonged pain           controls were experiencing the pain they
                                signals traveling to the brain.13                   reported in the same way.15
                                   Levels of substance P—a primary trans-
                                mitter of pain impulses—are significantly
                                higher in CSF of fibromyalgia patients              Treating the whole patient
                                compared with controls.14 This finding,             As a clinician who specializes in fibromyal-
                                in addition to low levels of serotonin and          gia, I counteract my patients’ and my own
                                norepinephrine, indicates that pain signals         frustration with this condition by structur-
                                are ascending unchecked to be processed             ing office visits, determining realistic treat-
                                by the brain.                                       ment goals, and treating all symptoms as
                                   Neuroimaging studies confirm this                part of a common syndrome rather than
                                observation. In a study using functional            individual illnesses.
                                magnetic resonance imaging (fMRI), re-
                                searchers applied pressure to the thumb-            Structure office visits. Before every visit,
                                nails of fibromyalgia patients and controls         have patients rate each symptom domain
                                until each subject reported pain:                   and write their top 2 or 3 concerns for that
                                   • Twice as much pressure was required            day (for a sample form, see this article at
                                before controls rated their pain at a level         CurrentPsychiatry.com). Focusing on the
                                similar to that of fibromyalgia patients.           patient’s most troublesome symptoms can
                                   • When controls and fibromyalgia pa-             help both of you feel greater satisfaction
           Current Psychiatry
     46    March 2009           tients reported similar pain, a very high           with treatment.

46_CPSY0309 46                                                                                                                       2/17/09 11:21:40 AM
Educate patients. Ask them to discuss their
           beliefs about fibromyalgia; many know oth-
           ers with this condition or have researched di-
           agnosis and treatment. Before developing a
           treatment plan, explain that their symptoms
           are chronic and all part of the same syndrome.
           Describe their pain as a complex phenomenon
           with possible peripheral and CNS components.
           Guide them to reputable Web sites and resourc-
           es (see Related Resources, page 50).

           Set realistic expectations. Many patients ex-
           pect to resume an energetic and pain-free life,
           which usually is not the case with fibromyalgia
                                                               Your search is over!
           (Box). Most medications are considered success-     DISCOVER CURRENT PSYCHIATRY’S
           ful if they reduce pain by 30% to 50%, and side
           effects can be problematic. Discuss side effects
           before treatment begins to reduce patients’ anxi-
           ety and improve compliance in the first weeks.
                                                               Ñ PSYCHIATRYFindit.com defined:
           Cognitive-behavioral therapy (CBT) for fi-            PSYCHIATRYFindit.com is a custom vertical search tool
           bromyalgia incorporates relaxation techniques,        that allows visitors to perform targeted searches of Web
                                                                 sites most relevant to psychiatrists and related clinicians.
           helping patients view symptoms as manage-
                                                                 PSYCHIATRYFindit.com covers hundreds of carefully
           able, reinforcing adaptive coping skills, and
                                                                 selected Web sites containing information directly related
           teaching them how to monitor thoughts, feel-          to psychiatric practice.
           ings, and behavior to change the view that
           they are helpless victims. A modest course of       Ñ PSYCHIATRYFindit.com delivers results from:
           6 weekly group CBT sessions significantly im-         •Peer-reviewed psychiatric journals
           proved physical functioning in 25% of fibro-          •Psychiatric professional associations
           myalgia patients (n=76) compared with 12%             •Government agencies
                                                                 •Patient advocacy sites
           in a standard-care group (n=69), even though
           patients’ pain severity did not improve.16          Ñ Benefits to psychiatrists are:
                                                                 • Targeted and relevant searches
           Recommend exercise, lifestyle changes.                • Time-saving tool
           Aerobic exercise can significantly improve            • Trusted source: CURRENT PSYCHIATRY
           well-being and physical functioning in fibro-       Ñ PSYCHIATRYFindit.com provides 3 convenient
           myalgia patients.17 Low-impact aerobics, such         search options:
           as done in warm water, usually are well tol-          • “CURRENT PSYCHIATRY” allows searches of current and
           erated, although any low-impact exercise can            archived issues.
           help. Because fibromyalgia symptoms often             • “Psychiatry sites” includes hundreds of the most
           increase with physical activity, counsel pa-            relevant sites selected by CURRENT PSYCHIATRY’s editors
           tients to begin with a few minutes daily and            and Editorial Board.
           increase very slowly each week.                       • “PubMed” includes 18 million citations from life science
                                                                   journals.
              Lifestyle changes are as important as medica-
           tions in controlling fibromyalgia symptoms. In
                                                               Visit us online at www.PSYCHIATRYFindit.com today!
           addition to exercise, recommend that patients:
              • follow a daily routine
              • pace activity to avoid exacerbating
                symptoms
              • reduce stress.                                          SYCH IATRY              CURRENTPSYCHIATRY.com
              Sometimes, I use the analogy of diabetes:
           treating fibromyalgia with medication but

