Multiple Diagnosis

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Fibromyalgia patients frequently carry multiple diagnosis’s, not surprising given Fibromyalgia is a syndrome that generally carries with it a number of co-morbid conditions. Some conditions most commonly diagnosed in conjunction with fibromyalgia include chronic fatigue syndrome, anxiety, depression, and sleep disturbances, as well as intestinal problems such as interstitial cystitis and irritable bowel syndrome. Many individuals will be diagnosed with a combination of these problems before ever being diagnosed with fibromyalgia. However, the receipt of multiple diagnoses (in the absence of a fibromyalgia diagnosis) often perpetuates confusion and frustration, as patients eventually find themselves on a cyclical path of ineffective symptom treatment and control. 

Once a diagnosis of fibromyalgia is finally achieved, if other comorbid conditions are still determined to be present – such as chronic fatigue syndrome, irritable bowel syndrome, or depression/anxiety – the fibromyalgia patient faces an even steeper uphill battle. Research has shown that individuals with both fibromyalgia and associated comorbid conditions are generally more disabled, with poorer overall quality of life, decreased health status, increased pain, and more disturbed sleep (Peters et al., 2011).

Chronic Fatigue Syndrome

Chronic fatigue syndrome (CFS) is a disorder marked by persistent, extreme fatigue that does not improve, even after a person rests, as well as muscle pain, impaired memory, headaches, sleep problems, and painful lymph nodes. It also occurs most often in women in their 40s and 50s. The incidence of fibromyalgia and CFS occurring together in the same patient ranges depending on the diagnostic criteria used for each condition, and a wide range has been reported in the medical literature. Estimates suggest that 20% to 80% of all patients with fibromyalgia also have CFS (Light et al., 2012). Additionally, individuals with a diagnosis of both CFS and fibromyalgia are generally more disabled, and have lower levels of physical functioning, overall health, and increased pain (Brown and Jason, 2007).

Because of its similarities to fibromyalgia, CFS and fibromyalgia may often be mis-diagnosed as each other. This can be troublesome for the fibromyalgia patient who is erroneously diagnosed as having CFS, as effective therapies – such as antidepressants, pain medications, and exercise-based interventions, all of which can be of great benefit to fibromyalgia patients – may not be pursued.

Sleep Disorders

Fibromyalgia is historically characterized in part by sleep that is of poor quality and un-restful in nature. As many as 85% – 90% of patients with fibromyalgia also experience comorbid sleep disturbances, including insomnia, non-restorative sleep, excessive daytime sleepiness and fatigue, sleep apnea, restless leg syndrome (RLS), periodic limb movement disorder, and bruxism. Individuals who suffer from a number of comorbid sleep conditions face even more challenging nighttime hours than the typical fibromyalgia patient.

Sleep apnea affects approximately 80% of patients with fibromyalgia and is a dangerous condition in which an individual periodically stops breathing while asleep. It leads to poor sleep quality, and feelings of fatigue and tiredness the following day. Some studies have suggested that as many as 64% of patients with fibromyalgia also experience comorbid restless leg syndrome (RLS) (Stehlik et al., 2009). RLS is a condition in which an individual feels the overwhelming urge to move the legs in order to stop unpleasant sensations. These symptoms usually occur at night while the individual is lying down, and are only relieved by walking or moving the legs, actions which result in a loss of sleep for the affected individual. Many researchers have documented that those with comorbid fibromyalgia and RLS experience greater sleep disturbances and difficulty maintaining sleep than those who have only fibromyalgia (Stehlik et al., 2009; Viola-Saltzman et al., 2010). Another disorder that is closely related to RLS is periodic limb movement disorder (PLMD). PLMD is characterized by regular, repetitive limb movements that occur while an individual is in the lighter stages of sleep. The legs, ankles, and feet are most often involved and movements include flexing of the big toe, ankle, knee, and hip. Individuals who suffer from PLMD report frequent nighttime awakenings, poor sleep quality, excessive daytime fatigue, and daytime sleepiness. Bruxism is a condition marked by the unconscious grinding, gnashing or clenching of one’s teeth. Bruxism may also be related to a disease that commonly affects fibromyalgia suffers – temporomandibular joint disorder (TMJD) – which causes severe pain in the jaw joint, as well as the face, neck, shoulders, and back. As many as 70% of fibromyalgia patients may have TMJD (Blasubramaniam et al., 2007).

