The origin of fibromyalgia—a syndrome characterized by widespread
pain and generalized tender points—is elusive. Psychologically stressful
events do not seem to trigger or reawaken fibromyalgia pain, a recent study of
persons impacted by the events of September 11, 2001, suggested
(Psychiatric News, January 17, 2003).
In contrast, since patients with fibromyalgia often have a history of major
depressive disorder, it's possible that a genetic predisposition toward
depression triggers fibromyalgia. Findings pointing to this hypothesis were
reported in the July issue of Pain. The study was headed by Karen
Raphael, Ph.D., an associate professor of psychiatry at New Jersey Medical
Even as early as the 1940s, there were suspicions that fibromyalgia and
depression were closely intertwined. Since then, numerous studies have found
that fibromyalgia patients are at increased risk for major depression. Some
researchers, in fact, are convinced that fibromyalgia is a psychiatric
disorder, and some people in the field have suggested that the term"
fibromyalgia" be replaced by terms such as "affective
spectrum disorder" or "somatoform pain disorder."
So Raphael and her coworkers decided to investigate whether fibromyalgia
and major depressive disorder share a common familial predisposition or
genetic origin. They decided to limit their study to women, since fibromyalgia
is markedly more prevalent in women.
First they called women in the New York-New Jersey metropolitan area to
locate subjects who had fibromyalgia, a history of a major depressive
disorder, both illnesses, or neither illness. They ended up with 274
individuals, whom they divided into four groups: 68 persons with both
fibromyalgia and a history of major depressive disorder; 22 with fibromyalgia
but no history of major depressive disorder, 144 without fibromyalgia but with
a history of major depressive disorder, and 40 persons with neither
fibromyalgia nor major depressive disorder.
The researchers then attempted to contact as many of the first-degree
relatives of the subjects in the above four groups as possible. They made
contact with 659 in all. They then looked to see how many relatives of
subjects in each of the four groups had ever had a major depressive disorder
and compared the numbers for the four groups. They found that the rates of
major depressive disorder were elevated to a comparable level in relatives of
persons in the first three groups compared with the fourth group. In other
words, relatives of subjects who had fibromyalgia but no major depression
turned out to have the same elevated risk of major depression as did relatives
of subjects who had major depression themselves.
This finding, the researchers concluded, implies that "fibromyalgia
is a depression spectrum disorder, in which fibromyalgia and major depressive
disorder are characterized by shared, familially mediated risk factors.... The
pattern of results leads us to reject the hypothesis that the comorbidity of
fibromyalgia and major depressive disorder is due to reactive depression, as a
function of the stress of living with fibromyalgia."
What are the implications of these results for psychiatrists? "Our
findings don't mean that depression is a form of somatization,
`masked depression,' or a psychiatric disorder itself," Raphael told
Psychiatric News. "This concept is highly stigmatizing to
fibromyalgia patients and not at all helpful. Although we write that our
results support the view of fibromyalgia as a `depression spectrum disorder,'
we shouldn't be misled by that terminology. One could just as easily say that
`major depression is a fibromyalgia-spectrum disorder' or, if we could clearly
identify the shared pathogenic mechanism, that both major depression and
fibromyalgia are perhaps `serotonergic system dysfunction
Rollin Gallagher, M.D., a psychiatrist and pain medicine specialist at the
University of Pennsylvania and one of the co-authors of the study, also
discussed the implications of the study for psychiatrists in an interview."
It appears that chronic pain of certain types related to bodily injury
of some sort or another seems to lead to depression in people who aren't even
vulnerable [to depression] based on family or personal history," he
said, "whereas fibromyalgia is a different story—a story of people
who appear to be vulnerable based on family history to both depression and
fibromyalgia. This is not surprising since there is a high rate of
comorbidity, but also since fibromyalgia is a central nervous system disorder
of modulation of sensation—in other words, there is a change in the
perception of pain in people with fibromyalgia so nonpainful stimuli cause
pain. That is a central nervous system phenomenon, not a peripheral
In terms of treatment for fibromyalgia, he added, "there is some good
news.... Some of the antidepressants that work for depression [such as]
serotonin-norepinephrine reuptake inhibitors.. .seem to work for both
fibromyalgia and depression. So psychiatrists should feel comfortable in
treating fibromyalgia with that kind of medication and also supporting
fibromyalgia patients in other ways."
Yet another study to see whether fibromyalgia and major depressive disorder
cluster in families has been conducted by Leslie Arnold, M.D., an associate
professor of psychiatry at the University of Cincinnati, and colleagues. But
instead of using individuals with major depressive disorder as a comparison
group, they used rheumatoid arthritis patients. They too found that
fibromyalgia and major depressive disorder co-aggregate in families and
reported their findings in the March Arthritis and Rheumatism.
"I was very excited to see Karen Raphael's results because they
confirm our findings," Arnold told Psychiatric News."
Both studies obtained similar findings using different designs, lending
support to the hypothesis that mood disorders and fibromyalgia share common
familial determinates.... Future work to understand the shared determinates
should command a high priority."
The study by Raphael and her team was financed by the National Institutes
An abstract of the study, "Familial Aggregation of Depression
in Fibromyalgia: A Community-Based Test of Alternate Hypotheses," can be
accessed online at<www.sciencedirect.com>
by clicking on "Browse A-Z of journals," "P,"