47_CPSY0309 47                                                                                                       2/17/09 12:04:49 PM
Table 4

                                 Off-label medications shown to benefit patients with fibromyalgia
                                 Drug                          Comment
                                 Amitriptyline27,28            Considered first-line because of studies supporting its use, low cost,
                                                               and wide availability; may be associated with more side effects than
                                                               newer medications

      Fibromyalgia               Gabapentin29                  Possible alternative to pregabalin but may not be as well tolerated
                                              30
                                 Tramadol                      May help with breakthrough pain; use with extreme caution in patients
                                                               taking antidepressants because of serotonin syndrome risk
                                 Fluoxetine31                  Dosages of 40 to 60 mg/d may help patients who do not tolerate SNRIs
                                                   32
                                 Venlafaxine                   Dosages of 150 to 225 mg/d may be an alternative to other SNRIs
                                 SNRIs: serotonin/norepinephrine reuptake inhibitors

                                without changing lifestyle is like pre-                     brain and spinal cord. This SNRI was
     Clinical Point             scribing medication for a diabetic patient                  first FDA-approved for diabetic periph-
     Pregabalin may be          without changing diet. Follow up on this                    eral neuropathic pain and major depres-
                                “homework” at each visit to reinforce that                  sive disorder. Approval for fibromyalgia
     a beneficial first
                                patients helping themselves is an impor-                    at 60 mg/d in June 2008 was based on 2
     choice for patients        tant part of treatment.                                     placebo-controlled, double-blind, 12-week
     who report pain and                                                                    trials comprising 874 patients.23,24 For de-
     sleep as major issues                                                                  tailed findings of these studies and a 6-
                                New direction with medications                              month fixed-dose trial,25 see this article at
                                Pregabalin is an anticonvulsant that binds                  CurrentPsychiatry.com.
                                to the alpha-2-delta subunits of neurons’                      In clinical trials, duloxetine dosages of
                                voltage-gated calcium channels. This ac-                    60 mg/d and 120 mg/d were significantly
                                tivity reduces calcium influx at nerve ter-                 more effective than placebo. The most com-
                                minals and inhibits release of excitatory                   mon side effects were nausea, constipation,
                                neurotransmitters, such as substance P                      excessive sweating, and somnolence.23-25
                                and glutamate.18 In June 2007, pregabalin
                                was the first medication FDA-approved                       Milnacipran is an SNRI that was approved
                                for fibromyalgia.                                           for treating fibromyalgia in January 2009
                                   Two placebo-controlled trials19,20 showed                at dosages of 50 mg bid and 100 mg bid.
                                that pregabalin at 150 mg bid, 225 mg bid,                  Like other SNRIs, milnacipran is thought
                                or 300 mg bid significantly reduced weekly                  to work by inhibiting pain signals through
                                mean pain scores in fibromyalgia patients.                  increasing serotonin and norepinephrine
                                For details of these trials, see this article at            in the brain and spinal cord. Milnacipran
                                CurrentPsychiatry.com. The most common                      has a higher selectivity for norepineph-
                                side effects—dizziness, somnolence, pe-                     rine reuptake compared with duloxetine,
                                ripheral edema, blurred vision, and weight                  which may mean these medications will
                                gain—were regarded as mild to moderate                      have different effects in different patients.
                                in 87% of patients.21                                       Although milnacipran is approved as an
      ONLINE
      ONLY                         Although a dosage of 300 mg bid also                     antidepressant in other countries, the FDA
                                was studied, the FDA approved pregaba-                      has not approved it for treating depression
     Details of clinical        lin at dosages of 150 mg bid and 225 mg                     in the United States.
     trials that supported
                                bid for fibromyalgia.22                                        For details of a 15-week, double-blind,
     fibromyalgia indications
     for 3 CNS medications.                                                                 placebo-controlled trial of milnacipran in
     CurrentPsychiatry.com      Duloxetine is a serotonin/norepineph-                       patients with fibromyalgia, see this article
                                rine reuptake inhibitor (SNRI) thought                      at CurrentPsychiatry.com. Side effects in
                                to inhibit dorsal horn neurons’ response                    clinical trials were similar to those of du-
                                to peripheral pain signals by increas-                      loxetine, with nausea, constipation, and in-
           Current Psychiatry
     48    March 2009           ing serotonin and norepinephrine in the                     creased sweating being most prominent.26