Myofascial Pain Syndrome

Fascia is the dense, fibrous connective tissue that surrounds muscles. Under normal conditions, fascia is able to relax and constrict painlessly, however when injury occurs, the fascia can become tight and restricted in its movement. This causes the fibers surrounding the injured area to “knot up” and create what are known as “trigger points.” When touched, these trigger points can be extremely painful. Myofascial pain syndrome is a type of chronic muscle pain that centers around these trigger points. It is a deep, aching pain that persists and worsens over time. Muscles, and their surrounding joints, may be stiff and extremely sensitive to touch. Due to the chronic pain of this syndrome, some individuals may have difficulty sleeping and participating in an active and fulfilling lifestyle.

As a result of their generalized pain presentation and overlapping features, myofascial pain may on occasion be misdiagnosed as fibromyalgia and vice versa. The potential overlapping of trigger points (in myofascial pain syndrome) and tender points (in fibromyalgia) also presents a problem in the diagnosis of these two conditions; it has been estimated that as many as 72% of patients with fibromyalgia have active trigger points (Cakit 2010). For individuals who legitimately have both myofascial pain syndrome and fibromyalgia, the aggregate symptoms can take an extreme toll on quality of life and productivity.

Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is predominantly characterized by severe abdominal cramping and distinctive changes in bowel movements. The cause of most cases of IBS is not known, however some cases may result from an intestinal infection or be triggered by a nerve problem. Like fibromyalgia, research has shown that IBS may start following a stressful life event or result from the body’s impaired ability to process pain. IBS is common and affects one out of six people in the United States, with women affected more often than men at a rate of two to one. The primary symptoms of IBS include abdominal pain, a sense of fullness, gas, and bloating, and can range in intensity from mild to severe.

Fibromyalgia patients experience an increased incidence of the condition compared to the general population. Some researchers have estimated that as many as 70% of fibromyalgia patients have IBS. Additionally, as many as two-thirds of all IBS patients may also have fibromyalgia. Those who have both conditions usually have more severe symptoms and a poorer overall quality of life than those who suffer from either fibromyalgia or IBS alone.

Interstitial Cystitis

Interstitial cystitis (IC) is a condition that is marked by frequent pain or discomfort in the bladder and pelvis. Symptoms vary among individuals and they may increase in intensity as the bladder fills with urine and after it is emptied. In addition to pain, people with IC may also feel the frequent urge to urinate. Women’s symptoms may worsen during menstrual periods or vaginal intercourse. IC alone can be severely debilitating, therefore when it coexists with fibromyalgia it can have a profound impact on a patient’s quality of life. The reason for the frequent co-occurrence of both conditions is not well understood, but many researchers believe the pain in both conditions is the result of malfunctioning nerve signals, and some believe that the chronic pain that is associated with IC may lead to the general pain sensitization associated with fibromyalgia. Furthermore, both conditions are much more common in women than in men, suggesting certain genetic or hormonal factors may be at play.

Depression & Anxiety

The pain and disability that accompany fibromyalgia, along with other fibromyalgia symptoms such as headache, sleep disturbances, and muscle pain, all make it difficult to function normally and can make people feel alone and hopeless. For many fibromyalgia sufferers, this all culminates in depression. It is estimated that 30% of all fibromyalgia patients have major depression at the time they are diagnosed, and as many as 20% have generalized anxiety disorder – a condition characterized by sustained elevated levels of anxiety, excessive worrying, and tension, even when no stimulus is present to trigger such symptoms.

The physical symptoms that often accompany generalized anxiety disorder, such as fatigue, headache, muscle aches, difficulty swallowing, and irritability, as well as panic attacks and feelings of inadequacy, perpetuate the pain and discomfort of fibromyalgia. Individuals who suffer from depression and fibromyalgia often modify their behaviors as a result of the depression, such as self-imposed isolation and inactivity. In fact, non-depressed fibromyalgia patients are more likely to be active, and physical activity is well-documented as a means of providing relief from the pain and fatigue of fibromyalgia. Therefore, depression and anxiety can indirectly modify the course of fibromyalgia if it is not treated appropriately, perpetuating the cycle of pain and fatigue and leading people with fibromyalgia to lead less active and fulfilling lives.

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