Identifying and Treating Common Psychiatric Conditions Comorbid with Myalgic Encephalomyelitis and/or Fibromyalgia

By Eleanor Stein, MD | January 18, 2013

Dr Stein is Clinical Assistant Professor in the department of psychiatry at the University of Calgary, Calgary, Alberta, and is in private practice dedicated to the treatment of myalgic encephalomyelitis/chronic fatigue syndrome, fibromyalgia, and multiple chemical sensitivity. She reports no conflicts of interest concerning the subject matter of this article.

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

Pages: 1 2 3 4

by James OBrien | February 14, 2013 12:18 PM EST

All these articles on comorbidity probably means that these categories aren't constructionally valid in the first place.

BTW, Frederick Wolfe MD, who described FM during its origins, has recanted and now states it is not a disease.

Also in this Special Report

Introduction: The Integrated Approach to Addressing Comorbidities—Part 1

Comorbidities in Borderline Personality Disorder

Identifying and Treating Common Psychiatric Conditions Comorbid with Myalgic Encephalomyelitis and/or Fibromyalgia

Migraine and Psychiatric Comorbidity

Treatment Implications for Comorbid Diabetes Mellitus and Depression

Comorbid Movement and Psychiatric Disorders

References

1. Carruthers BM, Jain AK, De Meirleir K, et al. Myalgic encephalomyelitis/chronic fatigue syndrome: clinical working case definition diagnostic and treatment protocols: a consensus document. J Chronic Fatigue Syndr. 2003;11:7-115.
2. Arnow BA, Hunkeler EM, Blasey CM, et al. Comorbid depression, chronic pain, and disability in primary care. Psychosom Med. 2006;68:262-268.
3. Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken). 2010;62:600-610.
4. Fuller-Thomson E, Nimigon J. Factors associated with depression among individuals with chronic fatigue syndrome: findings from a nationally representative survey. Fam Pract. 2008;25:414-422.
5. Nater UM, Lin JM, Maloney EM, et al. Psychiatric comorbidity in persons with chronic fatigue syndrome identified from the Georgia population. Psychosom Med. 2009;71:557-565.
6. Hickie I, Lloyd A, Wakefield D, Parker G. The psychiatric status of patients with the chronic fatigue syndrome. Br J Psychiatry.1990;156:534-540.
7. Jason LA, Evans M, Brown A, et al. Sensitivity and specificity of the CDC empirical chronic fatigue syndrome case definition. Psychology.2010;1:9-16.
8. Courjaret J, Schotte CK, Wijnants H, et al. Chronic fatigue syndrome and DSM-IV personality disorders. J Psychosom Res.2009;66:13-20.
9. Nater UM, Jones JF, Lin JM, et al. Personality features and personality disorders in chronic fatigue syndrome: a population-based study. Psychother Psychosom.2010;79:312-318.
10. Fietta P, Fietta P, Manganelli P. Fibromyalgia and psychiatric disorders. Acta Biomed.2007;78:88-95.
11. Thieme K, Turk DC, Flor H. Comorbid depression and anxiety in fibromyalgia syndrome: relationship to somatic and psychosocial variables. Psychosom Med.2004;66:837-844.
12. Arnold LM, Hudson JI, Hess EV, et al. Family study of fibromyalgia. Arthritis Rheum.2004;50:944-952.
13. Raphael KG, Janal MN, Nayak S, et al. Psychiatric comorbidities in a community sample of women with fibromyalgia. Pain.2006;124:117-125.
14. Gracely RH, Ceko M, Bushnell MC. Fibromyalgia and depression. Pain Res Treat.2012;2012:486590. Epub 2011 Nov 19.
15. Pae CU, Luyten P, Marks DM, et al. The relationship between fibromyalgia and major depressive disorder: a comprehensive review. Curr Med Res Opin. 2008;24:2359-2371.
16. Stein E. Let Your Light Shine Through. http://eleanorsteinmd.ca. Accessed December 5, 2012.
17. White PD, Goldsmith KA, Johnson AL, et al; PACE Trial Management Group. Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial. Lancet. 2011;377:823-836.
18. Lorig KR, Sobel DS, Ritter PL, et al. Effect of a self-management program on patients with chronic disease. Eff Clin Pract. 2001;4:256-262.
19. Vercoulen JH, Swanink CM, Zitman FG, et al. Randomised, double-blind, placebo-controlled study of fluoxetine in chronic fatigue syndrome. Lancet. 1996;347:858-861.
20. Wearden AJ, Morriss RK, Mullis R, et al. Randomised, double-blind, placebo-controlled treatment trial of fluoxetine and graded exercise for chronic fatigue syndrome [published correction appears in Br J Psychiatry. 1998;173:89]. Br J Psychiatry. 1998;172:485-490.
21. Häuser W, Wolfe F, Tölle T, et al. The role of antidepressants in the management of fibromyalgia syndrome: a systematic review and meta-analysis. CNS Drugs. 2012;26:297-307.
22. Arnold LM, Rosen A, Pritchett YL, et al. A randomized, double-blind, placebo-controlled trial of duloxetine in the treatment of women with fibromyalgia with or without major depressive disorder. Pain. 2005;119:5-15.
23. Nishishinya B, Urrútia G, Walitt B, et al. Amitriptyline in the treatment of fibromyalgia: a systematic review of its efficacy. Rheumatology (Oxford).2008;47:1741-1746.
24. Fisher MM, Rose M. Anaesthesia for patients with idiopathic environmental intolerance and chronic fatigue syndrome. Br J Anaesth. 2008;101:486-491.
25. Fitzcharles MA, Ste-Marie PA, Goldenberg D, et al. 2012 Canadian Guidelines for the Diagnosis and Management of Fibromyalgia Syndrome. Oshawa, Ontario: Canadian Pain Society; 2012:1-44.
26. Sublette ME, Ellis SP, Geant AL, Mann JJ. Meta-analysis of the effects of eicosapentaenoic acid (EPA) in clinical trials in depression. J Clin Psychiatry. 2011;72:1577-1584.
27. Jazayeri S, Tehrani-Doost M, Keshavarz SA, et al. Comparison of therapeutic effects of omega-3 fatty acid eicosapentaenoic acid and fluoxetine, separately and in combination, in major depressive disorder. Aust N Z J Psychiatry. 2008;42:192-198.
28. The International Fish Oil Standard Program. http://www.ifosprogram.com/industry-home. Accessed December 5, 2012.
29. Linde K, Berner MM, Kriston L. St John’s wort for major depression. Cochrane Database Syst Rev. 2008;(4):CD000448.
30. Rahimi R, Nikfar S, Abdollahi M. Efficacy and tolerability of Hypericum perforatum in major depressive disorder in comparison with selective serotonin reuptake inhibitors: a meta-analysis. Prog Neuropsychopharmacol Biol Psychiatry. 2009;33:118-127.
31. Arnold LM, Clauw DJ, Dunegan LJ, Turk DC; FibroCollaborative. A framework for fibromyalgia management for primary care providers. Mayo Clin Proc. 2012;87:488-496.

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Identifying and Treating Common Psychiatric Conditions Comorbid with Myalgic Encephalomyelitis and/or Fibromyalgia

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