48_CPSY0309 48                                                                                                                          2/17/09 12:04:57 PM
Other medications, such as the first-line        CASE CONTINUED

           agent amitriptyline, have shown beneficial       Not as hopeless
           effects in fibromyalgia but are not FDA-         Ms. D’s primary care physician confirms your
           approved for this indication (Table 4).27-32     presumptive diagnosis of fibromyalgia. He
                                                            prescribes a trial of amitriptyline, which she
           Choosing medications. When prescribing           does not tolerate well because of sedation and
           one of the FDA-approved medications to           weight gain. At her next psychiatric visit, she
           treat fibromyalgia, consider their benefits      tells you she remains very frustrated about her
           and side effects.                                physical symptoms and reports that her doc-
              Pregabalin may be a beneficial first choice   tor “has given up on me.”
           for patients who report pain and sleep as            You discuss what a fibromyalgia diagnosis
           major issues. Although the medication’s          means to her and educate her about the syn-
           label recommends starting with twice-daily       drome. You refer her to a colleague who does
           dosing, patients might better tolerate an ini-   CBT with chronic pain patients and start her
           tial dose of 50 to 75 mg in the evening, with    on a low dose of duloxetine (30 mg once daily)
           the morning dose added later. Pregabalin         to minimize side effects. You discuss possible
           can be useful in patients taking multiple        side effects and that she may need a higher                        Clinical Point
           medications because of its renal clearance,      dose to notice improvement in her pain. She                       Milnacipran’s more
           resulting in low risk of interactions with       seems receptive to starting a graded exercise
                                                                                                                              selective effect on
           drugs metabolized by liver enzymes. It also      program, and you encourage her to reduce
           can be useful in patients who have not toler-    physical and emotional stress in her life.                        norepinephrine
           ated antidepressants in the past or in whom          When she returns, she reports her pain                        could be beneficial
           antidepressants are contraindicated.             is somewhat improved and medication side                          for patients with
              If a patient has a history of depression      effects have subsided. She is not as hopeless
                                                                                                                              excessive fatigue
           or discontinuing medications because of          and tells you she is up to 10 minutes of walk-
           sedating side effects, an antidepressant         ing daily. You increase duloxetine to 60 mg/d
           such as duloxetine or milnacipran may be         and reinforce her ability to exercise and man-
           more successful than starting with prega-        age her stress.
           balin. In general, if a patient does not re-
           spond to one of these SNRIs, moving on to        References
                                                             1. Wolfe F, Smythe HA, Yunus MB, et al. The American College
           the other might help. Milnacipran’s more             of Rheumatology 1990 criteria for the classification of
                                                                fibromyalgia. Report of the Multicenter Criteria Committee.
           selective effect on norepinephrine could             Arthritis Rheum. 1990;33(2):160-172.
           be beneficial for some patients, especially       2. Aaron LA, Buchwald D. Chronic diffuse musculoskeletal pain,
                                                                fibromyalgia and co-morbid unexplained clinical conditions.
           those with excessive fatigue. Others, es-            Best Prac Res Clin Rheumatol. 2003;17(4):563-574.
           pecially those with a high level of anxiety,      3. Arnold LM, Hudson JI, Keck PE, et al. Comorbidity of
                                                                fibromyalgia and psychiatric disorders. J Clin Psychiatry.
           might respond better to a more balanced              2006;67(8):1219-1225.
           SNRI such as duloxetine.                          4. Pope HG Jr, Hudson JI. A supplemental interview for forms

