In Dr. Sharon (Shay) Stanford’s discussion of the DSM-IV-TR diagnosis of fibromyalgia in “Fibromyalgia: Psychiatric drugs target CNS-linked symptoms” (Current Psychiatry, March 2009), she mentions somatization disorder but fails to note that the DSM-IV-TR diagnosis that would more closely fit fibromyalgia patients is a pain disorder. As the chair of the DSM-IV and DSM-IV-TR committees on pain disorders, I am sad to see that this diagnosis that was added to address the overlap between physical and psychological problems associated with pain would not be mentioned in a discussion of fibromyalgia.
Steven A. King, MD, MS
New York, NY
Dr. Stanford responds
I appreciate Dr. King’s letter because it gives me the opportunity to further discuss the classification of fibromyalgia. American College of Rheumatology (ACR) criteria for fibromyalgia more closely match DSM criteria for pain disorder, although the ACR criteria are noted to be more useful for research than for the clinical setting.
Many fibromyalgia experts are advocating for different diagnostic criteria that would include symptoms these patients experience other than pain. I mentioned somatization disorder in particular because of the high comorbidity of symptoms and syndromes involving multiple systems.
In my article, I touched on the fact that many physicians might diagnose fibromyalgia patients with a somatoform disorder, and classifying any patient with physical symptoms of unknown etiology is controversial.
The controversy lies in whether psychological factors play a major role in symptom onset and severity, as required by DSM for a somatoform disorder diagnosis. It has been common for physicians to label symptoms of unknown etiology as psychologically driven, and the medical community remains divided on how to classify fibromyalgia as either a medical or psychological phenomenon. I have treated patients who meet diagnostic criteria for fibromyalgia, have no psychiatric diagnosis, and psychological symptoms have very little role in their symptom onset or severity, yet they have been told by the referring physician that they are depressed and “just don’t realize it.”
Because of growing evidence supporting augmentation of pain processes in these patients, most fibromyalgia researchers are discounting classification of fibromyalgia as meeting DSM criteria for a somatoform disorder. How this affects psychiatrists will largely depend on how somatoform disorders, including pain disorder, are defined in the future and whether the medical community at large accepts research indicating biologic abnormalities as a basis for fibromyalgia symptoms.
Sharon (Shay) Stanford, MD
Assistant professor of psychiatry and family medicine,
Assistant director,
Women’s Health Research Program,
University of Cincinnati,
Cincinnati, OH