The cases
Maggie has FM, which developed secondary to chronic injury pain. Acute and chronic pain are common triggers of FM. Over time, depression developed secondary to FM, and she had a decrease in quality of life. Treatment for her should include psychotherapy to target her low mood and low motivation. She may also benefit from an antidepressant if psychotherapy alone is ineffective. As hope increases, self-management can be introduced.
Ben has coincident ME and anxiety. His anxiety has not responded to any SSRI. He does not want to use benzodiazepines, since he heard that they decrease deep sleep and may worsen his daytime functioning. He takes a small dose of doxepin(Drug information on doxepin) at night to improve sleep and has focused on optimizing self-management strategies, such as pacing his daily activities and active resting. He may benefit from psychotherapy for anxiety if his current methods of treatment are ineffective.
Depression was misdiagnosed in Joyce. FM developed secondary to sleep deprivation after the birth of her second child. Then, when the child started school, she developed ME. As is sometimes the case, the trigger is unidentified. Her treatment consists of symptom management, including a low-dose TCA to improve sleep initiation, fludrocortisone(Drug information on fludrocortisone) to increase blood pressure and blood volume (treating orthostatic symptoms), and careful activity pacing. Since Joyce does not have any psychiatric disorder, no psychiatric treatment is indicated. She may benefit from psychosocial support.
Conclusions
Accurately diagnosing ME, FM, and any comorbid psychiatric conditions (when present) is the key to successful treatment. Careful review of the diagnostic criteria/symptom profile for ME and FM and identifying the pathognomonic symptoms that are not part of any psychiatric condition will allow accurate diagnosis.
Psychiatric conditions can be comorbid with ME and FM. They should be looked for in every patient. If they are present, the treatment will vary depending on whether the psychiatric symptoms began before, coincident with, or after the physical condition. In cases of confusion, clarity often occurs over time as the patient and physician are able to analyze the symptom and response patterns and draw more accurate conclusions.
CLINICAL RESOURCES
• ME/CFS Primer for Clinical Practitioners (donation requested). http://www.iacfsme.org/Home/Primer/tabid/509/Default.aspx
• 2012 Canadian Guidelines for the Diagnosis and Management of Fibromyalgia Syndrome. http://www.canadianpainsociety.ca/pdf/Fibromyalgia_Guidelines_2012.pdf
• ME/FM Consensus Documents. http://www.mefmaction.com/index.php?option=com_content&view=article&id=215&Itemid=262
• Let Your Light Shine Through: Strategies for Living With Myalgic Encephalomyelitis/Chronic Fatigue Syndrome, Fibromyalgia and Multiple Chemical Sensitivity. Available for purchase in electronic version and hard copy. http://eleanorsteinmd.ca