           Bottom Line
           Consider fibromyalgia in patients with pain, depression, sleep problems, fatigue,
           and cognitive dysfunction beyond what is expected for a primary mood disorder.
           Two antidepressants and an anticonvulsant that target the CNS are FDA-approved
           for fibromyalgia, although other medications may help. Encourage patients to share
           in symptom management by exercising and making lifestyle changes. Cognitive/
                                                                                                                                Current Psychiatry
           behavioral techniques can help patients manage frustration and hopelessness.                                               Vol. 8, No. 3   49

49_CPSY0309 49                                                                                                                                 2/17/09 12:05:02 PM
of “affective spectrum disorder.” Int J Psychiatry Med. 1991;
                                    21(3):205-232.
                                 5. Wolfe F, Ross K, Anderson J, et al. The prevalence and
                                                                                                       Related Resources
                                    characteristics of fibromyalgia in the general population.         • Arthritis Foundation. Fibromyalgia. www.arthritis.org/
                                    Arthritis Rheum. 1995;38(1):19-28.                                 disease-center.php?disease_id=10.
                                 6. Arnold LM, Hudson JI, Hess EV, et al. Family study of
                                                                                                       • National Fibromyalgia Association. www.fmaware.org.
                                    fibromyalgia. Arthritis Rheum. 2004;50(3):944-952.
                                 7. Bondy B, Spaeth M, Offenbaecher M, et al. The T102C                • Self-management program for patients with fibromyalgia,
                                    polymorphism of the 5-HT2A-receptor gene in fibromyalgia.          cosponsored by the National Fibromyalgia Association and
                                    Neurobiol Dis. 1999;6(5):433-439.                                  Eli Lilly and Company. www.knowfibro.com.
                                 8. Offenbaecher M, Bondy B, de Jonge S, et al. Possible asso-
      Fibromyalgia                  ciation of fibromyalgia with a polymorphism in the serotonin
                                                                                                       Drug Brand Names
                                    transporter gene regulatory region. Arthritis Rheum. 1999;         Amitriptyline • Elavil, Endep     Milnacipran • Savella
                                    42(11):2482-2488.                                                  Cyclobenzaprine • Flexeril        Pregabalin • Lyrica
                                 9. Gürsoy S, Erdal E, Herken H, et al. Significance of catechol-      Duloxetine • Cymbalta             Tramadol • Ultram, Ultracet
                                    O-methyltransferase gene polymorphism in fibromyalgia              Fluoxetine • Prozac               Venlafaxine • Effexor, Effexor
                                    syndrome. Rheumatol Int. 2003;23(3):104-107.                       Gabapentin • Neurontin              XR
                                10. Russell IJ, Vaeroy H, Javors M, et al. Cerebrospinal fluid
                                    biogenic amine metabolites in fibromyalgia/fibrositis              Disclosure
                                    syndrome and rheumatoid arthritis. Arthritis Rheum.                Dr. Stanford receives grant/research support from Eli Lilly and
                                    1992;35(5):550-556.                                                Company, Pfizer Inc., Cypress Bioscience, and Allergan.
                                11. Fields HL, Basbaum AI. In: Wall PD, Melzack R, eds. Textbook
                                    of pain. 4th ed. New York, NY: Churchill Livingstone; 1999:
                                    309-329.
     Clinical Point             12. Clauw DJ, Crofford LJ. Chronic widespread pain and
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           Current Psychiatry
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50_CPSY0309 50                                                                                                                                                        2/17/09 12:05:07 PM
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